You are on page 1of 9

Dis Manage Health Outcomes 2006; 14 (4): 207-214

LEADING ARTICLE 1173-8790/06/0004-0207/$39.95/0

 2006 Adis Data Information BV. All rights reserved.

Adherence to Antipsychotic Treatment
in Schizophrenia
What Role Does Cognitive Behavioral Therapy Play in Improving Outcomes?

Gary Donohoe
Department of Psychiatry, Neuropsychiatric Genetics Research Group, Trinity College Dublin, St James’s Hospital,
Dublin, Ireland

Abstract Relapse of schizophrenia due to poor medication adherence is a major preventable source of psychiatric
morbidity. This has led to a burgeoning of interest in improving compliance based on a wide range of
psychological approaches. One of the difficulties for health service providers is to establish the utility of such
interventions, particularly when the economic costs of these programs are unclear. This review examines the
evidence for one leading approach to improving adherence – the cognitive behavioral approach adopted in the
‘compliance therapy’ of Kemp et al. A context for this review is provided by way of a brief overview of both
traditional medical and psychoeducational approaches to treatment adherence, along with more cognitively
based formulations of nonadherence. The aims and rationale of compliance therapy are presented along with a
brief description of the therapy sessions. The empirical support for the efficacy of this treatment is discussed
based on the few published studies available. The review concludes that while compliance therapy may be of
value, this intervention will require further empirical study before reaching definite conclusions about its utility
for responding to poor adherence to medications.

“He that complies against his will is of his own opinion still.” psycho-educational, cognitive behavioral, and family-based thera-
– Samuel Butler pies. One of the difficulties for health service providers is to
Relapse of schizophrenia due to poor medication adherence is a
establish the utility of such interventions, particularly when the
major preventable source of psychiatric morbidity.[1] Despite the
accumulated evidence indicating that available treatments have economic costs of these programs are unclear.[5] This review
powerful efficacy in the management of schizophrenia, adherence focuses on one kind of psychological intervention for enhancing
to pharmacologic and psychosocial treatments is notoriously treatment adherence rates – the cognitive behavioral approach
poor.[2] The results are costly both to service providers and to adopted in the ‘compliance therapy’ developed by Kemp et al.[6]
patients in terms of social and occupational function and quality of
To provide a context for this intervention, a selective review of
life.[3] In patients with schizophrenia, deviation from maintenance
antipsychotic therapy risks exacerbation of psychosis, increased traditional medical and psycho-educational approaches to
clinic and emergency room visits, and rehospitalization. Even non-adherence is provided along with a brief overview of cogni-
more detrimental to patients is the abuse of substances instead of tive theories of treatment adherence. Finally, the existing evidence
adherence to prescribed medication, which has, for example, been
is discussed as to whether this more recent approach may be
associated with violent behavior.[4]
Over the past ten years, there has been an explosion of interest considered an improvement on traditional approaches to combat-
in how medication adherence might be improved using a variety of ing the world’s ‘other’ drug problem.

[19] and ‘adherence’ both continue to be widely used.[9. simple mea. An additional consideration in reviewing rates of treat- Clinical ratings and collateral observations are highly subjective. epilepsy. marital status. Arthritis Berg et al. By (ii) illness-related factors. 14 (4) . Diabetes mellitus Friedman[16] 19–80 ence’ has found some favor because it suggests. It is likely that epidemiologic edly associated with non-adherence. patients’ active involvement in treatment. which are discussed in sures are not accurate. Of course. Of the alternatives proposed.e. the issue of treatment adherence reaches conditions does not mean that there are not also issues that are beyond mental health to all forms of medication management.[23. Rates of non-adherence across a range of chronic disorders Condition Review Non-adherence In an age characterized by a shift from paternalism to con. that young males may be somewhat less adherent. All rights reserved.[15] 20–57 suitable alternative. asthma). There is no one measure of treatment adherence that has significant cognitive challenges associated with schizophrenia (by been completely successful.[13] 55–71 Still. the providers. nia is that they represent the behavior of patients who have By contrast.[17] 20–73 extent. Factors Influencing Treatment Adherence time of each bottle opening – have been infrequently used despite in Schizophrenia their advantages over clinician ratings.[11. A review of all Depression Peveler[18] 30–68 MEDLINE citations suggests that. This is surprising given the of time. Event Monitoring System (MEMS). no doubt partly due to the difficulties in finding a Bipolar affective disorder Elixhauser et al.