Vol 6 n° 1 - Predictors of Response to Treatment in Neuropsychiatry
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he appearance of pharmacological treatments in the 1950s was a milestone in modern psychiatric his- tory. Today, the  goals  of  psychiatric  treatment  are  to reduce and, ideally, eliminate symptoms, and prevent new episodes of illness. The final objective is remission, an asymptomatic state in which the patient returns to a fully functional  personal, family, and  social  life. With  psy- chotropic drugs, therapy has changed from a moral and human  approach  to  treatment  based  on  the  biopsy- chosocial concept of the illness, as defined by the World Health Organization (WHO). While drugs are effective in treating psychiatric disorders, some patients have no or only a partial response to treat- ment. This affects not only the patient, but also the fam- ily and the professionals caring for that patient.The lack of response should be considered as a multifaceted prob- lem, involving variables inherent to the illness itself, as well as those relating to the patient and psychosocial fac- tors. Although it may seem very basic, one of the main factors  to  be  considered  when  evaluating  a  patient responding poorly to treatment is the way in which the treatment is being carried out. There  are  two  concepts  related  to  the  way  in  which treatment  is  carried  out: compliance  and  adherence. Compliance includes many variables, but refers mainly to the degree to which patients follow physicians’ instruc- tions (primarily the number of pills taken daily accord- ing to the schedule prescribed). For many authors, com- pliance is a passive behavior on the part of the patient. In contrast, adherence implies active behavior in which a patient’s beliefs with respect to mental illness and drugs are key to the decision of whether to cooperate volun- tarily with the treatment regimen.1,2 In most psychiatric cases, patients with the freedom to do so choose profes- sionals who have the same ideas as themselves, which should increase likelihood of adhering to the prescrip- tions. However, in a group of patients in primary health care, suffering from dysthymia and mild depression, it Keywords: adherence; compliance; depression; schizophrenia; psychosocial factor Author affiliations: Professor of Psychiatry, Faculty of Medicine, Universidad de los Andes, and Hospital del Trabajador Santiago, Chile Address  for  correspondence:  César  Carvajal,  MD,  Facultad  de  Medicina, Universidad  de  los  Andes,  San  Carlos  de  Apoquindo  2200,  Las  Condes, Santiago de Chile, Chile (e-mail: cesarcar@mi-mail.cl) C l i n i c a l   r e s e a r c h 9 3 Poor response to treatment: beyond medication César Carvajal, MD T In psychiatry, one of the main factors contributing to poor response  to  pharmacological  treatment  is  adherence. Noncompliance with maintenance treatments for chronic illnesses such as schizophrenia and affective disorders can exceed 50%. Poor adherence can be due to drug-related factors (tolerance, complexity of prescription, side effects, or  cost),  patient-related  variables  (illness  symptoms, comorbidity, insight capacity, belief system, or sociocul- tural environment), and physician-related factors (com- munication or psychoeducational style). Psychosocial treat- ments  must  be  used  in  conjunction  with  medication during the maintenance phase to improve adherence to treatment and to achieve—through the management of psychological variables—better social, work, and family functioning. This article reviews the concepts of adherence and noncompliance, and their impact on maintenance treatments, as well as the effect of dealing with psy- chosocial factors in psychiatric treatment. © 2004, LLS SAS Dialogues Clin Neurosci. 2004;6:93-103. Copyright © 2004 LLS SAS.  All rights reserved www.dialogues-cns.org