On resiste a l’invasion des armies, on ne resiste pas l’invasion des idees [An invasion of armies can be resisted, but not an idea whose time has come]

.
       Victor Hugo (Histoire d’un Crime, 1852)

I feel fortunate to have lived long enough to see the “integration model” of health care taking hold! Or have I? Or has it? In a world that seems at times to be coming apart, it is heartening to see the words “integration” and “collaboration” in such prolific use. Can we be hopeful in what it portends for general and mental health?

The idea of integrated care did not magically emerge, but has a rather tortuous history, an accretion of many iterations over decades, if not centuries. It has struggled against barriers that have resisted the seemingly natural impulse to retain mind and body as a unified entity, joisting at times with religious, philosophical, political, economic, and inter- and intra-professional oppositions.

Integration is a word with so many meanings as well as functional applications that one can never be certain what it refers to. It ranges from civil rights advances, to electronic circuits, to economies, to institutions and their various components, to the components of living organisms.

In psychiatry, it most often refers to some adumbration of efforts to link aspects of mind and body, perhaps best illustrated by consultation-liaison psychiatry. But words like “integration” and “collaboration” are probably better understood than “consultation-liaison” psychiatry.

In today’s world with its health focus, we see it applied fundamentally in 3 ways:

 Clinically, related to mind-body interaction and holistic medicine

 Disciplinarily, with alliances between programs and services

 Institutionally, involving coordination with administration, finances, data, records, mergers, and so on

Clinically, endeavors to reunite psychiatry with medicine have arguably shown greatest sustainability in the special field of consultation-liaison psychiatry. Evidence has been manifest in the very foundations of consultation-liaison psychiatry, in psychosomatic medicine, general hospital psychiatry departments, inpatient milieu programs, med-psych units, double boarding, biopsychosocial medicine, and behavioral medicine.

Early “toe in the water” innovative overtures include 

 an internist disciple of George Engel, broadened gastroenterology to include greater biopsychosocial emphasis. Proponents of family medicine have, for years, advocated systems that integrate behavioral medicine with primary care.

The urgency and benefits of looking at how medicine deals with the complexity and barriers of achieving the objective have not been lost on Institute of Medicine reports, recommendations for curriculum changes, presidential commissions on health (especially mental health), philanthropic agencies, and surgeon generals’ reports.

 internist director of the Medical Science Division of Rockefeller Foundation in the 1930s, recognizing the deplorable state of professionalism in psychiatry, funneled millions of dollars into the establishment of psychiatric departments in major medical schools, with special emphasis on general hospital psychiatry, psychosomatics and, by extension, consultation-liaison psychiatry.

 a Hungarian general practitioner-cum-psychoanalyst, emphasized the need for general practitioners to include a psychological awareness of their patients’ and their own emotional involvement in the care of patients. Balint Groups spread and continue to this day. He said it would take 100 years (this was the 1950s) before this idea would be accepted in medicine (we are almost there and maybe on the cusp!).

The 1950s also saw the flourishing of psychopharmacology, which facilitated the deinstitutionalization of patients to community mental health centers, where the democratizing of team treatment took place in both inpatient milieu units and community centers, staffed not exclusively by psychiatrists.

At Kaiser-Permanente, the first full-service health maintenance organization, psychologist 

 documented the “medical” benefits of treating patients with psychotherapy in the 1960s. Around the same time, the founding of the Integration Clinic at Boston’s Beth Israel Hospital began with a psychiatrist, a social worker, advanced psychiatry residents, and the primary care physicians (PCPs) of 45 clinics that fragmented patient care into disease entities or body parts.

The program was absorbed into a comprehensive ambulatory care model, Beth Israel Ambulatory Care. Both programs demonstrated the decreased emergency department visits, hospitalizations, and medication use by adding a psychosocial component to patient medical care, especially of those with chronic illness.

Consultation-liaison psychiatry, as the closest model to integrated care, was hampered by poor reimbursement as well as failing support by eminent psychiatrists. For example, Thomas Hackett advised dropping the activity of liaison, since it was “nothing more than kicking a dead horse.” Later, largely attributed to the efforts of James Eaton of National Institute of Mental Health,

 the full-bodied relevance of consultation-liaison gave a prominent boost to the concept of team-based integrated care.

A recommendation for parity began with President Kennedy in 1963; it was “officially” enacted in 2008 and only reluctantly began to be observed by 2015 with President Obama’s Affordable Care Act. In 2008, Senator Domenici

 said, “It’s amazing, not only because we got it done, but because for a nation, it has taken us so long.” The advent of managed care both hurt and helped by “carving out” mental health services from comprehensive care, the disastrous fragmenting effects met a robust counteraction to bring fragmented medicine together again.

