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APNA 29th Annual Conference Session 4026: October 31, 2015 Hamrin 1

Evaluation of Motivational Interviewing in Adolescents to Improve Medication Adherence

Vanya Hamrin DNP PMHNP Associate Professor Vanderbilt University

Conflict of Interest

• I have no conflicts of interest to report
• This study was funded by private donors‐

Ronald and Leanne Crabbe who also have no conflicts of interest

Problem

• Medication adherence rates in adolescents are alarmingly

low ranging from 34% to 89% in 14 studies with various methods of measuring adherence.

• In the study with 89% orally reported stimulant adherence

saliva test showed 50% were adherent (Pappadopoulos, 2009)

• TORDIA study (2012) found 50% of 190 adolescents were

taking their antidepressant 70% of time at 3 months as measured by clinician pill count

• Non‐white adolescents with depression are at greatest risk

for nonadherence. (WHO, 2003)

• Medication non‐adherence results in poorer mental health
• utcomes.

Literature Review

• MI as an intervention occurred in youth with diseases

such as diabetes, asthma, substance use and dietary adherence.

• These studies demonstrated improved physical and

mental health behaviors, reductions in HBA1C levels, patient self‐reported readiness for change, increased blood glucose monitoring, decreased substance use, improved asthma symptom scores, significant reduction of calories from fat intake, and significant decreases in cholesterol levels

• (Berg‐Smith et al. 1999; Channon et al. 2007;D’Amico et al., 2012; Lundahl

et al. 2010; Seid et al. 2012;).

Literature Review

• In a RCT using the medication electronic monitoring

system (MEMS) cap as the primary measure, 50 Latino adults on SSRI medication for depression received brief MI (two to three sessions) intervention that resulted in significant improvement (30%) in medication adherence rates from 42% at baseline to 72% at completion (p <.01) (Interian et al. 2013).

• This is the first study to evaluate if brief (2 sessions) of

motivational interviewing can improve medication adherence in 41 adolescents ages 12 to 18 taking psychotropic medications for mood disorders

Objectives

• 1) Examine if 2 Motivational Interviewing (MI) sessions

improve medication adherence in 41 adolescents taking antidepressants and mood stabilizers

• 2) Evaluate if Drug Attitudes correspond with

Medication Adherence

• 3) Evaluate rates of self‐reported adherence to
• bjective electronic recordings of bottle openings
• 3) Determine if 24 hours of MI training plus

individualized feedback on audio taped sessions was adequate training for 6 mental health prescribers to score beginning proficiency on use of MI skills.

APNA 29th Annual Conference Session 4026: October 31, 2015 Hamrin 2

What is Motivational Interviewing

• Motivational Interviewing (MI) is a collaborative, goal‐
• riented style of communication attention to the language
• f change.
• Strengthen personal motivation and commitment to a

specific goal by eliciting and exploring a person’s own reasons for change within an atmosphere of acceptance and compassion (Miller & Rollnick, 2012).

• The key elements of MI:
• improve the clinician’s working alliance with a client
• teach clinicians to manage resistance, to express empathy

towards clients, and to help clients build motivation to change while addressing ambivalence to change (Miller & Rollnick, 2012).

Methods

• The quasi‐experimental study trained 6

prescribers (4 NP’s and 2 child psychiatrists) to perform MI

• Measured adolescent medication adherence

to antidepressants/mood stabilizers using Medication Electronic Monitoring System (MEMS) before and after 2 MI sessions delivered by the prescriber in standardized 30 minute medication appointments.

Design

• Inclusion Criteria:
• Eligibility included adolescents 12 to 18 years of age, of either gender and

any ethnicity, currently receiving SSRI/SNRI or mood stabilizing treatment at the university outpatient clinic for a minimum of one month. There was no maximum length of time on medication.

• The adolescents needed to be able to read, write, and speak English to

complete the rating scales.

• Exclusion Criteria:
• Adolescents with verbal communication deficits were not included in the

study, as MI requires significant dialogue between the clinician and adolescent.

