Noncompliance: The Real Barrier to Effective Treatment
Dr. Steven L. Dubovsky
has been in practice for over 30 years, and he’s spent most of the last 20
dealing with complicated and refractory psychiatric illnesses. It’s no surprise
that Dr. Dubovsky has seen his share of noncompliance—in that he’s not unique;
where Dr. Dubovsky stands out is in his dedication to facing noncompliance
head-on at a time when many clinicians seem to have thrown up their hands and
accepted noncompliance as here to stay.
The Root of the Problem
Dr. Dubovsky is the first to admit that there are no easy
answers to the problem of nonadherence. Part of the difficulty is the sheer
number of possible contributing factors.
“There are a myriad of
reasons patients don’t comply to treatment,” Dr. Dubovsky says. “Many regimens
are too costly and aren’t adequately covered by insurance. Then there are
overly complex treatment regimens (as is well illustrated with the frustration
so many seniors are experiencing trying to navigate the new Medicare benefit),
negative side-effect profiles, patients who don’t like being dependent on
medication and/or their psychiatrist, patients who want to stay ill because it
garners attention and/or confers a sense of power, psychotic patients who have
delusional beliefs about their medication, and even patients who form
adversarial relationships with their clinicians and feel the need to “defeat” them by not getting better.”
Complex or not, though, noncompliance is a real problem.
Roughly 50% of psychiatric patients don’t properly adhere to treatment, and not
only does that prolong their illnesses, it costs extra money, and starting and
stopping drugs can worsen conditions as well. It’s a problem that clinicians
are well aware of, even if many of them feel powerless to do anything about it;
Dr. Dubovsky notes that while reactions to the recent CATIE study were mixed,
few clinicians were surprised at the 85% noncompliance rate among the study
cohort. “It sounds shockingly high, but it’s almost conventional wisdom:
schizophrenics don’t take their meds.”
The first step in dealing with noncompliance is to find out
why a patient isn’t taking his or her medicine.
The complication here,
as Dr. Dubovsky explains, is that “with the way insurance has gone, many doctors
don’t get paid for talking to their patients for any length of time, so the
doctor writes a prescription, the patient is dissatisfied for whatever reason,
and stops taking their medication. They don’t get better, go back to the
doctor, the doctor writes another prescription, and the cycle continues.”
Sometimes the noncompliance can even be the result of the patient’s not feeling
that the doctor is giving his or her treatment the time and consideration the
patient feels it merits.
Dr. Dubovsky believes that clinicians need to commit to
getting to the bottom of their patients’ noncompliance.
“You’ve got to find out why they’re not taking the
medication,” he says. “If it’s because of sexual side effects caused by
antidepressants, change antidepressants or treat the side effect separately. If
the patient can’t afford their medication, help him or her examine available
options for reducing prescription costs. If the patient tells you that he or
she “doesn’t deserve to be well,” that’s an issue for psychotherapy. There are
ways to deal with most of the causes of noncompliance, but the causes have to
be identified first.”
Dr. Dubovsky dubs his method “psychotherapeutically
informed prescribing.” Often, spending some time finding out how a patient
feels about taking medication before prescribing anything can make all the
While clinicians could
do more, the fault is certainly not only theirs. Dr. Dubovsky believes that a
major factor is the direction insurance has gone in the last few decades.
Despite data demonstrating that having one clinician both prescribe medication
and engage in psychotherapy of some sort with his or her patients is both more
clinically effective and cost-effective, most insurers set up their plans so
that patients go to one doctor for drugs, and another for therapy. This results
in many psychiatrists having neither the time nor the money necessary to truly
delve into their patients’ problems.
“At some point, and I’ve seen this happen, psychiatrists
get fed up and drop their overly restrictive insurance plans,” Dr. Dubovsky
says. “However, clinicians can’t band together across practices—for fear of
violating anti-trust laws—and exert consistent pressure on the insurance
companies. Still, if enough individual practices stand up to the insurers, real
change is feasible.”
Treatment adherence is a
thorny issue, with responsibility being apportioned out among patients,
clinicians, and insurers. Practitioners can do their part by affirming the
importance of the issue, and dedicating themselves to taking the time necessary
to treat each patient as an individual with specific and possibly unique issues
1. Weiden PJ, Olfoson M. Cost of relapse in schizophrenia. Schizophr Bull. 1995;214:419-429.
2. Johnson DA, Pasterski JM, Ludlow JM, et al. The discontinuance of maintenance neuroleptic therapy in chronic schizophrenic patients: drug and social consequences. Acta Psychiatr Scand. 1983;67:339-352.
3. Lieberman JA, Koreen AR, Chakos M, et al. Factors influencing treatment response and out-come of first-episode schizophrenia: implications for understanding the pathophysiology of schizophrenia. J Clin Psychiatry. 1996;57(suppl 9):5-9.
4. Swartz MS, Swanson JW, Hiday VA, et al. Taking the wrong drugs: the role of substance abuse and medication noncompliance in violence among severely mentally ill individuals. Soc Psychiatry Psychiatr Epidemiol. 1998;339(suppl 1):75-80.
5. Hunt GE, Bergen J, Bashir M. Medication compliance and comorbid substance abuse in schizophrenia: impact on community survival 4 years after a relapse. Schizophr Res. 2002;54:253-264.