Medication adherence and treatment fatigue — formative SAQs

SAQ 1 — Assessment and measurement (10 marks)

A 15-year-old with epilepsy has been seizure-free for two years on a single antiseizure medicine. At review the level is subtherapeutic; the young person reports taking every dose and asks whether they can stop now that they feel well. [1] [4]

Questions

1. Define medication adherence and distinguish its three phases. (3 marks) [3]
2. Outline how you would assess adherence in this young person, naming the modalities and their limitations. (4 marks) [1] [4]
3. Explain the principle behind the young person's request to stop, and your immediate non-pharmacological response. (3 marks) [1] [5]

Model answer

Definition and phases (3). Adherence is the extent to which a person's behaviour in taking medication corresponds to agreed recommendations. It has three phases: initiation (whether the medicine is ever started), implementation (whether it is taken as prescribed day to day), and persistence (whether it is continued over time). A subtherapeutic level with reported perfection is an implementation failure until shown otherwise, and the request to stop is a persistence question. [3] [1]

Assessment (4). Open with a non-judgemental, normalising frame and time alone. Take a structured, behavioural history (of the last seven days, how many had all doses). Measure multimodally: self-report opens the conversation; refill or pharmacy records estimate implementation over time; the drug level and any objective data triangulate it, while recognising white-coat adherence can raise a pre-visit level and mask chronic non-adherence. Screen for mood and the meaning of the medicine. No single measure captures the whole behaviour. [1] [4]

Request to stop (3). This is the asymptomatic-on-treatment trap: success of the medicine removes the symptoms that signalled its necessity, so the young person reasons it is no longer needed. Withdrawal risks seizure cluster and raises sudden unexpected death in epilepsy risk. Respond with curiosity rather than confrontation — explore what stopping would mean, share the rationale for continuation, and build a shared plan rather than issue an instruction. [1] [5]

SAQ 2 — Tailored intervention and safety (10 marks)

A 17-year-old liver-transplant recipient nearing transfer to adult care has had two consecutive subtherapeutic tacrolimus levels and missed the last clinic. They disclose, alone, that they sometimes skip doses because the medicine "makes me feel different from my friends." [1]

Questions

1. Outline a tailored, stepwise adherence-promotion plan for this young person. (6 marks) [5] [6]
2. State the red-flag considerations and the role of transition in this case. (4 marks) [1]

Model answer

Tailored plan (6). Frame with a non-judgemental, normalising stance and acknowledge the identity load the medicine carries. Measure multimodally (self-report, refill, tacrolimus level) and map the barrier: here the dominant domain is patient and development — identity and stigma — alongside the system domain of transition. Agree shared goals with motivational interviewing that connect continuation to what the young person values. Simplify the regimen only with the transplant team where licensed and safe; add reminders or an app for the unintentional component; offer behavioural or psychology support for the identity and peer-burden driver. Name the next contact, schedule re-measurement, and build a low-threshold way back in. The outcome is sustained engagement, not perfect compliance. [5] [6]

Red flags and transition (4). Lapsed immunosuppression drives rejection and graft loss, so suspected non-adherence with subtherapeutic levels needs urgent transplant-team involvement; any sign of graft dysfunction (jaundice, tenderness, rising liver enzymes) exits the routine pathway to acute care. Transfer to adult care is the highest-risk window — the transition cliff — and is a predictable, preventable cause of graft loss. Strengthen transition readiness, arrange a warm handover, protect adolescent-only time, and keep follow-up loops closed across the transfer. [1]