Compliance is a crucial determinant of the treatment outcome of any medical
condition. Poor treatment compliance may affect the therapeutic alliance;
create skepticism in both therapist and patient; create resistance; worsen the
disease or the prognosis; and increase health care costs (Osterberg
and Blaschke, 2005). Unfortunately, poor treatment
compliance is often associated with blame, and noncompliant patients are
sometimes punished with involuntary administrative discharge from treatment.
There are multiple indicators of treatment compliance that can be measured
using direct or indirect methods. Among the direct methods, investigators and
clinicians have used actual attendance to therapy sessions, direct observation
or video-recording of sessions, measurement of medication blood levels,
surrogate markers of medication, or expected changes in laboratory values. The
indirect methods include self-reported compliance, pill counts, evidence or
absence of expected side effects, and electronic monitoring devices.
Unfortunately, the direct methods are expensive, and the indirect ones can be
subject to biases.
In psychiatry, treatment compliance may be affected by factors associated
with the therapist's characteristics, the service, the nature of the treatment
and the patient's idiosyncrasies. The therapist may not adhere to the
recommended treatment guidelines or the therapy manual. The services may affect
compliance if they are hard to access or have long wait times, long lapses
between appointments or complex administrative procedures. Treatments that
involve complex procedures, are hard to follow, have unpleasant side effects,
take a while to produce the desired effect, and are either unavailable or
difficult to access may increase the chances of poor compliance. The
characteristics of the patient, such as the presence of comorbid
mental illness and substance use disorders (SUDs),
can greatly affect treatment compliance.
The interest in psychiatric comorbidity increased
with the publication of results from the Epidemiologic Catchment
Area Study (Regier et al., 1990) and the National Comorbidity Study (Kessler et al., 1994). More recently,
Kessler et al. (2005) showed that the relative magnitude of associations of
having at least one substance use disorder in the past 12 months was
significant for all but two mental conditions. The prevalence of mental health
service use in the past year was only 41.1% and 38.1% for individuals who had
any mental disorder or any substance use disorder in that time period,
respectively (Wang et al., 2005).
Unfortunately, little is known about the proportion of individuals in the
general population who use mental health services and actually adhere to their
treatment plan. A survey of psychiatrists showed that 40% of their patients
with SUDs had treatment compliance problems (Herbeck et al., 2005). Both clinical and nonclinical factors appeared to be associated with
treatment compliance problems. Among the clinical factors, patients with low
treatment compliance were more likely to have personality disorders, lower
global assessment of functioning scores and medication side effects than those
without treatment compliance problems (Herbeck et
It has been reported that the rates of completion of clinical trials for
chronic medical conditions are only between 43% and 78% (Osterberg
and Blaschke, 2005). It is likely that for those with
psychiatric disorders, particularly with comorbid SUDs, this percentage may be even lower. According to a
meta-analysis of medication compliance, the mean compliance rate for patients
with physical disorders was 76%, whereas the ratio for patients taking
antidepressants was 65% and 58% for antipsychotics
(Cramer and Rosenheck, 1998). It has been estimated
that medication noncompliance accounts for about 40% of re-hospitalizations of
patients with schizophrenia (Weiden and Olfson, 1995).
The concurrence of mental illness and SUD seems to have a negative
synergistic effect. It has been suggested that comorbid
psychiatric disorders can further increase the risk of relapse and can have
important implications for predicting treatment outcomes (Compton et al.,
2003). The rates of treatment compliance among patients with SUD vary greatly,
depending on the type of SUD and treatment, severity of the disorder, degree of
psychosocial support, and the presence and severity of psychiatric comorbidity. Patients with only alcohol use disorders have
significantly higher treatment retention rates (42%) than those with drug use
disorders (20%) or combined alcohol and drug use disorders (26%) (McCaul et al., 2001).
Furthermore, clinical trials of treatments for cocaine and other stimulant use
disorders have difficulty retaining participants. In contrast, clinical trials
of opioid agonist medications have better compliance
rates (De Castro and Sabate, 2003).
1 Aharonovich E, Nunes E, Hasin D (2003), Cognitive impairment, retention and
abstinence among cocaine abusers in cognitive-behavioral treatment. Drug
Alcohol Depend 71(2):207-211.
2. Barber JP, Connolly MB,
Crits-Christoph P et al. (2000), Alliance predicts patients' outcome beyond
in-treatment change in symptoms. J Consult Clin Psychol 68(6):1027-1032.
3. Broome KM, Flynn PM, Simpson DD (1999), Psychiatric comorbidity
measures as predictors of retention in drug abuse treatment programs. Health Serv Res 34(3):791-806.
4. Carroll KM, Ball SA, Nich C et al. (2005),
Motivational interviewing to improve treatment engagement and outcome in
individuals seeking treatment for substance abuse: a multi-site effectiveness
study. Drug Alcohol Depend. Available online Sept. 28.
5. Compton WM 3rd, Cottler LB, Jacobs JL et al.
(2003), The role of psychiatric disorders in
predicting drug dependence treatment outcomes. Am J
6. Cramer JA, Rosenheck R (1998),
Compliance with medication regimens for mental and physical disorders. Psychiatr Serv 49(2):196-201 [see
7. De Castro S, Sabate E (2003), Adherence to heroin
dependence therapies and human immunodeficiency virus/acquired immunodeficiency
syndrome infection rates among drug abusers. Clin
Infect Dis 37(suppl
8. Fals-Stewart W, Schafer J (1992a), The relationship between length of stay in drug-free therapeutic
communities and neurocognitive functioning. J Clin Psychol 48(4):539-543.
