10 - Improving adherence

Improving adherence

© SPMM Course Factors affecting adherence

 Patients with poor insight may still take medications – accepting label is less important than enhancing awareness of drug effects  Dose strength – the relationship between dose strength and adherence is probably curvilinear, with very low doses being associated with poor efficacy and very high doses with excessive side-effects  The health belief model of adherence outlines four main belief categories that a patient considers before making a decision regarding prescribed medications:

1. Benefits
2. Costs
3. Susceptibility
4. Secondary benefits of medication and adherence.

Improving adherence Adherence enhancement is possible if the patient’s perceptions are altered. Most patient/family directed psychoeducational programmes focus primarily on imparting knowledge without focusing on attitudinal and behavioural change; hence they are largely ineffective in enhancing adherence. Factors with no influence on adherence Factors with no influence on adherence •Age at illness onse •Age at first hospitalization •Sex •Socioeconomic status, •Marital status •Ethnicity Factors that reduce adherence: Factors that reduce adherence: •Asymptomatic stage of illness •Cognitive deficits •Comorbidity – alcohol and substance misuse •Devaluation of medication effects by the physician •Fear of side-effects. •High frequency of daily doses •Homelessness •Lack of insight (most common cause) •Long duration of illness (chronic diseases) •Oral formulations have poorer adherence than depots •Past history of non-adherence •Polypharmacy •Prophylactic or maintenance treatments •Psychopathology of hostility, suspiciousness and disorganization Factors that increase adherence Factors that increase adherence •Presence of family support •Liquid or sublingual forms •High enthusiasm fromclinican •Good patient-clinician relationship •Continued access to clincians

© SPMM Course  Cognitive-based interventions target the patient’s attitudes and beliefs towards medication to influence the personal construction of the meaning of medication and illness (Zygmunt et al., 2002).  Behaviour-modification interventions assume that behaviour is learnt and can be modified. Patients are provided with instructions and strategies (e.g. reminders, selfmonitoring tools, cues and reinforcements) to improve adherence (Zygmunt et al., 2002).  Motivational interviewing enables the patient to express personal reasons for and against improving their treatment adherence.  Compliance therapy is a brief intervention based on motivational interviewing and cognitive approaches. In compliance therapy, a patient’s ambivalence towards medication is explored initially, followed by a discussion of the consequences of medication cessation. Analogies with chronic physical illness are made, and the pros and cons of medication are considered during the course of treatment.

© SPMM Course Notes prepared using excerpts from:  Deb, S et a (2008). International guide to prescribing psychotropic medication for the management of problem behaviours in adults with intellectual disabilities. World Psychiatry; 8(3); 181-86  Ernst, E. (2001) Towards a scientific understanding of placebo effects. In Understanding the Placebo Effect in Complementary Medicine. Theory, Practice and Research (ed. D. Peters), pp. 17–30. London: Churchill Livingstone.  Ian M Anderson & Ian C Reid. Fundamentals of clinical Psychopharmacology (2nd edition)  Kaur H, Mariappan TT, Singh S. Behavior of uptake of moisture by drugs and excipients under accelerated conditions of temperature and humidity in the absence and presence of light Part-III, Various drug substances and excipients. Pharma Technology 2003:52-56  Mayberg HS, Silva JA, Brannan SK, Tekell JL, Mahurin RK, McGinnis S, Jerabek PA: The functional neuroanatomy of the placebo effect. Am J Psychiatry 2002; 159:728-737  Oken BS . Placebo effects: clinical aspects and neurobiology (2008), 131, 2812^2823  Patel, M & David, A. Medication adherence: predictive factors and enhancement strategies Psychiatry, 3, 10:41-44.  Quitkin, FM et al (1991) Heterogeneity of clinical response during placebo treatment. American Journal of Psychiatry, 148, 193 -196  Rajagopal, S. The placebo effect. Psychiatr Bull 2006 30: 185-188  Sadock, BA & Sadock, VA (ed). Kaplan & Sadock's Comprehensive Textbook of Psychiatry. Lippincott Williams & Wilkins; 8th edition  Ter Riet et al (1998) Is placebo analgesia mediated by endogenous opioids? A systematic review. Pain, 76, 273 -275  The use of drugs in Psychiatry; John Cookson, David Taylor and Cornelius Katona. (5th edition)  Vallance, AK. Something out of nothing: the placebo effect. Advan. Psychiatr. Treat., July 1, 2006; 12(4): 287 - 296. DISCLAIMER: This material is developed from various revision notes assembled while preparing for MRCPsych exams. The content is periodically updated with excerpts from various published sources including peer-reviewed journals, websites, patient information leaflets and books. These sources are cited and acknowledged wherever possible; due to the structure of this material, acknowledgements have not been possible for every passage/fact that is common knowledge in psychiatry. We do not check the accuracy of drug related information using external sources; no part of these notes should be used as prescribing information.