Alfred Freedman, renowned psychiatrist/psychoanalyst, launched a short-lived journal in 1983, 

Integrative Psychiatry: An International Journal for the Synthesis of Medicine and Psychiatry

. . . a challenging adventure to explore the impact-present and potential-of many sciences on psychiatry and, no less, of psychiatry on those sciences . . . [to solicit] papers pertinent to convergence and integration, [to show] how psychiatry, medicine, and all the biological and behavioral sciences can be integrated for the advancement of knowledge, for the stimulation of research, and for mutual enrichment . . . alter our comfortable fragmented manner of looking upon behavior as a matter of simple linear cause and effect and . . . start creating fresh systems and models better able to account for normality and abnormality . . . we must be jarred into experimenting with new manners of thinking in order to insure progress in the field of behavior.

This echoed Rene Dubos’ earlier (1968) projection that “A new kind of knowledge is needed to unravel the nature of the cohesive forces that maintain man in an integrated state, physically, psychologically and socially, and enable him to relate to his surroundings.”

 Perhaps such visions were premature and too esoteric to be sustainable at the time, but served as launching pads for later innovation, with other publications beginning to address the benefits of integration.

An innovative entrepreneurial psychiatrist, Michael Freeman,

 founded the organization Behavioral Healthcare Tomorrow with a journal of the same name, bringing clinicians, industry, and behavioral health organizations together for cutting-edge mental health programs. This venture also was not sustainable at the time but clearly moved the needle forward toward an integrated model. New journals, 

International Journal of Psychiatry in Medicine and General Hospital Psychiatry: Medicine, Psychiatry and Primary Care

Psychosomatics, Psychosomatic Medicine, Journal of Psychosomatic Research

 to promote increased research and publication of consultation-liaison topics.

More recently, the idea of integrated care has evolved, with recognition of new opportunities for psychiatrists to assume not only leadership but also team roles. Organizations such as the Academy of Psychosomatic Medicine, American Psychosomatic Society, Association for Academic Psychiatry, and others have for many years addressed these issues in their annual meetings.

 an internist/psychoanalyst, suggested (after Bertalanffy) the need for a new (biopsychosocial) model of health care, he attracted great attention, but the approach was underutilized in the breach. PCPs of the 1970s seemed enthralled with the concept but inept at incorporating it into quotidian practice. A host of books promoting this mission went essentially unread, or at the very least, unable to be absorbed because of differences in language, training, skill, and practice style.

 a former director of consultation-liaison services at the University of Washington, with Jurgen Unutzer and other innovative colleagues, recognized that psychiatrists trying to train PCPs was a frustrating and low-yield objective, and concluded that the consultation-liaison model was insufficient to the task at hand. They implemented and documented a series of controlled studies that showed how training and utilizing nonphysician intermediaries such as nurses and case managers could facilitate effective collaborative biopsychosocial patient care.

The idea evolved further with the creation of “medical homes” and “accountable care organizations” catalyzed by President Obama’s courageous effort at attaining health care for all. Preparing for adoption of this new way of thinking about and implementing a merger of biobehavioral and medical approaches has propelled the need for new training programs and curricula alteration. The support of the American Psychiatric Association has helped draw attention to this rapidly evolving reality.

On the cutting edge of an integrated approach

Now, at last, we do seem on the cutting edge of an integrated approach to health care. The maturing of the “boomer generation,” greater openness and tolerance of social diversity, and increased need of psychosocial health services-especially fostered by the HIV/AIDS epidemic and opioid crisis-have lessened the insistence on professional silos. The value of physician assistants, nurse practitioners, social workers, counselors, health “managers,” and other ancillary caretakers is finally being recognized. And, we’re seeing greater opportunity for “thinking outside the box” in health care programs.

 working with family doctors in Canada, began experimenting with models of “integration” and “collaboration,” words that do not carry the stigma of psychiatry or the puzzlement over the meaning of “consultation-liaison.” Advances in technology, such as neuroimaging, biochemical assays, and neuroscientific discoveries, have brought greater “respect” to the science of psychiatry, enhancing acceptance by those who once dismissed the specialty as “fuzzy thinking,” or “word surgery.”

 wrote in 1927, “the secret in the care of the patient is in caring for the patient,” and in abandoning a one-sided view of medical care. At this time, the surge toward integrated health care seems to hold great promise. The challenges that remain will be those of familiarizing team players with one another’s attitudes, merging clinical styles, ensuring equitable financial support, data sharing, and encouragement of public and political acceptance.

Putting people together in the same space is only the beginning! Growing interests in shared decision-making and patient-centered medicine have been adjunct developments, but as cautioned by Stein,

 “We should be careful not to entirely jettison metaphors of the doctor-patient relationship that emphasize caring rather than only collaborating or consuming.”

We may at last experience this evolution in our lifetime. Physicians may finally become not dualists or monists, but holists and integrationists!

