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Treatment-adherence in bipolar disorder: A patient-centred approach

World Journal of Psychiatry 2016年第4期6卷 399-409页

作者： subho chakrabarti Department of Psychiatry Postgraduate Institute of Medical Education and Research (PGIMER)

About half of the patients diagnosed with bipolar disorder(BD) become non-adherent during longterm treatment, a rate largely similar to other chronic illnesses and one that has remained unchanged over the years. Non-adherence in BD is a complex phenomenon determined by a multitude of influences. However, thereis considerable uncertainty about the key determinants of non-adherence in BD. Initial research on nonadherence in BD mostly limited itself to examining demographic, clinical and medication-related factors impacting adherence. However, because of inconsistent results and failure of these studies to address the complexities of adherence behaviour, demographic and illness-related factors were alone unable to explain or predict non-adherence in BD. This prompted a shift to a more patient-centred approach of viewing nonadherence. The central element of this approach includes an emphasis on patients' decisions regarding their own treatment based on their personal beliefs, life circumstances and their perceptions of benefits and disadvantages of treatment. Patients' decisionmaking processes are influenced by the nature of their relationship with clinicians and the health-care system and by people in their immediate environment. The primacy of the patient's perspective on non-adherence is in keeping with the current theoretical models and concordance-based approaches to adherence behaviour in BD. Research over the past two decades has further endorsed the critical role of patients' attitudes and beliefs regarding medications, the importance of a collaborative treatment-alliance, the influence of the family, and the significance of other patient-related factors such as knowledge, stigma, patient satisfaction and access to treatment in determining non-adherence in BD. Though simply moving from an illness-centred to a patientcentred approach is unlikely to solve the problem of nonadherence in BD, such an approach is more likely to lead to a better understanding of non-ad

关键词： Non-adherence Bipolar disorder Attitudes Health-beliefs Treatment-alliance Familial influences Knowledge Stigma

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Medication non-adherence in bipolar disorder: Review of rates, demographic and clinical predictors

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World Journal of Meta-Analysis 2017年第4期5卷 103-123页

作者： subho chakrabarti Department of Psychiatry Postgraduate Institute of Medical Education and Research

AIM To conduct a systematic search for all studies examining rates and demographic and illness-related determinantsof medication non-adherence in bipolar disorder(BD).METHODS A comprehensive literature search was undertaken of six English-language databases to identify published articles on medication non-adherence in BD from inception till December 2016. Any article, either a review or an original-research article was examined for its relevance to the subject. All such articles were manually searched to locate any further articles containing relevant information. Studies were included only if they had adequately described the patient sample, assessment methods and statistical procedures, presented their results systematically and their conclusions were congruent with the *** The initial search yielded 249 articles on the subject; of these 198 articles were included. Of the 162 originalresearch studies, 132 had provided information on rates of medication non-adherence in BD. There was a wide variation in rates ranging from universal adherence(100%) to almost universal non-adherence(96%); this discrepancy was more due to methodological differences than true variations in rates. Notwithstanding the significant discrepancies in methodology, based on these 132 studies mean rates of 41.5%-43% and median rates of 40%-41% were obtained for medication non-adherence in BD. Rates of adherence with mood stabilizers were significantly lower than those for antipsychotics, or for medications of all classes. None of the demographic attributes were unequivocally linked to medication non-adherence in BD. Similarly, medication-related variables such as type of medications, doses, treatment regimens and side effects did not demonstrate consistent associations with non-adherence. Among clinical characteristics the presence of comorbid substance use disorder and absence of insight were the only two factors clearly linked to non-adherence in *** Medication non-adher

关键词： Medications Demographics Rates Non-adherence Illness characteristics Treatment variables Bipolar disorder

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Usefulness of telepsychiatry:A critical evaluation of videoconferencing-based approaches

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World Journal of Psychiatry 2015年第3期5卷 286-304页

作者： subho chakrabarti Department of Psychiatry Postgraduate Institute of Medical Education and Research

