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Table of Contents
Year : 2021  |  Volume : 18  |  Issue : 1  |  Page : 55-60

Efficacy of psychoeducation to improve medication adherence among bipolar affective disorder: A systematic review

1 Faculty, Department of Mental Health Nursing, College of Nursing, AIIMS, Jodhpur, Rajasthan, India
2 Professor and HoD, Department of Mental Health Nursing, Dharwad, Institute of Mental Health and Neurosciences, Dharwad, Karnataka, India

Date of Submission24-Dec-2020
Date of Decision20-Jan-2021
Date of Acceptance21-Jan-2021
Date of Web Publication17-Jun-2021

Correspondence Address:
Mrs. Jaishri
Department Mental Health Nursing, College of Nursing, AIIMS, Jodhpur, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/iopn.iopn_61_20

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Bipolar affective disorder is a chronic disorder with evidence of lack of medication adherence, a high relapse rate, significant general disability and burden of psychosocial impairment that often persists for long time. Therefore, Enhancement of treatment adherence in bipolar disorder is a necessary and promising management component as an adjunct to pharmacotherapy. The objective of this systematic review is to determine the effects of psycho-educational interventions on medication adherence among BPAD patients. An electronic literature search was performed using PubMed, cochrane library and google scholar other sources like reports, thesis, or dissertation from May 2012 to March 2020. Search was focused on full text articles available in english, studies had been conducted among adult patients, quantitative RCTs, experimental studies on individual and group psychoeducational intervention. The present review included 10 experimental studies published online. The most literature supports the usefulness psychoeducation on medication adherence in bipolar affective disorder.

Keywords: Bipolar affective disorder, medication adherence, psychoeducation

How to cite this article:
Jaishri, Rentala S. Efficacy of psychoeducation to improve medication adherence among bipolar affective disorder: A systematic review. Indian J Psy Nsg 2021;18:55-60

How to cite this URL:
Jaishri, Rentala S. Efficacy of psychoeducation to improve medication adherence among bipolar affective disorder: A systematic review. Indian J Psy Nsg [serial online] 2021 [cited 2021 Nov 30];18:55-60. Available from: https://www.ijpn.in/text.asp?2021/18/1/55/318675

  Introduction Top

The maxim, “there is no health without mental health” underlines the fact that mental health is an integral and essential component of health.[1] Mental disorders are among the leading causes of nonfatal disease burden in India and across the world.[2] In 2017 a study estimates that 792 million people lived with a mental health disorder. This is slightly more than one in ten people globally (10.7%).[3] The prevalence of bipolar disorder across the world varies from 0.3%–1.2%. Globally it is estimated that 46 million people in the world had bipolar disorder in 2017 with 52 and 48 percent being female and male, respectively. In India one in seven is affected by a mental disorder and the overall weighted prevalence for mental morbidity was 13.7% lifetime and 10.6% current mental morbidity (National Mental Health Survey of India 2015–2016).[1] In India the prevalence of (bipolar affective disorder [BPAD]) is 0.4%–0.5%, 1-year prevalence is 0.5%–1.4% and lifetime prevalence 2.6%–7.8% and the prevalence of affective disorder ranges from 0.51 per thousand population to 20.78 per thousand population (Department of Psychiatry, SVS M C, Telangana, India 2018).[4]

Approximately 50% of bipolar patients do not recover from acute manic episode within 1 year and only 25% achieve full recovery of function. Rates of recurrence average 40%–60% in 1–2 years even when patient undergo pharmacotherapy. Patients spend as much as 47% of their lives in symptomatic states, especially depressive states.[5] For example, a large data base study in the United States of America showed that approximately half of the patients with BD were nonadherent with lithium and maintenance medications over a 12-month period.[6] Factors associated with nonadherence include adverse effects of medication, complex medication regimen, negative patient attitudes to medication, poor insight, lack of social support, and substance misuse.[8] Hence, BPAD patients suffer with persisting symptoms, cognitive problems, decrease in quality of life, frequent episodes, limited social support and poor social functioning and also comorbid psychiatric disorders, such as personality disorders and substance abuse are common.[7]