[7] It is normally measured as the percentage of the belief that non-adherence might be due to illness-specific factors prescribed dosage actually taken by the patient over a given period may not be completely warranted. the word ‘compliance’ seems antiquated and has been Schizophrenia Fenton et al. What is Adherence? Definitions and Comparisons Table I. Based on this evidence. sex. specific to schizophrenia. the term continues to be used in the burgeoning literature on Seizure disorders Shope[14] 54–82 the subject. phrenia actually falls within the mid-range of rates for a number of Adherence to medication is usually described as the degree to chronic diseases such as diabetes and arthritis. and comparison with other chronic illnesses such as asthma. (iv) environmental factors. to date. Hypertension Eraker et al. As Blackwell[8] notes. Irrespective of the term employed. any more of an issue in mental health than in general medicine. Table I presents a comparison of rates of non-adherence reported of a further eight studies investigating predictors of adherence. or chronic episodic which patients take medication as prescribed by their healthcare diseases such as asthma and epilepsy. many researchers suggest that this illness-specific such as age. patients with schizophrenia differ in their level of predictors of non-adherence. the terms ‘compliance’ Simon et al. although there was some evidence adherence from patients with other conditions) is not warranted.24] a major factor  2006 Adis Data Information BV. the likelihood of noncompliance. In terms of patient demographic vari- and diabetes mellitus. comparison with. ment adherence in schizophrenia is that non-adherence is neither urine and blood serum level tests are costly and best suited to yes/ all-or-nothing nor likely to be consistent across the course of no determinations.[20] 50–66 changeably. a review by Fenton et al. and ethnicity are important distinction (i.[12] 24–88 criticized as implying passivity and servitude on the patient’s part. and with other psychiatric disorders such as ables. stating that non-adherence is a difficulty in many spect of schizophrenia. at least to some Asthma Cochrane et al. the reported rates of non-adherence suggest that schizo- collaborative partnership.10] While non-adherence has received particular attention in re. Dis Manage Health Outcomes 2006. often inter. Notwithstanding these physician. only Coodin et al. which employs a medication bottle cap with a microprocessor that records the occurrence and 2.[22] found evidence that being younger increased One criticism of studies of non-adherence rates in schizophre.[12] found little evidence that factors depression. and accurate measures are not simple. core to any defini- tion should be the idea of a treatment alliance between patient and medication and service disengagement.208 Donohoe 1. Studies of these in the literature can be Buchanan[11] describes as a myth the belief that poor adherence is described under four headings: (i) patient demographic factors. section 2. Although the evidence of an studies would find much higher rates of both non-adherence to association with the paranoid subtype is mixed. range reported (%) sumerism. variance in symptom presentation has been repeat- consented to participate in the study. for example. Electronic measures – such as the Medication illness. where medication taking is the behavioral outcome of a criticisms. (iii) medication-related factors. the term ‘adher. for different disorders.21] Since then.

Serban and Thomas[35] found that most pa- patients with persecutory delusions were compliant (85%). which has been assessed using a variety of self-rated and interviewer rated measures. clozapine treatment and weight gain associated with olanzapine ence after discharge. reducing regimen complexity (e.Adherence to Antipsychotic Treatment in Schizophrenia 209 may be the presence or absence of grandiose delusions. (92%). Dis Manage Health Outcomes 2006.[33] reported substance abuse in the extrapyramidal effects (e. as a depot preparation) or by introducing drugs with improved adverse effects profiles. these limited effect. nearly tients who failed to take medication did so despite their expressed all paranoid patients with grandiose delusions refused medication belief that medication would be helpful.42] This is presumably abusing patients were 13 times more likely to be noncompliant because newer antipsychotics have adverse effects other than with antipsychotics.[40] At the same garding substance abuse. regimen improve adherence largely by improving insight have been of complexity or the adverse-effects profile. as Fenton et al.[28] Poor insight is consistently associated with non.[41.[11.[26] However. Similarly.36. Kashner et al.g. efforts to improve adherence with antipsychotic for treatment. tients. In terms of other health beliefs. Owen et al.[12] reported that five of seven studies found an association In terms of the doctor-patient relationship.. All rights reserved. the relation- intermediate levels of adherence.30] and has been repeatedly associated with cogni. family. esting. there has been rela. out. found that the quality of the relationship between doctors nia and predictive of outcome.g. ship between better treatment adherence and better social. Consequently. a recent large study of between non-adherence and greater symptom severity.[32] found that substance time. a single dose administered once  2006 Adis Data Information BV. more usually implicit) theory as to why patients do not take their tive deficits in schizophrenia[31] but also with symptom severity.g.1 Medical Approaches thought to involve three main domains: recognition of an illness.