Beliefs about Anti-Seizure Medications-A Possible Reason for Low Adherence

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Adherence to anti-seizure medications (ASMs) is one of the several important epilepsy-related challenges. Adherence is an extremely intricate and poorly understood subject but clearly a health-promoting behavior, both in general and for epilepsy. Besides several operational and culture-related reasons, one of the infrequently explored culture-oriented possible reasons for non-adherence among epilepsy subjects is the beliefs epilepsy patients have about ASMs. In general, it is reported that patient’s (or probably family’s as well) beliefs affect adherence and outcome of treatment. Also, it is reported that beliefs of those who intentionally adhere are different from those of intentional non-adherers. With regards to epilepsy, only three studies have been reportedly performed, all in Westernized populations, that have provided mixed results regarding patient’s beliefs and their relation to non-adherence. 

Another survey amongepilepsy patients in an American population found patient’s beliefs robust enough to determine treatment outcome. How this may work in societies that are hierarchical, cultureoriented, and take decisions collectively in a family? In a recent survey in Tehran (Iran), it was found that patients do have inherent concerns regarding ASMs, particularly regarding dependence and long-term use of ASMs, however ‘necessity’ of ASMs prevailed for them over ‘concerns’ of ASMs since most patients (78.2%) were found to have good adherence, as tested with a locally-validated medication adherence rating scale. This was despite the fact that 54.5% consider epilepsy as supernatural, 91.2% had convulsive seizures and 52.2% were on polytherapy. Thus, it is likely that despite their inherent concerns about ASMs, patients may still remain adherent to ASMs. Having concerns (real or myth) about use of medications is not limited to ASMs but widely present for other medications as well, such as insulin which are widely considered as addictive. From our work in Iran, it was also observed that such beliefs may only have a partial impact on adherence. For instance, 14.0% estimated possible variance in adherence due to ‘worry about becoming too dependent on ASMs in the longterm’. 

Moreover, the impact of such patient’s undue beliefs about ASMs can be mitigated through good patient-doctor interaction as well as being in a hierarchical society with unequal power dynamics between patients and doctors. Support for these can be taken from results as well, for instance ASMs was not considered a ‘mystery’ by most patients (73.9%) which may support a good communication and ‘concordance’ between patient and doctor; a method of positive health outcome. Also, when patients adhere despite concerns about medications may suggest a traditional medical model wherein relationship between doctor and patient is of unequal power dynamics and patient may not necessarily be the one who ultimately decides whether or not they adhere to the recommended regimen. Overall, use of medications would almost always have some concerns in patient’s mind. Such concerns are not limited to ASMs. Undue patient beliefs may be present but may not always be practically influential towards medication adherence in every society. Moreover, patient beliefs may explain practical influence on non-adherence to a partial extent alone. Undue patient beliefs can be mitigated through good doctor-patient interaction and being in a traditional medical model with unequal power dynamics. A concordance (such as between patient and doctor) is therefore essential to keep patients adherent to medications.