Treatment alliance and adherence in bipolar disorder

Table 1 Treatment alliance and adherence in bipolar disorder

Ref.	Details of the studies	Findings
Connelly et al[58], 1982	48 outpatients on lithium; cross-sectional study; adherence by serum levels; alliance by self-designed questionnaire based on the HBM	Satisfaction with the clinician and perception of continuity of alliance was not associated with medication adherence. Perception of continuity linked to appointment adherence
Connelly et al[59], 1984	75 outpatients on lithium; cross-sectional study; adherence by serum levels and SCQ; alliance by self-designed questionnaire	Satisfaction with the clinician and perception of continuity of alliance was not associated with medication adherence. Perception of continuity linked to appointment adherence
Cochran and Gitlin[60], 1988	48 outpatients on lithium; cross-sectional study; adherence by self-report questionnaire; alliance as a part of an “Attitude Questionnaire”	Treatment alliance and positive attitudes to treatment explained about half of the variance in adherence. Alliance mediated the relationship between attitudes and adherence
Ludwig et al[61], 1990	118 outpatients and inpatients; 37 with BD; cross sectional study; adherence by physician judgment; alliance by two attitude scales: COSS and KK Skala	Adherence was associated with “reliance on the physician” using the COSS scale, but not with the KK Skala scale
Lee et al[62], 1992 Taylor et al[63], 2001	50 Chinese outpatients on lithium; cross-sectional study; adherence by serum levels, case-notes review and patient reports; knowledge by self-designed questionnaire 30 trial patients on maintenance lithium treatment and psychotherapy; cross-sectional study; adherence by RBC lithium levels; alliance by TATIS scale to assess therapists' techniques	A high rate of adherence was found despite inadequate knowledge about lithium. Authors concluded that an effective treatment alliance was of greater importance in ensuring adherence than imparting information TATIS scores were significantly associated with RBC lithium levels. Medication adherence improved with increased focus on collaborative relationship building, positive treatment-attitudes, acceptance of BD and necessity for long-term treatment
Kleindienst and Greil[64], 2004	171 trial patients on lithium or cabamazepine; 2.5 yr follow-up; adherence indexed by time to dropout; alliance by the ICS scale	Trust in medications, trust in clinicians and absence of negative treatment expectations were associated with longer time to dropoutin those on lithium, but not carbamazepine.
Patel et al[65], 2005	32 African-American and Caucasian adolescent outpatients; cross-sectional study; adherence by patient reports and from records; alliance by subjective perceptions of medications and mental health contact helpfulness	Medication adherence in African-American adolescents was significantly correlated with ratings of drug usefulness and helpfulness of mental health contacts. Helpfulness of mental health contacts was not associated with adherence among Caucasian adolescents
Guandiano and Miller[66], 2006	61 trial patients on medications and family intervention; 28 mo follow-up; adherence indexed by number of months in treatment; alliance by WAI - P and C versions	Alliance was associated with number of months in treatment, dropout rate, percentage of time depressed and expectations from treatment
Sajatovic et al[67], 2006	184 trial inpatients; cross-sectional study; adherence by patient interviews; alliance by WAI - P and C	Alliance scores did not differ between adherent and non-adherent groups
Lecomte et al[68], 2008	118 patients from early intervention services; 13 with BD; cross-sectional study; adherence by the MAS scale; alliance by WAI-P	Alliance scores were not associated with medication adherence but predicted poor service engagement
Sajatovic et al[69], 2008	302 trial patients; 3 yr follow-up; adherence by patient interviews; alliance by WAI - P and C	Alliance scores did not differ between adherent and non-adherent groups
Zeber et al[70,71], 2008 and 2011	435 inpatients and outpatients; cross-sectional study; adherence by patient-report of missed medication days and MMAS; alliance by HCCQ	Overall alliance scores were associated with self-report of missed medication days and individual items of the HCCQ were linked to MMAS and missed medication days
Perron et al[72], 2009	429 inpatients and outpatients; 1 year follow-up; adherence by MMAS; alliance by HCCQ	Treatment alliance demonstrated a small but significant association with medication at baseline, but not at follow-up
Cely et al[73], 2011	124 outpatients; cross-sectional study; adherence by MMAS; alliance by self-designed questionnaire	A negative perception of the treatment alliance among patients was significantly more common in the non-adherent group compared to the adherent group
Sylvia et al[74], 2013	3037 outpatients from the STEP-BD study; 1 yr follow-up; adherence by a clinical monitoring form; alliance by HAQ	Patients' perceptions of the strength of the treatment alliance were associated with adherence Perceptions of collaboration, empathy and accessibility were the elements of the alliance linked to adherence
Kassis et al[75], 2014	628 inpatients and outpatients; 76 with BD; cross-sectional study; adherence by patient-report and from records; alliance by PDRQ	Patients in the adherent group were more satisfied with their psychiatrists, including availability and accessibility of psychiatrists and agreement with them on symptoms
Kutzelnigg et al[76], 2014	891 outpatients on olanzapine and mood-stabilizers; 2 yr follow-up for 657 patients; adherence by clinician judgments; alliance by self-designed scale	Patients in the highly adherent group had a better treatment alliance than those in the non-adherent group at baseline but not during the follow-up period
Novick et al[77], 2015	903 outpatients on olanzapine; 291 with BD; 1 yr follow-up; adherence by MARS; alliance by WAI-C	Alliance scores were associated with medication-adherence both at baseline and after 1 yr of follow-up

COSS: Compliance self-rating scale; HAQ: Helping alliance questionnaire; HBM: Health belief model; HCCQ: Health care climate questionnaire; ICS: Illness concept scale; KK Skala: Krankheits konzept skala; MARS: Medication adherence rating scale; MAS: Medication adherence scale; MMAS: Morisky medication adherence scale; PDRQ: Patient doctor relationship questionnaire; SCQ: Standardized compliance questionnaire; STEP-BD: Systematic treatment enhancement program for bipolar disorder; TATIS: Treatment adherence training interventions scale; WAI - P and C: Working alliance inventory - patient and clinician versions.