Routine psychiatric management of medication adherence in adult outpatients with schizophrenia

Patient nonadherence to medication regimens is a widespread phenomenon that compromises the efficacy of pharmacological treatment and results in considerable human and financial costs. This problem is particularly challenging in the treatment of schizophrenia, where symptoms of the disorder itself, as well as the need for long-term treatment, pose threats to adherence. Due to the prevalence of nonadherence, experts have recommended a proactive approach that includes attention to adherence even if a problem has not yet developed. Although there is a substantial body of research regarding risk factors for nonadherence, methods of assessing nonadherence, and interventions for nonadherence, very little is known about psychiatric management of adherence in routine clinical practice. The current report presents a profile of "good adherence management" that involves proactive focus on common roots of nonadherent behavior. Based on available practice guidelines, the clinical research literature, and recommendations of adherence experts, the model includes attention to 3 typologies of nonadherence identified by Koocher, McGrath, and Gudas (1990): patients' inadequate knowledge of the medication regimen, psychosocial resistance, and adaptive nonadherence. This model provided the basis for a national survey of adherence management among psychiatrists treating adult outpatients with schizophrenia. Data from 53 psychiatrists are presented. Findings suggested that psychiatrists were providing comprehensive adherence management for some of their patients, some of the time, but approximately half did not follow World Health Organization recommendations to include attention to patient adherence at every visit with all patients. Unstructured patient interviews were the most commonly utilized tool to assess adherence. Psychiatrist self-efficacy and self-reported familiarity with the adherence research literature were consistently associated with more intensive adherence management behaviors. Contrary to expectations, specific training in adherence issues was not associated with more intensive adherence management. Conceptualizing medication adherence as an ongoing treatment goal, as well as focusing greater attention on common causes of nonadherence during routine medical visits, may have the potential to improve outcomes for adult outpatients with schizophrenia while substantially reducing healthcare costs.