[Therapeutic alliance, a stake in schizophrenia]

Adherence to (or compliance with) a medication is one of the foremost issues in the assumption of patients with psychiatric illness and, in particular, in schizophrenia. Adherence to medication is generally defined as the extent to which patients take medications as prescribed by their health care providers. There is no consensus to define an acceptable compliance.

The methods available for measuring adherence can be broken down into direct and indirect methods of measurement, each one having advantages and disadvantages. Clinical summations of studies were realized, the problem of poor adherence to medication concerned 25% of patients with schizophrenia and 74% of the 1493 schizophrenia patients recruited for the Catie study discontinued their assigned study medication before 18 months, a rate that was considered to be very high in a study in which the primary outcome measure was discontinuation of the study drug for any cause and approximately 30% stopped the treatment of their own motivation. In two thirds of cases, rehospitalisation is the result of complete or partial non-compliance. One year after first hospitalsation, 40% of relapse results from non-adherence to medication.

Medication adherence problems increase hospitalisation, morbidity and mortality. Social consequences, professional and family problems linked to hospitalisations lead to low quality of life for patients and high cost for society. Indicators of poor adherence to a medication regimen are a useful resource for physicians to help identify patients who are most in need of interventions to improve adherence. It is usual to identify quatre categories of factors causing disparity: 1: factors due to psychiatric disorders; 2: factors due to medication; 3: factors linked to patients; 4: factors depending on the therapeutic relationship with the clinician. Patients with psychiatric illness typically have great difficulty following a medication regimen, but they also have the greatest potential for benefiting from adherence. Some effective actions to improve compliance are described in reply to the factors influencing the adherence. The communication attitude of the clinician, therapeutic relationship and prescription use are main points of alliance. Information and communication with the patient, simplification of the therapeutic plan, consultation planning and account of side effect are simple and effective actions. Social support is very important for improvement of therapeutic alliance. Poor therapeutic alliance is common, contributing to substantial worsening of disease and more research on compliance and therapeutic alliance evaluation is needed. Information and tools must be proposed to practitioners.