Improving Adherence and Compliance in Adults and Adolescents With ADHD
By William W. Dodson, MD
Published by Medscape Psychiatry & Mental Health. 2006;11(1)
Posted 05/30/2006
The author outlines three “Major Causes of Noncompliance/Nonadherence,” which are actually categories of causes, but provide, in any case, a useful structure for understanding noncompliance in ADHD:
- Poor Understanding on the Part of Patients and Physicians Alike
- Misperceptions About “Curing” ADHD
- Perceived Ambivalence of Physicians
He is unflinchingly adamant and clear about the state of the art of compliance enhancement:
Considering the low level of treatment adherence, surprisingly little information is available on interventions that improve long-term involvement in treatment. What we know has been transferred from experiences and research of other chronic conditions. The only interventions directly referable to ADHD come from specialty clinics that exchange information when clinicians get together at meetings. Only bits and pieces emerge in published sources. Consequently, despite widespread use, many of the techniques discussed here have not yet been proven to be effective in long-term follow-up studies.
He is similarly unrepentant in his pragmatism, as illustrated by these excerpts:
1. Use the vigilance effect. If a teacher gives a homework assignment but says that you never have to turn it in and that he will never check it, how many people do you suppose will actually complete the assignment? Probably very few. And yet, this is how most clinicians prescribe most medications. The leading cause of medication failure is that the medications are never taken in the first place. Simply having a staff member count pills and divide that number by the number of days since the prescription was filled can provide a good estimate of compliance rates and improve compliance directly. In our practice, the first time we checked our ADHD patients’ medications we found that roughly 6 pills were taken every 7 days. When the patients knew that we were going to check, the rate jumped to 15 pills every 7 days, a number much closer to the prescribed dose. Few other interventions have such immediate and lasting benefits.
2. It is a false economy to prescribe immediate-release formulations, because most patients simply do not take them frequently enough or consistently enough to achieve their full capabilities. The prescription of immediate-release formulations only gives a notoriously forgetful patient population another opportunity to forget.
Commentary
I have little to add other than noting that this is a paper worthy of reading by anyone interested in compliance, whether the patients carry a diagnosis of ADHD or not.