From compliance to alliance when talking about medication: Why current definitions of “compliance” or “adherence” have done more harm than good!

Here is a problem for doctors and patients alike. The accepted definition of adherence is shown here.  The World Health Organization’s [WHO] official definition of medication adherence is: “The extent to which a person’ s behavior, taking medication, following a diet, or making healthy lifestyle changes, corresponds with agreed-upon recommendations from a health-care provider” World Health Organization, 2003.
The problem is that this definition is more about obedience to the recommendation (e.g. Does the patient do what the doctor recommended?) than it is about getting help (e.g. Is the recommended treatment effective?). The definition is also silent about whether or not (or to what degree) would any non-adherence be harmful to desired treatment goals (e.g. Sometimes stopping medications briefly is very risky, but other times it is not a big deal.) After 30 years of research on medication adherence, I have come to believe that the current definition of adherence is not just wrong but can be harmful. Here is why it is harmful. The focus is on whether the patient does what is asked of her.  It is amazing how, when obedience to a directive is required of one party,  that the conversation can sour. Fear of retribution on the patient ‘s part sometimes turns what should be a useful conversation about adherence concerns into something that is unpleasant and difficult for both patients and doctors alike.  The patient is thinking something like,  “I better not say I stopped medication because I don’t want my doc to be pissed off”) and decides that disclosing non-adherence is too risky. On the other side of the stethoscope, the doctor is thinking something like, “Of course my patient is following my recommendation because she trusts me”.  Together, these social forces place a lot of pressure on both parties to avoid or ignore crucial information about problems or concerns with the prescribed treatment resistance. It turns into a medical version of “don’t ask-don’t tell”. The misinformation is usually one of omission, in that a medication or treatment was not taken but the doctor thinks it was. But the missing information can be hazardous to the patient ‘s health. The missing information can trigger treatment decisions that are clearly wrong if only the true situation were known. It is a testimony to desire to avoid unwelcome conversations that leads many patients be exposed to major safety problems or accept less-than-optimal outcomes just to avoid the feeling of being “a bad patient”
Peter J. Weiden, MD, is a Professor of Psychiatry and Director of the Psychotic Disorders Program at the Center for Cognitive Medicine at University of Illinois Medical Center (UIC) in Chicago, Illinois.He received his undergraduate degree at Swarthmore College in Swarthmore, Pennsylvania, and his medical degree at SUNY Stony Brook. Dr. Weiden completed his psychiatric residency at Payne Whitney Clinic-New York Hospital in 1985 and a psychiatric epidemiology fellowship at Mailman School of Public Health at Columbia University in 1999.Dr. Weiden has focused on improving clinical outcomes for patients with schizophrenia. In particular, his research career has focused on bridging psychopharmacology and public health issues in the treatment of schizophrenia. He has published extensively on the problem of medication nonadherence (noncompliance) in schizophrenia and has helped develop some of the current models and measures for non-adherence.


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