CLINICAL REVIEW Integrating psychology and medicine in CPAP adherence e New concepts? Megan R. Crawford a, d, * , Colin A. Espie b, d , Delwyn J. Bartlett c, d , Ron R. Grunstein c, d a Rush University Medical Center, Chicago, IL, USA b Nuffield Department of Clinical Neurosciences/Sleep & Circadian Neuroscience Institute, University of Oxford, UK c Woolcock Institute of Medical Research, Sydney, Australia d NHMRC Centre for The Integrated Research and Understanding of Sleep (CIRUS) Sydney Medical School, University of Sydney, Sydney, Australia article info Article history: Received 18 July 2012 Received in revised form 7 March 2013 Accepted 8 March 2013 Available online 29 May 2013 Keywords: Continuous positive airway pressure Biopsychosocial model Interaction Adherence summary To date, continuous positive airway pressure (CPAP) is the most effective intervention in the treatment of obstructive sleep apnoea, but adherence to this treatment is often less than optimal. A variety of factors and interventions that influence and improve CPAP use have been examined. There is increasing recognition of the multifaceted nature of CPAP adherence: the patient’s psychological profile and social environment have been recognised, in addition to the more extensively researched patient’s treatment and physiological profile. Understanding how these multiple factors impact on CPAP use in an integrative fashion might provide us with a useful holistic model of CPAP adherence. This concept of integration e a biopsychosocial (BPS) approach to health and illness e has previously been described to understand care provision for various chronic health disorders. This paper proposes an adherence framework, whereby variables integrally affect CPAP use. The BPS model has been considered for nearly 35 years; the presence of poor CPAP adherence was acknowledged in the early 1990s e it is timely to incorporate this approach into our care pathway of CPAP users. Ó 2013 Elsevier Ltd. All rights reserved. Introduction The whole is greater than the sum of its parts. e freely adapted from Metaphysica, Aristotle (384e322 BC). Aristotle understood that a holistic approach is crucial to a complete understanding of all aspects of life. More than 2000 years later, medicine has seemingly caught up with the value of inte- gration as opposed to reductionism. In the quest to deliver optimal patient care, psychiatrist George Engel’s seminal paper published in 1977 1 was a call towards a biopsychosocial model (from here on referred to as the BPS model), recognising that multiple domains (biomedical, psychological and social) integrally and interactively influence health and illness. It was envisaged as an addition to the medical model, rather than its replacement. The viewpoint that health and illness are defined by biological processes, resulting from injury, biochemical imbalances, bacterial or viral infections 1,2 often overlooked important individual experiential factors 3 and/or significant social or cultural variables, 4 which merit consideration alongside biomedical factors. The aetiology and progress of a dis- ease is thus influenced by biological processes, psychological experience and social behaviours, which are reciprocally related. 5 To warrant optimal treatment outcome for these diseases, there is then a need for interventions to target all three domains. Haynes stated that “[e]ffective ways to help people follow medical treatments could have far larger effects on health than any treatment itself.”, 6(p10) and this importance of adherence has recently been acknowledged by the World Health Organisation (WHO) in 2003. 7 Implicit within these claims, is the need to study adherence within an integrative framework. Non-adherence is now considered a public health concern: around 30,000 articles have been published on patient adherence, a figure similar to asthma (50,000) and 1/3 of what has been published on diabetes (Medline search with MeSH headings ‘patient compli- ance’, ‘asthma’ and ‘diabetes’). A recent meta-analysis reported that the average non-adherence rate of approximately 25% for complex treatment interventions translates to 188.3 million medical visits in the US resulting in patients failing to implement recommendations and equating to a monetary waste of potentially US$ 300 billion a year. 8 Apart from this economic cost, non-adherence inhibits the evaluation of treatment efficacy at the research level, and can hinder treatment effectiveness at the clinical level. * Corresponding author. Sleep Disorders Service and Research Center, Rush University Medical Center, 710 S Paulina, Chicago, IL 60612, USA. Tel.: þ1 312 942 0549. E-mail address: megan_crawford@rush.edu (M.R. Crawford). Contents lists available at SciVerse ScienceDirect Sleep Medicine Reviews journal homepage: www.elsevier.com/locate/smrv 1087-0792/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.smrv.2013.03.002 Sleep Medicine Reviews 18 (2014) 123e139