High-yield techniques in brief CBT sessions can promote adherence

SAN ANTONIO – Treatment adherence is a problem for about half of all psychiatric patients, but certain high-yield techniques for enhancing adherence can be used effectively during brief cognitive-behavioral therapy sessions, according to Dr. Donna M. Sudak and Dr. Jesse H. Wright.

Maximizing the collaborative therapeutic relationship is particularly important, as this can facilitate open discussion about adherence, Dr. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia, and Dr. Wright, professor and director of the depression center at the University of Louisville (Ky.), said in a joint presentation at the annual meeting of the American College of Psychiatrists.

"No electronic reminder is as helpful for adherence as having a good relationship with the patient and asking regularly [about adherence]," Dr. Sudak said.

It is important, however, to ask in a way that helps patients tell you about any difficulties they are having.

Asking a patient, "You’re taking your medicine every day, right?" will typically elicit an affirmative response, in part because people just want to be good patients, Dr. Sudak said.

Encouraging open dialogue about how hard it can be to remember to take medication every day, and explaining to patients that the goal is to have them take their medication as often as possible – and discussing ways to reach that goal – will likely do more to encourage patients to discuss adherence problems, she said.

In addition to normalizing the illness and adherence problems through such dialogue, providing patients with printed educational materials about the importance of adherence – and repeating these efforts at intervals to reinforce the message – is also important, Dr. Sudak said, noting that this is particularly important for patients who have just been discharged from the hospital, because these patients might have particular difficulty remembering instructions.

Asking first about the benefits of medication, rather than about side effects, also is an important strategy; this puts the focus on the positive aspects of treatment, instead of reminding the patient about the potential negative aspects, she said.

And remember that adherence issues change across the life cycle. For example, when a patient transitions from home to a college dorm or to independent living, adherence issues can arise. Thus, adherence should be routinely monitored.

Collaboration, a nonjudgmental approach, and realistic expectations are important throughout treatment.

Other strategies for promoting adherence include involving the patient’s family if possible and if helpful; linking adherence to the patient’s goals and most distressing symptoms; and simplifying medication regimens when possible.

Jointly and relentlessly pursuing solutions to side effects also is imperative; pointing out that medication has effects that are desired, as well as effects that are not – and working to minimize the undesirable effects – will encourage persistence on the part of the patient, Dr. Sudak said.

She and Dr. Wright provided numerous specific behavioral and cognitive methods for improving adherence.

Behavioral methods that might help patients with adherence include storing medication in a place where it will be seen each day, pairing medication taking with routine activities, and using a reminder system, such as a 7-day pill container.

"These are very commonsense kinds of approaches ... but they can really be very helpful," Dr. Wright said.

Behavioral contracts and written adherence plans also can prove helpful, he said, adding that it also is important to analyze barriers to adherence and to devise written methods for overcoming those barriers.

An example of a barrier might be running out of samples of medication before a scheduled doctor visit; a potential solution would be to have the patient count pills carefully, call the nurse a week before more samples will be needed, and make a plan to pick them up during a weekday while the nurse is available.

Another barrier might be a voice telling a patient that the medication is causing harm; a possible solution would be to remind the patient that the voices are a symptom of the patient’s illness, and that it is not necessary to do what the voices say. The patient also could be instructed to review a list of positive reasons to take the medication.

These and other behavioral techniques and barriers/solutions can be written on 3-by-5 "coping cards" that capture the key points of the session. The patient can take these cards home to serve as reminders.

As for cognitive methods, Dr. Sudak and Dr. Wright recommended eliciting cognitions about taking medication, and about the illness, to identify and modify dysfunctional family beliefs about medication, and to write down the old belief and the new more-functional belief.

Cognitions that can interfere with adherence include:

• Specific ideas about the illness or medication – such as a belief that antidepressant medications are addictive. Education should be provided to counter these beliefs.

• More general beliefs (family or cultural beliefs/values) about physicians or medication – such as beliefs that individuals should be able to handle medical problems on their own. These beliefs should be examined, and logical analysis should be employed to explore and correct them.

• Beliefs about medication that echo beliefs about the self. For example, a patient might believe he is vulnerable in general, and thus believe he is prone to side effects. Belief work can help in these cases.

• Basic mistrust and interpersonal beliefs that interfere more globally. More specific trust work can help in these cases.

Additional cognitive strategies that can help with adherence are pro/con lists, evaluating thoughts for accuracy, developing new rules and beliefs about medication, problem solving and planning, and cognitive rehearsal, they said.

Dr. Sudak and Dr. Wright are two of four coauthors of the book, "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide (Washington: American Psychiatric Publishing, 2010). They both receive book royalties from American Psychiatric Publishing; Lippincott, Williams & Wilkins; and John Wiley & Sons. Dr. Sudak also serves on an editorial board, receives honoraria from Elsevier, and is a consultant for Takeda Pharmaceuticals. Dr. Wright also receives royalties for the development of software (Empower Interactive, Mindstreet).

