Using the Concordance Approach with Mental Health Service-Users

Transcription

1 Using the Concordance Approach with Mental Health Service-Users a practical resource for Mental Health Practitioners Produced by: John Butler Consultant Nurse (PSI) Edition: Winter 2009

2 Contents Section Page No. Introduction 2 Introducing the Concordance Approach 3 Using Structured Therapeutic Strategies to Promote 8 Concordance 1. Discussing Treatment & Care Options 8 2. Core care-plan for achieving concordance 9 3. Stress Vulnerability: understanding the need for 11 taking action 4. Developing an illness timeline Exploring beliefs and attitudes about illness, 16 medication and treatment: a short questionnaire 6. Exploring ambivalence about treatment options Providing Explanation about Medication Talking about Beliefs & Concerns about Medication Monitoring medication effects & side effects: 25 LUNSERS and other tools 10. Problem solving the side-effects Planning for the Future 29 References 31 1 Using the Concordance Approach / John Butler / 2009

3 Introduction There is a considerable and growing body of research available providing evidence of the effectiveness of psychosocial interventions for the severely mentally ill, which include: case management; cognitive-behavioural intervention; family work; and, the concordance approach. Also known as medication management, compliance or adherence therapy (Kemp et al 1997, Gray et al 2002, Harris 2002), the concordance approach involves the collaborative use of a series of practical strategies with the mental health service-user, which include: reviewing illness history with the service-user; exploring his/her ambivalence about taking medication; testing his/her beliefs about medication; structured problem solving; and, planning for the future (Gray et al 2002, Kemp et al 1998). The aim of this resource is to provide a series of practical tools and strategies for use with people who are experiencing and living with mental health problems, with the aim of promoting their active engagement in their own treatment and care towards recovery and staying well. Many of the short practical exercises provided within this resource are written for the serviceuser, although it is highly recommended that the practitioner provides guidance and support in helping the person to gain the most from some of these exercises. This will mean introducing the selected exercise or strategy, providing a rationale for practice, explaining how to complete or practice the strategy, working through at least part of the exercise / strategy together within an individualised session, establishing practice goals, monitoring and reviewing progress, and praising and reinforcing positive effort. This resource focuses upon the practical use of the concordance approach in the context of implementing a care-plan aimed at promoting the service-user s concordance with treatment and care. It is the responsibility of the practitioner to select exercises and strategies that are appropriate and relevant for the person, which should ideally be linked to an agreed formulation of their problems and needs and to their care-plan not all of the exercises may be relevant for each person. 2 Using the Concordance Approach / John Butler / 2009

4 Introducing the Concordance Approach (Butler 2005, 2006; Neurolink 2006) To maximise the effectiveness of any treatment, the service-user needs to not only believe that it may help, but also actively participate in the treatment process and accept their share of responsibility in their recovery. Past approaches to improving treatment effectiveness emphasised the importance of compliance or adherence (which evoked a rather paternalistic model of the doctor knows best and patients should do as they re told ), and focused on overcoming practical barriers to medicine taking, such as the complexity of the regimen. In more recent years, it has been recognised that the service-user s beliefs about their illness and treatment are the most important factors in how they use treatment (Horne & Weinman 2004). Therefore, although compliance and adherence remain valid terms to describe the extent to which a service-user s behaviour aligns with prescribed treatment, there has been a shift in emphasis towards the idea of concordance. Concordance describes an approach to prescribing and medicine-taking based on a two-way collaborative process between the doctor or care professional and the service-user to decide on the most appropriate treatment for the individual (Perkins & Repper 1999). The characteristics of this collaborative alliance or partnership are as follows: o ensuring the person has enough information about their illness and treatment options to participate as a partner in any decisions about treatment o making joint decisions about treatment o supporting the person in medicine taking after a decision has been made Promoting concordance has been the subject of much research and has proven to be a highly sophisticated art and science, yet there are a number of particularly helpful approaches which may be used to help achieve it: o normalising o tailoring an individual approach o providing explanation and education o ongoing engagement and monitoring Normalising To gain a good level of empathy with the service-user, it may be useful to think about their adherence to treatment within the context of your own personal experience of taking medicines. Consider your own personal experience Think back to when you were last prescribed a medication did you take it as prescribed and finish the course? If not, what affected your behaviour? What made your adherence more likely? For example: you may have felt very unwell, experienced an acute illness such as lobar pneumonia, or had a good understanding of the risk benefit of antibiotics. What made your adherence less likely? For example: perhaps you didn t feel the effects of the illness directly, needed to take the medication over the long term, or experienced unpleasant medication side effects. Now consider your professional experience What can affect adherence to treatment in general? Some of the important factors are shown in Fig. 1 (Perkins & Repper 1999). 3 Using the Concordance Approach / John Butler / 2009

