17 - Factors that may influence the patients use o

Factors that may influence the patient’s use of and adherence to medication

940 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 14 Factors that may influence the patient’s use of and adherence to medication How the individual views themselves, and others, will influence many aspects of a person’s behaviour. These issues include their personal and cultural beliefs, readiness to change, ambivalence, expectations of treatment, attachment style and treatment preference. In addition, patients might use medication in countertherapeutic ways. We address each of these in turn in terms of their practical implications.6,7 Personal and cultural beliefs The religious, cultural and socioeconomic contexts shape our beliefs around concepts of illness, health and disability.8 Adherence to treatments is affected by the patient’s subjective beliefs and averages roughly 50% in almost all conditions.9 Recommendation: When it comes to prescribing within a culturally diverse population, prescribers need to reflect on their own cultural biases, enquire about the patient’s cultural beliefs, and work collaboratively with communities and families.10 Readiness to change Patients’ motivation and readiness to change can affect treatment outcomes. Beitman et al.11 examined stages of change and response to medication in patients with panic disorder and found that readiness to change was associated with better outcomes. The transtheoretical model12 proposes that people move through different stages of change and that interventions must match the stage of readiness. This model can also be useful for the treatment of other mental health conditions including personality disorder.13 Recommendation: The clinician’s appreciation of the stages of change, and the work involved in lasting change, can increase compassion and avoid wrongly timed interventions (including wrongly timed prescribing). A recovery-­focused and patient-­centred approach may help patients to understand entrenched patterns of behaviour, and to actively participate in behavioural change. Ambivalence Patients may worry about the safety of psychotropics, and mistrust clinicians. Further, symptoms may have an adaptive and protective function thus making them harder for the patient to relinquish. For example, a patient who has elicited care might be ambivalent about getting better and losing this care. Recovery might portend, for example, confronting a difficult relationship or working through an intolerable loss.14 Recent advances in the field of neuropsychoanalysis suggest that unpleasurable feelings at a biological level indicate that the patient’s underlying emotional needs are not being satisfied, serving as homeostatic ‘error signals’. It is not a surprise then that symptoms (associated with feelings states) can be stubbornly resistant to symptom-­focused treatments when the patient’s basic emotional needs continue to be unmet.15 Recommendation: Exploring patients’ ambivalence towards medication and healthcare professionals, and their previous experiences of care, can deepen the therapeutic relationship and is crucial in understanding patients’ concerns. Understanding the

Prescribing psychotropics CHAPTER 14 patient’s (often unconscious) underlying conflicts and motivations can explain symptom perseverance despite pharmacological endeavours. Acknowledgement of the patient’s ambivalence during the recovery process may help validate their experience, facilitate rapport and enable conversations that the patient might otherwise be reluctant to approach. Expectations of treatment: placebo and nocebo effect Expectations of improvement or harm when taking medication exert a significant impact on treatment responses. The powerful ‘placebo’ response has been well described in medicine as a genuine psychobiological event.16 Conversely, expectations of harm are associated with negative treatment outcomes known as the ‘nocebo’ effect. Patients often expect harm from taking antidepressants, fearing dependence and loss of control of their emotions.17 Interestingly, patients who discussed adverse effects of antidepressants with their doctors were reported less likely to discontinue therapy than patients who did not discuss them.18 Recommendation: These findings emphasise the need to use all the elements of the therapeutic relationship in the care of patients.19 Clinical management of the nocebo effect includes awareness and recognition, focusing on the treatment alliance, carefully naming and working through mistrust, and careful disclosure of potential drug-­related adverse effects, while remaining honest and clear.20 Attachment style Healthcare staff often represent attachment figures21 as they treat patients in times of need and distress. The attachment is particularly important when it comes to the management of long-­term conditions. In one study, diabetic patients with dismissive attachment had significantly worse glucose control than patients with preoccupied or secure attachment style, but the effect was mitigated by improved communication between doctors and patients.22,23 Concerns about rejection, abandonment, control and intimacy24 are likely to affect patients’ use of their medication. Patients with a dismissive attachment style may fear dependence on medication and services and not adhere to the prescribed interventions. Patients with a fearful-­anxious attachment might need regular reassurance, while patients with a disorganised attachment might evoke disorganised and chaotic responses from healthcare staff. Recommendation: Consider attachment patterns when prescribing. Particular attention and consistency are needed to deliver coherent and reliable care alongside pharmacological interventions. Treatment preference The chronic illness model encourages consideration of the patient’s treatment preferences. Research suggests that matching treatment to preference might improve outcomes for patients with depression.25 An RCT matching patients to treatment preference for major depressive disorder concluded that patients had better outcomes on their preferred treatment.26 These observations might apply to other conditions.