Clinical reviewIntegrating psychology and medicine in CPAP adherence – New concepts?
Introduction
The whole is greater than the sum of its parts.
– freely adapted from Metaphysica, Aristotle (384–322 BC).
Aristotle understood that a holistic approach is crucial to a complete understanding of all aspects of life. More than 2000 years later, medicine has seemingly caught up with the value of integration as opposed to reductionism. In the quest to deliver optimal patient care, psychiatrist George Engel's seminal paper published in 19771 was a call towards a biopsychosocial model (from here on referred to as the BPS model), recognising that multiple domains (biomedical, psychological and social) integrally and interactively influence health and illness. It was envisaged as an addition to the medical model, rather than its replacement. The viewpoint that health and illness are defined by biological processes, resulting from injury, biochemical imbalances, bacterial or viral infections*1, 2 often overlooked important individual experiential factors3 and/or significant social or cultural variables,4 which merit consideration alongside biomedical factors. The aetiology and progress of a disease is thus influenced by biological processes, psychological experience and social behaviours, which are reciprocally related.5 To warrant optimal treatment outcome for these diseases, there is then a need for interventions to target all three domains.
Haynes stated that “[e]ffective ways to help people follow medical treatments could have far larger effects on health than any treatment itself.”,6(p10) and this importance of adherence has recently been acknowledged by the World Health Organisation (WHO) in 2003.7 Implicit within these claims, is the need to study adherence within an integrative framework.
Non-adherence is now considered a public health concern: around 30,000 articles have been published on patient adherence, a figure similar to asthma (50,000) and 1/3 of what has been published on diabetes (Medline search with MeSH headings ‘patient compliance’, ‘asthma’ and ‘diabetes’). A recent meta-analysis reported that the average non-adherence rate of approximately 25% for complex treatment interventions translates to 188.3 million medical visits in the US resulting in patients failing to implement recommendations and equating to a monetary waste of potentially US$ 300 billion a year.8 Apart from this economic cost, non-adherence inhibits the evaluation of treatment efficacy at the research level, and can hinder treatment effectiveness at the clinical level.
There has been a major growth in the medical literature related to continuous positive airway pressure (CPAP) adherence following the initial reports on covert electronic surveillance of CPAP use by Kribbs et al.9 This work is most frequently cited for the commonly used, yet arbitrary cut-off of ≥4hrs per night on 70% of the nights. Fig. 1 depicts, based on a Medline search, the 386 articles published since 1984 with the terms ‘continuous positive airway pressure’ and ‘adherence/compliance’ appearing in the title or as MeSH headings (not exploded). A clear surge of articles is evident after 2003, possibly denoting the recognition that psychosocial variables influence CPAP use.
Our understanding of what mediates CPAP use has increased considerably in the last decade. Undoubtedly, the recognition that various biomedical, psychological and social variables may impact adherence has advanced the field and contributed to the development of more comprehensive interventions to improve use. Despite the awareness of its multifaceted nature, an integrative model has not been proposed for CPAP adherence. As previously proclaimed by Aristotle, a holistic approach requires more than simply taking account of and summing the variables. The objective of this paper then, is to outline new concepts for our field in light of our current knowledge of CPAP adherence. It is timely to pursue a holistic approach to this problem and consider potential interventions to improve adherence in terms of a biopsychosocial framework.
Section snippets
A brief review of CPAP adherence
Failure to adhere to CPAP, which is a demanding and invasive treatment, may compromise service delivery and treatment effectiveness. There is evidence of improved treatment effectiveness when the CPAP mask is worn for a large proportion of sleep time.10 This means that cut-offs of “good adherence” may be sub-optimal. However, approximately 25% of patients do not take up CPAP or discontinue in the first 2 wk.11, 12, 13, 14, 15
Furthermore, for those who continue long term (>1 mo), ‘adequate’
Conceptualisation of adherence
The transition from the study and reporting of biomedical variables, to psychosocial variables at the research level, parallels a transition in emphasis from compliance to adherence on the conceptual level (see Table 2); a shift in thinking urged by the World Health Organisation (WHO). ‘Compliance’, defined as “the extent to which a person's behaviour (in terms of taking medications, following diets or executing lifestyle changes) coincides with medical or health advice”150(pp2,3) was replaced
Components of the BPS model
Before considering potential interactions, it is important to take account of all possible variables. Fig. 2 therefore provides a visual representation of the proposed biopsychosocial model for CPAP adherence.
As can be seen, the model comprises biomedical, psychological and social domains. Each of these subsume variables at the person- illness- and treatment-specific level.
The biomedical domain encompasses variables that are descriptive of the patient's (mostly static) clinical or medical
Summary
This review has provided an overview of how a biopsychosocial model could be adopted for the management of CPAP adherence on both a research and a clinical level. Following the success of this approach in other disease entities, both in advancing knowledge and in improving clinical practice, we now call for a biopsychosocial approach to CPAP adherence and perhaps to OSA management more generally. We know that CPAP adherence is multifaceted, and that patient-centred research is vital to advance
Acknowledgments
This work was completed as part of a postgraduate doctoral degree funded by a UK Medical Research Council (MRC) student scholarship and the National Health and Medical Research Council (NHMRC, Australia) Centre for Integrated Research and Understanding of Sleep (CIRUS).
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