KNOWLEDGE AND COMPLIANCE TOWARDS LITHIUM THERAPY AMONG CHINESE PSYCHIATRIC PATIENTS IN HONG KONG Sing Lee, Y.K. Wing, K.C. Wong
Although patient education is believed to promote medication compliance, the exact relationship between the acquisition of drug knowledge and compliance during lithium treatment is unclear. A survey of 50 Chinese patients on maintenance lithium therapy revealed that their medical knowledge about lithium treatment, as measured by a “Lithium Questionnaire,” was very limited. Nonetheless, 70% of these patients were found, by multiple criteria, to be good compliers, and lithium compliance was apparently not affected by the amount of drug knowledge that patients possessed. It is argued that in the process of conducting patient education to enhance lithium compliance, a sound therapeutic alliance is more important than sheer knowledge acquisition. Australian and New Zealand Journal of Psychiatry 1992; 26:444-448 Lithium is now firmly established in the treatment of recurrent mood disorders. and its side-effects, dangers of toxicity and the need for monitoring have been well documented 111. However, non-compliance remains an important cause of treatment failure in 2 5 5 0 % of patients (2-51. Despite extensive studies, the exact causes of lithium non-compliance are by no means certain but there are some consistent results. Generally, patients’ sex, age, education, severity and duration of illness and side-effects are unrelated to compliance, but personality trait problem, substance abuse, cognitive deficit. unipolar mania and longer duration of treatment could be adverse factors in cer-
Department of Psychiatry, Chinese University of Hong Kong, Shatin, Hong Kong
Sing Lee MRCPsych, Senior Lecturer Y.K. Wing MRCPsych. Lecturer K.C. Wong. Research Assistant Correspond with Dr Lee
tain populations [2,4,5]. The importance of medical knowledge and patient education in improving compliance, however, is more often claimed than demonstrated. Although education material on lithium therapy is easily available in many Western countries [6],there have been few studies which specifically surveyed patients’ attitude and knowledge towards lithium treatment [2,7]. Recently, two such studies indicated that regular attenders at well established lithium clinics knew “dangerously little” [8] and held a surprising number of misconceptions [9] about their medication. As a result, it was claimed that patient education was vital for enhancing lithium compliance 18.101. However, data regarding the relationship between knowledge and compliance, at least in non-lithium studies, are neither consistent nor clear-cut [ 1 11. In the treatment of hypertension and coronary heart disease, evidence in fact existed that increased medical knowledge did not improve treatment compliance
Downloaded from anp.sagepub.com at Psychiatrische Universitatsklinik Zurich on May 7, 2015
SING LEE, Y.K. WING. K.C. WONG
[ 12,131. Although Peet & Harvey [9] recently reported a favourable change in attitude among patients who received an education programme on lithium treatment, it was unclear from their study whether it was the amount of information delivered or the interpersonal process of education which actually produced the improvement. In fact, there has been no attempt, to the best of our knowledge, to specifically examine the relationship between patients’ compliance and knowledge of lithium treatment. This is a pertinent question because if compliance is positively related to knowledge, then more effort should be spent purely on information provision to patients on lithium therapy. On the other hand, if no relationship exists between them, simple distribution of medical information may be a waste of time [ 141 as far as the specific purpose of improving lithium compliance is concerned. Apart from systematically surveying the knowledge of Chinese patients on various aspects of lithium treatment, the following study specifically investigated the relationship between knowledge and lithium compliance. Other clinical variables which may affect compliance among Chinese patients on lithium therapy will be explored in a future paper.
