Motivational Pharmacotherapy Can Improve Medication Adherence

Columbia Irving Medical Center

Medication adherence is recognized as critically important for successful pharmacotherapy. Yet in psychiatry, medication evaluation sessions with patients are usually simple, didactic discussions that fail to capture the many factors that might influence medication adherence. While all patients want to get better, they also have concerns about side effects, addiction risk, and the stigma associated with medication use.

The strategies to improve medication adherence during patient sessions are inconsistent. While simple interventions, such as psychoeducation, are minimally effective, more proven approaches, such as case management or intensive behavioral interventions, can be difficult to implement in routine care settings (1). One approach that I have found to be effective at promoting antidepressant adherence is Motivational Pharmacotherapy, which incorporates elements of Motivational Interviewing into a standard pharmacotherapy discussion. Specifically, Motivational Pharmacotherapy employs the four central processes of Motivational Interviewing: engaging the patient, focusing on desired behavior change, evoking and reinforcing a patient’s own stated reasons for wanting to change, and planning steps to achieve this goal (2). Throughout this process, Motivational Pharmacotherapy remains highly collaborative and respectful of the patient’s decisions, as is typical of Motivational Interviewing interventions.

During Motivational Pharmacotherapy, psychiatrists elicit and reinforce “change talk,” in which patients discuss their own desire, need, and ability to change. When people talk about their own reasons for change, they are more likely to see it through than if the clinician or someone else talks about it. By eliciting and responding to change talk, Motivational Pharmacotherapy reshapes the physician-patient interaction from an assessment of symptoms and side effects to a conversation about the patient’s treatment experience, treatment goals, and progress toward those goals (3). In this format, the physician and patient are equal co-decision makers.

Motivational Pharmacotherapy (which I developed together with my colleagues Iván Balán, Ph.D., and Theresa Moyers, Ph.D.) was set up to be feasible in the timeframe of a typical pharmacotherapy session. Motivational Pharmacotherapy begins with the psychiatrist welcoming the patient to the session, affirming the commitment to treatment, and suggesting a brief overview of the forthcoming session. The psychiatrist then asks the patient about changes in his or her condition using pointed questions that encourage further dialogue (see box below).

During these conversations, it is important that the psychiatrist brings up the topic of medication adherence and asks the patient what steps he or she has taken to stay adherent and/or what obstacles are hindering optimal adherence. Strategies to improve adherence can then be discussed, though the patient should be asked to offer suggestions first to promote self-efficacy. The session then wraps up with a review of the treatment regimen and a joint decision about any changes in medication treatment or dose.

Since depression frequently saps motivation and energy, I find that using structured materials, such as sorting cards (depicting treatment goals or patient values) and bubble sheets, during sessions facilitate active patient participation.

It is also critical to ensure the Motivational Pharmacotherapy design is culturally congruent and factors in patients’ understanding and fears of psychotropic medications as well as their expectations of care. Based on cultural views of illness and treatment, some people may have worries over the side effects of medications, for example, while others may think the medicine should only be taken on days when symptoms are worst to avoid addiction.

Developing the skills to successfully incorporate Motivational Interviewing into your practice can take time. In addition, Motivational Pharmacotherapy is a significant shift in how pharmacotherapy discussions are conducted, and not every psychiatrist may be comfortable with such a cultural change.

For psychiatrists who may be hesitant about Motivational Pharmacotherapy, another possibility is Motivational Enhancement Therapy for Antidepressants, developed by my colleague Alex Interian, Ph.D. (4). This is a similar approach grounded in Motivational Interviewing principles, but rather than integrating Motivational Interviewing directly into the pharmacotherapy sessions, Motivational Enhancement Therapy for Antidepressants intersperses adjunctive Motivational Interviewing sessions by a trained psychotherapist in between the standard psychiatry sessions.

I believe Motivational Pharmacotherapy and Motivational Enhancement Therapy for Antidepressants both offer a relatively straightforward path toward improving patient motivation and medication adherence for many people with depression, especially people who are highly ambivalent about taking their medications. We initially developed Motivational Pharmacotherapy for low-income Latino populations, among whom ambivalence about medications is heightened due in part to elevated concerns that antidepressants are physically harmful or addictive.

In an open-label pilot trial of Motivational Pharmacotherapy with 50 Latino patients with depression, we found that 12 weeks of therapy resulted in a treatment discontinuation rate of 20 percent; this is far lower than the 36 percent to 46 percent treatment discontinuation rate commonly reported at the same clinic (5). The average session duration was 36 minutes for the initial visit and 24 minutes for follow-up visits, which is reasonable in most clinical situations. We have recently completed a larger randomized clinical trial and are currently analyzing the data.

To learn more about Motivational Pharmacotherapy, check out the complete Motivational Pharmacotherapy manual. ■