Optimizing Adherence: Bipolar Disorder and the Therapeutic Motivational Alliance

Bipolar disorder is a severe, recurrent, and chronic disorder, with attendant morbidity and mortality (2). Suicide rates among people with bipolar disorder are 12 times higher than those in the general population (3). The functional disability that individuals experience from this disorder varies widely.

Medications and psychosocial interventions are often very effective in managing symptoms and minimizing the suffering associated with this disorder (2). As with other chronic illnesses, following an effective treatment regimen is necessary for optimal prognosis. However, adherence to medication is a common problem in bipolar disorder, and one that contributes substantially to poor outcomes (3, 4). Despite the increase in the number of effective medications, the efficacy-effectiveness gap in clinical practice suggests that lack of adherence is a major problem in the treatment of bipolar disorder and contributes substantially to functional disability and even death (3–5).

Hassan and colleagues noted that “the quality of the professional-patient relationship in the treatment of mental illness predicts patient outcomes” (6). A collaborative relationship in the treatment of individuals with psychiatric disorders has been found to predict treatment outcomes across a range of therapeutic settings (7). This may be particularly important for successfully engaging patients who have previously demonstrated reluctance to engage in mental health services (8).

In fact, in the Treatment of Depression Collaborative Research Program (9), the therapeutic alliance was associated with a higher variance in outcome (21%) compared with any specific psychotherapy or pharmacotherapy. Study authors posited that the therapeutic relationship may be a nonspecific, positive factor in treatment response. In addition, this alliance may provide a “holding environment” in which issues related to taking medication can be addressed (9). Likewise, the National Depression and Manic-Depression Association survey (10) reported that patients who were more satisfied with their provider were able to come to terms with their illness more readily, felt more able to cope with their illness, were less angry and ashamed about the illness, and were more likely to adhere to their medication regimen. The connection with the patient and hope that the clinician conveys may be communicated to the patient in a sustaining manner.

In a study of patient experience by Bilderbeck et al. (11), individuals with symptoms of unstable mood described the importance of receiving an explanation for their symptoms. They also noted the value of having a collaborative relationship with their clinicians, of being listened to and acknowledged, and of being informed about and involved in clinical decisions regarding their care. These authors highlighted the importance of eliciting the patient’s goals and values regarding his or her care in the development of a strong therapeutic relationship. Effective and collaborative doctor-patient communication improves outcomes (6, 12–14).

Balán, Moyers, and Lewis-Fernández (15) described a therapeutic approach—motivational pharmacotherapy—that improves medication adherence and incorporates elements of motivational interviewing into a standard pharmacotherapy session. Motivational pharmacology uses four central processes: engaging the patient, focusing on the patient’s desired behavior change, evoking and reinforcing the patient’s own stated reasons for wanting to change, and planning steps to achieve this goal. According to Lewis-Fernández, “by eliciting and responding to ‘change talk,’ Motivational Pharmacotherapy reshapes the physician-patient interaction from an assessment of symptoms and side-effects to a conversation about the patient’s treatment experience, treatment goals, and progress toward those goals. In this format, the physician and patient are equal co-decision makers” (16).

The basic frame of motivational pharmacotherapy begins with the psychiatrist welcoming the patient, affirming the commitment to treatment, and suggesting a brief overview of the forthcoming session. The psychiatrist asks directly about what steps the patient has taken to stay adherent to the treatment and what obstacles may be interfering with optimal adherence. The patient is encouraged to suggest strategies he or she may use to improve adherence. The session wraps up with a review of the treatment regimen and a collaborative decision about any changes to the medication treatment. It is also critical to ensure that the motivational pharmacotherapy is culturally congruent with the patient’s worldview, hopes, and fears.