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I'm really excited to talk about one of my favorite topics and that is engaging patients in treatment. So by the end of our session today, you'll be able to identify at least three strategies to enhance patient engagement and education in the management of major depressive disorder. So to start out, I just wanna put us all on the same foundation to know we're not that different from our patients. We all experience change whether that's just the change that happens with time passing unexpected events that are introduced into our life or the intentional change that we have in developing ourselves. And all the change theory data suggest that it's hard, it's hard when you want to change. It's hard when the situation is forcing you to change. It's change is difficult because it brings uncertainty. It takes a lot of time and effort. It often feels forced, but it's especially hard when you're trying to change by yourself or outside of supports. Specifically, when you think about depression care and mental health care in general, I think it's important to understand how do people get help for mental health symptoms compared to other problems for so long we were driven by this um theoretical model, the health belief model that talked about perceived benefits, perceived barriers, this kind of logic based discussion that was primarily driven by symptoms. To say one of my symptoms are ha are difficult enough or um making it hard for me to function. As long as I have kind of a self efficacy, I will be triggered to action and then I would engage in help, promoting behavior like getting help. But time and time again, when we study the ways in which people seek help for mental health issues, this model really fails to explain delays in treatment seeking. So um that um there has been some epidemiological studies that shows those delays that are especially in depression and other mental health symptoms despite severe symptoms could be 1015, 20 years of delay. So there was a sociologist, Bernice PCO Solito that introduced a model called the network episode model that was proposed to center an individual within a social network. And this was back in the eighties. So this was actually before social media, this was literally looking at the social network of who people talk to how and when and how they were connected and how closely they were connected and their social network either will um help you to understand how it's activated and whether the activation of that network is gonna promote or inhibit treatment seeking for mental health. So since it was first introduced, many people have studied and validated and shown the ways in which yes, the population characteristics and the organizational constraints are factors. But it's this interplay between the illness career of a person or their journey of care and how they interact with their informal networks as well as their formal treatment networks. I'm gonna come back to that when we talk about the ways in which you can help engage patients better in care. So this recent um the study was in 2015. So not very recent, but it's a nice overview of describing social network activation. This describes that people manage or are managed through their health problemss by both those lay and professional network ties which may recognize, define or dismiss symptoms, they may recommend or provide health services, they might offer emotional or instrumental support, they might attempt to regulate health behaviors, appointments and medication compliance. And there's been some subs studies looking at disclosure response in terms of what is the impact if you disclose depressive symptoms in your social network and they are dismissive of those symptoms, the impact of that response could cause you to delay your care saying maybe this really isn't that big of a deal. What we find is that when people have a large health discussion at work characterized by close ties and a culture of support for medical care at the point of entry into treatment, they enjoy better outcomes. Therefore, achieving a state of recovery may be facilitated by cultivating a social safety net that can provide targeted health-related advice, affirmation, and instrumental aid that supports the treatment process and helps to advance self-sufficiency and productivity. So, activating the social network is a really important aspect of recovery. But if your social network does not promote health or if it dismisses care, it can have the opposite effect. So I think one important aspect of improving engagement and education is by improving community knowledge. So I highlighted here to advocacy organizations, the national lines of mental illness often called refers to as NAMI provides education and support programs for individuals and families impacted by mental issues. They uh oper across the country in every states in the United States. But there's also a lot of information. If you're not in the United States that you can access online, they offer free programming for um family members to get support from each other as well as for people with lived experience to get support education and hope for their future. Mental health. America also has public education. They focus a lot on policy and research, but they're um they have a lot of nice online self assessment tools. So I included both of those websites, I always would recommend my patients to look at those resources to engage in their local organizations or if there's some where you practice to support that engagement in the community, if they've already gotten care. But these organizations also do a lot of work before people are seeking care to help improve community knowledge. So going, let's dig down into the clinical process. Um There um this study was in 2020 that talked about a way of how you manage ambivalence in terms of uh a depressed person seeking treatment. I highly recommend this as a great kind of skill building article. She goes into a lot more detail just gonna give you the highlights because when people actually do get help for depression, it doesn't mean that they're all in. And