• Intellectual impairment (IQ below 70) and self‐care impairment were

excluded as the intervention of MI involves planning and processing skills as well as independence in activities of daily living.

• Illiteracy and lack of self‐care skills and current psychosis.

Interventionist Participants

• 12 prescribers were invited to participate from the outpatient child

and adolescent clinic, four training fellows declined to participate in the study and two child psychiatrists declined due to not being able to participate in the 3 day MI training

• 6 faculty (4 nurse practitioners & 2 child psychiatrists) voluntarily

agreed to participate in the study & signed IRB consent.

• All prescribers were Caucasian and female.
• 3 nurse practitioners were master’s prepared
• 1 nurse practitioner was doctorally prepared.
• The two child psychiatrists were both doctorally prepared.
• Of the prescribers, five had greater than 10 years of experience,
• ne had 3 years of experience, none of the prescribers had any

previous formal training in MI.

Design

• Evaluation of each participant’s practice of taking

medication for 30 days by MEMS cap and the attitude

• f each adolescent toward medication occurred before

and after 2 MI sessions were completed.

• Only the SSRI/SNRI and mood stabilizer adherence was

monitored by the MEMS cap system. Patients were on average of 2.5 psychiatric medications

• The study evaluated if MI (independent variable) plus

standardized medication treatment improved psychotropic medication adherence (dependent variable) compared to medication adherence at baseline.

Design

• During the first month (30 days), patient

adherence to medication was monitored electronically using the MEMS cap & patient

• ral report.
• Drug attitude score (DAI) obtained at baseline
• At the start of the 2nd and 3rd months, each

patient had 1 MI session within their monthly medication management in 30 minute appointment with a trained MI prescriber

APNA 29th Annual Conference Session 4026: October 31, 2015 Hamrin 3

Design

• At the end of the four‐month monitoring

period, the patients returned the MEMS caps to the principal investigator, completed post intervention ratings using the DAI, CEMI, and patient satisfaction survey.

• Adolescents received the MI treatment alone;

parents were not included in the MI training since the consistency for the MI needed to be the same for all participants.

Design

Participant recruitment took place over a two‐ month period 6 (4 nurse practitioners & 2 child psychiatrists) prescribers agreed to receive 24 hours of MI training. None of the prescribers had formal MI training A certified MINT trainer provided the 24 hours of training in a group format & evaluated each clinicians tape of a 20 minute MI session using the MITI 4.1 evaluation tool at baseline and midpoint

Study Measures

• Medication Electronic Monitoring System (MEMS) was

selected as the primary measure to determine rates of medication adherence

• The MEMS has been shown to be a more accurate and
• bjective measure of adherence compared to clinician

report, patient report, or parent report (Interian et al. 2013; Nakonezny et al., 2010).

• The MEMS cap measures how many times the patient
• pens the pill bottle during the time of evaluation of

medication monitoring period and records the date, times and frequency of the opening of the pill bottle

Study Measures

• The Drug Attitude Inventory (DAI) is a 30 item,

yes/no format comprised of seven components including: positive and negative attitudes toward medication, an illness model, external and internal locus of control, relapse prevention, and a measure of harm/toxicity. Total scale scores range from ‐30 to +30, with negative scores being associated with nonadherence and positive scores being associated with adherence.

Drug Attitude Inventory‐30 True or False

• I do not need to take the medication once I feel

better.

• For me, the good things about medication outweigh

the bad.

• Even when I am not in the hospital, I need

medication regularly.

• If I take medication, it is only because of pressure

from other people.

• I am more aware of what I am doing, of what is

going on around me, when I am on medication.

• Taking medications will do me no harm.
• I take medications of my own free choice.
• Medications make me feel more relaxed.
• I am no different on or off medication.
• The unpleasant effects of medication are always

present.

• Medication makes me feel tired and sluggish.
• I take medication only when I am sick.
• Medication is a slow‐acting poison.
• I get along better with people when I am on

medication.

