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Managing Compliance

Managing Compliance

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.

Addressing Side Effects

Patients may not adhere to medication treatment for various reasons, e.g., due to the belief that the medication is not working, patients are feeling better, encouragement by others not to take "mind-controlling" substances or simply running out of medication. However, side effects are clearly a major reason for noncompliance.

Most psychotropic medications -- old and new -- have comparable levels of efficacy within their respective group, such as antidepressants or antipsychotics. However, old and new psychotropic medications have different troublesome side effects, ranging from sleep disruption and jitteriness in the case of newer drugs to serious cardiovascular side effects or peripheral and central anticholinergic side effects, such as dry mouth and constipation, in the case of older drugs. Improved tolerability, i.e., lesser frequency and severity of side effects of newer psychotropic medications (especially selective serotonin reuptake inhibitors and other new antidepressants and atypical antipsychotics), has been the major advancement of modern psychopharmacology. Nevertheless, even the newer drugs could have some deleterious side effects and a major impact on quality of life. Discussion of side-effect management should be part of any counseling patients receive. Clinicians should emphasize that almost any medication side effect can be managed.

Side effects of the newer psychotropic medications that have recently received increased attention from clinicians and patients include sexual side effects and weight changes. Both of these side effects could have a major impact on the patient's quality of life and could lead to noncompliance.

Sexual Dysfunction

Sexual side effects of psychotropic medications (and medications in general) are fairly common (Crenshaw and Goldberg, 1996; Gitlin, 1997; Segraves, 1999a, 1997). The exact incidence of sexual dysfunction (SD) with various psychotropic medications is not known. For instance, the estimates of SD associated with antidepressants vary from 2% to 90%. However, most evidence points toward an incidence between 30% and 50%. The incidence and characteristics of SD associated with different antidepressants vary. The SSRIs have the highest incidence of SD, close to 40% to 50%. The incidence of SD associated with bupropion (Wellbutrin), mirtazapine (Remeron) and nefazodone (Serzone) is fairly low, usually less than 10%. Crenshaw and Goldberg (1996) suggested that bupropion has beneficial effects on sexual functioning, and it has been used as one of the antidotes for SSRI-associated SD. The incidence of SD associated with venlafaxine (Effexor) falls between the SD associated with SSRIs and the mentioned newer antidepressants. The incidence of SD may vary even within the group of medications; for example, among the SSRIs, paroxetine (Paxil), sertraline (Zoloft) and fluoxetine (Prozac) may have a bit higher incidence of SD than citalopram (Celexa) and fluvoxamine (Luvox) (e.g., ejaculation was less delayed with citalopram and fluvoxamine than with fluoxetine, paroxetine and sertraline in experiments by Waldinger and colleagues [2001, 1998]), although hard evidence is lacking. With regard to the character of SD, SSRIs are associated with a higher degree of delayed orgasm or anorgasmia, while tricyclic antidepressants are more frequently associated with erectile dysfunction.

Antipsychotic drugs are also known to cause SD (Collins and Kellner, 1986; Compton and Miller, 2001; Segraves 1999a, 1997), although, similar to depression, the baseline sexual functioning of patients could be a confounding variable. The exact incidence of SD with antipsychotics is unknown, but estimates for specific agents vary from 25% for haloperidol (Haldol) to almost none with clozapine (Clozaril) (Segraves, 1999a). Clozapine has been associated with a lower incidence of SD than conventional antipsychotics during maintenance therapy of schizophrenia (Aizenberg et al., 2001). Well-known examples of SD associated with antipsychotics include erectile and ejaculation dysfunction with most antipsychotics (mainly the conventional ones), increase of prolactin secretion with older drugs and risperidone (Risperdal), retrograde ejaculation with thioridazine (Mellaril), and priapism with various older and newer antipsychotics.


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