Faculty Bibliography

OBJECTIVE: Nonadherence to medications for mental disorders substantially limits treatment effectiveness and results in higher rates of relapse, hospitalization, and disability. Accurate measurement of medication adherence is important not only in adherence research but also in clinical trials in which medications are being evaluated and in clinical practice where failure to detect nonadherence results in premature medication changes, unnecessary polypharmacy, and greater likelihoods of functional deteriorations and hospitalizations. This is a review of psychiatric treatment adherence methods and measures arising from a meeting on "Methodological Challenges in Psychiatric Treatment Adherence Research" held on September 27-28, 2007, in Bethesda, MD, and organized by the National Institute of Mental Health (NIMH). METHODS: This paper reviews the range of modalities currently available for assessing adherence behavior including pill counts, pharmacy records, technology-assisted monitoring, biological assays, and a range of self-report and interviewer-rated scales. Measures of adherence attitudes are also reviewed. RESULTS: Each of the adherence measures described are imperfect estimates of actual medication ingestion, but each provides informative estimates of adherence or the attitudinal factors associated with adherence. Measure selection depends on a range of factors including the patient sample, the context in which the measure is being used, and the clinical outcomes expected from various levels of nonadherence. The use of multiple measures of adherence is encouraged to balance the limitations of individual measures. CONCLUSION: While adherence assessment has become increasingly sophisticated in recent years, there remains a need for refinement and expansion on currently available methods and measures.

Although the mercury sphygmomanometer is widely regarded as the gold standard for office blood pressure measurement, the ban on use of mercury devices continues to diminish their role in office and hospital settings. To date, mercury devices have largely been phased out in United States hospitals. This situation has led to the proliferation of nonmercury devices and has changed (probably forever) the preferable modality of blood pressure measurement in clinic and hospital settings. In this article, the basic techniques of blood pressure measurement and the technical issues associated with measurements in clinical practice are discussed. The devices currently available for hospital and clinic measurements and their important sources of error are presented. Practical advice is given on how the different devices and measurement techniques should be used. Blood pressure measurements in different circumstances and in special populations such as infants, children, pregnant women, elderly persons, and obese subjects are discussed

The diagnosis of masked hypertension has been made easier with the widespread availability of home blood pressure monitoring devices with levels of accuracy comparable to ambulatory blood pressure monitoring. The negative impact of masked hypertension on cardiovascular morbidity and mortality is evidenced by numerous well-designed clinic-based and population-based studies. The relationship of masked hypertension and target organ damage is also well documented. These two factors, combined with the robust evidence of reduced cardiovascular morbidity and mortality achieved with blood pressure treatment, makes the argument for actively identifying patients with masked hypertension and prescribing treatment similar to that for patients with sustained hypertension. In this paper, we review the evidence for the cardiovascular prognosis of masked hypertension compared with sustained hypertension, we review its impact on target organ damage, we propose an algorithm for the treatment of patients with masked hypertension, and we point out the pitfalls in adopting such an approach

Cardiovascular diseases are the leading cause of death among adults in developed countries. An increase in prevalent cardiovascular risk factors (e.g., obesity, hypertension and diabetes) has led to a concerted effort to raise awareness of the need to use evidence-based strategies to help patients at risk of developing cardiovascular disease and to reduce their likelihood of suffering a stroke. Sleep apnea has emerged as an important risk factor for the development of cardiovascular disease. Epidemiologic and clinical evidence has prompted the American Heart Association to issue a scientific statement describing the need to recognize sleep apnea as an important target for therapy in reducing cardiovascular disease risks. This article examines evidence supporting associations of sleep apnea with cardiovascular disease and considers evidence suggesting cardiovascular risk reductions through sleep apnea treatment. Perspectives on emerging therapeutic approaches and promising areas of clinical and experimental research are also discussed