Overcoming the myths surrounding adherence

Clinicians lack a clear understanding of why patients do not always follow recommendations. Here are some practical strategies for improvement. 

Limited adherence to health-care recommendations is a common problem that can interfere with treatment efficacy across medical disorders. Clinicians have tried to understand this perplexing problem in hopes of finding a remedy, but to date no single clear-cut solution has emerged. Part of the difficulty may arise because clinicians know how they want the therapeutic process to go, i.e., an ideally followed treatment regimen will result in success, if only their patient would comply. This article will clarify some common misconceptions about adherence and offer a model for addressing patients' individual challenges when attempting to follow medical advice and instructions.

Common misconceptions

Patients are either compliant or noncompliant. Some clinicians believe that compliance is tied to personality, i.e., there are patients who are more compulsive than others about their self-care behaviors. While it is true that organizational skills and self-discipline vary from person to person, when it comes to treatment adherence, those traits do not necessarily apply. In fact, studies suggest that patients vary over time in the amount of effort they put toward following their treatment regimens.1

If the medication is prescribed, patients will take it. It may be a reasonable expectation that patients presenting for treatment and provided with care will follow the instructions of their provider. Unfortunately, despite their need for treatment and their good intentions, patients have difficulty sticking with treatment regimens, especially when they are long term. For example, studies of medication adherence show that only 40%-90% of patients prescribed antidepressants consistently take them.2 The same is true for general medical conditions. One study assessed adherence rates in various patient populations and found 61% adherence with medications for seizure disorder, 51% adherence for osteoporosis, and only 37% adherence for gout.3

If the instructions are clear, patients will follow them. There is some validity to this assumption. For example, when written instructions are provided in addition to verbal instructions, patients presenting with sore throat are more likely to follow treatment instructions.4

If it is good for patients, they will do it. Bipolar disorder requires continuous treatment with medication. Taken consistently, pharmacotherapy can control symptoms and reduce the risk of relapse. When symptoms are under control, there is less disruption in patients' lives. Despite these facts, treatment adherence in bipolar disorder remains a significant problem. A meta-analysis of medication studies in mood disorders found that depending on the definition of adherence, there was a .53 to .63 probability of adherence with medication.5 Assessing adherence by tracking medication refills, other studies found that 33% of patients with bipolar disorder filled their prescriptions irregularly,6 and 64% of patients hospitalized for bipolar disorder had not been taking their medications regularly prior to relapse.7

If the consequences for nonadherence are great, patients will comply. It stands to reason that if deviating from treatment will cause significant distress or complications, the individual will be more likely to follow the provider's recommendations. In the case of asthma, in which the consequences for nonadherence can be dire, one study found that 85%-90% of prescriptions were not refilled in the first year of treatment.8 Perhaps more surprising are the low adherence rates with antirejection drugs in transplant patients. According to one study, more than a third of patients did not consistently adhere to their medication regimen even when fully aware of the potential life-threatening consequences.9

Adults won't follow treatment guidelines for themselves, but they will for their children. Unfortunately, adults are no better at following treatment guidelines for their children than they are for themselves. For example, up to 65% of adults do not enforce the use of car restraints by their children,10 and 28% do not follow recommended vaccination schedules.11 In the first month following diagnosis of new-onset epilepsy in children, 20% of parents did not adhere to the prescribed medication regimen.12 Similarly, compliance with refilling prescriptions for children's asthma medications is low.8

Smart patients will comply. In many studies involving psychiatric populations, education is not a significant predictor of adherence to treatment.13 The same is true for such medical conditions as type 2 diabetes: Educational status was unrelated to how well patients followed their provider's medication and self-care recommendations.14

Patients are in denial. As frustrated clinicians try to understand how patients can neglect their health, they sometimes infer interference of psychological processes (e.g., denial of illness severity). Diagnoses of major medical conditions can be difficult to accept, especially when the disorders are chronic or life-altering. A study of diagnosis acceptance by patients with bipolar disorder found that only 16% of variance in nonadherence could be accounted for by denial.15 Many patients with chronic illnesses understand and accept their diagnoses and see the need for treatment, but this does not guarantee that their actions will fall in line with their logic.
Because adherence waxes and wanes over time, the longer an illness lasts, the more likely clinicians are to see those fluctuations. It also appears that the consequences of nonadherence, whether short term or long term, do not motivate most patients to comply (at least not for very long). While very few patients always adhere to treatment, the majority follow most health instructions much of the time. There is more to this problem than denial.

