Enhancing Medication Compliance for People with Serious Mental Illness

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Medication compliance is an important factor in treatment outcomes for all medical and psychiatric disorders (Cramer and Spilker, 1991). Unfortunately, no population can be assumed to be excellent compliers with prescribed regimens (Cramer et al., 1989). Although a number of investigators have established that poor compliance is a problem in psychiatric disorders (Hogan et al., 1983; Weiden et al., 1994), effective interventions to enhance compliance have yet to be evaluated. We previously surveyed the literature to assess the extent of compliance with medications for schizophrenia and mood disorders in comparison to physical disorders (Cramer and Rosenheck, 1998). Overall compliance rates were 58% for antipsychotic medication, 65% for antidepressant medications, and 76% among medications for physical disorders. However, the apparent differences might have been attributable to the methods used to estimate compliance.We developed the Medication Usage Skills for Effectiveness (MUSE) program to teach severely mentally ill patients simple techniques to remember daily medication doses. This study was designed as a prospective, randomized clinical trial of the effect of MUSE on medication compliance and health outcomes among a diagnostically heterogeneous sample of psychotic and nonpsychotic patients participating in an acute care day program.MethodsThe study was conducted within the Veterans in Crisis day program at the VA Connecticut Healthcare System. The program treats patients who are in crisis and require stabilization to avert hospitalization or who need intensive support after discharge. Patients with an axis I clinical diagnosis were invited to participate in MUSE if: a) they lived in an unsupervised setting, b) were prescribed an oral psychotropic medication, c) were responsible for taking medications without assistance, and d) were willing to use a special bottle for the medication. If multiple psychotropic medications were used, the one with the highest number of daily doses (e.g., TID as contrasted with BID) was selected for monitoring. Symptom severity was assessed with the Brief Symptom Inventory© (NCS Assessments, Minneapolis, MN; Derogatis and Derogatis, 1996). After complete description of the study to the patients, written informed consent was obtained.Randomization was made to either the intervention group (special instruction and other reinforcing techniques) or the control group (standard care). Follow-up assessments were completed monthly for 6 months. All patients were asked to use microelectronic devices (MEMS©; APREX, division of APRIA Inc.) to monitor compliance. MEMS units are special caps that attach to standard medication vials that record the date and time of each bottle opening. Data can be downloaded to a computer using proprietary software to display dosing patterns as calendar plots, lists of dose times, or dose intervals. The intervention group used caps with digital displays showing the number of times the bottle had been opened that day, and number of hours since the previous opening; the control group used caps without digital displays. Patients were instructed to use only the special bottle and cap for the medication and to remove only one dose at a time.The intervention group received instruction on life skill techniques from a lay research assistant. At the initial session (approximately 15 minutes), patients were taught how to develop cues to remember dose times. They were asked to define a cue that would fit into their lifestyle, such as a specific clock time, mealtime, or another daily ritual (e.g., shaving or other bathroom activity, watching the evening news, etc). Patients were also instructed to regularly check the display of data on the cap to see when the next dose was due. During monthly follow-up visits, intervention patients were given visual feedback by displaying a calendar on the computer monitor.

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