Motivational interviewing for patients with severe mental illness 2nd Mental Health Case Manager Workshop Hong Kong 2012 Motivational interviewing for patients with severe mental illness Darrin Cowan: CNC Practice development NSLHD You have 7 minutes maximum for your presentation including time for questions from the floor. The presentation provides an opportunity for you to practice your presentation skills in a safe environment. Therefore the presentation should be as polished and professional as though you are presenting to your executive – it is not simply a means of bringing your program colleagues up to date with your progress. This means that you need to be able to talk to each slide succinctly drawing out the main point(s) or messages. Slides should only contain key words that you will speak to - don’t simply read the slides to the audience. For text that you want to be reminded of, but that isn’t on the slide, use the notes section HERE. Also focus more of your time on the most instructive points. For example, if you are experiencing issues with your project that you believe others would benefit from hearing about, then allocate more time to this part of your presentation. Photos of your project / context / people / surrounds help your audience visualise your project. Where too much text can compete with what you’re saying, a photo can complement your verbal delivery.

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.

“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.

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

Risk of hospitalization Even 1–10 days therapy missed per year leads to an increased risk of hospitalization Recent Californian Medicaid assessment (n>4000 patients) Risk of hospitalization Missed therapy over 1 year n=327 n=1710 n=1166 n=1122 p=0.0042 p<0.001 1 2 3 4 0 days 1–10 days 11–30 days 30+ days Looking at the effect of medication gaps, even missing 1-10 days of medication leads to nearly twice the odds of hospitalization compared with a person who has no medication gaps. The odds increase to nearly 3 times greater with a gap of 11-30 days, and for a maximum gap of >30 days, the odds of hospitalization are about 4 times higher than for a person with no medication gaps. All of these increases in odds are significant. Most patients in the study did have a gap in therapy, and many had a gap >30 days. This study clearly shows the detrimental impact of missing even a few days of medication on the hospitalization rate. p values given with 0 days as the referent Weiden et al. Psychiatric Services 2004;55:886–891

Cumulative proportion surviving Relapse after antipsychotic discontinuation in remitted subjects after 24-month continuous treatment Survival function Complete 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 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

Predictors of treatment outcome Male sex Poor premorbid adjustment Early age of onset Longer duration of untreated psychosis POOR OUTCOME Poor medication adherence Inherent refractoriness Reduced brain volume 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 Pharmacological intervention 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

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

Has been adapted for all kinds of interventions. 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.)

Initially used in substance abuse field. 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.

Initially used in substance abuse field. 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.

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. Motivation for change can be shaped and is particularly formed in the concept of relationships. No one is completely unmotivated. We all have hopes and aspirations. The way in which we talk to people can influence their motivation for change. With MI it is a partnership instead of an uneven power relationship where the helping person or health care provider is the expert. Instead of giving people what they lack be it medication, knowledge, skills or insight, MI seeks to evoke the person’s own motivations and resources for change. Even though the person may not be motivated in the direction you would like, every person has personal goals, values, aspirations and dreams. Part of the art of MI is connecting behavioral health change with the persons values and concerns. This can only be done by understanding the person’s perspectives and evoking their own good reasons and arguments for change. There needs to be a certain detachment from outcomes – not an absence of caring but an acceptance that people can an do make decisions about the course of their lives. By acknowledging the person’s freedom not to change, it makes change possible. With MI there is an acceptance that people make choices and despite what helpers may tell them, they ultimately make the decision.

Express empathy Develop discrepancy Roll with resistance PRINCIPLES OF MOTIVATIONAL INTERVIEWING Express empathy Develop discrepancy Roll with resistance 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.