Compliance With Medical Regimens: An Annotated Bibliography

Bass LW , Wilson TR : The pediatrician's influence in private practice measured by a controlled seat belt study. Pediat 33:700-704, May 1964 . After receiving personal letters and direct advice from their physicians, 43 percent of 221 families complied with advice to get seat belts installed. In three comparatively matched groups, in which families received a non-physician personal letter, an impersonal letter or no letter at all, under 20 percent of each group had seat belts installed.

Berkowitz NH et al: Patient follow-through in the outpatient department. Nurs Res 12:16-22, Winter 1963 . Using a short, well described questionnaire, the authors evaluated 3,800 patients in 13 separate medical and surgical clinics on compliance with medications, treatments, visits, referrals, lab tests, and activity restrictions.

A Concurrent Comparison of Home and Sanatorium Treatment of Pulmonary Tuberculosis in South India, Tuberculosis Chemotherapy Centre, Madras. WHO Bull 21:51-144, 1950. The Madras report, in which the compliance to PAS at home and at the center, as checked by urine tests and pill counts, are compared. The results showed that males complied better than females, and that the relapse rate of non-compliers was equal to that of compliers. 44 references.

Davis MS , Eichhorn RL : Compliance with medical regimens: a panel study. J Health Hum Behav 4:240-249, Winter 1963. This frequently quoted article discusses many factors related to cardiac patients with a medical regimen requiring change in work, diet, or personal habits. The patient's age, work orientation, length of disability, educational background, the doctor-patient relationship, and other factors are investigated as they apply to compliance. The study utilizes interview techniques. 22 references.

Davis MS : Predicting non-compliant behavior. J Health Soc Behav 8:265-271, December 1967. Using various sophisticated methods, analysis of data from an interview schedule is utilized to attempt to correlate over-all patient compliance with behavioral changes. Three hundred sixty-nine farmers were evaluated, but their compliance was found not to be predictable.

Davis MS : Physiologic, psychological, and demographic factors in patient compliance with doctor's orders. Med Care 6:115-122, March-April 1968. Using a population of 154 patients in a general medical clinic, and utilizing interview techniques, tape recorders, questionnaires, and chart reviews, compliance with different medical regimes was evaluated. Results showed that attitudes and demographic factors did not seem to affect compliance; it was the physiologic factors primarily the amount of disability in daily life, and the psychological factors which appeared to affect patient compliance.

Davis MS : Variations in patients' compliance with doctors' advice: an empirical analysis of patterns of communication. Amer J Public Health 58:274-288, February 1968. A study of the doctor-patient interaction factors and their possible effects on patient compliance are discussed. A review of the literature emphasizing the doctor-patient relationship is presented. 41 references.

Davis MS : Variations in patients' compliance with doctors' orders: analysis of congruence between survey responses and results of empirical investigations . J Med Educ 41:1037-1048, November 1966. This is a literature review of factors affecting compliance of patients with a wide variety of illnesses. The article compares results in the literature with those estimated by senior and junior physicians in respect to the effect of numerous social and demographic factors. 36 references.

Donabedian A. , Rosenfeld LS : Follow-up study of chronically ill patients discharged from hospital. J Chronic Dis 17:847-862, September 1964. The article discusses variables which affect the compliance and non-compliance of 82 chronically ill patients with heart disease, strokes, or arthritis. An excellent review of the literature. 44 references.

Elling R. , Whittemore R. , Green M. : Patient participation in a pediatric program. J Health Hum Behav 1:183-191, Fall 1960. This is an often-quoted article which discusses the various factors affecting participation in a pediatric cardiology clinic by 80 families with children on prophylaxis for rheumatic fever. It points out the difference between the 55 percent high participating and the 45 percent low participating families.

Fox W. : Self-administration of medicaments: a review of published work and a study of the problems. Bull Int Un Tuberc 32:307-331, July 1962. An outstanding review article concerning many facets of compliance, including different ways to test for compliance, reasons stated by patients for non-compliance, and alternatives to self administration. 98 references.

