1. Non-adherence to treatment Clinical Coaching Brief Advice Behaviour Change Councelling Motivational Interviewing

2. Topics Non-adherence to treatment Motivation Clinical Coaching Brief Advice Behaviour Change Councelling Motivational Interviewing

3. Adherence to treatment

4. Adherence vs. compliance to treatment Adherence: active involvement of the patient in treatment processes Compliance: patients simply follow doctor´s orders Better adherence = better clinical outcomes

5. Non-adherence to treatment Taking too little (drug or excercise too little, etc..) Taking too much Not taking at the prescribed intervals (or excercising too or less frequently as required) Taking other medication without the knowledge of the prescribing medical professional Not taking the treatment for the prescribed duration 30% of patients Examples?

6. Clinical example: Course of psychotic disorders and the prescribed duration of the treatment Early warning signs 1st. attack 1st. relapse Remission C C

7. Antipsychotics (neuroleptic medication) for psychotic disorders: Recommendation for the relapse prevention After 1-st episode: 1-2 years After 2nd episode: 5 years Three and more episodes: life-long treatment Reality?

8. 10 days 6 months12 months 24 months 25% 33% 40% 76% 69% discharge nonadherence (%) Perkins, 2002; Kamali et al., 2006, Lam et al, 2002; Weiden et al., 1997 Psychotic disorders:Treatment nonadherence

9. Disease factors: No or few or mild symptoms Fluctuating course Lack or no insight Healthcare factors: Poor availability, Long waiting time Psychosocial factors: poor support Psychological factors: Depression; Attitude, beliefs, perceived benefits Treatment factors: Complex regimen Side effects MD´s factors Ability to communicate and provide information Why?

10. Case: Jirka

11. Promoting adherence Discuss the patient´s beliefs, concerns, and intentions relating to treatment Where possible customize the regimen in accordance with the patient´s wishes Simplify the regimen Provide simple, clear instructions for taking medication Elicit the patient´s feelings about his ability to follow the regimen and discuss stratgegies for enhancing adherence Consider the use of medication-taking systems including electronic reminders Emphasize the value of prescribed regimen and the importance of adherence for producing the best treatment outcomes Obtain any necessary help from family members, friends, etc.

12. Promoting adherence Monitor adherence. Watch for the mardkers of nonadherence such as missed appointments, missed refills, and a lack of response to medication Express approval of adherence and encourage continued adherence. Ask the patient about nonadherence and barriers to adherence in an understanding, non confrontational way If adherence appears unlikely, prescribe medication with lon half-lives, depot (extended release) or transdermal medication

13. How to do it???

14. Adherence and non- adherence: Patient´s attitude not symptom! How to influence patient´s attitude?

15. What do they have in common ?

17. Clinical Coaching Education Motivational Interviewing Barrier-free Access doctor as sparingpartner, shares knowledge, communicates comprehensibly, respects patient´s opinion, negotiates procedure, offers choice doctor searches for inner motives for change, addresses ambivalence respects wishes, solves problems together Doctor educates to the patient´s needs

18. InterventionBrief Advice (BA) Behaviour Change Councelling (BCC) Motivational Interviewing (MI) Time5-15 minutes5-30 minutes30-60 minutes SettingMostly opportunistic Opportunistic or help- seeking Mostly help-seeking Goals Demonstrate respect, communicate risk, provide information, initiate thinking about change in problem behaviour (Ask, Assess, Advise, Assist, Arrange) BA + Establish rapport, identify client goals, exchange information, choose strategies based on client readiness, build motivation for change BA + BCC+ develop relationship, resolve ambivalence, develop discrepancy, elicit commitment to change Practitioner- recipient Active expert – Passive recipient Councelor-active participant Leading partner - partner

19. Motivational Interview How to influence the clients´s attitude and promote behavioural change

20. Motivational Interviewing Diet and physical activity change Smoking cessation Behavioural and drug addiction councelling Medication adherence HIV prevention Chronic illnesses: diabetes and cardiovascular diseases Public health problems: preventing infection (ebola!!)

21. Motivation Motivation is a drive to act Motives: Biological (to eat, to reproduce): to ensure homeostasis of an organism Psychological and social (to achieve particular status, need to influence or control others; to make impression on others..) What is your motivation to study medicine?

22. Theory of motivation: Incentive theories External factors trigger and regulate motivation Expectations and values Knowing more about motives means we can address the situation more constructively

23. Theoriy of motivation: Drive theory Drive theories: behaviour to ensure the stability in bodily functions that is necessary to survive. A lack of equilibrium between our current state and our needs creates a tension which we are motivated to reduce Give an example of abnormal extremes of biological drives. Give an example of a disorders with strong motivational component

24. Motivation to drink alcohol ????

25. Craving Strong motivational effect Worsening of cognitive functions Physiological symptoms: increase of heart rate and increase of skin conductance The same as stress

26. Reward System Basic neurobiological system for survival and reproduction. A collection of brain structures to regulate and control behavior by inducing pleasurable effects. When activated, reinforces behaviors. Primary evolutionary natural incentives: air, water food, Sexual partner Safety dopamine

27. Nonnatural incentives: Drugs: Activate the systém more than natural podněty and Change the activity of the reward systém Reward System: Abused by drugs!