|
websites like adherence.cc may be offering or implying authorization to use the MMAS-4 or MMAS-8. We want to unequivocally state that adherence.cc or any other entity issuing licenses is invalid unless it bears the signature of Dr. Donald Morisky himself.
Dr. Morisky is the sole copyright holder, and researchers, clinicians, and organizations must ensure that any license they obtain is directly signed by Dr. Morisky to be legally and ethically valid.
0 Comments
Understanding the Copyright and Licensing of the Morisky Medication Adherence Scale (MMAS)7/24/2025 The Morisky Medication Adherence Scale (MMAS), developed by Dr. Donald Morisky, is a globally recognized tool for assessing medication adherence in research and clinical settings. Available in two versions, the MMAS-4 and MMAS-8, these scales are widely used to evaluate patient adherence to prescribed medication regimens. However, it is critical to emphasize that both versions of the MMAS are protected by copyright owned exclusively by Dr. Donald Morisky.
Copyright Protection The MMAS-4 and MMAS-8 are proprietary instruments, and their use is strictly regulated under copyright law. Unauthorized use, reproduction, or distribution of these scales—whether in print, digital, or any other format—without explicit permission from Dr. Morisky constitutes a violation of intellectual property rights. Licensing Requirements Researchers, clinicians, and organizations seeking to use the MMAS in any capacity, including academic research, clinical practice, or digital applications, must obtain a valid license directly from Dr. Donald Morisky or his designated licensing agent. This requirement applies to all uses, including but not limited to: • Academic and clinical research studies • Integration into electronic health records or digital health platforms • Use in clinical trials or healthcare interventions • Educational or training purposes To ensure compliance, users must secure a signed license agreement from Dr. Morisky. Any license or agreement that does not bear Dr. Morisky’s signature is invalid and does not grant permission for use. Why Licensing Matters Obtaining a proper license ensures that users are adhering to legal and ethical standards while supporting the continued development and validation of the MMAS. The licensing process also provides access to the most current and validated versions of the scale, ensuring accuracy and reliability in your work. Avoiding Unauthorized Use Unfortunately, there have been instances of entities falsely claiming ownership or authorization to distribute the MMAS. To protect the integrity of your research or clinical practice, we strongly advise verifying the authenticity of any MMAS-related materials or agreements. Only licenses signed by Dr. Donald Morisky are legitimate. How to Obtain a License To request permission or inquire about licensing the MMAS-4 or MMAS-8, please contact Dr. Donald Morisky or his designated licensing agent directly. Ensure that all agreements are formalized in writing and signed by Dr. Morisky to avoid any legal or ethical issues. The following questionnaires are copyrighted, requiring permission or licensing for use, especially for commercial purposes or modifications: 1. Morisky Medication Adherence Scale (MMAS): • Purpose: Assesses medication adherence, commonly used for chronic conditions like hypertension or diabetes. Variants include the MMAS-4 (4 items) and MMAS-8 (8 items). • Copyright Status: The Morisky Scales are copyrighted by Donald E. Morisky and licensed through MMAR, LLC. Use requires permission and often a licensing fee, even for non-commercial research. The MMAS-8, for example, is explicitly noted as requiring a license for use, with restrictions on reproduction, translation, or adaptation without approval. • Conditions: Contact MMAR, LLC (via their website or authorized distributors like ePROVIDE by Mapi Research Trust) for licensing agreements. Fees may apply, and unauthorized use can lead to legal consequences. Proper citation to Morisky et al. is required. 2. Clinically Useful Depression Outcome Scale (CUDOS): • Purpose: A brief self-report scale (18 items) assessing depressive symptoms over the past week, covering DSM-IV criteria for major depressive disorder and dysthymic disorder. It takes less than 3 minutes to complete and is sensitive to change in clinical settings. • Copyright Status: Developed by Zimmerman et al. as part of the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, CUDOS is copyrighted. Permission is required for use, particularly for commercial purposes or modifications. It is available through specific publishers or the authors, often with licensing terms. • Conditions: Contact the authors (e.g., via the Rhode Island Hospital or related publications) or check with distributors like NP Psych Navigator for access. Use in research may require permission, and fees may apply for commercial use. Proper citation to Zimmerman et al. (2008) is necessary. 