Book Reviews

"Improving Medication Adherence: How to Talk with Patients About Their Medications"

by Shawn Christopher Shea, M.D.
Click here for sample chapter

Quick Reviews:

". . . . extraordinarily useful book for physicians at the beginning of their careers. As I indicated at the start of this review, first-year students and fourth-year students should have this as required reading . . . . It should then go on their bookshelf to be drawn upon throughout the rest of their careers."

Psychiatric Services, August 2008

"Easy to read, unique . . . . Discusses approximately forty very useful vignettes and strategies for talking with patients (about medications across all drug categories)."

Human Psychopharmacology, 2007

1. Review from Psychiatric Times, July 2007;

Reviewer - Mark Vanelli, MD, MHS

Improving Medication Adherence: How to Talk with Patients About Their Medications by Shawn Christopher Shea, MD - In the United States and other Western countries, the most common health care intervention is not delivered by a physician or performed while in a hospital but is carried out by patients themselves, at home, through the simple, yet critical act of taking a medication to manage a chronic illness. Many previously fatal illnesses are now chronic ones that can be managed with a simple catch - positive outcome depends on the person taking the medication over months, years, and sometimes even decades. How frequently does this type of adherence occur?

Sadly, not often enough. In the United States, 30% to 70% of patients who fill an initial prescription for hypertension, hypercholesterolemia, cancer, or depression (among others) will not refill their prescription in the following 12 months. The result: treatment that should succeed often fails.

Improving Medication Adherence: How to Talk with Patients About Their Medications, by Shawn Christopher Shea, is a slim and excellent primer on the verbal strategies and interviewing tips that clinicians can use to improve medication adherence. Shea, a practicing psychiatrist and assistant professor of psychiatry at Dartmouth Medical School in New Hampshire, correctly and critically observes that medication adherence is an extension of the clinical alliance. To this end, the book provides both general strategies and specific tips (43 in all, which are conveniently listed in the appendix) on how to develop a clinical alliance that promotes medication adherence. Examples include asking the patient about the dreams the illness has destroyed and how the use of medication might help restore them (eg. how asthma medication might help a child play sports again); assessing the patient's past response to medication as a basis for anticipating and managing personal bias for or against future medication use; and not forcing the initial decision to try medication on the patient, but clarifying which symptoms of the illness are worth treating so the patient ultimately makes the choice to try medication.

The list, of course, goes on, which is why you should read this book. One of the things I most liked is how the book models specific language, questions, and thinking that can be used to improve medication adherence. As a psychiatric resident, I often found it frustrating to hear senior clinicians conduct patient interviews that seemed impossible to replicate. Here, however, the extensive use of clinical vignettes and the tips provided succeed in making this a practical "how to" guide for prescribers and nonprescribers in medical and mental health settings.

Future editions of the book might do well to include graphs with population-based data showing how patient tendency to continue using a medication is dismally short-lived across medication classes, especially in the first 30 days after the initial outpatient prescription is filled. Otherwise, this fine resource may end up preaching to the converted rather than reaching the broader audience it deserves.

While our professional journals spill over with research finding, this wonderfully practical book takes us back to the core of our profession - helping us make contact with those we treat so that the medications we prescribe, and the good outcomes they can enable, are used to their utmost advantages.

Dr. Vanelli is the chief medical officer at Adheris, Inc. He also is a lecturer in psychiatry at Harvard Medical School in Boston.

2. Review from the Bulletin of the American Psychiatric Nurses Association, June, 2007;

Improving Medication Adherence: How to Talk with Patients About Their Medications - Listening, caring, developing trust - they all lie at the heart of the nurse-patient relationship. Improving Medication Adherence: How to Talk with Patients About Their Medications by Shawn Christopher Shea, MD introduces a caring approach to developing an alliance with patients around medications that will benefit experienced clinicians and nursing students alike. He describes his approach from a perspective of the patient's "medication interest" as opposed to their "adherence or compliance" and he shares practical steps to engaging patients in working as a team to help them make the best choices for their own medications. Dr. Shea uses humor and case studies to teach his simple step-by-step investigative approach to tackling the issues of efficacy, cost, convenience and side effects from the initial appointment to the follow-up and beyond. This is definitely a book that you will reach for again and again, so buy multiple copies because if you lend it to someone, they'll surely want to keep it."