SAN ANTONIO – Treatment adherence is a problem for about half of all psychiatric patients, but certain high-yield techniques for enhancing adherence can be used effectively during brief cognitive-behavioral therapy sessions, according to Dr. Donna M. Sudak and Dr. Jesse H. Wright.

Maximizing the collaborative therapeutic relationship is particularly important, as this can facilitate open discussion about adherence, Dr. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia, and Dr. Wright, professor and director of the depression center at the University of Louisville (Ky.), said in a joint presentation at the annual meeting of the American College of Psychiatrists.

"No electronic reminder is as helpful for adherence as having a good relationship with the patient and asking regularly [about adherence]," Dr. Sudak said.

It is important, however, to ask in a way that helps patients tell you about any difficulties they are having.

Asking a patient, "You’re taking your medicine every day, right?" will typically elicit an affirmative response, in part because people just want to be good patients, Dr. Sudak said.

Encouraging open dialogue about how hard it can be to remember to take medication every day, and explaining to patients that the goal is to have them take their medication as often as possible – and discussing ways to reach that goal – will likely do more to encourage patients to discuss adherence problems, she said.

In addition to normalizing the illness and adherence problems through such dialogue, providing patients with printed educational materials about the importance of adherence – and repeating these efforts at intervals to reinforce the message – is also important, Dr. Sudak said, noting that this is particularly important for patients who have just been discharged from the hospital, because these patients might have particular difficulty remembering instructions.

Asking first about the benefits of medication, rather than about side effects, also is an important strategy; this puts the focus on the positive aspects of treatment, instead of reminding the patient about the potential negative aspects, she said.

And remember that adherence issues change across the life cycle. For example, when a patient transitions from home to a college dorm or to independent living, adherence issues can arise. Thus, adherence should be routinely monitored.

Collaboration, a nonjudgmental approach, and realistic expectations are important throughout treatment.

Other strategies for promoting adherence include involving the patient’s family if possible and if helpful; linking adherence to the patient’s goals and most distressing symptoms; and simplifying medication regimens when possible.

Jointly and relentlessly pursuing solutions to side effects also is imperative; pointing out that medication has effects that are desired, as well as effects that are not – and working to minimize the undesirable effects – will encourage persistence on the part of the patient, Dr. Sudak said.

She and Dr. Wright provided numerous specific behavioral and cognitive methods for improving adherence.

Behavioral methods that might help patients with adherence include storing medication in a place where it will be seen each day, pairing medication taking with routine activities, and using a reminder system, such as a 7-day pill container.

"These are very commonsense kinds of approaches ... but they can really be very helpful," Dr. Wright said.

Behavioral contracts and written adherence plans also can prove helpful, he said, adding that it also is important to analyze barriers to adherence and to devise written methods for overcoming those barriers.

An example of a barrier might be running out of samples of medication before a scheduled doctor visit; a potential solution would be to have the patient count pills carefully, call the nurse a week before more samples will be needed, and make a plan to pick them up during a weekday while the nurse is available.

Another barrier might be a voice telling a patient that the medication is causing harm; a possible solution would be to remind the patient that the voices are a symptom of the patient’s illness, and that it is not necessary to do what the voices say. The patient also could be instructed to review a list of positive reasons to take the medication.

These and other behavioral techniques and barriers/solutions can be written on 3-by-5 "coping cards" that capture the key points of the session. The patient can take these cards home to serve as reminders.

As for cognitive methods, Dr. Sudak and Dr. Wright recommended eliciting cognitions about taking medication, and about the illness, to identify and modify dysfunctional family beliefs about medication, and to write down the old belief and the new more-functional belief.

Cognitions that can interfere with adherence include:

• Specific ideas about the illness or medication – such as a belief that antidepressant medications are addictive. Education should be provided to counter these beliefs.

• More general beliefs (family or cultural beliefs/values) about physicians or medication – such as beliefs that individuals should be able to handle medical problems on their own. These beliefs should be examined, and logical analysis should be employed to explore and correct them.

• Beliefs about medication that echo beliefs about the self. For example, a patient might believe he is vulnerable in general, and thus believe he is prone to side effects. Belief work can help in these cases.

• Basic mistrust and interpersonal beliefs that interfere more globally. More specific trust work can help in these cases.

Additional cognitive strategies that can help with adherence are pro/con lists, evaluating thoughts for accuracy, developing new rules and beliefs about medication, problem solving and planning, and cognitive rehearsal, they said.

Dr. Sudak and Dr. Wright are two of four coauthors of the book, "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide (Washington: American Psychiatric Publishing, 2010). They both receive book royalties from American Psychiatric Publishing; Lippincott, Williams & Wilkins; and John Wiley & Sons. Dr. Sudak also serves on an editorial board, receives honoraria from Elsevier, and is a consultant for Takeda Pharmaceuticals. Dr. Wright also receives royalties for the development of software (Empower Interactive, Mindstreet).

