Medication adherence as a learning process: insights from cognitive psychology

ABSTRACT

Non-adherence to medications is one of the largest contributors to sub-optimal health outcomes. Many theories of adherence include a ‘value–expectancy’ component in which a patient decides to take a medication partly based on expectations about whether it is effective, necessary, and tolerable. We propose reconceptualising this common theme as a kind of ‘causal learning’ – the patient learns whether a medication is effective, necessary, and tolerable, from experience with the medication. We apply cognitive psychology theories of how people learn cause–effect relations to elaborate this causal-learning challenge. First, expectations and impressions about a medication and beliefs about how a medication works, such as delay of onset, can shape a patient’s perceived experience with the medication. Second, beliefs about medications propagate both ‘top-down’ and ‘bottom-up’, from experiences with specific medications to general beliefs about medications and vice versa. Third, non-adherence can interfere with learning about a medication, because beliefs, adherence, and experience with a medication are connected in a cyclic learning problem. We propose that by conceptualising non-adherence as a causal-learning process, clinicians can more effectively address a patient’s misconceptions and biases, helping the patient develop more accurate impressions of the medication.

KEYWORDS:

• Adherence
• causal learning
• value–expectancy
• self-management

Disclosure statement

Dr Gellad is an unpaid member of the Board of Advisors for HealthPrize, a medication adherence company. Drs Rottman, Marcum, and Thorpe report no conflicts of interest.

ORCID

Benjamin Margolin Rottman http://orcid.org/0000-0002-4718-3970

Zachary A. Marcum http://orcid.org/0000-0002-4690-2304

Notes

1. We thank an anonymous reviewer for this suggestion.

Additional information

Funding

This research was supported by NSF 1430439 (Rottman) and a VA HSR&D Career Development Award (Gellad); U.S. Department of Veterans Affairs [IIR 14-297].