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| CONCEPT PAPER |
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| Year : 2022 | Volume
: 19
| Issue : 2 | Page : 171-175 |
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Medication adherence and role of psychiatric nurse
Kankana Chakraborty1, Sandeep Kollipara2
1 PG student, Department of Psychiatric Nursing, LGB Regional Institute of Mental Health, Tezpur, Assam, India
2 Tutot, Department of Psychiatric Nursing, LGB Regional Institute of Mental Health, Tezpur, Assam, India
| Date of Submission | 30-Aug-2022 |
| Date of Decision | 30-Sep-2022 |
| Date of Acceptance | 30-Oct-2022 |
| Date of Web Publication | 27-Dec-2022 |
Correspondence Address:
Ms. Kankana Chakraborty
LGB Regional Institute of Mental Health, Tezpur, Assam
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/iopn.iopn_64_22
Pharmacotherapy is the most common strategy used for restoring health. Taking treatment has a positive outcome on the illness but in between treatment and outcome, an important role is played by adherence. A systematic review and meta-analysis found the prevalence of nonadherence ranges from 7% to 83%. Nonadherence can be of different types such as primary nonadherence where medication was prescribed but never initiated by the patient; secondary nonadherence where the medication is not taken as prescribed and nonpersistent; and nonadherence where the medication is stopped without the physician's order after starting. Poor socioeconomic status, low level of education, long distance, cost of medication, cultural belief, poor patient–provider relationship, overburden of health-care provider, chronic disease condition, asymptomatic condition, complex medical regimen, long duration treatment, misunderstanding of treatment instruction, medication side effect, and forgetfulness are the most common factors affecting adherence. Although there are no gold standards for assessing adherence, some subjective methods, for example, patient-kept diaries, interviews, and objective methods such as determining the presence of drugs in a patient's body fluid and the use of electronic monitoring can be taken into consideration. Nurses are playing an important role in guiding the patient and their family members regarding different ways to be adherent to medication by providing psychoeducation, motivational interview, different behavioral therapies, compliance therapy, and cognitive behavioral therapies. They should be nonjudgmental and address specific issues during discharge counseling of patients and families for better adherence.
Keywords: Medication adherence, nurses role, psychiatry
How to cite this article:
Chakraborty K, Kollipara S. Medication adherence and role of psychiatric nurse. Indian J Psy Nsg 2022;19:171-5 |
| Introduction | |  |
Patient during sickness uses various strategies to maintain their optimum health. Pharmacotherapy is the most common strategy used for restoring health. Patient with chronic illness needs long-term therapy and adherence to the therapy is the key to success in treatment. Nonadherence can limit the benefits of medications and increases the chances of health-care cost and hospitalization even death. In 2003, the WHO reported that 50% of patients with chronic illnesses do not have adherence to medication.[1] In the literature, the ranges of nonadherence were found from 7% to 83%.[2] In the case of major psychiatric disorders, it is 49%. A cross-sectional study conducted in South India among patients having noncommunicable diseases found that 32.7% are not adherent to medicine.[3] Taking treatment definitely has a positive outcome on the illness, but in between treatment and outcome, an important role is played by adherence.
| Compliance versus Adherence | | |
In health-care settings, the terms compliance and adherence are used synonymously, but there is a difference between the two. The term compliance is defined as “the extent to which a person's behavior coincides with medical advice,” whereas adherence is an active, voluntary, and collaborative involvement of the patient in a mutually acceptable course of behavior to produce a therapeutic result. Hence, adherence is an active process where the patient and the provider both choices the treatment with a mutual understanding; on the other hand, compliance is a passive process where the client is following the prescriber's order only. Hence, it is better to use the term adherence.[4]
| Definition of Adherence | | |
”The extent to which a person's behavior – taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider.”[1] --WHO.
Active, voluntary, and collaborative patient involvement in a mutually acceptable course of behavior to produce a therapeutic result.[5]
| Types of Nonadherences | | |
| Factors Influencing Adherence | | |
The WHO describes medication adherence as an interplay between five factors which will be described as follows:[7]
Socioeconomic factors
Socioeconomic factors are having an effective role in medication adherence. There are some factors that lead to nonadherence. They are low-socioeconomic status and low literacy level, especially illiteracy, unemployment, lack of effective social support network, unstable living conditions, high cost of transport, high cost of medication, cultural and lay beliefs about illness and treatment, family dysfunction, etc.
Health care system-related factors
When patients are coming for the consultation in any health-care setup, they used to get prescribed medication from that setup itself. However, there are a few factors that hinder adherence are the poor relationship between patient and therapist, lack of clear instruction from the health-care provider, poorly developed health services, irregular or poor medication distribution system, and poor knowledge of health-care providers regarding the management of chronic disease, overburden of health-care provider, lack of adequate remuneration, short discussion time with the patient, scarcity of patient education system, poor facility of patient follow-up, poor community support system, and inadequate health insurance plan.
