The most prevalent psychiatric problem worldwide passes below the radar screen of almost all psychiatrists. Our colleagues in medicine, pediatrics, and surgery have virtually given up approaching psychiatrists for help with patients whom they believe suffer from this problem. Indeed, if they do request consultation for this problem, they most frequently ask a psychologist or social worker. Within the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR),1 this problem receives a scant paragraph of discussion in its V-code hiding place. No medications exist to treat this problem (perhaps one explanation of why psychiatry ignores this problem). Furthermore, even if medications did exist, the patients with this problem almost certainly would not take them properly! This problem is nonadherence with medical therapy.
Across a variety of chronic medical illness the observed adherence rate with long-term, “disease-controller” medications averages around 50%.2,3 Adherence rate indicates doses taken divided by doses prescribed times 100%. Indeed, even more shocking data have emerged as technology using electronic devices has enhanced adherence measurement, measuring the specifics of medication use with ever finer granularity. For example, only about 25% of patients with asthma take their prescribed inhaled anti-inflammatory medication in a fashion consistent with its pharmacologic function (ie, regular, daily use without prolonged periods of nonuse that exceed the “coverage” of the medication).2,4 Hence, the above-quoted 50% average adherence likely underestimates the number of patients at risk by their medication use behavior.
Observations in clinical trials5 and field studies4 have delineated a phenomenon termed “dumping.” Study participants, despite presumably knowing the monitored status of their medication usage, routinely discharge their asthma inhalers repeatedly during a short period of time immediately before a follow-up visit. Apparently, these patients wish to give the investigators what the participant perceives them to want — empty, “used” canisters of medication. In addition, when patients are given only general information about the abilities of such devices (eg, that they “measure the way you use your medication”) observed rates of dumping measure at around 30%.5 However, when they receive more complete information about of the electronic monitoring device's capacities (ie, that it can monitor usage with daily or better precision), rates of dumping behavior drop to close to, but still not quite, zero.
Outside of respiratory medicine, patients took acarbose, an antidiabetic agent intended for lifelong administration, with a median persistence (ie, time from initial prescription to discontinuation by the patient) of only 83 days and 105 days for two groups of recipients.6 Similarly, median persistence for statins, once again medications intended for long-term lipid control, in fact entered patients' bodies for only about 6 months before they stopped use.3
In another example, highly active antiretroviral therapy has changed HIV infection from a lethal to a chronic illness. This therapy requires life-long therapy with adherence rates of at least 95%, but this remains only a goal because a majority of patients fail to sustain usage despite motivations for adherence, such as risks of progression to AIDS and emergence of viral resistance.7 Multi-drug–resistant tuberculosis also has resurfaced as a top infectious problem worldwide, with nonadherence to therapy playing an important role with both antitubercular and antiretroviral therapies.
The remainder of this article discusses how the various explanatory models in contemporary psychiatry explain the behavior of nonadherence with medical therapy, ending with a discussion of the social brain model, more fully articulated elsewhere in this issue. The explanatory models other than the social brain model are presented as caricatures, because like a good political cartoon, such caricatures express important underlying weaknesses in these models. This article concludes with a discussion of how the social brain model can help psychiatrists re-enter the “fellowship of the helpful” for patients with adherence problems, as well as for medical colleagues who would like the assistance of psychiatrists in treating patients with this difficulty.
The “Silver Bullet” Model
An overwhelmingly important, albeit implicit, assumption in the “chemical imbalance” or “bent or deficient molecule” models of mental illness holds that patients can be relied upon to take prescribed “silver bullet” medications for their brain problem. If this doesn't happen, the 15-minute “medication check” appointments allowed by managed care providers give the psychiatrist time to inquire about side effects only and to adjust dosage. However, this model is clearly misguided, because at best only a minority of patients likely take their psychiatric medications as prescribed, given nonadherence with other medications.
To date, no medication approved by the Food and Drug Administration can be prescribed to help patients take their other prescribed medications. Although some hold out hope for long acting “depot” medications that permit longer intervals between treatments, patients still will need to return at some point when their coverage wears off. Therefore, such long-acting formulations would likely help only in special circumstances, as when public health concerns require limits on personal freedom, such as directly observed therapy for tuberculosis.8,9 An analogous example is clozapine, whose above-average adherence compared with other antipsychotics stems from regulations established by the pharmaceutical company and FDA that require documentation of blood work prior to dispensing refills.10 Accordingly, the “silver bullet” model's favored solution to diagnosed problems — “give a new medication” — does not resolve adherence problems.