[[{"type":"media","view_mode":"media_crop","fid":"61989","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_1278255544597","media_crop_h":"276","media_crop_image_style":"-1","media_crop_instance":"7847","media_crop_rotate":"0","media_crop_scale_h":"194","media_crop_scale_w":"150","media_crop_w":"213","media_crop_x":"5","media_crop_y":"6","style":"font-size: 13.008px; float: right;","title":" ","typeof":"foaf:Image"}}]]I was thrust into a world of uncertainty! The Great Depression. FDR’s death from stroke while I was in prep school. Under pictures of graduating classmates was a designation of their next step. Mine said “uncertain.” Even worse, my college yearbook had my picture over someone else’s name.

I always had curiosity about how things went together (or didn’t). I didn’t lie in bed like Descartes thinking deep thoughts about mind and body. Mostly, I took things apart like the family TV, radios, clocks, tape recorders, even an upright piano, to see how they were integrated (not always with best results!). In college, it was physics/math or psychology? In med school, it was radiology or psychiatry, both with vague and fuzzy images?

Psychoanalysis and psychiatry seemed good places to look for answers. Consultation-liaison psychiatry and psychosomatics showed the promise of putting things together. Maybe Descartes was on to something! Along the way, I founded a psychiatry department, the Integration Clinic, and 2 journals to attract more interest in getting psyche and soma together.

I am grateful for the education received from patients, students, and colleagues, Boston University, University of Vermont College of Medicine, Albert Einstein Medical Center (Bronx), NIMH, and Boston Psychoanalytic Society and Institute (BPSI). Thirty-six years as an editor and a presidency of the International College of Psychosomatic Medicine (ICPM) kept me in touch with colleagues, authors, reviewers, researchers, and scholars around the world-a vast education in itself. Stepping down after 30 years’ running a department, I finally had time to write and publish a book, 

Foundations of Consultation-Liaison Psychiatry

 (Routledge), a book I promised a publisher 30 years earlier.

I am proud to see the legacy of old friend Wayne Katon and his University of Washington associates break through the fog and launch a vibrant movement into integrated and collaborative care. I am also proud to have earned the Hackett Award and to have an award established in my name for innovation in collaborative and integrated health care by the Academy of Psychosomatic Medicine. While a high honor indeed, my most cherished moments have come from my wife, Merna, and our 2 sons, Eric and Steven.

Dr. Lipsitt is Professor of Psychiatry (part time), Harvard Medical School, Cambridge, MA.

Foundations of Consultation-Liaison Psychiatry: The Bumpy Road to Specialization

IPOS Sutherland Memorial Lecture: an international perspective on the development of psychosocial oncology: overcoming cultural and attitudinal barriers to improve psychosocial care

 Dush DM. Trends in hospice research and psychosocial palliative care. 

 Drossman DA. Gastrointestinal illness and the biopsychosocial model. 

Psychiatric services and medical utilization in a prepaid health plan setting, II

 Frank RG. Realizing the promise of parity legislation for mental health. 

 Freedman AM. A prospectus for integrative psychiatry. 

. New York: Charles Scribner’s Sons; 1968.

 Freeman M. Six trends to shape the field’s future. 

The need for a new medical model: a challenge for biomedicine

 Katon W, Gonzalez J. A review of randomized trials on psychiatric consultation liaison studies in primary care. 

 Von Korff M, Katon W, Lin EH, Wagner EH. Evaluation of psychiatric consultation-liaison in primary care settings. 

 Kates N, Craven M, Crustolo AM, et al. Integrating mental health services within primary care: a Canadian program. 

 Peabody FW. The care of the patient. JAMA. 1927;88:877-882.

 Stein DJ. Psychiatric practice: caring for patients, collaborating with partners, or marketing to consumers? 

Articles

Integration Redux

The World Health Organization defines adherence as “the extent to which a person’s behavior-taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care professional.” Suboptimal adherence is pervasive among individuals with chronic health conditions, including psychiatric disorders, and nearly always contributes to worse outcomes.

Much time, effort, and resources have been devoted to developing psychotropic drugs that are safe and effective, and that improve health outcomes. However, drugs don’t work if patients don’t take them. Rates of poor adherence can exceed 60% among patients with schizophrenia. Moreover, poor adherence is associated with relapse, hospitalizations, and high financial costs. Among patients with bipolar disorder, rates of nonadherence are estimated at 20% to 60%, and they are similarly associated with more relapse, higher costs and, in worst-case scenarios, suicide.

Approximately 30% of patients stop taking antidepressants after 1 month and 45% to 60% after 3 months. Poor adherence to evidence-based medication treatment is a problem that crosses psychiatric diagnoses and types of psychotropic medications. Fortunately, an emerging literature on the topic of adherence enhancement provides input on how clinicians might address adherence with their patients.

