On-line version ISSN 1025-9848
Health SA Gesondheid (Online) vol.19 n.1 Cape Town Jan. 2014
Mosidi B. SerobatseI; Emmerentia Du PlessisII; Magdalena P. KoenII
IWitrand Hospital, Potchefstroom, South Africa
IISchool of Nursing Science, North-West University, Potchefstroom Campus, South Africa
BACKGROUND: Non-compliance to treatment remains one of the greatest challenges in mental healthcare services, and how to improve this remains a problem.
AIM: The aim of this study was to critically synthesise the best available evidence from literature regarding interventions to promote psychiatric patients' compliance to mental health treatment. The interventions can be made available for mental health professionals to use in clinical practice.
METHOD: A systematic review was chosen as a design to identify primary studies that answeredthe following research question: What is the current evidence on interventions to promote psychiatric patients' compliance to mental health treatment? Selected electronic databases were thoroughly searched. Studies were critically appraised and identified as answeringthe research questions. Evidence extraction, analysis and synthesis were then conducted by means of evidence class rating and grading of strength prescribed in the American Dietetic Association's manual.
RESULTS: The systematic review identified several interventions that can improve patients' compliance in mental health treatment, for example adherence therapy and motivational interviewing techniques during in-hospital stay.
CONCLUSIONS: Conclusions were drawn and recommendations formulated for nursingpractice, education and research.
AGTERGROND: Geen-samewerking met behandeling bly steeds een van die grootste uitdagings in geestesgesondheidsorgdienste, en genoegsame kennis oor hoe om dit te verbeter, is steeds 'n probleem.
DOELWIT: Die doel van hierdie studie was om die beskikbare bewyse vanuit literatuur aangaande intervensies ter bevordering van psigiatriese pasiënte se samewerking met geestesgesondheidsbehandeling krities te sintetiseer. Hierdie intervensies kan aan professionele gesondheidsorgpersoneel beskikbaar gestel word ter bevordering van psigiatriese pasiënte se samewerking met geestesgesondheidsbehandeling.
METODE: 'n Sistematiese literatuuroorsig is gekies as die ontwerp om primêre studies te identifiseer wat die volgende navorsingsvraag beantwoord: Wat is die huidige kennis ten opsigte van intervensies wat psigiatriese pasiënte se samewerking met geestesgesondheidsbehandeling bevorder?.
RESULTATE: Studies is ingesluit vir kritiese gehalte-beoordeling ten opsigte van metodologie, en is uiteindelik geïdentifiseer as bronne van bewyse wat die literatuuroorsigvraag toepaslik beantwoord. Bewysonttrekking, -analise en -sintese is gedoen deur middel van die beoordeling van bewysklas en -gradering van bewyssterkte, soos voorgeskryf in die American Dietetic Association se handleiding. Die sistemiese literatuuroorsig het aangedui dat daar heelparty intervensies is wat psigiatriese pasiënte se samewerking met behandeling kan verbeter, byvoorbeeld samewerkingsterapie en motiveringsonderhoudstegnieke.
GEVOLGTREKKING: Gevolgtrekkings is gemaak en aanbevelings is geformuleer vir die verpleegpraktyk, verpleegonderrig en navorsing in verpleging.
There is a widespread problem with psychiatric patients not remaining compliant to their mental health treatment (Patel & David 2007:357). Complete compliance is difficult to achieve with most psychiatric patients, and non-compliance is compounded by the need to take medication over extended periods of time. This article systematically explains the background and rationale to use of a systematic review, the research objectives, research design and method, steps of the systematic review and conclusion statements regarding interventions to promote psychiatric patients' compliance to mental health treatment. The study was approved by the Post Graduate Committee of the School of Nursing Science of North-West University.
Background to and rationale of the study
Compliance with treatment, or adherence, is a very important healthcare issue (Bolon 2002:1). Both healthcare provider and patients share responsibility for adherence, which is rarely an all-or-none phenomenon (Patel & David 2007:357). According to Bolon (2002:1), in prescribing medication compliance usually means 'the extent to which the patient takes the treatment as prescribed.' The term compliance used in this study is intended to be non-judgemental, and issued as a statement of fact to ensure that both psychiatric patients and healthcare providers take responsibility to promote psychiatric patients' compliance to mental health treatment.
