Both in general medicine and psychiatry, the number one cause of treatment failure is not taking medications as prescribed. In numerous studies people with chronic illnesses often discontinue their medications or do not take them as prescribed.
Many psychotropic medications require weeks of treatment before the first signs of clinical improvement are experienced. Most psychiatric disorders (most notably, depression) result in pessimistic and hopeless feelings in the patient.
Even if they have been told about the need to wait in order to see improvement, patients frequently conclude that the drug is not working out, and they discontinue the medication. They also may drop out of treatment altogether.
What makes this especially difficult to deal with is that they often do not share their feelings and concerns with the treatment provider. Thirty percent of depressed patients never fill the first prescription, which is a testament to the impact of feelings of hopelessness interfering with treatment.
Side Effects Cause Fear
Side effects often lead to discontinuation of medication. At times, side effects are intense and unpleasant enough to frighten the patient. A common example is when the side effect activation (acute onset anxiety) occurs after the first dose of an antidepressant that was prescribed for a person suffering from an anxiety disorder. Intense anxiety may not only lead to medication discontinuation, but also leave the patient troubled to the point of deciding never to seek psychiatric treatment again.
This decision (especially for those with chronic mental illnesses) can lead to lifelong consequences (i.e., never again seeking treatment that could potentially do a lot to reduce their suffering). Often side effects such as weight gain or sexual dysfunction are the cause of patient-initiated discontinuation.
Missed Doses Are Contributing Factor
Missing doses is another contributing factor to nonadherence. This is more likely to occur when a patient is taking medications that require multiple dosing during the day (e.g., twice-a-day dosing). This certainly occurs for many people in general who are being treated for a variety of medical illnesses, but it’s often even more pronounced in psychiatric patients.
Impaired memory (seen in many mental illnesses) may be a significant factor. Complex dosing for instance, taking a number of different medications can also be a factor contributing to missed doses.
Fears and worries about adverse medication effects, such as addiction, are not uncommon. (These fears exist not only for patients, but also for parents who have their child in treatment).
Another common and very understandable fear has to do with possible increases in suicidality in those taking antidepressants. Antidepressant advertisements on television always state that increased suicidality may occur with antidepressants. One of the biggest problems is when such fears go unexpressed; patients may, for various reasons, not tell their doctors.
If the concerns are brought to the prescriber’s attention, it is generally addressed by providing information from studies that show, for instance, that stimulant treatment for ADHD actually decreases rates of substance abuse in teens with ADHD. Or, it may be addressed through discussion of the complex issues anticipated with antidepressant treatment and possible increases in suicidality.
However, often, providing this kind of information is not effective. What patients and parents need first is to really be heard. There is a time and place to provide information about these risks, but until our patients have had a chance to truly discuss their fears, such information may fall on deaf ears.
*This article is based on Dr. Moore’s latest book “Handbook of Clinical Psychopharmacology for Therapists” published by New Harbinger Press and coauthored by John Preston, John O’Neal, and Mary Talaga.
Preston, J., O’Neal, J., Talaga, M., & Moore, B. A. (in press). Handbook of Clinical Psychopharmacology for Therapists-Ninth Edition. Oakland, CA: New Harbinger Press.