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Noncompliance with Medication for Psychiatric Disorders

Reasons and Remedies

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Summary

Noncompliance remains one of the greatest challenges when prescribing psychotropic medication and can render any treatment regimen wasteful and ineffective. While rates reported in studies of noncompliance vary widely, non-compliance can clearly increase treatment costs and prolong the duration of hospitalisation. Furthermore, noncompliance has a human cost in terms of morbidity and mortality.

The reasons for noncompliance can be divided into 3 categories: medication-, patient- and provider-specific factors. Adverse effects are likely to be the most common reason for patients to not comply with prescribed medication regimens. Ineffectiveness, complexity of the regimen and cost are also important medication-related factors contributing to noncompliance. The use of newer effective medications that have fewer adverse effects, drug holidays and low-dose treatment strategies may ameliorate adverse effects. In addition, the aggressive treatment of adverse effects such as antipsychotic-induced extrapyramidal syndromes and akathisia and tricyclic antidepressant-induced anticholinergic effects can increase compliance. In some cases, the complexity of regimens and the cost of medications can be reduced.

The symptoms of a psychiatric disorder, the presence of substance abuse, and culture and attitude are patient-specific factors that may interfere with compliance. Noncompliance related to patient attitudes can be remedied through improving the patient-provider relationship, using depot antipsychotics and possibly medicating patients by force of judicial orders. Treatment of dual diagnosis, greater understanding of a patient’s culture and the involvement of families in treatment can all be used to foster increased compliance. Psychosocial rehabilitation can also help increase compliance.

Noncompliance increases when practitioners’ views of their patients’ prognosis or the effectiveness of treatment differ from that of their patients. How physicians communicate and what information they present to their patients and families plays a significant role in determining compliance. Physicians who believe in the medications they are prescribing and actively involve their patients in treatment decisions are likely to increase compliance. Expressing an understanding, empathic and caring manner will further promote compliance. Compliance should increase when good and clear lines of communication exist and patients feel free to ask questions. Specialised treatment options that practitioners can use to increase compliance include education, cognitive behavioural interventions, behaviour modification techniques, and using direct rewards for compliance. Psychotherapy can also be used as a tool to improve the practitioner-patient relationship.

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References

  1. Blackwell B. Compliance. Psychother Psychosom 1992; 58: 161–9

    Article  PubMed  CAS  Google Scholar 

  2. Fawcett J. Compliance: definitions and key issues. J Clin Psychiatry 1995; 56 Suppl. 1: 4–8

    Google Scholar 

  3. Frank E, Perel JM, Mallinger AG, et al. Relationship of pharmacologic to long term prophylaxis in recurrent depression. Psychopharmacol Bull 1994; 30: 231–5

    Google Scholar 

  4. Frank E, Kupfer DJ, Siegel LR. Alliance not compliance: a philosophy of outpatient care. J Clin Psychiatry 1995; 56 Suppl. 1: 11–6

    Google Scholar 

  5. Silva RR, Munoz DM, Daniel W, et al. Causes of haloperidol discontinuation in patients with Tourette’s disorder: management and alternatives. J Clin Psychiatry 1996; 57 129–34

    PubMed  CAS  Google Scholar 

  6. Lin EHB, Von Korff M, Katon W, et al. The role of the primary care physician in patients’ adherence to antidepressant therapy. Med Care 1995; 33: 67–74

    Article  PubMed  CAS  Google Scholar 

  7. Sweet RA, Brown EJ, Heimberg RG, et al. Monoamine oxidase inhibitor dietary restrictions: what are we asking patients to give up. J Clin Psychiatry 1995; 56: 196–201

    PubMed  CAS  Google Scholar 

  8. Goodwin FK, Jamison KR. Manic-depressive illness. New York: Oxford University Press, 1990

    Google Scholar 

  9. Prince BS, Goetz CM, Rihn TL, et al. Drug-related emergency department visits and hospital admissions. Am J Hosp Pharm 1992; 49: 1696–700

    PubMed  CAS  Google Scholar 

  10. Hodge SK, Appelbaum PS, Lawlor T, et al. Aprospective, multi-center study of patient’s refusal of antipsychotic medication. Arch Gen Psychiatry 1990; 47: 949–56

    Article  Google Scholar 

  11. Remington GJ, Adams ME. Depot neuroleptic therapy: clinical. Can J Psychiatry 1995; 40 Suppl. 1: S5–11

    Google Scholar 

  12. Corrigan PW, Liberman RP, Engel JD. From noncompliance to collaboration in the treatment of schizophrenia. Hosp Comm Psychiatry 1990; 41: 1203–11

