Issues With Medication Compliance in Psychiatric Disorders

My intention in writing these posts is to share the experiences that I went through with my son, starting with the first manifestation of his illness and our journey through numerous subsequent episodes. It's also to provide commentary as a parent and psychiatrist on issues that these experiences bring up, such as how the diagnostic process works in mental health, and how to work with treatment providers and medication issues. My hope is that reading this may be helpful for people with mental health issues and also their families and friends.

Source: James from Pixabay

For some patients and their families there is a terrible realization that the medicines they have been prescribed haven’t kept them well—but was this because they hadn’t taken the medicine consistently, the dose was insufficient, the time duration wasn’t sufficient to elicit a response, or the illness was particularly severe and so it didn’t respond? Each of these could be a potential explanation and needs to be explored.

In Bill’s case I was initially blindsided by his non-compliance with medication. I didn’t realize until later, reading his journals, that often he had not taken the medicine as prescribed. Or that, at other times, he was taking the medicine but it was not able to keep him stabilized and he was quietly psychotic, hiding his symptoms from me, his treatment team, and his friends and acquaintances. With illness recurrence I learned skepticism, and to trust my instincts and rely on my clinical knowledge. I had to evaluate the facts and symptoms with a critical eye. Even when told that everything was "fine," as a mom I had to learn that I couldn’t trust what he said. He wanted to be normal, or better yet, to be high—and the brain’s reward system is very powerful, fully capable of sabotaging rational thinking. That is a tricky road to work: to guide him and question him while also feeling his pain. I had to develop a dose of radical empathy for somebody who was so sick.

Back to the hospital

Bill called to tell me he was sleeping less and starting to feel high. He was willing to take increased doses of medicine so I quickly got him on a higher dose of his antipsychotic medication and a mood stabilizer was added.

One of the frustrating things about trying to treat people with bipolar disorder is how quickly the illness can escalate. Bill was getting worse, with more rapid speech. This time we managed to get him hospitalized before he became so psychotic that he was unable to control his actions. I convinced him that his mild but clearly detectable thought disorder was part of a worsening of his bipolar symptoms. Although he resisted at first, he admitted that he was sleeping less and feeling more irritable. I prevailed upon him to consider how close he was to graduation and that it would be a shame to undercut himself. He went voluntarily to the hospital with the goal of adjusting his medication doses to levels that would keep him stable.

Finding the right type and dose of medicine can be a complicated process when treating bipolar disorder—or any psychiatric disorder. The type of neuroleptic he was on—Olanzapine (Zyprexa)—is part of a class of drugs known as atypical neuroleptics, with different properties than typical neuroleptics such as Haloperidol (Haldol). Atypical neuroleptics are more sedating and calming but can produce weight gain leading to “metabolic syndrome.” Typical neuroleptics have a significant risk of “extra-pyramidal” side effects, including severe leg spasms (like those that Bill had while skiing), tremors, and a syndrome called tardive dyskinesia, which usually develops after many years of taking the medicines and involves involuntary muscle movements such as puckering of the lips, grimacing, or twitching. Both types of neuroleptics also have the beneficial effect of reducing or stopping the psychotic symptoms of hallucinations, delusions, and thought disorder. Because Bill’s symptoms always included restlessness, agitation, and profound decrease in sleep, he had been switched during his last hospitalization from haloperidol to olanzapine. However it had now become clear that the dose was not sufficient to keep him stable. While in the hospital he could be monitored while increasing his dose. It is always a little unsettling to be upping the dose to higher than the usual daily dose but that was clearly what he needed. He had an uneventful hospital stay and then returned to finish out the semester.

Antidepressants and the risk of precipitating mania

The development of manic symptoms two weeks into treatment with an antidepressant indicates that the antidepressant was likely the cause—14 days is the usual time course for achieving antidepressant effects—and is one of the risks of treating depression in someone with bipolar disorder, even in the depressed phase of the illness. His psychiatrist had thought that since he was on a neuroleptic (haloperidol) as well as a mood stabilizer, that this would protect him from developing manic symptoms; however this clearly had not sufficiently protected him. I felt discouraged that he had bounced into mania and at the same time had side effects from haloperidol; clearly the neuroleptic was a high dose.

I felt once again how difficult it was to treat his illness. It seemed clear to me at this point that he had bipolar disorder and not schizophrenia, as had been his diagnosis for the first several years. And it also seemed clear that the so-called “typical neuroleptics” such as haloperidol were not the right medication for treating his psychosis. They are more potent, mg for mg, than the atypical neuroleptics, but their strong effect on the motor system caused significant side effects in Bill. Atypical neuroleptics such as olanzapine and clozapine have less motor effects but produce more sedation and have a serious adverse effect producing weight gain and metabolic syndrome, a precursor to diabetes. One way to counteract this effect is to take a medicine such as metformin to stabilize glucose metabolism—or, now, the new glucagon-like peptide 1 receptor agonists (GLP-1 agonists), initially developed for diabetes but which can also help with pre-diabetes or metabolic syndrome.

I explained to Bill that he needed to be on medicine ending in “pine”—olanzepine, clozapine, etc.—and not medicine ending in “ol” like haloperidol, resperidol, etc. He understood the distinction and said he would pay attention in the future to make sure he was not put on the wrong medication.