Compliant A

Compliance
Patient Compliance
• definition extent to which a person’s behavior coincides with medical

advice,e.g., taking medication or engaging in other prescribed treatments.
• patient compliance to any treatment recommendation is a complex
behavior related to many factors that are patient, provider, and disease
based.
• are contextual factors that influence patients’ compliance to prescribed
medication, such as the increasing influence of managed care,
pharmaceutical direct-marketing strategies, and stigma of psychiatric
medication. Adequate medication compliance is achieved by agreement
between the doctor and patient, rather than a unilateral decision by either.
• Rates of medication compliance/noncompliance depend on many
factors:
• whether the prescribed regimen is short term or long term,
• whether the medication is for prophylaxis or for treatment of disease.
• approximated that the average compliance for short-term regimens is 62%
versus a range of 33–94% for long-term preventive regimens and 41–69% for
long-term treatment regimens.
• A patient may be more or less compliant to a prescribed medication
depending on the complexity of the regimen, the severity and type of illness,
side effects, past experience with medication, and trust in their physician.
• Patients prescribed more than one medication may take one medication but
not others. Patients also may initially adhere to medication recommendations,
but later may discontinue their medication without informing their physician.
• Failure to comply with medication-taking may include
• omissions of doses,
• taking more than the prescribed dose,
• errors in dosage or prescribed frequency of doses,
• taking medication for the wrong reason,
• taking medication as needed rather than on a regular schedule, and
discontinuing medication early.
Measurement of Medication
Compliance
• Measurement of medication compliance is difficult. Physician
estimate is a poor measure of compliance and more experienced
clinicians do no better than trainees. Faithfully attending
appointments does not ensure compliance with prescribed
treatment, although compliance is much worse in those who fail to
keep appointments.
• In general, measures of compliance to medication treatment can be
classified as direct or indirect:
Direct Measures
• Supervised Doses
This is impractical and often unreliable. Even under direct observation by trained staff
on an inpatient psychiatric unit, patients can feign medication ingestion. For
adolescent patients, direct observation, particularly by parents, may provoke negative
emotions in the adolescent struggling for autonomy.
• Blood Levels
Blood levels of drugs and/or their metabolites are only useful when accurate
measurements of all significant active metabolites of the drug are available and there
is a known relationship between the clinical effects of the drug and blood/serum
concentration Even for medications with reliable pharmacokinetic information, many
drugs achieve target levels after a few doses so that appropriate administration for a
few days before a blood draw (“white coat” compliance) could result in normal levels
Indirect Measures
• Patient/Other Self-Report
Patient self-report is the most widely used method of measuring
compliance to prescribed treatment. In usual practice, clinicians do not
use standardized methods; instead questions regarding compliance, if
asked, are often closed and relatively leading; “are you taking your
medication?” One difficulty of self-report data is the risk of
misreporting. questioning during a patient interview has been proven
inadequate to evaluate medication compliance because patients tend
to tell doctors what they think the doctor wants to hear. A second
limitation is lack of reliability of patient recall. Daily diaries have been
used to circumvent this problem;
• Pill Count
This refers to counting tablets returned in bottles at scheduled
appointments. Patients often for- get or are reluctant to bring bottles to
appointments. Some patients put their medication in other containers.
Patients, perhaps in an attempt to please their doctor, may discard or
hoard remaining tablets and bring the empty bottle.
Risk Factors for Noncompliance
• Commonly reported reasons for medication discontinuation include:

• Level of distress/Low perceived necessity for medication; “Only really sick people
take medication,” “I feel better so I don’t need medication”
• Medication is not perceived as beneficial Negative influence of family and friends
• Learned helplessness
• Complex medication regimen
• Side effects; “I don’t feel like myself,” weight gain, sexual dysfunction
• Fear of side effects; e.g., “I won’t be able to feel my emotions,” “Medication will
make me a zombie,” “The medication will change my personality”
• Avoidance of dependency
• Concern about stigma/discrimination; “Only crazy people take psychiatric
medication
Patient-Related Factors
• Patient Beliefs/Attitudes about Medication

