BI POLAR AFFECTI VE DI SORDER: MEDI CATI ON ADHERENCE AND SATI SFACTI ON W I TH
TREATMENT AND GUI DANCE BY THE HEALTH TEAM I N A MENTAL HEALTH SERVI CE
1Adr iana I nocent i Miasso2 Mar ist ela Mont eschi3 Kelly Gr azian i Giacch er o4
Miasso AI , Mont eschi M, Giaccher o KG. Bipolar affect iv e disor der : m edicat ion adher ence and sat isfact ion w it h t reat m ent and guidance by t he healt h t eam in a m ent al healt h service. Rev Lat ino- am Enferm agem 2009 j ulho-agost o; 17( 4) : 548- 56.
Bipolar Affect ive Disorder ( BAD) is a chronic disease and requires m edicat ion t reat m ent . This st udy verified t he ad h er en ce of p eop le w it h BAD t o m ed icat ion an d com p ar ed , am on g ad h er en t an d n on - ad h er en t p at ien t s, sat isf act ion w it h t h e h ealt h t eam an d t r eat m en t . Tw en t y - on e pat ien t s w it h BAD r eceiv in g car e in a m en t al healt h unit part icipat ed in t he st udy. The Morisky- Green t est and anot her inst rum ent elaborat ed by t he researchers w er e used for int er v iew s. Dat a w er e analy zed w it h qualit at iv e and quant it at iv e appr oaches. Result s show ed t h at t h e m aj or it y of pat ien t s did n ot adh er e t o t h e m edicat ion t r eat m en t du e t o “ n on - in t en t ion al beh av ior ” ( negligence or forget fulness) . The m aj orit y report s sat isfact ion wit h inform at ion received regarding t he m edicat ion and it s effect iveness, t hough t here were report s of collat eral effect s, doubt s and lack of m ot ivat ion t o keep up t h e t r eat m en t . Th is r esear ch sh ow s t h e n eed f or st r at egies dir ect ed at pr om ot in g adh er en ce t o m edicat ion t herapy in pat ient s w it h BAD.
DESCRI PTORS: bipolar disor der ; pat ient car e t eam ; pat ient sat isfact ion; dr ug adm inist r at ion schedule
EL TRASTORNO AFECTI VO BI POLAR: ADHESI ÓN AL MEDI CAMENTO Y SATI SFACCI ÓN
CON EL TRATAMI ENTO Y ORI ENTACI ONES DEL EQUI PO DE SALUD DE UN
NÚCLEO DE SALUD MENTAL
El t r ast or n o af ect iv o bipolar ( TAB) es cr ón ico y r equ ier e t r at am ien t o m edicam en t oso par a su con t r ol. Est e est udio verificó la adhesión de personas con TAB a la m edicación y com paró, ent re adherent es y no adherent es, la sat isfación en cu an t o al equipo de salud y al t r at am ient o. Par t icipar on del est udio 2 1 pacient es con TAB at endidos en un Núcleo de Salud Ment al. Fue realizada una ent revist a con aplicación de la prueba de Morisky-Gr en y d e u n in st r u m en t o elab or ad o p or las in v est igad or as. Los d at os f u er on an alizad os con u n ab or d aj e cualit at ivo y cuant it at ivo. Los result ados m ost raron que la m ayor part e de los pacient es no adhiere al t rat am ient o m ed icam en t oso p or “ com p or t am ien t o n o in t en cion al” . La m ay or ía d e ellos af ir m a t en er sat isf ación con la efect iv idad del m edicam ent o y con las infor m aciones r ecibidas sobr e est e, sin em bar go fuer on ident idificados r elat os d e ef ect os colat er ales, d u d as y f alt a d e m ot iv ación p ar a seg u ir el t r at am ien t o. Est a in v est ig ación ap u n t a p ar a l a n ecesi d ad d e el ab o r ar est r at eg i as d i r i g i d as a l a p r o m o ci ó n d e l a ad h esi ó n a l a t er ap i a m edicam ent osa en pacient es con TAB.
DESCRI PTORES: t r ast or n o b ip olar ; g r u p o d e at en ción al p acien t e; sat isf acción d el p acien t e; esq u em a d e m ed icación
TRANSTORNO AFETI VO BI POLAR: ADESÃO AO MEDI CAMENTO E SATI SFAÇÃO COM O
TRATAMENTO E ORI ENTAÇÕES DA EQUI PE DE SAÚDE DE UM NÚCLEO DE SAÚDE MENTAL
O t r an st or n o af et iv o b ip olar ( TAB) é cr ôn ico e r eq u er t r at am en t o m ed icam en t oso p ar a seu con t r ole. Est e est udo v er ificou a adesão de pessoas com TAB à m edicação e com par ou, ent r e ader ent es e não ader ent es, a sat isfação quant o à equipe de saúde e t rat am ent o. Part iciparam do est udo 21 pacient es com TAB at endidos em u m Nú cleo d e Saú d e Men t al. Foi r ealizad a en t r ev ist a com ap licação d o t est e d e Mor isk y - Gr een e d e u m in st r u m en t o elabor ado pelas pesqu isador as. Os dados f or am an alisados com abor dagem qu ali- qu an t it at iv a. Os r esu lt ad os m ost r ar am q u e a m aior p ar t e d os p acien t es n ão ad er e ao t r at am en t o m ed icam en t oso p or “ com por t am ent o não int encional” . A m aior ia deles afir m a sat isfação com a efet ividade do m edicam ent o e com as infor m ações r ecebidas sobr e o m esm o, m as for am ident idificados r elat os de efeit os colat er ais, dúv idas e falt a de m ot ivação para seguir o t rat am ent o. Est a pesquisa apont a para a necessidade de est rat égias direcionadas à pr om oção da adesão à t er apia m edicam ent osa em pacient es com TAB.
DESCRI TORES: t r an st or n o bipolar ; equ ipe de assist ên cia ao pacien t e; sat isf ação do pacien t e; esqu em a de m ed i cação
Escola de Enferm agem de Ribeirão Pret o, Universidade de São Paulo, WHO Collaborat ing Cent re for Nursing Research Developm ent , Brazil: 1This research was support ed by FAPESP; 2RN, Facult y, e- m ail: am [email protected]; 3Undergraduat e st udent in Nursing, e- m ail: m arist elam ont [email protected] .br; 4
RN, Mast er ’s st udent in Nursing, e- m ail: [email protected] .br.
I NTRODUCTI ON
B
i p o l ar Af f ect i v e Di so r d er ( BAD) co n si st s i n a ch r o n i c d i so r d e r ch a r a ct e r i ze d b y i m p o r t a n tm o o d o sci l l a t i o n s b e t w e e n t h e p o l e s o f e u p h o r i a
( m an ia) an d depr ession . I t af f ect s ar ou n d 1 . 6 % of
t h e p o p u l a t i o n( 1 ) a n d h a s a n i m p o r t a n t i n f l u e n ce
o n p a t i e n t s ’ l i f e , s i n c e i t c a n c a u s e e x p r e s s i v e
f u n c t i o n a l p r e j u d i c e s , d i f f i c u l t i e s f o r s e l f - c a r e ,
in ad eq u at e b eh av ior an d in t er p er son al r elat ion sh ip
p r o b l e m s( 2 ).
