Many psychiatrists have patients who they know would do better if their adherence to treatment could be optimized. Here's a case in point.
Many psychiatrists have patients who they know would do better if their adherence to treatment could be optimized. The following story of a 64-year-old white man highlights this.
This patient has had mental health problems since the age of 15 after suffering childhood neglect and abuse. He has a history of aggressive outbursts and schizophrenia onset in his late 20s. He has been in contact with local secondary mental health care services for the past 8 years and is prescribed an oral antipsychotic. He collects his prescription regularly from his family physician and gets his medication from a local pharmacist. He sees his psychiatrist when he is in crisis; his illness is considered treatment-resistant.
As a result of persecutory delusions, he had an outburst of verbal aggression at the local library. His psychiatrist reassessed him, and a decision was made that he would benefit from a collaborative approach to his care. He was assigned a primary care mental health case manager who arranged a home visit and found that, although he was collecting his medication from the pharmacist regularly, he was not taking his medication as prescribed. The case manager arranged a multidisciplinary case conference at his primary health clinic attended by his psychiatrist.
Regular visits were initiated to support him with lifestyle changes; his case manager helped him get to follow-up appointments in primary and secondary care and worked with him to put in place a system to remember to take his medication. He was also referred for cognitive behavioral therapy (CBT). Within 2 months of this intervention, his mental state improved, and the primary care mental health case manager supported him to obtain work as a volunteer at a local charity shop.
Consequences of treatment nonadherence
Patients with a mental disorder often exhibit poor treatment adherence. Nonadherence to antipsychotic medication is observed in about 50% of people with schizophrenia and is a major preventable cause of psychiatric morbidity.1 Patients who stop their antipsychotic medication have a 3- to 5-fold risk of relapse compared with patients who continue to take their medication. Patients who are nonadherent to antipsychotic medication are also at increased risk for suicide.2
Patients commonly seen by psychiatrists with illnesses such as schizophrenia, bipolar affective disorder, and moderate to severe depressive disorder die 10 to 20 years earlier than the general population as a result of a variety of preventable causes, including cardiovascular disorders, respiratory disorders, and infectious diseases. Much of this physical health comorbidity can be better managed by specialists working in collaboration with primary care to provide earlier opportunities to make lifestyle and behavioral changes such as tobacco cessation, weight management, and regular screening. Partnering with primary care teams can lead to earlier recognition and referral to specialists when needed.
Collaboration between primary care and secondary mental health services provides a platform for medication and adverse-effect monitoring. Collaboration helps primary care clinicians improve their knowledge and skills in mental health care-and helps psychiatrists enhance their knowledge of physical health care.
Improving treatment adherence
Earlier research to promote treatment adherence in psychiatric disorders concluded that there are many effective interventions that promote adherence. Many were not actively pursued because they were considered too time-consuming and labor-intensive-and thus considered unfeasible to implement in everyday clinical practice.
Cost-effective ways to promote better adherence to treatment that are acceptable to the patient are needed. Partnering with primary care is cost-effective and safe. Many patients value empathy and accessibility to care, and psychiatrists can improve accessibility for patients through collaboration with other specialties such as primary care to promote adherence.
Promoting adherence through collaborative care
Adherence to treatment is not just about medication but about concordance with the full care package so that the person is treated as a whole. The full range of skills available in primary, secondary, and community care is utilized in the best interests of the patient.
A personalized care plan for adults with chronic health conditions can be delivered to a high standard in a primary care setting. With collaborative care, the primary care clinician provides a safe, cost-effective, holistic approach that can be delivered at a lower cost than in secondary or primary care alone. Comorbid physical health conditions can be tackled simultaneously, which leads to improved mental and physical health outcomes.
Liu and colleagues3 suggested that premature mortality in patients with mental health problems can be resolved by adopting a multi-level intervention framework that addresses multiple risk factors, including poor treatment adherence. One clinician rarely has all the skills and expertise needed. Psychiatrists in collaboration with primary care can ensure that patients get the right care from the right person at the right time.
Useful strategies to promote adherence
In psychiatry and mental health, making the right medical choice is often more challenging than in other branches of medicine. Many patients feel overwhelmed by the information they are given about treatment. This leads to higher levels of decisional conflict in patients and requires a personalized approach from the clinician so that more psychological support can be provided during the decision-making process. Many psychiatrists have this skill but need to bring it to consciousness. Primary care physicians can also contribute because they have a long-term relationship with many of their patients. Moreover, it may be easier for the patient to process information about treatment options in a familiar primary care setting because of lessened anxiety, which decreases decisional conflict and may foster improved adherence.
There is no single intervention that promotes treatment adherence across all diseases, populations, and settings because there are multiple reasons for treatment nonadherence, including personal, social, cultural, structural, financial, and educational reasons as well as adverse effects of prescribed medications. A patient may have multiple reasons for nonadherence to treatment, which may or may not be obvious to the physician. Therefore, to address nonadherence requires a range of tools and skills that may not be solely located in the psychiatric setting because of cost, manpower shortage, or lack of expertise. This gap can be bridged through collaborative care, which allows clinicians to make use of the full range of skills available in both primary and secondary care in the interest of the patient.
