Introduction

Medication compliance is a significant issue in the care of people with mental health conditions, particularly if the mental health condition is of an enduring and severe nature. The reason for this is that there is an increased likelihood of symptoms returning without the individual maintaining adherence to a prescribed medication regime. Conditions such as schizophrenia, psychosis and bi polar disorder fall under the remit of severe and enduring mental illness and it is reported that medication non compliance is likely to have severe implications to an individual’s psychological health and wellbeing (Le Page, 2010).

Leahy (2006) estimates that up to 70% of recurrent depression patients and around one half of schizophrenia patients are noncompliant with their prescribed medication and there is also a direct relation between medication noncompliance and an increased need for hospitalisation. This in turn has a whole range of implications in terms of the impact this has on employment, relationships, income, and parental responsibility and of course the impact on resources provided by health providers such as the NHS should also be acknowledged.

This assignment will examine and reflect on the case of a 40 year old gentleman with a diagnosis of schizophrenia. The gentleman, who shall be referred to as Mr Smith for the purpose of this assignment (names have been changed to ensure client confidentiality as per NMC guidelines) has been receiving neuroleptic depot medication (Flupenthixol) to treat the symptoms of a schizophrenic condition, however Mr Smith has stated that he no longer was willing to accept the administration of the depot injection because he ‘felt better’.

The assignment will start by briefly exploring the concept of compliance and the consequences of Mr Smith declining to take the prescribed medication and the potential impact this will have on his mental health. The second part of this assignment will reflect on how the practitioner responsible for the care of Mr Smith addressed the issue of facilitating the ongoing adherence to prescribed medication by focusing on theoretical frameworks that supported and encouraged Mr Smith to review his decision and continue to accept his depot injection. Consideration will also be made to legal and ethical frameworks that should be adopted in clinical practice when addressing the issue of medication compliance.

Defining Compliance in Mental Health Care

The term compliance is defined by the Cambridge dictionary (2010) as being a process where people obey an order, rule or request and that individuals become willing to do what others want, particularly if the other person is a figure of authority. A core definition of compliance provided by Harvey (2004-09) suggests that compliance is the undertaking of activities or establishing practices or policies in accordance with the requirements or expectations of an external authority.

Compliance has been defined as the extent to which a person’s behaviour coincides with medical or health advice (Haynes, 1974) and although this is an outdated definition the term compliance persists in mental health care today. In contemporary mental health care there are suggestions that the term compliance has negative connotations and it infers that an individual who does not comply is not doing as they are ‘told’ by the mental health professional (Gray, 2002). Language and communication is an important tool in mental health and it is important to place the individual with mental health problems first by using terminology that is widely acceptable to both service providers and service users (Manzi, 2008).

Repper & Perkins (1998) support this point of view and indicate that the use of words like compliance infers that patients are passive recipients of health care who should obey instructions from professionals. As modern mental health care is concerned with developing therapeutic alliances to improve outcomes (Hakan and Jan-Ake, 2010) consequently it has been proposed that the term concordance (Gray, 2002) or the phrase medication adherence (Velligan et al., 2009) should replace the use of the word compliance in an attempt to remove the unequal and passive tone the word compliance has.

For the purpose of this assignment the word compliance will be substituted by the term adherence as this implies a more collaborative approach between service providers and service users to approach the issue of medication and treatment.

Consequences of Medication Non Adherence in Schizophrenia

Schizophrenia is a complex condition and diagnosis is made on the evidence of an individual’s reported experiences (symptoms) and observable behaviours (signs) which commonly may include; delusional thinking; hallucinations, thought interference; ideas of reference, thought disorder; social withdrawal; anxiety and depression (Keen, 2003). Psychiatric treatment for individuals almost always involves drug therapy to stabilise psychotic symptoms and to reduce the individual’s risk of relapse (Barker, 2003).

There are many different pharmacological preparations available for the treatment of symptoms experienced by an individual diagnosed with schizophrenia and they may include preparations that are taken orally or delivered by intramuscular depot injection. Our Client Mr Smith had been having a depot injection called Flupenthixol to treat the symptoms he experienced following his diagnosis of schizophrenia; as a result it is reported that he had felt better and therefore did not want to have the depot any more.

Mr Smith had made a decision not to accept his depot medication any longer however it is well documented in the research and evidence base that this course of action and decision will have a significant impact on his health and global well being. Novick et al. (2010) indicates that non adherence with anti psychotic medications, such as Flupenthixol for patients with schizophrenia and psychosis, is significantly associated with an increased risk of relapse, hospitalization and suicide attempts. There is a significant body of evidence that highlights that the symptoms of schizophrenia return without pharmacological treatment and medication adherence and that there are potentially devastating consequences to the individual with a serious mental illness such as schizophrenia if this behaviour of non adherence is adopted (Velligan et al., 2010).