• is a close association between beliefs and attitudes toward treatment-
seeking, expectancies of change, and actual illness outcome.
• Noncompliant patients can be classified into subgroups based on their
particular risk factors or barriers to compliance:
• Testing—The patient stops medication in order to “test” whether it is needed
and/or effective
• Control of dependency—The fear that medication is a crutch; fear of dependency on
medication; medication becomes a symbol of the dependence created by a chronic
illness and is a constant reminder of the illness
• Destigmatization—The fear of societal stigma of illness and “ flight to health”;
avoiding medication is a way to avoid the stigma of the illness
• Patient Concerns about Medication
• Many patients have substantial suspicions about prescribed
medication and these beliefs may influence how information about
medication is interpreted and acted upon. Certain beliefs about
medication are highly prevalent across diverse populations, e.g.,
medications are addictive and accumulate in the body to produce
adverse long-term effects.
Patient Concerns about Mental
Illness Stigma
• The word stigma literally means “mark of shame.”
• Stigma is defined as any trait of individual or group that evokes a
negative or punitive social response. people refer to the stigma
associated with individual traits (e.g., skin color, obesity), events (e.g.,
personal history of psychiatric hospitalization, incarceration, or
substance abuse), or groups (e.g., persons with mental illness,
persons who are HIV+). Mental illness stigma specifically refers to
status loss and discrimination due to negative stereotypes about
people labeled with mental illness.
• Perceived Efficacy of Medication Treatment
Patients’ perceptions of the efficacy of medication may not be the same
as those of their doctors. An individual’s perception of the effectiveness
of a treatment depends on whether the outcome of treatment matches
their expectations. For example, a patient who believes that effective
treatment of depression means that they will be “happy” after taking
medication for one week is likely to be disappointed.
Perceived efficacy of prescribed medication has a complex relationship
to perceived necessity for medication and compliance to prescribed
medication
Provider-Related Factors
• Ability
A physician’s ability to facilitate patient compliance with medication is in uenced by
innate talents, interpersonal skills, empathy, psychological mindedness, confidence,
openness, quality of training, and clinical experience.
• Therapeutic Alliance
Patients’ medication compliance is substantially influenced by perceived support from
their physician. Doctors and patients develop a relationship that is based on
communication that includes information, affect, and social learning. Therapeutic
alliance is as important for success in psychopharmacology as it is for psychotherapy.
With increasing pressure from all sides for doctors to perform “medication checks,” the
interpersonal aspects of the doctor–patient relationship are dismissed. Optimal
therapeutic alliance depends on mutual trust, respect, honesty, openness, and comfort
between doctor and patient, all of which take time.
Contextual Factors
• Family Factors
• Is an association between relatives’ beliefs about illness and their beliefs
about treatment and found evidence that family beliefs influence patient
compliance. They observed that family members who consider mental
illness caused by a chemical imbalance strongly reinforced the use of
medication in the patient.
• Financial Factors
• For patients without health insurance , the cost of medication and
medical care may be a significant barrier to medication compliance.
Patients with health insurance may still sustain significant medical costs
that effect medication compliance
Clinical Factors
• Medication Regimen
Studies of the number, type, dose, frequency, and time of medication
prescribed in relationship to medication adherence have revealed
variable results is an inverse relationship between number of daily
doses and adherence.
• Severity of Illness/Level of Distress
multiple studies of patient medication compliance, across a range of
chronic illnesses, have shown that physicians’ assessments of
medication necessity or illness severity often have little correlation with
patients’ level of medication compliance
Mental Status Examination
• is central to the psychiatric evaluation of the medically ill patient.

• must be taken to complete it in a systematic fashion
• diagnostic clues from a combination of observation and questioning.
Level of consciousness
• depends on normal cerebral arousal

• A patient whose level of consciousness is impaired will inevitably
perform poorly on cognitive testing. The finding of disorientation
implies cognitive failure in one or several domains, and it is helpful to
test orientation near the start of the mental status examination.
• Alert, drowsy, somnolent, stuporous, comatose
Appearance and behavior
• • Overall appearance, grooming, hygiene

• Cooperation, eye contact, psychomotor agitation or
• retardation
• Abnormal movements: tics, tremors, chorea, posturing
Attention
• Attention. The form of attention most relevant to the clinical mental

status examination is the sustained attention that allows one to
concentrate on cognitive tasks. Disruption of attention—often by
factors that diffusely disturb brain function, such as drugs, infection,
or organ failure—is a hallmark of delirium. Sustained attention is best
tested with moderately demanding, nonautomatic tasks such as
reciting the months backward or, as in the Mini-Mental State
Examination.
Memory
• Working memory is tested by asking the patient to register some

information (e.g., three words) and to recall that information after
an interval of at least 3 minutes during which other testing prevents
rehearsal. This task can also be considered a test of recent memory.
Semantic memory is tapped by asking general-knowledge questions
(e.g., “Who is the President?”) and by naming and visual recog- nition
tasks.
Language
• characteristics of the patient’s speech and then assess comprehension

• Speech: rate, volume, fluency, prosody
• Comprehension and naming ability
• Abnormalities include aphasia, dysarthria, agraphia, alexia, clanging, neologisms,
echolalia
• Expressive (Broca’s or motor) aphasia is characterized by effortful, nonfluent speech

with use of phonemic paraphasias (incorrect words that approximate the correct ones
in sound), reduced use of function words and well-preserved comprehension.
• Receptive (Wernicke’s or sensory) aphasia is characterized by fluent speech with both
phonemic and semantic paraphasias (incorrect words that approximate the correct
ones in meaning) and poor comprehension.
Mood
• refer to the patient’s emotional state

• Depressed
• Euphoric
• Iritable
• Fast changing mood
Perception
• hallucinations and illusions

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Compliance

• definition extent to which a person’s behavior coincides with medical

• Commonly reported reasons for medication discontinuation include:

• Patient Beliefs/Attitudes about Medication

• is central to the psychiatric evaluation of the medically ill patient.

• depends on normal cerebral arousal

• • Overall appearance, grooming, hygiene

• Attention. The form of attention most relevant to the clinical mental

• Working memory is tested by asking the patient to register some

• characteristics of the patient’s speech and then assess comprehension

• Expressive (Broca’s or motor) aphasia is characterized by effortful, nonfluent speech

• refer to the patient’s emotional state

• hallucinations and illusions

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