Improving Medication Concordance in Mental Health- A Review of the Literature
Where a man is against his will, that to him is a prison. Epictetus
There has been much discussion on why concordance with antipsychotic medication and treatment appears to differ from other fields of medicine. Does the literature support this contention? This review aims to seek out best practice and apply the principle of informed choice in assessing concordance and using appropriate interventions to educate individuals with psychosis.
Abstract Introduction Compliance or concordance? Client centered therapy Administration of medicines and patient capacity
Competent or non-competent?
Schizophrenia in comparison with asthma and epilepsy
Antipsychotics- Hobson’s choice?
Education - the patient’s view
Psychosocial treatment interventions
Conclusion and Recommendations
The aim of this literature review is to identify if possible, what simple, easily introduced refinement may be useful on an acute mental health ward, with the aim of better understanding the factors affecting concordance with both medication and treatment provisions. The review of the evidence was necessarily broad, for two reasons. Firstly, the premise that concordance is poorer with mentally ill patients (Hughes, et al.1997, Marland and Cash, 2005), compared with those suffering from physical illnesses (although acknowledging the considerable over-lap). This premise has been personally encountered whilst on practice placements. Secondly, whether any advantage might be gained from other areas of practice and applied to the chosen patient group.
The literature search strategy was carried out by initially accessing the “Pub med” and “Ovid” databases, using the terms “concordance”, “compliance” and “adherence”. Attention was focused on research papers that dealt with both physical and mental conditions. Priority was given to any evaluation of techniques potentially useful in improving concordance, and research papers frequently referred to by other authors, or otherwise indicated as seminal. The review was limited to studies carried out in the UK, Ireland, and the USA. It was of course, necessary to limit the final discussion to a representative number, which aim to reflect some changing views, with emphasis on recent research.
Gray, et al. (2002) note that non-compliance with antipsychotic medication is a major preventable cause of relapse in psychotic patients. The causes of non-compliance are seldom immediately clear, and the literature suggests a large number of factors interplay, and individual reasons for stopping medication can be arbitrary. Evidence-based medication management aimed at enhancing treatment concordance should include a collaborative, educational approach to working with patients, tailoring medication regimes to the patient. Gray, et al. advocate using therapeutic techniques such as compliance therapy, discussed in this review, in order to empower individuals, and preserve their right to choice.
Compliance or concordance?
Repper and Perkins (1998) highlighted the importance of terminology in mental health, and suggest that the use of words like compliance infer patients should be passive recipients of health-care, and should obey professionals. It has recently been proposed that “concordance” should replace the words “compliance” and “adherence”.
Concordance emphasizes patient rights, and the importance of two-way decision making. More controversially, it also suggests patients have the right to make choices such as stopping medication, even if clinicians do not agree with the decision. This principle conflicts with traditional psychiatric practice, and potentially with the provision of treatment under the Mental Health Act 1983.
Since this review reflects the source literature, the three terms are retained, and may be read as synonyms, unless the context dictates otherwise.
Client centered therapy
Rogers (1975) Client centered therapy, described five factors affecting health behaviour; severity, susceptibility, response, self-efficacy and fear. Focusing on the latter two factors, self-efficacy has been defined as a person’s belief in his ability to accomplish a given task (Bandura, 1977, quoted by Hughes, 2004).
How a person thinks an illness will affect him is determined by previous knowledge or experience, as well as fear, or threat appraisal. Belief that a change would improve coping strategies, and the person is empowered to undertake such a change, can improve considerably the ability of the patient to be more independent, and concordant with medication strategies.
Administration of medicines and patient capacity
The law imposes a duty of care on those that administer medication to others (Griffith, et al. 2003). Administration of medication is not without its complications. Minor prescribing errors, adverse drug reactions, interactions with food, or herbal products, overdoses (intentional or otherwise), and even possible genetic problems or death.
These potential problems are reflected in the strict legal framework that regulates the prescribing and distribution of medication.
There is however, still widespread concern in the UK over the administration of non-prescribed medicine and the practice of covert administration in the non-compliant (Wright, 2002).
The law is clear that covert administration is only justifiable in cases of incapacity. Incapacity occurs where the patient is unable to comprehend and retain information material to the decision, or the patient is unable to weigh up the information as part of the process of an informed decision (Nys, et al. 2004).
In the case of covert administration to an adult there would be a need to demonstrate that the patient is incapable. The nurse should be able to justify the techniques of administration were in the patients best interests, and the crushing of tablets, for example, was safe. In practice this should be a multi-disciplinary team decision. The covert administration of medication observed on placement was one reason I have chosen to explore the literature, and examine any methods used that may be applied to adults who are non-conc...