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 1 st month of treatment. AD discontinuation rates: 1 st wk- 16%, 2 nd wk- 41%, 3 rd wk- 59%, 4 th 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]
ADHD Compliance dropped to 80% by 1 year and 52% by 3 years [ 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 Supervised doses Blood levels DIRECT MEASURES Self-reporting, clinician’s interview Pill count Pharmacy records Electronic monitoring INDIRECT MEASURES
REASONS FOR NON-COMPLIANCE Medication specific factors Patient specific factors Provider specific factors
MEDICATION SPECIFIC FACTORS 1.ADVERSE REACTIONS: F ears 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.
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
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...