Co n t i n u o u s m e d i c a t i o n t r e a t m e n t i s
n ecessar y f or BAD con t r ol. Wit h ou t t h e t r eat m en t s
c u r r e n t l y a v a i l a b l e , p a t i e n t s u s e d t o s p e n d a
q u ar t er of t h eir ad u lt lif e in h osp it al an d h alf of it
w i t h se r i o u s f u n ct i o n a l l i m i t a t i o n s. Th e e f f e ct i v e
m e d i ca t i o n s u se d , co m b i n e d w i t h p sy ch o t h e r a p y,
p e r m i t 7 5 - 8 0 % o f p a t i e n t s w i t h BAD t o l e a d a n
essen t i al l y n o r m al l i f e( 3 ).
Ef f icacy of m edicat ion t r eat m en t is dir ect ly
r e l a t e d t o a d h e r e n ce t o i t . H o w e v e r, a co m m o n
p r ob lem in BAD t r eat m en t is t h at p at ien t s d o n ot
a l w a y s t a k e m ed i ca t i o n s r eg u l a r l y. Th i s a sp ect i s
r elev an t f or h ealt h pr of ession als, as n on adh er en ce
c a n i n c r e a s e t h e r e c u r r e n c e o f m a n i a , t h e
f r eq u en cy of d ep r essiv e ep isod es, h osp it alizat ion s
a n d su i ci d es, co m p r o m i si n g t h e q u a l i t y o f l i f e o f
p at ien t s an d r elat iv es an d in cr easin g cost s f or t h e
h ealt h sy st em( 4 - 5 ).
Th e co n ce p t o f a d h e r e n ce v a r i e s a m o n g
d i f f e r e n t a u t h o r s , h o w e v e r, i n g e n e r a l , i t i s
u n d er st ood as t h e d eg r ee t o w h ich p at ien t s f ollow
m ed ical or h ealt h p r of ession als’ r ecom m en d at ion s,
r e t u r n t o t h e se r v i ce a n d m a i n t a i n t h e i n d i ca t e d
t r eat m en t( 1 ). I t i s h i g h l i g h t ed t h at au t h o r s d ef i n e
t h e t e r m a d h e r e n c e a c c o r d i n g t o t h e i r
u n d er st an d in g ab ou t t h e r ole of t h e act or s in t h e
p r o c e s s . T h e m o s t u s e d t e r m s i n En g l i s h ,
a d h e r e n c e a n d c o m p l i a n c e , h a v e d i f f e r e n t
m e a n i n g s. Co m p l i a n ce, w h i ch i n Po r t u g u e se ca n
b e t r an slat ed as ob ed iên cia, pr esu pposes a passiv e
r o l e o f t h e p at i en t , an d ad h er en ce, o r ad er ên ci a,
is u sed t o iden t if y a f r ee ch oice of people t o adopt
a cer t ain r ecom m en d at ion or n ot( 6 ).
Non - ad h er en ce t o m ed icat ion t h er ap y is a
p h en o m en o n su b j ect t o t h e i n f l u en ce o f m u l t i p l e
f act or s r elat ed t o sociodem ogr aph ic con dit ion s, t h e
d i sease, t h er ap y, t h e r el at i o n sh i p b et w een h eal t h
p r o f e s s i o n a l s a n d p a t i e n t s a s w e l l a s p a t i e n t s
t h e m se l v e s( 2 - 3 ). On e f a ct o r w h o se i m p o r t a n ce i s
i n c r e a s i n g l y a c k n o w l e d g e d i s t h e c o n f i d e n c e
p a t i e n t s h a v e i n t h e p r e s c r i b e d m e d i c a t i o n , i n
t r eat m en t as a w h ole, in t h e ph y sician r espon sible
f or p r escr ib in g , an d in t h e en t ir e h ealt h t eam( 7 ).
Am on g t h e pr esu pposit ion s sev er al au t h or s
a s s u m e t o s t u d y a d h e r e n c e , t h e m o s t e v i d e n t
d i f f e r e n ce s a r e b e t w e e n t h o se w h o f o cu s o n t h e
p h e n o m e n o n i n p a t i e n t s a n d t h o se w h o se e k t o
u n d e r s t a n d i t t h r o u g h e x t e r n a l f a c t o r s . I t i s
h ig h lig h t ed t h at p at ien t - r elat ed f act or s, h ar d er t o
c o n t r o l , a l w a y s h a v e g r e a t i n f l u e n c e o n t h e
a d h er en ce i ssu e( 8 ).
Con sid er in g t h e d escr ib ed asp ect s an d t h e
f act t h at pat ien t / h ealt h t eam in t er act ion r epr esen t s
a r e l e v a n t f a ct o r f o r t r e a t m e n t a d h e r e n ce , t h i s
st u dy v er if ied t h e adh er en ce of pat ien t s w it h bipolar
a f f e c t i v e d i s o r d e r t o t h e p r e s c r i b e d m e d i c a t i o n
t h e r a p y , u s i n g t h e M o r i s k y - G r e e n t e s t( 9 ), a n d
com par ed sat isf act ion w it h t h e h ealt h t eam an d t h e
m ed icat ion t h er ap y b et w een p at ien t s id en t if ied as
adh er en t an d n on adh er en t . Th is k in d of st u dy giv es
i m p o r t a n t s u p p o r t f o r t h e i m p l e m e n t a t i o n o f
in t er v en t ion st r at eg ies in h ealt h ser v ices, d ir ect ed
at m ed i cat i o n ad h er en ce b y BAD p at i en t s as w el l
as t h e qu alit y of car e t o t h is clien t ele.
METHODS
T h i s c r o s s - s e c t i o n a l , d e s c r i p t i v e ,
q u alit at iv e an d q u an t it at iv e st u d y w as car r ied ou t
i n a Me n t a l He a l t h Se r v i ce ( MHS) i n t h e ci t y o f
Ribeir ão Pr et o, st at e of São Pau lo, Br azil, w h ich is
par t of t h e Un if ied Healt h Sy st em . Th e pr oj ect w as
d ev el o p ed a f t er a u t h o r i za t i o n b y t h e m a n a g er o f
t h e m e n t i o n e d s e r v i c e a n d a p p r o v a l b y t h e
i n s t i t u t i o n ’ s Re s e a r c h a n d Et h i c s Co m m i t t e e
( Pr o t o co l n . 2 0 6 / CEP- CSE- FMRP- USP) .