Francis V. , Korsch BM , Morris MJ : Gaps in doctor-patient communication: patients' response to medical advice . New Eng J Med 280:535-540, March 6, 1969. Through chart review, tape recordings, interviews, and checking the amount of medication left in bottles, compliance to medical regimen was evaluated in 587 patients. Forty-two percent showed high compliance, 38 percent, moderate compliance, and II percent, low compliance. 20 references.

Hansen AC : Broken appointments in a child health conference. Nurs Outlook 1:417-419, July 1953. This study reviews 384 clinic appointments to a general well-baby clinic involving 98 families. Different possible variables, such as completed immunization, weather, and race are examined and related to the compliance with clinic appointments.

Hardy MC : Follow-up of medical recommendations, results of a health checkup of a group of well children in Chicago. JAMA 136:20-27, January 3, 1948. This article evaluates adherence of 789 children to medical care recommendations for defects found in physical examination. The authors feel parental understanding of the defect and availability of care are the most important factors in securing medical care. Only 36 percent of 2,227 recommendations were not complied with at all.

Hardy MC : Parent resistance to need for remedial and preventive services. J Pediat 48:104-114, January 1956. Of 6,731 children referred for evaluation of hearing or visual abnormalities, only 35 percent were evaluated by professional personnel. Some possible reasons are given for parental non-compliance to the recommendations to seek care. These include social and demographic characteristics.

Johannsen WJ , Hellmuth GA , Sorauf T. : On accepting medical recommendations — experiences with patients in a cardiac work classification unit. Arch Environ Health 12:63-69, January 1966. Using 127 patients in a cardiac work classification unit, compliance to medical, psychosocial, and vocational recommendations are studied through case history reviews: 92 percent of the medical, 66 percent of the psychosocial, and 76 percent of the vocational recommendations were complied with.

Ludwig EG , Adams SD : Patient cooperation in a rehabilitation center: assumption of the client role . J Health Soc Behav 9:328-336, December 1968. Using medical records, this study evaluates possible factors affecting compliant or non-compliant behavior to complete rehabilitation services. Of 406 patients, 44 percent completed services as recommended.

MacDonald ME , Hagberg KL , Grossman BJ : Social factors in relation to participation in follow-up care of rheumatic fever. J Pediat 62:503-513, April 1963. The authors analyze social, demographic, and interpersonal reactions of 123 patients with rheumatic fever and place them into the following three groups (based on interviews and chart reviews): (1) consistent compliance; (2) minor lapses; and (3) lack of compliance to medical regimens of drug taking, keeping of appointments, and general health measures. The groups had 57, 37, and 29 cases respectively.

Mather WG et al: Social and economic factors related to correction of school-discovered medical and dental defects. Penn Med J 57:983-989, October 1954. Which factors determine parental action in correcting medical and dental defects were analyzed through 1,117 interviews in the homes of children with such defects. Prior knowledge of the defect, parent education, P.T.A. attendance, income and other factors are ranked in order of their importance in causing corrective action.

Prickman LE et al: Does the executive health program meet its objective? follow-up study of examinations of 231 management executives . JAMA 167:1451-1455, July 19, 1958. Of 231 management executives who had received two complete physical examinations, 15 percent did not comply at all with the medical recommendations. Seventy-one percent complied fully, and 14 percent complied partially.

Schwartz D. et al: Medication errors made by elderly, chronically ill patients, Amer J Public Health 52:2018-2029, December 1962. Different types of medication errors in 178 elderly patients with at least one chronic illness are presented. Of these, 105 were not following care recommendations and were making one or more errors. The seriousness of the error, the type of error, and the personal characteristics of the study population are examined.

Shirkey HC : Drug administration. J Pediat 66:909-917, May 1965. Presents general discussion of the administration of drugs and a short discussion of the problems of compliance. Not a research paper. 42 references.

Andersen S. , Banerji D. : A sociological inquiry into an urban tuberculosis control programme in India . WHO Bull 29:685-700, 1963. Of 295 patients undergoing care for tuberculosis, 139 defaulted by not acquiring medications. Both those patients who defaulted and those who complied were evaluated for many sociological variables, including age, sex, religion, and income, but no differences were found.

