Managing Medication Adherence in the Community

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In mental health, from the discovery of the drug Chlorpromazine in the 1950’s, which was a major breakthrough in the treatment of mental illness, medication played an important role in the move from the big psychiatric asylums to care in the community (Howland 2007). Several studies continue to demonstrate the effectiveness of neuroleptic medication in the treatment of mental illness, and psychiatric nurses have an important role to play in the management of medication adherence (Gray et al 2004).

However, something we psychiatric nurses experience regularly in our practice, which is also referenced well in the literature, is the failure of patients with mental illness to adhere to their prescribed medication (Valenstein et al 2004, Razali 2010). Gray et al (2002b) argues that despite the effectiveness of new and modern antipsychotics, poor adherence to treatment remains common in people suffering from schizophrenia.

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This presents a big challenge for psychiatric nurses working in the community, especially since poor adherence to medication might cause deterioration in mental state, reduce quality of life and might lead to hospitalization. Poor adherence to medication might also imply an increase in the risk profile, which can be one of the main concerns for community psychiatric nurses, since they cannot rely on the hospital environment to safeguard and deal with the immediate consequences of non-adherence.

Moreover, apart from the suffering non-adherence bring to the patients and their families, poor adherence can have a global impact, since it can result in disruption of services, hospitalizations and increase bed use, lead to unemployment, and also presents a gap between the efficacy of (expensive) treatment and its delivery (Gray et al 2010). Gray et al (2002a) argues that considering the improvement and advances in pharmacological interventions in psychiatry, the desired benefits of this medication is still not being reached due to the phenomenon of non-adherence.

They insist that this presents a public health crisis, which continue to show the need for more studies and research in the area of medication adherence. Definition Throughout the literature, the word compliance and adherence is used intermittently. However, it seems that the word adherence is the most commonly used, also since it implies some degree of collaboration and involvement from the patient, unlike the word compliance, which describes the patient as a passive recipient who just obeys (or not) and follows the practitioner’s advice (Gray et al 2002a).

Concordance seems to be the ideal way for the health practitioner to work with the patient, as it entails working in collaboration, involving the patient in decision making and respecting the patient’s opinions and decisions, even if the practitioner does not agree with them (Gray et al 2002a). An interesting point raised by Horne et al (2005) is that total adherence or non-adherence is rare. It is not common that patients take their medication exactly the way it was prescribed.

This is something which occurs commonly in the community, where the management of the medication is left almost solely to the patient, and sometimes their family. Patients take the control of the medication in their own hands (which is also something we encourage them to do) however this might result in missing, skipping, increasing or reducing the dose of the medication, against the prescriber’s advice. Throughout this essay, the word adherence is going to be generally used, which portrays an amount of patient’s participation in the treatment plan.

Factors influencing medication adherence Psychiatric nurses, need to look at the factors and understand why patients do not adhere to their treatment in order to manage adherence. In a retrospective study to determine the factors influencing medication adherence in patients suffering from bipolar disorder, Busby and Satajovic (2010) identified three major categories of factors associated with non-adherence. These were patient factors, treatment factors and system related factors.

Among the patient related factors were the symptoms of the illness, mainly grandiosity and manic symptoms and a common issue encountered in our practice is the reluctance of patients in the manic phase to get off the “happy” feeling they experience. Other factors included poor insight into the illness, poor belief in the effectiveness of the treatment, fear of side-effects (especially of Lithium therapy), substance misuse and poor relationship with health practitioners.

The treatment factors included complex treatment regimen, polypharmacy, and side-effects of typical antipsychotics. Again this is something which is very evident locally, as complex treatment regimens and polypharmacy are still a common occurrence, and typical anti-psychotics are still widely used. Few studies were found in the system related factors but these included the level of accessibility to services, structure of services, location and case management. They also mention the knowledge and skills of practitioners in dealing with non-adherence.

However, the authors point out the difficulties that studies have in ascertain if the patient is actually taking or not taking the medication due to lack of rigorous methods in monitoring adherence. In another study to identify risk factors associated with non-adherence in a group of patients suffering from schizophrenia, McCann et al (2008) found that age, side-effects and access to the psychiatrist were the main factors influencing adherence. The study showed that older patients were more likely to take their medication than younger ones.

The authors explain that this could mean that patients who are older are more likely to understand the need to take their medication as they might have more experience of their illness. Side-effects were of much concern for the patients, which might be more linked to the typical anti-psychotics than the newer ones. Interestingly, Robson and Gray (2005) found that patients were more concerned about sedation from the medication rather than sexual side-effects or weight gain, which are more related to the newer medication.

