Medication Adherence among Patient with Bipolar Disorder:
A Literature Review
Fardelin Hacky Irawani
1
, Weena Chanchong
2
, Wandee Suttharangse
2
1
Department of Psychiatric and Mental Health Nursing, Syiah Kuala University, Banda Aceh, Indonesia
2
Department of Psychiatric and Mental Health, Prince of Songkla University, Hatyai, Thailand
Keywords: medication adherence, medication non-adherence, bipolar disorder, medication adherence and bipolar
disorder
Abstract: Bipolar disorder is one of the chronic mental health disorders. It is ranked the seventh leading cause of non-
fatal burden in the world. Patients with bipolar disorders encounter several disturbances in their moods,
cognitions, and behaviours which express differently during mania and depressive episodes. These
difficulties can affect a patient’s life functionings, especially in regards to social functioning. Bipolar
disorder can be treated and the patients can become productive and be able to live meaningfully. However,
non-adherence with medication is common problem among patients with bipolar disorder that is associated
with elevated rates of relapse, hospitalization, suicidal behaviour, greater cost of caring, and consequently a
poor quality of life. Several factors contributed to medication adherence among patients with bipolar
disorder have been discussed including age, gender, marital status, substance abuse, phase/stage of illness,
medication knowledge, individual’s beliefs, illness representation, social support, and medication side
effects. This literature review aims to explore the importance of medication adherence to patients with
bipolar disorder and several factors influencing to medication adherence. PubMed, CINAHL, Science
Direct, Google Scholar were used to search the articles published from 2000 to 2013 in English that
combined the search terms “bipolar disorder”, “medication adherence”, “medication non-adherence”, and “
medication adherence and bipolar disorder”. In order in helping to enhance medication adherence in
patients, health care providers indeed need to understand the phenomenon of medication adherence.
1
INTRODUCTION
Bipolar disorder is a chronic mental health disorder
with periods of remission and relapse (Macneil,
Hasty, Conus, Berk, & Scottt, 2009). It is estimated
to be the seventh leading cause of non-fatal burden
in the world (Ayuso-Mateos, 2001). Globally, the
lifetime prevalence of bipolar spectrum disorder is
approximately 3% to 7% of the population
(Williams, Ruekert, & Lum, 2011) and
approximately 0.5% to 5% for prevalence in any
type of bipolar disorder (Vieta et al., 2011), with the
average age of onset being 15 to 30 years (Williams
et al., 2011). The prevalence of bipolar disorder in
Indonesia is unknown yet. However, based on the
Global Burden of Disease 2000 survey, the prevalence
of bipolar disorder in the sub-region SearB (South-
East Asia) in which Indonesia was included, showed
the highest number per population in the 30-44 year
age group (Chisholm, van Ommeren, Ayuso-Mateos,
& Saxena, 2005).
Despite not being ranked the first among mental
health disorders, bipolar disorder causes a significant
burden (Vieta, 2005), such as relapse, re-
hospitalization, suicidal behavior, and a greater cost
to caring (Adam & Scott, 2000; Colom, Vieta,
Tacchi, Sanchez-Moreno, & Scott, 2005; Depp,
Lebowits, Patterson, Lacro, & Jeste 2007; Sajatovic,
Bauer, Kilbourne, Vertrees, & Williford, 2006; Scott
& Tacchi, 2002) which ultimately affects
functioning in everyday life (Nieng, 2011).
Medication is one of the treatment approaches in
bipolar disorder. Thus, if individuals get the proper
medication, they would be able to regain a
productive life like others (National Institute of
Mental Health [NIMH], 2009). However, non-
adherence with medication in bipolar disorder is a
common problem (Lingam & Scott, 2002), with the
228
Irawani, F., Chanchong, W. and Suttharangse, W.
Medication Adherence among Patient with Bipolar Disorder: A Literature Review.
DOI: 10.5220/0008396800002442
In Proceedings of the Aceh International Nursing Conference (AINC 2018), pages 228-233
ISBN: 978-989-758-413-8
Copyright
c
2022 by SCITEPRESS Science and Technology Publications, Lda. All rights reserved
incident rate ranging from 20% to 60% (Berk, Berk
& Castle, 2004; Colom & Lam, 2005; Lingam &
Scott, 2002).
