Dr. David B. Adams – Psychological Blog

Psychology of Injury, Pain, Anxiety and Depression

Disobedience

“Disobedience” :  $290 billion is the estimated cost of medication to the US healthcare system each year.

In a study of over 240,000 patients who were given a new prescription for an antidepressant, less than 30% were still taking the medication 6 months later. It is one of the most pressing issues in healthcare today. This was once called non-compliance, and it is now called “adherence.” Why the change? Well, compliance is a paternalistic concept where someone speaks and you comply. It is akin to servitude, and this is no longer politically correct. So research now focuses upn why people do not adhere to prescribed medications.

“Compliance” implies that patients are passive actors in managing their chronic conditions. “Adherence,” according to the World Health Organization (WHO), suggests just the opposite: that doctors and patients team up to help patients actively engage in maintaining their health.

Research on adherence has some very interesting findings, and one thing is certain: Different patients have different reasons for their non-adherence or disobedience.

In 2011, Consumer Reports published a survey of 660 primary care physicians; 37% of physicians said that lack of adherence greatly affected patient care. Disobedience:

  • In the United States, some 3.8 billion prescriptions are written every year, yet over 50% are taken incorrectly or not at all.
  • In another survey of 1000 patients, nearly 75% admitted to not always taking their medications as directed.
  •  A study of over 75,000 commercially insured patients found that 30% failed to fill a new prescription, and new prescriptions for chronic conditions such as high blood pressure, diabetes, and high cholesterol were not filled 20-22% of the time.
  • Even among chronically ill patients who regularly fill their prescriptions, only about half the doses are taken as directed.
  • Poor adherence accounts for 33-69% of drug-related adverse events that result in hospital admissions.
  • Even after a life-threatening event, compliance with medication regimens remains surprisingly poor.

A very real concern is that even with cooperative patients:

  1. The patient must receive the correct prescription. How often is a patient started on an antidepressant or two or three only to see that prescription repeatedly changed over months?
  1. The new prescription must then be filled, the seemingly simple act of which can be a major barrier to compliance.
  1. The patient must then make it through the first 6 months on the medication, when the risk for noncompliance is highest.
  1. If the medication is for a chronic condition, it must then be taken indefinitely.
  1. Medications may become unaffordable, so the patient stops taking them, or cuts the pills in half to make them last longer, or skips some doses.
  1. After a divorce, job loss, or any traumatic event, taking medication as directed may be the last thing on the patient’s mind.
  1. Up to 20% of patients stop taking medication because of perceived side effects.
  1. Health is not necessarily the patient’s main priority.

What has proliferated with both pain and depression is that patients are seen briefly and prescribed medication for depression which is then repeatedly adjusted in subsequent followup brief appointments. Surplus medication accumulates in drawers and medicine cabinets and antidepressants can be a very lethal means of self-harm. Unless adherence is assured, dispensing the medications as a primary treatment for depression becomes a notable concern.

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