The articles in this 2-part Special Report spotlight the issue of poor adherence, particularly 

, and take on some of the multiple areas where interventions may be possible. In part 1, one article focuses on 

. A key emphasis is that changing adherence is a process that takes time and effort to master. The other article addresses the 

importance of culture as a factor in adherence

. Effective adherence enhancement is never “one size fits all,” and culture-specific factors need to be targeted to move the adherence dial.

Treatment Adherence: Strategies and Best Practices

In part 2, coming in the September issue, one article addresses 

-an approach that appears effective in other health conditions and may also translate to psychiatric disorders. While one might argue that good health is its own “reward,” compensating individuals for positive health behaviors is likely to be a win-win situation for patients, payers, and care systems. The issue of motivation as it affects medication adherence is the focus of 

 focuses on the benefits of partnering with primary care providers. Collaborative care can be an effective way to target suboptimal adherence, particularly given the multi-morbidities experienced by many patients with mental health disorders.

I am a Professor of Psychiatry and of Neurology at Case Western Reserve University School of Medicine in Cleveland, Ohio.

 I am a researcher, educator, and clinician and have devoted myself to the study and treatment of traditionally hard-to-treat populations with CNS disorders for the past 3 decades.

Relevant to the topic of the Special Report on treatment adherence in this issue, my interest in adherence began in 2003, when I was the recipient of a National Institute of Mental Health career development research grant (K-award). The K-award allowed me to focus on this topic and learn research methods, including those borrowed from the field of medical anthropology. Approaching the topic of suboptimal treatment adherence from the perspective of a person with a health condition can be an important way to understand adherence behavior.

Understanding why a person does or does not take medication is valuable in being able to apply methods of intervention that consider benefits versus burdens of treatment. In addition, the K-award mechanism is a wonderful opportunity to learn new skills that can make one a better and more competitive researcher. Collaborations and relationships that were established during my own K-award definitely amped up my grant-writing skills by orders of magnitude!

Since 2009, I have had an academic appointment in the Department of Neurology at University Hospitals of Cleveland and have been conducting research in brain disorders that affect behavior, such as epilepsy, stroke, and dementia. I run a health services center called the Neurological and Behavioral Outcomes Center. This has allowed me to interact with a whole new range of colleagues and reminds me how very closely the disciplines of psychiatry and neurology are intertwined. More recently, I have been involved in global brain health research with colleagues in Uganda and in Tanzania.

Dr. Sajatovic is Professor of Psychiatry and of Neurology at the Case Western Reserve University School of Medicine, University Hospitals Case Medical Center in Cleveland, OH.

Dr. Sajatovic reports no conflicts of interest concerning the subject matter of this Special Report. 

The articles in this 2-part Special Report spotlight the issue of poor adherence, particularly medication adherence, and take on some of the multiple areas where interventions may be possible.

Introduction: Problems of Poor Adherence

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.

 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.

 Even when treatment is received, it is often inadequate. Moreover, it is important to note that early treatment discontinuation increases the risk of recurrence.

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.

Compared with non-Latino whites, racial/ethnic underserved groups have lower rates of antidepressant initiation and retention.

 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.

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.

 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.

MI can be very useful for addressing ambivalence about psychopharmacologic issues. Two approaches have been developed that show initial efficacy. The first is to integrate MI directly into the procedures followed by the prescriber. This approach is called motivational pharmacotherapy (MPT). The second approach is to add adjunctive MI sessions by a psychotherapist to the psychopharmacologic regimen. This approach is called motivational enhancement therapy for antidepressants (META). Both approaches are focused on galvanizing patients’ internal motivation to feel better while navigating their ambivalence about taking medication. Both elaborate an empathetic and non-confrontational process to sidestep initial resistance to treatment and work to highlight patients’ strengths and build self-efficacy. The clinician and the patient contribute their expertise in making treatment decisions-patients are the experts on their reactions to a medication, and clinicians are the experts on the medication itself (eg, adverse effects, dosage).

MPT and META were initially developed for use with low-income, largely Spanish-dominant Latino immigrants with MDD. The goal of both approaches is to attain cultural congruence with the values, attitudes, and illness representations common in some Latino populations, while being mindful to personalize care to the individual patient and not operate based on stereotypes. Although initially developed for a specific study population, MPT and META can be beneficial for many patient groups through simple tailoring procedures for a patient’s culture and disorder(s).

). Each session affirms a patient’s commitment to feel better and explores the current illness experience and medication adverse effects using open-ended questions. Improvements are reflected back to the patient and explored to elicit commitment language and change talk (ie, statements that reflect some resolution of ambivalence).

Adherence successes are highlighted in an attempt to build self-efficacy, and obstacles are identified. Exercises are added at strategic points to elicit a patient’s commitment to overcoming depression or to starting antidepressants. For example, in the first week, patients are asked about a success story from their life. They are asked to recall challenges they faced during that particular journey toward success and to explore the uncertainty they experienced but overcame. Throughout the exercise, the clinician reflects back any statements of self-confidence and determination (eg, so you were surprised at how effective your efforts proved to be).

