Theoretical Approaches to Enhancing Motivation for Adherence to Antidepressant Medications.

PROBLEM: Adherence to antidepressants is a major challenge in our health care system, with a high percentage of patients discontinuing their medications within six months. AIMS: The purpose of this position paper is to discuss theoretical frameworks that address the psychological beliefs, benefits and barriers and feelings of autonomy that affect a person's willingness and motivation to take anti-depressant medications within a therapeutic relationship with a nurse practitioner. METHODS: Three theoretical frameworks were selected to highlight particular perspectives relevant to enhancing patient motivation for medication adherence. The Self-Regulation Model, Health Belief Model, and Self-Determination Theory combined with motivational interviewing all offer guidance on strategies for improving adherence to antidepressants. CONCLUSIONS: The Self-Regulation Model underscores the importance of illness representations that prompt considering patient perceptions of depression that affect adherence. The Health Belief Model focuses on cost-benefit considerations that affect patient's adherence, along with perceived control. Finally, Self-Determination Theory combined with motivational interviewing offers strategies that enhance autonomy and optimize collaboration and motivation for adherence. RELEVANCE FOR CLINICAL PRACTICE: These three theoretical models are applied to a vignette for a patient who is having difficulty with adherence to antidepressant medication.

Evaluation of Motivational Interviewing to Improve Psychotropic Medication Adherence in Adolescents.

PROBLEM: Medication adherence rates in adolescents are poor. The World Health Organization identified that those at greatest risk were nonwhite adolescents with depression. Medication nonadherence results in poorer mental health outcomes. OBJECTIVE: The first aim of the study was to investigate if two motivational interviewing (MI) sessions would improve medication adherence in adolescents taking antidepressants and mood stabilizers. The second aim was to evaluate if attitudes toward medication correlated with adherence. The third aim was to determine if self-reported adherence scores were similar to electronic adherence data collected. METHODS: The quasi-experimental study contained an MI intervention, including a baseline and postintervention assessment of adherence over 30 days. A total of 48 adolescents, ranging in age from 12 to 18 years, were recruited from a university mental health center to participate in the study; 41 completed the study. Four nurse practitioners and two child psychiatrists mastered the MI techniques evaluated with standardized measures. The Medication Electronic Monitoring System (MEMS) was the primary measure of medication adherence. The Drug Attitude Inventory (DAI) was used as a secondary measure. Finally, participants completed the client evaluation of MI and a satisfaction survey of MI. RESULTS: At endpoint, 70.7% of the participants were taking their medications between 80% and 100% of the time, as measured over 30 days, compared with 43.9% of participants at baseline. Mean adherence scores significantly improved by 17% after two MI sessions. Mean baseline adherence scores were 63.7%, whereas mean endpoint adherence scores were 80.6% (p < 0.0001). The effect size was 0.65, demonstrating moderate effect. Participants (n = 29) who demonstrated 80% or greater adherence had DAI mean scores of 16.48, whereas those below 80% had a DAI mean of 15.5 (p = 0.73), demonstrating no significant difference on drug attitudes between the two groups at endpoint. DAI baseline mean scores were 14.2, whereas endpoint mean scores were 16.2. There was a significant difference between self-rated adherence and objective data collected from the MEMS caps as participants over-reported medication adherence by an average of 18.4% at baseline (t = 6.84, df = 40, p < 0.001). Participants reported a high degree of satisfaction with MI. CONCLUSIONS: MI is a promising intervention for adolescents to improve psychotropic medication adherence.

Teaching a Systems Approach: An Innovative Quality Improvement Project.

BACKGROUND: Nurse practitioners are required to navigate complex health care systems. Quality improvement (QI) projects provide the opportunity for nurse practitioner students to learn systems knowledge and improve health care outcomes in patient populations. A gap in the literature exists around how to systematically teach, apply, and measure QI curricular objectives at the master's level. METHOD: Six faculty evaluated the QI project for the psychiatric nurse practitioner master's program by identifying the most challenging QI concepts for students to apply, revising their teaching strategies to address gaps, and retrospectively evaluating the outcomes of these curriculum changes by comparing student outcomes before and after the curricular changes. RESULTS: A significant difference was noted on QI project performance between students in the 2014 and 2015 graduating classes, measured by the scores earned on students' final papers (t[92] = 1.66, p = .05, d = .34, r(2) = .0289). CONCLUSION: Theoretical principles of adult and cooperative learning were used to inform curricular changes to enhance student's acquisition of QI skills.

Motivational interviewing: a tool for increasing psychotropic medication adherence for youth.

