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World Journal of
Psychiatry
World J Psychiatr 2018 November 9; 8(5): 114-136
EDITORIAL
114 Treatment alliance and adherence in bipolar disorder
Chakrabarti S
REVIEW
125 Women who suffer from schizophrenia: Critical issues
Seeman MV
ABOUT COVER Editorial Board Member of World Journal of Psychiatry , Vicki A Nejtek, PhD,
Associate Professor, Director of Co-Occurring Disorders Research, University
of North Texas Health Science Center, Texas College of Osteopathic Medicine,
Taxs, TX 76107-266, United States
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EDITORIAL
Subho Chakrabarti
Subho Chakrabarti, Department of Psychiatry, Postgraduate has its origins in psychotherapy, but has also been
Institute of Medical Education and Research (PGIMER), influenced by several other constructs such as patient-
Chandigarh 160012, India centred care (PCC) and shared decision-making (SDM).
Similarly, there has been a shift in conceptualization
ORCID number: Subho Chakrabarti (0000-0001-6023-2194). of treatment-adherence in psychiatric disorders
including bipolar disorder (BD) from illness-centred and
Author contributions: Chakrabarti S conceived the study and
drafted the manuscript and approved the final version of the clinician-centred approaches to patient-centred ones.
article. Moreover, the traditional compliance based models
are being replaced by those based on concordance
Conflict-of-interest statement: The author has no conflict of between clinicians and patients. Newer theories of
interest to declare. adherence in BD place considerable emphasis on
patient related factors and the clinician patient alliance
Open-Access: This article is an open-access article which was is considered to be one of the principal determinants of
selected by an in-house editor and fully peer-reviewed by external treatment-adherence in BD. Likewise, current notions
reviewers. It is distributed in accordance with the Creative of treatment alliance in BD also stress the importance
Commons Attribution Non Commercial (CC BY-NC 4.0) license,
of equal and collaborative relationships, sensitivity to
which permits others to distribute, remix, adapt, build upon this
work non-commercially, and license their derivative works on patients’ viewpoints, sharing of knowledge, and mutual
different terms, provided the original work is properly cited and responsibility and agreement regarding decisions
the use is non-commercial. See: http://creativecommons.org/ related to treatment. Accumulated evidence from
licenses/by-nc/4.0/ quantitative research, descriptive accounts, qualitative
studies and trials of psychosocial interventions indicates
Manuscript source: Invited manuscript that efficacious treatment alliances have a positive
influence on adherence in BD. Then again, research
Correspondence to: Subho Chakrabarti, MD, Professor, on the alliance-adherence link in BD lags behind the
Psychiatry, Department of Psychiatry, Postgraduate Institute existing literature on the subject in other medical and
of Medical Education and Research (PGIMER), Chandigarh
psychiatric conditions in terms of the size and quality
160012, India. subhochd@yahoo.com
of the evidence, the consistency of its findings and
Telephone: +91-172-2756808
Fax: +91-172-2744401 clarity about underlying processes mediating this link.
Nevertheless, the elements of an effective alliance
Received: July 9, 2018 which could have a positive impact on adherence in
Peer-review started: July 10, 2018 BD are reasonably clear and include PCC, collabora
First decision: August 24, 2018 tive relationships, SDM, open communication, trust,
Revised: October 7, 2018 support, and stability and continuity of the relationship.
Accepted: October 23, 2018 Therefore, clinicians involved in the care of BD would
Article in press: October 23, 2018 do well to follow these principles and improve their
Published online: November 9, 2018 interpersonal and communication skills in order to build
productive alliances with their patients. This could go a
long way in confronting the ubiquitous problem of non-
adherence in BD. The role of future research in firmly
Abstract establishing the alliance-adherence connection and
The clinician patient relationship lies at the core of uncovering the processes underlying this association will
psychiatric practice and delivery of mental health care also be vital in devising effective ways to manage non-
services. The concept of treatment alliance in psychiatry adherence in BD.