Pa r t i ci p a n t s w e r e p a t i e n t s w i t h BAD w h o
r e ce i v e d ca r e i n t h e MHS i n Ma y 2 0 0 7 a n d w h o
m e t t h e f o l l o w i n g i n cl u si o n cr i t e r i a : h a v i n g BAD
d iag n osis g iv en b y t h e p h y sician f r om t h e ser v ice,
h av in g a p r escr ip t ion of m ed icat ion of con t in u ou s
u se f or BAD t r eat m en t , b ei n g 1 8 y ear s of ag e or
o l d e r, b e i n g a b l e t o c o m m u n i c a t e v e r b a l l y i n
Po r t u g u e se , a g r e e i n g t o p a r t i ci p a t e i n t h e st u d y
an d si g n i n g t h e f r ee an d i n f o r m ed co n sen t f o r m .
st u d ied p er iod b u t w h o d id n ot m eet t h e in clu sion
cr i t er i a w er e ex cl u d ed .
Recor d ed sem i - st r u ct u r ed i n t er v i ew s w er e
u sed f or d at a collect ion . Th e d eg r ee of ad h er en ce
w as def in ed by t h e Mor isk y - Gr een t est( 9 ). Th is t est
per m it s t o ident ify t he pat ient ’s degr ee of adher ence
and discr im inat e if occasional non adher ence is due
t o int ent ional behavior ( quest ions: “ when you feel well,
do y ou at any t im e not t ak e y our m edicat ion?” and
“ w h en y ou f eel bad, t ak in g t h e m edicat ion , do y ou
som et im es not t ake it ?” ) or non int ent ional ( quest ions:
“ do you, at any t im e, forget t o t ake your m edicat ion?”
and “ are you, som et im es, careless regarding t he t im e
t o t ake your m edicat ion?” ) . The t est was validat ed by
ot h er st u d ies an d h as alr ead y b een t r an slat ed an d
applied in Br azil.
Valu es of 0 ( zer o) an d 1 w er e at t r ib u t ed t o
t h e an sw er s. Th e v al u e 1 w as at t r i b u t ed t o each
p o si t i v e a n sw er i n w h i ch t h e a d m i t t ed f r eq u en cy
w as on ce a m on t h or less, an d t h e v alu e 0 ( zer o)
t o o t h e r p o s s i b i l i t i e s o f f r e q u e n c y. Th e c r i t e r i a
ad op t ed t o classif y t h e d eg r ee of ad h er en ce w er e:
“ a d h e r e n t ” p a t i e n t s w h o sco r e d 4 p o i n t s o n t h e
M o r i s k y - Gr e e n t e s t( 8 ) a n d “ n o n a d h e r e n t ” w h o
scor ed f r om 0 t o 3 p oin t s.
To c o l l e c t i n f o r m a t i o n o n t h e p a t i e n t ’ s
p e r c e p t i o n , a n i n s t r u m e n t d e v e l o p e d b y t h e
r esear ch er s w as u sed , w h ich in v est ig at es: op in ion
a b o u t t h e c a r e o f f e r e d b y t h e M H S t e a m ,
sat isf act ion w it h m edicat ion t r eat m en t an d w it h t h e
o r i e n t a t i o n s r e c e i v e d a t t h e MH S , e x i s t e n c e o f
d o u b t s ab o u t m ed i cat i o n s i n u se an d su g g est i o n s
t o im pr ov e car e. Th is in st r u m en t w as applied af t er
car r y in g ou t a pilot st u dy t o t est it s su it abilit y.
Descr ipt iv e st at ist ics w as u sed f or an aly sis
o f t h e d a t a r e l a t e d t o m e d i ca t i o n a d h e r e n ce . A
q u a l i t a t i v e a p p r o a c h , a c c o r d i n g t o M i n a y o ’ s
p r e s u p p o s i t i o n s , w a s u s e d f o r d a t a r e g a r d i n g
p at ien t s’ p er cep t ion ab ou t t h e h ealt h t eam( 1 0 ).
RESULTS AND DI SCUSSI ON
Char act er izat ion of st udy subj ect s
I n t ot al, 21 pat ient s part icipat ed in t his st udy,
b et w een 2 3 an d 7 9 y ear s of ag e. Th e t ab le b elow
pr esent s t he sociodem ogr aphic char act er ist ics of t he
st udy par t icipant s.
Table 1 – Charact erizat ion of subj ect s part icipat ing in
t he st udy
I t i s o b s e r v e d , i n Ta b l e 1 , t h a t m o s t
( 8 5 . 7 % ) i n t er v i ew ees w er e f em a l e, a l t h o u g h a n y
si g n i f i can t d i f f er en ce i n BAD d i st r i b u t i o n b et w een
g en d er s h as n ot b een p r ov ed . Th e h ig h n u m b er of
w om en in t h is st u d y can b e ex p lain ed b y t h e f act
t h at m en w it h BAD seek h ealt h ser v ices sign if ican t ly
less t h an w om en( 1 1 ).
A h i g h e r p e r ce n t a g e ( 4 2 . 8 % ) o f m a r r i e d
p ar t i ci p an t s w as o b ser v ed . Reg ar d i n g ed u cat i o n al
l e v e l , m o s t p a t i e n t s h a d c o m p l e t e d p r i m a r y o r
u n iv er sit y edu cat ion ( 5 2 . 5 % ) . I t is h igh ligh t ed t h at
1 4 . 3 % o f p a t i e n t s w e r e d i v o r c e d , a n d a l l g o t
d i v o r ced af t er t h e ap p ear an ce o f BAD . Of t h e 2 1
p at ien t s, on ly 2 3 . 8 % h ad a f or m al j ob , 1 9 . 1 % w er e
u n em p loy ed , 9 . 5 % w er e on leav e b y t h e Nat ion al
So ci a l Secu r i t y I n st i t u t e ( I NSS) a n d 1 4 . 3 % w er e
r et ir ed d u e t o t h e m en t al d isor d er. Th ese asp ect s
a r e r e l e v a n t a s, w i t h o u t a j o b , p e o p l e w i t h BAD
l o s e t h e i r s o c i a l r o l e s a n d t h e i r s e l f - e s t e e m ,
e x p e r i e n c i n g f e e l i n g s o f s o c i a l e x c l u s i o n . Ev e n
w h en so ci al secu r i t y b en ef i t s r ed u ce t h e f i n an ci al
p r ob lem s, f eelin g s of w or t h lessn ess an d f ailu r e in
p r ov id in g f or f am ily n eed s can occu r( 2 ).
