Substance abuse and the management of medication nonadherence in schizophrenia

To compare the clinical characteristics and psychiatric management of antipsychotic nonadherence among outpatients with schizophrenia who either do or do not have current or past comorbid substance use disorders, a national survey was conducted of psychiatrists engaged in the management of schizophrenia. Respondents reported on the presentation and management of one adult patient who had been under their care for at least 1 year and who had been nonadherent with oral antipsychotic medications at some point in the last year. The response rate was 69.3%. Patients with schizophrenia only (N = 190) were compared with patients with schizophrenia and a history of a co-occurring substance use disorder (N = 105). Approximately one third (35.6%) of antipsychotic nonadherent schizophrenia patients had a comorbid substance use disorder. Denial of illness was the most commonly cited primary reason for antipsychotic nonadherence. Psychiatrists were significantly less likely to discuss with comorbid patients than patients without comorbid substance use linkages between antipsychotic adherence and progress toward personal goals (64.5% vs. 78.9%), and significantly less likely to explore the meaning of taking medication to the patient's identity (59.2% vs. 73.3%). However, psychiatrists were approximately two times more likely to add another antipsychotic for patients with substance use disorders (22.8% vs. 11.0%). There were no perceived differences between the two groups in effectiveness of interventions to manage medication nonadherence. Comorbid substance use disorders are common among psychiatric outpatients with schizophrenia who are nonadherent with antipsychotic medications. Some psychological approaches tend to be used less often with patients with comorbid substance use disorders, although when they are used, psychiatrists report they are no less effective than they are for schizophrenia patients without comorbid substance use disorders. These findings suggest that some psychological interventions may tend to be underutilized in the management of medication nonadherence among patients with comorbid schizophrenia and substance use disorders.