What, if any, methods do doctors use to make sure their patients are compliant? For example, someone in the US with major mental illness who might have poor insight. Do they check blood work and talk with family members, or do they just rely on talking with their patient and hope he's telling the truth?

Median wrote:What, if any, methods do doctors use to make sure their patients are compliant? For example, someone in the US with major mental illness who might have poor insight. Do they check blood work and talk with family members, or do they just rely on talking with their patient and hope he's telling the truth?

It depends. If someone is taking a depot antipsychotic (where the medication is given by injection every few weeks) you can be certain whether they are receiving the medication. In other instances, as you suggest, plasma levels or having compliance monitored by family or other caregivers can help. But, yeah, much of the time you just have to trust the person's word.

I didn't even think about depots. I guess that's a great option if they have poor insight or aren't compliant. For the patients not taking depots, shouldn't doctors be required to test plasma levels every once in a while to make sure they are compliant?

If the doctor doesn't trust what the patient says, then bloodwork would be the only alternative. I'm not sure how requiring the doctor to do bloodwork would work outside of court mandated treatment and I'm fairly certain that is pretty rare.

Shrunk wrote:But, yeah, much of the time you just have to trust the person's word.

Or not. Most doctors, in my experience as a drug rep, have a pretty dim view of their patients' adherence.

Sciwoman wrote:If the doctor doesn't trust what the patient says, then bloodwork would be the only alternative. I'm not sure how requiring the doctor to do bloodwork would work outside of court mandated treatment and I'm fairly certain that is pretty rare.

If someone who is mentally ill is receiving benefits from the government then can't that change things? I'm pretty sure in the US, at least in some states, people who are on welfare are required to take drug tests. So it makes sense to me if people who are mentally ill and are on government assistance would be required to tested for compliance every now and then.

Median wrote:

Sciwoman wrote:If the doctor doesn't trust what the patient says, then bloodwork would be the only alternative. I'm not sure how requiring the doctor to do bloodwork would work outside of court mandated treatment and I'm fairly certain that is pretty rare.

If someone who is mentally ill is receiving benefits from the government then can't that change things? I'm pretty sure in the US, at least in some states, people who are on welfare are required to take drug tests. So it makes sense to me if people who are mentally ill and are on government assistance would be required to tested for compliance every now and then.

Why must the "mentally ill", of all social services clients, be required to submit to drug testing?

Mental Illness and the Freedom to Refuse Treatment
Drug Testing Welfare [TANF] Recipients

The testing that some states do is for illegal drugs, not medically prescribed drugs.

Median wrote:

Sciwoman wrote:If the doctor doesn't trust what the patient says, then bloodwork would be the only alternative. I'm not sure how requiring the doctor to do bloodwork would work outside of court mandated treatment and I'm fairly certain that is pretty rare.

If someone who is mentally ill is receiving benefits from the government then can't that change things? I'm pretty sure in the US, at least in some states, people who are on welfare are required to take drug tests. So it makes sense to me if people who are mentally ill and are on government assistance would be required to tested for compliance every now and then.

As Gallstones points out the patient has rights - anything done without their consent constitutes an assault, so without establishing that they are incapable of consent, checking up on them without consent is unacceptable. If they are incapable, then you doctors must choose the least intrusive approach possible - so blood tests are definitely more intrusive than pill counting, in addition many drugs do not have reliable available monitoring kits, and there is often a highly variable relationship between dose consumed and blood levels.
I get the impression you have a specific individual case in mind - the first question you must ask is do they understand the consequences of non compliance? - as long as they understand, then even if you disagree with their assessment of the liklihood or importance of a bad outcome, they retain the right not to comply. Often non compliance has to do with the side effects of medicines, have alternative approaches been considered?

Made of Stars wrote:

Shrunk wrote:But, yeah, much of the time you just have to trust the person's word.

Or not. Most doctors, in my experience as a drug rep, have a pretty dim view of their patients' adherence.

Although, from what my psychiatrists girlfriend tells me, patients are often very honest about their adherence around these parts. They'll tell you that they stopped taking their drugs, either because they don't like the side-effects or because they think they're already over the proverbial hill, almost proudly. It's not that they have a dim view because they don't trust their patients' honesty, it's because the patients are basically telling them where to stuff the drugs.
Besides, with certain patients, e.g. bipolar patients in highly manic phases, you can bet your ass most of the time that they aren't taking anything anyway, sometimes simply because they like being manic.

I don't know if this is true in all states in the US, but apparently in some states you're not considered mentally ill if you're not on medication. You'd think it would be a problem in the states eyes if the patient is receiving benefits from the state for being mentally ill, yet not on medication and therefore not considered mentally ill.

Patients regularly have their blood tested, so what's wrong with adding another check for compliance once or twice a year?

Mazille wrote:

Made of Stars wrote:

Shrunk wrote:But, yeah, much of the time you just have to trust the person's word.

Or not. Most doctors, in my experience as a drug rep, have a pretty dim view of their patients' adherence.

