Managing Compliance

by Richard Balon, M.D.

May 2002, Vol. XIX, Issue 5

---

Compliance with treatment, or treatment adherence, is a very important clinical issue. In prescribing medication, compliance usually means "the extent to which the patient takes the medication as prescribed" (Fawcett, 1995). Many mental disorders require more than just a brief medication intervention. For some patients, several months or years of medication or even lifelong medication is necessary. For instance, the recommended treatment time for the first episode of depression is six to 12 months, but almost half of patients stop taking their antidepressant within three months for various reasons (Lin et al., 1995). Noncompliance can have serious consequences, such as relapse or recurrence of the illness. Therefore, enhancing medication compliance (or preventing noncompliance) is an important treatment goal for patients and clinicians. The first step in this process is the recognition and prevention of factors that could lead to noncompliance.

Factors Affecting Compliance

Factors that may affect patients' compliance with medication can be summarized along five dimensions (Fawcett, 1995):

• patient characteristics (e.g., attitudes toward illness and medication, socioeconomic considerations, social supervision);
• the treatment setting (e.g., primary care versus specialty office and inpatient versus outpatient);
• medication characteristics (e.g., side effects, individual sensitivity to side effects, simple versus complicated medication regime);
• clinical features of the disorder (e.g., chronicity, exaggerated feelings of guilt in depression, suspiciousness in schizophrenia, substance abuse and comorbid anxiety); and
• clinician expertise (e.g., knowledge of pharmacology, empathy, instilling hope, successful integration of pharmacology and psychotherapy).

Salzman (1995) emphasized that noncompliance may be an especially serious issue in the elderly, where its prevalence may be as high as 75%. He identified three common forms of treatment nonadherence in the elderly: overuse and abuse, forgetting, and alteration of schedules and doses. Overuse of prescribed drugs could lead to emergence of or increase in side effects.

Treatment Adherence

Strategies to improve treatment adherence include: 1) recognition of factors leading to noncompliance; 2) establishment of a strong alliance with the patient (Frank et al., 1995); 3) patient education about the illness and the importance of maintenance treatment; 4) patient education about the medication, drug interactions, pharmacokinetics and side effects; 5) simplification of medication regime(s); 6) providing medication compliance assistance, such as pillboxes; 7) considering over-the-counter medications as a possible source of noncompliance with prescribed medication (Salzman, 1995); and 8) emphasizing the doctor/patient relationship (Salzman, 1995).

During the initial visit, the physician should: define illness from the patient's point of view; define target symptoms and severity; convey sympathy, support and understanding of the patient's experience; provide rationale for use of medication (mention beneficial effects, disclose side effects); elicit patient resistance to medication; explain the importance of taking the prescribed dose; convey hope and optimism; establish a therapeutic alliance; and discuss alternative treatments (Fawcett, 1995).

However, follow-up visits are also very important for enhancing and monitoring compliance. During these visits, response should be assessed and possible side effects evaluated and managed.