The single most significant reason why individuals with schizophrenia and bipolar disorder fail to take their medication is because of their lack of awareness of their illness (anosognosia). Other important reasons are concurrent alcohol or drug abuse and a poor relationship between psychiatrist and patient.
Updated April 2011
SUMMARY: The single most significant reason why individuals with schizophrenia and bipolar disorder fail to take their medication is because of their lack of awareness of their illness (anosognosia). Other important reasons are concurrent alcohol or drug abuse and a poor relationship between psychiatrist and patient. Medication side effects, widely assumed to be the most important reason for medication nonadherence, are, in fact, a less important reason compared to the other factors cited.
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BACKGROUND: The failure of individuals with schizophrenia and bipolar disorder to take prescribed medications (usually antipsychotics and/or mood stabilizers such as lithium) is one of the most serious problems in psychiatric care. It often leads to relapse of symptoms, rehospitalizations, homelessness, incarceration in jail or prison, victimization, or episodes of violence. The failure to take medication is referred to as noncompliance or nonadherence; the latter is a better term. Nonadherence is also a problem for other medical conditions for which medication must be taken for long periods, including hypertension, diabetes, epilepsy, asthma, and tuberculosis. Nonadherence may be total but is more often partial; it has been suggested that partial adherence be defined as a failure to take 30 percent or more of the prescribed medication during the past month.
Scott J, Pope M. Nonadherence with mood stabilizers: prevalence and predictors. Journal of Clinical Psychiatry 2002;63:384–390.
The single best study of why individuals with severe psychiatric disorders do not take medication was done by Kessler et al. (The prevalence and correlates of untreated serious mental illness, Health Services Research 2001;36:987–1007). In interviews with those not taking medication, the single most common reason, cited by 55 percent of the individuals, was that they did not believe they were sick. They had .
Other reasons for not taking medication were cited much less frequently:
- 7 percent “scared about hospitalization against own will”
- 6 percent “concerned about what others might think”
- 5 percent “not satisfied with available services”
- 1 percent “could not get an appointment”
- 0 percent “language problem”
The Kessler et al. study thus contradicts claims that many individuals with serious mental illnesses do not seek treatment because of fears of involuntary hospitalization, stigma, or dissatisfaction with available services. It is commonly claimed that “if you make the psychiatric services attractive enough and culturally relevant, then individuals with serious mental illnesses will utilize them.” This appears to not be true. Very few individuals cited “not satisfied with available services,” “could not get appointment,” “language problem,” etc., as a reason why they were not in treatment. The greatest reason for nontreatment by far was the person's lack of awareness of their illness. Such individuals will not voluntarily utilize psychiatric services, no matter how attractive those services are, because they do not believe that they have an illness.
Lack of awareness of illness, also called anosognosia
In a review, 10 of 14 studies that examined lack of awareness of illness and medication nonadherence in schizophrenia reported that the two are strongly associated.
Lacro J, Dunn LB, Dolder CR et al. Prevalence of risk factors for medication nonadherence in patients with schizophrenia: a comprehensive review of recent literature. Journal of Clinical Psychiatry 2002;63: 892–-909.
The other four studies were carried out in countries in which there is a very high rate of patient adherence to medications (e.g., Ireland, 80 percent adherence) because most patients still do whatever the doctor tells them to do; this high adherence rate makes it difficult to measure the effects of lack of awareness.
Garavan J, Browne S, Gervin M et al. Compliance with neuroleptic medication in outpatients with schizophrenia; relationship to insight, subjective response to neuroleptics and attitudes to medication [abstract]. Schizophrenia Research 1997’24:264–265.
Other studies have also reported a strong association between lack of awareness and medication nonadherence.
Nosé M, Barbui C, Tansella M. How often do patients with psychosis fail to adhere to treatment programmes? A systematic review. Psychological Medicine 2003;33:1149–1160.
Mutsatsa SH, Joyce EM, Hutton SB et al. Clinical correlates of early medication adherence: West London first episode schizophrenia study. Acta Psychiatrica Scandinavica 2003;108:439–446.
For example, a study of 218 outpatients reported that the correlation between awareness of illness and adherence with medication was highly statistically significant (p
Trauer T, Sacks T. The relationship between insight and medication adherence in severely mentally ill clients treated in the community. Acta Psychiatrica Scandinavica 2000;102:211–216.