Key words: Treatment; Alliance; Adherence; Bipolar partnerships), holism (bio-psychosocial approach),
disorder; Components; Mediators individualization (personalized care), communica
tion (information sharing), access, coordination and
© The Author(s) 2018. Published by Baishideng Publishing continuity of care
[1-3,7,8]
. SDM is derived from the PCC
Group Inc. All rights reserved. paradigm and is based on the same guiding principles
of patient autonomy, informed choice and collaborative
Core tip: A collaborative treatment alliance is central alliances between with clinicians
[9-14]
. Additionally, it
to tackling the ubiquitous problem of non-adherence is an evidence based and patient-centred process of
in bipolar disorder (BD). Studies examining the link decision-making consisting of information sharing,
between alliance and adherence in BD have shown elicitation of patients’ preferences, mutual deliberation
that an effective alliance positively impacts adherence.
and agreement on the treatment decisions between
However, the existing literature is relatively limited, [9,15,16]
patients and clinicians . The traditional, paternalistic
often of variable quality, and has not been able to
model of clinician-centred care, which was in vogue
clearly delineate the mediators of the alliance-adherence
prior to these approaches, had been criticized for vesting
connection. Nevertheless, the key elements of produ
power in the clinician to make all treatment decisions,
ctive alliances in BD which could positively influence
treatment-adherence are reasonably clear. They can often overlooking patients’ preferences. In contrast,
[3,7,8,17] [9,12,15,18]
be readily implemented in clinical practice to enhance both the PCC and SDM approaches pro
adherence in BD, till future research further clarifies the pagated power sharing and mutual responsibility for
alliance-adherence association. the treatment undertaken. Thus, they shifted the locus
of care from the clinician to the patient and reduced
the disparity between them. These attributes made
Chakrabarti S. Treatment alliance and adherence in bipolar these new approaches more ethical, more acceptable
disorder. World J Psychiatr 2018; 8(5): 114-124 Available from: to patients, and enhanced their potential to improve
URL: http://www.wjgnet.com/2220-3206/full/v8/i5/114.htm health-care outcomes
[3,4,18-20]
. Not surprisingly, the notion
DOI: http://dx.doi.org/10.5498/wjp.v8.i5.114 of collaborative treatment alliances has constituted
[1,3,7,21,22]
one of the chief components of PCC as well as
[12,23-26]
SDM . Moreover, these constructs have led to a
broader understanding of the concepts of treatment-
INTRODUCTION adherence and engagement with services
[2,8,26-28]
. The
principles of autonomy, holism and humanistic care
The changing face of mental health care [29-31] [18,19,26,32,33]
espoused by the PCC and SDM models
With the introduction of the concepts of patient-centred
had always been a part of mental health care. In fact, a
care (PCC) and shared decision-making (SDM) since the
second report of the Institute of Medicine was devoted
1990s the face of health-care delivery has undergone
exclusively to the application of principles of PCC to
a remarkable transformation. The preceding years had [29,34]
mental and substance use disorders . Nevertheless,
seen many clinical, economic and social changes such as
implementation of both PCC and SDM in mainstream
the growing numbers of elderly patients and those with
psychiatric practice has been poor and there is limited
chronic conditions, the increasing complexity and cost
research regarding their impact on mental health
of treatments, together with repeated calls for greater [18,26,32,33,35]
outcomes .
patient autonomy and choice by consumer advocacy
groups. The PCC and SDM approaches were driven
by the need to reorient and redesign an increasingly TREATMENT ALLIANCE IN PSYCHIATRIC
fragmented system of health-care in order to face these
[1-4]
challenges . PRACTICE
The concept of treatment alliance in psychiatry has
PCC and SDM
[36-39]
its origins in psychoanalysis and psychotherapy .
