Medication adherence in adolescents – challenges and interventions
- Adhering to treatment for chronic disease is a significant issue, especially in teenage-young adult patients1,2.
- Patient’s emotional functioning, developmental stage, and family environment are some of the key factors that affect treatment adherence in this age group2.
- Strategies enhancing greater patient adherence in teenage-young adults include managing mental health, collaborating with patients, customizing the regimen, imparting knowledge, and motivational enhancement therapy2.
Adherence to treatment in adolescents is a major challenge for doctors and healthcare professionals. Adherence rates in the adolescent population vary widely from 10% to 89% for chronic diseases2. There are many repercussions of low adherence in teens, with obvious consequences for themselves, their families, and the health care system. For chronic conditions, low adherence increases morbidity and medical complications (hospitalization), contributes to poorer quality of life (fatigue, poor social life, and school absenteeism), and an overuse of the health care system (unnecessary medical consultations and investigations)2.
Although classified as children, teenage-young adults identify themselves more as adults. They display a higher need for emotional, physical, and financial independence as compared to younger children. This reflects in their tendencies to make decisions independently without consulting their parents and not conforming to a set of rules that they might perceive as a threat to independence. This often leads to conflict between adolescents and parents/caregivers/other professionals like teachers or administration2.
Teenage and young adults with chronic illness appear to be less treatment-adherent when they are experiencing high levels of stress and poor mental health High levels of anger and low self-esteem have also been associated with greater nonadherence in adolescents3.
Understanding barriers to treatment adherence in teenage-young adult patients
Medication non-adherence is a major concern in patients with chronic diseases out of which a significant number has been reported during the adolescent year like mental health issues, cancer, diabetes, and asthma. Scientific evidence shows that a considerable proportion i.e. 63% of teenage and young adult patients with cancer experience challenges in adhering to the treatment. Similarly, data from various studies showed that ~25% of adolescents with type 1 diabetes were found to neglect insulin injections2,4.
Teens experiencing a dysfunctional family environment, mental health problems, emotional trauma, and social isolation are less keen on medication. The ones with depression and other psychological issues also tend to invest less in treatment plans. While, others with a positive family environment, close friends, and treatments with immediate benefits rate better on adherence2.
Factors with a negative impact4:
- Fear of dependence and losing autonomy, or taking on the responsibility for which adolescents might not yet be fully prepared emotionally or physically is a major challenge.
- Parental intrusiveness or over-involvement can enhance non-adherence as a response to enforced dependency.
- Poor family environment, especially a difference in the perceptions of the family environment between adolescent patients and their parents correlates with enhanced non-adherence4.
- Poor mental health such as higher levels of depression and lower self-esteem is also associated with increased non-adherence2.
- Mental health issues with caregivers also negatively impact adherence in teenage-young adults.
- Patients’ health beliefs orperception of disease severity and vulnerability is associated with treatment refusal in teenage-young adult patients2.
- Peer pressure, social interactions, and a fear of social boycott arecommon reasons for non-adherence to chronic disease medications. Teens do not want to stand out from their classmates, which might result in denial or hiding their disease from them2.
- Financial constraints negatively affect adherence as teenage-young adults are financially dependent and cannot afford the costs of their medications2.
- Poor health literacy contributes to non-adherence. Adolescents with learning disabilities are reported to fare poorly in medication adherence5.
- Treatment-related side effects impede medication adherence, while treatments with immediate benefits rate better owing to the impatient nature and reliance on quick fixes in this patient group.
- Complicated regimens and inability to recall instructions along with poor time management results in higher chances of forgetfulness negatively impacting medication non-adherence1.
Table 1: Treatment non-adherence in teenage-young adult patients4
| Illness | Incidence of non-adherence | Source |
| Cancer | 11%- 47% | Kondryn et al., 20114 |
| Inflammatory Bowel Disease | ~ 31% | Lim et al., 20206 |
| Severe mental illness | < 34.1% | Edcomb et al., 20187 |
| Asthma | 40%-50% | Taddeo et al., 20082 |
| HIV | 50% | Taddeo et al., 20082 |
| Liver transplant | 30%-48% | Taddeo et al., 20082 |
| Type 1 Diabetes | 25% | Taddeo et al., 20082 |
Strategies to improve adherence to treatment in teenage-young adults
A range of interventions has been used in teenage-young adult patients to enhance adherence in chronic illness eg, behavioral interventions (designed to influence behavior), educational interventions (designed to educate and inform), motivational interventions (persuade to change behavior), and social interventions (designed to improve social support)2.
Table 2: Interventions to improve adherence in teenage-young adult patients1
| Strategy | Role of patient | Role of healthcare professionals | Role of parent/caregiver |
| Developmental Strategies | Voice concerns Collaborate with HCPs and parents for meeting treatment milestones | Provide personalized guidance Open communications about treatmentDiscussions about the flexibility of scheduleRegular follow-ups and monitoring | Normalize medication taking Structuring a routine for self-careSupport social and extracurricular activities |
| Educational Strategies | Understand the effects of treatment and medication | Provide knowledge about the disease, treatment, future health outcomes, and confidence in the recoveryAddress concerns and offer alternatives | Seek and gain knowledge about the disease and treatment |
| Communication Strategies | Discuss issues and concerns with parents/support person and HCPs | Encourage enhanced communication.Provide transparent health and medication information Regular updates and follow-ups Monitor progress in patient’s awareness and treatment | Be wary of controlling behaviors and serious disagreementsImprove family communication |
| Psychological and social support | Minimize psychological distress by attending support services when offered | Awareness about potential psychological distress in patientsEncourage social supportAssess for distressInvolve mental health workers throughout the treatmentProvide access to a wide range of support networks of interest | Acknowledge the potential for psychological distressNormalize seeking professional helpEncourage social networks. |
| Other Strategies | Use reminder systems (eg, alarms, pill-monitoring system)Collaborate about responsibilities for medication administration | Discuss adherence barriersRoutine assessment for nonadherence (via self-report, pill counts, etc)Decrease negative side effectsIdentify risk factors for nonadherence and provide preemptive interventions | Have ongoing involvement in the treatment processRemind teenage-young adult patients to take medication when required |
Impact of mental health of teenage-young adult patients on medication adherence:
Mental health is an important barrier to non-adherence in teenage and young adults. Non-adherence to the treatment plan is frequently a sign of mental health issues like depression or other psychosocial problems3. Adolescents and young adults with mental health issues have a lack of motivation and lose interest, especially if they are struggling with other issues in their lives. This underscores the importance of consultation with a mental health professional to identify and diagnose such issues and take appropriate treatment/support for emotional or mental health problems3.
