Inconsistent adherence to psychotropic medication is a common problem in the primary care setting and a frustration for treatment providers. Studies show that 3 months after initiating treatment for MDD, only 50% of patients are adherent to the prescribed medication. Adherence rates for patients with schizophrenia are 50-60% and for patients with bipolar disorder can be as low as 35%. Here are some useful strategies to improve adherence in a way that also helps patients feel empowered in the decision to take the prescribed medication.
Participatory pharmacotherapy is a treatment model where the patient becomes a partner in the process of treatment choices and decision-making. It encourages patients to provide their own opinions about medication use. It implies establishing a therapeutic alliance with the patient prior to initiating pharmacotherapy.
There are 10 basic components:
- Encourage patients to share their opinion about what a desirable treatment outcome should be. Clarify with the patient what would be a realistic expectation of pharmacotherapy and modify the patient’s beliefs to be compatible with a more probable outcome.
- Encourage patients to share their ideas of how the desirable outcome can be achieved. Understanding the patient’s expectations of how treatment is carried out can help the provider clarify misinformation and establish a more realistic view of treatment.
- Engage patients in choosing the best medication for them. Understanding a patient’s preference for a specific medication is important because, if the medication choice is appropriate, the provider can take advantage of the patient’s “buy in”. It can also be helpful to ask patients about their previous experiences with medications, paying particular attention to which medications works best for the patient and family members diagnosed with a similar condition.
- Involve patients in setting treatment goals and which symptoms to target with treatment. For example, after eliciting a list of concerning symptoms, ask the patient to prioritize that list to determine which symptoms the patient would like to focus on first.
- Engage patients in choosing the best delivery system of the prescribed medication. This can be particularly important in children and elderly patients, but also adults who report having difficulty with swallowing. For patients with schizophrenia and other life-long severe psychiatric illnesses, this can include a discussion about the option of long acting injectable medications.
- Involve patients in determining time and frequency of medication administration. For example an antidepressant with a sedating side effect profile could be used for a patient with depression and insomnia. Some patients prefer taking a medication once a day to make it easier to remember to take it. Other patients may wish to take a medication several times a day so they can feel confident that if they need a medication for immediate symptom relief (this can be a placebo effect), it will be readily available.
- Teach patients to self-monitor changes and improvements in target symptoms. Engaging patients in a system of self-monitoring improves their chances of achieving successful treatment outcomes. It can be as simple as creating a list of symptoms and monitoring the intensity and frequency of each symptom using a rating scale of 1 to 5.
- Instruct patients to call you to report any changes, including minor successes. Telling a patient to call if there are any problems might inadvertently lead the patient to create a list of problems in order to have a reason to call. Asking a patient to call 1-2 weeks after starting a new medication to check in even if s/he is feeling better feeds the expectation to the patient that s/he is going to feel better with the medication.
- Encourage patients to monitor their successes by relabeling and reframing their symptoms. For example insomnia as a presenting symptom can be reframed as improving sleep as a treatment goal. This discussion can even help patients reframe side effects, which can help their ability to tolerate side effects.
- Harness the placebo effect to increase chances of achieving the best treatment outcomes. Use the patient’s language as a way of pacing yourself to the patient’s description of his or her distress.
These strategies can be useful in the primary care setting to improve patient adherence to medication and therefore treatment response.