Both in general medicine and in psychiatry, the number one cause of treatment failure is not taking medications as prescribed. There are a number of reasons for non-adherence, ranging from physical side effects to psychological issues. Here, we’ll discuss the most common reasons for non-adherence, and some strategies for helping your patients stay on their meds.
Many psychotropic medications require weeks of treatment before the first signs of clinical improvement. Many psychiatric disorders, especially depression, result in patients feeling pessimistic and hopeless. Even if they have been told about the need to wait in order to see improvement, after a few days frequently patients conclude that the drug is not working and discontinue the medication. This may be particularly true among adolescents, who want instant gratification. What makes this especially difficult to deal with is that often teens won’t share their feelings and concerns with the treatment provider.
At times, side effects are so intense and unpleasant that they may frighten a patient or greatly concern the parents. A common example is activation (acute onset anxiety) following the first dose of an antidepressant prescribed for depression or an anxiety disorder. Intense anxiety not only may lead to medication discontinuation, but also may leave the patient traumatized by the experience to the point that they decide to never seek psychiatric treatment again.
Often side effects such as weight gain or sexual dysfunction are the cause of patient-initiated discontinuation.
Worries about adverse medication effects such as addiction are not uncommon, despite not being based on real evidence. These fears often exist not only for patients, but also for their parents.
Another common and very understandable fear is related to the risk of suicide from antidepressants. Antidepressant advertisements on television always state that increased suicidality may occur with antidepressants. Research shows that most antidepressants used in kids, with the exception of venlafaxine (Effexor), have a similar low risk for causing suicide—certainly a lower risk than untreated depression itself.
The list of possible adherence problems due to psychological issues is long and complex. Here are some of the most common problems encountered in clinical practice.
Feeling of loss of control. The experience of loss of control accompanies many psychiatric disorders. Medication side effects can, at times, exacerbate that experience.
False ideas about prescriber’s goals. The perception that the prescriber sees their problem only from a biological perspective can lead to non-adherence. The patient perceives that a drug may or may not help, but that their personal, emotional issues are ignored.
Desire to remain “sick.” There may be secondary gain from continuing to be sick. This may be conscious or unconsciously motivated. Examples include the young person’s need to induce guilt and punish their parents or how some children learn that they get needed attention and care from their parents when they are sick.
Wanting the doctor to fail. Sometimes defeating the doctor is gratifying. Intentional or not, non-adherence leads to repeated medications failures. Often this dynamic is seen in patients who have a history of significant child abuse. They may sincerely ask for help to reduce painful symptoms. However, the unconscious need to control, punish, or in other ways render the prescriber impotent, may drive non-adherence. This dynamic does not go away unless it is unearthed and explored in therapy.