Discrimination between psychotropic and non-psychotropic treatment by patients

Perecherla & Macdonald¹ state that they found no evidence that patients discriminated between psychotropic and non-psychotropic treatment. Elsewhere, a lack of concordance with psychotropic medication has been reported to be as high as 75% over the course of a year.² Although this may be on a par with adherence to non-psychotropic medications, there were significant factors which were not taken into consideration in Perecherla & Macdonald's study.

Only patients who could communicate in English were included. This may have excluded patients from ethnic minority groups and other backgrounds, thereby ignoring their cultural and religious beliefs regarding medication. This surely must reduce the relevance of the results to populations with a significant proportion of ethnic groups. Further, the authors were unable to ascertain the duration of treatment in participants. This is an important factor as adherence improves with development of insight.³ The opposite is true of acute relapse.

In addition, it is not clear whether the sample was drawn from acute or long-stay wards and whether it consisted of patients who were stable on psychotropic medication and had insight or were acutely unwell. It is quite possible that most of the sample were patients who were stabilised on a drug regime, had insight and knew the purpose of their psychotropic medication. However, this may not be the case in acute episodes of care where the patient often lacks insight and questions the need to continue psychotropic medications. The authors state that in case of participants on more than two psychotropics, the ‘longest-term treatment option’ was selected. We fail to understand how this was established if duration of treatment was unknown. In the example given of a patient with bipolar disorder, the mood stabiliser was selected rather than the antipsychotic as the primary treatment; this was based on the assumption that mood stabilisers had been used first. However, it is well known that many patients are treated with antipsychotics as first-line medication. It is quite possible that antipsychotic medication was the initial intervention used and the patient took it as a matter of routine.

In summary, medication adherence is a complex issue that can be affected by various factors, such as lack of insight, religious and cultural beliefs, level of education and socioeconomic status, comorbid alcohol misuse, to name a few.⁴ We believe further studies are needed in this area.