Fenton W S, Blyler C R, Heinssen R K
Chestnut Lodge Hospital, Rockville, MD 20850, USA.
Schizophr Bull. 1997;23(4):637-51. doi: 10.1093/schbul/23.4.637.
Advances in psychopharmacology have produced medications with substantial efficacy in the treatment of positive and negative symptoms of schizophrenia and the prevention of relapse or symptom exacerbation after an acute episode. In the clinical setting, the individual patient's acceptance or rejection of prescribed pharmacological regimens is often the single greatest determinant of these treatments' effectiveness. For this reason, an understanding of factors that impede and promote patient collaboration with prescribed acute and maintenance treatment should inform both pharmacological and psychosocial treatment planning. We review the substantive literature on medication adherence in schizophrenia and describe a modified health belief model within which empirical findings can be understood. In addition to factors intrinsic to schizophrenia psychopathology, medication-related factors, available social support, substance abuse comorbidity, and the quality of the therapeutic alliance each affect adherence and offer potential points of intervention to improve the likelihood of collaboration. Because noncompliance as a clinical problem is multidetermined, an individualized approach to assessment and treatment, which is often best developed in the context of an ongoing physician-patient relationship, is optimal. The differential diagnosis of noncompliance should lead to interventions that target specific causal factors thought to be operative in the individual patient.
精神药理学的进展已产生了对治疗精神分裂症的阳性和阴性症状以及预防急性发作后的复发或症状加重具有显著疗效的药物。在临床环境中，个体患者对规定药物治疗方案的接受或拒绝往往是这些治疗效果的最大单一决定因素。因此，了解阻碍和促进患者配合规定的急性和维持治疗的因素，应能为药物治疗和心理社会治疗规划提供参考。我们回顾了关于精神分裂症药物依从性的大量文献，并描述了一个经过修正的健康信念模型，在该模型中可以理解实证研究结果。除了精神分裂症精神病理学的内在因素外，药物相关因素、可得的社会支持、物质滥用合并症以及治疗联盟的质量都会影响依从性，并提供潜在的干预点以提高配合的可能性。由于不依从作为一个临床问题是由多种因素决定的，在持续的医患关系背景下通常能最好地制定的个体化评估和治疗方法是最佳的。对不依从的鉴别诊断应导致针对被认为在个体患者中起作用的特定因果因素的干预措施。
