A spoonful of cognitive-behavioral therapy (CBT) makes the medicine go
down, three clinicians told listeners at APA's annual meeting in Washington,
D.C., last month.
Episodes of CBT during brief pharmacotherapy sessions offer psychiatrists
the chance to improve medication adherence, lessen symptoms of anxiety or
depression, and help patients manage dysfunctional thinking about their
illness and its treatment, they said.
Judith Beck, Ph.D., and Jesse Wright, M.D., Ph.D., alternate roles as
patient and therapist to demonstrate how introducing "high-yield"
cognitive-behavioral interventions during brief med checks can help patients
and pave the way for improved medication compliance.
Credit: David Hathcox
Such "high-yield interventions" can make use of a long list of
possible tools, from exposure therapy to problem-solving techniques to written
goals, among others, said Donna Sudak, M.D., Judith Beck, Ph.D., and Jesse
Wright, M.D., Ph.D. Clinicians can choose at each session from the treatment
menu based on the patient's diagnosis, symptom severity and complexity, and
the phase of treatment.
CBT can be used in any of several contexts, said Wright, a professor of
psychiatry at the University of Louisville. For a typical case of bipolar
disorder, he may see the patient once for an evaluation, then another seven or
eight times for therapy sessions of standard length, followed by shorter
maintenance therapy visits that include CBT. Alternatively, he may refer
patients to a social worker for standard-length sessions and see them less
frequently to monitor medications and do some CBT.
Adding CBT to a medication check is more than a clinical bonus, said Sudak,
an associate professor of psychiatry at Drexel University. A CPT code
(90843) covers a 20- to 30-minute session combining therapy and medication
Patients may have both practical problems (that is, financial or access
problems) and psychological problems in adhering to their medication regimen,
said Beck, an associate professor of psychiatry at the University of
Pennsylvania. Adherence might be tied to cultural or religious beliefs about
illness or medication use. Some patients may tell themselves that"
medications are a last resort"—and then don't fill the
prescription. When patients say they have a 50 percent likelihood of taking
their meds every day, that may mean they aren't taking them at all, she
Physicians, too, may contribute to poor adherence if they see writing the
prescription as the end of their responsibility or hold rigid ideas of how
patients should act.FIG1
To overcome these barriers, Beck suggested strengthening the therapeutic
"explain the rationale for the drugs and link the medications to the
patient's own goals, like getting back to work or improving
relationships," she said. "Include family members and have the
patient write down the discussion."
Identify the barriers to adherence, then find solutions, said Wright. Tying
pill taking to some specific daily activity like toothbrushing may simplify
the thinking needed to take drugs consistently.
"The point is to get the patient on board," said Wright."
Figure out why the patient won't do the meds, show empathy, and spend
Beck suggested that clinicians be alert to affective responses and probe
the automatic thinking that derails medication use: "When you didn't
take your medications, what were you thinking?" Writing down those
dysfunctional thoughts on "coping cards" makes them easier to
discuss. In fact, written discussions and goals are key tools. Some
practitioners use index cards, plain sheets of paper, or cheerfully preprinted
notes. Some patients bring along "therapy notebooks." Wright
sometimes hands over his prescription pad to the patient and asks, "What
would you prescribe?"
Writing down a schedule of pleasant, meaningful activities can help
patients with depression defeat the tendency to withdraw and fall back into
reminders of their illness. Picking one or two concrete, achievable events
turns the exercise into a no-lose proposition when coupled with a brief
discussion of predictable obstacles and ways to avoid them. If an activity
doesn't work out and the patient feels worse, don't treat the event as a
failure, advised Wright. "Look at the barriers, and also ask yourself
whether you prepared the patient properly."
Combining medication with behavioral interventions may also resonate with
views expressed in the popular media, said Beck. The idea that medication
alone is not enough to alleviate symptoms opens the way for more patient
Patients with anxiety may benefit from exposure and response exercises,
cognitive restructuring, relaxation training, or breathing training to calm
themselves during a panic attack.
These can be discussed in the office but carried out between visits.
Exposure therapy for someone with a fear of cooking and serving food might
begin with a five-minute exercise heating a frozen dinner in the microwave,
then advance through a dozen lengthier and more complex steps up to cooking
Thanks-giving dinner for the entire family—an example Wright drew from
his own practice.
Of course, not all of these interventions would be used in any single
visit, said Sudak.
"The doctor has to decide on the fly which intervention will be most
helpful to talk about that day," she said. "Save another approach
for the next time."
Empathy and a strong therapeutic alliance are keys to motivating patients,
but they look for a therapist to be a "friendly teacher," not a
friend, said Sudak. ▪