Treatment adherence

The term ‘adherence’ is often used incorrectly and synonymously

with the term ‘compliance’.

Compliance is the extent to which

a patient’s behaviour coincides with the medical prescription

and recommendations.

Adherence, on the other hand, refers

to the willingness and ability of patients to follow health-related

advice, to take medication as prescribed, to attend scheduled

appointments, and to complete recommended investigations.

Compliance implies an obligation on the part of the patient to

blindly follow the practitioner’s instructions, while adherence

implies a therapeutic alliance with the practitioner. Previously

patients were classified as either adherent or non-adherent but

now it is more evident that there is a continuum, with many

patients showing some degree of adherence.

Patients with psychiatric disorders show a greater degree of

non-adherence to treatment than those with physical disorders.

The adherence rates range from 40 - 70% to 60 - 92% in the

respective disorders. About 30% of all patients with psychiatric

disorders discontinue their medication in the first month and 44%

discontinue it within the first 3 months of initiation of treatment.

4,5

The recent CATIE (Clinical Antipsychotic Trials of Intervention

Effectiveness) study

reports that patients on antipsychotics

discontinue their assigned treatment because of inefficacy and

intolerable side-effects of medication. In total, 74% of the 1 493

schizophrenia patients recruited discontinued their assigned study

medication within 18 months of initiation. Of the newer atypical

antipsychotics, olanzapine was found to be the most effective in

terms of the rates of discontinuation compared with quetiapine,

risperidone, and ziprasidone and conventional antipsychotic

agents. Because of high discontinuation rates, the Diagnostic

and Statistical Manual of Disorders (DSM IV TR)

has included

‘non-compliance’ as a condition that may be a focus for clinical

attention.

Non-adherence to treatment in general may manifest in the form

of failure to begin a treatment programme, premature cessation

of treatment, missed clinic appointments, refusal to enter hospital,

and incomplete adherence to instructions.

More specifically,

non-adherence to medication may take the form of failure to fill

a prescription, refusal to take medication, stopping medication

prematurely, taking medication at the wrong times or taking the

incorrect dosage.

Consequently, non-adherence with medication

is more difficult to detect than non-adherence to treatment, with

the result that the problem is not addressed.

A great deal of psychiatric care takes place in the community

setting, and involves patients with chronic mental disorders. Their

adherence to treatment cannot always be guaranteed and this

may lead to relapses and re-hospitalisation.

9,10

Relapses may

also lead to acts of deliberate self-harm, serious social problems

and the ‘revolving door’ phenomenon.

Weiden et al.

postulated that a hypothetical medication that improves efficacy

and adherence by 50% could lead to a 37% reduction in re-

hospitalisation costs. Partial adherence is also a strong predictor

of treatment outcome

and is associated with reduced functioning

and quality of life, even in patients who do not relapse.

Aside from relapse and re-hospitalisation, non-adherence

to treatment greatly compromises the efficiency, quality and

promptness of care of the community staff. It carries a major direct

cost of increased in-hospital treatment and an indirect cost of

patient or carer absenteeism from work.

Further, these effects are

borne not only by the mental health service, but also by the family

and wider community.

Almost half of these costs could be saved

through strategies directed at improving adherence.

Therefore,

the purpose of this article was to look at the various forms of

assessing adherence, the factors associated with adherence, and

ways in which to improve adherence.

Treatment adherence

M Y H Moosa, MMedPsych, FCPsych, MCFP

F Y Jeenah, MMedPsych

N Kazadi, MD

Department of Neurosciences, University of the

Witwatersrand, Johannesburg

Patients with psychiatric illnesses show a greater degree of

non-adherence than those with physical disorders. Adherence

to treatment may be assessed using biological measurements,

clinician ratings, patient self-report, pill count, caregiver reports

and side-effects of medication. Reasons cited for non-adherence

include factors related to the treatment, patient-related factors,

health care, and socio-economic circumstances. It is important

not to make prejudicial predictions of non-adherence based

on these factors, or the use non-adherence as an excuse to

blame the patient for an unfavourable outcome. Rather, non-

adherence should be seen not only as the patient’s inability

to follow treatment recommendations but also as the health

system's failure to provide adequate care and to meet the

patient’s needs.

Volume 13 No. 2 June 2007 - SAJP

articles

Volume 13 No. 2 June 2007 - SAJP

Assessment of adherence

Adherence to treatment may be assessed using biological

measurements, clinician ratings, patient self-report, pill count,

caregiver reports and side-effects of medication.

Biological measurements

This is a direct method of assessing adherence through the

presence of the medication or its metabolites in serum or urine

samples. This method is reliable for measuring adherence to

medication but it is also inconvenient and expensive.