• I cannot concentrate on anything when I am taking

medications.

• Permission obtained from Hogan, Awad (1987)
• I know better than the doctor when to go off

medication.

• I feel more normal on medication.
• I would rather be sick than taking medications.
• It is unnatural for my mind and body to be

controlled by medications.

• My thoughts are clearer on medication.
• I should stay on medication even if I feel alright.
• Taking medication will prevent me from having a

breakdown.

• It is up to the doctor when I go off the medication.
• Things that I could do easily are much more difficult

when I am on medication.

• I am happier, feel better, when taking medications.
• I am given medication to control behavior that
• ther people (not myself) do not like.
• I cannot relax on medication.
• I am in better control of myself when taking

medications.

• By staying on medications, I can prevent getting

sick.

Video Assessment of Simulated Encounters

• The video assessment of simulated encounters‐

revised (VASE‐R) is a video‐based exam method used for evaluating MI skillfulness that involves videotaped vignettes simulating real‐world clinical encounters

• Reflective listening, responding to resistance,

summarizing, eliciting change talk, and developing discrepancy are the five subscales used in the VASE‐R scale to assess clinician training and MI skill level

• (Rosengren, Hartzler, Baer, Wells, & Dunn, 2009).

APNA 29th Annual Conference Session 4026: October 31, 2015 Hamrin 4

Client Evaluation of MI

• The CEMI is a 16‐item scale measuring the participant’s

evaluation of the technical and relational aspects of the implementation of MI used by the clinician.

• The CEMI questions assess collaboration, evocation,

respecting autonomy, expressing empathy, rolling with resistance, developing discrepancy, supporting self‐ efficacy, open questions, affirmations, reflections and summaries that the clinician uses with the patient

• Four point Likert type scale (1 = never to 4 = a great

deal).

Client Evaluation of MI Counseling

• Please rate each response on the scale below relating to your most recent session with your
• counselor. 1‐4 scale
• Focus only on your weaknesses.
• Help you to talk about changing your behavior.
• Act as a partner in your behavior change.
• Helped you to discuss your need to change your behavior.
• Make you feel distrustful of him/her
• Help you examine the pros and cons of changing your behavior.
• Help you to feel hopeful about changing your behavior.
• Argue with you to change your behavior.
• Change the topic when you became upset about changing your behavior.
• Push you forward when you became unwilling to talk about an issue further.
• Act as an authority on your life.
• Tell you what to do.
• Argue with you about needing to be 100% ready to change your behavior.
• Show you that she/he believes in your ability to change your behavior.
• Help you feel confident in your ability to change your behavior
• Help you recognize the need to change your behavior.
• Permission obtained from Madison (2013)

MITI ‐4.1

• The Motivational Interviewing Training Integrity Scale, or MITI, is a one‐pass behavioral

coding system designed to measure treatment fidelity for motivational interviewing. The 4th edition of this scale, the MITI 4.1, was utilized in this study.

• There are 2 components of the MITI, the global scores and the behavior counts. The global

score takes into consideration the whole of the conversation or the “gestalt” and scores how the MI clinician creates a partnership that exudes empathy. The behavior counts focus on the behaviors of the clinician in the sessions.

• There are two passing scores: fair and good. In order to be classified in the fair competency

range, the clinician should foster collaboration, make demonstrated efforts to understand the client’s point of view, consistently reflect the client’s change talk, and avoid emphasis on the status quo.

• Behavioral Counts: Clinician should use more reflections than questions. The ratio goal is one

question for every reflection for the fair competency, and two reflections for every question for the good competency. Reflections should consist of more complex rather than simple

• reflections. For the fair competency at least 40% of the reflection should be complex, and for

the good competency at least 50% should be complex. Furthermore, in order for the conversation to meet standards for motivational interviewing there should be no clinician confrontations.

• For the purposes of this study, clinicians needed to demonstrate basic beginning proficiency

(fair) prior to providing MI to clients in the study and once again at the study midpoint by having a 20 minute section of an MI session evaluated by a MINT trainer.

