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Mental Health Patients’ Non-Adherence to Treatment Regimens

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    Non-Adherence to Treatment Regimens: Reasons of Mental Health Patients
    Abstract

                This study will answer the question why mental health patients fail to adhere to their treatment regimens.  This research is critical in nursing practice, as it will define the role of the nurses in promoting adherence. The primary assumption of this study is that the main reason for the non-adherence of the patients is the lack of monitoring on the part of the medical professionals. Moreover, the conceptual framework that will be used for this study is the Health Belief Model (HBM). The factors of non-adherence to treatments, outcomes of non-adherence, improving adherence and empirical studies related to the topic were presented coherently in the literature review. This current study is a qualitative research and will make use of secondary data analysis and interviews in gathering data. The subjects of this research will be doctors, nurses and patients, mainly outpatients, in an urban area.  Two sets of interview schedules will be used, one for the medical professionals and another for patients.

    Introduction

                According to Hussar (2007), adherence is the measurement of the extent to which a person follows the prescriptions that are given to him.  It is crucially important for a person to adhere to their treatments; unfortunately, only about 50% percent of individuals that are given prescriptions actually follow them.  Throughout the years, treatments for mental health have significantly improved; however, a significant percentage of patients still choose not to comply with their treatment regimens (Corrigan, 2004).  Non-adherence to treatment regimens can be as simple as forgetting to take the prescribed doses of medication, intentionally not taking them, skipping days and weeks of scheduled therapy, or totally ceasing attendance to therapy (Sturt, 2006).

    Non-adherence to one’s medication regimen is a grave problem that affects not only patients, but also other parties involved – healthcare professionals – that provide and are partly accountable for the medical prescriptions (Richards, Fortune & Griffiths, 2005).  Treatment non-adherence affects response efficiency. According to Knapp, King, Pugner and Lapuerta (2004), not adhering to medical treatments cause the amplifying number of patients that experience relapse. In addition, non-adherence also leads to a significant increase in the costs of treatment.  It is possible that patients who do not adhere to their medications may need to undergo substantial treatment and support from different types of medical services (Knapp, et al, 2004).

    Schizophrenia, a type of mental illness, has accounted for 40% of re-hospitalization due to treatment non-adherence after being discharged for two years. Moreover, about 25 to 80% fall short in taking their medications properly (Knapp, et al., 2004).  Cases like these have been studied comprehensively; however, there is still no clear understanding as to why there remains to be a significant non-adherence among patients.  According to Hussar (2007), one possible reason is that patients forget to adhere to their prescriptions.

    There are reasons why scrutinizing non-adherence is empirically difficult.  For one, there are various forms of medical treatments that a patient could comply with and correspondingly, there are also various means not to adhere with the medical treatments. To add to this complex equation, it is also hard to know if the patient has adhered or not in reality (Sturt, 2006).  Recent studies regarding non-adherence also amount to discouraging outcomes. Patients either simply do not follow their prescriptions or they are taking it in an incorrect manner or they have stopped complying with the prescription without asking for the advice from medical professionals, hence, all of these three are not being opened up with the professionals (AIDS Program Office, 2001).

    Research Problem

                Medical professionals are confronted with the crucial issue of non-adherence of mental health patients to their treatment regimens. Despite the vast number of empirical studies regarding non-adherence to treatment regimens, there are still matters that remain to be explored.  Hence, the main problem of this research is why mental health patients fail to adhere to their treatment regimens. Consequently, this main problem will be further subdivided into several sub-problems, as follows:

    1.      What are the common reasons why mental health patients do not adhere to their treatment regimens?

    2.      What are the effects of non-adherence to treatment regimens?

    3.      How can non-adherence to treatment regimens be solved?

    Objectives of the Study

                This study will center on determining the reasons why mental health patients do not adhere to their prescribed regimens.  In order to attain this main goal, this study will also identify the reasons that were already distinguished from various studies conducted in the past.  Moreover, this study will focus on determining the possible effects of not adhering to treatments and finding out the most effective way to solve this issue.

    Significance of the Study

                Non-adherence to treatment regimens is a very serious issue in the realm of medicine.  Hence, it affects medical professionals in totality, doctors, specialists and nurses, who share a common thrust of working towards patient well-being. Nurses primarily look after the patient while they are undergoing treatment within the hospital; they ensure that their patients take their prescribed treatments properly and effectually.  However, once patients are released from confinement, most of them no longer have nurses who will look after them with the same painstaking care and meticulousness. Moreover, there are only few who avail of the services of a private nurse.  This study will assist nurses in what they may do in order to lessen treatment non-adherence among mental health patients.  Through this, they will be able to identify their contribution to avoid or reduce the probability of relapses among those who do not comply and to ensure the continuous treatment and eventual recovery of their patients.