Accessibility to the psychiatrist was an important factor observed in McCann et al (2008) which which continues to strengthen the importance of a good relationship with the practitioners. Other factors that can influence adherence, and which are observed regularly in our practice are the stigma associated with taking medication, and the inconvenience of having to remember and to take medication regularly. Challenges for Community Psychiatric Nurses

Since the introduction of new and innovative treatments, medication and psychological approaches, mental health care seems to be focused more towards the community, and the prevention of hospitalization (Burns 2004). This has also brought with it the development of the role of community psychiatric nurses (CPNs), and among its functions of assessment, monitoring and caring it involved the role of managing patients’ medication (Gournay 2000) which involved a number of challenges for CPNs. CPNs are usually seeing the patient away from their base, and the security that the hospital might provide.

Mostly this entails seeing patients at their own home or in an environment which is considered as ‘their territory’. This might diminish the influence the nurse or health care professional might have over the patient, and this might present new challenges for the profession, so in continuing with Gray et al (2002a) nurses have to find innovative and creative interventions in dealing with medication adherence. Also, psychiatric nurses need to be up to date in their pharmacological knowledge.

We have to provide information about medication, and if the patient asks us, we need to be well informed. A study by Jordan et al (1999) showed that community psychiatric nurses had poor knowledge of pharmacotherapy and it was suggested that pharmacology needs to be ongoing training for mental health nurses. However this study had some limitations due to the small number of participants, and as the authors stated, the data might have been affected by the ‘Hawthorne’ and ‘John Henry’ effects, since also the sample where a group of self selected nurses who obviously knew they were being studied.

Another challenge in the community is the difficulties in monitoring adherence, which is also mentioned in a number of studies (Homedes 1991; Busby and Sajatovic 2010; Weiss 2004). Most of the time we have to rely on the patients and their family report, counting of tablets and the patients’ mental state to monitor adherence, which all have their own inaccuracies. Also, with the patient being in the community, other factors might influence the patients’ attitude towards the treatment including family and friends, the media and social events.

When considering these challenges in relation to the concept of concordance, where as Gray et al (2002a) argues that we should respect the patient’s decision, even if the patient refuses their medication, it is not easy to abide by it, and we might be inclined in leaning towards making the patient ‘comply’. Knowing that the patient is not taking his or her medication, might cause some anxieties in health care professionals, and in certain circumstances, (for example where these is risk of harm) we might have to adopt a patronizing approach, and ‘force’ the patient to take his or her medication, which might help in our own reassurance.

However, models of care which include patient empowerment, promoting independence and recovery continue to demonstrate the effectiveness of using these approaches in psychiatry (Gordon et al 2005), and studies show that not only they increase job satisfaction among psychiatric nurses but also improve the patient’s outcome.

This confirms that psychiatric nurses require models and evidence based methods to deal effectively with non-adherence while using a collaborative approach. Interventions and models to enhance medication adherence One of the oldest interventions in dealing with non-adherence to medication in patients with mental illness was the use of depot medication, which is given to patients by intramascular injection once or twice a month.

This might have been a refreshing peace of mind for mental health professionals looking after people with mental illness in the community, as it makes it easier to deal with adherence (Walburn et al 2001), however its therapeutic activity can be questionable and psychiatric nurses need to look into improving the practice by allow space to include education, a positive climate and open communication and not just the task of pricking each patient with a needle (Muir-Cochraine 1998).

Gray et al (2002a) looked at six studies that assessed educating patients about their illness and the treatments, with the aim of increasing their knowledge and encouraging adherence. They report that although the studies show that patient education (individual or group sessions) increased the patients’ knowledge about their illness and the treatments and improved patients’ satisfaction, no evidence was found that patient education enhanced adherence to treatment.

Adherence therapy (or compliance therapy) by Kemp et al (1996), is an intervention designed with the aim of improving medication adherence. It is a technique based on cognitive behavioural therapy which incorporates motivational interviewing and collaboration and looks at the patients’ belief about their illness and treatment, and addressing any concerns the patient might have. Adherence therapy is also based on the concept of concordance, where the nurse and the patient are working together to reach the same goal, and the patient’s decisions and opinions are respected (Gray et al 2002a).

