Elsevier

Current Opinion in Psychology

Volume 5, October 2015, Pages 31-36
Current Opinion in Psychology

Treatment burden and treatment fatigue as barriers to health

https://doi.org/10.1016/j.copsyc.2015.03.004Get rights and content

Highlights

  • Burden associated with chronic care management may undermine treatment adherence.

  • Treatment fatigue may index when patient demands exceed coping capacity.

  • Treatments should aim to minimize treatment burden and increase patient capacity.

  • Technological innovations offer promising tools to reduce patient burden.

  • Additional research is needed to better understand treatment burden and fatigue.

Effective management of chronic diseases involves sustained changes in health behavior, which often requires substantial effort and patient burden. As treatment burden is associated with reduced adherence across several chronic conditions, its assessment and treatment are important clinical priorities. The balance between patient demands and capacity (e.g. coping resources) may be indexed by patients’ subjective experience of treatment fatigue. We present a modified workload–capacity model that incorporates evidence that treatment fatigue may, firstly, be caused by increased workload due to treatment burden (e.g. intensity, complications) and secondly, undermine adherence. Emerging technology-based interventions may be well-suited to reduce treatment burden, prevent treatment fatigue, and increase treatment adherence.

Section snippets

Chronic disease and health behaviors

The leading causes of chronic disease and preventable death are attributed to modifiable risk behaviors [1], such as minimal physical activity, poor nutrition, tobacco use, and overconsumption of alcohol. Although numerous interventions have been found to promote health behaviors within clinical trials, these often fail to translate into sustained, real world effectiveness. This disconnect has been attributed, in part, to poor adherence to self-administered treatments (e.g. medication,

Treatment burden

The science of treatment burden has advanced substantially since 2012. Several qualitative studies have been conducted to conceptualize patient concerns [10], [11], and examine how well these are addressed by primary care providers [12]. These studies are complemented by systematic reviews of studies that examined treatment burden both qualitatively [13], [14] and quantitatively [15•], [16]. Studies reviewed rarely focused on treatment burden specifically, but a priori definitions of burden

Treatment fatigue

Beyond assessment of treatment burden (i.e. how much effort is required for a given health behavior), a growing area of interest focuses on the impact of that burden. There is extensive research on physical fatigue caused by specific interventions (e.g. chemotherapy among cancer patients), but we focus on the psychological fatigue associated with treatment engagement, herein called treatment fatigue. This nascent literature is mostly restricted to diabetes and human immunodeficiency virus (HIV)

Integrative model and clinical implications

The treatment fatigue literature within diabetes and HIV both point toward the need for common terminology, definition, and measurement tools. A broader conceptualization of fatigue, across a range of chronic health behaviors, would facilitate a transdiagnostic understanding. Our workload–capacity model (Figure 1) incorporates the evidence that treatment fatigue may, firstly, be caused by increased workload due to treatment burden (e.g. intensity, complications) and secondly, undermine

Potential applications

With the exception of one study [29••], the concepts of treatment burden and fatigue have not been applied to understand the most common sources of morbidity and mortality: obesity, nicotine dependence, or alcohol dependence. These are chronic and relapsing conditions that require substantial effort to change, and may be susceptible to the same patterns described above. It is unclear if burden and fatigue will manifest differently when attempting to change behaviors that are hard to reduce

Future of chronic care

Behavioral intervention technologies offer scalable approaches to reduce patient efforts [33], [34], [35], [36], and are evolving rapidly [37], [38], [39]. Mobile phones are owned by 90% of American adults [40], representing a platform to increase accessibility to chronic care. Mobile health interventions (mHealth) can facilitate communication between health care providers and patients, thereby reducing burden associated with travel (e.g. transportation costs, time). Although mHealth has

Conclusions

Chronic disease management requires substantial effort, and is associated with both positive and negative consequences. The balance between patient demands and capacity may be indexed by treatment fatigue, and will determine the sustainability of the behavioral change (i.e. adherence). This suggests the need for ongoing efforts to reduce treatment burden and/or increase patient capacity to undertake necessary health behaviors. Innovations in technology-based interventions (e.g. mHealth) are

References and recommended reading

Papers of particular interest, published within the period of review, have been highlighted as:

  • • of special interest

  • •• of outstanding interest

Conflict of interest

None declared.

Acknowledgements

Funding for this research was provided by National Institute on Drug Abuse awards T32 DA007288 (BWH), and F32 DA036947 (ARM).

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