I. Introduction

Medication. It is one of the most important, if not the most important, treatment available to the mentally ill. Introduced in the 1950s,  psychotropic medications have virtually revolutionized the treatment of many types of mental illness.  Without them it may not have been possible to successfully move the treatment  of the mentally ill out of state hospitals and into the community or for many seriously mentally ill persons to “recover”.  Today, psychiatric medications are so widely used that they are almost omnipresent in most treatment settings.

Psychotropic medications are a powerful therapeutic tool and, like other powerful tools,  they generate major issues, problems and questions as well as benefits. Side effects and their management, keeping track of when to take several different prescriptions,  payment, using more than one source for prescriptions are just some of the  everyday concerns associated with their use.

 Medication plays a central and complex role in the lives of mental health consumers.

So as to better understand this role and, hopefully, provide information that County officials, managed care administrators,  service providers and others may use to further develop and improve the delivery of medication services,  the Montgomery County Consumer Satisfaction Team conducted a survey of  users of mental health services with respect to multiple aspects of their medication related behaviors and attitudes.

II. The Survey

Between January, 1999 and April 2000, the Satisfaction Team surveyed  adults (18 years and older)  who were participating in one or more elements of Montgomery County’s mental health program regarding  various aspects of their medication usage and related behaviors, attitudes and experiences. We interviewed 335 adult  clients at  26  mental health program sites throughout the county (see Appendix I for a list of sites and the number of interviews conducted at each).

The questionnaire we used was the product of a collaborative effort. Consumers, a psychiatric RN consultant, staff of the County Office of Mental Health and Consumer Satisfaction Team staff all contributed to the questionnaire development process. All interviews were conducted by consumer members of CST’s staff.  

We interviewed widely and extensively. However,  a statistical sample was not selected.  Potential respondents were chosen  at the interview site by CST staff and asked if they wished to participate in the survey.  A description of the demographic characteristics of Montgomery County’s entire adult consumer population was not available nor was an estimate of the total size of this population.  We consider the implications of these facts in the next section, Respondent Population

iii. respondent population

To what degree is  the respondent population representative of the entire Montgomery adult consumer population ? This is a key question for those interested in using the results of the survey to support or change relevant aspects of the County’s mental health system.

 As noted in the previous section,  the respondent population does not constitute a statistical sample of the adult Montgomery County consumer population. Consequently, we are unable to generalize our findings with a known degree of confidence. In the absence of a description of the demographic characteristics of the entire client population we are unable to offer observations regarding the extent to which the characteristics of the respondent population “mirrors” that of the larger  population. This inability further limits the utility of the survey. At the same time, our experience with conducting  surveys of sub-groups (CHIPPS clients, persons attending partial hospital programs, clients living in Community Rehabilitation Residences and others)  of  Montgomery County’s  consumer population and an inspection of that data suggests that the demographic characteristics of our respondent population may not be significantly different than the universe of Montgomery County adult consumers. However,  given that we know nothing definitive about the composition of the universe from which the respondents were drawn, our findings must  be treated as rough indicators of what may be the medication related experiences and behaviors of Montgomery County mental health consumers. 

Table 1 shows the age and gender characteristics of the respondent population. Their age range is 18-77 and the average age 43.8 years.  More men (57%)  than women (43%) were interviewed. Substantially more Caucasians (80 %) than African-Americans (15 %) are included in the respondent population (Table 2).  Four percent of 

Table 1 Sex and Age Of Respondents

Number^*

* No Response = 12

Percent

Table 2: Race Of Respondents^*

            * No Response = 3

Table 3: Respondents Of  Hispanic Origin

                                                               No Response = 9

those interviewed identified themselves as of Hispanic origin (Table 3). Based on the

racial and ethnic makeup (91.5 % white, 5.7% African-American, 1.2 % Hispanic origin) of  Montgomery County in 1990 ( 1990 United States Census, Summary Tape STF3A) it does not appear that African-Americans or Hispanics are seriously over or under represented in the respondent population. At the same time we must remember that we have “. . . an inadequate understanding of the prevalence of mental disorders among minority groups in the United States” (Mental Health: A Report Of the Surgeon General, 1999) and, consequently, an imperfect set of expectations.

Thirty three percent of those participating in the survey had not completed High School (Table 4) and 43 percent had a High School Diploma or equivalent. The remaining 24 

had varying levels of college experience.

Table 4: Respondent Education^*

                                                     No Response = 2

iv. Findings

iv A. extent of medication usage

Respondents taking multiple prescription and over-the-counter medications on a regular basis. As Table 5 shows, 86 percent of respondents reported they regularly 

Table 5: Number of All Types Of Medications Taken

take more than 1 medication and 40 percent say are taking between 3 and 6. On average, respondents reported they are taking 3.58 medications.  As expected, clients also indicated that they are taking a number of different types of medicines (Table 6)

Table 6: Types Of Medications Taken

Respondents report  they take a number and variety of types of medications. They also report that they have been taking medications for a significant proportion of their adult lives¹.  On average,  clients report that they have been taking medication for 17.3 years. If we control for the length of time taking medication by the age of the respondent ______________________________________

1.      Our attempt to determine how long respondents had been taking medication raised a methodological question. We found that a number of respondents offered answers to this question in an obviously inconsistent manner and we wondered about some answers even though we retained and used them. While we believe that  the general shape of the data are a reasonable reflection of what actually goes on in respect to clients use of medication over time, we do question the precision of the information. It is, perhaps, unrealistic to expect respondents to accurately recall when an often distant  event occurred, no matter how important. Consequently, we do not feel appropriate to make extensive use of the information on the length of time clients say they have been using medication. It would be possible to more closely determine how long clients have been taking medication by looking at the medical record. However, it is ethically and, perhaps, legally questionable as to whether any Consumer Satisfaction Team      should have access to a consumer’s records. 

(see Table 7) it appears, by inspection,  that medication is a constant in the lives of many consumers from the time of their initial diagnosis.

Table 7: Number of Years Taking Medication By Age Group

Although it may not be a point that anyone would question, the data support the idea

that medication is a central and persistent factor in the lives and treatment of the

mentally ill. As such, it  should be a subject for close and consistent consideration from a variety of perspectives.

Finally, we have attempted to find some way to describe the complexity that face clients in respect to the every day management of their medication. For instance, a client might take one dose of one type of medication once a day. Another client might take two doses of one medication once a day, one dose or another medication three times a day and have an injection once a week. Our purpose in identifying these different levels of complexity was the possibility that they might  influence some aspects of consumer behavior and attitude. To measure the complexity of the medication management task, we developed the Medication Management Index (Table 8).

Table 8: Medication Management Index^*

                                              No Response = 10

To develop this table a index score was calculated for each respondent The score was calculated by adding the number of different medications that the client reported they are taking to the number of medication sequences ( 3 times a day, 2 times a day, 1 time a week etc.)they must manage and the number of pills/injections they must take. For instance, a respondent who takes 1 pill of 1 anti-psychotic medication once a day would have an index score of 3 (1+1+1). If the client took 1 pill of 1 anti-psychotic medication twice a day would have an index score of 5 (1+2+2). We did not find any strong relationship between the index and other measures.

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