Posted by gardenergirl on July 22, 2007, at 1:54:51
From Medscape Psychiatry & Mental Health
Expert Interview
Improving Antipsychotic Adherence in Schizophrenia Using Cognitive Behavioral Therapy: Expert Interview with Peter J. Weiden, MD
Posted 06/28/2007Begin excerpt:
Editor's Note:After relapse, nonadherence rates among patients with schizophrenia are higher than those for any other psychiatric illness. To find out how to reduce this problem, Elizabeth Saenger, PhD, Editorial Director, Medscape Psychiatry and Mental Health, interviewed Peter J. Weiden, MD. Dr. Weiden is Director of the Psychosis Program, in the Department of Psychiatry, at the University of Illinois Medical Center, Chicago, Illinois.
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Dr. Weiden: Well, the starting point here is that nonadherence to psychiatric medication is a huge public health problem. As most clinicians know, patients with schizophrenia will routinely stop their antipsychotic medications. In fact, nonadherence rates after relapse range from 50% to 80%.[2] This is a huge problem because the benefits of treatments do not matter if you don't take your medications.
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When we look at psychosocial interventions for nonadherence in schizophrenia, studies of standard patient-based psychoeducation, we see that unfortunately patient education, for example, teaching about the biomedical model of schizophrenia and the necessity of medication to control symptoms, does not work; it does not improve medication adherence. Now, it is important to differentiate patient psychoeducation from family psychoeducation. Family psychoeducation has been shown to improve medication adherence for patients with families.
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With schizophrenia, it is very different. The patient who says, "I don't have schizophrenia. I don't need treatment," is just the kind of patient we want to reach out to and help with their adherence problem. Yet, there is this catch-22 -- if we set up an adherence intervention for the person's schizophrenia that includes an educational program for his or her schizophrenia, we run the risk of turning off the very patient we want to help engage in treatment. That is, in my opinion, one of the central problems to psychosocial interventions to improve adherence in schizophrenia -- the lack of insight and not acknowledging having schizophrenia or whatever name for the psychiatric disorder is used is a real barrier to engaging people into taking medication.
We think, though, that we have found an answer to this problem, and that is what we were studying here -- are there ways that we can get around that fundamental problem?
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Dr. Weiden: Since we know that many patients [with schizophrenia] do not acknowledge having an illness, some [of our] research has evaluated why patients do take their medication. Patients are more likely to take their medicine if you can find something that helps them feel better from the patient's point of view, especially if you can get the patient to come up with something on their own; that tends to be a very powerful motivator for adherence. Our work has uncovered another big reason why patients take their medicine -- their relationships. Research studies have shown, for instance, that married people are more adherent to regimens than single people,[3] because there are many of us, like myself, who if I don't take my statin, for example, my wife will kill me.
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So I turned to the literature in England where there has been a growing body of evidence over the past 10 years showing that cognitive behavior therapy, or CBT, modified for patients with psychosis or schizophrenia (not the same CBT you give to someone with depression or anxiety) can actually help reduce core symptoms of schizophrenia, such as positive or negative symptoms.
The caveat for these CBT interventions is that the CBT is always added onto ongoing medication regimens. CBT is not a substitute for antipsychotic medications. In other words, for patients with schizophrenia who have persistent symptoms and are adherent to their medicine, a course of CBT has been shown to help reduce symptoms of schizophrenia.
Professor Turkington has done a study showing that CBT can be taught to primary care and mental health nurses in England, who can then treat patients] and improve patient outcome even after a brief course of CBT.[4] Outcome measures here included:
Negative symptoms of schizophrenia;
Relapse prevention; and
Insight into the need for treatment, not so much insight into having schizophrenia.
When I learned of this, I thought "aha!" We can use this CBT program as a platform to base a more targeted adherence intervention. CBT, as it is practiced, does not insist on the patient accepting a diagnosis of schizophrenia, does not insist on a medical model. And, it is very patient-centered in the sense that a primary technique in CBT for psychosis is to begin with what bothers the patient -- where is the patient hurting; where is the patient suffering? To develop a formulation or a treatment plan that addresses where the patient is suffering from the patient's point of view.
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Medscape: How, then, did you translate recognition of this theory into the practical setting you describe?
Dr. Weiden: It was very important for me to make sure that we did not lose sight of the basic principles of CBT, which include:
Patient-focus;
Goal-orientation;
Not insisting on a biomedical model; and
Staying with the patient's agenda.
Then I had to merge adherence principles and adherence interventions into this platform. [I] then retrained [faculty and clinicians in the adherence aspects specifically], and we conducted a pilot study where patients who consented to receiving a 12-session CBT program, targeted for adherence, were randomized to psychoeducation and CBT vs psychoeducation alone. We now call this program CBT Adherence Intervention or CBT AI to make sure that people know it is not the exact same intervention as CBT Insight Program developed by Dr. Turkington....
Dr. Weiden: What we found was very encouraging. We found that the patients who were randomized to the CBT Adherence Intervention stayed on their medication longer. This was [in large part] because virtually all of the patients in the comparison group, the treatment as usual group, had stopped their medication completely within 4 months. While in the CBT intervention group, only about half -- actually, slightly under half -- of the patients stopped. That was a very large difference. Given the small sample size, the trend level was significant, but had a very large effect.
Remember that the theory here is to not force ourselves or our message onto the patient. We were not going to lecture at them or tell them why medicines were "good" for them. We felt that that was not the way to go; [but rather,] if we stayed focused on the patient's agenda and then brought the role of medication into their agenda so that they could explore it and understand it from their own perspective, that would be a success.
Interestingly, it turns out that at the end of the sessions, the CBT intervention group reported to us more reasons why they did not want to take medicine as well as more reasons why they wanted to take medicine.
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But, [your question] does call to mind the very important issue that, when it comes to adherence, there is no one treatment that will work for everyone. If a patient is taking a medicine that does not work for him or her, or is having lots of side effects, the CBT intervention probably will not help adherence. Or, if another patient is so impaired with cognitive problems or with confusion or psychosis that he or she cannot even find their way to the pharmacy to pick up the medicine, I don't think that a therapy where they are talking about goals is going to help necessarily.
One of the things we need to do better as a field is to tailor the specific adherence intervention or the way to help the patient with the actual problem that is making it hard for them to take the medicine.
In this case, we believe that a CBT-based adherence intervention is going to be ideal for a person who:
Rejects "having schizophrenia";
Does not like the idea of a label of mental illness; or
Does not want a biomedical model teaching approach;
but is still willing to engage with someone to talk about what is distressing him or her.
End excerpt.http://www.medscape.com/viewarticle/558835?src=mp
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thread:771086
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