A New Way to Talk to Patients about Medication
The Carlat Psychiatry Report, Volume 17, Number 9, September 2019
Shawn Christopher Shea, MD
Director of the Training Institute for Suicide Assessment and Clinical Interviewing. Internationally recognized innovator in the fields of clinical interviewing and suicide prevention and author of seven books, several of which are included in Doody’s Core List of the most important books in psychiatry and medicine.
Dr. Shea has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
TCPR: We all want to communicate better with patients, particularly around medications. You’ve lead workshops on this for several decades. Tell us about the model you developed out of that work.
Dr. Shea: The Medication Interest Model (MIM) is a set of over 100 interview techniques that create shared decision making regarding all disease states from psychiatric illnesses to diabetes, congestive heart failure and AIDS. The MIM techniques were created to help experienced clinicians maximize patient interest and follow-through with medications in their day-to-day practices. The model is designed for psychiatrists, as well as general medical providers and trainees—anyone who talks with patients about their medications. It addresses everything from creating motivation to uncovering side effects and collaboratively matching medication choice to the unique cultural needs of the patient.
TCPR: How do we need to shift our mindset to do this work?
Dr. Shea: Here’s a good place to start: If patients don’t want to take a particular medication, they probably have a logical reason for not doing so. They are not being resistant; they are actually making the decision that we ourselves would make if we believed what they believe. There are usually three beliefs that a person generally needs to have in order to stay on a medication.
TCPR: What are those?
Dr. Shea: The first is that there is something wrong, or else they wouldn’t need the medication. Second, they have to believe that a medication is a reasonable option, and third, that the pros of that medication outweigh the cons. We call this the “Choice Triad”, and it fits with most patients, just as it would for us. Occasionally there are patients that might have characterological problems and don’t take the medications because they are oppositional. But that is not what is going on with the vast majority of patients. It’s not defiance. They legitimately do not think this medication is appropriate for them. And sometimes they are right.
TCPR: How does the Choice Triad play out in psychiatric patients?
Dr. Shea: Take schizophrenia. Many people who are in their first psychotic break do not think that there is anything wrong with them. Well, none of us would take a medication if we didn’t believe that there was something wrong with us, especially if it causes side effects like tardive dyskinesia. When we understand that they are making a wise decision for what they believe to be true, it changes the interaction; the way it feels to be in the room with them. The problem is not the patient; the problem is that the patient has a belief that is different than our own.
TCPR: Sounds like you need to understand the patient’s beliefs first. How do you get to that?
Dr. Shea: Ask how they feel on their medication right now and just take it from there. Often, they barely have to answer because it comes through in their body language. If it seems they’re on a medication that they clearly love, I’d give it some real thought before recommending a change. Sometimes we assume, or are pressured by administration to think, that we need to do something different at the first meeting. But that’s not always the case. Sometimes the medication regimen a person is on is the best one for them, even if they’re not getting total relief (see box below for MIM sample questions).
TCPR: How do you approach side effects?
Dr. Shea: I’ll ask, “What does it mean to you that you get lightheaded? What impact does that have on your life?” I’m looking for their perception, their fears. That’s what causes people to stop their medications; not simply the side effects but their beliefs about them. If it was just about the severity, no one would take chemotherapeutic agents for cancer, but they do. For a teacher or an actor, a “simple” dry mouth may be viewed as job-threatening, and they may feel that they need to stop the antidepressant no matter how much relief from their depression it is providing. In contrast, a patient who is no longer sexually active may find serious sexual side effects to be of no concern whatsoever.
TCPR: Empathy sounds very important here.
Dr. Shea: Yes. It’s all too easy to minimize side-effects. One thing that’s helped me avoid that is the realization that side effects are actually a disease. They fit Webster’s definition: A disease is something that causes pathophysiologic changes in the body. So, when we cause side effects, we are giving the patient a disease. We’re asking people to swap diseases. Is the disease that I have worse than the disease that these medications are causing? They are also struggling with the financial costs of the medicine and its psychological toll. What does it say about me that I have to take this medication?
TCPR: Patients often lose interest in medications when they are on them for prevention. How do you work with that?