5 Fig. 1: Factors that affect Concordance Tailoring an individual approach Bearing the above in mind, the following points may be useful considerations in achieving concordance with a person experiencing depression for the first time for example. o What are their key concerns? o What questions do they have about the illness, treatment and prognosis? o What will it take to gain their agreement with a treatment approach? (Discuss the pros and cons of various treatment options.) o What is their attitude towards the illness and treatment in general? o What is their attitude towards depression and its treatment specifically? o What self-management skills do they possess, or could you help develop (e.g. problem solving, relaxation techniques etc.)? o What sort of relationship (therapeutic alliance) do you have / could you develop with the patient? Expressing concepts visually can be a useful exercise to check that you both understand each other. In addition, such diagrams can serve as a history and record of progress for the patient. For example: you could develop an individualised timeline with the patient, exploring how things have changed over time, and what has helped or worsened the situation in the past. 4 Using the Concordance Approach / John Butler / 2009

6 For example: you could agree a rationale for treatment based upon the patient s current and future vulnerability to stress. A Summary of the Evidence Gray, Wykes & Gournay (2002) have summarised some of the evidence for interventions that enhance concordance, which include providing education (Smith et al 1992, Macpherson et al 1996, Gray 2000), behavioural tailoring (Boczkowski et al 1985) and cognitive-behavioural intervention, which includes compliance therapy (Hayward et al 1995; Lecompte & Pelc 1996; Kemp et al 1996, 1998). Educational Intervention Smith et al (1992) studied the impact of educational interventions on knowledge about medication, insight and attitudes towards treatment, dividing their intervention into four sessions, each of which covered a different aspect of schizophrenia: the concept of schizophrenia, including the possible causes and outcome; the symptoms of schizophrenia; the advantages, limitations and side effects of the treatment of schizophrenia; basic symptom management strategies. In a group of 28 participants, a significant gain in their knowledge of treatment was observed at post intervention, although there were no significant changes in insight or compliance. MacPherson et al (1996) conducted a randomized controlled trial of providing education about drug treatment, randomly assigning 64 patients with schizophrenia to one of three groups: (1) one session of education about medication; (2) three sessions of education about medication; (3) standard care. The educational sessions were based upon a specially designed booklet drawn from the psycho-educational literature and each lasted from minutes. Prior to intervention, participants showed a poor KMQ score Providing Education (MacPherson et al 1996) Education about drug treatment 64 Patients DSMIIIR schizophrenia Sessions based on psychoeducation literature Measures Knowledge about medication questionnaire (KMQ) SAI PANSS Baseline scores indicate poor understanding of treatment Ratings not blind No impact on compliance CN Ed / John Butler understanding of their treatment, as measured by their completion of the Knowledge about Medication Questionnaire. Receiving both one and three educational sessions led to improvements in understanding compared to standard care, with three sessions leading to significantly greater knowledge gain. Baseline One ses sion Three session Control Immediate One month post post intervention intervention 5 Using the Concordance Approach / John Butler / 2009

7 Gray (2000) examined the effects of education about medication on patients who were taking clozapine: 44 patients were randomly assigned to receive either three educational sessions or standard care, with educational sessions being focused on the concept, symptoms and treatment of schizophrenia. Knowledge of the potential side-effects of medication increased, although no changes were reported in participants attitudes towards treatment or insight. Compliance Behavioural Tailoring (Boczowski et al 1985) Behavioural tailoring Time 1 Time 2 Time 3 36 male chronic patients with schizophrenia CN Ed / John Butler Behavioural Tailoring Boczkowski et al (1985) assigned 36 male patients with chronic schizophrenia to receive one session of either behavioural tailoring, patient education or a control intervention. Behavioural tailoring involved informing patients of the importance of complying with their medication and helping the patient to tailor their prescribed regimen so that it was better suited to their personal habits and routines. Compliance was measured by pill counts at preintervention, one-month and threemonth follow-up. Their findings suggested that patients who received behavioural tailoring were more compliant following treatment than were the other groups. BT PE Control RCT Patient received one session Behavioural tailoring Patient education Control discussion about topic unrelated to medication Pill count Cognitive-behavioural Approaches Lecompte & Pelc (1996) offered a cognitive-behavioural programme based around the five therapeutic strategies of: engagement; psychoeducation; identifying prodromal symptoms and developing coping strategies; behavioural strategies for reinforcing compliant behaviour; and correcting false beliefs about medication. In their study, 64 non-compliant patients were randomly assigned to receive either the cognitive behavioural intervention or the control intervention of unstructured conversation. Patients receiving the cognitive-behavioural intervention spent significantly less time in hospital than those in the control group, although it was not clear whether this improvement was related to improved compliance. Hayward et al (1995) conducted an evaluation of medication self-management based upon the motivational interviewing approach, allowing patients and clinicians to work collaboratively to examine medication issues. In their study, 21 patients were randomly assigned to receive three 30-minute sessions of either medication self-management or the control intervention of nondirective discussion on any issue other than medication. Although there were differences between groups in insight, attitude towards treatment and compliance, none reached statistical significance, which may in part have been due to the limitations of the study: small sample; short duration of intervention; unsophisticated measure of compliance. However, this work led to the development of a longer more structured intervention: compliance therapy. 6 Using the Concordance Approach / John Butler / 2009

