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Review Article

Efficacy of Psychoeducation to Improve Medication Adherence among

Bipolar Affective Disorder: A Systematic Review
Jaishri, Sreevani Rentala1

Faculty, Department of Bipolar affective disorder is a chronic disorder with evidence of lack of medication

Abstract
Mental Health Nursing,
College of Nursing,
adherence, a high relapse rate, significant general disability and burden of
AIIMS, Jodhpur, Rajasthan, psychosocial impairment that often persists for long time. Therefore, Enhancement
1
Professor and HoD, of treatment adherence in bipolar disorder is a necessary and promising
Department of Mental management component as an adjunct to pharmacotherapy. The objective of this
Health Nursing, Dharwad, systematic review is to determine the effects of psycho-educational interventions
Institute of Mental Health on medication adherence among BPAD patients. An electronic literature search
and Neurosciences, Dharwad,
Karnataka, India
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

Introduction per thousand population (Department of Psychiatry,

SVS M C, Telangana, India 2018).[4]
T he maxim, “there is no health without mental
health” underlines the fact that mental health is
an integral and essential component of health.[1] Mental
Approximately 50% of bipolar patients do not recover
from acute manic episode within 1 year and only 25%
disorders are among the leading causes of nonfatal achieve full recovery of function. Rates of recurrence
disease burden in India and across the world.[2] In average 40%–60% in 1–2 years even when patient
2017 a study estimates that 792 million people lived undergo pharmacotherapy. Patients spend as much as 47%
with a mental health disorder. This is slightly more of their lives in symptomatic states, especially depressive
than one in ten people globally (10.7%).[3] The states.[5] For example, a large data base study in the
prevalence of bipolar disorder across the world varies United States of America showed that approximately half
from 0.3%–1.2%. Globally it is estimated that 46 of the patients with BD were nonadherent with lithium
million people in the world had bipolar disorder in and maintenance medications over a 12‑month period.[6]
2017 with 52 and 48 percent being female and male, Factors associated with nonadherence include adverse
respectively. In India one in seven is affected by a effects of medication, complex medication regimen,
mental disorder and the overall weighted prevalence negative patient attitudes to medication, poor insight,
for mental morbidity was 13.7% lifetime and 10.6%
current mental morbidity (National Mental Health
Address for correspondence: Mrs. Jaishri,
Survey of India 2015–2016).[1] In India the prevalence Department Mental Health Nursing, College of Nursing, AIIMS,
of  (bipolar affective disorder  [BPAD]) is 0.4%–0.5%, Jodhpur, Rajasthan, India.
1‑year prevalence is 0.5%–1.4% and lifetime prevalence E‑mail: [email protected]

2.6%–7.8% and the prevalence of affective disorder This is an open access journal, and articles are distributed under the terms of the
ranges from 0.51 per thousand population to 20.78 Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, as long as
appropriate credit is given and the new creations are licensed under the identical
Access this article online terms.
Quick Response Code:
Website: For reprints contact: [email protected]
www.ijpn.in
How to cite this article: Jaishri, Rentala S. Efficacy of psychoeducation
to improve medication adherence among bipolar affective disorder:
DOI: A systematic review. Indian J Psy Nsg 2021;18:55-60.
10.4103/iopn.iopn_61_20
Submitted: 24-Dec-2020; Revised: 20-Jan-2021; Accepted: 21-Jan-2021; Published: 17-Jun-2021

© 2021 Indian Journal of Psychiatric Nursing | Published by Wolters Kluwer ‑ Medknow 55

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Jaishri and Rentala: Psychoeducation for medication adherence in BPAD

Table 1: Studies focused on psychoeducational intervention on medication adherence

