Special article

Early discontinuation of treatment for osteoporosis

We investigated if improving a patient's memory for the content of their treatment, via the Memory Support Intervention, improves illness course and functional outcomes. The platform for investigating this question was major depressive disorder (MDD) and cognitive therapy (CT). Adults diagnosed with MDD (N = 178) were randomly allocated to CT + Memory Support (n = 91) or CT-as-usual (n = 87). Both treatments were comprised of 20–26, 50-min sessions over 16 weeks. Blind assessments were conducted before and immediately following treatment (post-treatment) and 6 months later (6FU). Patient memory for treatment, assessed with a free recall task, was higher in CT + Memory Support for past session recall at post-treatment. Both treatment arms were associated with reductions in depressive symptoms and functional impairment except: CT + Memory Support exhibited lower depression severity at 6FU (b = -3.09, p = 0.050, d = −0.27), and greater reduction in unhealthy days from baseline to 6FU (b = −4.21, p = 0.010, d = −1.07), compared to CT-as-usual. While differences in illness course and functional outcomes between the two treatment arms were limited, it is possible that future analyses of the type of memory supports and longer follow-up may yield more encouraging outcomes.

ClinicalTrials.gov NCT01790919. Registered October 6, 2016.

Patient memory for the contents of treatment sessions is poor and this is associated with worse treatment outcome. Preliminary findings indicate that treatment provider use of memory support can be helpful in enhancing patient memory for treatment and improving outcome. The development of a novel Memory Support Intervention is currently underway. A key step in this process is to establish the dose of memory support that treatment providers deliver in treatment-as-usual, as well as the optimal dose of memory support needed to maximize patient memory for treatment points and outcomes.

Forty-two adults with major depressive disorder (MDD) were randomized to receive either cognitive therapy plus memory support (CS + Memory Support; n = 22) or cognitive therapy as-usual (CT-as-usual; n = 20). Patients completed a free recall of treatment points task at post-treatment. Outcome measures were administered at baseline and post-treatment.

Treatment providers delivering CT-as-usual used, on average, 8.39 instances of memory support and 3.40 different types of memory support per session. Receiver Operating Characteristics (ROC) analyses using the combined sample indicate that 12.45 instances of memory support and 3.88 to 4.13 different types of memory support are needed to maximize patient recall and functional outcome.

Dosing recommendations were established using a limited sample of participants receiving cognitive therapy for MDD.

Treatment providers appear to deliver a suboptimal amount of memory support. Delivering the optimal dose of memory support could improve treatment outcome.

The development of these guidelines is sponsored by the American Association of Clinical Endocrinologists (AACE) Board of Directors and American College of Endocrinology (ACE) Board of Trustees and adheres with published AACE protocols for the standardized production of clinical practice guidelines (CPGs).

Recommendations are based on diligent reviews of the clinical evidence with transparent incorporation of subjective factors, according to established AACE/ACE guidelines for guidelines protocols.

The Executive Summary of this 2020 updated guideline contains 52 recommendations: 21 Grade A (40%), 24 Grade B (46%), 7 Grade C (14%), and no Grade D (0%). These detailed, evidence-based recommendations allow for nuance-based clinical decision-making that addresses multiple aspects of real-world care of patients. The evidence base presented in the subsequent Appendix provides relevant supporting information for the Executive Summary recommendations. This update contains 368 citations: 123 (33.5%) evidence level (EL) 1 (highest), 132 (36%) EL 2 (intermediate), 20 (5.5%) EL 3 (weak), and 93 (25%) EL 4 (lowest). New or updated topics in this CPG include: clarification of the diagnosis of osteoporosis, stratification of the patient according to high-risk and very-high -risk features, a new dual-action therapy option, and transitions from therapeutic options.

This guideline is a practical tool for endocrinologists, physicians in general, regulatory bodies, health-related organizations, and interested laypersons regarding the diagnosis, evaluation, and treatment of postmenopausal osteoporosis. (Endocr Pract. 2020;26 (Suppl 1):1-44)

Despite multiple efforts at changing patient and provider behaviors to improve the use of pharmacologic medication for osteoporosis, the rates of compliance and persistence are still below desirable levels. This is a multifaceted problem that stems from a lack of knowledge, poor patient–provider communication, and powerful fears of the side effects of osteoporosis medications in general. This chapter covers issues of compliance and persistence as well as the ways in which osteoporosis causes or exacerbates psychosocial problems, including depression. Previous attempts to modify patient behavior in compliance and persistence have consistently failed, even though they have been well designed and based on the literature. I suggest here that cognitive reframing of osteoporosis in the minds of both patients and providers is essential to overcoming problems brought about by the media, the Internet, and websites that contain false information, and the poor educational efforts most patients receive.

Bisphosphonates that have been widely used in the treatment of osteoporosis are popular and effective agents with robust evidence for fracture risk reduction. Bisphosphonates bind avidly to bone and reduce osteoclastic bone resorption. These agents are generally safe and well-tolerated, although concerns about long-term use have emerged. For most patients with osteoporosis, the benefits of treatment outweigh the risks. Because these agents accumulate in bone with some persistent antifracture efficacy after therapy is stopped, it is reasonable to consider a bisphosphonate “holiday.” The duration of treatment and the length of the holiday should be based on individual assessments of risk and benefit.

Patient memory for treatment is poor and associated with worse outcome. The Memory Support Intervention was designed to improve outcome by enhancing patient memory for treatment. Half of the strategies comprising the Memory Support Intervention (termed constructive memory support strategies) involve therapists inviting patients to construct new ideas, inferences, or connections related to treatment material that go beyond information already presented by therapists. This study investigated the relationship between patient responses to therapist use of constructive memory support strategies and patient recall of treatment contents. Therapist uses of constructive memory support strategies were coded from sessions recorded during a pilot trial of the Memory Support Intervention in the context of cognitive therapy for depression (n = 44 patients). Patients who successfully constructed new ideas, inferences, or connections (termed patient constructive learning behavior) in response to therapist use of constructive memory support strategies showed greater recall of treatment contents. Mediation analyses provided some evidence that patient constructive learning behavior may be a mechanism through which the Memory Support Intervention results in enhanced patient memory. Results highlight patient constructive learning behavior as a potential pathway for improving patient memory for treatment.