Participatory pharmacotherapy: 10 strategies for enhancing adherence

For example, Ms. J, a 38-year-old married mother of 2, was diagnosed with bipolar II disorder. She listed her highest priority as controlling her impulsive shopping rather than alleviating depression, insomnia, or overeating. She had been forced to declare bankruptcy twice, and she was determined to never do so again. She also wanted to regain her husband’s trust and her ability to manage her finances. Ensuring that Ms. J felt understood regarding this issue increased the chances of establishing a solid treatment partnership. Providing Ms. J with a menu of treatment choices and asking her to describe her previous experiences with medications helped her and the clinician choose a medication that is compatible with her desire to control her impulsive shopping.

5. Engage patients in choosing the best delivery system for the prescribed medication. For many medications, clinicians can choose from a variety of delivery systems, including pills, transdermal patches, rectal or vaginal suppositories, creams, ointments, orally disintegrating tablets, liquids, and intramuscular injections. Patients have varying beliefs about the efficacy of particular delivery systems, based on personal experiences or what they have learned from the media, their family and friends, or the Internet. For example, Ms. S, age 28, experienced recurrent, disabling anxiety attacks. When asked about the best way of providing medication to relieve her symptoms, she chose gluteal injections because, as a child, her pediatrician had treated her for an unspecified illness by injecting medication in her buttock, which rapidly relieved her symptoms. This left her with the impression that injectable medications were the best therapeutic delivery system. After discussing the practicalities and availability of fast-acting medications to control panic attacks, we agreed to use orally disintegrating clonazepam, which is absorbed swiftly and provides fast symptom relief. Ms. S reported favorable results and was pleased with the process of developing this strategy with her clinician.

6. Involve patients in choosing the times and frequency of medication administration. The timing and frequency of medication administration can be used to enhance desirable therapeutic effects. For example, an antidepressant that causes sedation and somnolence could be taken at bedtime to help alleviate insomnia. Some studies have shown that taking a medication once a day improves adherence compared with taking the same medication in divided doses.¹³ Other patients may wish to take a medication several times a day so they can keep the medication in their purse or briefcase and feel confident that if they need a medication for immediate symptom relief, it will be readily available.

7. Teach patients to self-monitor changes and improvements in target symptoms. Engaging patients in a system of self-monitoring improves their chances of achieving successful treatment outcomes.¹⁴ Instruct patients to create a list of symptoms and monitor the intensity of each symptom using a rating scale of 1 to 5, where 1 represents the lowest intensity and 5 represents the highest. As for frequency, patients can rate each symptom from “not present” to “present most of the time.”

Self-monitoring allows patients to observe which daily behaviors and lifestyle choices make symptoms better and which make them worse. For example, Mrs. P, a 38-year-old married mother of 2, had anxiety and panic attacks associated with low self-esteem and chronic depression. Her clinician instructed her to use a 1-page form to monitor the frequency and intensity of her anxiety and panic symptoms by focusing on the physical manifestations, such as rapid heartbeat, shortness of breath, nausea, tremors, dry mouth, frequent urination, and diarrhea to see if there was any correlation between her behaviors and her symptoms.

8. Instruct patients to call you to report any changes, including minor successes. Early in my career, toward the end of each appointment after I’d prescribed medications I’d tell patients, “Please call me if you have a problem.” Frequently, patients would call with a list of problems and side effects that they believed were caused by the newly prescribed medication. Later, I realized that I may have inadvertently encouraged patients to develop problems so they would have a reason to call me. To achieve a more favorable outcome I changed the way I communicate. I now say, “Please call me next week, even if you begin to feel better with this new medication.” The phone call is now associated with the idea that they will “get better,” and internalizing such a suggestion allows patients to talk with the clinician and report favorable treatment results.

9. Tell patients to monitor their successes by relabeling and reframing their symptoms. Mr. B, age 28, has MDD and reports irritability, insomnia, short temper, and restlessness. After reviewing his desired treatment outcome, we discuss the benefits of pharmacotherapy. I tell him the new medication will improve the quality and length of his sleep, which will allow his body and mind to recharge his “internal batteries” and restore health and energy. When we discuss side effects, I tell him to expect a dry mouth, which will be his signal that the medication is working. This discussion helps patients reframe side effects and improves their ability to tolerate side effects and adhere to pharmacotherapy.