Transcript Slide 1

Bipolar Disorder – treatment –
current and future…
Kurt Weber, PhD
Mental Health America – Brown County
Bemis International Center
St Norbert College
May 13, 2008
BD is a…
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long-term illness that can be effectively
treated
currently has no cure
staying on treatment, even during well
times, can help keep the disease under
control and reduce the chance of having
recurrent, worsening episodes
basics
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treatment plan for bipolar disorder primarily
consists of
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pharmacological intervention (medications)
and sometimes psychological therapy
psychiatric hospitalizations may be necessary to
safely reach a point of stability
also treatment options that are less common and
those that are usually considered only in extreme
circumstances – we’ll discuss them later!
medications
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primary goal of drug treatment is to stabilize the
extreme mood swings of mania and depression
also common for medications to be prescribed for
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extreme symptoms such as psychosis or
co-occurring disorders such as anxiety
generally fall into the following categories
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Anti-Anxiety and Sedatives
Antidepressants
Antipsychotics
Mood Stabilizers
Calcium Channel Blockers
Psychotherapeutic interventions
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Goals
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increase compliance of taking medications
create bonds with others who have the same condition
reduce negative behaviors
learn new coping skills
key types of therapy include
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Cognitive Behavioral Therapy
Dialectical Behavioral Therapy
Family/Marriage Counseling
Gestalt Therapy
Group Therapy
Psychoanalytic Therapy
Inpatient hospitalization
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allow specialized staff
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to monitor patients closely
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changing medications as necessary to achieve stabilization
to provide concentrated, frequent sessions of therapy
also vital for those who are struggling with
thoughts of suicide
majority of hospital stays are inpatient
outpatient programs are becoming more common
Alternative therapies…
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usually considered only in extreme
circumstances
Bilateral Cingulotomy
 Electroconvulsive Therapy
 Light Therapy
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Review of mental health
professionals
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Psychiatrists
Medical doctors with a specialty in psychiatry - the
branch of medicine that deals with the diagnosis,
treatment, and prevention of mental and
emotional disorders
formal medical training and licensing
several years of specialized training
American Board of Psychiatry and Neurology
usually the ones who prescribe psychotropic
medications
psychopharmacologists
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general practitioners and psychiatrists
specialty in the branch of pharmacology that
deals with the study of the actions, effects,
and development of psychoactive drugs
often involved in clinical research studies for
medications
an excellent resource for those with bipolar
disorder due to the complicated medication
regimens often required
psychologists
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trained to perform psychological research, testing, and
therapy
licensed psychologists have a PhD or PsyD and have
completed a licensure exam
many different fields of psychology
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e.g., clinical
social
industrial/organizational
child/adolescent
cognitive
known for conducting therapy sessions, but many are
active researchers
General Practitioners /
Primary Care Physicians
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well-rounded approach to medicine
treating an array of illnesses
monitoring patience’s overall health and well-being
BD is most often treated with medications
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as a result, it can greatly complicate the treatment of
other physical ailments
the involvement of the family doctor in overall
healthcare as well as the treatment of this disorder is
vital
also physicians can make referrals to other healthcare
professionals when needed
psychiatric nurse practitioners
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nurses
advance dergee specializing in mental health
often work in psychiatric treatment centers
and hospital units
serve as
crisis intervention specialists
 counselors
 often monitor treatment progress
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may also serve as consultants and teachers
social workers
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Licensed clinical social workers (LCSW)
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usually have a degree in social work
license to practice at the state level through completion
of a supervision program and state certification exam
Social Workers (MSW) have achieved a master’s
degree.
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most often serve as patient advocates ensuring access
to necessary treatments, assisting with financial aid
applications, and securing legal assistance if needed
may also serve as counselors or therapists
therapists -- counselors
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many different professionals such as those
noted above serve as therapists and
counselors
generally conduct therapy sessions
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individual, family and group
goals of
changing behavior
 learning new skills towards improving overall
mental health
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bipolar disorder is much better controlled if
treatment is continuous rather than
intermittent...
even if treatment regimen is followed
mood changes can occur and should be
reported immediately to MHP
 MHP may be able to prevent a full-blown
episode by making adjustments to the
treatment plan
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Medications
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recommended that people with bipolar
disorder see a psychiatrist for treatment
psychiatric nurse practitioners are also
recommended if psychiatry not available, or
affordable, or easily obtainable
how to find a psychiatrist (stolen
from about.com)
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1. If you have a university within a reasonable driving
distance, call their Department of Psychiatry. These
psychiatrists are often on the cutting edge of research.