SAN ANTONIO – Treatment adherence is a problem for about half of all psychiatric patients, but certain high-yield techniques for enhancing adherence can be used effectively during brief cognitive-behavioral therapy sessions, according to Dr. Donna M. Sudak and Dr. Jesse H. Wright.

Maximizing the collaborative therapeutic relationship is particularly important, as this can facilitate open discussion about adherence, Dr. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia, and Dr. Wright, professor and director of the depression center at the University of Louisville (Ky.), said in a joint presentation at the annual meeting of the American College of Psychiatrists.

"No electronic reminder is as helpful for adherence as having a good relationship with the patient and asking regularly [about adherence]," Dr. Sudak said.

It is important, however, to ask in a way that helps patients tell you about any difficulties they are having.

Asking a patient, "You’re taking your medicine every day, right?" will typically elicit an affirmative response, in part because people just want to be good patients, Dr. Sudak said.

Encouraging open dialogue about how hard it can be to remember to take medication every day, and explaining to patients that the goal is to have them take their medication as often as possible – and discussing ways to reach that goal – will likely do more to encourage patients to discuss adherence problems, she said.

In addition to normalizing the illness and adherence problems through such dialogue, providing patients with printed educational materials about the importance of adherence – and repeating these efforts at intervals to reinforce the message – is also important, Dr. Sudak said, noting that this is particularly important for patients who have just been discharged from the hospital, because these patients might have particular difficulty remembering instructions.

Asking first about the benefits of medication, rather than about side effects, also is an important strategy; this puts the focus on the positive aspects of treatment, instead of reminding the patient about the potential negative aspects, she said.

And remember that adherence issues change across the life cycle. For example, when a patient transitions from home to a college dorm or to independent living, adherence issues can arise. Thus, adherence should be routinely monitored.

Collaboration, a nonjudgmental approach, and realistic expectations are important throughout treatment.

Other strategies for promoting adherence include involving the patient’s family if possible and if helpful; linking adherence to the patient’s goals and most distressing symptoms; and simplifying medication regimens when possible.

Jointly and relentlessly pursuing solutions to side effects also is imperative; pointing out that medication has effects that are desired, as well as effects that are not – and working to minimize the undesirable effects – will encourage persistence on the part of the patient, Dr. Sudak said.

She and Dr. Wright provided numerous specific behavioral and cognitive methods for improving adherence.

Behavioral methods that might help patients with adherence include storing medication in a place where it will be seen each day, pairing medication taking with routine activities, and using a reminder system, such as a 7-day pill container.

"These are very commonsense kinds of approaches ... but they can really be very helpful," Dr. Wright said.

Behavioral contracts and written adherence plans also can prove helpful, he said, adding that it also is important to analyze barriers to adherence and to devise written methods for overcoming those barriers.

An example of a barrier might be running out of samples of medication before a scheduled doctor visit; a potential solution would be to have the patient count pills carefully, call the nurse a week before more samples will be needed, and make a plan to pick them up during a weekday while the nurse is available.

Another barrier might be a voice telling a patient that the medication is causing harm; a possible solution would be to remind the patient that the voices are a symptom of the patient’s illness, and that it is not necessary to do what the voices say. The patient also could be instructed to review a list of positive reasons to take the medication.

These and other behavioral techniques and barriers/solutions can be written on 3-by-5 "coping cards" that capture the key points of the session. The patient can take these cards home to serve as reminders.

As for cognitive methods, Dr. Sudak and Dr. Wright recommended eliciting cognitions about taking medication, and about the illness, to identify and modify dysfunctional family beliefs about medication, and to write down the old belief and the new more-functional belief.

Cognitions that can interfere with adherence include:

• Specific ideas about the illness or medication – such as a belief that antidepressant medications are addictive. Education should be provided to counter these beliefs.

• More general beliefs (family or cultural beliefs/values) about physicians or medication – such as beliefs that individuals should be able to handle medical problems on their own. These beliefs should be examined, and logical analysis should be employed to explore and correct them.

• Beliefs about medication that echo beliefs about the self. For example, a patient might believe he is vulnerable in general, and thus believe he is prone to side effects. Belief work can help in these cases.

• Basic mistrust and interpersonal beliefs that interfere more globally. More specific trust work can help in these cases.

Additional cognitive strategies that can help with adherence are pro/con lists, evaluating thoughts for accuracy, developing new rules and beliefs about medication, problem solving and planning, and cognitive rehearsal, they said.

Dr. Sudak and Dr. Wright are two of four coauthors of the book, "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide (Washington: American Psychiatric Publishing, 2010). They both receive book royalties from American Psychiatric Publishing; Lippincott, Williams & Wilkins; and John Wiley & Sons. Dr. Sudak also serves on an editorial board, receives honoraria from Elsevier, and is a consultant for Takeda Pharmaceuticals. Dr. Wright also receives royalties for the development of software (Empower Interactive, Mindstreet).