Treatment Compliance in Patients With Co-Occurring Mental Illness and Substance Abuse

Treatment Compliance in Patients With Co-Occurring Mental Illness and Substance Abuse

By Ivn D. Montoya, M.D., M.P.H.

Compliance is a crucial determinant of the treatment outcome of any medical condition. Poor treatment compliance may affect the therapeutic alliance; create skepticism in both therapist and patient; create resistance; worsen the disease or the prognosis; and increase health care costs (Osterberg and Blaschke, 2005). Unfortunately, poor treatment compliance is often associated with blame, and noncompliant patients are sometimes punished with involuntary administrative discharge from treatment.

There are multiple indicators of treatment compliance that can be measured using direct or indirect methods. Among the direct methods, investigators and clinicians have used actual attendance to therapy sessions, direct observation or video-recording of sessions, measurement of medication blood levels, surrogate markers of medication, or expected changes in laboratory values. The indirect methods include self-reported compliance, pill counts, evidence or absence of expected side effects, and electronic monitoring devices. Unfortunately, the direct methods are expensive, and the indirect ones can be subject to biases.

In psychiatry, treatment compliance may be affected by factors associated with the therapist's characteristics, the service, the nature of the treatment and the patient's idiosyncrasies. The therapist may not adhere to the recommended treatment guidelines or the therapy manual. The services may affect compliance if they are hard to access or have long wait times, long lapses between appointments or complex administrative procedures. Treatments that involve complex procedures, are hard to follow, have unpleasant side effects, take a while to produce the desired effect, and are either unavailable or difficult to access may increase the chances of poor compliance. The characteristics of the patient, such as the presence of comorbid mental illness and substance use disorders (SUDs), can greatly affect treatment compliance.

Epidemiology

The interest in psychiatric comorbidity increased with the publication of results from the Epidemiologic Catchment Area Study (Regier et al., 1990) and the National Comorbidity Study (Kessler et al., 1994). More recently, Kessler et al. (2005) showed that the relative magnitude of associations of having at least one substance use disorder in the past 12 months was significant for all but two mental conditions. The prevalence of mental health service use in the past year was only 41.1% and 38.1% for individuals who had any mental disorder or any substance use disorder in that time period, respectively (Wang et al., 2005).

Unfortunately, little is known about the proportion of individuals in the general population who use mental health services and actually adhere to their treatment plan. A survey of psychiatrists showed that 40% of their patients with SUDs had treatment compliance problems (Herbeck et al., 2005). Both clinical and nonclinical factors appeared to be associated with treatment compliance problems. Among the clinical factors, patients with low treatment compliance were more likely to have personality disorders, lower global assessment of functioning scores and medication side effects than those without treatment compliance problems (Herbeck et al., 2005).

It has been reported that the rates of completion of clinical trials for chronic medical conditions are only between 43% and 78% (Osterberg and Blaschke, 2005). It is likely that for those with psychiatric disorders, particularly with comorbid SUDs, this percentage may be even lower. According to a meta-analysis of medication compliance, the mean compliance rate for patients with physical disorders was 76%, whereas the ratio for patients taking antidepressants was 65% and 58% for antipsychotics (Cramer and Rosenheck, 1998). It has been estimated that medication noncompliance accounts for about 40% of re-hospitalizations of patients with schizophrenia (Weiden and Olfson, 1995).

The concurrence of mental illness and SUD seems to have a negative synergistic effect. It has been suggested that comorbid psychiatric disorders can further increase the risk of relapse and can have important implications for predicting treatment outcomes (Compton et al., 2003). The rates of treatment compliance among patients with SUD vary greatly, depending on the type of SUD and treatment, severity of the disorder, degree of psychosocial support, and the presence and severity of psychiatric comorbidity. Patients with only alcohol use disorders have significantly higher treatment retention rates (42%) than those with drug use disorders (20%) or combined alcohol and drug use disorders (26%) (McCaul et al., 2001). Furthermore, clinical trials of treatments for cocaine and other stimulant use disorders have difficulty retaining participants. In contrast, clinical trials of opioid agonist medications have better compliance rates (De Castro and Sabate, 2003).

Some psychiatric comorbidity factors that can affect SUD treatment include the type of psychiatric disorder, severity of the comorbid psychiatric condition, early onset of illness and level of cognitive impairment (Broome et al., 1999; Rowe et al., 2004). The clinical features of some types of psychiatric disorders may become risk factors for poor treatment compliance. For example, among patients with schizophrenia, the lack of awareness of the illness, paranoid ideation, persecutory delusions and lack of initiative can worsen treatment compliance (Owen et al., 1996).

One of the psychiatric aspects that can greatly affect SUD treatment compliance is the patient's level of neurocognitive functioning (Aharonovich et al., 2003; Fals-Stewart and Schafer, 1992a). Attention, mental reasoning and spatial processing are some of the cognitive domains that are significantly affected among noncompliant patients (Aharonovich et al., 2003).

