What Chronic Conditions Have the Highest Rates of Nonadherence and Why?

Mental Health Disorders

Medication nonadherence is a critical concern when treating mental health disorders, with significant implications for patient outcomes and public health. Severe mental health disorders, like schizophrenia, major depressive disorder (MDD), and bipolar disorder, are among the leading causes of disability worldwide, frequently requiring long-term medication management for successful treatment (Mathers & Loncar, 2006; National Institute of Mental Health, 2023; World Health Organization, 2023). Despite the essential role of medication in both the acute and chronic phases of these disorders, nonadherence rates remain alarmingly high (McEvoy et al., 1989; Semahegn et al., 2020). Studies indicate that nonadherence to medications affects about 56% of patients with schizophrenia, 50% of patients with MDD, and 44% of those with bipolar disorder (Kelleci & Ee, 2011; Semahegn et al., 2020; Thompson & McCabe, 2012; Trivedi et al., 2007). Furthermore, nearly 40% of patients with severe mental health conditions discontinue their medications within the first year they begin taking them, rising to 75% by the end of two years, underscoring the ongoing challenges in maintaining long-term adherence (Mental Health America, 2023).

Nonadherence to medication in patients with mental health disorders can lead to a rapid progression of symptoms of the illness, reduced effectiveness of treatment, and poor response to subsequent therapies (Zygmunt et al., 2000). Resultantly, it is crucial to consider the complex interplay of factors that contribute to medication nonadherence among patients with mental health disorders. For instance, one primary cause is poor insight into these illnesses, with many patients failing to recognize the severity of their condition and the necessity for ongoing medication (Nageotte et al., 1997; NAMI, 2020). In patients with schizophrenia, the presence of positive symptoms, such as delusions and hallucinations, can further impair judgment and adherence (Lu et al., 2021; Moritz et al., 2013). Additionally, side effects of psychotropic medications, including weight gain, drowsiness, and sexual dysfunction, can also contribute significantly to patients discontinuing their medication in an attempt to avoid these adverse effects (DiBonaventura et al., 2012; Substance Abuse and Mental Health Services Administration, 2020). The stigma surrounding mental illness can also lead to patients attempting to hide their condition and neglect their treatment (Semahegn et al., 2020). Furthermore, inadequate doctor-patient communication and a lack of trust in healthcare providers can further diminish adherence, as patients may not fully understand their treatment plan or feel adequately supported in their healthcare journey (Akincigil et al., 2007; Teferra et al., 2013; Substance Abuse and Mental Health Services Administration, 2020). Thus, addressing nonadherence in mental health requires a multifaceted approach that addresses these diverse and interrelated factors.?

HIV/Aids

Medication nonadherence is a significant barrier to effective HIV/AIDS treatment, with various factors contributing to this challenge. Among individuals living with HIV/AIDS, adherence to antiretroviral therapy (ART) is crucial for achieving viral suppression and improving long-term health outcomes (U.S. Department of Health and Human Services, 2014). However, nonadherence rates remain alarmingly high, with multiple studies reporting that about 40% of patients do not consistently adhere to their prescribed ART regimens. Nonadherence can lead to treatment failure, increased viral load, drug resistance, and higher transmission rates, highlighting the critical need for consistent ART adherence (Nachega et al., 2014). For instance, participants who were less than 80% adherent to their ART regimens were 34% more likely to visit the emergency room and 25% more likely to have a prolonged hospital admission (Abara et al., 2017).?

The U.S. Department of Health and Human Services Guide for HIV/AIDS Clinical Care (2014) lists several factors that contribute to high rates of nonadherence among HIV/AIDs patients. First, the complexity of ART regimens, which often involve multiple medications at numerous points in the day, can be overwhelming for patients to remember. Additionally, the side effects of ART, which can include nausea, diarrhea, and fatigue, often discourage patients from maintaining their regimen. Psychological factors such as depression and anxiety also play a significant role, with individuals with mental health issues less likely to adhere to their medication schedule. Social determinants particularly damage adherence, with stigma and the lack of social support exacerbating nonadherence. Patients who feel stigmatized may avoid taking their medication in public or skip doses to hide their condition from others (De los Rios et al., 2021; Treisman & Kaplin, 2002).?

