So, we have a few very interesting questions that have come in, so this one came in a little bit early before your engagement part, but did you, this person said, I didn't hear anything too much about family or use of peer support to help with adherence or engagement. Have you found those methods to be helpful? I can take that. This is Donna. Yes, and I didn't have a lot in this presentation on family and peer support. I have that towards the end. I know that that's a tremendous piece of recovery and support for patients. We do have another webinar on peer support that is available and some other resources in our knowledge base, and we do have an upcoming webinar on family engagement and care that Terry Brister from NAMI will be developing, so look for that very soon. Terrific. This person said, I'm a supervisor at a community mental health clinic. How do you talk to your trainees to help them address non-adherence in patients? This is Amber. I can take that one. One of the best ways to help with, as a supervisor training people of how to address non-adherence in patients is, first of all, trying to understand from the patient where this non-adherence is coming from. Sometimes this non-adherence can come from patient's fears. It could come from having experienced side effects in the past. It can come from even sometimes their disease process, so trying to engage them and trying to understand and build this rapport with them on where some of this fear or where some of this is coming from, and then trying to work with the patient in developing ways to either get them to take the medications or talking with the providers or the staff and how to better, you know, maybe there's something different that they could take or maybe there's something that they're agreeable to do, you know, so trying to compromise and work with that resident or with that patient in order to help them to take medications will always help build adherence. Terrific. There are two questions around injectables. So the first question is, can you provide an example where you address non-adherence with a patient without just moving to injectables? Like what did you say to keep them adherent to pills? Oh, absolutely. I can take that one too. This is Amber again. And so one of the things that I have used, because sometimes it's maybe what I have prescribed for the patient was not something, maybe they've taken that in the past and it has created an adverse reaction or it's created a problem for the patient, so engaging the patient in that conversation on, you know, if you can take your medications, is there a particular medication that you've taken before, one that you've used with success, one that has created less side effects for you, you know, even talking to them about, you know, their disease process and maintaining, you know, adherence to medications is going to prevent further hospitalization. And if, you know, using long-acting injectables may be necessary in your future if we're not able to get you to be compliant with medication. So simply talking to the patient about that will help them understand that even when they're feeling better, that these medications are part of that feeling better and being successful. And so I always engage my patients in talking to them about medications or about what we can use or what the patient would be agreeable to take or what has worked for them in the past. And I've always been very successful at getting them on medications and keeping them compliant with taking them that way. That's great. So it sort of follows on this next question. I think I'm feeling a little resistance in the audience about sort of just moving people immediately to injectables. So this person said, how do you, how do you talk with patients about moving to injectables? Like what do you tell them are the positives and negatives? So this is Amber again. I can take that one. And so what I tell them as far as positive and negative are a lot of what I covered in that pros and cons sheet. You know, we talk about that. We do talk about, you know, I do talk with my patients about what is keeping them from being adherent. You know, is it because they can't remember to take pills daily? Is it because, you know, we've tried all these other interventions and nothing is really working. I also look at frequency of hospitalizations. You know, these patients have had four or five hospitalizations in the last year. That shows me non-adherence is very high. And therefore I talk with the patients about long-acting injectables being an option. I never tell my patients you have to take these medications. What I say is this is another option that can be presented to you where we can give you an injectable medication that will, you know, and I give them the pros and the cons of the injectables. But I also tell them that if adherence to taking your medication daily is a problem, then this is a way that we can get your plasma level stabilized. You know, a lot of the newer formulations, you know, they're not just once a month injections or every two-week injections. Now we have some that are six weeks, eight weeks, sometimes even up to three months in injections. And so I can talk to them about, you know, keeping them stable for longer periods of time when they're not as good at being adherent with taking medications or remembering to take them daily. And most of my patients that end up on long-acting injectables choose to be on long-acting injectables because they know it's what's going to help keep them stabilized. They can go in for a visit every four to six to eight weeks, get an injection, and knowing that if they miss medication, you know, they're not going to have to take medications or if they miss them, they're still stabilized and the medication is still staying in their bloodstream preventing re-hospitalization or relapse in their condition. But every time, especially in schizophrenia, every time they have a relapse, the risk of medications not working as effectively are higher and higher each time they relapse. And I found with patients that do try a long-acting injectable and have some success with that, that a lot of times they do end up preferring that spread out dosing, that that becomes a very convenient thing in their lives. That's what I was just going to say, what I was hearing from Amber, that it sounds like it almost becomes its own testimonial because once an individual ends up moving to an injectable, it sounds like you have both experienced that many of them prefer that in the long run. Right. Oh, absolutely. They end up preferring it in the long run and they end up, you know, you know, then they can become very productive members in society. I mean, I have patients that have stayed stable that are now able to work or able to do things in the community that they wouldn't have been able to do otherwise. And in terms of organizing a clinic around an injectable, maybe you have an injectable clinic or a day or something, how do you do that? Because it's, you know, can you use, do you use an LPN? Who do you, who gives the injection? So tell us a little bit about how you sort of organize a clinic to make it smooth to