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Maximizing Treatment Success for Patients with SMI ...
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Hello and welcome. I'm Amy Cohen, the Associate Director for SMI Advisor and a clinical psychologist. I am pleased that you are joining us for today's SMI Advisor webinar, Maximizing Treatment Success for Patients with SMI, Promoting Adherence and Treatment Engagement. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Now I'd like to introduce you to the faculty for today's webinar, Amber Hoberg and Dr. Donna Rowland. Amber Hoberg is a psychiatric nurse practitioner working for Wellbridge Hospital, an inpatient psychiatric facility. Her background as a psychiatric advanced practice registered nurse includes psychiatric evaluations, pre-psychotherapy, and medication management for individuals of all ages with significant mental health conditions and cognitive impairment in long-term care, inpatient psychiatric hospitals, outpatient psychiatric clinics, and group home settings. Dr. Donna Rowland is a clinical associate professor and the director of the Psychiatric Mental Health Nurse Practitioner Program at the University of Texas. Dr. Rowland serves on the National Board of Directors of the American Psychiatric Nurses Association and is a core member of SMI Advisors Clinical Expert Team. Amber and Donna, thank you for both for leading today's webinar. Hi, this is Amber Hoberg and just to give my disclosure, I receive honorarium and speak for Avenir, Acadia, and PEBA. Hi, this is Donna Rowland and I have no relationships or conflicts to disclose. In this webinar today, we will cover scope and common causes of non-adherence to treatment among persons with serious mental illnesses, strategies to improve adherence, and processes for optimizing and engaging treatment. In this section of the webinar, we'll identify the scope and common causes of non-adherence to recommended treatments for persons with serious mental illness diagnoses, those of bipolar disorders, schizophrenia, and treatment-resistant depression. What is non-adherence anyway? It's a disagreement whereby a patient's actions do not match their recommended treatment plan, and this can be viewed in degrees. When a patient-provider relationship is positive, adherence to treatment plans can be fostered, and more on this will be talked about in the treatment engagement section later that Amber covers. Let's look at some statistics. In the United States, the prevalence of having any mental illness is right at 19%, and that of having a serious mental illness is 4.5%. This is a lot of people that we're talking about. Among patients with serious mental illness, non-adherence overall is consistent with that of other chronic medical conditions. For example, hypertension and asthma. This estimate says that 50% of patients with serious mental illness and without serious mental illness are non-adherent to the recommended treatment plans. This is per Rosenstock in his seminal work on adherence in conjunction with the establishment of the health belief model back in the 1950s, and again, Amber will talk a little bit more about this in a minute. Large numbers of patients with serious mental illness are non-adherent to medications and treatment modalities, not only impacting their overall symptom management, but also impairing their quality of life. Less than 50% of patients with serious mental illness continue to take their medications and adhere to the plan of care after six months. The prevalence of non-adherence by specific diagnoses are shown here. Specifically, 50% to 60% non-adherence for persons with schizophrenia, 35% non-adherence for persons with bipolar disorders, and 50% non-adherence for persons with depressive disorders. Medication adherence can be measured in various ways. Some attempt to be objective, examining quantities. Pharmacy claims data can examine timeliness of refills and something called the medication possession ratio formulas. Pill counts can also be physically performed. I used to do psychiatric home care visits in New York, and part of my job was to fill weekly pill boxes and counting previous fills, counting how many pills were left in the box each week, et cetera. Self-reported adherence can also be useful if it's tracked daily. In 2017, an ingestible event marker sensor was embedded into a pill and approved by the FDA. This was called Abilify Mycite. This pill remains controversial, especially with patients who might have symptoms of paranoia and delusions, yet it is an interesting step in the quantitative objective measurement market. This pill is swallowed and it is actually tracked. There are also electronic pill bottle caps, which Amber will discuss further. So why do people not take medications as prescribed? For so many very good reasons. They may have complicated and possible medication regimens to follow. They may have access to pharmacy issues, access to medication issues that may stem from expenses. They may have adverse side effects that they may or may not discuss with the provider and the provider may or may not ask about. Some elements of non-adherence