Identifying Patients' Treatment Goals Helps Overcome Noncompliance

To stem what some call an “epidemic” of medication noncompliance for patients with serious mental illness, psychiatrists must tie treatment directly to patients' goals.

This was a key message delivered to mental health consumers, family members, psychiatrists, and mental health professionals who attended the 2005 annual conference of the National Alliance for the Mentally Ill in Austin, Texas, in June.

“Patients often have trouble connecting taking their medications to getting what they want,” said Jacqueline Feldman, M.D. Patients want exactly what everyone else wants, she noted, such as an education, a job, and a romantic relationship.

Feldman is the Patrick H. Linton Professor of Psychiatry and director of the Division of Public Psychiatry at the University of Alabama at Birmingham. Two of her family members have serious mental illness, she noted.

What the psychiatrist wants for the patient is not always what the patient wants. “I may want the voices to go away, while my patients want to get a life,” she said. “I have many patients who tell me, `I can put up with the voices. If I could just get a job, I'd be in heaven.'”

Feldman explained that people in general have a “spectrum of acceptability” for certain medications, with psychiatric medications being at the bottom of the acceptability spectrum. For instance, medications such as Percodan and Valium have an immediate and desired effect for those who are in pain or experiencing anxiety. People have little problem taking them.

Other medications, she noted, such as antihypertensives, have little perceived therapeutic effect and minimal side effects. “Often, you can't tell when you are hypertensive, so the incentive to take the medication is somewhat decreased,” she explained.

Some medications used to target psychiatric symptoms “have little perceived effect and cause tremendous side effects,” she noted.“ We're fighting an uphill battle.”

Patients taking psychotropic medications may experience weight gain, fatigue, dry mouth, blurry vision, urinary retention, decreased libido, muscle rigidity, and akathisia, for example.

“How many of you would willingly take a medication that has these side effects for the rest of your lives?” she asked. “And yet I ask my patients to do just that.”

Suzanne Vogel-Scibilia, M.D., a NAMI board member and psychiatrist practicing in Beaver County, Pa., listed a number of additional reasons that consumers may avoid taking medications, including the stigma associated with mental illness, impaired judgment caused by mental illness, and restrictions imposed by insurance companies, such as treatment caps and formularies, that prevent physicians from being able to prescribe certain medications that may benefit patients.

Another compliance obstacle she cited is that psychiatrists expect their patients to take medications to treat an illness that many feel they don't have. In its most severe form, this belief is called anosognosia, which literally means, “unawareness of illness” (Psychiatric News, September 7, 2001).

Vogel-Scibilia advised psychiatrists to avoid confronting patients with anosognosia directly about their beliefs regarding their illness status.

Some of her patients, for instance, ask her whether she believes that people are harassing them. She tells them, “I can't say what your experience is. There may be people harassing you. Many people with your concerns have a psychiatric illness.”

It may seem surprising that any of her patients with anosognosia take their medications regularly, but they do. “They tell me, `When I take these pills, I'm not hospitalized against my will, the police don't arrest me, and I don't get evicted from my place.'”

For others, it is the relationships with loved ones that influence their medication decisions.

“Some say, `I don't believe these pills work because I don't have a mental illness, but when I tell my family that I'm going to stop taking them, they get so upset and seem so concerned. I love them dearly and can't stand to see them worry, so I just take the pills.'”

Overall, psychiatrists can begin to prevent medication nonadherence by building an alliance with patients to help them achieve their goals with treatment that works, she said. ▪