Table of Contents
Theoretical Basis for Study…………………………………………………………………………………. 6
Human Subject Issues……………………………………………………………………………………….. 15
Bipolar disorder (BPD) is a serious disease that afflicts approximately six million Americans. Two types of BPD are recognized, BPD type I (BPD-I), which is the more severe form of the condition including at least one manic or mixed manic/depressive episode, and BPD-type II (BPD-II) in which the manic episodes are more moderate or hypomanic; the level of depressive symptoms may be as severe as in BPD-I, however (Puri & Gilmore, 2011). BPD-II is closely associated with a prevalence of anxiety disorders, and longer or more frequent depressive phases (Puri & Gilmore, 2011).
BPD is a serious illness, and frequently is found in patients with other psychiatric disorders such as substance abuse, anxiety, ADHD, eating disorders, and others (Sansone & Sansone, 2011). Other issues are that BPD patients are at substantially higher risk of suicide (both attempts and completions) than patients with other psychiatric disorders, with as many as one in five attempting suicide at least once in their lifetime, and untreated BPD patients have a suicide rate twenty to thirty times higher than in the general population (Sansone & Sansone, 2011). Thus, BPD may be the most lethal of all psychiatric disorders (Sansone & Sansone, 2011).
Diagnosing BPD is challenging because it primarily presents in the depressive part of the cycle and thus is often mistaken for simple depression (Baldessarini et al, 2010). Some distinguishing characteristics of BPD are that it is almost equally prevalent in males as females; it often appears in adolescence or early adult years particularly in cases with a family history of mood disorders (Baldessarini et al., 2010). BPD-I appears at younger ages than BPD-II, and BPD-II generally appears at younger ages than depression (Baldessarini et al., 2010). BPD also has a high recurrence rates, with substantial mood shifts about once or twice a year typically, and, in some patients, even more rapid cycling of four or more episodes a year (Baldessarini et al., 2010). As a result of these and other difficulties, it is often five to ten years after initial symptoms before correct diagnosis and treatment is begun (Baldessarini et al., 2010).
However, the treatment of BPD is controversial. Guidelines suggest that treating BPD patients solely with an antidepressant is not a good idea because it may induce a manic state—yet multiple studies offer evidence exists that fluoxetine in depressed BPD-II patients is actually reasonably effective on at least a short-term basis for depressed phases (Sansone & Sansone, 2011). The treatment for the manic episodes in BPD patients is equally controversial, with antipsychotics and lithium being notorious for their side effects. Common side effects, including weight gain, increases the risk formedical complications such as hypertension, hyperlipidemia, diabetes, asthma, and joint pain (Sansone & Sansone, 2011). Given the current epidemic of obesity in this country, weight gain associated with their BPD treatment regimens, reported in about 30% of BPD patients, is itself a serious problem, with nearly one in five developing hyperlipidemia and 8.6% developing diabetes (Baldessarini, Perry & Pike, 2008). Psychiatrists note that critically needed improvements in available treatments including the need for better mood stabilization, medications that do not lead to weight gain, and better treatment for depression that does not respond to current treatments (Baldessarini, Perry & Pike, 2008).
A diagnosis of BPD can be expensive for the patient and third-party payers. Hassan and Lage (2009) report that caregiving costs associated with BPD are nearly $5 billion a year, while lost productivity within the family as a result of relapses was $6.2 billion a year (Hassan & Lage, 2009). Thus, controlling relapses via medication is important for BPD patients. The medications used to treat BPD can be expensive. Many of the newer BPD medications are brand-name rather than generic, making them more expensive. In addition, some BPD medications such as some of the antipsychotics also require regular laboratory tests as part of the dosage monitoring process, making them even more expensive for patients (Sansone & Sanson, 2011). Qiu, Fu, Liu, and Chirstiensen (2010), however, investigated the actual annual medical expenses of BPD patients in one state (North Carolina) using Medicaid data. They found that prescribing atypical antipsychotic medications alone had higher medication costs, but lower overall medical care costs than those receiving only a mood stabilizer, making the overall cost of those two options approximately equivalent. The most expensive treatment option from a third-party payer perspective was that of combining antipsychotic medications with a mood stabilizer (Qiu et al., 2010).