Some

patients may object to giving blood specimens, regarding these

as unnecessary and intrusive.

Clinician ratings

The clinician’s subjective rating of the patient’s response to

treatment is another method of assessing adherence. This method

has not proved to be accurate. Outcomes of therapy may be

reliable only for certain forms of medication (e.g. anticonvulsants

that lower the number of seizures, etc.). For most other forms of

treatment this approach is not sufficiently sensitive or ineffective.

Patient self-report

The most commonly used method is an interview. Other methods

are daily records, charts, or graphs. Generally these methods rely

on the patient’s memory, e.g. a patient is asked how many doses

were missed in the last day, 2 days or 2 weeks. Non-adherence

rates are higher and often inaccurate where longer recall times

are used. Responses are also influenced by the patients’ desire

to provide socially acceptable answers, particularly when the

interviewer is a health worker whose role has been to exhort

patients to adhere. Other inaccuracies may result from imprecise

or inconsistent questioning.

Pill count

This method involves either a standard pill count or use of drug

packs with a built-in counting system. The pill count system

requires that patients co-operate in bringing their pills to the health

visits. Pill counts tend to show increased adherence as it may be

that patients dispose of their medication rather than taking it.

The medication event-monitoring system, with a micro-processor

in the cap of the drug container, records when the container is

opened. However, this requires that patients only remove one

dose at a time. Moreover, it is argued that the caps only measure

bottle opening and not actual medication ingestion. Both methods

require that the patients do not share their pills.

Caregiver reports

This method involves utilising the observations of relatives,

housemates or caregivers for the adherence data, and may be

unreliable.

Side-effects of medication

The presence of side-effects is a limited way of showing

adherence as patients are often unreliable in reporting side-

effects. This is supported by the occurrence of side-effects when

patients are taking placebo in double-blind control trials.

Factors associated with non-

adherence

The World Health Organization (WHO)

cited the following

reasons for non-adherence, viz. discomfort resulting from treatment,

costs of treatment, personal value judgement/religious/cultural

beliefs about the advantages and disadvantages of the treatment,

maladaptive personality traits, and the presence of a co-morbid

mental disorder. Factors influencing non-adherence may be

broadly categorised into factors related to the treatment, patient-

related factors, health care, and socio-economic circumstances.

Treatment-related factors

Adherence is influenced by the patient’s acceptance of the

treatment,

the length of treatments, previous treatment failures,

frequent change of treatments and whether treatment is inpatient

or outpatient.

Patients usually respond to treatment with a single

drug, although the use of polypharmacology is acceptable when

switching drugs or in the case of augmentation.

Complex treatment regimens are less user-friendly

27,28

and

lead to unpleasant side-effects (extrapyramidal, sexual, and

metabolic disturbances) which cause subjective distress and

discontinuation.

2,6

In the black population of southern Africa

cultural and social beliefs and attitudes towards treatment are

cited as reasons for non-adherence.

Strategies to address treatment-related factors

Clinicians must reduce the complexity, duration and the cost

to the patient of treatment regimens. This must be followed up

with education on the nature and possible untoward effects of

the treatment, and continuous monitoring and reassessment of

treatment to decrease the likelihood of missed appointments.

The general consensus is that depot antipsychotic agents are

more effective than their oral equivalents in that they increase

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Volume 13 No. 2 June 2007 - SAJP

adherence and reduce relapse rates.

31-34

As depot treatment must

be given by a health care professional, any lack of adherence will

be detected immediately and with certainty. Further, as the rate of

decline in serum drug levels is lower with depot formulations,

missing a depot injection is potentially less serious than missing

doses of oral medication.

However, physicians have a number of misconceptions

about depot medication, viz. that they are old-fashioned and

stigmatising,

that they should only be used to treat patients who

are considered ‘incurable’, and that they have a higher incidence

of side-effects than oral medication.

This is compounded by the

belief that patients will not accept depot medication,

and that

patients are fearful of injections and feel that depot medication is

‘controlling’ or ‘humiliating’.

These misconceptions have been

refuted.

36,37

It must be highlighted, though, that conventional

depot antipsychotics are associated with an inferior safety

profile

38,39

and are less efficacious in managing negative

symptoms

than atypical depots. As a long-acting atypical depot,

Risperdal Consta has the potential to further increase adherence

and thereby improve the long-term prognosis of patients with

schizophrenia.

Patient-related factors

These include factors such as age, sex, and social status. The

non-adherent patient is more likely to be younger,

of lower

socio-economic status and to have a lower level of education.

Other factors include forgetfulness, anxiety about side-effects,

inadequate knowledge, lack of insight, lack of motivation, fear of

being stigmatised, lack of financial resources, and dual diagnosis

of schizophrenia and substance abuse.

