Medication Adherence

Знак вопроса из медицинских таблетJessie has put in a sick call request because she is depressed and anxious.  You see her later in the day; she is worried about her children, who are under the care of their aunt while Jessie is incarcerated. She is unable to sleep, tearful and was sanctioned recently for not following orders. She is having difficulty getting along with her cellmate and prefers to stay in the corner of the dayroom.  You note in her record that Jessie has diagnoses of schizoaffective disorder, asthma and hypertension.  She takes several different medications and misses taking them about half of the time.  Jessie uses sick call frequently and has declared several medical emergencies for chest pain and shortness of breath; later diagnosed as anxiety. Jesse missed a recent mental health appointment and claimed she was not notified. She unsure about her work and program assignments and her appearance at the sick call is disheveled.

This is a classic example of a patient seen in the correctional setting; one who has a chronic mental health condition, comorbid chronic health problems and a likely history of substance abuse, who is only partially compliant with treatment. How many times have you wondered what else you might do to better support her and other patients like this to adhere to the plan of treatment?

The first step is to congratulate yourself that you identified non-adherence to treatment as a primary reason for the symptoms she is experiencing. What would Jessie’s clinical condition be like today if she were taking medication as prescribed, keeping her appointments with mental health providers and engaged in work and other program assignments? When you ask Jesse why she is not taking her medication her answer is vague. She professes to have a good relationship with the psychiatric nurse practitioner but cannot tell you what medications she is prescribed or why.

According to the World Health Organization (Sabaté 2003) approximately 50% of patients with chronic illnesses do not take medications as prescribed. Failure to take medications as prescribed is associated with poor patient outcomes, relapse, increased mortality and increased hospitalization (O’Malley 2013). Adherence is defined as the extent to which a person’s behavior corresponds with the recommendations for treatment to which the patient agreed. Adherence is complex, involving the patient’s knowledge, beliefs and attitudes, and their relationship with health care providers. Adherence also changes over time and may vary from day to day. The nature of the treatment itself, health care provider behavior and the system that provides the patient care impact adherence.

One of the most important factors affecting adherence among inmates is the patient’s experience of symptom relief (Mills et al. 2011, Ehret et al. 2013). In Jessie’s case, the anxiety and depression she is experiencing probably is because she is missing half of her medications. Several studies report good adherence rates among prisoners because of directly observed therapy (Gray et al. 2008, Westergaard et al. 2013, Saberi et al. 2012). However, even with directly observed therapy, inmates miss taking their medication because the request for refill was not made timely, the inmate was asleep or not present at the time medication was administered, the inmate forgot or was experiencing unwanted side effects (Mills et al. 2011, Ehret et al. 2013).

Viewing the patient as solely accountable for adherence is considered an uninformed and destructive model. Experts suggest instead that helping patients’ increase adherence would have a greater effect on health outcomes than any other specific medical treatment (Brown & Russell 2011, Sabaté 2003).  In an expert guideline series on adherence two first-line interventions were recommended:

1. Symptom and side effect monitoring

2. Medication monitoring and environmental supports

Listed below are specific actions that can be taken which are consistent with these two interventions. They provide guidance about how to assist our patient, Jessie.  Monitoring and support of patients to improve adherence are independent functions and within the scope of practice for registered nurses.

Symptom and side effect monitoring

Medication monitoring and environmental supports

  • Monitor closely for symptom response using a daily checklist or chart
  • Institute directly observed therapy
  • Increase frequency of contact
  • Provide reminders to take medication
  • Address side effects promptly
  • Provide reminders to get medication refills
  • Consider how distressing the side effect is for the patient
  • Target support to address barriers
  • Provide information about how to manage side effects
  • Increase visit frequency to monitor for relapse
  • Simplify the medication regime
  • Involve family or other social support
  • Consider the patient’s preference for dosing regime

(Velligan et al. 2010)

Poor adherence is due to multiple factors and requires several concurrent strategies to effect change. The goal of our interventions is not adherence, per se, but to achieve the best possible outcome for the patient. Involving the patient in the identification of the outcome she wants to achieve will provide clarity and motivation for the patient. Tailoring the medication experience, as much as possible, to the patient’s goals will improve their adherence.

The next post will describe the various factors affecting adherence among our patients and provide more strategies which have evidence to support their use to improve adherence. Until then, we invite you to tell us about the most challenging aspects of supporting patient adherence to prescribed medication in your setting?  Please share your opinions by responding in the comments section of this post.

Read more about monitoring and supporting patient compliance with prescribed medication in Chapters 6 and 12 in the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

References: 

Brown, M. T. & Bussell, J.K. (2011) Medication adherence: WHO cares? Mayo Clinic Proceedings 86 (4) 304-314.

Ehret, M.J., Barta, W., Maruca, A., et al. (2013) Medication adherence among female inmates with bipolar disorder: results from a randomized controlled trail. Psychological Services, 10 (1), 106-114

Gray, R., Bressington, D., Lathlean, J. & Mills, A. (2008) Relationship between adherence, symptoms, treatment attitudes, satisfaction, and side effects in prisoners taking antipsychotic medication. The Journal of Forensic Psychiatry & Psychology, 19 (3), 335-351

Mills, A., Lathlean, J., Forrester, A., Van Veenhuyzen, W., & Gray, R. (2011) Prisoners’ experiences of antipsychotic medication: influences on adherence. The Journal of Forensic Psychiatry & Psychology, 22 (1) 110-125

O’Malley, P. A. (2013) Medication adherence and patient outcomes. Part 1: Why patients fail to take prescribed medications. Clinical Nurse Specialist, 227-228

Sabaté, E., ed. (2003) Adherence to Long-Term Therapies: Evidence for Action. Geneva, Switzerland: World Health Organization. Accessed 11/20/2013 at http://www.who.int/chp/knowledge/publications/adherence_introduction.pdf

Saberi, P., Caswell, N.H., Jamison, R., Estes, M. & Tulsky, J.P. (2012) Directly observed versus self-administered antiretroviral therapies: preference of HIV-positive jailed inmates in San Francisco. Journal of Urban Health 89 (5) 794-801

Velligan, D.I., Weiden, P.J. & Sajatovic, M., et al. (2010) Strategies for addressing adherence problems in patients with serious and persistent mental illness: recommendations from the Expert Consensus Guidelines. Journal of Psychiatric Practice 16 (5) 306-324

Westergaard, R.P.; Spaulding, A. C., Flanigan, T.P. (2013) HIV among persons incarcerated in the USA: a review of evolving concepts in testing, treatment and linkage to community care. Current Opinion in Infectious Disease 26 (1) 10-16

Photo credit:© Sylverarts -Fotolia.com

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