How to Improve Medication Adherence Rates Among Patients With Schizophrenia

(Part 2 of 2)

In this video, Jacob Ballon, MD, MPH, Standford University, California, discusses the main reasons patients do not adhere to their medication treatment and tips for clinicians to improve medication adherence rates.

Dr. Ballon expands on his recent session at the Psych Congress Elevate virtual meeting titled “A Focused Schizophrenia Update: Emerging Pharmacological Solutions for Management of Metabolic Disruptions”.

In the previous part 1 of this video, Dr. Ballon discussed key best practices for matching patients with schizophrenia with an effective antipsychotic and how to mitigate the adverse effects experienced by patients.

Q: What are the main reasons patients do not adhere to their medication treatment?

A: There could be a number of different reasons that people don't want to take medication. Regardless of whether a person appreciates their illness or not, many people find taking medication to be difficult.

They don't want to endure side effects and they don't want to be part of something where they feel like they are people who have to take medication.

When you add in the possibility of anosognosia, or difficulty in appreciating illness that a person might have, it makes it even more difficult for a person to want to take medication if they can't appreciate that there's even a reason they should be taking it.

When you add in side effects like weight gain and sedation that can be there, many people are going to say, "That doesn't make me feel better anyway. Why would I want to endure something like this?"

Making sure that thinking about what those side effects are that people are having and thinking about ways to mitigate them, whether through adjunctive medications, through diet and exercise, or through working with people on how to schedule the medication in the best possible manner are ways that I would think about helping to mitigate the risk of side effects.

Q: What tips do you have for clinicians to improve medication adherence rates among their patients?

A:  It's important when thinking about how to improve adherence that you are working with patients on a shared vision of what their treatment is supposed to look like.

From the very outset, I'm working with people to understand that we're having a shared decision-making approach in the office. That means recognizing that the patient is an expert, and I'm an expert, and their family are experts. Everybody here is an expert on their piece of the treatment puzzle.

The more we can be on alignment, the more likely a person is going to feel like they're part of what they're doing and that it matters to them. That they are choosing to do this and they're likely to benefit. Focusing on keeping everybody on the same page, to me, is the best way to help manage adherence.

In doing so, it helps me to also make sure that I'm being responsive to the challenges that might arise. That maybe don't start out initially but that can come up over the course of treatment so that we can all continue to work together and figure out what's going to be the best course forward.

Q: Are there any misconceptions about this topic that you would like to clear up?

A:  When I think about what are some misconceptions that people might have about treating people with schizophrenia, one thing that comes to mind is thinking about what people's behaviors are and whether their behavior is logical or not.

What is this person doing? Is it bizarre, or is what they're doing the result of faulty inputs? They're getting bad information, because they're hearing voices, or they're feeling paranoid, or having delusions. Their behavior in the moment makes sense based on those inputs.

It's important to think about how to structure a medication regimen, to understand what patients are understanding, and to fit in things together.

Similarly, when we're thinking about trying to include diet or exercise to folks, it's easy for us to fall back and say, "Well, it's negative symptoms or it's inherent to the illness that people are unmotivated or unlikely to want to participate."

We've seen time and again, when we use appropriate motivators, incentives, and include people in their treatment planning, that people are willing to take on new things that they might not otherwise do. It's important to think big and work with your patients to try to take on real challenges together.

Q: Any final thoughts?

A: Final thoughts, I would say when you're starting out a medication, be methodical. Think through the side effects, think through the risks and benefits with the patient.

Work together on a shared decision-making platform so the two of you and any other relevant parties all feel like they have an adequate say in what's going to happen.

Together with that, thinking big, prompting people to work on achieving their goals, and aligning the treatment with goals as opposed to symptoms, to me, is the best way to help people to make the biggest gains in their lives.

Jacob S. Ballon, MD, MPH, specializes in the treatment of people with psychotic disorders including schizophrenia. He is the Co-Director of the INSPIRE Clinic at Stanford, California, which provides interdisciplinary care for people experiencing psychosis. He is also the medical director of H2 acute inpatient unit and the co-director of the specialty psychiatry clinics section in the Department of Psychiatry. Dr. Ballon completed his residency at Stanford in 2009 and in 2011 a Schizophrenia Research Fellowship at Columbia University, New York, New York.