The concept of PCC began attracting increasing attention However, rather than the transference based psycho
from the 1990s as a result of two landmark publications analytic concepts of therapeutic relationships, psychiatry
by the Picker Institute and the United States Institute has found it easier to adopt the pan-theoretical construct
[5,6] [40]
of Medicine . PCC began to be acknowledged as a of working alliance proposed by Bordin , which focuses
central component of health-care when the Institute on a “here and now” approach to alliance. The central
of Medicine included it as one on the six components characteristic of working alliance which determines its
[6]
of high quality care . The principle attributes of PCC beneficial effects is therapist and client collaboration.
include responsiveness (sensitivity to patients’ values Within this collaborative framework working alliance is
and preferences), respect (according dignity to patients), composed of three elements: An affective bond between
autonomy (acknowledging patients’ rights of informed the client and the therapist, mutually shared goals, and
choice), empowerment (enabling patient and family agreement on treatment tasks. However, even this
participation in care), collaboration (equal and supportive concept is not easily extrapolated to routine psychiatric
practice because of several differences between psycho environment. Eventually, traditional compliance-based
[37,39,41-43]
therapeutic and psychiatric settings . These approaches to medication-taking which were rooted
include a wider range of patients, professionals and in unequal and paternalistic clinician patient relation
settings; greater variability in treatment goals and ships, gave away to adherence and concordance based
[49]
interventions; and, differences in frequency and duration approaches . The concepts of concordance, PCC
of contact in clinical practice. Patients with severe and SDM are all based on the common principles of
illnesses compromised awareness and increased risks collaboration, responsiveness, open communication
of harm to self or others pose the greatest problems and mutual agreement on treatment between patients
[8,24,25,28]
for establishing a working alliance. The necessity for and clinicians . It was therefore not surprising
use of coercive treatment measures in this group that psychiatry readily embraced these concepts in an
directly conflicts with the clinician’s role as a therapist. effort to deal with the common and unrelenting problem
Consequently, a number of other theoretical constructs of treatment non-adherence
[50-53]
. More pertinently,
have been utilized to establish the concept of alliance concordant and collaborative approaches to treatment
in psychiatry. Apart from the PCC and SDM models, have currently gained widespread recognition in the
these have included theories of health-behaviour, newer existing research on adherence in BD
[44,54-57]
.
concepts of medication-taking such as concordance,
and the use of recovery-orientated approaches to define The association between treatment alliance and
[41,44-46]
the success of psychiatric treatment . However, adherence in BD
regardless of the conceptual framework it amply Despite this recognition the evidence linking treatment
clear that collaborative partnerships, personal bonds alliance with adherence is still quite limited in BD,
and mutual agreement on tasks and goals between especially compared to other psychiatric and medical
patients and clinicians lie at the heart of the treatment disorders. The table below summarizes this research.
alliance in psychiatry. Moreover, these are the very The majority of studies included in the Table 1
same characteristics that determine the positive impact have found a positive association between alliance and
of effective alliances on several treatment outcomes medication-adherence, while only five have failed to
including adherence to treatment. A systematic review find such an association
[58,59,67-69]
. However, there was
[45]
by Thompson and McCabe identified 10 studies, considerable variation in study designs. Measures of
which had examined the association between treatment medication-adherence linked with alliance have varied
alliance and adherence. The majority of the studies had from patient reports or clinician ratings, to persistence
been conducted among patients with either depression with treatment, dropout rates, missed medication days,
or psychosis, while only three had included patients with and adherence with appointments or service engage
bipolar disorder (BD). Eight of these 10 studies found ment. Only about half of the studies have used validated
a significant association between adherence and some scales of alliance; the rest have relied on self-designed
component of the treatment alliance. A collaborative questionnaires, treatment-attitude scales, or ratings of
relationship, agreement on treatment tasks and stability therapist interventions. Similar to studies of treatment
of the alliance were the more salient determinants of alliance in other psychiatric disorders, the Working
adherence with treatment. Alliance Inventory, based on Bordin’s construct, was the
[45]
most common scale used . However, such overreliance
TREATMENT ALLIANCE AND on one instrument may have limited the scope of
[37]
findings . Though prospective studies are better
ADHERENCE IN BD indicators of the alliance-adherence link, three studies
The changing concepts of treatment-adherence with longitudinal designs were unable to demonstrate an
Newer approaches to medication-taking in chronic association between alliance and adherence on follow-up
[69,72,76]
illnesses had also started to emerge around the 1990s. despite finding a positive association at baseline .