For patients' long-term benefit the ultimate goal is adherence, but when involuntary patients are psychotic and very disabled by illness, the immediate objective is compliance (Vuckovich 2010:78). Compliance to treatment is a major problem, especially for patients repeatedly hospitalised for psychiatric disorders. In Britain it has been estimated that 20% - 50% of the patient population is at least partially non-compliant, and that non-compliance rates can run as high as 70% - 80% in patients diagnosed with schizophrenia and related psychiatric disorders (Nosé et al. 2003:197).Although psychiatric medication is effective in reducing relapse and rehospitalisation, 30% - 40% of psychiatric patients in the United States of America relapse within one year after discharge, despite receiving maintenance medication (Kneisl & Trigoboff 2009:377).
According to the literature many factors contribute to non-compliance to treatment, including:
- lack of insight, lack of social support, poor quality of patient-doctor relationship, limited effectiveness and severity of side-effects of psychiatric medication (Montes et al. 2010:274);
- forgetting and losing or running out of medication, thinking that it was not needed, not wanting to take the drug, poor awareness of illness and embarrassment at having to take daily medication (Razali 2010:69);
- lack of clear markers of efficacy, and the complexity of treatment regimen (Brondolo & Mas 2001:137); and
- psychiatric patients' easy access to alcohol and other chemicals (Rothbard & Kuno 2000:19; Lamb & Bachrach 2001:1039).
Poor compliance to treatment can create a multitude of problems, such as a longer hospital stay, elevated costs, increased risk of attempted and completed suicide, and poor outcome related to impaired patient functioning (Montes et al. 2010:274). Poor compliance to antipsychotic medication increases the risk of relapse, and relapse leads to an increased potential for assault and dangerous behaviour by psychiatric patients, especially during periods of psychosis (Zygmunt et al. 2002:1653).An increase in symptoms and in the potential for assault and dangerous behaviour, and a decrease in quality of life have all been attributed to failure to comply with prescribed treatment (Vuckovich 2010:79).
Non-compliance to treatment amongst psychiatric patients is also considered a problem in South Africa. In South Africa, as part of the deinstitutionalisation movement that escalated during the late 1990s, patients with mental illness were discharged from hospitals as soon as possible or when the acute episode was resolved; they then went for follow-up treatment at their nearest community mental health clinics (Kazadi, Moosa & Jeenah 2008:52). Treatment at these clinics focuses mainly on pharmacotherapy, with few psychosocial support services owing to a lack of human and material resources as well as difficulties in integrating various treatment modalities (Kazadi et al. 2008:52). There is therefore a need for a synopsis of more current interventions that can promote psychiatric patients' compliance to mental health treatment.
The above discussion led to the following research question: What is the current evidence on interventions to promote psychiatric patients' compliance to mental health treatment?
The objective of the research was to critically synthesise the best available evidence on interventions to promote psychiatric patients' compliance to mental health treatment. Such a synthesis may be considered by mental health professionals for implementation in their context.
In this research 'best available evidence' refers to evidence generated through the most appropriate and valid method (Maltby et al. 2010:360). 'Critical synthesis' refers to a summary of best available evidence obtained through a systematic review, bringing the results of individual studies together, appraising the strength of evidence generated in these studies and summarising the evidence (Centre for Reviews and Dissemination 2009:76).
Research method and design
The design in this study was explorative and descriptive, and aimed at exploring and describing the identified best available scientific evidence regarding interventions to promote psychiatric patients' compliance to mental health treatment (Centre for Reviews and Dissemination 2009:48).
The research method selected for this research was a systematic review of interventions to promote psychiatric patients' compliance to mental health treatment. Systematic reviews are research reviews that combine the evidence of multiple studies regarding a clinical problem to inform clinical practice (Whittemore & Knafl 2005:547). The research method is discussed below according to the five steps of systematic review.
