Why psychotic patients stop taking antipsychotics: study reveals drug levels tell the real story
Researchers using blood tests instead of patient self-reporting found that worsening psychiatric symptoms—not lack of insight—drive medication non-adherence in first-episode psychosis. The finding matters for healthcare systems and insurers designing interventions: targeting symptom management may work better than focusing solely on patient awareness or understanding of illness.
Originaltitel: The impact of symptoms and illness insight on treatment adherence in first-episode psychosis: a one-year follow-up study using therapeutic drug monitoring
Objektiv adherensmätning öppnar vägen för bättre prognoser vid förstaepisod psykos. En finsk långtidsstudie på 78 patienter visar att aktuella positiva symptom är den starkaste förklaringsfaktorn till behandlingstrogenhet — varje punkt högre på symptomskalan motsvarar cirka 4–5 procent lägre adherens — medan tidigare icke-trogenhet paradoxalt förutsäger senare trogenhet. Forskarna använde terapeutisk läkemedelövervakning (TDM) genom plasmakoncentrationsmätningar av antipsykotika vid baseline, två månader och tolv månader. Traditionell väisdom om insikt och negativa symptom som adherensdrivare fick inget stöd. Fynden innebär att kliniker bör fokusera on-demand insatser på perioder med höga positiva symptom snarare än på statiska baslinjemål. Regioproducenters inköpsstrategier för TDM-kapacitet och tidiga interventionsprogram bör byggas på dynamisk symptomövervakning.
Abstract Background Despite extensive research on adherence in first-episode psychosis (FEP), reliance on self-report or clinician judgment has limited accuracy and obscured nuanced clinical associations. Objective This longitudinal study examined the predictive value of psychopathology, insight, and functioning for objectively measured treatment adherence across a one-year follow-up using therapeutic drug monitoring (TDM). Methods Seventy-eight FEP patients were assessed at baseline, 2 months, and 12 months. Clinical measures included the Brief Psychiatric Rating Scale (BPRS), Scale for the Assessment of Negative Symptoms (SANS), Social and Occupational Functioning Assessment Scale (SOFAS), and the Schedule for the Assessment of Insight–Expanded version (SAI-E). Adherence was defined by comparing plasma antipsychotic concentrations to prescribed doses according to international consensus guidelines. Generalized linear mixed models (GLMMs) were used to model time-dependent associations. Results While overall adherence declined, time alone was not a significant predictor. Instead, current positive symptom severity (approximately 4–5% lower odds of adherence per BPRS point) was associated with lower odds of adherence, while prior non-adherence predicted subsequent adherence. In contrast, insight, negative symptoms, and functioning showed no consistent association with adherence. A marginal association between improved functioning and better adherence was observed at 12 months. Conclusions Adherence in FEP appears to fluctuate in relation to current clinical state rather than follow a stable linear pattern. These findings highlight the value of objective TDM monitoring and early intervention, supporting predictive models that incorporate evolving symptom patterns rather than static baseline measures. Trial registration Clinical trial number: not applicable.