ADHERANCE TO TREATMENT IN PSYCHIATRIC NURSING

MARTIN WARD

DEFINITION

• Adherence can be described as the extent to which a persons behaviour - taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a healthcare provider (WHO 2003)

Good adherence is based upon patient self management

• There is a difference between compliance and adherence

• Compliance suggests the patient is passively doing what the nurse tells him/her to do. Once the nurse is no longer present the patient is more likely to make their own decisions, with 'non-compliance' being one of them

• Adherence suggests mutual agreement and partnership between patient and nurse. Once the nurse is no longer present the patient is more likely to 'adhere' to treatment because they agreed it was right for them.

(Gray et.al. 2002)

Theoretically……..

Giving people choices and allowing them to make a contribution to the decisions about their on-

going care, as an equal partner, should increase their commitment to their agreed treatment

programme.

• Adherence is often thought of as being a wasteland where nursing staff wander aimlessly around in search of an answer to the age old problem of convincing their patients to comply with agreed treatment programmes!

EARLY ONSET, FIRST EPISODE PSYCHOSIS

• These patients are more like not to comply with treatment programmes

• Up to 60% of patients do not continue taking medication after their first admission

• Re-admissions are much higher in this group of patients

(Brown et.al. 2012)

VIEWS OF RELAPSE

• Staff views of the process of relapse differs from those of patients

• Staff may see none adherence as defiance

• They may also see this as a challenge to their authority

• Patients may suffer quality care issues as a consequence, especially if they are re admitted on a regular basis

• Patients may be blamed for non-adherence

• Patients may feel that their views and opinions have not been taken account of, or listened to (Hayes 2001)

• Patients may feel that if they do not do as they are told they will be 'punished'

• Patients may feel guilty that they have not been able to adhere, even though they may not have properly prepared

PEER SUPPORT

• There is evidence to suggest that patient peer support can be extremely effective in increasing treatment adherence, especially amongst individuals with similar conditions

WHY DO PATIENTS NOT FOLLOW TREATMENT REGIMES?

• There is no single reason and it may be a combination of things

• Each patient's situation must be assessed individually

• They may feel well and consider their medication unnecessary

• They just do not like taking medication

• They may be experiencing challenging side effects and stop taking medications in an attempt to address this

• They may self medicate using recreational drugs as an alternative to prescribed medication

• They may be too disturbed to appreciate when and how to take their medication

• They have unintentionally not taken their medication due to circumstances (Shultz 2009)

RELATIONSHIP ISSUES

• They may not trust their care worker and will therefore not take account of any adherence advice they are given

• They may feel that mental health services are trying to force them to do something against their wishes

• They may not have a good working relationship with professional care staff (McCabe et.al. 2012)

• They may not have experienced adherence therapy

• They may have had bad experiences in the past and are unwilling to repeat these again

• Learning how to prevent relapse is perhaps one of the biggest challenges to nurses working in acute psychiatric care

• Unfortunately, few appear to know anything about relapse therapy

– RICHARD GRAY

"Working collaboratively with staff is one of the main benefits of AT "

ADHERANCE THERAPY

• All patients should have a risk assessment undertaken to establish non-adherence potential

• Individual programmes should be devised to address specific patient problems

• Usually involved psycho-education

• Must be given over time

• Starts at the beginning of treatment programme

• Must be agreed with the patients

• Usually repeated once every month as a back up and opportunity for reassessment

• There is no one single approach that fits all the needs of ever patient

• Nurses need to have a 'tool-kit' of options to enable them to meet the neds of individual patients

• But, certain principles must be followed to ensure the patients has what they need to increase the potential for adherence

• Sessions must be incremental, meaning that a patient should progress through a series of competency based tasks, completing one before moving to the next

• Ideally, the sessions are delivered by the same health care worker each time for both collaborative and relationship reasons

• Staff attitudes are as important as those of patients and staff need to have training in delivering these packages

FOUR KEY ELEMENTS

• A structured assessment

• Dealing with resistance

• Exchanging information

• Five key skills: problem solving; looking back; exploring ambivalence; talking about beliefs about medication, looking forward (Gray 2007)

• The WHO (2003) estimated that non-adherance to treatment in chronic illness in the developed countries was as much as 50%, and greater in non-developed ones

• Adherance therapy has been shown to increase treatment compliance by as much as 40%

• Increasing treatment compliance can be more effective than seeking other treatment options

• Relapse can be reduced by 60%

• Adherence therapy has not been shown to have any effect on patients quality of life (Gray et.al 2006)

• Adherence therapy can be successful across a broad cross section of mental health as well as physical health problems (Safren 2013)

NO ADHERENCE, NO RECOVERY

REFERENCES

• Brown E, Gray R, Jones M, Whitfield S. (2012) Effectiveness of adherence therapy in patients with early psychosis: A mirror image study International Journal of Mental Health Nursing

• Gray R., Wykes T. & Gournay K. (2002) From compliance to concordance: a review of the literature on interventions to enhance compliance with antipsychotic medication. Journal of Psychiatric and Mental Health Nursing  9:277–284

• Gray, R. (2005) Adherence therapy manual. http://www.academia.edu/2436503/Adherence_therapy_manual

• Gray R. et.al. (2006) Adherence therapy for patients with schizophrenia: European multi centre randomised control trial. British Journal of Psychiatry 189:508-514

• Hayes, R.B. (2001) Interventions for helping patients to follow prescriptions for medications. Cochrane Database for Systematic Reviews -issue 4. Oxford.

• McCabe R, Bullenkamp J, Hansson L, Lauber C, Martinez-Leal R, et al. (2012) The Therapeutic Relationship and Adherence to Antipsychotic Medication in Schizophrenia. PLoS ONE 7(4): e36080. doi:10.1371/journal.pone.0036080

• Safren S, Gonzalez J, Wexler C et.al. (2013) A randomized controlled trial of cognitive behavioural therapy for adherence and depression (CBT-AD) in patients with uncontrolled type 2 diabetes. http://care.diabetesjournals.org/content/early/2013/10/22/dc13-0816.abstract

• Schulz M. (2009) Adherence therapy for people with schizophrenia: a multi-centre project. World mental health day. Cyprus. Horatio: European Psychiatric Nurses. www.horatio-web.eu/

• WHO (2003) Adherence to long-term therapies: Evidence for action. World Health Organisation. Geneva