3. Review from the Annals of Clinical Psychiatry, June, 2008

Improving Medication Adherence: How to Talk with Patients About Their Medications by Shawn Christopher Shea, M.D. published by Lippincott Williams & Wilkins - As the author of this little book suggests in its preface, "this is a small book about a big topic" (p. xiii). Medication adherence, compliance or whatever we call it is a very important, if not, according to some, the most important part of pharmacotherapy. Patients may not get better without taking the medication and without taking it as prescribed. Yet, as the author, Dr. Shea, writes, patients with chronic diseases take their medications as prescribed only about 50% to 60% of the time (p.3). He also cites findings that "about one third of patients comply reasonably well with recommended treatment, about one third have moderate problems with adherence, and about one third take their medicines poorly or not at all (p3-4). We, as a profession (and I mean all medicine, not just psychiatry), clearly have a huge problem on our hands. A lot has been written about this issue, yet most of the literature on adherence/compliance issues describes and analyzes the issue rather than telling us what to do about it.

Dr. Shea took a different approach. Combining his own vast clinical experience with the ideas and advice given to him by the audiences of his numerous workshops on medication adherence, he wrote a small book focused on how to talk to patients to improve their medication adherence. The book consists of Preface, Foreword (written by the former Surgeon General C. Everett Koop), nine brief chapters and one Appendix.

In the first chapter, "Nonadherence: the extent of the problem," Dr. Shea outlines the scope of nonadherence and also points out that there is clear evidence that patients who do not adhere to their medication regimen fare worse than those who stick to it. The second chapter, "The crux of the problem: the nature of medication nonadherence," discusses the many roots of nonadherence, such as cognitive problems, confusing directions, not enough money, lack of trust and other reasons. The following chapter, "How do patients choose to take a medication?" brings up the "choice triad" which people use when deciding to take medication:

1. They feel that there is something wrong with them;
2.They feel motivated to try to get help with what is wrong through the use of medication; and
3. They believe that the pros of taking the medication will, in the long run, outweigh the cons (p23).

This chapter also points out how difficult it is for patients to adhere to medication during the initial phases of some chronic illnesses (e.g. diabetes mellitus) when their symptoms are minimal or the disease is just defined with "abnormal" numbers (e.g. hypertension). The fourth chapter, "Is it really noncompliance," the author discusses the difficulties with the terms adherence and compliance, and then introduces what he calls "medication interest" (p38). This term suggests, according to the author, that we are primarily teachers and motivators in the process of administering medication. This chapter also explores the issue of "medication sensitivity" (p40) and the inaccurate view of many patients that they are unusually sensitive to medication.

The following four chapters explore why patients choose to stop medication. The fifth chapter, "Outside the office: the weighing of the pros and cons", emphasizes that there are three different belief sets that determine whether a patient will stay on medication:

1. efficacy of medication,
2. cost of medication, and
3. psychological meaning of medication.

Each of these belief sets forms its own continuum (p52-53).

The next three chapters, chapters 6-8, explore these three issues. The chapter on efficacy brings up the issue of "proactively recommending discontinuation" (p69). The chapter on cost discusses another interesting issue - the hidden costs, e.g., inconvenience to get the medication (e.g. elderly patient driving to the pharmacy). The chapter also provides some useful tips on how to remind patients to take medications as prescribed by association with some routine (e.g. medication next to toothbrush or alarm clock). The chapter on the medication meaning focuses on some very important issues, such as dismantling the myth of addiction (e.g. in the case of antidepressants), dismantling the myth of crutch, how to approach tapering the medication if the patient is determined to do it anyway, probing the resistance from the patient's spouse/partner and anticipating friends' opinions on medications.

The last chapter, "Medication interest redux - caring for the patient," discusses how to help patients in making the right choice. It summarizes the core principles of the "medication interest" philosophy. It also, among others, suggests how to deal with alternative methods of treatment and people who practice it - the author suggests showing the patient that one is open to these methods and willing to discuss them.

I have, so far, summarized the main content of the chapters, however I left out the most important component of this book: interviewing tips. The text of the chapters is interspersed ( in appropriate places) with 43 interviewing tips on addressing nonadherence. These tips are very useful and based on the author's vast clinical experience. The author starts with motivating tips such as the inquiry into the patient's lost dreams, and covering numerous issues such as tapping into family motivators, providing a visual reminder for family motivators, family inquiry on dosage, probing impending discontinuation and many others (exactly 39 more!). These tips are properly discussed in the text, but they are also summarized in the Appendix (Tip Archive: "Quick Reference").

There have been many texts written on the issue of nonadherence or poor compliance. Many of them summarize the issue from a scientific point of view and overwhelm the reader with numerous, not always very useful, facts. This book is different. It is rooted in the author's clinical practice and his profound understanding of this issue. It also summarizes the experience of many members of the author's workshop audiences. It is, as pointed out on its cover, really the first book on "how to talk with patients about their medications" and about taking them, and taking them as prescribed. It is a pleasant, simple reading, the tips are easy to understand and use. I believe that every practicing clinician, even the most experienced, will find it useful and handy. I also believe that residents in every clinical discipline should read and use the tips daily.

Richard Balon, M.D.
Wayne State University
Detroit, Michigan

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Improving Medication Adherence