3. Clinically Useful Anxiety Outcome Scale (CUXOS): • Purpose: A self-report scale assessing anxiety symptoms, designed to be brief and clinically useful, similar to CUDOS. It covers DSM-IV anxiety disorder criteria and is used in clinical and research settings. • Copyright Status: Like CUDOS, CUXOS is copyrighted by Zimmerman et al. and part of the MIDAS project. Permission is required for use, reproduction, or adaptation, especially for commercial purposes. Access may be facilitated through publishers or the authors. • Conditions: Contact the authors or check with authorized distributors for licensing. Use in non-commercial research may be permitted with permission, but commercial use or modifications require explicit approval. Cite Zimmerman et al. for ethical use. 4. Patient Health Questionnaire (PHQ-9): • Purpose: Screens for depression severity (9 items). • Copyright Status: Copyrighted but freely available for non-commercial use by Pfizer. No permission is needed for clinical, research, or educational purposes, provided the tool is not altered. • Conditions: Modifications or commercial use require permission from the copyright holder (e.g., Department of Medical Social Sciences for related tools). Cite Kroenke et al. (2001). 5. Generalized Anxiety Disorder Scale (GAD-7): • Purpose: Screens for generalized anxiety disorder (7 items). • Copyright Status: Copyrighted but freely available for non-commercial use by Pfizer. No permission is required for standard use, but modifications or commercial applications need approval. • Conditions: Use as published and cite Spitzer et al. (2006). 6. Mini Mental State Examination (MMSE): • Purpose: Assesses cognitive impairment. • Copyright Status: Originally public domain (published 1975 without notice), but copyrighted since 2000 by MiniMental, LLC, and licensed to Psychological Assessment Resources (PAR), Inc. Use requires permission and often fees. • Conditions: Contact PAR, Inc. for licensing. Unauthorized use risks legal action. 7. Beck Depression Inventory (BDI-II): • Purpose: Measures depression severity (21 items). • Copyright Status: Copyrighted by Pearson, with strict licensing requirements. Use typically involves per-administration fees or licenses. • Conditions: Obtain permission from Pearson and cite Beck et al. (1996). Public Domain Diagnostic Self-Reported Questionnaires These questionnaires are free from copyright restrictions and can be used without permission, though citation is required for ethical use: 1. Center for Epidemiological Studies Depression Scale for Children (CES-DC): • Purpose: Screens for depression in children/adolescents (ages 6–17). • Copyright Status: Public domain, with no copyright restrictions noted. Freely available for use with proper citation. • Conditions: Cite Radloff (1977). No permission needed. 2. Adverse Childhood Experiences (ACE) Questionnaire: • Purpose: Assesses childhood trauma (10 items). • Copyright Status: Public domain, developed for the ACE study. Freely available for use. • Conditions: Cite the original study (Felitti et al., 1998). No permission required. 3. International Personality Item Pool (IPIP) Scales: • Purpose: Measures personality traits (analogs to commercial scales). • Copyright Status: Explicitly public domain, developed by Lew Goldberg. Free for use in research and education. • Conditions: Cite IPIP and Goldberg. No permission needed. 4. WHO Disability Assessment Schedule 2.0 (WHODAS 2.0): • Purpose: Measures health-related disability across six domains. • Copyright Status: Developed by the World Health Organization, freely available without copyright restrictions for non-commercial use. • Conditions: Cite WHO. No permission required. 5. Zung Self-Rating Depression Scale: • Purpose: Assesses depression severity. • Copyright Status: Published in 1965, often considered public domain due to age and lack of active copyright enforcement, but users should verify. Widely used without permission in research. • Conditions: Confirm status and cite Zung (1965). What is Unintentional non adherence? Introduction: The Hidden Barrier of Unintentional Non-Adherence7/12/2025 Unintentional non-adherence refers to the failure of patients to follow the prescribed treatment regimen due to factors beyond their control. These factors include forgetfulness, confusion about instructions, cognitive impairment, or practical barriers to medication access or administration. It is a significant issue in healthcare, affecting patients with chronic conditions and leading to suboptimal health outcomes. Understanding and addressing unintentional non-adherence is crucial for improving medication adherence and patient care Medication adherence is critical for managing chronic conditions like hypertension, diabetes, and asthma, yet up to 50% of patients struggle to take their medications as prescribed. While some choose to skip doses intentionally, many miss them unintentionally due to forgetfulness or logistical challenges. This phenomenon, known as unintentional non-adherence, is a major hurdle in healthcare, leading to worse health outcomes and increased costs. The 8-item Morisky Medication