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2006 HSR&D National Meeting Abstract

1019 — Ethnicity, Perceptions of Therapeutic Alliance, and Adherence in Patients with Bipolar Disorder

Author List:
Xu X (CHERP / Pittsburgh VA)
Good CB (CHERP / Pittsburgh VA)
Fine M (CHERP / Pittsburgh VA)
Kilbourne AM (CHERP / Pittsburgh VA)

Despite the implementation of practice guidelines for bipolar disorder, outcomes remain suboptimal, largely due to poor treatment adherence. Maintaining a beneficial therapeutic or working alliance with providers is one important strategy for improving adherence. The episodic nature of bipolar disorder frequently disrupts appropriate patient-provider dynamics, leading to self-medication with substance use, incarceration, and other factors which subsequently inhibit treatment adherence. Incorporating previously documented ethnic differences in medication adherence and diverse cultural expressions of treatment priorities, we examine the association between perceptions of the healthcare environment and adherence among veterans with bipolar disorder.

Participants were recruited from the Continuous Improvement for Veterans in Care - Mood Disorders (CIVIC-MD) study on veterans with bipolar disorder (N=253). Seven individual items (range 0-6) and a summary score from the Health Care Climate Questionnaire (HCCQ) solicited patient evaluations of their therapeutic environment, used as predictors for two adherence measures (Morisky scale, missed medication days). Multivariate logistic analyses adjusted for relevant patient characteristics, substance abuse, and non-VA utilization.

A significant segment of the sample (27-28%) reported difficulty with medication adherence on both outcomes. Fewer minority veterans endorsed good Morisky adherence than white patients (55% versus 79%, p=.01), but no ethnic differences were noted in perceptions of working alliance. Multivariate results for HCCQ items indicated that positive therapeutic relationships were associated with better adherence. Notably, 1) patients reporting “their providers informed them what constitutes good bipolar care” were more likely to be adherent (adjusted OR =1.2, p=.04); 2) as were patients whose “providers regularly review their progress” (adjusted OR=1.3, p=.006). However, binge drinking was the strongest predictor of non-adherence (adjusted ORs 3.6-4.0), independent of demographic factors and mania symptomatology.

Nearly 30% of patients acknowledged adherence problems per conservative self-report measures. Favorable perceptions of trust and satisfaction with bipolar treatment existed across all ethnic groups. The strong association between medication adherence and therapeutic alliance with bipolar treatment supports intervention efforts to strengthen the patient – provider relationship, a bond likely to yield positive clinical outcomes.

Recognizing how veterans with debilitating bipolar disorder view their treatment environment will enable the VA to better target clinical relationships towards improving medication adherence.

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