Telepsychiatry, i.e., the use of information and communication technologies to provide psychiatric services from a distance, has been around for more than half a century now. Research over this period has shown that videoconferencing-based telepsychiatry is an enabling and empowering form of service delivery, which promotes equality of access, and high levels of satisfaction among patients. The range of services offered by videoconferencing-based telepsychiatry, potential users and points of delivery of such services are theoretically limitless. Telepsychiatry has both clinical utility and non-clinical uses such as administrative, learning and research applications. A large body of accumulated evidence indicates that videoconferencingbased telepsychiatric assessments are reliable, and clinical outcomes of telepsychiatric interventions are comparable to conventional treatment among diverse patient populations, ages and diagnostic groups, and on a wide range of measures. However, on many aspects of effectiveness, the evidence base is still relatively limited and often compromised by methodological problems. The lack of cost-effectiveness data in particular, is a major hindrance, raising doubts about the continued viability of telepsychiatric services. Added to this are the vagaries of technology, negative views among clinicians, poor uptake by providers, and several legal, ethical and administrative barriers. These hamper the widespread implementation of telepsychiatry and its integration with routine care. Though further advances in technology and research are expected to solve many of these problems, the way forward would be to promote telepsychiatry as an adjunct to conventional care, and to develop hybrid models, which incorporate both traditional and telepsychiatric forms of mental health-care.

关键词： Videoconferencing Telepsychiatry Telemental-health Assessment Management Reliability Efficacy Effectiveness Outcome

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What's in a name? Compliance, adherence and concordance in chronic psychiatric disorders

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World Journal of Psychiatry 2014年第2期4卷 30-36页

作者： subho chakrabarti Department of Psychiatry Postgraduate Institute of Medical Education and Research

About half or more of the patients with chronic psychiatric illnesses, either do not take their medications correctly, or completely stop taking them. The problem of poor initial compliance or adherence is often compounded by a continued decline in compliance/adherence over time. The failure to take medicines, adversely affects the outcome of treatment, and places a huge burden of wasted resources on the society. Three terms have been used to describe medication-taking among patients with chronic psychiatric disorders. Compliance is defined as "the extent to which the patient's behaviour matches the prescriber's recommendations". Though compliance has been frequently employed to describe medication-taking behaviour, it has proved problematic because it refers to a process where the clinician decides on a suitable treatment, which the patient is expected to comply with unquestioningly. Studies over the past few decades have emphasized the importance of patients' perspectives in medicationtaking, based on their own beliefs, their personal circumstances, the information and resources available for them. Adherence has been used as a replacement for compliance in an effort to place the clinician-patient relationship in its proper perspective. Adherence refers to a process, in which the appropriate treatment is decided after a proper discussion with the patient. It also implies that the patient is under no compulsion to accept a particular treatment, and is not to be held solely responsible for the occurrence of non-adherence. Adherence has been defined as "the extent to which a person's behaviour, taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider". To overcome certain problems in the concept of adherence, a third term concordance has been used. The concept of concordance has evolved from a narrower view, emphasizing an agreement between the clinician and the patient, which takes in

关键词： Compliance Adherence Concordance Chronic psychiatric disorders

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Cultural aspects of caregiver burden in psychiatric disorders

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World Journal of Psychiatry 2013年第4期3卷 85-92页

作者： subho chakrabarti Department of Psychiatry Postgraduate Institute of Medical Education and Research Chandigarh 160012 India

Caring for a mentally ill family member is well known to be mostly a stressful, distressing and burdensome experience. The dominant model for examining the process of caregiving has been the stress-appraisalcoping paradigm, in which interactions between stressors, appraisals, coping, and various mediators produce the eventual outcomes in terms of distress or wellbeing among caregivers. Ethnic and cultural factors have traditionally received the least research attention as mediators of the caregiving process. However, a large body of accumulated research evidence has clearly demonstrated that culturally-defined values, norms, and roles are among the major determinants of the caregiving experience. This research is based mainly on cross-cultural comparisons between caregivers of minority ethnic groups residing in the West and the native Caucasian population. It has been supplemented, to a limited extent, by research carried out among caregivers belonging to different cultures and residing in their countries of origin. Most of this research has been carried out among caregivers of elderly people with dementia; other psychiatric disorders such as schizophrenia have received much less attention. Results of this research have documented important differences in caregiving experiences and outcomes across cultural and ethnic groups. Cultural factors which could mediate these differences have been identified, and theories, which could provide a coherent framework to understand these differences, proposed. Though limited by methodological difficulties, this research has provided important insights into the impact of cultural and ethnic factors on the whole spectrum of the caregiving experiences. An improved understanding of the area is, nevertheless, required because it will eventually help in devising appropriate ways to reduce burden and distress among caregivers from diverse ethnic and cultural groups.

