on

Adheren
ce
in Mental Health
A Quality Improvement Project
by
Jon Webber, Jon Dimaya, Jon Onigama
and Christina Post

What is medication adherence?

ADHERENCE=
Compliance + Persistence
(Medication consumed as instructed) + (Duration of time consumed as instructed)
Non-adherence occurs when a patient does not initially fill or refill a prescription,
discontinues a medication before therapy is complete, or does not follow instructions for
dosing and schedule.
Non-adherence to antipsychotic medication has been associated with psychotic relapses,
admissions to hospitals and poorer patient outcomes including arrests & suicide (Aldrige,
2011). The cost of non-adherence (generally) in the United States alone could be up to 300
billion dollars per year (Kane, Kishimoto, and Correll, 2013).
According to the Journal of the World Psychiatric Association (2013), factors associated
with non-adherence involve characteristics of the PATIENT, the PROVIDER, the
MEDICATION, FAMILY/SUPPORT and RESOURCES.

mental illness
refuse their medications?
1. Anosognosia: The person is unaware of their illness and does not think they are sick.
2. Alcohol and/or drug abuse
3. Poor relationships with mental health provider
4. Medication side effects

Nonadherence among patients with severe mental illness has been estimated
to be between 30% and 65%.
The following non-adherence rates have been reported: 30% to 66% for major
depression, 30% to 65% for bipolar disorder, and 40% to 50% for
schizophrenia (Pharmacy Today, 2013). According to 2013 State of the States:
Adherence Report by CVS Health, the percent of Hawaii patients with
depression that refilled their prescriptions after the first fill is about 30.8%.

Methods of Medcompliance
Reinforcement: Increases behavior
Positive: giving something (money, benefits, food, privileges) to
reward behavior
Negative: taking something away (money, benefits, food,
privileges) to discourage behavior
Escape: taking noxious stimuli away (release from restraints)
Active avoidance: behavior avoids noxious stimulant (avoiding
other patients to avoid confrontation)
Punishment: Decreases behavior
Positive: Add noxious stimuli to decrease behavior
(physical/chemical restraints)
Negative: Remove stimulus following behavior (send patient to
their room)

Quality Improvement Tool

DAILY POINTS SYSTEM
Points awarded for positive behaviors including- medication compliance*,
participation in group activities, following behavior plan*, etc.
Points are used to move up in levels. Higher levels offer the patient more
privileges, such as eating in the cafeteria, supervised outings, and use of
electronic devices.
Points can also be cashed in for money that patients can use to buy snack
items not usually offered
A public board on the unit with patient names and points accumulated are visible
and keep all patients up-to-date on points earned
*More daily points are earned for medication compliance & following behavior
plan
For medication non-adherence, points are taken away, jeopardizing patients
level & privileges

Daily Points System

Currently Utilized
Kahi Mohala utilizes a daily points system integrated into their main
communication board. It includes:
Patient names, room number, legal status, and physician
Current privilege status (e.g. able to leave unit, leisure day)
Daily points (from attending activities, treatment, and taking
medications)
Daily & weekly percentage of points accumulated per patient
After speaking with both the patients and staff, patients attempt to follow
the rules of the milieu, promote good behavior, and comply to treatment
with goals to increase privileges. When privileges are taken away for
negative behavior, patients seem to want to try and get their privileges
back. This encourages them to try again.

Evidence Based Research of Positive and Negative

Reinforcement
Two groups of HIV positive methadone using patients were studied with one group being offered
incentives (voucher group) versus the comparison group (control). This study started with a 4 week
baseline evaluation for medication adherence, which was followed by the 12 week study/intervention,
followed by a 4 week follow up. Doctors, medication coaches, staff would meet with each patient within
each group twice a week to determine adherence and reward them accordingly. HIV-positive methadone
patients showed greater medication compliance (78% vs 56%) for the experimental group vs control group
when treatment vouchers were the reward (Barnett, Sorensen, Wong, Haug, & Hall, 2009)
A study was conducted on schizophrenic patients using at least one antipsychotic medication with other
medication such as SSRIs, mood stabilizers, etc for at least 2 months. These patients were tested using
various trials or tests to determine learning retention via neural and behavioral reinforcements.
Schizophrenic patients taking antipsychotics showed increased sensitivity to negative reinforcement and
trial-by-trial feedback when monetary loss was involved (Insel et al., 2014)

