Encephale. 2002 Sep-Oct; 28(5 Pt 1): 389-96.

[Autonomy attitudes in the treatment compliance of a cohort of subjects with continuous psychotropic drug administration]

Baumann M, Trincard M.

MaÃ®tre de confÃ©rences des universitÃ©s en Sociologie de la SantÃ©, FacultÃ© de MÃ©decine, UPRES EA3444, Ecole de SantÃ© publique, Nancy, Cedex, France.

Prescriptions for psychotropic drugs are part of a general practitioner's daily routine. As with all drugs, they need to be controlled by a phenomenon of observance. Respecting prescriptions is in fact a major public health concern. Our problematic is centred on the analysis of the association between observance and autonomy in order to gain a better understanding of the links between the drug, how it is to be taken, and how the patients adapt and control it. Identifying and comparing autonomous practices psychotrope users associated with attitudes put into play by those who claim to observe or not to observe their treatment is the aim of this project. The qualitative analysis of the speech is based on the categorial analysis of the contents of 46 transcriptions of 23 women et 23 men continuous (regular monthly intake for at least 5 years), aged between 50 and 65. The majority live in couples, have professional activities, and are executives. The psychotropes with the largest consumption are: anxiolytics and antidepressors. The average duration of their consumption is more than 17 years. Two types of attitude can be distinguished through the qualitative analyse. The attitudes of non-observers towards the psychotropic drug and dependence show controlled, autonomous acts. Autonomy is an influencing factor in their observation of the prescribed treatment, it is a major component of their non-observance regarding psychotropes; thus our hypothesis is confirmed. The strategy adopted around the medication arises from autonomy of action. Organising the treatment is seen as a sign of autonomy, as taking an initiative in relation to the medical prescription, and not as rebellious, or carefree behaviour, or as a sign of inconsistency. Non-observers seem more to be involved in a step towards self-regulation. Active taking verbs such as stop, diminish, increase , and success verbs succeed the I is greatly used, reinforced in some cases by myself ; this vocabulary situates the patient as an actor facing the drug and shows that he is capable of action. For observers, taking the drug is qualified as regular and some users categorically refuse to bypass the doctor's advice never . Looking for additional information is an act of autonomy. It is found partly with the doctor; but also from the media, the exchanges with the others and the reading of the notes. But talking to other people and reading the information leaflets are more often done by non-observers. Recognizing oneself in the indications and the dosage marked on the leaflet seems to be the first step to adopting the drug so as to know it better and to gain mastery of it. Autonomy is gained through finding alternative, substitutive or complementary solutions with a large share left to herbal medicine and homeopathy. Non-observers seem to be more active than observers in diminishing or stopping taking psychotropes. Affirming one's autonomy is also shown in the direction given to each person's trajectory of life, behaviour referring to it, the projection into the future, and the dynamics of life. These actions underlie a capacity of resistance, non-observers using evocative terms such as taking things in hand , recognizing the while, in certain cases, the need to be supported. This capacity of action is far less present in observers who acknowledge their difficulties in facing up to events. The intentionality and the determination of their behaviour and their choices depend on the autonomy of willpower. Adjusting the amount taken is shown by expressions of intention, and justifies self-regulation. Non-observers direct their behaviour towards a reduction in the medication and commit themselves not to go over a certain amount. Stopping usage is declared as certain , it is planned. On the other hand, it remains unpredictable for observers for whom consumption is linked to the description of a need to have long-lasting health. Observers describe taking their medication as automatic, routine, and easy. A sort of fatality and resignation is attached to the prescription, linked to a negative perception of their health. The medication is at the same time nourishing and destructive . The disagreeable sensations caused by its suppression and the secondary effects appear less important than the benefits to be had from it. Autonomy can be recognized in the type of commitment established with the professional. It can be shown around a prescription negociated for treatment and delivered in mutual agreement. It places the patient in an active partnership. The presence of I and of more frequent active verbs in non-observers shows the role played by the patient. His conversation organizes itself round how the medication is to be taken. Systematic use of the prescription reinforces the instrumental recourse to the doctor for a renewal especially for non-observers. For observers, the prescription is followed despite disagreements. The professional is appreciated for his expertise in advice, how to use the medication . Confidence results from this know-how. The feeling of fear inspired by the psychotrope puts taking the medication into perspective and removes the guilt from non-observance. This process contributes to the patient's carrying on taking the medication. The positive effects found again thanks to the medication strengthen the later's perpetuation. When the patient is asked to participate in the prescription, this participation is described differently in the two groups. In observers, it is understood from the viewpoint of the doctor-patient association with, us and for the other group from the viewpoint of cooperation I, one . In non-observers, a type of delegation is highlighted leave it to be managed , the patient's confidence in the doctor lets him manage his medication under medical control . The autonomy of willpower is shown by the degree of openness to the Other Person. Non-observers have quite open and trendy character traits and give a rather positive image of themselves. These elements are absent from the speech of observers in favour of a negative self-image. The autonomy of willpower shows up in their free expression within the family, and with friends, the patient is freed from the influence of other people. For non-observers it is admitted easily . Observers show reserve through a concern of being discrete; rules of good behaviour do not allow them to speak about their consumption since it lifts the veil on their person and its affects. Two types of attitude can be distinguished: Observers for whom the psychotrope supports them against an unhappy life and is part of a habit which is hidden from other people, they keep to the prescribed doses and don't try to change them, they have absolute confidence in the medical profession; non-observers for whom psychotropes are a crutch which they mistrust. They are conscious of the bad effects and state their intention and their will to control this medication by planning on a reduction in, or even an end to, consumption. In order to give a meaning to the prescription and to avoid too great a feeling of guilt, they legitimize the later by an obligation created by a need, and by an improvement in symptomatology, and they minimize the quantity and the effects of taking the medication. They cooperate with the doctor and are involved in a close relationship with my doctor . They show a certain familiarity to the medication and talk openly about their consumption. Autonomy is a means to responsibility and to valorise a part of the patients in particular those which are non-observing so as to strengthen their capacity to manage their health as best they can. It contributes to a better observance of treatment in as much as autonomous patients are more inclined to negotiate with their doctors. Looking for self-regulatory behaviour allows us a better understanding of those patients non-observers who are willing, and helps them to develop their aptitude to face up to their illness.