Patients report that the greatest frustrations of having BPD are mood swings, depression, the need to take medication daily, the stigma of being “mentally ill,” difficulty with interpersonal relationships, and medication side effects (Baldessarini, Perry & Pike, 2008). The result of these frustrations with their condition can lead some patients to be non-compliant with their treatment program.
The questions raised by these issues regarding BPD result in some serious treatment questions, specifically:
What reasons do patients cite for not being compliant with their BPD medication regimens?
The objective behind this research question is to better understand noncompliance from the patient’s perspective, and thus have an understanding of what interventions may be most useful in improving patient compliance. The approach that will be taken is one of a qualitative study to determine patient rationales for their noncompliance. The issue is of particular importance in an advanced nursing practice since understanding why patients do not comply with their medications directly impacts providing quality patient care. If nurses can better understand the rationales patients have for not taking their medications, strategies can be developed to overcome these barriers to proper compliance with the patients’ medication regimens.
The basis for this study is Orem’s self-care deficit nursing theory. This theory assumes that patients intrinsically want to care for themselves, and thus should be assisted to do as much self-care as possible (Grando, 2005).As this theory applies to the current research study described in this paper, such self-care extends to BPD patients taking the correct dosages of medications at appropriate times on their own rather than under immediate supervision. Since BPD medication is not a cure but a method of managing the condition, it is unrealistic to have daily medication dosages controlled by other than the patient. Despite this, however, it is the case that many BPD patients are non-compliant on their medications. Understanding this phenomenon can assist with developing interventions or techniques that increase the degree of self-care with respect to their medications that BPD patients can successfully implement themselves.
Significance of Study
Noncompliance with medications is a serious problem in treating bipolar disorders. As many as 39% of patients in one study admitted missing at least one dose of their psychotropic medication in the previous 10 days, and one out of five missed at least one full day of medication (Baldessarini, Perry & Pike, 2008). Furthermore, one out of forty in this nationwide study admitted not taking any of their medications during the 10 days prior to the survey (Baldessarini, Perry & Pike, 2008). Thus, a better understanding of reasons patients have for not complying with their treatment regimens is essential to better understand what strategies may be used to improve BPD patient compliance with their prescribed medication regimens.
When patients do not comply with their treatment programs, they run serious risks to their health and well-being. Patients who are compliant at least 75% of the time with their medication treatment program have only 63% of the likelihood of being rehospitalized (0.60 compared to 0.948) for any reason and about 61% of the likelihood of being rehospitalitized (0.608 compared to 0.992) for mental health reasons. Thus, compliance is a significant reduction in risk of hospitalization for BPD patients (Hassan & Lage, 2009).
From the patient’s perspective, life with BPD is challenging because it impacts their entire life (Rusner et al., 2009). Rusner et al (2009) recommend a holistic view of BPD patients, recognizing that such patients have an ongoing struggle to come to terms with their lives, and live with a persistent anxiety that their symptoms will return (Rusner et al., 2009).
Patients with BPD often report a variety of issues, particularly when they are first diagnosed with the disorder. Of particular importance to these new patients were the issues of medication side effects, symptoms of their disorder, reactions (of themselves and their family and friends) to the diagnosis, uncertainty about the course of their future, and the potential stigma of being labeled with a “mental disease” (Proudfoot et al., 2009).
