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 Table of Contents  
Year : 2022  |  Volume : 10  |  Issue : 1  |  Page : 55-58

Strategies for promoting treatment adherence in schizophrenia

School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia

Date of Submission22-Feb-2021
Date of Decision08-May-2022
Date of Acceptance10-May-2022
Date of Web Publication23-Jun-2022

Correspondence Address:
Ms. Shae-Leigh C Vella
School of Medicine, University of Wollongong, Wollongong 2522, New South Wales
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/amhs.amhs_55_21

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Promoting treatment adherence in schizophrenia remains a primary challenge, with nonadherence resulting in a range of challenges across the biological, social, and psychological spectrum. While unknown nonadherence is a central cause of failed psychopharmacological treatment resulting in the initiation of more complex treatment regimens and higher antipsychotic doses, leading to a cycle of further unknown nonadherence and illness exacerbation. This article reviews the importance of treatment adherence including a discussion that can be utilized for promoting treatment adherence in schizophrenia. The following strategies are discussed; the importance of the therapeutic alliance, the use of motivational interviewing, nonpharmacological interventions, pharmacological interventions, and long-acting injectable (LAI) antipsychotics. The article concludes by restating the importance of treatment adherence in schizophrenia and making the patient aware of the consequences of nonadherence. Further, the role of LAI antipsychotics in adherence is highlighted.

Keywords: Adherence, antipsychotics, schizophrenia

How to cite this article:
Pai NB, Vella SLC. Strategies for promoting treatment adherence in schizophrenia. Arch Med Health Sci 2022;10:55-8

How to cite this URL:
Pai NB, Vella SLC. Strategies for promoting treatment adherence in schizophrenia. Arch Med Health Sci [serial online] 2022 [cited 2023 Feb 9];10:55-8. Available from: https://www.amhsjournal.org/text.asp?2022/10/1/55/347972

  Introduction Top

One of the primary challenges in the treatment of schizophrenia is the patient adhering to their prescribed treatment. As medication adherence is known to be poor across psychiatric disorders and is even poorer in persistent psychiatric disorders.[1] It is known that approximately 75% of the patients with schizophrenia become nonadherent to their medication within 2 years of discharge from the hospital.[2] It has been surmised that increasing adherence to medication regimens would have a larger impact on population health than the development of new treatments.[3]

Nonadherence is known to result in a myriad of biological, psychological, and social consequences. Biologically, relapses are known to be associated with further neurodegeneration. Each relapse results in a longer time until remission is achieved. Psychologically, the patient may become demoralized, hopeless, and suffer extremely poor self-esteem, thus, resulting in further psychological consequences such as increased isolation, disruption to the family, and an increased risk of suicide. Social consequences may include involuntary treatment, negative impacts on social connections, increased risk of violent behavior, and increased risk of victimization. Further consequences include higher direct costs such as service use and hospitalizations and indirect costs to the consumer and their family.

Unknown nonadherence remains a central cause for what is thought to be failed psychopharmacology. That is the efficacy of the prescribed antipsychotic is questioned or the patient is believed to be treatment resistant.[4] This results in higher doses of antipsychotics and polypharmacy. Which further exacerbates the issues pertaining to adherence as if the patient failed to adhere to a less invasive and simpler treatment regimen why would they adhere to a more complex regimen with more than likely, a higher side effect burden?[4],[5] This results in a cycle of nonadherence, deteriorating illness, and longer periods between relapse and remission if remission is still achievable.

Therefore, a primary concern associated with this challenge is the problem of engaging patients in their own treatment. There are a range of factors that can impact on the patient adherence to their medication, to name a few; prescriber effects, patient characteristics, the therapeutic alliance, and setting of administration. Obviously, there are additional factors beyond these that also impact on treatment adherence.

