Preventing Noncompliance in Psychotic Patients

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Non-adherence to medication and medical recommendations in patients is very common across all branches of the healthcare field. In fact, it is one of the challenges healthcare providers face on a daily basis with their patients. We all know or have heard of the patient with diabetes type 2 consuming carbohydrates in excessive amount regularly or the elderly man who recently suffered from a heart attack eating food high in cholesterol regularly or even the patient with a microbial infection rejecting the full course of the antibiotic treatment prescribed by the physician. I have to admit that I have been guilty of the latter. So, when patients become noncompliant to their medications, it makes it very difficult to provide effective medical care. Unfortunately, for psychotic patients, these noncompliant behaviors can pose greater risks, as studies show a higher frequency of noncompliance in psychotic patients.

Many psychotic patients rely on their medications alone to control and regulate their mental disorders. Neuroleptic drugs are essential in treating psychotic disorders such as bipolar disorder, schizophrenia, clinical depression and many more. Some patients require several months or years of medication or even lifelong medication is necessary.  However, up to 80% of psychotic patients fail to comply with their treatment (1). This is a major problem! I think the first question we need to ask ourselves is why so many patients with mental disorders are either rejecting treatment, self-medicating with illegal drugs, or discontinuing a prescribed medication? Is it due to the patient’s negligence? Carelessness? In the case of an acquaintance with schizophrenia that is not the case. He informed me that his medication was making him gain an excessive amount of weight, something he despises. He proceeded to tell me he felt like a “zombie”. I asked him if he was still taking his medication but he informed me that he was self-medicating with marijuana. A few months later, I found out he relapsed and got hospitalized. Sadly, this has been an ongoing battle with many patients. For many the side effects are just too much to bear.  You see, one of the major reasons these patients are noncompliant to their treatment is due to the side effects of these drugs. Although these medications can cause great relief to a mental condition that has been affecting the lives of these individuals, they are not of small risks.

Almost all psychotropic medications cause some serious side effects which can be life-threatening and irreversible. In many cases, these psychotropic medications fail to help patients. So, it really makes me wonder if these patients are being treated in the most effective way. Healthcare providers can only hope that their patients are actually following the course of treatment. Unfortunately, it is difficult to ensure compliance. According to the National Institute of Neurological Disorders and Strokes of the National institutes of Health, antipsychotic drugs can cause neuroleptic malignant syndrome (NMS)(3). NMS is characterized by fever, muscular rigidity, altered mental status and autonomic dysfunctions. One of the most common side effects of antipsychotic drugs is a condition known as akathisia. Between 20 to 75 percent of patients develop this condition.(4) Akathisia is a movement disorder characterized by uncontrollable physical restlessness, agitation, shaking of arms and legs, anxiety and panic. The condition can develop as soon as the patient start taking the drug. Many of these side effects are associated with older neuroleptic drugs. There have been major advancement of modern psychopharmacology with the development of newer drugs. But even with these new drugs, weight gain and sexual dysfunction can be two of the most common side effects associated. Some other common side effect associated with these drugs are nausea, dizziness, sleepiness, Diarrhea, suicidal behaviors etc.

There are many factors associated with noncompliance in psychotic patients. The lack of insight and lack of awareness of the illness itself pose a challenge especially in schizophrenia.(2) However, we cannot deny that adverse effects of these psychiatric drugs contribute greatly to this critical issue. So, what is the solution? How do we reduce the lack of compliance due to psychotic drugs’ adverse effects? Firstly, it is the responsibility of clinicians to educate their patients on the illness and the different side effects of the drugs prescribed. In addition, patients need to be part of the decision-making process. Pharmacological strategies such as dose adjustment and the use of long-acting injections would be a great way to ensure patients comply with treatment. Dose adjustment is especially important because prescribing medication is not a “one size fits all” process. Reducing medication dose can reduce the side effects in patients. Of course, I understand that some patients require higher dose and in that case, clinicians could add another class of medication, such as anticholinergic for extrapyramidal side effects.(2) Another interesting approach would be the use of psychotherapy in addition to drug therapy. Psychotherapy provides a holistic approach to treating a psychotic patient, something that drugs cannot do on their own. There are different types of psychotherapy and research has shown that Cognitive Behavioral Therapy can change thinking and behavior patterns that are harmful or ineffective and replace them with functional behaviors.(4)

There is not just one strategy to use to improve compliance. Every patient is different and has different requirements.  Some clinicians use a combination of strategies and approaches to improve compliance in their patients. The ultimate goal is to ensure that psychotic patients are being treated efficiently and thoroughly to avoid relapse and psychiatric hospitalization. In the end, we need to put more emphasis on new drugs development, the use of psychotherapies and drugs adjustments to reduce noncompliance in patients with psychotic disorders and improve the quality of life of these patients.

References:

1.Gray, R. “Compliance Therapy in Psychotic Patients. Many Ethical Questions Arise from Study.” BMJ (Clinical Research Ed.)., U.S. National Library of Medicine, 18 May 1996,

2.Kane, John M, Taishiro Kishimoto, and Christoph U Correll. “Non-Adherence to Medication in Patients with Psychotic Disorders: Epidemiology, Contributing Factors and Management Strategies.” World Psychiatry 12.3 (2013): 216–226. PMC. Web. 30 Nov. 2017.

3.Medical Whistleblower Advocacy Network.” Psychiatric Drugs Side Effects | Medical Whistleblower, medicalwhistlebloweradvocacynetwork.com/psychiatric-drugs-side-effects-.

4.Pareck, Ranna. “What Is Psychotherapy.” Psychiatry.org, July 2016, www.psychiatry.org/patients-families/psychotherapy.

5.Balon, Richard. “Managing Compliance.” Managing Compliance | Psychiatric Times, 1 May 2002, www.psychiatrictimes.com/articles/managing-compliance/page/0/1.

By Tressie Charles, Master of Science in Medical Sciences, University of Kentucky