The Importance of Taking a Pill

Non adherence to antipsychotic medication and possible remedies detailed in recent report

(RxWiki News) Taking a pill everyday can be a challenge but, depending on your condition, it may be necessary. Although all conditions have some rate of medication non-adherence, skipping a pill plays a particularly important role in those patients with schizophrenia.

In a recent study, the researchers found not taking prescribed medications can lead to condition relapses, re-hospitalization, disability and difficulties in various social environments.

The report authored by Oliver Freudenreich, MD, and Corinne Cather, PhD, from the Department of Psychiatry at the Massachusetts General Hospital and Harvard Medical School, examined the factors that caused 41 percent of people on antipsychotic medicine to skip their medication.

The report concluded that the method used should be tailored toward the individual and their specific needs.

"Talk to your pharmacist about taking your medication."

Predicting factors of medication non-adherence may include poor insight, negative attitude toward medication, past lapses in taking medication, drug abuse, shorter illness duration, inadequate aftercare or discharge planning and poorer therapeutic alliance.

The authors of this report focused mainly on lack of insight and negative attitudes toward medication in their examination and recommendations.

Lack of insight is a common problem for those who have psychotic disorders. It can be defined as not having awareness of symptoms, not recognizing a mental illness and not accepting the need for treatment.

Insight is a good predictor of medication adherence and treatment outcome in patients.

Patients with poor insight may be deemed incompetent or receive court mandates that require them to take their medication, although poor insight may not inhibit the patient if they are still willing to go through with the treatment. In addition, partial insight may be sufficient enough to allow clinicians and patients to work together to achieve proper treatment.

The patient’s attitude toward their medication is also important to antipsychotic drug adherence and successful treatment.

A patient’s initial opinion of their medication can be vital as studies have shown it is not likely to change, even when a new generation of the drug with different or fewer side effects is introduced.

Side effects such as sedation, movement difficulties, weight gain and sexual dysfunction can all negatively affect a patient’s attitude towards their medication.

For patients with a willingness to receive treatment, there are several measures that can be taken to ensure they will stick with their prescription, including a positive relationship with their treatment provider, compliance therapy, long-acting injectable antipsychotics, cognitive adaption training, directly observed therapy and financial incentives.

Particularly in the early phases of treatment, perceived support from a doctor or therapist can help patients stick with their medication. A lack of trust, a feeling of coercion or a negative relationship with the prescriber all inhibit adherence, meaning that the overall treatment experience is as important as the medication itself.

Compliance therapy helps patients weigh the risks and benefits of adhering to their medication and teaches them to align their actions with their goals. Studies of this form of treatment have shown mixed results.

Long-acting injectable (LAI) antipsychotics are often suggested for patients with low insight who do not wish to take medication as they do not provide the patient with the opportunity to miss medication. In a trial of 369 schizophrenia patients, oral antipsychotics and those given LAIs had the same rate of effectiveness on hospitalization rates, symptom improvement and quality of life.

Cognitive Adaptive training seeks to tackle schizophrenia-associated neurocognitive impairment and has shown long-term effectiveness. This treatment uses strategies such as pill containers with alarms, organization of belongings and activity checklists to prompt medication adherence in an individual's home environment.

Directly Observed Therapy (DOT) is commonly used when taking medication is extremely critical. It involves direct observation of the patient taking the medication and is often implemented in psychiatric homes.

Technology may make DOT easier, as patients can report to their treatment providers via Skype or cell phone. A cell phone based telemonitoring system trial of this method showed a reduction in hospitalization by 60 percent compared with the same time period prior to participation.

Although compensation methods have been used in the past to encourage certain behaviors in patients, financial compensation can raise some ethical questions. Regardless, the method has undergone some trials that show success and a randomized incentive trial is currently underway in Great Britain.

In order to understand which adherence system is best, the individual patient, his drug attitudes and insight need to be understood. Interventions need to be deployed with increasing intensity and tailored toward specific needs.

Most importantly, any non-adherence needs to be recognized as even inadvertently missed medication can exacerbate psychotic symptoms, and patients and clinicians are both often unaware of missed medication.

Psychiatrist and professor, Glen R. Elliott, PhD, MD, agrees that the issue of medication adherence is central to good outcomes in any chronic disorder where there is no cure. "Estimates of adherence, as the authors note, are always much higher than the reality. "

"Even direct observation can have limited success if the patient is motivated not to take the medication—a not-infrequent occurrence. Therapeutic alliance is a wonderful goal and can indeed help a lot; but, with mental disorders, it often is weakest just when it is most needed, that is, when the patient begins to have worsening symptoms."

The report was published in the spring 2012 edition of The Journal of Lifelong Learning in Psychiatry.

Dr. Freudenreich is a consultant for Beacon Health Strategies and Transcept, receives research grants from Pfizer and receives honorarium from Reed Medical Education. Dr. Cather reports no competing interests.

Review Date: 
August 2, 2012