How can clinicians help patients to take their psychotropic medication?: Invited commentary on... Why don't patients take their medicine?

Enhancing a patient’s adherence to psychotropic medicationregimens is one of the challenges facing all mental health professionals.Medication is part of an overall care package that often dependson patients’ engagement with the clinician or service.The therapeutic alliance might be improved by more active listeningto patients. A reduced capacity may limit a patient’sability to make a treatment choice. This can be improved byprovision of more time and information. If these techniquesare insufficient, closer monitoring may be achieved by workingwith relatives and carers, or more frequent visiting. Strategiesto avoid covert non-adherence could include checking for pickedup prescriptions and the use of depot preparations. Finally,the use of compulsory powers may be appropriate, with attentionto preserving or rebuilding the therapeutic alliance.

Mitchell & Selmes (2007, this issue) have provided a comprehensiveaccount of the reasons that lead people with a wide range ofmental disorders to miss their medications. They have illustratedmany factors that such individuals share with patients withphysical disorders, and also those more specific to people withmental disorders, for example illness beliefs and capacity.The challenge is to use this information to directly influenceclinical practice to help psychiatrists and non-medical casecoordinators to optimise their patients’ adherence toprescribed medications and improve overall outcomes. This commentarywill focus on four main areas: engagement, the therapeutic alliance,information and capacity, and the use of more assertive andcompulsory strategies.

Engagement

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Engagement

Before concentrating on specific medication issues it is importantto remember that medication is not the sole focus of a mentalhealth intervention. For people with severe and enduring mentalhealth problems, it is necessary to attempt to help the patientimprove their quality of life by finding meaningful occupation,helping family relationships and extending social networks.In addition, the care plan may focus on help or liaison withagencies providing support with utilities, benefits, housingand debt advice. These can be seen as a means of engaging withpatients and also creating an environment of therapeutic trustand hope, conditions that may help the patient to see the valueof taking their medication.

The therapeutic alliance

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The therapeutic alliance

It should not be forgotten that the problem of inadequate adherencemay be the responsibility of the clinician rather than the patient.For example, Johnson & Rasmussen (1997) found that cliniciansoften recommended inadequate periods of maintenance antipsychotictreatment for people with schizophrenia. More likely, as Mitchell& Selmes illustrate in their review, treatment adherenceproblems are related to the interaction between the mental healthprofessional and the patient – the therapeutic alliance.At the most basic level, a poor therapeutic alliance may resultfrom genuine problems in the relationship between the care coordinatoror psychiatrist and a patient. This can lead to poor treatmentadherence, which in turn may engender frustration and negativeattitudes among mental health professionals, further worseningthe situation. Such difficulties should be acknowledged anddiscussed within team supervision. A change of professionalmight be considered if the difficulties within a therapeuticrelationship cannot be accommodated.

Specific problems with the therapeutic alliance include doctorsfailing to acknowledge patients’ concerns, an exampleof which is the failure to respond to patients who talk abouttheir auditory hallucinations in schizophrenia (McCabe et al, 2002).Furthermore, doctors appear not to appreciate the degree ofdistress caused by certain antipsychotic side-effects (Day et al, 1998).There is therefore a need to listen more effectively to patientsand elicit their particular concerns about their illness andits treatment.

There are few data from research aimed at improving the therapeuticalliance. However, a current controlled, multicentred Europeanstudy is looking into the effects of improving the therapeuticalliance by providing regular assessment of patient needs, treatmentsatisfaction and quality of life (Priebe et al, 2002).

Many relatively straightforward approaches to enhancing treatmentadherence are regularly adopted by psychiatrists themselves(Chaplin et al, 2007). These include checking with general practitioners(GPs) about collected prescriptions, working with families andcarers to administer or monitor tablets, checking the strategiesof how people remember to take their pills and the routine practiceof copying to patients letters written to their to GPs. In addition,psychiatrists participating in Chaplin et al’s study statedthat they put into place many of the practical aspects of compliancetherapy (Kemp et al, 1996) such as exploring ambivalence totaking medication, addressing the experience of stigma and promotingmedication as a means of self-efficacy or a coping mechanism.

Information and capacity

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Information and capacity

One of the greatest problems in treating people with severemental illness relates to capacity. Indeed many patients withlong-term mental illness lack capacity but still remain adherentto their medication. A possible explanation is that insightmay not be the only predictor of engagement or adherence. Forexample, Tait et al(2003) showed that, regardless of their insight,patients with an integrative recovery style had better engagementwith services. Patients should be presented with informationabout their treatment on more than one occasion, in a form theycan understand. Since it is difficult to judge how much informationto impart, this could be augmented with the use of informationleaflets. Research has shown that people with schizophreniacan achieve enhanced capacity to consent to a research studyby such interventions (Carpenter et al, 2000).

Assertive and compulsory strategies

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Assertive and compulsory...

Mitchell & Selmes provide a framework for improving adherencethat encompasses patient-centred practice and more intrusivemethods of assessing adherence such as pill counts and checkingwhether prescriptions have been collected. In most situationsthe aim is to facilitate the patient’s autonomy, but thereare times when more intrusive practices are unavoidable andthese may threaten the therapeutic alliance. For certain individualsat specific periods, closer supervision may be required. Thismay be achieved by more regular contact with the community mentalhealth team, referral to a crisis or home treatment team, orto an assertive outreach team if close supervision is neededon a long-term basis. The use of depot antipsychotic medication,or orodispersible forms of antipsychotic drugs administeredby carers or professionals, helps reduce covert non-adherence,but these preparations may of course be refused.

If these techniques do not enable the individual to achieveadherence and they cannot be managed in a less restrictive manner,psychiatrists are required to consider the use of compulsion(if the legal criteria are met) to ensure engagement with servicesso that treatment can be offered. Although supervised dischargeorders (SDOs) in England and Wales specifically prohibit thecompulsory administration of medication, they may provide aframework within which the patient engages with a service andattends to receive treatment, with the option of refusing it.Pinfold et al(2001) found that the majority of a selective groupof patients who were subject to SDOs had complied with the specifiedconditions. Supervised discharge orders also appeared to beeffective in achieving adherence with medication despite theabsence of any formal legal power to enforce treatment.

There is a small literature on the use of compulsory treatmentin the community and it shows mixed results. In England, Sensky et al(1991)found improved outcome in terms of time spent in hospital andtreatment adherence for patients given extended leave from section3 of the Mental Health Act 1983 when compared with matched controls.However, in Australia, Preston et al(2002) demonstrated no advantagesin clinical outcomes over matched controls for patients treatedunder compulsory community treatment orders. Compulsory management,of whatever type, can be discontinued once the individual’scondition has stabilised. Compulsory treatment may be achievedin many instances without permanent damage to the therapeuticalliance.

Conclusions

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Conclusions

Adherence to prescribed medication is unlikely to be achievedin patients with severe mental illness who are not well engagedwith psychiatric services and who are not experiencing goodtherapeutic relationships. Clinicians need to examine theirown roles in the formation of the therapeutic alliance, includingtheir attitudes, their ability to listen and respond to patients’concerns (and beliefs about medication), and the quality andquantity of information they give. However, with some peopleat specific times of their illness, more assertive and, infrequently,restrictive practices might be the only ways to ensure thatthey receive care and treatment.

Declaration of interest

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Declaration of interest

None.

Footnotes

See pp. 336–346, this issue.

References

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