may be inherent in certain disorders. For example, a lack of motivation or cognitive issues with schizophrenia that may not be well controlled, or impaired insight, judgment, and impulsivity with bipolar disorder that may not be well controlled. Testing at the lab, especially with much frequency, if that's required for a certain medication, may be difficult for patients to remain adherent. Lastly, values and beliefs impact adherence. Some people have a denial of illness or need for medication at all. Amber will further expand upon medication attitudes. There is a scale called FIBSR, which may be useful in evaluating medication side effects. It stands for Frequency and Intensity of Burden of Side Effects Rating. This is a brief self-report scale for frequency and intensity and burden of side effects. This tool is fast to use. It's reliable and valid. In fact, it was used in the STAR-D trials. And it's easy and quick to apply clinically. Non-adherence to treatment leads to relapse in episodes or symptom exacerbations of a person's serious mental illness, and it decreases recovery efforts and quality of life. Non-adherence also increases the risk of hospitalization, even multiple hospitalizations in some cases. This disruption of care and stability often further extends the time in which a person will spend in inpatient facilities. Additionally, it's estimated that hospitalizations due to non-adherence cost more than $100 billion a year in the United States. Other consequences of treatment non-adherence include consequences in physical health and self-care, employment issues, and problems with relationships and families. And I'll now pass over to Amber who will talk about strategies. We will now explore strategies to improve adherence to include long-acting injectables, meds strategies, and adjunctive support. It is important that patients with serious mental illness are active participants in their care with providers and also community support. Improving patients boosts adherence and improves their overall outcomes. The Health Beliefs Model by Rosenstock was established in 1950. In 1974, he furthered his work specific to medication adherence. Let's look closely at the behavioral interventions within the Health Beliefs Model. Susceptibility. This depends on the person's thought processes. This varies between no threat of illness to feeling extremely in danger of illness. This will shape and develop the person's thought process for the overall risk of illness. Seriousness. This degree will vary as well and depends on the emotional situation the illness creates. It will also include what difficulties the illness causes for the patient. Benefits or barriers of action. This is based on the belief about availability and effectiveness of treatment and its alternatives. If the belief that action is beneficial, then patients will most likely engage in an action versus if their belief is low that action is beneficial, then they will normally forfeit action. Adherence is high when patients feel they have some control in decision making. When a medication is prescribed, it should be discussed with the patient, also taking into account minimizing adverse drug reactions. A positive engagement between the patient and their provider increases adherence to medications and follow-up care. Providers should always be sensitive to patient concerns and not pose judgment on the patient's thought process. You must determine the patient's attitude and thoughts about using medication. It is important to determine which part of the spectrum does the patient's attitude fall. Do they have pharmacophobic, which means they have fear of medication? Are they skeptical or ambivalent about taking medications? Indifferent or maybe even accepting, all the way to pharmacophilic, which is med-seeking behavior or enjoying the use of medication. Also, how does the patient perceive pharmacotherapy? Do they see drugs as a solution to their illness or problem, or do they see it as the enemy or something that will harm them in the end? Let's look at the benefits of using long-acting injectable medications. Long-acting injectable formulations might be appropriate for many patients, especially ones that suffer from schizophrenia, schizoaffective disorder, and bipolar disorder. Long-acting injectable formulations can be beneficial when adherence to oral medications are low or there is an increased risk of frequent hospitalization due to SMI. Long-acting injectables help maintain stability for longer periods of time when access to care is a barrier for patients. Let's look at the pros and cons of using long-acting injectables in this population. On the left-hand side, you will see the pros column. Some of the pros include increased adherence and steady plasma levels within the blood, which always decreases the need for oral medications on a daily basis. One of the other pros is clinic visits or nurse visits. This allows for consistent relationships and monitoring by providers and staff. On the right-hand side, you will see the cons list. Some of the cons include slower titration periods. However, some of the newer formulations of these