Many research studies have highlighted the phenomenon of the “healthy adherer” — people who take their medications consistently demonstrate more healthy behavior overall. Backing up this idea are studies showing better outcomes for patients who consistently take their pills, even when those pills are a placebo. The patients’ feeling of being cared for and caring for themselves may sometimes be the key to recovery.
Other good health habits, combined with good medication compliance, can help treatment success. According to Dr. Betty Chewning of the University of Wisconsin-Madison, “it is quite possible that people who adhere to healthy lifestyles also tend to take care of themselves by greater adherence to prescribed treatments.”
Recent evidence to support the healthy adherer concept comes from a large study at the University of Alberta, Canada. Dr. Scot Simpson and colleagues performed a meta-analysis of data from 21 studies with almost 47,000 participants. They found that when patients diligently took pills, their mortality rates dropped by almost half compared with those patients who were less diligent. The lower mortality rates were similar whether the pills were real medication or inactive placebos.
The authors theorize that those who do not always take their medication may be depressed or have other conditions which affect adherence. About one in four patients do not keep to prescribed drug therapy.
Another study of the healthy adherer concept focused on chronic heart failure patients. Dr. Bradi Granger and colleagues at Duke University, North Carolina, categorized nearly 7,600 patients on the drug candesartan (Atacand) as either good or bad adherers. (The good adherers took more than 80 percent of their study medication.) After three years, good adherence was linked to lower all-cause mortality in all patients, even those on placebo.
Previous studies have found a great deal of evidence to support the healthy adherer effect. One review looked at 12 studies on the outcomes of drug adherence on patients with coronary artery disease and congestive heart failure. Adherence to placebo was linked to improved outcomes in three of the studies, suggesting that such behavior may be a useful marker of better outcome.
A more recent review of three decades of research on adherence and treatment outcomes showed that the risk of a poor health outcome is 26 percent lower in participants with good adherence.
“Traditionally, the healer’s greatest tool has been to listen and build on the patient’s story and its meaning,” Dr. Chewning said. “Coupled with other patient-centered approaches, practice based on these hypotheses could yield extra value in treatment regimens that patients agree to, believe in, and will sustain over time.”
Further research is needed to find out whether adherence can be effectively taught or encouraged, but Dr. Chewning would like to see structured patient interviewing — for example, asking a patient “what would make it worth while for you to take this medication in the next month?” could bring out the patient’s fears, values and social pressures. Physicians could use that information to inform treatment and prescribing decisions.
Simpson, S. H. et al. A meta-analysis of the association between adherence to drug therapy and mortality. British Medical Journal, Vol. 333, July 1, 2006, pp. 15-18.
Chewning, B. Commentary: The healthy adherer and the placebo effect. British Medical Journal, Vol. 333, July 1, 2006, pp. 18-19.
Granger, B. B. et al. Adherence to candesartan and placebo and outcomes in chronic heart failure in the CHARM programme: double-blind, randomised, controlled clinical trial. The Lancet, Vol. 366, 10 December 2005, pp. 2005-11.
McDermott, M. M. et al. Impact of medication nonadherence on coronary heart disease outcomes. A critical review. Archives of Internal Medicine, Vol. 157, September 22, 1997, pp.1921-29.
DiMatteo, M. R. et al. Patient adherence and medical treatment outcomes: a meta-analysis. Medical Care, Vol. 40, September 2002, pp. 794-811.