Collaboration in Psychopharmacotherapy

Abstract

Collaboration in pharmacotherapy implies a professional willing to prescribe an effective medication and a patient willing to adhere to the therapeutic regimen in order for both to achieve their common goal. This relationship requires trust in the relationship, collaboration in goal setting, and effective means for promoting and restoring mental health. Variables like illness insight and patients’ attitudes towards medication should be dealt within a collaborative relationship. Several methods of shared decision making, culled from the research literature and clinical experience, promote such prescriber-patient collaboration and, even more specifically, medication adherence. Detailed physician-patient interactions in 2 cases, one of a depressed patient and one of a patient suffering from schizophrenia, serve to highlight common difficulties in the management of pharmacotherapy in the context of a collaborative relationship.

Pharmacotherapy is among the first treatment options for serious and/or chronic mental disorders like schizophrenia, bipolar disorder, and some anxiety disorders. Psychotherapy is another first treatment option for a variety of mental disorders, either as an alternative to or in combination with medication. The focus of this article will be on those cases when pharmacotherapy is combined with psychotherapy, no matter whether these two treatments are provided by the same clinician or by different professionals.

In this article, I begin by tracking the demise of the paternalistic medical model and then addressing the rise of collaboration in prescriber-patient relationships. Several evidence-based means of promoting shared or collaborative decision making are then reviewed. I present verbatim physician-patient exchanges from two cases of pharmacotherapy to illustrate several key points. The article concludes with a review of the recommended practices to foster collaboration in pharmacotherapy for the mental disorder.

Rise and Fall of a Paternalistic Medical Model

Although the medical model in psychiatry relates to the organic etiology of mental illnesses, it also incorporates therapeutic knowledge of a scientifically valid nature. Accordingly, it is grounded in the therapeutic relationship (Shagass, 1975). The medical model also implies that doctors are given by society the authority to probe bodies and minds in ways permitted to no one else, and patients, without protest, permit themselves to be subjected to unpleasant, frightening, and even humiliating experiences. Special knowledge about medicine, the belief that a physician functions for the good of the patient, and faith in a doctor's knowledge are three kinds of authority.

Despite the abuses and misuses of the medical authority model, it adheres persistently to a value system centered around the benefit of the individual patient. The model also follows the medical tradition of applying the test of pragmatic relevance to new ideas and procedures. When they achieve desirable purposes they are adopted, even though this means changing previous explanations (Shagass, 1975).

Contemporary pharmacotherapy seems to have quite different qualities from the original medical model. According to the Royal College of Psychiatrists (2006), “A consultant psychiatrist values and respects the views and perspectives of the individual and their carer(s), and is committed to working in partnership with them. The consultant seeks to establish a collaborative approach, providing information and education about the disorder, risks and benefits of treatment, to guide and assist the service user in making choices and decisions about care” (p. 14). The consultant demonstrates a variety of skills, including “Pharmacological treatment; detailed knowledge and understanding of risks and benefits, wide experience of application of such treatments. Recognition of the importance of a collaborative approach and of establishing a concordance with the individual” (p.16).

Collaboration, Adherence, and Concordance

Collaboration in any given treatment relationship applies, to begin with, to the joint goal of restoring a patient's health and then to the effective means for such a task. It is evident that collaboration in pharmacotherapy implies a professional willing to prescribe an effective medication and a patient willing to adhere to the therapeutic regimen in order for both to achieve their common goal. Adherence, contrary to the earlier medical model term of compliance, refers to the extent to which the patient's behavior matches agreed recommendations from the prescriber. Further, the term implies that the patient is free to decide whether to adhere to the doctor's recommendations; adherence is considered nonjudgmental and a patient's failure to adhere should not be a reason to blame him (Horne, 2006).

Although the efficacy of most medications for improving or controlling long-term health conditions is well established, poor adherence to medication is a major clinical problem. Improving adherence is an essential element in reducing the global burden of disease. Especially in chronic conditions, adherence is far from being satisfactory. Medication adherence in the psychiatric population does not differ significantly from that in patients with general medical conditions. It is estimated that rates of medication nonadherence in the most serious mental disorders are 28%-52% for major depressive disorder, 20%-50% for bipolar disorder, 20%-72% for schizophrenia, and 57% for anxiety disorders (Julius, Novitsky, & Dubin, 2009).