Noncompliance with medications is a serious problem in treating bipolar disorders. Baldessarini, Perry, and Pike (2008) studied the factors associated with bipolar patients lack of adherence to medication regimens to determine what risk factors determined such compliance or noncompliance. Their study considered 429 bipolar patients recruited from a nationwide survey, plus responses from psychiatrists experienced with and currently treating bipolar patients. After analyzing the demographics of the respondent cases with their responses in terms of medication compliance, Baldessarini et al. noted that noncompliance was associated with complex treatment regimens involving multiple psychoactive medications or requiring multiple doses per day. This was of special relevance for BPD patients since they frequently are placed on such complex or multiple-medication regimens (Baldessarini, Perry & Pike, 2008). Of additional interest was the difference between patient self-reporting of compliance and psychiatrist perception of compliance. For example, about one patient in three reported missing at least one dose of medication in the previous ten days, but psychiatrists considered only one out of six of these patients (i.e., about one out of sixteen of the total population) as being “noncompliant” with their medications; the study authors suggest that psychiatrists considered missing only one dose in ten days as not clinically significant, and thus not necessarily an indication of noncompliance (Baldessarini, Perry & Pike, 2008). Yet more than half of the patients (57.2%) reported missing two or more doses in the previous ten days and one out of five reported missing at least one complete day’s medications in the previous ten days (Baldessarini, Perry & Pike, 2008). While patient compliance numbers were based on self-reports, underreporting of such failures to take prescribed medications seems more likely than overreporting (Baldessarini, Perry & Pike, 2008). Also, nearly one-third (32.9%) reported that at some point in the past they had discontinued all psychotropic medications without informing their physician (Baldessarini, Perry & Pike, 2008). When asked about their reasons for such self-initiated discontinuation of treatment, the most common factors raised were that they didn’t need it any longer, they no longer wanted to take it, they didn’t like the side effects, and they were feeling better at the time they discontinued the treatment (Baldessarini, Perry & Pike, 2008). These authors also noted that many of the same patients who reported major defaulting on their medications in the past, were the ones also reporting minor defaulting on their medications in the past ten days (about one-third of the total sample in each case, 32.9% with prior discontinuations, and 33.8% with current minor defaults).
Depending on setting, the compliance rate with medication regimens can be even worse. Pusey-Murray, et al. (2010) reported that in Jamaica, the noncompliance rate for mentally ill patients in general is as high as 65%. In this culture, men were more likely to be compliant, as were those with better family support (primarily males), and those with greater insightfulness (primarily females). Most of those who were not compliant claimed that outside forces were a great controller of their lives and their disorder (Pusey-Murray, et al., 2010).
A separate assessment of medication compliance reported by Basco & Smith (2009), noted that a study of Medicaid prescription refills corroborated the high rate of noncompliance in BPD patients. They reported that about one-third of Medicaid patients did not refill their prescriptions regularly and almost half (48%) of veterans with BPD were similarly inconsistent in their prescription refills (Basco & Smith, 2009). Other studies have shown long-term noncompliance rates in BPD patients as high as 80% and between 8% and 13% reported taking their medication on completely adherent basis only about one-third of the time. This study was particularly noteworthy in that it confirmed patient self-reports with checks on expected blood plasma levels and found good consistency between patient self-reports of noncompliance with actual blood levels of the medications prescribed (33% vs. 36%).
Sajatovic et al. (2006) evaluated treatment adherence when antipsychotic medications werre used with BPD patients in addition to antidepressants. This study investigated compliance in veterans with BPD and noted that just under half (45%, 32,993) were prescribed such antipsychotics. Noncompliant patients tended to be both younger and to have significant psychiatric comorbidities (substance abuse, for example, or post-traumatic stress disorder (PTSD)). Only a little over half (51.9%) were fully compliant with their medication regimen with respect to the antipsychotics. In this study, being younger, being in a minority, having substance abuse comorbidity, and being homeless all were factors increasing the likelihood of noncompliance (Sajatovic et al., 2006).
Some studies have identified risk factors that are associated with patient noncompliance with BPD medications. Comorbid conditions often include obsessive-compulsive disorder and alcohol dependence; Additonal risk factors include,not being in full remission of BPD symptoms; treatment side effects, cognitive impairment or autonomic functioning issues; recent episode of mania or hypomania; frustration with medication side effects; having more affective symptoms, and being younger rather than older (Baldessarini, Perry & Pike, 2008). This study also noted that factors that were not associated with compliance or noncompliance included sex, ethnicity, whether the patient had BPD-I or BPD-II, or the type of treatment (Baldessarini, Perry & Pike, 2008).
Basco and Smith (2009) assessed the issue of what type of BPD patient are likely to be noncompliant with medications.. These authors noted that the most consistent characteristic is that patients with significant psychiatric comorbidities—which affects up to 60% of BPD patients—are most likely to be noncompliant.
Berk, Berk, and Castle (2004) noted that some factors tend to improve compliance in BPD patients. These authors summarized these factors as being older rather than younger, being married, having more education, having social support, having others favorably respond to their treatment plan, recognition of the threat of illness and benefits of treatment, understanding the negative consequences of noncompliance, and being dependent on others (i.e., others control their medication schedule) (Berk et al., 2004).
