Taking Their Medicine

Among the very few early clues dropped by law enforcement officials in answer to the “why” behind Thursday’s deadly shootings at Northern Illinois University: The killer, Steven Kazmierczak, had recently gone off his medication (reported to be anti-anxiety medication by the Chicago Tribune), becoming “erratic.”

Nationally and across the board for all types of disorders, experts say about half of all prescribed or recommended health regimens aren’t properly followed. Outcomes like Thursday's at Northern Illinois are highly unlikely and extreme -- the motives and real reasons behind the murders still not understood -- and clearly a student's decision to stop medication doesn't always or automatically pose risks to the self or others. But what are some of the particular challenges regarding compliance with prescribed medications among college students – or graduate students like Kazmierczak, who studied social work at the University of Illinois at Urbana-Champaign?

“They may stop abruptly, they may not take it correctly, they may take things that they shouldn’t take with it, particularly alcohol,” said Stewart E. Cooper, director of counseling services and a professor of psychology at Valparaiso University, in Indiana, and co-editor of Pharmacological Treatment Of College Students With Psychological Problems (Haworth, 2007). Cooper said that between 30 and 50 percent of people taking medication for psychiatric disorders voluntarily -- as most college students on those drugs are -- don’t comply properly with prescribed regimens in one way or another.

Some of the commonly cited reasons associated with taking or not taking one's medicine are attitudes about one’s illness and medication (fears of dependence can play a role, for instance), the relationship with a doctor and continuity of care, unwanted side effects, stigma, and, over a period of years, cost. And for psychiatric medications, some of the disorders being treated, like depression and bipolar disease, are risk factors for non-compliance in themselves. Studies have shown, for instance, that heart disease patients who are depressed are less likely to stay on medications than those who aren’t.

But among the factors especially pertinent to college students or even young graduate students, Cooper cited peer pressure (from friends who may not see the need for the drug), alcohol use (alcohol can interfere with or be potentially dangerous when used in conjunction with most psychiatric drugs), the “practice effect” (many young people haven’t regularly taken medication before) and, not surprisingly, matters of maturity.

“The risky period,” said Alan Christensen, a professor of psychology at the University of Iowa who has studied compliance, “clearly is late adolescence, middle-to-late adolescence. Certainly that would in part include the early college years.”

“If you think about the multitude of changes that are going on during that period I think all of them explain part of the risk,” Christensen said. Apart from the stress of being away from home, and not having mom or dad as monitors, Christensen mentioned increased emotional instability and interpersonal conflicts, the fight for independence, and hormonal changes as possible contributing factors at that stage in life.

After late adolescence, Christensen said, adherence to medications “improves really incrementally and almost continuously until old age, older adults, who at some point start to decline again.” In other words, generally speaking, a 37-year-old is more likely to take his or her prescription medication than a 27-year-old, who’s more likely to comply than a 17-year-old.

But graduate students, although less well-studied, may face special challenges. Jerald Kay, chair of psychiatry at Wright State University and chair of the American Psychiatric Association’s Committee on College Mental Health, pointed out that graduate students tend to be involved in more intense and demanding academic study than undergraduates. They're less likely to be in structured and supervised environments and more likely to have young children. They’re at higher risk for suicides; they are often financially strapped and in debt. And, given the high proportion of graduate students from foreign countries, cultural barriers to seeking help can create risk factors as well.

“They may have different needs, and we haven’t really been very sensitive to their needs,” said Kay. Some universities, he said, do a good job of offering mental health care to graduate students, by providing them quality health plans for care off campus and/or delivering services to them on-campus. But other campus health and counseling centers deny coverage to graduate students and their health plans can be woefully inadequate. “I feel,” Kay said of graduate students, “they frequently get lost.”

Insurance issues can be a problem for undergraduates as well, though. “A graduate student might have health insurance that’s in his or her name, versus an undergraduate that might be insured with families,” said Chris Brownson, a psychologist and director of the counseling center at the University of Texas at Austin. “I know that undergraduates are reluctant at times to take psychiatric medication because maybe their parents would find out and maybe they wouldn’t want their parents to know what they’re struggling with.”

“Of course,” Brownson added, “the reasons for discontinuing medications are oftentimes around stigma, and also around side effects of the medication itself,” he said. Students wonder not only what friends and family will think of them, but, also, “What does it mean that I have to take this medication?”

Experts like Kay, of Wright State, cited the importance of continuity in care, of ensuring for instance that care continues from the high school to college and that someone is checking up with the student on a medication, even if it’s by phone. "It is not sufficient to send a student to college on September 1 and, in the case of significant illness, not plan for some kind of continuity in care," Kay said. Part of the psychiatrist's job, he said, is to "maximize adherence to the reigmen" over time.

"We try to find the meaning of the medication to the patient," he said. "It is fairly common for people to have irrational thoughts that to take medicine means they're sick or defective. Their family may say something like, 'You don't want to do that kind of thing, you'll get hooked on it'.... Most people do have meanings they attribute to taking medication. Much of this is outside their awareness."

A 2005 paper published in the Journal of American College Health by three business and management professors -- prescription misuse in the United States is estimated to cost more than $20 billion annually -- makes the case for campus-wide advertising that would advocate adherence to prescriptions. "Rarely are health issues that promote individual responsibility and each student's effect on the health of other students a subject" of advertising in campus newspapers and alumni magazines, Chalmer Labig, an associate professor of management at Oklahoma State University and lead author of the study, said via e-mail. "On the other hand, students often give excuses for missing class that the professor would not want me to expose other students to my virus or similar claims. Thus, there appears to be potential for persuasive messages in alerting students to what they can do to prevent health problems of their peers, including support for those with emotional issues."

The "exploratory" study finds that in a convenience sample of 195 undergraduates in marketing and management classes, the beliefs of college students about health and prescription drugs influence their compliance with medications more than their relationships with physicians, in part perhaps because of limited contact with doctors and insufficient time spent discussing compliance.

“Looking at undergraduate students who were mostly 20 to 23, they are likely to be forgetful or stop taking their [prescriptions] when their symptoms moderate,” Labig said. “They are less affected by the quality of their relationship with their physicians than with their own beliefs about health" and, especially among males, "a self-cure orientation."