8 In a seminal study, Kemp et al (1996, 1998) evaluated the effectiveness of compliance therapy a brief pragmatic intervention based upon motivational interviewing and cognitive-behavioural therapy that aims to help patients to work through ambivalence about behaviour change. Their approach emphasises collaboration, personal choice and responsibility, and focuses upon concerns about treatment. Compliance Therapy (Kemp et al 1998) SAI(E) Schedule for the assessment of insight pre-int postint Non-specific counselling Compliance therapy 6m fu 12m fu 18m fu 74 inpatients Compliance Therapy Non-specific counselling Ratings to 3 months not blind Significant improvements Compliance Attitudes Insight Time to readmission longer Expert study Key skills of the approach include the CN Ed / John Butler use of inductive questioning, reflective listening, regular summarising, investigating the pros and cons of alternative courses of actions and exploring and reinforcing adaptive attitudes and behaviours, provided through three phases: (1) reviewing illness history / experiences of treatment; (2) discussing common concerns about treatment & the not so good & good aspects of treatment; (3) long-term prevention strategies for avoiding relapse. In a randomised control trial of 74 patients, assigned to receive either 4 6 sessions lasting an average of 40 minutes each, of either compliance therapy or non-specific counselling, those receiving compliance therapy showed significantly greater improvements in attitudes towards treatment, insight and compliance, which were sustained at six-month follow-up. 7 Using the Concordance Approach / John Butler / 2009

9 Using Structured Therapeutic Strategies to Promote Concordance 1. Discussing Treatment & Care Options (adapted from: Neurolink / Butler 2006) From the first time you meet the person, it is important to find out what they think about their current problems or difficulties, exploring what they understand about their situation and explaining the signs and symptoms of the illness. This will involve giving some meaningful information about the illness at a level that they can understand, using their own language and checking that they have understood. There are many available written materials that may be useful when discussing the signs symptoms and experiences of an illness this will include information sheets, leaflets and workbooks. It may be useful to ask the person to monitor their own symptoms between sessions, as this may help to raise awareness of the frequency, duration and intensity of symptoms and highlight particular patterns for example, they may find that they feel worse at particular times of the day or in specific situations. Many tools are available for self-monitoring the common signs and symptoms for example: the Mind Over Mood Patient Workbook (Greenberger & Padesky 1995). You will need to find the most effective way of asking about each symptom and its impact. How you ask this will depend on the person s understanding of their situation, your relationship with them and their communication style. You may have to ask the same question in different ways to get the information you need. For people who have a history of relapse or recurrence, it is important to explain that it may be better to consider their problem or illness as one that is ongoing rather than episodic perhaps like hypertension or asthma. For these people, it is important to take a positive approach in explaining the likelihood of relapse or recurrence, emphasising what they can do to reduce the chance of any further relapse or recurrence. A helpful way of doing this is to explain the role of stressors and vulnerabilities in contributing to their current stage of illness and making a future relapse or recurrence more likely (see No. 3 of this section). You can also explain the potential benefits of relapse prevention measures encouraging them to put into action those things that they have found helpful before, in addition to new strategies that they can try out. It is important to explain the probable course of the illness in developing a rationale for treatment and care. One helpful way of doing this is to sketch out an individualised timeline of their experiences (see No. 4 of this section). It is very helpful to assess their attitude towards their illness and treatment and care options, engaging them in a discussion about their views (see Nos. 5, 7 & 8 of this section). You will need to directly respond to their concerns, with the aim of increasing their understanding and prompting their consideration of different treatment and care options. Working closely with the person, encourage them to consider the pros and cons of the available treatment and care options. Together, you could help to sketch this out and give it to them to take away and consider further (see No. 6 of this section). 8 Using the Concordance Approach / John Butler / 2009

