Nonadherence to medical therapy is a widespread and complex problem that is a significant variable in the treatment of psychiatric illness and in patients’ prognosis. More than 50% of people who have a chronic illness struggle to comply with their medication regimen—for many reasons.1
Many variables predict poor adherence, so it cannot be expected that a single solution will solve the problem entirely.2 Novel adherence technologies are available, as we discuss in this article, and more are in development.
What is nonadherence to medical therapy?
Nonadherence can be defined primarily as not taking prescribed medication in the recommended dosage or frequency, or not taking prescribed medication at all.3 Nonadherence can result in an increased risk of relapse, hospitalization, poor therapeutic response, and delayed remission and recovery.
Secondarily, non-attendance or irregular attendance at appointments with providers is a form of nonadherence that can have a negative impact on treatment outcomes.4
Why is medical adherence important in psychiatry?
Medication nonadherence has major consequences for psychiatric patients5 and for the greater health care system; it is estimated that, in the United States, the cost of nonadherence is as high as $300 billion a year.6 In psychiatry, the rate of nonadherence to medical therapy has been reported to be 11% to 80% of patients with schizophrenia; 12% to 64% with bipolar disorders; and 30% to 60% with depression.7-9 These surprising statistics make it imperative to design treatment strategies that include an effective patient-centric medication adherence plan, based on diagnosis, patient need, education, and support.
Why are patients nonadherent?
Many variables lead to patient nonadherence (Figure 1). The most common reason is that patients simply forget to take their medication.10 Among psychiatric patients, other reasons are:
- lack of insight
- negative emotional reaction to taking medication11
- feeling better and no longer believing that the medication is needed12,13
- distress associated with side effects14,15
- high cost of medication15
- patient’s perception that medication won’t be effective16,17
- concern about substance abuse18
- fear of dependency19
- complicated dosing regimen20
- general lack of motivation.21
Emotional barriers to medication nonadherence are an underestimated area that can benefit greatly from the expertise and understanding of psychiatrists. These barriers include a sense of losing control, self-stigmatization, denial, poor insight, and beliefs about illness and medications.
Additional patient variables that contribute to nonadherence include:
- suboptimal health literacy
- stigma and shame about the need for psychiatric treatment
- lack of patient involvement in treatment decision-making.
Who is responsible for adherence?
Adherence to medical therapy is not the patient’s responsibility, exclusively. Rather, it is a collection of complex components that generally includes physicians and the health care system. Because barriers to medication adherence are complex and varied, solutions to improve adherence must be multifaceted.
Providers. Patients’ care often is managed by multiple physicians, which can lead to communication lapses about complicated drug regimens and potential adverse effects. To assist patients in adhering to their medication regimen, physicians should recognize, and acknowledge to the patient, that many psychiatric patients have difficulty taking their medications and provide advice and information in how to address this problem.
Families. Likewise, it is important to educate patients and their family about the need for medication—helping the patient see that it is his (her) choice and, indeed, his direct responsibility to take his medication and improve his health. The risk–benefit balance of treatment should be explained to the patient and his family, as well as the nature of the psychiatric diagnosis and how effective patient–physician collaboration can help him function and adhere to his medication regimen in a consistent, reliable manner.
The larger system. Health care systems can contribute to medication adherence by reducing time constraints on visits to providers, to allow time to discuss all aspects of medication adherence. Limited visits in the clinic means physicians are not able to (1) spend adequate time discussing the medication regimen to ensure full patient comprehension and (2) conduct an assessment of medication-taking behaviors. Team-based approaches could improve efficiency, patient understanding, adherence, and early detection of adherence issues.22,23
Strategies such as additional clinic visits and reminder calls to discuss adherence carry a cost, but their long-term advantage is that, if patients understand how to better adhere to their medication regimens, their actions will have a positive impact on their health care costs and outcomes and on the wider health economy—as a result of reduced hospital admissions and reduced need to care for patients whose condition deteriorates because of nonadherence. It is imperative that we build strong relationships with other providers to show that we are committed to building supportive, effective adherence support programs that focus on the individual patient’s needs.