s c i t s i r e t c a r a h
C N %
r e d n e G e l a m e
F 18 85.7
e l a
M 3 14.3
l a t o
T 21 100
s u t a t s l a t i r a M d e i r r a
M 9 42.8
e l g n i
S 8 38.1
d e c r o v i
D 3 14.3
g n it a t i b a h o
C 1 4.8
l a t o
T 21 100
l e v e l l a n o it a c u d E e t a r e t il
lI 2 9.5
e t i r w d n a d a e r o t w o h s w o n
K 2 9.5
n o it a c u d e y r a m i r p e t e l p m o c t o n d i
D 6 28.5
n o it a c u d e y r a m i r p d e t e l p m o
C 7 33.3
n o it a c u d e y r a d n o c e s e t e l p m o c t o n d i
D 1 4.8
n o it a c u d e y r a d n o c e s d e t e l p m o
C 1 4.8
n o it a c u d e y t i s r e v i n u d e t e l p m o
C 1 4.8
s e i d u t s e t a u d a r g d e t e l p m o
C 1 4.8
l a t o
T 21 100
n o it a p u c c O d e r it e
R 3 14.3
d e y o l p m e n
U 4 19.1
t c a r t n o c l a m r o f h t i w r e k r o
W 5 23.8
e v a e l k c i s n o r e k r o
W 2 9.5
e f i w e s u o
H 7 33.3
l a t o
T h e b e h a v i o r r e l a t e d t o m e d i c a t i o n t r e a t m e n t
a d h e r e n c e
Ad h e r e n c e t o m e d i c a t i o n t r e a t m e n t w a s
a s s e s s e d b y t h e M o r i s k y - G r e e n t e s t( 9 ), w h i c h
p e r m i t s t o e v a l u a t e i f p a t i e n t s’ o cca si o n a l n o n
-adh er en ce is du e t o in t en t ion al beh av ior ( n ot t ak in g
m ed icat ion b ecau se of f eelin g w ell or f eelin g b ad )
o r n o n - i n t e n t i o n a l ( f o r g e t f u l n e s s a n d c a r e l e s s
b eh av i o r r eg ar d i n g m ed i cat i o n t i m e) .
A m o n g t h e r e s e a r c h e d p a t i e n t s , m o s t
( 5 7 . 2 % ) ar e n o n - ad h er en t d u e t o n o n i n t en t i o n al
beh av ior, 1 4 . 3 % is n on - adh er en t du e t o in t en t ion al
b e h a v i o r a n d o n l y 2 8 . 5 % i s a d h e r e n t . T h e s e
f i n d i n g s co r r o b o r a t e r e se a r ch r e su l t s t h a t r e p o r t
h i g h n o n - a d h e r e n c e r a t e s i n b i p o l a r d i s o r d e r,
r ep r esen t in g 4 7 % at som e st age of t h e t r eat m en t ,
an d t h at n ear l y 5 0 % of b i p ol ar p at i en t s i n t er r u p t
t h e t r eat m en t at least on ce, w h ile 3 0 % of t h em do
it at least t w ice( 4 ).
N o n - a d h e r e n ce t o p r e scr i b e d m e d i ca t i o n
c a n i n c r e a s e t h e o c c u r r e n c e o f m a n i a a n d
e x p e r i e n ce s o f d i so r d e r cr i se s. Th e se a r e t w o o f
t h e c a u s e s r e l a t e d t o r e - h o s p i t a l i z a t i o n a n d
su icid e( 4 ). Also, t h e cr ises an d h osp it alizat ion s ar e
gr adu ally f ollow ed by af f ect iv e an d cogn it iv e losses,
f in an cial, w or k , leisu r e an d st u dy lim it at ion s, am on g
o t h er s i n o t h er a r ea s o f d a i l y l i f e, co m p r o m i si n g
t h e q u al i t y o f l i f e o f p at i en t s an d t h ei r r el at i v es,
b e s i d e s g e n e r a t i n g h i g h c o s t s f o r t h e h e a l t h
ser v i ces( 2 ). Th u s, n o n - ad h er en ce t o m ed i cat i o n i s
r e sp o n si b l e f o r g r e a t f r u st r a t i o n s i n p sy ch i a t r y,
d eser v i n g sp eci al at t en t i on f r om h eal t h m an ag er s
w h o a c t i n t h i s a r e a . T h e s e a s p e c t s s h o w t h e
im por t an ce of pu t t in g in pr act ice, in h ealt h ser v ices,
co m b i n e d i n t e r v e n t i o n s a i m i n g t o o b t a i n h i g h e r
r a t e s o f a d h e r e n ce a n d b e t t e r ca r e su p p o r t f o r
m en t al d i so r d er t r eat m en t s. Th ey al so r ev eal t h e
n eed f or et h ical r ef lect ion , in w h ich r ecogn izin g an d
r e s p e c t i n g i n d i v i d u a l i t y a n d f r e e w i l l i s a n
est a b l i sh ed a n d f o l l o w ed p a r a m et er i n t r ea t m en t
or ien t at ion an d m ain t en an ce( 1 2 ).
Adh er en ce t o m edicat ion t r eat m en t an d sat isf act ion
w it h t h e h ealt h t eam
At t h i s st a g e , r e su l t s a n d d i scu ssi o n w i l l
b e p r e se n t e d i n t o p i cs, a cco r d i n g t o t h e co n t e n t
an d st at em en t s of each gr ou p of pat ien t s, classif ied
b y t h e Mo r i s k y - Gr e e n t e s t( 9 ) i n t o p a t i e n t s w h o
adh er ed t o m edicat ion , w h o u n in t en t ion ally did n ot
ad h er e an d w h o in t en t ion ally d id n ot ad h er e.
Opin ion r egar din g car e pr ov ided by t h e MHS h ealt h
t e a m
I t w a s o b s e r v e d t h a t a l l p a t i e n t s w h o
a d h e r e d t o m e d i c a t i o n t r e a t m e n t g a v e p o s i t i v e
r e p o r t s o f t h e h e a l t h t e a m , m e n t i o n i n g b e i n g
sat isf ied w it h it . Th is f in d in g su p p or t s r esu lt s of a
b ib liog r ap h ic r ev iew( 8 ) on ad h er en ce t o m ed icat ion
t h er a p y, w h ich id en t if ied sev er al p u b licat ion s t h at
sh o w p a t i en t s’ co n f i d en ce i n p r escr i p t i o n s a n d i n
t h e h ealt h t eam as d ecisiv e f act or s f or ad h er en ce.
Am on g pat ien t s w h o u n in t en t ion ally d id n ot
a d h e r e , i t w a s o b se r v e d t h a t m o st ( 8 3 . 3 3 % ) o f
t h em ex p r essed sa t i sf a ct i o n w i t h ca r e o f f er ed b y
t h e h ealt h t eam . Nev er t h eless, t h er e ar e p at ien t s
w h o e x p r e s s r e l a t e d d i s s a t i s f a c t i o n , m a i n l y
r e g a r d i n g t h e t i m e i n t e r v a l b e t w e e n s c h e d u l e d
m e d i ca l a p p o i n t m e n t s, t h e l a ck o f a v a i l a b i l i t y o f
t h e ser v ice t o r eceiv e pat ien t s w h en t h ey w er e n ot
sch ed u led t o r et u r n , t h e d elay an d st an d ar d izat ion
o f ca r e ( f i r st co m e f i r st - se r v e d ca r e a n d l a ck o f
n o t i c e w h e n m e d i c a l c o n s u l t a t i o n s a r e
r e sch e d u l e d ) .
. . . I t h in k car e is d elay ed , I m ean . . . it is d if f icu lt t o receive us when we need t o, at t he m om ent ... And t he scheduled con su lt at ion s ar e v er y f ar on e f r om t h e ot h er , t h en I b eliev e t h at it is n ot v er y g ood ( A) .
