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Melike ERTEM, Research Assisstant, MsC, PhD. Zekiye ÇETİNKAYA DUMAN, Associate Proffesor

MOT I VAT I ONAL INTERV I EW I NG I N A PAT I ENT W I TH SCH I ZOPHREN I A TO ACH I EVE TREATMENT COLLABORAT I ON: A CASE STUDY. Melike ERTEM, Research Assisstant, MsC, PhD. Zekiye ÇETİNKAYA DUMAN, Associate Proffesor Dokuz Eylül University Nursing Faculty.

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Melike ERTEM, Research Assisstant, MsC, PhD. Zekiye ÇETİNKAYA DUMAN, Associate Proffesor

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  1. MOTIVATIONAL INTERVIEWING IN A PATIENT WITH SCHIZOPHRENIA TO ACHIEVETREATMENT COLLABORATION: A CASE STUDY Melike ERTEM, Research Assisstant, MsC, PhD. Zekiye ÇETİNKAYA DUMAN, Associate Proffesor Dokuz Eylül University Nursing Faculty

  2. Medication nonadherence in patients diagnosed with schizophreniamay result • deterioration of psychotic symptoms, • a five-foldincrease in the risk of relapse, • lengthened hospital stays, • comorbidsubstance abuse, • increased suicidal and • homicidal tendencies and • violentbehavior 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  3. The reasons for medication nonadherence • Lack of insight about their disease(s); • psychopathology at a psychoticlevel; • fear related to medication use; • intolerable disease course; • undesirableside effects 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  4. The reasons for medication nonadherence(continued) • The complexity of adherence for a given treatment regimen • Insufficient social support • Financial difficulties • Lack of information about treatmentor misinterpretations of treatment • Perceived difficulties of medication use conflicting 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  5. The reasons for medication nonadherence(continued) • Environmental factors in the hospital or residential neighborhood; • Pre-existing negative attitude toward medications and mental diseases; • Cultural beliefs • Lack of knowledge or misconceptions aboutthe disease(s) and management 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  6. Motivational Interview (MI)is an emerging therapeutic approach to increase medication adherence. 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  7. METHODS • In this case study, we examined the process of enhancing treatmentcollaboration through the use of MI in a patient diagnosed as schizophrenicand resistant to treatment. • Patient Ö.N. was followed in theSchizophrenia Outpatient Clinic of DokuzEylül University Hospital. 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  8. Measurements • TheMoriskyMedication Adherence Scale • The Drug Attitude Inventory 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  9. MotivationalInterviews: • 45 minutes to1 hour, • One-to-one and face-to-face • Once a week for6 weeks 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  10. Preparation Process • The researcher participated in a 20-hour course, including supervision on MI from an MI specialist. • After each interview, the counselor and the researcherevaluated the content of the interview and requested advicefrom an experienced specialist. 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  11. Case Presentation • Ö.N. was male, 22 years old and a university student. • He stoppedattending his university classes at the end of the first academic yeardue to his inability to focus on his studies. 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  12. Case Presentation • The patient did not takehis prescribed medications regularly • He was unwilling to take themon his own. • He only took medication under the supervision of his parents. 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  13. Case Presentation • He had been hospitalized at his own request, • He complainedof fatigue, opposition, unhappiness, and introversion, • He exhibiteddecreased self-care, decelerated movements and impaired function. 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  14. Case Presentation • He stared into space, stood motionless and was unable tospeak. • Doctors determined his final diagnosis to be schizophrenia (for 2 years) 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  15. After discharge, he regularly attended doctor's follow-up visits in the schizophrenia outpatient clinic. • He was prescribed antidepressant, anxiolytic and antipsychotic drugs. 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  16. Examination of MentalStatus. • He had hallucinations in which he receivedmessages from the television, noticeable thought blocking/alogia • The flat affect • Considerablepsychomotor retardation • He answeredthe questions without any additional dialog 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  17. INTERVIEWS 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  18. INTERVIEWS Step 1: Creation of Motivation (Interviews 1, 2, 3 and 4) 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  19. Interview 1 The patient was given information about theaim of the study and the process, content of the interviews. Hewas also asked to complete: • The Morisky Medication Adherence Scale • Drug Attitude Inventory 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  20. Morisky Medication Adherence Scale-“Yes” • I stop taking medications when I feel good; • I stop taking medicationswhen I feel bad; • I forget to take my medications on time LOW ADHERENCE!! 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  21. Interview 1 • Hemarked the response “Always” to the statements in theDrug Attitude Inventory: 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  22. “I have difficulty using medications (dividingdrugs, changes in doses of drugs, taking multiple drugs and taking thewrongmedication)”, “Taking drugs makes me tired and lethargic”, “My family and friends remindme to takemy medication”, “I think takingdrugs for a long timehas harmful effects (constipation, increased appetite,weight gain, difficulty in concentrating, etc.)” and “I becomeaddicted to drugs if I take them for a long time”.