so this article talks about the ways in which you can use ethnographic interviewing, as well as motivational interviewing as a strategy to help engage someone and motivate them into treatment. Um Many people have heard of motivational interviewing. So I thought it would be helpful to go into a little bit of detail about ethnographic interviewing. This is really about a posture similar to motivational interviewing. The posture of an ethnographic interviewer is one really driven by curiosity where the clinician instead of assuming the role as an expert, they're assuming the role of an open curious, interested learner who's giving up control to the patient and inviting them to be the expert teacher. Tell me what this is like for you help me to understand your experience with. And she describes the phases of this engagement interview as eliciting the story, helping them to use their own words to describe their experience with depression to then with curiosity uncover their treatment, history, but also their hopes for treatment. So all of them are trying to get a history of what medication you tried and what has worked and what didn't work. But what are your hopes and dreams? What do you hope would happen? Um What would success look like for you and then giving some feedback about things that stood out to them after you've listened intently and then providing some psychoeducation again, using motivational interviewing, which is very much helping to help the person to come to an understanding rather than being directive or just giving them unsolicited advice. And then in order to um formally engaged too, it's important to address the barriers that you've been seeking in that initial engagement interview and then finalizing with that commitment. Um And I'm gonna talk to some examples um within, in the context of medication management. But those um it really applies, even if you're talking about psychotherapy engagement, I think engagement and care is one of the most important parts of care because you can't help somebody who's not coming back to care. And um engagement is something that I think is important to pay attention to in that first, those 1st 1 to 3 contexts, as well as throughout the course of care, noticing signs that the person is not engaging and trying to address that proactively. Um measurement based care refers to the use of patient reported outcome measures. And um I like to think of measurement based care as an engagement strategy. The reason why I think it helps engage patients in in care is because it's also helping to transfer that autonomy and power to the patient. It enables them to self assess between visits. So you may not be seeing them for three weeks and you can encourage them to use the tool between visits to detect on their own if they're doing better, if what they're trying is working or not working. Um It also can provide an objective measure of treatment success. Um Definitely when people come in with depression, they may have a lot of negative scripts, including I'm not that bad. Some people have it worse and you can really help to counteract some of that um distorted counterproductive thinking by into context. What does it mean that your P HQ nine is a 22? And what does it mean in terms of why I'm recommending medications as opposed to just um exercise, for example. And I will often use the scoring on the P HQ nine to help to explain why I'm making a certain treatment recommendation um in and of itself the tool itself that we use for depression also helps to educate the patient on the symptoms associated with depression. And if they have other cooccurring issues like chronic pain or um PTSD, using those scales can also help to have a conversation about the differences between depression versus those other conditions. So I am a big proponent of using measurement based care as an engagement. Two. So for most of our time today, I'm gonna talk about um medication adherence or globally, this issue of adherence and walk through some examples of how you can um change the way in which you're talking to patients to improve engagement and care. And you're also educating through the process now to start it, it's important. What are we really, what are we really talking about? So when we, when we talk clinically about non adherent, oftentimes, we think about someone who's intentionally oppositional, like they're just like not doing what we tell them to do. And in my experience, this is a very low percentage aspect that often there are other factors such as practical limitations, confusions over directions, even sometimes cognitive problems that can drive adherence. But also I think there is an opportunity to kind of flush out. Why does someone actually take a medication and how can we get ahead of some of the barriers to engage them in care in general? I would encourage you after today to not use the term non adherence or noncompliant and just take it out of your lingo and I'm gonna give you something else to talk about. But here's why I think non adherence fails as a communication term. Both of these terms presume that it's the prescriber, the physician and the person directing the treatment who's in control of making the recommendation and that the job of the patient is to comply or a here to the plan. So it really underscores power dynamics, whereas only a small percentage of people are purposely going to go against care. It doesn't distinguish between the reasons for non adherence. And there's not really a great way to talk to your patient about treatment adherence without setting up a fight. So I'm not gonna really go into great detail with these points here. But the point is that a lot of people don't take medications. Most of us, if you've been given uh antibiotic course, you might have stopped it soon cause you felt better. And we do know that not taking medications is associated with treatment failure and poor outcomes. But it's not unique to people with depression. We've even studied, um, people with chronic diseases such as heart disease for which not taking, it can really cause you physical problems that you notice and you're looking