Sessions are also used to elicit information about obstacles and how to resolve them, including exploring thoughts about early termination. In addition, sessions include review of medication dosage and collaborative decision-making about the treatment plan. Importantly, this is not done in a didactic way but by eliciting the patient’s opinions as to how to proceed.

A patient returns for his follow-up appointment. He had been prescribed an antidepressant for MDD to be taken for 9 months. He reports various adverse effects and informs his psychiatrist that he decided to discontinue the medication a week ago. He highlights his clinical improvement thus far and states that his body is now “rejecting” the medication. The following dialogue is an example from an MPT session.

 So, what would your plan be, what would be the next step?

 You are the doctor, so you decide. We had decided that I would take the medication for the next 9 months, but since I had to stop the medication-not because I wanted to but because my body was rejecting it-I would like to continue with treatment for the 9 months and see how my body is doing without the medication. I don’t know if you would be in agreement with that.

 So continuing to come, but evaluating the need for the medication; not necessarily taking it, but evaluating how you continue without it and seeing if there is a need for change.

 If you want to, you can even give me the medication, though I wouldn’t take it. And if there is a problem, I would have it there.

 Yes, to take if anything happens. But more than anything I would like you to do an evaluation after 3 months to see what my reaction is to not taking the medication.

 What you propose is interesting. I think it’s fine. It’s a process during which we evaluate jointly what needs to be done. What you are proposing is that we can evaluate your situation without you necessarily taking the medication, something that your body is telling you that, at this specific time, it shouldn’t take. The advantage is that we can continue to evaluate you without you having to take the medication.

 Because in reality, I would like you to continue treating me in this manner and see what happens.

 Yes, I think that is perfectly fine. The concern that I have-and it’s a concern that we can talk about and don’t have to reach a decision about today-is that there is a risk that the depression might return more quickly if you take the medication for less time. That is, you have been taking the medication for a few months, and that is good; you have that treatment in your body, no one can take that from you, and it might be sufficient to protect you.

 If it were up to me . . . I would continue to take the medication longer. If it were possible, I would do so, but in reality-maybe it sounds illogical-but really it’s my body that is rejecting the medication.

 I understand, that is very clear. Because I like your plan, how about if we do the following? We are in agreement about you staying in treatment for 9 months, evaluating you and seeing you. During the visits, we would see how you are doing and based on that decide if it’s worth trying to start the medication again or not. As we continue, we’ll decide on a month-to-month basis. I can even give you some medication in case you decide you want to take some. As you said, having it just in case is a good idea.

 Yes, I brought back the pills I didn’t take, and I can take those back with me. I don’t like to take a medication unless I have to, and right now, I don’t need it. I feel strong, so I don’t think I need the medication now, but as you say, maybe in the future I might relapse. I really want to continue treatment with you.

 I agree, the main point is to continue treatment.

One month later, the patient reports that he restarted the antidepressant 2 weeks earlier when he noted worsening of depression symptoms. He continued to take the antidepressant as originally planned and completed the 9 months of pharmacotherapy.

The initial open trial of MPT focused on retention at 3 months, which revealed low levels of discontinuation compared with historical controls at the same clinic (20% vs 45%) among a traditionally underserved and resource-limited population.

 Responder and remitter rates were 82% and 68%, respectively. Notably, the average duration of the sessions was 36.7 minutes for the initial visit and 24.3 minutes for follow-up visits. This illustrates that MPT sessions do not have to be longer than a typical pharmacotherapy session. Results from a larger, randomized controlled trial are currently being analyzed.

Motivational enhancement therapy for antidepressants

META is a 3-session MI-based intervention that a psychotherapist administers adjunctively to pharmacotherapy sessions. It differs from MPT chiefly in that there is no direct integration with pharmacotherapy sessions, which take place with another clinician, and in its time-limited 3-session framework.

A randomized controlled trial that focused on adherence revealed that META participants had significantly higher antidepressant adherence than usual-care recipients at 5 weeks (72% vs 42%) and at 5 months (60% vs 34%).

 In adjusted analyses, META participants were significantly more likely to show symptom remission.

Armed with information on MPT and META, how would you handle the dilemma presented by the patient at the beginning of the article? She is an immigrant from the Dominican Republic who was seen in the MPT trial and responded very well to MI techniques that explored her concerns about medication adverse effects. She revealed her fear that the tremor indicated the onset of a progressive nervous system condition that would result in total loss of motor control if she continued the antidepressant-her nerves would be irrevocably altered. This would lead to permanent disability and the destruction of her family, who depended on her.

