The Medication Adherence Report Scale (MARS-5) in a Swedish sample with bipolar disorder - a pilot study

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Annika Bäck
Karolina Andersson Sundell
Robert Horne
Mikael Landén
Ann-Charlotte Mårdby


Objectives: To test the acceptability and reliability of the Swedish translation of the Medication Adherence Report Scale-5 (MARS-5) in a sample of patients who use mood stabilising medicines for bipolar disorder. A further aim was to compare the Swedish translation of the MARS-5 with the Swedish translation of the four-item scale Morisky Medication Adherence Scale (MMAS-4).Method: The study population (n=47, 70% women) was recruited through patient education sessions, at a Patient Association meeting, in Gothenburg, Sweden, as well as through advertisements on the home pages and newsletters of the Swedish patient associations. Participants received the Swedish translations of the MARS-5 and the MMAS-4, and questions on age, education, and country of birth. Reliability was examined for internal consistency (Cronbach’s α) and test-retest (intraclass correlation (ICC), MARS-5: Pearson’s correlation coefficient (r), MMAS-4: Spearman’s rho (ρ)). The acceptability of the MARS-5 was examined with a correlation analysis between the MARS-5 and the MMAS-4 and for face validity.Results: In the study population 53.3% were categorised as adherent with the MARS-5 and 82.6% using the MMAS-4. The value of Cronbach’s α was 0.66 for the MARS-5 and 0.37 for the MMAS-4. The test-retest of the MARS-5 resulted in r=0.90 and ICC=0.91. Corresponding values for the MMAS-4 were ρ=0.84 and ICC=0.85. The correlation between the MARS-5 and the MMAS-4 was 0.55. The face validity resulted in four comments regarding difficulties in answering the MARS-5.Conclusion: The Swedish translation of the MARS-5 ought to be used instead of the MMAS-4 to measure self-reported adherence in a Swedish sample with bipolar disorder. The MARS-5 showed good psychometric properties.

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Author Biographies

Annika Bäck, Social Medicine, Department of Public Health and Community Medicine at Institute of Medicine, Sahlgrenska Academy at University of Gothenburg

Professional rank: Research AssistantAcademic rank: MSc

Karolina Andersson Sundell, Nordic School of Public Health

Professional rank: Associate ProfessorAcademic rank: MPharmSc, PhD

Robert Horne, Center for Behavioural Medicine, the School of Pharmacy, University of London

Professional rank: ProfessorAcademic rank: BSc MSc PhD MRPharm

Mikael Landén, Department of Psychiatry and Neurochemistry at Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg

Professional rank: ProfessorAcademic rank: MD PhD

Ann-Charlotte Mårdby, Social Medicine, Department of Public Health and Community Medicine at Institute of Medicine, Sahlgrenska Academy at University of Gothenburg

Professional rank: LecturerAcademic rank: Pharmacist, MSc, PhD


Sajatovic M. Bipolar disorder: disease burden. Am J Manag Care 2005 Jun;11(3 Suppl):S80-4.

Miklowitz DJ, Johnson SL. The psychopathology and treatment of bipolar disorder. Annu Rev Clin Psychol 2006;2:199-235.

Carney SM, Goodwin GM. Lithium - a continuing story in the treatment of bipolar disorder. Acta Psychiatr Scand Suppl 2005(426):7-12.

Rosa AR, Marco M, Fachel JM, Kapczinski F, Stein AT, Barros HM. Correlation between drug treatment adherence and lithium treatment attitudes and knowledge by bipolar patients. Prog Neuropsychopharmacol Biol Psychiatry 2007 Jan 30;31(1):217-24.

Scott J, Pope M. Nonadherence with mood stabilizers: prevalence and predictors. J Clin Psychiatry 2002 May;63(5):384-90.

Skeppar P, Adolfsson R. Bipolar II and the bipolar spectrum. Nord J Psychiatry. [Review]. 2006;60(1):7-26.

Keck PE, Jr., McElroy SL, Strakowski SM, West SA, Sax KW, Hawkins JM, Bourne ML, Haggard P. 12-month outcome of patients with bipolar disorder following hospitalization for a manic or mixed episode. Am J Psychiatry 1998 May;155(5):646-52.

World Health Organization. Adherence to long-term therapies: Evidence for action. Geneva 2003.

Bates JA, Whitehead R, Bolge SC, Kim E. Correlates of Medication Adherence Among Patients With Bipolar Disorder: Results of the Bipolar Evaluation of Satisfaction and Tolerability (BEST) Study: A Nationwide Cross-Sectional Survey. Prim Care Companion J Clin Psychiatry 2010;12(5).

Gonzalez-Pinto A, Reed C, Novick D, Bertsch J, Haro JM. Assessment of medication adherence in a cohort of patients with bipolar disorder. Pharmacopsychiatry 2010 Nov;43(7):263-70.