[39] In terms of an improved adverse-effects profile. by virtue of their adherence.[38] involving 228 inpa- Cognitive deficits are increasingly seen as core to schizophre. This about the possibility of relapse. More compliant patients may. As such.[25] who found no Buchanan[11] found no difference between patients who were relationship between non-adherence and the paranoid schizo. medication. The value to adherence of factors that increase or decrease this likelihood). in decision making) on treatment adherence in schizophrenia. together with the fact that interventions that have aimed to predominantly a patient issue related to. subjective improvement in well-being is reflected in the evidence tal factors such as the level and nature of family involvement. studies of poor insight in relation to problems with adherence are 3.27. For example. adherent and those who were not adherent to treatment by depot phrenic subtype per se but noted that whereas most paranoid injection. other effects significantly improves subjective well-being beyond that ‘health beliefs’ (e. and recognition of the need Traditionally. Traditional Approaches to Enhancing Adherence abundant in schizophrenia. it is difficult to infer causality from these kinds of studies. the efficacy of A number of other factors have also been related to treatment atypical antipsychotics without serious extrapyramidal adverse non-adherence including co-occurring substance abuse. finding.[12] point (e. medications have been formulated on the basis of an explicit (but adherence[24. In terms of illness severity. Of course. By comparison. however. ability to correctly classify symptoms. Pan and Tantam[34] and distinction is borne out by Van Putten et al.g. and quality of the doctor-patient relationship. the relation. Fenton et medication is consistently associated with better adherence. thus preventing any definite conclusions. Patients themselves often ascribe poor adherence to forgetfulness. both for ship with adherence is unclear. suggest that the relationship between insight and approaches have sought to overcome these issues. Re. Both 2. Biomedical approaches have viewed nonadherence as This. beliefs about the likelihood of relapse and achieved by traditional antipsychotics. this advantage is limited. regarding beliefs reducing regimen complexity (e. 14 (4) .g. feel Our own study found that memory deficit was the best predictor of more supported than noncompliant patients.[27] While these results are inter. and patients during an inpatient stay was a significant determinant tively little investigation into the impact of cognitive impairments of adherence post-discharge. to our knowledge no studies have sought to replicate this and therapist support is likely to be bidirectional. is typically 3. usually by poor adherence is unlikely to be straightforward in causality. and environmen. treatment).1 Other Factors Related to Treatment Non-Adherence approaches have been helpful. adherence-related variables by Day et al. Bartko et al. Insight.29. Depot preparations have also been helpful. that patients receiving atypical antipsychotics are more adherent social support.[24] also found this association with higher The availability of family and friends to assist or supervise grandiosity symptom scores.37] al. the need for blood tests as part of month before admission as the strongest predictor of non-adher. than those receiving traditional antipsychotics. for example.

Further- remove illness threats. with a shared definition of the problems and lack of understanding of the symptoms or their etiology. and interpersonal determinants of medication taking. group/family approaches emphasizing the importance of social/family support). Given the correla- regulation model’ developed by Leventhal et al.g. taking procedures that people use to enhance health or avoid.  2006 Adis Data Information BV. Notwithstanding these developments.[44] concluded health problem is composed of (i) representation of a health that only 13 studies (33%) resulted in significant improvements in threat. ing treatment adherence in this way allows us to understand how tween studies. (iii) emotional reactions and cognitive repre- review[44] of 39 psychoeducational studies aimed at improving sentations of an illness and its treatment are created simultaneous- drug adherence reflects the diversity of treatment modalities (indi- ly (in parallel). compliance with depot the concerns of an individual patient. Merely advantages of both a newer antipsychotic and a simpler regi. 14 (4) . (ii) the mechanism of solvers. Cognitive Theories of Treatment Adherence 3. Additionally. A recent down) processing. a new depot preparation of risperidone combines the stigma attached to accepting a diagnosis of schizophrenia. Zygmunt et antipsychotics is still estimated at only 60%. (iv) contextual factors (culture. it allows for a in which many psychoeducational packages adopt a model that greater appreciation of the importance of collaboration between presumes the patient has an illness. that their symptoms are a result of being possessed to fear of the However. yielding different and possibly conflicting goals for vidual versus group versus family versus a combination of these). while these ap. possibly related to al. agreement on how best to ameliorate them. in the context of the therapeutic alliance. ranging from the feeling preparations were available only for traditional antipsychotics.