Concordance is a newer and more complex idea relating to the patient/prescriber relationship and it describes the degree to which the prescription represents a shared decision, in which the beliefs and preferences of the patient have been taken into consideration. Concordance is the processes that is considered necessary for the patients to become more likely to be motivated to take medication and it is achieved when they accept they have an illness, they agree with the treatment proposed, they have accurate information about the medication and its effects, they are involved in the decision making process, and they have talked about their concerns about medicines and these concerns have been seriously addressed (Gray, 2009)

Enhancing Shared or Collaborative Decision Making

The patient's role has transformed from being passive to that of an active partner or collaborator. Shared decision making (SDM) is increasingly advocated as an ideal model of treatment decision making (Charles, Gafni, & Whelan, 1997). SDM is seen as a mechanism to decrease the informational and power asymmetry between professionals and patients by increasing patients’ information, sense of autonomy, and/or control over treatment decisions that affect their well-being.

Shared treatment decision-making possesses four necessary characteristics: (a) at a minimum, both the professional and patient are involved in the treatment decision-making process, (b) both share information with each other, (c) both take steps to participate in the decision-making process by expressing treatment preferences, and (d) a treatment decision is made and both the professional and patient agree on the treatment to implement (Charles et al., 1997). Mere information sharing and treatment decision making are two separate goals; shared treatment decision making needs to be a two-way exchange of not only information but also treatment preferences.

Makoul and Clayman (2006) reviewed the literature on SDM and proposed an integrative model of SDM. In order for SDM to occur, patients and providers must first define and/or explain the problem that needs to be addressed, and that discussion will likely lead to a presentation of options. Physicians then should review options, and patients should raise options of which they may be aware. Physicians and patients should discuss the pros and cons of options raised, particularly because they may have different perspectives on the relative importance of benefits, risks, and costs, including convenience and opportunity cost. These individual perspectives become evident through explication of patient values and preferences—including ideas, concerns, and outcome expectations—as well as physician knowledge and recommendations in the context of the decision at hand. Discussion of patients’ ability, or self-efficacy, to follow through with a plan is a critical component of assessing the viability of options. Throughout the process, both patients and providers should periodically check understanding of facts and perspectives, providing further clarification as needed. Decisions are not always ‘‘made’’ when problems are first discussed, because they may be explicitly deferred for a later time. Thus, it is essential that physicians and patients arrange follow-up to track the outcome of decisions that have been made or reach resolution on those that have not.

Mauksch, Dugdale, Dodson, and Epstein (2008) also reviewed the research findings to propose methods of promoting relationship, communication, and efficiency in SDM. Four skill sets provide ongoing influence: rapport building and relationship maintenance; mindful practice (attentive observation of the patient and of the physician's own thought processes to guard against cognitive shortcuts and physician dominance of the agenda); topic tracking (summarization, process transparency, and goal alignment); and acknowledgment of patient social or emotional clues with empathy. Three skill sets occur in a sequence: up-front, collaborative agenda setting, understanding the patient perspective, and reaching mutual agreement on/ co-creating a plan. Understanding the patient perspective, of course, entails numerous skills, such as examining his or her health behavior change, ascertaining underlying thoughts and feelings, assessing family or cultural factors that influence patient beliefs and behavior, and exploring psychosocial problems that diminish patient function.

The importance of communication in collaborative decision making has been repeatedly stressed in a number of articles. One recent review (Politi & Street, 2011) summarized strategies to enhance such collaborative communication: providing clear explanations, checking for understanding, eliciting the patient's values and needs, finding common ground, reaching consensus on a treatment plan, and establishing a mutually acceptable follow-up plan. It is interesting that the authors use the term “collaborative decision making” instead of “shared decision making,” although they ascribe a broader meaning to collaboration. They argue that collaboration implies a process of mutual participation and co-operation among multiple clinicians, patients, and family members, whereas “shared” connotes that participants (physician and patient) made the decision together.