10 2. Core Care Plan for Achieving Concordance The care-plan should give direction, meaning and guidance to the treatment and care that is provided, meet the identified goals / objectives, provide a means of communicating and organising the activities of the care team, and provide a basis for the continuity of care. For service-user s who present issues of non-compliance with medication or other treatment components, it may be helpful to consider implementing a care-plan aimed at achieving concordance. To assist the practitioner, a core care-plan template is provided which describes the practical concordance (or medication management) approach. If deciding to use this template, it is important to first personalise the core care-plan template by adding a specific and detailed problem statement and inserting the service-user s name in the relevant sections of the care-plan. Every opportunity should be taken to achieve the active involvement of the service-user in planning, implementing and reviewing their own care. However, the level of active involvement that a person may have with care-planning will depend upon a number of factors, such as their level of insight, needs, abilities, stage of illness, and, importantly, the nature of the relationship with the named practitioner. 9 Using the Concordance Approach / John Butler / 2009

11 Care Plan (standard care-plan for concordance) This standard care-plan describes the expected goals and interventions to be implemented for service-users who show no or only a limited agreement and acceptance of care interventions. Please individualise this standard care-plan and evaluate at least weekly. Full Name MPI No. Unit / Team Specific details of care-plan Care Plan Priority No. (if more than one care-plan) Summary of Main Problem / Area of Need (write a specific individualised description of the person s concordance issue) Goals / Objectives For to: a. clearly understand the likely value of specific care interventions: within weeks. b. agree and accept specific options for care: within weeks. c. be actively involved in monitoring the effects of care interventions and in decisions about ongoing treatment and care: within weeks. Specific Care Plan Interventions (for use by the individual practitioner to record specific actions undertaken using tick boxes) To listen to and accept personal experiences and views, working together in reaching decisions about planned care interventions. To identify and discuss views and attitudes towards proposed or prescribed care interventions. To involve in creating a personalised sketch of their experience of the illness / problems / difficulties over time, as a way of becoming more aware of what has helped in the past (for example this will involve drawing a personalised illness timeline) To explore with the pros and cons of specific care interventions / prescribed medication. To educate and provide clear and understandable explanations to about specific care interventions / prescribed medication. To provide and explain available written information / leaflets about specific care interventions / medications. To clarify and directly respond to any questions and queries that has about specific care interventions / prescribed medication. To explore and encourage to consider ways of checking out their beliefs and views of specific care interventions / prescribed medication (for example by monitoring personal experiences or asking others). To regularly involve in monitoring their level of compliance with specific care interventions / prescribed medication, and their experience of positive effects and unwanted / side effects (for medication, this will involve the use of a side-effects monitoring questionnaire called LUNSERS). To involve in using a structured problem-solving approach for managing any obstacles or difficulties that are experienced OR any side-effects of prescribed medication. As recovers, to involve them in the use a structured problem-solving approach towards achieving specific personal / practical goals. To involve in reviewing the helpfulness of specific care interventions / medication. please record care evaluations on the service-user review record at least weekly Signature of Service-User Date Signature of Named Nurse Date Record date of distribution to the following: Case-notes / File Care Coordinator Service-User CMHN / Social Worker References: Day et al 1995 (LUNSERS), Gray 2003 (Concordance Approach), Neurolink 2006 (Concordance Approach) 10 Using the Concordance Approach / John Butler / 2009

12 3. Stress Vulnerability: understanding the need for taking action You may have noticed a link between times when you have felt very stressed and times when you have become unwell. You may also have noticed that some of the things that you have tried to do have not actually helped, and may in fact have made things worse. However, it is important to recognise that just because you feel stressed doesn t mean that you will definitely relapse or experience symptoms it just means that it is more likely. We all have different levels of vulnerability, which is rather like having a coping threshold if we experience something that pushes us beyond our coping threshold, then we may experience symptoms. Some events will be more stressful than others, and two stressful events that occur at the same time are likely to have more effect on us than one stressful event. To try to ensure that stress does not push us beyond our coping threshold, we can be prepared by learning various methods and techniques for managing stress. This will have the effect of keeping our stress levels low, so that it is well within our coping range and, in fact, increase our coping threshold as we learn new coping strategies. An example of this shown is shown by the dotted line in the diagram below. Stress = current stress level exceeds coping threshold levels Started an antidepressant Increased support systems Using problemsolving skills Restarts medication Current stress level Coping threshold Traumatic event when younger Poor housing and financial problems Misusing alcohol in an effort to cope Stopped tablets as had felt better Relationship break down Time 11 Using the Concordance Approach / John Butler / 2009

