Taking Medication as Prescribed Benefits the Mind Too

Of all of those lifestyle habits that have been demonstrated to benefit the mind and body, it seems that the easiest one to practice should be taking medication as prescribed. Compared to the struggle to overcome an addiction to smoking, or enduring the sweaty workouts and the deprivation of a weight loss diet to reduce obesity, taking a few pills everyday shouldn't be a hardship.

Yet, the evidence is that the percentage of patients adhering to prescribed drug regimens are comparable to the success rates of smoking cessation and weight loss programs. Well under half are successful. And the dangerous consequences of non-compliance for mental ability and physical health are comparable to smoking and obesity.

Here's an example. In the year following a serious heart attack, most survivors don't take the medication prescribed by their doctors to prevent them from having another coronary. A recent article in the New England Journal of Medicine reported on the compliance rate of 5,855 men and women followed for a13 months after their myocardial infarctions. Only 38% of these patients regularly took the medications as ordered. Failure to take these drugs as directed doubles their risk of having another cardiovascular episode.

This study highlights the problem of patient non-compliance, a phenomenon well known to the medical profession. Follow-up studies of people with other serious medical conditions such as hypertension routinely find that less than half of patients take their meds as ordered, with one 2011 article reporting an 11% adherence rate. The National Council on Patient Information and Education has called medication non-adherence "America's other drug problem."

Non-Compliance: A Risk to Mental Ability

Nearly every serious medical condition is linked to lower scores on tests of mental ability. Consider the effect of untreated high blood pressure on the intellect. Three different longitudinal studies of more than 6,000 adults correlated hypertension with scores on mental tests. People with elevated systolic and diastolic blood pressure readings showed a greater decline in global intelligence and were at greater risk for dementia than their non-hypertensive contemporaries.

High blood pressure is the disease whose adverse effect on the intellect has been most thoroughly documented in the past three decades. Interest in the cognitive impact of other chronic afflictions-cardiovascular disease, atrial fibrillation, diabetes, sleep apnea, and chronic pain-has grown dramatically in the 21st century. While the research so far has been largely clinical in nature and with small numbers of patients, no doubt remains that chronic medical conditions adversely affect mental ability as well as health.

Most of the follow-up studies of people with these medical conditions reported a greater decline in cognitive skills when the disease is not treated. Compared to their contemporaries not on medication, for instance, those hypertensives that took prescription medication had only 60% of the risk of developing cognitive impairment. Other scientists found that untreated individuals with high blood pressure had lower scores for just about every mental ability measured compared to those who took their medication regularly. Especially vulnerable to untreated hypertension are executive functions (concentration, memory, reasoning, and mental flexibility).

Improving Compliance Rates

While the word has gotten out about the health benefits of other lifestyle practices such as not smoking or exercising regularly, it is fair to say that the importance of compliance has not received nearly the attention it deserves.

It is fair to say that many medical providers, and most of their patients, don't fully appreciate the value to the intellect of adhering to medical instructions. We might imagine that just acquainting people with these facts would motivate them to be more compliant. If this mid-career hypertensive woman knew that she has a good chance of losing IQ points by not taking her meds as prescribed, that knowledge should motivate her to be compliant. If that older man recently diagnosed with obstructive sleep apnea understood that wearing a continuous positive airway pressure (CPAP) mask would raise his odds of being more alert and quicker when playing board games with his grandchildren, he would have a strong incentive to use it regularly.

Evidence is that these assumptions are wrong. It is a good bet that both of these people will be just as unresponsive to the news that non-compliance may dim their intellectual lights as the recent heart attack patients were numb to the threat of another cardiovascular episode if they didn't take their medication as prescribed.

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There are, however, hopeful signs that the importance of compliance is being more widely recognized. An example is the next publication of Healthy People by the U.S. Department of Health and Human Services will contain guidelines for improving compliance rates-increasing the percentage of hypertensives who take their medication as directed and raising the proportion of adults with diabetes who monitor their blood glucose at least once daily.

Another positive sign are the accumulating research publications demonstrating that efforts to improve compliance can be successful. A 2008 review of seven new approaches to improving adherence compared a group of hypertension patients receiving an intervention with a matched group that was given the usual care The interventions ranged from a 4-minute conversation with a computer once a week to periodic 30 to 60 minute sessions with a nurse or clinical pharmacist, a thorough explanation of the medication, including the hazards on non-compliance, and medication dispensed in time-specific packages. Follow-up at 6 to 8 months found all but one of the interventions achieved adherence rates above 90%.

That's the good news. The bad news is that the compliance rates often dropped when the research study came to an end. This reminds us that adherence to prescription medication, like any other healthy habit, needs to be a lifelong practice for the sake of our minds as well as our physical well being.

Selected References

Choudhry, N. K., Avorn, J., Glynn, R. J., Antman, E. M., Schneeweiss, S., Toscano, M.,
Reisman, L., Fernandes, J., Spettell, C., Lee, J. L. Levin, R., Brennan, T., & Shrank, W. H. (2011). Full Coverage for Preventive Medications after Myocardial Infarction. New England Journal of Medicine, November 14. (10.1056/NEJMsa1107913)

Haynes, R. B., Ackloo, E., Sahota, N., McDonald, H. P., & Yao, X. (2008). Interventions for enhancing medication adherence. Cochrane Database of Systematic Reviews, 2,
CD000011. DOI: 10.1002/14651858.CD000011.pub3.

Healthy People 2020 (http://www.healthypeople.gov/2020/default.aspx)

National Council on Patient Information and Education. (1997). The other drug problem: Statistics on medicine use and compliance. Bethesda, Md: National Council on Patient Information and Education.

Ruppar, T. M., Conn, V. S., & Russell, C. L. (2008). Medication adherence interventions for older adults: Literature review. Research and Theory for Nursing Practice: An International Journal, 22, 114-147