Physicians’ awareness of potential nonadherence of their patients was rather low when they were generally asked for reasons for hospital admission but rose when directly asked about potential nonadherence. Psychiatrists implemented a plethora of interventions that in many cases merely constituted intensive talks, not structured interventions. Of the four core interventions examined in our survey, the implementation rates were surprisingly high for antipsychotic depot prescription (>30%) and psychoeducation of patients but low for the arrangement of a follow-up visit and psychoeducation for relatives.
Patients with poor previous adherence (according to physicians’ estimates) received more adherence measures. In addition, patients with involuntary admission were more likely to receive depot medication, and psychoeducation was more often implemented for younger patients and for patients at university hospitals.
Implementation of adherence-enhancing measures
Physicians reported implementing a variety of measures to improve their patients’ adherence. The most frequently taken action was talking to the patients. Because physicians did not specify any of the techniques they used, we can only speculate as to what these talks addressed and how they were undertaken. Communication generally is a good thing (
12), but specific techniques, approaches, and content might be required to convey information, motivation, and support (
13). Whether or not the physicians in our study had specific communication skills training is questionable because only five of them named a specific approach (shared decision making).
Although depot medication has been shown to be superior to oral treatment (
9), psychiatrists have been reticent about using it (
14). The proportion of our sample receiving depot treatment (32%) was surprisingly high (
15) and may indicate a very positive view of German hospital psychiatrists toward this treatment option. In our sample, circumstances indicating an “obvious necessity” for receiving depot medication—specifically, a patient with proven nonadherence and involuntary hospitalization—served as a potent facilitator, whereas supposed adherence or nonavailability of a depot-appropriate compound (clozapine, for example) and patients’ refusal served as barriers. We could not determine whether patients indeed refused treatment or whether physicians anticipated or assumed refusal without really communicating about adherence issues. Nevertheless, patients’ refusal may be a result of suboptimal communication, which could be overcome by enhanced communication strategies. Nondirective approaches, such as shared decision making (
16) or motivational interviewing (
17), may be helpful strategies in avoiding refusal.
Psychoeducation for patients is especially popular in Germany (
18) and is seen as an effective way to improve patients’ adherence. Therefore, it is not surprising that many patients received this intervention. Nevertheless, there are groups of patients who still do not benefit from psychoeducation, especially those being admitted to closed wards of state hospitals. In view of promising results of family interventions (
19), the low implementation rate of psychoeducation for patients’ family members is disappointing. We must also note that a considerable minority of patients do not have relatives or do not have a connection with them.
For both psychoeducational approaches, variables concerning patients’ setting and resources seem to play an important role. If patients were in university hospitals, psychoeducation was more likely to be used. In addition, psychoeducation is, for whatever reason, only seldom offered to patients on closed wards.
Finally, many psychosocial measures were implemented (including day treatment centers, legal guardianship, and intensified outpatient care) that may in fact enhance adherence. Evidence for the effectiveness of these interventions is limited because research in this area very much depends on health care system issues.
Nevertheless, the fact that physicians reported that the next outpatient visit was arranged for only 18% of the patients cannot be explained by a lack of scientific evidence but suggests suboptimal discharge planning. The most frequently cited barrier to an arrangement of the next outpatient visit was the lack of an exact discharge date. Thus the physicians in our sample obviously did not schedule discharge planning for their patients but rather practiced a kind of “sudden discharge” to free up beds for new, emergency admissions. Because patients who are linked to outpatient treatment clearly have higher rates of treatment adherence (
20), physicians risk higher relapse rates among their patients because of insufficient discharge planning.
Are the findings generalizable to other health systems?
Physicians’ underestimation of (the impact of) their patients’ nonadherence has been shown in various health care contexts (
2) and therefore may be generalizable to other health care systems. Physicians’ responses toward suspected nonadherence obviously may be influenced by the resources available in different health care systems.
Depot treatment for schizophrenia is available worldwide, although implementation rates vary considerably (
15). For this measure, our data may be only partly generalizable to other health care systems because setting variables may vary, including cost containment and availability of medical staff to give the injections (
15). However, the most frequently cited reasons for not using depot medication in our study (such as assumed good adherence and patients’ refusal) are well known from other studies (
15).
We are aware that psychoeducation is viewed less optimistically by mental health professionals in the United States and elsewhere compared with Germany (
21). However, psychoeducation may be seen as a proxy for any psychosocial intervention that is viewed favorably in the respective context (here, German psychiatry) but consumes time and resources when thoroughly implemented. In addition, the positive effect of these interventions pays off only in the long run.
Finally, arrangement of a follow-up appointment is generally seen as very important to guarantee an uninterrupted flow of services (
22). It may serve as a proxy for any organizational factor that could be done easily and does not necessarily consume additional resources.
Opportunities to improve management of nonadherence
The main barriers to a more intensive response to patient nonadherence are physicians’ underestimation of the “adherence problem,” organizational deficits (such as no proper discharge planning), and limited resources (such as staff shortages). In addition one might speculate whether or not psychiatrists address the issue of adherence properly when talking to their patients in order to avoid patients’ refusal of adherence interventions.
In order to reduce unawareness of adherence problems, a structured appraisal of the patient’s adherence (including objective measures such as plasma levels) might help physicians to become more aware of this problem.
Physicians’ citation of limited resources may reflect true staff shortages or be an excuse for suboptimal organization. If, for example, psychoeducational groups take place at a specialized ward in one hospital and not in the acute ward, then sessions might be organized in such a way that acute ward patients could visit the group session on the neighboring ward. In addition, moderators of psychoeducational groups may be recruited from different professional groups (including nurses) or be performed by specially trained peers to compensate for potential shortages of physicians or psychologists (
23,
24).
All three barriers may be addressed and overcome within so-called integrated care programs (
25–
28) that in many cases specifically address adherence issues, foster the communication between inpatient and outpatient treatment, facilitate the implementation of adherence measures, and encourage involvement of patients in clinical decisions.