Medication non-adherence is associated with
elevated rates of relapse, hospitalization, suicidal
behavior, greater cost to caring (Adam & Scott, 2000;
Colom, Vieta, Tacchi, Sanchez-Moreno, & Scott,
2005; Depp, Lebowits, Patterson, Lacro, & Jeste
2007; Sajatovic, Bauer, Kilbourne, Vertrees, &
Williford, 2006; Scott & Tacchi, 2002), and
consequently a poor quality of life (Crowe, Wilson, &
Inder, 2011). Several factors contribute to
medication non-adherence among patients with
bipolar disorder including age (Baldessarini, Perry, &
Pike, 2007; Berk et al., 2010; Hou, Cleak, & Peveler,
2010), gender, marital status, substance abuse (Berk et
al., 2010; Clatworthy, Bowskill, Rank, Parham, &
Horne, 2007; Sajatovic, Bauer, Kilbourne, Vertrees,
& Williford, 2006; Sajatovic, Velligan, Weiden,
Valenstein, & Ogedegbe, 2010), phase/stage of
illness (Berk et al., 2010; Colom et al., 2005),
medication knowledge (Berk et al., 2010; Rosa et
al., 2009; Seo & Min, 2005), an individual’s beliefs
and attitude (Adams & Scott, 2000; Clatworthy et
al., 2007; Clatworthy et al., 2009; Lan, Shiau & Lin,
2003; Scott & Pope, 2002), cognitive illness
representation (Brown et al., 2001; Hou et al., 2010;
Lobban et al., 2003; Sajatovic et al., 2009a),
theurapeutic alliance (Berk et al., 2004; Lingam &
Scott, 2002), social support (Berk et al., 2010; Seo &
Min, 2005), and medication side effects (Clatworthy
et al., 2009; Patel & David, 2007; Sajatovic et al.,
2011).
In the following article, we review the literature
on medication adherence among patient with bipolar
disorder and discuss the small research based on
how the concepts are linked.
2
FINDINGS
2.1 Definition and Nomenclature
In the literature review, there are three terms related
to a patient’s medication taking behavior;
compliance, adherence, and concordance. In terms
of compliance and adherence, these terms reflect
different meanings in a patient’s action in taking
medication. However, some authors have often used
compliance and adherence interchangeably because
they want to shift away from negative connotation of
compliance which is coercion. Even though they used
adherence to replace compliance, however, they may
use the same measurement. For instance, in Berk’s
literature review (as cited in Berk et al., 2010), some
studies used adherence and the others used
compliance. However, among those studies, the
same measurement to measure variables of taking
medication was used.
Currently, since compliance and adherence have
different meanings, some authors have defined these
two terms. In terms of compliance, Vukovich (2010)
defined that compliance is a patient’s acceptance of
medication and other psychiatric treatment because
he/she is forced, persuaded, or pressured to take
his/her medication. In compliance, patients yield to or
obey to physicians’ instructions. It implies conformity
to medical defined goals only. Based on Seo and Min
(2005), compliance is more likely a person’s
behavior of taking medication in the correct dose,
and time as prescribed by the doctor. Based on Mullen
(as cited in Cohen, 2009), compliance implies
obedience and the expectation that patients will
passively follow the order. It refers to behavior
characterized by the extent to which people obey,
follow the instructions, or use the prescriptions
assigned by a health-care provider (Brawley &
Culos-Reed, 2000). Meanwhile, Patel and David
(2007) defined compliance is the extent to which a
person’s behavior coincides with medical advice. From
these definitions, it shows that compliance occurs
because of control or force by other people to follow
the prescriptions (external control), therefore, in this
condition, the patient is a passive patient.
Adherence, on the other hand, refers to patients’
voluntary behaviors to take their recommended
medication from their own commitment (Vukovich,
2010). Adherence is the patients’ choice to take their
medication under their own responsibility and they
can interpret their medication correctly because of
their understanding (Patel & David, 2007). It implies
that patients have their own choice to plan their
behavior to take medication and implement their
medication by their own motivation and action
(Brawley & Culos-Reed, 2000). Adherence is the
patient’s agreement to take medication and continue to
use it for a period of time (Velligan et al., 2006).
Patients’ attempts to maintain health behavior
related to behaviors to take their medication are
based on their active participation and agreement
(Cohen, 2009). Based on Lutfey and Whisner
(1999), adherence is the patients' behavior to take
their medication as independent, intelligent, and
autonomous people, therefore, the patients are
voluntary and become active participants in their
medical treatment. Furthermore, Horne (2006)
defined adherence as “the extent to which the patient’s
Medication Adherence among Patient with Bipolar Disorder: A Literature Review
229
behavior matches agreed recommendations from the
prescriber” (p. 66S).
Nevertheless, to achieve adherence, adherence
needs concordance that is emphasized on patient
decision-making and patient agreement. Vukovich
(2010) defined concordance as the agreement
between the patient and the treatment team on the
goals and means of the treatment. It implies that
concordance is a necessary way to achieve
adherence.