There are serious outcomes to nonadherence to psychotropic medications in children and adolescents, including poor school performance, prolonged duration of illness, increased psychopathology, poor interpersonal relationships, increased psychiatric episodes, and suicide attempts. Medication treatment has demonstrated improved psychiatric functioning and a 50% reduction in suicidal behavior. more than 50% of youth with mental health problems are nonadherent with psychiatric medications. A review of literature examining motivational interviewing (MI) for the problem of treatment adherence in children and adolescents is discussed. MI has great potential to improve psychiatric medication adherence in adolescents. An example of how to implement MI with youth is provided.

Evaluation and management of pediatric and adolescent depression.

Youth who have mental health issues are more likely than their peers to seek primary care services. The primary care setting is an appropriate venue for screening and identifying pediatric depression. Additionally, nurse practitioners can provide initial management or referral to psychiatric mental health professionals for evidence-based treatments.

Pediatric psychotropic medication initiation and adherence: a literature review based on social exchange theory.

TOPIC: Psychotropic medication initiation and adherence is an identified problem. This literature review explores factors that determine families' decisions to initiate, sustain, or discontinue use of psychotropic medication in children and adolescents. Social exchange theory is used as a framework to explore decisions to initiate and adhere to psychotropic medications. PURPOSE: Contributing factors related to psychotropic medication initiation, adherence, and discontinuation are explored. Themes in the literature encompassing costs and benefits of psychotropic medication adherence include family experiences with adverse effects, previous psychotropic medication experience, medication psychoeducation, stigma, societal views about psychotropic medication, particular diagnosis, the effect of comorbid diagnosis on adherence, attitudes and beliefs about medication by both children and parents, and relationships with the provider. The impact of family demographics including parent gender, age of the child, ethnicity, and parent educational level on psychotropic medication adherence is evaluated. SOURCES: International and U.S. studies from Medline, Cumulative Index for Nursing and Allied Health Literature and PsychInfo evaluating medication initiation and adherence in the pediatric psychiatric population and social exchange theory was incorporated from relevant textbook resources. CONCLUSIONS: Rewards experienced from medication treatment include improvement in symptoms, school performance and family relationships, and reduced level of parenting stress. Identified costs include impact of adverse side effects, social stigma, lack of response, fears of addiction, and changing the child's personality. Acceptance of the diagnosis influences adherence while medication education has varying effects. Families' attitudes, beliefs and perceptions about psychiatric illness and treatment play a large role in medication treatment decisions. A trusting provider relationship has a positive effect on adherence. Psychosocial treatment alternatives are preferred. With maturation, adolescents have more influence on decisions related to adherence.

Psychopharmacology of pediatric bipolar disorder.

This comprehensive literature review incorporates research studies evaluating the effectiveness of psychotropic medications in children and adolescents with pediatric bipolar disorder. Research articles were obtained using Medline. Open-label studies, prospective and retrospective chart reviews and randomized controlled trials evaluating the effectiveness of medication in pediatric bipolar disorder with greater than ten subjects are included in this article. Antipsychotics, anticonvulsants and lithium as monotherapy, as well as their use in combination treatment, were evaluated to determine their effectiveness in pediatric bipolar disorder. Clinical recommendations of medication and management strategies are made from a synthesis of the data. In addition, adherence concerns caused by adverse effects and nonresponse as they impact physical and mental health are addressed.

A review of ecological factors affecting inpatient psychiatric unit violence: implications for relational and unit cultural improvements.

This review examines the research on ecologic factors that may contribute to or lessen the likelihood of inpatient unit violence. Understanding these factors can provide psychiatric inpatient unit staff with valuable therapeutic relational and cultural strategies to decrease violence. International and US studies from OVID Medline, CINAHL, and PsycInfo that evaluated aggression and violence on psychiatric inpatient units between 1983 and 2008 were included in this review. The review revealed that violence results from the complex interactions among the patient, staff, and culture of the specific unit. Inpatient psychiatric staff can decrease the potential for violence by using therapeutic relationship strategies such as using good communication skills, advocating for clients, being available, having strong clinical assessment skills, providing patient education, and collaborating with patients in treatment planning. Cultural improvements include providing meaningful patient activities and appropriate levels of stimulation and unit staffing.

Assessment and diagnostic issues in pediatric bipolar disorder.

