Academic Psychiatry 29:203-210, June 2005
© 2005 Academic Psychiatry
Teaching Medication Compliance to Psychiatric Residents: Placing an Orphan Topic Into a Training Curriculum
Peter J. Weiden, M.D. and
Nyapati Rao, M.D.
Dr. Weiden is Director of Schizophrenia Research Service at SUNY Downstate Medical Center, Brooklyn, New York. Dr. Rao is Director of Residency Training at SUNY Downstate Medical Center, Brooklyn, New York. Address correspondence to Dr. Weiden, Psychiatry, Box 1203, SUNY Downstate Medical Center, 450 Clarkson Ave., Brooklyn, NY 11203; peter.weiden{at}downstate.edu (E-mail). Copyright © 2005 Academic Psychiatry.
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ABSTRACT
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OBJECTIVE: Medication compliance is an orphan topic. Training in the understanding and management of noncompliance does not neatly fall within the domain of psychopharmacology, nor does it clearly fit into other core curricula areas, such as clinical interviewing or psychotherapy training. The objective of this article is to increase awareness about this vagueness among academic psychiatrists and to offer a suggested curriculum to facilitate implementation. METHODS: The authors present a curriculum covering major aspects of the theory and practice of compliance. The proposed curriculum is divided into five core components that can be used together or separately. These components are: 1) definition of compliance and noncompliance; 2) understanding how compliance depends on efficacy; 3) assessment of compliance and noncompliance; 4) the importance of the therapeutic alliance; and 5) pharmacological and psychosocial strategies to improve compliance. These five sections can be modified into specific lectures that are added to ongoing psychopharmacology, psychiatric interviewing, or psychotherapy courses. RESULTS: A careful review of the American Board of Psychiatry and Neurology (ABPN) core curriculum found no mention of medication compliance/adherence as a specific training goal, and our residency program, like many others, did not have a specific course that focused on this issue. To address this omission, the authors designed and taught a five-session course for PGY-III and PGY-IV psychiatry residents that specifically addressed assessment and management of noncompliance. It was piloted in the 2003-2004 academic year. The course was very well received and formed the basis of this material presented in this review and discussion. CONCLUSION: The principles of understanding, assessing, and managing medication compliance should be a part of the core curriculum for every psychiatric residency training program.
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INTRODUCTION
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The topic of patient "compliance" or "adherence" is of great importance in all fields of medicine (1, 2). In psychiatry, there is little question that medication compliance plays an enormous role in the success—or failure—of many psychopharmacological treatments. What sets psychiatrists apart from their medical colleagues is not so much that psychiatric patients stop their medications more often than patients with medical conditions, but it is that psychiatrists deal with more complex compliance situations. As such, psychiatrists are viewed by their medical colleagues as more adept in understanding, assessing, and managing noncompliance. It is ironic that many psychiatric residency programs have little in the way of formal training on the topic of medication compliance given that psychiatrists are viewed as compliance experts. One explanation for this limited attention is that medication compliance is an orphan topic—it does not clearly fall within the domain of psychopharmacology, nor does it clearly fit into other formal parts of a psychiatric residency curriculum.
This article makes the case for having a formal teaching program on the topic of medication compliance. We propose a course outline and training goals and discuss implementation strategies for integrating a compliance curriculum into an ongoing curriculum. The suggested core components are described in a way that will maximize flexibility of curriculum planning, and each component has been outlined in a way that may be incorporated on its own without necessarily using the other component(s).
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Justifying Formal Training for Medication Compliance
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Medication noncompliance is an urgent public health problem, with noncompliance rates well over 50% for most medication treatments of major psychiatric disorders. Noncompliance is probably the single greatest modifiable risk factor for unfavorable outcomes in psychopharmacology. For example, it is well known that one of the most common causes of medication "nonresponse" in psychopharmacology is noncompliance that is not recognized by the psychiatrist (3). Medication noncompliance is associated with rehospitalization for depression (4), bipolar disorder (5), and schizophrenia (6). Fortunately, there are many effective, evidence-based pharmacological (7) and psychosocial (8, 9) treatments that are known to improve compliance to psychiatric medications. Ideally, the underlying principles of these successful interventions should be taught to psychiatric residents.
