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TREATMENT NON- COMPlIANCE IN PSYCHIATRY

TREATMENT NON- COMPlIANCE IN PSYCHIATRY. TREATMENT NON-COMPLIANCE IN PSYCHIATRY. NON-COMPLIANCE: PREVALENCE REASONS CLINICAL CONSEQUENCES - Dr. Ashish Srivastava , M.D. NON-COMPLIANCE. INTRODUCTION PATTERNS OF NON-COMPLIANCE THEORETICAL MODELS PREVALENCE

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TREATMENT NON- COMPlIANCE IN PSYCHIATRY

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  1. TREATMENT NON-COMPlIANCE IN PSYCHIATRY

  2. TREATMENT NON-COMPLIANCEIN PSYCHIATRY NON-COMPLIANCE: • PREVALENCE • REASONS • CLINICAL CONSEQUENCES - Dr. AshishSrivastava, M.D.

  3. NON-COMPLIANCE • INTRODUCTION • PATTERNS OF NON-COMPLIANCE • THEORETICAL MODELS • PREVALENCE • MEASUREMENT OF NON-COMPLIANCE • REASONS FOR NON-COMPLIANCE • CLINICAL CONSEQUENCES

  4. ½ to 2/3rds of patients either fail to seek treatment or are non-compliant with treatment …[ Kessler 2001, Regeir 1993] • No. of studies published BUT interventions developed have LIMITED IMPACT on the problem! [Haynes, 2005]

  5. Mental illness stigma & ubiquitous fears about psychiatric medications IMPORTANT In determining compliance. [ Corrigan & Watson,2006] • Compliance/ N.C. is a continuous process with multiple dimensions rather than a univariate and dichotomous one.

  6. DEFINING COMPLIANCE... • The extent to which a person’s behavior in terms of taking medications, following diets or executing lifestyle changes coincides with medical health advice. [ Blackwell, 1992] • The extent to which a patient takes medications as prescribed… [ Fawcett, 1995]

  7. Biological N.C. : concept of involuntary factors affecting compliance eg. metabolism. [Frank 1994] • Treatment adherence: practitioners have the important role of forming alliance with the patient to effect successful treatment. [ Frank 1995]

  8. PATTERNS OF N.C. • Total N.C. - rare ! • Intermittent/ partial N.C. • Late compliance • Rarely… N.C. by overuse of medications.

  9. Unintentional v/s intentional N.C. • Drug Holidays • White coat compliance

  10. THEORETICAL MODELS OF HEALTH BEHAVIOR • Health belief model [Budd 1996, Lingam & Scott 2002] • Theory of reasoned action (TRA) and theory of planned behavior (TPB) [Ajzen 1980,1988] • Stages of change theory [Prochaska 1994] • Protection motivation theory (PMT) [Rogers 1983]

  11. All assume that medication compliance can be predicted by • Patient’s perception of threat from medical/psychiatric condition • Their expectancy regarding the consequences of medical compliance

  12. PREVALENCE OF NON-COMPLIANCE • 20-50% of any patient population is likely to be at least partially non-compliant… • Sackett & Snow : - short term regimens : 62% - long term preventive regimens: mean 57% - long term treatment regimens: mean 54%

  13. EVIDENCE SHOWS. . . • N.C. rates higher when treatment prescribed for long duration. • Medication compliance tends to decline over time. • Baseline compliance is strongest predictor of long term compliance. • Past h/o N.C.  N.C. in future.

  14. In-patient v/s out-patient N.C… • Non-compliance more prevalent in out-patient treatment (20-65%) than in-patient treatment (5-37%). [ Hodge 1990, Remington 1995]

  15. SUDs : variable degree of N.C. (upto 70-80%) • Increased rate of N.C. in developmentally disabled and cognitively impaired patients.

