The importance of treatment acceptability to patients

Antipsychotic drug treatment plays a central role in the care of patients with schizophrenia. The chronic nature of the illness means that most patients are likely to require long-term antipsychotic medication to alleviate symptoms and to prevent recurrence of an acute psychotic episode. Unfortunately, a high proportion of patients with schizophrenia do not comply with medication and this has profound consequences in terms of the number and severity of relapse episodes, rehospitalization rates, worsening of residual symptoms and social costs, including substance misuse, homelessness and the burden on carers. Ensuring that antipsychotic treatment is acceptable to the patient is fundamental to managing adherence. Side-effects, particularly mental and extrapyramidal symptoms (EPS), are the cause of much distress to patients and dissatisfaction with treatment, so a treatment regimen with a low side effect profile will help to improve adherence to the treatment. Such regimens have unmasked many of the other side-effects of treatment that were previously viewed as subsidiary to EPS; but the physical and psychological consequences of side-effects such as antipsychotic-induced sexual dysfunction or weight gain are highly distressing to the patient, and as likely as EPS to trigger non-adherence to medication. Consequently, careful selection of antipsychotic agent and dose regimens is essential to maximize the efficacy of the antipsychotic and to minimize the overall burden of side-effects. Satisfaction also depends very much on the extent to which the patient understands the treatment and its side-effects. Therefore, a close therapeutic alliance between the patient and the psychiatrist must underpin all attempts to increase the acceptability of treatment. This will allow the clinician to determine how the illness and its treatment are affecting all aspects of the life of the patient, and then to tailor the treatment continuously to obtain the best possible outcome for the patient.