In Time for RXmas:
Motivational Pharmacotherapy

Maria Bradshaw
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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.[1]

 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.”[2] 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. [3] [4]

In a review of a book titled Treatment Resistance and Patient Authority, Ronald Pies, editor-in-chief emeritus of Psychiatric Times, cited this explanation for medication non-compliance:
“Thus, even (or perhaps, especially) in the space of a 15 or 20 minute meeting, the psychiatrist must be prepared not only to listen empathically, but also to view apparent conflicts over “meds” in psychodynamic terms. For example, many of us—including those of us who have worked as psychopharmacology consultants—are familiar with ‘the patient who can’t take any medication.’ When deconstructed, this term often describes a patient who seems to develop intolerable side effects (many not listed in the PDR!) to virtually every medication prescribed. This patient may be characterized as ‘treatment resistant’, which is true in a sense. But often, the ‘resistance’ is a consequence not of biological intolerance, but of psychological conflict; for example, between the wish to get better, and the need to hang on to one’s symptoms. As Mintz and Belnap note, ‘patients are often ambivalent about relinquishing their symptoms, albeit unconsciously . . . [since] those symptoms may solve other problems’ for them; e.g., allowing them to avoid painful family conflicts (p. 45). If the psychiatrist fails to explore and understand such conflicts, the patient is likely to remain ‘resistant’ to medications indefinitely.”[1]
In other words, patients may refuse to take medications because they want to remain sick, and they may ‘invent’ adverse reactions– and even tell of adverse reactions not listed in the PDR – as an explanation for not wanting to take a medication.  At least in this passage by Dr. Pies, the implication is that if a patient’s complaints about an adverse reaction is not listed in the PDR, this is evidence that the reported problem may not be ‘real.’  Of course, an alternative explanation for why a patient might complain of an adverse reaction not listed in the PDR is that the list of adverse events for a drug in the PDR is known to be incomplete, and that patients may experience many adverse reactions not listed in that reference book. The patients are providing new information to the medical community with their reports, which the field would do well to listen to, and incorporate into the PDR.
The psychodynamic explanation described by Dr. Pies ultimately provides a rationale for a psychiatrist to discount what the patient is experiencing, and for the psychiatrist to seek to promote medication compliance. “The doctor knows best.” Psychiatry now is bringing in a new team of health professionals to help ensure patients take their psychiatric medications. They are the Community Pharmacists.

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.”[5] 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.”[5]

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.[5]

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.

 


[1] Eric M. Plakun, Ed. Treatment Resistance and Patient Authority: The Austen Riggs Reader. W.W. Norton, 2011. 305 pp. Reviewed by Ronald Pies

[3] 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

[4] Abimbola Farinde, Adherence to Antidepressants, July 02, 2013

[5] 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.

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Maria Bradshaw
DelusionNZ: Maria Bradshaw lost her only child to SSRI induced suicide in 2008. Co-founder and CEO of CASPER (Community Action on Suicide Prevention Education & Research), Maria promotes a social model of suicide prevention focused on strengthening community cohesion, addressing the social drivers of suicide and providing communities with the knowledge and tools required to reclaim suicide prevention from mental health professionals. Maria has an MBA from Auckland University and particular interests in sociological and indigenous models of suicide prevention, prescription drug induced suicide, pharmacovigilance and alternatives to psychiatric interventions for emotional distress. Maria has researched and written a number of papers challenging the medical model of suicide prevention.

21 COMMENTS

  1. Thanks for another great article!

    Yeah, I’ve seen some people who list “compliance” as one of their major research interests, etc. Some people think these things as their work. So many of psychiatric papers, articles, etc, are about compliance and related things. Schizophrenics have anosognosia, lack of insight and paranoia, so they won’t take meds. I just saw an advertisement of a new book by a psychiatrist about bipolar disorder, the back cover of which repeats twice the problem with medication; in the manic state bipolar patient is so exalted that he thinks he doesn’t need meds. They’re worried about adherence with depression too.

    Certainly part of it comes from pharma related marketing, like in your examples, but I think there are other issues as well, such as that doctors and psychiatrists these days feel they have been losing authority because of internet, alternative treatments and so on.

    In my case, I personally went to doctor and requested SSRI because I thought it might help with some stuff (maybe some depression, anxiety, etc). I got a very authoritative psychologist and psychiatrist to treat me, and I was almost immediately put on neuroleptics too and got diagnosis of bipolar and then finally schizophrenia within less than a year, after of which I was made basically incapable of doing any work and transferred to another doctor. Now, I hated how they treated me in a very authoritative style and saw the ill effects on me, so I began to fight back, tapered off neuroleptics, got back to work and so on. I had not read Whitaker or any other critique of psychiatry at this point, I realised that I had to act on my own mainly because it was so obvious to me they were treating me like shit.