at 50 per, per 50 to 60% of the time you're not taking the medications. And then even if you're taking a medication that has blood monitoring, like lithium, a lot of times unconsciously, people just catch up with medications right before their followup appointment. So even if you're taking a blood test, it might not tell the truth about whether or not they're taking the medication. Um, the key thing here is that if there is resistance, it's not that the person is oppositional. They're not doing what you want, but you're not doing what they're not what they want. So, it's not just a behavior that a person does. It's an experience that two people share and both parties are kinda not happy with it. How do you get around it? Resistance? Well, it's not by trying to convince or proceed or push the nature of resistance is that the more intensely you resist, the more intensity you will push back. The converse is true. It, even if you yield a little bit, it resolves that resistance. So in the past, we used to think about resistance related to medication adherence as a patient problem. And those techniques were on how to change their oppositional thoughts. But if you can lessen how much the person feels pressured to take a medication, the likelihood that they'll choose to take it may paradoxically increase. So what I'm setting up here is the main principle around motivational interviewing. Um One of the key ideas here is rolling with resistance, what drives the intensity of the resistance is not how much we're truly opposing them, but their perceptions and their perception is not created so much by what we say, but how we say it. And so I'll encourage you to think about the way in which you convey relationship with your words. And how can you join to be to really show that you're on the same side as the patient that you have the same goals when you're working together. So how do people choose to take a medication? There's three main parts of this choice. Triad. First, you have to believe that something is wrong with you, that you have to be motivated to get help with what's wrong to prevent future problems through the use of medications and believing that the pros of taking the medication in the long run will outweigh the cons. So these three aspects are they all have to be true in order for you to choose to take medication. So instead of non adherence and noncompliance, I prefer that we use this term medication interest. And I would also encourage you to use that term even when you're documenting in your record. Cause if you're trying to talk about medication interest, but you're still using non-compliance or recurrence in your charting, it's gonna come out, the patient's gonna notice. So here's an example of a script that, um, that you might use to start this conversation. Hey, my goal is the doctor is to give you the best advice, whether that's advice to start a medication, stay on it or get off it together. We wanna find a medication that you're genuinely interested in taking because it makes you feel better. You're the one that's putting the medication in your body. So it's your opinion. That's most important, not mine. So please always let me know exactly what you think about the medications that we're trying cause I need your input, you know, your body better than I do. And I think we can be a great team in finding a medication that works well for you that makes you feel better. How's that sound? That's an example of an intro. You can come back to that when it comes to setting up ex expectations around. How long will it take to get better? Um, how many different medications will I have to try in order to make, um, to, to see that I'm better. This really undermines the idea of people feeling like a guinea pig. You're gonna feel like a guinea pig. If you think my doctor doesn't know what they're doing, they're prescribing two or three medications. Versus if you had a conversation upfront about we're gonna try this medication. Here's what the course is gonna look like. If you're not getting better in 2 to 3 weeks, four weeks, we're gonna change the dose, we're gonna change the medication. Just give them a preview of what to expect with treatment. So, some questions to start, um, to think about yourself, how interested is the patient in taking the medication? And if they have started the medication, what percentage of doses do you think that they are taking? Um, how do they list the pros and cons that lead to their low interest? If they're not interested in medication? They may believe that it's a crutch. They may have fears that they will become addicted to the medication, they may be concerned about side effects. So basically going back to those three domains, what step of that choice triad is their low interest related to? And did you, what ideas you have about increasing their inr interest and how interest is their family in taking the medication? Um, one way that I think it's helpful to help you get outside of your perspective because you wanna help the person, you're seeing them have a lot of symptoms. You want them to feel better, understood, but put yourself into their shoes and understand what is efficacy look like from their point of view. So by just opening up conversation and say hi, I'm interested in how you think about the pros and cons, you're already um giving power back to the person and you're communicating that you care about their opinions. Um, you can also help to instill positive expectations by being proactive and how you check in with them. A lot of times prescribers will start a medication, say come and see me in three week. I don't like to do that. I like to check, especially if there's been some signs in that engagement interview that a person might be reluctant or nervous about side effects. I say, hey, I'm gonna call you in a week, two weeks to see. Were you able to pick up the medication? Did you take a couple of doses? And this also gives me an opportunity to walk them through some of those initial side effects to get them reassurance and encouragement. If you wait three weeks or a month, then they're gonna try, they're gonna have the story