4: Treatment Adherence

Published on 24/05/2015 by admin

Filed under Psychiatry

Last modified 24/05/2015

Print this page

rate 1 star rate 2 star rate 3 star rate 4 star rate 5 star
Your rating: none, Average: 0 (0 votes)

This article have been viewed 1982 times

CHAPTER 4 Treatment Adherence

Megan Moore Brennan, MD, John B. Herman, MD

KEY POINTS

• Rates of treatment nonadherence are alarmingly high.
• Treatment adherence is associated with better outcomes, lower relapse rates, improved adherence to treatments for nonpsychiatric illnesses, and lower hospitalization rates.
• Practitioners should routinely identify risk factors for nonadherence, assess overall risk for nonadherence, and include ongoing adherence assessment and intervention in treatment plans.
• Standardized definitions and assessment techniques of adherence are needed to allow for comparison across studies and translation to clinical work.
• Treatment adherence should become a standard component of mental health professional training curricula and continuing medical education.

OVERVIEW

Treatment compliance is defined as the degree to which a patient carries out the recommendations of the treating practitioner. The term connotes a disappearing paternalistic model (in which the doctor determines what treatment the patient should have, and the patient faithfully and unquestioningly accepts it), and it implies that a noncompliant patient is unruly or bad. Instead, the term adherence has increasingly gained favor over compliance, and represents a shift toward collaboration between the health care professional and the patient.

EPIDEMIOLOGY

Studies suggest that rates of nonadherence with psychiatric treatment are alarmingly high (24% to 90%). In a large meta-analysis, with a pooled sample of over 23,000 patients, the mean rate of nonadherence was 26%.1

Rates of treatment adherence vary depending on the population, the diagnosis, and the pharmacological intervention. Particularly high rates of treatment nonadherence occur among those with psychotic disorders. This was made clear in the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) investigation, which reported high rates of treatment discontinuation (74%) among the intent-to-treat group of 333 patients, within 4 months.2 A majority of patients were unable to remain in treatment, largely due to inadequate efficacy of treatment or to intolerable side effects. Reasons for nonadherence are multiple, complex, and varied.

Data on nonadherence include the following: only 45% of patients referred for psychotherapy from a general hospital psychiatry outpatient department showed up for one or more appointments3; nonattendance rates for patients with scheduled medical appointments are high (19% to 28%); nonadherence with medical recommendations accounts for 5% to 40% of hospital readmissions; medication doses are delayed or omitted by 30% to 50% of patients; patients with chronic diseases take their medications as prescribed only half of the time; 20% of patients stop filling their prescriptions within 1 month of their issue; approximately one-fourth of patients do not inform their physician about having stopped their antidepressant medications4; and in a follow-up study of inpatients with suicidal ideation, 52% of patients were nonadherent with use of medications at 12 weeks.5

CLINICAL AND ECONOMIC IMPACT OF ADHERENCE AND NONADHERENCE

Clinical outcomes are directly related to treatment adherence, which in turn is related to resource utilization and to the economic burden of mental illness. Adherence with psychiatric treatments is associated with better outcomes, a lower relapse rate, improved adherence with treatment regimens for nonpsychiatric illness, and lower rates of hospitalization.6–8 Nonadherence has been associated with a greater risk of psychiatric hospitalization, use of emergency services, arrests, violence, victimizations, lower mental function, lower life satisfaction, and more prevalent use of substances.9 Rates of suicidal ideation are significantly greater among patients who are treatment nonadherent following hospitalization.5

Given the clinical impact of treatment nonadherence, the economic burden incurred through nonadherence is significant. Data derived from the Global Burden of Disease Study conducted by the World Health Organization, the World Bank, and Harvard University revealed that mental illness, including suicide, accounts for over 15% of the burden of disease in countries such as the United States.10 Additionally, since major depression is the leading cause of disability worldwide among persons age 5 or older, adherence to treatment can reduce the economic burden of mental illness.

Although little studied, the negative impact (including feeling frustrated, underappreciated, helpless, ineffectual, and “burned out”) of treatment nonadherence on clinicians should also be considered. Treating clinicians are affected when their patients are nonadherent with treatment. Future studies will undoubtedly measure the dispiriting impact when clinicians feel underappreciated and disaffected.

RISK FACTORS AND PREDICTORS OF TREATMENT NONADHERENCE

The reasons for treatment nonadherence are incompletely understood; however, they are undoubtedly multiple, com-plex, and varied. Any effort to understand this multifactorial challenge must include consideration of the elements in Figure 4-1 and Table 4-1.

image

Figure 4-1 Multifactorial Aspects to an Understanding of Treatment Adherence.