    Afterwards I found Whitaker’s Anatomy of an Epidemic, MiA community, many interesting scientific papers and found out that there’s actually credible critique of psychiatry. I had thought earlier that just I had been misdiagnosed and that those people who tried to treat me were incompetent. I also hadn’t paid much attention to “anti-psychiatry”, even after what happened to me I thought the critique of psych drugs was by some “loonies”. There were those other people who really need their meds, they made a mistake on just my case.

    Connecting this personal story to the topic of the post, maybe if those first psychiatrists and psychologists weren’t so authoritative, paternal and controlling, if they were actually friendly people who I’d like and whose ideas seemed at least a bit more believable to me, I’d currently still be maybe eating SSRI and some neuroleptic and living a crappier life than I currently do, maybe with a diagnosis of bipolar. Maybe it was a blessing in disguise in my case that the first people I met weren’t very skilful with these other types of adherence techniques. 😉

  2. My pharmacist MUST have seen the downward spiral as the collection of prescriptions I brought in every month just grew and grew. My desperate sounding phone calls “do you have Xanax XR 2mg in stock ????? and Dexedrine ???” plus Remeron and the evil Zyprexa.

    If anyone is sees the damage being done its the pharmacists.

  3. Thanks Maria!
    “Drug profitability requires three parties to work together – drug companies to make the drugs, psychiatrists to prescribe them and consumers to take them.”
    One addition: insurance companies to pay for them.
    And another: Government to work hand in hand with insurance companies.

  4. “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.”

    Okay.

    Reorient the focus and ask people to state they notice / see / perceive / recognize / know / comprehend / understand about the following:

    “‘patients are often ambivalent about relinquishing their symptoms, albeit unconsciously . . . [since] those symptoms may solve other problems’ for them; e.g., allowing them to avoid painful family conflicts (p. 45). If the psychiatrist fails to explore and understand such conflicts, the patient is likely to remain ‘resistant’ to medications indefinitely.”[1]”

  5. The Austen Riggs Center is a small, not-for-profit, open psychiatric continuum of care specializing in the psychotherapeutic treatment of psychiatric disorders. Internationally known for its respectful work with emotionally troubled individuals who have failed to benefit from previous treatment, Riggs is located in the small town of Stockbridge, Massachusetts, on Norman Rockwell’s Main Street.

    http://www.austenriggs.org/about-austen-riggs-center

  6. It is fascinating for Pies to talk like this about the client “wanting to hang onto his/her symptoms” because they receive some secondary gain from them. This is right out of the world of Freud and psychotherapy/psychoanalysis! It seems like the ultimate irony that a biopsychiatrist like Pies, whose ilk have been committed since the 80s to eliminating the influence of psychotherapy or at least dramatically limiting its scope, should resort to psychodynamic explanations or techniques as a means of manipulating his clients into “taking their meds.” In a weird way, it approaches an admission that the symptoms themselves have nothing to do with biology. Though I doubt he’d ever admit that.

    Weird!

    — Steve

    P.S. Love the new picture, Marcia! Thanks for another enlightening article!

  7. The funny part is even with things like antipsychotics the documentation that comes with them state that it’s only supposed to be taken for months at a time.

    So why do these psychiatrists never arrange for these drugs to only be used short term, like it even says in their documentation.

  8. Maria,

    Great post, but the point I want to make is that dark hair favors you more than blonde hair. No kidding. I did not make the connection to your previous posts with the new picture. Just a suggestion… :D.

    Otherwise, the writing is wonderful.

    I wish you all Merry Christmas and Happy New Year!

  9. thanks for this post, Maria. I can’t speak to how others maybe trying to co-opt Motiv Interviewing for under-handed purposes, but they way you are describing it is not entirely accurate. Bottom-line; Mot Interv is about informed choice and empowerment. It encourages people to seriously consider reasons why and why not they may decide on a course of action.
    The rub may come in when a practitioner has an agenda, and wants someone to do what they think is best (which is so often the case when it comes to med compliance or mothers trying to bathe their children).
    I’ve heard that used car salesman also try this technique, but like trying to get someone to take meds – it is a corrupt application. Just saying, because I do like this approach when honestly trying to help someone follow their own mind & values.

    • I agree with you that this can be used in ways it was not meant for. Mot Interv was not used the way you describe when they tried to use it on me. It was a sneaky and very coercive tool that they tried while they kept these sickly smiles pasted on their faces. They thought I was some kind of stupid idiot who couldn’t see through their very crude attempts to get me to do what they wanted me to do. I still said thanks but no thanks and shoved the scrip back at them.