43,44

The presence of

paranoid delusions, grandiosity, cognitive impairment and

disorganised behaviour also increases the risk of medication non-

adherence.

Insight implies that patients judge some of their perceptual

experiences, cognitive processes, emotions, or behaviours to be

pathological in a manner that is congruent with the judgement of

involved mental health professionals. Patients with insight believe

they need treatment, perceive the benefits of the treatment

25,46

and

are therefore usually adherent to treatment. Alternatively, those

lacking insight have been reported to be highly associated with

non-adherence.

Improvements in insight are linked to improved

adherence, greater expressed willingness to take medication and

less likehood of hospitalisation.

Stigma results from negative attitudes, separation between

‘us’ and ‘them’, status loss, and discrimination. The fear of

being stigmatised may lead the patient, family, caregivers and

neighbours to deny symptoms and illness and to search for others

explanations for the disorder.

Many patients with psychiatric

illness are likely to consult traditional healers before, during or

after the course of their treatment, making it important to explore

the cultural meaning and discuss patient concerns on these

issues.

Strategies to address patient-related factors

Educational strategies to improve adherence are based on the view

that poor adherence is linked to insufficient information. Psycho-

educational strategies aim to both motivate and educate patients

regarding their illness and treatment.

Patients must understand

what is expected of them because often written information alone

is insufficient in long-term therapy. Reminder schedules, pharmacy-

generated refill reminders and special medication containers or

packaging have been shown to improve adherence significantly.

Patients should also learn about self-management (behavioural

and educational). This requires a co-ordinated effort by the mental

health team and the other agencies and carers involved with the

patient. Evidence-based practice suggests that education must be

a responsibility shared by clinicians and patients.

Health care-related factors

Poor patient-health care provider relationships may cause poor

adherence. Failure of physicians to establish good rapport with

patients may determine much of the effectiveness of care.

37,50

good therapeutic alliance with a doctor who is enthusiastic about

treatment and its outcome will ensure better adherence.

The

patient’s perception of the physician’s interest in him or her as a

person is the best predictor of adherence,

and regular contact

is necessary. However, the development of negative counter-

transference may destroy the patient-physician alliance and result

in poor adherence.

Other factors that might impact negatively on adherence include

poorly developed services, poor medication distribution systems,

poor staff training, overworked health care providers, poor

capacity to educate patients and to provide continuity of care,

and inability to establish community supports. Long waiting

periods between first contact and initial appointment,

54,55

lack

of continuity and poor liaison between the hospital and the

outpatient teams may be associated with aftercare and treatment

dropouts.

An active and interested attitude by all staff is essential

for success.

Strategies to address health care-related factors

Health care providers must be aware of and concerned with the

extent of patient non-adherence and its effects on quality of care.

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Volume 13 No. 2 June 2007 - SAJP

They should be educated on the use of medicines, management

of disease in conjunction with patients, multidisciplinary care, and

should be trained in monitoring adherence. Early identification of

signs of aggravation of the condition or co-morbidities that affect

adherence is essential.

Attendance at initial and subsequent clinic appointments can be

improved by shortening waiting times, telephone reminders and

letter prompts.

The referring professional from the emergency

service should make the initial contact with the receiving agency

and, if possible, obtain an appointment for the patient.

Clinics

and hospitals should have a flexible and accommodating intake

procedure to facilitate the referral process.

Aftercare appointments should be scheduled before patients are

discharged, and the time interval between the discharge and first

outpatient appointment must be minimal.

Treatment dropouts

could be reduced by orientating the patient on initial contact,

introducing treatment early and making the goals of treatment

realistic. For certain groups of patients such as the chronically

mentally ill, treatment may need to be delivered wherever they

are, such as in their homes or hostels.

Factors related to socio-economic

circumstances

These include suboptimal socio-economic conditions, level

of education and literacy, unstable or poor living conditions,

access to clinics (long distance from the centre, high cost of

transport), support system, and stigmas and attitudes associated

with suffering from a mental disorder. The availability of support

in the form of family, friends, or caregivers to assist or supervise

medication is associated with increased outpatient adherence to

treatment.

Strategies to address patient-related factors

Improving the support system by getting the family involved in

management of the patient, empowering them with educational

and behavioural techniques, and improving patient living

conditions will improve adherence.

Conclusion

It is important not to make prejudicial predictions of non-adherence

based on patient characteristics or to use non-adherence as an

excuse to blame the patient for an unfavourable outcome. From

a systemic point of view, non-adherence can be seen not only as

the patient’s inability to follow treatment recommendations, but

also as the health system's failure to provide adequate care and

to meet the patient’s needs. Adherence is a major health issue

with outcomes related to levels of morbidity, mortality and cost-

utilisation, and as such every effort should be made to improve

it.

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