Hong Kong has a population of 6 million, of which 98% are Chinese. Lithium has been used for over 15 years, but systematic information on lithium therapy is lacking. In September 1990 a lithium clinic was set up at the Prince of Wales Hospital, which is a general teaching hospital serving a regional population of 0.5 million. The clinic operates every Tuesday and accepts any patient on lithium therapy. It is the first of its kind in Hong Kong [ 151. Based on an adult outpatient database, 50 Chinese patients on maintenance lithium treatment were identified out of about 3,000 active adult outpatients and were then referred by their case doctors to the lithium clinic for continuation of care by one of the authors (SL). Previously. they had been seen at 4-16 week intervals by various psychiatrists who routinely maintained patients’ serum lithium levels a t 0 5 1 .Ommol/l. Typically, these patients were not given systematic or written medical information prior to the initiation of lithium therapy. Our clinical impression was that they knew little about the nature of any psychotropic medications they received.
445
Demographic and clinical data were obtained by thorough case-note review, and were confirmed during clinical interviews. Diagnoses were based on the ICD-9 [ 161. The serum lithium level was assayed flame photometrically and its imprecision at the concentration of 1.88 mmol/L was less than 1%. As the mean of two consecutive serum levels checked prior to this study was used for analysis, patients were not previously aware that the blood tests would be used for the assessment of their lithium compliance. During their first visit, all patients were clinically stable and interviewed in Chinese (Cantonese) with a semi-structured Lithium Questionnaire (LQ) designed by the author (SL). An English version of the LQ was shown in Table 1. Apart from “Yes” and “No” types of replies, space (not shown) after each question was allowed so that specific details of patients’ answers might be recorded. Each LQ took about 20 minutes to administer. No new information on lithium therapy was given to patients until it was completed. From thirteenofthequestions(nos. 1-1 I , 13, 151,a“Lithium Questionnaire Score” (range 0- 13) was calculated by awarding one point for each correct answer, and its relationship to non-compliance was then statistically examined. Non-compliance was based on 3 criteria: ( 1 ) a mean lithium level of less than 0.45 mmolflitre, (2) thorough examination of clinical notes in the 1 year prior to referral (by one of us, YKW, blind to the patients) for case doctors’ recording of drug defaulting; ( 3 ) patients’ subjective report of non-compliance by careful interrogation during clinical interview. Non-compliance was regarded as “present” when any one or more of these criteria was met. The data were statistically analysed by the SPSS PC+ statistical package for calculating mean values k SD, Pearson correlation coefficients and the MannWhitney test. The significance level was set at p
Although patient education is believed to promote medication compliance, the exact relationship between the acquisition of drug knowledge and compliance during lithium treatment is unclear. A survey of 50 Chinese patients on maintenance lithium therapy revealed that their medical knowledge about lithium treatment, as measured by a “Lithium Questionnaire,” was very limited. Nonetheless, 70% of these patients were found, by multiple criteria, to be good compliers, and lithium compliance was apparently not affected by the amount of drug knowledge that patients possessed. It is argued that in the process of conducting patient education to enhance lithium compliance, a sound therapeutic alliance is more important than sheer knowledge acquisition. Australian and New Zealand Journal of Psychiatry 1992; 26:444-448 Lithium is now firmly established in the treatment of recurrent mood disorders. and its side-effects, dangers of toxicity and the need for monitoring have been well documented 111. However, non-compliance remains an important cause of treatment failure in 2 5 5 0 % of patients (2-51. Despite extensive studies, the exact causes of lithium non-compliance are by no means certain but there are some consistent results. Generally, patients’ sex, age, education, severity and duration of illness and side-effects are unrelated to compliance, but personality trait problem, substance abuse, cognitive deficit. unipolar mania and longer duration of treatment could be adverse factors in cer-
Department of Psychiatry, Chinese University of Hong Kong, Shatin, Hong Kong
Sing Lee MRCPsych, Senior Lecturer Y.K. Wing MRCPsych. Lecturer K.C. Wong. Research Assistant Correspond with Dr Lee