Berry D. et al: Self-medication behavior as measured by urine chemical tests in domiciliary tuberculous patients. Amer Rev Resp Dis 86:1-7, July 1962. From 92 patients, a random sample of 26 patients was chosen and 70 percent of the urine samples were acquired at surprise home visits and tested for PAS and INH. Results showed that an estimated 90 percent of the patients took the drugs half of the time.

Berry D. , Ross A. , Deuschle K. : Tuberculous patients treated at home, comparison of regular and irregular self-medication groups. Amer Rev Resp Dis 88:769-772, December 1963. Description of the social and demographic characteristics of patients in the article, "Self-Medication Behavior as Measured by Urine Chemical Tests in Domicilary Tuberculous Patients" by Berry D et al.

Breite MJ : Urine test for the detection of PAS in ambulatory tuberculous patients . Amer Rev Resp Dis 79:672, May 1959. Upon analyzing a single sample of urine from each patient, results showed that-35 percent of 76 ambulatory patients had PAS derivatives in the urine.

Chaves AD : A simple paper strip urine test for para-aminosalicylic acid. Amer Rev Resp Dis 80:585-586, October 1959. Evaluation of the "Phenistix" test revealed that positive urine results for up to 12 hours after ingestion of three or four grams PAS will be positive. Citing a study involving 145 patients, this method is considered to be a reliable way to check compliance.

Chaves AD : Results of the PAS urine test (Phenistix) study done in May and June, 1959 . Amer Rev Resp Dis 81:111-112, January 1960. This is a short paper describing the results of spot urine checks for PAS on 2,622 outpatients in New York City clinics. The reasons why this should be done routinely are emphasized.

Deuschle KW , Jordahl C. , Hobby GL : Clinical usefulness of riboflavin-tagged isoniazid for self-medication in tuberculous patients . Amer Rev Resp Dis 82:1-10, July 1960 . The article discusses the value of adding riboflavin as a tracer to INH in order to check compliance.

Dixon WM , Stradling P. , Wootton ID : Outpatient PAS therapy. Lancet 2:871-872, November 2, 1957. This presents one of the earliest compliance studies, describing the basic characteristics of 151 tuberculosis outpatients. In this study only 50 percent took their PAS. The urine was tested by a modification of the ferric chloride method.

Fox W. : The problem of self-administration of drugs with particular reference to pulmonary tuberculosis. Tubercle 39:269-274, October 1958. Of 79 patients, 20 percent had negative urine checks for PAS at least once in the first six months, and 14 percent had a negative urine check at least one time in six months. Some reasons cited for stopping the drug were hunger, side effects, and forgetfulness.

Gordon CG : A method of controlled home treatment of pulmonary tuberculosis in Tanganyika . Tubercle 42:148-158, July 1961 . The results of a study in rural Africa showed that 41 of 94 patients had one or more negative urine checks, but only 13 of 94 had two or more negative urine checks for anti-tuberculous drugs.

Hobby GK , Deuschle KW : The use of riboflavin as an indicator of isoniazid ingestion in self-medicated patients. Amer Rev Resp Dis 80:415-423, September 1959. A description of the technical method for measuring riboflavin in the urine is presented. The authors conclude that riboflavin tracer would be a good method for determining compliance to INH therapy.

Ireland HD : Outpatient chemotherapy for tuberculosis. Amer Rev Resp Dis 82:378-383, September 1960. The author reports that after one year, up to 43 percent of 264 outpatients stopped their medication at least 50 percent of the time. He concluded this after studying which patients returned to the clinic regularly to receive medications as prescribed.

Kent DC : Assay of antituberculosis drugs in tuberculous patients. Dis Chest 49:595-599, June 1966. Review of different methods used to test for PAS and INH in the urine. 16 references.

Kraus P. , Krausova E. : Paper strip urine test for checking the intake of isoniazid. Tubercle 46:206-208, June 1965 . Describes an accurate paper strip method to detect metabolites of INH in the urine.

Luntz GR , Austin R. : New stick test for PAS in urine: report on use of "Phenistix" and problems of long-term chemotherapy for tuberculosis. Brit Med J 1:1679-1684, June 4, 1960. A description of the Phenistix test for PAS in urine. The article cites a study in which this urine test was applied to 705 outpatients on PAS for tuberculosis. Of these, 34 percent were non-compliers. The effects of patient age, sex, and the duration of drug therapy are evaluated. 26 references.