have a good amount of patients on injectables. I can start. I can take that one. You want to go ahead? And then I'll finish up. Okay. I think it depends on the type of clinic. So if you have a public mental health clinic, you will definitely have an RN or an LPN there who can do the injections. And I think that it doesn't necessarily have to all be on one day. At least that's what I've seen here in Austin, that the patients will come in at whatever day they're scheduled to see other members of the treatment team for whatever other business that they have, or sometimes the nurses will actually go to their homes and do the shots on the day that they're due. And then also these injections are given in private practice as well. So some patients with schizophrenia are seen in private practice. Certainly a lot of patients with bipolar disorder are seen in private practice, and the reps will even have samples of these medications on hand in the private practices. And so those injections are given there, and there are not necessarily nurses there, but the prescribers, the MPs, and the physicians can give the shots themselves as well. And also where that may not be, to kind of piggyback off this, where that may not be an option of any of those things, there's lots of pharmacies that actually are filling injectable medications and do have pharmacists or somebody on site at the pharmacy location to give the patients their injectables. This is something I see in like some of the rural areas where maybe access to a clinic or care is very difficult. So they will chain some of their pharmacy staff within the pharmacy to give these injectables to the patients on the intervals that they need them to keep them compliant and stable. Perfect. One person said, I didn't hear anything about substance use. How can this impact treatment adherence? Well, you want me to, I'll take that one. I recently did a webinar for SMI advisor on substance use disorders. Definitely substance use disorders will almost always impact medication adherence in a negative way, meaning that medications will either be stopped altogether or be taken sporadically. So that's something, if there's a comorbid substance use disorder, would need to be addressed either concurrently or first address the substance use disorder, or it's very unlikely that the serious mental illness will be stable. So do you feel like you address the substance use at the same time that you talk about adherence? Do you consider this person for injectables? Like how do you sort of handle it? Because you've got a person who's maybe escalating in their psychotic symptoms and they're using and you're really struggling sort of balancing all of these things. Sure. Sure. Yeah. You want to do that one, Donna? Or you want me to? I mean, one thing I can say is that I feel like you have to do it concurrently. You have to address the substance abuse at the same time you're addressing the schizophrenia or the bipolar, because a lot of times both are out of control. Now, of course, sometimes a huge history of substance abuse can actually exacerbate some of the symptoms of schizophrenia or bipolar. And so sometimes, you know, looking at the substance abuse first, you know, can sometimes help. But I always find that concurrently looking at them at the same time and addressing them along with adherence is important and it's going to end up boosting compliance and adherence to a program if you're doing them simultaneously. And I think the only time that it would be dangerous for us to treat concurrently with a long-acting injectable is in a case where we didn't have a good history for the patient or they're unable to communicate that history to us or if they're in an active detox, we would have to certainly deal with that first and get more information. But otherwise, there's definitely no reason not to treat both concurrently. Wonderful. What about, this is another question, what about patients who don't take their meds because they don't think they need to take it? Again, this goes back to explaining the disease process and that a lot of times what happens is we get them stabilized on medications or, you know, they go into an inpatient hospitalization, whether voluntary or involuntary, and, you know, they get put on medications and they feel like they stabilize. And then they feel like, well, I'm stable. I don't need medication. So it goes back a lot to education, goes back to educating about the disease process, about what their disease process is, about the fact that sometimes they can be stable for short periods of time and then have cycles, you know, where it can manifest itself in ways. And so that staying on medications, you know, is super important, you know, and also talking to them about when we're on medications, talking to them about, you know, adverse events, calling them in between visits, you know, making sure that you're not putting them, their follow-up appointments too far out, especially if compliance is an issue, you know, so that you can constantly talk and provide that psychoeducation to your patients so that they continue to maintain adherence to medicine. Right. And I would just like to add that that's the kind of case that is generally usually a good case for a long-acting injectable because that person might be thinking somewhat differently when they are on medication and then once the medication stops, like Amber said, then they are thinking differently. So if they get a long-acting injectable medication and they stay consistently focused and they stay consistently in a space where they recognize that medication is working for them, then that might be a very successful type of patient for a long-acting injectable. Right. This sort of goes along with another question that I'd sort of put on ice until now, but I think it flows really well here, which is, do you feel like there's any overlap or conflict between patient-centered care and a choice to be adherent? So how do you, as practitioners, we all really want the patient to be part of this conversation, right, about their medication and their adherence. And I've heard that from both of you during this, that you do a lot of education, a lot of talk, but there are certainly a subgroup and there's a movement within the patient groups for some people to go without medication. And so how do you sort of balance that, I guess, professionally, ethically? How do you think, just how do you think about that? I can take this. I can try to take this. I believe that patients do have the right to not take medications and it is absolutely their choice and they're part of the planning and the treatment planning. And only in the case of significant danger are we ever going to force someone to take any kind of medication in an inpatient setting, for example, when someone is extremely dangerous. And so that's something that we see a lot, actually. And so we'll see people kind of cycling or if we have a less severe case, we might not even see that person in treatment and we might not be known to treatment and they might be doing OK, but living a life that that maybe they're not doing as well as they possibly could be or functioning