Clinical condition-related factors
The clinical condition and understanding of the disease process also influence medication adherence. The important factors are inadequate understanding of the disease process, concept, and nature of the illness, asymptomatic patients, depression, forgetfulness, memory deficit, psychiatric comorbidities, and chronic disease.
Therapy-related factors
Although the patient is having proper knowledge, some factors related to the therapy affect adherence such as complexity in the medical regimen, prolonged treatment duration, inadequate/misunderstanding of instructions, changing the treatment frequently, and side effects of medicines.
Patient-related factors
The patient-related factors influencing medication adherence are forgetfulness, misunderstanding of treatment instructions, fear of injections, not perceiving the need for treatment, anxiety about medication dependence and possible adverse events, denial of diagnosis and refusal to take medication, delusional thinking, felt stigma, inadequate knowledge, and skills regarding techniques of medication administration.
| Assessment of Treatment Adherence | | |
No gold standards have been formulated for the assessment of medication adherence, but there are various ways that are in use for the assessment of medication adherence. Basically, we can categorize it into two:
- Objective indicators or direct methods[6],[8]
- Subjective measures or indirect methods.[6],[9]
These two categories help to detect adherence behavior. Along with this, adherence attitude also should be assessed which will help to identify the factors associated with nonadherence.
Objective indicators or direct methods
The objective indicators or direct methods are more accurate way than other methods, but these are expensive too. Following are a few commonly used direct approaches to medication adherence:[6]
Biologic measures
Biological measures include measuring the presence of drugs in a patient's body fluids specifically in blood, saliva, or urine. Although this method provides very accurate evidence, it has drawbacks too. It does not show any pattern of nonadherence instead only gives a result of whether the patient has taken medication or not. Few medications like psychotropic drugs can be present in the patient's blood for a long time even after stopping the medication. This procedure further needs skilled technicians or professionals for carrying out the tests.[9],[10]
Technology-assisted monitoring
In the modern era, there are various technology-guided methods that help in measuring adherence. Electronic medication packaging devices are considered highly accurate devices for assessing adherence. A microprocessor is embedded in the medication packaging, which helps to note the date and time of taking medicine. These devices have various features such as digital display, real-time monitoring, an audiovisual reminder for the next dose, recording of the dosing events, storing of the adherence records, and feedback on adherence.[11] There are various devices such as Medication Events Monitoring System (MEMS), Med-eMonitor, eCaps, and Medsignals feasibility of this app is questionable, as it is costly and requires unique expertise to operate.
The MEMS is the most commonly used device. It is based on the principle that, whenever a medication will be taken out of the container, the microprocessor will record the date and time. This system helps identify the consistency of medication adherence and helps to detect any abnormal pattern of behavior. Although electronic monitoring is most widely used, there are some drawbacks too. These devices are expensive and need the skill to operate. The bulkiness of the container makes the patient not carry it always. Even it can provide false data in some situations like a patient may take out more than his prescribed dose at a time for future use or simply can open the box to check the remaining medicine.[9],[10]
Pill count
It is an easy and inexpensive objective method that helps in counting the dosage which was taken between two scheduled appointments. It helps to determine the missing pills from the container and compare the number with the actual number of pills that should be taken within a specific time. Thus, it provides an estimation of adherence. This method is also having a few drawbacks. The patient may simply discard the medication which will provide misleading data. Pro re nata (prn) medications are not possible to count by this method.[9],[10] This method accompanied by direct observation of patients during medicine intake can be used.
Subjective measures
Patient diaries
It is a self-report method, in which the patient documents his prescribed regimen. In this method, if the patient forgot to bring the diary or makes a false increase in reporting then it will create false data.[10]
Patient interview
It is basically an easy, low-cost, subjective method where the patient is asked regarding his behavior which is related to the medication. The questions may be asked such as the frequency of not following the medication regimen, name, schedule, and indications of medications. Thus, it will provide baseline data regarding adherence.[10]
Measuring adherence attitude
The adherence attitude basically helps to identify the cause of nonadherence and other factors leading to nonadherence. There are different attitude scales which mainly help to provide data in the following three domains: (I) subjective response to medication (II) insight and awareness measures, and (III) comprehensive measures of adherence influences.[9] Here, we will discuss a few commonly used adherences attitude scales.
Rating of medication influences
Rating of medication influence is basically used to assess the adherence attitude of psychiatric patients. There are two subscales. The first scale separates the reason for adherence from the reason for nonadherence and the second part helps to identify different factors which influence patients' subjective opinions on adherence.[9]
Drug attitude inventory
Drug attitude inventory (DAI) is a self-report scale consisting of 30 items. It is mainly used in patients with schizophrenia to evaluate their subjective effects of antipsychotic drugs. It helps to assess the insight of the person with the illness. There is a short version of DAI that consists of 10 items.[9]
Medication Adherence Rating Scale
The Medication Adherence Rating Scale (MARS) is a 10-item, self-reported scale which is based on the Drug Attitudes Questionnaire and the Medication Adherence Questionnaire. It is used for schizophrenia and psychoses patients. There are three factors in MARS. The factors help to measure adherence behaviors and adherence attitude which include attitude toward taking medication and adverse effects and attitude to psychotropic medication.[9]
Adherence starts with knowledge-20 adherence barrier survey
It helps to assess the barriers to medication adherence by 20 clinical actionable items and find out the factors affecting medication adherence.[9]
Other questionnaires and scales
There are various other questionnaires and scales. These questionnaires are validated against other methods which can be answered by the patient or the attendant. Examples of some commonly used medication adherence attitude tools are the Brief Adherence Rating Scale, Medication Adherence Questionnaire, the Morisky Medication Adherence Scale, Brief Medication Questionnaire, the Hill Bone Compliance Scale, Tablet Routine Questionnaire, Treatment Adherence Checklist, etc.