    Definition of Terms

    Mental health patients – patients with mental problems (i.e. Schizophrenia) (Mental health patients ‘let down,’ 2006).

    Adherence – is the extent of which a person follows the schedule and dosage of intake of the prescribed drugs or treatments given to him (Hussar, 2007).

    Non-adherence – forgetting or intentionally not taking prescribed medications and not attending scheduled therapy (Sturt, 2006).

    Treatment regimen – a formulated plan of treatment that is expected to yield positive results (MedicineNet, 1998).

    Assumptions

                This study assumes that the primary reason of mental health patients’ non-adherence to treatment regimens is the lack of monitoring by medical professionals. Patients may forget to take in their prescriptions or just simply stop without informing their doctors. Moreover, they might think that their treatment is already adequate or is not making any difference in improving their present condition.  However, at the status quo, medical professional wait for their patients to return for further diagnosis, at which point, their conditions have already been aggravated. Medical professionals are in the best position to proactively carry out means that address non-compliance to treatment regimens of mental health patients and meet their patients half-way through.

    Conceptual Framework

                The Health Belief Model (HBM) is used as a theoretical framework for the current study, since it is the most conventional and cohesive model for explaining adherence to treatment regimens.  Morgan (2000) used this model in his study entitled A Decade Review: Methods to Improve Adherence to the Treatment Regimen among Hemodialysis Patients.  This model was developed by Hochbaum, Rosenstock and Kegels – a group of psychologists back in the 1950s – in order to understand the failure of a free tuberculosis health screening program. HBM was built in the assumption that a person will resort to health-related measures if he or she believes that unfavorable health conditions can be prevented; that he would not experience any negative health conditions if the prescribed treatment is complied with; and, lastly, if the patient thinks that he can easily comply with the prescribed treatment (Universiteit Twente, 2004).

                According to HBM, a patient formulate his decision of adherence or non-adherence to the proposed treatment regimen according to his assessment about the chances that the disease will occur, its seriousness, and the benefits that the patient will receive from compliance to the prescribed treatment (Morgan, 2000).  Understanding HBM requires the corresponding comprehension of four main concepts, namely, perceived susceptibility, perceived severity, perceived benefits and perceived barriers.  These four when aggregated explain the patients’ “readiness to act” (Universiteit Twente, 2004).  In addition, new concepts like cues to action and self-efficacy are recently added. The former is said to be the variable that sets the patient in motion, while the latter pertains to the confidence of the patient of his capability in performing the recommended action (Universiteit Twente, 2004).

                Perceived susceptibility refers to an individual’s opinion of the possibility of acquiring an unfavorable health condition. Consequently, perceived severity pertains to judgment of a person on the extent of gravity of the health condition. The third concept, perceived benefits, refers to the outlook of a person about the effectiveness of the treatment in lessening the amount of risk or susceptibility to such risk.  Lastly, perceived barriers refer to one’s evaluation of the evident costs that may be incurred with the prescribed action. Figure 1 below illustrates the Health Belief Model (Glanz, et al., 2002, as cited by Universiteit Twente, 2004):

    Figure 1: Health Belief Model

    Source: Universiteit Twente (2004)

    Literature Review

    Factors the Influence Non-Adherence to Treatments

                Hussar (2007) enumerated the following as the reasons of patients non-adherence to their treatment regimens: forgetfulness, misunderstanding of instructions, existence of side effects, unfavorable taste and smell of the drugs, uncomfortable restrictions, frequent intake of the drugs, denial, believing that the treatment is not effective, believing that he or she is finally cured, fear of being drug-dependent, financial costs, unwillingness to be treated, difficulties and inhibitions, and inability to trust the medical professional. In addition, according to Sturt (2006), forgetfulness may occur due to the other activities of the patient. For instance, out-of-town trips, work, sports, among others. In addition, a patient might only avail the treatments during their pay day due to financial constraints. Moreover, they may only take half of the prescribed medicine.  Consequently, though patients stop adhering to their treatments because they think they are already well, this reason is said to be rare. Other reasons are laziness in adhering to the treatment and stress from unexpected life occurrences (Sturt, 2006). However, it could also be that the psychological disorder itself inhibits mental health patients from adhering to their treatment regimens, specifically disorders such as panic attacks, anxiety and depression (Davies, Jackson, Potokar & Nutt, 2004).

