Motivational interviewing for patients with severe mental illness

1. 2ndMental Health Case Manager Workshop Hong Kong 2012 Darrin Cowan: CNC Practice development NSLHD Motivational interviewing for patients with severe mental illness

2. 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.

3. “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 non-adherence.

5. 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 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

6. p<0.001 4 Risk of hospitalization p<0.001 3 p=0.0042 2 1 n=327 n=1710 n=1166 n=1122 0 0 days 1–10 days 11–30 days 30+ days Missed therapy over 1 year Even 1–10 days therapy missed per year leads to an increased risk of hospitalization Recent Californian Medicaid assessment (n>4000 patients) p values given with 0 days as the referent Weiden et al. Psychiatric Services 2004;55:886–891

7. Relapse after antipsychotic discontinuation in remitted subjects after 24-month continuous treatment Survival functionComplete Censored 1.2 1.1 94% relapse rate Median time to relapse = 15 wks 1.0 0.9 0.8 0.7 Cumulative proportion surviving 0.6 0.5 0.4 0.3 0.2 0.1 0.0 0 10 20 30 40 50 60 70 80 n=33 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

9. Predictors of treatment outcome Malesex Poor premorbid adjustment Early age of onset Longer duration of untreated psychosis POOR OUTCOME Poor medication adherence 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

10. Interventions to improve adherence Psychosocial and programmatic interventions Pharmacological intervention • 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 Adherence Velligan et al. J Clin Psychiatry 2009;70(suppl 4):1–48

11. 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: • Express empathy • Develop discrepancy • Roll with resistance • Support self efficacy

13. 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: • 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.)

14. 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: • Compliance therapy • Adherence therapy • Adherence Coping Education • These have specifically targeted adherence to medication.

15. 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). Interventions that are longer in duration with continual focus on adherence. Problem solving interventions particularly those accompanied by innovative technical aids. Individually tailored approaches.

16. 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.’

17. 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.

18. 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.

19. PRINCIPLES OF MOTIVATIONAL INTERVIEWING Express empathy Develop discrepancy Roll with resistance Support self efficacy

20. 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.

21. 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.