Step 1: Formulation of focused review question
The review question guided the systematic review, and for this study was formulated according to the PICOT format (Table 1), namely: Population; Interventions; Comparison; Outcome; and Time frame (adopted from American Dietetic Association [ADA] 2008:6). The review question was: 'What is the current evidence on interventions to promote psychiatric patients' compliance to mental health treatment?'
Step 2: Gathering and classifying the evidence
The next step in conducting a systematic review is to gather all the relevant literature using a structured search strategy. The search process should be as transparent as possible and documented in a way that enables it to be evaluated and reproduced (Centre for Reviews and Dissemination 2009:16).
A comprehensive search was conducted to ensure inclusion of many studies and to minimise selection bias (Akobeng 2005:847). The search strategy was not limited to the English language, since this would introduce language bias (Centre for Reviews and Dissemination 2009:17). Selected electronic databases that were accessible were thoroughly searched; SA-Nexus (National Research Foundation), ProQuest, EBSCOhost Platform, ScienceDirect, Web of Knowledge, Cochrane Library, Sabinet and Google Advanced Scholar were searched for primary studies published from June 2001 to June 2011. Primary studies in any language with an abstract in English were included in the search results. The following keywords were used in the search: intervention, mental health treatment, psychiatric treatment, compliance, adherence, psychiatric patients, mental healthcare user, and combinations thereof. Scanning reference lists of papers identified by the database searches allowed further studies of interest to be identified. The search strategy was conducted under the supervision of experienced researchers who are familiar with conducting systematic reviews.
Studies were selected using inclusion and exclusion criteria (Table 2), determined to make certain that the boundaries of the review question were clearly defined. The aim of the search was to include all studies relevant to the research question.
Articles were retrieved through the databases, using the keywords. Google and library loans were used to obtain all possibly relevant articles. An experienced librarian at the North-West University assisted in a specific search strategy in Nexus (a national electronic database).
The study selection was first conducted by screening titles and abstracts against the inclusion criteria to identify potentially relevant papers and to check for availability of evidence. The studies that appeared to meet the inclusion criteria were selected after reading the abstract. This was followed by a screening of the full papers identified as possibly relevant in the initial screen as described by Centre for Reviews and Dissemination (2009:13). Accurate record-keeping was maintained throughout the process for audit purposes to enhance rigour. The total number of studies included for critical appraisal was 16. Studies identified, excluded and included are tabulated in Figure 1.
Step 3: Performing the critical appraisal
Critical appraisal is the process of carefully and systematically examining research to judge its trustworthiness, value and relevance in a particular context (Burls 2009:1). The purpose of the critical appraisal is to determine the validity of the research, to interpret the results and evaluate applicability of the research in clinical practise, in public health and in future research (Abalos et al. 2001:15).
The first step in critical appraisal of a review is to establish its methodological quality to determine the validity of the result. In this study primary studies selected for critical appraisal were evaluated for methodology and quality using standard checklists from the Critical Appraisal Skills Program (CASP) and John Hopkins Nursing Evidence-Based Practice (JHNEBP) research evidence appraisal tool (Newhouse et al. 2007:206). The CASP tool was used for all studies of randomised control trials (RCT) and JHNEBP for non-experimental and quasi-experimental studies. The scoring was adapted by the researcher for inclusion and exclusion purposes after appraisal of both the CASP and JHNEBP instruments.
Individual studies were identified with symbols used for quality rating, as shown in the quality criteria checklist of primary studies. The study was rated either positive (+), indicating that the report clearly addressed issues of inclusion or exclusion, bias, generalisability, and data collection and analysis; neutral (ø), indicating that the report was neither exceptionally strong nor exceptionally weak; or negative (-), indicating that these issues were not adequately addressed.
