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New tools for managing non-adherence

April 1, 2010
by William M. Glazer, MD
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Providers recognize the value of compliance, but what can they feasibly do about it?

Adherence to psychiatric medications poses a formidable challenge to behavioral health clinicians working with seriously mentally ill (SMI) patients.

Consider this case:

Sally is a 42-year-old single, unemployed woman with a diagnosis of paranoid schizophrenia since her first hospitalization at the age of 23. Sally is treated by Dr. Kathleen Degen, the medical director at Sound Community Services Inc., a private, not-for-profit community mental health center located in New London, CT. For three years in treatment with Dr. Degen, Sally has avoided hospital-level care, lived in her own apartment, and kept her outpatient appointments regularly. Recently, she appeared for an appointment with behavioral changes: She would stare, her eyes would dart around suspiciously, and she was observed to be muttering to herself.

When asked, Sally reported that people were coming into her apartment and “switching things around.” Sally swore that she was taking her oral antipsychotic medication as directed, and the on-site pharmacist told Dr. Degen that Sally had been picking up her medications regularly. The pharmacist reminded Dr. Degen that Sally was receiving six different medications-three for her psychiatric condition and three for medical problems that included asthma, diabetes, and hypertension. She took these medications at three different times of the day.

Suspecting that Sally might have gotten confused about taking her medication regimen accurately, Dr. Degen decided to ask the on-site pharmacy to provide her medication via a blister pack card. The blister pack card's design included the days of the week above each time that the dose of the medication was prescribed. This integrated design is meant to help ensure that patients accurately follow the labeling and adherence information throughout the regimen.

Dr. Degen asked Sally to bring in the blister pack card at each visit so that they could review the accuracy of her medication consumption together. After one month, Sally appeared more organized: She spoke in complete sentences, maintained good eye contact, and exhibited no more muttering to herself. Dr. Degen concluded that Sally had been missing doses and had been under-treated until the medications were organized into the blister pack card format.

Untangling the complexity of non-adherence

This case demonstrates one of many explanations for non-adherence in patients with severe behavioral health disorders. While Sally intended to follow the doctor's orders, the cognitive dysfunction associated with her schizophrenia impaired her ability to organize her medications. Sally's situation reflects only the tip of the iceberg in terms of the reasons for non-adherent behavior.

Medication non-adherence is a complex issue, involving much more than side effects or “recalcitrant” patients. The risk factors for non-adherence include demographic, clinical, psychological, and administrative themes.1 Interventions for non-adherence involve the detection of significant behaviors first, and then the implementation of strategies and tactics to diminish these behaviors.2 Sally benefitted from both Dr. Degen's good clinical judgment as well as good administrative planning and support from the clinic.

So what efforts to manage non-adherence are currently utilized in behavioral healthcare organizations that treat SMI patients?

In January, a Behavioral Healthcare online poll asked participants to report on their facility's efforts to combat non-adherent behaviors. Of the respondents:

  • 11.1 percent reported using administrative tactics such as pharmacy feedback to providers and reporting of missed patient appointments,

  • 22.2 percent of respondents used clinical interventions to detect or measure patient adherence like routine use of pill counts and therapeutic blood or urine monitoring,

  • 22.2 percent reported using clinical interventions to encourage patient adherence, including home visits, psycho-educational courses, and rewards for adherence, and

  • 44.4 percent reported using “none” of these tactics at all.

The “none” response seems high given repeated studies documenting the significant rates (up to 50 percent) and costs of non-adherence among SMI patient populations. It also lags behind what employers are doing. According to a new report sponsored by the National Pharmaceutical Council (NPC) titled “Employer Medication Compliance Initiatives,” a survey of employers' views and strategies on compliance, found that:

  • 89 percent of employers acknowledge the importance of compliance to employee health, and

  • 95 percent of those surveyed said that they are taking some sort of action to address compliance.3

Allying the pharmacy, clinic, clinicians, and patients

Mark Peterson, RPh, is Vice President of Genoa Healthcare, one of several nationwide providers of on-site pharmacy support services tailored to the needs of SMI persons. The company sets up full-service, on-site pharmacies within the clinical organization and partners with clinical and administrative staff to address the problem of non-adherence.

“On-site pharmacies make a tremendous difference in community mental health,” says Peterson. “They allow us to partner with administrators, clinicians, and patients to battle the ongoing problem of non-adherence.”