Medication Compliance

The term compliance has the connotation of "giving in," going along with, or submitting to a more powerful authority. Medication compliance refers to adhering to the prescribed schedule of time, dosage, and amounts of medication. Many individuals, indeed most individuals with long-term disorders, struggle with complying or adhering to their medication regimens. Unfortunately, noncompliance rates are about 50% (Gray et al., 2002). Although this percentage sounds high, it may be no higher than the rates of noncompli-ance for all disorders and all medical conditions (Gray et al., 2002). Noncompliance is also potentially a preventable cause of the serious consequences of relapse (Gray et al., 2002).

Injectable medications, also known as depot antipsychotics, are sometimes used for individuals who do not want to take pills or cannot remember to take them regularly. As mentioned earlier, individuals taking depot antipsychotics experience greater symptom reduction and relapse less often, suggesting better medication compliance (Adams et al., 2001). Clearly, for some people, taking an intramuscular injection at an interval somewhere between once a week and once a month is less troublesome than taking pills daily.

An inability to remember, an unwillingness to be reminded repeatedly of one's illness, serious side effects, or insufficient therapeutic effects may all be contributing to medication noncompliance. Feeling better or improving is also a cause of noncompliance, because in the face of improved or eliminated symptoms, stopping the medication seems a logical step (Fox, 2004). Some experts, to avoid the connotation of submission and disempower-ment, refer to the issue as medication "adherence," sticking to a prescribed schedule and dose.

Another factor consistently associated with decreased medication compliance is substance abuse (Heyscue, Levin, & Merrick, 1998). Some individuals discontinue medication when drinking alcohol or abusing substances. Some of these individuals also take to "self-medicating" with both legal prescription drugs and illicit drugs on a dosage and schedule they choose. This is discussed in more detail in Chapter 8, which addresses dual diagnoses.

Because of their awareness of the relationship between medication nonadherence to the aggravation of symptoms and the advent of relapses, many PsyR staff understandably feel compelled to promote medication compliance. Indeed for some it becomes a preoccupation and, occasionally, staff fall into the trap of blaming individuals for their own relapses, assuming medication noncompliance was necessarily involved.

The issue of medication compliance is a sensitive and emotional one. Many consumers have had the experience of medications being misused as "chemical restraints." In other words, they were given high dosages of medication to obtain a sedative effect intended to control psychotic symptoms very quickly. Many others have had the experience of troubling side effects that indeed are not only very distressing, but also potentially harmful, as they can cause serious health problems.

People taking psychotropic medications are often reluctant to discuss these matters with their doctors. They may not have the confidence to confront, disagree, or even question a physician or other professionals. They may not even know they are "allowed to," or have no experience working collaboratively with a psychiatrist. Sometimes, in one's role as a patient, it is just easier to say "I'm fine" and not bring up troubling concerns. Some may even lie about what might be going on to avoid hospitalization.

How then can the right medication be prescribed at the right dosage in a manner that maximizes therapeutic effects, reduces side effects, and informs consumers about the choices they actually have? Can communication about these issues be improved, so that consumers can exercise informed choice and self-determination over their medication? Would not better communication regarding symptoms and side effects empower doctors as well, by helping them to be better informed on these issues?

Kim Mueser and colleagues (2003) discuss two related solutions to these problems called collaborative psychopharmacology and illness management and recovery services. Both are based on the same premise as a chain store's advertisement slogan, "An educated consumer is our best customer."

Collaborative Psychopharmacology

Collaboration means laboring or working together. Collaborative psychopharmacology involves consumers working with their psychiatrists and other professionals to determine the right medications to use according to up-to-date guidelines. Although medications are clearly effective, research has also found that many psychiatrists do not follow the appropriate dosage ranges nor take into account the time course for therapeutic response and dosage adjustment, also known as titration (Lehman & Steinwachs, 1998). Similarly, guidelines on the identification and management of side effects, and methods for the treatment of refractory symptoms are frequently not followed by psychiatrists (Lehman & Steinwachs, 1998).

Because of the complexity of pharmacological treatment for severe mental illness, as well as the rapid evolution in the field as new medications are developed, a recent trend has been to establish algorithms for prescribing medications based on research (SAMHSA-CMHS, 2005). Algorithms are step-by-step instructions to proceed with certain actions based on specific conditions and responses to previous steps. Many of these recommendations require adding expert clinical consensus to the scientific evidence. Implementation procedures for collaborative pharmacological treatment have been developed that include a standard approach to documenting and monitoring symptoms and side effects, guidelines for systematically making decisions about medications, and attempts to engage consumers in decision making about medication-related decisions.

Illness Management and Recovery

Integral to collaborative psychopharmacology is the fact that individuals with mental illness need to be educated and informed in order to make sound decisions regarding their medication. Illness management and recovery (IMR) training is an evidence-based practice intended to help consumers acquire the knowledge and skills to work effectively with professionals in their treatment and rehabilitation in order to minimize the effects of the mental illness on their lives and pursue personally meaningful goals. A variety of methods are aimed at helping consumers deal more effectively with their disorder, including the following:

1. Psychoeducation: knowing the factual information about mental illness and its treatment.

2. Medication management education: teaching strategies that promote effective use of medication.

3. Relapse prevention skills: identifying symptoms and precursors for relapses, as well as planning ahead for crises. This may include assisting consumers in establishing advance directives, which are legal documents that empower consumers to make decisions about their treatment prior to becoming too ill to do so themselves.

4. Cognitive behavioral approaches, strategies for thinking about and understanding problems and symptoms.

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