This document discusses medication non-compliance in chronic mental illnesses. It notes that non-compliance is the number one cause of increasing disability in these illnesses. It outlines reasons for non-compliance including disease factors like poor insight and treatment factors like side effects. Consequences of non-compliance include relapse and worsening of symptoms over time. The document recommends strategies like psychoeducation, family support, and long-acting injectable medications to improve medication adherence.

1. NOT TAKING MEDICINE PROPERLY
CAN BE DANGEROUS!!!
Non-compliance to medicine is the
number one cause of increasing
disability in chronic mental
illnesses…

2. Outline
• Definition
• Why is compliance a challenge?
• Reasons for non-compliance
• Factors affecting medication adherence
• Consequences of non compliance
• Strategies for effective outcome for non
compliance

3. Compliance
Adherence/compliance is defined as
“The extent to which a person’s behavior
– taking medication, following a diet,
and/or executing lifestyle changes,
corresponds with agreed
recommendations from a health care
provider”

4. Why is adherence still a challenge
in patient care?
• Non-adherence is more common than treatment refusal or
discontinuation
• Medications with improved safety and tolerability profiles
have not improved adherence rates
• HCPs focus on difficult-to-treat patients on maintenance therapy
– Patients who openly refuse or repeatedly discontinue treatment
• Lack of awareness of patients’ non-adherence impacts
prescribing behaviour and patient outcomes
• HCPs may not consider partial adherence a worthy issue
• Partial adherence may be perceived as inevitable and unavoidable
Masand et al. Prim Care Companion J Clin Psychiatry 2009;11:147–154
HCP, healthcare practitioner
4

5. Chronic Disorders Relapse Fact Sheet
• 5-20% mental illness patients relapse every year
• 20 to 30% patients do not have adequate recovery on
treatment.
• Some patients relapse even when on medicines
• Maximum loss of ability to work, take care of oneself and
have a fulfilling life tends to occur in the first 5 years of the
onset. If not treated earlier with appropriate doses for
sufficient time, the illness becomes chronic.

6. Relapse Fuels the Progression of Illness..
With each relapse
• Recovery can be slower and impairments increase with
every relapse
• Frequent and longer admissions to hospital are needed
• Illness can become more resistant to treatment
• Increased risk of self-harm and homelessness
• Regaining previous level of functioning is harder
• Loss of self-esteem
• Social relations wither and vocational progress is lost
• Increased burden on families, caregivers
Lieberman JA. European Neuropsychopharmacol. 1996;6(Supplement 3):155.
Szymanski S et al., Am J Psychiatry. 1995;152(5):698-703.
Lieberman J. et al., Arch Gen Psychiatry. 1993;50(5):369- 76.

7. Disease-related
Poor insight
Disease severity
Cognitive impairment
Motivational deficits
Human nature
Full adherence is difficult for anyone
to maintain, eg exercise, diets
Patient does not believe medication
necessary once response achieved
Reasons for non-compliance
Treatment-related
Side effects
Efficacy
Lack of clinician awareness
Complexity of regimen
Poor therapeutic alliance
Access to treatment
Cost
Singh et al. J Pharm Pract 2006;19:361–368; Kane. J Clin Psychiatry 2006;67(suppl 5):9–14;
Borras et al. Schizophr Bull 2007;33:1238–1246; Heerey & Gold. J Abnorm Psychol 2007;116:268–278;
Turner et al. Poster presented at ECNP, October 13–17 2007, Vienna, Austria
Psychological/social
Stigma (of disease and medication)
Environmental stressors
Level of support from family/friends
Irregular daily routine
Substance abuse
Religious beliefs
7

8. Psychological factors affecting medication
adherence
• Patient related factors
• Factors related to service delivery system
• Relationship factors

9. Continued…
Patient-related factors
• Lack of insight
• Attitudes and past behaviours
• Demographic factors
• Environmental factors
• Cognitive impairment
• Medication-related factors
COMMON DENOMINATOR

10. Conti…
Factors related to service delivery system
• Inadequate discharge planning and aftercare.
• Dissatisfaction with level of information provided
regarding medication (side effects, etc)
• Lack of funding for necessary medication.
• Level of access to psychiatrists

11. Conti…
Relationship factors
• Therapeutic alliance
• Family and social support

12. Not taking medicines leads to relapse i.e.
makes the illness recur and hard to treat

13. Predictors of treatment outcome
Poor medication
adherence
Reduced
brain volume
POOR
OUTCOME
Poor
premorbid
adjustment
Longer
duration of
untreated
psychosis
Inherent
refractoriness
Cognitive
impairment
Male
sex
Early age of
onset
Modifiable factors

