APNA 29th Annual Conference Session 2037: October 29, 2015 Kristin - PDF document

APNA 29th Annual Conference Session 2037: October 29, 2015 Kristin McKenzie DNP , PMHNP-BC • Funding for this study was supported by a Coletta A. Klug Fund Award, The State University of New York, University at Buffalo, 2012 & 2013. • The study findings have been published in Perspectives of Psychiatric Care , ISN 00315990. “The Effect of Nurse-Led Motivational Interviewing on Medication Adherence in patients with Bipolar Disorder. Written by Kristin McKenzie DNP , PMHNP and Yu-Ping Chang PhD, RN. • The speaker has no conflicts of interest to disclose. • 1. Review the procedures and outcomes of a pilot study that utilized Motivational Interviewing to improve medication adherence in client’s with Bipolar Disorder. • Discuss a theoretical model of adherence, and how motivational interviewing can be used to address medication taking behaviors. • 2. Explore how evidence can be translated into clinical nursing practice in the outpatient mental health setting McKenzie 1

APNA 29th Annual Conference Session 2037: October 29, 2015 • Bipolar Disorder (BD) treatment outcomes and prognosis are dependent upon medication adherence, yet non-adherence rates average between 35-60% for this population. (Berk et al., 2010; Sajatovic, Valenstein, Blow, Ganoczy, & Ignacio, 2006; NIMH, 2008; Otto, Reilly- Harrington, & Sachs, 2003; Scott & Tacchi, 2002; Stahl, 2009). • Lack of Evidence-based Nursing Interventions or Standards of Practice for promoting medication adherence in outpatient psychiatry (APA, 2002; NIMH, 2008) • Need for an applicable nursing theory and model of adherence to support further use of MI by psychiatric nurses * See Handout (Adamian, et al., 2004) • Four principles of MI : 1. Express Empathy 2. Develop Discrepancy 3. Support Self Efficacy 4. Roll with Resistance • The Spirit of MI : • Collaboration- Build rapport with empathy and understanding • Autonomy- Explore Internal Motivators + Barriers to Change • Evocation- Reflective statements, Empowerment, Praise McKenzie 2

APNA 29th Annual Conference Session 2037: October 29, 2015 Medication Adherence Rating Scale (MARS) Sajatovic, et al. (2010), Thompson, et al. (2000). Timeline Follow Back (TLFB) Braithewait et al. (2005) Motivational Rulers ( MIR ) Miller & Rollnick (2002) Self-Efficacy and Appropriate Medication use Scale (SEAMS) Risser, Jacobson, & Kripalani (2007) Patient Satisfaction Questionnaire • Aim 1 : To measure changes in medication adherence by comparing pre and post scores on the MARS & TLFB calendar during a one month MI intervention • Aim 2 : To determine if the MIR and the SEAMS can demonstrate change in scores collected over a three week intervention period. • Aim 3 : To evaluate treatment satisfaction after three MI sessions using the Participant Satisfaction Questionnaire INTERVENTION - Exploratory Pretest-Posttest design - Intervention Manuscript used by PI during all 3 MI interventions. - Participant Packet sent home to complete during telephone sessions. McKenzie 3

APNA 29th Annual Conference Session 2037: October 29, 2015 INTERVENTION 4 week Motivational Interviewing intervention * See Handout 1. MI Session 1: Onsite 1:1 intervention = 35-60 minutes 2 . MI Session 2: Telephone session = 10-25 minutes 3 . MI Session 3: Telephone session = 15-25 minutes 4. Post-test: Onsite follow-up testing = 10-15 minutes • SAMPLE • 14 total participants received MI and completed post-test • All Caucasian, English speaking, w/Bipolar 1, 2 or NOS diagnosis • 11 Females, 4 Males • Age range 23-57 years old, with a mean age of 35 (11.1) • 80% (N=12) of subjects graduated from high school • DATA ANALYSIS - Descriptive Statistics: Measure of variability and central tendency - Paired Samples T-tests: Pre-Post data from MARS, TLFB, and SEAMS - Repeated measures ANOVA on Pre-Mid-Post data from MIR and SEAMS McKenzie 4