    CAS  Google Scholar 

  13. Adams SG, Howe JT. Predicting medication compliance in a psychotic population. J Nerv Ment Dis 1993; 181: 558–60

    Article  PubMed  Google Scholar 

  14. Preskorn SH, Burke MJ, Fast GA. Therapeutic drug monitoring: principles and practice. Psychiatr Clin North Am 1993; 16: 611–39

    PubMed  CAS  Google Scholar 

  15. Harvey NS, Kay R. Compliance during lithium treatment, intraerythrocyte lithium variability, and relapse. J Clin Psychopharmacol 1991; 11: 362–7

    Article  PubMed  CAS  Google Scholar 

  16. Compliance statistics. http://www.epill.com/epill//comfac.html

  17. Coambs RB, et al. A summary review of the scientific literature on the prevalence, consequences, and health costs of noncompliance and inappropriate use of prescription medication in Canada. http://www.pmac-acim.org/special-report/ coambs/c_sty.html

  18. Littrell RA, Mainous AG III, Karem Jr F, et al. Clinical sequelae of overt noncompliance with psychotropic agents. Psychopharmacol Bull 1994; 30: 239–44

    PubMed  CAS  Google Scholar 

  19. Weiden P, Olfson M. Cost of relapse in schizophrenia. Schizophr Bull 1995; 21: 419–29

    PubMed  CAS  Google Scholar 

  20. Suppes T, Baldessarini RJ, Faedda GL, et al. Risk of recurrence following discontinuation of lithium treatment in bipolar disorder. Arch Gen Psychiatry 1991; 48: 1082–8

    Article  PubMed  CAS  Google Scholar 

  21. McGlashan TH, Johannessen JO. Early detection and intervention with schizophrenia: rationale. Schizophr Bull 1996; 22: 201–22

    Article  PubMed  CAS  Google Scholar 

  22. Buckley PF, Buchanan RW, Schultz SC, et al. Catching up on schizophrenia. Arch Gen Psychiatry 1996; 53: 456–62

    Article  PubMed  CAS  Google Scholar 

  23. Group for the Advancement of Psychiatry. Resident’s guide to treatment of people with chronic mental illness. Washington, DC: American Psychiatric Press, 1993

    Google Scholar 

  24. Calabrese JR, Woyshville MJ. Lithium therapy: limitations and alternatives in the treatment of bipolar disorders. Ann Clin Psychiatry 1995; 7: 103–12

    Article  PubMed  CAS  Google Scholar 

  25. Johnstone EC. Schizophrenia: problems in clinical practice. Lancet 1993; 341: 536–8

    Article  PubMed  CAS  Google Scholar 

  26. Atwood JR, Haase J, Rees-McGee S, et al. Reasons related to adherence in community-based field studies. Patient Educ Couns 1992; 19: 251–9

    Article  PubMed  CAS  Google Scholar 

  27. Awad AG, Hogan TP. Subjective response to neuroleptics and the quality of life: implications for treatment outcome. Acta Psychiatr Scand 1994: 89 Suppl. 380: 27–32s

    Article  Google Scholar 

  28. Buchanan A. A two-year prospective study of treatment compliance in patients with schizophrenia. Psychol Med 1992; 22: 787–97

    Article  PubMed  CAS  Google Scholar 

  29. Van Putten T, May PRA, Marder SR. Response to antipsychotic medication: the doctor’s and the consumer’s view. Am J Psychiatry 1984; 141: 16–9

    Google Scholar 

  30. Harrison G. New or old antidepressants? New is better. BMJ 1994; 309: 1280–1

    Article  PubMed  CAS  Google Scholar 

  31. Ruscher SM, de Wit R, Mazmanian D. Psychiatric patient’s attitudes about medication and factors affecting noncompliance. Psych Serv 1997; 48: 82–5

    CAS  Google Scholar 

  32. Razali MS, Yahya H. Compliance with treatment in schizophrenia: a drug intervention program in a developing country. Acta Psychiatr Scand 1995: 91: 331–5

    Article  PubMed  CAS  Google Scholar 

  33. Salzman C. Medication compliance in the elderly. J Clin Psychiatry 1995; 56 Suppl. 1: 18–22

    Google Scholar 

  34. Miklowitz DJ. Longitudinal outcome and medication noncompliance among manic patients with and without mood incongruent psychotic features. J Nerv Ment Dis 1992; 180:703–11

    Article  PubMed  CAS  Google Scholar 

  35. Johnstone EC, Geddes J. How high is the relapse rate in schizophrenia? Acta Psychiatr Scand 1994: 89 Suppl. 380: 6–10

