Now listen. This is the season to be good and compliant. It’s Christmas for goodness sake. People are making lists of who is naughty and nice and it has come to the attention of the World Health Organisation, a bunch of psychiatrists, and Pfizer that only 23% of you are following your doctor’s recommendations in taking your antidepressants. The rest of you are failing to get your prescriptions filled, taking your drugs irregularly, taking ‘drug holidays’ and discontinuing your meds before the recommended 6 months treatment duration.
So for Christmas this year you are all getting the gift of ‘Motivational Pharmacotherapy’ and although you may not realize it yet, this is just what you’ve always wanted.
Drug profitability requires three parties to work together – drug companies to make the drugs, psychiatrists to prescribe them and consumers to take them. Too often, though, patients have failed to play nicely and do their bit. They have banged on about tiresome things like adverse reactions and alternative treatments, they have expressed foolish opposition to the very concept of pharmacotherapy and questioned its efficacy. They have become medication non-compliant and undermined the profits of the pharmaceutical industry and the authority of psychiatry. They have been bad and landed themselves on a lot of people’s naughty lists and made WHO very sad and worried.
While compulsory treatment orders are one way resistant patients can be brought into line, they require a lot of time and resource and don’t present the best public relations opportunity. Persuading non-compliant patients that they actually want to take their drugs is a far more elegant solution to the issue of non-compliance.
As one psychiatrist put it;
The patient is not a passive battleground between the doctor and the disease. Instead, he or she is an important ally, or adversary, and the outcome of pharmacological treatment depends largely upon recognizing and using this stance.
So how do doctors and the industry turn patients from adversaries to allies?
When my son Toran was a 2 year old I had a clear goal of getting him into the bath each night before bed. His objective on the other hand was to avoid the bath until sometime into middle age. Like many mothers, I shamelessly manipulated him into doing what I wanted him to do while making him think it was his idea. “Shall we hop like a bunny to the bath or do you want Mummy to carry you?” Both choices furthered my goal and dismissed his as an option. Being given a choice made him feel like he was in control. He complied with my agenda without me having to deal with his objections or outright resistance in the form of a tantrum. Should he raise an objection, I would just start bunny hopping down the hall and ignore him until he joined in. My agenda became his without him even realizing it as I turned him from an adversary into an ally.
Motivational Pharmacotherapy is something similar, an intervention developed and tested by a group of psychiatrists, with financial assistance (and some free Sertraline) from Pfizer. It combines motivational interviewing with pharmacotherapy as a means of increasing adherence to treatment.
Motivational Interviewing is a counselling method that “addresses the common problem of ambivalence about change and is designed to strengthen an individual’s motivation for and movement toward a specific goal.” It involves reinforcing any acceptance of the therapists goals and avoiding discussion of any of the patient’s objections. Motivational Pharmacotherapy is designed to overcome people’s objections to taking their drugs and strengthen their goal of working towards compliance with clinician recommendations for drug treatment . . . and make them think it was their own idea.
Patient attitudes to medication including preference for alternatives to drug treatment and perceptions of antidepressants being both harmful and unnecessary and their experience of side effects have been shown to be the best predictor of compliance.  
A significant amount of research has been undertaken in the last couple of years on the role of pharmacists in addressing antidepressant non-adherence issues and enrolling them in monitoring medication adherence. According to a recent review of the literature, “findings from recent systematic reviews indicate that pharmacist interventions can be effective in the improvement of adherence to antidepressant medications.” The authors suggest pharmacists can play an important role by exploring barriers to accepting treatment, clarifying common misconceptions, and providing key educational messages about antidepressant medications. Pharmacists can also refer non-compliant patients back to their doctor so the doctor can “increase the dosage of the medication, prescribe adjunct treatment, switch the patient to another antidepressant, and/or refer the patient to psychotherapy services.”
Not surprisingly, the recruitment of pharmacists as members of the medication compliance team has encountered some resistance from those uncomfortable with being the enforcers of antidepressant treatment rather than advocates for patient welfare. Seems they may be in for a bit of motivational interviewing themselves;
Our study also indicates the need to strengthen pharmacists’ roles in medication adherence monitoring, in addition to having important adherence-related discussions with patients on antidepressant treatment. In fact, it has been suggested that pharmacists may experience role conflict if they perceived their primary role as being to reinforce the physician’s instructions rather than an advocacy role which takes into account patients’ needs and concerns about their treatment. From the current study, it appears that this is still a major challenge that needs to be addressed, because it may have implications for the pharmacist’s role in collaborative problem-solving and supporting patients in making treatment decisions. It also signifies the importance of integrating pharmacists into a multidisciplinary collaborative approach in order to provide truly effective care to patients with mental illness.
Rather than reinforcing negative attitudes to medication through using coercion to achieve compliance, it makes sense that the industry would mount a charm offensive, smiling and nodding while we report adverse reactions while they persuade us to bunny hop along to the pharmacy. The pharmacy where a nice person in a white coat will remind us why we should take our drugs while distracting us with a nice soap or a new shade of lippy. Next stop McDonalds, perhaps, where we can upsize our prescription and get fries with it.
While we continue to fight compulsory treatment let’s also be aware that that the pharmaceutical companies and psychiatry are using a seemingly benign but much more dangerous method of enforcing compliance with their drug promotion agenda and fight motivational pharmacotherapy too. Let’s do what we can to support pharmacists in remaining skeptical about jumping on the bandwagon of enforcing medication compliance. Let’s resist this insidious attack on our rights to refuse treatment.
 Eric M. Plakun, Ed. Treatment Resistance and Patient Authority: The Austen Riggs Reader. W.W. Norton, 2011. 305 pp. Reviewed by Ronald Pies
 Carlos De las Cuevas, Wenceslao Peñate, Emilio J. Sanz; Risk factors for non-adherence to antidepressant treatment in patients with mood disorders. European Journal of Clinical Pharmacology. September, 2013
 Wei Wen Chong, Parisa Aslani, Timothy F. Chen; Adherence to antidepressant medications: an evaluation of community pharmacists’counseling practices, Patient Preference and Adherence, 2013:7 813–825 Dove Press
Editor’s correction: This blog, when first posted on December 17, included a paragraph about Dr. Ronald Pies’ beliefs toward medication non-compliance that did not accurately reflect his writings on the matter. Maria Bradshaw wrote: “Dr. Pies doesn’t believe adverse reactions have anything to do with patients not taking their drugs.” In fact, he has co-authored an article in which he wrote: “One of the most important causes of non-adherence is adverse drug reactions.” In addition, in a quote that Maria Bradshaw attributed entirely to Dr. Pies, she did not correctly note, in a latter part of the quote, that Dr. Pies was citing what others had written. We regret the error.