Severe psychiatric disorders: causes & interventions for medication non-adherence
- The key challenges to medication adherence for patients with severe psychotic disorders include -medication side effects, complexity, and duration as well as patient’s insights, beliefs, social stigma, and lack of support1.
- Psychoeducation, Cognitive Behavior Therapy (CBT), and motivational interviewing are the typically used strategies to improve adherence2. The digital medicine system is a novel and revolutionary tool to address non-adherence in psychotic disorders3.
- An integrated approach that combines patient-centric solutions with a supportive environment can potentially be a more effective solution to medication non-adherence2.
Living with a psychiatric disorder can be quite debilitating for the patient as well as the caregiver. Although pharmacological treatment is effective in managing the symptoms, non-adherence to psychiatric medications is a significant challenge in such patients. Research reveals that psychiatric patients have a high prevalence of medication non-adherence, ranging from 41-50% in schizophrenia, 13%- 52% for depression, 68% for patients with opioid dependency, 57% in patients with anxiety disorders4, and 20–60%, in bipolar disorder5.
Suboptimal medication adherence in these patients can have serious consequences like:
- Poor prognosis and slow recovery; eventually increasing the risk of relapse and rehospitalization
- Reduced quality of life due to worsening psychotic symptoms.
- Suboptimal usage of resources and a higher social and economic burden 6
Factors contributing to non-adherence:
Specific causes leading to non-adherence in psychotic disorders are detailed below.
A. Patient-related factors:
- Attitude towards medication: Psychiatric patients often have a gloomy outlook towards the use of medication, disbelief in the efficacy, or subjective belief that the medication doesn’t work. Additionally, lack of awareness and poor understanding of the disease can add to medication non-adherence2.
- Psychotic symptoms: Persistent negative symptoms interfere with the patient’s motivation or ability to take medication. Similarly, persistent psychotic symptoms interfere with a patient’s understanding of the need to take medications. For example, patients may experience psychotic symptoms such as hallucinations/paranoia that doesn’t allow the patient to take medication or to visit pharmacy to pick up medication1,7.
- Cognitive impairments: Cognitive deficits interfere with understanding the benefits of or the ability to take medications. Poor memory and impacted executive function in patients with psychiatric disorders are significant predictors of non-adherence6.
- Socio-demographics: Young (<34 years) and older (>60 yrs) patients show poor adherence to medication use. Additionally, female patients are found to be less adherent to both antipsychotic and antidepressant medication due to lower priority to self-care. The educational level also affects medication adherence; patients with lower educational levels are less adherent1,2,8.
- Substance abuse: Drug & alcohol abuse is a key driver of non-adherence in patients with psychiatric disorders. Either patients tend to stop the medication because of intoxication issues or because they believe, they should not take medication while using alcohol or drugs9.
B. Treatment-related factors:
- Medication side effects: Use of anti-psychotics is associated with extrapyramidal side effects such as akathisia and parkinsonism, peripheral anticholinergic problems, nausea, diarrhea, prolactin elevation, and sexual dysfunction. Weight gain is the most common side effect affecting the patient’s motivation to continue the treatment6. Similar side effects also contribute to the non-adherence to antidepressants8
- Type of treatment: Although the evidence is inconclusive, patients on second-generation antipsychotics (SGAs) show better adherence compared to patients on first-generation antipsychotics (FGAs). Switching from an FGA to an SGA also shows a significantly higher adherence rate2,6.
- Complex medication schedule: Too many pills and/or too many times a day influences a patient’s adherence to medication. Oral drugs have lower adherence as compared to injectable or depot formulations1.
- Access to mental healthcare: Low-income countries have poorly developed healthcare systems. In addition, there is a lack of access to mental health facilities or psychiatrists and psychotropic medications are not easily accessible at government health facilities. Buying drugs from private pharmacies put a substantial economic burden on the patients and their families; eventually causing them to discontinue the medication1,9,10.