A recent study examined medication adherence and its relationship with patient perceptions about the doctor-patient relationship in a representative sample of 45,700 participants from 24 European countries (Stavropoulou, 2011). Unresolved issues during the consultation were shown to be large barriers in the doctor-patient relationship. Reluctance to ask the doctor questions, for example, was a significant factor leading to nonadherence, indicating that when people do not clarify their questions, they may leave the appointment with confusion regarding their medication and likelihood of consequent nonadherence. Nonadherence was also attributed to patients feeling that their doctors do not tell the whole truth. This may as well be related to unvoiced patient's agenda, another implicit variable relating to nonadherence.

Interestingly, the way people perceive the professional's role in prescribing predicted nonadherence: nonadherence related to the patient's unmet expectations of being given a medication, as well as being given the medication he wanted the doctor to prescribe. It is clear, thus, that when the prescriber ends the consultation he needs to make explicit the reasons not only why he or she prescribes a (certain) medication but also why he or she may not. These findings point to the fact that individuals’ perceptions of the doctor-patient relationship is key to nonadherence. Conversely, involving patients in the decision-making process, treating them as equals, and avoiding leaving unresolved issues all contribute to a better doctor-patient relationship and improve adherence. A recent meta-analysis of studies on the link between treatment adherence and physician-patient communication (Haskard Zolnierek, & DiMatteo, 2009) showed that the relation between respondents’ adherence and their physicians’ communication was strongly positive and significant. The authors concluded that physician skill at communicating during the visit may be the central factor in achieving patient adherence because it improves the transmission and retrieval of important information, facilitates patient involvement in decision making, allows open discussion of benefits and risks, explores barriers to adherence, builds rapport and trust, and offers patients verbal and nonverbal support and encouragement.

Adherence Interview

Weiden's (2011) recent article on conducting a clinical interview with a focus on adherence provides several valuable clinical pointers. His article reviews common interview mistakes about adherence that can occur in medication management visits, offers specific recommendations that can improve the quality of adherence information obtained, and sets the stage for matching the intervention with the cause of nonadherence while strengthening the therapeutic relationship. Common interview mistakes are as follows: improper tone at start of interview (starting the interview with possible adherence problems); failure to ask about adherence (taking the proper medication adherence for granted); assumption of adherence (clinician's overconfidence in the ability to detect nonadherence); negative attitudes after discovery of nonadherence (taking it personally/conveying anger or irritation); assigning of blame (automatically blaming the patient for willful nonadherence); assuming patient attitudes (both pro and con); overestimations of efficacy (overselling the benefits of medication); and linking medication to a diagnosis of serious mental illness (in patients who reject this diagnostic label).

Weiden (2011) offers the following numerous recommendations for improving the adherence assessment while strengthening the alliance: accepting nonadherence (normalizing it); discussing desired outcomes (seeing adherence as a mediator between medication and better outcomes); turning focus away from obedience (viewing nonadherence as a potential barrier to better outcomes); asking about adherence attitudes (inquiring about the reasons for and against taking medication); respecting reasons for nonadherence (assuming that the reason for nonadherence is reasonable in the context of the patient's situation); assessing patient cooperation (defining the intentional or unintentional nature of nonadherence); and anticipating potential nonadherence and prevention (discussing possible relapse or trying to prevent aversive consequences).

Collaboration and Adherence

Poor adherence to medication can have devastating consequences for patients with serious mental illness. Consequently, an expert consensus survey on adherence problems was conducted on schizophrenia and bipolar disorder and was recently published (Velligan et al., 2010). The following psychosocial and pharmacologic interventions were rated first-line for improving adherence: ongoing symptom/side-effect monitoring for persistent symptoms or side effects, services targeting logistic problems, medication monitoring/environmental supports for lack of routines or cognitive deficits, and adjusting the dose or switching to a different oral antipsychotic for persistent side effects. Psychosocial/programmatic interventions that received high second-line ratings in a number of situations included medication monitoring/environmental supports, patient psychoeducation, more frequent and/or longer visits, cognitive behavioral therapy, family-focused therapy, and services targeting logistic problems. The consensus experts stressed the importance of improving the therapeutic alliance and acknowledged that research supports the importance of a collaborative partnership and SDM when treating patients with antipsychotic medications.

