Noncompliance With Schizophrenia Therapy Usually Persists

Nancy A. Melville

November 10, 2012 (San Diego, California) — When patients with schizophrenia discontinue oral antipsychotic therapy soon after initiation, as is common, chances are not good that they will become adherent to the therapy later in their illness, new research shows.

"What these findings show is [that] schizophrenia patients who don't comply early with oral antipsychotics continue to not comply for the next year, while the patients who comply early maintain with modestly good compliance," lead investigator Bruce J. Wong, MD, from the University of Pennsylvania in Philadelphia, told Medscape Medical News.

Dr. Wong presented the study findings here at the 2012 US Psychiatric and Mental Health Congress (PMHC).

Noncompliance with medication recommendations is a common clinical challenge in most fields, but the issue is especially common and is particularly problematic among patients with schizophrenia.

In fact, results from the Clinical Antipsychotic Trial of Interventional Effectiveness (CATIE) show that up to 74% of patients discontinue antipsychotic medications soon after initiation.

To better understand the implications of nonadherence, Dr. Wong and colleagues conducted a retrospective study of 1462 commercially insured patients with an average age of about 39 years and 354 Medicare-insured patients with an average age of about 70 years.

Patients were identified from data in the Thomson Reuters MarketScan Commercial and Medicare Research Claims Databases of patients with schizophrenia who initiated oral antipsychotics from July 1, 2005, through June 30, 2010.

In the commercially insured group, 873 were adherent with medications and 589 were nonadherent, which was defined as a medication gap of 30 or more days in the first 90 days after drug initiation.

In the Medicare group, 192 were adherent and 162 were nonadherent.

Most Pressing Unmet Need

Medication adherence in the follow-up period of 1 year was determined according to the patient's medication possession ratio, calculated as the total number of days of drug supply divided by the total number of days in each quarter of the follow-up period.

Results showed that the medication possession ratio in commercially insured patients declined from .99 in the adherent group at baseline to .60 at the fourth quarter follow-up, and the ratio declined from .57 in the nonadherent group to .25 at the fourth quarter (P < .0001).

In the Medicare group, the rate in the adherence group declined from .98 at baseline to .59 at the fourth quarter follow-up, and the rate dropped from .58 at baseline to .24 at follow-up (P < .0001) in the nonadherent group.

In looking at clinical characteristics, researchers found that those in the early nonadherence group had a mean Deyo-Charlson Comorbidity Index (CCI) score of .47 (standard deviation [SD], 1.02) among commercially insured patients and 1.63 (SD, 1.77) in the Medicare group, and the scores were .54 (SD, 1.20) among adherent patients in the commercial group and 1.94 (SD, 1.96) in the Medicare group.

"Early noncompliance begets later noncompliance — you never get compliance back again, so if you're going to manage compliance, manage it early — try to avoid that first episode of noncompliance," said Dr. Wong.

The key question is How, but solid solutions remain elusive.

"There are many suggestions for fostering compliance in the literature, but none are very successful," he added.

Either way, noncompliance in schizophrenia is clearly pervasive.

"We think it's the most pressing area of unmet medical need in psychiatry today. Drugs for schizophrenia can be very effective, but only if you take them," said Dr. Wong.

Part of the Disease

According to Peter Weiden, MD, a psychiatrist with the University of Illinois at Chicago Medical Center, one useful approach to noncompliance may be to work tactfully to remove the guilt factor from the equation.

"Clinicians are probably better off if they view noncompliance as part of the disease process — to expect it and not take it personally when it happens," he told Medscape Medical News.

"That's important because a lot of patients will simply not disclose their noncompliance because they are afraid of the repercussions. Rightly or wrongly, they may think the doctor will punish or criticize them or will think they are not good patients."

"In as much as you can move the conversation away from 'Why are you not obeying me' to 'What is it that we can do together to achieve a better or healthier life for you,' you can then have a more honest dialogue and make it safer for [patients] to tell you that they haven't taken their medicine."

That won't solve all the adherence problems, but it will improve the quality of information, which is important, he said.

"It will allow an assessment and an ability to address adherence in a way that maintains or strengthens the alliance with the patient rather than damaging [the] therapeutic relationship."

Dr. Wong's study is also notably important in demonstrating a useful approach to determining whether or not a patient is compliant, Dr. Weiden added.

"I would bet if you'd asked many of those nonadherent patients [in Dr. Wong's study] if they were taking their medications, they would have said Yes when they weren't," he said.

"So in that sense, what [these data] also [show] is how helpful it can be to get pharmacy refill records in clinical practice as an additional tool to help [clinicians] get better quality information about their patients' adherence."

"If they're not picking up their prescriptions, it's unlikely they are taking their medication."

This research was supported by Otsuka America Pharmaceutical, Inc., and by H. Lundbeck A/S.

US Psychiatric and Mental Health Congress: Poster abstract 118. Presented November 9, 2012.