The management of BPAD with medication is first-line treatment, intended at a treating acute, chronic episode, reducing the severity, frequency of future episodes and improving psychosocial functioning between episodes. Even though significant advancement in the pharmacological treatment of bipolar disorder, most bipolar patients cannot be maintained on drug treatments alone. Therefore, various researchers have shown that nonpharmacological therapeutic approaches like Interpersonal and social rhythm therapy, family-focused therapy, and cognitive-behavioral therapy are effective for treatment of bipolar disorder.[8] One of these methods is psychoeducation, it is designed to provide information about their disorder, its treatment and condition that causes stress to person. Better understanding of condition leads to feeling to control and results in reduced stress associated with the condition. An education about their condition is more likely to make people actively participate in their self-management and relapse prevention. This tends to brings about the individual self-efficacy and the accompanying benefits from other psychotherapies and medications. Psychoeducation is highly effective in preventing relapse, identification of early warring sings, and treatment adherence.[9],[10],[11] Consequently, researcher would like to see the collective effect of psychoeducation on medication adherence through the studies conducted in India and western setting.

Search methods for identification of studies

Studies were searched using search engines, from the main electronic databases PubMed, Cochrane library, Google Scholar, and other sources such as reports, thesis, or dissertation. The database was searched using the search terms “bipolar,” “psychoeducation,” “group psychoeducation,” “individual psychoeducation,” “compliance,” “medication adherence.”

Eligibility criteria

Studies were included in the systematic review, if they fulfill the following eligibility criteria. The criteria were as follows:

Inclusion criteria

  • Full text or abstracts available in English
  • Studies had been conducted among adult patients (18 years and older)
  • Quantitative Randomized controlled trials (RCTs), experimental studies on psychoeducational intervention on medication adherence with BPAD patients
  • Individual and group psychoeducational studies
  • Online and offline psychoeducational studies.

Exclusion criteria

  • Studies focused only on bipolar disorder (symptom, outcome, course)
  • Studies focused on incidence and prevalence BD
  • Studies focused factor influence on non-adherence to medication.

  Results Top

The search returned 1977 papers, after the deletion of duplicates 1517, 460 scientific papers remained for further assessment. After assessing these papers on the basis of title and abstract and setting, the remaining papers were [Figure 1]. The present systematic review included 6 (60%) RCT, 4 (40%) quasi-experimental studies [Table 1]. In these 3 individuals and 7 group psychoeducational studies, among these 70% studies had follow-up. It is noted that, individual psychoeducation, group psychoeducation with follow up reinforcement intervention appear to be more effective for medication adherence. This suggests that patients with bipolar disorder might benefit from psychoeducation through recognition of symptoms, making patients to understand treatment strategies, develop insights about their illness within a supportive setting, increased competence in self-management techniques and enhanced relationships with family members, caregivers and professionals.
Table 1: Studies focused on psychoeducational intervention on medication adherence

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Figure 1: Diagrammatic presentation of the selection process of studies for systematic review

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  Discussion Top

Summary of main result

Most of the existing research evidence on psychoeducational management of bipolar disorder available at western population and only few available in Indian population. The Indian (30%) and western (70%) studies are included for critical appraisal of this study. Evidence from two Indian RCTs of Patel et al. and Mishra et al. studies shown that clinical efficacy of psychoeducation on medication adherence and QOL for BPAD, whereas Sara et al. study findings is contradicting, that the psychoeducation intervention does not produce any significant improvement in adherence to treatment, though the study showed all participants in experimental group had 100% adherence. Hence, the psycho education can be incorporated along with other modalities of treatment for person with BPAD.

India and western studies individual and group psychoeducation compared with standard treatment such as pharmacotherapy, treatment as usual, placebo with pharmacotherapy is effective in terms of expected outcome. The results communicated that, there was improvement in the medication adherence thereby decreasing negative consequences of nonadherence. More these studies also showed there was an improvement in knowledge and attitude towards disease, QOL, global functioning, and reduced relapse rate, length of hospitalization and readmission.