Serial Years Objectives Sample size/design and Tools Results
number setting
India 2020 To see the role of 24 sample size Medication adherence Mean of MARS score 7.08±1.24
studies psycho‑education in improvement Pretest and posttest design rating scale for psycho‑education group and
of medication adherence among 5.41±1.08 for the (TAU) Group,
OPD
bipolar disorder[9] difference in adherence seen
between the groups, found to
statistically significant Z=−3.07,
P>0.002
RCT, To assess the impact of 73 sample size Medication adherence Mean improvement in
2017 pharmacist‑psychiatrist Pretest and posttest design rating scale medication adherence in test
collaborative patient education on groups 2.06±0.15 were found to
OPD
medication adherence and QOL be significant at P<0.001
of BPAD patients[12]
RCT, To find the effect of 50 sample size The adherence was The difference in adherence seen
2013 psycho‑educative intervention Pretest and posttest design checked by counting between the groups, however the
on adherence to treatment among tablets difference was not statistically
OPD
persons with BPAD[13] significant (P=0.111)
RCT, To compare of mobile app‑based 500 sample size Self‑Report The three group Bip. app alone +
2020 psycho‑education, group Prospective cohort design adherence and pills TAU, Group PE + TAU, Group
psycho‑education, and the count PE + Bip App + TAU. Mobile
OPD
combination of both on enhancing app‑based psycho‑education
adherence to antipsychotic found statistical significance at
treatment for bipolar disorders[14] P<0.01
Western 2019 To evaluate the feasibility, 38 sample size Tablets Routine Bipolar drug adherence
studies acceptability, and preliminary Prospective cohort design Questionnaire improvement was significant
efficacy of psychoeducation plus between screen and baseline,
IPD
an automated text‑messaging screen and 8‑week, screen and
intervention to improve adherence 12 weeks
for anti‑hypertensives and bipolar
disorder medication[15]
2017 To investigate a nurse‑led 24 sample size Self‑reported Study reveals that posttest
psycho‑educational program Matched‑ pairs two group medication adherence MARS scores were greater in
“Balancing My Swing” improves pretest posttest design rating scale the BMS group than in the TAU
medication adherence Among group at P<0.05
OPD
bipolar II disorder[16]
RCT, To investigate the effect of group 76 sample size Medication adherence The difference in adherence seen
2016 psychoeducation on medication Pretest and posttest design check list and between the groups, however
adherence in female patients with medication adherence the difference was statistically
Female psychiatric ward
bipolar mood disorder type I[17] rating scale significant at P<0.05
2014 To determine the efficacy of group 45 sample size Medication adherence The differences between
psycho‑educational on medication Quasi‑experimental study rating scale the groups were statistically
adherence and global functioning significant P=0.0001
OPD
of patients with bipolar disorder
Type I[18]
RCT, To assess the impact of a simple 108 sample size Medication adherence The intervention group had
2013 individual psycho‑education Pretest and posttest design rating scale a statistically significant
program on quality of life, rate of enhancement in medication
OPD
relapse and medication adherence compliance at P=0.008
in bipolar disorder patients[19]
RCT, To examine the effectiveness of 71 sample size Medication adherence the intervention group MARs
2012 a six weeks psycho‑education Pretests posttests design rating scale scores increased from 40.0%, to
program on the medication 86.7%, found to be significant at
OPD
adherence of among BPAD P<0.05
patients[20]
TAU: Treatment as‑usual, MARS: Medication adherence rating scale, OPD: Outpatient department, RCT: Randomized clinical trial

lack of social support, and substance misuse.[8] Hence, problems, decrease in quality of life, frequent episodes,
BPAD patients suffer with persisting symptoms, cognitive limited social support and poor social functioning and

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Jaishri and Rentala: Psychoeducation for medication adherence in BPAD

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

also comorbid psychiatric disorders, such as personality associated with the condition. An education about
disorders and substance abuse are common.[7] their condition is more likely to make people actively
participate in their self‑management and relapse
The management of BPAD with medication is first‑line
prevention. This tends to brings about the individual
treatment, intended at a treating acute, chronic episode,
self‑efficacy and the accompanying benefits from other
reducing the severity, frequency of future episodes
psychotherapies and medications. Psychoeducation is
and improving psychosocial functioning between
highly effective in preventing relapse, identification
episodes. Even though significant advancement in the
of early warring sings, and treatment adherence.[9-11]
pharmacological treatment of bipolar disorder, most
Consequently, researcher would like to see the collective
bipolar patients cannot be maintained on drug treatments
effect of psychoeducation on medication adherence
alone. Therefore, various researchers have shown
through the studies conducted in India and western
that nonpharmacological therapeutic approaches like
setting.
Interpersonal and social rhythm therapy, family‑focused
therapy, and cognitive‑behavioral therapy are effective Search methods for identification of studies
for treatment of bipolar disorder.[8] One of these methods Studies were searched using search engines, from the
is psychoeducation, it is designed to provide information main electronic databases PubMed, Cochrane library,
about their disorder, its treatment and condition that Google Scholar, and other sources such as reports,
causes stress to person. Better understanding of condition thesis, or dissertation. The database was searched using
leads to feeling to control and results in reduced stress the search terms “bipolar,” “psychoeducation,” “group

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Jaishri and Rentala: Psychoeducation for medication adherence in BPAD

