edited by William T. O'Donohue and Eric R. Levensky; New York, Sage Publications, Inc., 2006, 472 pages, $79
Dr. Petzel is an adult and geriatric psychiatrist in Hallowell, Maine, and is also affiliated with the Department of Community and Family Medicine, Dartmouth Medical School, Hanover, New Hampshire.
William O'Donohue and Eric Levensky remind us in Promoting Treatment Adherence that between 20 and 80 percent of our patients do not complete or continue the treatments we prescribe for them. Reasons for poor adherence can be astounding: one reason cited by the authors is "patients and clinicians often disagree whether a medication has been prescribed." Poor adherence is expensive. Wasted medication prescriptions for elderly patients alone cost more than $1 billion in 2007, to say nothing of the cost in human suffering.
The decision to focus on "adherence" rather than "compliance" sets a positive tone for this text. Organized in five sections with different authors for each chapter, the book presents strategies for assessment, which is surprisingly hard to do; improving adherence, with a very nice chapter on the stages of change; adherence to specific treatments, such as exercise or treatments for hypertension or HIV; and working with specific populations, including ethnic minorities and those with cognitive disorders. Most of the information did not strike me as particularly new, but there is much food for thought.
As this book notes, it is easier to change oneself than to expect others to change. It's a sad commentary that the more doctors involved in a patient's care, the more likely the patient will be to experience polypharmacy and adverse medication reactions. We can't expect patients to trust that medications are going to work if they frequently don't.
This book would be most useful for psychiatrists working in a consultation-liaison role, although the intended audience is a broader swath of health care providers. The chapters on specific illnesses give a succinct review of treatments for disorders such as asthma. The chapter on smoking cessation is excellent. Although I found the chapter on difficult patients motivating, my primary care colleagues may not have enough of a comfort level with the material to make it useful to them. I would have preferred this chapter to be aimed at primary care providers rather than at therapists, because many primary care providers feel unprepared for dealing with this patient population.
High points of the book are the chapters on motivational interviewing and on substance use treatment and the discussion of the role of fear and anxiety in nonadherence.
Some notable omissions include the use of technologies such as telehealth—which is being used with some success at VA facilities—and an expanded discussion of care management in chronic illness. The chapter on HIV lacked in-depth discussion of the impact of sexuality or substance abuse on adherence to treatment.
The chapter on diabetes management best summarized the crucial elements of care: recognize the importance of human contact as an agent of change and healing, treat depressionto improve outcomes in physical illness, and create strong links between health and mental health.
Information empowers, fear disempowers. We as physicians need to ask about adherence issues, and we need to depend more on communication than on medication.