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Dr Christina Jackson, explains how health psychology can shed light on the issue of medication non-adherence in Inflammatory Bowel Disease, a relapsing, remitting condition involving inflammation of the colon, which affects over five million people globally.

Why don’t people with IBD take medication as prescribed?

Most studies find that between 30 – 45% of people with Inflammatory Bowel Disease (IBD), do not take their medication as prescribed (Jackson, Clatworthy et al. 2010).

Non-adherence to maintenance medication is associated with an increased risk of active disease (Higgins, Rubin et al. 2009), which in turn can lead to a 20-fold increase in health care costs (Bassi, Dodd et al. 2004). Consequently, healthcare services should be focused on maintaining remission and prompt, optimal outpatient management of disease flare-ups (IBD Standards Group 2009). Such focus requires both appropriate management by healthcare professionals and adherence to medical recommendations by people with IBD.  

Quantitative adherence research in IBD has generally ignored psychosocial factors but where included these factors show promise (Jackson, Clatworthy et al. 2010). Qualitative studies have shown that perceptions of illness and treatment are important in explaining adherence in IBD. Experiences of symptoms might be used to judge both the necessity and efficacy of treatment (Jackson, Cooper et al. 2010). For example, in asymptomatic times medicine might not be perceived as necessary, and if symptoms do not respond as the individual expects, medicine might not be perceived as effective (Hall, Rubin et al. 2007, Jackson, Cooper et al. 2010). Concerns about side effects might discourage adherence, with steroids in particular being negatively viewed (Hall, Rubin et al. 2007).

An individual’s relationship with their healthcare professional is also important.  For example, lack of agreement between the patient’s and physician’s perceptions of the patient’s health status following hospital visit is associated with non-adherence (Jackson, Clatworthy et al. 2010). Additionally the experience of conflicting medical advice can lead to confusion and subsequent non-adherence (Jackson, Cooper et al. 2010).

How can health psychology be applied in practice today?

Interventions to improve adherence to medication for IBD should focus on known predictors of non-adherence.  A recent pilot study used psychological techniques from cognitive behavior therapy to address treatment concerns in an interactive, online intervention. This single-session, brief intervention was successful at reducing concerns, with effects that were sustained over time (Jackson, Cooper et al. 2011). 

Tips for clinical practice

• Ask your patient about any difficulties managing their regimen
• Encourage your patient to share their beliefs about treatment so that you can provide information where misperceptions exist: focus on perceived need for treatment, perceived efficacy of treatment, and concerns about treatment
• Make sure that your IBD patients understand the rationale for treatment, your expectations regarding symptom improvement and your recommendations regarding treatment escalation or involvement of healthcare professionals at the first signs of active disease

References

Bassi, A., S. Dodd, P. Williamson and K. Bodger (2004). "Cost of illness of inflammatory bowel disease in the UK: a single centre retrospective study." Gut 53(10): 1471-1478.

Hall, N. J., G. P. Rubin, A. P. Hungin and A. Dougall (2007). "Medication beliefs among patients with inflammatory bowel disease who report low quality of life: a qualitative study." BMC Gastroenterol 7: 20.

Higgins, P. D., D. T. Rubin, K. Kaulback, P. S. Schoenfield and S. V. Kane (2009). "Systematic review: impact of non-adherence to 5-aminosalicylic acid products on the frequency and cost of ulcerative colitis flares." Aliment Pharmacol Ther 29(3): 247-257.

IBD Standards Group (2009). Quality Care: service standards for the healthcare of people who have Inflammatory Bowel Disease (IBD). http://www.bsg.org.uk/attachments/160_IBDstandards.pdf.

Jackson, C. A., J. Clatworthy, A. Robinson and R. Horne (2010). "Factors associated with non-adherence to oral medication for inflammatory bowel disease: a systematic review." Am J Gastroenterol 105(3): 525-539.