Medication Adherence

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    • #11309

      I have experienced many clients wanting to stop their medication since I began working with EPI and in my current role in inpatient psychiatry. I think some helpful ways of encouraging my clients to adhere to medication guidelines is first empathizing and listening to their experience with side effects. Next, I usually encourage clients to discuss any side effects with their psychiatrist because there are many solutions to side effects that don’t involve stopping meds. I think it’s also important to weigh pros and cons of stopping meds with clients and determining the actual risk of another psychotic episode if stopping meds. Also, providing education to clients about some of the meds and how they work can help clients understand the importance of medication adherence.

      One of the ways my coworker (the OT) and I are approaching a discussion around sexual side effects of medications is through a group that we developed based on Sex, Love, and Relationships. We are running this group around Valentines day. We noticed that there isn’t much discussion around sexual side effects from psychiatric meds, and our clients would benefit from having these discussions in a safe space. As well, we are talking about healthy relationships, consent, communication tips and tricks, and other topics on sexual wellness.

    • #11312

      Hey Katelyn,

      I think beginning the conversation with empathy for the client would be key as well. I know if I started gaining a bunch of weight, my self image would probably plummet. I cant imagine its an easy thing to shake off. Opening up the conversation using the pros and cons topic is great, it usually generates some deeper thoughts. I usually use this in regards to discussing substance use.
      I was wondering if you (or anyone else in the cohort!) have run into a situation where a client wants to use a form of alternative medicine, or rely on religion over prescribed medication. I’m curious as to how to navigate this scenario ethically and morally.

      • #11313

        Hi Jacob and Katelyn,

        Jacob, you asked if anyone has ever run into a situation where a client wants to use a form of alternative medicine. While I haven’t had this experience with any of my EPI clients as of yet, I have had an experience with a client in the past requesting prescribed cannabis from their psychiatrist. At that time, we had an up front discussion with the client around evidence-based practice and the fact that there is not enough research to support the use of medicinal cannabis for the client’s current condition. I had cautioned the client on the risks and benefits of cannabis use for the symptoms they were experiencing and offered psychoeducation around same. However, I also honoured the client’s right to choose their treatment path and validated their ambivalence around the western medical model approach and simply asked that they notify us if they decide to go down the alternative route so we can stay informed. In the end, the client decided to stick with the recommendations of their treating team.

        Katelynn, I have also had discussions with clients around wanting to stop their medications due to side effects. I find having the discussion with them up front about finding that balance between a high enough dose to treat their symptoms and low enough dose so that they don’t have side effects can be helpful. I try to reassure them that it sometimes takes time to find that right balance and emphasize that we want them on the lowest dose possible to treat their symptoms without side effects but also don’t want the dose so low that they are struggling.
        Very cool that your team has created a group venue for clients to potentially bring up sexual side effects! I’d be interested to hear how that goes! It sounds like it would be a very beneficial group for our EPI population. The only way I’ve successfully brought this up with clients is by normalizing the symptom (ie. “a lot of people taking this medication experience this symptom, is this something you are experiencing?”) and addressing it specifically as most clients find it a hard topic to bring up on their own.

    • #11314

      Hi Katelyn,

      I like how you discuss the pros and cons of stopping medication with client so they can weigh out the cost/benefit of stopping meds before they make a decision. Explaining what the purpose of the medication is, and how it works with the brain and brain chemistry I believe is helpful to medication adherence as well in language that is understood by the client. I think sometimes psychiatrists may not explain the medication as much as is helpful to clients, so assisting in this for the clients understanding would be beneficial.

    • #11318

      Yes Jacob – empathy is key. Start with that. Clients won’t mind you trying to be aware of, and understand, what it is like to be them day to day.

      Katelyn and Breeanne
      I feel every clinician, new or seasoned, has had the experience of a client who is either resistant to their medication, or starts then stops, or declines to take the medication to from the start. Especially the standard first and second generation antipsychotics. Especially with the open world of the internet to access information about these pharmaceutical substances, it can make education, support and medication adherence challenging. As you have mentioned above, it’s about at least really listening to the client and their questions and concerns, providing that education (including when it appears under-provided by the psychiatrist) including risks and benefits, and conclude that the common and primary goal is to keep someone out of hospital, keep them happy and healthy (as best we can), and support them in identifying and pursuing their life goals, desire, ambitions. Hopefully their life goals aren’t to just not take antipsychotic medications. If we aren’t aware of their concerns then we certainly can’t help them a way that may be the most supportive.

      I have a client now that became unwell again, likely aggravated by heavy Cannabis use and psilocybin, and then was able to settle and reduce his psychotic symptoms through common antipsychotics Loxapine, Risperidone, and some short-term clonazepam. Now that he’s more lucid and organized he has stopped taking said medication because he doesn’t want “to get hooked on the pharmaceutical wheel of dependence/addiction”. He said he’s started taking CBD oil for his mental health (While still smoking THC Cannabis 2-3x/week “only when I’m offered). I endorse the effectiveness of antipsychotics but sympathize with clients as to the reluctance and resistance to not taking them. They have harmful side-effects for many clients, but of course the argument that it keeps them out of hospital and closer to having a ‘normal life’ then they would have otherwise. My client appears to be doing pretty good absent the medication and taking the CBD oil. Medications is at the foundation of the medical model of treatment for clients; if they have stopped taking the medication or resistant (assuming they’re a voluntary client) I think it is always important to stay connected, maintain the working relationship. For me, keeping that connection focused on their wellness has resulted in clients being at least a little more open to the possibility of taking some medication (which some of re-started) that will keep them a little better, and a little safer, and give them a little more of their life back.
      The client and I talked about research in the area of CBD and psychosis and how, like many new, ‘alternative’ options of support are growing much research (Random controlled trials for example) need to be done; this takes a lot of time and money.
      I found a meta-analysis study to review if you like.

      https://link.springer.com/article/10.1007/s00213-021-05905-9#ref-CR49

    • #11333

      Katelyn, your Sex Love and Relationships group is such a wonderful initiative. Not only are you opening conversations that are often stigmatized/minimized but you are also helping people realize that they are not alone in their experience. Hats off you you and your colleague!

