A Copyright Harvard Health Publications
Two recent reviews offer advice about assessing and improving treatment adherence.
Many patients with bipolar disorder or schizophrenia, like those with other chronic health conditions, find it difficult to follow a prescribed medication regimen (see table). This is unfortunate, as studies consistently show that the more carefully such patients take medications as prescribed, the less likely they are to experience a relapse or hospitalization.
|Following a medication regimen is difficult for many patients with chronic health problems, not just those with psychiatric disorders.|
|Medical condition||Rates and caveats|
|Bipolar disorder||Long-term adherence to mood stabilizers: 34% to 80%|
|Schizophrenia||Depending on patient population (stable outpatients are most likely to follow a medication regimen): 11% to 80%|
|Cardiovascular disease||Persistently taking medication over 6 to 12 months:
Aspirin to reduce risk of heart attack: 71%
Beta blockers for blood pressure: 46%
Cholesterol-lowering drugs: 44%
|Osteoporosis||Adherence to medication regimen:
At 1 to 6 months: 53%
At 7 to 12 months: 43%
Problems with treatment adherence can also disrupt the therapeutic relationship. This is especially true when conversations about medication escalate into a power struggle, distracting attention from the shared goal of recovery. (One reason that the term “treatment compliance” has fallen out of favor is because it suggests that the patient is to blame.)
Two reviews, including one that presented what are believed to be the first consensus guidelines on this topic, sought to distill the research findings and present practical advice about improving adherence.
Adherence challenges in schizophrenia
Studies have generated a wide range of adherence rates for patients with schizophrenia, with the variations in findings reflecting both the quality of the research and the selection of patient population (such as recently discharged inpatients versus stable outpatients). A review of 39 studies of patients with schizophrenia found that rates of treatment nonadherence varied from 20% to 89%, with a mean of 41% to 50% when only the most rigorous studies were included. Contrary to initial expectations, patients are no more likely to continue taking second-generation antipsychotics than first-generation drugs.
Patients with schizophrenia most often stop taking medication because they don’t think they have an illness or, even if they do, aren’t convinced that they need medication (attitudes commonly referred to as lack of insight). Other factors include side effects, persistent symptoms, substance abuse, financial difficulties, unstable living situations, lack of social support, and difficulty establishing a therapeutic relationship.
Whatever the reason, poor medication adherence increases the chances of bad outcomes. One study involving 49,003 patients with schizophrenia treated at U.S. veterans hospitals found, for example, that 23% of those who took their medication less than 80% of the time were hospitalized within one year, compared with 10% of those who took it more often.
Lithium and other mood stabilizers provide the fundamentals of treatment for bipolar disorder. Studies of long-term treatment have found that 20% to 66% of patients with bipolar disorder, or a median of 41%, do not take mood stabilizers consistently.
Although lack of insight and cognitive difficulties may affect treatment adherence in patients with bipolar disorder, other common factors include side effects, persistent manic symptoms, and concurrent substance abuse.
Many studies of patients with bipolar disorder have shown that poor adherence is associated with greater likelihood of relapse and hospitalization. For example, one study that compared pharmacy data with hospitalizations found that 73% of patients with bipolar disorder who did not take their medication on a regular basis were admitted to a hospital within a year, compared with 31% of those who regularly filled their prescriptions.
Patients tend not to mention whether they are taking all their medication, while clinicians may wrongly assume that they are. As a result, a clinician may erroneously believe that a patient is not responding to a medication because the dose is too low, when the real issue is missed doses.
For example, one small study found that 5% of patients with schizophrenia or schizoaffective disorder told clinicians that they were not taking their antipsychotic as prescribed, while the clinicians treating them estimated that 7% were not. Yet an electronic monitoring system (which recorded the day and time a pill bottle was opened) indicated that 57% of the patients were not following the prescribed medication regimen. Another study found that clinicians incorrectly assessed the treatment adherence of patients with bipolar disorder about half the time.
The consensus guideline on this topic suggests that one way for clinicians to better assess treatment adherence is to ask questions that are less confrontational and more probing. The idea is to word such questions in a way that acknowledges that many people, not only psychiatric patients, have trouble following medication regimens. Instead of simply asking “Are you taking your medicine?” they advise trying questions such as the following:
- When do you take your medication?
- We all forget to take medications sometimes. Do you ever forget?
- In the last week, how many doses of your medication did you miss?
Education and psychotherapy
Patient education about illness and treatment obviously forms the basis of any treatment plan, but in itself may not be sufficient to improve adherence to a medication regimen. However, several studies have found that providing this type of education both to families and loved ones can improve medication adherence and reduce relapses in patients.
Cognitive behavioral therapy.
When a patient lacks insight into the illness or is not convinced of the need for medication, cognitive behavioral therapy (CBT) may help clarify how medication adherence can reduce symptoms or improve health. A variation known as cognitive adaptation combines CBT with environmental supports tailored to each patient, such as reminders, checklists, or electronic pill bottles.
Motivational interviewing, first developed for addiction treatment, is sometimes combined with CBT to help patients progress from thinking more positively about medication to actually taking it. For example, a technique known as “rolling with resistance” involves finding out why a patient is not taking a medication. The idea is not to confront patients in an adversarial way, but to better understand their concerns as a first step toward clarifying shared goals of treatment.
Studies have found that CBT can improve medication adherence both in patients with schizophrenia and bipolar disorder.
Interpersonal and social rhythm therapy.
This therapy, which helps patients resolve difficulties with other people and maintain a stable daily routine, has been investigated mainly in patients with bipolar disorder. Several studies found that patients who have undergone such therapy are more likely afterward to follow medication regimens and avoid relapse.
The best approach depends on why the patient is having trouble adhering to a medication regimen.
Symptom and side-effect monitoring.
Because side effects can discourage patients from taking medication, ongoing monitoring of both symptom relief and side effects may help address concerns early on, before a patient stops taking the medication. Providing a patient with a daily checklist or a mood chart to bring to the next visit will help the therapist better understand what might be of concern. Then informed decisions can be made about changing or adjusting the dose of a medication.
Medication monitoring or prompts.
Low-tech devices, such as pill boxes with compartments to divide doses by days of the week, can help remind patients to take medications. Other useful prompts include signs, checklists, or even electronic devices to remind patients to take medication.
Injectable medications that are effective for extended periods of time may improve medication adherence and reduce risk of relapse in patients with schizophrenia. They have been less well studied in bipolar disorder, but appear effective at preventing manic relapse during maintenance treatment. The research also suggests that this strategy is best combined with psychotherapy and education, so that the patient understands the rationale behind it.
Building a therapeutic alliance
No matter what specific intervention is used, the research consistently demonstrates that a strong therapeutic alliance is one of the most powerful ways to encourage patients to take medication as prescribed. We’ve written in detail about how to build a therapeutic alliance, but the main components, as with any relationship, are mutual trust and respect.
Alliance building takes a long time. But the results may be worth it, for both patient and clinician.