                The reasons for non-adherence, according to Sturt (2006), can be grouped into four classifications – the characteristics of the regimen, the cognitive-emotional aspect, the psychosocial aspect, and the beliefs and knowledge of the patient.  For the first classification, the characteristics of the regimen, non-adherence can be because of convoluted regimens; moreover, the patient will also not adhere to the regimen if it proves to be tedious and would have to be complied with for a long period of time, or it will be very costly (Sturt, 2006).

    On the cognitive-emotional facet, patients may not remember all the instructions and advice that the doctor has relayed to them, even if they have been informed repeatedly. Patients are inclined to keep in mind what they are told first and what is important according to their judgment. There is also no difference between intelligent patients and patients of average intellectual capability, older and younger patients, and slightly anxious and totally anxious patients, when it comes to remembering what the doctor have told them regarding their regimen.  The patient may be able to remember most of what he was told if he has sufficient amount of medical knowledge (Sturt, 2006).

    As for psychosocial factors, non-adherence can be caused by the degree of social support and the personality of the patient. The latter particularly pertains to their dispositional attitudes, emotional state, and their knowledge and attitudes. In connection to the last aspect of psychosocial factors, the last classification of reasons for non-adherence is knowledge or beliefs which consist of lack of necessary knowledge, denial and apparent invulnerability (Sturt, 2006).

    Outcomes of Non-Adherence

                Basically, if there is non-adherence to the treatment regimen, the symptoms and the disease itself may not be treated.  Along with the worsening of the current health condition is the financial burden that it shall imply.  According to Hussar (2007), if patients would only adhere to their prescribed treatment and medication, 23% of nursing admission, 10% of hospital admission, and numerous doctor appointments, medical tests and supplementary treatments can be averted.  The quality of life of the patient will also be aggravated, if he does not adhere to the treatment (Hussar, 2007).  Other consequences of non-adherence are increased visits to the doctor; lessened level of responsiveness to the treatment; increase in the severity of the side effects of the treatment; increase of possible health problems in the future which come along with increased unsuitable medical advice; and lastly, this may also damage the relationship of the patient with his doctor (Christophersen & VanScoyoc, 2005).

    Improving Adherence among Patients

                One possible and effectual way of improving adherence is to build and cultivate a symbiotic relationship between the patient and the medical professional attending to him.  In order to make such a relationship possible, two-way communication is a definite requisite (Hussar, 2007). Establishing good communication starts with exchanging information through asking and answering questions. Through such dialogue, the two parties will get to discuss the gravity of the health condition has which can be followed by the formulation of the apt treatment regimen. This also includes the discussion of the advantages and disadvantages of the proposed treatment regimen.  The patient could also voices out his concerns regarding the treatment; hence, the doctor will be able to clear misconceptions that may inhibit the effectiveness of the treatment. These exchanges between doctor and patient must all be built on a high sense of trust and thus of transparency (Hussar, 2007).

                Doctors should also extensively explain the reasons behind how the medicines should be taken, why these should be taken, and what should take place during the whole treatment process (Hussar, 2007).  Through these, the patient will be reassured that adherence to their prescribed treatment will garner favorable health outcomes. Moreover, it may also be advantageous to give written instructions to the patients for better recall. If the patient has more than one medical professional attending to him, communication and collaboration between them is ideal for increased awareness about the treatments prescribed to the patient and to optimize the impact of the combined treatments (Hussar, 2007). There is also a possibility of being able to formulate a simpler treatment towards increased adherence. However, there should also be substantial participation on the part of the patient to increase the probability of treatment success. According to Hussar (2007), patients who participate in their treatment regimen even in the planning stage have a much higher adherence rate.  With participation, comes ownership and responsibility over the treatment; hence, the patient will be even be the one monitoring the progress of the treatment because of his high involvement in the process (Hussar, 2007).

                Another important factor is the doctor’s extent of involvement in the treatment. The patient will follow the prescribed treatment if he perceives that the doctor really cares about the course of the treatment. Moreover, it may be helpful if all the medications will be availed from only one pharmacist so that records of the drugs that the patient will avail are easily documented and remembered. The pharmacist may also monitor if the drugs that the patient purchases are the right ones and if they go well with one another, without adverse effects.  Pharmacists will also be able to instruct the patient on how to take the medications.  Involvement of support groups with the treatment is likewise critical, as these support groups will help emphasize to the patient the value of adherence to their treatment regimen (Hussar, 2007).  Doctors should also recommend memory aids in order to avoid forgetfulness; these aids can be as common as a wristwatch alarm or containers which have the instructions for drug intake, and which can be provided by the pharmacist (Hussar, 2007).

