Are Most of Your Schizophrenic Patients Non-adherent to Treatment?

presented recently at the International Early Psychosis Association (IEPA) Congress in Amsterdam, Netherlands, shows that psychiatrists feel 53% of the patients with schizophrenia are either non- or partially adherent to prescribed medication. The Adherence in Schizophrenia (ADHES) research used information taken from a large survey of more than 4,5000 psychiatrists who represented 4.45 million patients with schizophrenia from 36 countries in Europe, the Middle East, and Africa.

The issue of non-adherence among patients with schizophrenia doesn’t stop with the fact that such patients are five times more likely to relapse than those who are adherent; their likelihood of being hospitalization is significantly increased, thus increasing the overall cost of care. Plus, frequent relapses and hospitalization and increase one’s isolation, making it more difficult for the person to find and keep a job, and relapse that occurs due to non- or partial adherence to medication can lead to increased tendencies for violent acts, like suicide and homicide, especially when a substance abuse is in the mix.

Psychiatrists interviewed for the study estimated that less than 20% of their patients stopped medication for more than five days without consulting them. The most frequent reasons for discontinuing medication, as identified by the psychiatrists were:

• Patient lack of insight into schizophrenia (36%)
• Patient felt better and thought medication was no longer necessary (26%)
• Irregular routine of difficult living circumstances (18%)

Compounding the issue of non-adherence is that less than half of patients are able to relate non- or partial adherence to a decline in illness or risk for relapse, according to 75% of responding psychiatrists. What’s more, lack of insight and disordered thinking recognized features of schizophrenia, with some studies suggesting about 50-80% of schizophrenics don’t believe they are ill.

One would think that psychiatric assessment of adherence during office visits doesn’t make much of an impact on medication adherence, with 76% of psychiatrists in the study stating they did so during nearly every visit—77% chose to do so by asking the patient directly, and 64% prefer to ask a caregiver, friend, or relative. However, most studied psychiatrists said they don’t regularly use drug plasma levels, log books, pill counting, or adherence assessment scales to track adherence on a more scientific and reliable level.

“The survey findings clearly illustrate the high levels of non-adherence in schizophrenia. Whilst we know the devastating effects relapse can have, we need to do more to actively address inadequate adherence levels if we are to break the current cycle of decline associated with schizophrenia,” said ProfessorJosé-Manuel Olivares, Department of Psychiatry, Meixoeiro Hospital, Vigo, Spain. “Enhancing medication adherence through the use of long-acting injectable antipsychotics, particularly early in the course of schizophrenia, helps us to know that the patient has received their medication. It is imperative not only to reduce the suffering and cost burdens associated with relapse in schizophrenia, but to improve the future outlook and overall quality of life for these patients.”

Problems with adherence strongly affect caregivers—both professional and non-professional—of patients with schizophrenia; 48% of responding psychiatrist said most of their patients need to be reminded by family members to take medication, with 28% saying they believed most of their patients relied on nurses, psychiatrist, or professional caregivers to do so.

“Family members play an invaluable role in helping people with schizophrenia to take their medication regularly, but it can be very challenging. The family should be given support and education to help them understand how best they can assist the person they care for keep on track with their treatment and help to maintain their well being”, said Kevin Jones, secretary general, The European Federation of Associations of Families of People with Mental Illness.

For more on the ADHES survey, access the following:

• Slide show highlighting key findings
• Full press release
• Poster presented at the International Early Psychosis Association Congress
• Background information on schizophrenia for patients

So, what’s a psychiatrist to do? How can you increase adherence among your patients? Is the issue similarly frequent in your practice? Would long-acting anti-psychotics make a difference? Would the difference be big enough? What else could help? Tell us what you thin about this important issue!