How to Uncover Covert Medication Nonadherence in Serious Mental Illness

CONFERENCE REPORTER

At the 2026 Jersey City Psychiatry Conference, meeting chair Christoph U. Correll, MD, who is also professor of psychiatry and molecular medicine at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell and professor and chair of the Department of Child and Adolescent Psychiatry at Charité Universitätsmedizin Berlin, discussed why nonadherence is so often missed and how clinicians can bring it up during routine visits.

"Nonadherence is one of the most common and most preventable reasons of relapses and hospitalizations, with relapse being the main enemy on the road to recovery," said Correll.

He estimated 70% to 80% of patients with schizophrenia, about 60% with bipolar disorder, and 40% to 50% with depression do not adhere to their prescribed medications.^1,2 Most of it goes unseen, he said.

Covert nonadherence is common. Patients may miss an occasional dose or stop entirely without telling their clinician. Partial adherence is especially hard to detect. Clinical worsening may take time to appear, and the only clue may be that patients report fewer adverse effects, or none of the ones they had before.

Asking Without Judgment

Correll said clinicians need to ask about nonadherence directly but in a way that does not feel threatening or judgmental. Asking "Have you taken your medications?" almost always gets a yes, because patients do not want to disappoint their clinician. He recommends a different question: "How many doses have you missed since we last saw each other?"

This wording assumes some missed doses are expected. "I do not have a problem with that. That is part of the human condition. Let's just quantify that," Correll said. Everyone falls short on something, whether diet, exercise, or keeping in touch with friends. Medication doses can slip when patients have cognitive dysfunction, feel unsure about adverse effects or benefit, or doubt they have the illness at all.

Addressing Barriers

Once missed doses feel safe to talk about, clinicians can ask why they happen and respond to the specific cause. Forgetting may be solved with something as simple as an alarm. Ambivalence and stigma need a different approach. Stigma here means the sense that the medication makes patients look or feel sicker than they want to be.

That is where motivational interviewing comes in, Correll said. It frames medication not only as treatment for an illness the patient may not fully accept, but as "a treatment that helps patients achieve their goals."

Dr Correll is professor at the Institute of Behavioral Science, Feinstein Institutes for Medical Research; medical director of the Recognition and Prevention Program in the Department of Psychiatry at Zucker Hillside Hospital; and professor of Psychiatry and Molecular Medicine at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell.

References

1. Kane JM, Kishimoto T, Correll CU. Non-adherence to medication in patients with psychotic disorders: epidemiology, contributing factors and management strategies. World Psychiatry. 2013;12(3):216-226.

2. Semahegn A, Torpey K, Manu A, et al. Psychotropic medication non-adherence and its associated factors among patients with major psychiatric disorders: a systematic review and meta-analysis. Syst Rev. 2020;9(1):17.