Standard psychopharmacology texts have extensive sections on treatment nonresponse but have, at best, cursory coverage of medication compliance. Thus, when the psychopharmacology course follows the textbooks, trainees will not spend much time learning about how to assess and manage noncompliance problems. It would seem that in-depth training on medication compliance would need to take place elsewhere, ideally as a separate course. Most residency programs do not have formal training on the topic of medication compliance. The omission of compliance as an important training agenda for psychiatrists seems to extend to The American Board of Psychiatry and Neurology (ABPN). The ABPN core competency section of somatic treatments for psychiatric residency training is silent about the topic of medication compliance (Section B3, items a-g, and B4, items a-c) (10). Similarly, the psychological issues of noncompliance are not mentioned in the ABPN sections on core competencies for clinical interviewing (see Section III A, items 1–8). It seems reasonable to conclude that, presently, there is no assurance in psychiatric residency standards that training in the psychological or pharmacological principles of medication noncompliance is covered anywhere in the curriculum during psychiatric residency training.
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Suggested Core Components of a Compliance Curriculum
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The following curriculum was developed to teach psychiatric residents the core aspects of compliance as it pertains to the medication management of patients with one of the major mental disorders. The curriculum addresses the definition and theory of compliance, assessment techniques, and interventions to improve compliance. The course curriculum is divided into five core components, each of which tackles an important aspect of the problem. These five components are 1) definition of compliance and noncompliance; 2) relationship between compliance and efficacy; 3) assessment of compliance and noncompliance; 4) importance of the therapeutic alliance; and 5) interventions to improve compliance. Because each training program has its own needs, interests, and schedules, these components are presented in a way that facilitates teaching them as individual classes, if preferred.
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Core Component 1: Defining Compliance and Noncompliance
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It is hard to define compliance and noncompliance when there is no universal definition, upon which all agree, and even the language itself is controversial. It is important for residents to understand the importance of the language used to describe compliance. The term noncompliance is often considered to highlight a power imbalance between doctor and patient and emphasizes obedience in a way that is pejorative to patients. On the one hand, most clinicians are comfortable with this term. As such, compliance and noncompliance can conjure up many strong emotions for clinicians and patients alike. A widely used synonym for compliance is adherence. The proponents of adherence and nonadherence hope that these terms will not reflect the same degree of power imbalance and coercion as the words "compliance" and "noncompliance." Nonetheless, most residents are more familiar with compliance than adherence. We have chosen to stay with the former, but there is a good case for using adherence instead. Regardless of the final choice of terminology, any compliance training course needs to make certain that residents be familiar with both compliance and adherence and understand the nature of the nomenclature debate.
For a more detailed review of the problems posed by definition, an excellent source is a classic work in the field of compliance by Sackett and Haynes, published in 1979 which remains an essential publication in the field of compliance to this day. The most common definition of medication noncompliance is a deviation or cessation of a medication regimen that is less than what was recommended by the doctor, or, as defined by Sackett and Haynes, "... failure or refusal to comply with treatment recommendations" (11). Residents should be taught that this standard definition of compliance focuses more on medication-taking behavior than attitude toward medication and, for better or worse, usually implies disobedience and intent on the patient’s part. One major problem with this definition is that it does not consider the efficacy of the treatment recommendation. This limitation is addressed in the next section.
The succeeding step is to demonstrate the complexity and presuppositions that are embedded in the routine clinical use of the word "noncompliance." Several presupposing criteria need to be met before someone would be considered noncompliant. It is assumed, without overt discussion, that the noncompliant patient has received adequate information about the condition being treated, has access to medication, and has the ability to take the medications as instructed. To illustrate the relevance of these presuppositions, after the trainees have discussed their own concept of noncompliance, the class can be asked whether a patient with Alzheimer’s disease who forgets to take his or her medication is noncompliant. In this case, most clinicians feel uncomfortable with calling this type of patient noncompliant, even though this vignette would fall under many
Another problem with the previously mentioned definition of "failure or refusal" is that very few people do exactly as the doctor tells them. Strictly speaking, just about everyone is noncompliant. Therefore, a starting point is to distinguish between patients who deviate from their medication regimen from those who willfully stop all of their medication. Compliance evaluated as the percent of regimen taken over time by patients who seem basically willing to follow the treatment was previously called "dosage deviation." More recently, this phenomenon is known as "partial compliance." Partial compliance is conceptually different (12, 13) from willful and intentional medication cessation that is contrary to the doctor’s recommendation. Generally speaking, partial compliance is better suited for discussions in psychopharmacology classes because partial compliance directly relates to characteristics of medication regimen, complexity, medication errors, route of administration, and dose-response issues concerning just how much medication has to be missed to have an adverse effect on outcome. On the other hand, issues concerning patients who intentionally decide to completely stop all of their medication against their doctor’s advice are more suitable for teaching the importance of medication attitudes and intrapsychic, interpersonal, and therapeutic alliance issues related to taking medication.
