STUDIES SHOW THAT PATIENTS with behavioral health conditions are less apt to be compliant with medications than other patients, but many of their reasons for non-compliance are equally applicable to all drugs.

MHE EXECUTIVE VIEW

In an article, "Drug Therapy: Adherence to Medication," in the New England Journal of Medicine, half of patients with major depression, for whom antidepressants have been prescribed, will not be taking the drugs three months after initiation of therapy. When adherence to drugs for physical diagnoses is compared with that for people with psychoses and depression, the mean rates are 76% compliance, 58% and 65%, respectively.

"When a patient is non-compliant with one medication, he or she is bound to be non-compliant with all of them," says Rhonda Robinson Beale, MD, chief medical office, OptumHealth Behavioral Solutions, based in Cypress, Calif.

Lawrence J. Nardozzi, MD, chief medical officer, behavioral health, Magellan Health Services in Avon, Conn., says that in his experience, patients with behavioral health problems are no more inclined than others to be non-compliant. "Compliance depends on understanding the use of a medication and the importance of staying on it, as well as communication between doctors and patients about side effects and effectiveness," he says. "If patients find value in a treatment, they will comply."

DRIVING COMPLIANCE

Many experts agree that non-compliance of medications by patients with behavioral health problems is affected by lack of immediate results; costs; problems filling a prescription; the stigma attached to drugs for mental health conditions; and by a lack of understanding about the nature of the illness and the drug's side effects and effectiveness.

"Medication adherence is driven by two significant factors," says George Van Antwerp, vice president, outsourcing and professional services, Silverlink Communications Inc., a Boston-based company providing outreach to patients in their homes. "First is the patients' view of prescriptions and belief in their ability to improve their health. Second, there are the experiential impacts of the regimen, such as realizing an immediate gain in health, the complexity of the therapy, the magnitude of the side effects and the cost to the patient.

"Since diagnosis of behavioral health conditions is not an exact science and the use of the medications can affect an individual's behavior in different ways, several new complexities join the adherence discussion," Van Antwerp continues. "Some patients with depression who have been prescribed an antidepressant, for example, may be thinking they should be feeling better very quickly. This is the kind of situation in which a patient can be reminded that it often takes a few weeks for the medication to begin working."

Once patients begin to feel better, they may believe it's appropriate to stop the medication.

"However, symptoms will likely return, which for some may lead to a situation in which response to medication the next time is less robust," adds John Emerick, MD, medical director, Companion Benefit Alternatives, a managed behavioral healthcare organization and subsidiary of BlueCross BlueShield of South Carolina in Columbia. "As many as 50% of individuals with depression may relapse within two years and in 15 years, the number rises to 85%. Patients with depression often have cognitive problems so regrettably, they may not think they need medications because their judgment is often impaired."

A COLLABORATIVE APPROACH

Depression is often associated with physical conditions, which may cause a higher degree of non-adherence with medications for chronic conditions. The correlation has driven some healthcare organizations to develop integrated medical and behavioral care programs.

Life Solutions is an integrated medical-behavioral care program developed by OptumHealth for patients with chronic medical conditions who are also identified with behavioral issues through pharmacy and medical claims data, health risk assessments, predictive modeling and tools. The Patient Health Questionnaire (PHQ-9), a patient-self-report depression assessment, serves as a primary tool. Care is coordinated through primary care physicians, nurses, mental health professionals and social workers.

Dr. Robinson Beale estimates that patients with medical conditions can cost as much as double if they also have depression.