Adherence Scale (MMAS-8) has emerged as a powerful tool to identify these barriers, with four key questions pinpointing forgetfulness. In this post, we dive into unintentional non-adherence, explore the MMAS-8’s role, and share actionable solutions to improve adherence. What is Unintentional Non-Adherence? Unintentional non-adherence occurs when patients miss medication doses due to accidental reasons, such as forgetting, being too busy, or facing logistical issues like travel. Unlike intentional non-adherence (e.g., skipping doses due to side effects), unintentional lapses are often tied to memory or routine disruptions. Studies, like one from PLOS One (2017), show that up to 62% of patients report forgetting their medications, making it a leading cause of non-adherence. The MMAS-8: A Game-Changer for Identifying Unintentional Non-Adherence The MMAS-8, developed by Dr. Donald E. Morisky, is a validated self-report tool used globally to assess medication adherence. Its eight questions distinguish between intentional and unintentional non-adherence, with four specifically targeting forgetfulness and logistical barriers: 1. Do you sometimes forget to take your medication? 2. When you travel or leave home, do you sometimes forget to bring your medication? 3. Did you take your medication the last time you were supposed to take it? 4. How often do you have difficulty remembering to take all your medications? These questions, validated in studies like Revista Portuguesa de Cardiologia (2018), form the unintentional non-adherence subscale, helping clinicians identify patients struggling with forgetfulness. Why Unintentional Non-Adherence Matters Unintentional non-adherence has serious consequences: • Health Risks: Missed doses can worsen chronic conditions, leading to complications like heart attacks or asthma exacerbations. • Economic Impact: Non-adherence costs the U.S. healthcare system $100–$300 billion annually, per a 2012 PMC study. • Patient Quality of Life: Inconsistent medication use reduces treatment effectiveness, impacting daily functioning. Understanding and addressing unintentional non-adherence can improve patient outcomes and reduce healthcare costs. Validating Forgetfulness: Insights from Academic Research Academic studies have rigorously validated the MMAS-8’s unintentional non-adherence questions using multiple methods: • Asthma Study (2017, PLOS One): Compared MMAS-8 responses with pharmacy refill records and patient interviews. Forgetfulness (item 1) was common, but discrepancies with refill data suggested some patients reported it to mask intentional non-adherence. • Gout Study (2016, Patient Preference and Adherence): Used Medication Possession Ratio (MPR) and patient-reported outcomes to confirm that forgetfulness (items 1, 4, 8) was linked to complex regimens or travel disruptions. • Psychiatric Study (2014, International Journal of Clinical and Health Psychology): Correlated MMAS-8 with psychological scales, showing that cognitive issues contributed to forgetfulness in psychiatric patients. • Technology Review (2020, PMC): Found that electronic monitoring (e.g., MEMS) and reminder interventions reduced missed doses by 20% in patients reporting forgetfulness, validating MMAS-8 responses. These studies confirm that forgetfulness is a real barrier, though sometimes overstated, requiring tailored interventions. Strategies to Overcome Unintentional Non-Adherence Based on research and the MMAS-8’s insights, here are proven strategies to address forgetfulness: 1. Medication Reminders: • Smartphone Apps: Apps like Medisafe send alerts for dose times, helping patients who forget (item 1). • Smart Pill Bottles: Devices track openings and send reminders, as validated in the 2020 PMC review. 2. Simplified Regimens: • Switching to once-daily dosing reduces memory demands, addressing item 8 (difficulty remembering multiple doses). 3. Pill Organizers: • Weekly pillboxes help patients track doses, especially useful for those forgetting during travel (item 4). 4. Routine Integration: • Linking medication to daily habits (e.g., brushing teeth) minimizes forgetfulness, as suggested by patient interviews in the 2017 asthma study. 5. Education and Support: • Clinicians can use MMAS-8 results to discuss barriers and offer solutions, like travel-friendly packaging for item 4. Challenges in Addressing Unintentional Non-Adherence Despite progress, challenges remain: • Self-Report Bias: Patients may over-report forgetfulness to avoid admitting intentional non-adherence, as noted in the 2016 gout study. • Resource Limitations: Tools like electronic monitors are costly, limiting access in low-resource settings (PMC, 2020). • Complex Causes: Forgetfulness may stem from cognitive issues, chaotic schedules, or psychological factors, requiring comprehensive assessment. H2: The Future of Tackling Unintentional Non-Adherence Emerging technologies and research offer hope: • AI and Predictive Analytics: Machine learning could predict forgetfulness risk based on MMAS-8 responses, enabling proactive