    Empirical Studies

                In a study conducted by Edlund, Wang, Berglund, Katz, Lin and Kessler (2002) entitled Dropping out of Mental Health Treatment: Patterns and Predictors among Epidemiological Survey Respondents in the United States and Ontario, the researchers focused on two main objectives. These are: (1) providing accurate and precise information regarding the widespread mental health treatment dropout from the different settings of specialty, general medical and human services; and (2) assessing the consequences of the four classes of dropout predictors which are clinical condition, treatment modalities, negative attitudes against mental health treatments and demographic features. Their study was centered on Ontario, Canada and the United States of America (Edlund, 2002).

    The results of their study suggest that the proportion of dropouts is almost similar in the USA (19.2%) and in Ontario (16.9%).  Both countries also have the same socio-demographic characteristics to which treatment dropout can be attributed to, and the same attitudes towards dropout. These socio-demographic characteristics are low income, young age and lack of insurance coverage. On the other hand, attitudes include the belief that the treatment is inefficient (Edlund, 2002).

    In another study conducted by Shi, Ascher-Svanum, Zhu, Faries, Montgomery and Marder (2007) entitled Characteristics and Use Patterns of Patient Taking First-Generation Depot Antipsychotics or Oral Antipsychotics for Schizophrenia, the authors compared the qualities and the antipsychotic use patterns of people treated using the depot first-generation antipsychotics and those who used oral antipsychotics. According to their literature review, there are about 58% of patients with schizophrenia who do not adhere to their treatment. This can also be between 24% to 90% non-adherence depending on the measurement of adherence that was used (Cramer & Rosenbeck, 1998, as cited by Shi, et al., 2007).  Furthermore, it was said that non-adherence among the patients with schizophrenia is due to psychotic relapse; unfortunately, it is difficult for medical professionals to distinguish adherents from the non-adherents, and they are also unable to tell who will not adhere in the future (Shi et al, 2007).

    Methodology

    Research Design
    This research is a qualitative research.  Qualitative research is based on data and information which have not been quantified, and are more centered on acquiring insights on a certain phenomenon.  This method is used when the researchers gathers information for the purpose of acquiring a global standpoint on the problem. The data that are required in a qualitative research may encompass issues about culture, attitudes, beliefs, values, emotion, socio-professional differences, among others, which are also referred as “soft data.”  These data are utilized in order to obtain a thorough understanding of a social or cultural occurrence (Myers, 1997).

    Subjects and Setting
    The subjects of the current study are medical professionals, namely, doctors and nurses.  However, these doctors and nurses should specialize on mental health patients as an inclusion criteria.  Moreover, the other set of subjects are patients who are diagnosed with mental health problems and are currently under treatment. The patients need not necessarily be within the hospital, and those who are considered outpatients will also be included. The research will be conducted in hospitals dedicated to taking care of mental health patients.  The hospital setting for the study will be located in an urban area.

    Research Methods
    Secondary data analysis is composed of, but not limited to, the scrutinizing of data that are gathered from different academic journals, books, marketing magazines, white papers, research theses, and internet articles.  Heaton (1998) also defined secondary data analysis as the use of data that were collected by a different person for a different study or purpose.  Analysis of secondary data is done through existing information from the articles that are published like texts, tables and grafts, appendices and the genuine source itself (Church, 2002).

    An interview is a focused face-to-face meeting between the interviewer – the researcher – and the interviewee – the respondent or subject (Treece & Treece Jr., 1977).  The researcher would choose an interview as a methodology so that he can collect qualitative responses for thematic analysis in his study.  The interviewer will ask several questions from the interviewee in order to have a better understanding of the topic. The interview method has several classifications, namely, structured, semi-structured and non-structured interviewing. The researcher for this study will make use of a semi-structured interviewing technique. Semi-structured interviewing is where the researcher, who will act as the interviewer, does not limit himself to the questions that he is set to ask. Hence, he could ask additional questions which he deems necessary in order to collect more in-depth information (Treece & Treece Jr., 1977).

