Several factors can contribute to non-adherence of long-term treatment
Patient Adherence to Psychiatric drugs to long-term use of a psychiatric drug regimen can pose a clinical challenge to providers.
Several variables can play a role in such non-adherence, including the type of psychiatric illness, the frequency of therapy, and various patient-specific factors.
“Similar to any area of medicine, adherence to long-term medication is definitely an issue,” explained Nathaniel Clark, MD, of Vanderbilt Behavioral Health in Nashville. “If you don’t take medications on an ongoing basis, just think back to the last time you had to take a course of antibiotics for 5 or 10 days. It can be a challenge, especially if the prescription is to take the pills more than once a day. Imagine extending that time course from days to years or decades.”
He told Med-Page Today that many patients will also simply stop taking the medication once they feel better. “Also, many long-term medications are to maintain wellness, and over time it can be easy to lose sight of the benefits of the medicine if you aren’t feeling well,” Clark said.
Role of Diagnosis
Certain psychiatric illnesses can also raise the risk for a patient being non-adherent to medication. These said the rate of non-adherence to medication is highest among younger patients with schizophrenia, as well as bipolar disorder.
“Men tend to be less adherent than women,” he added.
Clark agreed, stating, “Diagnostically, there is still research being done, but it does appear that while medication adherence is an issue regardless of diagnosis, severe bipolar disorder and severe schizophrenia can present specific challenges to the prescribing clinician.”
However, healthcare providers should consider each patient individually when judging their risk for non-adherence, taking into account multiple factors in addition to their diagnosis, he said.
“There appear to be multiple risk factors in why any particular individual may not take medications long-term. Some of these include not agreeing with the diagnosis, having multiple comorbid illnesses, especially substance use disorders, having worse side effects to medications, irregular attendance at follow-up appointments, and having a worse relationship with your prescribe or poorer experiences with the medical field as a whole,” Clark continued. “On the other hand, having high motivation for wellness, good support for recovery, and good education around the reasons for medication and side effects appear to be helpful.”
Recommendations for Increasing Adherence
When it comes to bolstering patient adherence to long-term psychiatric drugs, having a strong patient-provider relationship is one helpful factor.
“Any person taking long-term psychiatric medication can benefit by having a strong patient-clinician relationship, with regular discussion about the patient’s treatment goals,” Clark emphasized, adding that a strong relationship “helps focus discussions on what really matters to the patient, and can help guide known strategies to improve medication adherence such as education about diagnosis and the reason for the medication, and frequent discussion about expectations and side effects.”
These agreed, recommending to other providers: “You want to try to establish a collaborative relationship and give patients the chance to talk about the things they don’t like about taking medication. Patients receiving psychotherapy tend to be more adherent to medications than patients only receiving medication: talking about these issues can help!”
“Sometimes, people have a sense that their complaints about side effects are not heard or not acted upon,” he continued. “Simplifying regimens helps — e.g., fewer medications, fewer dose times.”
As for patients on anti-psychotics, long-lasting first- and second-generation therapies delivered via depot injections into a large muscle that are given every 2, 4, or even 6 weeks could be a preferable option, Thase suggested. These include aripiprazole (Abilify Maintena), aripiprazole lauroxil (Aristada), fluphenazine (Prolixin), haloperidol (Haldol Decanoate), olanzapine pamoate (Zyprexa Relprevv), paliperidone (Invega Sustenna, Invega Trinza), and risperidone (Perseris, Risperdal Consta).
There is “strong evidence that long-acting injectable medications are helpful for reducing the risk of relapses and hospitalization for those with schizophrenia and substance use disorders,”
“Keep in mind the quote ‘without mental health, there can be no true physical health,’ and prioritize adherence to psychiatric medications with those with comorbid illnesses,” he concluded.
Psycho-therapeutic Strategies to Enhance Medication Adherence
Treatment non-adherence in psychiatric patients contributes to increased suicide rates, illness exacerbation, hospitalization, and mortality. Non-adherence affects family relationships and society as a whole by both direct costs and loss of productivity. Most experienced clinicians do not need data to convince them of the widespread nature of this problem, but some recent work illustrates how pervasive it is.
Findings indicate non-adherence rates of 40% to 60% for anti-psychotics, 30% to 97% for antidepressants, and 18% to 56% for mood stabilizers.1-4 Julius and colleagues5 examined the rate of medication nonadherence based on diagnosis. The rate of non-adherence was 28% to 52% for MDD, 20% to 50% for bipolar disorder, 20% to 72% for schizophrenia, and 57% for anxiety disorder. An inpatient cross-sectional study showed that the rate of nonadherence was 45.5% for bipolar disorder, 12.1% for schizophrenia/schizoaffective disorder, 18.2% for depression, and 24.2% in other disorders.6
Patient outcomes may be improved by systematically targeting adherence in all patients who are given psychotropic medication; the
Adjunctive cognitive-behavioral therapies
CBT for bipolar disorder can enhance treatment adherence and improve overall treatment outcome. Cochran obtained significant improvement in adherence in outpatients with bipolar disorder by applying CBT strategies to enhance knowledge about treatment and to change attitudes toward treatment. Another CBT study in bipolar disorder showed decreased relapse rates with increased medication adherence. Randomly assigned patients with bipolar disorder and comorbid substance use disorders—a particularly difficult group to manage—received 12 weeks of low-intensity medication monitoring alone or in combination with CBT. The CBT group showed improved medication adherence on a compound measure derived from both patient self-report and blood levels of mood stabilizers.
