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2nd Mental Health Case Manager Workshop
Hong Kong 2012
Motivational interviewing for patients
with severe mental illness
Darrin Cowan: CNC Practice development
NSLHD
• Session Outline:
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Introduction.
What is adherence?
Who is adherent?
The importance of medication adherence in Schizophrenia.
Adherence / compliance strategies.
Motivational Interviewing.
Life after MI.
Conclusion & questions.
“Drugs don't work in patients who don't
take them.”
— C. Everett Koop, M.D.
• Adherence to treatment may be defined as the extent to which the patient's
history of therapeutic drug-taking coincides with the prescribed treatment.
• The point that separates "adherence" from "non-adherence" would be
defined as that in the natural history of the disease making the desired
therapeutic outcome likely (adherence) or unlikely (non-adherence) to be
achieved. As yet there is no empirical rationale for a definition of nonadherence.
Preventing relapse in schizophrenia
• Preventing relapse is a key goal highlighted in many
international clinical guidelines1–3
• Medication discontinuation is one of the top
predictors of relapse in schizophrenia4
– Treatment discontinuation increases the relapse
risk five-fold4
– The chance of relapse is decreased if pharmacotherapy
continues uninterrupted5
• Other risk factors include:3
– Substance abuse, residual symptoms, poor insight
Relapse prevention strategies should ensure periods of
non-adherence to medication are minimized3
1. NICE Schizophrenia Guidelines CG82, March 2009; 2. APA Practice Guidelines, 2004.
http://www.psychiatryonline.com/pracGuide/loadGuidelinePdf.aspx?file=Schizophrenia2ePG_05-15-06; 3. Barnes et al. J Psychopharmacol
2011;25:567–620; 4. Robinson et al. Arch Gen Psychiatry 1999;56:241–247; 5. Kane. J Clin Psychiatry 2007;68(suppl 14):27–30
Even 1–10 days therapy missed per year
leads to an increased risk of hospitalization
Recent Californian Medicaid assessment (n>4000 patients)
p<0.001
Risk of hospitalization
4
3
p<0.001
p=0.0042
2
1
0
n=327
0 days
n=1710
n=1166
1–10 days
11–30 days
Missed therapy over 1 year
n=1122
30+ days
p values given with 0 days as the referent
Weiden et al. Psychiatric Services 2004;55:886–891
Relapse after antipsychotic discontinuation
in remitted subjects after 24-month
continuous treatment
Survival function
Complete Censored
Cumulative proportion surviving
1.2
1.1
94% relapse rate
Median time to
relapse = 15 wks
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
0
n=33
10
20
30
40
50
60
70
80
Survival time (weeks)
Patients with recent onset psychosis who achieved remission relapsed after stopping
treatment with RLAI, therefore, treatment continuation should be considered
RLAI, risperidone long-acting injectable
Emsley et al. Eur Neuropsychopharmacol 2009;19(suppl 3):S486
Predictors of treatment outcome
Poor
premorbid
adjustment
Longer
duration of
untreated
psychosis
Male
sex
Early age of
onset
Poor medication
adherence
POOR
OUTCOME
Reduced
brain volume
Inherent
refractoriness
Cognitive
impairment
Modifiable factors
Robinson et al. Am J Psychiatry 2004;161:473–479; Emsley et al. J Clin Psychiatry 2006;67:1707–1712
Interventions to improve adherence
Psychosocial and
programmatic
interventions
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Cognitive behavioural therapy
Compliance therapy
Cognitive adaptation
Patient/family psycho-education
Symptom/side effect monitoring
Behavioural strategies.
Social skills training.
Living skills training.
Supportive therapy.
Adherence
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Pharmacological
intervention
Dose correction to reduce
side effects
Simplified medication regimen
First generation long-acting
injectable antipsychotics
Second-generation long-acting
injectable antipsychotics
Velligan et al. J Clin Psychiatry 2009;70(suppl 4):1–48
Motivational
interviewing:
Where does it fit?
• It is relatively new.
• Developed in the early 80’s by Miller.W & Rose.G.
• Based on the fundamental philosophical
components of Collaboration, Evocation and
Autonomy.
Key Principles:
1. Express empathy
2. Develop discrepancy
3. Roll with resistance
4. Support self efficacy
• It is relatively new.
• Has been adapted for all kinds of
interventions.
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Initially used for substance misuse.
Good data for this area.
Only recognised as an intervention with psychosis in the last 10 years.
Other studies have assessed its use for:
Obesity
Oral health
Smoking
Stigma
Medication adherence. (inconsistent outcomes)
(Barkhof.E et al. 2011. Interventions to improve adherence to antipsychotic medication in patients with
Schizophrenia.-A review of the past decade.)
• It is relatively new.
• Initially used in substance abuse field.
• Has been adapted for all kinds of
interventions.
• Is not a ‘treatment’.
• Most studies with good outcomes have used MI as an adjunct to
other therapeutic models.
• It has been combined with other approaches to be variously known
as:
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Compliance therapy
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Adherence therapy
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Adherence Coping Education
• These have specifically targeted adherence to medication.
• It is relatively new.
• Initially used in substance abuse field.
• Has been adapted for all kinds of
interventions.
• Is not a ‘treatment’.
• Shows promise for ‘treatment adherence’
when used in conjunction with
established therapeutic models.
(Barkhof.E et al. 2011).
1.Interventions that are longer in duration with continual focus on
adherence.
2.Problem solving interventions particularly those accompanied
by innovative technical aids.
3.Individually tailored approaches.
Life after MI:
•Requires competence in basic therapeutic skills.
•Must be influenced by a theory of ‘mind’.
•Requires close alliance between treating team members.
•Requires thorough understanding of treatment goals.
•Is not a ‘quick fix.’
Case study
Patient X
•21 years of age
•Case managed in the community.
•Maintenance dose of 117mg Invega
•2 previous admissions to inpatient unit.
•Discharged 2 months ago on LAI.
•Previous trial of Aripiprazole failed.
•Non-compliance led to decompensation and 2nd admission.
•Good symptom control at present.
•Pt X has expressed reluctance to continue medication.
•Also uses THC on occasion.
•Feeling depressed about social/work situation.
Characteristics of Motivational
Interviewing
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Guiding, more than directing
Dancing, rather than wrestling
Listening, as much as telling
Collaborative conversation
Evokes from a person what he/she already has
Honoring of a person’s autonomy
Source: S. Rollnick, W. Miller and C. Butler Motivational Interviewing in Health Care,
2008.
PRINCIPLES OF MOTIVATIONAL
INTERVIEWING
1. Express empathy
2. Develop discrepancy
3. Roll with resistance
4. Support self efficacy
Develop Discrepancy
• Difference between the person’s core values and life goals
and their health behavior
• Difference between where the person is now and where
he/she would like to be in the future
Elicit client goals & values.
– Evaluate client’s current state with regard to those goals & values.
– Emphasize the discrepancy between them.
• Best if the individual makes the argument for change.
Conclusions
• It seems that at least 50–70 % patients with schizophrenia
are not taking their medication properly.
• Non-adherence is associated with poorer functional
outcomes.
• Non-adherence is influenced by treatment, social and
disease-related factors.
• LAIs are playing an increasing role in relapse prevention.
• Case managers can play a significant role in the treatment
adherence of their patients.
• MI, in combination with existing therapeutic models, and
tailored to individual needs shows promise as a model for
maintaining treatment adherence.