Poor adherence to treatments for chronic diseases, including depression and other mental disorders, is "a worldwide problem of striking magnitude" that continues to grow as the burden of disease grows and that disproportionately affects the poor, according to a 200-page report by the World Health Organization (WHO). The report, Adherence to Long-Term Therapies: Evidence for Action, summarizes existing knowledge about the many factors that contribute to poor adherence and reviews literature on methods of measuring and improving adherence.
The diseases and conditions reviewed in the report—asthma, cancer, depression, diabetes, epilepsy, HIV-AIDS, hypertension, nicotine addiction, and tuberculosis—represented 54 percent of the global burden of disease in 2001 and will exceed 65 percent by 2020. Treatment adherence among patients with these diseases averages only about 50 percent in developed countries, with much lower rates in poorer nations. Thus interventions aimed at improving adherence would produce a significant positive return on investment through primary prevention of risk factors and secondary prevention of adverse health outcomes, the report notes. Increasing the effectiveness of adherence interventions is likely to have a far greater impact on health than any improvement in medical treatments, including highly promising advances in biomedical technology.
Assessment and prediction of health outcomes are bound to be inaccurate if they focus solely on the efficacy of interventions and the provision of treatment and fail to examine indicators of "health care uptake," the report notes. Interventions that address adherence can help close the gap between the clinical efficacy of interventions and their effectiveness when used in the field.
A repeated message of the report is the need to turn away from conceptualizing the problem as one of "compliance," which emphasizes patient-related factors—in effect blaming the patient for the problem—and tends to neglect other determinants. The report describes adherence as a multidimensional phenomenon that is determined by the interplay of five sets of factors. In addition to patient-related factors are social and economic factors, disease factors, therapy-related factors, and factors involving the health care team and health system. Changes in systems are a particular focus of the report, which describes important ways in which systems affect patients' behavior and capacity to adhere to their treatment. For example, systems direct the duration of outpatient appointments, set fee structures, and determine continuity of care. Providers' lack of time and financial reward for patient counseling and education seriously threaten adherence-focused interventions, as do disruptions in treatment, according to research cited in the report.
Although several interventions have been shown to improve adherence, such as education in patient self-management, pharmacy management programs, behavioral interventions, and follow-up and reminders, they tend to be used alone, which limits their effectiveness. The most effective approaches are multilevel, targeting more than one factor with more than one intervention, the report points out. It describes research on factors in the five dimensions and highlights promising areas for greater attention. In the systems dimension, practitioners must be ensured access to specific training in adherence management. Training should address three main topics: information on adherence, a clinically useful way of using information and thinking about adherence, and behavioral tools for creating and maintaining habits. Providers should understand that good adherence requires a continuous and dynamic process, and they should not assume that all patients are motivated to follow a best-practice protocol. The report cites behavioral research on the effectiveness of assessing a patient's level of readiness to follow health recommendations and matching the treatment plan to the correct level. An "adherence counseling toolkit" is urgently needed, according to the report—one that is adaptable to different socioeconomic settings and that will systematically assess a patient's adherence, suggest interventions, and support patient follow-up.
The chapter on depression treatment emphasizes that the clinical effectiveness of drug therapies is limited not just by adherence problems but also by underdiagnosis and suboptimal treatment by physicians in primary care, where most depressed patients are treated. The chapter summarizes research conducted in the past decade on methods of measuring adherence to drug treatments and predictors of adherence, such as frequency of dosing, education, and drug type. Studies show that if the problem of poor adherence is not addressed, 30 to 40 percent of depressed patients will discontinue their medication after 12 weeks, regardless of side effects or perceived benefits. In addition to patient education and counseling, interventions shown to be effective include individual and family psychotherapy, patient-tailored prescriptions and treatment plans, multidisciplinary care, adherence training for professionals, telephone consultation and follow-up, and continuous monitoring and reassessment of treatment. Little evidence was found that treatment with the newer antidepressants leads to better rates of adherence.
