Adherence Problems in Patients with Serious and Persistent Mental Illness
J Clin Psychiatry 2009;70(suppl 4):1-48
© Copyright 2014 Physicians Postgraduate Press, Inc.
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Objectives: Poor adherence to medication treatment can
have devastating consequences for patients with mental illness.
The goal of this project was to develop recommendations
for addressing adherence problems to improve patient
Methods: The editors identified important topics and
questions concerning medication adherence problems in
serious mental illness that are not fully addressed in the literature.
A survey was developed containing 39 questions
(521 options) asking 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. Results of the literature review and survey
were used to develop recommendations for assessing
and improving adherence in patients with serious mental
Results: ASSESSING ADHERENCE: The experts endorsed percentage
of medication not taken as the preferred method of
defining adherence, with 80% or more of medication taken
endorsed as an appropriate cut-off for adherence in bipolar
disorder and schizophrenia. Although self- and physician
report are the most common methods used to assess adherence
in clinical settings, they are often inaccurate and may
underestimate nonadherence. The experts recommend that,
if possible, clinicians also use more objective measures (e.g.,
pill counts, pharmacy records, and, when appropriate,
serum levels such as are used for lithium). Use of a validated
self-report scale may help improve accuracy.
SCOPE OF THE PROBLEM: The majority of the experts
believed the average patient with schizophrenia or bipolar
disorder in their practices takes only 51%–70% of prescribed
FACTORS ASSOCIATED WITH NONADHERENCE: The experts
endorsed poor insight and lack of illness awareness, distress
associated with specific side effects or a general fear of side
effects, inadequate efficacy with persistent symptoms, and
believing medications are no longer needed as the most
important factors leading to adherence problems in schizophrenia
and bipolar disorder. The experts considered
weight gain a side effect that is very likely to lead to adherence
problems in patients with schizophrenia and bipolar
disorder; sedation was considered a more important contributor
to adherence problems in bipolar disorder than
schizophrenia. The experts rated persistent positive or negative
symptoms in schizophrenia and persistent grandiosity
and manic symptoms in bipolar disorder as the most important
symptomatic contributors to adherence problems in
INTERVENTIONS: It is important to identify the specific factors
that may be contributing to a patient’s adherence problems
in order to customize interventions to target those
problems. Multiple problems may be involved, requiring a
combination of interventions.
Conclusions: Adherence problems are complex and multidetermined.
The experts recommended customized interventions
focused on the underlying causes.