    Article  Google Scholar 

  36. Brennan AF, Davis MH, Buchholz DJ, et al. Predictors of quality of life following cardiac transplantation. Psychosomatics 1987; 28: 566–71

    Article  PubMed  CAS  Google Scholar 

  37. Boehnert CE, Popkin MK. Psychological issues in treatment of severely noncompliant diabetics. Psychosomatics 1986; 27: 11–20

    Article  PubMed  CAS  Google Scholar 

  38. Hoffman H, Wyler A, Kuppler Z. Age as a factor in identifying young adult chronic patients who are difficult to treat. Psych Serv 1995; 46: 404–6

    Google Scholar 

  39. Ellison JM, Adler DA. Psychopharmacologic approaches to borderline syndromes. Compr Psychiatry 1984; 25: 255–62

    Article  PubMed  CAS  Google Scholar 

  40. McMullen P, Ross AJ, Rees JA. Problems experienced with medicines by psychogeriatric patients in the community. Pharm J 1991 Aug 10; 247: 182–4

    Google Scholar 

  41. Pilowsky I. The concept of abnormal illness behavior. Psychosomatics 1990; 31: 207–13

    Article  PubMed  CAS  Google Scholar 

  42. Pilowsky I. Aspects of abnormal illness behavior. Psychother Psychosom 1993; 60: 62–74

    Article  PubMed  CAS  Google Scholar 

  43. Geisen L, Feuer E. The treatment resistant patient and the need to stay crazy. Psychiatry Q 1984; 56: 75–82

    Article  CAS  Google Scholar 

  44. Pristach CA, Smith CM. Medication compliance and substance abuse among schizophrenic patients. Hosp Comm Psychiatry 1990; 41: 1345–8

    CAS  Google Scholar 

  45. Wolpe PR, Gorton G, Serota R, et al. Predicting compliance of dual diagnosis inpatients with aftercare treatment. Hosp Comm Psychiatry 1993; 44: 45–9

    CAS  Google Scholar 

  46. Owen R, Fisher EP, Booth BM, et al. Medication noncompliance and substance abuse among patients with schizophrenia. Psych Serv 1996; 47: 853–8

    CAS  Google Scholar 

  47. Lee S. The prevalence and nature of lithium noncompliance among Chinese psychiatric patients in Hong Kong. J Nerv Ment Dis 1993; 181:618–25

    Article  PubMed  CAS  Google Scholar 

  48. Razali MS, Yahya H. Compliance with treatment in schizophrenia: a drug intervention program in a developing country. Acta Psychiatr Scand 1995 May: 91(5): 331–5

    Article  PubMed  CAS  Google Scholar 

  49. Bertschy G, Vandel S. Clomipramine plasma levels among depressed outpatients in Benin, West Africa; drug compliance and comparison with Caucasian patients. J Clin Psychopharmacol 1992; 12: 334–6

    Article  PubMed  CAS  Google Scholar 

  50. Kroll J, Linde P, Habenicht M, et al. Medication compliance, antidepressant blood levels, and side effects in Southeast Asian patients. J Clin Psychopharmacol 1990; 10: 279–83

    Article  PubMed  CAS  Google Scholar 

  51. Morlino M, Martucci G, Musella V. Patients dropping out of treatment. Acta Psychiatr Scand 1995: 92: 1–6

    Article  PubMed  CAS  Google Scholar 

  52. Goodman A. Recognition of psychodynamics in pharmacotherapy. Psychiatr Times 1995; Oct: 17-21

  53. Lieberman III JA. Compliance issues in primary care. J Clin Psychiatry 1996; 57 Suppl. 7: 76–82

    Google Scholar 

  54. Bastiaens L. Compliance with pharmacotherapy in adolescents: effects of patients’ and parents’ knowledge and attitudes toward treatment. J Child Adolesc Psychopharmacol 1995; 5: 39–48

    Article  Google Scholar 

  55. Van Putten T, Marder SR, Wirshing WC, et al. Surreptitious noncompliance with fluphenazine in a voluntary inpatient population. Arch Gen Psychiatry 1990; 47: 786–7

    Article  Google Scholar 

  56. Koch A, Gillis LS. Nonattendance of psychiatric outpatients. S Afr Med J 1991; 80: 289–91

    PubMed  CAS  Google Scholar 

  57. Cleare AT. Deciding which selective serotonin reuptake inhibitor to prescribe [letter]. BMJ 1995; 311: 1641

    Article  PubMed  CAS  Google Scholar 

  58. Davis MS. Variations in patient’s compliance with doctors orders: analysis of congruence between survey responses and results of empirical investigations. J Med Educ 1966; 41: 489–94