long-acting injectables have decreased the initial titration period. There is a potential for pain at the injection site, especially in the gluteal or deltoid muscle. This also depends on the size of the injection as well. A lot of times, side effects can take longer to dissipate. This is mainly due to increased plasma level stabilization. Clinic visits or nursing visits are required for these injections. However, as stated in the pro column, this helps improve consistency with visits and monitoring. Also, now, there are also more options to frequency of injections. There is also a stigma associated with long-acting injectable antipsychotic medications. However, now, there are lots of long-acting injectable formulations being used to manage other physical health conditions, such as rheumatoid arthritis or osteoporosis. With the use of these long-acting injectable formulations in other physical health conditions, it should help lessen the stigma. Let's look at this nice little comprehensive table, and this is available for the different long-acting injectables and FDA indications. As you can see, most long-acting injectables are indicated for schizophrenia. Two have been used in bipolar maintenance, and one has been identified as being appropriate for ages 12 and up. There is also one injection that can be administered subcutaneously. The column on the right includes dosing tips, frequency of medication administration, and oral overlap, if necessary, with medication. One of the injections, as you can see, has a risk called post-injection delirium sedation syndrome. So what is that? It's very rare, less than 1% of cases, but a very serious adverse drug reaction that can occur. This happens when the medication accidentally is given intervascularly instead of intermuscularly. It looks like an overdose on the medication. It's usually developed in one hour, but it's now mandated that the patients have to be monitored for three hours after this injection due to the risk. Let's look at what are some pharmacy strategies that can be implemented. Automatic refills decrease the need for missed medications and keep patients consistent on a weekly basis. Patients' weekly psychoeducation includes counseling patients about adherence, talking about side effects, reviewing medications, and their current medication regimen. Drug monitoring systems are helpful. Using things like pill boxes, timed automatic boxes, and devices to determine levels of medications in the system are very helpful. Pill counts between treatments also help keep the patient adherent and accountable. In order to manage adverse drug reactions, it is important to talk with the patient at weekly intervals. Reporting patient side effects to providers where meds can be adjusted has helped to maintain adherence. Frequent phone calls and follow-up care by providers or staff help remind the patient to take their meds, provide brief psychoeducation, and help improve compliance and satisfaction. Oral medication strategies are ways to help improve compliance with medications, such as, as I said before, pill boxes and automatic dispensers. This can be done on weekly intervals and helps keep patients accountable. When I was working in the home health as well, I was one of my duties to fill pill boxes and automatic dispensers for patients. Using timers helps remind patients to take meds at the same time every day and provides reminders to minimize missed doses. Implementing smart device monitoring systems determines if patients took meds. These can be embedded in bottles or weekly pill box monitoring systems. Daily phone calls help remind patients, and this can be done by pharmacists or providers, and this helps build compliance and improve adherence. Psychoeducation strategies are also important. We must discuss diagnoses and reasons for patients to continue medications. This helps boost their awareness and reasons to stay on medications. Also important to make sure we discuss all medication classes, current dosages, and reasons for use to help support and build rapport. We must identify ways to build compliance, identify relapse prevention and triggers in order to help boost compliance. Additionally, providers can help identify sources for education material in print or online. Managing adverse drug reactions is very important, and it's important that we talk about what is expected when prescribing a new medication, including all common and serious adverse drug reactions. We want to discuss with your patient about length of time they may experience these adverse drug reactions and when or if they will improve. It is important to allow patients ample time to ask questions. Having the pharmacist and provider reach out to the patient weekly between visits ensures improvement in care. Using technological assistance for patients with SMI is important. Teaching them how to use mobile devices and have access to info about illness, self-management, and relapse prevention helps promote adherence to medications and their overall treatment outcome improves. Providing education, supporting their recovery, and promoting wellness and symptom monitoring all build