- Financial constraints: Psychiatric disorders require long-term medication use. However, psychotropic medication is quite expensive and health insurances have higher patient cost sharing. Since the specialized medical facilities are fewand located far away, the costs of traveling and accommodation add to the financial burden of the disease7,11.
C. Social structure and influence of cultural beliefs:
- Poor family or social support: Patients with psychiatric disorders are often dependent on their families or caregivers to take medications. Failure of familial support in medication-taking routine, lack of family compliance to follow-up with physicians, having old-age parents or no caregivers, and subjective belief of the family towards medication result in adherence issues. Likewise, discrimination by the community and a lack of social support centers for caregivers contribute to non-adherence11.
- Stigma: Psychiatric disorders have a stigma attached to them. The fear of not being accepted by society drives the patients to either reject the medication or seek treatments at general hospitals, rather than going to a psychiatric hospital. Patients feel embarrassed about their condition and refrain from taking the medication9,11.
- Cultural or religious beliefs: Psychiatric disorders are often associated with cultural or religious practices beyond scientific justification. Patients & their families prefer alternative treatment modalities such as psychotherapy or spiritual approaches to medication use11,12.
Strategies to improve medication adherence in psychotic disorders:
Modifying the patient’s behavior is the cornerstone of improving adherence. In addition, targeting forgetfulness with the use of technological interventions and offering support to the patients and their families can be quite helpful.
A. Behavior and cognition enhancement via:
- Psychoeducation: It involves counseling the patients to help them understand their disease, medication use, and its potential side effects using written and audio-visual aids.
- Cognitive behavior therapy: This includes linking medication adherence to symptom reduction via skills training, practicing activities, positive conditioning, and offering rewards, cues & reminders.
- Motivational interviewing: Patient-centred directive method to enhance the intrinsic motivation to change, rather than challenging the resistance to change. The therapy entails, asking patients open-ended questions to help them analyze their behaviors and prompt them to change based on the pros & cons of their behaviors.
- Cognitive adaptation training: Involves a series of compensatory strategies and environmental supports to improve adaptive functioning including medication adherence.
- Combination adherence therapy: A twelve-session therapy that includes a combination of motivational interviewing, CBT, and psychoeducation2,4.
- Financial incentives: It is a behavioral method that links medication intake with a financial incentive13.
B. Building a strong therapeutic alliance with the physician:
This can help psychiatrists and nurses to understand patients ’ insights and identify specific factors for non-adherence and to create a tailored treatment plan for the patient11.
C. Using technological interventions:
- Electronic reminders: Reminding patients to take daily medications via reminder apps on a phone or device and text messaging7.
- Electronic drug monitoring: It includes measuring medication intake or pill count with the use of smart or electronic pill containers. The data then can be used to improve adherence through direct patient reminders to take medicine and/or by facilitating adherence feedback to the patient2,14
- Digital Medicine System: A digital medicine system (DMS) is a next-generation adherence-monitoring tool that can track the actual intake of a pill through an inbuilt sensor. Once the ingested pill reaches the stomach, the acid in the stomach activates the sensor. The sensor then sends a signal to a wearable sensor patch that in turn sends the information to a mobile device app. The information can also be stored in a cloud-based server. Patients and physicians can then view the medication intake information on the web-based portal. Abilify MyCite is the first DMS approved by the FDA in 2017. It is a tablet formulation of the antipsychotic drug aripiprazole embedded with a small edible sensor 3.
D. Service based support:
- Telephone intervention problem solving: A telephone nursing intervention used to provide weekly support to outpatients2.
- Offering annual prepayment cards to reduce the total cost of prescriptions over a year, thus helping patients financially7.
Medication non-adherence in patients with psychiatric disorders is associated with adverse consequences like risk for relapse, persistent/worsening symptoms, and threat to life6. In addition to the patient’s cognitive inability to adhere to medication, the lack of well-knitted infrastructure to support patients & their families contribute to non-adherence. Local community-based mental health services and a supportive social structure are essential to alleviate non-adherence in these patients11. Health care practitioners should focus on building a close alliance with the patient & their families to offer customized & integrated solutions4.
