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Why don't patients take their medicine? Reasons and solutions in psychiatry

  • Alex J. Mitchell and Thomas Selmes
Abstract

Over the course of a year, about three-quarters of patients prescribed psychotropic medication will discontinue, often coming to the decision themselves and without informing a health professional. Costs associated with unplanned discontinuation may be substantial if left uncorrected. Partial non-adherence (much more common than full discontinuation) can also be detrimental, although some patients rationally adjust their medication regimen without ill-effect. This article reviews the literature on non-adherence, whether intentional or not, and discusses patients' reasons for failure to concord with medical advice, and predictors of and solutions to the problem of non-adherence.

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References
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Why don't patients take their medicine? Reasons and solutions in psychiatry

  • Alex J. Mitchell and Thomas Selmes
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Response to correspondance re Why don�t patients take their medicine

Alex J Mitchell, Consultant Liaison Psychiatrists
30 October 2007



We would like to thank those who have helpfully responded to our article with illuminating further points. Taking Dr Beales point first on the paper from Pound and colleagues (2005). We fully agree this is a valuable and comprehensive review and we have actually cited this article elsewhere (Mitchell 2006; Mitchell 2007). It certainly serves to highlight widespread and understandable “caution about taking medicines and highlighted the lay practice of testing medicines, mainly for adverse effects.” We recommend this paper for further reading.

Dr Kelbrick seems to share a similar philosophy to us regarding the importance of a good therapeutic relationship and it is particularly refreshing to hear this echoed from someone working mainly with detained patients. This area was under-emphasized in our article, but establishing and maintaining trust in this group is clearly both challenging and essential. Regarding compliance therapy we had reviewed this evidence in more detail than was presented but it was edited due to space restrictions. In any case good reviews are available elsewhere (McDonald et al, 2002; McIntosh et al, 2006; Nadeem et al, 2006).

Drs Khokhar and Ali helpfully highlight the issue of cultural factors with regard to medication habits. This is a useful reminder. We recently conducted a study in Leicester on ethnic differences regarding treatment preferences (rather than adherence) in a cancer setting (Roy et al, 2005). More Asian than Caucasian patients wanted to receive critical information from their GP rather than hospital doctor and this was linked with their level of distress. Additionally more Asian patients received "bad news" alone. We are currently trying to find out whether this has an effect on illness outcomes in a prospective study.

McDonald HP, Garg AX,Haynes B. Interventions to Enhance Patient Adherence to Medication Prescriptions JAMA. 2002;288:2868-2879.McIntosh AM, Conlon L, Lawrie SM, Stanfield AC. Compliance therapy for schizophrenia. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD003442. Mitchell AJ. Hypothesis: adherence behaviour with psychotropic medication is a form of self-medication. Medical Hypothesis 2007 68(1): 12-21.Mitchell, AJ. High medication discontinuation rates in psychiatry – how often is it understandable? Journal Clin Psychopharm. 2006 Volume 26(2): 109-112.Nadeem, Z., McIntosh, A. & Lawrie, S. Schizophrenia: adherence to antipsychotics (follow link to Compliancetherapy). BMJ Clinical Evidence. 2006

Roy R, Symonds RP, Kumar DM, Ibrahim K, Mitchell AJ, Fallowfield L. The use of denial in an ethnically diverse British cancer population. A cross-sectional study. Br J Cancer 2005 92(8): 1393-1397
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Resisting medicines

Daniel M Beales, Specialist Registrar in Forensic Psychotherapy
11 October 2007

Mitchell and Selmes (2007) in their review of the reasons patients "don't take their medicine" neglect a key reference that is useful in developing our understanding of this issue.

Pound and colleagues (2005) conducted the qualitative equivalent of ameta-analysis of the issues around compliance, adherence and concordance and out of this identified the concept of "resistance" to taking medication. This is a significant conceptual and practical theme to be further developed and has particular importance as it links the issue of compliance with psychotropic medication with compliance with medication ingeneral.

The concept of resistance is important as it emphasises how taking medication interacts with a patient's sense of self, and how not taking medication needs to be understood in this context.

Mitchell A and Selmes T (2007) Why don’t patients take their medicine? Reasons and solutions in psychiatryAdvances in Psychiatric Treatment;13:336-346.

Pound P, Britten N, Yardley L, Pope C, Daker-White G, Campbell R (2005) Resisting medicines: a synthesis of qualitative studies of medicinetaking. Social Science & Medicine; 61(1):133-155.
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Compliance - a modern day challenge

Marlene M Kelbrick, Staff Grade Psychiatrist
09 October 2007

I read with great interest the article by Mitchell & Selmes exploring the reasons why patients don’t take their medicine, and offeringpotential solutions as to how this problem could be dealt with.

Non-concordance and non-adherence with medication (previously termed ‘compliance’) is an issue that stretches across the borders of the different specialities in medicine. In psychiatry however this is of particular importance as it carries an element of risk with great implications for the person, the public and the health service. Management in psychiatry is based on a biopsychosocial model of treatment and although there has been a lot of focus on psychological interventions,medication remains the mainstay of treatment for most psychiatric disorders.The NICE guidelines for the treatment of schizophrenia, published in 2002 recommend that the choice of antipsychotic medication should be made jointly based on an informed discussion including a risk-benefit analysis.The Mental Capacity Act 2005 has brought the issue of informed consent to the foreground re-enforcing the current movement to a more patient-centredservice.

