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Compliance, concordance and mental health

Charles Broomhead
MB ChB MRCGP DA DRCOG
GP and GP
Trainer
Sutton Coldfield
Honorary Clinical Lecturer
Birmingham Medical School
E:charles.broomhead@lineone.net

The term "mental illness" encompasses a wide range of disorders. It includes such conditions as depression, anxiety, grief and bereavement reactions, schizophrenia, bipolar affective disorders, personality disorders and eating disorders. Alcohol and drug dependence may also be viewed as related problems.
The majority of psychiatric care takes place in primary care, and most patients are well managed by their GPs and nursing staff. Only the most severely ill patients need specialist care. This situation means that any member of the primary care team is liable to encounter a patient with mental health problems. Up to 40% of consultations in primary care are said to have a mental health component, and an estimated 20% of adults have a mental health problem at any one time.(1) Anxiety and depression, often coexisting, are the most common disorders. Their prevalence is highest in elderly patients - more than 35% of those over the age of 65 and particularly those in nursing homes are affected.
Many of these disorders might be regarded as normal, self-limiting life experiences and, particularly in their milder forms, will have been experienced by most of us. When the problems are more severe, however, medication is often indicated to facilitate recovery or to allow the patient to function more normally.
Compliance is a problem, with all prescribed medication, whatever the mental status of the patient, and may actually be no worse in the case of mental illness.(2) However, it does become worse the more drugs that are prescribed and the more complicated the treatment regimen, often a problem with mental health. Medicines with unpleasant side-effects that produce only a slow, often imperceptible, improvement in the patient's symptoms can exacerbate this problem. A specific concern may be paranoia or confusion that a mental illness itself produces. The provision of therapy may be interpreted as an attempt to poison or otherwise harm the patient, or the medication may simply be forgotten. Table 1 lists some of the particular reasons for poor compliance in this patient group.

[[NIP13_table1_22]]

Consequences of poor compliance
In the major psychiatric conditions such as schizophrenia, poor compliance causes particular concern. Failure to take medication correctly is more likely to result in hospital admission, perhaps on a compulsory basis. Those so admitted are often very ill, needing considerable inpatient stays, and they also have an increased risk of suicide. Conversely, improving compliance offers the prospect of a significantly better quality of life for both the patient and their carers.
Poor compliance isn't just about failing to take prescribed medicines. Overuse or addiction to drugs, particularly the benzodiazepines (diazepam, lorazepam, nitrazepam or temazepam), represents an enormous problem. Some would argue that there is no place for these medications, except for very acute situations, and that their use is almost always inappropriate. Certainly if they are to be used they should be prescribed with care and for very short periods only.

Improving compliance
Reducing the complexity of the treatment regimen is an obvious first step, as is ensuring that dosing instructions are included on all prescriptions. "Take as directed" is not adequate and will diminish the likelihood of therapeutic success. Devices such as pill organisers will simplify matters, and many pharmacies will prepare blister packs of each day's medication. At the same time, ensuring that repeat prescriptions are "lined up" and run out at the same time will reduce the chances that medicines are forgotten by either the patient of their carer. Similarly, simple alarms can prove effective as a reminder that a dose of medication is due.
One common practice to overcome the problem of noncompliance is to administer drugs in the form of depot injections. This can be effective, but unfortunately it is generally the older drugs that are available in this form, thus depriving patients of the therapeutic advantages associated with newer preparations. Notwithstanding this, it would be naive to think that depot injections of drugs can ever solve the entire problem of poor compliance. Indeed, except in a very few exceptional circumstances, imposing treatment on an unwilling patient is not something that society should be prepared to condone. Assertive outreach techniques may improve contact with patients who are reluctant or unable to attend for follow-up appointments, but many will still refuse injections. In some, paranoia about such treatment may result in efforts to treat the patient being interpreted as attempts to inflict harm and make compliance even less likely.