    Google Scholar 

  59. Eraker S. Understanding and improving patient compliance. Ann Intern Med 1984; 89: 33–8

    Google Scholar 

  60. Catt S, Stygall J, Catalan J. Acceptance of zidovudine (AZT) in early HIV disease: the role of health beliefs. AIDS Care 1995; 7: 229–5

    Article  PubMed  CAS  Google Scholar 

  61. Kemp R, Hayward P, Applewhaite G, et al. Compliance therapy in psychotic patients: a randomised controlled trial. BMJ 1996; 312: 345–9

    Article  PubMed  CAS  Google Scholar 

  62. Meichenbaum D, Turk DC. Facilitating treatment. New York: Plenum Press, 1987

    Book  Google Scholar 

  63. Risch SC. Pathophysiology of schizophrenia and the role of newer antipsychotics. Pharmacotherapy 1996; 16: 11S–4S

    Google Scholar 

  64. Simon GE, VonKorff M, Heiligenstein JH, et al. Initial anti-depressant choice in primary care. JAMA 1996; 275: 1897–902

    Article  PubMed  CAS  Google Scholar 

  65. Anderson IM, Tomenson BM. Treatment discontinuation with selective serotonin reuptake inhibitors compared with tricyclic antidepressants: a meta-analysis. BMJ 1995; 310: 1433–8

    Article  PubMed  CAS  Google Scholar 

  66. Owens D. New or old antidepressants? Benefits of new drugs are exaggerated. BMJ 1994; 309: 1281–2

    Article  PubMed  CAS  Google Scholar 

  67. Kane JM. Drug maintenance strategies in schizophrenia. Washington, DC: American Psychiatric Press, 1984

    Google Scholar 

  68. Balon R. The effects of antidepressants on human sexuality: diagnosis and management. Prim Psychiatry 1995; 2: 46–51

    Google Scholar 

  69. Henry JA, Hale AS. Unsuccessful treatment may be related to non-response or non-compliance [letter]. BMJ 1994; 309: 1083

    Article  PubMed  CAS  Google Scholar 

  70. Eisen SA, Miller DK, Woodward RS, et al. The effect of prescribed daily dose frequency on patient medication compliance. Arch Intern Med 1990; 150: 1881–4

    Article  PubMed  CAS  Google Scholar 

  71. Jerrell JM, Ridgely MS. Comparative effectiveness of three approaches to serving people with severe mental illness and substance abuse disorders. J Nerv Ment Dis 1995; 183: 566–76

    Article  PubMed  CAS  Google Scholar 

  72. Nikkei R, Coiner R. Critical interventions and tasks in delivering dual-diagnosis services. Psychosoc Rehabil J 1991; 2: 57–66

    Google Scholar 

  73. O’Malley SS, Jaffe AJ, Chang G, et al. Naltrexone and coping skills therapy for alcohol dependence. Arch Gen Psychiatry 1992; 49: 881–7

    Article  PubMed  Google Scholar 

  74. Evans K, Sullivan JM. Dual diagnosis: counseling the mentally ill substance abuser. New York: Guilford Press, 1990: 69–94

    Google Scholar 

  75. Glantz K, Goisman RM. Relaxation and merging in the treatment of personality disorders. Am J Psychother 1990; 44: 405–13

    PubMed  CAS  Google Scholar 

  76. Moffic HS. Cultural issues in community psychiatry. In: Vaccaro JV, Clark Jr GH, editors. Practicing psychiatry in the community: a manual. Washington, DC: American Psychiatric Press, 1996: 407–16

    Google Scholar 

  77. Goldstein MJ. Psychoeducational and family therapy in relapse prevention. Acta Psychiatr Scand 1994; 89 Suppl. 382: 54–7

    Article  Google Scholar 

  78. Kelly GR, Scott JE. Medication compliance and health education among outpatients with chronic mental disorders. Med Care 1990; 28: 1181–97

    Article  PubMed  CAS  Google Scholar 

  79. Gerlach J. Oral versus depot administration of neuroleptics in relapse prevention. Acta Psychiatr Scand 1994; 89 Suppl. 382: 28–32

    Article  Google Scholar 

  80. Hale AS. Will the new antipsychotics improve the treatment of schizophrenia? Depot preparations still hold the key to compliance. BMJ 1993; 307: 749–50