关键词： Culture Ethnicity Caregiving Caregiverburden Psychiatric disorders

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Family interventions in schizophrenia:Issues of relevance for Asian countries

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World Journal of Psychiatry 2011年第1期1卷 4-7页

作者： subho chakrabarti Department of Psychiatry Postgraduate Institute of Medical Education and ResearchChandigarh 160012India

A growing body of research evidence has confirmed the efficacy of family-interventions as adjuncts to antipsychotics for the treatment of *** of the recent evidence for such interventions derives from Asian,principally Chinese,*** trials have shown that relatively simple forms of familyinterventions have wide ranging benefits,and can be implemented successfully in routine clinical *** the accumulation of this evidence in their favour,family-interventions for schizophrenia in Asia are poised to take the next critical step,that of wider implementation and improved accessibility for potential ***,several issues merit ***-interventions need to be based on a culturallyinformed theory,which incorporates cultural variables of relevance in these *** the ideal format for conducting family-interventions is still to be determined,it is quite evident that for such interventions to be useful they need to be simple,inexpensive,needsbased,and tailored to suit the socio-cultural realities of mental health systems in Asian *** evidence also suggests that delivery by non-specialist personnel is the best way to ensure that such services reach those who stand to benefit most from these treatments ***,there are several existing challenges to the process of dissemination of *** major challenges include the achievement of a critical mass of trained professionals capable of delivering these interventions,and finding innovative solutions to make family-interventions more acceptable to *** these hurdles are overcome,we could look forward to a genuine collaboration with families,who have always been the mainstay of care for the mentally ill in Asia.

关键词： Asia Culture Family interventions Schizophrenia

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Dissociative disorder presenting as foreign accent syndrome

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World Journal of Psychiatry 2013年第4期3卷 103-106页

作者： Nikita Rajpal subho chakrabarti Department of Psychiatry Postgraduate Institute of Medical Education and ResearchChandigarh 160012 India

The foreign accent syndrome(FAS) is a rare speech disorder, characterised by the appearance of a new accent, different from the speaker's native language and perceived as foreign by others. In the majority of patients, FAS is secondary to focal brain damage caused by stroke or other neurological disorders. Infrequently, FAS has been reported in association with psychiatric disorders, including dissociative or conversion disorders. The case of a young woman with recurrent episodes of speaking with a foreign accent is described. Repeated neurological examinations, imaging and electroencephalography did not reveal any brain abnormality. However, there was a history of a difficult childhood, alcohol dependence in the father, parental discord, alleged sexual abuse in the past, interpersonal difficulties and parental death. Episodes were precipitated by stressful life circumstances and resolved spontaneously, or with supportive treatment. She had additional "suspect" symptoms such as non-epileptic seizures, aphonia and motor paralysis. All these features indicated that a dissociative disorder was involved in the genesis of her FAS. The influence of external factors such as the media was unclear. Generally biological factors have been implicated in the onset of FAS, but the presentation in this young woman suggests that psychological factors such as personality, trauma, stressful life events and psychiatric disorder; familial factors such as parental discord and parental death and family conflicts; and, social factors such the possible influence of the media may also be involved in the production of foreign accents by patients.

关键词： Foreign accent syndrome Dissociative disorder Conversion disorder Psychosocial

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Health-care needs of remitted patients with bipolar disorder: A comparison with schizophrenia

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World Journal of Psychiatry 2016年第4期6卷 431-441页

作者： Rajarshi Neogi subho chakrabarti Sandeep Grover Department of Psychiatry Postgraduate Institute of Medical Education and Research (PGIMER)

AIM To investigate health-care needs and their correlates among patients with remitted bipolar disorder(BD) compared to patients with remitted schizophrenia. METHODS Outpatients with BD(n = 150) and schizophrenia(n = 75) meeting clearly defined remission criteria were included in the study along with their relatives. Diagnostic ascertainment was carried out using the Mini International Neuropsychiatric Interview. Demographic and clinical details were recorded using structured formats. Residual symptoms were assessed using standardized scales. Health-care needs were assessed on two separate scales. The principal instrument employed to assess health-care needs was the Camberwell Assessment of Need-Research version(CAN-R). To further evaluate health-care needs we felt that an additional instrument, which was more relevant for Indian patients and treatment-settings and designed to cover those areas of needs not specifically covered by the CAN-R was required. This instrument with a structure and scoring pattern similar to the CAN-R was used for additional evaluation of needs. Patients' level offunctioning was assessed using the Global Assessment of Functioning Scale and their quality of life(QOL) using the World Health Organization Quality Of Life-BREF version in *** An average of 6-7 needs was reported by patients with BD as well as their relatives. Commonly reported needs were in the areas of economic and welfare needs, informational needs, social needs and the need for treatment. According to the CAN-R, both patients and relatives reported that more than 60% of the total needs were being met. However, over 90% of the needs covered by the additional evaluation were unmet according to patients and relatives. Needs in the areas of economic and welfare-benefits, information, company, daytime activities and physical health-care were largely unmet according to patients and relatives. Total, met and unmet needs were significantly higher for schizophrenia, but the m

