April 6, 2019

Overcoming medication non adherence in schizophrenia

: strategies to improve adherence

PIT IV PDSKJI SUMUT- Fave Hotel

Elmeida Effendy
Department of Psychiatry
Faculty of Medicine- Universitas Sumatera Utara
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 CURRICULUM VITAE

April 6, 2019
 Dr. dr Elmeida Effendy, MKed(KJ),SpKJ (K)
 Riwayat Pendidikan
 Dokter – FK USU 1997
 Psikiater- FK USU 2004
 Magister Kedokteran Jiwa FK USU 2012
 S3 FK USU 2013
 Konsultan Psikiatri Biologi 2014
 Riwayat Pekerjaan
 Dokter PTT Puskesmas Bandar
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Baru 1997-1999

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 Staf Pengajar Dep. Psikiatri FK USU 1999 – sekarang
 Sekretaris Departemen Psikiatri FK USU 2005-2007
 Sekretaris Program Studi Psikiatri FK USU 2007 -2010
 Ketua Program Studi Psikiatri FK USU 2011-2016
 Ketua Departemen Psikiatri FK USU 2017- sekarang
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Outlines

• Introduction

• Consequences of non adherence

• Factors influence adherence

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• Assessment of non adherence
• Strategies to improve adherence

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• Schizophrenia: a group of disorders
which signs and symptoms are
variable and include changes in
perception, emotion, cognition,
thinking and behavior

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• Persists throughout life
• Affects persons of all social classes

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• Pharmacologictreatment of
schizophrenia requires
longterm and continuous
antipsychotic treatment.
• Adherence to
pharmacological treatment is

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essential for schizophrenia.

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About 50 % of patients with
schizophrenia who respond well to
medications are nonadherent to

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their pharmacologic treatment

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• Poor
adherence is not limited to
medication-taking and
encompasses other treatment
recommendation or “healthy
behaviors”, such as exercise and
diet

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• Medicationadherence : the extent
to which a patient’s medication-
taking matches that agreed with
the prescriber.
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Consequences of Nonadherence
• Increase
risk of relapse,
rehospitalization, and self-harm
• Increase inpatient costs
• Lowers quality of life violence

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• Substance use
• Attempted suicide

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Prevalence of Antipsychotic
nonadherence

Non adherence to medication can

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range from treatment refusal due to
lack of acceptance to irregular use
due to financial or forgetfulness

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 Factors Associated with

April 6, 2019
Medication Nonadherence

• Lack
of insight ; adherence is higher
among patient who have insight &
awareness to take medication to alleviate
symptoms and avoid hospitalization.

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• Attitude and belief about the nature of
illness
• Direct
impact of symptoms ( including
depression, cognitive impairment,positive
and negative symptoms
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• social isolation
• inability
to pay for the
medication,
• comorbid substance

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misuse
• stigma

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• Somepatients do not
respond to antipsychotic
medication, some patient
cannot tolerate to side
effects of antipsychotic.

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Factors associated with nonadherence
• Consider
intentional or unintentional
nonadherence
• Intentional
nonadherence : when a
patient makes a deliberate decision

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not to take medication as prescribed

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• Unintentional nonadherence : occurs
when practical problems interfere
with adherence include the patient
forgetting to take medication not
understanding the instructions that
they were given about medication-
taking, having difficulty collecting

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repeat prescriptions from a pharmacy
due to travel issues or the medication
cost

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Assessment of Nonadherence

Objective
adherence Subjective

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measurement adherence
measurement

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Objective Adherence Measurement
• Medication container with electronic
monitoring
• Pill count
• Biological marker

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• Observed intake
• Medication plasma level
• Electronic ingestible event marker
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Subjective Adherence Measurement
• Clinician’s view on adherence
• Patient or key other report
• Patient diary of medication intake

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• Questionnaires : Drug Attitude Inventory

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Basic Strategies to
Accompany Prescribing
• Quality of the therapeutic
relationship and clinician-patient
communication influence
adherence
• Enhancing therapeutic

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relationship may lead to better
outcomes
• Shared decision – making about
medication is crucial to
improving adherence

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• Regular assessment of adherence
• Simplification of the medication
regimen
• Ensuringthe treatment is effective
and that side effects are managed

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Strategies to Improve Adherence
• Psychosocial interventions :
 psychoeducation : intervention that
increases patient’s knowledge &
understanding of disorder
 behavioral interventions : encompass skills

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building, practicing activities, behavioral
modeling & reinforcement strategies

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 motivational interviewing : directive
client-centered counseling style that
elicits behavioral change by helping
clients to explore and resolve
ambivalence; it included behavioral
analysis, and attempts to allow a person

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to discover the advantages and
disadvantages of their behavior for
themselves

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• cognitive
approaches: adaptations of
cognitive behavioral therapy to try to
improve medication adherence

• antipsychotic LAIs

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• Electronic
reminders : short message
service text message
• Service interventions
• Financial incentives

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• Nonadherence with antipsychotic
treatment is a frequent problem in the
management of schizophrenia
• Strategies
to improve adherence

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needs to be addressed more
systematically in clinical practice

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References
• Higashi K, Medic G, Littlewood KJ, Diez T, Granstom O, De Hert M.
Medication adherence in schizophrenia : factors influencing adherence
and consequences of non adherence, a systematic literature review.
Ther Adv Psychopharmacol (2013)3 (4) 200-218
• Haddad PM, Brain C, Scott J. Nonadherence with antipsychotic
medication in schizophrenia : challenges and management strategies.
Patient related outcome measures (2014)

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• El Mallakh P, Findlay J. Strategies to improve medication adherence in
patients with schizophrenia : the role of support services.
Neuropsychiatric Disease and Treatment 2015 : 11 1077-1090
• Sadock BJ., Sadock, VA, 2015, Kaplan & Sadock’s Synopsis of Psychiatry
: Behavioral Sciences/Clinical Psychiatry, 11 th edition, Lippincott
Williams & Wilkins, Philadelphia : Lipincott Williams & Wilkins
• Stahl SM, 2013. Essential Psychopharmacology, Neuroscientific Basis
and Practical Applications, 4 th ed. Cambridge University Press

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