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PubMed1982

Behavioral treatment of hyperlipidemia: techniques, results, and future directions.

The present review examines the role of several target behaviors in the treatment of hyperlipidemia, including diet, exercise, cigarette smoking, Type A pattern, and medication adherence. Modification of the typical American diet (high in cholesterol, fat, and sodium) is emphasized in the treatment of hyperlipidemia since a multitude of laboratory, clinical, and epidemiological studies have shown that diet plays a crucial role in the pathogenesis of this condition and an increase in coronary risk. Factors affecting patient compliance such as health beliefs and family support are discussed in terms of their impact on behavior change efforts aimed at reducing plasma lipids through dietary and drug regimens. Intervention studies are reviewed in the behavioral treatment of hyperlipidemia. These programs have focused on diet modification, exercise, and medication adherence to reduce plasma lipids and coronary risk. The role of other target behaviors (i.e., Type A pattern and smoking) is explored not only in determining coronary risk but also in terms of their direct impact on plasma lipids. Further research is necessary to clarify the relationship between these target behaviors and plasma lipid levels and to investigate the effects of innovative family- and group-based intervention procedures in promoting and maintaining habit change related to coronary risk reduction.

Behavior Therapy↗
PubMed2006

A randomized trial of primary intensive care to reduce hospital admissions in patients with high utilization of inpatient services.

Randomized controlled trials of case management in primary care have been infrequent and contradictory. The aim of this study was to determine if a clinic-based ambulatory case management intervention, Primary Intensive Care (PIC), would reduce hospital utilization and total cost and/or improve health outcomes among primary care patients with a recent history of high use of inpatient services. Current patients with > or =2 hospital admissions per year in the 12-18 months prior to recruitment in an urban primary care clinic were enrolled in a randomized clinical trial. Patients were randomized to the PIC intervention or usual care. PIC patients underwent a comprehensive multidisciplinary assessment with the result being a team-generated plan. The PIC team nurse practitioner served as case manager for the 12 months of follow-up and provided services designed to implement the care plan for those in the experimental group. Health care use, function, and a medication adherence scale were measured at baseline and at 12 months. There were no significant differences when either comparing the number of admissions pre and post enrollment within groups or the followup results post intervention between groups. A similar result was noted for the number of emergency department visits. The number of clinic visits increased in the intervention group by 1.5 visits per year which was statistically significant when compared to the control group. Overall functional status, health outcomes, and the Mental Health Functional Status subscore did not change significantly in either group during the study. We were unable to detect a difference in hospital use or functional status, mental health function, or medication adherence among patients who require frequent hospital admissions using our intervention.

Adult↗
PubMedDate not supplied

Randomized clinical trial of cognitive behavioral stress management on human immunodeficiency virus viral load in gay men treated with highly active antiretroviral therapy.

OBJECTIVE: Human Immunodeficiency Virus (HIV)-positive individuals treated with highly active antiretroviral therapy (HAART) may experience psychological burdens and negative mood states, which could impair their ability to derive maximum benefits from their medical treatment. We tested whether a cognitive behavioral stress management (CBSM) intervention in combination with antiretroviral medication adherence training (MAT) from a clinical pharmacist influences HIV viral load more than MAT alone. METHODS: HIV-positive men who have sex with men were randomized to either a 10-week CBSM + MAT intervention (n = 76) or a MAT-Only condition (n = 54). Data were collected at baseline immediately following the 10-week intervention period, at 9 months postrandomization, and at 15 months postrandomization. RESULTS: We found no differences in HIV viral load among the 130 men randomized. However, in the 101 men with detectable viral load at baseline, those randomized to CBSM + MAT (n = 61) displayed reductions of 0.56 log10 units in HIV viral load over a 15-month period after controlling for medication adherence. Men in the MAT-Only condition (n = 40) showed no change. Decreases in depressed mood during the intervention period explained the effect of CBSM + MAT on HIV viral load reduction over the 15 months. CONCLUSIONS: A time-limited CBSM + MAT intervention that modulates depressed mood may enhance the effects of HAART on suppression of HIV viral load in HIV+ men with detectable plasma levels.

Anti-HIV Agents↗
PubMed2005

Ritonavir-based highly active antiretroviral therapy in human immunodeficiency virus type 1-infected infants younger than 24 months of age.

