Bipolar Disorder: Keys to Improving Compliance

BRIEF COMMUNICATION

Non-adherence to prescribed medication by patients with psychiatric disorders is one of the greatest challenges reported by clinicians: “Over the course of a year, about three-quarters of patients prescribed psychotropic medications will discontinue, often coming to the decision themselves.”¹ It is because of this perennial professional conundrum that Dr Julie Carbray of the University Illinois-Chicago and I will be presenting “Partnering for Recovery: Reaching Concordance with Psychopharmacology in the midst of Bipolar Disorder” at this year’s PsychCongress in Orlando, Florida.

There are many predictors for psychopharmacological non-adherence that range from duration of regimen to cognitive impairment.^1(pp336-346) Dr Carbray and I will focus on  the doctor-patient relationship and the creation of a foundational and dynamic therapeutic alliance to create greater levels of adherence and better long-term treatment outcomes.

We will concentrate on therapeutic teaming techniques that can be done within “real world” time constraints of modern practice, such as the 15-minute medication check and other truncated clinical encounters.

Many workshops and studies on improving an alliance between clinician and patient focus only on the clinician and from a “purely practical standpoint, [but] there is far more opportunity to implement substantial interpersonal trainings for healthcare professionals than there is to do the same for patients . . . (as the) ratio of patient to clinician is extremely large.”² Recognizing this trend and building on it, we will review current evidence-based practices in reaching concordance with psychopharmacological interventions. We will include formatted live discussion regarding the emotional components of the patient-clinician relationship concerned with emotional care.²

This segment of the workshop will entail a formal role-play by clinician and “patient” working together in the abbreviated 15-minute appointment by moving toward communion in the narrative perspective of treating psychiatric disorders. Harvard psychiatrist, Dr Arthur Kleinman, described this difference of perspective as the gap between the “patient’s experience of the illness and the doctor’s attention to disease.”^3(pxii)

Recovery vs. symptom abatement
Divergent narrative perspectives can force the patient to become the object of treatment. The patient risks losing their subjective identity with the “narrative surrender”^4(p6) of their first-hand experience of bipolar disorder. The physician, too, becomes the “spokesperson for the disease,”^4(p6) using medical language that a patient is neither fluent in nor attached to as a visceral framework of self-narration.

For there to be lasting collaboration in medication management, it is best to intervene early with patients while they are euthymic to develop an understanding between both parties. The workshop will elucidate the clinical perspective on concordance, as well as the concordance biases as the patient tries to come to terms with the “label” of a serious mental illness and the “societal rhetoric of illness”^4(p21)-specifically psychiatric illness.

The patient is facing a new reality after the lived experience of psychotic symptoms and hospitalization. This new reality will disallow the patient from orientating back to their life using the same destination and maps^4(p1) they have previously used to set goals, determine dreams, and gauge familial relationships.

The patient’s identity often suffers a catastrophic fracturing of what was once familiar and he will need to team with the clinician to develop a new self-perspective, one that involves psychopharmacological interventions and regimen adherence.Behavioral scientist and expert on depression and suicidal behavior, Hartmut B. Mokros PhD, notes, “Identity is a relational achievement,”⁵ and this newly forged identity will involve the focused effort of clinician and patient to achieve this foundational goal.

The workshop will also discuss how to integrate medications into this new identity. It will investigate the fears of being a “permanent patient” with regimen protocols that are often open-ended and the tethering of diagnosis biases to medication. Dr Carbray and I will attempt to show an example of a therapeutic alliance that can weather the strains of early treatment and that allows clinicians to anticipate more easily some of the existential hurdles of diagnostic acceptance that undermine treatment adherence and to improve concordance in psychopharmacological interventions.

Disclosures:

Mr Arauz is Adjunct Instructor at Rutgers/Robert Wood Johnson Medical School, Department of Psychiatry, in New Brunswick, New Jersey. He is owner of AIE, a behavioral health consulting company located in East Brunswick, New Jersey. He is the author of An American’s Resurrection: My Pilgrimage from Mental Illness and Child Abuse to Salvation. He is a current steering committee member of Psych Congress and keynoted last’s year event. Mr Arauz reports an affiliation with the North American Center for Continuing Medical Education (NACCME) and the Psych Congress Steering Committee for 2015. His website is www.ericarauz.com.

References:

1. Mitchell AJ, Selmes T. Why don’t patients take their medicine? Reasons and solutions in psychiatry. Adv Psychiatr Treat. 2007;13:336-346.
2. Kelley JM, Kraft-Todd G, Schapira L, et al. The influence of the patient-clinician relationship on healthcare outcomes: a systematic review and meta-analysis of randomized controlled trials. PLoS ONE. 2014;9:e94207.
3. Kleinman A. The Illness Narratives: Suffering, Healing, and the Human Condition. New York: Basic Books; 1988.
4. Frank AW. The Wounded Storyteller: Body, Illness, Ethics. Chicago: University of Chicago Press; 1995.
5. Mokros HB. Suicide and shame. Am Behav Sci. 1995;38:1091-1103.