# 131 January 2011

“Faith is taking the first step when you cannot see the end of the stairs.”

Martin Luther King, Jr.

(continues below)

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# 131 January 2011

Taking the Heat Off of the Decision to Start a Medication

TISA Description of the Problem: Both the Medication Interest Model (MIM) and motivational interviewing emphasize the importance of allowing a patient to arrive at his or her own choice. If a patient perceives that he or she is being pressured, then interest in taking a medication may often lessen or disappear altogether. In the following clinical interviewing tip from Raphaelle Butler, we can see this principle put into practice with a simple, yet effective, interviewing technique.

Tip: When I sense that a patient is very reluctant to consider the use of a specific medication, I don’t write a prescription. Instead, I give them a sample and say:

“I think your hesitation makes good sense. It’s smart to weigh the pros and cons. I know I would. Here is a small sample of the medication that I think might help. You can go home and think about what we have been talking about and perhaps go on the web and check out information on the medication (I often provide specific websites that are factual and balanced in their information). If you decide you want to give it a try, then you can start it up yourself the way we discussed and see how it goes.”

Patients vary on what they do, but always seem pleased with the lack of “push”. Some check it out on the web and don’t try it, some decide to start it, others have questions at the next appointment and start it subsequently.

TISA Follow-up: In this clinical interviewing tip, Raphaelle Butler clearly takes the heat off of the decision and places the decision exactly where it belongs " with the patient. I also think it is very wise to provide specific websites that are balanced (a random search by the patient may lead them to pharmaceutical house sites that may be biased towards the medication or “rant sites” that are biased against all medications). After checking out the balanced sites, the patient can more effectively explore other sites and make their own informed decisions about the quality of the information on the sites.

I have seen clinicians use an almost identical approach but they provide a prescription instead of a sample. One might argue that providing a prescription instead of a sample might create more of a sensation of an implied commitment by the patient creating a mild increase in the sense of “push”. A prescription will also require the patient to make a trip to the pharmacy and spend some money (both of which could function as deterrents). In contrast, a sample makes it extremely easy to start the medication if one desires to do so. Perhaps the most effective approach, if possible, would be to provide both a small sample and a prescription. In any case, the clinician can flexibly adapt this strategy to best suit the needs of the patient.

Tip provided by:

Raphaelle Butler, M.D.
Eureka, California

TISA is a site dedicated to advancing the science and art of preventing suicide and teaching clinical interviewing