Much like PCC, a patient-centred view of treatment- Finally, quite a few of the studies had small sample sizes
adherence began to replace the earlier illness-centred and almost all included hospital attendees rather than
orientations as it gradually became apparent that community based patients, which meant that the results
patients’ views on medication-taking played a central role were not readily applicable to all patients with BD.
[47]
in determining adherence . This change was driven by Thus, the somewhat inevitable conclusion from these
years of research on predictors of non-adherence, which studies is that though there is definite evidence linking
revealed that demographic, clinical and treatment related treatment alliance with adherence in BD, an unequivocal
determinants were not able to fully account for the association between the two is still lacking.
extent of non-adherence. Simultaneously, the emergence Fortunately though, several other types of studies
of a number of health-behaviour models prompted a have endorsed the notion that effective treatment
move away from biomedical to bio-psychosocial appro alliances have an important bearing on treatment-
[48] [78]
aches to adherence . This put the emphasis back on adherence in BD. Frank et al provided their subjective
patients’ perceptions, the clinician patient relationship, impressions about “alliance building” among patients
and on other influences in the patient’s sociocultural with mood disorders undergoing trials of acute and
WJP|www.wjgnet.com
Taylor et al[63], 2001 review and patient reports; knowledge by self-designed questionnaire concluded that an effective treatment alliance was of greater importance in ensuring adherence
30 trial patients on maintenance lithium treatment and psychotherapy; cross-sectional study; than imparting information
adherence by RBC lithium levels; alliance by TATIS scale to assess therapists' techniques TATIS scores were significantly associated with RBC lithium levels. Medication adherence
improved with increased focus on collaborative relationship building, positive treatment-
attitudes, acceptance of BD and necessity for long-term treatment
Kleindienst and Greil[64], 2004 171 trial patients on lithium or cabamazepine; 2.5 yr follow-up; adherence indexed by time to Trust in medications, trust in clinicians and absence of negative treatment expectations were
dropout; alliance by the ICS scale associated with longer time to dropoutin those on lithium, but not carbamazepine.
Patel et al[65], 2005 32 African-American and Caucasian adolescent outpatients; cross-sectional study; adherence by Medication adherence in African-American adolescents was significantly correlated with ratings
patient reports and from records; alliance by subjective perceptions of medications and mental of drug usefulness and helpfulness of mental health contacts. Helpfulness of mental health
health contact helpfulness contacts was not associated with adherence among Caucasian adolescents
Guandiano and Miller[66], 2006 61 trial patients on medications and family intervention; 28 mo follow-up; adherence indexed by Alliance was associated with number of months in treatment, dropout rate, percentage of time
117
number of months in treatment; alliance by WAI - P and C versions depressed and expectations from treatment
Sajatovic et al[67], 2006 184 trial inpatients; cross-sectional study; adherence by patient interviews; alliance by WAI - P and C Alliance scores did not differ between adherent and non-adherent groups
Lecomte et al[68], 2008 118 patients from early intervention services; 13 with BD; cross-sectional study; adherence by Alliance scores were not associated with medication adherence but predicted poor service
the MAS scale; alliance by WAI-P engagement
Sajatovic et al[69], 2008 302 trial patients; 3 yr follow-up; adherence by patient interviews; alliance by WAI - P and C Alliance scores did not differ between adherent and non-adherent groups
Zeber et al[70,71], 2008 and 2011 435 inpatients and outpatients; cross-sectional study; adherence by patient-report of missed Overall alliance scores were associated with self-report of missed medication days and
medication days and MMAS; alliance by HCCQ individual items of the HCCQ were linked to MMAS and missed medication days
