Clinical and Sociodemographic Correlates of Poor Medication Adherence in Bipolar Disorder
Clinical Takeaway
Poor medication adherence in bipolar disorder is consistently linked to factors including substance use, younger age, and lower insight into illness. Clinicians should routinely screen for these correlates when evaluating treatment plans for patients with bipolar disorder. Addressing modifiable barriers to adherence, such as substance use and health literacy, may meaningfully reduce relapse risk.
#31 Clinical and Sociodemographic Correlates of Poor Medication Adherence in People With Bipolar Disorder: A Systematic Review and Meta-Analysis.
Citation: Bartoli Francesco et al.. Clinical and Sociodemographic Correlates of Poor Medication Adherence in People With Bipolar Disorder: A Systematic Review and Meta-Analysis.. Bipolar disorders. 2026. PMID: 42267732.
Design: 6 Journal: 0 N: 0 Recency: 3 Pop: 2 Human: 1 Risk: -2
- Preclinical only
Abstract: OBJECTIVES: Poor adherence to psychopharmacological treatment may contribute to relapses in bipolar disorder (BD). We performed a systematic review and meta-analysis to identify factors associated with poor adherence in BD. METHODS: The protocol was registered in Open Science Framework Registries (https://doi.org/10.17605/OSF.IO/2KZFJ). We searched main electronic databases through March 2025. Random-effects meta-analyses were performed to obtain pooled odds ratios (ORs) and standardized mean differences (SMDs) for relevant correlates. RESULTS: We included 19 studies. Subjects with poor adherence were more likely to be younger (SMD = -0.22, 95% CI: -0.42–0.02) and to have lower education (SMD = -0.34, 95% CI: -0.55–0.12), and less likely to be in a relationship (OR = 0.54, 95% CI: 0.34-0.86). Moreover, earlier age at onset (SMD = -0.29, 95% CI: -0.53–0.04), psychotic features (OR = 1.58, 95% CI: 1.30-1.92), a history of suicide attempts (OR = 1.36, 95% CI: 1.03-1.78), a higher number of manic (SMD = 0.34, 95% CI: 0.08-0.61) and mixed (SMD = 0.16, 95% CI: 0.03-0.28) episodes, and more hospitalizations (SMD = 0.53, 95% CI: 0.32-0.73) all emerged as correlates of poor adherence. Also, cannabis (OR = 2.34, 95% CI: 1.79-3.07) and alcohol use disorders (OR = 1.71, 95% CI: 1.39-2.12), comorbid generalized anxiety disorder (OR = 3.70, 95% CI: 1.90-7.22), and comorbid personality disorders (OR = 5.54, 95% CI: 1.32-23.15) were associated with poor adherence. Finally, poorly adherent individuals had higher global severity (SMD = 0.21, 95% CI: 0.01-0.41), lower insight (SMD = -0.74, 95% CI: -1.08–0.41), and lower global functioning (SMD = -0.60, 95% CI: -0.87–0.34). No differences were estimated for other variables. CONCLUSIONS: This meta-analysis showed that poor adherence in people with BD is associated with specific correlates. Although evidence was generally weak due to small effect sizes, imprecision, inconsistency, and potential publication bias, our findings highlig
What This Study Teaches Us
Poor medication adherence in bipolar disorder clusters around specific risk factors: cannabis use nearly doubles the odds of non-adherence, while comorbid personality disorder raises it five-fold. Patients with more episodes, hospitalizations, lower insight, and reduced functioning are significantly less likely to take their medications consistently.
Why This Matters Clinically
Clinicians managing bipolar disorder need to screen for these modifiable and non-modifiable risk factors early, especially cannabis and alcohol use, comorbid anxiety and personality pathology, and insight deficits. Understanding who is at highest risk for non-adherence allows proactive intervention before relapse cycles accelerate.
Study Snapshot
| Study Design | Systematic review and meta-analysis of 19 observational studies |
| Population | People with bipolar disorder; exact total N not stated in abstract. Studies searched through March 2025. |
| Intervention | None (observational studies only; examined factors associated with adherence to psychopharmacological treatment) |
| Primary Outcome | Poor medication adherence and its clinical, psychiatric, and sociodemographic correlates |
| Key Result | Cannabis use disorder (OR 2.34), comorbid personality disorder (OR 5.54), and comorbid GAD (OR 3.70) were strongest associations with poor adherence; also lower insight (SMD -0.74) and lower functioning (SMD -0.60) |
Where This Paper Deserves Skepticism
This is an aggregate of observational studies with inherent limitations: causality cannot be determined (does cannabis use cause non-adherence or does non-adherence lead to heavier cannabis use?), publication bias likely favors studies that found associations, and the abstract does not specify heterogeneity or quality assessment of included studies. The finding on personality disorder rests on only a few studies (wide CI: 1.32-23.15) and may be unstable. No information is given about how adherence was measured across studies, medication types, or regional/healthcare system differences that might affect both adherence and these correlates.
Dr. Caplan’s Take
I read this as a useful clinical map rather than a causal roadmap. The strength of association between cannabis and poor adherence (2.34 OR) deserves our attention in counseling bipolar patients, though we must acknowledge the bidirectional problem: untreated mood instability drives substance use, and substance use destabilizes mood and motivation. The dramatically elevated odds with personality disorder and the finding of reduced insight suggest these patients need not just better pill bottles but integrated care addressing personality structure and psychoeducation. The younger age and lower education correlates point toward a population that may need different access or communication strategies.
Clinical Bottom Line
Screen bipolar patients for cannabis use, alcohol use disorder, comorbid personality pathology, and insight deficits as early markers of non-adherence risk. Addressing these factors, especially substance use and insight, may matter more than changing medications alone.
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