Th e i ssu e o f a v a i l a b i l i t y a n d q u a l i t y i s a
p r ob lem in p u b lic ser v ices in g en er al, n ot on ly in
t h e MHS. Af t er t h e im p lem en t at ion of t h e Un if ied
Healt h Sy st em ( SUS) , t h eor et ically, any per son h as
t h e r i g h t t o f r ee car e, h o w ev er, t h e g u ar an t ee o f
access t o q u alit y car e is st ill a d ist an t d r eam( 1 3 ).
I n t h is con t ex t , pat ien t s’ st at em en t s r ev eal
t h e i r d i sco n t e n t m e n t w i t h t h e st a n d a r d i za t i o n o f
in t er v en t ion s. Th ey f eel disr espect ed f or n ot h av in g
a n i n d i v i d u a l sch e d u l e f o r m e d i ca l co n su l t a t i o n s.
Th ey com plain , t h u s, of t h e delay in car e, t h e lack
o f n o t i c e s w h e n m e d i c a l c o n s u l t a t i o n s a r e
r esch ed u l ed an d f i r st co m e f i r st - ser v ed car e.
Lat ely , t hey hav e scheduled ev er y body for 1pm , t o be r eceiv ed in or der of ar r iv al. I believ e it is n ot r igh t t o sch edu le pat ien t s in or d er of ar r iv al ( H) .
Lit er at u r e( 1 4 ) r ev eals t h at t h e f ailu r es in car e
s e s s i o n s , s u c h a s t h e l o n g d e l a y s a n d
p o s t p o n e m e n t o f c o n s u l t a t i o n s , a r e d a i l y a n d
“ d e h u m a n i z i n g ” p r a c t i c e s , w h i c h n e e d t o b e
r et h o u g h t t o o p t i m i ze an d i m p r o v e t h e q u al i t y o f
ca r e .
Am o n g p at i en t s w h o i n t en t i o n a l l y d i d n o t
a d h e r e , i t w a s v e r i f i e d t h a t , o f a t o t a l o f t h r e e
p at ien t s, on e w as d issat isf ied w it h car e of f er ed b y
t h e h ealt h t eam , af f ir m in g n ot t o f eel saf et y in t h e
r elat ion sh ip w it h t h e phy sician . How ev er, t h e r epor t
of t h e p at ien t is n ot r est r ict ed t o t h e p h y sician of
t h e MHS on ly, bu t r ef er s t o psy ch iat r ist s as a w h ole.
. . . h e ( p h y sician ) does n ot giv e m e con f iden ce. . . He look s lik e cr azy , ev er y p sy ch iat r ist is lik e t h at . . . look s m or e lik e cr azy t h an w e w h o h av e a p r ob lem ( V) .
These aspect s are relevant as, when pat ient s
do not feel safe in t he physician/ pat ient r elat ionship,
su r el y t h ey w i l l h av e d i f f i cu l t i es t o b el i ev e i n t h e
pr escr ibed t r eat m ent and adher e t o it( 8).
Sa t i sf a ct i o n w i t h t h e e f f i ca cy o f t h e m e d i ca t i o n
t r e a t m e n t
As t o t h e sat i sf act i on w i t h t h e ef f i cacy of
t h e m ed icat ion t r eat m en t , it w as v er if ied t h at , of
t h e si x p a t i en t s w h o a d h er ed, t h r ee ( 5 0 % ) w er e
sat isf ied, on e ( 1 6 . 7 % ) h ad dou bt s abou t it s ef f icacy
an d t w o ( 3 3 . 3 % ) p at ien t s w er e d issat isf ied .
I t i s h i g h l i g h t e d t h a t , a l t h o u g h p a t i e n t s
sat isf ied w it h t h e m ed icat ion in u se b eliev e t h at it
is w or k in g, all of t h em , at som e poin t , com plain ed
of t h e collat er al ef f ect s an d t h e n eed t o ex per ien ce
t h em .
I t is w or k in g. . . I h ad lon g h air , I w as t ak in g v alpr oic acid , all m y h air f ell ( N) .
I t is w or k in g , b u t I am g ain in g w eig h t . . . I g ain ed 1 0 k ilos ( Q) .
I t hink so ( t hat it is w orking) ... but I get sleepy ( F) .
I t i s sh o w n t h r o u g h t h e st a t em en t s t h a t ,
w h e n t h e o p t i o n i s t o a d h e r e t o t h e m e d i ca t i o n
t r e a t m e n t , t h e p e r s o n w i t h B A D s t a r t s t o
ex per ien ce t h e collat er al ef f ect s of t h e psy ch ot r opic
d r u g s , w h i c h c a n e n t a i l p h y s i c a l a n d e m o t i o n a l
con sequ en ces. Possible ef f ect s in clu de h air loss an d
w e i g h t g a i n , c h a n g i n g p a t i e n t s ’ p h y s i c a l
a p p e a r a n ce , w h i ch ca n co m p r o m i se se l f - e st e e m ,
c a u s e d i s c o m f o r t , r e s t r i c t d a i l y a c t i v i t i e s a n d
ch an g e t h e social id en t it y( 2 ).
A d h e r e n t p a t i e n t s , w h o r e p o r t e d
d issat isf act ion w it h t h e ef f icacy of t h e m ed icat ion ,
assu m ed act iv e b eh av ior, seek in g m ed ical car e t o
so l v e t h e p r o b l em .
Now I cam e h er e ex act ly t o t alk t o t h e p h y sician , I h av e in som n ia, I d o n ot k n ow w h at h ap p en ed , I cam e t o t alk t o h im ( M) .
Reg ar d in g p at ien t s w h o u n in t en t ion ally d id
n o t a d h e r e , i t w a s v e r i f i e d t h a t , d e s p i t e t h e
f o r g et f u l n ess o r o ccasi o n al car el essn ess i n t ak i n g
t h e m e d i ca t i o n , h a l f o f t h e m r e p o r t sa t i sf a ct i o n
r egar din g t h e ef f icacy of t h e m edicat ion t r eat m en t .
Ho w ev e r, ev en p a t i en t s w h o co n si d er t h em sel v es
s a t i s f i e d r e p o r t o n n e g a t i v e a s p e c t s , s u c h a s
a l w a y s h a v i n g t o t a k e t h e m ed i ca t i o n , ex cess o f
m e d i c a t i o n a n d s l e e p i n e s s , r e v e a l i n g t h a t
sat isf act ion is n ot f u ll.
Th ey ar e r eally w or k in g , b u t at t h is m om en t I am t oo sleepy , I feel m u ch sleepin ess. I t alk ed t o h im ( ph y sician ) ,
t h at is w h y h e d ecr eased it ( E) .
I b eliev e it is w or k in g b ecau se I f eel f in e an d d o n ot ev en t h in k I can b e ill. . . I b eliev e it is t oo m u ch m ed icat ion , it cou ld b e d ecr eased a lit t le ( D) .