2. If the National Alliance for the Mentally Ill (NAMI) has a
branch in your area, get in touch with their offices for a
reference. You can also get in touch with their state offices.
3. Join the local chapter of the Depression and Bipolar
Support Alliance (formerly NDMDA). This way you can ask
individual members for their recommendations and be part
of a supportive group at the same time.
4. Phone the psychiatric ward of a hospital in your area and
ask the head nurse whom she would see if she needed a
psychiatrist.
5. Review the list of approved mental health care providers
from your insurance company.
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6. Ask your general practitioner and therapist for their
recommendations.
7. Scan the yellow pages. Look for certifications such as "Board
Certified in Psychiatry" or "Board Certified in Pediatric Psychiatry."
Those who specialize in Psychopharmacology may be a good choice.
8. You may want to contact the information and referral (I&R) services
of the United Way in your town - particularly if you are in need of
financial assistance.
9. Many companies offer employee assistance programs that may be
able to provide the names of psychiatrists. Ask your Human Resources
Department for information.
10. Call family members and friends for their advice.
11. Telephone the referral service of the hospitals in your city.
12. Your pastor or rabbi may be able to suggest the names of
appropriate psychiatrists to you.
before your visit…
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Do you have a strong preference for a male
or female doctor? Are the doctor's religious
beliefs an issue for you?
Set up your first visit as a short consultation.
This will allow you to meet the psychiatrist
and his staff without shelling out a lot of
money. me may offer a free consultation.
considerations for bipolar meds
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1) Does it treat bipolar mania?
2) Does it treat bipolar depression?
3) Does it act prophylactically to prevent
mania and/or depression?
Mood stabilizers
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prescribed to help control bipolar disorder
several different types of mood stabilizers
available
people with bipolar disorder can continue
treatment with mood stabilizers for
extended periods of time
other medications may be added for shorter
periods to treat episodes of mania or
depression that break through despite the
mood stabilizer
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The NIMH funded STEP BD research
program
after two years of excellent treatment
58% of clients achieve full recovery
 ~50% will experience a relapse
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72% to depression.
Lithium
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time-honored treatment for manic-depression
seems to have a suicide reducing effect that the
other mood stabilizers do not
People don't like to take it because it
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makes them drink a lot of water and urinate a lot (35%)
causes memory problems (28%)
tremor (27%)
weight gain (19%)
gives them a metallic taste in their mouth
can also affect the kidneys and the thyroid
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dosed according to blood levels
if the lithium level gets too high, death can
result
if someone becomes dehydrated, the lithium
level rises with vomiting and diarrhea,
confusion, coarse tremor, muscle twitching,
slurred speech, and seizures
requires emergency medical attention
stopping lithium suddenly may cause a
relapse and increase in suicidality
And… they even know what the
mechanism of its effectiveness!
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University of Wisconsin researchers found that
lithium exerts a dual effect on receptors for the
neurotransmitter glutamate
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acting to keep the amount of glutamate active between
cells at a stable, healthy level, neither too much nor too
little
could be postulated that too much glutamate in the
space between neurons causes mania, and too little,
depression.
giant step forward in understanding the biological basis
of bipolar disorder
anticonvulsants
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cann have mood-stabilizing effects
may be especially useful for difficult-to-treat
bipolar episodes
divalproex sodium - Depakote
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used for mania in bipolar disorder
evidence that it works to prevent depression is not
convincing
generally has fewer side effects than lithium
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patients like it better
can cause GI problems, pancreatitis, liver problems, birth
defects, decrease in platelets, and hair loss
some evidence that it may provide prophylaxis for new
episodes
new extended release preparation
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patients will require a higher dose with the extended release
preparation.
