Patients who could benefit from medication for mental health conditions may be among the most reluctant to take – and stay on – the medications they need. 

“Patients who are depressed are less likely to take their medications as prescribed,” according to an article on the American Medical Association (AMA) website. “Physicians and other health professionals may be able to uncover this by sharing issues and asking if the patient can relate to it. To reduce embarrassment, express that many patients experience similar challenges.” 

Medication adherence is an especially critical part of psychiatric medication management. To help patients get better, medications often play a central role in the treatment plan for mental health conditions.  

While one meta-analysis showed a 25% non-adherence across a wide range of non-psychiatric conditions, another meta-analysis found that for mental health conditions, non-adherence was higher: 56% for schizophrenia, 50% for major depressive disorders, and 44% for bipolar disorders. 

This poses a challenge for psychiatrists, primary care physicians and other prescribers who have evaluated the patient, weighed the benefits and risks of medication for the patient’s specific case, and written one or more prescriptions as part of the treatment regimen. 

Despite these disparities between overall and mental health medication adherence, it’s possible to help your mental health patients accept being prescribed a medication and assist them in staying adherent. With so many medication options available today, the need for clinician involvement in medication adherence is greater than ever. 

“Overall, there are a lot more treatments now than there were 40 years ago, and the treatments really can help a lot,” Andrew Nierenberg, MD, a psychiatrist at Massachusetts General Hospital and professor of psychiatry at Harvard Medical School, said in a November 2023 webinar sponsored by the National Alliance on Mental Illness (NAMI). 

Of course, there are no guaranteed results to any intervention aimed at improving medication adherence. But success in having patients take their medications when needed begins by understanding why some are hesitant to try prescription drugs, unsure about the potential benefits, or struggling to remain on their medications. 

Many factors contribute to non-adherence 

There are many reasons why patients with a psychiatric condition might not initiate or stay on a mental health medication or medications as part of their treatment.

The NAMI website cites six common reasons:

1. “Side effects”
   
2. “Denial, embarrassment or poor understanding of mental illness”
3. “Difficulty remembering to take medications”
4. “Don’t feel the medication is working”
5. “Treatment success”
6. “Cost”

In addition to these reasons that stem from patient behavior and perceptions as well as system and structural factors (e.g., stigma and cost), clinician involvement is frequently cited for its role in whether patients begin their mental health medications and stick with them.  

When physicians don’t provide sufficient instruction about  taking a particular medication, don’t involve their patients in making decisions about their treatment, and fail to follow up, higher rates of non-adherence may result in patients with major depression, according to an article published in the Annals of General Psychiatry, which generated a checklist that can be used to help address these and other adherence-related issues (more on this below). 

Impaired reasoning skills among people with psychiatric disorders might also play a role, according to an editorial published in 2002 in the international journal Acta Psychiatrica Scandinavica. The authors note that poor insight among patients may contribute to non-adherence with prescribed medications. 

When these barriers are overcome, patients often report improvements in their condition. Four in five patients (81%) with a mood disorder reported in a NAMI survey that routine or maintenance medications were somewhat or very helpful. The survey found that nearly half (48%) of patients used a routine or maintenance medication as part of their treatment. 

Tips for helping with mental health medication adherence 

To help patients take and stay on mental health medications, multiple approaches and interventions may be required.  

“Comprehensive approaches targeting the factors that affect medication non-adherence can bring tremendous positive outcomes,” wrote the authors of the meta-analysis of studies on medication adherence in patients with major psychiatric disorders. 

Among the possible actions cited in studies and in commentary by clinicians, researchers have outlined these broad steps as likely to be effective for clinicians treating mental health patients: 

Open communication 

Clear and open communication with patients makes a difference when using medications. Patients need an understanding of treatment options, why particular medications have been recommended, and what they can expect when they take them. 

For patients who aren’t taking their medications, clinicians may share reasons other patients may stop taking medications. Developing and communicating physician priorities in a logical sequence may be another way to help ensure effective two-way communication. For example, as noted above in the Annals of General Psychiatry, the team of researchers developed a checklist designed for clinician discussions and interventions with their patients. They conducted an analysis of medication adherence findings among people with major depressive disorder, then developed a consensus among a working group of 35 psychiatrists that led to the checklist.  

It includes these sequential steps: 

1. Confirm and explain the diagnosis
2. Discuss the need for medication treatment and the patient’s expectation
   
3. Provide information on the specific medication selected with respect to the patient’s clinical features
4. Offer and explain the short-term (three to four weeks) treatment plan and explain how they will be monitored, which includes evaluation of how well the patient is tolerating the medication, the patient’s adherence, and feedback on the medication’s effectiveness
5. Provide a longer-term (or mid-term) treatment plan involving periodic evaluation of the short-term plan
6. Consider other support to help with adherence, including involvement of family members and access to additional clinicians 

Ongoing evaluation  

Once a patient begins medication, it’s critical for clinicians and patients to evaluate the effectiveness of each medication and adjust the treatment when needed. 

A meta-analysis published in the journal BMC Psychiatry showed that multiple types of interventions – involving either the patient, the clinician, the healthcare delivery system, or some combination of these – may help patients take and stay on their medications in the short run (six months or less). Careful evaluation by the clinician, based on feedback from the patient, can lead to better outcomes as patients take their prescribed therapy. 

But studies on adherence are inconclusive when psychiatric medication management is needed over longer periods of time, according to the meta-analysis. The study’s findings suggest that regardless of chosen interventions, the need for ongoing evaluation by clinicians is important. 

The best results tend to come when doctors and patients work together to evaluate medication effectiveness. Regarding patient involvement in medication choices, Dr. Nierenberg noted on the NAMI webinar how the array of medication options – especially when taking more than one drug at a time – makes patient-physician collaboration an imperative. 

“I think that when you work with the person who’s prescribing for you, it’s really important to let them know what is working and what is not working,” he said. 

For more information about similar topics, please read these articles: 

• Top 5 Reasons Patients Stop Their Mood Disorder Treatment 

•  The Value of Thinking Through a Communication Strategy with Patients 

• A Clinician/Patient Disconnect May Hamper Effective Depression Care### 

Our articles are for informational purposes only and are reviewed by our Medical Information team, which includes PharmDs, MDs, and PhDs. Do not make any changes to your current medications or dosing without consulting your healthcare provider. 

The GeneSight test must be ordered by and used only in consultation with a healthcare provider who can prescribe medications. As with all genetic tests, the GeneSight test results have limitations and do not constitute medical advice. The test results are designed to be just one part of a larger, complete patient assessment, which would include proper diagnosis and consideration of your medical history, other medications you may be taking, your family history, and other factors. 

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