My friend Peter Conrad published a remarkable paper in 1985 entitled The Meaning of Medications: Another look at compliance. Peter is a Professor of Sociology at Brandeis University who is interested in social aspects of health. In his paper, he was trying to understand why people with epilepsy took or did not take their medications. What were their reasons and what were they trying to achieve? In contrast to prior theories of compliance which focused on the doctor-patient relationship, Peter was trying to understand the patient’s experience of taking medication – and he called this “medication practice”, i.e. how did the patient approach the daily practice of taking medication? “Medical practice offers a patient-centered perspective of how people manage their medication, focusing on the meaning and the use of medications”. In other words, he was interested in the relationship between a patient and their medications. Recall that Peter was interested in people with epilepsy. One could imagine that people with epilepsy would, of course, take their medication religiously since their medication would reduce or eliminate their seizures – and who would want to have seizures if they could be avoided? But Peter found something much more interesting.
He found that people took or didn’t take their medication to regulate themselves. Those who took their medications as prescribed took them because they viewed the medications as their “ticket to normality”. Taking medication eliminated seizures or reduced their worry about having another seizure. Those who did not take or modified how they took their medication were also trying to regulate themselves but around different issues: they were testing if they still needed to take their medications – maybe they would not have a seizure if they stopped their meds; others did not like the feeling of being dependent on the meds and if they stopped, they would no longer need them; while others felt that they were “different” because they had to take their meds and by stopping them, they would no longer feel stigmatized. But they also would reduce the dose to reduce adverse effects. One said that she reduced the dose because “… I feel like I flatten out a little bit. I don’t like that feeling. It’s just a feeling of dullness, which I don’t like, almost a feeling that you’re on the edge of laziness.” Thus, if someone thought that the medication impaired their social roles, they would change the way that they took medication to lessen the impact.
I was struck by Peter’s work by how much it applied to people living with anxiety and depressive disorders. So many get relief from long term medications and try to self-regulate. I believe that it is time to abandon the terms compliance and adherence and, instead, use the term concordance which I learned from my good colleague Gary Sachs. Let the patient and their clinician explore the meaning of medications and agree on the best path to achieve shared outcomes.
About the Author:
Andrew A. Nierenberg, MD is Director of the Dauten Family Center for Bipolar Treatment Innovation at Massachusetts General Hospital (MGH), Professor of Psychiatry at Harvard Medical School.
He is also the Associate Director of the Depression Clinical and Research Program, and Director of Training and Education for the MGH Research Institute. He holds the Thomas P. Hackett, MD, Endowed Chair in Psychiatry at MGH and has been listed among the Best Doctors in North America for the treatment of mood and anxiety disorders continuously since 1994.