Factors effecting adherence and more evidenced based strategies

young african nurse explaining medical test resultWe were introduced to your patient, Jessie, in the post last week on medication adherence. She had come to sick call because she was feeling depressed and anxious.  She was only taking about half of her prescribed medications and she didn’t know what the medications are or why they had been prescribed. You have been thinking about how to help Jessie take her medication more regularly.

One of the recommendations from a study by Megan Ehret and her colleagues (2013) is to identify those inmates at risk for non-adherence and intervene early.  This study builds on a literature review by Shelton et al. (2010) which found these variables associated with medication adherence among inmates:

  • Older age
  • Male gender
  • Personal motivation
  • Inmate involvement in care
  • Therapeutic relationship with healthcare providers
  • Positive outcomes of treatment
  • Prior experience with treatment

In Jessie’s case many of these variables are absent so she is at greater risk for non-adherence.  The next step is to explore her reasons for non-adherence. Motivational interviewing (MI) is an evidenced based technique that has been found to improve medication adherence by prompting the patient to consider and adopt behavior that is consistent with their goals (Julius et al. 2009, Velligan et al. 2010, Shelton et al. 2010). Using this technique you help Jessie articulate that she wants relief from feelings of depression and anxiety and yet does not link taking the medication to feeling better.  How can you help Jessie to adopt behavior consistent with her goal?

Your first inclination is to educate Jessie about the medications and why each has been prescribed but recall that education alone is ineffective in improving adherence (Brown & Bussell 2011, Velligan et al. 2010, Julius et al. 2009, Haynes et al. 2008). Instead you look again at her prescriptions and decide to talk with her providers to see if the number of medications and number of doses can be simplified. It is likely that when Jessie was seen by her providers she reported still not feeling well. The MAR is not routinely available to the provider when the patient is seen so the provider asked Jessie if she was taking her meds. She said yes. Patients in general, not just our patients, overestimate their adherence (Velligan et al. 2009, Julius et al. 2009). So over time higher doses have been prescribed and more medication added.  If the number of medications and doses per day are reduced you are sure her adherence will improve (Ehret et al. 2013, Haynes et al. 2008, Brown & Bussell 2011).

Your next step is to find out Jessie’s past experience and preferences when taking medications to determine what kind of schedule or routine works best. She has some cognitive deficits (not knowing her schedule, missed medications and appointments, and disheveled appearance) so you want to embed taking medication into a regular part of her day (Shelton et al. 2010, Velligan et al. 2010). She says that she used stickers on a calendar to remember her children’s appointments and it worked pretty well for her. She thinks that something like a reminder on a calendar or daily diary would help her remember. She also thinks that morning would be the best time to take her meds because she is an early riser and by the end of the day she is too preoccupied with her anxiety to remember.

You schedule her for a return visit in three days. By then you will have talked to the providers and know whether her medication regime can be simplified. She has a calendar so you ask her to bring it to the appointment and you will develop a medication reminder with her. You are also planning to provide some education about the most important medication she is taking but need some time to think about how to link the information to her short term goals and low health literacy. See a prior post on this subject.

Lastly you ask her what has worked in the past to manage feeling anxious. She says that she has had some success with breathing exercises and thinks that she can use this technique to help her now. You suggest adding some visual imagery to the breathing. She agrees with the plan and you are on to your next patient.

Summary: Supporting medication adherence among inmates
  •   Identify patients at risk for non-adherence to intervene early.
  •   Explore the patient’s reasons for non-adherence and motivation for treatment.
  •   Develop multifaceted plan that links medication taking behavior to the patient’s strengths and  motivation (education alone is not enough).
  •   Increase frequency of visits to monitor treatment efficacy and support behavior change.

For more about patient adherence and monitoring treatment efficacy read 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.  

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

Haynes, R.B., Ackloo, E., Sahota, N. McDonald, H.P. & Yao, X. (2008) Interventions for enhancing medication adherence (Review). Cochrane Database of Systematic Reviews, Issue 2. Art.

Julius, R. J, Novitsky, M.A. & Dubin, W.R. (2009) Medication adherence: a review of the literature and implications for clinical practice. Journal of Psychiatric Practice, 15 (1) 34-44.

Shelton, D., Ehret, M.J., Wakai, S., Kapetanovic, T. & Moran, M. (2010) Psychotropic medication adherence in correctional facilities: a review of the literature. Journal of Psychiatric and Mental Health Nursing, 17, 603-613.

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

Velligan, D.I., Weiden, P.J., Sajatovic, M. et al. (2009) The expert consensus guideline series: adherence problems in patients with serious and persistent mental illness. Journal of Clinical Psychiatry, 70 (suppl 4) 1-48.

Photo credit: © michaeljung -Fotolia.com

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