Perron et al[72], 2009 429 inpatients and outpatients; 1 year follow-up; adherence by MMAS; alliance by HCCQ Treatment alliance demonstrated a small but significant association with medication at baseline,
but not at follow-up
Cely et al[73], 2011 124 outpatients; cross-sectional study; adherence by MMAS; alliance by self-designed A negative perception of the treatment alliance among patients was significantly more common
questionnaire in the non-adherent group compared to the adherent group
Sylvia et al[74], 2013 3037 outpatients from the STEP-BD study; 1 yr follow-up; adherence by a clinical monitoring Patients' perceptions of the strength of the treatment alliance were associated with adherence
form; alliance by HAQ Perceptions of collaboration, empathy and accessibility were the elements of the alliance linked
to adherence
Kassis et al[75], 2014 628 inpatients and outpatients; 76 with BD; cross-sectional study; adherence by patient-report Patients in the adherent group were more satisfied with their psychiatrists, including availability
and from records; alliance by PDRQ and accessibility of psychiatrists and agreement with them on symptoms
Kutzelnigg et al[76], 2014 891 outpatients on olanzapine and mood-stabilizers; 2 yr follow-up for 657 patients; adherence Patients in the highly adherent group had a better treatment alliance than those in the non-
by clinician judgments; alliance by self-designed scale adherent group at baseline but not during the follow-up period
Novick et al[77], 2015 903 outpatients on olanzapine; 291 with BD; 1 yr follow-up; adherence by MARS; alliance by Alliance scores were associated with medication-adherence both at baseline and after 1 yr of
WAI-C follow-up
COSS: Compliance self-rating scale; HAQ: Helping alliance questionnaire; HBM: Health belief model; HCCQ: Health care climate questionnaire; ICS: Illness concept scale; KK Skala: Krankheits konzept skala; MARS: Medication
adherence rating scale; MAS: Medication adherence scale; MMAS: Morisky medication adherence scale; PDRQ: Patient doctor relationship questionnaire; SCQ: Standardized compliance questionnaire; STEP-BD: Systematic treatment
Chakrabarti S. Treatment-alliance in bipolar disorder
enhancement program for bipolar disorder; TATIS: Treatment adherence training interventions scale; WAI - P and C: Working alliance inventory - patient and clinician versions.
[75,78,84,96,98]
maintenance treatment. They noted that information- BD . The most compelling evidence however,
exchange, active patient participation and collabora comes from the growing evidence of the efficacy of
tive decision-making all promoted alliance and led psychosocial interventions in augmenting treatment-
[99,100]
to very high rates of medication-adherence and low adherence in BD . It has been proposed that the
[79]
dropout rates. Havens and Ghaemi stated that a efficacy of psychosocial treatments largely stems from
[44,57,101]
sound treatment alliance could have inherent mood their collaborative and patient-focused elements .
stabilizing effects and could supplement the benefits
obtained by medication treatment of BD. Scott and SDM
[80]
Tacchi have shown that psychosocial interventions Similar to PCC, SDM is not only one of key components of
promoting concordant relationships have the ability to an efficacious treatment alliance in BD, but also the one
enhance medication-adherence in BD. Finally, findings most likely to influence adherence
[56,88,102,103]
. However,
from qualitative studies have found that a successful literature on SDM in BD is sparse. A recent systematic
clinician patient relationship is one of the most important review found only 13 studies on the subject . Ne
[89]
[81-84]
determinants of adherence in BD . However, many vertheless, these studies have shed light on several
participants of these studies seem to have found such important aspects of SDM in BD. This review found that
healthy relationships hard to come by, and mostly most treatment related decisions in BD involved those
reported unhelpful and frustrating interactions with pertaining to adherence. The greater part of patients with
[85-87]
mental health professionals . BD preferred a SDM approach and wanted information
about treatment choices, but many relied on their
clinicians to take the final treatment related decisions.