13 By discussing this with your named nurse / care coordinator or doctor, try to identify the things that cause you stress and things from your past or personal characteristics that might make you vulnerable they may include some of the following examples: this makes me example tick if this applies to you Stressed difficulties at school, university or work Stressed loss of relationship Stressed problems within the family Stressed isolation / lack of support Stressed drinking alcohol / using drugs Stressed housing problems Stressed financial problems Vulnerable a family history of mental health problems Vulnerable having a sensitive personality Vulnerable traumatic things that happened in your past Exercise: Write down your own list of the things that tend to cause you stress or that make you vulnerable, and then add some of the things that help you when feeling stressed or vulnerable. Your named nurse / care coordinator or doctor will be able to help you to complete your list. Things that cause me stress / make me feel vulnerable: Things that help to manage stress: You may also find it helpful to sketch this out as a timeline your named nurse / care coordinator or doctor will help you to do this. 12 Using the Concordance Approach / John Butler / 2009

14 4. Developing an Illness Timeline (adapted from: Gray 2003) A useful strategy for raising awareness of the links between helpful treatment & care interventions and recovery from problems or illness, this involves working closely with the service-user to identify when they, or significant others, first realised they had mental health difficulties / problems and then plotting the course of their illness and the positive & negative effects of treatment and care interventions over time. You will need to help the service-user to identify when their mental health has been particularly good and when it has not been so good. You will also need to help the service-user to make links between stopping medication or other treatment and care interventions and worsening symptoms, examining in detail any negative experiences. Through discussion, actively involve the service-user in creating a sketch which represents their illness timeline, as in the example below. Illness Timeline plot graphically or produce in tabulated form e.g.: +ve taking medication = olanzapine many sideeffects stopped medn. first admission second admission -ve MHTU / John Butler To begin, simply draw a horizontal line across a blank page to represent time, and a vertical line to represent the person s rating of positive / good or negative / bad experiences. Negotiate with the person where they would like to start the timeline from and then engage them in rating and plotting their experiences over time, adding notes to the emerging sketch. This exercise can be started within a short session with the service-user and completed as a practice or homework task. 13 Using the Concordance Approach / John Butler / 2009

15 very good experience time in years very bad / difficult experience 14 Using the Concordance Approach / John Butler / 2009

16 Use the space below to make notes about personal experiences when sketching an illness timeline: When did this happen? Notes: 15 Using the Concordance Approach / John Butler / 2009

17 5. Exploring Beliefs and Attitudes about Illness, Medication and Treatment Your Name: Date completed: For Office Use prescribed medications: The purpose of this short questionnaire is to help us to understand your views and concerns about mental illness and its treatment with psychiatric medication. Please read each of the following statements and decide whether you disagree or agree from I disagree strongly through to I agree strongly. Place a tick in one of the columns for each statement to indicate how much you agree with the statement for example: Statement Medication is addictive disagree strongly disagree neither agree nor disagree agree agree strongly If any of the statements do not apply to you, then skip them and move on. Work through this questionnaire as quickly as you can and please remember to give your own opinion. Statement Medication is addictive disagree strongly disagree neither agree nor disagree agree agree strongly It is wrong to take medication Medication treats the symptoms and not the causes of illness Taking medication will make me feel much worse I should be able to cope with the illness on my own Medication alone is the answer I can t be ill I have no reason to be No one can help me with my illness If I talk about my illness, it will only get worse I m always prescribed the best medication for me Stopping medication will cause side-effects I can take the medication when I feel like it If I wake up feeling worse, I can always take an extra dose of the medication 16 Using the Concordance Approach / John Butler / 2009

18 My illness will get better by itself I won t be able to work if I take the medication Medication should not be taken for too long Natural approaches for mental illness, such as exercise, healthy eating and relaxation, are better than medication My family would not want me take the medication Medication can prevent future episodes of mental illness I can stop taking the medication as soon as I feel better I get on better with people when I am taking the medication I only take medication because of pressure from other people I am no different on or off medication If I wake up feeling much better, I can always skip a dose of my medication I don t like taking the medication because of the side-effects Readiness How ready or prepared are you to take the medication, as prescribed? Place a mark on the following scale to show how ready or prepared you think you are: not prepared at all very prepared Importance How important is it to you to take the medication, as prescribed? Place a mark on the following scale to show how important you think this is: not important at all very important Confidence How confident do you feel in your ability to take the medication, as prescribed? Place a mark on the following scale to show how confident you feel: no confidence very confident Please use the space below to write any other thoughts or concerns that you have about the illness or its treatment. Thank-you for taking the time to complete this short questionnaire. 17 Using the Concordance Approach / John Butler / 2009

