Targeting Non-Compliance in Patients with Psychosis
Brendan T. Carroll, MD
Teaching Objectives
1. To identify factors associated with non-compliance in patients with schizophrenia and other neuropsychiatric illnesses.
2. To evaluate the different variables in case studies and legal cases: Steele v. Hamilton Cty. Community Mental Health Bd.(2000), Ohio Supreme Court, and Charles T. Sell v. United States (2003), US Supreme Court.
3. To compare the clinician focused strategies to identify and enhance compliance.
|
Case 3: 52 yo WM with multiple hospitalizations, develops fibrosis at injection sites.
* Uncomfortable side effects. Specifically, pain on injection and akisthesia.
* Pleasant hallucinations or delusions – autoerotic choking.
* Alcohol or substance abuse.
* Lack of medication /education – family supportive.
* High negative expressed emotions (EE) - frequent fights in group home.
* Popcorn sign – multiple popping sounds when room is vacuumed.
Was placed on Zyprexa Zydis 10 mg qpm + oral Haldol and has not needed to get back on shots.
|
Case Series
Case 1: 54 year old WM who was found to have a clozapine level of Zero.
* Few or no symptoms.
* Uncomfortable side effects * complains of sedation.
* Pleasant hallucinations or delusions * believes he is a great musician .
* Alcohol or substance abuse * tries to score Artane.
* Lack of medication /education * picks and chooses his meds from group home sponsor
* Complex regimens * did not like the blood draws with clozapine
Placed on Prolixin dec. and Zyprexa Zydis 10 mg qhs and doing well, but still wants *Artane.
|
Case 4: 72 yo WM in shot clinic, requested to stop Prolixin dec.
* Uncomfortable side effects. Specifically, EPS.
* Pleasant hallucinations or delusions.
* Lack of medication /education – does not believe that he needs APs
* High negative expressed emotions (EE).
Placebo Risperdol M-Tab, failed to dissolve after several minutes. Will attempt trial of Zyprexa Zydis and monitor for compliance.
|
Case 2: 36 yo WM with multiple hospitalizations, some for setting his bed on fire.
* Poor Insight – does not think that he is ill.
* Uncomfortable side effects. Specifically, sedation on clozapine.
* Pleasant hallucinations or delusions – seems preoccupied in the interview
* Alcohol or substance abuse – by history
* Lack of medication /education – seems not to learn from several sessions
* Popcorn sign – multiple popping sounds when room is vacuumed.
Was placed on Haldol dec. when it was learned he would return to Cols Clinic. Never returned to any clinic for blood draws.
|
References
1. Oehl M, Hummer M, Fleishhacker WW: Compliance with Antipsychotic Treatment. Acta Psychiatry Scand Suppl 102: 83-86, 2000
2. Lacro et al: Prevalence of and Risk Factors for Medication Nonadherence in Patients with Schizophrenia. A Comprehensive Review of Recent Literature. J Clin Psych 63:892-909, 2002
3. Steele v. Hamilton Cty. Community Mental Health Bd.(2000), Ohio Supreme Court (search on www.FindLaw.com) “Forced medication does not require dangerousness”
4. Charles T. Sell v. United States (2003), US Supreme Court. “Antipsychotics can be given to restore competency in the absence of dangerousness where the state has a compelling interest”.
5. Dr. John Kennedy of Summit Behavioral Health uses the following guidelines for Zydis : Court-ordered admission, Lack of Insight, H/O Non-compliance, Positive Haney Sign+ (a tendency to hesitate or bargain regarding meds), and the Need for the Court Order to Medicate. Patient may transition to oral Olanzapine if cooperative and demonstrating more compliance by 30 to 60 days. Usually they are competent to stand trial.
CME-type Questions for self - assessment:
Compliance is favorably influenced by each of the following except:
A) Insight
B) Therapeutic alliance
C) Positive reinforcement
D) Dysphoria from Standard Antipsychotics
Answer: D
The risk of non-compliance is correctly estimated by clinicians:
A) True
B) False
Answer: B
Non-compliance is most likely with which medication:
A) Quetiapine
B) Loxitane
C) Risperidone
D) Ziprasidone
Answer: B
A supervised living arrangement will:
A) Reduce compliance
B) Allow for supervision of medication compliance
C) Be less effective than monthly outpatient visits
D) Will worsen pre-existing substance abuse
Answer: B
|
