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Noncompliance: The Real Barrier to Effective Treatment

Professor and Chair, Department of Psychiatry, State University of New York at Buffalo School of Medicine and Biomedical Sciences

 

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.”

Treating Noncompliance

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 difference.

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.”

Conclusion

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 and problems.

References

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.