Therapeutic alliance perceptions and medication adherence in patients with bipolar disorder

J Affect Disord. 2008 Apr;107(1-3):53-62. doi: 10.1016/j.jad.2007.07.026. Epub 2007 Sep 5.


Background: Despite the dissemination of practice guidelines for bipolar disorder, outcomes remain suboptimal, largely due to poor treatment adherence. The episodic nature of bipolar disorder disrupts appropriate patient-provider dynamics, interfering with appropriate care. Maintaining a beneficial therapeutic alliance with providers is one important strategy for improving adherence. We examine the association between adherence and therapeutic environment perceptions among veterans with bipolar disorder.

Methods: Participants were recruited from the Continuous Improvement for Veterans in Care--Mood Disorders (CIVIC-MD) study (N=435). Individual items and a summary score from the Health Care Climate Questionnaire (HCCQ) for bipolar disorder solicited patient evaluations of their therapeutic environment. Multivariable logistic analyses examined the association between therapeutic alliance and two measures of adherence (missed medication days and intrapersonal barriers), adjusting for relevant patient characteristics.

Results: Adherence difficulty was reported on both measures, with substantial differences between perceived barriers and actual medication behavior. Significantly fewer minority veterans endorsed good adherence than white patients (59% versus 77%), although no ethnic differences were noted in therapeutic environment perceptions. Multivariable results indicated that positive therapeutic alliance was associated with better adherence (HCCQ effect sizes 13-20%). Notably, patients reporting providers encouraged "staying in regular contact" were more likely to be adherent, as were patients whose "providers regularly review their progress".

Limitations: Generalizability from observational study; adherence defined by cross-sectional patient self-report.

Conclusions: The observed association between medication adherence and therapeutic alliance with bipolar treatment supports intervention efforts to strengthen the patient-provider relationship, a bond likely to yield positive clinical outcomes.

Publication types

  • Comparative Study
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Antipsychotic Agents / therapeutic use
  • Attitude to Health*
  • Bipolar Disorder / drug therapy*
  • Bipolar Disorder / psychology*
  • Cross-Sectional Studies
  • Female
  • Humans
  • Male
  • Middle Aged
  • Minority Groups / psychology
  • Patient Compliance*
  • Professional-Patient Relations*
  • Prospective Studies
  • Surveys and Questionnaires
  • United States
  • United States Department of Veterans Affairs
  • Veterans / psychology
  • Whites / psychology


  • Antipsychotic Agents