When No is the Answer: Examining Therapeutic Non-Compliance

01/21/2014

There is a lot that is frustrating about working in healthcare. There are the usual culprits – low reimbursement rates, no-shows, scheduling difficulties – but one of the most ubiquitous problems is non-compliance, the refusal to follow the treatment plan. I was just reading several articles about physician frustration with drug non-compliance for patients with chronic conditions when it struck me that this is a problem that affects mental health practitioners as well. It’s the same problem, just with a different dynamic and outcome.

One of the articles quoted former Surgeon General C. Everett Koop who said, “Drugs don’t work in people who don’t take them.” No emoticonThe same is true in counseling as well. Behavioral interventions are ineffective when people won’t use them. As I often tell people, you can lead a horse to water but you can’t make it drink! While citing that quotation makes me sound relatively unconcerned about the situation, in reality it is really quite exasperating. Sessions can quickly become annoying when you constantly ask, “Did you try the techniques we discussed last time?” and the answer is either “No” or “I tried it once and it didn’t work.”

In fact, non-compliance is such a huge issue (especially for the drug companies!) that many studies have been done on it. Researchers have concluded that there are several factors involved: forgetfulness, low levels of patient engagement, and a lack of short-term incentives. A variety of programs have been developed to try and combat these things. The latest rage involves automated hovering apps that transmit data to a treatment teams or a pill bottle cap (!!!) that will call if the user misses a medication dose. So-called “smart pills” also are coming in which tiny sensors embedded in a pill can transmit internal data to a treatment team (perhaps I have been watching too much television but I can think of lots of things that make this invention creepy and dangerous).

Drug non-compliance researchers have also initiated open physician notes to increase higher engagement and the use of monetary incentives to get people to take their pills. Big business is getting in on this with approximately 85% of large employers using incentives for health behavior in some form in 2013.

So, physicians have studied this problem and taken steps to correct it. All that is great and I am certainly in support of people being more compliant with their physical health but I have yet to notice the same attention being given to mental health. There are a number of tried and true behavioral techniques for stress reduction, decreasing anxiety and helping alleviate depression yet non-compliance with these interventions does not appear to be studied in great detail. Moreover, I haven’t observed big business taking steps to increase mental health incentives.

Part of the problem is that pharmaceutical interventions seem like easier options for treatment because behavioral interventions take time and effort. Plus, medicinal interventions also have been pushed a lot harder than behavioral ones. However, I think the largest issue with mental health non-compliance is that the stigma surrounding mental illness keeps too many people in the dark about what can be done. For example, lots of people know about diabetes, so if a diabetic’s blood sugar is low, someone might know to suggest drinking some fruit juice to compensate. Yet the same type of scenario rarely happens for an anxiety attack or excessive negative cognitions.

If prevention of mental illness and promotion of mental health was more of a societal goal, non-compliance wouldn’t be as big of an issue as it is now. Students in elementary schools would learn empathy and how to relax. Middle school and high school students would take classes on healthy relationship skills. Big businesses would include breathing techniques and thought substitution as part of their orientations while also making sure that programs that foster mental health were in place. And the general public would know how to recognize and manage an anxiety attack.

While I’m being a bit playful (but just a bit), the truth is that these things would go a long way toward helping alleviate therapeutic non-compliance. If people were reminded by others to do their breathing and relaxation exercises, then they wouldn’t forget. If mental health issues weren’t still so secretive, people would be more engaged in their treatment. And if learning how to behaviorally manage their health made people more successful both at home and at work (i.e., if they had incentives), then all bases would be covered.

Until that happens though, I guess I’m going to have to continue handing out written treatment plans, encouraging loved ones to help my patient remember, and figuring out individual reasons for non-compliance. But could someone else get on the societal valuing of mental health thing? I really would appreciate it!

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