Medication non-adherence

Introduction

This study shall critically examine the health factors which might complicate a specific patient’s (George) adherence to his prescribed medication Risperidone, using current Mental Health Nursing evidence to support nursing strategies which can assist the patient in complying better with his prescribed medication.  This essay will consider the factors affecting George’s condition and those preventing him from taking his medications.  It will also provide insight on his reasons for not wanting to take his medications.  Numerous peer-reviewed studies and other related references will be used to develop evidence and efficient strategies to improve the patient’s adherence to his prescribed medication.

Main Body

Analysis/Context

This paper revolves around 27 year old George who is single and who has been admitted numerous times to the local acute Mental Health (MH) service with a diagnosis of schizophrenia.  He was first diagnosed when he was in his late teens and he has never felt comfortable with it, nor has he agreed with it.  This has made him antagonistic and resistant to any prescribed medications.  He was recently admitted to the acute unit following an assessment order because he was non-adherent to medication, specifically Risperidone. George has also long had a history of using cannabis and he prefers it to Risperidone as a means of treating his illness.

A diagnosis of mental illness is never welcome, especially to patients.  George’s rejection of his diagnosis is the primary cause of his refusal to adhere to his prescribed medication.  A diagnosis of mental illness has historically been tumultuous, especially as there has always been a stigma attached to it (Seeman, Tang, Brown & Ing, 2016).  Watson and colleagues (2017) discuss that while modern medicine has presented a scientific and a better understanding for mental illness, the social stigma against mental illness has not been completely eliminated.  For George, a diagnosis of mental illness is understandably unwelcome.  El-Malakh and Findlay (2014) point out that even when presented with the necessary diagnostic results to support a diagnosis for schizophrenia, it would not be easy or natural for a person to accept such diagnosis.  It would therefore not be out of place for George to reject the schizophrenia diagnosis and also for him to not adhere to his prescribed medication.  El-Malakh and Findlay (2014) further point out that schizophrenia is also a disease which can alter a person’s insight and judgment, often making it difficult for them to deal with their situation and their daily activities.  Amador and Johanson (2000) were two of the first authors to discuss about anosognia or lack of insight and the fact that when present, there is nothing also which can convincingly explain to the patient that they are ill. Lack of insight is part of the symptomatology of schizophrenia (Mintz, Dobson, & Romney, 2003). This lack of insight affects the awareness of the person about his need to be treated and also impacts on how he would understand the symptoms he is experiencing.  For schizophrenia patients, they cannot make any decisions about their illness because they do not believe they are ill or that there are any changes in their behavior.

In the systematic review and seminal study by Mintz and colleagues (2003) they established that the lack of insight is a major issue for schizophrenia patients because if it is not managed, the disease would further progress and their normal functions would be significantly compromised.  Lack of insight has also been considered a major factor affecting schizophrenia patients’ treatment-seeking or adherence behavior and the period or the length of their treatment (Lopez-Morinigo, Ramos-Ríos, David & Dutta, 2012).  El-Malakh and Findlay (2014) emphasize that with schizophrenia being a lifelong ailment without any cure available as yet, the lack of insight for these patients is “one of the most troubling roadblocks that people face when attempting to learn to live with this disease”.

Aside from lack of insight, there are also other factors often affecting medication adherence among schizophrenia patients. For one, numerous mental health patients do not like and find much discomfort in the side-effects of their medications (Samalin, de Chazeron, Blanc, Brunel, Fond & Llorca, 2016).  The medications may also not provide much assistance in managing symptoms (Samalin, et al., 2016).  The medication regimen may also be very complicated that the patient simply does not want to bother or he is confused about his regimen (Lien, et al., 2016).  In George’s case, he lacks insight and he has an impaired judgment which has also directed him towards cannabis use – what he believes to be the appropriate treatment for whatever is ailing him.  Another factor affecting poor adherence to medication is the poor relationship between the patient and his caregiver or health personnel managing his care (Lien, et al., 2016).  In the latter case, the health personnel may not have fully explained George’s disease to him, and as such he may not fully understand his disease and the importance of treatment.  George’s cannabis use is also a barrier to his recovery as cannabis use and dependence is usually a comorbid condition for schizophrenia patients (Machielsen, 2017) and it appears also a comorbid condition in George.  Further tests however are needed to determine cannabis abuse in George’s case.  If results are positive for abuse, these outcomes are not be surprising because cannabis abuse is an all too often issue among schizophrenia patients (Machielsen, 2017).

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Strategies to improve adherence/critical evaluation

In order to improve adherence in the George’s medication, support services can be improved, services which would primarily include family and clinician support/education.  In the study by Farooq, Nazar, Irfan, Akhter, Gul, Irfan and Naeem (2011), the authors set forth an intervention where they trained family members on how to be primary care supervisors on their ailing family member.  Their study revealed a significant increase in medication adherence for the intervention group.  The improved outcomes noted in the intervention group may however be credited to the free drugs given to the group (Farooq, et al., 2011).  The free medications in the trial may have distorted the results of the study.  Still, the Farooq, et al., (2011) study presents well-supported results which are also confirmed by other studies.  Kopelowicz, Zarate, Wallace, Liberman, Lopez, and Mintz (2012) for instance provide similar results in the use of support services for schizophrenia patients as alternate strategies to promote medication adherence.  Kopelowicz, et al., (2012) presents results affecting multifamily groups where the intervention was tailored to Spanish-speaking patients.  These patients underwent family psychotherapy sessions and a family workshop where the members of the family were taught about planned behaviors.