In follow-up studies, Mishra et al. gave a two reminder (a week before and day before the follow-up by telephone) and on the day of follow up in the test group who is not adherent to medication were provided patient and carers education session. In this Mishra et al. and Patel et al., have representing that minimum 2 months of follow up is required for good improvement in medication adherence. Further Bahredar et al. the mean score of the psycho-educational group in the second assessment was a little lower than that in the first assessment at follow-up, this difference was not statistically significant (P = 0.72), but the long-term study of Javadpour et al. shows that patients in the intervention group had a statistically enhancement in medication compliance at P = 0.008 during follow up session. This difference result found because the intervention is continued during follow up period, using scheduled monthly telephone contact to remind the patients for their next appointment. Each telephone contact consisted of a 10-min question and answer session thereby patient's queries were thoroughly responded for subsequent 18 months.

More Pozza et al.'s study hypothesized that the combination of standard group PE and smartphone-based PE can offer a more powerful option to improve the patient's self-monitoring and self-management processes, which can increase adherence to the prescribed treatment. Therefore, as mentioned in few above studies, present study suggests that not education at one time alone is effective, it need continuous reinforcement during the follow-up with text message and psychoeducational/motivational content to have expected outcome.

Quality of the evidence and intervention

The quality of RCT studies assessed with JADAD scale, in many studies mentioned about randomization but only few studies mentioned their appropriate method of randomization and blinding. Here not able to assess potential publication bias of the article. In all study psychoeducation used as an intervention to compare with standard treatment. In most of study sample were selected from outpatient department with age ranges from 18 to 65 years. The content of psychoeducation in most of the studies related to bipolar disorder illness awareness, role of medication, managing mood symptoms and side effects of medication, dealing with stress, etc., Style of intervention delivered was by using flip charts, poster, leaf lets, and handbooks prepared by investigator. The sessions of interventions ranged from 8 to 10 with a 1-week interval for minimum 45 min to 90 min for each session. The Sara L et al. had 4 sessions with 30 min of psychoeducation showed no significance differences, but more study findings show significance differences, which had maximum sessions (8–10) with >45 min duration, 70% studies had follow-up among that 30% used reinforcement. Therefore, the present study suggests that frequency and duration should be adequate and reinforcement at follow-up period for efficacy of medication adherence.

Adherence measures

Most of the study used medication adherence rating scale. 30% Indian studies do not explain about validity and reliability of the tool whereas 60% western studies explained in detail about it. Few studies like George et al. study medication adherence was checked by counting the tablets and checking dairy at the time of follow-up. The adherence rate was calculated based on the tablets prescribed for a period and the tablets missed by the participant. However, subjective measurement and most pill counts can clearly be altered by the patient. Which are known to overestimate adherence, since inability to measure adherence accurately and reliably. Therefore, it is necessary to use more objective measures such as physiological parameters and pharmacy records to observe medication adherence. It is a productive step forward in the field of adherence research, as it will lead to further valid and reliable results.

  Conclusion Top

Bipolar disorder is a complex illness that requires a comprehensive and long-term management includes combines pharmacotherapy, psychological management and life style modification. The present review found that psycho-education is promising management component along with pharmacotherapy and it is one of the easiest, flexible, and cost-effective intervention to enhance treatment adherence. It should be made routine practice in health care service at inpatient as well as outpatient department. Mobile-based psychoeducation and follow up with reinforcement can be provided for long-term management of medication adherence.[20]


It is with great pleasure and deep satisfaction I owe my sense of gratitude to many around me who contributed towards the successful completion of systemic review, Dr. G. Balamurugan, Registrar (Administration), Ramaiah Institute of Nursing Education and Research, Bangalore, Dr. Deviga T, Mrs. Mohana Sundari, and Mrs. Nancy Kurien Tutor/Clinical instructor at all India institute of medical sciences, Jodhpur.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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