19 6. Exploring Ambivalence about Treatment Options (adapted from: Gray R (2003) Concordance Skills Manual. London: Institute of Psychiatry) This may be a useful exercise for most people, as experience suggests that the majority of people have a degree of ambivalence about taking medication or completing treatment, but will be particularly useful with people who have a variety of beliefs about treatment and are uncertain about the importance of taking medication or committing time to a treatment option. It involves helping the person to draw up a balance sheet, highlighting the positive and negative aspects of medication or other treatment option. Try to make a distinction between the short & long-term benefits of the treatment option, emphasising the less obvious or indirect effects of the treatment e.g. staying out of hospital, getting into fewer arguments, having fewer problems with the neighbours. Depending upon the person s level of functioning, this exercise may either be completed with the person within one or more short sessions or given as an exercise to be completed. As an example, part of a balance sheet for someone weighing up the pros and cons of taking an anti-depressant is shown on the next page, following which a blank record sheet is provided. 18 Using the Concordance Approach / John Butler / 2009

20 Balancing Up: considering the pros & cons EXAMPLE Taking an antidepressant Pros Antidepressants did help me last time I was unwell Cons I don t like taking tablets Prescriptions are expensive I can t have a drink It s embarrassing Stopping the antidepressant I ll save money on prescriptions I won t need to remember to take the medicines I might become depressed again 19 Using the Concordance Approach / John Butler / 2009

21 Make a list of what you consider as the pros & cons of the proposed treatment option / current medication Deciding to Pros Cons proposed treatment option OR current medication Deciding NOT to proposed treatment option OR current medication 20 Using the Concordance Approach / John Butler / 2009

22 7. Providing Explanations about Medication From the assessment and subsequent sessions, the service-user may have raised various questions and concerns about their medication. There are also a number of frequently asked questions (FAQs) that can be discussed with the service-user (Neurolink / Butler 2006) for example: o How do these drugs work? o How will I know the medication is working? o What are the side effects? How common are the side effects? o Is this medication addictive? o Will I get withdrawal effects? o Why can t I stop taking the medication when I feel better? These questions / concerns will often relate to the service-users attitudes and beliefs about medication. It is important to work with the service-user to establish what are their key questions and concerns about illness and medication, then using the self-help literature & meaningful analogies to engage them in open and honest dialogue about the illness, medication & other treatment components. Using Analogies: explaining how medication works Communication between nerve cells happens as a result of chemical messengers being released from one nerve cell, which then reach and bind with receptors on the next nerve cell. These chemical messengers are therefore very important an example is serotonin. In depression, psychosis and other mental illnesses, the functional level of some of these chemicals is either too low or too high, causing symptoms. Medication is therefore prescribed to restore one or more of these chemical messengers to a normal functional level. It might be useful for you to think about an analogy in trying to understand this basic idea about how medications such as antidepressants and antipsychotics have their effect. Consider the ideas on the following page. 21 Using the Concordance Approach / John Butler / 2009

23 Understanding how medication works: the car engine Communication between nerve cells in depression can be likened to the car engine that is short of fuel, oil or water, or where the timing of the engine is too slow. Just as different antidepressants have their effect in different ways, the car engine will run better if it has a good supply of fuel, oil and water, if the plugs and leads are clean, if there is nothing blocking the fuel pipe and if the timing is correct. As with the antidepressants, too much fuel, oil and water may also cause problems. Understanding how medication works: the dripping tap Antidepressants: In depression, certain chemical messengers are in short supply, which is rather like a tap in your home that does no more than drip when you turn it on. Antidepressants have their positive effects by increasing the functional level of one or more of these chemical messengers: noradrenaline, serotonin. The antidepressant effect is therefore rather like restoring the water flow from the tap to a normal level. This analogy may also be useful in explaining side-effects: the increased flow of water may cause it splash and wet the floor, just as the increased concentration of the chemical messenger may cause some side-effects. Antipsychotics: the overflowing tap In psychosis and schizophrenia, there is too much of a certain chemical messenger, which is rather like the tap spurting out water everywhere when you turn it on. Antipsychotics have their positive effects by reducing the functional level of a chemical messenger: dopamine. The antipsychotic effect is therefore also like restoring the water flow from the tap to a normal level. You may of course be able to think about your own analogies for best understanding the main actions of some of these drugs. 22 Using the Concordance Approach / John Butler / 2009

