Motivational Interviewing to Improve Long-Acting Injectable Antipsychotic Discussions

Motivational interviewing is a studied option in the use of long-acting injectable (LAI) antipsychotics and clozapine, and Jose Rubio, MD, PhD considered it relevant to both. Ambivalence in patients with psychosis resembled that seen in substance use disorder: patients recognized that something was wrong and that change was needed, but they were not very open to antipsychotics because of the medications' side effects and associated stigma. Disentangling these mixed feelings required more than a single conversation.

Ambivalent patients who recognized a problem could be prompted by repeated hospitalizations to consider a different approach.¹ Patients without insight, who could not connect their rehospitalizations to psychotic symptoms, presented a greater challenge. According to Rubio, "You have to meet patients where they are. You have to understand what is valuable to the patients, what are their goals." Relationships, independent living, and employment were common goals.

Open-ended questions helped identify what stood in the way of those goals, and clinicians could then link them to treatment—for a patient who feared being followed and stopped taking medication, the resulting hospitalizations signaled that something needed to change. These conversations did not need to be completed within 15 to 20 minute visits; Rubio recommended spreading it across several visits while keeping it at the top of the treatment plan. He acknowledged that the task was not easy for clinicians.

Clinicians generally were not taught how to talk about LAIs or clozapine with patients, according to Rubio. Adherence was assumed once a medication was prescribed, and medical education emphasized the evidence supporting LAIs without teaching how to present them. Rubio said clinicians "don't talk enough about the fact that maybe after you dispense medication, the patient may or may not take it." Applying motivational interviewing to LAI discussions was therefore a step in the right direction.² Rubio framed the conversation around 3 questions: what the patient wanted from life, what was getting in the way, and how LAIs could help. He stressed open-ended questions, listening, and tying LAIs to the patient's own aims.

Dr Rubio is an assistant professor of psychiatry at the Zucker School of Medicine at Hofstra University.

References

1. Barkhof E, Meijer CJ, de Sonneville LMJ, et al. The effect of motivational interviewing on medication adherence and hospitalization rates in nonadherent patients with multi-episode schizophrenia. Schizophr Bull. 2013;39(6):1242-1251.

2. Bröms G, Cahling L, Berntsson A, et al. Psychoeducation and motivational interviewing to reduce relapses and increase patients' involvement in antipsychotic treatment: interventional study. BJPsych Bull. 2020;44(6):265-268.