10 - References

References

934 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 14 to arise in cancer medicine regarding the benefits and risks of anti-­cancer medications.63 One must assume that we are likely to meet the same difficulties in psychiatry. We also need to consider that our patients may have a very different explanatory model for what is happening to them. For example, not so long ago, only just over a third of white English patients viewed schizophrenia as having a substantially biological origin.64 So our explanations for a person’s psychosis may not be as convincing to them – and their families – as we might imagine. One simple step that might help is to encourage patients with a serious medical illness to read their own notes; one study reported that this helped such patients to better understand why they were prescribed medications.65 However, this begs the question of why they did not understand in the first place. The range of practical interventions described in Table 14.3 – and, to a great extent, the psychological interventions contained in the original model of compliance therapy – will need to be tailored to the needs of the individual patient. But this assumes that clinicians have an awareness of the issue, the requisite skills and the time available to use them. The current RCPsych curricula, although they refer to some of the psychological skills modalities mentioned, do not include the management of adherence as an issue in either the core curriculum or the general psychiatry curriculum.66 Conclusion Establishing and maintaining adherence is a quintessentially biopsychosocial activity. It is central to the practice of medicine and, hence, to psychiatry. It demands both an awareness of the problem, a knowledge of practical strategies for its improvement and a repertoire of psychological skills. The neglect of this area of therapeutics in training should not deter prescribers from recognising non-­adherence and taking active steps to manage it. An initial gambit might be, at the end of any first prescription, to ask ourselves ‘What have I done to help this patient take this medication?’ and to record this answer as part of the care plan, as a reminder to ourselves and our colleagues that this issue needs our conscious, structured and regular attention. References

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