One of the five appendixes, "Behavioural Mechanisms Explaining Adherence: What Every Professional Should Know," provides a useful summary of basic behavioral principles and models of behavioral change that are relevant to adherence. Another appendix presents statements by representatives of key stakeholder groups—patients, primary care physicians, drug industry leaders, nurses, pharmacists, and psychologists—about the roles of these groups in improving adherence.
Adherence to Long-Term Therapies: Evidence for Action can be ordered on the WHO Web site (http://bookorders.who.int) for $27.
Sweeping changes to the federal Medicaid program proposed by the Bush Administration "could have immediate and devastating consequences for Medicaid recipients with mental illnesses," according to a new report by the Bazelon Center for Mental Health Law. The proposed changes could also increase overall state, local, and federal spending.
In its report, Making the Right Choices: Reforming Medicaid to Improve Outcomes for People Who Need Mental Health Care, the national advocacy group documents Medicaid's significance as the single most important source of revenue for state mental health systems. About 10 percent of the 37 million people with low incomes who receive Medicaid use mental health services—16 percent of enrolled adults and 8 percent of children under age 21.
The report analyzes the impact on people with mental disabilities of several approaches that have been proposed for reducing federal Medicaid expenditures. One approach would fundamentally alter the structure of Medicaid, converting the entitlement program to a grant program with capped federal funds and thereby eliminating the federal match for state spending. Currently, states receive 57 cents from the federal government for every 43 cents they spend on a Medicaid service to a covered individual. The capped amount of resources could not increase if a state needed to expand its program. If health costs increase or more people become eligible—for example, as a result of an economic downturn and a rise in unemployment—states would be forced either to pay up to 100 percent of the cost or to deny services, the report points out.
Another proposal for reform would shift some or all covered recipients to a benefit package modeled on private insurance. However, coverage for mental health care is particularly limited in private insurance plans. The report cites experience with this model in the State Child Health Insurance Program (S-CHIP) indicating that this approach would eliminate access to many of the most effective rehabilitative services now available to adults and children with serious mental disorders and, in many cases, constrain mental health care below effective treatment levels.
One stated purpose of the proposed changes is to free up funds to cover currently uninsured people by creating a separate program for recipients enrolled in Medicaid under optional eligibility categories created by a state. The separate program would have fewer benefits and higher copayments than Medicaid. Nearly 4 million low-income adults, 4 million children, and 1.5 million people with disabilities qualify for Medicaid under the optional eligibility categories, including people with psychiatric disabilities who receive Social Security Disability Insurance. The report cites evidence that people in these categories have a greater need for mental health services than non-Medicaid populations and asserts that reducing their benefits in order to provide benefits to a larger segment of the uninsured population "is neither cost-effective nor humane."
The report describes some improvements that would assist both states and beneficiaries. One such improvement would be the creation of more flexible Medicaid service definitions, allowing states to fund integrated community-based programs that encourage recovery and facilitate redirection of funds from institutions. Medicaid could also improve eligibility criteria to cover some single adults who are now excluded, the report notes. Improved criteria would not only provide a more effective safety net for many individuals but also save states some of the dollars now spent on jails, hospitals, and services for the homeless.
Even without federal policy change, many states are already moving to cut back their Medicaid programs because of severe state budget shortfalls in the past two years, the report points out. "This is not the time to pull the financial rug of Medicaid out from under public mental health systems," the report concludes.
Making the Right Choices is available on the Bazelon Center's Web site at www.bazelon.org.
SAMHSA's eight-state antistigma campaign: The Substance Abuse and Mental Health Services Administration (SAMHSA) has launched a three-year campaign, the Elimination of Barriers Initiative (EBI), in eight states: California, Florida, Massachusetts, North Carolina, Ohio, Pennsylvania, Texas, and Wisconsin. The initiative will identify effective public education approaches to combat stigma and discrimination associated with mental illnesses. Funded with $5.4 million over three years, the initiative will hold a series of meetings in each state to reach consensus on steps that states can take to reduce stigma. Strategies developed by the EBI are expected to focus on opportunities for action in schools and businesses. More information is available on SAMHSA's Web site at www.samhsa.gov.