It is unclear whether and to what degree financial barriers impact treatment utilization in bipolar disorder. The strength of these risk factors may differ depending on the kind of nonadherence that is being assessed. Intentional nonadherence involves a conscious decision not take medication, and may

relate more strongly to Thiazovivin purchase dissatisfaction with treatment and lack of perceived need for treatment.48 Unintentional nonadherence may relate to cognitive deficits and to lower health care literacy, and may be of particular concern given the cognitive deficits associated with bipolar disorder. Adherence is described Inhibitors,research,lifescience,medical by Park and colleagues55-57 as including a series of cognitive processes: 1 . Working memory in transferring data from pill-bottle labels 2. Prospective memory and executive functioning in organizing and planning to take medications 3. Pong-term memory in recalling medication dosage times. This model has been applied to adherence and interventions for medically ill older adults,57,58 although not to latelife psychiatric disorders. Cognitive Inhibitors,research,lifescience,medical impairment has been identified as a risk factor for nonadherence in bipolar disorder.48,59 In a study of older

adults prescribed antidepressants, cognitive impairment was the greatest risk factor for unintentional nonadherence.60 From the larger body of literature on cognitive abilities and adherence Inhibitors,research,lifescience,medical in other chronic illnesses (eg, HIV), evidence suggests that memory deficits are not the sole cognitive ability implicated in nonadherence.61 Deficits in executive function and attention relate to worse adherence61,62 and medication management ability.63,64 Cognitive Inhibitors,research,lifescience,medical deficits may reduce ability to comprehend the purposes and instruc tions of medications, which may also contribute to problems with adherence.57 Interventions to enhance medication adherence in bipolar disorder Among

therapeutic modalities for bipolar disorder, some address adherence more Inhibitors,research,lifescience,medical centrally than others. In a review of the effectiveness of psychotherapy for enhancing medication adherence in bipolar disorder, 7 of 11 clinical trials reviewed showed positive effects on medication adherence,65 with greater effect found for multicomponent interventions that focused on medication adherence versus interventions that very covered a broad set of problems or those that only included education. The goal of psychosocial interventions focusing on medication adherence enhancement is typically to alter attitudes toward bipolar illness and need for medication, thus targeting intentional adherence. An implicit assumption is that once the participant is willing to take the medication, they will be able to manage medications and maintain adherence. However, examining the broader spectrum of interventions that have been evaluated in older adults with schizophrenia66 or other chronic illnesses,67 multicomponent interventions include training in medication management skills, as well.