Dr. Shea: Let’s say a person with bipolar disorder is euthymic on a combination of lithium and Depakote, and they are thrilled. They truly believe that the medications have helped. But with the passage of years that patient might still have a very normal human question: “Do I still need these meds?” They’re unlikely to share that doubt with me unless I ask them to: “You’ve been doing really well on your lithium and your valproate for the past two years. Some of my patients have told me that they start to wonder at this point, ‘Do I actually need these medications?’ Sometimes, they even have thoughts like ‘Maybe I should stop them or lower the dose’, and I’m just curious, have you had any thoughts like that?”
TCPR: And if they intend to stop them?
Dr. Shea: After gently reviewing the pros of staying on the medication in a non-defensive fashion I might say: “You know, I will always tell you what I believe. My personal belief is that I really think you should stay on these medications. On the other hand, if you definitely are going to stop them, then I think we ought to do it together. It’s usually not wise to stop a medication suddenly. It is safer to taper off slowly, one at a time, and I’d be willing to do that with you.” It’s important that the patient understand I’m on their side. “I hope you are able to stay well off the Depakote. The less medication one needs the better. My fear is that the bipolar disorder will come back. Let’s hope it doesn’t. Let’s do this together and let’s agree that you will call me if you get any of your early warning signs of mania or depression.”
TCPR: When is it better to step in more actively and challenge the patient?
Dr. Shea: For that to work they need to understand your philosophy around medications first. I usually explain that in the initial meeting. Here is just one example of a MIM technique for doing this called Introducing Shared Expertise: “I’d like to make sure you’re comfortable with my approach to using medications, because you are the one who’s putting them in your body; not me. My own feeling about medications is that they can be invaluable and even save lives. But I’m aware they can also cause bad side effects. This is a shared journey and we are both experts. I view myself as an expert on medications and their side effects, but you are the only person that knows what you are feeling on them. If for any reason, you decide there is a problem with a medication, please tell me. I’ll always want to know. Don’t stop it immediately; call me and I’ll try to help you figure out what’s going on.” Another thing I’ll say is: “I view it as my responsibility to let you know whether a medication seems to be working. If I see a problem with it, I’m gonna tell you that I think we should stop the medication.” The message that I am a watchdog for problems with medications—not a pill-pusher—means an enormous amount to patients.
TCPR: You explain what can happen if patients stop their meds, but can that ever backfire? Like when fear is used to motivate?
Dr. Shea: Yes, in the MIM we teach that one has to be careful with fear. Humans usually can’t tolerate high amounts of fear for long periods of time. Their defense mechanisms may kick in and they will either deny it’s a problem or rationalize it away. It is important for a person to legitimately be aware of the risks of the disease, including death in some instances, but without causing a terror that can backfire. But there are exceptions. There are patients that actually respond well—and require—being frightened. Like a coach, the art is figuring out when to do that and when not to.
TCPR: How do you work with patients who feel—accurately or inaccurately—that they are sensitive to medications?
Dr. Shea: At some point in the first meeting, when the patient is telling me what meds they’re on, I might say, “You know I’m really curious, do you think you’re particularly sensitive to medications?” If they hesitate, they probably are sensitive, or think they are. Then I’ll ask for examples. And if I think their examples are just common, benign side effects like nausea on SSRIs, I don’t challenge them on that. In an initial encounter such a challenge may set back the alliance because if I challenge them I am essentially saying, “I don’t believe you; you’re wrong.” Not exactly a good way to start off a therapeutic alliance.
TCPR: Any techniques for sensitive patients?
Dr. Shea: After I start to write the prescription, I’ll stop, and the patient will notice that I’ve stopped. And I will look at them and say, “You know what, if it’s okay with you, I would like to start this at half the recommended starting dose. I want to let your body get a chance to see what this feels like. And if everything is okay, we can then start to raise it to help with your symptoms. At this tiny dose it might not even help, but I just think it is a smart way to start up with this medication because of your history with sensitivity to medications. Would that be all right with you, to start that low?” The patient may very well go home and tell their spouse, “That’s the first damn doctor that ever listened to me.”
TCPR: Thank you for your time Dr. Shea.
Editor’s note: Dr. Shea covers the MIM in more detail in The Medication Interest Model (Philadelphia, PA: Lippincott Williams & Wilkins; 2018). He has also written a version focused on psychiatric patients in the online supplement to Psychiatric Interviewing: The Art of Understanding, 3rd Edition (Toronto, ON Canada: Elsevier;2017).