Table_2_A systematic review of approaches to improve medication adherence in homeless adults with psychiatric disorders.pdf

IntroductionMedication non-adherence is a significant problem among homeless individuals with psychiatric disorders in the United States. We conducted a systematic review to identify strategies to improve psychiatric medication adherence among homeless individuals with psychiatric disorders, including substance use disorders.
MethodsWe searched seven databases (MEDLINE, Embase, PsychInfo, Scopus, Web of Science, CDSR, and CENTRAL) and screened 664 studies by title and abstract followed by full-text review. Our inclusion criteria were studies that: involved an intervention for homeless adults with psychiatric disorders, reported a quantitative outcome of medication adherence, and were published in English in a peer-reviewed journal. We rated the relative effectiveness of strategies described in each study using a self-designed scale.
ResultsEleven peer-reviewed studies met criteria for inclusion in this review. Within these studies, there were seven different approaches to improve medication adherence in this population. Three studies were randomized controlled trials (RCTs) and the remaining were observational studies. Outpatient interventions included Assertive Community Treatment, Cell Phone-Assisted Monitoring, Customized Adherence Enhancement plus Long-Acting Injectable Medications, and Homeless-Designated Pharmacy Clinics. Residential, shelter-based, and inpatient interventions included use of the Housing First model, Modified Therapeutic Communities, and Homeless-Designated Inpatient Care. The approaches described in four of the eleven studies were rated as scoring a 3 or higher on a 5-point scale of effectiveness in improving medication adherence; none received 5 points.
DiscussionThe interventions with the strongest evidence for improving medication adherence in this population were Assertive Community Treatment, Customized Adherence Enhancement plus Long-Acting Injectable Medications, and Housing First. Overall, studies on this topic required more rigor and focus on medication adherence as an outcome in this population. This review highlights several promising strategies and the need for larger RCTs to determine effective and diverse ways to improve medication adherence among homeless adults with psychiatric disorders.

引言
药物不依从性是美国患有精神疾病的无家可归者群体中亟待解决的严峻公共卫生问题。本研究开展一项系统综述，旨在识别可改善此类人群（合并物质使用障碍者亦纳入范畴）精神药物依从性的干预策略。

方法
本研究检索了MEDLINE、Embase、PsychInfo、Scopus、Web of Science、CDSR及CENTRAL共7个数据库，首先通过标题与摘要筛选出664项研究，随后开展全文审阅。本研究的纳入标准为：针对患有精神疾病的无家可归成人的干预性研究、报告了药物依从性的量化结局指标、且以英文发表于同行评议期刊。我们采用自行设计的量表，对每项研究中提及的干预策略的相对有效性进行评级。

结果
共有11项符合纳入标准的同行评议研究纳入本次综述。上述研究中共涵盖7种针对该人群改善药物依从性的不同干预路径。其中3项为随机对照试验（randomized controlled trial, RCT），其余均为观察性研究。门诊类干预措施包括：主动社区治疗（Assertive Community Treatment）、手机辅助监测（Cell Phone-Assisted Monitoring）、定制化依从性强化方案联合长效注射剂药物，以及无家可归者专属药房门诊（Homeless-Designated Pharmacy Clinics）。居住类、收容所类及住院类干预措施则包括：住房优先模式（Housing First model）、改良式治疗社区（Modified Therapeutic Communities），以及无家可归者专属住院护理（Homeless-Designated Inpatient Care）。在11项研究中，有4项研究提及的干预策略在5分制有效性评分中获得3分及以上，无任何策略获得满分5分。

讨论
针对该人群改善药物依从性且证据强度最高的干预措施为主动社区治疗、定制化依从性强化方案联合长效注射剂药物，以及住房优先模式。总体而言，本主题相关研究仍需提升严谨性，且应更聚焦于将药物依从性作为该人群的核心研究结局。本次综述明确了数项颇具前景的干预策略，同时指出亟需开展更大样本量的随机对照试验，以确定可有效且多元地改善患有精神疾病的无家可归成人药物依从性的方案。