COMPONENTS OF AN EFFECTIVE
Certain demographic factors such as age, gender,
TREATMENT ALLIANCE IN BD educational level and ethnicity had some bearing on
Since treatment alliance is a multi-dimensional concept, preferred involvement in SDM, though the findings were
an understanding of specific aspects of the alliance not always consistent. Similarly, it was not clear whether
that influence medication-taking may inform efforts to patients with BD sought greater involvement in decision-
[45]
prevent non-adherence . Studies of BD have revealed making than patients with other psychiatric disorders.
the following as the principal components of an effective Symptom severity, rather than diagnosis appeared
alliance, which have a bearing on adherence. to have a greater impact on patient involvement in
SDM. However, regardless of the preferred level of
PCC involvement, almost all patients reported that SDM was
First and foremost a successful alliance in BD is built not as commonly practiced in actual clinical settings as
on the principles of PCC
[44,88,89]
. Studies of BD have they had wanted. Though the implementation of SDM
shown that patients favour a patient-centred approach was low in routine care, collaborative decision-making
and may be less likely to engage in treatment when was more likely if decisions were of complex nature
faced with paternalistic and authoritarian approaches and when patients initiated the process. Patients also
based on the traditional medical model
[90-92]
. Awareness wanted clinicians to pay attention to both interpersonal
and sensitivity to views of patients is also crucial to a and affective elements of SDM. A sound alliance based
[74]
patient-centred approach . A large number of studies on SDM was associated with a number of positive
of BD have shown considerable differences between outcomes, mostly greater patient satisfaction, while
views of patients and clinicians regarding medication- the association with treatment-adherence was found in
[74,104]
taking
[81,93-96]
. It is obvious that this clinician patient only two studies . These findings were remarkably
divide can only be overcome if clinicians are aware of similar to what has been found among patients with
[8,18,105,106]
patients’ views and preferences and respond to them medical illnesses , as well as those with other
[23,25,33,107,108]
appropriately .
[44]
psychiatric disorders . Moreover, a similar
profile of patient preferences, patient and clinician
Collaboration involvement in SDM, and low implementation of SDM
A collaborative clinician patient relationship appears to in clinical practice has been found in a number of other
[109-112] [82-84,92,98]
be one of the principal facets of treatment alliance that quantitative and qualitative studies of BD ,
[96,113]
fosters adherence in BD
[44,57,97]
. Sylvia et al
[74]
found as well as surveys of patients with BD . Another
that more than any other aspect of alliance, patients’ aspect that deserves mention is the use of decision-aids
perceptions of collaboration in their relationships with to further the process of SDM in BD. Decision-aids are
clinicians was associated with adherence in BD. In tools based on updated evidence, which help patients
another qualitative study, patients with BD felt that compare different treatment options and provide them
[34,114]
interactive relationships with their clinicians, based structured assistance through all steps of SDM .
on equal participation and sharing of responsibilities Though decision-aids have been used for other
[82] [23,25,34,107]
were more likely to result in adherence . Similar psychiatric disorders , they have not yet been
[115]
results have been obtained by several other studies of developed for BD . A particular concern about the use
of SDM among patients with psychiatric disorders has productive treatment alliances were associated with
been the problem of decisional incapacity. When acutely greater levels of social support among patients with BD.
ill, patients might not have the capacity of making Similarly, the importance of a supportive relationship
proper decisions; this may represent a significant barrier with the clinician in alliance building has formed a major
[83,98,125]
to application of SDM to psychiatric disorders. Advance theme in several qualitative studies of BD .
