treatment non- compliance in psychiatry
DESCRIPTION
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 - PowerPoint PPT PresentationTRANSCRIPT
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TREATMENT NON-COMPLIANCE IN PSYCHIATRY
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TREATMENT NON-COMPLIANCEIN PSYCHIATRY
NON-COMPLIANCE:
PREVALENCE REASONS
CLINICAL CONSEQUENCES
- Dr. Ashish Srivastava, M.D.
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NON-COMPLIANCE• INTRODUCTION
• PATTERNS OF NON-COMPLIANCE
• THEORETICAL MODELS
• PREVALENCE
•MEASUREMENT OF NON-COMPLIANCE
•REASONS FOR NON-COMPLIANCE
• CLINICAL CONSEQUENCES
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• 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]
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•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.
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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]
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•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]
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PATTERNS OF N.C.
•Total N.C. - rare !
•Intermittent/ partial N.C.
•Late compliance
•Rarely… N.C. by overuse of medications.
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•Unintentional v/s intentional N.C.
•Drug Holidays
•White coat compliance
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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]
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• 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
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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%
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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.
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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]
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DEPR
ES
SIO
N 10% never follow up, compliance decreases over
time, greatest within 1st month of treatment.
AD discontinuation rates: 1st wk- 16%, 2nd wk- 41%, 3rd wk- 59%, 4th
wk- 68% [Johnson 1981]30% of patients stopped Rx within
1 month and 45-60% by 3 months
[Hotopf 1997]
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BIP
OLA
R
DIS
OR
DER
18-52% , 50% some degree of N.C., 32% partial N.C.
[Scott & Pope 2002, Rosa 2007]
Increased N.C. in patients with co-morbid substance use disorder
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SC
HIZ
OPH
REN
IA74% discontinued treatment within
18 months [Liebermann 2005]
N.C. rates > 50%, associated with young age, SUD, hospitalization, use
of TAPs, negative symptoms [Valenstein 2006, Rettenbacher
2004]
Significant N.C. within 1 week of discharge in patients with co-morbid
SUD[Olfson 2000]
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AD
HD
Compliance dropped to 80% by 1 year and 52% by 3 years
[ Thiruchelvam 2001]
26% refused treatment at the onset55% stopped treatment by 10 months
[Firestone 1982]
Less than 10% of families discussed prior to discontinuation
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•SUDs : variable degree of N.C. (upto 70-80%)
•Increased rate of N.C. in developmentally disabled and cognitively impaired patients.
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MEASUREMENT OF NON-COMPLIANCE
DIRECT MEASURE
S
• Supervised doses• Blood levels
INDIRECT MEASURE
S
• Self-reporting, clinician’s interview
• Pill count• Pharmacy records• Electronic
monitoring
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REASONS FOR NON-COMPLIANCE
•Medication specific factors
•Patient specific factors
•Provider specific factors
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MEDICATION SPECIFIC FACTORS
1. ADVERSE REACTIONS:Fears regarding side effects more
predictive of N.C. than the actual side effects of medications...
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- side effects considered mild by a psychiatrist may have significant impact on medication compliance.
- troublesome, fearful, difficult to describe, embarrassing, persistent, permanent side effects.
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2. INEFFECTIVENESS:
- at best 80% efficacy can be expected
- efficacy-effectiveness gap
- perceived effectiveness
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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.
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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.
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PATIENT SPECIFIC FACTORS
1. Attitudes/ beliefs of patients and their families
2. Age3. Abnormal illness behavior4. Culture/ religious beliefs5. Psychiatric disorders and symptoms
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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).
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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
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•Other problems areas:- fear of being dependent on
medications- fear of drug accumulation and side-
effects- concerns about mental illness
stigmaLink (2004) stated that mentally ill are the most stigmatized social group.
- family factors
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•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.
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Psychiatric Disorders and Symptoms:
•Depressionamotivatio
n
anergia
cognitive impairme
nts
reduced task
initiation
cognitive triad
suicidal ideas
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•Bipolar disorders
- disorganization, sleep disturbances, hypomanic Sx, grandiosity and psychotic features in manic phase.
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•SchizophreniaPoor judgment and insight, expressed
emotions, affective symptoms
Cognitive deficits
Negative symptoms
disorganization
Psychotic features
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•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
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•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
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•ADHD- distractability, inattention,
disorganization, comorbidity, child’s / parent’s beliefs
•Developmentally disabled
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PROVIDER/ PRACTITIONER SPECIFIC FACTORS
1. Practitioner’s ability
2. Practitioner’s motivation
3. Awareness of patient’s compliance
4. Therapeutic alliance
5. Continuing medical education
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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
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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.
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•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…
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Having looked at the problem, solutions need to be seeked ...
THANK YOU…