Transcript Document

TREATMENT
NON-COMPLIANCE
IN PSYCHIATRY
TREATMENT NON-COMPLIANCE
IN PSYCHIATRY
NON-COMPLIANCE:
PREVALENCE
REASONS
CLINICAL CONSEQUENCES
- Dr. Ashish Srivastava, M.D.
NON-COMPLIANCE
• INTRODUCTION
• PATTERNS OF NON-COMPLIANCE
• THEORETICAL MODELS
• PREVALENCE
• MEASUREMENT OF NON-COMPLIANCE
• REASONS FOR NON-COMPLIANCE
• CLINICAL CONSEQUENCES
• ½ to 2/3rds of patients either fail to seek
treatment or are non-compliant with treatment
…[ Kessler 2001, Regeir 1993]
• No. of studies published BUT interventions
developed have LIMITED IMPACT on the
problem! [Haynes, 2005]
•Mental illness stigma & ubiquitous fears about
psychiatric medications IMPORTANT In
determining compliance.
[ Corrigan & Watson,2006]
•Compliance/ N.C. is a continuous process with
multiple dimensions rather than a univariate
and dichotomous one.
DEFINING COMPLIANCE...
•The extent to which a person’s behavior in
terms of taking medications, following diets or
executing lifestyle changes coincides with
medical health advice.
[ Blackwell, 1992]
•The extent to which a patient takes medications
as prescribed…
[ Fawcett, 1995]
•Biological N.C. : concept of involuntary factors
affecting compliance eg. metabolism.
[Frank 1994]
•Treatment adherence: practitioners have the
important role of forming alliance with the
patient to effect successful treatment.
[ Frank 1995]
PATTERNS OF N.C.
•Total N.C. - rare !
•Intermittent/ partial N.C.
•Late compliance
•Rarely… N.C. by overuse of medications.
•Unintentional v/s intentional N.C.
•Drug Holidays
•White coat compliance
THEORETICAL MODELS OF HEALTH BEHAVIOR
•Health belief model [Budd 1996, Lingam & Scott 2002]
•Theory of reasoned action (TRA) and theory of
planned behavior (TPB) [Ajzen 1980,1988]
•Stages of change theory [Prochaska 1994]
•Protection motivation theory (PMT) [Rogers 1983]
• All assume that medication compliance can be
predicted by
 Patient’s perception of threat from
medical/psychiatric condition
 Their expectancy regarding the consequences
of medical compliance
PREVALENCE OF NON-COMPLIANCE
• 20-50% of any patient population is likely to
be at least partially non-compliant…
• Sackett & Snow :
- short term regimens : 62%
- long term preventive regimens: mean 57%
- long term treatment regimens: mean 54%
EVIDENCE SHOWS. . .
•N.C. rates higher when treatment prescribed for
long duration.
•Medication compliance tends to decline over
time.
•Baseline compliance is strongest predictor of
long term compliance.
•Past h/o N.C.  N.C. in future.
In-patient v/s out-patient N.C…
•Non-compliance more prevalent in out-patient
treatment (20-65%) than in-patient treatment
(5-37%).
[ Hodge 1990, Remington 1995]
DEPRESSION
10% never follow up, compliance
decreases over time, greatest within 1st
month of treatment.
AD discontinuation rates: 1st wk- 16%, 2nd
wk- 41%, 3rd wk- 59%, 4th wk- 68%
[Johnson 1981]
30% of patients stopped Rx within 1
month and 45-60% by 3 months
[Hotopf 1997]
BIPOLAR DISORDER
18-52% , 50% some degree of N.C., 32%
partial N.C.
[Scott & Pope 2002, Rosa 2007]
Increased N.C. in patients with co-morbid
substance use disorder
SCHIZOPHRENIA
74% discontinued treatment within 18
months [Liebermann 2005]
N.C. rates > 50%, associated with young age,
SUD, hospitalization, use of TAPs, negative
symptoms
[Valenstein 2006, Rettenbacher 2004]
Significant N.C. within 1 week of discharge in
patients with co-morbid SUD
[Olfson 2000]
Compliance dropped to 80% by 1 year and 52%
by 3 years
ADHD
[ Thiruchelvam 2001]
26% refused treatment at the onset
55% stopped treatment by 10 months
[Firestone 1982]
Less than 10% of families discussed prior to
discontinuation
•SUDs : variable degree of N.C. (upto 70-80%)
•Increased rate of N.C. in developmentally
disabled and cognitively impaired patients.
