A consumer-centred intervention to enhance antipsychotic medication adherence

While the efficacy of antipsychotic medication in improving outcomes among people with serious and persistent psychotic disorders is well established, non-adherence with psychiatric medication is common and is associated with an increase in rehospitalisation and poorer outcomes. Symptoms of psychosis are also associated with an elevated risk for violence, and non-adherence with psychiatric medication may increase the rate of offending among those with serious mental illness. While prescribing medications remains in the domain of psychiatrists, psychologists are well positioned to improve medication adherence among people with chronic psychotic disorders through psychological interventions including cognitive behavioural therapy (CBT) and motivational interviewing techniques. One such intervention originally developed in the United Kingdom, called adherence therapy (AT), has demonstrated some success in enhancing medication adherence among people with serious mental illness. Although AT approaches have a growing international evidence base, only recently has a study been conducted on its use in an Australian forensic population.

The problem of medication non-adherence

Non-adherence with psychiatric medication is common for those with serious mental illness, with estimated rates of non-compliance between 50 per cent (Nose et al., 2003) to as high as 75 per cent (Lieberman et al., 2005). Non-adherence with psychiatric medication is associated with an increase in rehospitalisation and poorer outcomes. For people with a psychotic disorder and a criminal history, medication compliance is particularly important as some research suggests that the perceived need for treatment is related to the risk of re-arrest and violence (e.g., Elbogen et al., 2007). Medication adherence is particularly important it would seem for people with psychotic disorders in the criminal justice system as it may decrease both the rate of relapse and reoffending. Although the statistics for non-adherence to psychiatric medication are alarming, they are surprisingly consistent with adherence rates for other conditions that require maintenance treatment, including diabetes and asthma. When viewed this way, treatment non-adherence may not always be a consequence of poor insight related to the psychotic illness but rather a decision made by the consumer based on the interplay of a range of factors.

Reasons for medication non-adherence

The way in which people make decisions about whether or not to take their medication is complex. Therefore, any interventions designed to enhance medication adherence among those with serious and chronic psychotic disorders must address the individual’s concerns about taking psychotropic medication. The boxed information lists some of the factors that have been found to make individuals more or less likely to take their medication

Adopted from Gary, David, and Qutro research group (2003)

Educating consumers about the nature of their illnesses and the medication used to treat them can increase their understanding of mental illness and medication. However, it is less successful in reducing the number of consumers who cease taking their medication. In addition, being labelled ‘noncompliant’ suggests a power imbalance where the consumer has not done what an ‘expert’ has told them to do (Gray, David & Quatro research group, 2003). For many consumers, a collaborative process of decision making regarding treatment may be more beneficial. The approach presented by AT seems promising in this regard.

What is adherence therapy?

AT is a collaborative, consumer-centred approach to enhancing medication adherence. It uses elements of CBT and motivational interviewing to address the individual’s beliefs about medication, identify treatment barriers and develop individually specific strategies to overcome these. The approach emphasises personal choice and responsibility and incorporates problem solving and goal setting techniques. It is divided into three phases which are administered sequentially. The first phase explores consumers’ previous psychiatric history and aims to highlight what has been effective for the consumer in the past to assist with symptom control and what has not. The second phase of AT deals with common concerns that consumers have about medication and the advantages and disadvantages with taking medication as well as ceasing medication. Finally, the third phase is concerned with long-term prevention of symptoms and the development of strategies to avoid relapse. During each phase the therapist and consumer work collaboratively, linking sessions together and setting an agenda.

Through open-ended questioning, reflective listening and using the consumer’s language, the therapist aims to build the consumer’s awareness of the importance of taking medication and develop confidence in adhering to his or her treatment regime. Delivering the three phases of treatment typically takes approximately eight sessions; however, the AT manual has been divided into building essential and discretionary skills. Essential skills are to be incorporated with each consumer, whereas discretionary skills are done on a case-by-case basis as indicated by the pre-treatment assessment (see Gray et al. (2010) for a comprehensive summary of AT).

To date, a number of international trials (including four randomised controlled trials in Europe and one in Thailand) have demonstrated that AT approaches can be effective in improving medication adherence (Kemp et al., 1996; Kemp et al., 1998; Maneesakorn et al., 2007; Gray et al., 2004; Staring et al., 2010). However, not all research has replicated such positive findings and more well-designed research is warranted (David, 2010).

Adherence therapy in an Australian forensic setting

Gray and his colleagues (2008) found that mentally ill offenders’ adherence to antipsychotic medication tended to be characterised by passive acceptance rather than by active participation. Only about 20 per cent of prisoners were taking some responsibility for their treatment. They concluded that AT may be a useful therapeutic approach for enhancing medication adherence in this population.

The first randomised controlled trial of an AT approach in a forensic mental health population was conducted at the Victorian Institute of Forensic Mental Health (Forensicare), the statewide forensic psychiatric service in Victoria (Cavezza, Aurora & Ogloff, submitted for publication). The effectiveness of eight sessions of an adherence intervention was compared to eight sessions of a health control intervention that controlled for the nature of the relationship and time spent with the therapist. The adherence intervention employed was slightly modified to fit with participants’ concerns. For example, participants were shown a brief video about an offender’s experience with mental illness which was used to foster a discussion about experiences with being labelled mentally ill. The final sample consisted of 48 forensic psychiatric patients randomly assigned to either the AT (n=24) or health control (n=24) conditions. Sessions were conducted twice a week for four weeks.

There were three notable positive differences between the experimental and control conditions following treatment. First, AT significantly enhanced participants’ positive medication-related attitudes. Second, when nurses (who were blind to treatment allocation) were asked to rate patients’ compliance on a scale from complete refusal to active participation before and after treatment, the average compliance rating for participants receiving AT significantly improved by 35 per cent, whereas it declined for those receiving standard health education. Third, when patients’ discharge summaries (where applicable) were examined, doctors (who were also blind to treatment allocation) expressed fewer concerns about the future medication adherence of patients receiving AT than those receiving standard health education. However, this last effect was present only when discharge occurred within three months of treatment ending which may suggest that ‘booster sessions’ are required to maintain the positive effects of treatment.

Conclusions

Certainly a ‘one size fits all’ approach to antipsychotic medication compliance will have limited usefulness among those with serious mental illness. The AT approach may be effective because it tailors the intervention to the specific needs of consumers, addressing the reasons for their non-adherence and empowering consumers to actively participate in their treatment. In the forensic context, AT interventions that are delivered in an intensive format with personally relevant accounts of mental illness may be more effective than brief and/or less intensive interventions. This is consistent with best practice principles recommending more intensive rehabilitation for moderate to high-risk offenders (Andrews & Bonta, 2010).

In order to achieve better outcomes for those with chronic psychotic disorders who may or may not find themselves involved in the criminal justice system, more clinical trials examining the effectiveness of consumer-centred medication adherence interventions like AT is required. It would be useful to know, for example, if AT can assist offenders with chronic psychotic disorders who are not on involuntary treatment orders. If these offenders can be empowered to actively participate in their treatment and take their psychotropic medication, this may serve to reduce their chances of being hospitalised and/or of reoffending. Finally, in light of the research to date and the chronic nature of these psychotic disorders, there is a strong need to further devise and evaluate interventions that address the long-term development of medication-related attitudes and the factors influencing changes in medication adherence over time.

The author can be contacted at [email protected]Acknowledgement

The author wishes to acknowledge the support of her colleagues Dr Meera Aurora MAPS and Professor James Ogloff FAPS in the preparation of this article.