    Article  PubMed  CAS  Google Scholar 

  81. Cournos F, McKinnon K, Stanley B. Outcome of involuntary medication in a state hospital system. Am J Psychiatry 1991; 148: 489–94

    PubMed  CAS  Google Scholar 

  82. Weiden P, Rapkin B, Zygmunt A, et al. Postdischarge medication compliance of inpatients converted from an oral to a depot neuroleptic regimen. Psych Serv 1995; 46: 1049–54

    CAS  Google Scholar 

  83. Neppe VM. Innovative psychopharmacotherapy. New York: Raven Press, 1988

    Google Scholar 

  84. Hiday VA, Scheid-Cook TL. Outpatient commitment for ‘revolving door’ patients: compliance and treatment. J Nerv Ment Dis 1991; 179:83–8

    Article  PubMed  CAS  Google Scholar 

  85. Hoge SK, Appelbaum PS, Lawlor T. A prospective multicenter study of patient’s refusal of antipsychotic medication. Arch Gen Psychiatry 1990; 47: 949–56

    Article  PubMed  CAS  Google Scholar 

  86. Walch TJ. Enhancing compliance in schizophrenic patients by weekly dosing with levothyroxine sodium [letter]. J Clin Psychiatry 1994; 55: 543

    PubMed  CAS  Google Scholar 

  87. Brewer, C. Controlled trials of Antabuse in alcoholism: the importance of supervision and adequate dosage. Acta Psychiatr Scand 1992: 86: 51–8

    Article  Google Scholar 

  88. Matar AM, Abdel-Mawgoud M, Skov S. Zuclopenthixol: a new generation of antipsychotic drugs. An open clinical trial. J Clin Psychopharmacol 1990; 10: 283–7

    Article  PubMed  CAS  Google Scholar 

  89. Gaebel W. Intermittent medication — an alternative? Acta Psychiatr Scand 1994; 89 Suppl. 382: 33–8

    Article  Google Scholar 

  90. Draine J, Solomon P. Explaining attitudes toward medication compliance among a seriously mentally ill population. J Nerv Ment Dis 1994; 182:50–4

    Article  PubMed  CAS  Google Scholar 

  91. Kjellgren KI, Ahlner J, Saljo R. Taking anti-hypertensive medication — Controlling or cooperating with patients? Int J Card 1995; 47: 257–68

    Article  CAS  Google Scholar 

  92. Myers ED, Branthwaite A. Outpatient compliance with antidepressant medication. Br J Psychiatry 1992; 160: 83–6

    Article  PubMed  CAS  Google Scholar 

  93. Pozsik CJ. Compliance with tuberculosis therapy. Med Clin North Am 1993; 77: 1289–301

    PubMed  CAS  Google Scholar 

  94. Stimmel GL. How to counsel patients about depression and its treatment. Pharmacotherapy 1995; 15: 100S–4S

    PubMed  CAS  Google Scholar 

  95. Allen JP, Litten RZ. Techniques to enhance compliance with disulfiram. Alcohol Clin Exp Res 1992; 16: 1035–41

    Article  PubMed  CAS  Google Scholar 

  96. DuRand CJ, Jaretz NJ, Laddis A. Clozapine refusal [letter]. Hosp Comm Psychiatry 1992; 43: 85

    CAS  Google Scholar 

  97. Paykel ES. Psychotherapy, medication combinations and compliance. J Clin Psychiatry 1995; 56 Suppl. 1: 24–30

    Google Scholar 

  98. Perri C, Skagerlind L. Cognitive therapy with schizophrenic patients. Acta Psychiatr Scand 1994; 89 Suppl. 382: 65–70

    Article  Google Scholar 

  99. Janssen. Data on file

  100. Medicine-on-time and the pharmacist. Available from: http://www.medicineontime.com/page3.html [Accessed 1998 Mar 16]

  101. e-pill. Patient compliance medication reminder service. Available from: http://www.epill.com/epill/ whatisep.html [Accessed 1998 Mar 16]

  102. Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve treatment guidelines. JAMA 1995; 273: 1026–31

    Article  PubMed  CAS  Google Scholar 

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  1. Public Psychiatry Training Program, William S. Hall Psychiatric Institute and University of South Carolina School of Medicine, Columbia, South Carolina, USA

    Robert Breen

  2. Residency Training Program, William S. Hall Psychiatric Institute and University of South Carolina School of Medicine, Columbia, South Carolina, USA

    Joshua T. Thornhill

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Breen, R., Thornhill, J.T. Noncompliance with Medication for Psychiatric Disorders. Mol Diag Ther 9, 457–471 (1998). https://doi.org/10.2165/00023210-199809060-00004

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