Adherence therapy is a good option for the enhancement of adherence (Gray, 2009). It is a collaborative, structured, and practical approach based on motivational interviewing (MI), cognitive-behavioral therapy (CBT), and compliance therapy. Interpersonal skills include using the patient's words (at a level of mutual understanding), using open-ended questions (facilitate discussion and sharing of information), reflecting listening (empathize with what the patient is communicating), summarizing (opportunity for clarification), and eliciting and responding to feedback (checking what patient and professional have correctly understood). Process skills include working collaboratively, setting a clear agenda, emphasizing personal choice and responsibility (enhancing self-efficacy), and safety.

Enhancing information and dealing with resistance are two important cornerstones to this adherence approach. In the MI tradition, useful strategies for dealing with resistance are emphasizing personal choice and control, backing off and coming alongside the patient, and reassessing how important it is for the patient to take medication and how confident the patient is in taking medication. Finally, five core skills are suggested when talking to patients about their medication: problem solving (for any identified practical difficulty), looking back (exploring a patient's previous experiences of treatment), exploring ambivalence (the degree of uncertainty or ambivalence about taking medication), talking about beliefs (that may influence patients decisions about taking medication), and looking forward (helping patients develop an understanding of the long term need for medication). Many of these core skills are exemplified in the following two case illustrations.

Case Illustration I: Major Depression

Research on the collaborative relationship between physician and a depressed patient demonstrate that improved patient involvement in treatment decision making can lead to higher likelihood of adherence, satisfaction, and positive clinical outcomes. Less often, a SDM intervention for primary care of depression may improve patient satisfaction and patient participation in treatment decision making, but has no effect on adherence or clinical outcome (Loh et al., 2007).

Anna, a 54 year-old woman, was referred by her oncologist for medication treatment of her depression. Anna had divorced, her 30-year-old son had been living abroad, and she had been living alone for the last 5 years. Four years ago, Anna was diagnosed with breast cancer, and consequently she underwent an operation, had adequate cycles of chemotherapy, and had a good response and long-term outcome. In the meantime, she had a surgery for breast reconstruction, and her depression started to emerge almost a year prior. Her mood was low, her self-care was rather inadequate, and she was reluctant to go out, meet with her friends, or do some of her favorite activities, like going to the cinema. She could not sleep at nights, and she preferred to stay in bed several hours a day. During that year, Anna also developed a kind of “bulimic” (as she described it) eating, and consequently she gained 12 kilos. Four months prior to her initial consultation, she visited a psychiatrist who prescribed an antidepressant (paroxerine) that was progressively increased to 40 mg per day. Due to a nonadequate response after several weeks, her doctor tapered paroxetine and at the same time prescribed another antidepressant medication, duloxetine (progressively increased to 90 mg per day; 60 mg in the morning and 30 mg at bedtime). Unfortunately, Anna's depression did not improve significantly and this was the reason for her current consultation.

During the evaluation interview Anna was motivated and could articulate effectively the presentation of her problems. Anna and her doctor agreed that since she had taken duloxetine for several weeks, it was a good choice to try another antidepressant. After discussing the medication options (different categories of antidepressants, with different mechanisms), her doctor suggested that mirtazapine, an antidepressant with a rather different mechanism of action from paroxetine and duloxetine, at an initial dose of 30 mg a day was a good option. Anna agreed. The advantage of miratzapine was that it improves sleep difficulties early in treatment. The consequent instructions were that Anna would stop taking the morning 60 mg dose of duloxetine, transfer the bedtime 30 mg duloxetine dose in the morning, and start taking the 30 mg mirtazapine dose at bedtime. They agreed that Anna would call her doctor in 2 weeks to review progress and, if everything was proceeding to plan, to stop the duloxetine 30 mg a day medication. They scheduled their next appointment in a month. The doctor made explicitly clear that they could not have a valid initial evidence of the new medication effectiveness unless they waited for at least 4 weeks.

