Mental health and health care
A MAJOR ISSUE in care for persons with serious mental illness (SMI) is medication management. Because psychotropic medications remain the single most effective treatment for reducing the active symptoms of psychosis (Lehman and Steinwachs 1998 and Fenton et al 1997), many studies and interventions have focused on improving adherence rates (Azrin & Teichner, 1997; Cramer & Rosenheck, 1999). The decisions that clients make about medications have long been of interest to health care providers and investigators and medication adherence has been the focus of many research studies (Brawley and Culos-Reed 2000; Rand, C.S. and Sevick, M.A., 2000. Ethics in adherence promotion and monitoring. Controlled Clinical Trials 21, pp. 241S–247S.Rand and Sevick 2000 and Sieber and Kaplan 2000).
Modern consumer involvement in health care decisions has led providers to focus on empowering clients to make good choices about health in general and about managing chronic conditions in particular (Holmberg and Kane 1999; Kemp et al 1998 and Swanson et al 1999). These concepts have prompted mental health providers to look beyond merely freedom from symptoms to examine adapting to life with chronic mental illness (Drake et al 2001 and Heinssen et al 2000). One aspect of the self-care and health promotion concepts prevalent in managing SMI is medication self-management. This article presents a conceptual framework for studying medication decision-making and it is developed as a basis for intervention development.
Client motivation is a significant factor in changing high-risk behaviors and adopting healthy ones (Prochaska and Velicer 1997 and Cox 1982). Effective health care requires informed, active, and independent clients who participate in determining the treatment goals, monitoring symptoms, evaluating the regimen, and in revising regimens if problems occur (Chewning and Sleath 1996; Cox 1982 and Holmes-Rovner and Rovner 2000). Greater participation in the client-provider interaction should result in better management of illness and produce more positive outcomes including greater quality of life (O’Brien et al 1992 and Kroll et al 2000). One area where client participation may be especially important for persons with SMI is medication decision-making.
Importance of medication management
Although psychotropic medications successfully control symptoms in most individuals with SMI, medication adherence rates are only about 50% (Fenton et al 1997 and Lehman and Steinwachs 1998). For persons with SMI, failure to take medications can have devastating consequences, such as symptom exacerbation, rehospitalization, major disruptions in relationships, and may even result in loss of housing and involvement in the criminal justice system (Pyne et al 2001 and Azrin and Teichner 1998). Factors that may affect the decision-making process of these clients with regard to medications are client motivation, client participation in client-provider interactions, and quality of life (QoL).
Medication administration, monitoring for effectiveness, side effects, need for adjustments and addressing medication adherence issues seems to have been the domain of nursing from the beginning of the community mental health movement. In an exploratory study into the role of community mental health nurses, Jordan et al. (1999) found that nurses are expected to manage and monitor medications accurately and adequately, are responsible for assessing any contraindications, recognizing and assessing side effects, and treatment responses.
Marland (1999) looked carefully at the question of depot medication and medication compliance. She questioned whether these important decisions were based on research evidence. She stressed the need for process consent even with depot medication to promote mutual decision-making because compliance is built on patient empowerment, not on route of administration. Compliance therapy may be helpful since true compliance cannot be imposed, but must be valued by the patient. In community mental health the nurse is an advocate and a point of reference, because long-term maintenance depends on allegiance with internalized values.
Conceptual framework of medication decision-making
The Interaction Model of Client Health Behavior (IMCHB) has been established as a useful model in guiding research and development of individually tailored clinical interventions (Cox 1982 and Carter and Kulbok 1995). The model subsumes many of the variables generated by other models of health behavior, with the addition of an emphasis on the client-provider interaction process (see Figure 1). The model assumes that: (1) clients are capable of making informed, independent, and competent choices, (2) those choices are affected by client singularity and by client-provider interactions, and (3) clients should be given the maximum amount of control feasible (Carter & Kulbok, 1995). The IMCHB model identifies explanatory relationships between client singularity, the client-provider relationship and subsequent client health care outcomes. These model components will be described and will be discussed in relation to medication decision-making for persons with SMI.
Tags: health care