Collaborative care can be delivered in a number of ways, including:
1) A psychiatrist being aligned to a primary care team using a consultation-liaison model
2) Primary care being aligned to a psychiatrist or a group of psychiatric providers
3) Primary care teams working in a collaborative way to deploy their resources so that care is delivered seamlessly to the patient
Many techniques can foster a collaborative approach between psychiatrists and primary care. What is important is to avoid “silo working” by bringing together the appropriate skills and expertise to address the patient’s needs, taking into account the severity of illness, complexity, disability, patient wishes, and the available resources.
Case management: There are many ways to deliver case management, but the main ingredient for success appears to be the quality of the relationship between the case manager and the patient. Any well-trained member of the primary care or psychiatric care team can perform the case manager role, and it is not necessary to be a psychiatrist or family physician. Patient outcomes in mental illness depend on multiple factors delivered by multiple providers, and a case manager supports the patient in navigating this maze.
Personalized care planning: The clinician and the patient collaborate to identify and plan specific goals. Once the goals are identified, the two agree on the way forward, and the most appropriate services are identified to work with the patient to achieve the goals.
Educational interventions: Educational interventions either for individual patients or groups of patients to support adherence have been shown to be effective but have not been widely adopted because they are costly and labor-intensive. There are growing opportunities to train expert patients to work in primary care settings to deliver such interventions more cost-effectively.1 In the UK, the growing movement of providing educational interventions in the community using people with lived experience and specialist mental health workers to co-produce and co-deliver education that supports mental health recovery is under evaluation and may provide another useful model to support improved adherence.4
Behavioral interventions: Reminders are useful strategies to improve treatment adherence. This can easily be provided at a primary care level by any member of the staff and not necessarily by the physician.
Cognitive behavioral therapy: CBT specifically designed to promote concordance with medication can enhance motivation, support self-management, and enable clinicians and patients to work in a more collaborative way (using manuals that can be easily adopted by primary care). CBT can be effectively delivered by nurses in a variety of clinical settings for a variety of psychiatric disorders (eg, depression, schizophrenia).5-7
Partnering with primary care
Collaboration in delivering patient care can be a rewarding experience for psychiatrists and primary care physicians because it enables them to pool resources, knowledge, and skills. Making this happen requires the development of a shared business plan, including an analysis of the financial implications associated with the type of partnership (Table 1). The steps are simple, easy to put in place, and yield success.
Challenges and opportunities
A number of key factors support collaborative care and enhance outcomes. Delivering these can be challenging because psychiatry and primary care may be coming from a different philosophy, a different ethos, different organizations, and different payment formulas. Table 2 includes ways to make collaborative care work to the benefit of the patient.
Nonadherence to treatment cuts across all medical specialties. Between one-third and one-half of all prescribed medications are not taken as recommended, which can lead to poor clinical and functional outcomes. Nonadherence may limit the benefit of medication for the individual and may lead to early relapse and poorer recovery. It should not be looked at as a patient issue but as a whole systems issue that involves the specialist, the patient, the primary care physician, and the wider community.
Because of issues of stigma, discrimination, and early mortality in patients with mental health problems, addressing nonadherence to treatment is critical, and collaboration with primary care provides an opportunity to do this better.
Professor Ivbijaro is Visiting Professor, NOVA University, Lisbon, Portugal; President, WFMH (World Federation for Mental Health); and Medical Director, Wood Street Medical Centre, Walthamstow London, UK. Professor Kolkiewicz is Visiting Professor, NOVA University, Lisbon Portugal; Consultant Psychiatrist and Associate Medical Director for Recovery and Wellbeing, East London NHS Foundation Trust, London, UK.
The authors report no conflicts of interest concerning the subject matter of this article.
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2. Staring ABP, Van der Gaag, Koopmans GT, et al. Treatment adherence therapy in people with psychotic disorders: randomised controlled trial. Br J Psychiatry. 2010;197:448-455.
3. Liu NH, Daumit GL, Dua T, et al. Excess mortality in persons with severe mental disorders: a multilevel intervention framework and priorities for clinical practice policy and research agendas. World Psychiatry. 2017;16:30-40.
4. Perkins R, Repper J, Rinaldi M, Brown H. Recovery Colleges Briefing. Centre for Mental Health: London; 2012. https://www.centreformentalhealth.org.uk/recovery-colleges-paper. Accessed June 4, 2017.
5. Prendergast J, Austin MP. Early childhood nurse delivered cognitive behavioural counselling for post-natal. Australasian Psychiatry. 2001;9:255-259.
6. Malik N, Kingdon D, Pelton J, et al. Effectiveness of brief cognitive behavioural therapy for schizophrenia delivered by mental health nurses: relapse and recovery at 24 months. J Clin Psychiatry. 2009;70:201-207.
7. Turkington D, Kingdon D, Turner T. Effectiveness of brief cognitive behavioural therapy intervention in the treatment of schizophrenia. Br J Psychiatry. 2002; 180:523-527.
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