Eliciting her ideas about possible treatment options resulted in her choosing to try a different antidepressant. This second medication did not produce a tremor, and she was able to complete the trial and achieve symptom remission.

Poor treatment adherence remains a substantial challenge. Novel strategies continue to emerge, including those adapted from MI. We encourage clinicians to incorporate them in their practice and to continue to improve on them. It is essential that all novel interventions address not only those communities with easier access to care, but also those who are traditionally underserved, among whom non-engagement is substantially worse. This can be facilitated by developing treatment modalities that incorporate the patient’s own views of illness and care.

The Table and the dialogue on page 14 are adapted from BalÃ¡n et al

 with permission from Taylor and Francis Group LLC.

Dr. Lewis-FernÃ¡ndez 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.

 Pratt LA, Brody DJ. Depression in the US household population, 2009-2012. NCHS data brief, No. 172. Hyattsville, MD: National Center for Health Statistics; 2014.

 Yau WY, Chan MC, Wing YK, et al. Noncontinuous use of antidepressant in adults with major depressive disorders: a retrospective cohort study. 

 Olfson M, Marcus SC, Tedeschi M, et al. Continuity of antidepressant treatment for adults with depression in the United States. 

 GonzÃ¡lez HM, Vega WA, Williams DR, et al. Depression care in the United States: too little for too few. 

 Cooper LA, Gonzales JJ, Gallo JJ, et al. The acceptability of treatment for depression among African-American, Hispanic, and white primary care patients. 

 Cabassa LJ, Lester R, Zayas LH. “It’s like being in a labyrinth”: Hispanic immigrants’ perceptions of depression and attitudes toward treatments. 

 Hettema J, Steele J, Miller WR. Motivational interviewing. 

 BalÃ¡n IC, Moyers TB, Lewis-FernÃ¡ndez R. Motivational pharmacotherapy: combining motivational interviewing and antidepressant therapy to improve treatment adherence. 

 Lewis-FernÃ¡ndez R, BalÃ¡n IC, Patel SR, et al. Impact of motivational pharmacotherapy on treatment retention among depressed Latinos. 

 Interian A, Lewis-FernÃ¡ndez R, Gara MA, et al. A randomized-controlled trial of an intervention to improve antidepressant adherence among Latinos with depression. 

This article explores how motivational pharmacotherapy and motivational enhancement therapy can galvanize depressed patients to get well.

Harnessing Patients’ Own Motivation to Engage in Pharmacotherapy

While nonadherence to psychiatric medications is a common barrier to recovery for many people with depression or schizophrenia, Latino individuals are at higher risk for antidepressant and antipsychotic nonadherence than non-Latino white patients.

 Even when socioeconomic status and access to quality care are controlled for, Latinos with depression have lower antidepressant adherence and engagement with depression care. For Mexican Americans with schizophrenia, nonadherence is close to 60%.

Potential contributors to nonadherence include lower socioeconomic status, lack of health insurance, barriers to quality care, and monolingual Spanish speaking (though with mixed results for antipsychotics). On the other hand, family support and psychotherapy can promote adherence.

US Latinos generally share Spanish-speaking ancestry or have emigrated from Latin America, but they are highly heterogeneous with widely varying backgrounds, acculturation, and socioeconomic circumstances. To better understand the many ways culture influences adherence, qualitative interviews and focus groups are particularly well-suited to elicit patients’ many nuanced experiences.

Maria is a 23-year-old unemployed, uninsured, bilingual Mexican American who is a devout Catholic. She lives with her parents, grandmother, and 2 younger siblings. Maria valued her friends and family but recently had been isolating herself, appeared progressively more unkempt, and mumbled to herself when alone. Her family, unaware of mental illness, became worried that she was possessed and prayed for the devil to leave her body. Her friend, Esperanza, became concerned after Maria told her she had been communicating with the devil.

Esperanza convinced Maria to see a psychiatrist, who diagnosed schizophrenia. After informing Maria about the diagnosis and reviewing medication options, including potential adverse effects, the psychiatrist prescribed an antipsychotic and scheduled a follow-up visit. Maria never returned.

Contrary to the psychiatrist’s explanation, Maria felt that she had wronged people and, in return, the devil gained control of her, which reinforced her grandmother’s trusted opinion. Maria had no hope that medication could get rid of the voices she heard and assumed she would not be able to afford the antipsychotic. Her mother was more open to medication but shared Maria’s concerns about adverse effects, particularly sedation, weight gain, and organ damage. Speaking only Spanish, Maria’s mother called the clinic to help Maria better understand the adverse effects, but she was unable to understand the monolingual English-speaking psychiatrist.

