Recent studies on improving treatment adherence in schizophrenia demonstrate a reciprocal interaction between medication and psychological interventions. Medication factors affecting treatment adherence include using depot (long-acting) formulations and attempting to minimize adverse effects by use of atypical antipsychotics.

Psychosocial interventions that may improve treatment adherence include case management, education, and behavioral skills training. An early study of adherence behavior indicated that 46% of the patients took less antipsychotic drug than prescribed. It is now well documented that reluctance to take antipsychotic medication is associated in part with extrapyramidal side effects, especially akathisia.

In clinical practice, a patient's outcome on antipsychotic medications is largely influenced by the adverse effects experienced. These subjective responses do not necessarily correlate with objective physical findings. Even so, they should be treated with great care because they can jeopardize medication adherence and interfere with social adjustment and/or participation in psychosocial treatment.

In order to detect subjective side effects, clinicians should carefully ask patients about any distress they experience from medication. In most cases, akinesia and akathisia are more distressing than tremor, rigidity, and dyskinesia.

In a previous study by Dr. Marder and his colleagues, patients were assigned to a program that supplemented skills training with weekly sessions designed to promote the use of newly acquired skills in the community (IVAST: in vivo amplified skills training). Patients were also randomly assigned to a double-blind comparison of risperidone versus haloperidol.

Brief Psychiatric Rating Scale scores showed greater improvement with risperidone than with haloperidol in ratings of anxiety/depression. Both risperidone and enhancement of skills training contributed to patient satisfaction with medication and longer retention in treatment. Akathisia also affected outcome. Patients without akathisia who underwent in vivo amplified skills training showed the best outcome.

In addition, medication and psychosocial strategies were shown to interact in a one-year, double-blind comparison of clozapine and haloperidol. Clozapine-treated patients were more likely to participate in psychosocial programs.

Dr. Marder closed by noting that improving treatment adherence in schizophrenia requires attention to mediating factors such as subjective response, understanding of the illness, and side effects. These factors are affected by both pharmacological and psychosocial interventions, which reinforce each other.