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Core Component 2: Relationship Between Compliance and Efficacy
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The major goal of this section to is help trainees understand that the main goal is to achieve better patient outcomes. As such, it is much better to consider noncompliance as a barrier to achieving the best outcomes rather than an act of disobedience that is upsetting or disruptive. To achieve this training goal, the course needs to move one step away from noncompliance in order to examine the efficacy of the prescribed treatment in the first place.
A fundamental rule in compliance theory is that noncompliance only matters for effective treatments. In other words, noncompliance does not matter when treatments are not effective. Compliance only matters for effective treatments, and noncompliance presupposes that the medication is prescribed properly and accurately. While it seems obvious, the physician needs to be sure that the diagnosis is accurate and that the patient and significant others have received a clear medication recommendation for a treatment plan. Residents and other trainees must learn the danger of skipping this step. The question should be, "Is my treatment effective in the first place?" If so, the next question should be, "Is the extent to which the patient is noncompliant harmful to this patient’s outcome?"
There are other important conceptual issues between efficacy and compliance. Residents must be careful not to automatically attribute an unexpectedly poor outcome to poor compliance without other confirmatory evidence. An excellent example of the difficulties in assessing whether poor outcome is the result of nonresponse or noncompliance can be found in studies that compare long-acting injectable antipsychotics with oral antipsychotic medications, which found significant relapse rates in the depot patients, despite the fact that their compliance was guaranteed by the nature of the medication delivery (14). The tendency for clinicians to misattribute the inadequate efficacy of their prescribed medication to noncompliance leads to lost opportunities to find more effective pharmacological interventions, while at the same time blaming the patient. It is more accurate and much better for the therapeutic alliance to blame the medication rather than the patient!
Noncompliance can really be a secondary complication of the lack of efficacy. Psychiatric relapse, unlike relapse from other medical conditions, often presents with a lack of insight and abrupt changes in cooperation. Patients who were perfectly compliant when stable can become noncompliant during relapse, even when noncompliance is not the root cause of the relapse. Residents should become familiar with this concept of secondary noncompliance as a result of breakthrough psychiatric symptoms. The educational goal is to help residents better evaluate the underlying causes of relapse, with poor compliance being only one of several causes.
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Core Component 3: Assessment of Compliance
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The first teaching point of this concept is that clinicians are very poor at judging the compliance status of their own patients. It has been repeatedly shown that clinicians underestimate the frequency and magnitude of noncompliance in their own patients (15). However, once this teaching point is established, it would be a mistake to leave it at that. The discussion should move to how to improve the accuracy of the compliance assessment, including how to best conduct a compliance interview and how to use other sources of information.
The most important interview skill is to emphasize that questions about compliance need to be done in a routine, nonthreatening manner. The tone of voice should convey curiosity, and the doctor’s expectation is that noncompliance is to be expected. On one extreme would be the shrill question, "So, you did take your medications, didn’t you?!" Another such question might be, "What? You stopped the medication! Why?" These types of questions are guaranteed to be the last time the patient would answer truthfully. It is much better to ask, in a gentle and curious way, "Tell me about when you last stopped your medication?" Framed this way, the interviewer normalizes medication noncompliance. If one can show—in words or behavior—that the patient will not be punished for telling the truth, it makes it easier for the patient to acknowledge that some medication(s) may have been left untaken. Punishment comes in many forms and can include scolding the patient; lecturing the patient imperiously; humiliating the patient; or withdrawing from the patient emotionally, disengaging from him or her. Then, after noncompliance is reported, the interview training should focus on the doctor’s emotional response to the information. It is much more supportive to the therapeutic alliance for the doctor to show appreciation for having been told the truth. Should the doctor become annoyed or frustrated, honest discussion will end right there, and the patient will likely become defensive. A caveat here is to mention that a gentle response does not mean that the doctor agrees with the patient. Rather, it allows for a more focused assessment to take place in a way that does not jeopardize the therapeutic alliance (16).
Another set of skills that should be utilized in the assessment of compliance behavior is to expand the assessment techniques beyond the clinical interview. Methods include finding other sources of information and identifying high-risk times for noncompliance. Not surprisingly, the availability of medication supervision can make a big difference in partial compliance. One study of predictors of medication compliance in residential settings found that the best predictor was whether the staff supervised the medication (17). Patients whose medications are supervised by their family are likely to miss their medications when their caretakers are away or working. The opinions about psychiatric medications of significant others in the patient’s network are a key factor of influence in compliance. The person influencing compliance may be a family member, significant other, or residential staff that provides a consistent presence in the patient’s life. Any disruption to that relationship may place the person at much higher risk for stopping his or her medication. Appendix 1 outlines other assessment methods to assess whether there have been gaps or problems in compliance behavior as well as some common clinical situations where patients are at much higher risk of becoming noncompliant, such that an in-depth assessment might be warranted (18–20).
