Many clients who have been identified as having a co-occurring mental disorder will likely have been prescribed medication for that disorder (such as antidepressants, mood stabilisers, anti-anxiety agents, or antipsychotics). Medications can be extremely helpful in managing mental health symptoms; however, their effectiveness relies upon them being taken as prescribed. There are many factors that may facilitate medication adherence including having strong social supports, a strong therapeutic alliance with healthcare providers, and insight and understanding of one’s mental health condition [783–785]. Conversely, factors that may adversely impact upon medication adherence include experiencing negative side effects and cognitive deficits [783–785].
Some people experience unpleasant and distressing side effects of varying levels of severity from psychiatric medications. These side effects may lead to reduced adherence, and some people will choose to live with some symptoms of the mental disorder rather than take medication [786]. It is important for clients to be aware that in most instances there is a choice of medication, but it may take time to establish which medication is best suited to their needs. Finding the best fit is particularly important for people with severe mental disorders such as psychotic, bipolar, and severe depressive disorders, as psychosocial interventions alone may not be sufficient.
When medications have been prescribed, it is important to assist the client adhere to medication scheduling, irrespective of whether a person experiences memory problems or other cognitive difficulties. In other illnesses such as diabetes and hypertension, medication adherence is recognised as an important issue in regaining good health and it is addressed proactively by the use of simple techniques to remind the client when they need to take their medication. MI, contingency management and cognitive behavioural techniques have been shown to be particularly useful in improving medication adherence, as have medication regime management and pharmacist consultations [787–789]. Community pharmacists may be able to assist in the preparation of dosage administration aids (e.g., Webster-paks), which may be especially useful for clients who have trouble remembering what medications/dosages should be taken and when. The SIMPLE model [790] is a useful tool for remembering different evidence-based interventions that can enhance medication adherence:
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Simplifying regimen characteristics. Adjust timing, frequency, and dosage. Match regime to client’s daily activities (e.g., mealtimes). Use adherence aids (e.g., pill boxes, alarms).
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Imparting knowledge. Clearly discuss the medication as appropriate with the client using simple everyday language. Do not overwhelm the client with information or instructions. Supplement verbal information with written materials or pamphlets.
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Modifying patient beliefs. Assess the client’s beliefs, intentions, and perceived ability to adhere to the medication regime. Encourage behaviour change by ensuring that the client perceives their condition to be serious, believes in the positive effects of the treatment, perceives themselves to have the skills required to stick to the medication regime, and has channels to express fears or concerns.
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Patient and family communication. Include the client in decisions about treatment. With the client’s consent, send reminders via mail, e-mail, or telephone. Actively listen to the client and avoid interrupting them. Involve family or social networks where appropriate.
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Leaving the bias. Studies have found small or no relationships between medication adherence and race, sex, education, intelligence, marital status, occupation, income, and ethnic or cultural background.
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Evaluating adherence. Ask the patient simply and directly, without judgement, about their medication adherence. Pill counting, measuring serum or urine drug levels can also be used.
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Adapted from Atreja et al. [790].