Lehner et al. (2007) looked at the compliance rates of outpatients with a variety of serious mental illnesses (not just BPD) based on a set of eleven different interventions. These included assertive case management; behavior therapy; coerced treatment; psychoeducation; and others. After an intense review of the literature, Lehner et al. concluded that assertive case management and behavior therapy were supported by the evidence. Psychoeducation was not supported by available evidence. Other interventions for which the evidence was inconclusive included an administrative-consultative team; client-focused case management; coerced treatment; consumer-employee approaches; dual diagnosis treatments; outreach referrals; payeeship; and structured educational support (Lehner et al., 2007).
Puri and Gilmore (2011) also suggested a series of interventions that might assist in increasing compliance, though their assessment was that the proposed interventions were not strongly evidence based. Their list of suggestions included reminders to patients about their medications, positive reinforcement, counseling, family interventions, supportive care, self-monitoring, and adding psychological therapy to the treatment regimen (Puri & Gilmore, 2011). The efficacy of these suggestions was not well supported by evidenc.e The authors did note key signposts that indicated a relapse on the part of a BPD patient. These signals included needing less sleep, higher activity levels, irritability, poor concentration, and jumping from topic to topic in conversation as signaling an imminent manic episode. Depressive signals included lower energy levels, extremely early morning waking, believing that they are worthless or useless or other suicidal thoughts (Puri & Gilmore, 2011). The presence of such signals implies the need for immediate consideration by a mental health professional.
BPD patients demonstrate a clear impairment in cognitive functioning, with approximately one-third showing significant disturbances neuropsychologically (Vieta & Martinez-Aran, 2008). While the prevalence of such disturbances is somewhat less than in schizophrenics, BPD patients demonstrate a similar pattern, and show dysfunctions in fluency of thought, verbal memory, attention, and executive functions (Vieta & Martinez-Aran, 2008). These deficits exist in BPD-II patients as well as BPD-I patients, though the symptoms tend to be less severe (Vieta & Martinez-Aran, 2008). Of these, the greatest impact on patients’ occupations and social lives may derive from problems with verbal memory (Vieta & Martinez-Aran, 2008). There may also be a genetic pattern that predicts the severity of the illness (Vieta & Martinez-Aran, 2008).
Basco & Smith (2009) reported that there are issues in BPD patients that interfere with being fully compliant with medication regimens. Specifically, they cite studies that indicate obstacles include denial; low insight into the patient’s need for medication; lack of trust in healthcare providers, staff, or facility; disagreements with the physician on the treatment plan; receiving competing medical advice from multiple sources; and side effects of the medication (Basco & Smith, 2009) Other issues are that studies have shown that BPD patients—even while under treatment—have cognitive reasoning problems and memory loss problems; this may lead them to use poor reasoning to determine when and whether to take their medications (Basco & Smith, 2009). These authors promote a three-pronged plan for improving compliance of improved patient education on their condition, a memory enhancement program to address memory issues, and exercises designed to improve patient decision-making (Basco & Smith, 2009).
In a brief letter, Benjamin (2007) cited a case of an athlete on a specific regimen for his BPD and noted that a critical issue for this particular patient was a treatment program that did not interfere with his ability to perform athletically, since that was an important part of his self-identity (Benjamin, 2007). Given the propensity of BPD treatments to generate weight gain, this implies that consideration of maintaining athletic skills may be an important aspect of maintaining treatment compliance at a high level. Benjamin (2007) suggested that taking patient emotional needs into consideration would improve patient compliance.
A cross-sectional study is like a snapshot in that it measures the state of the study group at a particular moment in time. The cross-sectional study design was chosen to obtain an understanding of the current typical types of rationales that noncompliant BPD patients offer when asked to explain why they do not take their medications as prescribed.
Qualitative research focuses on the context, conversation and interpretation of the study participants with respect to the research question under consideration. This research design is suitable for a study that has small sample size. A combination of interviews, document reviews, and observation are the primary tools for gathering data for this research design (Saunders et al., 2007).