Martinez-Aran A, Scott J, Colom F, et al. Treatment nonadherence and neurocognitive impairment in bipolar disorder. J Clin Psychiatry 2009 Jul;70(7):1017-23.

Hassan M, Lage MJ. Risk of rehospitalization among bipolar disorder patients who are nonadherent to antipsychotic therapy after hospital discharge. Am J Health Syst Pharm 2009 Feb 15;66(4):358-65.

DelBello MP, Hanseman D, Adler CM, Fleck DE, Strakowski SM. Twelve-month outcome of adolescents with bipolar disorder following first hospitalization for a manic or mixed episode. Am J Psychiatry 2007 Apr;164(4):582-90.

Bagalman E, Yu-Isenberg KS, Durden E, Crivera C, Dirani R, Bunn WB, 3rd. Indirect costs associated with nonadherence to treatment for bipolar disorder. J Occup Environ Med 2010 May;52(5):478-85.

DiMatteo MR. Variations in patients' adherence to medical recommendations: a quantitative review of 50 years of research. Med Care 2004 Mar;42(3):200-9.

Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005 Aug 4;353(5):487-97.

Gaudiano BA, Weinstock LM, Miller IW. Improving treatment adherence in bipolar disorder: a review of current psychosocial treatment efficacy and recommendations for future treatment development. Behav Modif 2008 May;32(3):267-301.

Velligan D, Sajatovic M, Valenstein M, Riley WT, Safren S, Lewis-Fernandez R, Weiden P, Ogedegbe G, Jamison J. Methodological challenges in psychiatric treatment adherence research. Clin Schizophr Relat Psychoses 2010 Apr;4(1):74-91.

Busby KK, Sajatovic M. REVIEW: Patient, treatment, and systems-level factors in bipolar disorder nonadherence: A summary of the literature. CNS Neurosci Ther 2010 Oct;16(5):308-15.

Garber MC, Nau DP, Erickson SR, Aikens JE, Lawrence JB. The concordance of self-report with other measures of medication adherence: a summary of the literature. Med Care 2004 Jul;42(7):649-52.

Jonsdottir H, Opjordsmoen S, Birkenaes AB, Engh JA, Ringen PA, Vaskinn A, Aamo TO, Friis S, Andreassen OA. Medication adherence in outpatients with severe mental disorders: relation between self-reports and serum level. J Clin Psychopharmacol 2010 Apr;30(2):169-75.

Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care 1986 Jan;24(1):67-74.

Morisky DE, Malotte CK, Choi P, Davidson P, Rigler S, Sugland B, Langer M. A patient education program to improve adherence rates with antituberculosis drug regimens. Health Educ Q 1990 Fall;17(3):253-67.

Horne R, Weinman J. Self-regulation and Self-management in Asthma: Exploring The Role of Illness Perceptions and Treatment Beliefs in Explaining Non-adherence to Preventer Medication. Psychology & Health 2002;17(1):17-32.

Menckeberg TT, Bouvy ML, Bracke M, Kaptein AA, Leufkens HG, Raaijmakers JA, Horne R. Beliefs about medicines predict refill adherence to inhaled corticosteroids. J Psychosom Res 2008 Jan;64(1):47-54.

Cohen JL, Mann DM, Wisnivesky JP, Home R, Leventhal H, Musumeci-Szabo TJ, Halm EA. Assessing the validity of self-reported medication adherence among inner-city asthmatic adults: the Medication Adherence Report Scale for Asthma. Ann Allergy Asthma Immunol 2009 Oct;103(4):325-31.

Mora PA, Berkowitz A, Contrada RJ, Wisnivesky J, Horne R, Leventhal H, Halm EA. Factor structure and longitudinal invariance of the Medical Adherence Report Scale-Asthma. Psychol Health 2011 Jun;26(6):713-27.

George J, Kong DC, Thoman R, Stewart K. Factors associated with medication nonadherence in patients with COPD. Chest 2005 Nov;128(5):3198-204.

Butler JA, Peveler RC, Roderick P, Horne R, Mason JC. Measuring compliance with drug regimens after renal transplantation: comparison of self-report and clinician rating with electronic monitoring. Transplantation 2004 Mar 15;77(5):786-9.

Byrne M, Walsh J, Murphy AW. Secondary prevention of coronary heart disease: patient beliefs and health-related behaviour. J Psychosom Res 2005 May;58(5):403-15.

Farmer A, Kinmonth AL, Sutton S. Measuring beliefs about taking hypoglycaemic medication among people with Type 2 diabetes. Diabet Med 2006 Mar;23(3):265-70.

Ediger JP, Walker JR, Graff L, et al. Predictors of medication adherence in inflammatory bowel disease. Am J Gastroenterol 2007 Jul;102(7):1417-26.

Mahler C, Hermann K, Horne R, Ludt S, Haefeli WE, Szecsenyi J, Jank S. Assessing reported adherence to pharmacological treatment recommendations. Translation and evaluation of the Medication Adherence Report Scale (MARS) in Germany. J Eval Clin Pract 2010 Jun;16(3):574-9.

