Grodno State Medical University
Department of Medical Psychology and
Psychotherapy
Lecture 2.
The Psychology of Treatment
Lector: Zhyhar Alena
Grodno, 2020
Compliance (or adherence) is a medical term that
is used to indicate a patient's correct following of
medical advice.
Most commonly it is a patient taking
medication (drug compliance), but may also
apply to use of surgical appliances such as
compression stockings, chronic wound care,
self-directed physiotherapy exercises, or
attending counselling or other courses of
therapy. The most effective way for a physician to
improve patient compliance is through a positive
physician-patient relationship.
Other factors that increase compliance:
Patient feeling ill
Limitations of patients activities due to disease
state
Written instructions for taking medication
Acute illness
Simple treatment schedule
Short time spent in waiting room
Physician recommending one change at a
time
Benefits of care outweigh costs
Causes for poor compliance include:
Forgetfulness
Poor rapport with physician
Few symptoms
Chronic illness
Recommendation not collected or not
dispensed
Purpose of treatment not clear
Supposed lack (отсутствие) of effect
Causes for poor compliance include:
Real or perceived side-effects
Instructions for administration not clear
Physical difficulty in complying (e.g. opening
medicine containers, handling small tablets,
swallowing difficulties, travel to place of
treatment)
Unattractive formulation, such as unpleasant taste
Complicated regimen
Cost of drugs
An estimated half of those for whom medicines
are prescribed do not take them in the
recommended way. Until recently this was
termed "non-compliance", and was sometimes
regarded as a manifestation of irrational
behavior or willful failure to observe
instructions, although forgetfulness is probably
a more common reason. But today health care
professionals prefer to talk about "adherence"
to a regimen rather than "compliance".
There have been many studies of the effects of
different strategies in improving adherence to
therapy. These include reducing the frequency
of administration during the day and reducing
the numbers of medicines a patient has to take.
However, there is no evidence that such
measures are effective.
Nevertheless, it seems likely that adherence can
be improved by taking care to explain the benefits
and adverse effects of a drug. In a busy clinic it is
too easy for the prescriber to give out a
prescription with little or no explanation. It
also makes sense to reduce the frequency of
taking medicine to once or twice a day: though
again, there is no evidence that this tactic is
effective.
It is estimated that only 50% of patients
suffering from chronic diseases in developed
countries follow treatment recommendations.
This may affect the health of the patient, as
well as that of the wider society when resulting
in complications from chronic diseases,
formation of resistant infections, or untreated
psychiatric illness. Compliance rates during
closely monitored studies are usually far higher
than in later real-world situations: for example,
there may be up to 97% compliance in some
studies on statins, but only about 50% of
patients continue at six months.
Again, the word “adherence” is preferred by
many health care providers, because
“compliance” suggests that the patient is
passively following the doctor’s orders.
Patients should not be passive: a treatment
plan must be based on a therapeutic alliance or
contract between the patient and the physician.
Yet at least one reference implies that both
terms are flawed, giving no meaningful
information.
A placebo is a sham treatment that may be used
clinically to placate a patient or experimentally to
establish the efficacy of a drug or other medical
procedure.
The placebo effect is the effect produced by
administering a placebo. In addition, active
medications may produce placebo effects as well
as drug effects and these may be additive. In this
case, the placebo effect is that portion of the
treatment effect that was produced
psychologically, rather than through physical
means.
Typically, placebos are physically inert
substances which are identical in appearance to
an active drug. Occasionally, active substances
are used as placebos. Active placebos have
side-effects that mimic those of the drug being
investigated, but do not possess the physical
properties hypothesized to produce the
beneficial treatment effect. Active placebos are
used to prevent patients from using the
sensory cues provided by side effects to deduce
the condition to which they have been
randomized.
Any medical procedure can have effects due to the
physical properties of the treatment and effects due to its
psychological properties. Just as the effects of the
physical properties of a medication can be tested
by comparing its effects to those of a sham
medication, so too the physically produced effects
of other medical procedures can be established by
comparison with sham procedures (e.g. sham
surgery). For example, real and sham surgery have
been compared in the treatment of angina and
osteoporosis of the knee. In both cases, the effects
appear to be due to the psychological properties of
the treatment, rather than to the surgical
procedures themselves.
The response to a medication is not the same thing as
the effect of that medication. This is because there are
many reasons by which a person might get better. One
is the natural history of the disease. People get better
from many conditions (e.g. the common cold)
regardless of whether they are treated or not.
Sometimes there is spontaneous remission in disorders
that aren’t always self-healing (e.g. depression or
cancer). There is also the statistical problem of
regression towards the mean, i.e. when you reassess
something, people who scored at the extremes will
tend to display scores closer to the mean. Finally, the
response to a medication includes the placebo effect.
Placebos are intended to control for all these sources of
improvement. Thus, the drug effect is assumed to be
the difference between the response to medication and
the response to placebo.