Therapeutic Interventions to Promote Adherence

As a mental health practitioner it would not be uncommon at some point to experience a clinical interaction with a patient who has made a decision not to continue with their prescribed medication, however the practitioner has the responsibility to understand the reasons behind the patients decision making process and to provide the patient with the biggest opportunity to make an informed and educated decision about declining treatment for a chronic and enduring mental health condition such as schizophrenia.

It is important for the mental health practitioner to obtain an understanding of the reasons behind Mr Smith’s decision to discontinue his depot medication and to do this the modality of cognitive behavioural therapy can be implemented. Cognitive Behavioural Therapy (CBT) is a form of psychological therapy and aims to help understand the link between thoughts, emotions and behaviour. It teaches individuals skills to overcome problematic thoughts, emotions and behaviour and to find ways of overcoming negative thinking and challenging unhelpful and inaccurate thoughts or beliefs (Royal College of Psychiatrists, 2008). The most favourable outcome from CBT is for the individual to develop skills and techniques that enables them to approach situations in a more reasoned and balanced manner which supports problem solving and increases the feelings of being in more control (Royal College of Psychiatrists, 2008).

An important consideration in relation to implementing CBT and for that matter other therapeutic interventions is that there needs to be an established therapeutic relationship between the client and the mental health practitioner to increase the opportunity for success and for both parties to engage in working towards a common goal; for example for Mr Smith and the mental health practitioner to work towards exploring the issues surrounding medication adherence. NICE (2010) recommends that managing the process of engagement requires professionals to have sensitivity to the perspective of the individual and to understand that the condition can have a profound effect on the person’s judgment, their capacity to understand their situation and their capacity to consent to specific interventions. The process of engaging successfully with individuals with schizophrenia may at times require considerable persistence and flexibility from professionals and the establishment of trust is crucial. Both parties may have differing views on what the main problem is and how it should be addressed, however the professional can help with finding common ground and this common ground can establish trust and collaboration (NICE, 2010).

To address the issue regarding Mr Smith’s decision to no longer adhere to his treatment plan and accept his depot medication for the symptoms of schizophrenia the mental health professional will need to enter into conversations to gain understanding of the patient’s perspective. One way of achieving this is for the mental health practitioner to adopt motivational interviewing so that the two parties can explore the decision (stopping of the depot injection) and negotiate behaviour change (acceptance of the depot) through the individual (Mr Smith) being able to identify, understand and articulate the benefits (remaining mentally well and symptom free) and costs involved (physical, emotional, family, employment for example will all be impacted upon greatly if symptoms return).

Rollnick et al. (2010) indicate that simply giving patient’s advice to change decisions or behaviour is often unrewarding and ineffective and by adopting motivational interviewing a guiding style helps to engage with patients, helps clarify strengths and aspirations, evoke their own motivations for change and promote autonomy of decision making. The four central principles of motivational interviewing are described by Treasure (2004) as being; the use of reflective listening in an empathetic manner to convey understanding of the patients point of view; tease out ways the behaviour or choice conflicts with the wish to be good or viewed as good; respond with empathy and understanding rather that confrontation and finally support the patient in confidence building to understand change is possible.

For Mr Smith and his decision to decline any further depot injections of Flupenthixol it may be very easy for the mental health practitioner and Mr Smith to become embroiled in conflict as the practitioner has the evidence base and clinical knowledge to know that a relapse is somewhat inevitable and the impact on Mr Smith’s global wellbeing and function would be significant; however Mr Smith believes that he is now well and therefore no longer needs treatment. By using motivational interviewing techniques the mental health practitioner can actively listen to Mr Smith’s reasoning behind the decision he has made in relation to medication adherence; support Mr Smith to see the pro’s and con’s of his decision; assess his confidence and elicit a view on his feelings fears and aspirations; exchange information; support with decision making and goal setting.

To give an example of how motivational interviewing may be implemented the practitioner may ask questions such as;

‘I want to try and understand Mr Smith about your decision not to have your depot anymore; can you give me your perspective on why you want to stop taking it?’

‘So Mr Smith if you were to stop taking your depot, where do you think that would leave you in terms of remaining well?’

‘How important is taking this medication for you right now?’

‘Would you mind if I shared with you some information and evidence I have about how the depot injection helps people with schizophrenia remain well and symptom free?’

And;

‘Okay, can I check with you your understanding of the risks of not accepting the depot anymore?’

This approach to supporting adherence to medication is reported to be beneficial and it is suggested that the body of evidence continues to grow in support of its effectiveness (Rollnick et al., 2010) and with the many applications in psychiatry it is particularly helpful for use in settings where there is resistance to change (Treasure, 2004). However there are some considerations that need to be identified that may impact on the efficacy of motivational interviewing as a technique to support medication adherence. Firstly one issue to consider is that motivational interviewing is a skill that mental health practitioners need to develop and practice and although the principles are described as easy (Treasure, 2004) putting these principles into practice may not be that simple.