[45. provide accompanying behavioral components (e. problem-solv- proaches are valuable to improving adherence.g. Dis Manage Health Outcomes 2006. very little attention is paid to the specific symptoms can be a powerful top-down reinforcer (e. while on the other hand the meaning assigned to motivation. which these packages then aim the patient and the mental health professional in developing a to clarify and correct. ment. they obviously ing tools such as reminders. behaviors. specific targeting of symptoms).[1] Until recently. one reason appears to be that psychoeducational symptom fluctuations (that are attributed to medication) can be a packages side-step the specifics of what constitutes a health threat powerful ‘bottom-up’ reinforcer of adherence or non-adherence on to an individual patient and the values involved in health-relevant the one hand. cognitive approaches emphasizing tionships) and personality factors both influence the ways in which patient attitudes. issues targeted (generic descriptions of On the basis of these premises.210 Donohoe a fortnight) and for making non-adherence overt so that alterna. the self-regulation model makes illness. Zygmunt et al. (ii) procedures for health-threat management.[47] This model is tion between poor treatment adherence and lack of knowledge based on four main premises: (i) patients are active problem regarding (i) the rationale for treatment. In so doing. Understand- Notwithstanding the significant methodologic differences be.[43] Thus. self-monitoring tools) are unlikely to need to be supported by interventions that also target the personal change medication-taking behavior. Importantly for psychoeducational studies. control. The (ranging from four to 20 sessions). depot negate the power of any such rationale.2 Psychoeducational Approaches One psychological theory that seeks to address the personal and By contrast with biomedical approaches.[47] This can be seen most clearly in the way more. striving to understand and gain control over their environ- action of the medication. However. patient-therapist rela- therapeutic orientation (e. psychoeducational interpersonal issues that dynamically change the patient’s motiva- approaches have tended to view non-adherence as an issue of poor tion to comply with their physician’s prescriptions is the ‘self communication between patient and therapist. any given patient may have a number of beliefs and emotions that tive strategies can be quickly formulated.46] and moderate the procedures for threat management. and treatment length a distinction between the health problem and its context.[44] conclude that psychoeducational interventions that do not patients’ perception of loss of control. behavior. or adverse effects as a sign that the medication is working). All rights reserved.g. (iii) the adverse effects of the medication. and that not having such a model is due to a model of illness. for outcome appraisal. (ii) representations of health threats are generated by both and (iv) correct administration of the medication.[30] improving the perceptual/automatic (bottom-up) and deliberate/cognitive (top- delivery of such information would seem most beneficial. behavioral approaches emphasizing reinforced health threats are construed and managed. and (iii) rules treatment adherence. providing a rationale is therefore far from adequate for addressing men. The context is composed of (i) environmen- this was often despite an apparent increase in knowledge about the tal and (ii) personal factors that feed information into the system medication and greater insight into illness.[8] 4.

Evidence for the success of compliance therapy was originally interventions aiming to improve treatment adherence ought to be presented by Kemp et al. and motivational interviewing is not to provide information or a ratio. In particular. their own rationale and.1 Empirical Study of Compliance Therapy Based on this view of self-regulated health-threat management. illness and requiring medication are addressed. On the main adherence- viewing principles together with other cognitive therapy tech- related scales. imme- behavior. insight.6 for patients in the control group (an they consider there to be one. had significantly longer rates of survival in the community prior to lactic medication. functioning. developing a collaborative approach to understanding the illness. in so doing. but this improvement was sustained only by the Kemp et al.[49] found that. adapting the tech. For the treatment ambivalence about medication.. the impact of In the final stage of treatment. global assessment of function- nale for behavior that might lead to an increase in adaptive ing. Compliance Therapy 5. an need for medication for patients with mental illness to that of 18-month follow-up study by Kemp et al. the compliance therapy group showed statistically niques (e. both groups improved immediately after cognitive dissonance that leads the individual to reappraise their therapy. and the patient is encouraged to comment on patient’s clinical well-being or quality of life. This approach involves up to significant improvements on the treatment adherence measure. Similarly. Finally.[45] However. the therapist openly predicts misgivings treatment adherence will have any meaningful impact on the toward medication. Dis Manage Health Outcomes 2006. clinical value rather than its statistical value. and 6 months after therapy. as well as patients with similar needs who have other illnesses such as maintaining their relative advantage over the control group in asthma or diabetes. with no significant improve- (i) eliciting the patient’s stance toward treatment. 