Communicating

With Patients About Antipsychotic

David A. Soskis and Richard

Drugs

L. Jaffe

HE QUALITY of communication between doctor and patient on the issue of medication has become the focus of increasing attention in recent years. A number of factors have given impetus to this, including efforts to restore a greater degree of humanity to the practice of medicine, and, from the other side of the relationship, a rising influence of the consumer movement in our society. In the field of clinical drug research, pharmacologists are increasingly recognizing the need to study the so-called “nondrug factors” in pharmacotherapy.’ In the treatment of schizophrenia with antipsychotic medications, communication appears to be of special importance. Despite the fact that clinicians in a wide variety of private-practice, institutional, and academic settings rank the administration of antipsychotic drugs as the most useful treatment available for schizophrenic illness.2 this enthusiasm is not reflected in studies of patient compliance. Studies of inpatients have produced up to a 20% noncompliance figure,” and studies of outpatients show that between 40% and 50% of schizophrenic patients do not take prescribed medications.4*5 In a review of medication compliance problems (which are not limited to schizophrenic patients), Blackwell has cited several high-risk factors, including chronicity of illness, symptom suppressive as opposed to curative action of the medication, delayed relapse with cessation of medications, ambivalent feelings about dependency issues, multiple medications, and social isolation.” Many of these factors are particularly applicable to schizophrenic patients receiving antipsychotic medications. Their relevance is confirmed by the marked dis: crepancy between intention and performance noted in one study of compliance in schizophrenic outpatients.’ These serious compliance problems may represent effects of the schizophrenia itself, the reaction to inevitable aversive drug effects, or reactions to problems within the doctor-patient relationship. The general thrust of much consumer-oriented literature has been that doctors should communicate fully with their patients concerning any proposed treatment, especially being sure that patients at-e aware of the benefits to be derived from the medication, and the side effects and risks involved, so that they can provide a meaningful informed consent and interact with the physician in a participatory model.

T

From Temple uniwrsif~ School of Medicine, Philnde/phitr , Pu. Temple Unil~ersify School qf DN\Vd A. Soskis, M.D.: Associate Prqfesuor of Psychictry, Medicine; Richurd L. Jaffee. M.D.: Assistcrnf Professor of Psychiutry, Temple University School of Medicine. A brief ~3ersioilof this paper HWSpresented ut the Anmrtrl Meeting of the Americrrn Psychirrrric Association. Atlrrnttr, Go., Mary 1978. Address reprint reywsts to Dnlid A. Soskis. M.D., Depwtment of Psychicltr>l. Temple University School of Medicine, Phiirdelphiu. Pn. 19140. @ 1979 by Grune & Strutton, Inc. 0010-440X17912002-0004$01.0010 126

Comprehensive

Psychiatry,

Vol. 20,

No. 2

(March/April),1979

COMMUNICATING

Many

ABOUT ANTIPSYCHOTIC

of these instructions

patients

have

sibilities

and have

physicians Thus,

come

who

from

actually

it appears

the points

them

of view

with

peutic about these

reflect

(3) When

doctor-patient drugs

each doctor

communication

process

in a congruence

be correlated

with

Patient

buhject\

States

receiving study

for this study

Naval

IO the be\t

medicaticui danger\

various

LIP

knowing

of their

knowledge

as a group

give

to

his own

patients.

i\ indi-

aspects

of anti-

doctor

attitudes

of doctors.

and

patients.

compliance

patient

or of the

or with

thera

option\

this

fl-om

were

Mere provided):

whether

ho-

much

Participating asked

chothel-spy. xhizophrenic

thi\

patients.

each of hi\ patient\

bar thi\ would

usefulnez\ each

were ;tw;re

on theye

\uhject\

for- thi\

W~I-e ached to

the antip\qchotic

(3) rea\on

fol- being given

of thiy

medication.

tht-ee \uhjective

quebtions

medication

heen to you?:

about

,III~

16)

of

you

thiy

posxihle

OI-

psychiatl-iqt medic;ltion of. or inquil-ed

WA\

asked

to ute

to p;ttients

group.