Anna did not call at the 2-week timeframe, but she came to her one-month appointment. She had a 30% improvement, evident in her better sleep and improved mood and social interactions. She had met with her friends a couple of times, and went to the cinema once. She definitely looked happier, and both Anna and her doctor agreed that it was a good and promising outcome. By reviewing her medication taking it was evident that she did not only call in 2 weeks as they had agreed, but she also took the initiative to stop her duloxetine medication. At the same time she increased her daily dose of mirtazapine to 45 mg (one and a half tablets) a day.

Doctor:

Hm! This is a surprise. I thought that we had agreed on another course of action.

Anna:

OK, I am sorry. I was just hoping to become better, so I stopped duloxetine at 2 weeks and increased the daily dose of the new medication at the same time.

Doctor:

I can understand how quickly you want to become well, and I am glad that the outcome seems to justify what you did. But to be honest, I am not happy since it was something that we had not agreed. Have you any ideas why I am not happy with this?

Anna:

I guess that I should have been consistent with what we had planned.

Doctor:

Was that so important to stay with the plan?

Anna:

I guess, yes.

Doctor:

Any ideas on why?

Anna:

You could probably suggest something different, not to stop duloxetine at that time … or not to increase the dose of the new medication.

Doctor:

It seems a good point. Any other idea on why it was so important to stay with the plan?

Anna:

Could that have an adverse effect? It could have, I guess. Maybe it could have been not a good time to make such changes to my medication.

Doctor:

I am not definitely sure about that, but yes, it could. Maybe I had not been very clear at our last appointment, but my concerns were first to make sure that the transition from one medication to the other would be smooth, and second to check for possible side effects of your new medication. My expectation was that having the chance to check these points in a 2-week time could make the whole picture clearer.

Anna:

Yes, I see your point now … I feel lucky that I had no problems.

Doctor:

OK, so we are both glad that there is a 30% improvement after having taken one and a half tablets of your new medication for 2 weeks.

Anna:

It seems so.

Doctor:

Is there a way to know whether you might have been the same well with taking only one tablet a day?

Anna:

No, I do not think there is.

Doctor:

So you say that there is no way to know whether you might have been the same well with taking only one tablet a day.

Anna:

Mmm, I see your point. You mean that I may have been the same well without having increased my daily dose?

Doctor:

Yes, and I can assure you that this is the case!

Anna:

How do you know?

Doctor:

I am just joking. There is no one on this earth that knows.

Anna:

I see what you mean. I could have been the same well even without having to increase the dose, but this is something we will never know. I haven't thought of that. I am sorry.

Doctor:

No, don't be sorry because you could be right. There is a 50% chance–just to give even possibilities–that if you had not increased your medication daily dose, you could have made no progress.

Anna:

So…?

Doctor:

We have two options, with their pros and cons. We either increase the daily dose quickly enough to achieve the best outcome the earliest possible, or take a more step-by-step approach that takes more time. The first option offers the possibility of an earlier relief from the symptoms of depression, but at the expense of probably unnecessary higher daily medication doses. The second option guarantees that one takes the lowest effective dose, that is no more medication than he needs, but it arrives at the same point a couple of weeks later.

Anna:

So, we have two options.

Doctor:

Personally, I am with the second option. I know that half a tablet of an aspirin does not usually relieve one from his headache, but if I can be well with a whole tablet, why should I take more? Would you like to give a second thought to these options?

Anna:

Yes, I think I should.

Doctor:

OK. I am glad that this discussion makes sense to you, but could that be useful in any way?

Anna:

I'll keep it in mind.

Doctor:

Can you apply what we have just learned to a decision we have to take right now?

Anna:

How to go on with my medication, you mean?

Doctor:

Quite right! Shall we go on and increase the daily dose of your medication to two tablets a day?

Anna:

[thinking]

Doctor:

You have a 30% improvement in your depression. It is a good initial response after 2 weeks at the current daily dose, but we both want a much better and quicker response. Shall we increase the daily dose today?

Anna:

Oh, I see what you mean. My answer is no.