I n t h e ab ov e r ep or t , t h e p at ien t d oes n ot
c o n s i d e r h i m s e l f i l l a n d , t h u s , b e l i e v e s t h e
m e d i c a t i o n c o u l d b e d e c r e a s e d . Th i s a s p e c t i s
r e l e v a n t , s i n c e , a t t h e s t a g e o f t r e a t m e n t
m a i n t e n a n c e , p a t i e n t s c a n p r e s e n t s y m p t o m
r e m i s s i o n a n d b e c a r e l e s s , c o m p r o m i s i n g t h e
ef f i cacy o f t h e p h ar m aco t h er ap y( 2 ).
T h e o t h e r h a l f o f p a t i e n t s w h o
u n in t en t ion ally d o n ot ad h er e t o t r eat m en t r ep or t ed
d i s s a t i s f a c t i o n r e g a r d i n g i t s e f f i c a c y . T h e y
m en t ion ed n ot p r esen t in g im p r ov em en t an d g oin g
t h r o u g h s e v e r a l r e a d j u s t m e n t s i n m e d i c a t i o n
t h er a p y, w h i ch ca n p a r t i a l l y b e ex p l a i n ed b y t h e
i n ap p r o p r i at e m ed i cat i o n u se i t sel f.
No. . . it d id n ot w or k w it h Teg r et ol, f lu ox et in e, w e d id som e t r ials, y ou k n ow. . . ( J) .
I t does n ot solv e t h e pr oblem . . . if y ou do n ot t ak e it , it is w or se ( O) .
I n t h e ab ov e r epor t , t h e p at ien t ex p r esses
d i s s a t i s f a c t i o n i n r e l a t i o n t o t h e m e d i c a t i o n
t o it , t h e sit u at ion w or sen s. Lit er at u r e( 2 ) r ev eals t h at
t h e pr esen ce of collat er al ef f ect s an d t h e per cept ion
o f t h e n e e d f o r t h e m e d i ca t i o n , co n si d e r i n g t h e
cr i si s an d r e- h o sp i t al i zat i o n s, m ak es am b i v al en ce
r e g a r d i n g m e d i c a t i o n a d h e r e n c e i n f l u e n c e t h e
en t ir e t r aj ect or y of p eop le w it h BAD.
Th e ch r on ic asp ect of BAD st ill im p oses a
p r o l o n g e d t r e a t m e n t o n p a t i e n t s a n d , i n t h i s
con t ex t , som e can b e af r aid of “ g et t in g ad d ict ed ”
t o t h e m edicat ion . Despit e t h is f ear an d f ailu r es in
a d h e r e n c e , t h e r e a r e p a t i e n t s w h o s e e t h e
m ed icat ion as a n ecessar y r ealit y f or t h e st ab ilit y
of t h e d isor d er.
I a m a f r a i d t h a t m y o r g a n i s m w i l l b e t o t a l l y dependent as t her e hav e been m any and m any y ear s, because I am y ou n g , I m ean . . . w e h av e lif e ex p ect an cy . . . an d t h is is m y r ealit y , I h av e t o t ak e all of t h em ( J) .
Am o n g t h e p a t i e n t s w h o i n t e n t i o n a l l y d o
n ot adh er e t o m ed icat ion t r eat m en t , som e ex p r ess
d i ssa t i sf a ct i o n w i t h t h e m e d i ca t i o n b e ca u se t h e y
do n ot con sider t h em selv es ill. Th e st at em en t below
sh ow s t h at t h e pat ien t “ w as t ak in g” t h e m edicat ion ,
e v e n b e l i e v i n g t h a t h e “ s h o u l d n o t ” t a k e i t ,
e x p r e ssi n g h i s t o t a l b e l i e f i n t h e m e d i ca l t r u t h ,
m ak in g h im p assiv e, su b m issiv e t o t h e p h y sician ’s
w i l l . Th i s b e l i e f c a n b e j u s t i f i e d b y t h e p o w e r
at t r ibu t ed t o ph y sician s, du e t o t h eir cu lt u r al bu r den
an d p r o f essi o n al t r ai n i n g .
T h e r e i s n o t h i n g w r o n g w i t h m y h e a d . . . h e
( p h y sician ) b eliev ed I h ad a h ead p r ob lem . . . h e g av e m e m ed icat ion an d I w as t ak in g it , b u t I alw ay s b eliev ed t h at I sh ou ld n ot t ak e t o t h e d r u g , t h en I st op p ed ( T) .
Th e ab ov e st at em en t an d lit er at u r e r ev eal
t h at pat ien t s w it h BAD, w h en t h ey do n ot per ceiv e
t h em selv es as ill, gen er ally do n ot iden t if y r eason s
t o f o l l o w t h e m e d i ca t i o n t h e r a p y, w i t h f r e q u e n t
ab an d on m en t( 2 ). I n g en er al, p r of ession als see t h is
d eci si o n a s f a i l u r e si n ce, a cco r d i n g t o t h em , t h e
o n l y a cce p t a b l e o p t i o n f o r u se r s i s t o f o l l o w t h e
h ealt h t eam ’s or ien t at ion s. On e of t h e pat ien t s w h o
in t en t ion ally does n ot adh er e t o m edicat ion r epor t s
t h at t h e t r eat m en t cau ses m u ch sleep an d p r ef er s
t o u se alcoh olic bev er ages. Th is aspect is r elev an t ,
as it h as been pr ov ed t h at im pr oper u se of alcoh ol
is t h e com or b id it y m ost associat ed t o BAD, b ein g
a b l e t o c h a n g e i t s e x p r e s s i o n , c o u r s e a n d
p r o g n o si s( 1 5 ).
I alr eady used t o dr ink befor e st ar t ing t he t r eat m ent , b u t I s t o p p e d a n d f o l l o w e d t h e t r e a t m e n t o n l y w i t h m ed icat ion s. . . Bu t w h en I r ealized I w as g et t in g in t r ou b le w it h m y p r iv at e lif e, t h en I lef t t h e m ed icat ion b ecau se it m ad e m e sleep y , I st ar t ed t o d r in k alcoh olic d r in k s, w h ich m ad e m e m or e con t en t an d d id n ot m ak e m e sleep y ( G) .
