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Strategies for Addressing 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®: September 2010 - Volume 16 - Issue 5 - p 306-324
doi: 10.1097/01.pra.0000388626.98662.a0

Poor adherence to medication can have devastating consequences for patients with serious mental illness. The literature review and recommendations in this article 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 (39 questions, 521 options) on adherence problems in schizophrenia and bipolar disorder was completed by 41 experts in 2008. This article first reviews the literature on interventions aimed at improving adherence. It then presents the experts' recommendations for targeting factors that can contribute to nonadherence and relates them to the literature. The following psychosocial/programmatic and pharmacologic interventions were rated first line for specific problems that can lead to nonadherence: ongoing symptom/ side-effect monitoring for persistent symptoms or side effects; services targeting logistic problems; medication monitoring/environmental supports (e.g., Cognitive Adaptation Training, assertive community treatment) for lack of routines or cognitive deficits; and adjusting the dose or switching to a different oral antipsychotic for persistent side effects (also high second-line for persistent symptoms). Among pharmacologic interventions, the experts gave high second-line ratings to switching to a long-acting antipsychotic when lack of insight, substance use, persistent symptoms, logistic problems, lack of routines, or lack of family/ social support interfere with adherence and to simplifying the treatment regimen when logistic problems, lack of routines, cognitive deficits, or lack of family/social support interfere with adherence. Psychosocial/programmatic interventions that received high second-line ratings in a number of situations included medication monitoring/environmental supports, patient psychoeducation, more frequent and/or longer visits if possible, cognitive behavioral therapy (CBT), family-focused therapy, and services targeting logistic problems. It is important to identify specific factors that may be contributing to a patient's adherence problems in order to customize interventions and to consider using a multifaceted approach since multiple problems may be involved.

*University of Texas Health Science Center, San Antonio

University of Illinois at Chicago

Case Western Reserve University, Cleveland, OH

§Institute of Neuroscience, Newcastle University, 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 for development of this article was provided to the authors, who declare no conflicts of interest related to its content.

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

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.

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.