Patients with psychiatric disorders have high rates of medication nonadherence. Though there are many factors that contribute to medication nonadherence, lack of patient understanding about how to manage medication-related problems when they occur is associated with medication discontinuation. This article describes the importance of teaching patients to solve medication-related problems and discusses the scientific evaluation of such a practice.

Patients with psychiatric disorders have high rates of nonadherence or discontinuation of medication, which range from 34% within 10 days1 to 74% within 18 months.2 Poor adherence to psychiatric medications increases a patient's risk of relapse, hospitalizations, emergency room visits, crime (including victimization), substance abuse, incarceration, suicide, and an overall poorer quality of life.3 These negative consequences affect not only the individual patient but society as a whole.

The reasons why patients are nonadherent to medications are multifactorial and include considerations that are patient-related, medication-related, social, environmental, and psychological.3,4 Patient-related factors such as continued symptoms, substance abuse, and cognitive deficits can result in difficulty remembering to take medications on a regular basis. Adverse effects, difficult regimens (e.g., multiple doses throughout the day) and lack of a daily routine are medication-related issues psychiatric patients commonly face. Social and environmental factors can also play a contributory role in medication nonadherence. Patients may lack a strong relationship with providers, transportation to and from appointments, or adequate financial resources to pay for their appointments or medication. Furthermore, their coordination of care may be poor and require frequent trips to physicians and pharmacies. Due to decreased public mental health funding, case management and other services that provide social support may no longer be available to patients. Finally, persons with mental illness may feel stigmatized by taking psychiatric medications. These patients often have poor insight into their disease, or anosognosia, as well as negative beliefs and attitudes regarding medication. Negative attitudes toward medication have not only been associated with nonadherence,5 but also with poorer outcomes such as increased likelihood of relapsing within the first year after a hospital discharge.6 

Psychoeducation alone does not appear to be effective in increasing rates of medication adherence.7 However, when techniques that result in changes in behavior, skills, attitudes, and feelings are incorporated, this may bring about not only greater adherence to medication8 but also decreased hospitalization rates and improved social functioning.9 Therefore, it is important for patients to learn how to handle medication-related problems appropriately and for the provider to assist the patient in developing problem-solving skills in this area.

The University of Arizona Medical Center-South Campus in Tucson, Arizona is an academic medical center with 62 acute adult and geriatric inpatient psychiatric beds. Patients are admitted voluntarily, by petition, or by court order due to nonadherence to treatment. The most common diagnoses for the patients are schizophrenia and mood disorders (e.g., bipolar disorder, depressive disorders). Additionally, patients often have comorbidities such as anxiety disorders, substance use-related disorders, and medical conditions such as diabetes, hypertension, and asthma. Many of the patients admitted are classified as having a serious mental illness (SMI) or would qualify for this designation if evaluated.

A psychiatric pharmacist on the adult units provides patient medication group meetings weekly for 30–60 minutes. Pharmacy residents and pharmacy students assist in co-leading the groups. The goal of these groups is to teach effective problem-solving skills regarding medication-related problems found to commonly affect adherence. The main teaching objectives include adverse side effects and how to handle them appropriately, the importance of adherence, techniques for remembering to take medication, and improving communication with providers. Other topics identified as medication therapy management needs for individual patients prior to the group are also covered. Examples of these topics include: concurrent use of prescription medications and illegal substances; use of herbal or alternative treatments; and how to pay for medications when uninsured.

Group members are asked questions to assess current problem-solving ability and discussion is held within the group to build upon existing knowledge and skills. Patients are encouraged to share techniques within the group setting that have worked for them. Building rapport with the patient through the use of reflective responses and active listening occurs throughout the group. Individual meetings with group attendees occur after the group upon patient request or when individual patient needs beyond the scope of the group are identified.

It is critical that outcomes from pharmacist-led patient medication groups be assessed to determine the value of these clinical pharmacy services. For this reason, the effect of this pharmacist-led medication group modality on psychiatric patient self-reported attitudes, knowledge, and confidence in managing their medications is being studied. Patients between the ages of 18 and 55 who voluntarily participate in the pharmacist-led medication group are offered the opportunity to complete a retrospective pre-post questionnaire. This method asks participants to respond at the end of the education group to each item twice: how they perceive themselves at present (post) and how they perceive themselves to have been (pre). This technique has been shown to limit response-shift bias due to changes in subject awareness from participation in the intervention.10,11 Additionally, demographic variables are collected that include age, gender, race or ethnicity, education level, whether this is the patient's first psychiatric hospitalization, and the presence of a patient-pharmacist relationship as an outpatient. Information on the number and duration of education groups attended is also collected.

It is hypothesized that: (1) patients will report a more positive attitude about medications after attending the pharmacist-led medication group; (2) patients will report greater knowledge about how to manage their medication after attending the group; (3) confidence in patients' ability to self-manage medications will increase after patients attend the medication group; and (4) patients who are admitted to the psychiatric unit for the first time will show a greater improvement in the above variables than those patients with previous inpatient psychiatric admissions. This study will run for up to 18 weeks with a target enrollment of 100 patients.

Psychiatric pharmacists can play a major role in helping patients become more adherent to medication regimens. However, it is important to employ techniques that have been proven to be effective. Measuring outcomes directly related to the service provided is a key element in determining which group modalities provided by a pharmacist produce the best results. This information, in turn, can be used to develop specific patient medication group interventions that can be incorporated as part of a patient's individualized medication-related action plan.

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