Pa r t i c i p a n t s ’ s t a t e m e n t s e v i d e n c e t h e
h e g e m o n y o f t h e b i o m e d i ca l h e a l t h ca r e m o d e l ,
w h i c h r e s u l t s i n a s o c i a l a n d s y m b o l i c p o w e r
r elat ion sh ip bet w een ph y sician an d pat ien t . I n t h is
m o d el , p r o f essi o n al s w h o co n si d er t h em sel v es as
ow n er s of t h e t r u t h ar e r espon sible f or gu idin g t h ose
w h o s u p p o s e d l y d o n o t k n o w a n y t h i n g , s o t o
i n c o r p o r a t e h a b i t s a n d a t t i t u d e s t h e y c o n s i d e r
h eal t h i er, o f t en i g n o r i n g t h e so ci al , h i st o r i cal an d
c u l t u r a l p r o c e s s e s i n w h i c h p a t i e n t s b u i l d t h e i r
iden t it y an d k n ow ledge. I n t h is con t ex t , t h e r ole of
p a t i e n t s i n t h e i r t r e a t m e n t d e s e r v e s t o b e
d i s c u s s e d , b o t h i n p r o f e s s i o n a l p r a c t i c e a n d i n
r esear ch , con si d er i n g t h em as soci al b ei n g s, w i t h
believ es, v alu es, ex pect at ion s, k n ow ledge an d w h o
at t r ibu t e m ean in gs an d sign if icat ion s t o t h e u se of
or r esist an ce t o u se t h e m edicat ion in t h eir illn ess
p r o ce ss.
Sat isf act ion w it h g u id an ce of t h e t eam an d d ou b t s
r eg a r d i n g m ed i ca t i o n t r ea t m en t
I n t h i s s t u d y , a l l a d h e r e n t p a t i e n t s
c o n s i d e r e d t h e o r i e n t a t i o n s r e c e i v e d f r o m t h e
h e a l t h t e a m su f f i ci e n t a n d d i d n o t h a v e d o u b t s
abou t t h e u sed m edicat ion s. I t is w or t h h igh ligh t in g
t h a t i n f o r m a t i o n o n t h e m e d i c a t i o n i s a b a s i c
c o n d i t i o n f o r t r e a t m e n t a d h e r e n c e . B e s i d e s ,
p at ien t s ar e en t it led t o h av e access t o it .
Regar din g pat ien t s w h o in t en t ion ally d id n ot
ad h er e t o m ed i cat i o n , i t w as o b ser v ed t h at m o st
( 9 1 . 7 % ) ar e sat isf ied w it h t h e or ien t at ion s r eceiv ed
f r om t h e h ealt h t eam . Th er e ar e, h ow ev er, pat ien t s
w h o pr esen t ed d ou b t s ab ou t som e m edicat ion s u sed
or w er e n ot r eally con v in ced of t h eir n eed .
I am (sat isf ied w it h t h e or ien t at ion s) , b ecau se I m ean , if I cou ld ch ose, I w ou ld n ot t ak e it , I w ou ld h av e d isch ar g ed m y self , I w ou ld n ot h av e t h e ob lig at ion t o t ak e t h e m ed icat ion , b u t t h ey say I can n ot ( U) .
T h e d e s i r e t o b e f r e e f r o m m e d i c a t i o n
b ein g a ch r on ic p at ien t , b ecau se t h e act of t ak in g
m ed icat ion r eg u lar ly sh ow s, all t h e t im e, t h at on e
i s a ch r o n i c p a t i e n t( 2 ). Th e sa m e p a t i e n t , w h e n
ask ed ab ou t t h e n am e of t h e m ed icat ion s in u se,
a n s w e r e d :
. . . I d o n ot r em em b er ( U) .
I n t h e ex am p le ab ov e, as t h e p at ien t w as
f eelin g f in e, sh e cou ld b eliev e t h at t h e m ed icat ion
i s n o t n ecessar y, an d n o t g i v e i m p o r t an ce t o t h e
i n f o r m a t i o n r ecei v ed i n t h e h ea l t h ser v i ce. Th u s,
e v e n w h e n p a t i e n t s a f f i r m sa t i sf a ct i o n w i t h t h e
p r ev iou sly r eceiv ed or ien t at ion s, it is im p or t an t t o
m ot iv at e t h em t o ad h er e t o m ed icat ion , t o ex p ose
t h eir dou bt s an d, m ain ly, t o assu m e an act iv e r ole
in t h eir t r eat m en t .
Th e p a t i e n t w h o u n i n t e n t i o n a l l y d i d n o t
a d h e r e a n d r e p o r t e d d i s s a t i s f a c t i o n r e g a r d i n g
o r i e n t a t i o n s r e c e i v e d f r o m t h e t e a m m e n t i o n e d
f o r g e t t i n g t h e i n f o r m a t i o n . Th e s t a t e m e n t a l s o
r ev eal s a p r ev i o u s o ccasi o n o n w h i ch t h e p at i en t
in t en t ion ally ab an d on ed t h e m ed icat ion t r eat m en t
an d n eed ed h o sp i t al i zat i o n .
I u n der st an d, bu t t h en y ou for get it all, I do n ot underst and anyt hing... Som et im es I do not t ake it , I have already st opped t aking m edicat ion... I have been hospit alized ( O) .
I t i s h i g h l i g h t e d t h a t a l l p a t i e n t s w h o
i n t e n t i o n a l l y d o n o t a d h e r e t o t h e m e d i c a t i o n
t reat m ent affirm ed having underst ood t he orient at ions
received from t he healt h t eam and not having doubt s
about t he used m edicat ions. How ever, even sat isfied
w i t h t h e i n f o r m a t i o n , t h e se p a t i e n t s so m e t i m e s
i n t e n t i o n a l l y i n t e r r u p t t h e t r e a t m e n t , w h i c h
dem onst r at es t hat t he lack of infor m at ion about t he
m ed icat ion is on e of t h e f act or s t h at cau ses n on
-adher ence, but alone does not j ust ify it .
I t i s w o r t h h i g h l i g h t i n g t h a t n o s t u d y
par t icipant m ent ioned nur ses w hen ask ed about t he
sat isfact ion w it h or ien t at ion s fr om t h e h ealt h t eam ,
evidencing t he non- recognit ion of t his professional as
r esponsible for such act iv it y. Lit erat ur e cor r oborat es
t h is f in d in g w h en r ev ealin g t h at , in m en t al h ealt h ,
nurses are t he professionals who least carry out direct
pat ient car e, occupy ing m ost par t of t heir t im e w it h
a ct i v i t i es t o o r g a n i ze t h e w o r k o f t h e i n st i t u t i o n s
w h e r e t h e y w o r k( 1 6 ).
Su ggest ion s t o im pr ov e car e pr ov ided by t h e h ealt h
t eam of t h e MHS
W h e n p a t i e n t s w e r e a s k e d t o g i v e
su g g est i o n s t o i m p r o v e ca r e o f f er ed b y t h e MHS
t e a m , o n l y o n e t h i r d o f t h e m m a n i f e s t e d
t h e m s e l v e s . S o m e p a t i e n t s r e p o r t e d t h a t
p r e s e n t i n g s u g g e s t i o n s c o u l d b e i n g r a t i t u d e , a
p ossib le of f en se t o t h e h ealt h ser v ice, or n eg at iv e
cr i t i ci sm . Th i s asp ect su g g est s t h at , m an y t i m es,
p at ien t s can assu m e a p assiv e at t it u d e so as n ot
t o d i sp l ease t h e p r of essi on al s w h o p r ov i d e car e.
I f I t old som et h in g, it w ou ld b e an of f en se t o p eop le w h o w or k h er e ( J) .
