TIPS and TOPICS
from David Mee-Lee, M.D.
Volume 8, No. 3
June 2010

In this issue
SAVVY and SKILLS Better working relationship with clients
SOUL Families are people too!
Until Next Time

Welcome to the June edition of TIPS and TOPICS.  Like you, I am inundated with information pouring daily into my e-mail inbox.  I save interesting bits and pieces in my “research news” folder. This edition you have the chance to take a peek at some of those.

SAVVY & SKILLS

(combined this month)

Research done in other health fields can spark innovations and application to our own behavioral health work.  In this TNT there are 10 SAVVY tips; I have written the implications for our field at the bottom of each number. These are the SKILLS “tips” for this issue.

1. Patients want to know the truth about their prognosis, nurse writes.

In the New York Times (5/12) “Well” blog, Theresa Brown, RN, wrote, “It’s easy for doctors and nurses to be bold when the news is good; more difficult when it’s not.” Brown noted, “It’s not easy to deliver or receive the news that you or someone you love has run out of options; that there is no hope. But people want the truth. In fact, they crave it.” She concluded, “It may be just as important to tell someone they are dying as to tell them that they aren’t.”

Reference

Implication:
You want your client to be an informed consumer.  Be sure to clearly and completely explain to them your evaluation, diagnosis and their treatment options.

2. Researchers examine some patients’ decision not to undergo lung cancer surgery.

The New York Times (6/22, D6, Rabin) reports that, in order to determine why some lung cancer patients refuse to undergo an operation which could prolong their lives, “researchers asked 386 new lung cancer patients who were eligible for the operation, called resection, to fill out detailed questionnaires about their backgrounds and access to health care.” They found that “patients who reported feeling that they did not communicate well with their doctors were less likely to have the operation, as were those who thought they would not necessarily be better off a year later if they had surgery.”

Reference

Implication:
Communicating with clients is not: just telling them what their problem is and to comply with treatment.
Communicating with clients is: collaborating with them about their options for treatment plus your recommendations.  It also involves inspiring in them a sense of hope and optimism for recovery.

3. Patient’s gender may determine how they feel about their physician.

In the New York Times (5/6) Doctor and Patient column, Pauline W. Chen, MD, wrote, “For two decades, spurred on by the rising number of women going to medical school…researchers have been studying the influence of gender on physician style.” Recent research has revealed that “the patient’s gender determines how patients feel about their doctors, as much if not more than the physician’s.” In fact, one study conducted by Swiss and American researchers showed that “patients, depending on their gender, evaluated their male and female physicians’ displays of concern for their patients differently.” A separate study appearing in the Journal of Women’s Health showed that “women patients were more likely to have discussions with doctors that focused on their illness experience and personal factors, regardless of the physician’s gender.”

Reference

Implication:
Whether you are a male or female clinician, you may experience that women clients may naturally offer more about their needs and treatment.  However you may need to be deliberate with male clients: Invite them to speak up and often; keep asking them about their needs and wants, and encouraging them to voice those.

4. Patients not taking medicine as directed is a national problem.

The Boston Globe (5/10, Smith) reports that “a common conundrum” is “patients who do not take their medication as directed.” Part of the issue can be economic. A study found “that a $5 increase in copayments for cholesterol-controlling statin drugs significantly reduced the likelihood prescriptions would be filled by veterans in Philadelphia. Still, that same study discovered that even when veterans were exempt from copayments, there was far from universal use of prescribed drugs.”

Reference

Implication:
Just creating a goal in your client’s treatment plan- “Medication Compliance”- can be meaningless…..unless they are actively involved in the decision to take medication…unless they actually agree to take their meds…..and unless they are consistently monitored to check if they are adhering to the plan.

5. Medication non-adherence costs over $170 billion in the US annually.

Pauline W. Chen, MD writes in the New York Times (5/21) Doctor and Patient column, “Like politics, religion and sex, medication non-adherence, or noncompliance, remains a topic of conversation that most of us try to avoid. While anyone who has ever tried to complete a full course of antibiotics can understand how easy it is to skip, cut down or forget one’s medications altogether, bringing the topic up in the exam room feels more like a confession or inquisition than a rational discussion.” In fact, “few of us want to talk about medication non-adherence, much less admit to it.” Data show that medication non-adherence costs “more than $170 billion annually in the United States alone.”

