How should I approach the management of a patient with schizophrenia who is non-compliant with their medication?

Management of a patient with schizophrenia who is non-compliant with medication should begin with a comprehensive assessment to identify reasons for non-adherence, including side effects, lack of insight, comorbid substance misuse, or cultural and personal beliefs about treatment. Engage the patient in shared decision-making to discuss the benefits, risks, and side effects of antipsychotic medication, tailoring the approach to their preferences and tolerances to improve adherence NICE CG178 Jackson et al. 2025.

Before initiating or adjusting antipsychotic treatment, consider an individual therapeutic trial starting at the lower end of the licensed dose range, with slow titration and close monitoring of response, side effects, and adherence over 4 to 6 weeks NICE CG178. Regular monitoring should include physical health parameters and side effects, as these can impact adherence NICE CG178.

Address comorbidities such as substance misuse and physical illnesses that may contribute to non-compliance NICE CG178. Offer psychological interventions such as individual cognitive behavioural therapy (CBT), ideally with at least 16 planned sessions, which has been shown to reduce relapse and improve symptoms and social functioning, supporting medication adherence indirectly NICE CG178,NICE CKS Mayer 2024.

Consider the use of long-acting injectable antipsychotics if oral medication adherence remains poor, as these formulations can improve compliance and reduce relapse risk NICE CG178. If the patient has not responded adequately to two different antipsychotics, clozapine should be offered, with careful monitoring and support to enhance adherence NICE CG178.

Develop a comprehensive care plan including a crisis plan and advance statement, involving the patient and carers where appropriate, to support engagement and adherence NICE CKS. Supportive employment and occupational activities may also improve overall functioning and motivation to adhere to treatment NICE CG178.

Involve multidisciplinary teams and consider specialist advice for complex cases or treatment-resistant symptoms, ensuring all off-label prescribing is communicated with the GP NICE NG181. Monitor drug levels where appropriate to assess adherence objectively NICE NG181.

Finally, consider digital health technologies as adjuncts to support symptom management and relapse prevention, which may enhance engagement and adherence NICE CKS.