Assessment of Adherence Problems in Patients with Serious and Persistent Mental Illness: Recommendations from the Expert Consensus Guidelines

Abstract

Poor adherence to medication treatment can have devastating consequences for patients with serious mental illness. The literature review and recommendations in this article concerning assessment of adherence are reprinted from The Expert Consensus Guideline Series: Adherence Problems in Patients with Serious and Persistent Mental Illness, published in 2009. The expert consensus survey contained 39 questions (521 options) that asked about defining nonadherence, extent of adherence problems in schizophrenia and bipolar disorder, risk factors for nonadherence, assessment methods, and interventions for specific types of adherence problems. The survey was completed by 41 (85%) of the 48 experts to whom it was sent. When evaluating adherence, the experts considered it important to assess both behavior and attitude, although they considered actual behavior most important. They also noted the importance of distinguishing patients who are not willing to take medication from those who are willing but not able to take their medication as prescribed due to forgetfulness, misunderstanding of instructions, or financial or environmental problems, since this will affect the type of intervention needed. Although self- and physician report are most commonly used to clinically assess adherence, they are often inaccurate and may underestimate nonadherence. The experts believe that more accurate information will be obtained by asking about any problems patients are having or anticipate having taking medication rather than if they have been taking their medication; They also recommended speaking with family or caregivers, if the patient gives permission, as well as using more objective measures (e.g., pill counts, pharmacy records, smart pill containers if available, and, when appropriate, medication plasma levels). Use of a validated self-report scale may also help improve accuracy. For patients who appear adherent to medication, the experts recommended monthly assessments for adherence, with additional assessments if there is a noticeable symptomatic change. If there is concern about adherence, they recommended more frequent (e.g., weekly) assessments. The article concludes with suggestions for clinical interview techniques for assessing adherence.

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder

“…Asking about adherence behaviour and attitudes in a non‐judgemental manner and exploring the reasoning behind poor adherence are important parts of treatment,341 as up to half of patients do not take their medications as prescribed 342, 343, 344. Unrecognized treatment non‐adherence can lead physicians to believe that the patient is non‐responsive, resulting in unnecessary dose increases (especially problematic for drugs with a narrow therapeutic index), medication switches, or adjunctive medications 341. Treatment withdrawal may precipitate recurrence; 50%‐90% of patients discontinuing lithium experience a recurrence within 3‐5 months,345, 346 with rapid lithium discontinuation associated with greater recurrence risk than gradual discontinuation 347.…”

Self-report measures of medication adherence behavior: recommendations on optimal use

“…Until then, randomized controlled trials of adherence interventions would benefit from a more objective method of adherence assessment as the primary study outcome (e.g., EDM devices, prescription refill measures, or multiple measures with complementary properties, such as selfreport and adherence biomarkers). Use of multiple measures in adherence research can triangulate intervention effects [34,72] and advance measurement science through comparisons with one another.…”

“…Basic approaches to assist recall include use of medication lists and pill diagrams, as well as anchoring recall to salient events through a timeline follow-back method [5,9]. Assessment of self-reported medication adherence among cognitively compromised populations may additionally benefit from more specialized techniques such as the conduct of daily or periodic ecologic assessments via text message or interactive voice response surveys regarding medication adherence over the last 24 h [72]. For groups characterized by severe cognitive impairment and memory deficits, the use of adherence measures other than self-report (e.g., pill counts, EDM, or drug levels) may be preferred.…”

Relationship between drug compliance, coping with stress, and social support in patients with bipolar disorder

“…Sufficient social support will favorably affect health protection and improvement, treatment and rehabilitation of disease treatments, so they will support patient compliance with the disease, and decrease social isolation so that patient's life quality is increased (26). Deficiencies in familial and social supports cause compliance problems, and negative effects on treatment (27). However, there are no studies in the literature investigating whether social support is a factor affecting drug compliance in patients diagnosed with bipolar disorder.…”