Reference

Implication:
Ask your client: “Are you even interested in taking medication?  If you are, can you anticipate what obstacles to taking it might arise? What situations in your daily life might prevent you from taking the medication faithfully?”

6. Small study indicates patient beliefs may affect medication adherence in bipolar disorder.

MedWire (1/5, Davenport) reports that, according to a study published online Dec. 14 in the journal European Psychiatry, “the treatment and illness beliefs of patients with bipolar disorder predict medication adherence and may represent a potential target for modification.” In a study of 35 patients with bipolar disorder, UK researchers found that “patients who were non-adherent were significantly younger than adherent patients…were prescribed significantly more psychiatric medications,” and “were significantly more likely to believe that their illness would have negative effects on their life, and would have a longer-term impact.” Finally, “age and beliefs about whether medications are overprescribed were significant predictors of non-adherence to medication.”

Reference

European Psychiatry
Volume 25, Issue 4, May 2010, Pages 216-219

Implication:
We should never dismiss or underestimate our clients’ belief about their illness and the effect on their lives.  This does affect their adherence to treatment.  Be proactive and elicit what your client understands and believes about their signs and symptoms; and how it does, and will continue to, affect their lives. What do you know about your diagnosis? The prognosis? How do you feel about this? Do you see yourself getting well? Or just living with it?

7.  Even severely-ill patients adhere better if they help choose their own treatment.

Even people with severe mental illness are more likely to adhere to their medication if they are given a voice in choosing it. Duke University psychiatrists found a 27% increase in medications prescribed and a significant improvement in adherence over 12 months among severely ill patients given the opportunity to create an advance directive for their own care.

Reference

“Medication Preferences and Adherence Among Individuals With Severe Mental Illness and Psychiatric Advance Directives”
Christine M. Wilder, M.D., Eric B. Elbogen, Ph.D., Lorna L. Moser, Ph.D., Jeffrey W. Swanson, Ph.D. and Marvin S. Swartz, M.D.

Psychiatric Services 2010, 61: 380-385

Implication:
Severely mentally-ill clients can be seen as hopeless to improve, and therefore are offered just stabilization and maintenance treatment. A recovery-oriented perspective expects and offers more: What does recovery for this person look like? Upgrade your conversation with them. Discuss and discover what is important to them: What do you want in how and where you live? How do you want to spend your time in doing something productive? In having fun?  Who are your friends? And what do you enjoy doing with them?

8. Researchers Identify Factors Predicting Non-adherence To Bipolar Disorder Treatments.

Med Wire (4/6, Czyzewski) reports that, according to a study published in the Journal of Clinical Psychiatry, “poor treatment adherence in bipolar disorder is associated with a number of socio-demographic and clinical factors.” After examining “data from the Systematic Treatment Enhancement Program for Bipolar Disorder,” researchers found that “several socio-demographic features were significantly associated with poor adherence” to treatment, “including younger age (odds ratio [OR]=0.89 per 10-year age increase), Hispanic race (OR=1.48), and having a household income less then $50,000 per year (OR=1.45).” Other “features associated with poor adherence included rapid cycling (OR=1.40), suicide attempts (OR=1.32), earlier onset of illness age (OR=0.77 per 10-year age increase), current anxiety disorders, (OR=1.47), and alcohol use disorders (OR=1.68).”

Reference

Implication:
Not all clients are the same.  Age, race, illness onset, other psychiatric conditions and more help sharpen the “profile” of who might be at greater risk for non-adherence to treatment.  When the odds are stacked against your client, be proactive and vigilant to track and engage that client. Think about more frequent check-in visits; or more social supports like a peer run drop-in center or club; closer case management. Sometimes an ounce of proactive prevention is worth a pound of cure and treatment.

9. Experts propose small financial incentives to help ensure medication adherence.

The New York Times (6/14, A1, Belluck) reports on its front page, “One-third to one-half of all patients do not take medication as prescribed, and up to one-quarter never fill prescriptions at all, experts say. Such lapses fuel more than $100 billion dollars in health costs annually because those patients often get sicker.” But “now, a controversial, and seemingly counterintuitive, effort to tackle the problem is gaining ground: paying people money to take medicine or to comply with prescribed treatment. The idea, which is being embraced by doctors, pharmacy companies, insurers and researchers, is that paying modest financial incentives up front can save much larger costs of hospitalization.” One physician noted that “although ‘economically irrational’…small sums might work better than bigger ones.”