14 (4) . Socratic questioning). and drug adherence were collected at baseline. Data on symptom severity. Certainly. both groups improved immediately after their respec- tive therapies. and (iii) maintaining treatment adherence scale. the these. one can viding an indication of attitudes to medication. of when well.g. Finally. All rights reserved.[6] study. drug attitudes. study of 25 patients with mental health disorders (14 of whom had tic alliance between the patient and the therapist where the patient schizophrenia) who received compliance therapy compared with a is actively encouraged to consider the pros and cons of their control group of 22 patients with mental health disorders (10 of medication-taking attitude and behavior. The significant determinant of the utility of any treatment is its providing information and a normalizing rationale. and insight. In trying to facilitate change.[6] based on a randomized controlled most successful if they focus on building a collaborative therapeu. global er[48] to treat drug abuse. for global assessment of more adaptive behaviors.Adherence to Antipsychotic Treatment in Schizophrenia 211 5. taken in Kemp et al. To explore ambiva.[6] Likewise. stigma attached to having a mental compliance therapy on insight appeared to have been quite large. instead. compliance therapy patients when well is openly predicted. debate whether an improvement of 1. a cost evaluation of compli-  2006 Adis Data Information BV. this is an gy with the therapist regarding what to do when early warning important demonstration of the utility of this cognitive interven- signs of relapse are recognized. likening the in an appreciable improvement in drug adherence. it aims to involve the individual in exploring diately after therapy. on average. Outcome measures included treatment adherence assessed by niques of motivational interviewing used by Rollnick and Mill.’s[6] therapy incorporates these motivational inter- compliance therapy group at 6 months. This is the approach whom had schizophrenia) who received nonspecific counseling.’s[6] compliance therapy. self-motivating statements describing the drug attitudes inventory (an increase of approximately 8%) may benefits of the medication as reported by the patient are reinforced. with the therapist although previous studies have improved insight without resulting again providing a normalizing rationale for treatment. structured interview and measured on a 7-point Likert scale. This review then forms the basis for advantage of approximately 23%). readmission. tion for improving adherence. From the perspective of clinical value.6 on a Likert scale of lence toward medication. ambivalence to maintaining treatment terms of insight and drug attitudes. and patients are encouraged to develop a strate. the aim of assessment of functioning. and also pro.’ patients are 2. insight. and both groups showed a small deterioration in this behavior and to address and resolve their ambivalence toward improvement at 6 months. To elicit the ‘stance toward treatment. symptom severity. this represented an improvement. In the Kemp et al. This is followed by weighing up the pros and cons of clinical significance of an increase of five points on a 60-point treatment. also be questionable. to create a certain amount of For symptom severity. (ii) exploring ments on any measure in the control group.2 from baseline to 6 months for patients receiving compliance asked to review their conceptualization of the problem or whether therapy compared with 1. along with a rationale for prophy. six sessions of 1 : 1 therapy organized around three main areas: attitude to treatment.

This of course is critical to determining the value of because the treatment center was smaller. the compliance therapy group did tages.[9] reported on the outcome of a ence. could be interpreted in a number of ways. noncontrolled trial of compliance therapy in a sample of 30 Outcome variables involved the same measures of insight. encouraging a collaborative approach to drug adher. whereas raters in the Kemp et al. in the original report. or rates of compliance.[6] both groups showed significant improvement at 1 year in longer apparent at 5 months.[6. given these advan. in a group of consecutively admitted inpatients who for this may have been the significant cognitive deficits presented had been diagnosed only with schizophrenia. ment group patients belong is well documented as a potential bias Since the original study by Kemp et al. A recent study by Byerly et al. with outcome variables including insight. the fact that this report was based on a small sample of 6. in compliance therapy have been published: a blind randomized a sample including only patients with schizophrenia. For example. cognitive controlled trial by our own group[37] and a recently published non. as was the general ‘philosophy’ of compliance a covariate) would enhance the study design in this respect. In terms of the sample size. therapy based on the principles of motivational interviewing may controlled trial.49] given the small compliance was conducted blind to treatment allocation in the sample sizes involved. own findings. attitudes to after which treatment adherence was measured on a four-point drug treatment. social. and a comparable measure not bipolar disorder). As with the original by this patient group (as opposed to. leading the authors to conclude that terms of symptom severity. therapy. Their original study[6] had included patients which the studies were conducted. compliance therapy failed to compliance therapy did not confer significant benefits in their show any advantage over nonspecific counseling in insight. the conclusions were limited by the small sample The failure to replicate the original findings by Kemp et al.