BACKGROUND: Few data are available regarding clinical outcomes or dosing requirements for the protease inhibitor ritonavir in human immunodeficiency virus (HIV)-infected children younger than under 24 months of age. METHODS: This prospective, multicenter phase I/II open label treatment trial used ritonavir, zidovudine and lamivudine to treat protease inhibitor-naive, HIV-infected infants between the ages of 4 weeks and 24 months. Two sequential dosing cohorts were treated with 350 or 450 mg/m(2) ritonavir every 12 hours; this report includes results of pharmacokinetics, safety, tolerability and efficacy through 104 weeks of follow-up of all subjects. RESULTS: Fifty HIV-infected children were treated. By week 16, 36 had achieved HIV-1 RNA <400 copies/mL (72% intent-to-treat, 84% as-treated analysis); by week 104, 18 maintained durable viral suppression (36% intent-to-treat, 46% as-treated). Poor medication adherence by caregiver report contributed to virologic failure. Few subjects experienced treatment-limiting toxicity: emesis or ritonavir refusal in 6 (12%); and severe but reversible anemia or elevated serum hepatic transaminases in 1 (4%) each. Apparent oral clearance was higher and the median predose concentrations were substantially lower than those found in adults. Median z scores for weight and height for age/gender were below normal at baseline but improved by week 104. CONCLUSIONS: A combination regimen of ritonavir, zidovudine and lamivudine was generally safe and produced sustained viral suppression in more than one-third of infants who initiated therapy before 2 years of age. Improved palatability of liquid preparations of protease inhibitors, supporting infrastructure and behavioral approaches to improve medication adherence with antiretrovirals will likely be necessary to further improve efficacy.

Age Factors↗
PubMed2006

Factors related to hospitalization in elderly manic patients with early and late-onset bipolar disorder.

OBJECTIVE: To identify factors contributing to relapse and hospitalization in elderly patients with bipolar disorder. METHOD: Retrospective chart review surveyed consecutive patients over age 65 admitted to the Johns Hopkins Hospital for a manic episode over a five year period (n=73). Factors precipitating index admission were compared in patients with early-onset bipolar disorder ( age 45, n=35). RESULTS: The distribution of ages of onset of bipolar disorder was most consistent with a bimodal pattern with a cut-point at age 45. Early-onset patients were more likely to have been aggressive and threatening prior to admission (p=0.014) compared to late-onset patients and were more likely to have been brought to the emergency room on emergency petition for evaluation (p=0.028). Early-onset patients were also more likely to have been non-adherent with prescribed psychiatric medication (p=0.032). CONCLUSIONS: Relapse and rehospitalization were common among elderly manic patients with early-onset and late-onset bipolar disorder. Strategies which improve medication adherence are needed to help prevent recurring hospitalization.

Age Factors↗
PubMed2004

Adherence to antiretroviral therapy: an update of current concepts.

The remarkable effectiveness of combination antiretroviral therapy (CART) in the treatment of HIV infection has placed a high premium on long-term adherence to therapy. Adherence levels to CART among HIV-infected individuals are similar to adherence levels with chronic medical conditions, such as diabetes and hypertension. However, unlike chronic medical conditions, medication adherence that is insufficient to maintain suppression of HIV replication will lead to drug resistance. Combination antiretroviral therapy regimen complexity and side-effect burden are clearly linked to adherence and are likely to be the factors most amenable to intervention. Adherence interventions that are multifaceted, flexible, and protracted are the most likely to be successful. Owing to the great benefits of CART even the small to modest gains in adherence that are achievable with adherence programs may prove to be cost effective.

Anti-Retroviral Agents↗
PubMed1989

Investigation of a cluster of deaths of adolescents from asthma: evidence implicating inadequate treatment and poor patient adherence with medications.

