Whenever two or more psychiatrists are gathered together...they complain about treatment adherence. What is adherence? It's the extent to which consumers stay on a treatment plan or take a medication routinely. It seems I cannot be in a meeting of psychiatrists, psychologists, psychiatric nurses or pharmaceutical company representatives without the conversation moving to the topic of the "problem with adherence." But they don't call it adherence...they call it compliance.
And that is my first problem. Compliance is a power word. My dog "complies" with my orders, especially when she has been bad. She has nothing to say about it; she simply must obey. The word compliance has no place in the lexicon of a mental health community that says it's seeking patient-centered care and a therapeutic alliance. If you're looking for compliance, you're not working with a patient-centered attitude; you're not using joint decision making. You may say you are, but you betray your actual intent by using a word that harkens back to the 1950s doctor-as-God model.
My second problem is that, when people in mental health circles talk about the "problem of adherence," they act as if this problem is unique to mental health consumers or, if not unique, just much, much worse. But this isn't the case. In fact, according to landmark research done by the World Health Organization (WHO), "[a]dherence to long-term therapy for chronic illnesses in developed countries averages 50%." That's all chronic illnesses including diabetes, HIV, asthma, etc.-not just depression or bipolar disorder.
My third problem with the adherence issue is that many doctors don't provide measurement-based care to achieve better treatment outcomes for us the consumers. Improvements in our lives (however small), or at least our symptoms, that are based on some measureable result would make us more hopeful...more motivated to show up for our 10-minute psychiatrist appointment every three months, to tolerate a medication's unpleasant side effects, to stick with a treatment plan that might be slow-going at first.
My fourth problem with the conversation about adherence is summarized by this statement from WHO's research: "Despite evidence to the contrary, there continues to be a tendency to focus on patient-related factors as the causes of problems with adherence, to the relative neglect of provider and health system-related determinants. These latter factors, which make up the health care environment in which patients receive care, have a major effect on adherence. Patients need to be supported, not blamed."
In other words, "It's the system, dummy, not the patient." If doctors don't take the time to educate us, their patients—or even more importantly, include medication in a treatment plan that is relevant to our lives and our concerns—how can we be blamed for not "adhering" to their treatment?
The biggest problem I have, though, with the concept of adherence is the mindset that many prescribers have towards medication. For most prescribers, the point of treatment is the medication. The medication leads to a change in symptoms that might be (although it's usually not) measured. But, for most consumers, the point of treatment is their life. The medication is a means to an end, an outcome they're seeking—not a reduction of symptoms but the creation of something...a full life.
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