Psychiatry training and practice are equally adept at producing questions as answers. Why the same patient and family adhere religiously to their anti-biotic or anti-hypertensive medications but not to the anti-depressants. During residency and fellowship training and now working along the USA-Mexico border, I have faced this phenomenon repeatedly.
Why is this? The higher rates of nonadherence to medications among our patient population are not completely accounted for by “mental illness” or “lack of insight”. Multiple factors play a role here: differences in end goals between the psychiatrist and the patient, transferential prescribing, hesitation of the psychiatrist in discussing uncomfortable topics, less than required attention to confounding social, cultural, and economic factors, all are significant.
Upon some introspection, I concluded that I, a trained physician, myself may have some reservations in taking an antidepressant over an antibiotic. I do doubt that it is just ‘stigma’ as I am convinced sufficiently by the biologic reductionistic explanations we have available for mental illness today. Mintz & Flynn’s “How (Not what) to prescribe: Non-Pharmacological Aspects of Psychopharmacology” sheds some light on the topic.
The dynamics of a ‘psychiatrist’-patient relationship are much different from ones influencing the regular doctor-patient relationship. A psychiatrist is someone who you are [hopefully] able to talk to a little longer, tell them more than “I am sad” but actually why you are sad. The fact that this relationship allows such communication itself changes the nature, expectations, and outcomes of interventions. One of my adolescent patients said it is a “paid friendship”, and even though this seemed demeaning to me at first, given that I had undergone nearly a decade of training to get to this point, I understood where he was coming from. The relationship lends itself to a greater level of understanding of the unique circumstances that come with each patient.
Frequently, our patients have a sense that the medication controls their minds. This often results in our imaginations giving medications undue credit of being able to take away the feeling of having free will or changing one's personality. Parents are concerned that “Will this change my child’s personality? Will he look like a zombie?”. This sense of free will is one of the basest needs of us humans. Even though other groups of medications, steroids, for example, may cause changes in mental function, these are rarely questioned as the prescribing doctor is generally a non-psychiatrist physician, thus sparing the stigma. We as psychiatrists have a special role to play in integrating the patient as a partner in the treatment process so that this feeling, of being in some control, often robbed by mental illness and medications is restored. I recently had a patient with obsessive-compulsive disorder with an intense fear of incapacitating control by medications and of control by ‘me’ through the medications. If I had prescribed him a medication during our first meeting and demanded adherence, the treatment would have likely failed. His collaboration and understanding were essential.
The confidence a patient feels with his doctor also greatly affects the outcome. Though it is a given that “you are supposed to talk freely and without hesitation to your psychiatrist/ psychologist,” a lot of this can be and is predetermined by our stance. If adherence to treatment is made a strict prerequisite, it may greatly hamper alliance. I have found that; my thinking that a patient needs medication in many cases may be far less important than the patient’s own thoughts and those of their parents, family members, partners, and friends. Our role thus incorporates including the patient as an equal partner in decision making. The fact that we use the word ‘insight’ in mental status exams, lends to our role in bringing it to the patient.
Patients with poor insight may not see obvious difficulties they have in everyday life. This needs gentle exploration and a safe space for the patient to think about them. “This is just me” is something I heard from a depressed patient who lies in bed all day, has poor sleep at night, isolates herself, and has anger outbursts. Pointing out and educating her about these classic symptoms of depression was a start. Bringing to light, the times the patient was happier and functional in the past and uncovering a hidden desire to do better was crucial. Inability to convince her would possibly stagnate treatment. “It is not who you are - its depression” – needed conveying.
Improving alliance starts with the creation of a safe space where the patient feels comfortable saying “I don’t want to take this medication”, and this is not taken as a personal rejection or question on our competency. I have frequently told my chronically non-adherent patients that “if you do not feel like taking medications, it is OK, but let me know. We will discuss other options.” I have frequently told my patients suffering from substance abuse disorders, “relapses are a part of the illness, it is important that we discuss them earlier than later and we will work out a plan to help you.” To my chronically suicidal patients, I have frequently said “I am not going to admit you to a psychiatric inpatient unit just because you mention the word suicide to me. We will evaluate the situation together and come up with a plan.”
Mintz & Flynn point out how reductionism is frequently used to explain all the factors involved in treatment. Though it helps in explaining how mental illness is in part a change in the biology of their brain it is incomplete as it ignores the patient’s role in recovery. The role of the patient is not confined to just being adherent to take medications, but also taking steps to take charge of their medical care, social, and work spheres. Personal responsibility should not be underestimated. This instills hope, as you are bringing back the control into the patient’s hands making them the most important agent of change.
STEPS FOR PATIENT-PHYSICIAN COLLABORATION:
1 Empathize with the illness/suffering and the resulting need for treatment.
2 Identify the patient’s goals and align treatment goals with those of the patients’.
3 Empathize with the wish to not need medication or avoid dependency.
4 Set up an open dialogue, genuinely help the patient be involved in decision making.
5 Discuss how medications/treatment will assist in achieving the goals of the patient.
6 Discuss how your goals as a psychiatrist are not medication adherence, but in fact, the patient’s improved functioning.
7 Constantly engage patients in providing feedback and accept negative feedback about medication/treatment so it can be fine-tuned in each individual case.
References:
1. Mintz DL, Flynn DF: How (Not what) to Prescribe: Non-Pharmacologic
Aspects of Psychopharmacology. Psychiatric Clinics of North America 2012; 35: 143-163.
2. Bellak, L. E. (1964). Handbook of community psychiatry and community mental health.
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