The Journal of Nervous & Mental Disease (C) 1999 Lippincott Williams & Wilkins, Inc. Volume 187(10), October 1999, pp 630-635 Motivational Interviewing and Treatment Adherence among Psychiatric and Dually Diagnosed Patients [Articles] SWANSON, ARTHUR J. Ph.D.1; PANTALON, MICHAEL V. Ph.D.2; COHEN, KENNETH R. M.D.1 1 Department of Psychiatry, St. Barnabas Hospital, Third Avenue & 183rd Street, Bronx, New York, 10457. 2 Department of Psychiatry, Yale University School of Medicine, CMHC/Substance Abuse Center, Room S209, 34 Park Street, New Haven, Connecticut 06519. Send reprint requests to Dr. Pantalon. Preliminary results of this study were presented at the annual meeting of the Association for the Advancement of Behavior Therapy (November, 1997) in Miami, Florida. The authors express their gratitude to Robert Basile, Jewel James, David Randall, and Jennifer Wilson for administering questionnaires, conducting motivational interviews, and collecting follow-up data; to Giselle Albuquerque, Wendy Bobadilla, Brian Klein, and Beatrice Martineau for their assistance in data management; to Drs. Richard Schottenfeld, Bruce Rounsaville, Marek Chawarski, Douglas Zeidonis, and Tony George for their helpful comments on an earlier draft of this manuscript; and to the staff and patients of St. Barnabas and Union Hospital's Department of Psychiatry who participated in this study. ---------------------------------------------- Outline Abstract Methods Subjects Dependent Measure Assessments Treatments Therapists Procedure Data Analysis Results Discussion Limitations Conclusions References Graphics Table 1 Table 2 Abstract The effect of motivational interviewing on outpatient treatment adherence among psychiatric and dually diagnosed inpatients was investigated. Subjects were 121 psychiatric inpatients, 93 (77%) of whom had concomitant substance abuse/dependence disorders, who were randomly assigned to: a) standard treatment (ST), including pharmacotherapy, individual and group psychotherapy, activities therapy, milieu treatment, and discharge planning; or b) ST plus motivational interviewing (ST+MI), which involved 15 minutes of feedback on the results of a motivational assessment early in the hospitalization, and a 1-hour motivational interview just before discharge. Interviewers utilized motivational techniques described in Miller and Rollnick (1991), such as reflective listening, discussion of treatment obstacles, and elicitation of motivational statements. Results indicated that the proportion of patients who attended their first outpatient appointment was significantly higher for the ST+MI group (47%) than for the ST group (21%; [chi]2 = 8.87, df = 1, p vs. 16% for ST only; [chi]2 = 7.68, df = 1, p ---------------------------------------------- Nonadherence to treatment recommendations (e.g., pharmacotherapy, attendance at outpatient mental health clinic appointments) among psychiatric patients is a major problem limiting the effectiveness of treatment (Chen, 1991; Green, 1988; Haywood et al., 1995). Indeed, surveys suggest that the rate of attendance at the first outpatient mental health clinic appointment after discharge from an inpatient psychiatric unit is low and quite variable (Axelrod and Wetzler, 1989), yet crucial for the continuation of treatment and prevention of readmission (Green, 1988; Sharma et al., 1995). Non-adherence is especially problematic for patients with concomitant psychiatric and substance abuse/dependence disorders (i.e., dually diagnosed; Zeidonis and Trudeau, 1997). The term "adherence" is used here instead of "compliance" as it connotes a collaborative rather than an authoritarian approach to treatment recommendations, which is theoretically consistent with motivational interviewing (Miller and Rollnick, 1991), the treatment under investigation in this study. Because nonadherence to treatment among psychiatric patients can lead to a number of adverse consequences, ranging from poor clinical outcomes (Eisenthal et al., 1978) to violent behavior, especially among dually diagnosed patients (Liberman et al., 1994), efforts to increase adherence have been attempted. Overall, these efforts have been unsuccessful and, at times, inflexible and authoritative, neglecting to take into account patient choice (Chen, 1991). However, there are notable exceptions. Eisenthal et al. (1978) suggest that the rate of adherence with outpatient psychiatric clinic appointments is significantly related to patients' responses to a "negotiated approach" to conducting an intake interview, where clinicians collaborated with patients and actively solicited their perspectives on problems and potential solutions (p. 394). Others suggest that adherence problems among schizophrenics, for example, are characterized by "the lack of collaboration between the patient and clinician. Failure to adhere to treatment does not derive from a patient's lack of motivation or resistance to treatment but from an inadequate working alliance" (Liberman et al., 1994, p. 95), or from poor matching of interventions to patients' stage of change or readiness for treatment (Prochaska et al., 1992). Heinssen et al. (1995) agree and suggest that viewing a psychiatric patient as a collaborative partner or "colleague" in