Among people living with schizophrenia, research consistently demonstrates low adherence to antipsychotic medication. Recent studies, for example, have shown nonadherence rates of 26.5% and 58.8% in this population.1 Adverse outcomes associated with nonadherence include increased risk for suicide, psychotic relapse (odds ratio =10.27), and hospital admission (4.00).2
Various factors have been linked with nonadherence in patients with schizophrenia, including side effects, substance abuse, relapse of positive symptoms, poor therapeutic alliance, low socioeconomic status, younger age, and poor insight.1,3,4 Alternately, greater insight into the illness, positive attitudes toward medication, and strong therapeutic alliances are associated with improved adherence.5,6
Although these factors have been explored across a range of quantitative studies, there has been inadequate focus on patients’ subjective experience with antipsychotics, according to a paper published in September 2018 in the International Journal of Nursing Studies.1 To that end, the authors conducted a narrative synthesis of 9 studies published over roughly a 10-year period that examined these themes among patients with schizophrenia or schizophrenia like illness (total n = 156).
“The most prominent ﬁnding is that what motivates the continuing of medication was the hope for and striving towards returning to an everyday living, including being able to participate in life activities and have functioning relationships with relatives,” they reported.1
Other key observations are highlighted below.
- Perceived support from professionals and relatives motivated patients to continue taking medication.
- Obstacles to adherence included side effects, pressure and compulsion from others to take medication, and rigid organizational aspects such as limited hours, inflexibility regarding appointment times, and long wait times.
- Patients were often uninformed about their medication beyond the name, dosages, and intervals. However, many indicated that they value conversations with health care providers on the topic, especially when clinicians discussed the patient’s subjective experience with the medication rather than positioning themselves as the experts whose advice is compulsory, and thus denying the patient an active role in his or her own treatment.
Taken together, these “ﬁndings enhance our understanding of the importance of adopting a person-centered approach to health care,” the authors concluded.1 “A reasonable approach to tackle this issue could be to ‘turn the tables’ and view the patient as an expert, while the professionals adopt a role that is similar to that of a ‘learner’ who supports and engages in the patients’ own recovery process.”
For an additional perspective regarding this topic, Psychiatry Advisor interviewed Rohan Ganguli, MD, professor of psychiatry at the University of Pittsburgh School of Medicine (UPMC), chair of the department of psychiatry at UPMC Mercy Hospital, adjunct professor of psychiatry and public health at the University of Toronto, and affiliate scientist at the Center for Addiction & Mental Health in Toronto.
Psychiatry Advisor: What does this study add to our understanding of why patients with schizophrenia often do not adhere to medication?
Dr Ganguli: The paper addresses an important topic because medicines don’t work if people do not take them, and many studies have found that a lot of people do not take medications as prescribed. This is generally found to be more likely the longer one has to take the medications, as would be the case for persons suffering from chronic conditions like hypertension, diabetes, asthma, peptic ulcers, and some serious mental illnesses such as schizophrenia.
The authors contend that while there is extensive literature documenting efforts to study the barriers in what quantitative studies, they say these studies don’t take into account the patient’s perspective – partially true. To be honest, I would say that this study adds relatively little to what we already know – not surprising, since they base their analysis on the results of previously published studies and there is already a much larger literature on the subject of nonadherence which is not from qualitative study designs, and from a number of patient-advocacy organizations. The latter have come to be incorporated into treatment recommendations, including by Community Care Behavioral Health, our local Medicaid behavioral health HMO in Allegheny County.
On the other hand, a very good journal did choose to publish the article, so they clearly disagree with my opinion above! Also, even though the “patient-centered” approach is widely accepted and recommended, our practice often falls short of the ideal approach, so maybe people should be encouraged to read the article anyway.
Psychiatry Advisor: What would you recommend to clinicians about how they can better support patients in medication adherence?
Dr Ganguli: In terms of supporting medication adherence, there are several things I would recommend that clinicians do in their interactions with patients and their caregivers.
The first is that they work on developing a therapeutic alliance with both of the above parties, as evidence shows improved adherence when the prescriber and patient feel they are on the same side. Developing a therapeutic alliance with someone who might not agree that they need to see a physician at all is not always easy because, as mentioned in the article, the patient may not feel that they are unwell and therefore don’t see how a medication could help.
My advice is to try to find some common ground with the patient. In doing so, one must have a genuine interest in the patient as a person and interest in what they think the “problem” is from their point of view. For example, she or he may not feel that they have an illness but may still complain about being stressed by experiences such as hearing voices, conflicts with their family, or sleep disturbance, for example. This could provide the opportunity to discuss how medications might reduce the distress, improve sleep, and fortify their ability to deal with school, jobs, and relationships, and so on.
I have also found that it is important to genuinely convey to the patient that you have more to offer to them than just medications. A willingness to listen to them attentively and offer advice and sympathy (if appropriate), suggest solutions, provide support, and connect them to resources that will help them, will go a long way in reassuring the individual that you are on their side and willing to make an effort to improve their situation, and that it may be okay to trust you.
The same principles and strategies would apply when dealing the patient’s family and other caregivers. A difficult situation to negotiate, however, is when the family and patients are at odds with each other – as is often the case. Family may have had to involuntarily commit the patient to the hospital, and the patient assumes that you agree with them, and if you are keeping him in the hospital, it will certainly look like you do.
I again emphasize to trainees/residents that it is important to listen carefully to the patient and elicit their preferences before recommending medications, and to keep the same listening attitude after patients start medications and report on how it has been affecting them. For example, as mentioned in the article, weight gain associated with medications might be absolutely unacceptable to some patients but of less concern to others. As another example, some patients find medication-induced somnolence intolerable, and others welcome that fact that the medication solves a severe insomnia.
Psychiatry Advisor: What should be the focus of future research pertaining to this topic?
Dr Ganguli: It is important to determine whether any of the recommendations offered by the authors actually affect the adherence of patients living with schizophrenia. The recommendations are derived from what patients said, and they make sense in an intuitive way, but this is no guarantee that they will affect behavior in the way we predict. There are actually a number of studies of interventions which were designed to increase adherence to medications in patients with schizophrenia, which did not appear to have that effect in rigorous clinical trials. So, we need to continue to develop strategies and test them to see if they make a difference, just as we do with pharmacologic compounds.
1. Salzmann-Erikson M, Sjödin M. A narrative meta-synthesis of how people with schizophrenia experience facilitators and barriers in using antipsychotic medication: implications for healthcare professionals. Int J Nurs Stud.2018;85:7-18.
2. Morken G, Widen JH, Grawe RW. Non-adherence to antipsychotic medication, relapse and rehospitalisation in recent-onset schizophrenia. BMC Psychiatry. 2008;8:32.
3. Higashi K, Medic G, Littlewood KJ, Diez T, Granström O, De Hert M. Medication adherence in schizophrenia: factors influencing adherence and consequences of nonadherence, a systematic literature review. Ther Adv Psychopharmacol. 2013;3(4):200-218.
4. 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.
5. Sendt KV, Tracy DK, Bhattacharyya S. A systematic review of factors inﬂuencing adherence to antipsychotic medication in schizophrenia-spectrum disorders. Psychiatry Res. 2015;225 (1-2):14-30.
6. Tessier A, Boyer L, Husky M, Baylé F, Llorca PM, Misdrahi D. Medication adherence in schizophrenia: the role of insight, therapeutic alliance and perceived trauma associated with psychiatric care. Psychiatry Res. 2017;257:315-321.