      I think what you all have written above captures excellent ways to support clients who have stopped taking medication or are considering stopping taking medication. One thing I would add is that I think monitoring for positive effects, negative side effects and persistent symptoms despite taking meds is important, I think it can be equally important if a client is choosing not to take meds. the same strategies can hold – checking in regarding improvements, side effects or persistent symptoms. Comparting the data before going off meds to the data after going off meds can be very powerful in highlighting the impact of medication (both good and bad) and helping a client make a decision (hopefully this is done with their prescribing doc) as to how they want to proceed.

      While my experience with this wasn’t psychosis related, I had a youth who was taking risperidone. The client was hesitant but agreed and so we decided to conduct an ‘experiment’ wherein we tracked the clients experience of all of the potential benefits and the potential side effects of the medication that the psychiatrist listed. Ultimately, after 5 or 6 months the client decided that they wanted to stop medication, against the recommendation of their psychiatrist, due to weight gain and the fact they didn’t think they needed it anymore. I respected my clients decision and we continued with our weekly appts in which we continued to capture data like we had done before. I forget the exact numbers now but as the client went off risperidone we noticed an increase in arguments with parents, damage to property at home, and lower mood (likely due to the discord). When the client saw the numbers they realized that the risperidone was likely correlated with symptom improvement and so decided to go back on. I’m not sure without the quantifiable evidence that the risperidone was working that the client would have decided to go back on the meds.

    • #11335

      My approach to addressing medication non-compliance aligns closely with the strategies you have all outlined above. Building a strong relationship and fostering rapport with clients is paramount. I prioritize actively listening to their concerns regarding medication, recognizing that each individual’s experience is unique and valuable.

      In addition to offering suggestions for managing medication side effects, I’ve come to recognize the importance of advocating for my clients. Collaborating with psychiatrists and advocating on behalf of clients has proven instrumental in enhancing medication adherence. While there are instances where medication adjustments are necessary and alternatives may be limited, I find that thorough client education, as well as involving their families when appropriate, significantly contributes to their understanding and cooperation.

      By ensuring that clients feel genuinely heard and supported, they often express a sense of empowerment and are more inclined to adhere to their medication regimens. When addressing sensitive topics such as sexual side effects, I approach the conversation directly, providing patient education and facilitating discussions with the psychiatrist to address concerns.

      Ultimately, my goal is to work with clients to enhance their quality of life and overall well-being. Through collaborative efforts and open communication, we can navigate challenges and optimize treatment outcomes together.

    • #11383

      Katelyn – I love this idea of your group approaching sex. I have had a number of clients stop their medications due to affect on lowering libido. I haven’t had the opportunity to run a group surrounding this, but I would love to hear more about how this groups goes and the tips and tricks that you share for sexual wellness. As an occupational therapist myself, I would like to recognize sex/intimacy as a meaningful occupation that medication side effects have a significant impact on.

      Jacob – I did have a client who would take copious amounts of ginkgo biloba , to the point where his circle of care were very concerned as we believed it was causing ill effects. Our approach was to ask the client whether he would be open to consultation from a naturopath on the current dosage of ginkgo biloba and consultation on supporting him with supplement recommendations, which this client was more open to, this consultation from the naturopath resulted in him taking less ginkgo biloba and recommendations that suited his needs.

    • #11393

      Katelyn- Your group sounds amazing!! This is such an important topic and I think so far from people’s comfort zones to talk about.
      Breeane- I really like this format for posing the tough question- ” “a lot of people taking this medication experience this symptom, is this something you are experiencing?” !!

      My previous role was a child abuse investigator and a primary role in this was to interview alleged offenders to determine their level of risk. This meant talking to folks about all things sexual and intimate. One of the most important things I would do when preparing to interview someone was to do a thorough self check and deep introspection. Was I tired/hungry/distracted? Was there anything about the case that felt too close to home? What were my biases? How will these affect my ability to support my clients?
      Being aware and understanding these things helped reduce any of my own judgements or discomforts from in leaking into my interviews and leading to countertransference. This ultimately allowed me to discuss so many intimate things with folks and ensure I maintained an objective approach. Even a micro response can be enough for a person to shut down or feel judged! Any serving profession should be in the practice of doing a quick self inventory before working with clients, particularly when we need to explore topics that might be socially taboo. Further to this, recognizing how culture impacts a client’s ability/willingness to speak about sexual side effects from medication could be helpful when broaching the subject!

    • #11427

      I think the idea of incorporating the sexual side effects experienced by people who take anti-psychotic medications into a group surrounding love, sex, and relationships is a great idea. I think this is an accessible way to touch on the topic and provide education to clients who may feel embarrassed or uncomfortable with addressing this. It is important to work this issue into our comfort levels and practice as it may be a reason that we miss if a client is starting to intentionally stop taking their medications as directed.

      As above, I think on an individual level, and even outside of sexual side effects, the intentional effort of building rapport cannot be understated. The foundation of trust around medication choices between care team and client is important in maintaining wellness, especially when considering that in some cases, medication may be needed on a life long basis.

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