Doctor:

How come?

Anna:

[smiles] If I can become well with one and a half tablet of my antidepressant, why should I take more?

Doctor:

[smiles too] So you suggest we should wait, but for how long?

Anna:

For another 2 weeks?

Doctor:

Yes, it will be a good time to reassess your response to medication.

Anna and her psychiatrist did so; they agreed to wait for another 2 weeks and discuss the option of increasing the daily dose after having the chance to reassess consequent progress. One of the side effects of mirtazapine is that it may cause weight gain. Anna noticed that although she had not started “binge eating” again, she had eaten more and consequently she gained 2 kilos in 4 weeks. Anna and her doctor discussed the pros and cons of continuing mirtazapine. They agreed that as a first step, Anna could try to take better control of her eating, and in case this was difficult, Anna could attend a free Solutions for Wellness program for people who take psychotropic medication and have weight problems.

Case Illustration II: Schizophrenia

Nonadherence is considered the single most important cause of relapse and readmission to hospital for patients suffering from severe mental illnesses, including schizophrenia. Recent findings indicate that the most favorable conditions for encouraging adherence include a positive relationship with the prescriber, involvement of the patient in treatment decisions, and, to a lesser degree, a medication that minimizes adverse effects (Day et al., 2005). Consequently, it is possible to maximize the perceived benefits of treatment by ensuring that the patient's response is carefully monitored and that the treatment is adjusted if the patient is distressed by adverse effects. Collaboration, in the words of Kingdon and Turkington (2005), does not mean that the professional is commanding the patient to do as he or she is told, but rather that the professional is negotiating with another human being who has the right to make decisions about what chemicals he or she ingests. This attitude is demonstrated in the next case illustration.

John is a 25-year-old university student suffering from schizophrenia. He had his first psychotic episode in the age of 21, and he took antipsychotic medication for almost 2 years thereafter. He relapsed almost after a medication-free year.

A year ago, John had to be hospitalized because of his unwillingness to take medication and the deterioration in his condition. John has now been on medication since his discharge from the hospital, but he makes intermittent use of his medication. The pattern seems to be that he reduces the daily amount of his medication (and some days he probably does not take it at all), his illness tends to recur, his family pushes him to take his medication as prescribed, and after his having done so, the overall condition seems to remit. John presents with the same risky situation now. Because of John's complaints of side effects of his previous medication, his doctor prescribed a new antipsychotic medication a couple of weeks ago. John still has complaints.

John:

My parents told me to let you know that I am not compliant with my medication.

Doctor:

Do you mean that you are not taking the medication at all?

John:

No. I do not take my morning pill, but I take the bedtime one.

Doctor:

Is it … no, please, tell me more about it.

John:

Look, it started by chance. I forgot to take it a couple of times and I realized that I felt better.

Doctor:

OK. So what made you feel better?

John:

I saw that I was feeling a bit better. My head was less heavy, my mind was more clear. I thought, “OK, I am better,” so I thought it is good not to take my morning pill.

Doctor:

Is this what your parents told you to let me know?

John:

Yes, they got angry at me and started to shout.

Doctor:

And what did you do in response?

John:

I tried to explain, but they do not seem to understand. They do not listen to me. They told me that I will be taken to the hospital. They made me angry too, and then I started shouting too.

Doctor:

I see that you all became very upset. It sounds very upsetting not to be heard.

John:

Yes, it really is. It makes me crazy.

Doctor:

And it also seems that your parents are very concerned that you do not take your medication.

John:

They fear that if I do not take my medication, I will then start hearing voices again, and be taken to the hospital. After all, I take my medication–a pill a day, that's all.

Doctors:

OK. So they think that you will, or at least you could, relapse, and it seems that they are very insistent on this. Are there any ideas on it?

John:

The usual story–if I hadn't stopped my medication last year, then I wouldn't have gone to hospital.

Doctor:

It reminds me of the discussion we had a couple of months ago. We agreed that this is a highly possible outcome, although no one can say for sure.

John:

That's exactly what I say too. No one can say for sure.

Doctor:

We also arrived at a couple of other key conclusions during that discussion, the ones we review from time to time. Do you remember them?