When impaired awareness of illness is compared with other reasons for medication nonadherence, it is invariably found to be the single most important reason.
Faruqui RA, Andrews MD, Oyewole R et al. Clinical correlates of adherence to antipsychotic treatment in pre-discharge patients with schizophrenia [abstract]. Schizophrenia Research 2003;60:322.
This is true for individuals with bipolar disorder as well as for those with schizophrenia.
Keck PE, McElroy SL, Strakowski SM et al. Compliance with maintenance treatment in bipolar disorder. Psychopharmacology Bulletin 1997;33:87–91.
Greenhouse WJ, Björn M, Johnson SL. Coping and medication adherence in bipolar disorder. Journal of Affective Disorders 2000;59:237–241.
Concurrent alcohol or drug abuse
The second most important reason for medication nonadherence in individuals with severe psychiatric disorders is concurrent substance abuse. This association has been reported in at least 10 studies (Lacro et al., op cit.).
Kamali M, Kelly L, Gervin M et al. Insight and comorbid substance misuse and medication compliance among patients with schizophrenia. Psychiatric Services 2001;52:161–163.
Hunt GE, Bergen J, Bashir M. Medication compliance and comorbid substance abuse in schizophrenia: impact on community survival 4 years after a relapse. Schizophrenia Research 2002;54:253–264.
Hudson TJ, Owen RR, Thrush CR et al. A pilot study of barriers to medication adherence in schizophrenia. Journal of Clinical Psychiatry 2004;65:211–216.
Lang K, Meyers JL, Korn JR et al. Medication adherence and hospitalization among patients with schizophrenia treated with antipsychotics. Psychiatric Services 2010;61:1239–1247.
Lambert M, Conus P, Cotton S et al. Prevalence, predictors, and consequences of long-term refusal of antipsychotic treatment in first-episode psychosis. Journal of Clinical Psychopharmacology 2010;30:565–572.
Hill M, Crumlish N, Whitty P et al. Nonadherence to medication four years after a first episode of psychosis and associated risk factors. Psychiatric Services 2010;61:189–192.
Novick D, Haro JM, Suarez D et al. Predictors and clinical consequences of non-adherence with antipsychotic medication in the outpatient treatment of schizophrenia. Psychiatry Research 2010;176:109–113.
In one such study it was found that “substance-abusing patients with schizophrenia were 13 times more likely than non-substance-abusing patients to be noncompliant with antipsychotic medication.”
Kashner TM, Rader LE, Rodell DE et al. Family characteristics, substance abuse, and hospitalization patterns of patients with schizophrenia. Hospital and Community Psychiatry 1991;42:195–197.
Among the reasons for this association is the fact that psychiatrists often tell patients to not drink alcohol when on medication (they therefore stop medication so they can drink) and the fact that some medications counteract the effects of the alcohol or drugs (so the person cannot experience their desired high).
Poor relationship between psychiatric staff and patients
Every study that has examined this has found a poor relationship between psychiatric staff and patients to be a factor in patients’ nonadherence to medications (Lacro et al., op cit.). It is often referred to as a poor therapeutic alliance. Such relationships include psychiatrists, psychologists, nurses, social workers, and psychiatric aides in both inpatient and outpatient units. It involves things such as taking the time to listen to patients, treating them with respect, explaining things to them, and involving them in treatment decisions insofar as this is feasible.
Day JC, Bentall RP, Roberts C et al. Attitudes toward antipsychotic medication. Archives of General Psychiatry 2005;62:717–724, 2005.
Medication side effects
This is often cited as the most important reason individuals with schizophrenia and bipolar disorder fail to take their medications. Studies, however, suggest that it is a much less important reason than the three reasons discussed above. In one review, only 1 out of 9 studies found a significant association between side effects and medication adherence in individuals with schizophrenia (Lacro et al., op cit.). Another study concluded that “adverse effects may have less influence on [medication] adherence than is currently presumed” (Day et al., op cit.).
Other factors known to contribute to medication nonadherence in individuals with schizophrenia and bipolar disorder include cost of medication, no improvement in symptoms, confusion, depression, lack of access to medication because of being homeless or in jail, and (for individuals with bipolar disorder) purposeful stopping of medication because they enjoy being manic.
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