The 16 studies included were appraised for reliability, validity and credibility by the appropriate criteria of the CASP to determine whether the findings could be considered as good-, medium- or low-quality evidence (CASP 2006:17). The studies included in this review were from medium to high quality and obtained a quality rating between 5/10 and > 8/10. The studies were appraised on the basis of criteria as recommended by the ADA Evidence analysis manual (ADA 2008:42) using a quality checklist for primary studies. A second reviewer independently appraised the selected studies for methodological quality and for inclusion in or exclusion from the systematic review. The checklists were completed and filed for audit purposes.
Sixteen quantitative studies were included for critical appraisal: 8 RCTs, 5 non-experimental studies and three quasi-experimental studies. The total number excluded was twonon-experimental studies because of poor quality. After critical appraisal 14 articles were included for data extraction.
Step 4: Evidence - findings and summarising
A summary of the evidence presents the cumulative information, data and quality of evidence for the most important outcomes; it also contains discussions on the data extraction and summary, data analysis strategy, and a summary of the findings.
Data extraction elements (Table 3) for each study involved the focus of the study, the main findings, and findings that were relevant to this systematic review. All data extracted were graded on the strength of their evidence supporting the conclusions or recommendations according to the ADA Evidence analysis manual (ADA 2008:62).
Primary studies of RCTs, non-experimental and quasi-experimental studies were included in this review. Where the primary studies use different designs, populations studied, interventions and comparisons used or outcomes measured, it is more appropriate to report the findings descriptively according to themes (Garg, Hackam & Tonelli 2008:253). Therefore thematic analysis was used as an appropriate analysis strategy to identify major or recurrent themes in the findings, followed by a summary of findings under these thematic headings (Dixon-Woods et al. 2006:27). The findings regarding each theme were combined and summarised; thereafter conclusion statements were made.
Step 5: Drafting findings, limitations and recommendations
This step and the findings, limitations and recommendations are outlined in the sections that follow.
In order to answer the review question a summary of the findings under thematic headings referring to psychiatric conditions (schizophrenic patients, psychiatric patients, depressed patients and seriously mentally ill patients) treated in specific settings, both public and private (hospital, community, clinics or outpatients), are provided.
Finding 1: Adherence therapy and motivational interviewing are effective in promoting compliance to treatment in hospital settings for schizophrenic patients
Findings indicated that Adherence therapy (AT) and motivational interviewing can improve schizophrenic patients' compliance to treatment in hospital settings. AT is a brief cognitive behavioural approach that evolved from compliance therapy. It is a collaborative, flexible, structured way of working and draws on cognitive behavioural therapy and motivational interviewing techniques.
AT is a detailed, phased approach to promoting treatment compliance in patients with schizophrenia (Maneesakorn et al. 2006:1302). The key therapeutic techniques used are exchanging information, developing discrepancy and effectively dealing with resistance to discussing psychiatric medication and treatment. AT strategies emphasise patient engagement and enable patients to make joint decisions about medication in cooperation with health professionals (Maneesakorn et al. 2006:1302). The findings of this study indicated that there was statistical improvement overall, including in psychotic symptoms, attitude towards medication, and satisfaction with medication in schizophrenic patients in the hospital setting. It is therefore important that healthcare professionals receive training on AT and motivational interviewing and put them into practice in hospital settings to promote compliance to mental health treatment.
Finding 2: Meds-Help and treatment Adherence therapy are effective in promoting compliance to treatment in community settings for seriously mentally ill patients
Valenstein et al. (2011:727-736) showed that a low-complexity pharmacy-based intervention (Meds-Help) improves antipsychotic compliance amongst patients with serious mental illness who live in the community and receive treatment at a clinic. The Meds-Help consisted of unit-of-use packaging that included all patients' medications; a medication and packaging education session; refill reminders mailed two weeks before scheduled refill dates, and notification of clinicians if patients failed to refill their treatment within 7-10 days. Meds-Help staff serve as contacts for patient questions regarding pharmacy services or doctors' prescriptions. Pharmacy technicians, with oversight by pharmacists, completed many of these intervention components. The medication education was done by pharmacists, usually in person, but occasionally by telephone. This intervention can therefore be implemented for outpatients (Valenstein et al. 2011:727-736).