APNA 29th Annual Conference Session 2037: October 29, 2015 Study Outcomes • Aim 1 : Review of the MARS and TLFB showed a significant increase in medication adherence at 30 day post-test. • Aim 2 : MIR showed a progressive ↑ in individual and total scores when rating Importance, Motivation and Confidence to change medication taking behavior. SEAMS demonstrated steady increase in scores over a 4 week period • Aim 3 : Overall Patient Satisfaction ranked between 4.6 and 5 /5= good to very good ratings; reflecting level of comfort with PI and the PI sensitivity to their needs during intervention • Pre-intervention testing showed participants started with moderate medication adherence scores on TLFB and MARS • Individual questions helped identify areas that needed change, which ultimately resulted in improved medication adherence • Self-efficacy is a causal element of change, and breakdown of collected data showed that self-evaluation skills and building confidence made a positive impact on adherence • Statistically Identified Barriers to Adherence : Forgetfulness, Medication side effects, and Daily routine Study Limitations - small homogenous sample - poor external and internal validity - lacking objective and longitudinal data - no double blind McKenzie 5

APNA 29th Annual Conference Session 2037: October 29, 2015 • MI Techniques applied in this study: - Discuss past/current experiences along with personal beliefs about medication - Provide empathy; Recognize and praise “change talk”; Use reflective listening - Assess readiness to change; Assist personal goal development; Support Self-Efficacy - The SEAMS and MIR can identify progressive change throughout MI intervention, and Pre/Post testing with MAR and TLFB can demonstrate change at one month follow-up • The application of fundamental elements of MI and the utilization of evidence- based rating scales can improve medication adherence when used in outpatient psychiatry. • Motivational Interviewing Training: Nurses require adequate training for the application of MI techniques in clinical practice • Future Nursing Research: 1. Expand clinical trials to provide a higher level of scientific evidence 2. Test and implement the use of medication adherence assessment tools • Client’s with Bipolar Disorder can change medication taking behaviors after 3 brief MI interventions • This Pilot study contributes to current evidence that supports the use of nurse-led motivational interviewing in outpatient mental health settings to improve medication adherence. • Need for further Nursing Research to inform clinical practice and promote the use of MI techniques as a standard of care for outpatient medication management McKenzie 6

APNA 29th Annual Conference Session 2037: October 29, 2015 Please take time to complete post-test questions, thank you American Psychiatric Association (2002) Practice guideline for the treatment of patients with bipolar disorder (revision). American Journal of Psychiatry, 159: 1–50. Adamian, M. S., Golin, C. E., Shain, L. S., & DeVellis, B. (2004). Brief motivational interviewing to improve adherence to antiretroviral therapy: Development & qualitative pilot assessment of an intervention. AIDS Patient Care and STDs, 18(4), 229-238. Berk, L., Hallam, K. T., Colom, F., Vieta, E., Hasty, M., Macneil, C., & Berk, M. (2010). Enhancing medication adherence in patients with bipolar disorder. Human Psychopharmacology: Clinical & Experimental, 25(1), 1-16. Braithwaite, R. S., McGinnis, K. A., Conigliaro, J., Maisto, S. A., Crystal, S., Day, N., . . . Justice, A. C. (2005). A temporal and dose-response association between alcohol consumption and medication adherence among Veterans in care. Alcoholism: Clinical and Experimental Research, 29(7), 1190-1197. DiClemente, C. C., Nidecker, M., & Bellack, A. S. (2008). Motivation and the stages of change among individuals with severe mental illness and substance abuse disorders. Journal of Substance Abuse Treatment, 34(1), 25-35. Garfinkle, P.E., & Goldbloom, D.S. (2000). Mental health- getting beyond stigma and categories. Bulletin of the World Health Organization, 78: 503-505. Miller, W.R., & Rollnick, S. (2002). Motivational Interviewing: Preparing people for change (2nd ed.). New York, NY: The Guildford Press. National Institute of Mental Health (2008). Bipolar Disorder. U.S. Department of Health and Human Services. http://nimh.nih.gov/health/publications/bipolar-disorder/index.shtml. Otto, M. W., Reilly-Harrington, N., & Sachs, G. S. (2003). Psychoeducational and cognitive behavioral strategies in the management of bipolar disorder. Journal of Affective Disorders, 73(1), 171-181. Risser, J., Jacobson, T. A., & Kripalani, S. (2007). Development and psychometric evaluation of the Self Efficacy for Appropriate Medication Use Scale (SEAMS) in low literacy patients with chronic disease. Journal of Nursing Measurement,15(3),203-219 Sajatovic, M., Valenstein, M., Blow, F. C., Ganoczy, D., & Ignacio, R. V. (2006). Treatment adherence with antipsychotic medications in bipolar disorder. Bipolar Disorders, 8(3), 232-241. Sajatovic, M., Velligan, D. I., Weiden, P. J., Valenstein, M. A., & Ogedegbe, G. (2010). Measurement of psychiatric treatment adherence. Journal of Psychosomatic Research, 69(6), 591-599. World Health Organization (WHO). (2003). Adherence to long-term therapies: Evidence for action. Geneva: WHO. McKenzie 7