In fact, over one-third fails to take their epilepsy medication at least 80% of the time. This is termed nonadherence and leads to high rates of morbidity and mortality.

Surprisingly, a single daily dose compared to 3 times a day improved adherence only from 57% to 65%. Depakote was taken least at 55% and Keppra most at 79%. This is unrelated to drug efficacy, and perhaps side effects were the cause.

Dr Paul Farmer, who established free medical clinics in Haiti and then went on to treat multidrug-resistant tuberculosis in Peru, said that noncompliance is the fault of the doctor, not the patient. If this is true, how can we improve compliance?

For patients, the main reason is forgetting, not depression, not denial. Warning patients about the risk of sudden death from a seizure and other intensive educational efforts seem to be of limited help. Simple memory aids seem better, such as associating doses with daily routines, using weekly pill boxes (very important), electronic pill bottle recording (not universally available), or setting alarms on smartphones. Pharmacies contacting physicians when medications are not refilled would also be helpful, but this would require extra time by the pharmacy and by the physician to contact the patient. According to Dr Edward Faught, who commented on the study, insurers should take this role because of potential cost savings.

Finally, giving patients “permission” to admit they do not take their medications consistently is critical. I would frame the question this way: “All my patients miss doses, how often do you?”

See Neurology, August 2, 2016, page 452-453 and page 466-472.

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