Mardby AC, Akerlind I, Jorgensen T. Beliefs about medicines and self-reported adherence among pharmacy clients. Patient Educ Couns 2007 Dec;69(1-3):158-64.

Linde M, Jonsson P, Hedenrud T. Influence of disease features on adherence to prophylactic migraine medication. Acta Neurol Scand 2008 Dec;118(6):367-72.

Axelsson M, Emilsson M, Brink E, Lundgren J, Toren K, Lotvall J. Personality, adherence, asthma control and health-related quality of life in young adult asthmatics. Respir Med 2009 Jul;103(7):1033-40.

Axelsson M, Brink E, Lundgren J, Lotvall J. The influence of personality traits on reported adherence to medication in individuals with chronic disease: an epidemiological study in West Sweden. PLoS One 2011;6(3):e18241.

Hunot VM, Horne R, Leese MN, Churchill RC. A Cohort Study of Adherence to Antidepressants in Primary Care: The Influence of Antidepressant Concerns and Treatment Preferences. Prim Care Companion J Clin Psychiatry 2007;9(2):91-9.

Bowskill R, Clatworthy J, Parham R, Rank T, Horne R. Patients' perceptions of information received about medication prescribed for bipolar disorder: implications for informed choice. J Affect Disord 2007 Jun;100(1-3):253-7.

Clatworthy J, Bowskill R, Parham R, Rank T, Scott J, Horne R. Understanding medication non-adherence in bipolar disorders using a Necessity-Concerns Framework. J Affect Disord 2009 Jul;116(1-2):51-5.

George CF, Peveler RC, Heiliger S, Thompson C. Compliance with tricyclic antidepressants: the value of four different methods of assessment. Br J Clin Pharmacol 2000 Aug;50(2):166-71.

Kim E, Gupta S, Bolge S, Chen CC, Whitehead R, Bates JA. Adherence and outcomes associated with copayment burden in schizophrenia: a cross-sectional survey. J Med Econ 2010;13(2):185-92.

Adewuya AO, Owoeye OA, Erinfolami AR, et al. Prevalence and correlates of poor medication adherence amongst psychiatric outpatients in southwestern Nigeria. Gen Hosp Psychiatry 2009 Mar-Apr;31(2):167-74.

Stavropoulou C. Perceived information needs and non-adherence: evidence from Greek patients with hypertension. Health Expect 2011 Apr 18.

Bowling A. Research methods in health: investigating health and health services 2nd edition ed. Buckingham: Open University Press; 2002.

Altman D. Practical statistics for medical research. London: Chapman and Hall; 1991.

Pallant J. SPSS Survival Manual. 4th edition ed. Maidenhead: Open university press/McGraw-Hill; 2010.

Streiner DL. Starting at the beginning: an introduction to coefficient alpha and internal consistency. J Pers Assess 2003 Feb;80(1):99-103.

Briggs S, Cheek J. The role of factor analysis in the development and evaluation of personality scales. Journal of Personality 1986;54(1):106-48.

McGraw K, Wong SP. Forming Inferences About Some Intraclass Correlation Coefficients. Psychological Methods 1996;1(1):30-46.

Deyo RA, Diehr P, Patrick DL. Reproducibility and responsiveness of health status measures. Statistics and strategies for evaluation. Control Clin Trials 1991 Aug;12(4 Suppl):142S-58S.

Assessing health status and quality-of-life instruments: attributes and review criteria. Qual Life Res 2002 May;11(3):193-205.

Hopkins WG. Measures of reliability in sports medicine and science. Sports Med 2000 Jul;30(1):1-15.

Leidy NK, Revicki DA, Geneste B. Recommendations for evaluating the validity of quality of life claims for labeling and promotion. Value Health 1999 Mar-Apr;2(2):113-27.

Koschack J, Marx G, Schnakenberg J, Kochen MM, Himmel W. Comparison of two self-rating instruments for medication adherence assessment in hypertension revealed insufficient psychometric properties. J Clin Epidemiol 2010 Mar;63(3):299-306.

Miasso AI, Monteschi M, Giacchero KG. Bipolar affective disorder: medication adherence and satisfaction with treatment and guidance by the health team in a mental health service. Rev Lat Am Enfermagem 2009 Jul-Aug;17(4):548-56.

Hou R, Cleak V, Peveler R. Do treatment and illness beliefs influence adherence to medication in patients with bipolar affective disorder? A preliminary cross-sectional study. Eur Psychiatry 2010 May;25(4):216-9.

Farmer KC. Methods for measuring and monitoring medication regimen adherence in clinical trials and clinical practice. Clin Ther 1999 Jun;21(6):1074-90; discussion 3.

Haynes RB, Taylor DW, Sackett DL, Gibson ES, Bernholz CD, Mukherjee J. Can simple clinical measurements detect patient noncompliance? Hypertension 1980 Nov-Dec;2(6):757-64.