Treatment Health Care

This essay begins with a critical review of the terms compliance and concordance in relation to pharmacological treatment. The main focus of the essay will highlight the issue of side effects, mainly Tardive Dyskinesia (TD) and akathisia while receiving treatment on anti-psychotic medication. I will also point out the interventions, skills and approaches, including various tools used in assessing and managing the client's distress in relation to the unwanted effects. Finally, the essay will conclude with an evaluation of the outcomes and effectiveness of the approaches along with suggestions on how I would do things differently from a personal and professional perspective.

Compliance, adherence and concordance are terminologies currently used by health care professionals in an attempt to encourage clients to take their prescribed medication. Haynes et al (1979) defined compliance as ‘the extent to which the patient's behaviour matches the prescriber's recommendation. Non-compliance, therefore, suggests that a client has not done what they were told by a mental health professional. It infers that clients are passive recipients of health care who should obey instructions from professionals. It seems to denote a relationship in which the role of the clinician is to decide on the appropriate treatment and issue the relevant instructions, whereas the role of the patient is to passively follow the doctor's orders. This is in direct contrast with the current ethos of modern mental health care, set out in the Department of Health (1999) white paper, ‘Modernising Mental Health Services', National Service Framework (NSF 1999) and The NHS Plan (2000), which is concerned with working together, and in partnership with clients, families and carers.

Other difficulties with the actual use of the term ‘non-compliance' is that it can mean different things, including failure to continue taking prescribed medicine, failure to keep appointments or even dropping out of after care altogether. Therefore to argue that a client has to be admitted to an in-patient unit on the basis that he/she has been non-compliant is inappropriate and does not carry much weight. So the term ‘non-compliance' must be specifically tailored to the actual behaviour of the client in order for it to be of significance. To add to the complexity of this term, clients can also be intentionally or unintentionally non-compliant. Both have the same end point, whereby the client does not adhere to the agreed schedule but for different reasons. The client may make a deliberate decision not to act in accordance with their treatment schedules but it could also be that the cause of non-compliance is external to the patient. For example, one may have misunderstood the guidance that they have been given or simply in the case of medication, one is unable to open the container.

The term ‘adherence' according to Barofsky (1978) is defined as the extent to which the patient's behaviour matches agreed recommendation from the provider. It emphasises negotiation between the clinician and patient but still implies a degree of passivity and obedience. Marinker et al (1997) pointed out that our models of adherence have taught us to try and persuade our patients to alter their viewpoint to bring it into alignment with ours but as Russell et al (2003) concluded, it is important to realise that it is unrealistic to expect all patients to simply comply with all the recommendations that we give them.

So we can see that both non-adherence and non-compliance are terms used to describe patient's behaviour with respect to a suggested treatment regimen in particular; they describe a process by which the patients deviate from the suggested intervention.

The two above terms do not conjure a vision of working together and hence to address the consequences of ‘failure to take medicine' the All Party Pharmacy Group (2000) concluded that concordance was a refreshing and innovative approach to achieving the best possible use of medication.

Medicines Partnership (2001) defined concordance as ‘ a new approach to the prescribing and taking of medicines'. It is an agreement reached after the negotiation between a patient and a health care professional that respects the beliefs and wishes of the patient in determining whether, when and how medicines are to be taken. Weiss and Britten (2003) argued that concordance is neither compliance nor adherence, but is about the status of the consultation. The focus is on the experience of the consultation and not the patient's ultimate behaviour. For this reason it is possible to have a non-compliant (or non-adherent) patient but not a non-concordant patient. Only a consultation or a discussion between the two parties concerned can be non-concordant.

In order to translate concordance into practice, Pollock (2001) argued that an understanding of lay explanatory models of illness, as well as patients' views about medicines is also necessary, however, patients' may not necessarily believe it to be appropriate to share knowledge, beliefs and opinions in the consultation, and therefore concordance may not always be feasible.

Another issue requiring consideration is whether the acceptability and feasibility of concordance varies according to the type of consultation. For example, an on-going relationship may be more suited to the development of concordance than a consultation that relates to an acute problem for which an immediate diagnosis and/or treatment is sought.

The client I have chosen is a 47-year-old married gentleman (referred to as John, in order to protect his confidentiality as stated in the Nursing and Midwifery Council (2004) code of professional code of conduct), who took an overdose in response to the voices who told him to do so.

John has a ten-year history of mental illness, treated with anti-psychotic and anti-depressant medication interchangeably as well as at times concurrently. Prior to this incident, he had been discharged to his GP from the Community Mental Health Team (CMHT) about eighteen months ago. John was discharged on Zotepine, an atypical anti-psychotic medication, 25mg, twice daily.