How behavioural factors affect the response to medication

Rob Horne, Professor of Behavioural Medicine at University College London School of Pharmacy, leads a research group focused on the psychology of medicines and understanding patient perspectives of treatment. IMI spoke to him to find out more about how behavioural science can inform consultations in community pharmacies.

Professor Horne originally trained as a pharmacist and practised as a hospital pharmacist for 10 years before embarking on PhD studies (into the psychology of medicines and understanding patient perspectives of treatment) supported by a Department of Health Pharmacy Enterprise scheme.  His research in this field has continued and he now leads a research group that is looking at the psychological and social factors that determine the outcomes of treatment. His teaching – on the M. Pharm course and post-graduate courses – is about understanding “behaviour as it relates to pharmaceuticals and [using] that understanding to improve the quality of care and support that we give to patients”, he says.

Why HCPs need to know about behavioural science/approaches

Behavioural factors are important for the effective use of medicines because they influence the “the whole issue of how patients engage with treatment and the issue of adherence”, explains Professor Horne. The other important area where psychological factors come into play is in determining the direct effects of a medicine. This is related to phenomena such as the placebo effect, where a physiological response is achieved using a substance that has no pharmacologically active ingredients, and the ‘nocebo’ effect, where patients experience side effects from placebo.

Professor Horne explains: “The element that we’re researching is how these non-specific effects – the psychological aspect of the treatment – are also relevant for active drugs. So, our psychology influences how well a pharmacologically active treatment works for us, but also our beliefs influence whether or not we get side effects – and these are some recent findings from our group. In summary, there are two effects, one is what we do – our behaviour – and the other is a direct effect of our psychology on physiological responses and treatment outcomes.”

Understanding of these factors can be used to help patients to get the best from their medicines. Many patients do not take prescribed treatment and that is particularly relevant for community pharmacy, says Professor Horne.  In fact, WHO estimates that half of medicines prescribed for long-term conditions are not taken as directed.  “From our research we can see that there are two main reasons why people don’t take medicines – they can’t or they don’t want to – it’s a lack of ability but also for many people a lack of motivation”, he says.

Some people want to take their medicines but they can’t because of barriers beyond their control; this could be because they are forgetful, they haven’t understood, they are unable to access the medicines, the medicines are too complicated to use or they simply cannot afford the medicines. “Pharmacy is traditionally very good at helping patients by making taking the medicines as simple and as easy as possible -and those things are very valuable, but the thing that’s often neglected is the ‘don’t want to’ [group]”, he says.

Professor Horne explains: “We know from our research that many patients ….. don’t come to the encounter with the pharmacist or the medicine as a blank sheet that we can write the instructions on;  they come with pre-existing ideas about the nature of their condition and about pharmaceuticals and whether that medicine is the best thing for them. The problem is those beliefs are often hidden because we don’t ask about them and patients are reluctant to tell us that they have a doubt [about] the treatment …. or that they’re not taking it, because they think that will offend the healthcare practitioner. So, what we’ve shown is that by having a better understanding of what the patient brings to the encounter with a medicine….. can be used to explain in a different way that overcomes doubts about whether they need it.” The doubts and concerns that a patient could have include whether the drug is still needed and fear of long-term side effects. “Once we understand what is in the patient’s head, if you like, what they’re thinking about the medicine, we can address misplaced concerns or doubts that are based on the mistaken understandings of the condition or the treatment”, he says.

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