Educational role for nurses
A more fruitful approach to improving compliance is to establish a long-term, trusted alliance with the health professional, often a nurse, responsible for supervising ongoing treatment. The time that would have been spent in giving an injection may be better invested in fostering and developing a good therapeutic relationship. We know that patients are often more prepared to discuss their concerns with nurses than with doctors. They are often viewed as less threatening, having more time to listen and being less intimidating than their physician colleagues. There can be no doubt that such an association offers an important opportunity to understand more about the patient's concerns and any issues that they may have about their treatment. Time invested in discussing medication, its frequency and timing, side-effects and particular problems that they experience in taking it is likely to produce significant dividends. It may reveal the reasons for therapeutic failure, allow treatment to be better tailored to the needs of the individual patient, and improve compliance and ultimate outcomes.
Many patients, and often their relatives, simply don't understand why they are taking their medicines and what they are supposed to achieve. Attempts should be made to involve the patient and their immediate carers in decisions about the treatment as better understanding, at whatever level, is likely to improve adherence to the proposed regimen, hence turning compliance into concordance.
There is evidence that patient education on its own may not significantly improve concordance.(3) In at least one study,(4) the way in which the patient felt about their medication and whether or not they felt better or worse while taking it was shown to be the factor that correlated best with the level of concordance. What the patient knows about their medication appears to be of secondary importance.
Using medication with as few side-effects as possible for the particular patient is essential. How many of us would be prepared to tolerate the things that we try to inflict on our patients? Would we put up with the sedation, dry mouth, blurred vision, Parkinsonism, dysphoria, weight gain, sexual dysfunction, galactorrhoea and other unpleasant side-effects that often occur? Almost certainly the answer is no, especially if we didn't know that these things were likely to happen before we noticed any improvement in our existing symptoms.
In general, newer drugs offer the prospect of considerable improvements in efficacy with fewer side-effects than their predecessors. A good example of this is the SSRIs (selective serotonin reuptake inhibitors), such as paroxetine, fluoxetine and sertraline, when compared with older tricyclic antidepressant drugs such as amitriptyline or imipramine. When first introduced the SSRIs were viewed with appropriate scepticism and were considered expensive. With the passage of time, however, we have come to recognise the significant advantages that this class of drugs offers and have adopted them for almost universal usage in spite of the additional cost.
As in other therapy areas, the most effective strategies to improve compliance and concordance are likely to be complex, flexible and tailored to the requirements of the individual patient. They should not only include the provision of information but also incorporate mechanisms to make the treatment convenient to the patient, to support the family and to provide regular reminders and reinforcement. Wherever possible, these strategies will promote active patient participation.

Conclusion
Concordance with medication is essential to ensure the best outcome for both patients and society, and the selection of drugs with as few side-effects as possible is likely to be a critical factor in optimising this.
We need to understand more about the reasons why patients fail to take their medication correctly, and we need to develop strategies to encourage them to do so. Most practice nurses are already heavily involved in the management of chronic diseases and are likely to encounter mental health problems on a regular basis. There seems no reason why they should not be specifically trained to work with the mentally ill. Their relationships with patients are significantly different and in many ways complementary to that of the doctors with whom they work. This situation offers the practice team unique opportunities to improve the overall quality of management of their mentally ill patients.

References

  1. Craig TKJ, Davies T. ABC of mental health. London:?BMJ Publications; 1998.
  2. MacPherson R, Jerrom B, Hughes A. Drug refusal among schizophrenic patients treated in the community.J Mental Health 1997;6:141-7.
  3. MacPherson R, Jerrom B, Hughes A. A controlled study of education about drug treatments in schizophrenia.Br J Psychiatry 1996;168:709-17
  4. Hogan TP, Award AG, Eastwood RA. Self report scale predictive of drug compliance in schizophrenics; ­reliability and predictive value.Psychol Med 1983;13:177-83.

Resources
Task Force on Medicines Partnership
W:www.concordance.org
Medicines Partnership
Royal Pharmaceutical Society of Great Britain (RPSGB)T:020 7572 2474
F:020 7572 2508
E:info@medicines-partnership.org
W:www.medicines-partnership.org