Professional Issues >> Standard of Care

The symptoms of diseases such as schizophrenia, schizoaffective and bipolar disorders are both scary and devastating. Consumers experience insomnia, nervousness, depression, fears, hallucinations, lack of concentration, feelings of suspicion and confused thinking. The good news is, all of these symptoms can be greatly reduced or eliminated by the recently developed, so-called atypical antipsychotic drugs that have fewer of the problematic side effects associated with the older antipsychotics. Properly used, these medications make possible further treatment successes for the consumer, leading in many cases to his or her eventual reintegration back to a useful life.

But there is bad news too. Half of all consumers with these serious mental diseases stop taking their drugs. As a result, they have an average risk of relapse that is 3.7 times greater than consumers who regularly take their medications.[i] Without drug treatments, consumers often end up re-hospitalized with worsening psychotic episodes, and they are derailed from the reintegration track.

Drug Non-Compliance and Lack of Insight

So why don’t many consumers take their medications? Many reasons are given by consumers including cost and side effects. But one commonly recurring theme is that many consumers simply don’t believe they are ill. Why would anyone take a medication they don’t need?

The condition of impaired awareness for ones own disease is called anosognosia and is common in severe mental illnesses such as schizophrenia. Because the brain is not functioning properly, it is not allowing its owner to comprehend his/her illness.

Therapists have long been aware of the drug non-compliance problem and its relationship to lack of insight. Much effort is underway to close the gap that now exists between pharmacological science and therapeutic approaches aimed at helping consumers to continue taking their medicine.

A study published in 2002, called “Interventions to Improve Medication Adherence in Schizophrenia,” was conducted in affiliation with Rutgers University by researchers Annette Zygmunt, Mark Olfson, Carol A. Boyer and David Mechanic.[ii] The study reviewed all the literature on the subject from 1980 to 2000, assessing therapies for their ability to increase drug compliance.

Different Approaches

Because most of the 39 studies reviewed by the team overlap with other approaches, the authors took care to stress the tentativeness of their findings. “There are many shortcomings in the research,” they wrote, “and it is apparent that no single strategy has yielded impressive results.” Nonetheless, some approaches and combinations of approaches seemed to work better than others in getting consumers to take their medications.

·         Some therapies attempted to educate consumers about their illness—the so-called psychoeducational approach. These approaches did not attempt to alter the consumer’s attitude or behavior to achieve medication adherence.

·         Cognitive treatments targeted patients’ attitudes and beliefs toward medication. These interventions centered on the assumption that adherence is a coping behavior that is heavily determined by the personal construction of the meaning of medication and illness.

·         Behavior modification techniques attempted to change consumers’ behaviors toward their medications through rewards and punishment, reinforcements and the promotion of self-management. These techniques identify the consumers’ perceived goals and behaviors and then use them to induce the consumer to change his behavior toward drug compliance.

·         The Rutgers study reviewed community programs that, “typically involved a complex variety of supportive and rehabilitative services delivered to clients in the community rather than in a clinic.” These approaches featured very regular and close monitoring of consumer behaviors.

·         Some techniques combined a number of approaches. Compliance therapy joined cognitive approaches with motivational interviewing, a technique that helps consumers connect indirect benefits of medication to adherence and the reduction of symptoms.

The more successful therapeutic approaches for getting consumers to take their medications did not necessarily include efforts to teach consumers about their medications. The Rutgers study found that the psychoeducational therapies that attempted to educate the consumer on the facts of the illness without a motivational, behavioral component and without community-based supportive services were “typically ineffective” in improving medication adherence in schizophrenia. Approaches that focused on motivating the consumer to change behavior without necessarily trying to instill insight into the consumer were more successful. As stated in the study, “Concrete problem solving or motivational techniques were common features of successful programs.” These motivational approaches were found to be even more successful when reinforced by aggressive community-based support, characterized by frequent interactions with consumers in their homes by various members of the therapeutic team.

Motivational Approaches

Many of the motivational therapies used to improve medication adherence in schizophrenia and related illnesses grew out of therapies that were developed to treat drug addiction. As with severe mental illnesses, drug addictions often obscure people’s ability to perceive themselves as addicted.

Many of these approaches are based on one key principle: self-motivation. Unlike confrontational treatment strategies in which the therapist confronts the patient’s denial and breaks down their defenses, the more promising motivational approaches allow the consumer to determine his own motivation for change.

Dr. Xavier Amador, a Columbia University psychologist and NAMI board member has studied the relationship between insight and drug compliance. His book, “I Am Not Sick I Don’t Need Help (VidaPress, 2000) distills the very practical motivational approach he has developed. He refers to it by the acronym LEAP, standing for the four steps of motivational enhancement: Listen, Empathize, Agree and form a Partnership. (You can read more about the LEAP approach in an interview with Dr. Amador in the current issue of Reintegration Today).

When consumers stay on a drug regimen, either through the LEAP approach or one of the other promising therapies and community-based supports, one of the benefits they gain is to develop more awareness of their illness. Ironically, consumers can gain insight of their disease by not focusing on gaining insight.

Currently, the Rutgers team is updating and refining their research by gathering first-hand impressions from both therapists and the consumers as well as continuing to evaluate new therapeutic approaches. As Carol Boyer, Ph.D., one of the authors of the study states, “The goal is to learn from the ground up about possible treatment strategies and approaches to promote adherence. By taking a non-judgmental, exploratory stance, we hope to learn about motivations and triggers for adherence and non-adherence.”

SIDEBAR

Therapeutic approaches used to get consumers to take their medications often overlap:

Motivational Interviewing is an approach to behavior change that helps consumers explore and resolve ambivalence. Consumers are encouraged to not only define their own problems, but also develop their own goals or solutions that they themselves have identified.  The focus is not on imposing new ways of thinking or the acceptance of an illness, but on achieving narrowly focused personal goals.

Motivational Enhancement Therapy (MET) utilizes motivational strategies to mobilize the consumer’s personal choice for change.  It differs from other cognitive behavior strategies that teach specific coping skills in that it focuses explicitly on motivation as the key factor and relies on the consumer’s natural change process and personal decisions as motivation for change.  

Cognitive Behavioral Therapy is a therapeutic approach that focuses on identifying and treating difficulties caused by irrational, dysfunctional or distorted thinking.  Coping and awareness techniques are used to address dysfunctional thoughts, perceptions and beliefs that may be the source of emotional distress, anxiety and depression. 

Compliance Therapy is a combination of cognitive approaches and motivational interviewing that may be used to impact medication adherence.  Consumers are encouraged to share their beliefs and ambivalence about antipsychotic medications while focusing on adaptive behaviors and the importance of staying well.  The goal is to connect the indirect benefits of medication to adherence and symptom reduction. 

Program of Assertive Community Treatment (PACT)

The PACT Team has as its mission to provide a holistic community-based array of services to people with severe and persistent mental illness. The PACT Team utilizes a multi-disciplinary approach in a highly diverse community, with the intention of consistently providing high quality services that are specifically designed to meet the acknowledged needs of consumers.

REFERENCES

Motivational Enhancement Therapy (MET) William R. Miller http://www.dualdiagnosis.org/library/nida_00-4151/9.html

Motivational interviewing http://motivationalinterview.org/clinical/principles.html

Cognitive Behavioral Therapy http://counsellingresource.com/types/cognitive-therapy/

Compliance Therapy  factiva “Interventions to improve medication adherence in schizophrenia” Annette Zygmunt; Mark Olfson: Carol A Boyer: David Mechanic: American Journal of Psychiatry, October 1, 2002