- Semahegn A, Torpey K, Manu A, Assefa N, Tesfaye G, Ankomah A. Psychotropic medication non-adherence and its associated factors among patients with major psychiatric disorders: a systematic review and meta-analysis. Syst Rev. Jan 16 2020;9(1):17. doi:10.1186/s13643-020-1274-3
- El Abdellati K, De Picker L, Morrens M. Antipsychotic Treatment Failure: A Systematic Review on Risk Factors and Interventions for Treatment Adherence in Psychosis. Front Neurosci. 2020;14:531763. doi:10.3389/fnins.2020.531763
- Papola D, Gastaldon C, Ostuzzi G. Can a digital medicine system improve adherence to antipsychotic treatment? Epidemiol Psychiatr Sci. Jun 2018;27(3):227-229. doi:10.1017/S2045796018000082
- Steinkamp JM, Goldblatt N, Borodovsky JT, et al. Technological Interventions for Medication Adherence in Adult Mental Health and Substance Use Disorders: A Systematic Review. JMIR Ment Health. Mar 12 2019;6(3):e12493. doi:10.2196/12493
- De Las Cuevas C, de Leon J, Penate W, Betancort M. Factors influencing adherence to psychopharmacological medications in psychiatric patients: a structural equation modeling approach. Patient Prefer Adherence. 2017;11:681-690. doi:10.2147/PPA.S133513
- Garcia S, Martinez-Cengotitabengoa M, Lopez-Zurbano S, et al. Adherence to Antipsychotic Medication in Bipolar Disorder and Schizophrenic Patients: A Systematic Review. J Clin Psychopharmacol. Aug 2016;36(4):355-71. doi:10.1097/JCP.0000000000000523
- Haddad PM, Brain C, Scott J. Nonadherence with antipsychotic medication in schizophrenia: challenges and management strategies. Patient Relat Outcome Meas. 2014;5:43-62. doi:10.2147/PROM.S42735
- Marasine NR, Sankhi S. Factors Associated with Antidepressant Medication Non-adherence. Turk J Pharm Sci. Apr 20 2021;18(2):242-249. doi:10.4274/tjps.galenos.2020.49799
- Velligan DI, Sajatovic M, Hatch A, Kramata P, Docherty JP. Why do psychiatric patients stop antipsychotic medication? A systematic review of reasons for nonadherence to medication in patients with serious mental illness. Patient Prefer Adherence. 2017;11:449-468. doi:10.2147/PPA.S124658
- Sajatovic M. et al. Correlates of poor medication adherence in chronic psychotic disorders. BJPsych Open. 2020; v.7(1)doi:10.1192/bjo.2020.141
- Deng M, Zhai S, Ouyang X, Liu Z, Ross B. Factors influencing medication adherence among patients with severe mental disorders from the perspective of mental health professionals. BMC Psychiatry. Jan 7 2022;22(1):22. doi:10.1186/s12888-021-03681-6
- Higashi K, Medic G, Littlewood KJ, Diez T, Granstrom O, De Hert M. Medication adherence in schizophrenia: factors influencing adherence and consequences of nonadherence, a systematic literature review. Ther Adv Psychopharmacol. Aug 2013;3(4):200-18. doi:10.1177/2045125312474019
- El-Mallakh P, Findlay J. Strategies to improve medication adherence in patients with schizophrenia: the role of support services. Neuropsychiatr Dis Treat. 2015;11:1077-90. doi:10.2147/NDT.S56107
- McGrady ME, Ramsey RR. Using Electronic Monitoring Devices to Assess Medication Adherence: a Research Methods Framework. J Gen Intern Med. Sep 2020;35(9):2707-2714. doi:10.1007/s11606-020-05905-z