Medication adherence involves quite complex
behaviors reflecting an integration of a person’s
mental state such as a person’s willingness as well as
external behaviors such as the actual actions of
medication taking. Those refers to (1) patients
behavior in taking their medication by their own
commitment/agreement (voluntarily), (2) taking
medication from their own
responsibility/plan/action/active participation as a
result of their understanding (actively), (3) taking
medication continuously for a period of time
(continuously), and (4) taking medication matching the
recommendation (taking medication correctly as
prescribed).
3.2 The Importance of Medication Adherence
Relapse prevention. Patients with bipolar disorder
who are on maintenance medication, especially
Lithium, but discontinue their medication, almost
always result in relapse, usually in weeks to months
after stopping (Peet & Harvey, 1991). A study by
Adam and Scott (2000) showed that patients who are
partially adherent are more likely to be relapsing
compared than those who are highly adherent.
Hospitalization prevention. Likewise, high
adherence to medication among patients with bipolar
disorder is more likely to result in a smaller number
of hospitalizations (Lage & Hassan, 2009; Sajatovic
et al., 2006). A study by Scott and Pope (2002)
about self-reported adherence in which psychiatric
hospitalization was one of the outcomes among
bipolar disorder patients showed that patients who
were partially adherent to medication had had a
higher number of psychiatric hospitalizations
compared to those who were fully adherent.
Reducing of symptoms severity. Taking
medication as prescribed can reduce symptoms
severity. A study by Adam and Scott (2002) showed
that patients with stronger beliefs about the benefits
of treatment were highly adherent compared with the
partially adherent subjects who had higher perceived
severity of illness scores. Moreover, individuals who
were non-adherent with prescribed medication
experienced more severe symptoms. (Sajatovic et al,
2009).
3.2 Factors Contributed to Medication
Adherence
Age. Younger aged patients were more non-adherent
than older patients, they have more negative views of
medicines, they perceive that their medicines can
harm them, and they perceive that they have more
personal control over managing themselves in relation
to their illness (Hou et al., 2010). A survey study of
429 patients with bipolar disorder related to treatment
adherence (Baldessarini et al., 2007) showed that
younger patients were more non-adherent.
Moreover, patients who received either lithium or
anticonvulsant medication were more likely to be
younger in non-adherence to medication. To sum
up, younger aged patients are more non-adherent
than older aged patients (Berk et al., 2010).
Gender. Females are more likely to be non-
adherent than males. Bipolar disorder in women is a
challenging disorder to treat because it differs with
male in various aspects, such as; women reproductive
cycle particularly postpartum, premenstrual phase of
menstrual cycle, peri-menopause, and menopause
(Parial, 2015). Sajatovic et al. (2010) in their study
about illness experience and reason for non
adherence showed that females were more likely to be
non-adherent. Similarly, Clatworthy et al. (2007)
also reported higher numbers of females for non
adherence. In additon, Kessing (as cited in Berk et
al., 2010) reported that females were significantly
more likely to have poorer adherence to lithium in a
naturalistic study in Denmark.
Marital status. There are differences results in
regards to marital status as a factor of medication
adherence. Clatworthy et al. (2007) reported that
there were no significant differences in marital status
for non adherence or adherence. Meanwhile, based on
Connely as cited in Berk et al., (2010) it appears that
marital status is a protective factor that increases
adherence. Similarly with Connely’s study,
Sajatovic (as cited in Berk et al., 2010) showed the
results that non-adherent patients were more likely
to be in the single status group. Individuals who get
married are less frequent to suffer bipolar disorder than
those who have divorced or never been married. (Aubry
et al., 2007).
Substance abuse. Individuals with bipolar disorder
who have any current substance abuse disorder will
be more likely to be non-adherent and individuals
who have any past substance use disorder showed no
significant difference between the adherence and
AINC 2018 - Aceh International Nursing Conference
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non-adherence group. The most common substance
abuse was alcohol (Sajatovic et al., 2006). Moreover,
Sajatovic, et al. (2010) reported that a high number
(65 % of 13 participants with bipolar disorder) of
substance use dependents are non-adherent in
regards to prescribed medication.
Phase/Stage of illness. Adherence problems also
can happen in different phases and stages of the
illness. For example, people who have an increasing
severity of manic symptoms are at risk for adherence
problems (Keck as cited in Berk et al., 2010). Related
to this problem, Colom et al. (2005) stated that
adherence problems may be prevalent at specific
stages in the course of the illness, for example late
adherence and late non-adherence. In late adherence,
patients were in adherence after experiencing
repeated relapses. Meanwhile in late non-adherence,
patients will be in non-adherence in long-term
treatment and they will feel that their treatment is
not working well.