Despite the near universal personal reaction clinicians seem to have when data documents nonadherence as a clinical problem — “but my patients do take their medications!” — research consistently has demonstrated that physicians' estimates of their patients' adherence does not associate with objective measures of adherence behavior.11,12 Although one does find statements in “silver bullet” model publications that nonspecific relationship factors influence medications' effects, these recommendations suffer from being vague, infrequent, and given only secondary status. Nonetheless, the success of this model stems from the fact that medications do have measurable effects; this, in turn, more readily allows scientific study. This, without question, has enormously contributed to the development of effective and specific treatments for psychiatric disorders.
The DSM “Symptom Checklist Defines Reality” Model
Despite numerous, undeniable successes of the empirical and phenomenological-based DSM taxonomies, the DSM model poorly conceptualizes nonadherence with therapy. A “V-code” diagnosis for adherence problems exists, but such codes provide no clear-cut guidance for therapy, and in practice, virtually all third-party payers fail to reimburse V-code problems.
One might go out on a limb and try to make poor adherence an indication of Axis II behaviors. However, given that, as stated above, the prevalence rates of less than optimal adherence may occur in around 50% to 75% of the population and “dumping” in 30% when given permissive situations, Axis II problems related to medication adherence would become the number one mental illness worldwide.
Furthermore, research suggests that major Axis I psychopathology (eg, mood or anxiety disorders), although a factor in medical nonadherence, do not explain the vast majority of the variance in this phenomenon.13,14 Hence, diagnosing and treating comorbid major psychopathology, although clearly useful, will also not resolve the problem of nonadherence.
Perhaps the most fundamental reason that the DSM model fails to explain adherence behavior hinges on the model's explicit statement that all mental illness exists “inside the head” of the patient. Consider one well-established factor for why many patients fail to take their medications: the drugs are expensive, and no insurance reimbursement is provided.15 It would be difficult to define poverty as existing only “inside the head.”
The Biopsychosocial Model
The biopsychosocial model's primary value hinges on its reminder to psychiatrists that human behavior possesses more complex and multifaceted features than those embodied in either of the previously discussed models. Nonetheless, this model offers little practical help in understanding adherence behaviors because it points to a universe of possible reasons for poor adherence but provides no guidance on which leads to follow. For example, poor adherence may relate to poor understanding of how the medications work (eg, a mistaken belief that long-term controller medications can be taken successfully on an as-needed basis); a need to defy authority figures derived from childhood experiences; inability to afford the medication; or cultural idiosyncrasy (eg, the belief that having a Chihuahua dog in the home cures asthma). Indeed, the literature supports that all these factors link to poor adherence.16
The biopsychosocial model problematically lacks focus. No reason exists to explain why red hair, enjoyment of chewing bubblegum, or foot fetishes would not also represent possible factors related to nonadherence. In other words, this model generates an extremely wide, even infinite, universe of potentially relevant factors. This panoply of possibilities overwhelms the practicing psychiatrist, who cannot scrutinize everything as potentially contributory and explanatory factors — especially not in the face of managed care time constraints!
Without focus, this model loses power, as the crucial needle(s) could be anywhere in the haystack. Consequently, no testable hypotheses have stemmed from this model; hypotheses that in turn might have advanced research in this (or most other areas of psychiatry). Despite the biopsychosocial model's importance in psychiatric education (eg, when creating diagnostic “formulations”) and as the last remaining bastion of cultural, psychological, and social forces in mainstream psychiatry, its lack of effect on either day-to-day clinical practice or research makes it sterile.
The Social Brain Model
The social brain model posits that the formation and maintenance of viable relationships across the lifespan represents each person's primary challenge. As such, this also represents the primary determinant of a person's psychiatric health. People who form and maintain viable vocational and intimate relationships possess psychiatric health; those who cannot present with psychiatric illnesses. Available data indicate a very wide range of different patterns of viable relationships consistent with psychiatric health, whereas on the other hand, fewer, more consistent, and definable pathways exist to explain episodic or persistent relationship difficulty. Indeed, relationship problems characterize all current Axis I and II DSM disorders.