Examples of Terms

• Open‐ended questions focus on the “what,” “which,”

“where,” and “how,” related to the client’s experience.

• Affirmations: “I appreciate how hard it is for you to....” “It

is very brave that you came to address this problem.”

• Complex reflections: Reflecting the deeper meaning of

what the client is saying back to them. “What you believe is....” “you want to have beer to serve your friends to be a good host, on the other hand, I wonder if it is tempting for you to have alcohol in the house...” (4)

• Summary statements: What you have discussed in your

time together and be specific in identifying any changes the client said they would try.

Population

• 41 adolescents between 12 and 18 years of age with mood

disorders including primary diagnosis of major depression(30), generalized anxiety(3), bipolar disorder(4), mood disorder NOS(2) and PTSD(2) who were receiving SSRIs, SNRIs, mood stabilizers, and aminoketone drugs for at least one month completed the study.

• These adolescents were on medications with both once and twice

daily dosing regimens.

• Participants included 17 males (41.5%) and 24 females (58.5%) and

average age of the participants was 15.6 years (SD=1.5) (Table 1). Twenty‐four adolescents had private medical insurance and 17 participants had state medical insurance.

• Racial backgrounds consisted of 32(78.1%) Caucasian youth, 3

(7.3%) Black youth, 3 (7.3%) Hispanic youth and 3 (7.3%) youth of mixed Hispanic and Black race. The majority of the adolescents had a primary diagnosis of major depressive disorder (n=30)

Population

• Average number of medication per pt: 2.5
• Drugs monitored in the study SSRIs, SNRIs,(36) mood stabilizers (5)
• Secondary drugs: antipsychotics, stimulants, alpha‐agonists,

buproprion, benzodiazapines (were not monitored)

• Average number of diagnosis per pt: 2.3
• Primary Diagnosis included: MDD(30), 20 MDD had comorbid GAD,

GAD (3) Bipolar Disorder (4) PTSD (2) and Mood disorder NOS (2)

• Comorbid diagnosis: ADHD(20), GAD (17) Panic Disorder, Substance

Abuse, Posttraumatic Stress Disorder, OCD(3), ODD, Autism Spectrum Disorder(5), social phobia(1), panic disorder(1), eating disorder(1) substance use disorder(1)

APNA 29th Annual Conference Session 4026: October 31, 2015 Hamrin 5

Population

• Thirty‐one (76%) adolescents reported

lifetime past medication nonadherence.

• Twenty‐seven (65.9%) participants received

medication treatment for more than 18 months prior to the study.

• Ten patients had been on medications

between 6 to 18 months

• Four patients had been on medication less

than six months.

Results

• Mean medication adherence scores improved by

17% after two MI sessions (p<.0001, S.D.=0.65).

• Mean baseline adherence scores were 63.7%

Mean endpoint adherence scores were 80.6%.

• Taking medication >80% of time was qualifier for

adherence

• Mean baseline adherence of greater than 80% of

the time was 40%

• Endpoint adherence greater than 80% of time in

30 days was 70% resulting in a 30% increase in ideal adherence.

Drug Attitude Inventory(DAI) Results

• 17 participants demonstrated increased scores on the DAI (range 2 to 18), 12

participants’ scores decreased on the DAI (range ‐2 to ‐14) and 12 participants DAI scores remained the same from baseline to endpoint.

• There was a nearly significant change of 2.0 points from baseline (14.2, sd=8.4) to

endpoint (16.2, sd=8.2) on DAI scores as a result of MI (t=1.99, df=40, p=0.054, Table 2).

• The eighteen participants who demonstrated greater than 80% adherence at

baseline had a higher DAI mean score of 17.1 (sd=5.5). than the baseline mean scores on the DAI of the 23 participants with less than 80% baseline adherence (significantly lower) with a mean of 12.0 (sd=9.7) (t=‐2.16, df=35.919, p=0.0377)

• Of the 29 participants who had greater than 80% adherence at endpoint, their DAI

mean score was 16.5 (sd=8.5) which was not significantly different than the 12 participants with less than 80% adherence at endpoint, with DAI mean score of 15.5 (sd=7.5) (t=‐0.35, df=39, p=0.73).