Maddock RK : Patient cooperation in taking medicines — a study involving isoniazid and aminosalicylic acid. JAMA 199:169-172, January 16, 1967. Urine tests on ambulatory TB patients showed that 30 percent of 50 patients on INH and 42 percent of 33 patients on PAS did not take their medication. The author presents comparative tables on compliance with tuberculosis drugs and other medications. 25 references.

Neves Almeida FD : On the reasons for irregular self administration of PAS. Tubercle 43:367-374, September 1962. For 1,036 inpatients and 469 outpatients, urine tests were found positive in 70 percent of the former and 47 percent of the latter group. The possible reasons for the difference are discussed.

Penman HG , Wraith DG : Two simple tests to detect omission of prescribed para-aminosalicylic acid . Lancet 2:552-553, September 15, 1956. Presents the initial study on patient compliance to PAS. Involving 22 patients, 9 out of 14 outpatients had positive urine tests, and 7 out of 8 inpatients had positive tests.

Pitman ER , Benzier EE , Katz M. : Clinic experience with a urine PAS test. Dis Chest 36:1-2, July 1959. Of 61 tuberculous outpatients on PAS, nearly 50 percent were not taking medication as prescribed. Compliance was tested through urine tests and patient interviews.

Pragoff H. : Adjustment of tuberculosis patients one year after hospital discharge . Public Health Rep 77:671-679, August 1962. Sociologic and environmental effects are investigated regarding compliance with drugs, diet, activity, and alcohol. Seventy-five percent of 66 tuberculous patients followed the drug regimen.

Preston DF , Miller FL : The tuberculosis outpatient's defection from therapy. Amer J Med Sci 247:21-25, January 1964. Compares physician evaluation of patient compliance with actual urine checks. Eighteen of 25 patients did comply, but physicians could accurately predict only four of the seven defaulters.

Quinlan M. : PAS in urine. J Irish Med Assoc 43:289-290, October 1958. Of 50 ambulatory tuberculosis patients on PAS, urine tests were positive in 44. The author feels this high compliance rate was due to careful instructions given the patients.

Roberts RW , Deuschle KW : Comparative study of urine tests for the detection of isoniazid. Amer Rev Resp Dis 80:904-908, December 1959. Within six hours after taking medication, a method using ammonium vanadate was able to detect urinary INH metabolites in order to check patient compliance.

Simpson J. : Simple tests for the detection of urinary PAS. Tubercle 37:333-340, October 1956. By using two methods for checking the urine, the author found 76 of 100 ambulatory TB patients taking PAS as prescribed. This is the first study on a large outpatient population.

Statt H. : Drug acceptability and chemoprophylaxis in underdeveloped countries . Bull Int Un Tuber 29:285-292, September 1959. This author reports that in Kenya, of 98 patients with suspect tuberculosis, compliance was checked by pill counts and only 30 percent took the INH medication satisfactorily. As there was attrition from the group, the percentage of compliers increased to 41 percent of 36 suspect patients.

Velu S. et al: Progress in the second year of patients with quiescent pulmonary tuberculosis after a year of chemotherapy at home or in sanatorium, and influence of further chemotherapy on the relapse rate. WHO Bull 23:511-533, 1960. In a study utilizing pill counts and urine checks of ambulatory tuberculosis patients, the results showed that the percentage of non-compliance for center visits was similar to that of surprise home visits. Home visits were also compared with patients in a Sanatorium, and compliance was approximately 75 percent. The one exception was in home visits to female patients (60 percent). 20 references.

Velu S. et al: Streptomycin plus pyrazinamide in the treatment of patients excreting isoniazid-resistant tubercle bacilli following previous chemotherapy . Tubercle 42:136-147, June 1961 . Cites a study in which 61 of 66 patients with relapse tuberculosis treated with streptomycin and pyrazinamide attended 85 percent or more clinic visits to receive I.M. Streptomycin. Outpatient therapy with streptomycin is felt to be feasible for relapsed tuberculous patients. 23 references.

