February 20, 2006 by Shawn Smith
Q: My father who lives with us recently went on medication for high blood pressure. He seems fine and he doesn’t have any memory problems. The problem is, he won’t take his medication unless we constantly remind him and it’s becoming a daily battle. How do we get him to take his medication? – Monique, Lansing, Michigan
A: Dear Monique,
We are blessed, you and I. We live in a society that devotes vast resources toward the development of wondrous medications. Unlike our ancestors, good health and longevity are ours but for the daily ritual of downing a small capsule filled with the God-like power to extend life.
And yet, Grampa leaves his pills at the bottom of his underwear drawer whenever he goes to Vegas. The irony is staggering.
Having never met your father, I can’t offer specific advice other than to check his underwear drawer. But I can tell you that you’re not the first to face this quandary. Medication adherence is a serious healthcare problem. The number of deaths related to non-adherence has been estimated at 125,000 annually. The cost of unnecessary ER, nursing home, and hospital admissions related to the problem is estimated to be in the billions of dollars.
Non-adherence is also a serious problem with psychotropic medications such as antidepressants and antipsychotics. All too often, a patient taking these meds will begin to feel better, abruptly stop taking the medication, and then – crash – they’re planning their suicide or taking dictation from the ghost of Elvis.
Being the costly problem that it is, medication adherence has led to a variety of gadgets ranging from day-of-the week pill boxes (you can find these at the grocery store) to high-tech alarms and reminders (just search the internet for “medication adherence”). Unfortunately, researchers have noted limited success with such gizmos.
There are also behavioral reminders, such as keeping medications in a special place, associating them with daily events like meals, or creating rewards for successful adherence. These, too, have shown lackluster results.
My guess is that you’ve tried gadgets and reminders to no avail. If so, you’re not alone. You and your father are facing one of the greatest challenges known to psychology: achieving lasting behavior change. Ironically, for many people, failed adherence is not a question of ability, skill, or knowledge. Taking meds is a simple act of ingestion, for goodness’ sake. Humans are built for it; Americans excel at it. You’d think it would be easy.
Yet it isn’t easy, and the solution isn’t obvious. Once we’ve ruled out factors such as absent-mindedness, mood disorders, poverty, side-effects, cognitive problems, lack of information, and other things that can impede adherence, we’re left with one important possibility: people like your father simply may not be invested in taking their medication. In fact, your report of “daily battles” suggests that he, like others, might actually be invested in not taking his little magic pills.
Parenthetically, I can’t help wondering if the pills were thrust upon him with minimal discussion and an unintentional message: “you’re gettin’ on in years, old fella. Best ye take these pills so you can run out the clock without causin’ a fuss.” It happens regularly to our elders, and you can see where it might interfere with adherence.
Regardless, many folks simply seem to lack a good reason to participate in their own medication plan. When that’s the case, the literature suggests that strengthening investment, not memory, is the key to solid adherence. Here are some strategies that have been found to improve medication adherence, at least a little bit:
- Informed consent: This means knowing what you’re getting into and what the trade-offs are. Let’s use Grampa as an example. Does he understand the medical ramifications of taking that junket to Vegas without his meds? Does he understand the possible side-effects of taking the pills? That’s the easy part of informed consent. The harder part is an examination of what Grampa wants his life to look like from now on. Maybe he wants to go fishing and golfing. Maybe he wants to enjoy his grandchildren. Maybe he still has a brilliant career ahead of him. On the other hand, maybe he’s content to sit in the basement and quietly whither away. When his goals and values are clear, so will be the role of medication in his life.
- Involvement of family and friends: Let’s say Gramps decides to exchange pill-swallowing and side-effects for reduced chances of stroke, heart attack, kidney damage, or loss of vision. He has better odds of following doctor’s orders when friends and family take an interest in his health (Gonzales, et al., 2004). That is not the same as coercion, which has been shown to degrade medication adherence (Seale, et al., 2005, noticed this phenomenon among psychiatric patients). Think of strolling next to someone on the beach, versus pushing and shoving to get them moving through the sand. One is bound to be the more pleasant journey.
- Positive mental health: This one is not rocket science. People without cognitive or mood problems are more likely to grasp the importance of medication and they’re less likely to forget (Gonzales et al, 2004). Any family member who seems sad, confused, manic, or otherwise out-of-sorts, needs to see a psychologist or physician. His or her medication problems may be a symptom of something larger.
- Relationship with healthcare providers: People are more likely to follow professional advice when they know their providers. Research suggests that helpful relationships are not limited to doctors, but can include nurses, pharmacists, or any other professional directly involved in the person’s healthcare.
- Mutual decision making: If you’ve been around humans for very long, you may have noticed that many of us have a rebellious streak and will do the opposite of what we’re instructed to do. But even the most hardened rebel finds it difficult to be unruly if he or she has participated in making the decision. If gramps’ physician won’t discuss something as important as tinkering with body chemistry then there are plenty of others who will. This is why God invented second opinions, which are a great way for patients to stay informed and involved in the decision-making process.
Finally, the experts tell us that a combination of strategies is the most promising approach. For patients who are motivated but forgetful, a combination of simple dosing schedules, reminders, and frequent contact with healthcare professionals seems to work best (Petrilla, et al., 2005). For those with a dependable memory but questionable motivation, something more may be needed.
In one recent study, patients who achieved 100% adherence to antiretroviral regimens did the following: They managed their own medication schedules (rather than relying on others), they had realistic expectations about the effects and side effects of the medication, they made their medication a priority in their lives (presumably because they had defined what they wanted to live for), they were educated about their medications, they believed in the efficacy of them, and they had strong relationships with their healthcare providers (Lewis, et al., 2006). Clearly, for these folks, medication adherence was more than a rote habit. It was tied to their values.
Psychology can a frustrating business, Monique. While the pharmaceutical industry makes fantastic leaps forward, we shrinks are still figuring out how to get pills past the average gullet.
Gonzales, J. S., Penedo, F. J., Antoni, M. H., Duran, R. E., Fernandez, M. I., McPherson-Baker, S., et al. (2004). Social support, positive states of mind, and HIV treatment adherence in men and women living with HIV/AIDS. Health Psychology, 23(4), 413-418.
Lewis, M. P., Colbert, A., Erlene, J., & Meyers, M. (2006). A qualitative study of persons who are 100% adherent to antiretroviral therapy. AIDS Care, 18(2), 140-148.
Littenberg, B., MacLean, C. D., & Hurowitz, L. (2006). The use of adherence aids by adults with diabetes: a cross-sectional survey. BMC Family Practice, 7(1).
Petrilla, A. A., Benner, J. S., Battleman, D. S., Tierce, J. C., & Hazard, E. H. (2005). Evidence-based interventions to improve patient compliance with antihypertensive and lipid-lowering medications. International Journal of Clinical Practice, 59(12), 1441-1451.
Seale, C., Chaplin, R., Lelliott, P., & Quirk, A. (2005). Sharing decisions in consultations involving anti-psychotic medication: A qualitative study of psychiatrists’ experiences. Social Science Medicine, December 8.