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Understanding Non-Adherence in Patients with Severe Mental Illness

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Understanding Non-Adherence in Patients with Severe Mental Illness
Grand Canyon University-NRS-433V
November 17, 2013

During many situations in nursing it may feel like fighting an uphill battle, especially when discussing the importance of compliance and long-term adherence to the treatment plans to our patients on a daily basis. Whether it be a patient with newly diagnosed diabetes, heart disease or a mental illness, continued follow up and care are essential for patient outcomes. A large part of compliance is continuing medication as prescribed, The Center for Disease Control and Prevention, (2012) estimates that of prescriptions written 20-30% are never even filled. For those suffering from severe mental illness the issue arises when adherence stops and symptoms take control of their daily lives, putting them at increased risk for substance abuse, assaultive behavior and lower quality of life. Despite continued evidence supporting the efficacy of psychiatric medications in improving symptoms only about half of those receiving medication treatment take it as prescribed. Even worse, in a recent randomized clinical-trial studying anti-psychotic for effectiveness it was reported that 74% of those prescribed medication discontinued use after 18 months (Roe, Goldblatt, Baloush-Klienman, Swarbrick & Davidson, 2009). But for many patients more medication means additional side effects, less freedom and change in their view of themselves. Professionals taking care of these individuals in acute care or long-term settings are left wondering how this vicious cycle can be stopped.
In order to further comprehend why individuals suffering from serious mental illness make the decision to discontinue their medication researchers developed a study based on the interview of seven participants with the diagnosis of either Schizophrenia Spectrum Disorder or Bipolar Disorder. Four women and three males were recruited using ads posted in newspapers and on the Internet. Individuals involved with this study had discontinued medications for at least a year. Data was gathered utilizing 90-minute interviews conducted by a psychology grad student or psychology bachelor graduate, trained in how to conduct narrative interviews. Participants were asked a series of questions including: the conditions is which they were first prescribed medication, perceived impact of being on medication, their reasoning behind their choice of self discontinuing medication and their reflections and feelings regarding not taking medication. Three authors of the study, Roe, Goldblatt, Baloush-Klienman analyzed interviews individually and later compared understandings, seeking agreement on present themes. Themes that failed to meet the consensus of the authors were omitted from the data utilized to make conclusions regarding the interviews. Qualitative analysis provided the researchers with a “hypothesized five-stage model of the process involved” in deciding to discontinue medication (Roe, Goldblatt, Baloush-Klienman, Swarbrick & Davidson, 2009).
Stage One is described as the person experiencing an emotional crisis. When participants were asked under what circumstances in which they were first prescribed psychiatric medications all participants describe an event in which they displayed bizarre behavior or symptoms of emotional crisis state. Present in Stage Two are the participants experience with medication, along with its consequences. The most prevalent consequences these participants discussed were side effects, perceived attitude and stigma towards patients and medication by the community and feeling of losing themselves mentally. All participants had comments regarding negative side effects, including weight gain and sexual dysfunction. Anti-psychotics such as Clozaril and Zyprexa which may be prescribed to these patients are known to cause moderate to marked weight gain (Rosko, 2011), often causing feelings of compromise for patients – “is it better to be fat and happy…I want to be skinny” (Roe, Goldblatt, Baloush-Klienman, Swarbrick & Davidson, 2009). Sexual side effects while common, often go unreported. In a study published by Rosenberg, Bleiberg, Koscis, and Gross (2003) 80 % of women experiencing sexual dysfunction failed to discuss it with their provider ultimately leading to 41.7 % making the decision to discontinue the medication altogether. Lastly participants noted the relationship between compliance and how they felt they were treated by providers when they discussed wanting to discontinue medication –“the doctor who prescribed me the medication was condescending and treated me as a chronic patient, so I stopped using it” (Roe, Goldblatt, Baloush-Klienman, Swarbrick & Davidson, 2009).
Stages Three and Four involve the patients conflict involved in making the final decision to discontinue medication. Many participants described it as an ongoing debate between wanting to please others, such as providers and family versus how the medication made them feel personally mentally and physically. Stage Five is described as participants developing a personal perspective on the use of medication, reflecting on their decisions (Roe, Goldblatt, Baloush-Klienman, Swarbrick & Davidson, 2009).
Provided by this study are personal experiences from patients that nurses may have interactions with on a daily basis. By offering the nursing profession with patient insight into why the choice to discontinue their medication was made care plans can be formulated with the future in mind. Nurses are on the front lines of patient communication, offering medication administration and education every day. If a trusting relationship is not formed with a provider, as shown by this study, individual’s negative side effects may go unreported. Rapport with patient also must be established, all health care providers are people, just as patients and should be treated equally. Persons receiving care should not feel as though they are being punished for not wanting to continue a medication due to its effects on patient’s life.
Although providing valuable information this study has it’s limitations. To improve upon future research a larger sample size may be considered. The use of qualitative analysis could also provide results with researcher bias. By altering interview questions qualitative data and analysis could provide concrete numerical data discussing percentages of certain side effects etcetera. Members of this study participated voluntarily and received information regarding the objectives and design of study as well as the risks and benefits of contributing. Names of participants were changed to protect identity and maintain privacy. The University of Haifa Review Board approved the above study (Roe, Goldblatt, Baloush-Klienman, Swarbrick & Davidson, 2009).
By improving upon adherence nursing and other health care individuals can decrease revolving door admissions and treatment failures. Support systems for patients will be less likely to suffer from burn out and can continue to provide patients’ suffering from severe mental illness with the encouragement they need. Whatever the reasoning, in order to provide our patients with the best care possible nurses and healthcare professionals must see passed the non-adherence and understand the meaning behind it in efforts to improve upon our patients quality of life.

Reference

Centers for Disease Control and Prevention. (2012). Medication adherence. Retrieved from http://www.cdc.gov/primarycare/materials/medication/docs/medication-adherence- 01ccd.pdf

Roe, D., Goldblatt, H., Baloush-Klienman, V., Swarbrick, M., & Davidson, L. (2009).Why and how people decide to stop taking prescribed psychiatric medication: Exploring the subjective process of choice. Psychiatric Rehabilitation Journal, 33(1), 38-46. doi:10.2975/33.1.2009.38.46

Rosenberg, K., Bleiberg, K. L., Koscis, J., & Gross, C. (2003). A survey for sexual side effects among severely mentally ill patients taking psychotropic medications: Impact on compliance. Journal Of Sex & Marital Therapy, 29(4), 289-296. doi:10.1080/00926230390195524

Rosko, T. (2011).Psychiatric medication and weight gain: A review. (Cover story). Bariatric Times, 8(3), 1-15.

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