Non-adherence to treatment

Clinical CoachingBrief Advice

Behaviour Change CouncellingMotivational Interviewing

Topics

• Non-adherence to treatment• Motivation• Clinical Coaching• Brief Advice • Behaviour Change Councelling• Motivational Interviewing

Adherence to treatment

Adherence vs. compliance to treatment

• Adherence: active involvement of the patient in treatment processes

• Compliance: patients simply follow doctor´s orders

• Better adherence = better clinical outcomes

Non-adherence to treatment

• Taking too little (drug or excercise too little, etc..)• Taking too much• Not taking at the prescribed intervals (or excercising too or

less frequently as required)• Taking other medication without the knowledge of the

prescribing medical professional • Not taking the treatment for the prescribed duration

30% of patients

Examples?

Clinical example: Course of psychotic disorders and the prescribed duration of the treatment

Early warning

signs

Early warning

signs

1st. attack

1st. relapse

Remission

CC

Antipsychotics (neuroleptic medication) for psychotic disorders: Recommendation for the relapse prevention

• After 1-st episode: 1-2 years• After 2nd episode: 5 years• Three and more episodes: life-long treatment

Reality?

10 days 6 months 12 months 24 months

25%

33%

40%

76%

69%

discharge

nonadherence(%)

Perkins, 2002; Kamali et al., 2006, Lam et al, 2002; Weiden et al., 1997

Psychotic disorders:Treatment nonadherence

Disease factors:No or few or mild symptoms

Fluctuating courseLack or no insight

Healthcare factors:Poor availability,

Long waiting time

Psychosocial factors:poor support

Psychological factors:Depression;

Attitude, beliefs, perceived benefits

Treatment factors:Complex regimen

Side effects

MD´s factorsAbility to communicate and provide information

Why?

Case: Jirka

Promoting adherence• Discuss the patient´s beliefs, concerns, and intentions relating to

treatment• Where possible customize the regimen in accordance with the patient´s

wishes• Simplify the regimen• Provide simple, clear instructions for taking medication• Elicit the patient´s feelings about his ability to follow the regimen and

discuss stratgegies for enhancing adherence• Consider the use of medication-taking systems including electronic

reminders• Emphasize the value of prescribed regimen and the importance of

adherence for producing the best treatment outcomes• Obtain any necessary help from family members, friends, etc.

Promoting adherence

• Monitor adherence. Watch for the mardkers of nonadherence such as missed appointments, missed refills, and a lack of response to medication

• Express approval of adherence and encourage continued adherence.

• Ask the patient about nonadherence and barriers to adherence in an understanding, non confrontational way

• If adherence appears unlikely, prescribe medication with lon half-lives, depot (extended release) or transdermal medication

How to do it???

Adherence and non-adherence:

Patient´s attitude not symptom!

How to influence patient´s attitude?

What do they have

in common ?

http://upload.wikimedia.org/wikipedia/commons/a/ac/Grabill_-_Tallyho_Coaching.jpg

Clinical Coaching

Education

Motivational Interviewing

Barrier-free Access

doctoras sparingpartner, shares knowledge,communicates comprehensibly, respects patient´s opinion, negotiates procedure,offers choice

doctorsearches for inner motives for change,addresses ambivalencerespects wishes,solves problems together

Doctor educates to the patient´s needs

Intervention Brief Advice (BA) Behaviour Change Councelling (BCC)

Motivational Interviewing (MI)

Time 5-15 minutes 5-30 minutes 30-60 minutesSetting Mostly opportunistic Opportunistic or help-

seekingMostly help-seeking

Goals Demonstrate respect, communicate risk, provide information, initiate thinking about change in problem behaviour (Ask, Assess, Advise, Assist, Arrange)

BA + Establish rapport, identify client goals, exchange information, choose strategies based on client readiness, build motivation for change

BA + BCC+ develop relationship,resolve ambivalence, develop discrepancy, elicit commitment to change

Practitioner-recipient

Active expert – Passive recipient

Councelor-active participant

Leading partner - partner

Motivational Interview

How to influence the clients´s attitude and promote behavioural

change

Motivational Interviewing• Diet and physical activity change• Smoking cessation• Behavioural and drug addiction councelling• Medication adherence• HIV prevention• Chronic illnesses: diabetes and cardiovascular diseases• Public health problems: preventing infection (ebola!!)

Motivation

• Motivation is a drive to act• Motives: • Biological (to eat, to reproduce): to ensure

homeostasis of an organism• Psychological and social (to achieve particular

status, need to influence or control others; to make impression on others..)

What is your motivation to

study medicine?

Theory of motivation: Incentive theories

• External factors trigger and regulate motivation

• Expectations and values• Knowing more about motives means we can

address the situation more constructively

Theoriy of motivation: Drive theory

• Drive theories: behaviour to ensure the stability in bodily functions that is necessary to survive.

• A lack of equilibrium between our current state and our needs creates a tension which we are motivated to reduce

Give an example of abnormal extremes of

biological drives.

Give an example of a disorders with strong

motivational component

Motivation to drink alcohol

????

Craving

• Strong motivational effect

• Worsening of cognitive functions

• Physiological symptoms: increase of heart rate and increase of skin conductance

• The same as stress

Reward System Basic neurobiological system for survival and reproduction.A collection of brain structures to regulate and control behavior by inducing pleasurable effects. When activated, reinforces behaviors.

Primary evolutionarynatural incentives:air, water food, Sexual partnerSafetydopamine

Nonnatural incentives:Drugs:Activate the systém more than natural podněty and Change the activity of the reward systém

Reward System: Abused by drugs!