Encouraging Patients to Take Medication as Prescribed

Two recent reviews offer advice about assessing and improving treatment adherence.

Many patients with bipolar disorder or schizophrenia — like those with other chronic health conditions — find it difficult to follow a prescribed medication regimen (see table). This is unfortunate, as studies consistently show that the more carefully such patients take medications as prescribed, the less likely they are to experience a relapse or hospitalization.

Problems with treatment adherence can also disrupt the therapeutic relationship. This is especially true when conversations about medication escalate into a power struggle, distracting attention from the shared goal of recovery. (One reason that the term "treatment compliance" has fallen out of favor is because it suggests that the patient is to blame.)

Two reviews — including one that presented what are believed to be the first consensus guidelines on this topic — sought to distill the research findings and present practical advice about improving adherence.

Adherence Challenges in Schizophrenia

Studies have generated a wide range of adherence rates for patients with schizophrenia, with the variations in findings reflecting both the quality of the research and the selection of patient population (such as recently discharged inpatients versus stable outpatients). A review of 39 studies of patients with schizophrenia found that rates of treatment nonadherence varied from 20% to 89%, with a mean of 41% to 50% when only the most rigorous studies were included. Contrary to initial expectations, patients are no more likely to continue taking second-generation antipsychotics than first-generation drugs.

Patients with schizophrenia most often stop taking medication because they don't think they have an illness or, even if they do, aren't convinced that they need medication (attitudes commonly referred to as lack of insight). Other factors include side effects, persistent symptoms, substance abuse, financial difficulties, unstable living situations, lack of social support, and difficulty establishing a therapeutic relationship.

Whatever the reason, poor medication adherence increases the chances of bad outcomes. One study involving 49,003 patients with schizophrenia treated at U.S. veterans hospitals found, for example, that 23% of those who took their medication less than 80% of the time were hospitalized within one year, compared with 10% of those who took it more often.

Bipolar disorder. Lithium and other mood stabilizers provide the fundamentals of treatment for bipolar disorder. Studies of long-term treatment have found that 20% to 66% of patients with bipolar disorder — or a median of 41% — do not take mood stabilizers consistently.