optimally. But that is absolutely their choice. I mean, absolutely, patients have rights to decide to take medicines or not to take medicine. And the only time that it's going to come to a matter where the decision will be taken out of their hand is an extreme danger to themselves or others. And so that's when you get into this ethical conflict that I can't put somebody back out into a community that is very dangerous to themselves or to others. And therefore, using medications or if needing long acting injectables would be very important in that particular patient. But, you know, I still go back to educating patients on the reasons for meds. And then, of course, they always have the right to decide yes or no to take them. Right. I remember a patient that I once had who was pretty high functioning, who had told me that they, you know, one of their goals was to go off of their meds. And I remember in this conversation that she said that she had a very good relationship with her physician and there was an agreement with them where they had identified what her initial symptoms looked like when she was having a relapse. So when she was off meds for long periods, when those came up, she had an agreement that she would contact the therapist and they would have a new conversation about getting back on meds. So it sounds like you could have something like that where you sort of have an agreement, you'd identify either triggers or early symptoms of having some relapse and then reassess at that point for medication. Sure. I mean, absolutely. In that case, you would have some other person that could be a point of monitoring or check in as well to support that and that kind of plan. So like a person's family or something like that. Right. Right. And the other thing that I can say is I've had patients make these decisions and I just always caution my patients that if they're on multiple medications, never just come off all of them. Let's start with the ones that maybe is less risky and work our way up to the ones that are more risky. And over time, either try to get you on less medications or over time, get you off the medications with that plan of having a family member to help recognize and help you and then develop goals and some motivational interviewing about, you know, what, you know, if things come back, what are some of their, you know, are they willing to go back on meds and having just a plan in place? Excellent. So someone wrote in and said, how do you track adherence when you see them infrequently, like quarterly? We don't have access to bottle caps that track, et cetera. So what might you do if you don't see them often? And that can be really difficult, you know, because for adherence, you know, especially if adherence is a problem in these patients, especially if they're on oral medications, frequency is important. You know, having the frequent visits, and I mean, you can utilize phone calls from the staff or phone calls from a pharmacist or set something up where somebody's touching base with them weekly or every other week just to see how are things going, you know, how are the medications working? Are you experiencing any side effects? Is there anything I need to bring you in sooner for, you know, so oral medications is something that they're on to increase adherence would be increase the touches to the patient even if it's not physically in the office, doing phone calls, doing some kind of reaching out to them just to see how things are going. If adherence continues to be a problem and they continue to have frequent hospitalizations on those patients, that's where long-acting injectables would be, you know, where they might be warranted, where you would have that conversation with the patient that in order to ensure your compliance and the fact that I only see you quarterly or bi-yearly, you know, and we've tried all these other alternatives, you know, this would be the next step in keeping you stable and your treatment optimal. And also if even though it's indirect information, getting the pharmacy claims data for that person could be helpful to see how often and what dates they're refilling their medication. Because if there's a big gap of three months since they refilled, there's a lot, for example, then you know that they can't possibly be taking it every single day. And that can be helpful information. Perfect. So this person writes in that they are a clinical supervisor at a community mental health clinic and they really like the idea of the FVDSR, although they had not heard about it before. They wanted to know how easy it is to train individuals to deliver the FVDSR and how long it takes and if there's a specific discipline who should be delivering that. I can take that. I actually have it sitting here in front of me and it is only three questions and the patient can actually fill it out themselves. It is in the public domain and it can be copied and used without permission. It does right on the bottom. And it was designed actually for use with antidepressant medications, but it can be used for any medications. And the questions are, choose a response that best describes the frequency of the side effects of the medication that you've taken in the past week. And then choices are no side effects present 10% of the time, 25, 50, 75, 90% or present all the time. So it's a checkbox. And the second question, choose a response that best describes the intensity or how severe the side effects are that you believe are due to the medication and rate the intensity. And the answers are no side effects, trivial, mild, moderate, marked, severe or intolerable. And the last question, choose a response that best describes the degree to which it says the antidepressant medication side effects that you have had over the last week have interfered with your day-to-day functions. And it's the similar, no impairment, minimal, mild, moderate, marked, severe or unable to function. And so it's very easy to complete. We can help them. It doesn't matter the discipline or the patient. If they're able to read and complete this themselves, themselves are able to do this, you know, even sitting in the lobby prior to their visit. So it's very useful clinical information and not very hard to get completed. Yeah, I like what you said there at the end where you could have your clerk hand these out while they're waiting in the waiting room and they could bring it into the clinical encounter and it could be acted on right then. Exactly. Or an iPad if you have your other screeners automated and an iPad where it zaps into your EMR. Some clinics do that. You could do the same with this one. Right. So someone just wrote in and said, could the public domain questionnaire be repeated? I missed its name. So it's called the FIBSR, the Frequency and Intensity of Side Effects Rating Scale. Correct? I can't remember right now. It's on slide number 14. Yes. So Frequency and Intensity of Side Effects Rating Scale. And who is the author? One second. It is, oh boy, Wisniewski. It's W-I-S-I-E-W-S-K-I. Great. Thank you so much.

medication adherence

mental health

Q&A session

family support

injectables

patient-centered care