Ms. Worley is a Family Psychiatric-Mental Health Nurse Practitioner in private practice, Cookeville, Tennessee, and Dr. McGuinness is Professor, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama.
The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support.
Address correspondence to Teena M. McGuinness, PhD, CRNP, FAAN, Professor, School of Nursing, University of Alabama at Birmingham, NB 320, 1530 3rd Avenue South, Birmingham, AL 35294-1210; e-mail: firstname.lastname@example.org.
Progress in psychopharmacology has been astounding in the past 20 years; however, this progress is for naught when medication regimens are not followed. Despite progress in the development of medications for all manner of illnesses, children and adolescents consistently do not adhere to the necessary regimens. This article will explore the current state of knowledge regarding medication adherence for youth in general as well as focus on psychotropic medication adherence in childhood and adolescence.
Medication adherence is the degree to which medications are taken in accordance with the prescriber’s intention (Dean, Walters, & Hall, 2010). Medication adherence rates for a variety of childhood chronic illnesses rarely exceed 50% to 55% (World Health Organization, 2003). Not surprisingly, nonadherence to medication schedules is associated with poor outcomes. While interventions to promote medication adherence may help, they are not consistently effective (Dean et al., 2010). Nevertheless, promoting medication adherence during childhood and adolescence does favor treatment effectiveness and long-term health.
Younger patients are not the only population not taking drugs as prescribed. In fact, nonadherence with medication regimens has been called “America’s other drug problem” (National Council on Patient Information and Education [NCPIE], 2007). The NCPIE, a nonprofit organization of more than 125 organizations working to improve communication on the appropriate use of medicines, proposed in 2007 that reducing adverse health and economic consequences of nonadherence should become a main concern. NCPIE (2007) outlined 10 steps to improve prescription medication adherence, including the important issue of using uniform terminology to address the problem. Is the problem noncompliance or nonadherence? Current literature on the topic uses the terms compliance and adherence interchangeably. Hack and Chow (2001) made one interesting observation: “To physicians, compliance generally means the extent to which the patient takes the medication as prescribed. Many in the field use the word adherence. Adherence places more of a burden to form a therapeutic alliance with the patient” (p. 59).
Psychiatric nurses understand that a therapeutic alliance is not a burden but an integral part of the healing relationship. In keeping with this approach, NCPIE (2007) suggested naming the issue adherence (as opposed to compliance, persistence, or concordance) and mounting a national education campaign to make adherence a national priority. NCPIE (2007) also called for developing a curriculum on medication adherence for use in medical schools and across all health care disciplines. This curriculum calls for the interdisciplinary coordination of resources so that all clinicians speak a similar language to give clear messages to consumers. NCPIE (2007) called for more research on medication adherence as well as professional training and education on this important topic.
Limited Literature on Psychotropic Medication Adherence and Youth
The majority of the medication adherence literature focuses on general pediatric medications. What literature there is on adherence to psychotropic medications and youth emphasizes medication for attentional deficits. Although important, psychotropic medications are frequently prescribed for conditions that co-occur with attentional problems, including pediatric mood and anxiety disorders. Below is a review of adherence to all types of medications for youth, with an emphasis on psychotropic medications where possible.
Addressing medication adherence for children in general involves the unique provider-caregiver-patient communication triad (Winnick, Lucas, Hartman, & Toll, 2005). Despite clear communication regarding the need for any medication, Winnick et al. (2005) identified several barriers, an obvious being the financial cost of the children’s medication. Cost of psychotropic medications continues to rise (Cuellar & Markowitz, 2007), and in these challenging economic times, cost may be one of the biggest barriers.
Another barrier that psychiatric nurses should explore is parental attitudes and beliefs about their child’s need for psychotropic medication; parents holding an anti-medication outlook could hinder adherence. Stevens et al. (2009) found that antidepressant medications were thought to be both beneficial and risky to 501 parents of depressed children. Fifty-two percent of parents somewhat or strongly believed that antidepressant drugs could make their children want to harm themselves. These parental concerns may have arisen when the U.S. Food and Drug Administration (FDA) placed warnings in 2004 regarding antidepressant agents and children, indicating there may be a slight increase in risk for suicidal behavior. Factors that may lead depressed children to experience suicidal ideation while taking antidepressant agents are complicated, and the FDA “black box” warnings concerning increased risk for children taking these medications have been controversial. A 2007 meta-analysis that included seven studies not examined by the FDA in 2004 (Bridge et al., 2007) revealed only a 0.7% increase in the risk of suicidal ideation or behavior in children taking antidepressant medications. In addition, Bridge et al. (2007) concluded that antidepressant drugs were effective treatments for mood and anxiety disorders for children. Benefits of antidepressant agents appeared to be much greater than the risk for suicidal ideation.
African American parents had less favorable views of antidepressant medication compared with parents of other ethnicities. Stevens et al. (2009) concluded that parental perceptions of the benefits and risks of antidepressant drugs were associated with future mental health service use. Parental beliefs about higher risks associated with antidepressant drugs were associated with a decreased likelihood for subsequent visits to evaluate medication effectiveness.
Accepting a psychiatric diagnosis can also be a major hurdle. Results of focus groups of parents of children diagnosed with attention-deficit/hyperactivity disorder (ADHD) showed that the process of seeking assistance, receiving a diagnosis, and accepting the label of ADHD was complex and difficult (Charach, Volpe, Boydell, & Gearing, 2008). Parents commented that they found the decision to medicate difficult, expressed fears about giving drugs to their children, and had experienced negative feedback from their families and even teachers regarding the use of medication. Thus, parental ambivalence and conflicting opinions of others are contributing factors to medication nonadherence.