Willis HS : Ground rules for home care of patients with tuberculosis. Amer J Med Sci 247:531-551, May 1964 . A general discussion of outpatient tuberculosis therapy, including an emphasis on compliance. 60 references.

Wynn-Williams N. , Arris M. : On omitting PAS. Tubercle 39:138-142, June 1958. In this article, 49 percent of 153 patients on PAS are classified as "defaulters" after testing urine by the ferric chloride and hypochlorite tests.

Zaki MH et al: Regularity of drug administration among hospitalized and ambulatory tuberculous patients. Amer Rev Resp Dis 97:136-139, January 1968. A description of technical methods used to test for INH and PAS metabolites. A study of 132 hospitalized patients is matched with 132 ambulatory tuberculous patients and reveals that 96 percent of inpatients took their medication. Of the outpatients, 52 percent took the PAS and 56 percent, the INH.

Bergman AB , Werner RJ : Failure of children to receive penicillin by mouth. New Eng J Med 268:1334-1338, June 13, 1963. This is a frequently quoted article citing a study in which pill counts were done on medicine given to 59 children for acute streptococcal infection. Eighty-two percent had stopped the medicine by the ninth day.

Charney E. et al: How well do patients take oral penicillin? a collaborative study in private practice. Pediat 40:188-195, August 1967. One of the first articles to try psychological tests to predict compliance. Of 459 patients, 56 percent complied with nine days of medication for streptococcal sore throat or otitis media. Compliance was tested by bacterial tests for penicillin in the urine.

Feinstein AR et al: A controlled study of three methods of prophylaxis against streptococcal infection in a population of rheumatic children. II. Results of the first three years of study, including methods for evaluating the maintenance of oral prophylaxis. New Eng J Med 260:697-702, April 2, 1959. This study reports the compliance of 391 children to penicillin or sulfa prophylaxis for rheumatic fever, as studied by pill counts and interviews. The difference in recurrent streptococcal rates among the compliers and noncompliers is discussed. Seventy percent said they complied, but pill counts showed that only about 50 percent complied.

Gordis L. , Markowitz M. , Lilienfeld AM : The inaccuracy in using interviews to estimate patient reliability in taking medications at home. Med Care 7:49-54, January-February 1969. Compliance to prophylaxis for rheumatic fever was tested through urine examinations and compared with interview responses at clinic visits. In 103 children the urine revealed 38 percent compliance whereas the interviews reported 71 percent compliance.

Gordis L. , Markowitz M. , Lilienfeld AM : Studies in the epidemiology and preventability of rheumatic fever. IV. A quantitative determination of compliance in children in oral penicillin prophylaxis. Pediat 43:173-182, February 1969. Of 136 children on penicillin for rheumatic fever prophylaxis, 36 percent did not take their medication one fourth of the time, when checked for the presence of penicillin in the urine. The predictive value of serial compliance checks is emphasized.

Heinzelmann F. : Factors in prophylaxis behavior in treating rheumatic fever: an exploratory study. J Health Hum Behav 3:73-81, Summer 1962. The author evaluated social, psychological and medical factors affecting whether 284 college students would comply with rheumatic fever prophylaxis. Nineteen percent were on prophylaxis.

Jackson H. et al: Streptococcal pharyngitis in rural practice —rational medical management. JAMA 197:385-388, August 8, 1966. The authors report that of 1,052 cases of proven streptococcal pharyngitis, 99 percent bought the medicine, and 76 percent returned for follow-up.

Leistyna JA , Macaulay JC : Therapy of streptococcal infections —do pediatric patients receive prescribed oral medication? Amer J Dis Child 111:22-26, January 1966. Of 162 patients with streptococcal infection of the throat, 144 or 89 percent received a satisfactory amount of penicillin. Compliance was tested in 144 patients by measuring medication unused, and in 96 patients by urine checks.

Lendrum BL , Kobrin C. : Prevention of recurrent attacks of rheumatic fever — problems revealed by long-term follow-up. JAMA 162:13-16, September 1, 1956. Of 100 children with rheumatic fever who were interviewed, 67 percent were on inadequate or incontinuous prophylaxis.

