Concordance

Past approaches to improving compliance have focused on professional and practical issues, but patient surveys suggest that the majority of reasons for non-collection of prescriptions relate to conscious patient decisions. Research shows that beliefs about medicines are the strongest predictor of compliance; the large majority of service users want to be more involved in decisions about treatment. Therefore, addressing service users beliefs and views is key to improving both compliance and patient satisfaction. But analyses of doctor-patient communications suggest that these beliefs and views are often not explored in prescribing consultations.

Concordance is a process of prescribing and medicine taking based on partnership and has three essential elements:

1. Service have enough knowledge to participate as partners
2. Prescribing consultations involve patients as partners
3. Service Users are supported in taking medicines

Moving from compliance to concordance requires a culture change; the implementation of concordance implies five long term goals:

1. Health professionals view prescribing as something they do jointly with patients
2. Patients expect to be involved in decisions about their medicines
3. Resources are available to help patients with different needs to understand their medicines
4. Different health professionals work in partnership with each other and with patients
5. Services operate to support patients taking medicines

Poor compliance with neuroleptics has been cited as an important cause of continuing illness and further hospitalisation. Noncompliance is often attributed to lack of insight (the individual does not understand or refuses to accept that she/he has an 'illness'). However:

(a) People's beliefs about their experiences are complex, and cannot be reduced to a simple dimension of insight. For example, some prefer to think of their problems in psychological terms rather than embracing the medical model.

(b) The strategies that people take in order to manage their medication are also complex. Many people are neither compliant nor non-compliant but vary their medication according to circumstances.

(c) For many people, the balance between the advantages of neuroleptic treatment (for example, a reduction in the frequency or intensity of psychotic experiences) and the disadvantages (for example, a d verse effects) is a fine one. In one study it was found that 'side effects' were as bothersome to people as their psychotic experiences.

Other studies have found that people harbour a wide variety of opinions about their drug treatment ,varying from the unequivocally positive to the unequivocally negative.

(d) People who refuse neuroleptic drugs completely do so for a variety of reasons. In one study it was found that some refused because they perceived their drug treatment to be ineffective and some because they were distressed by adverse effects. Only a few gave reasons that were judged to be psychotic.

(e) In general levels of 'noncompliance' with psychiatric medication are similar to those in the physical health field and the reasons for noncompliance are also similar.

For these reasons it is wrong to assume that it is always rational to comply with neuroleptic treatment. Any constructive approach towards ensuring that people receive optimum medical treatment must take into account people's views on and personal experience of their drug treatment.