Mental Illness and Medication Compliance

by Charles O’Meara, RN

disclaimer: this essay is not meant to replace information from your doctor or other prescriber. if you have questions or concerns about medication you are taking you should contact your doctor.

Compliance is a word you hear a lot in medication, but most especially in the field of mental health. It refers to the fact that someone has sought medical advice and listened to the prescriber’s recommendations and agreed to follow them — but doesn’t. In other words, you ignore your doctor’s advice.

One of the clearest and most common examples of non-compliance is someone who is medically overweight or obese. Their doctor tells them they have dangerously high blood pressure or type II diabetes or a bad heart or other problems and they really, really, really, really need to lose weight. Or quit smoking. Or both. And they do neither, so the inevitable happens. And the inevitable is both unpleasant and preventable.

Non-compliance with medication is the most common reason that people with mental illness are hospitalized (or re-hospitalized, or re-re-re-re-hospitalized). It’s a familiar revolving door for those of us who work with the chronically mentall ill: the patient is unstable and symptomatic when they come to us, they take medication and become stable. They are given prescriptions and appointments. They don’t have the prescriptions filled or they don’t take the medication correctly and they don’t show up for follow up appointments. They end up in the emergency room/hospital where the cycle starts yet again. I’ve worked in psychiatric nursing for twenty-three years and I’ve never seen anyone who thought they were Napoleon, but every working day I see someone who is non-compliant with medication and having compliance-related problems.

Compliance with medication for psych patients (and everyone else) doesn’t just mean taking the pills. It means taking the right dosage at the right time and doing it consistently and avoiding things that might interfere with your body’s absorption and metabolism of the medication. You simply would not believe how many times I’ve seen the following:

* the patient ‘doubles up’ on their medication without talking to their prescriber because they ‘had a bad day’

* the patient’s symptoms disappear for a long period of time so the patient concludes that they are ‘cured’ and just quit taking their meds

* they lose their meds on the bus, leave them at a friend’s house, accidentally throw them out, etc.

* they intentionally throw them out

* they read some dopey thing on a dopey internet site written by some dopey misinformed and uneducated dope that convinces them to quit taking their meds.

* they don’t like the side effects

These are the reasons or excuses I’ve heard over and over and over and over.

Try this simple experiment. Get a drinking glass. Pour a couple of spoonfuls of baking soda into it. Get another glass. Fill it about halfway with vinegar. Now look at the glasses. Is anything happening? Nope. The vinegar and the baking soda are just sitting there. Now pour the vinegar into the glass with the baking soda, then get a rag or a paper towel to clean up the mess. Wow! Something happened!

This is what happens inside your body when you take medication, more or less. Your body is going along, doing it’s thing. A pill is in a bottle, doing nothing. You put the pill in your body and now there’s a set of reactions. The pill dissolves and starts interacting with the fluids in your body.

Again, medication compliance doesn’t just mean taking the pills, it means taking them correctly. For example, if it says on the label ‘take with food,’ there’s a reason for that. If the label says ‘do not use alcohol with this medication’ there’s a reason for that. There isn’t someone at the FDA with a screwball sense of humor who makes this shit up just to mess with your mind. Medication is chemicals and food is chemicals and all the fluids in your body contain chemicals. And all these chemicals have particular properties and they interact with each other inside your body. Some chemicals get flushed out through your kidneys while others are cleared through the liver. Some medications interact with each other to produce all sorts of entertaining and spectacular side effects, such as extremely high blood pressure, extremely low blood pressure or even death. Some medications bind to certain things in your blood (albumin, for instance) and if you don’t have enough of that ‘thing’ in your blood, the medication just wanders around your bloodstream, and doesn’t do much of anything.

I don’t care how smart you think you are or how many degrees you have, unless you’ve studied anatomy and physiology, organic chemistry, pharmacology and microbiology you shouldn’t be messing around with your medication on your own. You shouldn’t share it with other people. You shouldn’t ignore labels, you shouldn’t start and stop it randomly or try anything else that seems like a good idea at the time.

And yet patients do.

Some of the reasons for this are verifiable. Maybe the medication causes weight gain, or erectile dysfunction or decreased sex drive or makes you tired. There are ways around these side effects, like lowering the dose of the medication or changing to a different but similar medication and so on. But this involves working with your prescriber and a lot of patients, sadly, would rather just say ‘fuck it’ and blame ‘the system’ or ‘big pharma’ or ‘that stupid doctor’.