There potentially could be many different variables as to why adopting motivational interviewing may not be effective in supporting medication adherence. Barriers that may impact on the success of motivational interviewing in supporting Mr Smith to maintain his medication adherence may include; there not being a therapeutic alliance established between the mental health practitioner and Mr Smith. The reasons for this can be numerous, for example Mr Smith may only recently have been discharged from hospital and the mental health practitioner is his new community psychiatric nurse that he has only met a couple of times; Mr Smith may prefer male workers to female workers and vice versa or even Mr Smith may not feel comfortable having mental health practitioners come to his home and feel unable to engage or discuss issues of importance. Another reason that may impact on the efficacy of the motivational interviewing process to support Mr Smith’s adherence to medication is that the mental health practitioner may be constrained by time and resources and therefore not able to deliver the therapeutic process accurately or in a timely.

Another issue to consider is that Mr Smith’s adherence to medication and decision not to continue to accept the depot may actually be based on the schizophrenic condition relapsing and the decision to withdraw from treatment is being made due to reduced insight and understanding. It is suggested that there are potentially a large range of risk factors that can be present and that are related to the patient’s individual behaviour and understanding of the impact of schizophrenia and psychosis. These variables are classified as patient related and include poor insight, negative attitude towards medication, symptom severity, history of previous non adherence, substance misuse and cognitive impairment. Other variables may also include treatment, environmental and societal issues such as side effects and complexity of medication regimes’ family support, side effects, financial problems and lack of access to treatment (Citrome, 2010).

Legal and Ethical Considerations

It is important for mental health practitioners to understand that there are occasions where more assertive and restrictive approaches such as treatment orders or inpatient hospital care are the only way for adherence to medication to be sustained (Chaplin, 2007). The Mental Capacity Act (2005) provides a framework for the making of decisions for people who lack capacity in England and Wales. Under the Capacity Act healthcare professionals are advised that they must work on the presumption that every adult patient has the capacity to make decisions about their care, and to decide whether to agree to, or refuse, an examination, and investigation or in this instance treatment. A patient is regarded as lacking capacity once it is clear that, having been given all appropriate help and support, they cannot understand, retain, use or weigh-up the information needed to make that decision, or communicate their wishes.

Therefore in this instance Mr Smith must be presumed to have capacity to make the decision not to adhere to the treatment plan unless there is evidence that he is no longer able to provide reasoned information to support his decision due to the presence of severe mental illness. It would be at this juncture that the mental health practitioner would look to ensuring Mr Smith’s best interests are explored and this may result in an assessment under the Mental Health Act (1983), however until this time the mental health practitioner may continue to use the therapeutic alliance and CBT and motivational interviewing techniques to support the adherence process.

The success of a therapeutic alliance is often based on trust and to establish trust the mental health practitioner must respect the patient’s ethical right to autonomy. Autonomy for Mr Smith would be the right to decide and determine whether or not to accept or decline his depot injection even if the refusal meant that his mental health would deteriorate and the consequences to his global wellbeing become severely impaired. It would be unethical for the mental health practitioner to coerce, threaten or manipulate Mr Smith into having the depot injection particularly if he has the mental capacity to make the decision to decline further treatment. For the mental health practitioner to behave in this manner would not only be a breach of professional and ethical conduct it would also potentially jeopardize any therapeutic alliance that had been developed.

Addressing Risk

Mr Smith’s decision to become non adherent to prescribed medication presents a requirement for detailed risk planning and assessment to ensure the well being of Mr Smith, his family and friends and those providing care to him is sustained. Mental health practitioners have a duty of care to assess risk using a formulated tool that has been adopted by their employer and mental health service. The calculation of risk must be based on the practitioners knowledge, skills and competence and value should be placed on the process of risk taking, following assessment and in the context of appropriate management, as it will increase the practitioner’s ability to help clients to achieve their potential. However, there should be awareness that there may be conflicts between professional accountability and the autonomy of the client (UKCC, 1998).

Risk issues that may be identified for Mr Smith are individual and related to the course and nature of his experience of Schizophrenia, this is why it is important for the practitioner to have established a therapeutic alliance with him so that discussions can be held about risk issues and care planning can be done collaboratively to reduce the risk impact.

Conclusion

Medication adherence in schizophrenia is a complex issue with the consequences of non adherence impacting significantly on the global function and mental well being of individuals who make the decision to not adhere to their medication treatment plan. Through the process of collaboration and the development of therapeutic alliances between mental health professionals and patients it is suggested that adherence can be improved and sustained and that interventions such as CBT and motivational interviewing makes psychoeducation a cornerstone of many adherence interventions (Zygmunt et al., 2002).

Mental health practitioners should have an understanding that medication adherence is less likely to occur in patients with severe mental illness who are not engaged with mental health services and who are not exposed to a good therapeutic relationship. One of the most common themes that have been identified throughout this assignment and in the evidence base is that the therapeutic alliance between a patient and mental health professional should never be underestimated particularly when it comes to supporting medication adherence in the treatment of schizophrenia.