Rhymes with Compliance

Depot antipsychotics – the kind which are given by injection once every few weeks – just got a lot longer-acting. The release of a‘new’ agent – it’s a medication that’s been around for awhile but has been modified – allows for just one injection every 3 months.

“With a dosing interval that can be measured in seasons, not days, people living with schizophrenia and their treatment teams can focus on recovery goals beyond short-term symptom control,” said trial investigator Joseph Kwentus, MD”.

Medical ampoules and syringe

There’s a part of me that bristles at the use of use of the term ‘recovery’ by a pharmaceutical company.

Depots have a role and I do not doubt the data. The company points out that “… 93 percent of patients treated with [this new agent] did not experience a significant return of schizophrenia symptoms.”  That is commendable.

Several months ago I attended an educational session where the speaker, a psychiatrist, gave what I thought was a sales pitch for depot meds.  After hearing the speaker use the term ‘compliance” for the umpteenth time a senior psychiatrist in attendance commented how “I like the word compliance because it rhymes with alliance”.

I agree; compliance is not what we should be striving for but if it takes us towards alliance that’s a positive step.  So-called ‘maintenance’ on depot antipsychotics should not be a recovery goal.

I believe in using depot meds and I believe there are times when forced medication treatment is the right thing to do (see my blog on Forcing Treatment).  But the goal should be to help patient/clients take on more and more responsibility for their recovery.

In a previous blog titled On Being Sane I included a comment from Lorna Moser that I see as relevant to this issue.  On forcing treatment Lorna wrote:

… It’s a very grey space to work within, and that is often underappreciated by many. In trainings, I have spoken about some teams/agencies/staff seemingly either too risk tolerant in the “name of recovery and personal choice,” and then there are those who are very quick to take control and be coercive. Finding the “sweet spot,” is knowing that conditions for outpatient commitment (as an example) are rarely black and white (“Must receive treatment” — what does that mean? receive therapy, but no meds? refuse 2 of 5 recommended meds?) — there is still personal choice within the apparent constraints of IOC/assisted outpatient treatment (AOT). It’s the skillful and caring clinician who knows how to best use such a shared decision making approach within the parameters of those leverages, and knowing the extent of the risks, which may in turn call for pushing the lever down — but in a measured way, where possible (you don’t have to go full throttle right away). For many people, whatever leverages that are in place will at some point go away, and if you didn’t do your work to build a trusting and caring relationship in the meantime, they, too, will go away when the leverage is lifted.”

Lorna recently posted a link to a 2014 video of Sam Tsemberis Interviews Len Stein about Assertive Community Treatment.  ACT clinicians should definitely watch it!  Thanks Lorna.

Share your thoughts. Maybe see you at the OAA Conference later this month.

Shalom Coodin

October 5, 2016


One comment

  1. Your article/post on teams and the client keeping focus on the role of both medication and meaningful recovery… life goals for the person is a super to remind us that at every kardex or treatment planning meeting, that we can’t focus on one, without discussing the other. That would be an useful rule to try out, It would be interesting if a few teams… let us know how that works if they are currently doing this, or how it goes if it was done as a little pilot.

    Michelle Salyers, in commenting on ACT team styles/cultures improvements notes “teams are more or less recovery oriented or clinician driven;”

    Below is a summary of her recommendations Recovery Orientation Improvements ACTT Model

    -Integrate other evidence-based practices on ACT teams;

    -monitor recovery orientation. -“teams are more or less recovery oriented or clinician driven;”

    –need training and supervision – recovery oriented work- that supports move away from a symptom oriented dominant view to: talents, strengths, emotional concerns;

    –hire consumers as ACT team staff members. Saylers, 2007 http://www.wpic.pitt.edu/education/CPSP/2%20IXC1%20Sess%20II%20-%20Salyers.pdf

    To further focus on medication, Manhattan ACTT has developed a Medication Tier assessment that fits well the recovery model and even matches the dual perspective approach of worker/client we use in the Ontario Common Assessment of Need (OCAN).

    The medication tier assessment is matched with a Recovery Assessment. These were provided to me by MacDara O’Sullivan. He notes that this is some kind of Beta model that has not been validated as a clinical practice tool. For me, it is promising as a resource for ACTT.

    I could post it in the OAA web page if there is interest, but go to http://www.eenetconnect.ca/ (you have to log in here, before accessing the ATR Forum if you want.

    Anyways, thanks for cheering us on to think about this.

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