that they're telling themselves. It's gonna be told over and over again for a whole month before you have a chance to weigh it again. So I really recommend that especially if you have some clues early on that they may have some ambivalence or not that interested in medications. And then you've gotta go back to what is their ongoing view about efficacy? So many times patients will have an attribution error, they would say, oh, this medication made me so sleepy. Now, sometimes medications can have unusual effects, but there's many that we know cause sedation and some or tend to be more activating. So, um, really getting them to tell you the details about their experience can help you to start to tease out any attribution errors or this one gave me the side effect. It's like not on the list of all of side effects but ask them openly walk me through a specific time. Was anything else going on? What did you do before? What did you do after? Um, is it a chance that this might have been, um, you know, did, did you try taking the medication again when you didn't eat that for breakfast, for example, but taking it seriously and expressing concern is helping you to build credibility with the patient ask them to give you a, a severity rating on a scale to 1 to 10. Show that you're evaluating their experience and problems solve ways to get a therapeutic dose. I'm also never afraid to start on a lower dose of medication and try to mitigate side effects. Always being clear that this is not a therapeutic dose of medication. So until we can get up to this dose of the medication, we're not gonna give a, a grade, but we're, I'm gonna help you work through some of these side effects. I've had a lot of success with that strategy. The other key trick here is probing for impending discontinuance and then proactively recommending discontinuance. Um This is one of my favorite ones because we have so many treatment options for depression. So if it's clear that someone says, oh, I started taking Zoloft, but then I talked to my friend, she said this is the first medication ever. I don't really know anymore. And then you also noticed that the persons haven't really taken it or they start to have side effect like, you know, why don't we just stop that medication? We have plenty of other options for you. Let's just stop that one. Let's try this one and see how it works. Um The other important thing is to really understand what is cost look like to the patient. It's not just the actual cost of the, the coinsurance. It could be just the inconvenience um of having to go to the pharmacy. Um Some of the patients I care for actually traveling is a big expense. So if I can call in their script or have a mail order order that helps to minimize inconvenience also, um trying to short circuit that shame cycle. So instead of asking them, are you taking your medication? Hey, did you notice any problems with the doses being inconvenient or did you find that you're missing any of the doses? And then let's talk about that. Um, some patients have stigma around actually taking the medication while they're at work, especially if there's a medication that's, um, needs to be taken during the work day. So I've talked to some patients about like how you can do that. Can you go, do you have, you know, if you don't have a close office, can you go into some, one of my patients actually use a restroom to take their medications? Anything that's gonna help you be more likely to take it? Let's have a conversation about it instead of putting it all on the patient to figure it out. Another one of my favorite strategies is negotiating a short term contract to say, hey, I'm not asking you to marry this medication for the rest of your life. I'm asking you to give it a fair shot for, I think three months, give me three months to work with you to try to get your symptoms under control. We might have to go through a couple of different things to get there. Can you commit to that? That really helps cause sometimes you have a lot of fears about, am I gonna have to take medication for the rest of my life? Let's just get you not at the severe range of depression. Now, let's just start with that and then express an interest in alternative treatments, especially those that are like non harmful. If it's not gonna hurt, just make it a part of your care. You don't want to set up a fight to say I'm either gonna use a lightbox for my depression or I'm gonna take this sri do both use both. It's OK. So to summarize the engagement strategies, the first is to engage and expand the social, the patient's social network to promote engagement in depression care. So if they don't have a supportive family, you really might wanna push, engaging in those community-based advocacy efforts. If they do have a family member that's concerned about how they're doing, bring them close into the care process so that they can get the same information with the patients so that you're not telling the patients something they go home, the person has questions and now they're not moving forward with treatment because their social network isn't on board. Second point, conduct an engagement interview initially to empower and motivate the patient to engage in care. And even if you can't dedicate a whole interview to that, use some of those strategies to be thinking about engagement at the first point of contact with the patient. Third point is to employ measurement based care as an engagement and patient education tool. Hopefully, are you doing that already? If not start doing it and see what feedback you get from patients on that? And then the last point is to use motivational interviewing to address medication, interest and elicit barriers to medications. Hopefully after today, you're not gonna be talking about patients as being not inherent or noncompliant that you will use the term interest as a way to talk with the patients and also refer to them in your documentation. It also helps you to um just communicate to yourself in all domains that you're on the same side. You have the same goals of the patient and you're there to help and support them, engage in care. Thank you.