Qualitative design was used in this study because it allowed open-ended conversation with the study participants in a way that more quantitative methods do not permit and because it is appropriate for the small sample size of this study. In this study, interviews were the primary tool used used to determine patient rationales for their compliance or lack of compliance for their prescribed medication regimens. Document reviews provided a confirmation of what medications and dosages the patients were supposed to be taking, thus determining whether the patients were compliant or not. Finally, observations were used only on a very limited basis in this study.
This study used two simple questions for the participants: “Are you taking your medications as prescribed?” and, if that answer is no, “What is stopping you from taking the medication as it was prescribed?”.
As part of the researcher’s job function at this clinic, patients are asked about their compliance with their treatment regimens. The researcher recorded the number of such patients treated in the course of 30 days, whether they said they had followed their treatment plan since their last visit, and if not, the reasons they cited for being noncompliant with their treatment plan. All information was recorded without identifying information about the patient—only their claims of compliance or noncompliance and their stated reasons for noncompliance were recorded. Since patients generally do not visit the clinic more often than once a month, no duplicate patients were recorded in this process
Human Subject Issues
When working with human subjects, ethical issues are important considerations. Generally speaking, with certain exceptions, human participants need to be given informed consent about their participation in any experiment. However, there are exceptions to this rule. In the case of this study, no intervention was performed on any subject; this study was one of gathering information rather than testing an intervention. Furthermore, the questions asked of the participants were those which were part of a normal appointment process with BPD patients—no additional information was solicited beyond that which would normally be asked in a regular clinical appointment. Aside from basic demographic detail (male or female, and age bracket of the patient), only two pieces of information were recorded: Did the patients claim compliance with their medication regimens, and, if not, what reason was presented for non-compliance. No identifying information about the patient, even in an encoded form, was associated with that data. In a study design of this sort, informed consent and IRB approval is not required.
Of the 26 patients seen with BPD during this four-week period, 19 self-reported that they were not perfectly compliant with their medication protocol. Table 1,Table 2, and Table 3 provides general demographic information and compliance rates by gender and age.
Table 1. Demographic Information about Participants.
Table 2. Noncompliance Rates for Participants by Gender.
|Males||4 (28.5%)||11 (71.5%)||15|
|Females||3 (27.3%)||8 (72.7%)||11|
|Total||7 (26.9%)||19 (73.1%)||26|
Table 3. Noncompliance Rates for Participants by Age Bracket.
|Age (18-25)||4 (25.0%)||12 (75.0%)||16|
|Age (25-50)||2 (22.2%)||7 (77.8%)||9|
|Age (50+)||1 (100%)||0 (0%)||1|
Of the noncompliant patients, nine missed one dose during the period, and eleven missed at least one full day of medication. (Typical doses for these clients required medication twice a day, but three are on only one medication dose per day, one of whom was noncompliant; this individual is counted as both “missed one dose per day” and “missed one day of medication”.) Six individuals missed two or more full days of medication. Table 4 defines the noncompliant patient data.
Of those who stated that they missed at least one dose of their medications, various reasons for their lack of compliance were provided. Table 5 presents the reasons offered, along with the frequency of those reasons.
Table 4. Noncompliant Information.
|Missed 1 dose||9|
|Missed only 1 day||4|
|Missed 2 or more days||7|
*Note that one patient missed one dose, where that was one complete day of medication for that patient. That patient is counted in both “missed one day” and “missed 1 dose”; a total of 19 individuals were noncompliant during this period.
Table 5. Reasons Given for Noncompliance.*
|Someone stole my medication||1|
|I lost the prescription/it was destroyed accidentally||2|
|I dropped the pills / they were ruined somehow.||1|
|I can’t afford the medication.||3|
|I didn’t have transportation to the drug store.||1|
|I left my pills at home/didn’t have them with me.||3|
|I don’t like the way they make me feel.||3|
|Someone told me they weren’t good for me.||2|
|I don’t like taking pills.||3|
|I lost my pills after I took some of them.||1|
*Note that some patients gave multiple reasons for noncompliance; thus the frequencies add to more than the number of individuals.
As can be seen in the results of this study, in this small sample, there was no significant difference between the compliance rate of males and females; the compliance rate for each gender was about the same as for the total group. In addition, there was no significant difference in compliance rates by age group seen in this study, which is not consistent with other reports (Sajatovic et al., 2006; Baldessarini, Perry & Pike, 2008). The noncompliance rate overall is substantially higher than reported in other studies, with about 3 out of 4 patients reporting some degree of noncompliance.