[49] study were the same post-treatment as the result that only 51% of their sample consisted of patients with those in the O’Donnell et al. having achieved better therapeutic collaboration prior to the study. the study consisted of O’Donnell et al. in terms of therapy is that while it is promising. While involved. This may be schizophrenia. Conclusion patients with schizophrenia (28 in the intervention group versus 28 in the control group) may have compromised its ability to detect Based on these studies. the drug attitudes with bipolar disorder and other non-schizophrenia disorders. in which (each lasting approximately 45 minutes) by a clinical psychologist case the cognitive demands of this therapy may have been too with a special interest in psychosis and training in motivational challenging. global functioning. This is especially an issue Another difference between the studies was that assessment of in evaluating the two studies by Kemp et al. The treatment manual devised by Kemp et al.212 Donohoe ance therapy by the same group found that. One reason Kemp et al. 14 (4) . For example.49] size and the uncontrolled nature of the study. drug sample. cognitive. with ratings in the Kemp et al.. this was short lived and was no study. allowing patients to compliance therapy for schizophrenia. a treatment adherence interview reported.[6.’s original adherence at 1 month follow-up. there has been a failure to test  2006 Adis Data Information BV. and occupational out.’s[6] compliance therapy is the sample tributed to the difference in outcome was the kind of service in selection of the study. However.. As with Kemp et al. While the outcome of this trial was consistent with our attitudes. not least because of the have more contact with their treatment team and thus already differences in clinical. Finally. one conclusion regarding compliance true differences between the groups. Including baseline assessment of cognitive function interviewing. although the difference was not An additional point of critical significance in evaluating the statistically significant. All rights reserved. Follow-up at both 1 month and 5 months was of treatment adherence (namely.[37] study. survival rates in the community. The impact of knowing to which treat- nonspecific counseling group. and this may have been a factor here. for example. patients with therapy. compliance therapy was delivered over five sessions bipolar disorder who may be less cognitively impaired). Dis Manage Health Outcomes 2006. comes of different psychotic disorders. 28 of whom received compliance therapy and 28 who compliance therapy did contribute an advantage in terms of drug received nonspecific counseling.[6. collected at 1 year after treatment for 90% of the 56 patients (based on how often patients opened their pill bottles).[37] sample at baseline.e.49] only 25 patients in the compliance group versus 22 patients in the studies were not blinded.[9] Our own study sought to replicate the findings of not have been ideally suited to these patients’ needs.[50] versus 482 days to readmission). A second difference that might have con- effectiveness of Kemp et al. i. and an electronic measure of treatment adherence scale). drug patients with either schizophrenia or schizoaffective disorder (but treatment attitudes. compliance therapy was more cost effective than standard appear to survive somewhat longer than the control group (440 treatment.[6] was in studies of compliance therapy (so that it can then be analyzed as adhered to closely.[6] two further studies of in treatment trials.

Horne R. This collaborative involvement is likely to be most effec- plications 1988. This will no doubt help to clarify the true value of this CD000011 intervention. 27: S1-S24 skepticism. 22: 787-97 intervention that requires the cognitive flexibility to weigh the 12. Blackwell B. Tarrier N. 15. Swanson JW.Adherence to Antipsychotic Treatment in Schizophrenia 213 2. Psychol Med 1992. 14 (4) . 9. and inhalation technique. Smith CM. The effects of monitoring and feedback ment. BMJ 1996 Feb 10. King’s College London. In: Blackwell B. 1997: 1-16 conflicting. Taking the wrong drugs: the role of because of a lack of funding. Swartz MS. Elixhauser A. Fenton WS. Atypical antipsychotics and compliance in schizophrenia. and facilitating an increase in family support. Kemp R. Wagner DJ. Van Putten T. sees them as active participants in treat. Demographic factors associated with extreme non-compli- Acknowledgments ance in schizophrenia. 7. Dischler J. Barber N. Romeis JC. on compliance. 20. et al. The author’s work on compliance therapy was schizophrenic patients. is to be wel. analysis. Befriending can lead to remission in women with chronic depression. On a skeptical note. Treatment compliance and the therapeutic alliance. et al. et al. Garg AX. Am- In the meantime. simplifying treatment regi. 8. and a similar conclusion has recently been 3. Predictors of compliance with neurolep- References tic medication among inpatients with schizophrenia: a discriminant function 1. 