Economic factors may also impact adherence. The cost of medications and lack of access to healthcare services can prevent consistent use of ART (Office of AIDS Research, 2024; U.S. Department of Health and Human Services, 2014). In low-income settings, where the burden of HIV is often highest, financial barriers are a primary reason for missed doses (Hardon et al., 2007; Office of AIDS Research, 2024). Finally, a lack of understanding about the importance of adherence and misconceptions regarding AIDS and treatment can lead patients to skip doses or stop treatment altogether, believing that intermittent adherence is sufficient (Office of AIDS Research, 2024; Simoni et al., 2006).?

Alzheimers

Nonadherence to medication for Alzheimer's disease (AD) is a multifaceted issue influenced by a wide variety of factors. The World Health Organization (2003) emphasizes that treatment adherence is a dynamic process impacted by both individual and familial variables, requiring consistent follow-up and involvement from healthcare professionals. With chronic conditions, like AD, nonadherence can result from excessive or omitted medication, significantly affecting health outcomes (Osterberg & Blaschke, 2005).?

For elderly patients with AD, the primary predictor of nonadherence is cognitive impairment, exacerbated by negative beliefs about medication, poor patient-healthcare provider relationships, and low education levels (Cooper et al., 2005; Gellad et al., 2012; Munoz-Contreras et al., 2022). Additionally, functional disabilities, poor vision, and miscommunication regarding medical instructions further complicate adherence (Beckman et al., 2005; Munoz-Contreras et al., 2022). Psychological morbidity, such as depression and anxiety, is also theorized to negatively impact adherence, although the literature is not unanimous on this association (Burke et al., 2019).?

Research also highlights the importance of social support and family involvement in medication adherence. Family supervision is crucial as it helps manage a consistent medication regimen, preventing forgetfulness and ensuring adherence (Munoz-Contreras et al., 2022; While et al., 2013). Psychological factors, such as awareness of the disease and coping strategies, also play significant roles. Awareness helps patients recognize the limitations and adhere to treatment, while problem-focused coping strategies have been shown to increase adherence as well (Arlt et al., 2008). Hence, addressing these diverse factors is essential to improve medication adherence in AD patients.?

Diabetes and HyperTension?

Nonadherence to medication regimens in chronic conditions, such as diabetes and hypertension, is influenced by a multitude of factors. These two conditions often coexist, with hypertension being a common comorbidity in individuals with diabetes, which exacerbates the risk of cardiovascular complications and increases the complexity of treatment regimens (Lago et al., 2007). For diabetes, patients face challenges related to the complexity of their condition, including the necessity for multiple medications, such as high-frequency doses and the perceived complexity of this regimen, and lifestyle changes, including side effects (Chowdhury et al., 2013; Wabe et al., 2011). Additionally, psychological factors, such as depression and diabetes distress, can significantly impair a patient’s ability to adhere to their treatment plan (Gonzalez et al., 2008). Socioeconomic factors, such as low income and lack of health insurance, also play an integral role, as they can limit access to medications and health services (Piette et al., 2004).?

With hypertension, nonadherence is also multifactorial. It often results from the asymptomatic nature of the disease, leading patients to underestimate the importance of a consistent medication regimen (Burnier, 2019). Without effective patient-provider communication and patient education, this can lead to patients forgoing or never beginning medication (Krousel-Wood et al., 2005; Peimani et al., 2020). The use of multiple medications, side effects, and complex dosing schedules further complicate adherence (Kennedy & Roberts, 2013; Vrijens et al., 2012). Furthermore, comorbid conditions, including diabetes and mental health issues, exacerbate nonadherence by adding to the burden of self-managing medication (Kim et al., 2018). Hence, improving adherence to these conditions requires multifaceted approaches addressing medical, psychological, and socioeconomic factors.

References

Abara, W. E., Adekeye, O. A., Xu, J., & Rust, G. (2017). Adherence to combination antiretroviral treatment and clinical outcomes in a Medicaid sample of older HIV-infected adults. AIDS care, 29(4), 441-448. https://doi.org/10.1080/09540121.2016.1257774.?