14. Psychosocial consequences of relapse
Kane. CNS Spectr. 2007;12(10 suppl 17):21–26
Loss of
functional
achievements
Loss of
self-esteem Potential
danger to self
and others
Family burden
and
estrangement
Increased
cost of care
Illness may
become resistant
to treatment
Harder to
re-establish
previous gains
Potential
neurobiological
sequelae
14

15. Medication plus psychosocial intervention
v/s medication alone
• In psychosocial intervention each month early schizophrenic
patients and their families received a day of 4 types of
evidence based interventions :
(a) Psychoeducation (b) Family intervention (c) Skills
training (d) Cognitive behaviour therapy.
 At one year follow up patients in the group receiving extra
interventions were more compliant with medications, had
fewer rehospitilization and had better quality of life
( X Guo, et al Arch Gen Psychiatry Sep 2010)

16. Combination of Strategies for effective outcome
• Greatest improvement in compliance was
seen with interventions employing a
combination of
Asia-Pacific Psychiatry ISSN
1758-5864
Behavioral
(social)
Cognitive
(psychological)
Biological
(Medicine)

17. Psychosocial treatments to promote
functional recovery
• Affects a number of dimensions important to recovery
• Broader effects on community functioning
Social skills
training
• Effective at reducing severity of positive and negative
symptoms
• Including some aspects of community functioning and
QoL
Cognitive
behavioural
therapy
• Integrates dimension-specific treatments to improve
multiple targets (eg cognition and work)
• Consistent with a recovery model
Cognitive
remediation
• Individuals can improve performance on tasks
measuring a range of social cognitive processes linked
to successful social functioning
(eg affect perception)
Social cognition
training
Kern et al. Schizophr Bull 2009;35:347–361
QoL, quality of life

18. Psychosocial Interventions
• Psychosocial treatment compliments medical treatment
• Family intervention involves reduction of adverse family atmosphere
• Enhancement of the capacity of relations to anticipate and solve
problems
• Anger and guilt reduction of family members.
• Keeping appropriate limits.
• Psychosocial intervention reduce relapse risk.
• Help in treatment compliance
(Source : Cochrane database of systematic review 2006 issue 4)

19. Interventions to improve adherence
• Cognitive behavioural therapy
• Compliance therapy
• Cognitive adaption
• More frequent and/or
longer visits
• Patient/family psycho-education
• Symptom/side effect monitoring
• Dose correction to reduce
side effects
• Simplified medication regimen
• First generation long-acting
injectable antipsychotics
• Second-generation long-acting
injectable antipsychotics
Velligan et al. J Clin Psychiatry 2009;70(suppl 4):1–48
Pharmacological
intervention
Psychosocial and
programmatic
interventions
Adherence
19

20. Long-acting injectables lead to increased
adherence
• Non-adherence may be both a cause and
consequence of worsening of illness1
• Long-acting injectable antipsychotic drugs can
help to:2
▫ Improve adherence
▫ Reduce relapse
▫ Lower hospitalization rates
• Any decision by the patient not to attend will be
signalled by failure not to attend for, or refusal of,
injection1
1. Barnes. Adv Psychiatr Treat 2005;11:211–213; 2. Kane. J Clin Psychiatry 2006;67(suppl 5):9–14
20

21. Improved
adherence
Focus on the
positive aspects of
the medication1
Improve patient
insight1
Include patient’s
preference and
needs when
designing the
treatment regimen3
Simplify the
therapeutic
plan2
Educate patient about
medication and
potential
side effects2
Focus on
strengthening
therapeutic
alliance1
How can attitudes to medication adherence be
improved?
Emphasise direct
(reduction of symptoms)
and long-term benefits
(relapse prevention) of
adherence to medication1
1. Kikkert et al. Schizophr Bull 2006;32:786–794; 2.Charpentier et al. Encephale 2009;35:80–89;
3. NICE Clinical Practice Guidelines in Schizophrenia, CG82, March 2009
HCP, healthcare professional
21

22. Psychoeducation
Psychoeducation refers to the process of giving insights
regarding the mental illness or diagnosis, it’s course,
consequences and treatment to the patient as well as the
caregivers..
Asia-Pacific Psychiatry ISSN 1758-5864

23. Conti…
Psychoeducation/ Insight sessions include
• Information regarding illness and it’s course
• Information regarding what and how the treatment works.
• Information about role of medicines, duration for which it
is supposed to be taken, probable side effects etc.
• Information about role of counselling and group therapy
• Guidelines about how to manage oneself in case of crisis