Won’t get well: Trying to understand medical non-compliance

How many unfinished prescriptions are left in your medicine box?

How many unfinished prescriptions are left in your medicine box?

This post was born out of discussions with my doctor friends, who frequently struggle with “revolving door” patients. The kind of people you discharge knowing you’ll be seeing them in a few weeks, maybe even a few days. Individuals who  grudgingly accept treatment, as though intent on remaining sick. Those who fail to follow medical advice, despite the pain and risks they then live with. Questions arise as to whether we should treat these patients at all, whether the resources are justified when they seem determined not to look after their own health.

“Non-compliance” has a very punitive ring to it. We comply with authorities, with court orders and sanctions. It suggests the existence of an external control and an absence of choice. The somewhat softer “non-adherence” is perhaps something all of us can relate to. Which amongst us have not been entirely adherent to medical advice? Perhaps we failed to complete a course of medicine, drank whilst on antibiotics or missed a few doses. This kind of non-compliance is one of the highest rated frustrations for doctors, but is very common.

Who is more likely to be non-compliant?

In a review of 102 papers, Jin, Sklar, Oh and Li (2008) found that those who do not comply are more likely to be male, younger, single, to have a lower level of education. Those who have a cognitive impairment (e.g. dementia), a mood disorder or use substances were also found to be more likely to be non-compliant. The complexity of treatment regime, level of medical knowledge, quality of relationship with the prescriber, and stigma attached with the treatment were also highlighted. However, it may not always be as clear “why” an individual is non-compliant, and attention needs to be given to the paradoxical nature of the behaviour.

Beliefs impacting on compliance

Research suggests that cognitive factors may lie behind this “everyday” non-compliance: faulty and inaccurate beliefs that guide behaviour. Patients may believe that the treatment will be ineffective or there will be minimal consequences to non-adherence. They may believe that they are not “truly” ill or that the treatment will impact them negatively. They may believe that the disease is uncontrollable or have religious beliefs regarding illness, or that an alternative method that will help them more.

Readiness to change

stages-change

Thinking of the “stages of change” model, many patients may still be at the ‘pre-contemplation’ stage in relation to changing their behaviour. They will need support, education and counselling to progress to a point where they feel capable of change. When medical emergency forces a patient to receive medical treatment, they may still not be ready to engage in change, despite professionals escalating the situation on their behalf.

A good relationship with a professional will be needed to open up a dialogue in which it may become apparent that patients hold these beliefs. In many cases education may be enough to shift the belief, but this will need to be provided in a respectful manner so it can be well received. Motivational interviewing techniques have been used successfully to help a patient to identify discrepancies between their behaviour and their goals.

But what of people with more “severe” forms of non-compliance? Those who seem to actively avoid treatment and seem to exacerbate their condition?

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Stop-Motion: Tim Andrews’ ‘Over The Hill’ Photo Project

Rosie Hardy

I’m often drawn to art that draws on ideas about the brain, mind and mental health, and the combination of these. Tim Andrews’ ‘Over The Hill’ project is one that I’ve followed for some time and I feel it speaks a lot about identity and illness, as well as creativity and pushing the boundaries of portrait photography. Tim was diagnosed with Parkinsons in 2005, when he was 54. A couple of years later, he answered an advert in Time Out from a professional photographer looking for people to pose for nude pictures. The experience was enlightening and prompted him to respond to other adverts, and he took to Gumtree to find other photographers to capture him. Now his project includes a couple of hundred different photographers, from students and amateur hobbyists to well-known professionals such as Rankin, who have all photographed Tim in their unique way. The pictures range from candid portraits to monochrome nudes, vibrantly styled pictures and more surreal and bizarre imagery. I was already familiar with some of the photographers Tim has worked with and I like seeing how they incorporated him into their signature-style.  As a photographer myself, the images offer me inspiration for the myriad of different things one could create with a model (as well as thinking about getting in front of the lens!).

Miss Aneila

On his blog Tim documents his experiences with each of the photographers. What comes across is his real passion for art and how much he enjoys getting to know the different artists and being a part of their work. It’s fascinating seeing the many different ways that they have represented him, sometimes in a very intimate manner, sometimes more fantastical. One of the most noticeable features of Parkinson’s is the motor tremor that individuals develop. Given this, it’s interesting how the images often give such a picture of stillness and of peace. They’re static representations, frozen micro-second captures of someone who’s life must be rippled with hard to control motion. Parkinson’s is unfortunately a neuro-degenerative condition for which there is no cure, and given the subject matter you could imagine that the project could be quite depressing, charting the body’s decline. However, as Tim takes encounters a wider range of photographers, travels to further locations and creates ever more striking images, he tells a story of someone pushing to get the most out of life.

Justyna Neyring

Rekha Garton

Interview with Tim in the Times here