24 8. Talking about Beliefs and Concerns about Medication From the assessment and subsequent sessions, the service-user s beliefs about their illness and medication may have emerged, which will often affect the importance that the serviceuser places on taking medication. There are also a number of common beliefs that people have about psychotropic medication (Gray 2003: 30-31, Hogan et al 1983) for example: o I think that medication is addictive o I think that medication controls me o The medication doesn t do anything o I can stop medication once I feel better o There is nothing wrong with me It will be helpful to further explore and discuss such beliefs, one by one, by asking the user to talk about the evidence for and against them. A helpful way of doing this is to use a modified version of a well-known cognitive-behavioural strategy: o ask the service-user to indicate their level of conviction for each belief on a scale if the belief is held with less than 100% conviction, then help them to explore and evaluate this o encourage the service-user to consider the evidence for and against their belief / view o ask the service-user to re-rate his/her level of conviction in light of what you have been discussing o help the service-user to construct a meaningful alternative view It is most useful to use a template for structuring this activity an example template is shown on the following page. Example showing the initial steps: Belief: I don t need to take medication once I feel better Conviction Rating: 65% Reasons For: if you get better, you shouldn t need to take it ; I don t like taking tablets Reasons Against: medication has helped me to recover ; other people tell me that I benefit from taking it ; they re not as worried if I keep taking it ; the illness has returned three times, and usually after I ve stopped taking the medication It is important to remember to back off if it seems that this process of exploring and testing beliefs is becoming a battle of wills, or is turning into a debate or argument. You can always return to the issue another time. It is important work at the client s pace, as this process is likely to take time. This process is best achieved by adopting a curious style, which involves working collaboratively through the use of open (Socratic) questioning, reflection & clarification. 23 Using the Concordance Approach / John Butler / 2009

25 Talking about Beliefs and Concerns about Medication Belief or Concern Conviction Rating: how strongly do you believe this (0 100)? Reasons For and Against the Belief or Concern FOR AGAINST Summary of Key Learning Points Conviction Rating: in light of what we have just been discussing, how strongly do you believe the belief / concern now (0 100)? Meaningful Alternative Belief / View 24 Using the Concordance Approach / John Butler / 2009

26 9. Monitoring Medication Effects & Side-effects: LUNSERS & other tools It is very helpful to monitor the unwanted side-effects that may be experienced from taking psychiatric and other medicines, as many of these can be unpleasant and may be so troublesome, severe or persistent, that the person decides to stop taking prescribed medication. Many research studies show that stopping certain medicines, like anti-depressants and antipsychotics, too early is associated with a greater risk of experiencing a relapse or further episode of the illness. The most effective way of assessing for the unwanted side-effects of medicines is to use one or more structured side-effect assessment tools at regular intervals. Recommended Structured Side-effect Assessment Tools: LUNSERS (Liverpool University Neuroleptic Side-Effect Rating Scale): a 51-item selfrating tool which covers a wide range of different types of side-effects SESCAM: a short general side-effect rating tool with both subjective and objective items BARNES Akathisia Rating Scale: a short tool for assessing the presence and severity of akathisia (general inner restlessness), with both subjective and objective items AIMS (Abnormal Involuntary Movement Scale): a short examination procedure for assessing the presence and severity of tardive dyskinesia Checklist of Anti-depressant Side Effects: a 30-item self-rating tool, designed using the LUNSERS format (Butler / Neurolink 2006) this tool is shown on the following page Remember: as unwanted side-effects are identified, they will need to be managed 25 Using the Concordance Approach / John Butler / 2009

27 26 Using the Concordance Approach / John Butler / 2009

28 10. Problem Solving the Side-effects (adapted from: Gray R (2003) Concordance Skills Manual. London: Institute of Psychiatry) It is very helpful to discuss specific problems with psychiatric medication, such as unwanted side-effects, using a structured problem-solving approach. This will involve asking you to order the unwanted side-effects you experience in order of how distressing or troublesome they are to you, choosing one unwanted side-effect to focus on, and, with the help of your named nurse or doctor, use a problem-solving approach to agree a goal / objective and form a detailed plan of how to achieve it. It is usually helpful to write out the steps of this plan as you work through the steps of problem-solving as shown below. Problem Solving the Side Effects What unwanted side effects of psychiatric medication do you experience? Put these in order, from most distressing to least distressing side effects. What is the problem side-effect you d like to work on? How severe / intense is it (rate this from 0 to 10)? How often does it occur? When it occurs, how long does it last? How does it affect you? What helps you to cope with it? 27 Using the Concordance Approach / John Butler / 2009

29 What is your goal? List all the possible solutions for achieving your goal What are the not so good and good things about each solution? Solution Not so good Good What is the best solution? Action Plan Review date: 28 Using the Concordance Approach / John Butler / 2009