The cognitive behavior approach to treatment adherence

Becker's Health Belief Model16 forms the foundation for the cognitive behavior therapy (CBT) approach to understanding  adherence.17 The underlying premise is that all patients are capable of adherence if the conditions are right. Specifically, the treatment must be acceptable, understandable, and manageable. To be acceptable, the patient must be in agreement with the health-care provider regarding the nature of her or his problem and the strategy for intervention. The responsibility for communication of medical information lies with the clinician, who must provide a clear explanation of the diagnosis and the treatment options.

Unfortunately, although a treatment plan may be acceptable, understandable, and manageable, many factors can interfere with patient follow-through. CBT aims at identifying potential obstacles and creating plans to avoid or cope with them if they begin to interfere with treatment. 

The most common obstacles to adherence across diagnoses and treatment types fall into five categories. To assess the potential for these obstacles to interfere with the treatment plan, begin by normalizing adherence problems (“Many people have trouble sticking with their treatment plan”) and then ask about potential obstacles (“What could keep you from following these instructions?” or “In the past, what kinds of things might have kept you from sticking with your treatment plan?”).

• Treatment-related obstacles: The treatment is too complex, causes discomfort or side effects, or is too expensive.
• Therapeutic environment: The therapeutic alliance is weak, support staff are rude or impatient, or the environment is unpleasant.
• Competing advice: Input on treatment from family and friends, the Internet, and the media is sometimes contrary to what is provided by clinicians.
• Practical problems: Forgetfulness, disorganization, lack of self-care skills, and poor decision-making abilities can keep patients from following through with treatment even when they have the best of intentions.
• Faulty beliefs: Misconceptions about illnesses and their treatment can cause anxiety. When overwhelmed with the implications of a diagnosis, patients can have difficulty processing information regarding treatment options or plans, additional assessments, and the need for follow-up.

Addressing obstacles to adherence

The general strategy for improving treatment adherence is to identify obstacles before they become a problem and make a plan to avoid or reduce them. Below are some strategies that can be used in any practice.

Be clear. Often what is needed to avoid obstacles is definitive information regarding the clinician's expectations of the patient. If the instructions provided are too general (“Watch your blood sugars more carefully”), the patient is left to infer what is needed (“My doctor wants me to give up everything I enjoy”). Be as specific as possible when giving instructions.

Keep it simple. Nonadherence worsens with the complexity of the intervention. Keep the plan as simple as is reasonably possible. The same goes for instructions. Avoid overwhelming the patient with details that may not be necessary in explaining the diagnosis and treatment.

Make eye contact.
Although busy practices may not allow time to visit with patients, make an effort to form an alliance and maintain that alliance by making eye contact, shaking hands, or showing interest. Staring at a chart or computer monitor depersonalizes the interaction and leaves patients feeling uncomfortable. An extra minute or two of personal contact will help strengthen the connection and increase the chance that patients will follow your instructions.

Write it down. Treatments can vary in complexity, but when a patient is not feeling well, even the seemingly simplest intervention can be difficult to comprehend or remember. Providing written instructions and asking the patient to repeat the instructions will reduce error.

Use visualization. Even the most effective interventions will fail if the patient is unable to manage the steps. It is worth your time to inquire about how patients will manage their treatments on a daily basis. Ask the following questions and encourage patients to visualize engaging in self-care behaviors. Use this interaction to troubleshoot the situation by identifying pitfalls and generating possible solutions.

• Who can help with treatment at home?
• What assistance or resources are needed?
• Where will supplies be kept?
• When will the medication be taken?
• How will she or he remember what to do?

