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Treatment Adherence

Jon G. Allen, PhD - Senior staff psychologist at The Menninger Clinic; Helen Malsin Palley - Chair in Mental Health Research and professor of psychiatry in the Menninger Department of Psychiatry and Behavioral Sciences at the Baylor College of Medicine.

 

Many patients who seek treatment at The Menninger Clinic feel stuck. They may have struggled for years, or even for most of their lifetime, with serious psychiatric disorders. Many have had extensive treatment; yet they come to a point where they feel stuck in treatment—they need something more and something different. Accordingly, we clinicians at The Menninger Clinic aspire to help patients become unstuck, that is, to move forward in treatment. Yet we recognize that a several-week inpatient stay—no matter how long it may seem to the hospitalized person—is a relatively brief episode in a longer course of treatment that will extend beyond the hospital. In the long run, recovery and wellness will hinge on treatment adherence—finding effective treatment and sticking with it.

 

Treatment adherence has become a central concern in psychiatry, given the chronic and recurrent nature of serious mental illnesses. In fact, failure to obtain adequate treatment accounts for a significant portion of the chronic and recurrent course of psychiatric disorders. Notoriously, for example, patients who suffer from major depression take antidepressant medication for a relatively brief period and feel somewhat better; they don’t refill the prescription, and they stop taking the medication; then they are at high risk for relapse. Similarly, many patients drop out of psychotherapy prematurely—or fail to seek it when they need it. Twelve-step programs for addictions, Alcoholics Anonymous most notably, are highly effective—if persons struggling with alcoholism or other addictions go to the meetings regularly.

 

How might a several-week inpatient stay help patients become unstuck such that they are able to make better use of treatment after discharge from the hospital? First, hospitalization provides respite from unmanageable environmental stress. Second, intensive treatment can provide relief from crippling symptoms such as anxiety, depression, and addictive behavior. Third, a structured routine of activity can lead to an improvement in functioning. Fourth, many persons who seek treatment have felt alone and demoralized; being with peers who understand their plight provides a sense of belonging, counters painful alienation, and instills hope.

 

Typically, patients who enter the hospital feel stressed out. They have been struggling hard to stay afloat in the face of life pressures and impaired functioning associated with their psychiatric symptoms. For example, a person might feel anxious and depressed and be hampered by insomnia and fatigue in the face of job pressures and marital conflict. Insidiously, he or she consumes increasingly high levels of alcohol to relieve the tension. The increased alcohol consumption only exacerbates the marital stress, contributes to worse insomnia and depression, and further erodes job performance. Floundering in the midst of such turmoil, it is impossible for the person to get a grip.

 

The combination of respite from external stress along with improved functioning and morale put the patient in a new position: perhaps for the first time in a long time, the person is able to take stock of his or her situation, to understand how the problems have unfolded, and to begin working on solutions. At The Menninger Clinic, we promote greater self-awareness along with an enhanced sense of agency, that is, taking an active role in treatment as well as a sense of personal responsibility more generally. Active engagement and persistence in treatment is the key to success, as it is in other areas of life. To get an education, you must go to school, attend class, do the work, and continue learning after graduation. Benefiting from psychiatric treatment is much the same.

 

In our view, enhanced self-awareness and a greater sense of agency will promote treatment adherence by enabling the patient to make better use of treatment, not only while at The Menninger Clinic but also—more importantly—after discharge. Agency is central to actively learning about one’s illness and to discovering what form of treatment is most likely to be helpful. At The Clinic, patients learn by doing, that is, by participating actively in treatment to find out what works best for them. From the standpoint of treatment adherence, perhaps the most crucial aspect of treatment at The Clinic is discharge planning—setting up a viable plan for future care that has promise of promoting continuing recovery and wellness. Most patients leave The Clinic with a feeling of confidence in their discharge plans and with an increased sense of hope. But then comes what patients routinely identify as the hardest part of treatment: leaving the hospital and implementing the discharge plan—treatment adherence. Then agency really looms large: it’s up to you, with continued help from others.

 

Copyright © 2006 The Menninger Clinic.