Commentary

Our fascination with medication compliance


 

As a forensic psychiatrist, I follow news relating to mental illness and crime. Like many of the judges and lawyers with whom I work, the media appear to have an obsession with medication compliance in those with mental illness. Being “off medications” has become a threatening term suggestive of unbridled impulsivity and violence – a term that can explain any behavior, implying that without medication, humans are routinely capable of all things without warning.

The year 2018 already has provided two stark examples of this phenomenon. During the first week of the year, two articles with the following headlines were published: “ ‘He was off his meds’: Son charged in mother’s murder1 and “A man lost his life in the subway after telling a teen off of his medication to ‘get away.’2 Those two articles describe awful events that, as the headlines suggest, are best explained by a lack of compliance with a psychotropic medication regimen.

Dr. Nicolas Badre
Dr. Nicolas Badre
“ ‘He was off his meds’: Son charged in mother’s murder” reports on a man in Worcester, Mass., who had “mental illness but had been off his medications.” Allegedly, persistent thoughts of hurting his mother eventually led to actual assault, and he hit and stabbed her to death. The article makes no attempt at providing alternative or additional explanations to the events and implies that being noncompliant is a satisfying explanation on its own.

“A man lost his life in the subway after telling a teen off of his medication to ‘get away’ ” reports on a 65-year-old man who was pushed onto New York’s subway tracks after interacting with an 18-year-old who “did not take medication that day for his mental illness.” This article provides some limited details on the state of mind of the defendant, indicating that he had been “talking to himself.” However, to reinforce the message, the article informs the reader that he had been prescribed three psychotropics – insinuating a multiplier effect for the role of noncompliance. Furthermore, the article implies that missing a single day of psychotropics is an explanation for the incident.

The media routinely use this bias in favor of the medication explanation in its analysis – or lack thereof – of violent behavior in people with mental illness. Recent stories include a man killing his nephew3 and a man killing his girlfriend4, and both were incidents apparently best explained by medication noncompliance. Another story reports of police officers who were charged with assault after an altercation with a patient with mental illness led to the patient’s death. In the latter case, the article suggests that the simple fact that the victim had been acting erratically warrants the comment that he was “likely was off his medications.”

My work in the jail system also has been tainted by this overreliance on the unquestioned dogma of medication compliance. Discussions pertaining to punishment and privileges of inmates with mental illness often would lead to the question: “Is he taking his meds?” I have witnessed countless times when crucial decisions about placement in solitary confinement were predicated on questions of medication compliance. My answer was always the same: “Why does it matter? If the inmate is following the rules and behaving respectfully, how does taking a pill provide more important information?”

What was once thought to be a predictor of relapse risk, despite limited evidence, has become the outcome itself. As a society, we have falsely equated mental illness with violence; we have furthermore falsely equated remission and safety with medication compliance. The consequences of those beliefs are severe as we have limited attention, and our focus on medications blinds us to much clearer risk factors. Better indicators of who should be released from solitary include following jail rules, not being actively threatening, and not being actively violent.5

The court system is equally riveted with this question. Judges and lawyers associate medication compliance with legal competency, safety in probation or parole, and general well-being. I have witnessed agitated patients being reprimanded for their lack of medication adherence, leaving me to remind lawyers that the patient has been compliant. Conversely, patients are congratulated for their medication adherence when appearing well, until I remind the lawyers that the patient missed his last two visits for long-acting injectables.

As our field is reconciling new evidence questioning the long-term role of antipsychotics in schizophrenia, I am questioning whether society has accepted their value as a foregone conclusion. Lex Wunderink, MD, PhD, and his associates challenged accepted dogma when conducting a long-term, randomized trial of antipsychotics, in which patients on a dose reduction and discontinuation arm did better at 7 years than the patients on the continuation arm.6 The then National Institute of Mental Health director, Thomas Insel, MD, wrote in his blog that for some schizophrenia patients, “remaining on medication long term might impede a full return to wellness.”7

A Cochrane review of the literature found that, over time, antipsychotics had a diminishing effect on relapse prevention. After 2 years, the effect approached zero.8 In 2016, Nancy L. Sohler, PhD, and her colleagues looked at the literature on antipsychotic use in longer trials. The data were of poor quality and inconclusive.9 However, stories in the popular press suggest that the best explanation for violent behavior in the mentally ill population is medication noncompliance.

Inextricably bound up with this dogma regarding noncompliance is the incorporation of the pharmaceutical industry into mainstream psychiatry. The promise of psychopharmacology to treat mental illness was adopted in a wholesale manner for financial and practical reasons as well as a desperate optimism to relieve seemingly intractable problems. Sadly, the failure of psychopharmacology to produce on said promises has not produced a backlash. Instead, there is a doubling down on this belief, which can be seen, for example, in the creation of Abilify MyCite – with its promise to keep clinicians informed about their patients’ medication compliance.10 The alternative to this prescribing culture would be an attentive reckoning of the ongoing limitations inherent in the treatment of those with mental illness. If noncompliance cannot explain violence in people with mental illness, we are left with the same complex and subtle issues surrounding violence that frustrate easy journalistic explanations, and relatively cheap and easy interventions for the care of this population. It feels better and is more cost effective to blame the patients for not fitting our biological models by being drug nonresponders or noncompliant.

Blaming pills is facile. It is tangible and easier to measure than looking into someone’s mind. Psychiatrists have promoted this idea by teaching the public about chemical imbalances and by focusing on medication management. However, when the consequences are as severe as placing people in solitary confinement or explaining murder, the evidence needs to be equally solid as the severity of the punishment. This must start with psychiatrists reeducating the public on the role, the power, and the limitations of psychotropics.

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre mentors residents on projects, including reduction in the use of solitary confinement of patients with mental illness and examination of the mentally ill offender. Dr. Badre can be reached at Badremd.com.

References

1. Worcester Patch. Jan. 2, 2018.

2. Rare News. Jan. 4, 2018.

3. WTSP.com. Dec. 31, 2017.

4. Wavy.com, Dec. 20, 2017.

5. U.S. Attorney General. 2016. U.S. Department of Justice Report and Recommendations Concerning the Use of Restrictive Housing.

6. JAMA Psychiatry. 2013 Sep;70(9):913-20.

7. Blogpost, by Thomas Insel, MD. Aug. 28, 2013.

8. Cochrane Database Syst Rev. 2012 May 16. doi: 10.1002/14651858.CD008016.pub2.

9. Am J Orthopsychiatry. 2016;86(5):477-85.

10. New York Times. Nov. 13, 2017.

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