Gray et al (2002a) reviewed four studies that assessed the efficacy of adherence therapy on improving adherence to treatment, and although the studies had their own methodological limitations, the findings were more positive compared to other interventions. However, in Gray et al (2006) there was no significant difference in a group of patients receiving adherence therapy and their level of adherence to treatment.

Gray et al (2006) argue that the study had a number of flaws, including poor sample size, bias since participants were a group of patients who were already adherent, and they felt that the 6 to 8 structured sessions of adherence therapy might have not been enough to produce the anticipated results. Also, Donohoe (2006) critiques the intervention as being too demanding for patients suffering from schizophrenia due to the resulting cognitive impairments of the illness. Gray et al (2004) described a medication management program for psychiatric nurses.

This involves adaptations of Adherence Therapy and includes ongoing monitoring of symptoms, side-effects assessment and management and psychopharmacological knowledge. The technique has been part of training packages offered to community mental health nurses in the U. K. and the intervention was assessed in three different studies (Gray et al 2010). One of the main variance of medication management is that the intervention is not offered as therapy (as in adherence therapy), but rather as an on-going intervention by the psychiatric nurse.

This has been found to have a better effect on medication adherence which is sustained for longer periods (Gray et al 2010). Gray et al (2010) argues that since managing medication is a fundamental part of the psychiatric nurses’ work, medication management training should be offered to all nurses working in mental health. They also assert that other interventions should be aimed to change the culture of the whole organization in improving medication management services and provide a treatment friendly environment.

In our clinical practice, medication management is still not available as part of our training. However, techniques used in medication management are being utilized possibly in an unstructured way by CPNs. One limitation that exists in our clinical practice is the lack of training in cognitive behavioural therapy. As per personal experience, CBT training is offered regularly to psychiatric nurses in the U. K. through such courses as the Thorn Program and the Specialist Community Practitioner course (Gourney 2000).

This equips nurses with an invaluable tool that can be utilized in building a therapeutic relationship with patients, and used in improving medication adherence. Several models have been described in assisting psychiatric nurses in dealing with adherence to treatment, including the Stages of Change model (Finnell and Osborne 2006) and the Health Behaviour Model (Corrigan 2002). These models can be enlightening and offer psychiatric nurses ideas and standards on how to improve care. Barker (2009) describes the Tidal Model as an innovative approach in working with people suffering from mental illness.

The tidal model is a program of recovery, based on the principles that the patient is the expert in his/her own life, and he/she works with the professionals to find the best possible way in dealing with his/her illness (Barker 2009). Barker argues that the patient is the expert, and we professionals are the helpers, and although we might have the academic knowledge and work experience in working with the mentally ill, the patient is an individual with his/her own life story, and we must be curious about it, allowing the patient to recount his/her story using his/her own words, so that we might learn how is the best way to help him/ her.

The principles of the tidal model, when applied to medication adherence are quite similar to the medication management program by Gray et al (2004) as the tidal model emphasizes respecting the patient’s decision, empowering the patient to take part in his care plan, and looking at the patient’s life story to explore his experience of his illness and the treatment the patient received.

Also, the Tidal model emphasizes the concept of recovery, and like medication management, it is a journey, which does not have an end but a continuum of being caught in a storm, struggling with the illness and recovering in calm waters before continuing the journey. In our practice, we are adopting the principles of the Tidal model continuously in our work, sometimes without even realizing it, and as per the ethos of psychiatric nursing, the Tidal model emphasize the importance of the therapeutic relationship to help the patient to make the best choices in his or her treatment plan.

Conclusion Medication remains one of the main important interventions in mental health care, and an important role of the community psychiatric nurse is to help and work with patients in managing their own medication. As Ward in Barker (2009) state, medication management should start in the hospital, as part of the discharge planning and this is an area where community psychiatric nurses can be involved in assisting patients to live their life as normally and independently as possible.

Throughout the studies mentioned in the essay, the importance of the therapeutic relationship has been continuously accentuated, and working within the mentioned models can provide job satisfaction, and rewards in delivering high standards of care, which will relate to patients’ outcomes. Psychiatric nursing has evolved through out the years and integrating models and evidence based practice continue to enhance the professionalism of the vocation.

Health needs assessments can continue to explore and develop new roles for psychiatric nurses and models like medication management and the Tidal model can continue to enrich our skills and stray away from traditional and patronizing ways of working. As Gray et al (2002a) concludes: “There is no evidence that telling patients to take medication works. Helping people make decisions that are right for them does! ” (Pg: 283)


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