9. Fals-Stewart W, Schafer J (1992b), The treatment of substance abusers diagnosed with
obsessive-compulsive disorder: an outcome study. J Subst
Abuse Treat 9(4):365-370.
10. Haynes RB, McDonald H, Garg AX, Montague P (2002),
Interventions for helping patients to follow prescriptions for medications.
Cochrane Database Syst Rev 2002(2):CD000011 [update].
11. Herbeck DM, Fitek DJ, Svikis DS et al. (2005), Treatment compliance in patients
with comorbid psychiatric and substance use
disorders. Am J Addict 14(5):195-207.
12. Kaminer Y, Tarter RE, Bukstein
OG, Kabene M (1992), Comparison between treatment
completers and noncompleters among dually diagnosed
substance-abusing adolescents. J Am Acad Child Adolesc Psychiatry 31(6):1046-1049.
13. Keck PE Jr, McElroy SL, Strakowski
SM et al. (1997), Compliance with maintenance treatment in bipolar disorder. Psychopharmacol Bull 33(1):87-91.
14. Kessler RC, Chiu WT, Demler O et al. (2005),
Prevalence, severity, and comorbidity of 12-month
DSM-IV disorders in the National Comorbidity Survey
Replication. [Published erratum in Arch Gen Psychiatry
62(7):709.] Arch Gen Psychiatry 62(6):617-627 [see comment].
15. Kessler RC, McGonagle KA, Zhao S et al. (1994),
Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the
United States. Results from the National Comorbidity
Survey. Arch Gen Psychiatry 51(1):8-19.
16. Lambert M, Conus P, Lubman
D et al. (2005), The impact of substance use disorders
on clinical outcome in 643 patients with first-episode psychosis. Acta Psychiatr Scand
17. Marlowe DB, Kirby KC, Festinger DS (1997), Impact
of comorbid personality disorders and personality
disorder symptoms on outcomes of behavioral treatment for cocaine dependence. J
Nerv Ment Dis 185(6):483-490.
18. McCaul ME, Svikis DS, Moore RD (2001),
Predictors of outpatient treatment retention: patient versus substance use
characteristics. Drug Alcohol Depend 62(1):9-17.
19. Montoya ID, Schroeder JR, Preston KL et al. (2005), Influence of
psychotherapy attendance on buprenorphine treatment
outcome. J Subst Abuse Treat 28(3):247-254.
20. Olfson M, Mechanic D, Hansell
S (2000), Predicting medication noncompliance after hospital discharge among
patients with schizophrenia. Psychiatr Serv 51(2):216-222.
21. Osterberg L, Blaschke T
(2005), Adherence to medication. N Engl
J Med 353(5):487-497 [see comments].
22. Owen RR, Fischer EP, Booth BM, Cuffel BJ (1996),
Medication noncompliance and substance abuse among patients with schizophrenia.
23. Petry NM, Tedford J,
Martin B (2001), Reinforcing compliance with non-drug-related activities. J Subst Abuse Treat 20(1):33-44.
24. Regier DA, Farmer ME, Rae DS et al. (1990), Comorbidity of mental disorders with alcohol and other drug
abuse. Results from the Epidemiologic Catchment
Area (ECA) Study. JAMA 264(19):2511-2518 [see comments].
25. Ross S, Dermatis H, Levounis
P, Galanter M (2003), A comparison between dually
diagnosed inpatients with and without Axis II comorbidity
and the relationship to treatment outcome. Am J Drug
Alcohol Abuse 29(2):263-279.
26. Rowe CL, Liddle HA, Greenbaum PE,
Henderson CE (2004), Impact of psychiatric comorbidity
on treatment of adolescent drug abusers. J Subst
Abuse Treat 26(2):129-140.
.27 Sajatovic M, Davies M, Hrouda
DR (2004), Enhancement of treatment adherence among patients with bipolar
disorder. Psychiatr Serv
28. Schaffer SD, Yoon SJ (2001), Evidence-based methods to enhance medication
adherence. Nurse Pract 26(12):44, 50, 52, 54.
29. Wang PS, Lane M, Olfson M et al. (2005),
Twelve-month use of mental health services in the United States: results from the
National Comorbidity Survey Replication. Arch Gen
Psychiatry 62(6):629-640 [see comments].
30. Weiden PJ, Olfson M
(1995), Cost of relapse in schizophrenia. Schizophr
31. Weiss RD, Greenfield SF, Najavits
LM et al. (1998), Medication compliance among patients with bipolar disorder
and substance use disorder. J Clin Psychiatry
32. Wise BK, Cuffe SP, Fischer T (2001), Dual diagnosis
and successful participation of adolescents in substance abuse treatment. J Subst Abuse Treat 21(3):161-165.
33. Zygmunt A, Olfson M,
Boyer CA, Mechanic D (2002), Interventions to improve medication adherence in
schizophrenia. Am J Psychiatry 159(10):1653-1664 [see