John:

OK. I have a sensitivity … a vulnerability that under stressful situations makes me experience strange and unpleasant symptoms. To minimize this, I have to take my medication, and not taking my medication puts me at the risk of becoming very ill again.

Doctor:

Good, you are right. We also agreed that although no one likes taking a medication, especially if it is for long, the benefits of taking it seems to overrun any risks related to not taking it.

John:

Even if taking it in the morning gives me a bad time?

Doctor:

OK. This is a good point we have to take care of right now. You said that you feel better not taking it.

John:

Yes, it makes me sleepy.

Doctor:

OK. I do not like the idea of someone being sleepy in the morning too. Do you have any ideas of how to manage it?

John:

Not taking it?

Doctor:

This is a very radical solution. But it also means that one takes just the half of the required daily dose. What else then?

John:

I guess you mean that I have to take it anyway.

Doctor:

I am afraid, yes.

John:

Taking my morning pill with my bedtime one?

Doctor:

Oh, yes. This is a rather good option.

John:

Taking it at midday?

Doctor:

Yes, another good option too.

John:

What if I feel sleepy at the afternoon?

Doctor:

This is a good question, but how could we find the answer?

John:

Try it as an experiment?

Doctor:

Excellent point. So taking it either at midday or at bedtime provides you with the recommended daily dose of your medication and does not probably interfere with your daily routines. Does it make sense?

John:

Yes, but what if I do not take it?

Doctor:

You have the choice not to, but I am sorry to say, I do not agree. It is your choice to take the risk, but it will be you … who will experience the consequences.

John:

This is my choice then.

Doctor:

You know it is, and I know it too. What really concerns me now is that you are raising a matter we have discussed again. You had some points, some thoughts, some attitudes related to medication taking and we worked them through. Has anything changed since then?

John:

Yes, I have thought it a bit again.

Doctor:

Would you like us to discuss it now?

In this case, John and his doctor will focus on unresolved matters related to John's attitudes about medication taking, and also negotiate options related to possible rescheduling the way John takes his medication. Because John's attitude is a major topic, they will either discuss it briefly at the current session or consider it as a topic for the agenda of the next session, something that will influence the discussion about John's current medication adherence and his consequent decisions. The reaction of John's parents to his medication nonadherence may probably call for an expressed emotion management with John's family, but this is something that the physician will discuss with the other members of the mental health team.

Clinical Practices and Summary

The pharmacotherapy of mental disorders has moved from the original paternalistic model to a collaborative decision-making model. This transition was not easy. A frequent difference between people who suffer from severe mental disorders, like schizophrenia or bipolar disorder, and people who suffer from nonmental disorders is their level of illness insight. Poor insight in people with severe mental disorders frequently leads to their not accepting an illness, not agreeing with the need for treatment, and, even worse, not seeing the need for a sometimes lifelong medication treatment. As a way of providing treatment to these people, the medical model tried to impose treatment, not always successfully. Prescribers found that even having successfully imposed treatment, the patient was not satisfied with the prescribers and there were reduced possibilities for a trusting relationship, and prescribers were often faced with a mutually confronting and rather argumentative clinical practice.

Contemporary pharmacotherapy has acknowledged the importance of a partnership between patient and clinician and SDM when treating patients with medications, in general, and antipsychotic medication, in particular, to improve treatment outcomes, satisfaction, and adherence. This approach enhances trust in the patient-physician relationship. Good trust building lowers the threshold for cooperation, substantially empowers the patient, and thus promotes treatment adherence. Increased trust in a professional probably increases the patient's willingness to seek care, the likelihood of early diagnosis and treatment, as well as early management of relapse and consequently positive health outcomes. Patients attitudes towards medication are also dealt within a collaborative relationship, because patients with a higher trust in medication have an increased probability of collaboration, whereas patients with lack of insight have a reduced probability of collaboration (Klingberg, Schneider, Wittorf, Buchkremer, & Wiedemann, 2008). Providing sufficient information about the benefit/risk ratio of the medication as well as about the illness itself improves collaboration and medication adherence.