interventions. • Digital Health Tools: Wearables and smart dispensers are becoming more accessible, building on the 2020 PMC review’s findings. • Integrated Validation: Future studies should combine cognitive tests, electronic monitoring, and caregiver reports to fully validate forgetfulness, addressing gaps in current research. How to Get Started with the MMAS-8 Clinicians and researchers can use the MMAS-8 to identify unintentional non-adherence. To access the scale, visit www.moriskyscale.com for licensing details, as it’s copyrighted by Dr. Morisky. Administering the MMAS-8 during patient visits can pinpoint forgetfulness and guide tailored interventions. Conclusion Unintentional non-adherence, driven by forgetfulness and logistical barriers, is a significant challenge in medication management. The MMAS-8’s four questions on unintentional non-adherence (items 1, 4, 5, 8) provide a validated framework to identify these issues, backed by studies in asthma, gout, psychiatric care, and technology reviews. By leveraging reminders, simplified regimens, and patient education, healthcare providers can address forgetfulness and improve outcomes. As research and technology advance, the fight against unintentional non-adherence is gaining ground, offering hope for better chronic disease management. Call to Action: Are you struggling with medication adherence? Talk to your healthcare provider about the MMAS-8 or try a reminder app today. Share this post to spread awareness about overcoming unintentional non-adherence! Medication non-adherence is a persistent challenge in healthcare, contributing to poor health outcomes and billions in avoidable costs. The 8-item Morisky Medication Adherence Scale (MMAS-8) has become a cornerstone for assessing adherence, particularly by distinguishing between intentional (deliberate) and unintentional (accidental) non-adherence. Four of its questions—items 1, 4, 5 and 8—specifically target unintentional non-adherence, such as forgetfulness or logistical barriers. Recent academic studies have rigorously validated these questions, using innovative methods to confirm that forgetfulness is a genuine barrier to medication adherence. In this blog, we take a deep dive into the academic literature that has solidified the role of these four MMAS-8 questions, exploring how researchers have used objective measures, qualitative insights, and interventions to validate unintentional non-adherence and transform patient care.
The MMAS-8 and Unintentional Non-Adherence The MMAS-8, developed by Dr. Donald E. Morisky and colleagues, is a widely used self-report tool to assess medication adherence in chronic conditions like hypertension, asthma, and psychiatric disorders. Its eight questions include four that focus on unintentional non-adherence: 1. Do you sometimes forget to take your medication? (Item 1) 2. When you travel or leave home, do you sometimes forget to bring your medication? (Item 4) 3. Did you take your medication the last time you were supposed to take it? (Item 5) 4. How often do you have difficulty remembering to take all your medications? (Item 8) These questions capture behaviors like forgetting doses, missing medications due to logistical issues, or struggling with memory, forming the unintentional non-adherence subscale. Validating these items is critical, as self-reports can be skewed by recall bias or patients masking intentional non-adherence as forgetfulness. Academic studies have tackled this challenge by integrating multiple methods to confirm the accuracy of these responses, offering a robust framework for understanding and addressing unintentional non-adherence. Key Studies Validating Unintentional Non-Adherence Academic literature has employed diverse approaches—objective monitoring, clinical correlations, qualitative interviews, and intervention trials—to validate the MMAS-8’s unintentional non-adherence questions. Below, we explore pivotal studies that have deepened our understanding of forgetfulness as a barrier. 1. Asthma Adherence Study (2017) • Source: Criterion validity of 8-item Morisky Medication Adherence Scale in patients with asthma, PLOS One (2017) • Methods: • Pharmacy Refill Records: Researchers collected community pharmacy claims data to measure asthma medication dispensing, comparing it with MMAS-8 responses. • Qualitative Interviews: Patients provided detailed accounts of treatment barriers, including forgetfulness, during introductory interviews. • Clinical Outcomes: The Asthma Control Test (ACT) and Saint George Respiratory Questionnaire (SGRQ) assessed asthma control and quality of life, correlating with MMAS-8 scores. • Findings: • In a cohort of 208 asthma patients (mean age 56, 59% female), 37% had uncontrolled asthma, and 22% experienced exacerbations, suggesting non-adherence. MMAS-8 responses to items 1, 4, 5 and 8 showed moderate correlation with pharmacy data but weaker alignment than expected, hinting that some patients reported forgetfulness to mask intentional non-adherence (e.g., avoiding side effects). • Interviews revealed that forgetfulness (item 1) was often tied to complex regimens, while travel-related lapses (item 4) stemmed from disrupted routines. These qualitative insights validated situational forgetfulness as a barrier. • Significance: By combining objective (pharmacy records) and subjective (interviews, clinical outcomes) methods, this study confirmed that forgetfulness is a significant but sometimes overstated barrier, emphasizing the need for contextual probing to validate MMAS-8 responses. 