Evidence shows that adolescents living with HIV are more likely to experience mental health challenges, interfering with their ability to adhere to antiretroviral treatment (ART). Higher anxiety, depression, and post-traumatic stress disorder (PTSD) symptom and impairment scores are significantly associated with ART adherence among adolescents living with HIV10..
Adolescents suffering from mental disorders also show suboptimal adherence to psychotropic medications. It has been reported that only two-thirds of teenage-young adult patients adhere to their prescribed psychotropic medication. Lower than desired adherence to medications in this age group can have disruptive effects on their life and development resulting in social isolation, difficulties in school, indulgence in criminal activities, and drug abuse. Poor mental health may also lead to unhealthy sexual activities resulting in unintended pregnancies and sexually transmitted diseases. The rate of non-adherence is directly related to the severity of the mental health issue. Teens suffering from attention deficit hyperactivity disorder (ADHD) or substance abuse are also prone to higher levels of nonadherence to medication. It is recommended that health improvements should not be limited to the individual but should also take into account legislative and structural changes that support and enhance mental health and mental health services for kids and teenagers11.
Conclusions:
Categorized as children, while wanting to be recognized as adults, teenage-young adult patients pose a unique challenge to both parents and HCPs in implementing therapeutic regimens. The rate of adherence for chronic diseases ranges from 10-89% in this age group. Engaging teens in non-judgemental communication by establishing a trusting relationship is pivotal for encouraging adherence and good health practices. Better caregiver-adolescent relationships and more social support are protective factors for good mental health and medication adherence among adolescents. Mental health professionals should work together with adolescents and parents to inform and create awareness about mental disorders and treatment options. Illness perceptions of both parents/caregivers and teenage-young adults’ are important determinants of medication adherence. Therefore, adherence behavior in teenage-young adults should be regularly evaluated and reinforced by providing repeated and targeted information.
“Effective communication depends much more on your tone and the body language than the words you say.” —Tom Raftery
References
1. Robertson E WC, Marshall K, Sansom-Daly U. Strategies to improve adherence to treatment in adolescents and young adults with cancer: a systematic review. Clinical Oncology in Adolescents and Young Adults 2015;2015 (5):35-49. doi: https://doi.org/10.2147/COAYA.S85988
2. Backes C, Moyano C, Rimaud C, Bienvenu C, Schneider MP. Digital Medication Adherence Support: Could Healthcare Providers Recommend Mobile Health Apps? Front Med Technol. 2020;2:616242. doi:10.3389/fmedt.2020.616242
3. Taddeo D, Egedy M, Frappier JY. Adherence to treatment in adolescents. Paediatr Child Health. Jan 2008;13(1):19-24. doi:10.1093/pch/13.1.19
4. Kondryn HJ, Edmondson CL, Hill J, Eden TO. Treatment non-adherence in teenage and young adult patients with cancer. Lancet Oncol. Jan 2011;12(1):100-8. doi:10.1016/S1470-2045(10)70069-3
5. Dharmapuri S, Best D, Kind T, Silber TJ, Simpson P, D’Angelo L. Health literacy and medication adherence in adolescents. J Pediatr. Feb 2015;166(2):378-82. doi:10.1016/j.jpeds.2014.10.002
6. Ho PM, Magid DJ, Shetterly SM, et al. Medication nonadherence is associated with a broad range of adverse outcomes in patients with coronary artery disease. Am Heart J. Apr 2008;155(4):772-9. doi:10.1016/j.ahj.2007.12.011
7. Edgcomb JB, Zima B. Medication Adherence Among Children and Adolescents with Severe Mental Illness: A Systematic Review and Meta-Analysis. J Child Adolesc Psychopharmacol. Oct 2018;28(8):508-520. doi:10.1089/cap.2018.0040
8. Dinwiddie R, Muller WG. Adolescent treatment compliance in asthma. J R Soc Med. Feb 2002;95(2):68-71. doi:10.1177/014107680209500204
9. Campagna BR, Weatherley K, Shemesh E, Annunziato RA. Adherence to Medication During Transition to Adult Services. Paediatr Drugs. Oct 2020;22(5):501-509. doi:10.1007/s40272-020-00414-2
10. Nguyen N. Mental health and ART adherence among adolescents living with HIV in Mozambique. AIDS Care. 2022 Mar 11;1-9. doi: 10.1080/09540121.2022.2032574
11. Dikec G. Perceptions and Experiences of Adolescents with Mental Disorders and Their Parents about Psychotropic Medications in Turkey: A Qualitative Study. Int J Environ Res Public Health . 2022 Aug 4;19(15):9589. doi: 10.3390/ijerph19159589