Bipolar Treatment:
Medications Compliance
Why individuals with Bipolar Disorder often do not take their medications
Welcome to our bipolar treatment adherence area. Here, we'll
discuss why people with bipolar disorder stop taking their medications, the
effects of that and what can be done to improve medication adherence.
Did you know that
the single most significant reason why individuals with 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, is in fact a less important reason compared to
the other factors cited.
The failure of individuals with 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
63:384-390, 2002.
The major reasons for nonadherence with medications for individuals with
bipolar disorder are the following.
Lack of awareness of illness, also called
anosognosia.
Lack of awareness
of illness is the single most important reason for nonadherance with
medications.
In a recent review, 10 of 14 studies that examined awareness of illness
and 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 63: 892-909, 2002.
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 24:264-265, 1997.
Other recent 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 33:1149-1160, 2003.
Mutsatsa SH, Joyce EM, Hutton SB et al.
Clinical correlates of early medication adherence: West London first
episode schizophrenia study. Acta Psychiatrica Scandinavica 108:439-446,
2003.
For example, a study of 218 outpatients reported that the correlation
between awareness of illness and adherence with medication was highly
statistically significant (p<0.007).
Trauer T, Sacks T. The relationship
between insight and medication adherence in severely mentally ill
clients treated in the community. Acta Psychiatrica Scandinavica
102:211-216, 2000.
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 60:322, 2003.
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 33:87-91, 1997.
Greenhouse WJ, Björn M, Johnson SL.
Coping and medication adherence in bipolar disorder. Journal of
Affective Disorders 59:237-241, 2000.
Concurrent alcohol or drug abuse
The second most important reason for medication nonadherence in
individuals with schizophrenia and bipolar disorder 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 52:161-163, 2001.
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
54:253-264, 2002.
Hudson TJ, Owen RR, Thrush CR et al. A
pilot study of barriers to medication adherence in schizophrenia.
Journal of Clinical Psychiatry 65:211-216, 2004.
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
42:195-197,1991.
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 psychiatrist and patient
Every study that has examined this has found it to be a factor in
patients’ nonadherence to medications (Lacro et al., op cit.). It is often
referred to as a poor therapeutic alliance.
Medication side effects
This is widely assumed to be crucial and is often cited as the
most important reason why individuals with 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 bipolar and schizophrenia (Lacro
et al., op cit.).
The comparative lack of importance of side effects in determining
medication adherence is also suggested by studies comparing medication
adherence in individuals taking first-generation antipsychotics (e.g.,
haloperidol/Haldol), which often have side effects bothersome to patients,
and second-generation antipsychotics (e.g.,
Seroquel (quetiapine), Zyprexa, Abilify, Geodon), which have
far fewer such side effects. Studies comparing adherence rates between
first- and second-generation antipsychotics have reported them to be
virtually identical.
Vanelli M, Burstein P, Cramer J. Refill
patterns of atypical and conventional antipsychotic medications at a
national retail pharmacy chain. Psychiatric Services 52:1248-1250, 2001.
Dolder CR, Lacro JP, Dunn LB et al.
Antipsychotic medication adherence: is there a difference between
typical and atypical agents? American Journal of Psychiatry 159:103-108,
2002.
Other factors
Other factors known to contribute to medication nonadherence in
individuals with bipolar disorder include cost of
medication, no improvement of 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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