tain populations [2,4,5]. The importance of medical knowledge and patient education in improving compliance, however, is more often claimed than demonstrated. Although education material on lithium therapy is easily available in many Western countries [6],there have been few studies which specifically surveyed patients’ attitude and knowledge towards lithium treatment [2,7]. Recently, two such studies indicated that regular attenders at well established lithium clinics knew “dangerously little” [8] and held a surprising number of misconceptions [9] about their medication. As a result, it was claimed that patient education was vital for enhancing lithium compliance 18.101. However, data regarding the relationship between knowledge and compliance, at least in non-lithium studies, are neither consistent nor clear-cut [ 1 11. In the treatment of hypertension and coronary heart disease, evidence in fact existed that increased medical knowledge did not improve treatment compliance
Downloaded from anp.sagepub.com at Psychiatrische Universitatsklinik Zurich on May 7, 2015
SING LEE, Y.K. WING. K.C. WONG
[ 12,131. Although Peet & Harvey [9] recently reported a favourable change in attitude among patients who received an education programme on lithium treatment, it was unclear from their study whether it was the amount of information delivered or the interpersonal process of education which actually produced the improvement. In fact, there has been no attempt, to the best of our knowledge, to specifically examine the relationship between patients’ compliance and knowledge of lithium treatment. This is a pertinent question because if compliance is positively related to knowledge, then more effort should be spent purely on information provision to patients on lithium therapy. On the other hand, if no relationship exists between them, simple distribution of medical information may be a waste of time [ 141 as far as the specific purpose of improving lithium compliance is concerned. Apart from systematically surveying the knowledge of Chinese patients on various aspects of lithium treatment, the following study specifically investigated the relationship between knowledge and lithium compliance. Other clinical variables which may affect compliance among Chinese patients on lithium therapy will be explored in a future paper.
Hong Kong has a population of 6 million, of which 98% are Chinese. Lithium has been used for over 15 years, but systematic information on lithium therapy is lacking. In September 1990 a lithium clinic was set up at the Prince of Wales Hospital, which is a general teaching hospital serving a regional population of 0.5 million. The clinic operates every Tuesday and accepts any patient on lithium therapy. It is the first of its kind in Hong Kong [ 151. Based on an adult outpatient database, 50 Chinese patients on maintenance lithium treatment were identified out of about 3,000 active adult outpatients and were then referred by their case doctors to the lithium clinic for continuation of care by one of the authors (SL). Previously. they had been seen at 4-16 week intervals by various psychiatrists who routinely maintained patients’ serum lithium levels a t 0 5 1 .Ommol/l. Typically, these patients were not given systematic or written medical information prior to the initiation of lithium therapy. Our clinical impression was that they knew little about the nature of any psychotropic medications they received.
445
Demographic and clinical data were obtained by thorough case-note review, and were confirmed during clinical interviews. Diagnoses were based on the ICD-9 [ 161. The serum lithium level was assayed flame photometrically and its imprecision at the concentration of 1.88 mmol/L was less than 1%. As the mean of two consecutive serum levels checked prior to this study was used for analysis, patients were not previously aware that the blood tests would be used for the assessment of their lithium compliance. During their first visit, all patients were clinically stable and interviewed in Chinese (Cantonese) with a semi-structured Lithium Questionnaire (LQ) designed by the author (SL). An English version of the LQ was shown in Table 1. Apart from “Yes” and “No” types of replies, space (not shown) after each question was allowed so that specific details of patients’ answers might be recorded. Each LQ took about 20 minutes to administer. No new information on lithium therapy was given to patients until it was completed. From thirteenofthequestions(nos. 1-1 I , 13, 151,a“Lithium Questionnaire Score” (range 0- 13) was calculated by awarding one point for each correct answer, and its relationship to non-compliance was then statistically examined. Non-compliance was based on 3 criteria: ( 1 ) a mean lithium level of less than 0.45 mmolflitre, (2) thorough examination of clinical notes in the 1 year prior to referral (by one of us, YKW, blind to the patients) for case doctors’ recording of drug defaulting; ( 3 ) patients’ subjective report of non-compliance by careful interrogation during clinical interview. Non-compliance was regarded as “present” when any one or more of these criteria was met. The data were statistically analysed by the SPSS PC+ statistical package for calculating mean values k SD, Pearson correlation coefficients and the MannWhitney test. The significance level was set at p