Another barrier is dosing schedule. Children of parents who administer medications that involve multiple daily dosages for their young children tend to have decreased adherence mainly because the parents forget to administer doses later in the day (Chacko, Newcorn, Feirsen, & Uderman, 2010). Fortunately, many psychotropic medications come in time-release form; some have dissolvable tablet formulations; and for ADHD, a daily patch preparation is available.
Special Challenges to Medication Adherence with Adolescents
At what point does the responsibility of medication adherence transition to an adolescent? There is no literature supporting the independent administration of medication by teenagers. Health care providers should be explicit with parents in stating that parents are responsible for making sure their child takes the medication. Nevertheless, involving teenagers in the process of medication management is imperative. Despite a maturing intellect, adolescents have difficulty with abstract concepts, particularly with imagining the future consequences of present actions (Nevins, 2002). This shortcoming strengthens the notion of invulnerability and the magical thinking that is characteristic of many teenage risk-taking behaviors (Nevins, 2002). Children with chronic disease often experience delays in personal maturation and independence. In turn, parents may overestimate how much responsibility the teenager can assume based on their age alone (Nevins, 2002). In cases of teenagers who take psychotropic medication, stigma associated with the medications may influence their identities; medication side effects also contribute to nonadherence (Charach et al., 2008).
Competing Sources of Health Care Information
Another factor contributing to poor medication adherence is a shift in the relationship between the patient, parent, and the health care system. Organizational changes in practice settings, often having to do with reimbursement, can impair continuity of patient contact and availability of time to spend with patients (Winnick et al., 2005). Increasingly, patients obtain medical information from a variety of sources that may compete with their health care professional’s recommendations; a pharmaceutical advertisement played repeatedly may suggest that consumers should ask their health care providers to add a specific medication. The Internet also competes as a source of information. With all of these resources at hand, consumers are more likely to make independent decisions about their medication, which may affect adherence (Winnick et al., 2005).
Currently, medication adherence rates for youth are at an unacceptable 50% rate. The term adherence has become the preferred term to address this issue as it reflects a therapeutic alliance between clinician and consumer. Many factors affect psychotropic medication adherence in youth; parental attitudes and beliefs about their child’s diagnosis and prescribed medication is an essential factor, so an alliance between parents and psychiatric nurses is crucial. As children get older, their views on their diagnoses and need for medication may become a challenge. Increasingly, health care professionals must compete with other sources of information such as the Internet, which can affect a parent’s or child’s willingness to adhere to prescribed medication regimens. Part 2 will focus on practical tips to improve medication adherence through communication, education, and behavioral strategies.
- Bridge, J.A., Iyengar, S., Salary, C.B., Barbe, R.P., Birmaher, B. & Pincus, H.A. et al. (2007). Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: A meta-analysis of randomized controlled trials. Journal of the American Medical Association, 297, 1683–1696. doi:10.1001/jama.297.15.1683 [CrossRef]
- Chacko, A., Newcorn, J.H., Feirsen, N. & Uderman, J.Z. (2010). Improving medication adherence in chronic pediatric health conditions: A focus on ADHD in youth. Current Pharmaceutical Design, 16, 2416–2423. doi:10.2174/138161210791959908 [CrossRef]
- Charach, A., Volpe, T., Boydell, K.M. & Gearing, R.E. (2008). A theoretical approach to medication adherence for children and youth with psychiatric disorders. Harvard Review of Psychiatry, 16, 126–135. doi:10.1080/10673220802069715 [CrossRef]
- Cuellar, A.E. & Markowitz, S. (2007). Medicaid policy changes in mental health care and their effect on mental health outcomes. Health Economics, Policy, and Law, 2(Pt. 1), 23–49. doi:10.1017/S1744133106006268 [CrossRef]
- Dean, A.J., Walters, J. & Hall, A. (2010). A systematic review of interventions to enhance medication adherence in children and adolescents with chronic illness. Archives of Disease in Childhood. Advance online publication. doi:101136/adc.2009.175125 doi:10.1136/adc.2009.175125 [CrossRef]
- Hack, S. & Chow, B. (2001). Pediatric psychotropic medication compliance: A literature review and research-based suggestions for improving treatment compliance. Journal of Child and Adolescent Psychopharmacology, 11, 59–67. doi:10.1089/104454601750143465 [CrossRef]
- National Council on Patient Information and Education. (2007, August1). America’s other drug problem poor medication adherence. Retrieved from the Marketwire website: http://www.marketwire.com/press-release/Americas-Other-Drug-Problem-Medication-Adherence-756583.htm
- Nevins, T.E. (2002). Non-compliance and its management in teenagers. Pediatric Transplantation, 6, 475–479. doi:10.1034/j.1399-3046.149.ptr1s077.1.x [CrossRef]
- Stevens, J., Wang, W., Fan, L., Edwards, M.C., Campos, J.V. & Gardner, W. (2009). Parental attitudes toward children’s use of antidepressants and psychotherapy. Journal of Child and Adolescent Psychopharmacology, 19, 289–296. doi:10.1089/cap.2008.0129 [CrossRef]
- U.S. Food and Drug Administration. (2004, October15). Suicidality in children and adolescents being treated with antidepressant medications. Retrieved from http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/DrugSafetyInformationforHeathcareProfessionals/PublicHealthAdvisories/ucm161679.htm
- Winnick, S., Lucas, D.O., Hartman, A.L. & Toll, D. (2005). How do you improve compliance?Pediatrics, 115, e718–e724. doi:10.1542/peds.2004-1133 [CrossRef]
- World Health Organization. (2003). Adherence to long-term therapies: Evidence for action. Retrieved from http://apps.who.int/medicinedocs/en/d/Js4883e/9.1.7.html