Q. I am a mental health clinician who is looking for alternatives to the challenges of non-compliance not only with medication but also psychosocial strategies. Currently there are legislative options that enforce treatment but I would like some other less intrusive options especially with the chronic disorders. Do you know of any?

A. The problem of non-compliance (or, less paternalistically, non-adherence) is a major barrier to effective treatment of psychiatric patients. As Gaebel notes [Int Clin Psychopharmacol. 1997 Feb;12 Suppl 1:S37-42], "Patient non-compliance is as high as 50% under outpatient conditions; potential reasons may be either illness-related (e.g. lack of insight or idiosyncratic concepts of the illness or its treatment), drug-related (e.g. intolerable side-effects) or related to inadequate treatment management (e.g. insufficient information or lack of environmental support)."

Thus, the approach to non-compliance first hinges on a thorough assessment of the underlying reasons for the behavior. For example, a patient with bipolar disorder who refuses to take lithium because "there's nothing really wrong with me" will require a different approach than a schizophrenic patient who believes that the medication will "take away my manhood"--though, in fact, sexual side effects are quite common with psychotropic medications.

In my own experience, the therapeutic alliance is a critical factor in promoting compliance with both medication and psychosocial interventions. This means not only mutual trust, but also a willingness to negotiate, within reasonable bounds. I remember bargaining with some of my schizophrenic patients over a few milligrams of medication! That I was even willing to do this often allowed them to feel empowered, and more likely to take the medication appropriately.

A number of novel approaches to non-compliance have been described; e.g., the self-management of psychiatric medications (Dubyna & Quinn, J Psychiatr Ment Health Nurs. 1996 Oct;3(5):297-302) and intensive "case management" services. In a study by Azrin & Teichner (Behav Res Ther. 1998 Sep;36(9):849-61), patients were matched and randomly assigned to receive in a single session either (1) information regarding medication and its benefits, (2) guidelines for assuring adherence which encompassed all phases related to pill-taking including filling prescriptions, use of a pill container, transportation, self-reminders, doctor's appointments, etc.; or (3) the same guidelines as (2) above but given in the presence of a family member who was enlisted for support. Adherence increased to about 94% after the guidelines were given for both the individual and family guideline procedure, whereas adherence remained unchanged at 73% after the medication information procedure.

In my own experience, involving the patient's family can make a big difference in compliance. Of course, there are innumerable psychodynamic reasons (resistances) why patients do not accept treatment recommendations. For more details on such treatment-resistant patients, you may be interested in the book edited by my colleague, Mantosh Dewan MD, and myself, entitled, "The Difficult-to-Treat Psychiatric Patient."

Good luck with your cases!

August 2002

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