Medication knowledge. Having a good level of
knowledge about their illness and treatment is one of
important factors among patients with bipolar
disorder. This condition can help patients in making
decisions about illness management and negative
beliefs about medications (Berk et al., 2010). Good
knowledge about medication was found to directly
improve medication compliance (Seo & Min, 2005).
Moreover, a correlation study by Rosa et al. (2009)
that assessed medication adherence and its related
factors in patients with bipolar disorder showed that
patients’ knowledge about their disorder and
medication positively correlated with treatment
adherence to lithium prophylaxis.
Individuals’ attitude. Attitude toward medication
had a significant positive effect on medication
compliance (Lan, Shiau & Lin, 2003). A study of
Clatworthy et al. (2009) focused on patients’
attitudes to medication showed that about 30% of
patients were reported with low adherence because
of greater doubts about personal need for treatment
and stronger concern about potential negative effects.
According to Scott and Pope (2002), not easy to
accept the illness may also influence medication non
adherence.
Individual’s beliefs and cognitive illness
representation. Adams and Scott (2000) reported that
highly adherent and partially adherent subjects are
significantly different in their perception of illness
severity, their beliefs about themselves and their
control over the disorder, and their concerns about
future hospitalization. Moreover, Clatworthy et al.
(2007) assumed that patients can make decisions about
taking medication or not based on their perceptions of
the illness and treatment. A study by Hou et al.
(2010) showed that participants who were in the
non-adherence group believed that their illness
caused more negative effects on their life
(consequences) and would have a longer-term
impact (timeline). In a preliminary investigation by
Brown et al. (2001), Brown stated that a patient’s
illness cognition (i.g. timeline, consequences, and
cause) were associated with medication adherence.
In their study, they also found that poor adherence
associated with interpersonal difficulties was a cause of
depressive symptoms. In addition, patients who
perceived their illness as a mental health identity,
with negative consequences, and high levels of belief
in treatment to control symptoms were more likely to
take medication as prescribed (Lobban, Barrowclough
& Jones, 2003). An individual’s perception of risks
and benefits of medication treatment were more likely
to affect treatment adherence in bipolar populations
(Scott as cited in Sajatovic et al., 2009b).
Therapeutic alliance. Therapeutic alliance is
important for affective disorder patients (Lingam &
Scott, 2002). Lingam and Scott reported that poor
interaction between the clinician and patient was
four times more common with non-adherent patients
compared to those who were adherent. Moreover, in
Zeber’s study (as cited in Berk et al., 2010) among
veteran patients with bipolar disorder, it showed that
therapeutic alliance was positively connected to
medication adherence.
Social support. Social support has been identified as
a factor to medication adherence. Seo and Min study
(2005) found that social support is the strongest direct
effect on medication compliance. This social support
can come from family, friends and health care
professionals. Family members will also influence the
patient’s attitudes and beliefs about the illness and its
treatment, and it also can affect adherence (Cochran
as cited in Berk et al., 2009). High expressed
emotions and particularly over involvement in the
family is considered being associated with poorer
adherence and poorer overall outcomes in bipolar
patients (Miklowitz as cited in Berk et al., 2010).
Medication side effects. Medication side
effects are a common reason for non-adherence in
psychiatric patients (Scott as cited in Patel &
David,
2007). Clatworthy et al. (2009) reported that
about 30% of the participants that were in low
adherence was predicted by greater doubts about
personal need for treatment and stronger concern
about potential negative effects. Then, Sajatovic et al.
(2011) reported that the side effects of a drug were
main reason for deciding not to take the medication.
Medication Adherence among Patient with Bipolar Disorder: A Literature Review
231
3
DISCUSSION
As medication is important for patients with
bipolar disorder, many research studies had been
conducted for bipolar disorder to see how non-
adherent to medication can have the negative
effects to patients with bipolar disorder. Nurses and
health care professionals usually use routine care
procedures in the hospital to enhance a patient’s
medication adhrence. Usually routine care focuses on
the patient’s problems, especially problems related
to symptom management, providing education
about the patient’s medication, the frequency of
taking medication, and indications and side effects
of the medication. In the psychiatric hospital,
patients follow this routine care and take medication
because of the order from the nurse or another health
care professional. There is no known specific study
that can enhance medication adhrence, especially in
patients with bipolar disorder.
4
CONCLUSIONS
Medication adherence is important for patient
with bipolar disorder, to prevent relapse and re-
hospitalization, to reduce symptoms severity, to
gain a better control of mood swings and to improve
functioning and quality of life. However, in fact, non-
adherence to medication is a common problem in
the psychiatric area including patients with bipolar
disorder. Prior to helping to enhance medication
adherence in patients, health care providers indeed
need to understand the phenomenon of medication
adherence.
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