A study by McKay et al.[6] found that the prescriber had a greater effect than the actual medication on the outcomes of the patient in the treatment of depression. Specifically, the top third of psychiatrists achieved better results with their patient on a placebo then the lower third psychiatrists' whose patients were on an actual medication.[6] Similarly, Browne et al.[7] found that prescriber variables were related to better medication adherence and less severe symptoms in schizophrenia. Moreover, depression has been identified as a primary reason for unintentional nonadherence in schizophrenia Hirakawa and Ishii, 2020.[8]

Regarding patient characteristics, numerous factors influence treatment adherence such as attachment style,[9] readiness to change,[10] expectations of the treatment,[11],[12] autonomy,[13] ambivalence,[14] treatment preference,[15] defensive style,[16] and neuroticism.[17] All these factors have been found to differentially affect adherence in patients. For example, readiness to change has been found to be one of the greatest determinants of a positive outcome outweighing both the medication being used, and the disorder being treated.[8] Similarly, it has been found that expectations of treatment also strongly influence treatment outcomes with more positive attitudes toward medication associated with better adherence.[18] That is patients with high expectations of their treatment have responded better to the treatment than those with low expectations for their treatment.[11] Further, low expectations regarding treatment are also associated with treatment discontinuation.[12]

Therefore, how can treatment adherence be promoted and thus increased in patients with schizophrenia? Research has indicated that most patients who are nonadherent to their medication are deliberately nonadherent rather than unintentionally nonadherent.[19] For example, most patients make the decision not to take their medication rather than simply forgetting to take their medication or a similar unintentional reason. Thus, the following section reviews strategies that can be utilized to increase patient adherence to their medications.

  Strategies for Promoting Treatment Adherence in Schizophrenia Top

Therapeutic alliance

The therapeutic alliance or therapeutic relationship is the relationship between the patient and the clinician. The therapeutic relationship is the means by which the clinician and the patient work together to on the patient's treatment. The therapeutic alliance is the foundation on which beneficial change can be fostered. The therapeutic alliance should be person-centered with a focus on shared decision-making. Further, the focus should be individualized, and the patient's most immediate needs or challenges should be addressed first.

Motivational interviewing

As many patients make the decision not to take their medication, the focus needs to be placed on motivating the patient to follow the prescribed medication regimen. Thus, motivational interviewing should be utilized to assist the patient to engage with their treatment. Motivational interviewing is essentially a collaborative conversation aimed at strengthening a person's own motivation and commitment to change. Motivational interviewing is a strategy that assists patients to deal with their own ambivalence toward adhering to their prescribed medication regimen.[20] That is it assists patients with identifying and resolving their own ambivalence toward the prescribed treatment.[20] Patients are more likely to be persuaded by what they hear themselves say.

Recently, a study[21] found that the success of motivational interviewing with patients who have schizophrenia to improve medication adherence is dependent on three critical factors. First, a strong therapeutic relationship between the patient and the clinician is fundamental. The second success factor pertains to the clinician's ability to utilize and individualize the motivational interviewing process for the patient's needs. The key factor here is eliciting 'change talk' in the patient. As mentioned earlier, the patient is more likely to adhere if they themselves argue for the importance of their adherence. The third success factor pertains to having an explicit conversation with the patient regarding their values and goals in relation to medication adherence and nonadherence and the associated consequences and potential impacts of each upon their values and goals. The purpose of this conversation is to promote intrinsic motivation for adhering to the medication as long-term adherence is only facilitated if taking the medication aligns with the important goals of the patient.

In sum, motivational interviewing assists the patient to make better decisions that align with their goals. This is facilitated through helping the patients weigh the pros and cons of their actions and considering how their actions impact on their goals. That is motivational interviewing helps the patients highlight the discrepancy between their goals and their actions to facilitate change.

Nonpharmacological interventions

Other nonpharmacological interventions that can assist with promoting adherence include psychoeducation, reminders, specialized pill packaging, and supervised intake of medication.[21],[22] Psychoeducation is a specialized intervention that seeks to provide information and support to patients and their families to help them understand the condition.[21] In respect to medication adherence in schizophrenia, the psychoeducation is aimed at educating the patients and their families of the importance of medication adherence in schizophrenia by highlighting the consequences of not adhering to the prescribed medication regimen.[21]

Other nonpharmacological interventions aim to assist patients to remember to take medication or to verify their adherence to their medication. For example, electronic reminders can be utilized to prompt patients to take their medication.[21] Specialized pill packaging can also assist with both reminding patients and verifying if they have taken the pill.[21] For example, packaging by daily dose by day or morning and evening per day depending on the patients' medication regimen can be set up to simplify taking the medication.[21] This is useful for patients who may forget whether or not they have taken their medication. More advanced electronic options are also available that can record the time and date the pill was accessed or even pills that have an ingestible event marker which results in ingestion being logged onto a mobile phone.[21] Another adherence-based intervention is supervised intake where someone watches the patient take their medications. This is usually carried out by a member of the patient's family.

