Understanding and addressing adherence issues in schizophrenia: from theory to practice.

If an easy answer to the problem of medication nonadherence in schizophrenia existed, it would have already been found. Despite the magnitude of the problem, in the past decade, significant advances have been made in understanding the nature of the adherence problem in schizophrenia. Just as there is no single adherence intervention but a range of interventions that can be matched to the specific challenges of the individual patient, there is not a single theory that explains adherence and non-adherence. Rather, there are a range of theories and concepts, with their own strengths and limitations. The goal of this article is to help provide a crosswalk from some of the emerging theories and concepts to practical clinical management approaches. To enhance understanding of this complex issue and help practitioners implement practical therapeutic interventions that encourage adherence, the following 5 theories regarding medication adherence are presented and suggestions made for applying them in clinical practice: (1) Adherence is not a clinical outcome and only matters as it interferes with outcome. (2) In schizophrenia, adherence problems are often entangled with efficacy limitations of antipsychotics. (3) Adherence can be viewed as a behavior (taking/not taking) or an attitude (prefers taking/prefers stopping). (4) When considering adherence attitudes, patient belief is always reality. (5) Adherence behavior changes and fluctuates over time and should be considered as part of the illness in the context of the long-term trajectory of desired clinical outcomes such as recovery.