A 39-year-old woman with MDD has been taking an antidepressant under your care for 3 weeks. Her dosage increases have been slow and steady, and she is starting to improve. But now she asks to discontinue her treatment. Her complaint? A mild tremor. “My nerves are becoming uncontrolled,” she says. You establish that the tremor does not interfere with functioning and provide psychoeducation that the tremor is mild and may decrease over time. She insists on stopping the medicine. What do you do?
Depression remains one of the leading causes of disability and early mortality in the US.1 Despite effective psychosocial and pharmacologic treatments for depression, their use remains low: fewer than 20% of Americans with moderate symptoms of depression saw a mental health professional in the past year.2 Even when treatment is received, it is often inadequate. Moreover, it is important to note that early treatment discontinuation increases the risk of recurrence.3
Antidepressants are a key therapeutic modality for depression, yet nonadherence remains a substantial barrier. In the US, 42.4% of adults with depression discontinue antidepressant therapy during the first 30 days and only 27.6% continue for over 90 days.4
Compared with non-Latino whites, racial/ethnic underserved groups have lower rates of antidepressant initiation and retention.5 Access and affordability are important reasons for this, but other key factors also contribute to lack of treatment. For example, Latinos and non-Latino blacks are less likely to receive guideline-concordant psychopharmacologic care than non-Latino whites, which may be the cause for lower confidence in treatment. Minorities are also less likely than non-Latino whites to find antidepressant medication acceptable.6
As with any patient, what is deemed acceptable to an individual is deeply influenced by that person’s specific social and cultural contexts. For example, cultural factors that influence some Latinos’ decisions about treatment with antidepressants include illness constructions that are inconsistent with antidepressant therapy and elevated concerns that medications are harmful or addictive.7 This may result in a marked ambivalence about taking medications for mental health problems.
On the one hand, many patients hope medications will help provide relief; on the other hand, they are afraid medications will harm them. An approach to pharmacotherapy that emphasizes an appreciation of patients’ sociocultural contexts is critical to addressing treatment adherence disparities and improving adherence among all patients.
Motivational interviewing (MI) is an intervention that at its very core is patient-centered. It lends itself to working synergistically with approaches that take into account the sociocultural contexts in which ambivalence about pharmacotherapy emerges. MI focuses on eliciting and utilizing the patient’s own intrinsic motivation as opposed to imposing outside pressure to facilitate behavior change. It incorporates open-ended questions, reflections, and affirmations to help patients explore their ambivalence about a choice. The aim is ultimately to assist the patient in resolving the ambivalence, especially by avoiding interactions that impede internally motivated change such as directing the patient to change or prematurely raising concerns about a patient’s behaviors—which can lead to defensiveness. MI’s strong emphasis on patient empowerment, values, and motivations makes it particularly well-suited for the personalization needed to make treatment culturally compatible. In a meta-analysis of 72 clinical trials that examined MI for a range of problems, observed effect sizes of MI were larger among ethnic minority populations.8
Dr. Lewis-Fernández is Professor of Clinical Psychiatry and Director of the New York State Center of Excellence for Cultural Competence, and Dr. Coombs is a Resident Physician in the Department of Psychiatry, Columbia University, and New York State Psychiatric Institute, New York, NY.
The authors report no conflicts of interest concerning the subject matter of this article.
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