    Operational Definition of Terms

    Patients – people who are diagnosed with mental health problems

    Treatments – medications, prescribed drugs, therapy

    Medical professionals – doctors, nurses, pharmacists

    Hospital – hospital which caters to patients with mental health problems

    Instruments

                The researcher of this study will make use of an interview schedule. An interview schedule is a list of questions that the researcher will ask during his interview sessions.  There will be two sets of interview schedules; one will serve as the interview schedule for the medical professionals while the other will be for mental health patients. Since these are self-constructed, the researcher shall subject them to content analysis. This shall entail presenting the interview schedules to subject matter experts and asking for their inputs on how the instrument can have increased validity.

    Procedures

                A letter will be submitted to the head of the hospital in order to obtain official permission for conducting a study in their hospital and to interview selected doctors, nurses and patients. As for patients outside the hospital, they shall be selected through snowball sampling. The doctors shall be asked for possible referrals. The researcher shall then send them letters soliciting consent, and likewise contact them via phone to set possible interview appointments.

    Limitations

                The problem of non-adherence is a global issue in the practice of the medical profession; however, this study will focus only on non-adherence among mental health patients and shall not include within its scope other disorders or diseases.  In addition, the study will only be conducted in a particular urban area. This suggests implications on the generalizability of the results whereby applicability and relevance are delimited to the setting itself and similar settings.

    References

    AIDS Program Office. (2001). Promoting adherence to antiretroviral treatment. Retrieved October 19, 2008 from http://www.columbia.edu/~fc15/adherence.pdf

    Christophersen, E. & VanScoyoc, S.M. (2005). Take as directed: Improving adherence in the

    primary care or specialist care setting. Development and Behavior News. Retrieved October 19, 2008 from: http://www.dbpeds.org/articles/detail.cfm?TextID=122

    Church, R. M., 2002. The effective use of secondary data. Retrieved October 20, 2008 from http://www.brown.edu/Research/Timelab/archive/Pdf/2002-02.pdf

    Corrigan, P. (2004). How stigma interferes with mental health care. American Psychologist, 59

    (7), 614-625.

    Davies, S.J.C., Jackson, P.R., Potokar, J. & Nutt, D.J. (2004). Treatment of anxiety and depressive disorders in patients with cardiovascular disease. British Medical  Journal, 328, 939-943.

    Edlund, M.J., Wang, P.S., Berglund, P.A., Katz, S.J., Lin, E., et al. (2002). Dropping out of mental health treatment: patterns and predictors among epidemiological survey respondents in the United States and Ontario. The American Journal of Psychiatry, 159 (5), 845-851.

    Heaton, J. 1998. Secondary analysis of qualitative data. Retrieved October 20, 2008 from     http://sru.soc.surrey.ac.uk/SRU22.html

    Hussar, D.A. (2007). Adherence to drug treatment. Retrieved October 19, 2008 from http://www.merck.com/mmhe/sec02/ch016/ch016a.html

    Knapp, M., King, D., Pugner, K. & Lapuerta, P. (2004). Non-adherence to antipsychotic medication regimens: Associations with resource use and costs. The British Journal of Psychiatry, 184, 509-516.

    Mental health patients ‘let down’. (2006). BBC News. Retrieved October 20, 2008 from http://news.bbc.co.uk/2/hi/uk_news/wales/5193188.stm

    Morgan, L. (2000). A decade review: methods to improve adherence to the treatment regimen among hemodialysis patients. Nephrology Nursing Journal. Retrieved October 19, 2008 from http://findarticles.com/p/articles/mi_m0ICF/is_/ai_n18611163

    Regimen definition. (1998). MedicineNet. Retrieved October 20, 2008 from http://www.medterms.com/script/main/art.asp?articlekey=5278

    Richards, H.L., Fortune, D.G. & Griffiths, C.E.M. (2005). Adherence to treatment in patients with psoriasis. Journal of the European Academy of Dermatology and Venereology, 20 (4), 370-379.

    Shi, L., Ascher-Svanum, H., Zhu, B., Faries, D., Montgomery, W., et al., (2007). Characteristics and use patterns of patients taking first-generation depot antipsychotics or oral antipsychotics for schizophrenia. Psychiatric Services, 58 (4), 482-488.

    Sturt, G. (2006). Why patients do not adhere to medical advice. Retrieved October 19, 2008 from: http://homepage.ntlworld.com/gary.sturt1/health/adherance.ppt

    Treece, E.W. & Treece, J.W. Jr. (1977). The elements of research in nursing (2nd ed.). Saint Louis: Mosby Company.

    Universiteit Twente. (2004). Health belief model. Retrieved October 20, 2008 from http://www.tcw.utwente.nl/theorieenoverzicht/Theory%20clusters/Health%20Communication/Health_Belief_Model.doc/

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