the treatment process, in conjunction with the use of behavioral contracts, leads to increased treatment adherence and improved clinical outcomes (p. 522). Similarly, motivational and behavior change processes that occur within the context of therapist/doctor-patient interactions have recently been studied in substance-abusing populations (Miller and Rollnick, 1991; Zeidonis et al. (1996) and in dually diagnosed patients (Carey, 1996; Zeidonis and Trudeau, 1997). These approaches emphasize that therapist-patient collaboration and flexibility with regard to the selection of treatment interventions directly influences the patient's level of motivation to quit using substances. In a transtheoretical model of change, motivation is conceptualized as a stage phenomenon in which individuals proceed through four stages (i.e., precontemplation, contemplation, action, and maintenance) as they modify their behavior (McConnaughy et al., 1989). In this model, effective collaboration best occurs when a therapist selects interventions that match the individual's particular stage of change, rather than adopting a "one-size-fits-all" approach. This approach does not view failure to pursue aftercare treatment as a sign of resistance or characterological problems, but rather as representing an early stage of a behavior change effort. This stage-of-change model has been applied to dually diagnosed patients by researchers who suggest that level of motivation and stage of change are important determinants of treatment adherence and outcome (Carey, 1996; Project MATCH Research Group, 1997; Zeidonis and Fisher, 1996). Motivational interviewing (MI; Miller and Rollnick, 1991) is a method that utilizes the stages of change to motivate substance abusers to change their addictive behaviors. MI emphasizes the importance of motivation as a context versus a personality trait, and minimizes the role of confrontation in the treatment of such individuals. Research on MI has demonstrated the positive effects of helping patients clarify goals, explore obstacles to treatment, and make commitments to change (Miller and Rollnick, 1991). MI seeks to address issues of motivation for change collaboratively with the patient, selecting as targets for change only those behaviors that are mutually agreed upon, most often generated by the patient him/herself. In the recently completed Project MATCH, MI was one of the three interventions tested in a NIAAA funded, multi-site treatment-matching study on alcoholism (Project MATCH Research Group, 1997). The results of this study suggest that MI, provided in the four sessions over a 12-week period, was as effective as a 12-step approach and a cognitive-behavioral treatment, each of which was provided in 12 sessions. The efficacy of MI for psychiatric patients alone or those with a concomitant substance abuse/dependence disorder has not been tested in randomized clinical trials. However, one case report suggests that adding MI to an intensive outpatient program improved individual and group therapy attendance and led to a reduction in cocaine use (Zeidonis et al., 1996). Additionally, Daley et al. (1998) conducted a non-randomized pilot study of outpatient treatment adherence among 23 cocaine-dependent depressed patients who were consecutively discharged from an inpatient dual-diagnosis unit. The investigators compared a modified motivational interviewing intervention (MI; 5 individual and 4 group sessions) with "treatment-asusual" (supportive therapy and psychoeducation) on an outpatient basis, and found that patients who received MI were significantly more likely to complete short-term outpatient treatment (30 and 90 days) and to attend more treatment sessions during this time. The authors also suggest that MI resulted in less frequent re-hospitalization. Thus, MI shows promise in treating dually diagnosed patients. In the current study, we attempted to influence adherence to outpatient intake appointments with brief motivational interviewing. The hypothesis tested in this randomized trial was that a significantly higher proportion of patients receiving standard treatment plus motivational interviewing (ST+MI) would attend their first outpatient appointment post-discharge than those receiving ST alone. Methods Subjects Subjects were psychiatric inpatients at two inner-city private, not-for-profit hospitals. All patients were on a voluntary status in the hospital after admission due to potential danger to themselves or others or due to grave disability. All patients admitted during a 4-month period were considered for inclusion except those with a diagnosis of dementia or mental retardation, and those who spoke little or no English. Patients who were acutely psychotic, manic, and/or hostile were also initially excluded until there was significant reduction of their symptoms. The study protocol was approved by the St. Barnabas Hospital Institutional Review Board. After complete description of the study to the subjects, written informed consent was obtained. Overall, 235 patients were available on the units during the study time period. All were approached about entering the study and 170 (72%) met all of the eligibility requirements. Reasons for ineligibility were as follows: a) 29 (12.3%) did not speak English, b) 17 (7.2%) were too severely psychotic or manic to understand the consent form, c) 9 (3.8%) had a diagnosis of dementia, d) 5 (2.1%) were mentally retarded, e) 3 (1.3%) were deaf, and f) 3 (1.3%) were medically unstable. Of the 170 who were eligible to participate in the study, 121 (71%) were enrolled. The primary reason for not being enrolled when eligible was a discharge during a weekend (when no research staff was available) or within 3 days of admission (a time period too brief to implement the protocol given our resources). This occurred for 41/170 (24%) eligible patients. Of the remaining eligible patients who were not enrolled, 8/170 (4.7%) refused to participate. Only two of these patients gave a reason for refusal; one felt the information might be used to keep him hospitalized longer than he wished and the other stated that he had "no problems" to discuss. Dependent Measure The dependent measure in the study was the proportion of patients who attended their first aftercare appointment. Attendance was assessed by calling or sending research assistants to the various referral sites and having on-site personnel check attendance databases. Assessments Diagnostic interviews, based on the DSM-IV (American Psychiatric Association, 1994), were conducted by two attending psychiatrists. Where there was disagreement, another psychiatrist reassessed the patient and a diagnosis by consensus was made. All patients were also administered the University of Rhode Island Change Assessment scale (URICA; McConnaughy et al., 1989), a psychometrically sound instrument designed to measure readiness for, or stage of, change. (Prochaska et al., 1992). Each stage of change is assessed with eight, Likert-type items, each ranging from one to five, with higher scores indicating greater endorsement of a particular stage. The four stages assessed were: a) precontemplation (when individuals are denying the existence of a problem), b) contemplation (when change and its pros and cons are being considered), c) action (when actual steps toward change are taken), and d) maintenance (when an individual attempts to sustain improvement). URICAs were completed based on the problem (i.e., psychiatric illness or substance abuse) that the patient considered to be of primary importance. Treatments Standard Treatment (ST). ST patients received an intake assessment by a multidisciplinary team, resulting in an individualized treatment plan, which identified psychiatric, psychological, medical, and social service needs. During the hospitalization, the patient worked with his/her team to accomplish the treatment plan objectives via pharmacologic and psychosocial methods. Before discharge, all patients were provided an outpatient psychiatric clinic appointment, and the importance of attending this appointment was emphasized routinely. Although patients in ST were administered the URICA, they were not given any feedback on the results. Standard Treatment plus Motivational Interviewing (ST+MI). Patients in this group received ST plus a 15-minute session of feedback on their URICA scores at the beginning of their hospitalization and 1-hour motivational interview 1 or 2 days before discharge. Specifically, URICA feedback included: a) a brief description of the instrument, b) the results in terms of profiles identified in previous research and composite scores, c) an interpretation of these results based on the stages of change model (the research therapists were provided with a script so that they could explain the profile or composite score that best described the patient), and d) a discussion of the patient's views of the results and how they may influence his/her commitment to adhere to treatment recommendations. Such feedback, given in a neutral manner, is an integral part of MI (Miller and Rollnick, 1991). The hour-long motivational interview involved a more in depth discussion regarding the patient's perception of his/her problem(s), and level of commitment to treatment after discharge, in light of the progress made while hospitalized and the feedback received earlier (which was briefly reviewed). Specifically, therapists focused on increasing patients' awareness of their clinical condition, asking them to consider their role in that improvement, discussing plans for aftercare treatment, and realistically assessing possible obstacles. Generally, therapists attempted to elicit, from patients, motivational statements suggesting a desire to take some responsibility for their continued treatment while also encouraging the patient to follow through on such statements. During this intervention, the therapist made full use of the main principles of MI to highlight the patient-stated advantages of change and treatment adherence (i.e., self-motivational statements). The five principles of MI are: a) express empathy, b) note discrepancies between current and desired behavior, c) avoid argumentation, d) refrain from directly confronting resistance, and f) encourage self efficacy, or the patient's belief that he/she has the ability to change. At the time of discharge, both the therapists and patients were aware of the discharge referral, and the approximate date of discharge. The social work