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Core Component 4: Importance of the Therapeutic Alliance
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Therapeutic alliance is described by the ABPN as the ability of the physician to "develop and maintain a therapeutic alliance with patients by instilling feelings of trust, honesty, openness, rapport, and comfort in their relationship with physicians" (10). By and large, in the psychopharmacology era, most psychiatrists, let alone residents, do not fully appreciate the central importance of the therapeutic alliance in promoting better medication compliance (21). The goal is to communicate to trainees that the therapeutic alliance is as important for success in psychopharmacology as it is for psychotherapy. Doctors tend to downplay interpersonal aspects of the therapeutic relationship in lieu of a reliance on the efficacy of the prescription (22, 23). As part of the teaching of this core component, there should be a brief discussion of the literature linking a positive therapeutic alliance with better compliance (24). A more advanced agenda on the therapeutic alliance core component could include a discussion of how noncompliance can elicit feelings of disappointment, anger, or distancing toward the patient (25, 26). Noncompliance that is overt can feel like a challenge to the doctor’s authority. Residents who come from cultural backgrounds where unquestioned obedience is expected from patients may have difficulty with noncompliant behavior. A common countertransference response is to blame the patient for the noncompliance (27, 28). Blame can be explicit when a physician remarks, "The patient is manipulative and does not want to get better." More often, however, blame is unspoken, and the clinician withdraws into making a tacit therapeutic stance by asking, "What could I do about it? The patient just did not cooperate with my treatment plan." Such an overall attitude is counterproductive. It erodes any potential for a therapeutic alliance and makes noncompliance much more likely to continue (21). Putting these kinds of reactions out in the open can help residents assume a more constructive approach when dealing with the noncompliant patient. Instead of blaming the patient, the doctor should try to assume an attitude of responsibility for the noncompliance. The residents can consider the point of view that medication noncompliance is a failure of treatment rather than a failure of the patient (27). Like medication nonresponse, it is up to the clinician to come up with a more effective treatment plan. The teaching goal is to move the therapeutic relationship away from power struggles and move toward a model where compliance is seen within the context of enhancing the therapeutic alliance. Appendix 2 shows some techniques for enhancing the therapeutic alliance when addressing compliance.
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Core Component 5: Interventions to Improve Compliance
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The goal of this section is to cover the major psychosocial and pharmacological approaches to improve medication compliance. There are a variety of theoretical approaches to interventions targeting compliance improvement as the main outcome. The systems perspective considers noncompliance as a lack of fit between the treatment system and the patient’s treatment needs (29, 30). The interpersonal perspective focuses more on how willingness to take medication is influenced by one’s relationships with significant others, be it community, family, partner, or doctor (16, 31–34). The intrapsychic perspective considers the psychology of the individual person that ultimately results in compliance or noncompliance (35). Each type of perspective has its own strengths and weaknesses, and perhaps each is most useful under some circumstances and not others. It is beyond the scope of this article to review these perspectives in detail, except to say that any course or teaching program on compliance can consider any or all of these perspectives, details of which are discussed in other texts on the topic (36).
When the goal is to introduce a psychological perspective that can be used as a psychotherapeutic intervention, an explanatory model known as the Health Belief Model (HBM) is helpful (37, 38). The HBM has been widely used as a theoretical model for a variety of chronic medical disease conditions, including tuberculosis, diabetes, and hypertension, and found to have predictive value with regard to compliance (11, 39–41). The training advantage of the HBM is that it has an extensive research literature that covers both medical and psychiatric diseases, is reasonably straightforward, and can be immediately applied to trainees’ clinical cases.
The HBM has two basic fundamental principles. The first principle is that patient perception is reality, at least as far as motivation for compliance is concerned. Compliance behavior is ultimately determined by patient perception, rather than the objective reality of the clinical situation. In other words, it is the perceived benefits or perceived side effects, as determined by the patient, that really matter in compliance decisions, and the actual therapeutic benefits or side effects, as judged by the physician, are not nearly as important. The second principle is that the patient’s ultimate compliance behavior is the net effect of weighing together all of the perceived benefits and risks of staying with the medication. According to the HBM, no single factor is the sole determinant of compliance. The HBM is a relatively straightforward and clinically useful model that can help residents move from a compliance assessment to a compliance intervention (42). Many of the techniques suggested in Appendix 2 and Appendix 3 are based on the principles of HBM.