An improved adherence to medication was noted following the implementation of family-based interventions.  For interventions which included clinician support and education, the study by Sajatovic, et al (2013) revealed improved adherence for homeless people who were taking long-acting antipsychotic injections.  A customized psychosocial adherence enhancement program was implemented based on medication routines and improved communication with clinicians.  This program produced a 76% adherence for the participants. However, following the study, adherence decreased (Sajatovic, et al., 2013).  Such family and clinician-based interventions however do not specifically take into consideration the lack of insight in schizophrenia patients.  Nevertheless these studies do present viable solutions in improving medication adherence among schizophrenia patients, helping promote the value of improved knowledge among patients and their family caregivers.

The link between caregivers and patients needs to be improved through improved health education in order to ensure that the caregivers understand the patient’s disease and the importance of following the medication regimen (Lien, et al., 2017).  This link is also very much important especially in managing and reducing George’s cannabis use.  Cannabis use is very much associated with poor patient outcomes among schizophrenia patients (Machielsen, 2017).  Health teachings and proper education for George about cannabis use and its effect on his health can improve George’s awareness about his health and can provide him the necessary tools in making better decisions about his self-improvement (Machielsen, 2017).

Another way of improving adherence is also to use technology-based methods.  Granholm, Ben-Zeev, Link, Bradshaw and Holden (2012) and Montes, Medina, Gomez-Beneyto and Maurino (2012) have studied the use of electronics-based strategies, including the use of text messages, pill counters, computerized alert systems, and pill dispensers to improve medication adherence.  Granholm and colleagues (2012) noted that text messages sent to patients with schizophrenia on matters related to medication adherence, socialization and auditory hallucinations helped improve their medication adherence and their ability to live independently.  There are however some issues with this study in terms of the computation of medication adherence findings especially as patients may not accurately report their medication adherence; self-reports are not as reliable as pill-counters.  Still, Granholm’s study does present reliable results which are supported by other studies and authors including Montes and colleagues (2012).  Montes, et al., (2012) discovered how daily text messages for three months sent to schizophrenia patients helped improve medication adherence, and when the sending of text messages was gradually reduced, medication adherence also declined. Sending text messages to schizophrenia patients therefore has a direct impact on improving outcomes for patients who have poor medication adherence.

Stip, Vincent, Sablier, Guevremont, Zhornitsky, and Tranulis (2013) also established how the use of electronic pill counters to evaluate medication adherence detected almost a 50% non-adherence rate among schizophrenia patients.  However following 6-8 weeks of intervention, improvements in adherence were reported especially for patients who had very poor adherence rates (Stip, et al., 2013).  There is however an imbalance between the two groups being compared by the authors including low rates of completion in the study groups (Stip, et al., 2013).  The sample size is also small which therefore reduces its generalizability.  The duration of the trial is also very short, at 6 weeks only; the study would have benefitted from a longer duration or period of study.

Priebe and colleagues (2013) were able to establish that using modest financial incentives, at 22 dollars per visit to the clinic within a 12 month trial period led to a significant increase in adherence rates.  This study however has some protocol violations and some data were missing during treatment at the baseline and study periods.  It was not possible to blind the clinicians, patients, or even the researchers and outcomes were reported for less than 50% of the sample (Priebe, et al., 2013).  These results cannot therefore be generalized as it only covers patients who were placed under long-acting depot injections (Priebe, et al., 2013).  Nevertheless, the study does present a viable option in improving adherence among patients like George.  Another suggestion for improving adherence was discussed in the study by Valenstein et al., (2011) where the authors used a pharmacy-based intervention, mostly unit-based prescriptions of medications in psychiatric patients which included medication education in the packaging as well as refill reminders mailed 2 weeks in advance.  This intervention led to a significant increase in medication adherence ratios (Valenstein, et al., 2011). This Valenstein, et al., (2011) study however was not double-blind when this option could have helped improve the reliability of its results.

The use of environmental support and home visits, as well as full cognitive adaptation training, improved medication adherence was also seen among schizophrenia patients according to Velligan, Mintz, Maples, Xueying, Gajewski, Carr, and Sierra (2013).  This translated to medication education and a patient-centered or tailored environmental support system for patients that also led to better medication and appointment adherence.  The noted improvement was not seen when the home visits stopped (Velligan, et al., 2013).  This Velligan, et al., (2013) study however noted how a good number of those approached to be participants refused with others being dropped within the 1 month baseline period. This meant that the results of the study may benefit from a larger target population and as such its current generalizability is limited.

Conclusion

George’s non-adherence to Risperidone is a significant but unsurprising issue in his care given that most schizophrenia patients lack insight about their condition and are likely to not accept that they have schizophrenia and are therefore also not likely to agree or adhere to any prescribed medications.  It is important to improve George’s adherence to his medication in order to help manage his symptoms and to give him a chance to be a functional and independent member of society.  One of the strategies which can be applied includes family support and clinician support interventions where he and his family would be taught more about schizophrenia and the importance of medication adherence.  Electronically-assisted methods can also be used to monitor his intake, using pill counters and text-messages to remind him of his due medication.  Visits to his place of residence by the health personnel can also help promote improved outcomes for George.  This would comprise a strong follow-up and monitoring outside the hospital or clinic.  Under these conditions, George’s medication adherence can be improved and he may be able to live a relatively normal life despite his mental health issue.