Reference

Implication:
Incentives for negative drug urine tests, attendance at treatment and meeting treatment goals in addiction treatment has been studied for decades.  There is a case to be made for broadening its application in behavioral health.
“Contingency management (CM) – the systematic reinforcement of desired behaviors and the withholding of reinforcement or punishment of undesired behaviors- is an effective strategy in the treatment of alcohol and other drug (AOD) use disorders.” (Stephen T. Higgins, Ph.D., and Nancy M. Petry, Ph.D. “Contingency Management – Incentives for Sobriety” Alcohol Research & Health, Vol. 23, No. 2, 1999, pp. 122-127

10. Placebo treatments may have actual biological effect in the body.

The  AP (2/19, Cheng) reports that, according to a review published online Feb. 19 in The Lancet, “there is increasing evidence that fake treatments, or placebos, have an actual biological effect in the body.” In a “review of previous research on placebos,” researchers found that “the doctor-patient relationship, plus the expectation of recovery, may sometimes be enough to change a patient’s brain, body, and behavior.” The review’s authors specifically cited studies in which patients with Parkinson’s disease who were given a placebo still experienced a dopamine release in the brain, as well as other brain-activity changes.

Damien G Finniss, Ted J Kaptchuk,  Franklin Miller, Fabrizio Benedetti (2010):
“Biological, clinical, and ethical advances of placebo effects”
The Lancet, Volume 375, Issue 9715, Pages 686 – 695, 20 Feb. 2010

Reference

Implication:
This research points to the power that exists when a client expects hope and recovery.  When a clinician (1) establishes a positive therapeutic relationship and (2) engenders this hope in the client, treatment succeeds.  These 2 factors are much more powerful indicators of effective outcomes than the evidence-based practice of a specific technique and model.  General health is just now discovering this to be true; however we in behavioral health have forgotten four decades of psychotherapy research which overwhelmingly proves this.

SOUL

Consider these three vignettes:

1. A 95 year old, relatively-healthy, widowed woman falls and breaks her left hip.  Her three children, well-educated and respectful, are worried.  They want the best available orthopedic surgeon to pin and plate the fracture; they are willing to pay whatever it takes, but have great difficulty finding out ahead of time what he will charge.  Nurses make the arrangement for the operation.  The surgeon talks to the worried family neither before nor after the surgery, even briefly, to inform the family pre-operatively or reassure them after.

Before you dismiss this as “a surgeon being a surgeon” and that behavioral health clinicians in would never be like that, read vignettes #2 and 3.

2. A clinician evaluates a mother of a two year old. The mother is seeking residential addiction treatment.  Her partner, and father of their child, has threatened to seek custody because of her out-of-control drug use. I ask the assessor: Is it true that the frustrated father would actually do that? Or is the father just so worried and frustrated that it could be an empty threat?  The clinician tells me he didn’t speak to the father.  I wonder: Who will empathize with, and support, this distressed father?  Or does he have to wait for family group which takes place- next week?!

3. A drug addicted woman shows up for admission at a large hospital which has addiction services. She is willing, but strung out; distressed and needs the support of her brother who has accompanied her to assist however he can.  As they both start walking into the admissions office, the staff person says: “Oh no, you can’t come in…just the patient.” The woman says she needs her brother’s support and is OK about confidentiality. The brother is still excluded.

The first vignette is about my mother in Australia who fell last week.  I’m on my way to see her and so far she is doing well.  If I happen to see her surgeon………!!

The second vignette occurred many years ago. I hope my supervision of this clinician paid off and has changed how he engages and empathizes with family members now.

The third vignette
Some years ago, I heard of this case in a presentation from, as I recall,  NIATx.*
The woman was the Vice President of Clinical Services of the hospital posing as the patient; and the “brother” was the Medical Director of the addiction service also posing as the family member. Since it was a large hospital, they were not immediately recognized. It was a real eye-opener to them on how their hospital treated family members.

*(NIATx helps behavioral health providers improve access to and retention in treatment for all of their clients. We do this primarily by helping treatment providers use process improvement methods. www.niatx.net).

I hope these are isolated and rare examples of how families are excluded, unsupported and left to deal with their stress of living with an addicted or mentally-ill loved one; or left to worry and wonder about the well-being of their mother.

I fear this still happens all too often.

Until Next Time

Thanks for reading.  See you in late July.

David

David Mee-Lee, M.D.