NEW YORK -- Psychotherapy can be a good way to improve medication adherence in patients with bipolar disorder. Michael Otto, Ph.D., said at the annual meeting of the American Psychiatric Association.
It won't work, though, unless patients feel that the treatment plan belongs to them, said Dr. Otto, who is director of the cognitive-behavioral therapy (CBT) program at Massachusetts General Hospital, Boston.
It is important to remember that a 50-minute session accounts for less than 1% of the average patient's waking hours. "I cannot win unless I co-opt the rest of the time." he said.
"I have to get the treatment over into the 99% of the time, so I get obsessed with helping the patient think about treatment and, indeed, become the cotherapist. You're relying on them to know when to call you and when to say. "This is preventive. Even if I feel better, I need to keep taking it.' You want them to be an effective therapist for themselves, even when they're not with you," he explained.
To do that, patients need to learn the true significance of their medications. "For bipolar, the most honest statement I've ever heard for a medication is when a woman said. 'You know, I miss my hypomania. I really miss it. But you know what? I'm not in trouble all the time.' This woman has got a sense of the tradeoff and what she gets personally." Dr. Otto said.
That kind of thinking can best be encouraged by using a particular prescribing style. For example, providers can take a history of the patient's bipolar disorder: "You were in college and what happened? 'I had an episode; I didn't finish the semester.' You were in a relationship and what happened? 'I had an episode.' In drawing the ups and downs of the patient's life, it gives them face-to face knowledge of what is the cost of the disorder." he said. "That can lead the patient to say. 'I want an alternative, doc. What you do have?'" he said. "That's also great social psychology."
Once patients see the need for taking medication, don't tell them they're going to get the perfect pill, Dr. Otto said. "Why would you not want to say that? Because half of them will go off it. And if someone decides the best you have to offer isn't good enough, will they come back? Will they discuss that with you if they're in trouble?"
Instead, simply say, "Here's a pill. Let's see how it works for you," he suggested. That short-term approach is also much easier to deal with than saying," 'I'd like you to take this medication ... for the rest of your life.' How do you buy in for that?"
One can see how daunting that prospect might be, especially for other decisions that are also long term, like marriage. Dr. Otto continued. …