Medication compliance is always going to be an issue when it comes to patients taking medication on a longterm basis for a psychiatric illness. It is the natural human condition not to want to take anything which is perceived to be foreign to the body. How many of us can say that we fully completed a 2 week course of antibiotics. Most people will stop taking their antibiotics, either consciously or forget, once they feel better. People with longterm physical illness will forget to take their medication from time to time.
Many studies show that patients with schizophrenia and other psychotic illnesses stop taking their medications within months after being started. The Catie Study showed that the 2 year non-compliance rate is 80% !! What this means to us is that the vast majority of patients WILL stop their medication for various reasons. Sometimes even their family and carers think that that it is okay to stop their medication after they get better. But patients need to continue with their medication for at least 2 years after they go into remission before they can consider stopping their medication.
But what is the importance of being compliant with medication.
With poor medication compliance there is a high risk of relapse. This usually occurs within months of stopping medication. Each relapse is actually a ‘toxic’ event for the brain in which there is damage occurring. We therefore want to limit these periods of relapse as much as possible.
With each new relapse, there is a decrease in response to medication. That is, the illness becomes more difficult to treat. With each new relapse and hospitalization there is added interruptions and costs to social and occupational functioning, and increasing costs to society for the hospitalizations.
Why are patients poorly compliant?
There are various reasons why patients are poorly compliant. One of the most important reasons is that they have poor insight into the illness. That is, they do not realize that they have an illness, and quite naturally they do not see the need to take medication.
Then there are the side effects of the medication which make patients reluctant to take antipsychotic drugs.
It is often the disorganised lifestyles of patients which makes it difficult to remain compliant. Patients might have all intention of remaining compliant but between getting up and going to sleep at all hours, and having no structure in their days, they forget to take their tablets.
Alcohol and drug abuse are often the main reason for non-compliance. 50% of patients with schizophrenia will abuse alcohol or illicit drugs.
Social factors like poverty and housing difficulties can also make it difficult for patients to remain compliant.
Negative symptoms result in patients who are poorly motivated with little drive. They would usually require a high degree of supportive nursing to ensure compliance.
Some patients suffer neurocognitive deficits from the schizophrenia. As a result they may have problems with memory and attention, and simply forget to taken their medication.
How can we help patients to be more compliant?
Depots have been shown improve medication compliance and remission rates. With depots everyone concerned in the patients care knows that they have taken their medication. Patients should be encouraged to use depot medication.
Psychoeducation for the patient and family, mental health awareness, medication awareness, drug and alcohol work are important therapeutic interventions which can help with compliance. Unfortunately the relapse rates following these interventions are still high but they do improve short term compliance and relapse rates.
Clinicians need to be proactive in enquiring about side effects of medication, especially sexual side effects. There is medication available (Viagra) to combat some of the sexual side effects, as well as the other common side effects. The metabolic effects like weight gain can also be an important reason for stopping medication. These have to be properly managed as well.
Sometimes changing the medication is the only choice available.
There are practical measures like supervised administration by family members and nursing staff, and assertive outreach by psychiatric nurses which can improve medication compliance.<