Mohler DN , Wallin DG , Dreyfus EG : Studies in the home treatment of streptococcal disease. I. Failure of patients to take penicillin by mouth as prescribed. New Eng J Med 252:1116-1118, June 30, 1955. This is the classical and initial article on penicillin compliance for streptococcal disease. Of 245 patients, of which 217 were under 15 years of age, 65 percent were said to take the prescribed medication as directed.

Mohler DN et al: Studies in the home treatment of streptococcal disease. II. A comparison of the efficacy of oral administration of penicillin and intramuscular injection of benzathine penicillin in the treatment of streptococcal pharyngitis . New Eng J Med 254:45-50, January 12, 1956. From a population of 127 patients, 90 stated they complied with medication instructions. Later 11 percent of the compliers and 32 percent of the noncompliers had reinfections of the throat.

Prevention of Rheumatic Fever - Second Report of the Expert Committee on Rheumatic Disease. WHO Tech Rep Series No. 126, 1957. Page 10: "Oral penicillin has the advantage of ease of administration but... has the disadvantages of requiring careful supervision to be sure of continuous prophylaxis." This statement reflects early recognition of the problem of non-compliance.

Wallace HM et al: Study of follow-up of children recommended for rheumatic fever prophylaxis. Amer J Public Health 46:1563-1570, December 1956. From patients seen by referral in the New York City Department of Health Cardiac Consultation Service Clinics, 644 patients with known rheumatic fever and recommended to have penicillin prophylaxis were chosen as the sample. A questionnaire was sent to 573 with known treatment agencies. Replies revealed that 231 of 444 patients were still with the referring agency, and 60 percent were on penicillin. Of the 213 children involved who were no longer being cared for by the referring agency, only 19 percent were on prophylaxis. Some possible reasons are discussed for the difference in compliance.

Bowen RG , Rich R. , Schlotfeldt RM : Effects of organized instruction for patients with the diagnosis of diabetes mellitus. Nurs Res 10:151-159, Summer 1961. This is a study of diabetics who were given instruction in many phases of diabetic self-management. The overall knowledge and skills of 23 patients in the experimental group, especially in compliance with dietary recommendations, improved from 70 percent to 95 percent after instruction, whereas patients in a control group regressed from 60 percent to 40 percent compliance with the diet.

Campbell GD , McNeill WG : Diabetes in the tropics. Brit Med J 2:633-634, October 3, 1959. The author estimates that in his experience, approximately 15 percent of diabetics in the tropics refused to take insulin correctly or at all, necessitating use of oral agents.

Cosnett JE : Diabetes among natal Indians. Brit Med J 1:187-192, January 24, 1959. The author feels that in an indigent, illiterate, and malnourished population, dietary and insulin therapy for diabetes is quite difficult, and that the medical regimen is very difficult to follow. No particular figures or population base.

Gabriele AJ , Marble A. : Experiences with 116 juvenile campers in a new summer camp for diabetic boys. Amer J Med Sci 218:161-171, August 1949. Of 83 diabetic boys who answered questionnaires concerning their diabetic regimen, 61 percent were irregular in following their prescribed diet, and 38 percent did not check their urine for glucose.

Root HF , Pote WH , Frehner H. : Triopathy of diabetes — sequence of neuropathy, retinopathy, and nephropathy in one hundred fifty-five patients. AMA Arch Intern Med 94:931-941, December 1954. In relation to complications of diabetes being related to control of the disease, 451 patients were surveyed. Of these, only 61 were in good or excellent control, as judged through interviews on how the patient complied with recommended urine checks, diet, and regular physician contact.

Stone DB : A study of the incidence and causes of poor control in patients with diabetes mellitus. Amer J Med Sci 241:436-442, April 1961. The author reports that of 160 patients evaluated, 126 were either in "Fair" or "Poor" control of their diabetes; non-compliance to dietary restriction was the major cause. 19 references.

Watkins JD et al: A study of diabetic patients at home. Amer J Public Health 57:452-459, March 1967. This study describes compliance and knowledge of self medication, insulin dosage, urine chccking, meals, foot care, and other variables in 60 patients, as checked by interviews and tests. Of 60 patients, 28 were unacceptable in four of five variables.

