Motivational interviewing for patients with severe mental illness

Darrin Cowan: CNC Practice developmentNSLHD

2nd Mental Health Case Manager Workshop Hong Kong 2012

• Session Outline:

• Introduction.• What is adherence?• Who is adherent?• The importance of medication adherence in Schizophrenia.• Adherence / compliance strategies.• Motivational Interviewing.• Life after MI.• Conclusion & questions.

• 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 non-adherence.

“Drugs don't work in patients who don't take them.”— C. Everett Koop, M.D.

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 relapserisk five-fold4

– The chance of relapse is decreased if pharmacotherapycontinues uninterrupted5

• Other risk factors include:3

– Substance abuse, residual symptoms, poor insight

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

Relapse prevention strategies should ensure periods ofnon-adherence to medication are minimized3

Even 1–10 days therapy missed per year leads to an increased risk of hospitalization

Weiden et al. Psychiatric Services 2004;55:886–891

Recent Californian Medicaid assessment (n>4000 patients)

p values given with 0 days as the referent

Ris

k of

hos

pita

lizat

ion

Missed therapy over 1 year

n=327 n=1710 n=1166 n=1122

p=0.0042

p<0.001

p<0.001

0

1

2

3

4

0 days 1–10 days 11–30 days 30+ days

Relapse after antipsychotic discontinuation in remitted subjects after 24-month

continuous treatment

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

94% relapse rateMedian time to relapse = 15 wks

n=33

Survival functionComplete Censored

Cum

ulat

ive

prop

ortio

n su

rviv

ing

0.00.10.20.30.40.50.60.70.80.91.01.11.2

0 10 20 30 40 50 60 70 80Survival time (weeks)

Emsley et al. Eur Neuropsychopharmacol 2009;19(suppl 3):S486

Poor medication adherence

Reduced brain volume

Predictors of treatment outcome

POOR OUTCOME

Poor premorbid adjustment

Longer duration of untreated psychosis

Inherent refractoriness

Cognitive impairment

Malesex

Early age of onset

Robinson et al. Am J Psychiatry 2004;161:473–479; Emsley et al. J Clin Psychiatry 2006;67:1707–1712

Modifiable factors

Interventions to improve adherence

• 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.

• 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

Pharmacological intervention

Psychosocial and programmatic interventions

Adherence

Motivational interviewing:Where does it fit?

• 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 empathy2. Develop discrepancy3. Roll with resistance4. Support self efficacy

• It is relatively new.

• It is relatively new.• Has been adapted for all kinds of

interventions.

• 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:o Obesityo Oral healtho Smokingo Stigmao 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:

o Compliance therapyo Adherence therapyo 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

• 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 empathy2. Develop discrepancy3. Roll with resistance4. 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.