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Rejecting Your Doctor's Advice, and Getting Help Anyway

Research offers a unique approach to reducing non-adherence.

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According to most estimates, 30 to 50 percent of psychiatric medications are not taken as prescribed. Some refer to this as non-compliance, which may come across as a pejorative characterization of "the pesky and disobedient patient." I prefer the term non-adherence, which acknowledges that patients are making a conscious and often informed decision to deviate from the plan presented by their doctor.

Articles on psychiatric medication non-adherence have been written and re-written a hundred times over. Most of these articles, however, focus on concerns for limited patient insight, potential concurrent substance use, fear of medication side effects, or patients simply forgetting to take their pills. Medication affordability is also frequently cited as a cause for poor adherence. While all of these ideas may very well be true, I would like to approach this issue from a slightly different angle.

I have spent considerable time mulling over why patients would refuse something offered to them that could potentially help—to allow them to feel better, to regain control of their life, and dare I say, shift one step closer to happiness. Then again, how many of us commit with a new calendar year to going to the gym and incorporating a healthier lifestyle and radically improved diet? Not to mention the adage that well-informed doctors tend to make the worst patients holds true more often than not. Taking care of oneself is not always as basic as it seems.

If a patient decided not to adhere to a recommended treatment and he or she simply chose not to follow up in the outpatient clinic, then although non-adherence would remain a public health concern, it would be less of a nuisance for the psychiatrist directly treating the patient. Non-adherent patients have the potential to frustrate mental health professionals because non-adherence in many cases stifles the patient’s road to recovery, which in turn can leave the doctor and patient both feeling helpless.

In clinical practice, I have undoubtedly witnessed patients who do not adhere because of psychotic delusions, limited education about their medication, poor insight into their psychiatric illness, or simply feeling like they don’t want or need to take pills. But I also see a large group of patients with very good insight, basic understanding of medication pharmacodynamics, and minimal substance abuse concerns who also confess, “Well, doctor, I stopped taking that one” when asked how their medications are going. I have often wondered if patients choose not to follow treatment recommendations—and they aren’t reporting side effects from a relatively benign medication—why follow up in clinic at all? Eventually, it occurred to me that non-adherent patients who follow-up regularly are choosing one specific treatment modality—pharmacotherapy—to deviate from, and psychiatrists have so much more to offer.

Even in medication management appointments, there is remarkable opportunity—aside from discussing indicated medications—to strengthen the therapeutic alliance (or quality of the relationship between the patient and healthcare provider). Therapeutic alliance has been shown to improve outcome measures in a broad range of psychiatric conditions and in some cases improve adherence. Understanding that in some diagnoses—bipolar disorder or primary psychotic disorders like schizophrenia, for example—patients are placing themselves at considerable risk by not taking medications. Doctors should strive to both educate patients and understand their choices.

Integrative psychiatry works to dismantle the hierarchical model of the medical doctor as one who sits atop a pyramid of other healthcare professionals, with the patient at the bottom. The integrative model is restructured to allow patient and doctor to approach decisions collectively as co-deciders—the patient as captain, and the doctor as first mate.

Recently, I began asking myself the question, what are non-adherent patients who follow up regularly in clinic trying to communicate? Rather than blaming patients for shunning expert opinion, these instances are a perfect opportunity for motivational interviewing—a concept historically rooted in addiction psychiatry that broadly draws attention on gauging a patient’s own desire for improvement or change.

Roberto Lewis-Fernández, a psychiatrist at the College of Physicians and Surgeons at Columbia University, coined the term motivational pharmacotherapy (MP). His research utilized MP in a group of depressed Latino patients and found that non-retention dropped from an expected 32 to 53 percent to 20 percent when MP was utilized (Lewis-Fernández). Much like traditional motivational interviewing, which focuses on open-ended questions, affirmations, and reflective listening, MP highlights engaging the patient to evoke change talk in a way that is respectful of the patient’s values and decision-making process.

MP might explore, with non-judgmental curiosity, why a patient has made a choice not to follow treatment recommendations and what other approaches the patient has pursued and found useful. Treatment plans are then designed collaboratively, instilling a sense of patient autonomy and encouraging physicians to be tolerant, within reason, of alternate approaches.

I can recall a patient who stopped a prescribed anti-anxiety agent, because she found both relief and stability with the routine of drinking ashwagandha tea, which has evidence-based benefits for reducing anxiety in otherwise healthy patients. Another patient did not like the idea of being prescribed three medications, so he chose to forgo his sleep agent due to dependency fears. Finally (and this is not uncommon), a depressed patient discontinued her antidepressant on her own because she felt better and could not bring herself to accept remission status while on a medication, even though she was well aware of the relapse risk involved.

From a patient perspective, coming to outpatient visits with specific goals, or areas of focus, and feeling comfortable enough with your mental health provider to inform them if medication changes are made in between visits may be helpful in improving outcomes. Recent studies focus on patients’ desire for autonomy in shared medical decision-making (Chakrabarti). It is important for mental health professionals and patients alike to appreciate that the psychiatric encounter is beneficial even outside the boundaries of prescription medications—it is a sacred opportunity for healing. In my view, the best treatment is multifaceted and flexible. We are all aware that non-adherence is a problem in psychiatric care. In the spirit of moving forward, and welcoming as many patients as possible to get the help they need, let us work together in finding better solutions.

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Roberto Lewis-Fernández, Iván C. Balán, Sapana R. Patel, J. Arturo Sánchez-Lacay, César Alfonso, Magdaliz Gorritz, Carlos Blanco, Andrew Schmidt, Huiping Jiang, Franklin Schneier & Theresa B. Moyers (2013) Impact of Motivational Pharmacotherapy on Treatment Retention Among Depressed Latinos, Psychiatry, 76:3, 210-222.

Subho Chakrabarti. (2014) What’s in a name? Compliance, adherence and concordance in chronic psychiatric disorders. World J Psychiatry Jun 22; 4(2): 30–36.