TREATMENT NON-COMPLIANCE IN PSYCHIATRY Slide 2 NON-COMPLIANCE:
PREVALENCE REASONS CLINICAL CONSEQUENCES - Dr. Ashish Srivastava,
M.D. Slide 3 NON-COMPLIANCE INTRODUCTION PATTERNS OF NON-COMPLIANCE
THEORETICAL MODELS PREVALENCE MEASUREMENT OF NON-COMPLIANCE REASONS
FOR NON-COMPLIANCE CLINICAL CONSEQUENCES Slide 4 to 2/3rds of
patients either fail to seek treatment or are non-compliant with
treatment [ Kessler 2001, Regeir 1993] No. of studies published BUT
interventions developed have LIMITED IMPACT on the problem!
[Haynes, 2005] Slide 5 Mental illness stigma & ubiquitous fears
about psychiatric medications IMPORTANT In determining compliance.
[ Corrigan & Watson,2006] Compliance/ N.C. is a continuous
process with multiple dimensions rather than a univariate and
dichotomous one. Slide 6 DEFINING COMPLIANCE... The extent to which
a persons behavior in terms of taking medications, following diets
or executing lifestyle changes coincides with medical health
advice. [ Blackwell, 1992] The extent to which a patient takes
medications as prescribed [ Fawcett, 1995] Slide 7 Biological N.C.
: concept of involuntary factors affecting compliance eg.
metabolism. [Frank 1994] Treatment adherence: practitioners have
the important role of forming alliance with the patient to effect
successful treatment. [ Frank 1995] Slide 8 PATTERNS OF N.C. Total
N.C. - rare ! Intermittent/ partial N.C. Late compliance Rarely
N.C. by overuse of medications. Slide 9 Unintentional v/s
intentional N.C. Drug Holidays White coat compliance Slide 10
THEORETICAL MODELS OF HEALTH BEHAVIOR Health belief model [Budd
1996, Lingam & Scott 2002] Theory of reasoned action (TRA) and
theory of planned behavior (TPB) [Ajzen 1980,1988] Stages of change
theory [Prochaska 1994] Protection motivation theory (PMT) [Rogers
1983] Slide 11 All assume that medication compliance can be
predicted by Patients perception of threat from medical/psychiatric
condition Their expectancy regarding the consequences of medical
compliance Slide 12 PREVALENCE OF NON-COMPLIANCE 20-50% of any
patient population is likely to be at least partially non-compliant
Sackett & Snow : - short term regimens : 62% - long term
preventive regimens: mean 57% - long term treatment regimens: mean
54% Slide 13 EVIDENCE SHOWS... N.C. rates higher when treatment
prescribed for long duration. Medication compliance tends to
decline over time. Baseline compliance is strongest predictor of
long term compliance. Past h/o N.C. N.C. in future. Slide 14
In-patient v/s out-patient N.C Non-compliance more prevalent in
out-patient treatment (20-65%) than in-patient treatment (5-37%). [
Hodge 1990, Remington 1995] Slide 15 DEPRESSION 10% never follow
up, compliance decreases over time, greatest within 1 st month of
treatment. AD discontinuation rates: 1 st wk- 16%, 2 nd wk- 41%, 3
rd wk- 59%, 4 th wk- 68% [Johnson 1981] 30% of patients stopped Rx
within 1 month and 45-60% by 3 months [Hotopf 1997] Slide 16
BIPOLAR DISORDER 18-52%, 50% some degree of N.C., 32% partial N.C.
[Scott & Pope 2002, Rosa 2007] Increased N.C. in patients with
co-morbid substance use disorder Slide 17 SCHIZOPHRENIA 74%
discontinued treatment within 18 months [Liebermann 2005] N.C.
rates > 50%, associated with young age, SUD, hospitalization,
use of TAPs, negative symptoms [Valenstein 2006, Rettenbacher 2004]
Significant N.C. within 1 week of discharge in patients with
co-morbid SUD [Olfson 2000] Slide 18 ADHD Compliance dropped to 80%
by 1 year and 52% by 3 years [ Thiruchelvam 2001] 26% refused
treatment at the onset 55% stopped treatment by 10 months
[Firestone 1982] Less than 10% of families discussed prior to
discontinuation Slide 19 SUDs : variable degree of N.C. (upto
70-80%) Increased rate of N.C. in developmentally disabled and
cognitively impaired patients. Slide 20 MEASUREMENT OF
NON-COMPLIANCE Supervised doses Blood levels DIRECT MEASURES
Self-reporting, clinicians interview Pill count Pharmacy records
Electronic monitoring INDIRECT MEASURES Slide 21 REASONS FOR
NON-COMPLIANCE Medication specific factors Patient specific factors
Provider specific factors Slide 22 MEDICATION SPECIFIC FACTORS
1.ADVERSE REACTIONS: F ears regarding side effects more predictive
of N.C. than the actual side effects of medications... Slide 23 -
side effects considered mild by a psychiatrist may have significant
impact on medication compliance. - troublesome, fearful, difficult
to describe, embarrassing, persistent, permanent side effects.
