Jenny is a 17-year-old patient with generalized anxiety and panic disorder whose parents divorced 10 years ago. You began treating her two years ago, and she responded well to sertraline 75 mg. In the last six months, she’s had more anxiety symptoms and some panic attacks. You ask how consistently she takes her medication. She says, “I take it most of the time.”

Psychiatric medications are pivotal for many of our patients, but nonadherence is common. In this article, we cover the most common drivers of nonadherence and practical strategies to address each one.

The scope of the problem

A systematic review of 28 studies involving youth with severe mental illness (~180,000 patients) found that one-third did not take medication consistently. Illness severity was inversely related to adherence: Those who need medication most are least likely to take it. On the other hand, positive attitudes toward care among patients and families, along with greater patient insight, promoted adherence. The therapeutic alliance is among our most powerful tools; the greatest positive effects on adherence were associated with ongoing psychotherapy and a strong clinician-patient relationship (Edgcomb JB and Zima B, J Child Adolesc Psychopharmacol 2018;28(8):508–520). This pattern is not unique to psychiatry; similar rates appear in studies of youth with asthma, diabetes, and epilepsy. As with all pediatric care, developmental stage and family dynamics play a central role.

Jenny stopped seeing her CBT therapist nine months ago when her symptoms improved. She has a positive view of you and the medicine, but she mentions that her routines have been disrupted as a result of her mother recently moving.

Forgetting and “forgetting”

Before assuming a patient doesn’t want to take their medication, rule out simpler explanations. If you’ve addressed the logistics but adherence is still inconsistent, that’s your cue to look deeper.

Addressing forgetfulness

Establishing and sustaining daily pill-taking requires stable executive function. “I should” is not enough. Nonadherence can stem from forgetfulness that you can address with concrete problem-solving. Ask parents to supervise children taking medicine. With teens, encourage autonomy within parental supervision. Engage them in discussions of:

• Where they will keep the medicine (eg, next to their toothbrush)
• When they will take it (eg, every morning before school, tied to a consistent anchor like breakfast)
• Who will remind them (eg, a parent gives a single, non-nagging prompt at a set time)
• How they will know when they miss a dose (eg, checking whether the day’s pill is still in the organizer by noon)
• How they will get refills (eg, the teen texts a parent when they’re down to a week’s supply, then the parent contacts the pharmacy)

Many families need to co-create new routines that support adherence. Practical strategies like pill organizers, linking medication to existing routines, and positive reinforcement outperform education-only approaches (Dean A et al, Arch Dis Child 2010;95(9):717–723).

You encourage Jenny to get a brightly colored pill box, place it where she’ll see it daily, and note when she misses a dose, framing it as good practice for college. Jenny mentions her father’s skepticism about medication: “He just wants me to be a regular kid again.” She also shares her own misgivings: “I wish I were normal like my sister. My dad likes her better because she isn’t weak.”

Other causes of nonadherence

When logistics aren’t the issue, the barrier is likely motivational or psychological. Nonadherence is also driven by motivations and perceptions: a desire for autonomy, concerns about judgment from peers or parents, unexpressed fears or resentment, insufficient understanding of why medication matters, or denial about symptom severity.

This calls for improved communication about the “why” and “how” of treatment, shared decision-making, and direct attention to stigma. Keep a prepared set of metaphors and explanations ready to connect symptoms to impairment, to explain how medicine helps, and to frame treatment in less pathologizing language that resonates with the child’s experience and aligns with their goals. See the “Helpful Metaphors for Explaining Psychiatric Medications to Patients” table for examples.

Adherence conversations should address both the patient and the family. With the patient, focus on psychoeducation, shared decision-making, and autonomy. With the family, explore routines, supportive (but non-coercive) parental involvement, and acceptance of the diagnosis and treatment. Tailor the intervention—what works for one patient won’t work for another.

Helpful Metaphors for Explaining Psychiatric Medications to Patients
Condition	Core Metaphor	What to Say
ADHD	Focus as a muscle	"Focus is like a muscle. When it’s weak, it’s hard to get things done, which is frustrating. This medicine strengthens your focus muscle, so you feel less frustrated at school and have better days."
Anxiety	Brain alarm center	"Your brain has an alarm center that goes off when something stressful or threatening happens. With anxiety, that alarm goes off too loud, or too long, or at the wrong time. The medicine helps turn down the volume on that alarm and lets you retrain it to go off at the right time, in the right places. When you have more control over the alarm, you have more control over your life."
Depression	Stuck in stress loops	"For most people, depression is a reaction to prolonged stress. The stress overwhelms your brain, and you get stuck in loops of bad feelings and negative thinking—it’s hard to have good feelings even when you’re doing good things. The medicine slowly reverses that stress reaction: Positive things in your environment will begin to get through to you, and it will be easier to turn away from negative thoughts and feelings. It happens slowly, and it’s important to keep doing positive things as much as possible while you’re taking it."
OCD	An annoying voice to ignore	"OCD is like an annoying person who keeps telling you that bad things are going to happen. The key to beating OCD is strengthening your mind so you can ignore the annoying voice. The medicine can make you stronger and OCD weaker, which will make it easier to ignore. After a while, OCD gets so weak you won’t notice it much at all."

Jenny agrees to meet with you and her dad. He voices his concern about medication but hears Jenny’s experience that it helps. To Jenny’s relief, he agrees to help observe the effects and side effects and participate in discussions about how long it makes sense to continue the medication.

Maintaining adherence

Adherence requires continuous encouragement: Intervention studies show that adherence declines substantially without ongoing support (Modi AC et al, Epilepsia 2026;67(4):1975–1991). Discuss medication consistency at every visit. Normalize the problem and set a specific time anchor. I might say, “It’s hard taking a medicine every day. People forget. I wonder, in the past week, how many days have you forgotten? How about the past two weeks?” Ask about specific short time frames to elicit recent information from the patient.

Nonadherence is strongly associated with poor physician-patient relationships, lack of family support, and parental stress. Keep the following in mind:

• Make your physician-patient relationship a priority.
• Use nonjudgmental language when discussing adherence and acknowledge that missing doses is common. Refill history can be an objective marker for nonadherence.
• Approach families as collaborators in identifying and solving specific barriers, such as forgetfulness, side effects, stigma, or cost. Each requires a different solution.
• Insight-oriented psychotherapy can help both patients and families.

A year later, Jenny sees you on a visit home from college. She remains motivated in treatment because she understands that the medicine helps her. You help her see herself as someone with a manageable condition that doesn’t define her and that won’t hold her back from a rich and fulfilling life.

CARLAT VERDICT
Supporting adherence is as important as finding the right diagnosis and the right medication. Education alone does not improve adherence. Promote adherence with pragmatic executive-function solutions (routines, scaffolding, concrete strategies). Address psychological themes that undermine motivation. Discuss adherence at every visit and communicate with parents. The therapeutic alliance is a powerful adherence-promoting intervention.