Pharmacological interventions

Pharmacological interventions to promote adherence include simplifying the patient's treatment regime and dealing with any negative side effects the patient may endure.[21],[22] Further including the patient in decisions regarding their own treatment and medication regime can greatly increase the patient's adherence to their medications.[21],[22] Another pharmacological factor that will be discussed next is the use of long-acting injectable (LAI) antipsychotics.

Long-Acting injectable antipsychotics

LAI antipsychotics facilitate transparency regarding adherence as the patient regularly attends for the administration of their LAI antipsychotic, thus it is clear if the patient is adherent to their medication by their attendance (or lack of).[23] Thus, LAI antipsychotics do not require daily dosing; rather they are taken at longer intervals such as monthly depending on the prescribed antipsychotic.[23] This also facilitates regular contact between the patient and the mental health team. Thus, if relapse does occur while using LAI antipsychotics it is clear that relapse has occurred for reasons beyond nonadherence.[20]

Clinicians can be ambivalent about discussing the option of LAI antipsychotics with their patients. This ambivalence and hesitation can affect the patient's attitude toward the use of LAI antipsychotics.[24] A previous study of psychiatrist and patient discussions regarding the use of LAI antipsychotics found that psychiatrists presented the use of LAI antipsychotics negatively.[24] Research has indicated that the majority of patients feel that they were not properly informed or given the option of LAI antipsychotic treatment by their psychiatrist conversely though the majority of psychiatrists felt that they had broached the subject with their patient and offered LAI antipsychotics as an option.[25] While another study has indicated that patient's with more than 3 months experience on LAI antipsychotics prefer them with 70% reporting that they felt better supported by the regular contact with their doctor or nurse.[26] Thus clearly, there is miscommunication regarding the topic of LAI antipsychotics.

[Table 1] below summarises the factors that influence treatment adherence as well as strategies to promote treatment adherence for each of the factors. Strategies involve both non-pharmacological as well as pharmacological interventions.
Table 1: Summary of the causes of non-adherence to treatment along with factors that assist with promoting adherence