rapport and treatment outcomes overall improve. Now Donna is going to talk about engagement in care. Engagement in care equates a partnership in treatment and care between patients and providers and implementation. In this section, we'll review the components of engagement. We'll illustrate the process by which patients with serious mental illness might fully engage in optimal care and treatment, including supportive psychotherapy, therapeutic alliances, shared decision-making, and family involvement in care. Supportive psychotherapy can be combined with medication management visits. This lengthens the visits to 30 to 50 minutes, and many patients find these longer visits quite valuable. Beyond hasty visits, reviewing checklists of symptoms and side effects, as traditional med management follow-up visits can be, this takes these visits toward assisting patients with mental and medical health promotion and growth. If a psychiatric prescriber doesn't provide this option, separate standalone therapy appointments can be established. Group psychotherapy can be tremendously beneficial for patients with serious mental illness as well. Whether they are in inpatient, intensive outpatient, or outpatient maintenance settings, groups can certainly promote recovery. Families or couples can engage in therapy together to support the patient in recovery as well, also to learn about expectations and gain support. Establishing and maximizing therapeutic alliances between providers and patients is essential to treatment engagement. It is not unusual for many people with chronic serious mental illness who do seek help to drop out from continued treatment after just one to two visits. An estimated 70% of such individuals stop receiving treatment due to poor interactions with their providers or a lack of understanding about the need for their treatment. A good fit between a patient and a provider can positively influence treatment outcomes. The provider can be honest, and the patient can trust the information. This information includes treatment options, risks and benefits, indications, patient preferences, side effects, ambivalence, etc. This therapeutic alliance relationship can ensure necessary dialogue, which is essential to appropriate treatment choices. Similar to the therapeutic alliance just discussed, shared decision making is a patient-centered approach to making treatment decisions. Treatment decisions are always a risk-benefit assessment, and informed decisions are made here by reflecting on patient values and goals made with clinicians through this shared decision making process. Decision A's are utilized to explore multiple treatment options with consequences. Shared decision making replaces the previous, more paternalistic treatment determination of the past. Family involvement and care, when family is available to a patient, can be extremely valuable. The National Alliance on Mental Illness, or NAMI, is the essential resource for families, both for education and for supporting their journey with a patient with serious mental illness. NAMI provides adherence tips, medication facts, and endless other resources and classes for families. Additionally, peer support specialists through the organization Mental Health America can be another tremendous support for persons with serious mental illness in maintaining their recovery. Thank you for your attention. Thank you for your attention.
Video Summary
The video is a webinar titled "Maximizing Treatment Success for Patients with Serious Mental Illness: Promoting Adherence and Treatment Engagement." It is hosted by Amy Cohen, the Associate Director for SMI Advisor and a clinical psychologist. SMI Advisor is an APA and SAMHSA initiative that helps clinicians implement evidence-based care for those with serious mental illness. The faculty for the webinar includes Amber Hoberg, a psychiatric nurse practitioner, and Dr. Donna Rowland, a clinical associate professor. The webinar focuses on the scope and common causes of non-adherence to treatment among individuals with serious mental illness, strategies to improve adherence, and processes for optimizing treatment engagement. Non-adherence to treatment is common among patients with serious mental illness and can have significant negative impacts on their symptom management and quality of life. Strategies discussed include long-acting injectables, medication strategies, adjunctive support, and psychoeducation. The webinar emphasizes the importance of patient-provider relationships, shared decision-making, and family involvement in care. Various tools and resources are highlighted, such as the Health Beliefs Model, medication adherence measures, and support organizations like NAMI and Mental Health America.
Keywords
Serious Mental Illness
Treatment Adherence
Treatment Engagement
Non-adherence Causes
Patient-Provider Relationship
Medication Strategies
Funding for SMI Adviser was made possible by Grant No. SM080818 from SAMHSA of the U.S. Department of Health and Human Services (HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, SAMHSA/HHS or the U.S. Government.
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