For the issues of nonadherence, the social brain model provides psychiatry with a focus lacking in the biopsycho-social model, while avoiding the reductionism of the “silver bullet” and “symptom checklist defines reality” models. Medical illness, in general, provides a specific set of relationship challenges to the social brain. Thus, the model posits that a clear and definable set of relational processes will exist in the medically ill patient to explain adherence behavior.
For example, relevant processes include the survival of self, the survival of kin, the need for nurturance and allies, and the acceptance of authority. Let us examine the face validity of some of these. Ill people seek to protect themselves and to protect key others in their social network. Their adherence behavior will reflect these goals. Hence, clearly specified and testable hypotheses can be formed to explain the empirical observations concerning adherence. Patients who regularly and consistently take their medication as prescribed more likely view their physician as a helpful and supportive ally. In support of such an argument, more adherent patients feel satisfied with their physician, report better alliance or communication with their physician, feel greater confidence in the advice of their physician, experience more conviction that taking their medication will improve their health, possess physicians who interact with them in more “patient-centered” and less authoritarian ways, and are less culturally different from their physicians.12,17–22
Similarly, the investigator can predict that patients who regularly take less than their full dose of mediation may have more competing demands (ie, “stress”) in their lives. For such people, adherence behavior represents a compromise between the advice of the physician and other demands from the relevant social environment. In support of this hypothesis, poor adherence more likely characterizes patients who live in more challenging socioeconomic circumstances, where other demands take precedence. Such demands include poverty or other socioeconomic deprivation,18,23 increased personal or family stress,13,23,24 poorer personal or family organization and ritualization.25,26
Just as the above cited research demonstrates convergent validity for certain hypotheses about nonadherence that grow naturally out of the social brain model, one also can see how discriminant validity flows from testing factors predicted to be not related, such as the red hair, predilection for bubble gum, and foot fetish mentioned previously. One of the most important features of the social brain model is this ability to permit and focus empirical psychiatric research, in areas either overlooked or underplayed by the “silver bullet” and “symptom checklist defines reality” models and underfocused in the biopsychosocial model.
The social brain model's final advantage hinges on the relatively simple and jargon-free fashion that it incorporates relationship conceptions into psychiatric formulations. These possess transparency to the majority of people, including our patients as well as our colleagues in other areas of medicine who often feel confusion and would like to be able to ask for psychiatric help with nonadherent patients. Statements to patients such as, “You seem to need an ally,” “You're right; he is a hard doctor to talk to,” and “Wow, you sure have a lot going on in your life now” are succinct, supportive, readily understandable, and fully consistent with and predictable from the social brain model. With a little imagination, one could come to believe that, with time, use of the social brain model might even help demystify and destigmatize psychiatry in both medical and broader communities.
The best psychiatrists are those whose humility allows them to recognize what they do not know, but whose humanism drives them to learn what they need to know. The best model for psychiatry should help them do both successfully. The social brain model, in the case of nonadherence with medical therapy, may help psychiatry achieve both these noble and important goals. The model helps psychiatrists understand, diagnose, treat, and research nonadherence with medical therapy, and in doing so allows them to promote more healthy relationships for their patients and with their medical colleagues from different disciplines.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders [text revision], 4th ed. Washington, DC: American Psychiatric Publishing; 2000.
- Milgrom H, Wamboldt F, Bender B. Monitoring adherence to the therapy of asthma. Curr Opin Allergy Clin Immunol. 2002; 2(3):201–205. doi:10.1097/00130832-200206000-00008 [CrossRef]12045415
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- Wamboldt FS, Rojas S, Bender B, et al. Patterns of MDI adherence in children with asthma. Am J Respir Crit Care Med. 2001;163(5):A317.
- Rand CS, Weeks K. Measuring adherence with medication regimens in clinical care research. In: Shumaker SA, Schron E, Ockene JK, McBee W, eds. The Handbook of Health Behavior Change, 2nd ed. New York, NY: Springer Publishing Co., 1998, pp 114–132.
- Catalan V, Couture J, LeLorier J. Predictors of persistence of use of the novel antidiabetic agent acarbose. Arch Intern Med. 2001; 161(8):1106–1112. doi:10.1001/archinte.161.8.1106 [CrossRef]11322845
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- Weiss KA, Smith TE, Hull JW, Piper AC, Huppert JD. Predictors of risk of nonadherence in outpatients with schizophrenia and other psychotic disorders. Schizophr Bull. 2002;28(2):341–349. doi:10.1093/oxfordjournals.schbul.a006943 [CrossRef]
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