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Trading Symptom Relief for Side Effect Relief

Why do people stop taking their psych medication?

Psychiatrists spend a lot of time on this question. They used to call it noncompliance. Then they figured out that the word fed the power struggle between doctor and patient. Now they call it nonadherence. Me, I am not convinced that the word change reflects an attitude shift on doctors' parts, i.e., that they have changed their attitudes toward noncompliant patients, have abandoned the power struggle themselves, and instead want to partner with their patients. I suspect the word change is a cosmetic shift designed to change the patient's attitude.

Psychiatric Times regularly publishes articles on why patients don't take their meds and best practices for improving adherence. Suboptimal adherence is pervasive among individuals with chronic health conditions, including psychiatric disorders... However, many mental health practitioners ascribe nonadherence to the mental illness itself.

Xavier Amador thinks it is because we don't understand that we are sick. His special word for it is anosognosia. It means lack of insight. He has developed a whole franchise around that word. Anosognosia is a real thing. It refers to a particular kind of brain damage. Amador's application of it to mental illness is, well, idiosyncratic. His solution to the nonadherence issue is relational. Patients take the medication not because they acknowledge that they need it, but because somebody they care about wants them to do so. Well, he says it worked with his brother.

A more mainstream approach recommended to doctors is Motivational Interviewing. The doc asks the patient about the patient's goals and builds a partnership to achieve those goals. The case studies presented in the linked article present patients with some [extreme] level of naiveté and ignorance, which does suggest the doc has his/her fingers crossed behind the back about the nature of this relationship. But that's what I get for reading articles written by and for doctors, not for me.

Psychotherapeutic methods assume that taking the medication is the best course, that the person who fails to adhere is making the wrong choice, and the eventual goal is to get the patient back on the bus. They say, Weigh your risks and benefits. But the prescribing sheet from the pharmacy, where the risks are actually listed, says This information should not be used to decide whether or not to take this medicine or any other medicine. Only the healthcare provider has the knowledge and training to decide which medicines are right for a specific patient. Hmm.

Okay, let me answer an objection here. Yes, psychiatrists have special knowledge in the area of psychiatric illness and psychotropic medication that most patients don't. They do not, however, have knowledge of the patient's life, goals, values, and culture. They do not generally understand what side effects really feel like and how they impact the patient's life, goals, values, and culture. Many are focused on symptom reduction and do not see the big picture. They also make mistakes. There is more to this issue than knowledge and training.

But there is also a third party not yet heard from in this transaction. Big Pharma. Let's be clear. These people don't care about power struggles. They don't care about autonomy. They don't even care about outcomes. Big Pharma wants to sell drugs. Sometimes it is helpful to consult people whose motives are naked and clear.

So I listened up when the American Journal of Managed Care reported on a survey by Alkermes, an international pharmaceutical company specializing in psych meds:

A recent survey of patients with bipolar I (BP1) disorder showed the extent to which they are so bothered by side effects to antipsychotic (AP) medications that they will stop taking them, or will trade more symptoms for fewer side effects.

The results, which were presented at a recent meeting of mental health professionals, found that dislike of side effects (54%) was the most common reason for nonadherence. Other common reasons for nonadherence included not liking taking medication (37%), thinking that they did not need their medication (31%), and thinking that their medication was ineffective (23%).

54% said the meds made them feel worse. 23% said the meds didn't work. (The total of all responses exceeds 100%, presumably because the responders could choose more than one answer.)

Now really. Would you take a med that made you feel worse and/or didn't work? What would you say to the doc who ascribes your nonadherence to a lack of insight? How about, Who exactly is lacking this insight?

Psychotherapeutic approaches address the concerns of a minority of patients. So why do doctors use them? Their advantage, I suppose, is that they do not challenge the wisdom of the healthcare provider who has the knowledge and training to decide which medicines are right for a specific patient.

I don't think Alkermes will use their continuing education seminars to teach doctors more effective ways to get their patients to take their meds. I think they will focus on reducing side effects. Side effects have always driven innovation in psych drug development. That's where the money is to be made. When they asked patients about their preferences for a new antipsychotic, they found that patients chose improvements in many side effects... over symptom relief. Interestingly, nearly 30% were willing to accept a slight worsening in symptoms in order to see fewer side effects in [weight gain and sexual dysfunction.]

I made that choice myself. In my case it meant not taking an antipsychotic at all and tolerating a moderate depression in favor of publishing a book. Actually, I kept reading Psychiatric Times and found an over the counter solution that resolved the depression.

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