  16. MEASUREMENT OF NON-COMPLIANCE

  17. REASONS FOR NON-COMPLIANCE • Medication specific factors • Patient specific factors • Provider specific factors

  18. MEDICATION SPECIFIC FACTORS • ADVERSE REACTIONS: Fears regarding side effects more predictive of N.C. than the actual side effects of medications...

  19. - side effects considered mild by a psychiatrist may have significant impact on medication compliance. - troublesome, fearful, difficult to describe, embarrassing, persistent, permanent side effects.

  20. 2. INEFFECTIVENESS: - at best 80% efficacy can be expected - efficacy-effectiveness gap - perceived effectiveness

  21. 3. REGIMEN COMPLEXITY: - inverse relationship between number of daily dosages and treatment adherence. [Claxton 2001] - higher compliance with twice daily(85%) v/s TDS/QID regimens (65%), evening doses missed twice as often as morning doses. [Kruse 1993] - increased N.C. with polypharmacy.

  22. 4. COST: - not only medication costs, additional expenses. - costs may be more than even disability income. - many health insurance plans do not include psychiatric disorders or only acute psychosis. In additions there are many riders.

  23. PATIENT SPECIFIC FACTORS • Attitudes/ beliefs of patients and their families • Age • Abnormal illness behavior • Culture/ religious beliefs • Psychiatric disorders and symptoms

  24. Attitudes/ beliefs of patients and their families: - Patient’s ability to comply with treatment is influenced by his cognitive and motor functioning and his knowledge about medications. - The attitudes/ beliefs of patients are at least as important as side-effects in predicting compliance (Lingam and Scott, 2002).

  25. Patient’s motivation to comply is influenced by many complex and inter-related factors like: - severity of symptoms - past experiences with medications - personal beliefs - treatment goals - temperament or personality

  26. Other problems areas: - fear of being dependent on medications - fear of drug accumulation and side-effects - concerns about mental illness stigma Link (2004) stated that mentally ill are the most stigmatized social group. - family factors

  27. Age factor: -adolescents and geriatric population has comparatively higher N.C. • Abnormal illness behavior: - denial, conscious and unconscious motivation influence compliance (Tilowsky, 1993). • Cultural/ religious beliefs.

  28. Psychiatric Disorders and Symptoms: • Depression

  29. Bipolar disorders - disorganization, sleep disturbances, hypomanicSx, grandiosity and psychotic features in manic phase.

  30. Schizophrenia

  31. Personality disorders - poor therapeutic relationship, transference and counter transference issues • Dementia / cognitive disorders - poor judgment and insight, executive function deficits, memory and other cognitive deficits, dependency needs, sensory deficits

  32. SUDs - medications interfere with sought after effects of the substance - fear that prescribed medications will interact with the substance and cause severe problems/ effects - increased risk of secondary depression, anxiety, insomnia - loss of confidence in medications - patient depleted of money, time and support - N.C. due to overuse of medications

  33. ADHD - distractability, inattention, disorganization, comorbidity, child’s / parent’s beliefs • Developmentally disabled

  34. PROVIDER/ PRACTITIONER SPECIFIC FACTORS • Practitioner’s ability • Practitioner’s motivation • Awareness of patient’s compliance • Therapeutic alliance • Continuing medical education

  35. PRAGMATIC ISSUES: • Location of mental health care facility • Communication and transportation services • Practices of third party payers • Communication between various health care providers • National health care policies and regulations

  36. CLINICAL CONSEQUENCES OF NON-COMPLIANCE • FINANCIAL COSTS: - US: $100 billion annually, cost of re-hospitalization for patients suffering from schizophrenia is nearly $2billion/ year (60% attributed to loss of effectiveness and 40% to N.C.). - Canada: 3.5 – 9 billion Can$/ year. - loss of manpower days.

  37. HUMAN COSTS: - increased number of hospitalizations (revolving door phenomenon). - poorer outcomes/ prognosis. - increased risk of suicide and harm to others. - poorer QOL, increased family burden, increased EE, counter transference issues…

  38. Having looked at the problem, solutions need to be seeked ... THANK YOU…

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