There have been significant developments in the medications used to treat psychiatric disorders over the past 60 years, leading to improvements in symptoms and social functioning, as well as prevention of relapse.

Rao Kn, George J, Sudarshan C, et al. Treatment compliance and noncompliance in psychoses. Indian J Psychiatry. 2017;59(1):69.

 

But despite these positive changes, the treatment of psychiatric disorders remains challenging, with a major obstacle being patient non-adherence to treatments—in particular, refusing to take their medications.

 

Defining nonadherence

The degree to which an individual’s behavior aligns with medical or health advice is defined as adherence. This term’s opposite, nonadherence, can be divided into primary and secondary nonadherence.

While nonadherence and nonadherence are used interchangeably, the terms adherence and nonadherence are thought to place the emphasis onto patients instead of clinicians.

 

Reasons for nonadherence

While studies report highly variable rates of nonadherence, these rates can reach 70% to 80% for the treatment of psychotic disorders. For the treatment of depression, nonadherence rates can reach 60%. While nonadherence is less prevalent in the inpatient setting, it still occurs 5% to 37% of the time, compared with 20% to 65% in an outpatient setting.

Breen R, Thornhill JT. Noncompliance with medication for psychiatric disorders: reasons and remedies. CNS Drugs. 1998;9(6):457–471.

 

Commonly prescribed psychiatric medications usually have one or more significant adverse effects, and patients may decide to not take their prescribed medication due to a negative impact on their quality of life.

For instance, antipsychotics can lead to Parkinsonian symptoms such as tremors, drooling, and muscle rigidity. In some cases, patients taking antipsychotics experience sedation, leading to challenges at home, at work, and with routine activities such as driving.

While antipsychotic medications have evolved since their introduction, no treatments are more than 80% effective and many are much less effective. Perceived ineffectiveness is another common underlying reason for medication nonadherence.

In some cases, there can be an additive effect, where patients who have concerns about a medication’s cost as well as its adverse effects discontinue taking a medication because they also see it as ineffective.

The complexity of medication regimens is another potential barrier to patient adherence.

 

Strategies for healthcare providers

To facilitate the discussion on why a patient is not taking their medication, healthcare provider awareness of such situations is a necessary first step.

Similarly, adherence can increase when healthcare providers enable patients to play an active role in their treatment decisions, including medications.

Maintaining open lines of communication with patients is also vitally important. To increase patient adherence, focus on the following:

• Understanding patient concerns

• Delivering medical information with empathy

• Providing patients with the education they need to make informed treatment decisions

• Ensuring that patients have reasonable expectations of the treatment

• Giving patients the opportunity to ask questions

 

Other ways to address nonadherence

Multiple support services are available to help you address patient nonadherence.

El-Mallakh P, Findlay J. Strategies to improve medication adherence in patients with schizophrenia: the role of support services. Neuropsychiatr Dis Treat. 2015;11:1077–1090.

 

Cognitive-behavioral therapy (CBT) can be used to help patients overcome their negative feelings about taking psychiatric medications. CBT is often utilized in combination with motivational interviewing to instill in patients the importance of taking medications and give them the confidence needed to adhere to a medication regimen.

These impairments can often lead to memory problems which can be managed through the use of pillboxes, alarms, and activity checklists.

Support services can also be instrumental to addressing other barriers to adherence, such as providing transportation to medical services and facilitating insurance benefits.