A treatment AT programme as an intervention improved compliance to treatment for patients with severe and persistent mental illness in outpatient departments at clinics. The programmes consist of community healthcare professionals trained in monitoring patients receiving treatment at community mental health centres (CMHCs). The programme uses alert systems at CMHCs 2-weekly when patients fail to refill their treatment. The medication possession ratio (MPR) scores were also monitored. Case managers and/or supervisors from the treatment AT programme at CMHCs participated in a 4-hour patients' adherence educational training seminar. Physicians and psychiatrists working at the centre are orientated regarding the treatment AT programme. Findings indicated that there was a statistically significant association between the treatment AT interventions and MPR score, and an improvement in antipsychotic medication compliance. Therefore training on the treatment AT programme should be encouraged for community mental health professionals. The above intervention can be implemented for outpatients in community healthcare centres, as it has been proven to promote psychiatric patients' compliance to mental health treatment (Patel et al. 2010:269-274).
Finding 3: Treatment initiation and participation programme and use of a depression management flowsheet are effective in improving compliance to treatment in clinic settings for depressed patients
Findings indicated that the treatment initiation and participation (TIP) programme is useful in improving early compliance to antidepressant therapy provided at clinics and primary care settings. Patients also showed a decrease in depressive symptoms. The TIP intervention format is three 30-minute individual meetings with the patient during the first six weeks of pharmacotherapy, followed by two follow-up telephone calls at 8 and 10 weeks. The three sessions allow the TIP counsellor and older adult participant to establish an alliance and work together on barriers to compliance (e.g. patient perceptions of stigma, illness severity and concern about treatment).TIP intervention uses a number of techniques, such as motivational interviewing, problem solving tasks and psycho-education. The TIP intervention has proven to be effective in treating adult depressive patients, and can be implemented for adults receiving treatment at urban clinics (Sirey, Bruce & Kales 2010:554-562).
Use of a depression management flowsheet coupled with patient education, a checklist for co-morbid disorders, a medical reference guide, a major depression guide and diligent follow-up, dramatically improved rate of treatment compliance amongst depressed patients at clinics. Patients were asked to complete a Patient Health Questionnaire (PHQ-9s) and medication side-effects were assessed two-weekly. They were also educated by the attending physician during their initial appointment, and were given information to explain the disease and the necessity of compliance to the prescribed regimen for a period of nine months. A flowsheet containing information relative to office calls, follow-up PHQ-9s and other summaries of medication, co-morbidities and treatment regimens was inserted into their folders. During their visits physicians stressed the need for continuing medication. A patient who did not return for a follow-up appointment after six months, as indicated by systematic chart review, was contacted by telephone by a registered nurse. This study indicated that the above intervention significantly improved compliance to mental health treatment by depressed patients. It is therefore important that the above intervention be conducted as it improves compliance to mental health treatment (Ruoff 2005:846-851).
The findings of a study by Gervasoni et al. (2010:265) proved that a brief, high-intensity structured telephone intervention alone does not improve compliance to treatment with antidepressent medication amongst patients treated at clinics.
Finding 4: Medication management training for community mental health nurses and antipsychotic medication combined with psychosocial interventions are effective in improving compliance to treatment used in outpatient settings for schizophrenic patients
Medication management training for community mental health nurses (CMHNs) is effective in improving schizophrenic patients' compliance to mental health treatments as it leads to improvement in overall psychopathology, attitude towards antipsychotic treatment and compliance. The training focused on teaching CMHNs the compliance therapy approach detailed in the treatment manual. A multidisciplinary team that included clinical nurse specialists, psychologists and psychiatric pharmacists provided the training. The findings of this study demonstrated that medication management training for CMHNs is effective in improving clinical outcomes in people with schizophrenia with a significant improvement in clinical skills. The training also equips nurses with the clinical skills and knowledge needed to improve psychiatric patients' compliance to mental health treatment. It is therefore important that CMHNs attend medication management training to promote psychiatric patients' compliance to mental health treatment in the community (Gray et al. 2004:157-162).
