MedicinesI have a friend who has diabetes.  When she doesn’t check her blood sugar or take her medication, people don’t say it’s because of her diabetes.  Another friend has hypertension.  When he doesn’t take his medication, people don’t say it’s because of his hypertension. But it’s a different story for my many friends and neighbors who take some form of psychotropic medication — if they don’t take their psychotropic medication, people assume the noncompliance is because of their mental illness.  Seriously?

Recently I’ve been exploring this issue of medication noncompliance and came across three articles representative of the subject. First is a very good article on MedScape titled “Medication Nonadherence: Finding Solutions to a Costly Medical Problem”,  in which author Harold Gottlieb asserts that “estimates of medication nonadherence rates typically range from 30% to 60%.” In the second, titled “The $289 Billion Cost of Medication NonCompliance and What to Do About It,” Atlantic journalist Brian Fung writes that “in some 20 percent of cases — and as many as 30 percent — prescriptions for medication are never filled. Up to 50 percent of medications aren’t taken as prescribed.”  Finally, a paper in the journal Circulation titled “Medication Compliance: Its Importance in Cardiovascular Outcomes” reports data similar the first Medscape article.

But not one of these recent, important publications explores medical nonadherence specifically in the population of people diagnosed with mental illness. This subset is largely overlooked, or largely lumped in with the rest of the population taking prescription medicines.

Traditionally, society attributes medical noncompliance in people with mental health diagnoses to lack of insight: these people (the story goes) can’t appreciate the severity of their condition and so see little reason to comply with medicines or other behavioral or medical prescriptions meant to alleviate the issue. But why isn’t this lack of insight used to explain the behaviors of my friends with diabetes or hypertension? Why is “lack of insight” used to oppress only people with diagnoses of mental illness?

We have a choice: we can either ascribe lack of insight as a cause of all medical noncompliance (irrespective of the diagnosis) , or we can ask what else might be going on for people with mental health diagnoses.  We need to point out—all of us—that the current double standard is unethical.

People who are aging, people with cardiovascular disease, and I’d bet at least a dozen donuts even people who are taking a dose pack of antibiotics miss or don’t take their medications for many reasons, most of which are completely separate from the disease itself.

Then with psychotropic medications, the effects of the medication on cognition, alertness, sleep, memory, weight, energy, pain, and other side-effects seem strong, reasonable reasons for noncompliance.  But instead of respecting the concerns of people diagnoses with mental illness, we fail to take their opinions as seriously as the word of, say, someone with hypertension.

What can you do about this?

1.       Own and challenge the double standard.

Would you expect compliance from 90% of the people who are not hospitalized for mental illness?  If a person without a diagnosis fails to follow medical advice to what would you attribute the noncompliance?  Expect those around you to recognize and challenge this double standard it and help them do so.  Anything that you believe is “because of a person’s mental illness” should be challenged.

2.       Recognize that people with diagnoses are the best authorities on how something impacts them.

The moment we decide for others why they experience something as they do is the moment at which we lose the ability to be helpful. We move into a power-over role that is at best representative of a critical parent, which can be a not-so-helpful and often re-traumatizing experience. Certainly this attitude wouldn’t be helpful for the 90% of people in public systems who have histories of childhood trauma, often including abuse and neglect. When someone says they don’t want to or can’t tolerate the effects of a medication, take them as seriously as you want your own intolerances considered.

3.       Re-read the three articles above

Though these studies don’t single out the population of people diagnosed with mental illness, due to the prevalence of mental concerns, these studies can’t help but include them.  The reality is that so many people are diagnosed, have been diagnosed in the past, or could be diagnosed that cross-sectional studies encompass the experience. Instead of blaming the easy target of lack of insight into a mental health condition for medical noncompliance, let’s look at the population of people with a mental health diagnosis just like everyone else – and maybe consider that reasons for noncompliance in this population may be the same as everyone else.

Believing that the mentally ill don’t take their medication because of their mental illnesses instead of for the same reasons others are noncompliant is stigmatizing.  There are far more ways in which we are all like than in which we are all different.

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