MEASUREMENT OF NON-COMPLIANCE
DIRECT
MEASURES
INDIRECT
MEASURES
• Supervised doses
• Blood levels
• Self-reporting,
clinician’s interview
• Pill count
• Pharmacy records
• Electronic monitoring
REASONS FOR NON-COMPLIANCE
•Medication specific factors
•Patient specific factors
•Provider specific factors
MEDICATION SPECIFIC FACTORS
1. ADVERSE REACTIONS:
Fears regarding side effects more predictive of
N.C. than the actual side effects of medications...
- side effects considered mild by a psychiatrist
may have significant impact on medication
compliance.
- troublesome, fearful, difficult to describe,
embarrassing, persistent, permanent side effects.
2. INEFFECTIVENESS:
- at best 80% efficacy can be expected
- efficacy-effectiveness gap
- perceived effectiveness
3. REGIMEN COMPLEXITY:
- inverse relationship between number of
daily dosages and treatment adherence.
[Claxton 2001]
- higher compliance with twice daily(85%)
v/s TDS/QID regimens (65%), evening doses
missed twice as often as morning doses.
[Kruse 1993]
- increased N.C. with polypharmacy.
4. COST:
- not only medication costs, additional
expenses.
- costs may be more than even disability
income.
- many health insurance plans do not include
psychiatric disorders or only acute psychosis. In
additions there are many riders.
PATIENT SPECIFIC FACTORS
1. Attitudes/ beliefs of patients and their
families
2. Age
3. Abnormal illness behavior
4. Culture/ religious beliefs
5. Psychiatric disorders and symptoms
Attitudes/ beliefs of patients and their families:
- Patient’s ability to comply with treatment is
influenced by his cognitive and motor
functioning and his knowledge about
medications.
- The attitudes/ beliefs of patients are at least as
important as side-effects in predicting
compliance (Lingam and Scott, 2002).
Patient’s motivation to comply is influenced by
many complex and inter-related factors like:
- severity of symptoms
- past experiences with medications
- personal beliefs
- treatment goals
- temperament or personality
•Other problems areas:
- fear of being dependent on medications
- fear of drug accumulation and side-effects
- concerns about mental illness stigma
Link (2004) stated that mentally ill are the most
stigmatized social group.
- family factors
•Age factor:
-adolescents and geriatric population has
comparatively higher N.C.
•Abnormal illness behavior:
- denial, conscious and unconscious
motivation influence compliance
(Tilowsky, 1993).
•Cultural/ religious beliefs.
Psychiatric Disorders and Symptoms:
•Depression
amotivation
suicidal ideas
anergia
cognitive
triad
cognitive
impairments
reduced task
initiation
•Bipolar disorders
- disorganization, sleep disturbances,
hypomanic Sx, grandiosity and psychotic
features in manic phase.
•Schizophrenia
Poor judgment and
insight, expressed
emotions, affective
symptoms
Cognitive deficits
Negative symptoms
disorganization
Psychotic
features
•Personality disorders
- poor therapeutic relationship,
transference and counter transference issues
•Dementia / cognitive disorders
- poor judgment and insight, executive
function deficits, memory and other cognitive
deficits, dependency needs, sensory deficits
•SUDs
- medications interfere with sought after effects
of the substance
- fear that prescribed medications will interact
with the substance and cause severe problems/
effects
- increased risk of secondary depression,
anxiety, insomnia
- loss of confidence in medications
- patient depleted of money, time and support
- N.C. due to overuse of medications
•ADHD
- distractability, inattention, disorganization,
comorbidity, child’s / parent’s beliefs
•Developmentally disabled
PROVIDER/ PRACTITIONER
SPECIFIC FACTORS
1. Practitioner’s ability
2. Practitioner’s motivation
3. Awareness of patient’s compliance
4. Therapeutic alliance
5. Continuing medical education
PRAGMATIC ISSUES:
• Location of mental health care facility
• Communication and transportation services
• Practices of third party payers
• Communication between various health care
providers
• National health care policies and regulations
CLINICAL CONSEQUENCES OF
NON-COMPLIANCE
•FINANCIAL COSTS:
- US: $100 billion annually, cost of
re-hospitalization for patients suffering from
schizophrenia is nearly $2billion/ year (60%
attributed to loss of effectiveness and 40% to
N.C.).
- Canada: 3.5 – 9 billion Can$/ year.
- loss of manpower days.
•HUMAN COSTS:
- increased number of hospitalizations
(revolving door phenomenon).
- poorer outcomes/ prognosis.
- increased risk of suicide and harm to
others.
- poorer QOL, increased family burden,
increased EE, counter transference issues…
Having looked at the problem,
solutions need to be seeked ...