Th e of f er ed su g g est ion s in clu d ed : h ir in g a
h i g h e r n u m b e r o f p r o f e s s i o n a l s i n t h e s e r v i c e ,
co n su l t at i o n s sch ed u l ed b y t i m e, m u l t i d i sci p l i n ar y
t h er apeu t ic su ppor t an d t h e in t r odu ct ion of cou r ses
l i k e o ccu p a t i o n a l a ct i v i t y, r ev ea l i n g t h e d esi r e o f
p a t i e n t s t o p a r t i ci p a t e i n a l t e r n a t i v e t h e r a p e u t i c
m o d a l i t i e s.
. . . t h er e is a lack of p sy ch iat r ist s, p eop le f r om t h e n u r sin g t eam , t h is is an u r g en t t h in g f or t h e q u an t it y of p at ien t s ( S) .
I b eliev e it is in cor r ect t o sch ed u le all p at ien t s in or der of ar r iv al, ev en becau se I w or k . . . Th u s, if it is sch edu led for one, at one I w ill be her e. . . I do not com e her e t o t ak e a day of f , n ot t o g et a h ealt h cer t if icat e ( H) .
I b eliev e t h er e sh ou ld b e m or e p sy ch olog ist s, t h er e is on ly on e f or all t h ese p eop le, t h er e ar e m an y p eop le ( V) .
Th e on ly t h in g I t h in k . . . t h er e sh ou ld b e, lik e it w as b ef or e, j ew elr y an d b ead cou r ses, I t h in k it is in t er est in g t o h av e it ag ain f or p eop le w h o ar e n ot w or k in g . . . ( E) .
Alt h ou gh m edicat ion t r eat m en t is essen t ial,
l i t e r a t u r e s h o w s t h a t a s s o c i a t e d p s y c h o s o c i a l
int ervent ions can help t o increase t he int erval bet ween
c r i s e s , d e c r e a s e t h e s e v e r i t y o f t h e e p i s o d e s ,
im pr ov ing t he social adj ust m ent of pat ient s bet w een
one and anot her crisis and helping t hem in t reat m ent
adherence. I n t his cont ext , pat ient s and fam ilies should
be offered a wide range of t herapeut ic opt ions. Above
al l , t h e p r esen ce o f t h e m u l t i d i sci p l i n ar y t eam i n
t r eat m ent and t he easy access t o m edicat ions, in a
sy st em a t i c a n d co n t i n u o u s w a y, ca n i m p r o v e t h e
FI NAL CONSI DERATI ONS
T h i s s t u d y e x a m i n e d a d h e r e n c e t o
m ed icat ion t r eat m en t in 2 1 p at ien t s w it h BAD an d
v er if ied t h at m ost of t h ese p at ien t s d o n ot ad h er e
t o t h e m ed icat ion d u e t o n on - in t en t ion al b eh av ior.
Hi g h d eg r ee o f sa t i sf a ct i o n w i t h t h e h ea l t h t ea m
w as id en t if ied , w h ich w as h ig h er am on g ad h er en t
p at i en t s, sh o w i n g t h at sat i sf act i o n w i t h t h e t eam
can be a f act or t h at is in f lu en cin g, in t h ese pat ien t s,
a d h e r e n c e t o t h e m e d i c a t i o n t r e a t m e n t . M o s t
p at ien t s af f ir m ed sat isf act ion w it h t h e ef ect iv en ess
of t h e m edicat ion an d w it h t h e in f or m at ion r eceiv ed
a b o u t i t , h o w e v e r, e v e n a m o n g t h o se sa t i sf i e d ,
t h er e w er e f r eq u en t r ep o r t s o f co l l a t er a l ef f ect s,
a b se n ce o f i m p r o v e m e n t , n e e d f o r r e a j u st m e n t s
i n t h e t h e r a p y a n d t h e f a c t t h a t t h e y d i d n o t
c o n s i d e r t h e m s e l v e s i l l . O t h e r m e n t i o n s w e r e
r e l a t e d t o d o u b t s a b o u t t h e m e d i c a t i o n s ,
f or g et f u ln ess ab ou t t h e in f or m at ion an d b elief t h at
t h e t r eat m en t i s u n n ecessar y.
Rep or t s of p at i en t s r ef l ect , t h u s, t h e l ack
of list en in g b y h ealt h p r of ession als an d t h at t h ey
d o n o t u n d er st a n d h o w p a t i en t s t h i n k , h o w t h ey
g iv e m ean in g t o t h e w or ld an d t h at t h ey ar e ab le
t o pr odu ce an d sy st em at ize k n ow ledge. I t can also
b e clear ly p er ceiv ed , in p at ien t s’ st at em en t s, b ot h
t ot al b elief in t h e m ed ical t r u t h an d d isag r eem en t
w i t h w h a t i s s t a t e d b y b i o m e d i c a l d i s c o u r s e ,
d e p e n d i n g o n t h e m o m e n t i n t h e h i st o r y o f t h e
d i so r d e r, w h i ch ca n p r o b a b l y p r o v i d e a b a se f o r
t h e n on su bm ission of t h ese pat ien t s t o t r eat m en t ,
t h u s ch ar act er i zi n g n o n ad h er en ce.
T h i s s t u d y b r i n g s , h e n c e , i m p o r t a n t
c o n t r i b u t i o n s f o r p r a c t i c e a n d r e s e a r c h i n t h e
m en t al h ealt h ar ea, sin ce k n ow in g t h e or igin of t h e
n o n a d h e r e n c e b e h a v i o r ( i n t e n t i o n a l o r n o n
in t en t ion al) is essen t ial t o dir ect t h e im plem en t at ion
o f s t r a t e g i e s , i n h e a l t h s e r v i c e s , t a r g e t i n g t h e
saf et y of t h is clien t ele in t h e m ed icat ion t h er ap y.
I n t h is con t ex t , t h e im p or t an ce of st u d ies
t h a t e v a l u a t e t h e s t r a t e g i e s u s e d b y h e a l t h
pr of ession als f or t h e edu cat ion of pat ien t s, as w ell
a s t h e n e e d f o r t r a i n i n g o n t h i s a c t i v i t y , i s
h i g h l i g h t e d . I t i s a l so n e ce ssa r y t o e n d o r se t h e
r el ev an ce o f t h e i m p l em en t at i o n o f st r at eg i es, i n
h ealt h ser v ices, t h at per m it pat ien t s t o ex pose t h eir
d o u b t s , t h e i r w i s h e s , d i f f i c u l t i e s , o p i n i o n s a n d
e x p e r i e n ce s r e l a t e d t o t r e a t m e n t . Fo r t h a t , su ch
st r at egies, in clu din g edu cat ion al on es, sh ou ld f ocu s
o n a d h e r e n c e a s a c o l l a b o r a t i v e r e l a t i o n a n d ,
a b o v e a l l , a s c o - r e s p o n s i b l e , d i r e c t e d t o t h e
h u m an izat ion of pat ien t s an d lin k ed t o t h eir r ealit y.
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