Nonadherence to psychotropic medications poses one of the greatest challenges in the treatment of patients with psychiatric illness. According to some estimates, more than 50% of psychiatric patients do not comply with their medication regimens.1,2,3
Nonadherence is responsible for poorer outcomes, including increased hospital admissions, suicide, violence, and mortality.4 An article by Chapman and Horne4 reviews causes and potential solutions to this serious problem.
The authors describe adherence to psychiatric medications as “a complex, dynamic behavior requiring patients to initiate treatment and continue to take their medications at the correct time, in the correct dose, for prolonged periods.” They note that nonadherence is often a “hidden problem” that can be difficult for clinicians to discern.
Reasons for Nonadherence
Adherence is affected by factors related to the patient and treatment, as well as social, cultural, and economic issues.5 Patients may intentionally discontinue taking medications due to concerns about side effects, stigma, inconvenience, costs, or availability. Unintentional nonadherence can be caused by forgetfulness, external distractors, or misunderstanding instructions.6 Anognosia (lack of insight) is arguably the most significant reason for nonadherence.5,7 Additional patient-related factors are severe illness, depression, psychosis, and cognitive impairment.6
Treatment-related factors include the duration and complexity of the regimen,6 and clinician-related factors include a poor doctor-patient relationship, poor empathy, poor explanation/communication, and inadequate follow-up.6 Social and economic barriers include financial concerns, lack of transportation, homelessness, cultural issues, and lack of family/social support.
Interventions to Maximize Adherence
It is important to identify specific factors that may be contributing to nonadherence, in order to customize interventions that target those problems.8
Use objective measures to assess adherence, including pill counts, pharmacy records, serum or urine drug levels (when relevant), and validated self-report scales.8 Every visit is an opportunity to inquire about medication problems, missed doses, and thoughts of discontinuation.6,8
Improve the therapeutic relationship by helping patients identify their treatment goals, acknowledging patients’ concerns (eg, distress regarding side effects), finding common ground with the patient, and expressing empathy.9,10
Psychoeducation provides “strategies to educate the patient and/or family about the illness, medications, side effects, and relapse prevention.”11 Patients increase their knowledge, learn how to cope with symptoms, and develop behaviors that help them move toward recovery. Families benefit by experiencing reduced family burden and higher quality of life.12
Motivational interviewing is “a style of patient-centered counseling developed to facilitate change in health-related behaviors” through “negotiation rather than conflict.”13 The “motivational” part of the term “underscores the fact that motivation is fundamental to change.” The word “interviewing,” in this context, “differentiates this method from treatment or counseling and enables patients and providers to examine events together.”14
Cognitive behavioral therapy utilizes “behavioral approaches including conditioning, rewarding, cues, reminders, and skill training.”10 It focuses on “understanding the patient’s perceptions of illness and treatment, explores resistance to medication, and identifies and modifies negative automatic thoughts about medications.”11
Simplifying the treatment regimen is recommended by the Expert Consensus Guidelines when logistical problems, lack of routines, cognitive deficits, or lack of family/social support interfere with adherence.8