In a study by Guoet al. (2010) it was found that antipsychotic medications combined with psychosocial intervention have proven effective in improving compliance to mental health treatment amongst patients with early-stage schizophrenia. Psychosocial interventions have also lowered the rate of treatment discontinuation or change, the risk of relapse and hospitalisation, and improved insight, quality of life, and social/occupational functioning. The psychosocial intervention strictly followed a detailed treatment manual and included four evidence-based practices: psycho-education, family intervention, skills training, and cognitive behaviour therapy. The findings indicated that these practices proved effective in treating patients with schizophrenia, and can be implemented at clinics (Guo et al. 2010:895-904).
Finding 5: Home care support and use of long-acting injectable treatments, and atypical antipsychotic treatment are effective in promoting compliance to treatment
Long-acting injections and the provision of home care may lead to continued treatment. These home care services include psychosocial interventions delivered by a community-based multidisciplinary team, linking patients to community resources. Home care visitors offer active services, such as encouraging the patients to seek medical advice and to keep in contact with their physicians. It is therefore important to make certain that patients receiving long-acting injection interventions must also home care to improve their compliance to mental health treatment (Chang, Tzen & Lung 2010:16-19).
Furthermore, psychotic outpatients with prescriptions for atypical antipsychotic treatment (risperidone, olanzapine and quetiapine) are more compliant to mental health treatment compared to patients with prescriptions for typical agents (haloperidol and perphenazine). Using interventions of atypical antipsychotic treatment has been proven to reduce the side- effects of antipsychotics, and can be used as it improves psychiatric patients' compliance to mental health treatment (Dolder et al. 2002:103-108).
Limitations of the study
The heterogeneity of the studies and interventions outcome measures prevented the possibility of comparing results between the studies directly by means of meta-analysis. Different interventions were identified, with more studies that looked at effective interventions for schizophrenia. These cannot be generalised to other psychiatric conditions. The systematic review was conducted on studies presenting with high-quality ratings - a mixture of class A and C evidence - and therefore generalisation is limited to specific settings and not all findings can be generalised to the wider population. In this review blinding was not used during the search or critical appraisal step, as there was no conflict of interest. This could be a limitation with regard to validity of appraisal.
The findings of the systematic review help to provide recommendations for nursing practice, nursing education and nursing research regarding best available evidence on interventions to promote psychiatric patients' compliance to mental health treatment.
Recommendations for nursing practice
Information on interventions to promote psychiatric patients' compliance to mental health treatment should be made available in nursing practice to improve patients' compliance to treatment in different healthcare settings. Integrating comprehensive therapy (psycho-education, family intervention, skills training, and cognitive therapy) with medication treatment in the early stage of schizophrenia is critically important to improve compliance to mental health treatment and should be implemented in outpatient settings.
CMHNs should be trained on medication management to equip them with skills to be effective in delivering compliance therapy and promoting psychiatric patients' compliance to mental health treatment in the community.
Schizophrenic patients receiving long-acting injectable treatment intervention must also have provision of home care to improve their compliance to mental health treatment.
Long-acting injectable antipsychotic treatment has been proven to improve compliance to mental health treatment more than oral medication in outpatients with schizophrenia; therefore long-acting injectables can be used more than oral medication for outpatients.
Interventions with atypical antipsychotic treatment have been proven to reduce the side- effects of antipsychotics and can be used since they improve psychiatric patients' compliance to mental health treatment.
Recommendations for nursing education
The current available evidence on interventions that promote psychiatric patients' compliance to treatment can be included in nursing curriculums to inform, educate and equip nurses with special skills to safely and effectively deliver nursing care in community healthcare centres and hospitals.
Recommendations for research
Further research is needed on interventions to promote psychiatric patients' compliance to mental health treatment, as most of the research identified was only recommended for specific settings and have small samples. Suggestions for further research include the following:
- Further research is recommended on the effectiveness of the interventions identified through this systematic review in the South African context.
