Staying on your medicine

Problems with Medication Adherence
Taken directly from:  Reiser, R. & Thompson. L. (2005) Bipolar Disorder: Advances in Psychotherapy- Evidence-based Practice. Hogrefe.

A review of the literature on serious mental illness suggest that almost 40-50% of clients are likely to have problems with medication adherence at some point.  It is rarely useful to become directive, confrontational or irritated with clients who have adherence problems.

Clients make decisions about their medication by weighing a number of factors including: trust in their healthcare providers, probable benefits [how likely are they to experience benefits?; how directly associated are benefits with taking the medicine?, etc.], side effects, social stigma associated with medication, reactions of family and significant others, culturally determined views, the effects of advertising, their sense of hopelessness or low self-efficacy ('Nothing I do works anyway!"), and internal beliefs about the meaning of taking medication ("Taking this means I am ill or a failure.”)

Addressing Problems with Medication Adherence
 
In dealing with medication adherence, it is useful follow a hierarchy of problem-solving strategies starting with the most simple, straightforward and pragmatic solutions.
 
  • Explore the problem directly and non-judgmentally
  • Attempt a problem-solving solution collaboratively with  the client (See Table below)
  • Address motivational issues through Motivational Interviewing
  • Address unhelpful beliefs about medication
 
Research supports the value of assisting clients in developing specific concrete strategies (called 'behavioral tailoring') to improve medication adherence (Mueser et al., 2002). For example, Meichenbaum & Turk,1987 (Page 140) review interventions designed to help the patient remember to take their medication (see Table I).
 
Table I. Behavioral Tailoring (adapted from Meichenbaum & Turk, 1987)
o   Involve family members when appropriate
o   Make use of alarms, small pocket timers or PDAs with alarm
o   Drug reminder chart
o   Yellow “Post-Its” on the medicine cabinet or refrigerator
o   Special calendars (available from the Depression and Bipolar  
      Support Alliance)
o   Medication boxes- separated by day and by time of dose
o   Special pill boxes with time alarm reminders
o   Medication strategically placed and coordinated with daily
       routine (e.g. bathroom sink, breakfast table)
o   Call patient to remind
 
If a specific behavioral tailoring approach does not appear to be effective then we would suggest proceeding to a motivational interview and finally to an analysis of the patient’s beliefs about medication and their illness in order to identify unhelpful beliefs that are compromising adherence. Table II summarizes key points from Meichenbaum & Turk (1987) associated with beliefs about their  illness and medication that interfere with adherence.
 
Table II. Reasons for Non-Adherence (adapted from Meichenbaum & Turk, 1987)
o   Uncertainty about the effectiveness of treatment
o   Negative expectations about the course of illness
o   Past experiences in treatment
o   Concerns about side-effects
o   Determination that costs might outweigh potential benefits
o   Stigma associated with psychiatric medication
o   Sense of hopelessness or fatalism
o   Conflicts with cultural or family belief systems
 
Motivational Interviewing
 
It is rarely useful to become directive, confrontational or irritated with patients who have adherence problems. As an alternative to more directive approaches, motivational interviewing  [See Motivational Interviewing] provides a non-coercive strategy that supports the client's concerns and issues. The goal of motivational interviewing (MI) is to avoid the trap of becoming directive and attempting to get patients to “comply” (e.g. give in) thereby damaging the therapeutic alliance and increasing conflict. MI attempts to engage the patient in a self-directed discussion of the pros and cons of medication adherence with a focus on getting the patient to recognize how non-adherence is ultimately inconsistent with other specified goals and values and may have negative consequences that they do not wish to experience.
 
Addressing Unhelpful Beliefs about Medication
 
Use of an “Unhelpful Thought Record” can address the client’s unhelpful and stigmatizing beliefs about medication and their illness. This is a powerful and useful strategy for tackling medication non-adherence. Problems with medication adherence often reflect ambivalent feelings resulting from stigmatizing and unhelpful thoughts about the meaning of having a chronic illness and having to take a psychiatric medication. Sometimes it can be helpful to use an analogy to patients with diabetes or other chronic illnesses who are faced with managing a long-term illness through consistent use of medication and a variety of other strategies including changes in lifestyle, behavior and careful monitoring.
 
Clients can be asked directly what thoughts they had prior to making a decision to stop taking their medication. These thoughts then become the basis for an “Unhelpful Thought Record”.  In some cases, patients will indicate that they no longer “feel ill” and believe that medication is no longer required. “I  began feeling so much better and so I decided to stop my medication”.  The therapist can develop specific strategies to cope with this line of thinking by emphasizing the chronic nature of the illness and the need to continue taking their medication as a part of staying healthy. Often with prompting clients will articulate a number of catastrophic beliefs about their illness which results in powerful feelings of pessimism and hopelessness. Clients can also experience their sense of “dependence” on medication as threatening to their sense of autonomy. For young adults, this sense of a loss of autonomy  may be even more threatening and may dovetail with other autonomy-independence struggles in which they view adults as trying to control their behavior.  This sense of threat of being controlled can be reframed as gaining personal freedom by  “taking control over the illness” and actively managing one's health.
 
References

Meichenbaum, D., & Turk, D. C. (1987). Facilitating treatment adherence: a practitioner's guide. New York: Plenum Press.
Mueser, K. T., Corrigan, P. W., Hilton, D. W., Tanzman, B., Schaub, A., Gingerich, S., et al. (2002). Illness management and recovery: A review of the research. Psychiatric Services, 53(10), 1272-1284.
Reiser, R. & Thompson. L. (2005) Bipolar Disorder: Advances in Psychotherapy- Evidence-based Practice. Hogrefe.
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