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.