  23. Interview 2 The questions focused on 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  24. At the beginning of the interview 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  25. He said; • “My parents say, if I stop takingthem, I may feel bad” asked, “doesn’t taking the medications lead toaddiction?” • “I felt depressed and as if my spirit left my body”. 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  26. Interview 3-4 • Further efforts were undertaken to improvethe patient's understanding of the disease • Evaluate and determinethe side effects and benefits of treatment • The side effects ofeach drug given to the patient were discussed. 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  27. Interview 3-4 • The patient describedthe side effects of the drugs as unwanted and negative and alignedthem with symptoms of schizophrenia. 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  28. Interview 3-4 • At this stage, we used open-endedand reflective interview questions to help the patient to distinguishsymptoms from side effects and to raise awareness of side effectsanddiseasesymptoms. • Confidence and Self-Efficacy Test was used 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  29. Hesuffered from side effects: • Lethargy, • Weight gain, • Inability toconcentrate, • Addictive effects, • Headache, • Shortness of breath, • Burningsensation in the eyes, • Pain in the arms and legs and pain throughoutthe whole body 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  30. He mentioned the positive effects of treatment: • Decreased severity of sleep problems, • Better mood • Improvedabilitytocommunicate 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  31. Hewas given an assignment to compare the positive and negative effectsof his treatment using the ruler method and to rate the severity of theside effects and effects of his treatment. • The objective of this assignmentwas tomake himaware of the effects and side effects of his treatment onhis body along with their severity and importance. 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  32. Interview 3-4 • The researcher asked the patient to rate the effects of his treatmentand the severity of his side effects again. • The differences between hisratings at home and those at the interview were compared, and thechanges were evaluated carefully. 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  33. Interview 3-4 • The researcher explained that Ö.N. was now moreaware of the importance of adhering to his treatment and coping withthe side effects of his medications. • His experiences werediscussed, and • He was encouraged to implement change. 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  34. Step 2: • Strengthening the Promise to Change (Interviews 5 and 6) 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  35. Interview 5 • At this interview, the patient's worries about starting to work andearning his own living were discussed. 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  36. His feelings (worries, regrets and fear of the unknown, etc.) The meaning of being successful at work, ways to succeed and the role of success at school and in his future career 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  37. Interview 5 Thepatient said that although he understood that success at school wouldplay an important role in his career and in earning his own living, he admittedthat he failed at school. 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  38. Interview 5 • Failure and the accompanying factorswere discussed • The role of treatment was questioned • The patientwanted time to think about the issue and agreed to talk about it at thenextinterview 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  39. Interview 5 • The focus of the interview was to help the patient accept theside effects of the treatment 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  40. Interview 5 • The patient noted that he had difficulty taking oral medications; • He said that during his previoushospitalization, drugswere administered by injection, asatisfactorymethod in his opinion. • Therefore, he requested consideration for beingprescribed an injectable form of his antipsychotic drug and time tothink about it. 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  41. Interview 5 • The researcher and patient discussed alternativeforms of drug administration • Theyclarified the goals of histreatment at the next interview • They agreed to discuss these topicsagain at the next meeting. 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  42. Interview 5 • Following this interview, the doctor responsible for the patient'streatment was informed about the patient's desire for an injectableform of the antipsychotic drug and agreed that this was a possibility. 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  43. Interview 6 • The aim of this interview was tosupport the patient's success in the continuation of his treatment, tofocus on being healthy and to evaluate effectiveness of prophylactic ormaintenance therapy. 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  44. Interview 6 • At the end of the interview, the patient hadchanged his mind and decided to fully collaborate with the health staff in his treatment. 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  45. Interview 6 • He verbalized an awareness of the negative aspectsof his current status and the advantages of a change in hisbehavior. • He noted thathe could use the injectable form of his drug more easily and that theoral form of his drug could be replaced by an injectable form. 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  46. DISCUSSION • The aimof this case studywas to improve patient collaborationwitha researcher for a treatment-resistant patientwith schizophrenia. 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  47. Although he was educated about hismedication and the side effects during clinical treatment by his doctor,he was ambivalent about his medication and, therefore, nonadherent. • Because he had features which were directly related to MI, this approachwas practiced for this case. 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  48. At the beginning of the MI process,Ö. N. revealed his ambivalent feelings about his treatment. • His awarenesswas raised by developing a discrepancy to facilitate distinguishingbetween treatment side-effects and disease symptoms. 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  49. The positive andnegative effects of his treatment on his body and life were assessed andthen discussed based on the patient's responses for the importance,confidence and self-efficacy ruler. 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

  50. The patient came to understand hisconfidence level for coping with the negative and positive effects oftreatment using homework assignments to facilitate better comprehensionfor both of these pieces of the puzzle 3. World Congress on Pharmacology, August 8-10 2016, Birmingham UK

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