The purpose of this article is to provide clinicians with detailed information on pediatric bipolar disorder (PBD) in children and adolescents to aid in the accurate assessment and diagnosis of the disorder. PBD is a complex condition that presents with a wide array of features, making it a difficult disorder to diagnose and treat. The debilitating nature of PBD makes it necessary for clinicians to address the disorder as early as possible to help ensure positive outcomes. The assessment and diagnostic process is an integral step toward determining appropriate treatment interventions. This article presents an overview of the assessment and diagnostic process, including diagnostic criteria, epidemiology, comorbidities, differential diagnoses, and risk factors. The distinctive childhood features of PBD and the diagnostic controversies are also addressed.

Clinical interventions for children with attachment problems.

TOPIC: Applying the current evidence to treating clinical populations with attachment disorders. PURPOSE: This study aims to review the literature regarding the treatment of childhood attachment disorders, with the goal of guiding clinicians towards evidence-based practice. SOURCES USED: MEDLINE, CINAHL, PsychBooks, EMBASE and PsychINFO were searched and all articles reporting results of a treatment intervention for attachment disorder were reviewed. Ancestry analysis garnered additional sources. CONCLUSIONS: There are few studies addressing therapeutic interventions for attachment disorder, but the literature supports benefits to the child-parent attachment relationship in biological families in the application of both psychoeducational and psychotherapeutic treatment modalities. A summary of the important components of applying these techniques in therapy is included. Foster and adoptive families with attachment disorders require different types of intervention than biological families. In particular, foster and adoptive parents need to help repair their child's negative internal representations by responding appropriately to their child's cues. Advanced practice psychiatric nurses are well-prepared to provide evidence-based interventions to both biological and foster families with attachment problems. More research is needed to determine the most appropriate treatment interventions for children with attachment disorders.

Current approaches to the assessment and management of anger and aggression in youth: a review.

BACKGROUND: Anger and its expression represent a major public health problem for children and adolescents today. Prevalence reports show that anger-related problems such as oppositional behavior, verbal and physical aggression, and violence are some of the more common reasons children are referred for mental health services. METHODS: An extensive review of the literature was conducted using the following online search engines: Cochrane, MEDLINE, PsychINFO, and PubMed. Published and unpublished articles that met the following criteria were included in the review: (a) experimental or quasi-experimental research designs; (b) nonpharmacologic, therapy-based interventions; and (c) study participants between 5 and 17 years of age. RESULTS: Cognitive-behavioral and skills-based approaches are the most widely studied and empirically validated treatments for anger and aggression in youth. Commonly used therapeutic techniques include affective education, relaxation training, cognitive restructuring, problem-solving skills, social skills training, and conflict resolution. These techniques, tailored to the individual child's and/or family's needs, can foster the development of more adaptive and prosocial behavior.

Pediatric bipolar disorder: evidence-based psychopharmacological treatments.

TOPIC: Pediatric bipolar disorder can cause severe disturbances in global functioning. Diagnosing pediatric bipolar disorder is challenging due to the range of symptom expression, developmental differences as compared to adults, presence of comorbid disorders, and developing diagnostic criteria. Treating this disorder can be equally challenging due to frequent symptom relapse and the dearth of research until recently on effective psychopharmacological interventions that guide clinical prescribing practices. PURPOSE: This paper will help child psychiatric nurses have a better understanding of the unique presentation of pediatric bipolar disorder to facilitate selection of appropriate medication treatment options, taking into account symptom presentation, presence of comorbid diagnosis, drug efficacy, adverse effects, and drug-drug interactions based on research findings. SOURCES: Literature specific to assessment and psychopharmacological treatment of pediatric bipolar disorder was reviewed. CONCLUSIONS: Screening of youth with mood spectrum problems for bipolar disorder should occur in every diagnostic assessment and should be ongoing due to range of mood symptoms and the cyclical and episodic nature of this disorder. Youth with bipolar disorder may manifest symptoms and course that differ from adults. Additionally, co-occuring disorders are common in this population, which can complicate medication selection. Psychopharmacological treatment with the use of specific mood stabilizers and/or atypical antipsychotic medications is warranted depending on symptom presentation; however, monotherapy with mood stabilizers has not demonstrated effectiveness in long-term remission of pediatric bipolar symptoms. Recent research indicates that a combined treatment with two mood stabilizers or a mood stabilizer and an antipsychotic holds promising results for pediatric bipolar I, for youth with acute manic symptoms plus psychosis, and for long-term remission of symptoms.

Randomized trial of parent management training in children with tic disorders and disruptive behavior.