Table 4-1 Factors That Affect Treatment Adherence

• The patient. The patient’s maturity, resilience, and experiences affect adherence. For example, an adolescent may find his or her illness a source of embarrassment, or a middle-aged person may have concerns about how disclosure of an illness might affect his or her work and health insurance premiums. Negative experiences with the health care system can create mental barriers to seeking necessary treatment.
• Co-morbid illnesses. Substance abuse, medical illnesses, and dementia also adversely affect adherence.
• The patient-clinician relationship. A lack of trust in a clinician or the medical system negatively affects adherence.
• Socioeconomic status. Many patients are impoverished and lack health insurance; therefore, they are unable to access timely and adequate care. Even small co-payments can result in medication nonadherence.
• Cultural and religious factors. Cultural beliefs affect all aspects of illness, from patients’ interpretations of symptoms to their beliefs about treatment. For example, a patient may choose prayer as the sole means of healing.
• Treatment. The structure or content of treatment itself may contribute to poor adherence. For example, a patient with paranoid schizophrenia is unlikely to continue in an unstructured psychodynamic therapy group, or a patient who does not have a car and who lives 45 miles away from a health center is unlikely to attend weekly appointments. Medication may directly cause nonadherence if it lacks efficacy or causes intolerable side effects.

Most studies of adherence focus on specific patient populations that are typically categorized by diagnosis.

Affective Disorders

Symptoms of both mania and depression directly affect treatment adherence. In depression, persistent dysphoria and hopelessness may make a patient feel that his or her condition is irreparable and that treatment is futile. Psychomotor retardation, decreased energy, poor concentration, and diminished self-care lead to missed medications and appointments. With hypomania and mania comes an elevated mood and an invigorated energy level that most patients experience as positive; this makes many unmotivated to take medications that slow them down. When insight and judgment are impaired, some patients do not believe that they have an illness that requires treatment.

Studies of treatment adherence in those with depression demonstrate that adherence is highest when the perceived need for medication is greatest and the harmfulness of medication is low.11 In addition, a patient’s skepticism about the efficacy of antidepressant medications predicts early discontinuation of them.12 Reasons for nonadherence include discomfort about psychiatric diagnoses, denial of the illness, problematic side effects, fears of dependency, and the belief that medications were unhelpful following resolution of the acute phase of illness.13

In a study of African American and Caucasian patients with bipolar I disorder, more than half of all patients were either fully or partially nonadherent with medications, 4 months after an episode of acute mania.14 More than 20% denied having bipolar disorder, and they cited side effects of medications as contributing to their nonadherence. African Americans (more often than Caucasians) cited the fear of addiction and medication as a symbol of illness as reasons for nonadherence, which suggests that different cultures or ethnic groups may differ in their reasons for nonadherence.

Among patients with bipolar disorder, insight into treatment has been positively correlated with medication adherence, and adherence at the time of remission predicted adherence at one year.15

Anxiety Disorders

Anxiety disorders are associated with hypervigilance regarding both the psychological and physical environment; this affects adherence in a number of ways. Illness may be so severe that a patient is too anxious to leave his or her home to keep appointments. Or it may be difficult to titrate and to taper medications, as a patient with an anxiety disorder may attribute any physical symptom to a medication side effect. With obsessive-compulsive disorder (OCD), counting rituals and fears of contamination may make it impossible for a patient to take medications, or to comply with pharmacological or other therapeutic recommendations.

Psychotic Disorders

Patients with schizophrenia have been intensively studied regarding their adherence to treatment, in large part because of the risks associated with treatment nonadherence. One post-hoc, pooled analysis of 1,627 patients with psychosis treated with atypical antipsychotics reported that 53% of the patients discontinued their medication soon after treatment began because of their perceptions of poor response and worsening symptoms (36%), followed by poor medication tolerability (12%).16 Other reasons for nonadherence include a lack of insight, positive symptoms, younger age, male gender, a history of substance abuse, unemployment, and low social function.1,17

For patients with first-episode psychosis, the likelihood of becoming medication nonadherent is greater in those who believe that treatment is not important or who believe that medications are of low benefit. High levels of positive symptoms at baseline, a lack of insight at baseline, and alcohol or drug misuse at baseline predict nonadherence.18,19

Among patients with schizophrenia, patient-reported reasons for nonadherence include feeling stigmatized by taking medications, having adverse drug reactions, being forgetful, and having a lack of social rapport. Other barriers to adherence include use and abuse of drugs and alcohol, a higher Positive and Negative Syndrome Scale score, and a higher mean Barnes Akathisia Score.20

Buy Membership for Psychiatry Category to continue reading. Learn more here

Related posts:

2: The Psychiatric Interview Default Thumbnail25: Factitious Disorders and Malingering Default Thumbnail53: The Suicidal Patient Default Thumbnail31: Psychiatric Illness during Pregnancy and the Postpartum Period 38: Grief, Bereavement, and Adjustment Disorders 79: Stroke