More severe comorbidity has been associated with poorer therapeutic alliance, and treatment alliance can predict patient retention (Barber et al., 2000). Patients with moderate and severe psychiatric problems are not likely to remain in treatment unless they develop a strong therapeutic relationship with their therapist (Petry et al., 2001).

Psychiatric Disorders

Studies have documented that treatment compliance can be affected by the concurrent presence of substance abuse (Keck et al., 1997; Lambert et al., 2005; Olfson et al., 2000). In patients with schizophrenia, medication noncompliance has been significantly associated with substance abuse, this in turn with a greater symptom severity than other groups (Olfson et al., 2000; Owen et al., 1996).

For patients with bipolar disorder (BD), noncompliance was significantly associated with the presence of a comorbid SUD, and the most common reported reason was denial of need for treatment. In a study by Weiss et al. (1998), compliance was significantly associated with treatment with divalproex (Depakote), compared to treatment with combined lithium (Eskalith, Lithobid). The study also showed that patients with BD and SUD who were prescribed benzodiazepines, neuroleptics and tricyclic antidepressants tended to take more medication than prescribed.

With regard to comorbid personality disorders and SUDs, results are not conclusive. However, borderline and antisocial personality disorders predict lower treatment retention rates (Marlowe et al., 1997). In addition, the concurrent presence of Axis II disorders on top of the Axis I disorders and SUD seems to worsen treatment compliance even more. A study showed that inpatients with triple comorbidity (Axis I and Axis II disorders plus SUD) were less likely to be compliant with the treatment plan than those without triple comorbidity (Ross et al., 2003).

Adolescent Compliance

Adolescents with comorbid mental illness and substance abuse are a unique clinical population because of the high risk that the problems will continue or worsen during adulthood. A retrospective record review of one year of admissions to a residential adolescent substance abuse treatment program showed that patients with attention-deficit/hyperactivity disorder and those with conduct disorder had the lowest treatment compliance (Wise et al., 2001).

In another study, investigators showed that adolescents with SUD who have comorbid affective and adjustment disorders have better compliance, whereas patients with conduct disorders have poorer compliance. Furthermore, patients who received psychotropic medications have better treatment compliance (Kaminer et al., 1992).

Interventions

Successful interventions to improve treatment compliance can be labor-intensive but ultimately cost-effective (Haynes et al., 2002). They should address factors such as the characteristics of the therapist, the service, the nature of the treatment and the patient.

Interventions to enhance treatment compliance have been categorized into the affective, behavioral and cognitive (ABC) domains (Schaffer and Yoon, 2001). They require an understanding of the therapeutic regimen; counseling about the importance of adherence; organizing medication-taking; rewarding and recognizing the patient's efforts to follow the regimen; and enlisting social support from family and friends (Haynes et al., 2002)

Some of the most promising strategies for improving treatment compliance are based on cognitive/motivational interviewing and behavioral techniques such as reinforcement (Carroll et al., 2005; Zygmunt et al., 2002). A review of the literature of measures to enhance treatment adherence among patients with BD showed that cognitive-behavioral therapy, interpersonal group therapy, group sessions for partners and education about the illness are effective in improving treatment adherence (Owen et al., 1996; Sajatovic et al., 2004).

Contingency management interventions that reinforce treatment compliance have been shown to improve SUD treatment outcome. These interventions can reinforce one or multiple aspects of the treatment plan such as therapeutic activities, counseling, attendance at Alcoholic Anonymous meetings or simply compliance with prescribed medications (Petry et al., 2001). Good attendance to individual standardized interpersonal cognitive psychotherapy has been positively correlated with objective measures of treatment outcome (e.g., urine drug testing) in patients with comorbid cocaine and heroin dependence (Montoya et al., 2005). Given that poor compliance is likely to recur, booster interventions are needed to reinforce and consolidate gains (Zygmunt et al., 2002).

Patients with comorbid mental illness and SUD can benefit from the simultaneous treatment of both disorders. A study of substance abusers dually diagnosed with obsessive-compulsive disorder showed that those who received a combined intervention that addressed their obsessive-compulsive symptoms and substance abuse stayed longer in treatment than a second group that received only substance abuse treatment (Fals-Stewart and Schafer, 1992b).

Clinicians, services, patients and treatment regimens should work in tandem to meet the particular clinical needs of patients with comorbid disorders. Patients need to be supported and not blamed or punished with administrative discharges for poor treatment compliance. Innovative approaches to improve treatment compliance for patients with comorbid mental illness and SUD can be cost-effective and make a significant public health contribution.

Dr. Montoya is clinical director of Pharmacotherapies and Medical Consequences Grants in the Division of Pharmacotherapies and Medical Consequences of Drug Abuse, National Institute on Drug Abuse.

See references

Last updated: 1/06

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