staff made referrals to outpatient programs for both groups. Overall, 62% of the patients were referred to a dual-diagnosis program; 15% to residential programs; 12% to a chronic psychiatric care program; 9% to an outpatient psychiatric clinic; and 2% to extended care facilities. Therapists The therapists for this study were four upper-level undergraduate psychology students who volunteered to assist with the study, and who had no other role on the units. Therapist training in MI included the assignment of relevant readings followed by 6 hours of didactic instruction. Authors modeled the approach, and each therapist rehearsed and role-played motivational interviewing techniques with feedback. In addition, the therapists received supervision on a daily basis. Procedure After the initial evaluation, a therapist who explained the study and sought the patient's consent to participate approached all eligible patients. Consenting patients were interviewed regarding demographic and historical data, and then administered the URICA. The therapist then consulted a random number table to determine group assignment. Patients assigned to ST were thanked for their participation and returned to the unit. For patients assigned to ST+MI, the URICA was immediately scored and a discussion followed regarding the meaning of the results in light of the patients' presenting problems and their own perceptions of their stage of change. After this discussion, ST+MI patients were informed that they would be meeting with the therapist again at some point, and returned to the unit. One or two days before discharge, ST+MI patients received a 1-hour motivational interview as described above. Data Analysis Chi-square analyses were used to test for differences between the two groups on categorical variables and the proportion of patients attending their first appointment. Independent t-tests were used to test for differences on continuous pretreatment variables. For all analyses, statistical significance was set at p Results Table 1 presents data on the pretreatment characteristics of patients in both groups (N = 121). Comorbid psychiatric and substance use disorders were diagnosed in 79% (45/57) of the ST patients and in 75% (48/64) of the ST+MI patients. The only pretreatment difference found was that significantly more ST patients reported having been in special, versus regular, education than ST+MI patients. This suggests that ST patients were significantly more likely to have had a special education classification, such as a learning disability, than ST+MI patients. However, subsequent analyses indicated that there was no significant association between education type and treatment adherence. In addition, there were no significant differences between the two groups on pretreatment levels of motivation as assessed by the URICA, nor were there statistically significant differences between the two groups regarding the proportions of patients referred to the different outpatient sites ([chi]2 = 3.94, df = 3, p = .268). ---------------------------------------------- TABLE 1 Pretreatment Characteristics of All Subjects (N = 121)a ---------------------------------------------- Results presented in Table 2 indicate that, when considering the total sample (N = 121), a significantly greater proportion of ST+MI patients attended their first appointment than did ST patients. When considering dually diagnosed patients alone, those in ST+MI also attended their first appointment at a significantly greater rate than those in ST. Although more non-substance-abusing psychiatric patients in ST+MI attended their first appointment than did those in ST, this difference did not reach statistical significance ([chi]2 = 1.20, df = 1, p = .274). ---------------------------------------------- TABLE 2 Treatment Adherence by Treatment Condition and Patient Type (N = 121) ---------------------------------------------- Similar results emerged for patients with psychotic and affective disorders. Among patients with psychotic disorders (i.e., schizophrenia and schizoaffective disorder), the proportion attending the first appointment was significantly higher for ST+MI than it was for ST (47% vs. 21%, respectively; [chi]2 = 3.90, df = 1, p 2 = 4.24, df = 1, p We also assessed whether the 15-minute feedback session regarding the results of the URICA (given only to the ST+MI group) had an effect on attendance at inpatient activity (AT) and cognitive-behavioral therapy (CBT) group sessions during hospitalization (attendance recorded by group therapists). Only nondually diagnosed ST+MI patients showed a trend toward attending more CBT groups than those in ST (46% vs. 17%, respectively; t = 1.97, df = 23, p = .061). Dually diagnosed patients in ST and ST+MI attended a comparable percentage of AT (64% vs. 58%, respectively) and CBT groups (49% vs. 44%, respectively) while hospitalized. Discussion The results of this study indicate that the addition of a brief (1 hour and 15-minute) intervention based on motivational interviewing to an already intensive inpatient treatment program (on average 14 days) may lead to substantially enhanced treatment adherence among psychiatric and dually diagnosed patients when considered together. The rate of initial