We investigated a cluster of five deaths of adolescents from asthma in St. Louis during a 3-month period in 1987. Although the cluster represented a statistically significant increase in the number of asthma deaths in this age group over that observed in previous years, no common exposure to environmental, infectious, or therapeutic agents could be identified. The patterns of hospital admissions for asthma and emergency room visits at the two pediatric hospitals in the community did not suggest an increase in the frequency or severity of asthma during this time. Despite the lack of evidence for common exposure, the decedents shared many personal and medical characteristics. All decedents were black patients and were of lower socioeconomic status. All were adolescents and were responsible for regulating their own medication schedules. Lack of appreciation of the severity of their asthma by medical personnel and the patients' families was evident. For example, two patients with severe asthma had not been prescribed inhaled corticosteroids. In addition, the four decedents tested had markedly subtherapeutic or zero serum theophylline levels measured at the time of the fatal episode, even though appropriate amounts of theophylline had been prescribed. Their theophylline levels were substantially lower than levels in patients of the same age observed at the emergency room or hospitalized for asthma during the same time period. Continued efforts to educate adolescent patients, their families, and medical care providers about the treatment of asthma are warranted.

Adolescent↗
PubMedDate not supplied

Understanding the psychodynamics of non-adherence to medical treatment in persons with HIV infection.

We present this medical-psychiatric case discussion to illustrate the psychodynamic aspects of nonadherence in a woman with AIDS. Our patient sustained severe, repeated abandonment and brutal emotional, physical and sexual trauma throughout her early and later childhood and adult life. Her care was considerably complicated by the sequelae of trauma including difficulty with trust and posttraumatic stress disorder. The additional problem of HIV dementia compounded the patient's nonadherence to treatment. We present a multidisciplinary biopsychosocial approach that enabled the patient to engage in both medical and psychiatric care.

AIDS Dementia Complex↗
PubMed2001

Variability of erythrocyte and serum lithium levels correlates with therapist treatment adherence efforts and maintenance treatment outcome.

This study investigated the relationship between psychotherapeutic interventions and pharmacologic measures of pharmacotherapy treatment adherence in patients with bipolar I disorder, as well as the relationship between these measures and treatment outcome. Subjects were participating in an ongoing maintenance treatment study. Audiotaped therapy sessions were rated for frequency of psychotherapeutic interventions related to pharmacotherapy treatment adherence. Pharmacologic measures of medication adherence were compared to the tape ratings as well as to treatment outcome. Variability in log erythrocyte (RBC) lithium-a marker of probable nonadherence to the pharmacotherapy regimen-for individual patients correlated significantly with treatment adherence interventions scale ratings. This marker of nonadherence was significantly related to maintenance treatment outcome, as was variability of the serum lithium level/dose (L/D) ratio; however, no relationship was found between treatment adherence interventions scale ratings and outcome.

Adult↗
PubMed1997

Social factors and the meaning of food in adherence to medical diets: results of a maternal phenylketonuria summer camp.

A Maternal PKU camp provided education and social support for 25 young women with phenylketonuria (PKU). Questionnaires were administered and blood samples were collected on the first and last days of camp to evaluate the psychological and medical impact of the programme. Long-term outcome was assessed through telephone interviews 7-14 months later. Knowledge of maternal PKU and the maternal PKU diet increased significantly. There was a significant increase in campers' ratings of the degree to which others supported the use of birth control to prevent late-treated pregnancies, although campers' comfort with contraception did not change. Mean blood phenylalanine concentrations were significantly reduced by 37% during camp and by 20% at follow-up. Ninety-six per cent of campers remained in contact with other campers after the summer. At follow-up, one pregnancy was reported, in which metabolic control was achieved prior to conception. Overall, attitudes about treatment and perceptions about ability to cope with PKU did not change to a significant degree. It is suggested that camps may be most successful in changing both behaviour and attitudes if they actively involve the campers in food preparation, address the psychological meaning of food in our culture, and provide social support.

Adolescent↗
PubMed1999

Assessment of irrational health beliefs: relation to health practices and medical regimen adherence.

The purpose of the present research was to provide initial validation of the 20-item Irrational Health Belief Scale (IHBS). Study 1 included 392 undergraduate psychology students. Results from Study 1 suggested that the IHBS total score is internally consistent and stable over an 18-month time period. Greater health-related cognitive distortion (higher IHBS scores) was associated with weaker internal health locus of control beliefs, lower positive affectivity, stronger chance health locus of control beliefs, and greater negative affectivity. Most important, greater cognitive distortion was uniquely and significantly associated with a less positive pattern of health practices. Study 2 involved 107 individuals with Type I diabetes mellitus. Results indicated that higher IHBS scores were significantly associated with both objective (hemoglobin HbA1) and self-reported diabetic regimen adherence independent of trait neuroticism and conscientiousness.

Adolescent↗