Medication Adherence

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    • #11319

      In my experience working in mental health I have encountered clients who are hesitant around medication and those who have stopped taking some of their medications altogether. I as well take an empathetic approach towards clients navigating this experience. I recently had two clients both stop taking their anti-depressants, but continue on with their anti-psychotics within EPI, both males, both stating they felt “numb”. I offered the education around the meds, maintained open conversation, made risk management plans, and advocated for clients during psychiatrist appointments. At the end of the day. I believe maintaining the relationship can be the most important factor in being able to facilitate other effect coping tools that these clients can put to use, if they are being resistant, that can still be effective.

    • #11327

      Hi Sage,

      I resonate with your experience of working through medication adherence with clients by prioritizing the relationship. In my few months with EPI I have worked with several clients who have hesitancy around medication and are eager to stop this part of treatment. Particularly I have noticed in a few cases that some folks see there first experience with psychosis as being an episode they recovered from, rather than a potential life long chronic illness. While recovery can maintain without medication in some cases, ideally EPI clients remain open to medication as a treatment option to help with relapse prevention. I have tried to maintain a strong therapeutic relationship with these clients that are hesitant, to build trust and empower their autonomy. However, I worry about potential traumatic relapse when clients have a rigid mindset against medication. Currently I am supporting a client at the start of a relapse who is very hesitant about medication. I am using motivational interviewing skills to explore the hesitancy for medical intervention, looking at harm reduction and risk management with symptoms and leaning on the strong therapeutic relationship we have been able to build. Involuntary re-hospitalization may be unavoidable and will likely provide harm but ultimately benefit. Maintaining the relationship in this process will be important to continued treatment. This has been one of the greatest challenges I have encountered as a new EPI clinician and I expect I will continue to learn a lot from this experience.

    • #11336

      I love to see the importance of relationship being discussed here. I have one client in particular who is very inconsistent with their medication and there is a very obvious correlation with their symptoms and when they are not taking their medication. With this client I ask about medication in no different way than I would their sleeping, substance use, or other factor. Encouraging the client to take stock of what is working and what is not is helpful in having them feel as though they are independent, advocating for themselves, and be able to have a clear picture of what is going on. Through relationship we can open up the conversation of what their hesitancy around medication is, if they so choose to have that conversation. I always tell my clients they have enough people telling them what to do in their life and I am not here to be another one. I am here to help them explore options and advocate for the best course of treatment to align with their goals.

    • #11337

      Hi everyone,

      In my experience, clients with no psychiatric history really struggle with the idea of having to take anti-psychotic medications for long term (2-3 years for stabilization or lifelong). They struggle with identifying themselves as someone with a mental illness and needing medications to stay well. If they have had traumatic experiences in hospital such as chemical restraints and involuntary treatment, it also negatively impacts their relationship and perspectives on medication moving forwards. We have a few clients on our caseload who are on extended leave and are required to take medications either oral or injection, and we try our best to educate about meds, listen to their concerns, and combat side effects as much as possible. However, they hold onto the belief that once they are decertified, medication compliance may potentially be an issue. They may feel like they are better and don’t need it anymore. This also relates to difficulties with insight and having to have tough conversations with out clients about reviewing what led them to hospital and working towards preventing relapse. If our clients are voluntary and make the decision to stop medications or lower dosages, we would try to monitor more frequently for re-emergence of symptoms and intervene if necessary.

    • #11338

      Hey Sage, I’ve had similar experiences with clients as well. In terms of medication adherence, it can be challenging to struggle with weight gain, or other side effects of the anti-psychotic medications. I see clients can see benefits to it, others may have limited insight to how it’s helping them but may comply due to family encouragement. However other clients can discontinue due to various reasons including side effects, feeling better, and not feeling they need it. For these clients, I think what you highlighted is really important, regardless if the client is or is not taking the medication, having a good therapeutic relation can be helpful, especially if the client was to relapse, it is still a service, team member the client can reach out to obtain support, however highlighting the importance of coping strategies, and stress management can be a beneficial theme as well to review with clients who struggle with medication compliance.

    • #11388

      Hi all,
      Echoing what has been said already, I have worked with a client who struggled with the side effects of their antipsychotic, specifically weight gain and the “numb” feeling Sage described. I also found another challenging layer to be the messaging coming from close family members around long term medications, and their doubts that it was necessary for long term success of the client.
      I approached the challenges in a similar way – focusing on maintaining a strong relationship. Offering a space to consider the concerns of the client, talk through possible scenarios, and make clear that ultimately I was in their corner to support their decisions regardless of what they may be. As challenging as it was, I found the client to be more open to problem solving together once they understood I was not there to direct them.

