Overcoming medication nonadherence in schizophrenia: Strategies that can reduce harm

Adequate support is essential

The therapeutic alliance plays a key role in patients’ attitudes toward taking medication. Magura and colleagues¹⁸ found that one-third of psychiatric patients (13% of whom had a diagnosis of schizophrenia) reported that their psychiatrist did not spend enough time with them explaining side effects, and felt “rushed.”

Patients with schizophrenia often require access to social support systems provided by family members, friends, and community agencies that provide case management and attendant care services. Patients who are adherent to medication tend to have greater perceived family involvement in medication treatment, and tend to have been raised in a family that had more of a positive attitude toward medication.¹⁹

In our practice, we have observed that recent state and federal budget cuts have resulted in patients having greater difficulty gaining access to case management and attendant care services, which then leads to increased rates of medication nonadherence. Be aware that variables such as limited office hours, financial hardship, and cultural and language barriers can compromise a patient’s ability to seek and continue care.

In the following section, we lay out techniques for improving adherence in patients with schizophrenia.

Employ general and specific strategies to boost adherence

How can you raise medication adherence concerns with patients, keeping in mind that they often overestimate their adherence?

Ask. Some clinicians ask questions such as “Are you taking your medication?”, although a more effective approach might be to ask how the patient is taking his (her) medication. Asking questions such as “When do you take your medication?” and “In the past week, how many doses do you think you missed?” might be more effective ways to inquire about adherence.⁷

The Expert Consensus Guidelines recommend asking patients about medication adherence monthly for those who are stable, doing well, and believed to be adherent. For those who are new to a practice or who are not doing well, inquire about medication adherence at least weekly.⁷

In our practice, patients who are unstable but do not require inpatient hospitalization typically are seen more often in the clinic, or are referred to intensive outpatient or partial hospitalization programs. If an unstable patient is unable to come in for more frequent appointments, we arrange phone conferences between her and her provider. If a patient is not doing well and has a case manager, we often ask that case manager to visit the patient, in person, more often than he (she) would otherwise.

Take a nonjudgmental approach when raising these issues with patients. Questions such as “We all forget to take our medication sometimes; do you?” help to normalize nonadherence, and improve the therapeutic alliance, and might result in the patient being more honest with the clinician.⁷ Because patients may be apprehensive about discussing adverse events, clinicians must be proactive about improving the therapeutic alliance and making patients feel comfortable when discussing sensitive topics. Clinicians should try to convey the idea that, although adherence is a concern, so is quality of life. A clinicians’ willingness to take a flexible approach that is nonpunitive nor authoritarian can aid the therapeutic alliance and improve overall adherence.

Be sensitive to financial, cultural, and language variables that can affect access to care. The Expert Consensus Guidelines recommend asking patients if they can afford their medication. In our practice, we have seen patients with schizophrenia discharged from the hospital only to be readmitted 1 month later because they could not afford to fill their prescriptions.

It is important to have translation services available, in person or by phone, for patients who do not speak English. Furthermore, it is important to understand the limitations that your practice might place on access to care. Ask patients if they have ever had trouble making an appointment when they needed to be seen, or if they called the office with a question and did not receive an answer in a timely fashion; doing so allows you to assess the practice’s ability to meet patients’ needs and helps you build a therapeutic alliance.

Make objective assessments. It is important for practitioners to not base their assessment of medication adherence solely on subjective findings. Asking patients to bring in their medication bottles for pill counts and checking with the patients’ pharmacies for information about refill frequency can provide some objective data. Electronic monitoring systems use microprocessors inserted into bottle caps to record the occurrence and timing of each bottle opening. Studies show that these electronic monitoring systems are the gold standard for determining medication adherence and could be used in cases where it is unclear if the patient is taking his (her) medication.^7,20 Such systems have successfully monitored medication adherence in clinical trials, but their use in clinical practice is complicated by ethical and legal considerations and cost issues.