The dropout rate was 25%, with attrition mostly due to

transportation problems and medical comorbidities. Small to moderate pre-post effect sizes were seen in self-reported adherence and some depressive symptoms. These preliminary results suggest that the group treatment was feasible, acceptable, and produced pre-post improvements along important, dimensions, although future clinical trials with objective measures of adherence and a credible control group would be necessary to ascertain its effectiveness. Provider-level interventions The interventions described above are all focused on enhancing adherence Inhibitors,research,lifescience,medical by increasing knowledge, acceptance, and management skills in the patient. However, there are a number of approaches to improve adherence

by changing provider behavior. These can be categorized into attempts to: (i) increase ease of administration and (ii) enhance the working alliance. Simplifying dosing strategics by consolidation can enhance adherence and providing reminders and pillboxes. The working Inhibitors,research,lifescience,medical alliance and satisfaction with treatment can be enhanced by providing client-centered care, making effort to involve the patient in planning Inhibitors,research,lifescience,medical medication strategies and outcomes, and defining patient, values in weighing treatment options.48,69 Emerging directions In addition to discovering the mediators and moderators of psychotherapy’s effectiveness in bipolar disorder, along with broadening access to evidence-based interventions, there are a number of other modalities that are in the earliest stages of development. Integrative interventions addressing medical comorbidities The Inhibitors,research,lifescience,medical medical burden in bipolar disorder appears to be higher than among nonaffected

individuals.70 The convergence of bipolar disorder and chronic physical illnesses, such as cardiovascular (eg, diabetes) and infectious diseases (eg, HIV, hepatitis) arise from a number of shared risk factors, including Inhibitors,research,lifescience,medical unhealthy lifestyles, risk-taking behaviors, and medication side effects.70 In addition to increasing the burden and complexity of adherence vis a vis higher intensity of medication management, comorbid medical conditions negatively impact quality of life and health care utilization.71 Thymidine kinase Furthermore, access to medical services may be diminished in bipolar disorder. Research FTY720 concentration identifying shared risk factors for nonadherence and other outcomes in bipolar disorder, such as cognitive impairment (sec Moore et al in this issue, p 256), will inform future interventions. Cognitive training and functional rehabilitation In light of the cognitive deficits that have been identified in bipolar disorder,72 it may be that cognitive remediation, either through restorative interventions (eg, boosting attention skills) or compensatory functional training (eg, using external reminders) could be useful. ‘Ihese interventions have been assessed in patients with schizophrenia.