To maximize compliance, psychopharmacological interventions should be addressed by the mnemonic of the four "Fs" : 1) effective, 2) flexible, 3) forgiving, and 4) user-friendly.
It goes without saying that the more effective the medication, the easier it will be to address compliance in the long run, with the caveat that the case needs to be presented in a way that is convincing from the perspectives of both the patient and the physician. Another indirect advantage of optimizing efficacy is that persistent psychiatric symptoms may interfere with the learning from experience and understanding psychoeducation about the importance of compliance. There are important medication strategies that can be extremely helpful in clarifying the relationship between nonresponse and noncompliance, especially when noncompliance is a sign of relapse. For example, in the maintenance treatment of schizophrenia, one major advantage of a long-acting, injectable antipsychotic (e.g., long-acting risperidone) over the oral atypical antipsychotic medication is that a long-acting route can help track whether any relapse is caused by noncompliance or by other reasons (43).
Flexibilty refers to keeping as many pharmacological options as possible. Nowhere is this most apparent in having many options to address noncompliance that is triggered by side effect distress. For example, the availability of multiple antipsychotic medications, with different side effect profiles, makes it much easier to tailor the choice of antipsychotic medication to minimize those side effects that are most distressing to the individual patient. At this point in the discussion, residents should be reminded that it is subjective distress about a perceived side effect that is most linked to noncompliance, rather than the side effect itself. For example, a woman who is distressed by a 3 lb weight gain is more likely to stop her medication than a man, who may be unconcerned about gaining 30 pounds (44).
Medications that are forgiving of dosage irregularities often have compliance advantages over ones that are unforgiving. An example of the latter is lithium use for the maintenance treatment of bipolar disorder. Although lithium is very effective when used exactly as directed, it is not very forgiving, in that small degrees of partial compliance can have devastating effects on outcome. On the other hand, long-acting injectable antipsychotics can be quite forgiving once steady-state is reached. Antipsychotic plasma levels will remain within therapeutic range even if the patient is a few days late for their medication injection, and the long half-life will reduce any problems associated with medication withdrawal (45).
Furthermore, there should be consideration of whether the medication regimen is user-friendly. There should be consideration of partial compliance and finding methods that are both prescriber and patient friendly. For example, using multiple pharmacological agents—of the same or different classes—has vastly increased in popularity in psychopharmacology. Regardless of the relative merits of multiple medications, the additional burden caused by the imposing medication regimen is often missed. It is better to have the patient be compliant to the single most important medication than to discontinue the whole slew of medications entirely. Unfortunately, this practical point tends to be considered only after the patient’s complicated medication regimen collapses under its own weight.
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Implementation of Compliance Training
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The scope and seriousness of the problem of medication noncompliance in psychiatry are strong arguments supporting its inclusion in core residency training. A stand-alone formal curriculum on medication compliance can be relatively brief. In the 2003–2004 academic year, our training program introduced a formal training program on medication compliance to PGY-IV residents. The curriculum described above was fully covered in four classes that ran 90 minutes each, for a total of 6 hours of didactic time. We chose the longer class time to allow for role playing exercises and case vignette presentations, which, in our experience, was a successful way to communicate the material covered in this article. Based on its success, the course has been moved to earlier in the residency curriculum, and will be taught to PGY-III residents. If preferred, the five core components can be divided, and integrated into ongoing psychopharmacology and interviewing courses. Components 1 (definition) and 2 (relation with efficacy) seem more suitable for a psychopharmacology course, and component 4 (therapeutic alliance) is more suitable for an interview or psychotherapy class. Core components 3 (assessment) and 5 (intervention) are material relevant to psychopharmacology and interview/psychotherapy, and the dividing line for these is fairly straightforward, as addressed in the formal curriculum.
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Summary
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Everyone knows the importance of compliance, yet it rarely has its own teaching focus. We recommend that residency training programs consider revising their formal curriculum to proactively include training on medication compliance. If so, we hope that the suggestions and structure offered in this article will be make the task less onerous, compared to starting from scratch. Is it worth it? Yes! We would argue that it clearly is worth the time and effort involved. Our rationale is that the topic of patient compliance has significant enduring value for the resident. Regardless of what happens in psychiatry and medicine, it seems safe to say that noncompliance will continue to be a major problem for years to come.
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ABSTRACT
INTRODUCTION