In addition to common factors that affect adherence, Maria’s case demonstrates how the complex interplay of elements in an individual’s sociocultural context influences choices to take and adhere to antipsychotic medication.

 highlights the most salient factors influencing adherence identified by low-income Mexican American adults with schizophrenia and their families living in Los Angeles (N = 14 patients and 20 key family members) and in a randomized, controlled trial of a highly effective multifamily group therapy for adherence (MFGT-A) designed specifically for Spanish-speaking Mexican Americans with schizophrenia who had been nonadherent to medication (N = 174).

In patients from many cultural backgrounds, concern about adverse effects and decreased illness insight are common barriers to adherence. Another barrier is the belief that medication will not work or should be used only during periods of symptom exacerbation. This belief is often based in culturally informed illness concepts, such as religious or folk explanations. Religious and spiritual beliefs are strong influences, sometimes discouraging adherence, as in Maria’s case, but notably also facilitating it. For example, during MFGT-A, patients and families come to see antipsychotics as the means by which God has helped or as part of a holistic approach to recovery using medications, religion, therapy, and other wellness-promoting activities.

Maria’s case demonstrates that even for a patient who is proficient in English, family members may not be, thus potentially excluding a valuable asset in promoting adherence and facilitating treatment alliance. Families exert a strong, generally positive influence; for example, they can help patients explain adverse effects or worsening symptoms to providers. The significantly improved adherence associated with MFGT-A is mediated by improvements in subjective norms (patients’ beliefs about significant others’ attitudes toward medication), but not patients’ attitudes toward medications or their perceived behavioral control. Such factors reinforce the need for family involvement in treatment planning.

, MFGT-A is highly effective. It employs a process-oriented approach that uses an individualized systematic assessment to identify the most significant cultural influences for each patient/family, which allows them to address identified problems. While most psychiatrists will not have access to this intervention, providers can learn from its emphasis on an individualized approach to assessing cultural influences on illness conception and medication.

Ricardo is 37 years old, recently unemployed, and married with 3 children. He is originally from the Dominican Republic, speaks primarily Spanish, and has diabetes. He went to an outpatient psychiatrist after his wife and primary care physician had forced him because of his low mood and energy, poor sleep, and worsened blood glucose levels.

Ricardo had previously worked as a grocery store stocker but injured his back at work. He did not inform his boss of the injury, and he ultimately missed several days of work because of the pain. Ricardo was fired soon after. Around the same time, he learned his mother had died. He was unable to find another job. He was devastated. To support their family, his wife started working. Ricardo felt worthless and guilty; he assumed he was failing his family.

He avoided his friends, lost enjoyment in life, became fatigued, and had insomnia. He denied thoughts of suicide, saying he would never consider it, but reluctantly admitted thinking his family would be better off without him. He attributed his symptoms to his ongoing back pain and diabetes. He tried an herbal tea to no avail. This scared him; he feared that he had a chronic, severe, perhaps incurable depression or even that he was “crazy.”

Ricardo was even more hesitant about antidepressants after hearing friends talk about another friend who took an antidepressant as being “lazy and just needing to put forth more effort.” After a long discussion with his psychiatrist about depression, he was prescribed an antidepressant. He took it for 2 weeks but with no effect, which led him to worry that he was truly “crazy.” Fearing that increasing the dosage would cause “addiction” and would mean he was not doing his part to recover, he stopped taking the medication.

The psychiatrist’s role in addressing barriers to treatment adherence

To better understand the cultural influences on medication adherence for at-risk patients, Interian and colleagues

 conducted qualitative focus groups and interviews with lower-income Latinos (N = 30 for each study). Their goal was to develop culturally adapted motivational interviewing interventions to improve adherence. Most of the participants were middle-aged, lower-income, primarily Spanish-speaking women from the Dominican Republic or Puerto Rico. The inclusion of mostly women in these studies may be because of higher rates of depression among women, but possibly also because of cultural barriers for Latino men to seek care. Findings from the studies (

) indicate that barriers to adherence include:

• Stigmatizing beliefs (both personal and among friends and family) about depression and antidepressant treatment (eg, feeling depressed is a sign of laziness or weakness, taking an antidepressant is a sign you are 

• Fear of adverse effects (eg, serious harm, being “drugged,” addiction, or dependence)

• Feeling that medication adjustments require a concerted effort

• Misunderstanding how medications work (eg, expecting immediate improvement, stopping medication when feeling better to avoid harmful effects, believing that alternative treatments are more effective and safer)

While many participants feared that antidepressants were addictive, they felt this could be allayed by working with a psychiatrist. Most of the study participants said they valued education from psychiatrists about depression and antidepressants, as well as psychiatrists’ help in working through medication adjustments.

