The art & science of prescribing

Overall, while written or recorded instructions appear to improve recall in most situations,³⁹ images have been shown to have the greatest impact.^36,37,40

Is the patient ready to adhere to treatment?

No matter how well or by what means you communicate, some patients are not ready for change. Patients in the “precontemplation” stage of change—who may not even recognize the need for change, let alone consider it—can benefit from supportive education and motivational interviewing, while those in the “contemplation” stage need support and convincing to reach the “preparation” stage. It is only in the “action” stage, however, that a patient is ready to collaborate with his or her physician in agreeing on and adhering to treatment.⁴⁰

Comorbid depression is a common condition, particularly in those with chronic illness, and one of the strongest predictors of nonadherence.^1,41 Thus, depression screening for all patients who are chronically or severely ill or nonadherent is strongly recommended, followed by treatment when appropriate.⁴¹

“Informed collaboration” is critical

Comorbid depression is particularly common among those with chronic illnesses, and one of the strongest predictors of nonadherence.

Research shows that if both physician and patient agree on the individual’s medical problem, it will be improved or resolved at follow-up in about half of all cases. In contrast, when the physician alone sees the patient’s condition as a problem, just over a quarter of cases improve, regardless of the severity.⁴² Compounding this difficulty is the finding that patients fail to report up to two-thirds of their most important health problems.⁴³ When physicians identify them, discord and denial typically result.⁴²

Thus, concordance (we prefer the term “informed collaboration”)—an overt agreement reached after a discussion in which the physician shares expert knowledge, then listens to and respects the feelings and beliefs of the patient with regard to how, when, or whether he or she will take the recommended treatment⁴⁴—is crucial.^42,43,45,46

One way to reach informed collaboration is to give patients problem lists or letters summarizing their health problems in simple and specific terms after each visit, in hopes that the written communication will encourage discussion and a physician-patient partnership in addressing them.⁴³ In a recent study of 967 psychiatric outpatients, adherence was significantly higher among those who cited concordance between their preferences and their treatment and felt that they had participated in decision making.⁴⁷

Problems can arise at any time

Even after a patient starts out fully adhering to his medication regimen, several issues can derail treatment. Inability to afford the medication is one potential problem.⁴⁸ Adverse effects are another major reason for discontinuation. Sexual dysfunction, caused by a number of drugs, is embarrassing to many patients and frequently goes unaddressed.⁴⁹ Thus, a patient may stop taking the medication without saying why—seemingly for no apparent reason. The best approach is to ask specifically why it was discontinued, including direct questions about sexual adverse effects.

Prescribing recommendations

Sexual dysfunction, caused by a number of drugs, is embarrassing to many patients and frequently goes unaddressed.

We believe that the outcome of treatment is being determined from the moment a patient steps into your office. Thus, we’ve compiled an evidence-based checklist (TABLE)^{24,33,40,41,47,49,50} with broad areas for discussion that constitute the art and science of prescribing. These fall into 3 main areas: 1) what to say before you write a prescription; 2) how to get patient buy-in (informed collaboration, rather than informed consent) when you’re ready to write the prescription; and 3) what to address to boost the likelihood of continued adherence at follow-up visits.

It is clear that allowing adequate patient participation and arriving at concordance and overt agreement lead to better clinical outcomes.⁵¹ The sequential steps we recommend may take a few extra minutes up front, but without them, nonadherence is highly likely. While physicians are supportive of shared decision making in theory, they are often less confident that this is achieved in practice.^52,53

It may help to keep in mind that every step need not be carried out by the physician. Using other members of the health care team, such as a nurse, medical assistant, or health coach, to provide patient education and support and take the patient through a number of the steps that are included in a physician visit has become increasingly necessary—and is easily accommodated in this case.

As the physician, you bear the final responsibility to ensure that the critical elements—particularly the overt agreement—are addressed. Ultimately supporting your patient's decision and reinforcing it will ensure continued adherence.

CORRESPONDENCE
Swati Shivale, MBBS, Department of Psychiatry, SUNY Upstate Medical University, 750 Adams Street, Syracuse, NY 13210; shivalsw@upstate.edu