carbamazepine - Tegretol
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second choice for manic-depression for
patients who could not tolerate lithium
requires blood levels
sedating
can cause an anemia and liver problems
too much carbamazepine will cause sedation
and lack of coordination
long-acting form has been approved –
Equetro
Newer anticonvulsants
lamotrigine - Lamictal
 shows moderate antidepressant action
 may be prophylactic for bipolar depression
 no good evidence for the treatment of mania
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Dizziness, diplopia, vomiting, and rash are most common
side effects and are generally mild
not to be used in patients under 16
discontinue if they get a rash
needs to be increased slowly
topiramate – Topamax
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not better than placebo for mania
in some reports, 20-50% of people taking
topiramate have lost weight
used with clozapine and olanzapine to
reduce weight gain
if dose is increased too fast, one may see
cognitive impairment
may cause kidney stones and glaucoma
oxcarbazepine – Trileptal
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similar to carbamazepine
minimal interactions with other drugs
may contribute to hyponatremia
slight evidence that it may be anti-manic and
prophylactic
Atypical antipsychotics
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being studied as possible treatments for bipolar disorder.
clozapine (Clozaril)
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olanzapine (Zyprexa)
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Evidence suggests clozapine may be helpful as a mood stabilizer for
people who do not respond to lithium or anticonvulsants.
Other research has supported the efficacy of olanzapine for acute
mania, an indication that has recently received FDA approval
Olanzapine may also help relieve psychotic depression.
risperidone (Risperdal)
ziprasidone (Zeldox)
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Aripiprazole (Abilify)
another atypical antipsychotic medication
 used to treat the symptoms of schizophrenia
and manic or mixed (manic and depressive)
episodes of bipolar I disorder
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combinations
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combinations… Anticonvulsant medications may
be combined with lithium, or with each other, for
maximum effect. 3
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G) olanzapine + fluoxetine - Symbyax - This is a
combination antipsychotic and antidepressant that
is geared toward treating bipolar depression. The
antidepressant treats the depression while the
atypical antipsychotic stabilizes the mood.
Although it is FDA approved for bipolar depression,
there is little field data on efficacy or effectiveness.
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Children and adolescents with bipolar disorder
generally are treated with lithium, but valproate
and carbamazepine also are used
Researchers are evaluating the safety and efficacy
of these and other psychotropic medications in
children and adolescents.
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some evidence that valproate may lead to adverse
hormone changes in teenage girls and polycystic ovary
syndrome in women who began taking the medication
before age 20
young female patients taking valproate should be
monitored carefully by a physician
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Women with bipolar disorder who wish to
conceive, or who become pregnant, face special
challenges due to the possible harmful effects of
existing mood stabilizing medications on the
developing fetus and the nursing infant
New treatments with reduced risks during
pregnancy and lactation are under study
the benefits and risks of all available treatment
options should be discussed with a clinician skilled
in this area
Bipolar depression
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people with bipolar disorder are at risk of switching
into mania or hypomania, or of developing rapid
cycling, during treatment with antidepressant
medication
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mood-stabilizing medications generally are required,
alone or in combination with antidepressants, to
protect people with bipolar disorder from this switch.
Lithium and valproate are the most commonly
used mood-stabilizing drugs today. However,
research studies continue to evaluate the potential
mood-stabilizing effects of newer medications.
pharmacological treatment
of bipolar depression
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should not be treated with antidepressants
alone
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not clear whether there is any benefit at all for
using them
lithium
lamotrigine
olanzapine
olanzapine + fluoxetine
bipolar maintenance
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lithium
lamotrigine
olanzapine
aripiprazole
Mays…
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Of clients who were stable for more than 6 months, only
26% were on lithium alone
Lithium alone offers
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83% probability against affective relapse at one year
52% at 3 years
37% at 5 years
47% suffer relapse on combination treatment.
The best evidence-based treatment for bipolar
maintenance at this time would be lithium plus a second
generation antipsychotic
however, 25% will show poor response even to multiple
medications.
insomnia
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high-potency benzodiazepine medication
clonazepam (Klonopin)
 lorazepam (Ativan)
 may be helpful to promote better sleep
 may be habit-forming
 best prescribed on a short-term basis
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Other types of sedative medications, such as
zolpidem (Ambien), are sometimes used
instead.