About half the noncompliant patients in this group (9 out of 19) missed only one dose; for one of these patients this constituted their complete daily prescribed medication dosage. About one-fifth of the patients missed one full day out of the 28. And about 37% of the noncompliant patients and 27% of all patients in the cohort missed at least two full days of medication.
These results are somewhat higher than reported in other studies. Although specifics of social demographics of these patients are not available, this clinic is located in a lower-income, urban community with highly mixed ethnicity. While ethnicity has not been shown to have an significant impact on compliance rates, the lower income/lower educational level of this community, plus that some of the patients are homeless or near homeless may help explain this high level of noncompliance.
In terms of the reasons provided by the patients for their noncompliance with their medication regimen, the number one reason offered was that the patient simply forgot (6) to take the medication when it was due.
Other top reasons offered by this group were that the patient could not afford the prescription (3) or had no transportation to the pharmacy to get the prescription filled (1). The community served by this clinic is also a fairly high crime area, so the reasons stated of having prescriptions or medications stolen are unfortunately plausible (1).
Another key set of reasons for not being compliant with the medication program involved the patients’ dislike of the side effects of their medication (3), dislike of taking pills (3) or they had been told by a family member or friend that the medications were not “good for them” (2). The last set of reasons, i.e., that a family member or friend told them not to take their medication, revealed what may be greater trust in the medical opinions of those family or friends than in the medical judgment of the clinic’s professional staff.
Another set of reasons for noncompliance involved losing the pills (1) or the prescription (2), or simply not having the medication available to take when it was due (3), i.e., leaving it at home when the patient was going to be away. These reasons may reflect in some cases the cognitive impairment that is common in BPD patients.
As with any qualitative approach, these responses develop a set of themes. In this case, there are several key themes that emerge from this study. First is the theme of general forgetfulness on the part of the patient. This may reflect issues of lack of attention or lack of organization in the patients’ lives.
A second theme is that of lack of resources or loss of resources to enable the patient to obtain the medication and keep it with them. This includes lack of money to pay for the medicines, lack of transportation to get them, and an inability to keep the medication secure from theft by others.
A third theme is the patients’ dislike of the impact of the medication or an unwillingness to take medication on a daily basis or information from family or friends that the medicine is not beneficial to the patients’ health.
A final theme derives from the patients simply not keeping the medications available when and where they need them, either by misplacing them or by leaving them someplace other than where they needed the pills to be. It is possible that these responses reflect some degree of the cognitive impairment that is not uncommon in BPD patients.
The key limitation of this study is that it is very small scale with only 26 participants. It is also limited by the specific clinical context in which it was taken. It is unclear how generalizable these results are to a broader context. Thus any follow-up study should be much larger scale and address a broader context than this one location.
This study considered the reasons BPD patients given for being noncompliant with their medication in a low income urban clinic context. Data was collected from patients presenting for follow-up visits at the clinic over a four-week period in January 2012. The patients were asked if they were compliant, and if not, why not. Four key themes emerged from this brief, small-scale, qualitative study. These themes explained the noncompliance on issues of general forgetfulness; lack of resources; mistrust in the medicine or the clinicians; and in cognitive impairment issues that are correlated with BPD.
In terms of future research on this topic, the most important issue is to do a larger-scale study covering a broader variety of patients. The participants in this study were fairly homogeneous in terms of income level and daily challenges. A future larger-scale study of this topic is needed to address these themes in more detail and to confirm whether these themes reflect valid understanding of the reasons patients have for not taking medications as prescribed. In addition, once the reasons for non-compliance are better understood, this could be followed up by designing interventions directed specifically at certain reasons for non-compliance. For example, for patients who claim “I forgot” as a reason for missing doses, specific cognitive behavioral training might be tested, perhaps in comparison with an clinic-based reminder system to determine whether either of those would improve compliance rates over the current procedures.