    • #11392

      Hi everyone,

      I wholeheartedly agree that forming and maintaining a strong therapeutic relationship is the best foundation for tackling this issue. This can create a safer space to carefully challenge thoughts, with less chance of them becoming defensive, and explore their understanding of risks associated with medication adherence. I am working with a young man right now that continues to trial medication for a matter of days before deciding that it is not effective for him and he will subsequently create his own concoction. I have tried to encourage him to bring in old medications to start from scratch and reduce the risks associated with this practice, but to no avail. I’ve leaned on my team a lot for consultations to try and come up with other solutions. For him, it seems he is looking for a miracle. My current approach has been to increase education around medication effectiveness and to reiterate the message that no medication will instantaneously cure all and be without side effects. I also find for him that the approach needs to be quite kind and gentle, as noted by others, he has pressures from enough outside sources that my support needs to feel like I am working alongside him rather than directing him in any way.

    • #11445

      I echo everyone’s previous comments about maintaining and building rapport and providing an empathy and education. As people have previously written, often times clients struggle to see the benefits of medications and focus on the negative side effects. I have found in my practice that reframing aspects of a persons recovery in the context of being on medication and giving clients agency over choices of medication has been successful. For example, I have seen psychiatrists provide clients with a choice of medication and allowing them to decide which medication, with the associated side-effect profile that they prefer.

    • #11480

      HI all,

      One challenge I’ve faced with clients is medication compliance due to concerns around sedative effects and traumatic, chronic experiences with the Mental Health Act and involuntary care. I have a client who has a dx of schizoaffective disorder (bipolar type) and was recently taken off Extended Leave under MHA. The client has had many encounters with the Mental Health act since a young age, often cycling between periods of unmedicated chronic psychosis (co-morbidities of PTSD and psychosis-inducing substance abuse) and extended involuntary hospitalization. Historically, the client would immediately stop taking medication once voluntary, consistently leading to a rapid relapse within 3-6 months. During the most recent involuntary admission to PES, the client was deemed appropriate for return to community on extended leave after a shorter hospitalization. While on extended leave, the client experienced a significant reduction in both positive and negative symptoms of psychosis despite ongoing stimulant-use. For the client, this was the most tolerable experience with the MHA and pharmacotherapeutic intervention. The client themselves has shown insight and identified tangible improvements associated with medication compliance. Throughout this period, the client has struggled with chronic fatigue and excessive sleeping during night and day. The client’s explanatory model associates these symptoms with both her LAI atypical antipsychotic and oral adjunct medication. While on EL, the client has consistently requested a decrease in dosage while recognizing that medication does have positive effects. There was significant concern that client would no longer adhere to medication and experience hx pattern of rapid decompensation and relapse once voluntary. However, there were a few things that had been helpful in encouraging continued medication compliance as a voluntary patient. It had been helpful taking a motivational interviewing approach to general treatment compliance, scheduling regular engagement with team clinicians to monitor early warning signs of relapse, and building trust with non-psychiatric medical professionals. For example, one of the client’s goals is reduce to drowsiness. Working with the client’s explanatory model and by empowering choice, the psychiatrist agreed to proceed with a reduction in medication dosage and provide a clinically supervised cessation of medication if client continues to insist on stopping medication. To provide ongoing psychosocial education, the client met regularly with the team clinicians to monitor positive and negative outcomes of dose changes, especially checking in with client on whether their experiences of tiredness has changed. In conjunction, regular appointments with their family physician were scheduled to explore physical health reasons contributing to fatigue, e.g. anemia, hormonal imbalances, poor nutrition, sleep patterns, etc. Regular and ongoing engagement with family physician began during recovery phase after being put on extended leave. Also, the team provided ongoing harm reduction and safer drug use education around how drug use, lifestyle, and environmental factors can contribute to and cause what the client identified as negative side effects of medication. Through these different interventions, the client was willing to continue on a lower dose of medication for maintenance even after taken off extended leave.

    • #11882

      The importance of rapport and education of client is key here. I recently had a client decide to discontinue his medication. Due to our rapport he was able to be open with me and his psychiatrist about why he wanted to discontinue. We all explored the risk and benefits involved with stopping medication together. We also gave him other medication options that could avoid side effects he was experiencing. At the end of it all he made the informed decision to stop his medications. Together with the client we came up with a plan if symptoms were to come back (ie. PRN medications, safety planning etc). We also took the time to review his relapse prevention plan and update it. His family of course were involved in this process so they took can help look out for symptoms of relapse.

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