Slide 24 2. INEFFECTIVENESS: - at best 80% efficacy can be expected
- efficacy-effectiveness gap - perceived effectiveness Slide 25 3.
REGIMEN COMPLEXITY: - inverse relationship between number of daily
dosages and treatment adherence. [Claxton 2001] - higher compliance
with twice daily(85%) v/s TDS/QID regimens (65%), evening doses
missed twice as often as morning doses. [Kruse 1993] - increased
N.C. with polypharmacy. Slide 26 4. COST: - not only medication
costs, additional expenses. - costs may be more than even
disability income. - many health insurance plans do not include
psychiatric disorders or only acute psychosis. In additions there
are many riders. Slide 27 PATIENT SPECIFIC FACTORS 1.Attitudes/
beliefs of patients and their families 2.Age 3.Abnormal illness
behavior 4.Culture/ religious beliefs 5.Psychiatric disorders and
symptoms Slide 28 Attitudes/ beliefs of patients and their
families: - Patients ability to comply with treatment is influenced
by his cognitive and motor functioning and his knowledge about
medications. - The attitudes/ beliefs of patients are at least as
important as side-effects in predicting compliance (Lingam and
Scott, 2002). Slide 29 Patients motivation to comply is influenced
by many complex and inter-related factors like: - severity of
symptoms - past experiences with medications - personal beliefs -
treatment goals - temperament or personality Slide 30 Other
problems areas: - fear of being dependent on medications - fear of
drug accumulation and side-effects - concerns about mental illness
stigma Link (2004) stated that mentally ill are the most
stigmatized social group. - family factors Slide 31 Age factor:
-adolescents and geriatric population has comparatively higher N.C.
Abnormal illness behavior: - denial, conscious and unconscious
motivation influence compliance (Tilowsky, 1993). Cultural/
religious beliefs. Slide 32 Psychiatric Disorders and Symptoms:
Depression amotivationanergia cognitive impairments reduced task
initiation cognitive triad suicidal ideas Slide 33 Bipolar
disorders - disorganization, sleep disturbances, hypomanic Sx,
grandiosity and psychotic features in manic phase. Slide 34
Schizophrenia Poor judgment and insight, expressed emotions,
affective symptoms Cognitive deficits Negative symptoms
disorganization Psychotic features Slide 35 Personality disorders -
poor therapeutic relationship, transference and counter
transference issues Dementia / cognitive disorders - poor judgment
and insight, executive function deficits, memory and other
cognitive deficits, dependency needs, sensory deficits Slide 36
SUDs - medications interfere with sought after effects of the
substance - fear that prescribed medications will interact with the
substance and cause severe problems/ effects - increased risk of
secondary depression, anxiety, insomnia - loss of confidence in
medications - patient depleted of money, time and support - N.C.
due to overuse of medications Slide 37 ADHD - distractability,
inattention, disorganization, comorbidity, childs / parents beliefs
Developmentally disabled Slide 38 PROVIDER/ PRACTITIONER SPECIFIC
FACTORS 1.Practitioners ability 2.Practitioners motivation
3.Awareness of patients compliance 4.Therapeutic alliance
5.Continuing medical education Slide 39 PRAGMATIC ISSUES: Location
of mental health care facility Communication and transportation
services Practices of third party payers Communication between
various health care providers National health care policies and
regulations Slide 40 CLINICAL CONSEQUENCES OF NON-COMPLIANCE
FINANCIAL COSTS: - US: $100 billion annually, cost of
re-hospitalization for patients suffering from schizophrenia is
nearly $2billion/ year (60% attributed to loss of effectiveness and
40% to N.C.). - Canada: 3.5 9 billion Can$/ year. - loss of
manpower days. Slide 41 HUMAN COSTS: - increased number of
hospitalizations (revolving door phenomenon). - poorer outcomes/
prognosis. - increased risk of suicide and harm to others. - poorer
QOL, increased family burden, increased EE, counter transference
issues Slide 42 Having looked at the problem, solutions need to be
seeked...
