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Medication adherence: Are we forgetting? Or do we even known why we take them?

Reasons and solutions from the forefront of Rehabilitation psychiatry.

Dr Vishnu Pradeep, Registrar in Rehabilitation Psychiatry

Over the course of a year, about three-quarters of patients prescribed psychotropics will discontinue
them. There are significant costs arising from a physical, mental and economical standpoint from
unplanned discontinuation and partial-nonadherence. In this short article we will review causes and
strategies we can utilize to address this issue. Before we begin, we need to clarify a few working
terminologies commonly attached to this type of health behaviour. Adherence (or compliance) is the
extent to which individuals attempt to change their health behaviour to coincide with medical advice.
Concordance, on the other hand is the degree to which clinical advice and health behaviour agrees.

Most common reason for non-adherence arise when there is a divergence in the views of the patient
and the treating team on the subject of treatment. Lack of a clear agreement formed at the onset of
treatment leads to high likelihood of discontinuation. Secondly, factors the affect the partial-
nonadherence include: complexity or the medications regimen, duration of treatment and lack of
follow-up contact/informal support. The more the regimen causes a disruption in the lifestyle of an
individual, the more likely it can lead to premature discontinuation. Additionally, the quality of formal
and informal support is important as it should be utilized to explore intentional factors leading to
premature discontinuation such as: concerns around side-effects, lack of perceived benefits, stigma,
cost concerns, availability and fears of creating a dependency. Unintentional factors such as lapses in
adherence and misunderstanding of instructions should be screened and addressed earlier during
treatment. Attention to clinician related factors such establishing therapeutic alliance and provision of
follow-up schedule should be strongly considered. Ownership for this process should be shared between
carers, supervising staff and clinicians if in cases adherence is compromised due to enduring mental
illness or cognitive impairment.

A few strategies have been evaluated to address the above concern: First-line intervention is through
the strategic provision of clinician and staff-led educational workshops and teaching activities for both
carer and service users addressing issues involving medication adherence. On a more practical level,
simple prompts to establish basic communication around medication literacy, setting technology-
assisted reminders and allowing for opportunities for evaluating adherence by exploring patient views of
discontinuation should be explored. A more direct means of assessing compliance in case of early
evidence of relapse signature is usually performed with consent from patients either through review of
blister pack, pill counting or serum drug levels. We should always advocate for a non-intrusive approach
for the assessment of adherence without disrupting therapeutic alliance with the service user.

The Adherence Toolkit:
• Access the following websites to get more information • Discuss options of simplying regimen with clinician • Provide positive feedback and allow for opportunities
on medications: • Talk to your pharmacist about getting your medications to discuss concerns
http://www.choiceandmedication.org/ireland/ in a blister pack • Ensure structured follow-up plans with GPs and
http://www.medicines.ie/ • Setting an alarm on your phone at intervals of 9:00 am, treating team.
6:00 pm and 10:00 pm with prompts such as
“Remember to take your medication” to help with
adherence.
• Download mobile application to set a reminder for
taking your tablets. Go to Android/Apple app store and
search “Pill reminder” and download app. Use app to
set specific reminders during the day.

SUPPORT SIMPLIFY
ASSESS
HEALTH REGIMEN & SET
ADHERENCE
LITERACY REMINDERS