2. Gout Adherence Study (2016) • Source: Utility of the Morisky Medication Adherence Scale in gout: a prospective study, Patient Preference and Adherence (2016) • Methods: • Pharmacy Refill Records: The Medication Possession Ratio (MPR) measured adherence to urate-lowering therapy (ULT). • Clinical Outcomes: Serum urate levels and remission status were correlated with MMAS-8 scores. • Patient-Reported Outcomes: The Gout Impact Scale (GIS) and EuroQoL-5 dimension (EQ5D) captured patient perspectives on adherence barriers. • Findings: • In a multiethnic Asian cohort, MMAS-8 showed good reliability (Cronbach’s alpha = 0.73), but its correlation with MPR was weak (r = 0.069, p = 0.521). Patients reporting forgetfulness (items 1, 4, 8) often cited side effect concerns or psychological factors (e.g., anxiety) via GIS/EQ5D, suggesting that forgetfulness may overlap with intentional non-adherence. • Item 4 (travel-related forgetfulness) was particularly relevant for patients with irregular schedules, validated by patient reports of logistical challenges. • Significance: The integration of MPR and patient-reported outcomes provided a nuanced view, confirming forgetfulness as a barrier while highlighting its potential as a socially acceptable excuse for intentional non-adherence. This study underscored the value of multi-method validation. 3. Psychiatric Outpatients Study (2014) • Source: Psychometric properties of the eight-item Morisky Medication Adherence Scale in a psychiatric outpatient setting, International Journal of Clinical and Health Psychology (2014) • Methods: • Qualitative Interviews: Conducted with 967 psychiatric outpatients to collect MMAS-8 responses and socio-demographic/clinical data. • Psychological Assessments: Correlated MMAS-8 with scales like the Drug Attitude Inventory and Multidimensional Health Locus of Control to explore cognitive and attitudinal factors. • Clinical Correlations: Adherence was compared across mental disorder diagnoses (e.g., schizophrenia, depression). • Findings: • Item 8 (“How often do you have difficulty remembering to take all your medications?”) had the highest factor loading (r = 0.74), indicating forgetfulness as a key barrier in psychiatric patients. Patients with higher psychological reactance or belief in chance-based health outcomes reported more forgetfulness, suggesting cognitive factors. • Interviews clarified that forgetfulness (items 1, 4, 8) was often linked to cognitive deficits or chaotic routines, validated indirectly by psychological scale correlations. • Significance: This study validated forgetfulness through psychological and clinical correlations, highlighting cognitive barriers in psychiatric populations. While lacking objective measures like electronic monitoring, it provided robust subjective validation. 4. Hypertension in Seniors Study (2009) • Source: New medication adherence scale versus pharmacy fill rates in seniors with hypertension, American Journal of Managed Care (2009) • Methods: • Pharmacy Refill Records: Compared MMAS-8 scores with pharmacy fill rates in hypertensive seniors. • Clinical Outcomes: Blood pressure control was used as a proxy for adherence. • Findings: • MMAS-8 responses, including forgetfulness items (1, 4, 5, 8), showed moderate concordance with fill rates. Patients reporting forgetfulness had lower fill rates, supporting the validity of these items, though discrepancies suggested some intentional non-adherence. • Better blood pressure control correlated with higher MMAS-8 scores (p < 0.05), indirectly validating reported adherence behaviors. • Significance: This study used objective pharmacy data and clinical outcomes to confirm that forgetfulness is a measurable barrier, though it highlighted the need for additional methods to rule out intentional factors. 5. Technology-Based Adherence Review (2020) • Source: Technologies for Medication Adherence Monitoring and Technology Assessment Criteria, PMC (2020) • Methods: • Electronic Monitoring Devices: Reviewed studies using Medication Event Monitoring Systems (MEMS) and video-based directly observed therapy (VDOT) alongside MMAS-8. • Intervention Trials: Evaluated reminder systems (e.g., smart pill bottles, apps) to test forgetfulness as a barrier. • Qualitative Studies: Analyzed patient experiences with adherence technologies. • Findings: • MEMS data showed that MMAS-8 forgetfulness items (1, 4, 8) overestimated adherence compared to actual bottle openings, with discrepancies in ~30% of cases. However, intervention trials with reminders reduced missed doses by 20% in