Evidence Based Research of Positive and

Negative Reinforcement Continued
A study of schizophrenic patients embraces medication non-compliance as a given, and
instead focuses on daily structuring and educating patients on interventions/training to deal
with short-term psychotic thrill versus long-term loss from a psychotic episode. The study
describes med non-compliance as a personal choice by patients to feel free or to feel a
rush which is dampened by medication, but through psychoeducation Brankovic describes
the tradeoff between the thrill and the consequences of a psychotic episode (Brankovic,
2015).

Collecting Data
Med-compliance data can be collected from the medical administration record
(MAR) of mental health facilities because it is documented that a patient:
complied to medical treatment
refused medical treatment
Data should be collected prior to initiating the tool.
The Daily Points Tool should be implemented for 2 months before collecting data a
2nd time to:
allow certain medications to reach therapeutic effects (SSRIs, TCAs, MAOIs)
allow time to observe med-compliance from acute and residential settings
allow time to observe outcomes of med-compliance (behavior, treatment
progress, patient insight/judgment, patient discharge status)

PLAN- what are we going to do?

Determine the unit and patient type
(residential or acute). Determine the
patients acuity level and medications
needed. Review patient hx of med
compliance/issues. Work with staff to
implement quality improvement tool.

PDS
A

DO- When and how do we do it?

With the staff, we introduce the daily point
system to the unit during a group meeting.
As patient takes medication, we assess for
cooperativeness/compliance non-verbal
signs and chart the points to be given/taken
away.

ACT- what changes are we going to

make based on our findings?
Based on research that Barnett, Sorensen, Wong,
Haug, & Hall (2009) conducted, 95% adherence is
optimal to maintain long term adherence.
Therefore we would review our data from our 2
month trial, and fine tune the tool to improve
compliance rates, and if we reach rates near 95%,
we can safely say that our tool is effective and can
be implemented in other units.

STUDY- What were the results?

Based on a 2 month trial of our QI/point
system, we project that there would be an
increase in med compliance due to an
incentive that the patient can work
towards.

References
Aldridge, M. (2011). Addressing non-adherence to antipsychotic medication: a harm reduction approach. Journal of Psychiatric and
Mental Health Nursing, 1-12.
American Pharmacists Association. (2013). Improving medication adherence in patients with severe mental illness. Pharmacy Today,
19(6), 69-80.
Barnett, P.G., Sorensen, J.L., Wong, W., Haug, N.A., Hall, S.M. (2009). Effect of incentives for medication adherence on health care use
and costs in methadone patients with hiv. Drug and Alcohol Dependence, 100(1-2), 115-121.
Brankovic, S. (2015). Boredom, dopamine, and the thrill of psychosis: psychiatry in a new key. Psychiatria Danubina, 27(2), 126-137.
CVS Health. (2013). SOS Adherence Report 2013. Retrieved from CVShealth.com: http://cvshealth.com/sites/default/files/SOSAdherence-Report-2013_Final_2.pdf
Insel, I., Reinen, J., Weber, J., Wager, T.D., Jarskog, L.F., Shohamy, D., & Smith, E.E. (2014). Antipsychotic dose modulates behavior
and neural responses to feedback during reinforcement learning in schizophrenia. Cognitive, Affective, and Behavioral Neuroscience,
14(1), 189-201.
Kane, J., Kishimoto, T., & Correll, C. (2013). Non-adherence to medication in patients with psychotic disorders: epidemiology,
contributing factors and management strategies. World Psychiatry, 12(3), 216-226.