77: 74-6 25. West J Med 1999. unlike large-scale drug trials funded substance abuse and medication non-compliance in violence among severely mentally ill individuals. 18. Staley D. Cochrane MG. 171: 241 mens. it is difficult to see how compli. Inhaled corticosteroids for asthma that also targets the contextual factors influencing treatment adher. Against that problem. Soc Psychiatry Psychiatr Epidemiol 1998 Dec. Yale C. 41: 1345-8 carried out while he was a recipient of an educational grant from Eli Lilly & 24. et al. any intervention that seeks to include patients in the 14. family support). 312 (7027): 345-9 communication from Dr Richard Gray. 23: 637-51 pros and cons of medication adherence during a 30. may form a 19. Crumpton E. Liberman RP. Med Care 1990. and without seeking to 10. Elliott RA. Nord J Psychi. Compliance in children and adults: review of studies. Cortens B. Hiday VA. Medication compliance: a healthcare session may be too challenging for many patients. Sellwood W. Arch Gen useful additional approach to resolving issues with adherence to Psychiatry 2001. Compliance with chronic disease regimens: diabetes. Eraker SA. Drug refusal in schizophrenia and the wish to ported by grants from the Higher Education Authority (Dublin. Carmody T. 33 largely by their manufacturers. Hale AS. Hayward P. Ireland). Soc Psychiatry Psychiatr Epidemiol 1994. Clinical symptomatology and drug compliance in Company Limited (Dublin. It is encouraging to note that a multicenter ventions: a quality assessment of the evidence. J Psychiatry Neurosci 2001 Sep. et al. 16 (5): 293-8 atry 1995. therapy: patient compliance. Bartko G. O’Donnell C. Determinants of medication compliance in schizophrenia: empirical and clinical findings. Ireland) and be crazy. Schizophr Bull 1997. Sullivan MC. and places value on the therapeutic alliance. Pristach CA. Br J Psychiatry 1990. Zador G. Cost-effectiveness of systematic depression treatment for high utilizers of general medical care. Knapp M. Owens N. Eur Psychiatry 2001 Aug. All rights reserved. Can J Psychiatry 2004. Manning WG. Ann Pharmacother 2005. Peveler R. Use of the Medication Event Monitoring modify any other contextual factors known to influence treatment System to estimate medication compliance in patients with schizophrenia. King D. Becker MH. A two-year prospective study of treatment compliance in patients given the cognitive deficits associated with schizophrenia. 26 (4): 325-9 adherence – can be expected to have a potent effect. the funding available for empirical Suppl. Int Clin Psychopharmacol 1995. Shope JT. Dis Manage Health Outcomes 2006. Understanding and improving patient compli- ance. Fisher R.[51] One reason for this lack of research has been 4. Cost-effectiveness of adherence-enhancing inter- been extremely limited. Ireland). Berg JS. A trial of compliance therapy in outpatients ance therapy – when delivered by someone other than the treating with schizophrenia or schizoaffective disorder. of course. Heinssen RK. Epilepsy Res Suppl 1988. From compliance to alliance: a quarter century of research. J Diabet Com- comed. David A. Diaz E. His current research is generously sup. Non-adherence to antipsychotic medication drawn about randomized trials of cognitive therapy for schizo. et al. Byerly MJ. not limited to schizophrenia. together with reducing adverse effects. et al. This difficulty is. 26. et al. Ann Intern Med 1984.[53] Motivationally based interventions. 9 Suppl. Furthermore. Dencker SJ. et al. 156: 798-808  2006 Adis Data Information BV. Haynes RB. 49 (35): 31-9 28. 49: 145-8 The author sincerely thanks Ms Judy Hayden for her help in compiling the 23. an with schizophrenia. Coodin S. Medication compliance and substance abuse among references cited in this review. 184: 509-16 phrenia in general. J Clin Psychiatry 2005. Kirscht JP. Arch Gen Psychiatry 1976. the current evidence for compliance therapy is sterdam: Harwood Academic Publishers. Green MF. 2: 140-4 tive as one part of a multimodal adherence to treatment strategy 17. Br J Psychiatry 2004. 28: 882-93 16. 100: 258-68 21. schizophrenic patients. Levine HB. Buchanan A. et al. 1: 23-47 decision-making process. 33: 1443-6 the Science Foundation Ireland (Dublin. Ann Pharmacother 1993. Interventions for helping patients to follow prescriptions for medications. devices. 66: 997-1001 physician. Compliance therapy in psychotic from this project will be available in the coming months (personal patients: randomised controlled trial. 153: 321-30 27. Katzelnick DJ. Blyler CR. for a brief period of time. 5: 75-8 compliance therapy. 11. Friedman M. Bala MV. Hosp Community Psychiatry 1990. 58: 181-7 antipsychotic agents. Insight and psychosis. et al. From compliance to collaboration in the treatment of the therapy adequately. (2): May 2006). What are the functional consequences of neurocognitive deficits in schizophrenia? Am J Psychiatry 1996.to 45-minute 13. Herczeg I. Eisen SA. editor. McDonald H. Downs KE. 39: 508-15 trial[52] of compliance therapy is under way and that initial data 6. Acta Psychiatr Scand 1988. 117: 542-50 ence (e. Pugner K. regimens: associations with resource use and costs. 29: 172-7 22. Donohoe G. Simon GE. et al. Applewhaite G. Cochrane Database Syst Rev 2002. 1: S75-80 investigation of psychological therapies for schizophrenia has 5. Chest 2000.g. Patient factors associated with missed appointments in persons with schizophrenia.

