Non-adherence to recommended treatment is a mundane problem with monumental consequences. It is estimated that about 50% of patients withchronic illness are non-adherent. However, the problem is even greater among patients with schizophrenia, where 75% of newly diagnosed patients are non-adherent within 2 years, and 50% of those discontinuing treatment will relapse within 3-10 months. A problem of this magnitude should command high priority in the awareness of clinicians, policy makers, researchers and the patients themselves.
The current issue of Hot Topics in Neurology and Psychiatry
endeavors to tell us why patients with schizophrenia are non-adherent and what we can do about it. As you might expect, the problem is complex and the answers are multifaceted. Whether a patient with schizophrenia is non-adherent due to an illness-related inability to sustain the treatment plan, lack of insight, shortcomings in clinical management or any of the other barriers to compliance identified by the authors, the repercussions of non-adherence can be dramatic. Acute relapses are costly and associated with functional impairment, rehospitalization and potential for exposure to the criminal justice system.
As practicing clinicians, we understand that improving adherence is not apanacea; nonetheless we can envision simple interventions for improving adherence as a potential opportunity for having a momentous impact on a large number of patients. Patients who stop medication due to lack of efficacy or intolerable adverse effects may suffer recurrences that might be considered unavoidable given the state of clinical art. However, those patients who discontinue efficacious treatment where a lack of concordance or adherence might be amenable to simple remedies represent the more lamentable problem of missed opportunities for clinicians to improve individual well-being and public health.
The following articles challenge us to not only improve our awareness of non-adherence and skill as collaborators with our patients, but also to maintain our own conscientiousness in adhering to the principles associated with better adherence by our patients. We are invited to consider factors which influence compliance across multiple domains, including “physician-related” issues. Patients benefit not only from the treatments that they undergo; our choice of words and the manner in which we relate to our patients are important influences on adherence and treatment outcome. In this spirit, I offer as prologue to these scholarly reviews, three concepts,which in my experience are useful in meeting the challenges to adherence:
- Assess concordance independently from adherence.
- Frame realistic expectations for the burden/benefit ratio for each intervention offered.
- Integrate measurement into the management plan.
Concordance refers to being in agreement with the recommended treatment plan whereas adherence is actually following through on the plan. Our concordant patients are likely to welcome recommendations for external support which patients who are discordant with the recommendations tend to find objectionable or intrusive. Similarly, those of us who are concordant with the recommendations for adherence-promoting interventions will find iteasier to embrace strategies that improve follow-through. These articles will offer clues for making a compelling case for treatment adherence to patients.
A substantial mismatch between the benefits patients hope for and the effects actually delivered can undermine confidence in the care provider. Providing a realistic appraisal of the burden/benefit ratio of a treatment will help patients understand what to expect and provide a bench mark for evaluating the utility of the treatment. Helping patients anticipate adverse effects may aid them in enduring unwanted effects, at least long enough to assess whether an ultimate benefit outweighs initial side effects or prolonged onset of action. Therapeutic optimism should not generate unrealistic expectations. Treatments that narrowly exceed realistic expectations may bemore valued and better sustained than treatments that only fall a little short of an optimistic promise to be totally effective. Conveying appropriate expectations of time required to assess potential burdens and benefits can also aid adherence. Being able to reliably deliver a modest improvement is actually a skillful and honest way of building a therapeutic alliance.
Undocumented and poorly documented treatment outcomes frustrate all concerned. Revisiting a previous treatment to confirm its inadequacy taxes the therapeutic alliance to no advantage. In contrast, routine prospective collection of even simple information from patients facilitates concordance and adherence in times of stress. Since lack of 25-30% improvement as a clinical trial endpoint over periods as short as a few weeks is associated with nonresponse, measure-guided care may accelerate the rhythm of assessing treatment outcomes to a degree which enables more patients to tolerate a definitive treatment trial. The prospect of evaluating an individual’s burden/benefit ratio in response to an optimized short-term course of treatment can motivate patient adherence in the short term, which in turncan provide evidence that treatment adherence can, in fact, lead to success in meeting patient objectives. Formal quantitative measures recorded in the chart over time are also a valuable asset to future treatment teams that mayhave the task of managing the patient over the course of time.
The specific suggestions proffered by the authors in the following articlesinvite us to go beyond the superficial, but the authors also acknowledge that the evidence base guiding these attempts to improve adherence is small. While further high quality evidence would be beneficial, significant advancescan already be made through appropriate and targeted treatment that is well monitored, even as we anticipate future evidence based guidance.
The information and recommendations offered here need not bring every patient to perfect adherence in order to have a dramatic public health benefit; the problem is so extensive that substantial public benefits and many gratifying individual successes can be had, simply by implementing theadherence promoting recommendations presented here by Hofer and Fleischhacker, as well as those suggested by Hardeman and colleagues.
Given the magnitude and immediacy of the risks non-adherent patients face, and the availability of low risk and low cost interventions (e.g., using a collaborative vocabulary and routinely assessing concordance as well as adherence), the articles that follow position us to harvest better outcomes as soon as today.