Oppositional, defiant, and disruptive behaviors are common in clinical samples of children with tic disorders. In this study, we sought to evaluate the short-term efficacy of a structured parent training program in children with tic disorders accompanied by disruptive behavior. Children with tic disorders and at least a moderate level of disruptive behavior were randomly assigned to a 10-session structured parent management training program or to continue treatment as usual. Twenty-four children (18 boys and 6 girls) between the ages of 6 and 12 years (mean 8.9 +/- 2.0 years) were enrolled; 23 subjects completed the study. At baseline, subjects showed moderate to severe levels of oppositional and defiant behavior. Twenty subjects (83%) were on stable medication. The parent-rated Disruptive Behavior Rating Scale score decreased by 51% in the parent management training group compared with a decrease of 19% in the treatment as usual group (P < .05). On the Improvement scale of the Clinical Global Impression, a rater masked to treatment assignment classified 7 of 11 subjects who completed parent management training as much improved or very much improved compared with 2 of 12 subjects in the treatment as usual group (Fisher exact test, P < .05). These results suggest that parent management training is helpful for short-term improvement in disruptive behavior problems in children with tic disorders. Larger randomized clinical trials are needed.

Evaluation of peer-led support groups for graduate nursing students.

The purpose of this article is to explore the educational and experiential benefits for graduate nursing students as both leaders and members of a peer-led support group. The published literature on the stress associated with nursing education and methods used to decrease nursing students' anxiety will be reviewed, and a peer-led support group model will be described. An evaluation of the outcomes for participants as they relate to the goals of decreasing the stress inherent in nursing education and assisting with nursing role transition will be examined. In addition, the benefits of using peer group leaders as part of their group therapy training will be discussed.

Selective serotonin reuptake inhibitors for children and adolescents with major depression: current controversies and recommendations.

Recent warnings about potential serious adverse effects with the selective serotonin reuptake inhibitors in children and adolescents with depression raises questions about the risk-benefit ratio of these drugs in this population. Published safety and efficacy trials of SSRIs for the treatment of youth with depression are critically reviewed. These data were augmented by information from regulatory hearings in 2003-2004 and selected open-label reports. Based on this review, recommendations for medication treatment and monitoring of children and adolescents with major depression on SSRIs are provided. Emerging data from several clinical trials show that the SSRIs provide moderate benefits for youth with depression. In addition, SSRI treatment may be associated with increased risk of behavioral activation, self-harm, and suicidal ideation. Appropriate use of the SSRIs in children and adolescents requires careful diagnostic assessment, evaluation of comorbidity, and close monitoring, especially early in treatment.

Decreasing the risk of complicated bereavement and future psychiatric disorders in children.

TOPIC: Decreasing the risk of complicated bereavement and future psychiatric disorders in children. PURPOSE: This literature will determine what major factors influence a child's response to death and to understand how children react to the death of a parent at different developmental stages. It will evaluate the following: a) What are children's emotional responses to the death of a parent? b) How can a surviving parent help the grieving child complete the tasks of grieving? c) What skills are important for a parent to learn in order to help the grieving child through the tasks of grieving and d) How can mental health providers help the grieving family and the grieving child? SOURCES: Relevant literature from child psychiatry, child psychology, and nursing. CONCLUSIONS: The death of a parent is a major stressful event for children and their families. This traumatic event can bring serious psychological and social distress to bereaved children and their families. Children who are not supported in the early phases of grieving can develop serious emotional and behavioral problems that can lead to the development of some major psychiatric disorders. Providing early prevention support programs for surviving parents and bereaved children can help both the parents and the children adapt to their losses. These structured programs can decrease the risk of complicated grief in bereaved families. More research studies are needed to validate the effectiveness of these early prevention program interventions.

The use of selective serotonin reuptake inhibitors in children and adolescents with major depression.

TOPIC: Recent warnings about suicidal thoughts and self-injurious behavior in youth treated with selective serotonin reuptake inhibitors raise fundamental questions about the risk-benefit ratio of this class of medications. METHODS: Data from placebo-controlled trials are used to elucidate the potential risks and benefits of the selective serotonin reuptake inhibitors (SSRIs) in children and adolescent with major depression. This analysis forms the basis of clinical recommendations. SOURCES: The review includes the six large-scale, placebo-controlled trials that have been published over the past decade. These data were augmented by information from regulatory hearings in 2003-2004 and selected open-label reports. CONCLUSIONS: Emerging data from several clinical trials show that the SSRIs have modest effects on childhood depression. In addition, SSRI treatment may be associated with behavioral activation, self-harm, and suicidal ideation. Appropriate use of SSRIs in children and adolescents requires careful diagnostic assessment, evaluation of co-occurring conditions, and diligent monitoring, especially within the first weeks of treatment.