Podcast: The Challenge of Medication Adherence With Martha Sajatovic, MD

Joseph F. Goldberg, MD, in this installment of "Brain Trust: Conversations in Psychopharmacology," sits down with Martha Sajatovic, MD, to discuss the multifaceted challenge of medication adherence in psychiatric practice.

Sajatovic opened by framing adherence as behavioral and attitude alignment with a prescribed treatment plan, noting that nonadherence was far more common than most clinicians recognized. Evidence suggests that roughly half of patients prescribed psychotropic medications had difficulty maintaining recommended regimens. Sajatovic emphasized that this gap had real consequences, including relapse, hospitalization, and misattributed treatment failure—situations in which clinicians might incorrectly escalate dosing or change medications without recognizing poor adherence as the underlying cause.

The discussion turned to practical strategies for initiating nonjudgmental dialogue. Sajatovic advocated normalizing adherence difficulties before asking patients whether they applied personally: “the evidence suggests that it's hard for people to stay on track with medications, and it's really common." Both Goldberg and Sajatovic agreed that the term "compliance" carried adversarial connotations and had been beneficially supplanted by "adherence," which invited shared decision-making rather than punitive evaluation.

Sajatovic identified self-efficacy as an emerging correlate of better adherence, drawing on National Institutes of Health-funded research showing that patients who felt empowered to influence their own health outcomes were more likely to remain on track. Additional barriers our experts addressed included fluctuating insight in bipolar disorder, stigma, polypharmacy burden, concurrent substance use, and negative family attitudes; Sajatovic noted that in one sample group of patients with bipolar disorder, up to 40% of family members did not believe medication was indicated.

Sajatovic described Customized Adherence Enhancement, a brief modular behavioral intervention she developed with colleague Jennifer Levin, MD, that targeted individualized barriers through psychoeducation, provider communication, substance-use counseling, and medication-routine strategies. The conversation concluded with a discussion of long-acting injectable antipsychotics, periodic medication reviews, and deprescribing—including a forthcoming paper by Goldberg and Sajatovic in JAMA Network Open reporting that over 90% of a Delphi expert panel endorsed regular, structured regimen reviews as standard practice.

Dr Goldberg is a clinical professor of psychiatry at The Icahn School of Medicine at Mount Sinai in New York, NY and the immediate-past president of the American Society of Clinical Psychopharmacology.

Dr Sajatovic is a professor of psychiatry and director of the geropsychiatry program at the Case Western Reserve University School of Medicine. She is also director of the Neurological and Behavioral Outcomes Center at the University Hospitals Cleveland Medical Center.