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  Conclusion Top

Due to the high rates of nonadherence to antipsychotics evident in patients with schizophrenia, it is imperative to promote factors that increase adherence while working to minimize factors that negatively impact adherence to antipsychotic medications. Further, it is important to effectively communicate the need for adherence; patients need to be made aware of the consequences of not taking their medication as prescribed. Individual-level factors have a strong impact on promoting adherence. Factors related to monitoring the intake of medication can also help to promote adherence. While pharmacological factors such as simplifying the treatment regime and dealing with the negative side effects the patient experiences can also be beneficial for adherence. However, the most beneficial pharmacological strategy is the use of an LAI antipsychotic. The use of an LAI ensures adherence as the patient receives their medication directly from their doctor or nurse; thus, the treating team can identify and rectify nonadherence promptly.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Blackwell B. The drug defaulter. Clin Pharmacol Ther 1972;13:841-8.  Back to cited text no. 1
Weiden PJ, Olfson M. Cost of relapse in schizophrenia. Schizophr Bull 1995;21:419-29.  Back to cited text no. 2
Haynes RB, McDonald H, Garg AX, Montague P. Interventions for helping patients to follow prescriptions for medications. Cochrane Database Syst Rev 2002;(2):CD000011.  Back to cited text no. 3
Velligan DI, Wang M, Diamond P, Glahn DC, Castillo D, Bendle S, et al. Relationships among subjective and objective measures of adherence to oral antipsychotic medications. Psychiatr Serv 2007;58:1187-92.  Back to cited text no. 4
Velligan DI, Kern RS, Gold JM. Cognitive rehabilitation for schizophrenia and the putative role of motivation and expectancies. Schizophr Bull 2006;32:474-85.  Back to cited text no. 5
McKay KM, Imel ZE, Wampold BE. Psychiatrist effects in the psychopharmacological treatment of depression. J Affect Disord 2006;92:287-90.  Back to cited text no. 6
Browne J, Nagendra A, Kurtz M, Berry K, Penn DL. The relationship between the therapeutic alliance and client variables in individual treatment for schizophrenia spectrum disorders and early psychosis: Narrative review. Clin Psychol Rev 2019;71:51-62.  Back to cited text no. 7
Hirakawa H, Ishii N. Depression as a factor in nonadherence in schizophrenia. J Clin Psychiatry 2020;81:20lr13262.  Back to cited text no. 8
Ciechanowski PS, Katon WJ, Russo JE, Walker EA. The patient-provider relationship: Attachment theory and adherence to treatment in diabetes. Am J Psychiatry 2001;158:29-35.  Back to cited text no. 9
Lewis CC, Simons AD, Silva SG, Rohde P, Small DM, Murakami JL, et al. The role of readiness to change in response to treatment of adolescent depression. J Consult Clin Psychol 2009;77:422-8.  Back to cited text no. 10
Krell HV, Leuchter AF, Morgan M, Cook IA, Abrams M. Subject expectations of treatment effectiveness and outcome of treatment with an experimental antidepressant. J Clin Psychiatry 2004;65:1174-9.  Back to cited text no. 11
Rutherford BR, Wager TD, Roose SP. Expectancy and the treatment of depression: A review of experimental methodology and effects on patient outcome. Curr Psychiatry Rev 2010;6:1-10.  Back to cited text no. 12
Zuroff DC, Koestner R, Moskowitz DS, McBride C, Marshall M, Bagby RM. Autonomous motivation for therapy: A new common factor in brief treatments for depression. Psychother Res 2007;17:137-47.  Back to cited text no. 13
Warden D, Trivedi MH, Wisniewski SR, Lesser IM, Mitchell J, Balasubramani GK, et al. Identifying risk for attrition during treatment for depression. Psychother Psychosom 2009;78:372-9.  Back to cited text no. 14
Raue PJ, Schulberg HC, Heo M, Klimstra S, Bruce ML. Patients' depression treatment preferences and initiation, adherence, and outcome: A randomized primary care study. Psychiatr Serv 2009;60:337-43.  Back to cited text no. 15
Kronström K, Salminen JK, Hietala J, Kajander J, Vahlberg T, Markkula J, et al. Does defense style or psychological mindedness predict treatement response in major depression? Depress Anxiety 2009;26:689-95.  Back to cited text no. 16
Steunenberg B, Beekman AT, Deeg DJ, Kerkhof AJ. Personality predicts recurrence of late-life depression. J Affect Disord 2010;123:164-72.  Back to cited text no. 17
Lawerence RE, Dixon L. The challenge of nonadherence. In: Psychiatric Nonadherence. E-Book. Switzerland: Springer; 2019.  Back to cited text no. 18
Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005;353:487-97.  Back to cited text no. 19
Palacio A, Garay D, Langer B, Taylor J, Wood BA, Tamariz L. Motivational interviewing improves medication adherence: A systematic review and meta-analysis. J Gen Intern Med 2016;31:929-40.  Back to cited text no. 20
Kane JM, Kishimoto T, Correll CU. Non-adherence to medication in patients with psychotic disorders: Epidemiology, contributing factors and management strategies. World Psychiatry 2013;12:216-26.  Back to cited text no. 21
Velligan DI, Sajatovic M. Practical strategies for improving adherence to medication and outcomes. World Psychiatry 2013;12:233-4.  Back to cited text no. 22
Brissos S, Veguilla MR, Taylor D, Balanzá-Martinez V. The role of long-acting injectable antipsychotics in schizophrenia: A critical appraisal. Ther Adv Psychopharmacol 2014;4:198-219.  Back to cited text no. 23
Weiden PJ, Roma RS, Velligan DI, Alphs L, DiChiara M, Davidson B. The challenge of offering long-acting antipsychotic therapies: A preliminary discourse analysis of psychiatrist recommendations for injectable therapy to patients with schizophrenia. J Clin Psychiatry 2015;76:684-90.  Back to cited text no. 24
Jaeger M, Rossler W. Attitudes towards long-acting depot antipsychotics: A survey of patients, relatives and psychiatrists. Psychiatry Res 2010;175:58-62.  Back to cited text no. 25
Caroli F, Raymondet P, Izard I, Plas J, Gall B, Delgado A. Opinions of French patients with schizophrenia regarding injectable medication. Patient Prefer Adherence 2011;5:165-71.  Back to cited text no. 26


  [Table 1]


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