Invite questions. Make sure you allow the patient time to ask questions about the diagnosis and treatment. This interaction will provide an opportunity for you to address misconceptions about the illness and clarify any misunderstandings about the treatment regimen. It is also a good time to find out what the patient has heard from others about the illness or its treatment and reconcile differences in opinion. Avoid giving lengthy lectures. Instead, ask patients what they think about the diagnosis. Does it make sense? Do they have any concerns about the treatment? Pay attention to facial expressions or body language that suggests worry or confusion and ask about it.

Talk openly and regularly about adherence. It is normal to have difficulty sticking with treatment, especially regimens that are long term, uncomfortable, or time-consuming. Letting patients know that others struggle with adherence too will open the door to discussion of the problem. Some clinicians worry that talking about it will encourage noncompliance. This is not the case. Patients will struggle with adherence whether you mention it or not. Open discussion communicates that you understand how difficult treatment can be and that you want to help them to follow directions as much as possible. 

Set realistic goals. Adherence is not an all-or-nothing proposition. It will vary over time among patients. Although it is preferable that patients adhere strictly to their prescribed regimens, it is not realistic to expect 100% adherence at all times. Expecting perfection will only lead to frustration for providers. Instead, the goal should be for patients to adhere to treatment guidelines as closely as they can and as often as possible. Helping them to eliminate obstacles will increase the probability of adherence.

Clinicians can help reduce problems with adherence by talking with patients about it early in the course of treatment. Asking simple questions such as, “Have you ever had trouble taking medication every day?” or “Most people have difficulty taking medications regularly. Has this ever been a problem for you?” can lead to discussion of adherence problems before they start. Be certain that the diagnosis and treatment are acceptable, that the directions for self-care are understandable, and that the patient has the skills and resources to manage it. Identify the obstacles that could keep your patients from getting the most out of treatment, and be creative in finding solutions. Make adherence a frequent topic of conversation with patients so that the issue stays fresh in their minds. If they know you are going to ask about it, they will be more likely to adjust their behavior so they have good news to report.

Dr. Basco is a clinical psychologist and assistant professor at University of Texas at Arlington.

References

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2. Cramer JA, Rosenheck R. Compliance with medication regimens for mental and physical disorders. Psychiatr Serv. 1998;49:196-201.
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4. Segador J, Gil-Guillen VF, Orozco D, et al. The effect of written information on adherence to antibiotic treatment in acute sore throat. Int J Antimicrob Agents. 2005;26:56-61.
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8. Breekveldt-Postma NS, Koerselman J, Erkens JA, et al. Treatment with inhaled corticosteroids in asthma is too often discontinued. Pharmacoepidemiol Drug Saf. 2008;17:411-422.
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10. Rangel SJ, Martin CA, Brown RL, et al. Alarming trends in the improper use of motor vehicle restraints in children: implications for public policy and the development of race-based strategies for improving compliance. J Pediatr Surg. 2008;43:200-207.
11. Luman ET, Shaw KM, Stokley SK. Compliance with vaccination recommendations for U.S. children. Am J Prev Med. 2008;34:463-470.
12. Modi AC, Morita DA, Glauser TA. One-month adherence in children with new-onset epilepsy: white-coat compliance does not occur. Pediatrics. 2008;121:e961-e966.
13. Compton MT, Rudisch BE, Weiss PS, et al. Predictors of psychiatrist-reported treatment-compliance problems among patients in routine U.S. psychiatric care. Psychiatry Res. 2005;137:29-36.
14. Lutfey KE, Ketcham JD. Patient and provider assessments of adherence and the sources of disparities: evidence from diabetes care. Health Serv Res. 2005;40(6 Pt 1):1803-1817.
15. Greenhouse WJ, Meyer B, Johnson SL. Coping and medication adherence in bipolar disorder. J Affect Disord. 2000;59:237-241.
16. Becker MH. The Health Belief Model and Personal Behavior. Thorofare, NJ: Charles B. Slack;1974.
17. Basco MR, Rush AJ.  Cognitive-Behavioral Therapy for Bipolar Disorder, 2nd Ed. New York, N.Y.: Guilford Press; 2005.

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