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Book Reviews   |    
Patient Adherence to Medical Treatment Regimens: Bridging the Gap Between Behavioral Science and Biomedicine
Reviewed by Anil Godbole, M.D.
Psychiatric Services 2006; doi: 10.1176/appi.ps.57.3.427
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by Alan J. Christensen; New Haven, Connecticut, Yale University Press, 2004, 192 pages, $45

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The author of Patient Adherence to Medical Treatment Regimens: Bridging the Gap Between Behavioral Science and Biomedicine, Alan J. Christensen, is a professor of psychology in the department of internal medicine at the University of Iowa. He is decidedly an astute observer and a keen reporter on the complexities of the phenomenon of nonadherence to prescribed treatment and its devastating and far-reaching impact on individuals as well as on society as a whole. During these times, when the health care field is struggling with disproportionately rising costs of care and little to show for it in terms of better outcomes, particularly in chronic disease states or in improving commonly recognized health indices, every facet of health care is under scrutiny. Patient adherence to treatment is that crucial aspect of clinical care that links the intentions of the practitioner with the expectations and capabilities of the patient. The most remarkably effective prescribed medication is of little value if the prescription is not even filled or if the recommended dosages, frequency, and duration are not adhered to.

In this book, Christensen rightly points out that as health care practitioners, our job is not done when we have just written out a prescription. The prescription is simply a starting point for a complex dynamic that unfolds and involves the patient and his or her real world. This world includes the patient's own expectations and needs, personality traits, relationship with and trust in the practitioner, pragmatic issues of cost and convenience of the regimen, and cultural and social factors that shape the patient's perspective about illness and recovery. The patient's own past experiences, as well as those of the patient's family and friends, also play a part.

Christensen provides extensive material on research findings to substantiate the idea that the phenomenon of nonadherence is of an "epidemic" proportion and describes it as a major public health issue. He examines the phenomenon of nonadherence through the theoretical lens of psychology and behavioral science and provides data from studies that have identified various determinants of this problem, such as characteristics of the treatment regimen, cultural and social aspects of patient demographic characteristics, personality traits of the patient, family and social support, and provider characteristics. The data do not lead to a definitive answer, but they elucidate the complexities and interactive nature of all these variables.

Christensen, who has spent several years working with patients undergoing renal dialysis and other vigorous medical regimens, has developed his own theory of "person and context interactive perspective," which takes into consideration patient characteristics and treatment context. Finally, he presents critical issues of designing and evaluating interventions that will potentially improve patient adherence to treatment regimens, and has suggested areas of further research, with emphasis on the conceptual and methodologic aspects that would enhance the application of knowledge to practical interventions in common practice settings.

Although the book held my interest, it seems that the subject matter, and the book's emphasis on findings of research based on literature review and discussion of various theories that postulate the explanation of this problematic behavioral phenomenon, will be of primary interest only to specialized readers, such as scientists, researchers, and policy makers who are involved with cost and quality-of-care issues. Most of the studies mentioned in the book involve behaviors of patients with medical disorders such as hypertension, diabetes, asthma, renal disease, and behaviors associated with health promotion activities such as smoking cessation and improved diet and exercise. There is very little mention of the vagaries of mental illness and the impact of stigma that further complicate patient behaviors in the mental health field.

As for the author's suggestion in his conclusion to include nonadherence as a specific "behavioral disorder" to be included in the DSM classification, I simply do not agree. The book deals with a very common and pervasive clinical phenomenon but does not give any take-home messages or practical pointers or bullet points that practitioners can quickly adopt in their practices to positively influence patient behaviors toward adherence to recommended treatment. The real value of this book is on shedding needed light on a subject of great importance and for making a case for further collaborative research involving behavioral psychologists and medical practitioners.

Dr. Godbole is chair in the department of psychiatry of Advocate Illinois Masonic Medical Center in Chicago.




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