I am responsible for the care of patients on an intensive care unit, and admittedly this patient group forms part of the more severe spectrum with acutely disturbed mentally disordered patients. All our patients aredetained under section of the mental health act and a large proportion does not have capacity to consent to treatment. In my experience the mostcommon causes for relapse are a combination of non-adherence or partial adherence with medication and substance misuse. Lack of insight, stigmatisation and side effects are all associated with non-adherence.

David et al (2002) published an interesting article looking at the concept of ‘compliance therapy’ in view of papers published such as those by Kemp et al (1996 & 1998), showing compliance therapy to reduce readmission rates and improve insight and compliance with medication. Compliance therapy is a combination of CBT techniques, motivational interviewing techniques and psycho-education, and aims to promote a good therapeutic alliance between doctor and patient with open discussion aboutthe risks and benefits of medication.

There is no doubt that a good therapeutic relationship forms part of the foundations of patient care and improves patient concordance and adherence. Relapse prevention is just as important as treating acute illness and non-adherence with medication is an important risk factor thatneeds close monitoring. It is our responsibility as clinicians to ensure that our patients have an understanding of their illness, the need for treatment and the importance of engagement with the services, and it is important that this should be in the context of a partnership between doctor and patient.

References:

1. David et al. (2002). Compliance therapy in psychotic patients:randomised controlled trial. Psychiatric Bulletin 26(1):12 - 15

2. Kemp et al. (1998). Randomised controlled trial of compliance treatment – an 18-month follow-up. British Journal of Psychiatry 172: 413 - 419

3. Kemp et al. (1996). Compliance treatment in psychotic patients: randomised controlled trial. British Medical Journal 312: 345 – 349

4. NICE Guidance –Core interventions in the treatment andmanagement of schizophrenia in primary and secondary care. (2002)
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WHEN TAKING MEDICATION IS A SIN!

Waqqas A. Khokhar, Specialty Registrar
05 October 2007

We read Mitchell & Selmes’s (2007) article with interest. It veryrightly points the readers to the multiple and complex factors underlying varying degrees of non compliance with psychotropic medication. We are however, intrigued by the absence of factors like cultural and religious beliefs and their potential influence on beliefs about mental illness and medication in this very comprehensive and informative article. Although itis generally believed that religious beliefs do not influence medication compliance, resolving non-adherence to pharmacotherapy should involve a comprehensive assessment of the patients’ demographics, social circumstances, and cultural and religious beliefs (Sattar et al, 2004). There is also evidence which suggests that not only do patients with strong spiritual values cope better with mental illness but their understanding of illness behaviour is also greater, giving them better insight into their condition. Such factors directly impact upon treatment compliance and engagement in therapy (Kirov et al, 1998).

Religious laws do not restrict the use of psychotropic medications but many do forbid the use of animal based derivatives, specifically gelatinous products and stearic acid. These are generally derived from beef and/or pork products. This has major implications for many patients, particularly the followers of Judaism, Islam, Hinduism, Buddhism, Seventh day Adventism and Christian Orthodox Church (Sattar et al, 2004). There are also over four million vegetarians in the UK and the number is ever growing (Food Standards Agency, 2005).

General Medical Council (1998) also clearly highlights the importanceof ‘therapeutic trust’. It explicitly asks all doctors to respect patient’s autonomy and take a proactive approach in finding about individual needs and priorities e.g. beliefs, culture, occupation or otherfactors that may have a bearing on the information patients need in order to reach a decision. Initial findings from a postal survey, which we conducted locally, suggest that many psychiatrists have remained ambivalent about the context of this discussion for the fear of further reduction in compliance with psychotropic medication. Results also suggestthat many psychiatrists are themselves unaware of the presence of ‘forbidden contents’ in psychotropic medication.

We believe that in order to instill a ‘spirit of trust’ in our patients and improve medication compliance, psychiatrists should have a basic familiarity with religious dietary restrictions. We should also tryour best in educating our patients about these important issues as part ofthe deliberation process before prescribing any psychotropic medication. Information on the gelatin or stearic acid content of medications can be obtained from the physicians’ desk reference or electronic databases such as www.PDR.net or www.rxlist.com.

REFERENCES:

1. Food Standards Agency (2005) Consumer Attitudes to Food Standards survey.

2. General Medical Council (1998) Seeking Patient’s Consent: the ethical considerations.

3. Kirov, G., Kemp, R., Kirov, K., David, A. S. (1998) Religious faith after psychotic illness. Psychopathology, 31, 234-235.

4. Mitchell, A. J. & Selmes, T. (2007) Why don’t patients take their medicine? Reasons and solutions in psychiatry. Advances in Psychiatric Treatment, 13, 336-346.

5. Sattar, S. P., Ahmed, M. S., Madison, J., et al (2004) Patient andPhysician Attitudes to Using Medications with Religiously Forbidden Ingredients. The Annals of Pharmacotherapy, 38, 1830-1835.

DECLARATION OF INTEREST:

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