patients reporting forgetfulness, validating these claims. • Qualitative data confirmed that forgetfulness was often tied to complex regimens or travel (item 4), supporting the situational nature of unintentional non-adherence. • Significance: This review demonstrated that electronic monitoring and interventions provide strong evidence for forgetfulness, with reminder trials offering practical validation by improving adherence. Why These Studies Matter These studies collectively validate the MMAS-8’s unintentional non-adherence questions by: • Cross-Referencing Objective and Subjective Data: Pharmacy refill records (e.g., asthma, gout, hypertension studies) and electronic monitoring (2020 review) provide objective benchmarks, while interviews and patient-reported outcomes add context, confirming forgetfulness as a barrier. • Testing Interventions: Reminder systems (2020 review) directly validate forgetfulness by showing improved adherence, as seen in trials where smart pill bottles addressed issues flagged by items 1 and 8. • Exploring Cognitive Factors: The psychiatric study (2014) links forgetfulness to cognitive and psychological barriers, offering indirect validation through correlations with mental health measures. • Highlighting Complexities: Discrepancies between MMAS-8 and objective measures (e.g., weak MPR correlation in gout study) reveal that forgetfulness may sometimes mask intentional non-adherence, prompting deeper investigation Academic literature has robustly validated the MMAS-8’s four unintentional non-adherence questions through integrated methods like pharmacy records, electronic monitoring, interviews, and intervention trials. Studies in asthma (2017), gout (2016), psychiatric care (2014), hypertension (2009), and technology reviews (2020) confirm that forgetfulness is a measurable barrier, though sometimes conflated with intentional non-adherence. These findings empower healthcare providers to tailor interventions—whether reminders, simplified regimens, or patient education—improving adherence and outcomes. As research continues to refine these methods, the MMAS-8 remains a vital tool for tackling one of healthcare’s biggest challenges. 1. Study: Validation of MMAS-8 in Asthma Patients (2017) • Source: Criterion validity of 8-item Morisky Medication Adherence Scale in patients with asthma, PLOS One • Methods Integrated: • Pharmacy Refill Records: Data on asthma medication dispensing were collected from community pharmacy claims to validate self-reported adherence. • Qualitative Interviews: Introductory interviews gathered patient-reported data on asthma treatment, exacerbations, and demographic characteristics to contextualize MMAS-8 responses. • Clinical Outcomes (Asthma Control Test, ACT): The study assessed criterion validity by correlating MMAS-8 scores with asthma control (ACT) and quality of life (Saint George Respiratory Questionnaire, SGRQ). • Findings: • The study included 208 asthma patients (mean age 56, 59% female). MMAS-8 responses, including items 1, 4, and 8 (forgetfulness-related), were compared with pharmacy claims data and clinical outcomes. • Asthma was uncontrolled in 37% of patients, and 22% had exacerbations, suggesting non-adherence. MMAS-8 showed moderate criterion validity, but forgetfulness (e.g., item 1: “Do you sometimes forget to take your medication?”) was not strongly correlated with pharmacy refill gaps, indicating possible intentional non-adherence or recall bias. • Qualitative interviews helped clarify that some patients reported forgetfulness due to complex regimens or situational factors (e.g., travel, item 4). • Relevance to Forgetfulness: The integration of pharmacy records and interviews helped validate whether reported forgetfulness aligned with objective non-adherence patterns, though discrepancies suggested some patients may misreport intentional non-adherence as forgetfulness. • Limitations: Pharmacy claims don’t confirm medication ingestion, and interviews may be subject to social desirability bias. 2. Study: MMAS-8 in Gout Patients (2016) • Source: Utility of the Morisky Medication Adherence Scale in gout: a prospective study, Patient Preference and Adherence • Methods Integrated: • Pharmacy Refill Records: Medication Possession Ratio (MPR) was used to measure adherence to urate-lowering therapy (ULT) and compared with MMAS-8 scores. • Clinical Outcomes: Serum urate levels and remission status were correlated with MMAS-8 responses to assess construct validity. • Qualitative Patient-Reported Outcomes: The Gout Impact Scale (GIS) and EuroQoL-5 dimension (EQ5D) collected patient perspectives on adherence barriers, including forgetfulness. • Findings: • The study involved a multiethnic Asian cohort on ULT. MMAS-8 had good internal consistency (Cronbach’s alpha = 0.73) and test-retest reliability (ICC = 0.702). However, there was no significant correlation between MMAS-8 scores and MPR (r = 0.069, p = 0.521), suggesting that self-reported forgetfulness (items 1, 4, 8) did not always align with refill data. • Patients reporting