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
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
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
"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. ▪