Compliance with appropriate, recommended, and prescribed mental health treatments simply means that a person is following a doctor's orders. Compliance is more likely when there is agreement and confidence regarding the medical diagnosis and prognosis. Compliance is complicated by uncertainty about the nature of an illness and/or the effects of certain treatments, particularly medications.
In everyday usage, the term compliance means deference and obedience, elevating the authority of medical expertise. Alternatively, adherence to medical advice refers to a somewhat more informed and equitable decision by a consumer to stick with appropriate medical treatment. In any case, a mental health treatment cannot be effective or even evaluated if a consumer does not follow a doctor's orders. A mental health treatment that is effective for one disorder may not be beneficial for other disorders, and diagnoses may evolve over time, complicating the issue of compliance.
Health providers and consumers
From a health provider's viewpoint, in order for effective medical treatments to have their desired effects, complying or conforming to treatments is absolutely necessary. The concept of medication management reflects this idea that the provider is responsible and in control, while the consumer is a docile body who is incapacitated by disease or condition. From the perspective of health consumers, adherence to medical treatment is enhanced when there is a good health care relationship and when consumers openly share their health beliefs and experience of illness with their provider.
Problems with compliance
In mental health care, uncertainty about compliance is a challenging source of variation in the effectiveness of treatments. Noncompliance can represent a significant risk and cost to the medical system. For providers, partial compliance or discontinuation of medications represents the difficulty of maintaining treatment successes over time. Problems with compliance are often attributed to the consumer, but may also reflect the appropriateness of a medication or treatment.
Rates of compliance with mental health appointments are the greatest challenge (estimated in one hospital at 91%), while medication noncompliance is the second most challenging problem in the treatment of persons with mental illness. Mental health medication compliance can be determined by questioning patients, counting pills or prescriptions, and through drug monitoring with urine, blood, or other test measures. Overall, recent research estimates compliance to be 58%. Patients who report lower rates are often considered unreliable indicators of compliance, while physicians report higher rates. Compliance with antidepressant medications is higher on average (65%). Mental health medication compliance rates are only somewhat lower than medication compliance in other types of health care, which have been estimated at 76%.
Explaining variation in compliance
Research in psychiatry, psychology, and sociology provides many explanations for variations in compliance. In psychiatry, clinical problems such as drug or alcohol abuse are sometimes used to explain noncompliance. Patients may also discontinue taking medications because of unwanted side effects. Health beliefs and patient-provider relationships are also recognized. In psychology and sociology, health beliefs and behaviors (in context of family, work, etc.) may enhance or limit compliance. If an individual's family member supports medication compliance, and the individual believes in the medicine's benefits, compliance may be enhanced. If an individual discontinues a medicine because it makes him or her drowsy and affects work, compliance may be reduced. People who have limited access to or trust in doctors or medical science, and people whose faith precludes them from certain types of medical care, are less likely to comply with treatment recommendations.
To a large extent, patient compliance is a direct reflection of the quality of the doctor-patient relationship. When provider and consumer achieve a successful treatment alliance, and when the treatment is practical and beneficial for both the provider and the consumer, cooperation reduces concerns about treatment for both parties. When consumers are empowered and motivated to improve their health with the help of a doctor, compliance or adherence to treatment is higher. When there is distrust, disagreement, or misunderstanding involved, as when mental health status is uncertain or treatment side effects are unwelcome, compliance is lower. One British study found that patients with mental disorders were likely to prefer the form of treatment recommended by psychiatrists with whom they had good relationships, even if the treatment itself was painful. Some patients preferred electroconvulsive therapy (ECT) to tranquilizers for depression because they had built up trusting relationships with the doctors who used ECT, and perceived the doctors who recommended medications as bullying and condescending. Since noncompliant consumers are less likely to continue in care, they are also less likely to find helpful providers or successful treatments. Thus, noncompliance with treatment may become a self-fulfilling cycle.
Compliance is higher when treatments, including medications, help consumers feel better, when a family supports the treatment, and when taking medication prevents relapse of symptoms. However, as mentioned, people may be distressed by potential side effects of any medication, including those psychiatric medications that limit functioning. Limited functioning through drowsiness, also a problem of the older generation of antihistamines, is the best example. It is an effect of many medicines, particularly those for mental disorders. Other unwelcome side effects of various psychiatric medications include weight gain, involuntary movements such as muscle twitching, and impaired coordination. Consumers may feel embarrassed about taking medication, may have difficulty getting a prescription for medication, and may have financial problems paying for treatment or medication. In some cases, when a patient is non-compliant or perceived to be at odds with treatment recommendations, they may risk losing autonomy over medical decisions. When at risk to self or others, people who are medication noncompliant may be pressured or forced to take medication at the risk of being involuntarily hospitalized.
Multiple challenges in mental health care
Compliance rates reflect the proportion of individuals in treatment who have the highest possibility of successful treatment. Noncompliance rates reflect those individuals who have either discontinued or avoided treatment, and thus have lower probabilities of treatment success. Sometimes patients do not want to get rid of their symptoms (mania, for example), or patients may not consider their experiences (called symptoms) to be indicative of a disorder. In addition, successful mental health care is hampered by the fact that many people with mental health problems either do not use or lack access to mental health care.
The National Co-morbidity Survey shows that only 40% of individuals with serious mental illness receive any treatment in a given year, and 39% of this group receives minimally adequate care. This means that merely 15% of all people in need receive minimally adequate care. Therefore, compliance with treatment is part of a larger national challenge to provide quality mental health care and to use it well.
Horwitz, Allan. Creating Mental Illness. Chicago: University of Chicago Press, 2002.
Pescosolido, Bernice, Carol Boyer, and Keri Lubell. "The Social Dynamics of Responding to Mental Health Problems." Handbook for the Study of Mental Health, edited by T. Scheid, and A. Horwitz. New York: Cambridge University Press. 1999.
Pescosolido, Bernice, and Carol Boyer. "How Do People Come to Use Mental Health Services?" Handbook of the Sociology of Mental Health, edited by C. Aneshensel and J. Phelan. New York: Kluwer Academic, 1999.
Bebbington, P. E. "The Contend and Context of Compliance." International Clinical Psychopharmacology 9, January 1995: 41-50.
Centorrino, Franca, Miguel Hernan, Giuseppa Drago-Ferrante, and others. "Factors Associated with Noncompliance with Psychiatric Outpatient Visits." Psychiatric Services 52, March 2001: 378-380.
Cramer, Joyce, and Robert Rosenheck. "Compliance with Medication Regimens for Mental and Physical Disorders." Psychiatric Services 49, February 1998: 196-201.
Wang, Philip, Olga Demler, and Ronald Kessler. "Adequacy of Treatment for Serious Mental Illness in the United States." American Journal of Public Health 92, no. 1 (2002): 92-98.
American Psychiatric Association. 1400 K Street NW, Washington D.C. 20005. <http://www.psych.org> .
American Sociological Association. 1307 New York Ave., Washington DC 20005-4701. <http://www.asanet.org> .
National Institute of Mental Health. 6001 Executive Boulevard, Rm. 8184, MSC 9663, Bethesda, MD 20892-9663. (301) 443-4513. <http://www.nimh.nih.gov> .
Substance Abuse and Mental Health Services Administration (SAMHSA). Center for Mental Health Services (CMHS), Department of Health and Human Services, 5600 Fishers Lane, Rockville MD 20857. <http://www.samhsa.org> .
Michael Polgar, Ph.D.