Participants commonly conceptualized depression as having “classes” of different severity, similar to “

” (nerves), a Latino concept of distress. Many expected a personalized approach (

) and to learn which “class” of depression had been diagnosed. Participants also commonly believed that antidepressants were reserved only for severe depression in chronic, incurable cases. While religion often influenced adherence, the researchers noted that some patients were comfortable with biological models, which emphasizes the importance of learning from patients what influences are most important.

 summarizes 2 culturally adapted motivational interviewing interventions that incorporate key cultural values expressed in the qualitative studies. These values were, at times, obstacles but were reframed to promote adherence. For example, many patients expressed the importance of 

 (putting forth effort/doing one’s part) or luchar (struggle), sometimes feeling they should avoid medications and just put more effort into overcoming depression. However, participants also viewed taking medications as a way to 

 in depression recovery. Interian and colleagues8 found that incorporating this reframing in Motivational Enhancement Therapy for Antidepressants highly effective.

 and Lewis-FernÃ¡ndez and colleagues10 developed Motivational Pharmacotherapy, which incorporates culturally adapted motivational interviewing into medication visits. Their findings indicate that only 20% of the patients discontinued treatment and the duration of visits was compatible with common clinical time constraints: 36.7 minutes for visit 1 and 24.3 minutes for subsequent visits. The full manual is available at: 

http://www.nyspi.org/culturalcompetence/what/reports.html

 is the translated Self-Reported Medication Taking Scale, a tool for quickly and more accurately assessing adherence.

We encourage psychiatrists to assess the important role that culture plays for any patient when they prescribe a psychiatric medication. Successful culturally adapted interventions to improve adherence among Latino patients with depression and schizophrenia confirm how important it is to understand a patient’s entire sociocultural environment, by gauging the most influential elements and incorporating patients’ perceptions of illness and treatment.

While factors such as cultural values affect adherence, it is important not to overgeneralize given the broad diversity of backgrounds and socioeconomic environments of US Latinos and the varying degrees individuals identify with their surrounding culture. As outlined in the Cultural Formulation Interview in DSM-5, a non-judgmental, patient-centered approach is recommended when exploring factors such as religion, illness insight, feared adverse effects, and personal and familial values as potential barriers to and facilitators for adherence. These approaches hold valuable lessons for treating all patients.

Dr. Martinez is a Resident Physician, and Dr. Lanouette is Associate Clinical Professor, Department of Psychiatry, University of California, San Diego.

 Lanouette NM, Folsom DP, Sciolla A, Jeste DV. Psychotropic medication nonadherence among United States Latinos: a comprehensive literature review. 

 Hosch HM, Barrientos GA, Fierro C, et al. Predicting adherence to medications by Hispanics with schizophrenia. 

 Hernandez M, Barrio C. Families and medication use and adherence among Latinos with schizophrenia. 

 Kopelowicz A, Zarate R, Wallace CJ, et al. The ability of multifamily groups to improve treatment adherence in Mexican Americans with schizophrenia.

 Kopelowicz A, Zarate R, Wallace CJ, et al. Using the theory of planned behavior to improve treatment adherence in Mexican Americans with schizophrenia. 

 Interian A, Martinez I, Rios LI, et al. Adaptation of a motivational interviewing intervention to improve antidepressant adherence among Latinos. 

 Vargas SM, Cabassa LJ, Nicasio A, et al. Toward a cultural adaptation of pharmacotherapy: Latino views of depression and antidepressant therapy. 

 Interian A, Lewis-FernÃ¡ndez R, Gara MA, Escobar JI. A randomized-controlled trial of an intervention to improve antidepressant adherence among Latinos with depression. 

 Interian A. A brief self-report measure to assess antidepressant adherence among Spanish-speaking Latinos. 

Successful culturally adapted interventions to improve adherence among Latino patients with depression and schizophrenia confirm how important it is to understand a patient’s entire sociocultural environment. 

Culture as a Factor in Adherence: Learning From Latino Experiences

Monday, July 1st
Twenty-two new residents
All with perfect teeth

Power out three days
Housestaff round with the charge nurse
Clipboards, pens, talking

Tanglewood rain storm
Interns staff the first aid tent
Hushed crowd, distant songs

Cardiac arrest
Blue body, tearful intern
The Attending shrugs

Running her first code
The resident looks outside
Geese fly south in V’s

M & M conference
Angry Chief of Surgery
Chairs perfectly still

Monday, July 1st...Twenty-two new residents...All with perfect teeth...

Vol 34 No 7

Integration Redux

Introduction: Problems of Poor Adherence

Harnessing Patients’ Own Motivation to Engage in Pharmacotherapy

Culture as a Factor in Adherence: Learning From Latino Experiences

Housestaff Haiku

Welcome to the Editorial Board, Dr. Miller!

Restless Legs Syndrome: Clinical Implications for Psychiatrists

Neuroscience Research for Psychiatry: The Brain and Behavior Link

Weighing the Benefits of Genetic Information in Clinical Psychiatry

Cannabis-Induced Psychosis: A Review

Taming Trichotillomania While Weeding the Garden

What’s New in Bipolar Depression?