Williams TF et al: The clinical picture of diabetes control, studied in four settings. Amer J Public Health 57:441-451, March 1967. Of 213 diabetic patients studied through questionnaires in four settings, 71 percent were felt to be in poor or very poor control of their disease. The authors feel this was partially due to the patients' non-compliance with the medical regimen. Some of the other characteristics that could cause poor control are also discussed.

Williams TF et al: Dietary errors made at home by patients with diabetes. J Amer Diet Assoc 51:19-25, July 1967. This article cites a study in which 17 diabetic patients kept a record of food intake for one week; over 75 percent of them did not comply with the prescribed diets.

Wilson JL , Root HF , Marble A. : Prevention of degenerative vascular lesions in young patients by control of diabetes. Amer J Med Sci 221:479-489, May 1951. The study reports that of 247 diabetics. only 15 percent were in good or excellent control. The authors feel that more people can be in good control with effort, and that this would reduce the complications of diabetes.

Forrest FM , Forrest IS , Mason AS : Review of rapid urine tests for phenothiazine and related drugs. Amer J Psychiat 118:300-307, October 1961. This paper presents a thorough discussion of the different methods used to test urine for phenothiazine and similar drugs. 60 references.

Frank JD et al: Why patients leave psychotherapy. Arch Neurol 77:283-299, March 1957. The authors report a thorough evalution of 91 psychiatric outpatients with psychoneurotic or personality disorders undergoing psychotherapy. They performed a comparison of those continuing and those not continuing therapy, based on the results of different psychological scales. Thirty-one percent left therapy prematurely. 31 references.

Havens LL : Problems with the use of drugs in the psychotherapy of psychotic patients . Psychiat 26:289-296, August 1963. The author states his views of why psychotic patients refuse completely, are noncommital, ur actually ask for, drug therapy. There are no figures mentioned.

Lipman RS et al: Neurotics who fail to take their drugs. Brit J Psychiat 111:1043-1049, November 1965. Evaluation of 254 neurotic patients in an outpatient psychiatric clinic showed that 55 percent adhered to taking their drugs. Compliance was tested by pill counts.

Parkes CM , Brown Gwi , Monck EM : The general practitioner and the schizophrenic patient. Brit Med J 1:972-976, April 7, 1962. Ninety-six schizophrenic men were given 120 courses of drugs as outpatients. Forty-four percent of these courses were not completed.

Willcox DR , Gillan R. , Hare EH : Do psychiatric outpatients take their drugs? Brit Med J 2:790-792, October 2, 1965. Forty-eight percent of 125 psychiatric outpatients on chlorpromazine and/or imipramine did not take their medication as prescribed. Compliance was tested by a chromatographic method which determined urinary metabolites of the drugs.

Wolff RJ , Colacino DM : A preliminary report on the continued post-hospital use of tranquilizing drugs . Amer J Psychiat 118:499-503, December 1961. This paper reports the percentage of psychiatric patients taking prescribed drugs as gathered through interviews. Of 145 patients 83 percent complied initially, but this fell to 66 percent of 109 within six months.

Hare EH , Willcox Drc : Do psychiatric patients take their pills? Brit J Psychiat 113:1435-1439, December 1967. Urine tests on 120 psytriatric inpatients and 27 day patients revealed that at least 19 percent and 37 percent respectively were not taking their medication adequately.

Pollack B. : The validity of the Forrest reagent test for the detection of chlorpromazine or other phenothiazines in the urine. Amer J Psychiat 115:77-78, July 1958. By specific urine tests, 75 general patients had not positive tests for phenothiazines and 91 out of 100 patients receiving chlorpromazine had trace or better amounts in the urine.

Gold S. , Griffiths PD , Huntsman RG : Phenothiazines in urine. Mental Sci 108:88-94, January 1962. With stress laid to the importance of testing for drugs in patients, approximately 90 percent of 329 psychiatric patients urines tested by one method were positive. Other methods were not as sensitive 24 references

Glennon JA : Weight reduction — an enigma. Arch Intern Med 118:1-2, July 1966. This author reports that of obese patients followed for 12 months or more, 23 of a population of 199 achieved and maintained a 20 pound or greater weight reduction. Thus, 13 percent were able to comply with the dicting prescribed.

