Increasingly Adherence Therapy (AT) is being encouraged for all types of mental health problems. Psychiatric nurses need to be aware both of its use as well as some of the reasons why so many patients relapse, in an attmpt to increase adherence to treatment programmes

1. ADHERANCE TO TREATMENT IN
PSYCHIATRIC NURSING
MARTIN WARD

2. DEFINITION
• Adherence can be
described as the extent to
which a persons behaviour
- taking medication,
following a diet, and/or
executing lifestyle changes,
corresponds with agreed
recommendations from a
healthcare provider (WHO
2003)

3. Good adherence is based upon patient self
management

4. • There is a difference between compliance and adherence
• Compliance suggests the patient is passively doing what
the nurse tells him/her to do. Once the nurse is no longer
present the patient is more likely to make their own
decisions, with 'non-compliance' being one of them
• Adherence suggests mutual agreement and partnership
between patient and nurse. Once the nurse is no longer
present the patient is more likely to 'adhere' to treatment
because they agreed it was right for them.
(Gray et.al. 2002)

5. Theoretically……..
Giving people choices and allowing them to make a
contribution to the decisions about their on-going care, as
an equal partner, should increase their commitment to
their agreed treatment programme.

6. • Adherence is often thought
of as being a wasteland
where nursing staff wander
aimlessly around in search
of an answer to the age old
problem of convincing their
patients to comply with
agreed treatment
programmes!

7. EARLY ONSET, FIRST EPISODE PSYCHOSIS
• These patients are more like not to comply with
treatment programmes
• Up to 60% of patients do not continue taking
medication after their first admission
• Re-admissions are much higher in this group of
patients
(Brown et.al. 2012)

8. VIEWS OF RELAPSE
• Staff views of the process of relapse differs from those of
patients
• Staff may see none adherence as defiance
• They may also see this as a challenge to their authority
• Patients may suffer quality care issues as a consequence,
especially if they are re admitted on a regular basis
• Patients may be blamed for non-adherence

9. • Patients may feel that their views and opinions have
not been taken account of, or listened to (Hayes 2001)
• Patients may feel that if they do not do as they are told
they will be 'punished'
• Patients may feel guilty that they have not been able to
adhere, even though they may not have properly
prepared

10. PEER SUPPORT
• There is evidence to
suggest that patient peer
support can be extremely
effective in increasing
treatment adherence,
especially amongst
individuals with similar
conditions

11. WHY DO PATIENTS NOT FOLLOW TREATMENT
REGIMES?
• There is no single reason and it may be a combination of things
• Each patient's situation must be assessed individually
• They may feel well and consider their medication unnecessary
• They just do not like taking medication
• They may be experiencing challenging side effects and stop taking medications in an
attempt to address this
• They may self medicate using recreational drugs as an alternative to prescribed medication
• They may be too disturbed to appreciate when and how to take their medication
• They have unintentionally not taken their medication due to circumstances (Shultz 2009)

12. RELATIONSHIP ISSUES
• They may not trust their care worker and will therefore not take
account of any adherence advice they are given
• They may feel that mental health services are trying to force them
to do something against their wishes
• They may not have a good working relationship with professional
care staff (McCabe et.al. 2012)
• They may not have experienced adherence therapy
• They may have had bad experiences in the past and are unwilling
to repeat these again

13. • Learning how to prevent
relapse is perhaps one of
the biggest challenges to
nurses working in acute
psychiatric care
• Unfortunately, few appear
to know anything about
relapse therapy

14. – RICHARD GRAY
"Working collaboratively with staff is one of the
main benefits of AT "

15. ADHERANCE THERAPY
• All patients should have a risk assessment undertaken to establish non-
adherence potential
• Individual programmes should be devised to address specific patient problems
• Usually involved psycho-education
• Must be given over time
• Starts at the beginning of treatment programme
• Must be agreed with the patients
• Usually repeated once every month as a back up and opportunity for
reassessment

16. • There is no one single approach that fits all the needs
of ever patient
• Nurses need to have a 'tool-kit' of options to enable
them to meet the neds of individual patients
• But, certain principles must be followed to ensure the
patients has what they need to increase the potential
for adherence

17. • Sessions must be incremental, meaning that a patient
should progress through a series of competency based
tasks, completing one before moving to the next
• Ideally, the sessions are delivered by the same health
care worker each time for both collaborative and
relationship reasons
• Staff attitudes are as important as those of patients and
staff need to have training in delivering these packages

18. FOUR KEY ELEMENTS
• A structured assessment
• Dealing with resistance
• Exchanging information
• Five key skills: problem solving; looking back; exploring
ambivalence; talking about beliefs about medication,
looking forward (Gray 2007)

19. • The WHO (2003) estimated that non-adherance to treatment in chronic
illness in the developed countries was as much as 50%, and greater in
non-developed ones
• Adherance therapy has been shown to increase treatment compliance
by as much as 40%
• Increasing treatment compliance can be more effective than seeking
other treatment options
• Relapse can be reduced by 60%
• Adherence therapy has not been shown to have any effect on patients
quality of life (Gray et.al 2006)
• Adherence therapy can be successful across a broad cross section of
mental health as well as physical health problems (Safren 2013)

20. NO ADHERENCE, NO RECOVERY

21. REFERENCES
• Brown E, Gray R, Jones M, Whitfield S. (2012) Effectiveness of adherence therapy in patients with early psychosis: A mirror
image study International Journal of Mental Health Nursing
• Gray R., Wykes T. & Gournay K. (2002) From compliance to concordance: a review of the literature on interventions to
enhance compliance with antipsychotic medication. Journal of Psychiatric and Mental Health Nursing 9:277–284
• Gray, R. (2005) Adherence therapy manual. http://www.academia.edu/2436503/Adherence_therapy_manual
• Gray R. et.al. (2006) Adherence therapy for patients with schizophrenia: European multi centre randomised control trial.
British Journal of Psychiatry 189:508-514
• Hayes, R.B. (2001) Interventions for helping patients to follow prescriptions for medications. Cochrane Database for
Systematic Reviews -issue 4. Oxford.
• McCabe R, Bullenkamp J, Hansson L, Lauber C, Martinez-Leal R, et al. (2012) The Therapeutic Relationship and Adherence
to Antipsychotic Medication in Schizophrenia. PLoS ONE 7(4): e36080. doi:10.1371/journal.pone.0036080
• Safren S, Gonzalez J, Wexler C et.al. (2013) A randomized controlled trial of cognitive behavioural therapy for adherence and
depression (CBT-AD) in patients with uncontrolled type 2 diabetes.
http://care.diabetesjournals.org/content/early/2013/10/22/dc13-0816.abstract
• Schulz M. (2009) Adherence therapy for people with schizophrenia: a multi-centre project. World mental health day. Cyprus.
Horatio: European Psychiatric Nurses. www.horatio-web.eu/
• WHO (2003) Adherence to long-term therapies: Evidence for action. World Health Organisation. Geneva