Leveling the Playing Field to Improve Medication Adherence

April 20, 2017

I was recently asked by a colleague at Elevate, “What do you do about medication noncompliance in your patients?” Those of us who work in health care are undoubtedly well aware of the problems that can ensue when patients don’t follow up on recommended treatment.

This question, simple on its face, became increasingly complex as we began to unpack it. First, let’s look at the word “compliance.” To comply is to submit to someone else’s authority. Now, I may be especially contrarian (you’ll have to ask my friends and family), but often, my first response when someone tells me that I have to do something is to start walking in the other direction, and I suspect many of our patients are no different. So how do we begin to change our language, so that language can reshape our attitudes? I prefer the term “nonadherence,” as it implies that what the patient wants and what I want aren’t “stuck together.” I have also been deeply influenced by the writing of Shawn Christopher Shea, MD,1 who prefers the term “medication interest.”

As a psychiatric nurse practitioner, I like to do what I can to reduce the power differential between my patients and myself. I often tell them that I am not there to tell them what to do, but rather, to act as a consultant who may have some ideas about how to help them, but ultimately (because my patients are all voluntary), they will be the ones who decide if they take the medication or not. In the end, patients vote with their feet, and even those patients who are compelled to treatment (a rare circumstance these days) are usually only compelled to treatment for a limited period of time, and while it’s sometimes essential for safety, forcing medication on a patient can be traumatic and set the stage for later medication resistance.

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If a patient is willing to take medication, they’re interested in what we are offering. If they’re not interested in what we’re offering, they won’t take it or they’ll only take it sometimes. They're going to be a lot more interested in taking it if it works, which is to say if it treats the symptoms the patient is interested in treating.  This makes a lot of sense, but so often, our lack of understanding comes from our inability to see the situation from the perspective of the patient. I might think that a patient with schizophrenia is benefitting from treatment if they are no longer hearing voices and are able to get out of bed and leave the house. The patient may care less about the change in hallucinations and feel much more enthusiastic about smoking fewer cigarettes (which perhaps they do to combat their negative symptoms), because a recent tax increase meant that their smoking routine ate up more of their meager income. Either way, it’s a win-win, and I’d be better off focusing on the perceived benefits of the medication from the patient’s perspective.

Of course, that’s an easy example, and more often, we’re faced with a patient who might be having fewer symptoms, but has gained a significant amount of weight, lost sexual function, or is sleepy all day as a result of medications. While we, as clinicians, may be excited about the decrease in symptoms, from the perspective of the patient, these gains are far outstripped by the burden of medication side effects. So they stop taking the medications. And, if we’re going to be honest, who can blame them?

Especially when I was fresh out of training, I often felt an unspoken pressure to “sell” a patient on my treatment plan, and if they declined it or didn’t follow my instructions, somehow I had failed as an NP. No supervisor ever said this to me, but somehow, I had absorbed this message and felt the need to defend against my own feelings of inadequacy and failure. So, when a patient did not do as I suggested, and if later they decompensated, I would do as many of us have learned to do—I would project my sense of failure onto the patient, thinking, “See, this is what happens when you stop your meds!” How many times have we heard this message, implicitly or explicitly, given to our patients, often when they are at their worst, on admission to a psychiatric hospitalization? As if people in that state are not suffering enough, do we need to place our sadistic projections of our own helplessness and inadequacy as clinicians onto them?

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What if we asked patients, bluntly—“What’s important to you from treatment? What do you want to get out of this? And what are you willing to do to get there?”—and truly respected that? Sometimes, it’s going to take all the artfulness we can muster as a clinician to help the patient make the connections between their actions (“so when you stopped taking the meds, you started hearing the voices and began yelling in the street?”) and the outcomes (“and the police took you to the hospital, which I know you don’t like”). It may take many repetitions of this cycle before the elusive “insight” begins to crystalize, or such insight may never form, the burden of a terrible disease like schizophrenia. But regardless, we keep trying, or we offer then an alternative means, like a long-acting injectable medication, so that they don’t have to remember to take the medication every day.

What if when our patients are nonadherent to our plans, we asked them, “What didn’t work? I want to keep working together. How can we make this better next time? If we could figure out a medication that would allow you to feel better tomorrow, what would you be able to do that you can’t do now?” (this line, which I have paraphrased from Dr. Shea, gets to the heart of what people lose when they have mental illness). Might then, would we get better results? I welcome your thoughts and your cases (both the ones that turned out well and the ones that didn’t), in the comments below.

Reference

1) Shea SC. Improving Medication Adherence: How to Talk with Patients About Their Medications. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.

Andrew Penn was trained as an adult nurse practitioner and psychiatric clinical nurse specialist at the University of California, San Francisco. He is board certified as an adult nurse practitioner and psychiatric nurse practitioner by the American Nurses Credentialing Center. Currently, he serves as an Associate Clinical Professor at the University of California-San Francisco School of Nursing. Mr. Penn is a psychiatric nurse practitioner with Kaiser Permanente in Redwood City, California, where he provides psychopharmacological treatment for adult patients and specializes in the treatment of affective disorders and PTSD. He is a former board member of the American Psychiatric Nurses Association, California Chapter, and has presented nationally on improving medication adherence, emerging drugs of abuse, treatment-resistant depression, diagnosis and treatment of bipolar disorder, and the art and science of psychopharmacologic practice. 

The views expressed on this blog are solely those of the blog post author and do not necessarily reflect the views of Psych Congress Network or other Psych Congress Network authors. Blog entries are not medical advice.