Gwinup G. , Poucher R. : A controlled study of thyroid analogs in the therapy of obesity. Amer J Med Sci 254:416-420, October 1967. Of 17 patients on thyroid preparations for obesity. 13 lost weight and completed the study. The remaining fout had to be withdrawn from the study due to side effects After all the patients were taken off drugs, they gained their weight back.

MacCuish AC , Munro JF , Duncan LF : Follow-up study of refractory obesity treated by fasting. Brit Med J 1:91-92, January 13, 1968. Twenty-five obese patients were treated by starvation in the hospital. After being díscharged and put on a diet, all gained weight at home and 12 defaulted from the clinic. Effectively the compliance was zero.

Stunkard A. , McLaten-Hume M. : The results of treatment for obesity —a review of the literature and report of a series. Arch Intern Med 103:79-85, January 1959. This paper the literature on obesity, emphasizing the generally poor results with dicting. It reports that in one series, only 12 of 100 patients complied to the extent of losing 20 pounds. 18 references.

Benstead N. , Theobald GW : Iron and "physiological" anemia of pregnancy . Brit Med J 1:407-410, February 23. 1952. Thirty-three percent of 36 anemic pregnant women in one group and 40 percent of 15 women in a second group could not take terrous sulphate. The authors estimate that between 30 percent and 40 percent of antenatal patients cannot tolerate ferrous sulfate, and thus do not take the medication as prescribed.

Haler D. : The therapeutic response of secondary anemias to organic and inorganic iron salts. Brit Med J 2:1241-1243, December 6, 1952. Although the author presents no data on compliance he feels that 25 percent of outpatients discontinue ferrous sulphate therapy.

Bruce-Chwatt LJ , Horn DW : Antimalarial drugs in Nigeria: results of a new survey. Brit Med J 2:869-876, October 11, 1958. On a questionnaire, only 10 of 2,202 whites stated that they didn't comply with antimalarial prophylaxis. The authors doubt this figure themselves.

Gilroy AB : Investigation of proguanil prophylaxis and co-existing parasitaemia . Ann Trup Med Parasit 46:72-84, May 1952 . Fifty-six percent of 742 adults supposedly taking antimalarial prophylaxis had positive urine tests. A discussion of the problem concerning malaria prophylaxis is presented.

Parker LB , Bender LF : Problem of home treatment in arthritis. Arch Phys Med 38:392-394, June 1957. The authors report that interviews in the clinic revealed that a drop-out rate of 43 percent had occurred among 56 patients on home therapy for arthritis.

Treusch JV , Krusen FH : Physical therapy applied at home for arthritis: a follow-up study with a supplementary sumnary of sedimentation rate of erythrocytes in two hundred and twenty-nine cases of arthritis. Arch Intern Med 72:231-238, August 1943. Through the use of a questionnaire, data were compiled on 218 cases of arthritis for evaluating the compliance to instructions concerning home care therapy. Seven percent of the patients gave themselves no therapy, but 64 percent continued therapy for at least three months.

Caron HS , Roth HP : Patients' cooperation with a medical regimen: difficulties in identifying the noncooperator. JAMA 203:922-926, March 11, 1968. In this study, 525 patients took 46 percent of their prescribed antacids Of 27 physicians, who tried to estimate this compliance, 22 overestimated the amount of antacid patients would take. Neither could the physicians predict which patients would comply.

Franch JM , Hawkins CF , Smith N. : The effect of a wheat-gluten-free diet in adult idiopathic steatorrhoea: a study of 22 cases. Quart J Med 26:481-499, October 1957. Of 22 patients with non-tropical spide, 16 improved with their special diet, she did not. Two of the improved returned to normal diet and relapsed Five of six unimproved went back to a normal diet, and four died. All 22 patients were supposed to continue on the special diet.

Roth HP , Berger DG : Studies on patient cooperation in ulcer treatment: 1. Observation of actual as compared to prescribed antacid intake on hospital ward. Gastroenterol 38:630-638, April 1960. This is an often quoted article showing a study in which 75 ulcer patients took 42 percent of their prescribed antacids, as measured by remaining antacids in the bottles.