forgetfulness often cited concerns about side effects or underlying anxiety/depression, identified through GIS and EQ5D, indicating that forgetfulness may mask intentional non-adherence. • The study identified patients with forgetfulness-related non-adherence (e.g., item 4: travel-related) who benefited from targeted education, suggesting intervention trials could validate these barriers. • Relevance to Forgetfulness: The combination of MPR and patient-reported outcomes helped distinguish genuine forgetfulness from other barriers, though weak correlation with MPR highlighted limitations in self-reports. • Limitations: MPR assumes medication is taken as prescribed, which may not reflect actual behavior. The study did not use electronic monitoring or cognitive assessments. 3. Study: MMAS-8 in Psychiatric Outpatients (2014) • Source: Psychometric properties of the eight-item Morisky Medication Adherence Scale in a psychiatric outpatient setting, International Journal of Clinical and Health Psychology • Methods Integrated: • Qualitative Interviews: Conducted with 967 psychiatric outpatients to collect MMAS-8 responses and socio-demographic/clinical data. • Cognitive Assessments (Indirect): The study correlated MMAS-8 scores with psychological measures (e.g., Drug Attitude Inventory, Multidimensional Health Locus of Control, Hong Psychological Reactance Scale) to assess cognitive and attitudinal factors influencing forgetfulness. • Clinical Outcomes: MMAS-8 was used to differentiate adherence levels across mental disorder diagnoses (e.g., schizophrenia, depression), indirectly validating forgetfulness through clinical patterns. • Findings: • The Spanish version of MMAS-8 showed adequate construct validity (one-factor solution) and significant correlations with psychological measures. Item 8 (“How often do you have difficulty remembering to take all your medications?”) had the highest factor loading (r = 0.74), emphasizing forgetfulness as a key barrier. • Patients with higher psychological reactance or belief that health depends on chance reported more forgetfulness, suggesting cognitive torpedoing as a cognitive issue. Qualitative interviews provided context for these responses. • No direct cognitive tests were used, but psychological scales indirectly assessed cognitive factors like memory or attention. • Relevance to Forgetfulness: The study validated forgetfulness (items 1, 4, 8) by linking MMAS-8 responses to psychological factors, suggesting that cognitive issues contribute to unintentional non-adherence in psychiatric patients. • Limitations: Lack of objective measures like electronic monitoring or pharmacy records limited direct validation of forgetfulness. The study relied heavily on self-reports and psychological correlations. 4. Study: MMAS-8 in Hypertensive Seniors (2009) • Source: New medication adherence scale versus pharmacy fill rates in seniors with hypertension, American Journal of Managed Care • Methods Integrated: • Pharmacy Refill Records: Pharmacy fill rates were compared with MMAS-8 scores to assess adherence in hypertensive seniors. • Clinical Outcomes: Blood pressure control was used as a proxy for adherence, correlating with MMAS-8 responses. • Findings: • The study found that MMAS-8 scores, including forgetfulness-related items (1, 4, 8), had moderate concordance with pharmacy fill rates (sensitivity and’) • specificity values not fully reported). Patients reporting forgetfulness (e.g., item 1) often had lower fill rates, supporting the validity of self-reported forgetfulness, though some discrepancies suggested intentional non-adherence. • Blood pressure control was significantly associated with higher MMAS-8 scores (p < 0.05), reinforcing the link between reported adherence and clinical outcomes. • Relevance to Forgetfulness: Pharmacy refill data provided an objective measure to validate self-reported forgetfulness, while clinical outcomes offered indirect evidence of adherence behaviors. • Limitations: No electronic monitoring or cognitive assessments were included, and pharmacy data cannot confirm actual medication ingestion. 5. Study: Technologies for Medication Adherence Monitoring (Narrative Review, 2020) • Source: Technologies for Medication Adherence Monitoring and Technology Assessment Criteria, PMC • Methods Integrated: • Electronic Monitoring Devices: Reviewed studies using Medication Event Monitoring Systems (MEMS) and video-based directly observed therapy (VDOT) to track adherence, often compared with self-reports like MMAS-8. • Intervention Trials: Discussed trials testing reminder systems (e.g., smart pill bottles, mobile apps) to address forgetfulness, measuring changes in adherence. • Qualitative Studies: Included qualitative analyses of patient experiences with adherence technologies, exploring reasons for forgetfulness. • Findings: • Electronic monitoring (e.g., MEMS) showed that self-reported forgetfulness on MMAS-8 (items 1, 4, 8) often overestimated adherence compared to device data, with discrepancies in up to 30% of cases in some