Adherence to treatments and medications as prescribed is a challenge across diagnoses and clinical contexts. There probably isn’t a disease state where people don’t struggle with adherence in some way. Side effects may flare, the medication doesn’t feel right or the dosing schedule doesn’t fit into daily life. In more serious cases, even temporary discontinuation of a medication can lead to destabilization and hospitalization, with real consequences for patients and the systems supporting them.
When it comes to serious mental illnesses (SMI), each condition is unique in its symptomatology, recommended treatment approaches, and individual patient experiences. In addressing nonadherence in the treatment of SMI, then, there’s no one unifying explanation as to why patients may stop taking medication as prescribed. This is certainly the case for bipolar I disorder (BD-I), which is acknowledged to be particularly complex to diagnose and manage. National healthcare provider data suggest that clinicians frequently identify medication adherence and long-term persistence as key challenges in the management of BD-I.
BD-I is so named because it is diagnostically defined by two extremes: mania or hypomania and depression. To meet the clinical criteria for BD-I, a person must have a documented history of both. The goal of treatment is to help keep someone in the middle, but that balance is contingent on many factors, including consistent medication and the realities of life pushing people in different directions.
As clinicians, we know that long-term outcomes with BD-I are influenced by efficient and effective treatment. Having an integrated care team in place, including pharmacists as experts in medication management, can help to facilitate treatment protocols and support people along their journey.
The structural challenges of adherence in BD-I
When someone is depressed, their energy and motivation tend to be low. As a consequence, daily routines become harder to maintain. In that state, taking medication consistently can be very difficult. This can contribute to a concerning feedback loop, whereby inconsistent medication adherence drives symptom recurrence, which in turn affects how a person thinks about their treatment.
When someone is in a manic or hypomanic state, the challenge is different. They may feel euphoric, productive and highly functional, sensations that they interpret in the moment as positive. Medications approved for the treatment of BD-I are designed to help stabilize mood over both the short and long term. A person who is experiencing mania may find that outcome, while clinically intended, to feel limiting or have a “dulling” effect, influencing their desire to use that medication.
On top of that, the medications themselves require careful consideration and should only be recommended as appropriate for that person’s needs. Historically, many of the older medications used to treat BD-I were associated with renal and hepatic risks, which limited long-term tolerability. Today, patients commonly report different concerns, such as weight gain, sedation and emotional blunting. Side effects are among the most frequent reasons patients living with BD-I disengage from treatment.
Considered together, the lived experience of BD-I, along with how medications can feel in the body, give me as a clinician insight into how adherence can be particularly fragile.
The role pharmacists play in supporting adherence
Pharmacists are one of the most accessible healthcare professionals. Whereas weeks or even months may go by between visits with a prescribing psychiatric provider, patients will tend to see their pharmacist more frequently for medication fulfillment. Coupled with the documented trust consumers have in pharmacists, this can create meaningful touchpoints for questions or concerns to be raised.
When it’s the first fill, pharmacists have the time to walk through the medication in detail, including its specific indication, dosing recommendations, guidance about how and when to take the medicine, what to expect and what to watch for, in a way that isn’t always possible in a brief office visit. Moreover, pharmacists have expertise in pharmacology, and confidential access to patients’ available prescribing history through pharmacy health records, and can identify potential concerns for interactions or contraindications. When patients return for refills, it opens the door for discussion about how the medication is making them feel, if it seems to be helping their symptoms and whether any side effects have arisen.
In addition, pharmacists can see adherence as it actually happens. Refill patterns tell a story and shifts in established routine provide a clear signal that something is going on. When a patient is picking up medication late or not at all, providers should take note.
What health systems can do differently
The role of pharmacists in SMI treatment is relevant to health systems, as well as at the retail and primary care levels. When pharmacists are not integrated into psychiatric care teams, health systems feel it downstream.
Medication nonadherence is one of the leading drivers of psychiatric hospitalization and readmission. Each lapse in treatment increases the risk of destabilization, emergency department visits and inpatient stays, all of which are costly, disruptive, potentially preventable, and detract from a person’s clinical outcomes and personal wellbeing over time.
Subsequently, it’s important to recognize the importance of continuity of care as related to hospitalizations and prescribing. Transitions of care, especially hospital discharge and return to community settings, are times when adherence often breaks down. Specifically, patients are regularly discharged with a prescription, but without medication in hand. They may run into insurance-related barriers, such as coverage restrictions or prior authorization requirements. Sometimes they leave on duplicate therapies or regimens that don’t translate well to the outpatient setting.
These are the kinds of issues pharmacists can pick up on right away. When pharmacists are part of the hospital care team, formulary problems, access delays and duplication can be addressed early, before they lead to destabilization or rehospitalization.
In addition, treatment innovation has led to the availability of a wide range of medication options approved to treat SMI, including BD-I. Some of the newer agents are shown to deliver improved tolerability, mitigating one of the most common reasons why patients stop taking their medication. For health systems, it’s not a matter of needing more medication options, but about identifying opportunities to improve care coordination and medication management through full utilization of the professionals already positioned to help.
For health systems looking to close adherence gaps, integrating pharmacists at all levels of psychiatric care is a practical, system-level approach — one that improves education, continuity and access at the exact points where adherence most often breaks down.
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