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The Practitioner Connection
Volume XXX, 2nd Quarter

The right help at the right time!

MEDICATION NON-ADHERENCE IN SCHIZOPHRENIA

When it comes to the treatment of schizophrenia, the primary treatment modality for effective symptom control is still antipsychotic medications. Along with medications, various psychosocial interventions and psychosocial rehabilitation can help with issues such as coping with the condition, improving treatment compliance and improved quality of life. Failure to take medications as prescribed remains a significant contributing factor to symptom relapse . Although research findings can vary, at least 40 %-50 % (some have reported even 50-80%) of individuals being treated for schizophrenia stop medications at some point. Some of the more common reasons for non-adherence include: denial of having the condition, the stigma of taking a medication for the disorder, a lack of awareness, co-occurring substance abuse, medication side effects, lack of medication efficacy, symptom severity, a poor therapeutic alliance, cognitive impairment, forgetfulness, limited support systems and multi-dosing.

The importance and benefit of a good therapeutic alliance in improving compliance is becoming more recognized, not just in treating those with schizophrenia but in all medical and psychiatric conditions. It is important in the therapeutic relationship to make a person feel that they are part of the treatment decisions and treatment plan. This allows the person to be more open and willing to discuss their treatment needs and what is important to them. In turn, this can contribute to improved compliance. For example, someone on an antipsychotic medication may be less concerned about making the voices they hear decrease if they are not bothersome. Instead, the individual may be more concerned about side effects from medications, such as feeling sedated or sexual dysfunction. These concerns may contribute to medication non-compliance. With this in mind, it is important to ask questions of the patient regarding their symptoms, the efficacy of the medication, quality of life, and medication side effects. The goal of asking questions and initiating dialogue is to allow the partients to be part of the decision making process and giving them the opportunity to discuss their biggest concerns with their condition or the medications they are taking. This type of approach helps to improve motivation, communication and to build a stronger treatment alliance.

It is also common for someone who has improved on medication to have thoughts about stopping their medication in order to test if they are better or if the condition is gone. At other times, the stigma of taking antipsychotic medications and having schizophrenia in itself can contribute to stopping medications. One way to preemptively address this is to ask the person during the course of treatment if they ever feel like stopping their medication. By getting someone to discuss this before they actually stop their medications the opportunity exists to address the patients’ issues and concerns.

Substance abuse is a very common cause of non-adherence in those who have schizophrenia. This needs to be identified and treated. It is important to monitor and consider it as a possible reason for someone who has increased symptoms or has been non-adherent to medications.

When thinking about psychosocial interventions some of the common ones include: social skills training, assertive community treatment programs, family interventions, psycho-education, supportive employment and certain forms of psychotherapy. When it comes to psychotherapy, a more supportive type of therapy has been the most widely used. However, in the last few years, a modified form of Cognitive Behavioral Therapy (CBT) specifically developed for schizophrenia has had increased interest in the practitioner community, as well as increased support in the research literature . It’s important to mention that the CBT used for schizophrenia is not the same CBT used for depression and anxiety disorders. Also, this modified CBT would in general not be very useful in a more acute phase of schizophrenia. Modified CBT can also be used to improve compliance by targeting the needs of the specific individual and in motivating them to become more actively involved with their treatment.

Other helpful interventions include electronic monitoring systems, pill boxes, avoiding multiple dosing when possible, family support and monitoring, in-home visits, use of injectable depot medications and increased community supports. Depot long-acting medications have been shown to be underutilized, yet beneficial to those individuals with repeated non-compliance.

When addressing lack of efficacy, it is first important to identify non-compliance in order to avoid unnecessary switching or increases in medications. Before assuming that a patient is treatment-resistant it is important to ensure that the lack of improvement or exacerbation of symptoms is not due to non–adherence or even partial non-adherence to medications. Partial non-adherence can include skipping dosages or cutting down the dosage without the practitioner being aware. Considering a second opinion, reviewing past treatment and other collateral information, meeting with family and all practitioners involved are good options to consider in treatment-resistant cases in order to discuss all possible options and to work on a uniform treatment plan going forward.

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