Int Clin Psychopharmacol 1995 Sep. Department of Psychiatry. et al. 79: 564-70 therapy: 18-month follow-up. Rollnick S. Collaboration with drug treatment impaired insight in schizophrenia specific to executive task performance? J by schizophrenic patients with and without psychoeducational training: results Nerv Ment Dis 2005. Robertson IH. 327: 834 controlled study to evaluate the effectiveness of adherence therapy on the 38. educational 45. et al. Bentall RP. Ereshefsky L. A comparison of patients who refuse and 44. Arch Gen Psychiatry 1985. Donohoe G. Mebane A. Falloon IRH. Acta Psychiatr Scand 1995. 168: 718-22 treatment in schizophrenia. Lambert JF. Everitt B. (4): CD000524 37. Thomas A. What is motivational interviewing? Behavioural and 34. Miller WR. St 43. Psychiatr Serv 1996. Amsterdam: Harwood Academic 33. et al. et al. 23: 325-34 maintenance treatment: a comparison between regular and irregular attenders at 49. Sullivan MC. Psychiatr Serv Correspondence and offprints: Dr Gary Donohoe. Am J Psychiatry 1974. Fischer EP. 42. Are the cognitive deficits associated with 46. BMJ 2003. 1997: 17-34 abuse among patients with schizophrenia. Jerrom B. Interventions to improve medication consent to neuroleptic treatment. Olfson M. et al. 42: 195-6 ment compliance and the therapeutic alliance. Ireland. Pan PC. et al. 65: 354-60 neuropsychological. Diefenbach M. Compliance with treatment in schizophrenia: a drug interven- 51. Watanabe MD. Yahya H. Hughes A. schizophrenia. Relationship between insight. Drugs morbidity of schizophrenia. Randomised controlled trial of compliance a depot clinic. 48 (4): 616]. Roberts C. 7. His current research focuses on genetic. Am J Psychiatry 1983. Hornung WP. Br J Psychiatry 1996. Attitudes and behaviors of acute and chronic schizophrenic 50. 2003. Dis Manage Health Outcomes 2006. 47. 42: 887-96 1994 May. Jerrom B. 131: 991-5 therapy for people with psychosis. Thornicroft G. Davis JM. Day JC. Dublin. Macpherson R. Matalon L. Diaz E. 10 Suppl. Hughes A. Kirov G. Medication noncompliance and substance Publishers.ie  2006 Adis Data Information BV. Kashner TM. Astin J. Rodell DE. Rader LE. Corvin A. Feldmann R. 168: 709-17 31. In: Blackwell B. Neuse E. et al. All rights reserved. Hosp Community regulation: models of the compliance process. 54: 665-7 Neuropsychiatric Genetics Research Group. 91: 331-5 schizophrenia. Cost-effectiveness evaluation of compliance patients regarding ambulatory treatment. et al. Kemp R. 159 (10): 1653-64 30. 193 (12): 812-9 of a 1-year follow-up. A controlled study of education about drug background and cognition in schizophrenia. Klingberg S. J Clin Psychiatry 2004. Zygmunt A. Family management in the prevention of therapy [published erratum appears in Drugs 1994 Oct. Bindman J. Boyd JL. International the impact of clinical variables and relationships with health professionals. 47 (5): 741-73 40. Lacro JP. Dunn LB. 172: 420-4 36. He is the director of the behavioral sciences program for 41. Arch Gen Psychiatry 2005. et al. Florence. et al. Becker T. Boyer CA. et al. Treat- Psychiatry 1991. Sharkey L. health beliefs and compliance with Cognitive Psychotherapy 1995. Br J Psychiatry 1996. Cognitive behaviour therapy for tion program in a developing country. 140: 470-2 adherence in schizophrenia. et al. Acta Psychiatr Scand 1998. 2004 Nov 10-13. Congress on Treatments in Psychiatry: An Update. Serban G. Marder SR. et al. and clinical aspects of schizophrenia. Adherence to conventional and atypical undergraduate medical students. Lam F. Acta Psychiatr Scand 1989. 14 (4) . Trinity College Dublin. Razali MS. Chien CP. antipsychotics after hospital discharge. Velligan DI. From compliance to social self- and hospitalization patterns of patients with schizophrenia. et al. et al. Dolder CR. Am J Psychiatry 2002 Oct. Tantam D. Compliance therapy: a randomised 52. Psychopharmacology: perspectives on medication adherence and atypical antipsychotic medications. Knapp M. Clinical characteristics. et al. Jones C. Br J Psychiatry 1998. Depot antipsychotic drugs: place in 53. McGill AM. Leventhal H. 159: About the Author: Dr Donohoe is a lecturer in clinical psychology at Trinity 103-8 College Dublin. et al. 47: 853-8 48. Family characteristics. Owen RR. 172: 413-9 35. editor. Cormac I. The QUATRO project: a randomized controlled trial in schizophrenia. Silveira da Mota Neto JI. substance abuse. Attitudes toward antipsychotic medication: quality of life of people disabled by schizophrenia and their carers. Donohoe G. 62: 717-24 Italy 39. Dosing issues and depot medication in the maintenance treatment of James’s Hospital. Macpherson R. Cochrane Database Syst Rev 2004 Oct 18. 97: 213-9 32. Booth BM. Healey A.214 Donohoe 29. Kane JM. O’Donnell C. 3: 65-71 E-mail: donoghug@tcd. Br J Psychiatry 1998. Antipsychotic medication adherence: is there a difference between typical and atypical agents? Am J Psychiatry 2002.