directives have been proposed as a solution to this
dilemma. They are documents completed by patients Stability and continuity
while still in possession of decisional capacity, regarding Continuity of care, ideally by a single treatment-team,
treatment decisions that could be made on their behalf frequent follow-ups and longer sessions with patients
in the event they lose the ability to make proper have all been emphasized as crucial elements of a
decisions when they are acutely ill. Some efforts have alliance in BD
[56,57,120] [70]
. Zeber et al found that treatment-
been made to implement advance directives among adherence was better when clinicians remained in
[25,108]
patients with schizophrenia , but research on such constant contact with their patients and regularly mo
[116]
directives in BD is still at a very preliminary stage . nitored their patients’ progress. Patient perceptions
regarding continuity of care were found to be associated
Communication
[58,59]
with attendance rates in other studies of BD . Patients
Constructive communication practices, referred to as with BD also consider stability, consistency and continuity
collaborative or participatory styles of communication of treatment alliances as critical influences on their
[83,85,92,98]
are based on the PCC and SDM approaches
[8,45,117,118]
. medication-taking behaviour .
A participatory style of communication not only helps
in building a strong alliance, but also has a positive Self-management
effect on treatment-adherence by promoting positive The recovery-orientated approach to care is currently
attitudes to treatment among patients
[44,45]
. A meta- being promoted as an key element of care in psychia
analysis among patients with various medical conditions tric disorders including BD. One aspect of recovery-
found that communication practices of physicians orientated care is its emphasis on self-management or
[126]
were significantly associated with adherence and poor self-directed care . Self-management strategies are
communication led to a 19% increase in non-adhe adopted by many patients with BD and are also essential
[44,127]
rence
[119]
. The review by Thompson and McCabe
[45]
components of psychosocial treatments for BD .
found treatment-adherence to be associated with some Promoting self-management has thus been advocated as
[88,89]
or the other aspect of communication practices in eight a necessary component of effective alliances in BD .
of the 12 studies of patients with psychiatric disorders.
Collaborative communication has a significant impact
on adherence among patients with BD as well
[44,97,120]
.
MEDIATORS OF THE ALLIANCE-
A two-way communication between the patients and ADHERENCE LINK IN BD
clinicians allowing open discussions and free expression The positive association between treatment alliance and
of patients’ concerns appear to be the main constituents adherence in BD could be attributed to a number of
[78,89,98,121]
of a beneficial communication pattern in BD . intervening variables or mechanisms. An effective alliance
Exchange of information, particularly about medications results in less negative attitudes, a greater acceptance of
[83,96,98,113,122]
is also accorded high priority by patients . illness, and the ability to tolerate medication side effects
Other clinician attributes considered important by eventually leading to improved adherence
[44,60,61,123,124]
.
patients with BD include clinicians’ ability to listen Other potential mediators, which have demonstrated a
to, understand and value their views on medication- positive association with treatment alliance in BD include
taking, along with flexibility regarding treatment options reduction of symptom severity
[66,72,77,124,128]
, enhancement
and devoting sufficient time to treatment related [77]
of insight , and improvement in patient functioning
[75,82,89,96,121]
discussions . or quality of life
[72,77,129]
. Certain psychosocial processes
could also mediate the association between alliance and
Trust and support adherence. An efficacious treatment alliance has been
Trust in the clinician is considered an important aspect of linked with increased patient satisfaction
[74,83,123,128,129]
,
[101,103] [64]
a successful alliance in BD . Kleindienst and Greil positive treatment expectancies
[64,66]
, reduced stigma ,
[124]
found that trust in the clinician was associated with improved self-efficacy
[128]
, higher levels of perceived
[124,125]
lower dropout rates among patients on maintenance support , and some aspects of locus of control
[130]
lithium treatment. Trusting and collaborative clinician- among patients with BD . However, the association
patient relationships can enhance adherence by foster between all these variables and alliance in BD has often
ing improved treatment-attitudes and aiding effective been inconsistent and largely correlational than causal.
[75,82,84,86,123]
decision-making . Both emotional and practical Therefore, there is still considerable uncertainty about
support are also essential components of a healthy the mechanisms underlying the beneficial effects of a
[124]
alliance in BD. Strauss and Johnson found that successful alliance on adherence in BD.
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