Although this questionnaire gives a rough measure of the patient's attitude toward medication adherence; however, actual aspects of adherence can be achieved only when the individual understands her clinical conditions.
| Methods for Improving Treatment Adherence | | |
The method for treatment adherence can be broadly categorized into two groups – psychosocial intervention and pharmacological intervention.
Psychosocial intervention
There are different psychological and social interventions that help to improve treatment adherence. These can be given in different settings such as hospitals or communities and different modes such as individual, group, family, or electronic media.
Motivational interviewing
It aims to increase the probability of taking medicine consistently. There is the use of the tool “decisional balance” where there is an activity that elicits the benefits and drawbacks of taking medication. A specific pro forma is used which helps to identify the adverse events and a plan of treatment is asked from the patient to overcome it.[12],[13]
Psychoeducation
The aim is to impart knowledge to the patient and/or family members about the illness, its treatment procedures, and probable side effects. It can either be given individually or in groups using different audiovisual materials. Psychoeducation is more effective when involves family and in combination with environmental and behavioral interventions.[14]
Compliance therapy
The main component of this therapy is the cognitive behavioral therapy approach. This approach helps the person to identify the relationship between relapse and nonadherence. The therapy helps in gaining insight, treatment acceptance, and adherence.[14]
Behavioral training
Behavioral interventions promote adherence. The techniques such as shaping, reminding (cues), or positive reinforcement can be used. Common memory cues that help to recall medication taking are an alarm on mobile phone, marking in the calendar, keeping medication on the dining table, and taking medication after some daily activities such as prayers and meals.[14],[15]
Cognitive
Behavioral therapies
In this approach, the patient is guided to identify the negative thought regarding medication and change their belief. Thus, the therapist helps the patient to change his view regarding the illness and the medication which ultimately leads to medication adherence.[14]
Family interventions
In family intervention, the patient's family member mainly the primary caregiver is taught the importance of medication and how it helps improve the patient's well-being. In some cases, it is required to teach the administration technique and the importance of supervising the patient during administration.[14]
Pharmacological interventions
The physician should select a simple treatment regimen where the drug should be carefully chosen to have better efficacy with minimum adverse effects. If one molecule is not giving an optimal effect, then shifting to another molecule is required. Patients including their family members should be taught regarding the probable side effects of the prescribed medication, its home-based management, and when to notify the physician. In some cases, long-acting medications are preferable.[14]
| Some Basic Techniques to be Practiced for Improving Adherence | | |
Therapeutic relationship
There should be a therapeutic relationship between the provider and the patient which should be based on trust. The provider must identify the patient's concern and consider his/her preference. The benefits and hazards of the treatment should be explained in the patient's language, and feedback must be taken.[16]
Appropriate patient and family education
The patient and their family members should be taught the basic concept of the illness and the importance of medication. The probable side effects of the prescribed medication and their home-based management should be explained. The importance of follow-up and the roles of family members in the treatment process are also very important concerns.[16]
Prescriber's responsibilities
The dose of the medicine should be adjusted as per the patient's current condition. The regimen should be as simple as possible. The effectiveness of the medication should be maximized, whereas the side effects should be minimized to maintain adherence. Different reminder techniques should be taught such as keeping the medicine near the daily activity station, keeping an alarm on a mobile phone, and charting the calendar.[16]
Periodical evaluation of adherence
The patient should be asked about the problem with the medication and any specific reason for missed doses or discontinuation of the medicine. A mutually agreeable goal should be established with the patient to assess adherence and further management if nonadherence is found.[16]
| Implication in Nursing Practice | | |
Medication nonadherence, relapse, and readmission are the kind of chain reaction cycle that usually happens in patients with mental illness. Nurses working in any setting need to be empathetic about the patient and family members and should not be judgmental, especially about nonadherence. This comprehensive nursing assessment should include the reason for relapse, and the reason for nonadherence to medication, and as a nurse, it is quite important to take into consideration of other factors responsible for nonadherence such as medication side effects, psychopathology of the patient, expressed emotion from family, stigma, and discrimination and include strategies to address these specific issues during discharge counseling of patient and families for better adherence.
| Conclusion | | |
Nonadherence to medication not only causes relapse and other health-related issues to the patient but also affects the family as well as the overall community by reducing productivity. The health-care providers should put all effort to maximize adherence and also carry out different research to identify different factors responsible for nonadherence and methods to improve adherence.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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