- Further research is recommended on effectiveness of compliance therapy to improve psychiatric patients' compliance to treatment in all settings.
- More research is needed on the effectiveness of treatment initiation and participative programmes in different settings.
- Further research is needed on the use of atypical antipsychotic treatment to improve psychiatric patients' compliance to mental health treatment compared to typical antipsychotic medication.
- Further research is needed on use of AT to improve compliance to mental health treatment in community settings.
- Further research is needed on a brief, high-intensity, structured telephone intervention to improve compliance to treatment for patients on antidepressant medication treated in psychiatric outpatient settings.
- Further research is needed on a pharmacy-based coaching programme to improve adherence to antidepressant treatment amongst primary care patients.
- Compliance therapy alone as an intervention to improve compliance to psychiatric patients' treatment has proven not to be effective; therefore further research is needed on this topic.
The objective of the review was to critically synthesise the best available evidence on interventions to promote psychiatric patients' compliance to mental health treatment. This objective was reached through conducting a systematic review. The findings of the systematic review were then used to draw conclusions and formulate recommendations for nursing practice, nursing education and research.
The researcher drew her conclusion from evidence gathered from findings of the studies to answer the research question. The conclusions are summaries or interpretations of the recurrent themes, for example, interventions, target group and settings, and are outlined below.
Concluding statement 1: AT and motivational interviewing techniques have the potential to improve compliance to treatment and overall psychotic symptoms in schizophrenic patients. Health professionals, particularly nurses who spend more time with the patients, should be able to deliver such interventions in the hospital setting.
Concluding statement 2: A treatment AT programme, with healthcare professionals trained on monitoring patients' compliance to treatment, can lead to improvement in compliance of patients with severe mental illness. Therefore training on treatment AT should be done for healthcare professionals working at the community healthcare centres to monitor patients who fail to come for their treatment, and improve patients' compliance to mental health treatment. A pharmacy-based intervention called Meds-Help has been proven to improve compliance to mental health treatment amongst severely mentally ill patients in outpatient settings. Therefore pharmacy-based interventions should be used to improve psychiatric patients' compliance to mental health treatment.
Concluding statement 3: The TIP programme has the ability to improve early compliance to antidepressant therapy provided at clinics and in primary care settings. The TIP model offers a framework for exploring and improving adherence in different settings where depression in older adults is being treated.
The use of a depression management flowsheet coupled with patient education, a checklist for co-morbid disorders, a medical reference guide, a major depression guide and diligent follow-up can dramatically improve the rate of treatment compliance for depressed patients at the clinic. The use of PHQ-9s is useful in assessing medication side effects. Compliance to mental health treatment can also be improved by health education given by pharmacists giving patients information material to explain the disease and the necessity of compliance to the prescribed regimen. The registered nurse can also do follow-up telephonically for patients who failed to keep their appointment to improve compliance to treatment.
Concluding statement 4: Training in medication management for CMHNs has proved to improve compliance to mental health treatment, clinical outcome and attitude to treatment of patients living in the community. Therefore, a medication management training manual package can be made available for CMHNs so that they can be trained and equipped with skills that can help to improve psychiatric patients' compliance to mental health treatment in the community.
Furthermore, medication combined with psychosocial interventions has the ability to improve compliance to mental health treatment.
The authors would like to acknowledge the North-West University, Potchefstroom Campus for financial support, as well as the Ferdinand Postma Library, North-West University, Potchefstroom Campus for support during the systematic review.
The authors declare that they have no financial or personal relationship(s) with other people or organisations that could have potentially prevented them from executing and publishing unbiased research.
M.B.S. (Witrand Hospital, Potchefstroom) conducted the research under the supervision of E.dP. and M.P.K. (both School of Nursing Science, North-West University, Potchefstroom Campus) and drafted the manuscript. E.dP finalised the manuscript, and M.P.K. acted as critical reader.
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Emmerentia Du Plessis
Private Bag X6001
Received: 21 Nov. 2013
Accepted: 14 July 2014
Published: 21 Nov. 2014