studies. • Intervention trials with reminders improved adherence in patients reporting forgetfulness, supporting the validity of these claims. For example, a study cited in the review found that smart pill bottles reduced missed doses by 20% in patients with high forgetfulness scores on MMAS-8. • Qualitative data revealed that forgetfulness was often linked to complex regimens or lack of routines, validating situational barriers (e.g., item 4: travel-related forgetfulness). • Relevance to Forgetfulness: The integration of electronic monitoring and intervention trials provided robust evidence that forgetfulness is a significant barrier, particularly when confirmed by reduced missed doses after reminder interventions. • Limitations: Electronic monitoring is a proxy measure (e.g., bottle openings don’t confirm ingestion), and qualitative data may be biased. The review noted high costs of MEMS as a barrier to widespread use. Key Insights from Integrated Approaches • Complementary Strengths: Combining objective measures (e.g., pharmacy refills, electronic monitoring) with subjective methods (e.g., MMAS-8, interviews) helps validate forgetfulness by cross-referencing self-reports with behavioral data. For example, the asthma study () used pharmacy data and interviews to confirm that forgetfulness was a common but sometimes overstated reason for non-adherence. • Intervention Trials as Validation: Studies testing reminder systems (e.g.,) provide strong evidence for forgetfulness when adherence improves post-intervention, as seen in trials where smart pill bottles reduced missed doses for patients reporting forgetfulness on MMAS-8. • Cognitive and Psychological Context: Psychiatric studies () highlight that forgetfulness may be influenced by cognitive factors (e.g., memory issues) or psychological reactance, validated through correlations with psychological scales rather than direct cognitive tests. • Limitations: • Objective measures like MEMS or pharmacy refills don’t confirm ingestion, only access to medication. • Self-reports, including MMAS-8, are prone to social desirability bias, where patients may over-report forgetfulness to mask intentional non-adherence (). • Few studies integrate all methods (e.g., cognitive assessments are rarely combined with electronic monitoring), limiting comprehensive validation. The 8-item Morisky Medication Adherence Scale (MMAS-8) has emerged as a gold standard for assessing adherence, offering a simple yet powerful tool to identify barriers. A key breakthrough in its application lies in pinpointing the four questions that specifically address unintentional non-adherence, such as forgetfulness, providing clinicians and researchers with actionable insights to improve patient care. In this blog, we explore these four questions, their significance, and how they’re reshaping our approach to medication adherence.
Below are key findings from relevant articles: • Cross-cultural adaptation and validation of a European Portuguese version of the 8-item Morisky Medication Adherence Scale (Revista Portuguesa de Cardiologia, 2018): • This study tested a two-dimensional model of the MMAS-8, separating items into unintentional and intentional non-adherence subscales. Items 1, 4, and 8 were explicitly included in the unintentional non-adherence subscale, focusing on behaviors like forgetting to take medication or missing doses due to reasons other than intentional choice. The study reported a Cronbach’s alpha of 0.65 for the unintentional non-adherence subscale, indicating acceptable internal consistency for these items. • Unintentional non-adherence to chronic prescription medications: How unintentional is it really? (PMC, 2012): • This article analyzed unintentional non-adherence using data from the Harris Interactive Chronic Illness Panel, involving 24,017 adults. It identified items 1, and 8 of the MMAS-8 as directly assessing unintentional non-adherence behaviors, such as forgetting to take medication (reported by 62% of respondents), running out of medication (37%), and being careless (23%). While item 4 (travel-related forgetfulness) was not explicitly highlighted in this study, it aligns with unintentional behaviors discussed in other sources. The study emphasized that unintentional non-adherence may be influenced by underlying beliefs, suggesting a complex interplay with intentional non-adherence. • Psychometric properties of the eight-item Morisky Medication Adherence Scale in a psychiatric outpatient setting (International Journal of Clinical and Health Psychology, 2014): • This study described the MMAS-8 as a tool designed to capture both intentional and unintentional non-adherence. It noted that items addressing forgetfulness and logistical barriers (e.g., items 1, 4, and 8) are associated with unintentional non-adherence, such as forgetting to take medication or failing to bring it when traveling. The article highlighted the scale’s ability to identify barriers like forgetfulness in psychiatric patients |
AuthorDr Donald Morisky. Archives
October 2025
Categories |
RSS Feed