Although, from what my psychiatrists girlfriend tells me, patients are often very honest about their adherence around these parts. They'll tell you that they stopped taking their drugs, either because they don't like the side-effects or because they think they're already over the proverbial hill, almost proudly. It's not that they have a dim view because they don't trust their patients' honesty, it's because the patients are basically telling them where to stuff the drugs. Besides, with certain patients, e.g. bipolar patients in highly manic phases, you can bet your ass most of the time that they aren't taking anything anyway, sometimes simply because they like being manic.

I'm afraid I don't have the reference, but a colleague told me of a study that demonstrated that psychiatrists are able to assess a person's adherence with very high accuracy - for other doctor's patients. With their own patients, they didn't do so well.

There is also considerable evidence that one of the best predictors of better outcome in schizophrenia is whether a person is taking depot medication. And that's the case even if the doctor "knows" the patient is taking oral medication.

(BTW, you're on speaking terms with your psychiatrist's girlfriend? )

Shrunk wrote:
I'm afraid I don't have the reference, but a colleague told me of a study that demonstrated that psychiatrists are able to assess a person's adherence with very high accuracy - for other doctor's patients. With their own patients, they didn't do so well.

Interesting... Did they say why that was, because that isn't what you would expect. Without having a history with the patient and no baseline, patients having different symptoms, and reacting to medication differently, I don't understand how a random doctor is better able to tell if the patient is compliant.

Median wrote:

Shrunk wrote:
I'm afraid I don't have the reference, but a colleague told me of a study that demonstrated that psychiatrists are able to assess a person's adherence with very high accuracy - for other doctor's patients. With their own patients, they didn't do so well.

Interesting... Did they say why that was, because that isn't what you would expect. Without having a history with the patient and no baseline, patients having different symptoms, and reacting to medication differently, I don't understand how a random doctor is better able to tell if the patient is compliant.

I haven't seen the study, so I can't answer. But I suspect it may have to do with how objective one can be in determining whether a person is telling the truth and what kind of personal investment you might have in wanting to believe them. The results don't really surprise me at all

Median wrote:I don't know if this is true in all states in the US, but apparently in some states you're not considered mentally ill if you're not on medication. You'd think it would be a problem in the states eyes if the patient is receiving benefits from the state for being mentally ill, yet not on medication and therefore not considered mentally ill.

Patients regularly have their blood tested, so what's wrong with adding another check for compliance once or twice a year?

If we are talking about TANF and SNAP a person has to recert every 6 months and renew every year. That means documentation to support need.

Bloodwork isn't free, the state would have to pay for it and it might be a HIPPA violation.

Gallstones wrote:

If we are talking about TANF and SNAP a person has to recert every 6 months and renew every year. That means documentation to support need.

Bloodwork isn't free, the state would have to pay for it and it might be a HIPPA violation.

I never heard of TANF or SNAP, but with Section 8 housing I believe they require annual inspections where you have to let someone in your home and inspect it. Ordinarily that could be a violation of privacy rights, but under the circumstances, it's legal. And like I said, I'm pretty sure some states require those on welfare to take drug tests. Sure the bloodwork isn't free, but it wouldn't cost that much more for a doctor to check for compliance once a year when he's doing the routine bloodwork, and in the long run it would save the state money.

Don't major mental health patients have to sign a document agreeing to a treatment plan? I would think that plan would include taking their medication, so why require them to sign it if they're not required to follow it?

Median wrote:Don't major mental health patients have to sign a document agreeing to a treatment plan?

Not where I work. Are things different in the US?

Shrunk wrote:

Median wrote:Don't major mental health patients have to sign a document agreeing to a treatment plan?

Not where I work. Are things different in the US?

From what I've heard they do in the US... Can anyone confirm?

Shrunk wrote:

Mazille wrote:

Made of Stars wrote:

Shrunk wrote:But, yeah, much of the time you just have to trust the person's word.

Or not. Most doctors, in my experience as a drug rep, have a pretty dim view of their patients' adherence.

Although, from what my psychiatrists girlfriend tells me, patients are often very honest about their adherence around these parts. They'll tell you that they stopped taking their drugs, either because they don't like the side-effects or because they think they're already over the proverbial hill, almost proudly. It's not that they have a dim view because they don't trust their patients' honesty, it's because the patients are basically telling them where to stuff the drugs. Besides, with certain patients, e.g. bipolar patients in highly manic phases, you can bet your ass most of the time that they aren't taking anything anyway, sometimes simply because they like being manic.

I'm afraid I don't have the reference, but a colleague told me of a study that demonstrated that psychiatrists are able to assess a person's adherence with very high accuracy - for other doctor's patients. With their own patients, they didn't do so well.

There is also considerable evidence that one of the best predictors of better outcome in schizophrenia is whether a person is taking depot medication. And that's the case even if the doctor "knows" the patient is taking oral medication.

(BTW, you're on speaking terms with your psychiatrist's girlfriend? )

I try not to talk too much and give nothing away, but you know how it is. How else am I to make her understand what the voices tell me?