They

Mere

OI- insight

p\h-

in the

treatment

01

re\pon\e

ol

the therapeutic

the pos\ihility

)ou!.

feeling’.’

euploratol-y

u hich that psychiatrist ahnut.

really

manipulation

choo\e

you talk with

in the patient

medication.

environmental

xe

rcsponx

could

value of communicating

that Mere smipled

antipsychotic

(graded

12) If )ou

i\nd (3) When

the way

to rate the therapeutic

psychotherapy

Finally.

of the

and p

rate the thera-

Jo patients

the doctors

i5 paired

communication

hasis.

who

who

and does the extent that

by the

question!,

do psychiatrists

specific

importance

respon-

issues from

and of those

the following

(2) What

medication.

reflected

of these consumer

How

to patients

and (4) Can any special

knowledge?. peutic

(I)

theil

on a day-to-day

and the physicians

medications?;

of their

patient-care

patients

to answer

medications:

with

less than enthusiastically

prescribe

inpatients

the relative

to communicate

or no direct

some

actually

of communicating

icsues?:

psychotic

who

was designed

of antipsychotic

vidual

to examine

of those

these aspects

little received

care for schizophrenic

antipsychotic

as a gt-oup

as to how

with

been

of schizophrenic

value

aspects

those

worthwhile

take the medications. The present study ing ;I group

to physicians

predictably

127

DRUGS

had prehcrihed. th;rt the other

Neithru group

w;~\

ih\ue\.

RESULTS The mean physician scores for patients about the various aspects patients who were able to respond these areas. are presented in Table important

to communicate

with

the therapeutic value of communicating of medication , as well as the percentage with meaningful information I. The psychiatrists felt that

the patient

about

to of

on each of it was most

why he is being given

medica

128

SOSKIS Table

1. Psychiatrist Ratings and Patient Knowledge Antipsychotic

of Information

AND JAFFE

on

Medications Patient

Psychiatrist

Ratings

Aspect of Medication

Value

Name Dose Why given How works Side effects Risks

2.4 2.3 3.8 3.0 3.7 3.5

(Mean

of Patient

Therapeutic

Koowmg)

(little-moderate) (little-moderate) (modqate-marked) (moderate) (moderate-marked) (moderate-marked)

(Percent

Knowledge With Correct

Information)

68 36 80 40 84 60

tion and then ranked slightly below this the information that is usually considered crucial for informed consent on side effects and risks. Information on how the medication works and on its name and dosage are seen as of less importance. This group of eight psychiatrists uniformly rated antipsychotic medication and supportive psychotherapy as being very useful in the treatment of schizophrenic patients and rated exploratory or insight psychotherapy as being of some or of little use. They rated 80% of their patients as showing moderate or marked improvement as a result of antipsychotic medications, and all patients were rated as showing at least some improvement. The patient data may be considered from two perspectives: (1) the absolute levels of knowledge shown by the patients. and (2) their relative ranking, especially in comparison with the psychiatrist ratings. Absolute levels of patient knowledge concerning various aspects of their medication appear to be at acceptable levels concerning side effects and reasons for being given the medication, but drop considerably for other aspects. Approximately one-third of the patients knew neither the name of the medication they were receiving not any of the risks involved in taking it. In general, however, the ranking of how much the patients know corresponds to the physician’s ranking (rank order correlation coefficient, r’ = +0.77, p = .(X5).In terms of responses that would reflect consumer satisfaction and predict compliance, 60% of the patients felt that the medication had been helpful to them, and 56% said they would take it on their own if they had the choice. In their ratings of their psychiatrist’s empathy, 60% felt that their doctor understood them “a lot,” 24% felt he understood them “a little,” and 16% felt that their doctor did not understand the way they were really feeling. In Table 2, the attitudes of individual physicians towards the various aspects of medication have been dichotomized and paired with a similar dichotomization of their own patients’ levels of knowledge on each of these aspects. When the aspects are examined individually, it is clear that there is a considerable lack of congruence between what this group of physicians rated as the therapeutic value of communicating specific information and what their own patients ended up knowing in each of these areas. In the areas of communication concerning side effects and why the patient is receiving medication, there is a fairly high degree of congruence with physicians considering these areas important and their patients generally knowing about them. A lower level of congruence is found in the area of dosage where the low level of importance given to