attendance in outpatient treatment for the group that received this motivational intervention was more than double the rates for the group that received only standard treatment. Similar results were found for dually diagnosed patients alone, who made up 77% of the total sample, but the small number of non-substance-abusing psychiatric patients made it difficult to demonstrate such a finding for these patients, when considered separately. The effectiveness of ST+MI was also comparable for psychotic and affective disordered patients, as rates of initial attendance for individuals with these diagnoses (including both dually and non-dually diagnosed patients) were significantly higher in the ST+MI group than in the ST group. Although we did not specifically hypothesize that rates of adherence to inpatient group therapy sessions would be affected by the initial 15-minutes of motivational feedback (administered only to the ST+MI patients), the results suggest that non-dually diagnosed ST+MI patients tended to participate in more CBT groups after the feedback than such patients in ST. Perhaps with a longer intervention, significant differences would have been observed. It is also possible that other factors, such as the ease of access to the groups (all of which were held on the units) or systematic monitoring of attendance, may have contributed to increased attendance in both treatment conditions. However, this finding points to the need to further study the length of time necessary for motivational interventions to effect change. These findings are consistent with the suggestion that MI may be effective in enhancing treatment adherence among psychiatric patients, including those with concomitant substance use disorders (Carey, 1996; Heinssen et al., 1995; Zeidonis and Trudeau, 1997). However, the degree to which any of the elements of MI is associated with outcome, cannot be addressed in this study. MI may have been effective due to one or more of its core components, such as refraining from directly confronting patient resistance or eliciting motivational statements (via reflective listening) regarding patients' intentions to change. However, it is also possible that merely reinforcing the importance of aftercare in an empathic manner accounted for the higher level of adherence among the ST+MI patients. Therefore, in subsequent studies, efforts should be made to delineate the relative effectiveness of each MI component. Limitations The generalizability of this study's findings is limited by the fact that no formal attention control group was used to experimentally rule out the possibility that the results were caused by the extra attention given to the ST+MI patients by the therapists. Although the interventions received by the ST+MI patients could be considered relatively minor additions of time to an already intensive program, it is not possible in this report to separate the effects of the motivational intervention from giving extra attention on a systematic basis. In addition, our study only reported on attendance at the first outpatient clinic appointment post-hospitalization, which is only a preliminary step, albeit an important one, toward demonstrating consistent treatment adherence. Therefore, it remains unclear whether the brief motivational intervention tested in this trial could increase longer-term outpatient treatment adherence among psychiatric and dually diagnosed patients. Finally, we did not systematically monitor (i.e., with audio- or video-tape recordings of sessions) the performance of the therapists. Therefore, we cannot assess the degree to which therapists adhered to the treatment protocol or how well they implemented each of the MI components. Conclusions The results of this study suggest that the systematic implementation of motivational interviewing procedures with psychiatric and dually diagnosed patients can significantly improve outpatient treatment adherence when added to standard psychiatric treatment. However, further research is needed to: a) replicate these findings in studies that control for the effects of attention and employ procedures for rating therapist adherence to and competence with treatment protocol, b) investigate the effect of motivational interviewing on longer-term outpatient adherence (i.e., rates of attendance beyond the initial appointment), c) determine the specific types of patients (e.g., depressed cocaine abusers versus schizophrenic alcohol abusers) who may benefit most from MI; and d) adapt the specific components of MI to psychiatric and dually diagnosed patients in order to further increase overall rates of treatment adherence. References American Psychiatric Association (1994) The diagnostic and statistical manual of mental disorders (4th ed). Washington, DC: Author. Axelrod S, Wetzler S (1989) Factors associated with better compliance with psychiatric aftercare. Hosp Community Psychiatry 40:397-401. 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Zeidonis DM, Trudeau K (1997) Motivation to quit using substances among individuals with schizophrenia: Implications for a motivation-based treatment model. Schizophr Bull 23:229-238. ---------------------------------------------- Accession Number: 00005053-199910000-00007