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changes overseen by psychiatrist, of
course…
of course, it never happens that a patient
changes meds on their own…
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thyroid concerns
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people with bipolar disorder often have abnormal
thyroid gland function
important that thyroid levels are carefully
monitored by a physician
rapid cyclers tend to have co-occurring thyroid
problems and may need to take thyroid pills in
addition to their medications for bipolar disorder
lithium treatment may cause low thyroid levels in
some people, resulting in the need for thyroid
supplementation
psychosocial interventions
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can lead to increased mood stability, fewer hospitalizations,
and improved functioning in several areas
licensed psychologist, social worker, or counselor typically
provides these therapies and often works together with the
psychiatrist to monitor a patient s progress
number, frequency, and type of sessions should be based
on the treatment needs of each person.
common interventions include
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cognitive behavioral therapy
psychoeducation
family therapy
interpersonal and social rhythm therapy
CBT
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Cognitive behavioral therapy helps people
with bipolar disorder learn to change
inappropriate or negative thought patterns
and behaviors associated with the illness
psychoeducation
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teaching people with bipolar disorder
about the illness and its treatment
 how to recognize signs of relapse so that early
intervention can be sought before a full-blown
illness episode occurs
 may be helpful for family members
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family therapy
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uses strategies to reduce the level of
distress within the family that may either
contribute to or result from the ill person s
symptoms
Interpersonal and
social rhythm therapy
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helps people with bipolar disorder both to
improve interpersonal relationships and to
regularize their daily routines
may help protect against manic episodes
of course…
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As with medication, it is important to follow
the treatment plan for any psychosocial
intervention to achieve the greatest benefit.
dialectical behavior therapy
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DBT is now being used in many settings as a viable therapy
for the treatment of bipolar disorder
Treatment in DBT has four parts
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Individual Therapy
Telephone Contact
Therapist Consultation - good communication between group
therapist and individual therapist is essential to the successful
outcome of DBT
Skills Training - Conducted by a behavioral technician or another
therapist usually in a group context
focus is on learning and practicing adaptive skills, not
personal or specific complaints of the clients
any specific or personal issues are redirected to be
discussed in individual therapy
DBT continued…
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Core Mindfulness Skills - These are derived from Buddhist
meditation techniques to enable the client to become
aware of the different aspects of experience and to
develop the ability to stay with that experience in the
present moment. - Treatment lasts for about 2 -3 weeks.
Interpersonal Effectiveness Skills - These focus on effective
ways of achieving one's objectives with other people: to
ask for what one wants effectively, to say no and be taken
seriously, to maintain relationships and to maintain selfesteem in interactions with other people (comparable to
assertiveness training). - Treatment lasts for about 8 weeks.
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Emotion Modulation Skills - These skills are ways of
coping with intense emotional experiences and
their causes. They also allow for an adaptive
experience and expression of intense emotions. Treatment lasts for about 8 weeks.
Distress Tolerance Skills - These include techniques
for putting up with, finding meaning for, and
accepting distressing situations if there is no
conceivable solution at present. - Treatment lasts
for about 8 weeks.
ECT
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if other interventions prove ineffective, or work too slowly
to relieve severe symptoms such as psychosis or suicidality,
electroconvulsive therapy (ECT) may be considered
ECT is a highly effective treatment for severe depressive,
manic, and/or mixed episodes
possibility of long-lasting memory problems, although a
concern in the past, has been significantly reduced with
modern ECT techniques
potential benefits and risks of ECT, and of available
alternative interventions, should be carefully reviewed and
discussed with individuals considering this treatment and,
where appropriate, with family or friends
herbals…
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not been well studied
little is known about their effects on bipolar disorder
FDA does not regulate their production
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different brands of these supplements can contain different
amounts of active ingredient
Before trying herbal or natural supplements, it is
important to discuss them with your doctor
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evidence that St. John’s wort can reduce the effectiveness of
certain medications
may cause a switch into mania in some individuals with bipolar
disorder, especially if no mood stabilizer is being taken
omega-3 fatty acids
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found in fish oil
being studied to determine their usefulness,
alone and when added to conventional
medications, for long-term treatment of
bipolar disorder
hospitalization
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Advance Psychiatry Directives
http://www.bazelon.org/issues/advancedire
ctives/index.htm
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http://bipolar.about.com/od/hospitalization/
a/packing.htm
finally…
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Treatment Adherence
Rates of noncompliance range from 18-53%
if one includes people who occasionally miss their
medications, it is >70%
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Clients have limited insight
not denial or wish to distort the facts
something in the illness that distorts the way clients see
themselves and the world.
Regardless, the best predictor of a poor outcome is
poor treatment adherence