COMMUNICATING

ABOUT

ANTIPSYCHOTIC

129

DRUGS

Table 2. Congruence Between Psychiatrists’ Ratings of Therapeutic Value of Information and Their Patients’ Actual Knowledge Psychiatrist: Psychiatrist: Valuable; Aspect

of Medication

lack of knowledge. comparisons

both

usefulness

or

response with

thereof

helpful

the patient’s (I’

medication patients, peutic

+0.37.

response

.05).

or

with

these outcome the various or

patient

with

rating

differences

variables

therapeutic

psychiatrists.

Interestingly.

process

either

of projected

among

the

nor with

psychiatrists

psychotherapy

who

Patients

gave significantly

with

paranoid (I- =

empathy

diagnoses -0.34.11

1’ < 0.05) but were

that they

would

of the actual study nificant whose

did

refuse

not correlate

levels

process

with

in response

of knowledge

congruent with their about these aspects.

on

lower

concerning

doctor

compliance

various

physician’s ratings and physician-patient

There

were

no in

ratings

of

in their

emphasis

or milieu

ratings

own.

their

variables.

or pryjected

of thera-

of empathy

CJII

were

innot

patients

Finally.

and patient i.e..

of their

physi-

t I.

of the medication

than nonparanoid

between

the outcome

in this

rating

more empathic. Among the pawith race or level of education.

likely

to take medications

communication

differences

not more

the

of doctors.

psychiatrists

greater

to drugs

< 0.05) and of the helpfulness

= -0.41.

take

psychiatrist

ratings

also

and

measured

patient

treating

placed

significantly correlations

qualities

with

patient

the patient’\

p < .05)

compliance.

eight

as opposed

of therapeutic

with

itself or

doctor

of

of the

not he would

of the specific

rated by their patients as being tients, there were no significant cian’s

rating

or

nor were there correlations modalities,

exploratory

None

communication

correlated

significant

Doctor

areit

evaluation

significantly

as to whether

is rein-

by combining

in specific

had been (I’ = +0.41.

decision

patients‘

table.

as to the global

correlated

Not

statistical

of congruence

congruence

medication.

/7


ambulatory

treatment.

1974

clinical

and he-

schizophrenic

Vertinsky

Measuring

1973

and chronic

131:991-995.

com-

paAm

J

Ment in

AA:

The

phenothiazine

Dih 1X):67-71. R. the

1960

Goldberg drug

Rickels

in Drug

K (ed):

Therapy.

SC:

the!-spy

ot

Non-

Springfield.

196X. p 126 IB. Thompson

decision

de: in Re\

1974

13. Van Putlen refu$e

P\!chiatry

to medics1960

the

Bonato

consumer

9:12l-134. tient>

131:64-69.

patients.

EH:

a~, ;I fat-

responses

and

factor\

drug>?

1965

G. Thomas

of acute

Psychiatry

Gillan

B: Drug

N Engl

haviors tients

DR.

outpatients

Dis

JO.

Di\

AS: Phy\i-

Wiener- G. Kurlnnd

J Nerv

Cole

xhizophrenic

psychiatric h.

tranquilizer\. I I.

patient>‘

physician

Nonspecific

1963

MeJ

JM. Ma\on chemotherapy

TE.

K. et

1969

toward Ment

psychiatl-ic

of

Acta

J Nerv

Rickels

DP. Sack\

attitude\

IO. Hanlon

EH.

and drug Irespon\e.

X):451-459.

9. Haefner

Psychiatry

1967

follow-up

EJinhurgh.

Sy\t

attitudes

tar in psychiatric

take

113: 1435s1439,

RS. Uhlenhuth

al: Medication

1972

inpatient\

A

and heurisJ Nerv

1970

xhi7ophrenia.

1:573-580.

al:

JB: Clinical

drug research.

to

T: Why take

!1:67-72.

clo schizophrenic

theif1974

drug\‘?

Arch

paGen