30 11. Planning for the Future A useful exercise once the person has started to recover, s/he is asked to look six to twelve months into the future and to identify a goal they would like to achieve. A problem-solving strategy can then be used to identify broad and specific actions needed to achieve the objective. Consider the following example: Goal: To return to work as a retail assistant within six months. Concerns: Continuing to take medication may make returning to work difficult, due to feeling sedated, having the shakiness, feeling embarrassed, being fearful of making mistakes, and time-keeping issues Concern about employer s attitude towards my wish to return to work Options (examples): Consider a change of medication (to an atypical such as quetiapine) but this would mean carefully weighing up the risks of changing medication Review medication on fortnightly basis Reduce the dose of medication Change the timing of the dose, to taking the medication late at night Self-monitor the frequency, severity and duration of side-effects, any coping strategies that are used / tried and any achievements Gradually structure the day-time activity from now, in preparation for returning to work in six-months time It is always more helpful to make a written record of what was discussed, which can be given to the person to refer back to an example of a simple record sheet is shown on the following page. 29 Using the Concordance Approach / John Butler / 2009

31 Planning for the Future What is your goal? Try to be very clear and specific. When is it to be achieved? What may stop you from achieving your goal? What are your concerns? What options or actions might help you to achieve your goal? What has been helpful in the past that might help you now to achieve your goal? What will you do now? Try to be very specific about your actions for example: what & when? 30 Using the Concordance Approach / John Butler / 2009

32 References Boczkowski JA, Zeichner A & DeSanto N (1985) Neuroleptic compliance among chronic schizophrenic out-patients: an intervention outcome report. Journal of Consulting Clinical Psychiatry 53: Butler J (2005) Enhancing Concordance: practical collaborative approaches. Advancing Practice in Bedfordshire 2(2s): Available on-line from: Day JC, Wood G, Dewey M & Bentall RP (1995) A self-rating scale for measuring neuroleptic side-effects: validation in a group of schizophrenic patients. British Journal of Psychiatry 166: Gray R (2000) Does user education enhance compliance with clozapine? A preliminary investigation. Journal of Psychiatric & Mental Health Nursing 7: Gray R (2001) A randomised controlled trial of medication management training for CPNs. London: Institute of Psychiatry / Kings College Gray R (2003) Concordance Skills Manual (Version IV). London: The Bethlem & Maudsley NHS Trust / Institute of Psychiatry Gray R, Rofail D, Allen J & Newey T (2005) A survey of patient satisfaction with and subjective experiences of treatment with anti-psychotic medication. Journal of Advanced Nursing 52(1): 31-7 Gray R, Wykes T & Gournay K (2002) From compliance to concordance: a review of the literature on interventions to enhance compliance with anti-psychotic medication. Journal of Psychiatric & Mental Health Nursing 9: Harris N (2002) Neuroleptic drugs & their management. IN Harris N, Williams S & Bradshaw T (Eds) Psychosocial Interventions for People with Schizophrenia: a practical guide for mental health workers, Chap 6: pp Basingstoke: Palgrave MacMillan Hayward P, Chan N, Kemp R, Youle S & David A (1995) Medication Self-Management: a preliminary report on an intervention to improve medication compliance. Journal of Mental Health 4: Hogan TP, Awad AG & Eastwood R (1983) A self-report scale predictive of drug compliance in schizophrenics: reliability and discriminative validity. Psychological Medicine 13: Horne R & Weinman J (2004) The theoretical basis of concordance and issues for research. IN Bond C (Ed) Concordance: a Partnership in Medicine Taking. London: Pharmaceutical Press 31 Using the Concordance Approach / John Butler / 2009

33 Kemp R, Hayward P, Applewhaite G, Everitt B & David A (1996) Compliance Therapy in Psychotic Patients: randomised controlled trial. British Medical Journal 372: Kemp R, Hayward P & David A (1997) Compliance Therapy Manual. London: The Bethlem & Maudsley NHS Trust Kemp R, Kirov G, Everitt B, Hayward P & David A (1998) Randomised controlled trial of compliance therapy: 18-month follow-up. British Journal of Psychiatry 172: Lecompte D & Pelc I (1996) A cognitive-behavioural programme to improve compliance with medication in patients with schizophrenia. International Journal of Mental Health 25: 51-6 MacPherson R, Jerrom & Hughes A (1996) A controlled study of education about drug treatment in schizophrenia. British Journal of Psychiatry 168: Neurolink & Butler J (2006) Working Together to Manage Depression: a practical guide for doctors and health-care professionals. London: Neurolink / IntraMed Perkins RE & Repper JM (1999) Compliance or Informed Choice. Journal of Mental Health 8(2): Smith JV, Birchwood MJ & Hadrell A (1992) Informing people with schizophrenia about their illness: the effect of residual symptoms. Journal of Mental Health 1: Using the Concordance Approach / John Butler / 2009