Akincigil, A., Bowblis, J. R., Levin, C., Walkup, J. T., Jan, S., & Crystal, S. (2007). Adherence to antidepressant treatment among privately insured patients diagnosed with depression. Medical care, 45(4), 363-369. DOI: 10.1097/01.mlr.0000254574.23418.f6.?

Arlt, S., Lindner, R., R?sler, A., & von Renteln-Kruse, W. (2008). Adherence to medication in patients with dementia: predictors and strategies for improvement. Drugs & aging, 25, 1033-1047. https://doi.org/10.2165/0002512-200825120-00005.?

Beckman, A. G., Parker, M. G., & Thorslund, M. (2005). Can elderly people take their medicine?. Patient education and counseling, 59(2), 186-191. https://doi.org/10.1016/j.pec.2004.11.005.?

Burke, A. D., Goldfarb, D., Bollam, P., & Khokher, S. (2019). Diagnosing and treating depression in patients with Alzheimer’s disease. Neurology and therapy, 8(2), 325-350. https://doi.org/10.1007/s40120-019-00148-5.?

Burnier, M. (2006). Medication adherence and persistence as the cornerstone of effective antihypertensive therapy. American journal of hypertension, 19(11), 1190-1196. https://doi.org/10.1016/j.amjhyper.2006.04.006.?

Centers for Disease Control and Prevention. (2023). Pharmacy-based interventions for medication adherence. U.S. Department of Health and Human Services. https://www.cdc.gov/dhdsp/pubs/medication-adherence.htm#:~:text=Important%20Definitions,provider%2C%20or%20health%20system%20level.

Chowdhury, R., Khan, H., Heydon, E., Shroufi, A., Fahimi, S., Moore, C., ... & Franco, O. H. (2013). Adherence to cardiovascular therapy: a meta-analysis of prevalence and clinical consequences. European heart journal, 34(38), 2940-2948. https://doi.org/10.1093/eurheartj/eht295.?

Cooper, C., Carpenter, I., Katona, C., Schroll, M., Wagner, C., Fialova, D., & Livingston, G. (2005). The AdHOC study of older adults' adherence to medication in 11 countries. The American journal of geriatric psychiatry, 13(12), 1067-1076. https://doi.org/10.1097/00019442-200512000-00006.?

De Los Rios, P., Okoli, C., Castellanos, E., Allan, B., Young, B., Brough, G., Muchenje, M., Eremin, A., Corbelli, G. M., McBritton, M., Hardy, W. D., & Van de Velde, N. (2021). Physical, Emotional, and Psychosocial Challenges Associated with Daily Dosing of HIV Medications and Their Impact on Indicators of Quality of Life: Findings from the Positive Perspectives Study. AIDS and Behavior, 25(3), 961–972. https://doi.org/10.1007/s10461-020-03055-1.?

DiBonaventura, M., Gabriel, S., Dupclay, L., Gupta, S., & Kim, E. (2012). A patient perspective of the impact of medication side effects on adherence: results of a cross-sectional nationwide survey of patients with schizophrenia. BMC psychiatry, 12, 1-7. https://doi.org/10.1186/1471-244X-12-20.?

Gellad, W. F., Grenard, J. L., & Marcum, Z. A. (2011). A systematic review of barriers to medication adherence in the elderly: looking beyond cost and regimen complexity. The American journal of geriatric pharmacotherapy, 9(1), 11-2. https://doi.org/10.1016/j.amjopharm.2011.02.004.?

Gonzalez, J. S., Peyrot, M., McCarl, L. A., Collins, E. M., Serpa, L., Mimiaga, M. J., & Safren, S. A. (2008). Depression and diabetes treatment nonadherence: a meta-analysis. Diabetes care, 31(12), 2398-2403. https://doi.org/10.2337/dc08-1341.?

Hardon, A. P., Akurut, D., Comoro, C., Ekezie, C., Irunde, H. F., Gerrits, T., ... & Laing, R. (2007). Hunger, waiting time and transport costs: Time to confront challenges to ART adherence in Africa. AIDS Care, 19(5), 658-665. doi:10.1080/09540120701244943.?

Kelleci, M., & Ata, E. E. (2011). Drug compliance of patients hospitalized in the psychiatry clinic and the relationship with social support. Journal of Psychiatric Nursing, 2(3), 105-110.?