In patients with schizophrenia, a number of studies have increased adherence to psychotropic medication by employing motivational interviewing and CBT. Gray and associates reported that CBT has significant effects not only on medication adherence but in improved attitudes of patients toward treatment.
All clinicians can employ principles of CBT in their work with patients. Even in brief medication management sessions, elements of CBT can be tailored to the needs of the patient to enhance outcomes.
Challenges to taking medication
For many patients, taking medication can be a challenge. Patients more easily discuss difficulty with adherence when clinicians are transparent about how universal the problem is. Judicious use of self-disclosure may help to make it safe enough for the patient to tell you the truth. If you are comfortable, let the patient know about your own problems with adherence. Most people have found an antibiotic capsule or two in the bottle at the end of a course of treatment.
Cultivating a warm and empathic therapeutic alliance is critical to collaborating about concerns that could upend the plan to take medication. In addition, the plan must be modified when life circumstances change and present new obstacles. Travel, moving, or loss of family support can affect the patient’s typical reminders or motivation to stay on track.
A defining feature of most psycho-therapeutic approaches is to individualize treatment based on a specific case formulation. Conceptualizing the patient’s difficulty with taking medication helps us to better manage complexity and tailor interventions accordingly. In a CBT model, we must understand what meaning the diagnosis, symptoms, and treatment have for the patient, in the form of thoughts and beliefs. If a patient thinks taking medication is a sign of weakness, for example, this thought will have a powerful effect on adherence.
Understanding the patient’s values and central concerns and linking these to the benefits of medication treatment is an excellent strategy to facilitate adherence. For example, if sleep is a problem, a good motivator for a patient to take nightly medication would be if it induces sleep. However, when sleep improves, the patient may be less likely to take medication as directed without using other prompts.
The formulation should identify aspects of the patient’s daily life that may interfere with the behavior of taking medication. Diagnostic characteristics of an illness such as hopelessness and memory problems can inherently produce problems. Trust issues, commonly seen in personality disorders, are another significant impediment. Stressors—whether from co-occurring medical problems, finances, or interpersonal relationships—will worsen adherence. Some patients have never cultivated or have significant impediments to routine; living in a shelter, for example, is hardly conducive to adherence.
Promoting desired behaviors
Very frequently our discussions with patients emphasize the adverse effects they are experiencing, particularly after symptomatic improvement. The practice of asking “Are you taking your medication?” followed by “How are the adverse effects?” will be less effective at obtaining accurate information—and will remind the patient that dry mouth, an orgasmic, and sedation are the result of taking medication. Emphasize the positive effects of the medication to counterbalance the adverse effects.
It is normal to forget much of what is said during a physician visit, so written information must accompany medication discussions. Teach patients to take notes and to write down questions between sessions to make them better partners. Genuine interest in the patient’s point of view enhances all aspects of the therapeutic alliance and, subsequently, adherence. Internet searches are commonly used for medication queries, not all of which produce positive results. Guide patients to reliable sites to help them be informed consumers. Bad information may be more harmful to adherence than no information at all!
Behavioral techniques are essential for forming habits, and taking medication regularly invariably involves habit change. Such techniques include self-monitoring (eg, charting medication taken each day) or reminder systems (eg, a pillbox, pairing medication doses with routine activities). Some less commonly used effective behavioral strategies include adding positive reinforcement (such as reading a favorite magazine) after several days of taking medication correctly.
Behavioral experiments can enhance the likelihood that patients will try a particular medication. For example, the patient may take a medication for the first time and spend the day in your waiting room when concerned about possible adverse effects of the drug.
Cognitive techniques are helpful when the patient’s thoughts about medication are a barrier to adherence. CBT interventions can be quite effective in developing alternative ideas about medication. A patient can use a decision matrix to list the pros and cons about a medication. This may be useful when the patient is unsure about pharmacotherapy. Evaluating negative thoughts about medications, psychiatric illnesses, or physicians may facilitate the willingness to take medication, or to take it more regularly.
Education, managing stigma and shame, and correcting misconceptions about health care providers may be subjected to behavioral experiments and evidence gathering. A basic CBT premise is not to tell the patient what to think, but to help the patient consider thoughts as testable hypotheses. For example, to help a patient develop more accurate ways of thinking about medications, ask him to consider what he would say if his child, spouse, or best friend required such medication. More global beliefs about the motives and trustworthiness of others may need special attention and efforts to build a trusting relationship with the patient over time. Empathic, validating comments, and open and direct communication about how difficult trust is may facilitate better adherence.