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Assessment of Adherence Problems in Patients with Serious and Persistent Mental Illness: Recommendations from the Expert Consensus Guidelines

Velligan, Dawn I., PhD*; Weiden, Peter J., MD; Sajatovic, Martha, MD; Scott, Jan, MBBS, MD, FRCPsych§; Carpenter, Daniel, PhD; Ross, Ruth, MA; Docherty, John P., MD

Journal of Psychiatric Practice®: January 2010 - Volume 16 - Issue 1 - p 34-45
doi: 10.1097/

Poor adherence to medication treatment can have devastating consequences for patients with serious mental illness. The literature review and recommendations in this article concerning assessment of adherence are reprinted from The Expert Consensus Guideline Series: Adherence Problems in Patients with Serious and Persistent Mental Illness, published in 2009. The expert consensus survey contained 39 questions (521 options) that asked about defining nonadherence, extent of adherence problems in schizophrenia and bipolar disorder, risk factors for nonadherence, assessment methods, and interventions for specific types of adherence problems. The survey was completed by 41 (85%) of the 48 experts to whom it was sent. When evaluating adherence, the experts considered it important to assess both behavior and attitude, although they considered actual behavior most important. They also noted the importance of distinguishing patients who are not willing to take medication from those who are willing but not able to take their medication as prescribed due to forgetfulness, misunderstanding of instructions, or financial or environmental problems, since this will affect the type of intervention needed. Although self- and physician report are most commonly used to clinically assess adherence, they are often inaccurate and may underestimate nonadherence. The experts believe that more accurate information will be obtained by asking about any problems patients are having or anticipate having taking medication rather than if they have been taking their medication; They also recommended speaking with family or caregivers, if the patient gives permission, as well as using more objective measures (e.g., pill counts, pharmacy records, smart pill containers if available, and, when appropriate, medication plasma levels). Use of a validated self-report scale may also help improve accuracy. For patients who appear adherent to medication, the experts recommended monthly assessments for adherence, with additional assessments if there is a noticeable symptomatic change. If there is concern about adherence, they recommended more frequent (e.g., weekly) assessments. The article concludes with suggestions for clinical interview techniques for assessing adherence. (Journal of Psychiatric Practice 2010;16:34–45)

*University of Texas Health Science Center, San Antonio

University of Illinois at Chicago

Case Western Reserve University, Cleveland, OH

§University of Newcastle and Royal Victoria Infirmary, Newcastle upon Tyne, UK

Comprehensive NeuroScience, Inc.

Ross Editorial

Cornell University

Disclosures: Expert Consensus Guidelines on Adherence Problems was developed by Expert Knowledge Systems division of Comprehensive NeuroScience, Inc. (EKS), and CME Institute of Physicians Postgraduate Press, Inc. (PPP), pursuant to an educational grant from Eli Lilly. The Guidelines editors, also authors of this article, received honoraria from EKS and PPP for work on the guidelines. No financial support was provided for development of this article; the authors received no financial support for work on the article and declare no conflicts of interest related to its content.

Please send correspondence to: Dawn I. Velligan, PhD, UTHSCSA, MS # 7792, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900.

Material in this article is reprinted with permission from Velligan DI, Weiden PJ, Sajatovic M, Scott J, Carpenter D, Ross R, Docherty JP. In: The expert consensus guideline series: Adherence problems in patients with serious and persistent mental illness. J Clin Psychiatry 2009;70(suppl 4). Copyright information for original publication: Copyright© of content 2009 by Comprehensive NeuroScience, Inc. Copyright© of format 2009 by Physicians Postgraduate Press, Inc. Readers can access the full Guidelines publication at, where CME credit is available until July 2012.

Acknowledgements. The authors thank the experts who completed the survey and Debby Jackson-Ricketts for data collection.

Disclaimer: Any set of published recommendations can provide only general suggestions for clinical practice. Practitioners must use their own clinical judgment in treating and addressing the needs of each patient, taking into account that patient's unique clinical situation. There is no representation of the appropriateness or validity of these recommendations for any given patient. The developers of the guidelines disclaim all liability and cannot be held responsible for any problems that may arise from their use.

Copyright © 2010 Wolters Kluwer Health, Inc. All rights reserved.