“Adherence is one of the most important issues in illness management,” according to Dawn I. Velligan, Ph.D, director of the Division of Schizophrenia and Related Disorders at the University of Texas Health Science Center. However, research suggests that about half of people with schizophrenia don’t adhere to treatment, she said.
Nonadherence has critical consequences, including worsening of symptoms and hospitalization. “Rates of relapse for those [patients] taking vs. not taking medications are about 44 percent and 20 percent respectively,” Velligan said.
What Predicts Nonadherence
When it comes to adhering to treatment, people with schizophrenia aren’t all that different from individuals with other chronic conditions, including diabetes and high blood pressure, Velligan said. Not taking medication seems to be a problem for conditions that require long-term treatment.
The major difference, however, is that individuals with schizophrenia can have poor insight into their illness, which makes them more likely to skip treatment. In fact, poor insight may be the biggest predictor of nonadherence. “Individuals don’t think they are ill, or don’t understand that when acute symptoms subside medication is still necessary,” Velligan said.
The very nature of schizophrenia can complicate adherence. For instance, consistency is key for following treatment. But people with schizophrenia have a hard time sticking to routines. “There is no regular pattern of behavior that can make adherence easy,” Velligan said.
They also struggle with cognitive impairments. Patients may intend to take their medication but simply forget. “In these cases sometimes as many as half the doses are missed, making the medication less effective,” Velligan said.
But the negative consequences of stopping medication aren’t obvious to patients. If a patient misses a pill, there are no immediate repercussions, she said. “Symptoms may not get worse for days, weeks or even months [which makes it] very difficult for the person to make the connection between poor adherence and rehospitalization,” she said.
Some patients skip doses or stop taking medication because of side effects. For instance, weight gain and movement side effects are especially bothersome to patients, Velligan said.
Also, patients with substance abuse problems are less likely to adhere to treatment, she said.
The service system itself can make adherence difficult. “Sometimes patients are given appointments with an outpatient doctor after hospital discharge that will occur after their prescription from the hospital will run out,” Velligan said.
Strategies That Improve Treatment Adherence
Cognitive-behavioral therapy (CBT) is effective in enhancing treatment adherence. CBT doesn’t challenge a patient’s resistance to medication; instead it explores why the person doesn’t want to take medication and helps them reevaluate their negative beliefs toward medication.
Also, CBT helps patients identify their recovery goals, and links them to treatment adherence, according to Velligan. For instance, many people with schizophrenia take their medication because of relationships, whether it’s a relationship with their spouse or family member. For these individuals, one goal may address relationship quality.
CBT incorporates motivational interviewing techniques and helps patients see a clear link between poor adherence and relapse. (This full-text article provides more information on CBT for schizophrenia.)
Visual reminders, such as signs, checklists and pill containers, facilitate adherence. Velligan and her colleagues have even used electronic pill containers to prompt patients and provide a slew of important information: “to tell patients when to take medication, remind the person of the dose and reason for medication, tell the person if they are taking the wrong medication or taking it at the wrong time, and download adherence data to a secure server so that a caregiver or caseworker can keep track of adherence are becoming more widely available.”
Another option is injectable medication. Several studies have shown that long-term injectable antipsychotics increase adherence and decrease relapse risk. (Learn more here and here.) “If a person does not show up for an injection, the treatment team knows there is an issue and can intervene in a timely way,” Velligan said. Other research has suggested that it’s also important to discuss the benefits of adherence with patients receiving injectable medication.
How Loved Ones Can Help with Adherence
When someone with schizophrenia stops taking medication or skips other treatments, it can be frustrating and difficult for loved ones. You may naturally feel powerless. However, you have more influence than you realize, Velligan said. Here are several ways you can help.
- Make your support contingent on adherence. It’s common for loved ones to support the person financially and provide them with a place to live, Velligan said.
- Help them find effective treatment. Get your loved one involved in therapy and working with an experienced psychiatrist, Velligan said.
- Set up reminders for medication. Use pill containers, checklists and signs to make remembering to take medication much easier, she said.
- Try injectable medication. “With an injection, the person does not have to face the decision every day about taking medication, and remind themselves every day that they have an illness,” Velligan said.
Velligan, D.I., Weiden, P.J., Sajatovic, M., Scott, J., Carpenter D., Ross, R., Docherty, J.P. (2009). The expert consensus guideline series: Adherence problems in patients with serious and persistent mental illness. The Journal of Clinical Psychiatry, 70, 1-46.