Even this small-scale study raises issues that clinicians can use to help increase sensitivity to issues patients have that may prevent them from being compliant with their prescribed medication. For example, issues of forgetfulness might be addressed by assisting the patient with memory enhancing exercises. Issues of lack of resources to obtain medications are more challenging, but working with social services or other community resources to ensure all patients can get the medications they need. Issues of mistrust of the medication or dislike of the medication can be addressed in part through patient education or by adjusting the medication regimen to something that is more acceptable to the patient. Finally cognitive impairment issues can be addressed through such techniques as cognitive behavior therapies to address the problems that make patients noncompliant.
Baldessarini, R. J., Perry, R., Pike, J. (2008). Factors associated with treatment nonadherence among U.S. bipolar disorder patients. Human Psychopharmacology: Clinical & Experimental, 23 (2), 95-105.
Baldessarini, R. J., Vieta, E., Calabrese, J. R., Tohen, M., Bowden, C. L. (2010). Bipolar depression: Overview and commentary. Harvard Review of Psychiatry, 18 (3), 143-157.
Basco, M. R., Smith, J. (2009). Faulty decision-making: Impact on treatment adherence in bipolar disorder. Primary Psychiatry, 16 (8), 53-58.
Benjamin, A. B. (2007). A unique consideration regarding medication compliance for bipolar affective disorder: Exercise performance. Bipolar Disorders, 9 (8), 928-929.
Berk, M., Berk, L., Castle, D. (2004). A collaborative approach to the treatment alliance in bipolar disorder. Bipolar Disorders, 6 (6), 504-518.
Depression and Bipolar Support Alliance (DBSA). (2011). Signs and symptoms of mood disorders. Depression and Bipolar Support Alliance Web site. Retrieved from: http://www.dbsalliance.org
Grando, V. T. (2005). A self-care deficit nursing theory practice model for advanced practice psychiatric/mental health nursing. Self-Care, Depending-Care & Nursing, 13 (1),4-8.
Hassan, M., Lage, M. J. (2009). Risk of rehospitalization among bipolar disorder patients who are nonadherent to antipsychotic therapy after hospital discharge. American Journal of Health System Pharmacy, 66 (4), 358-365.
Lehner, R. K., Dopke, C. A., Cohen, K., Edstrom, K., Maslar, m., Slagg, N. B., Yohanna, d. (2007). Outpatient treatment adherence and serious mental illness: A reviewof interventions. American Journal of Psychiatric Rehabilitation, 10 (4), 245-274.
Proudfoot, J. G., Parker, G. B., Benoit, M. Manicavasagar, V., Smith, M. Gayed, A. (2009). What happens after diagnosis? Understanding the experiences of patients with newly-diagnosed bipolar disorder. Health Expectations, 12 (2), 120-129.
Puri, R., Gilmore, M. (2011). Understanding bipolar disorder and the role of support workers. British Journal of Healthcare Assistants, 5 (8), 372-376.
Pusey-Murray, A. E., Bourne, P. A., warren, S., LaGrenade, J., Charles, C. A. (2010). Medication compliance among medically ill patients in public clinics in Kingston and St. Andrew, Jamaica. Journal of Biomedical Science & Engineering, 3 (6), 602-611.
Qiu, Y, Fu, A. Z. Liu, G. G., Chrisensen, D. B. (2010). Healthcare costs of atypical antipsychotic use for patients with biploar disorder in a Medicaid programme. Applied Health Economics and Health Policy, 8 (3), 167-177.
Rusner, M., Carlsson, G., Brunt, D., Nystrom, M. (2009). Extra dimensions in all aspects of life—the meaning of life with bipolar disorder. International Journal of Qualitative Studies on Health & Well-Being, 4 (3), 159-169.
Sajatovic, M., Valenstein, M., Blow, F. C., Ganoczy, D., Ignacio, R. V. (2006). Treatment adherence with antipsychotic medications in bipolar disorder. Bipolar Disorders, 8 (3), 232-241.
Sansone, R. A., Sansone, L. A. (2011). Manaaging bipolar disorder in the primary care setting: A perspective for mental health professionals. Innovations in Clinical Neurosciences, 8 (10), 10-13.
Saunders, M., Lewis, P. & Thornhill, A. (2007), Research methods for business students. 4thed. Essex: Pearson Education Limited.
Vieta, E., Martinez-Aran, A. (2008). Cognitive functioning in bipolar disorder. Actas Espanolas de Psiquiatrioa, Supplement 1, 36, 58-60.