关键词： Health-care needs Bipolar disorder Schizophrenia Remission Patients Relatives

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Gender differences in caregiving among family- caregivers of people with mental illnesses

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World Journal of Psychiatry 2016年第1期6卷 7-17页

作者： Nidhi Sharma subho chakrabarti Sandeep Grover Depart-ment of Psychiatry Postgraduate Institute of Medical Education and Research

All over the world women are the predominant providers of informal care for family members with chronic medical conditions or disabilities, including the elderly and adults with mental illnesses. It has been suggested that there are several societal and cultural demands on women to adopt the role of a family-caregiver. Stress-coping theories propose that women are more likely to be exposed to caregiving stressors, and are likely to perceive, report and cope with these stressors differently from men. Many studies, which have examined gender differences among family-caregivers of people with mental illnesses, have concluded that women spend more time in providing care and carry out personal-care tasks more often than men. These studies have also found that women experience greater mental and physical strain, greater caregiver-burden, and higher levels of psychological distress while providing care. However, almost an equal number of studies have not found any differences between men and women on these aspects. This has led to the view that though there may be certain differences between male and female caregivers, most of these are small in magnitude and of doubtful clinical significance. Accordingly, caregivergender is thought to explain only a minor proportion of the variance in negative caregiving outcomes. A similar inconsistency characterizes the explanations provided for gender differences in caregiving such as role expectations, differences in stress, coping and social support, and response biases in reporting distress. Apart from the equivocal and inconsistent evidence, there are other problems in the literature on gender differences in caregiving. Most of the evidence has been derived from studies on caregivers of elderly people who either suffer from dementia or other physical conditions. Similar research on other mental illnesses such as schizophrenia or mood disorders is relatively scarce. With changing demographics and social norms men are increasingly as

关键词： Gender Family-caregiving Schizophrenia Elderly Dementia Mood disorders

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Comparative effectiveness of quetiapine and haloperidol in delirium:A single blind randomized controlled study

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World Journal of Psychiatry 2016年第3期6卷 365-371页

作者： Sandeep Grover Sudhir Mahajan subho chakrabarti Ajit Avasthi Department of Psychiatry Postgraduate Institute of Medical Education and Research

AIM To evaluate the effectiveness of quetiapine and haloperidol in patients of delirium referred to psychiatry consultation liaison *** The study followed a single blind randomised controlled trial ***-two patients in the haloperidol group and 31 patients in the quetiapine group were assessed at the baseline and 6 consecutive *** dosing regimen(haloperidol:0.25-1.25 mg;quetiapine 12.5-75 mg/d) was *** Rating Scale-Revised-98(DRS-R-98) and mini mental status examination(MMSE) were the primary and secondary efficacy measures *** Baseline DRS-R-98 severity score and MMSE scores did not differ between the 2 study *** baseline to day 6,there was significant reduction in the total DRS-R-98 scores,DRS-R-98 cognitive domain scores,DRS-R-98 non-cognitive domain scores and significant increase in the MMSE scores in both the *** the groups did not differ on any of the assessments in terms of DRS-R98 and MMSE *** effectiveness of both the medications was similar in adult and elderly(≥ 60 years) *** the end of the trial,68.75% and 67.74% of subjects in the haloperidol and quetiapine group respectively had mean DRS-R-98 scores below *** 6th day,12(37.5%) patients in haloperidol group and 9(29.03%) patients in the quetiapine group hadDRS-R98 score of "0" with no significant difference between the two groups(P = 0.47).CONCLUSION Quetiapine is as effective as haloperidol in the management of delirium.

关键词： Delirium Quetiapine Effectiveness Atypical antipsychotics

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