Both in general medicine and in psychiatry, the number one cause of treatment failure is not taking medications as prescribed. There are a number of reasons for non-adherence, ranging from physical side effects to psychological issues. Here, we’ll discuss the most common reasons for non-adherence, and some strategies for helping your patients stay on their meds.
Many psychotropic medications require weeks of treatment before the first signs of clinical improvement. Many psychiatric disorders, especially depression, result in patients feeling pessimistic and hopeless. Even if they have been told about the need to wait in order to see improvement, after a few days frequently patients conclude that the drug is not working and discontinue the medication. This may be particularly true among adolescents, who want instant gratification. What makes this especially difficult to deal with is that often teens won’t share their feelings and concerns with the treatment provider.
At times, side effects are so intense and unpleasant that they may frighten a patient or greatly concern the parents. A common example is activation (acute onset anxiety) following the first dose of an antidepressant prescribed for depression or an anxiety disorder. Intense anxiety not only may lead to medication discontinuation, but also may leave the patient traumatized by the experience to the point that they decide to never seek psychiatric treatment again.
Often side effects such as weight gain or sexual dysfunction are the cause of patient-initiated discontinuation.
Worries about adverse medication effects such as addiction are not uncommon, despite not being based on real evidence. These fears often exist not only for patients, but also for their parents.
Another common and very understandable fear is related to the risk of suicide from antidepressants. Antidepressant advertisements on television always state that increased suicidality may occur with antidepressants. Research shows that most antidepressants used in kids, with the exception of venlafaxine (Effexor), have a similar low risk for causing suicide—certainly a lower risk than untreated depression itself.
The list of possible adherence problems due to psychological issues is long and complex. Here are some of the most common problems encountered in clinical practice.
Feeling of loss of control. The experience of loss of control accompanies many psychiatric disorders. Medication side effects can, at times, exacerbate that experience.
False ideas about prescriber’s goals. The perception that the prescriber sees their problem only from a biological perspective can lead to non-adherence. The patient perceives that a drug may or may not help, but that their personal, emotional issues are ignored.
Desire to remain “sick.” There may be secondary gain from continuing to be sick. This may be conscious or unconsciously motivated. Examples include the young person’s need to induce guilt and punish their parents or how some children learn that they get needed attention and care from their parents when they are sick.
Wanting the doctor to fail. Sometimes defeating the doctor is gratifying. Intentional or not, non-adherence leads to repeated medications failures. Often this dynamic is seen in patients who have a history of significant child abuse. They may sincerely ask for help to reduce painful symptoms. However, the unconscious need to control, punish, or in other ways render the prescriber impotent, may drive non-adherence. This dynamic does not go away unless it is unearthed and explored in therapy.
Being overwhelmed. Some patients truly cannot adequately take in and process what their physicians tell them about medication treatment and what to expect from this treatment. For example, depression alone can cause difficulty with memory owing to decreased capacity for maintaining attention and concentration.
Stigma. Negative stigma regarding mental illnesses persists. Taking a medication is a concrete reminder that, “I have a psychiatric disorder.” This is a significant issue that can lead to non-adherence.
Pressures from family and friends. Finally, messages from close friends and family may undermine treatment. For example, “Hey man, I heard that that drug can make you suicidal,” or “You don’t need medicines; if you just try harder you can pull yourself out of this.”
In some 12-step programs there is pressure put on members to stay away from all “mind altering” drugs, including psychiatric medications. Certainly some classes of drugs do pose real dangers of addiction in those vulnerable to substance abuse; however most classes of psychiatric drugs are not addictive. The impact of these social and interpersonal pressures can be substantial.
How to Combat Non-Adherence
All of these reasons for non-adherence should be kept in mind, especially when a patient isn’t getting better. According to psychiatrist Shawn Shea, patients always weigh the pros and cons of medication they are taking. This often is done in a non-systematic and disorganized way and the decision “to take or not to take” is not shared with their doctors (Shea SC, Improving Medication Adherence: How to Talk with Patients About Their Medications. Lippincott, Williams and Wilkins: Philadelphia; 2006).
So, what to do? When you first prescribe a medication, preemptively bring up the prospect of your patient deciding not to stay on the drug. As you work with your patient, remember to do the following:
Consider the pros and cons: Explain the effectiveness of the drug versus side effects and any psychological issues that may lead the patient to want to discontinue. Be proactive and tell patients and parents not to hesitate to bring up any concerns that might arise.
Anticipate side effects: Share with the patient, “I’m sure you know that some medications have side effects, and you may experience this. It matters a lot to me to make sure this therapy is effective, so please don’t hesitate to tell me if you encounter any side effects. If you do, we’ll find a way to deal with it.” The weighing of pros and cons is best done in your office where things can be systematically evaluated by both the patient and the clinician.
When side effects do emerge it is important to evaluate how severe they are. Are they tolerable? Are they disabling or interfering with important life activities? Might the side effects diminish with time?
Check in: Periodically ask the patient for an assessment of the medication. Ask, “How well would you say you are doing on the medicine?” Inquire about what family members or a child’s friends are saying about the patient’s medical treatment. This often has a huge impact on medication adherence.
An important key to good treatment outcomes is to give patients and their parents time to really explore any concerns or worries that they might have about the psychiatric medication being recommended.
For instance, patients may express fears of addiction if they take an antidepressant. Just giving them information about the drug being non-addictive often is not effective. It is considerably more helpful to explore in some detail with the patient how they feel about it and what they have been told about the drug.
Truly hearing the patient’s concerns is, first and foremost, a decent way to interact with a fellow human being. It also may flesh out worries that have gone unspoken. This kind of thoughtful way to address fears and worries not only helps reduce non-adherence, but it can also contribute to establishing a positive therapeutic alliance.