Nonadherence to medications--reply.

Nonadherence to Medications To the Editor The Viewpoint by Dr Marcum and colleagues1 outlined the difficulties in identifying medication nonadherence, accurately diagnosing the reasons behind nonadherence, and improving patient adherence. We believe that behavioral science could offer some insights. First, behavioral science could help to diagnose patient behavior and make sense of what might seem irrational. Of the 6 nonadherence phenotypes identified by the authors, 3 have behavioral causes: the patient’s belief that the costs outweigh the medication benefits, the burden of complex prescriptions, and the patient’s lack of vigilance. In exploring these causes of nonadherence, it is important to acknowledge that much of what influences behavior is subconscious, so conventional qualitative research techniques often provide little insight. Psychological tools such as disrupting behavior, using imagery to aid articulation, simple observation, or technological tracking of behavior could offer more reliable information. Individuals often do not know why they behave a particular way and can be considerably affected, often unconsciously, by environmental and social contexts and individual cognitive biases. For example, people tend to put off unpleasant things until tomorrow, preferring to enjoy today—a cognitive bias called time inconsistency. Because medication often has shortterm, unpleasant adverse effects or is inconvenient to take, patients may be less vigilant. Another is status quo bias—a dislike of change to daily routines that can lead to inertia. There is also the hold that habits have on individuals. Deeply engrained in brain and muscle memory, it can take 2 months or more to build new habits. Taking a complex program of medication involves building new habits and adapting existing habits and routines. Second, behavioral science could also suggest solutions to improve medication adherence with nudging behavior. There are already some innovations on the market such as electronic pill bottles that help reduce forgetfulness and combat the lack of routine in taking medication.2 Other solutions have tackled the problem of costs outweighing benefits by providing incentives such as daily lotteries or free cell telephone minutes.3 In a preliminary report, 1 trial succeeded in raising the uptake of statins by 78% simply by redesigning the patient letter to make the benefits and costs more salient.4 A meta-analysis of 37 randomized clinical trials to improve adherence found that behavioral interventions had the greatest effect, especially those that simplified dosages.5 These innovations are only the beginning of ways that behavioral science could help to improve medication adherence. Elizabeth Barker, MA, MSc Crawford Hollingworth, BA