When patients tell me that a medication they were given “doesn’t do anything” or “doesn’t work” I immediately start asking the obvious questions suggested by the above paragraphs: did you take every dose? did you take it as prescribed? did you forget some days? were you drinking/smoking weed/using heroin at the same time? If the patient is honest and/or I have a good rapport, I can usually find out that — lo and behold! — they are not 100% compliant. In fact they’re probably 35% complaint, at best. They will eventually say “I smoked weed a few times” (i.e., every day) or “I might’ve forgot to take it a couple of days” (i.e. for the last three weeks) or “I ran out of their meds because I gave a couple to this friend of mine.” So, to be blunt, the reason the medication didn’t work for this patient is almost certainly because they were grossly noncompliant. We in the health care field are never supposed to blame patients. On the other hand, as I often say, my patients are over 21, they are citizens in a free society and there are no laws against bad judgement, so we we can’t make them do the right thing. Which means that when it comes to not taking your medication as it was prescribed, you, my friend, have to shoulder the blame. Not me, not the doctor, not the APRN, not ‘big pharma’, not any of us. You’re holding the bottle, we told you to call us and ask questions, we gave you instructions but you did it your way.

The problem with non-compliance is that it produces nothing good and a lot that is bad and counter productive and frustrating for the prescriber, the patient’s family and the patient themselves. When chronically non-compliant patients would say to me “I hate this hospital. It sucks.” I would often reply, “I agree. This is no place anyone should want to come to. So take your medication and quit drinking and keep your appointments and don’t come back.” And for the record, there are many, many people out there who do take their medication and take it correctly and guess how many times they come back to the hospital? Often times the answer is never. Or if they do come back it’s often a short stay to address some particular issue with their medication or change their dosage.

Some of the most common reasons psychiatric patients don’t take their medication comes down to — surprise! — psychological or psychiatric reasoning. The patient is a paranoid schizophrenic who believes his neighbor is a witch and the doctor works for the army and they are both conspiring to drive him crazy. So when the doctor tells him to take his meds he thinks “Aha! I know what he’s up to! He’s under the witch’s spell. I’m not dumb enough to take these meds!” Or it might come down to a simple issue of control. The patient has all sorts of issues with authority figures for whatever reason. Dr Authority says ‘take your pills’ and the patient says (or thinks) ‘You can’t tell me what to do. You’re not my boss. You don’t know me. Fuck you.’ In hospitals where the staff is predominantly white, you have an added layer of issues with minority patients. A black patient is told to take medication by a white doctor. What have white people done for this black patient lately? A white cop shot a kid on her block. Her white landlord won’t fix the toilet in the slum where she lives. The high school she went to in the inner city isn’t remotely as nice as the high school where the doctor’s kids go. So why the fuck should this black woman listen to me or any other white person in the hospital? Take the politics out of it, I’m just saying that when it comes to complying with a doctor’s orders patients bring their own issues to the table.

Another reason for non-compliance is the internet. I’m not kidding. For every accurate piece of information on the internet there are 1,000 pieces of stupid, inaccurate, outdated and flat-out wrong pieces of information. And those are the ones that psychiatric patients find. Why? Well, they’re suspicious of the system in the first place so they gravitate toward ‘alternative’ websites that offer ‘holistic’ or ‘herbal’ or other non-medical remedies for curing symptoms. Which means they throw away our prescriptions and sleep with crystals in their ears and avoid computers because they put out ‘mind control’ signals. And that’s one step away from the medieval cure I once read about that involved having the patient stand in a pit filled with goat urine and feces.

Doctors and nurses have to learn to listen, learn to be tolerant of the patient’s reasoning and fears when it comes to medication. And let’s ‘be keeping it real’ — patients have to speak up and follow directions.

Let’s conclude with a joke that illustrates my point. Some of you might find it offensive so you’ve been warned.

A guy goes to the doctor and says ‘My ass hurts’. The doc examines him and says ‘Well you have hemmarhoids. I’ll call in a prescription to your pharmacy for suppositories. Are you OK using them?’ The patient doesn’t want to look dumb so he says, “Um, sure.”

So the patient goes to the pharmacy and picks up the prescription. He gets home and looks at the bottle and it says “Use one twice a day.” The patient gets a big glass of water and swallows the suppository. When the suppositories are all gone, he returns to the doctor with the same complaint.

The doctor examines him again and says ‘Gee I don’t understand it. You should be fine. Did you use the suppositories the way the label said to?’ And the patient replies “Yeah but I might as well have shoved ’em up my ass for all the good they did.”

from my blog ‘A Nurse Speaks’