Compliance and Satisfaction
Subjective distress and other factors that hinder patient adherence to therapy
By Miles Dumalagan
 A patient is a doctor's customer. As such, not only is it important that patients and their families be involved in the decision-making process about their treatment; their expectations and their satisfaction also need to be met. In the psychiatric scene, patients are no longer viewed as passive recipients of treatment, but as service consumers. Their views, attitudes towards their own care, and own level of satisfaction have become increasingly important.
"We cannot ignore anymore what our patients are telling us," said psychiatrist Edgardo Tolentino of the Makati Medical Center and The Medical City in a talk before the recent annual convention of the Philippine Psychiatric Association.
"Changes in psychiatric care have focused on satisfaction as one of the results of this revolution," he said. "It is now being considered not only as an important attribute of medical care, but as an outcome in its own right particularly in chronic illnesses like schizophrenia that requires long-term treatment, and for which no real cure has been found yet."
When people talk of successful management, there is a need to explore a whole spectrum to define "success." The intervention cannot be solely pharmacologic. There have to be psychosocial support, individual and family psycho education, and rehabilitative efforts.
Tolentino noted that newer antipsychotics have improved much in terms of tolerability. But how it translates to improvement in patient satisfaction especially in terms of "value for money" also needs to be considered. Are patients getting their money's worth; in other words, are they receiving the treatment that they should get from their doctors?
Literature reveals an enormous discrepancy between how the patients view the services given to them by physicians, and vice versa. Moreover, meeting patient expectations is associated with higher rates of patient satisfaction, although some doctors fail to address this issue. What matters is usually related more to the subjective distress of the patients rather than to the actual severity of the side effects of their medication.
Subjective distress is more than what manifests externally. It is influenced by many factors that may not even directly relate to the pharmacological effects of the drugs given to them. However, these are not quantitative measures of such state.
Tolentino admits that most clinicians are trained to evaluate the side effects of drugs rather than being taught to ask the patient, "how do you feel?" and "are you distressed by the side effects?"
The determinants of patient feelings of subjective distress vary. For one, positive symptoms may influence how side effects are perceived, sometimes wrongly. Explained Tolentino: "For example, a patient having hallucination may actually believe that he has been transformed into a robot as a translation of the robotic side effects of his medication. On the other hand, negative symptoms may dull the patient's perceptions and may cause indifference. This state may be so dangerous that in some studies schizophrenic patients on antipsychotics undergoing angina were not able to feel the chest pains, and this may lead to serious medical complications."
The subjective responses to medication are partly shaped by the level of concern shown by physicians regarding the outcome of treatment, and whether the patient was forewarned about any distressing side effects.
Tolentino acknowledged that the relationship between psychological factors and subjective distress may be seen in how the patient reacts to the medication, but it also depends on a variety of factors beyond the expected central nervous system consequences. "For example, if a patient anticipates that he will actually look like a zombie, more often than not he will not want to take those drugs," he said.
Treatment Goals
Tolentino defines compliance as the degree to which the desired treatment goals are achieved. It is not a singular but a continuous act that encompasses the whole treatment or management plan.
To make this possible, communication between the patient and the physician is vital. Tolentino said this has been borne out in some local studies that cite a doctor's communications skills as one of the things that encourages the patient to comply with medication and keep seeing his or her doctor.
A doctor must be able to communicate clearly to the patient what medicine is to be taken and at what dose, how it is to be taken, and when it is to be taken.
Tolentino said the following are important factors that help predict patient compliance:
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accessibility, effectiveness, and consistency of treatment,
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treatment delivery system,
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social and demographic factors,
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age and gender.
He added that the character of the individual and his or her particular illness are also important. Studies have shown that psychotic conditions, particularly schizophrenia, predict poor treatment adherence. Personality factors, intelligence level, and lack of support may further impair treatment compliance.
Tolentino noted that noncompliance in long-term antipsychotic therapy is seen in up to 48 per cent of patients in the first year. It goes up to 74 percent in the first two years.
Affordability of medication also plays a role in this regard.
Cognitive impairment or forgetfulness is too simplistic an explanation as to why patients stop taking medication. Noncompliance appears to be multifactorial. The patients' belief about their illness and their experience of side effects are highly influential according to most studies.
Tolentino said a paradigm by which we could understand patient compliance is anchored on the health belief model. This model indicates the extent to which the patient will comply with the treatment, which results from the patient's ability to weigh the benefits and cost of treatment. The perceived cost is not just monetary, but includes side effects. It is not about the clinician; it is how the patients actually perceive the benefits and cost to them.
The model explains that there is no single subjective factor that could totally account for compliance.
Tolentino pointed out that compliance would ultimately be determined by the sum of all subjective factors. Some will support compliance, others will promote noncompliance. Thus, the perceived benefits of medication play a role in compliance behavior, the same way as subjective distress.
Tolerability
Life satisfaction for schizophrenic patients is more of a cumulative index of the impact of schizophrenia. For most patients, many facets of their lives such as their independence, being able to care for themselves, self-esteem, and overall quality of life are gradually eroded.
Drug therapy in schizophrenia is designed to ease psychotic symptoms, decrease relapse liability, maintain clinical stability, and possibly, prevent long-term deterioration. Patients may feel dissatisfied with their treatment if the drug does not considerably ease their symptoms and their personal distress. On the other hand, if the adverse effects become troublesome, they can sometimes overshadow the benefits of treatment.
Drug tolerability has a direct impact on patient adherence, which in turn is a major factor in relapse prevention and successful outcomes. Dosing is also important because without the right dosing, proper efficacy will never be achieved.
In a recent study on the quality of life of patients with schizophrenia, severe symptoms and side effects associated with antipsychotic drugs emerged as critical predictors of patient satisfaction. Subjective distress, therefore, remains a moving target affected by social expectations, knowledge, and alternative choices.
The newer antipsychotics appear to repair at least partially the cognitive dysfunction in schizophrenia, and enhance clinical outcomes by improving attention, memory, and executive skills. Each atypical antipsychotic has its own advantages. The different agents seem to have different effects on various cognitive domains.
For example, Tolentino said clozapine would improve attention, verbal fluency, and some executive functions but not working verbal or spatial memory. On the other hand, quetiapine would have its effects mainly on executive functions important for decision making, working memory, attention, and verbal fluency.
Enhancing Morale
"We need a rational selection of atypicals. Clinicians should customize treatment to accommodate patient susceptibilities," said Tolentino.
Summing up, Tolentino emphasized that clinicians should view patient morale besides mortality and morbidity. Said Tolentino: "Morale is enhanced when management is tailor-made to the needs of individual patients mindful of their totality. Raising morale and achieving patient satisfaction constitute only the beginning and not an end point in the long, and at times disconcerting, battle with schizophrenia. Failure to attain patient satisfaction in the first place, and complacency in maintaining satisfaction thereafter, could cost time, money, joy, or even life itself."
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