psychoeducation,” “individual psychoeducation,” Mishra et  al. studies shown that clinical efficacy of
“compliance,” “medication adherence.” psychoeducation on medication adherence and QOL for
BPAD, whereas Sara et al. study findings is contradicting,
Eligibility criteria
that the psychoeducation intervention does not produce
Studies were included in the systematic review, if they
any significant improvement in adherence to treatment,
fulfill the following eligibility criteria. The criteria were
though the study showed all participants in experimental
as follows:
group had 100% adherence. Hence, the psycho education
Inclusion criteria can be incorporated along with other modalities of
• Full text or abstracts available in English treatment for person with BPAD.
• Studies had been conducted among adult India and western studies individual and group
patients (18 years and older) psychoeducation compared with standard treatment
• Quantitative Randomized controlled trials (RCTs), such as pharmacotherapy, treatment as usual, placebo
experimental studies on psychoeducational with pharmacotherapy is effective in terms of expected
intervention on medication adherence with BPAD outcome. The results communicated that, there was
patients improvement in the medication adherence thereby
• Individual and group psychoeducational studies decreasing negative consequences of nonadherence. More
• Online and offline psychoeducational studies. these studies also showed there was an improvement
Exclusion criteria in knowledge and attitude towards disease, QOL,
• Studies focused only on bipolar disorder (symptom, global functioning, and reduced relapse rate, length of
outcome, course) hospitalization and readmission.
• Studies focused on incidence and prevalence BD In follow‑up studies, Mishra et  al. gave a two
• Studies focused factor influence on non‑adherence to reminder (a week before and day before the follow‑up
medication. by telephone) and on the day of follow up in the
test group who is not adherent to medication were
Results provided patient and carers education session. In
The search returned 1977 papers, after the deletion of this Mishra et  al. and Patel et  al., have representing
duplicates 1517, 460 scientific papers remained for that minimum 2 months of follow up is required
further assessment. After assessing these papers on the for good improvement in medication adherence.
basis of title and abstract and setting, the remaining Further Bahredar et  al. the mean score of the
papers were [Figure 1]. The present systematic review psycho‑educational group in the second assessment
included 6 (60%) RCT, 4 (40%) quasi‑experimental was a little lower than that in the first assessment
studies [Table 1]. In these 3 individuals and 7 group at follow‑up, this difference was not statistically
psychoeducational studies, among these 70% studies had significant  (P = 0.72), but the long‑term study of
follow‑up. It is noted that, individual psychoeducation, Javadpour et al. shows that patients in the intervention
group psychoeducation with follow up reinforcement group had a statistically enhancement in medication
intervention appear to be more effective for medication compliance at P = 0.008 during follow up session.
adherence. This suggests that patients with bipolar This difference result found because the intervention
disorder might benefit from psychoeducation through is continued during follow up period, using scheduled
recognition of symptoms, making patients to understand monthly telephone contact to remind the patients
treatment strategies, develop insights about their illness for their next appointment. Each telephone contact
within a supportive setting, increased competence in consisted of a 10‑min question and answer session
self‑management techniques and enhanced relationships thereby patient’s queries were thoroughly responded
with family members, caregivers and professionals. for subsequent 18 months.
More Pozza et  al.’s study hypothesized that
Discussion the combination of standard group PE and
Summary of main result smartphone‑based PE can offer a more powerful
Most of the existing research evidence on option to improve the patient’s self‑monitoring and
psychoeducational management of bipolar disorder self‑management processes, which can increase
available at western population and only few available in adherence to the prescribed treatment. Therefore, as
Indian population. The Indian (30%) and western (70%) mentioned in few above studies, present study suggests
studies are included for critical appraisal of this study. that not education at one time alone is effective, it need
Evidence from two Indian RCTs of Patel et  al. and continuous reinforcement during the follow‑up with text

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Jaishri and Rentala: Psychoeducation for medication adherence in BPAD

message and psychoeducational/motivational content to that psycho‑education is promising management

have expected outcome. component along with pharmacotherapy and it is one
Quality of the evidence and intervention
of the easiest, flexible, and cost‑effective intervention to
enhance treatment adherence. It should be made routine
The quality of RCT studies assessed with JADAD scale,
practice in health care service at inpatient as well as
in many studies mentioned about randomization but
outpatient department. Mobile‑based psychoeducation
only few studies mentioned their appropriate method
and follow up with reinforcement can be provided for
of randomization and blinding. Here not able to assess
long‑term management of medication adherence.
potential publication bias of the article. In all study
psychoeducation used as an intervention to compare Acknowledgments
with standard treatment. In most of study sample were It is with great pleasure and deep satisfaction I owe my
selected from outpatient department with age ranges sense of gratitude to many around me who contributed
from 18 to 65 years. The content of psychoeducation towards the successful completion of systemic review,
in most of the studies related to bipolar disorder illness Dr. G. Balamurugan, Registrar (Administration), Ramaiah
awareness, role of medication, managing mood symptoms Institute of Nursing Education and Research, Bangalore,
and side effects of medication, dealing with stress, etc., Dr. Deviga T, Mrs. Mohana Sundari, and Mrs. Nancy
Style of intervention delivered was by using flip charts, Kurien Tutor/Clinical instructor at all India institute of
poster, leaf lets, and handbooks prepared by investigator. medical sciences, Jodhpur.
The sessions of interventions ranged from 8 to 10 with a Financial support and sponsorship
1‑week interval for minimum 45 min to 90 min for each Nil.
session. The Sara L et  al. had 4 sessions with 30 min
of psychoeducation showed no significance differences, Conflicts of interest
but more study findings show significance differences, There are no conflicts of interest.
which had maximum sessions (8–10) with >45 min
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