Drug Attitude Results

• MI did not significantly improve attitudes towards

medications from baseline to end point in the entire group

• Attitudes toward medications were higher in the adherent

group vs nonadherent groups at baseline.

• Nonadherent patient’s attitudes toward medication

improved to similar scores as those who were adherent at endpoint

• MI’s focus on behavior change can work independently

from attitudes towards medications.

• Questions on intrinsic motivation revealed 75% of youth

took their medication of their own free choice at baseline and 78% of youth took medication of own free choice at endpoint

Pt reported Adherence vs MEMS cap Adherence at Baseline

• Baseline mean patient reported

adherence=82.1%

• Baseline mean MEMS cap adherence=63.8%
• Patients over‐reported medication adherence

by 18.4%

• This is a significant difference (p.001)
• Pt reported adherence is overestimated, and

not a reliable source of information

VASE‐R and MITI 4.1 Findings

• 5 out of 6 prescribers passed the initial MITI‐

4.1. One prescriber passed the second time

• 6 out of 6 prescribers passed the MITI‐4.1 at

midpoint for treatment fidelity

• Pre MI training performance on VASE‐R was

predictive of post training performance on VASE‐R and MITI in this prescriber sample

APNA 29th Annual Conference Session 4026: October 31, 2015 Hamrin 6

MITI 4.1 Scores

Clinician Behavior-Count or Summary- Score Thresholds Prescriber Scores: 1st Evaluation Prescriber Scores: Midpoint Evaluation Global Clinician Ratings: Relational Partnership Mean: 4.3 Range: 4-5 Mean: 4.3 Range: 4-5 Global Clinician Ratings: Empathy Mean: 4.3 Range: 4-5 Mean: 4.5 Range: 4-5 Global Clinician Ratings: Cultivating Change Talk Mean: 3.2 Range: 3-4 Mean: 3.3 Range: 3-4 Global Clinician Ratings: Side Stepping Change Talk Mean: 3.2 Range: 3-4 Mean: 3.1 Range: 3-4 Reflection to Question Ratio (R:Q) Mean: 1.27:1 Range of reflections: 1-1.5 Mean: 1.97:1 Range of reflections:1.4- 4 Percent Complex Reflections (%CR) Mean: 60.5% Range: 40%-80% Mean: 57% Range: 42%-68% Percent MI-Adherent (% MIA) Mean: 90% Range: 90 to 100% Mean: 90% Range: Range 90 to 100%

Client Evaluation of MI at Endpoint (CEMI)

• CEMI‐Relationship (Empathy & Partnership)
• 25.0 (4.0) out of 32 (78%)
• CEMI‐Technical Score (Chasing Change Talk and

Side Stepping Sustain Talk)

• 25.8 (4.8) out of 32 (80%)

Pt Reported Satisfaction

• 10.2 out of 12
• 1‐4 scale
• How would you rate the quality of the MI?
• How satisfied are you with the motivational

interviewing treatment?

• Has the motivational interviewing you

received help you deal more effectively with taking your medication

Limitations

• Lack of Randomization and Control
• Only one drug the patient was on was evaluated so

variability between drugs not captured

• MEMS cap monitoring could influence adherence‐

Studies found MEMS as an intervention did not improve adherence

• Long term effects were not monitored
• MEMs measures if pill bottle opened, not swallowed
• Majority of youth in the study were Caucasian, did not

represent all ethnicities.

Suggestions for Future Research

• Randomization and control group
• Don’t enroll patients who actually are adherent at

baseline (greater than 92%)

• Evaluate if psychiatric symptoms correspond to

adherence rates by using a depression measure

• Use MEMs for 2 months at baseline to decrease

novelty vs one month

• Evaluate long term outcomes of MI
• Larger sample size to account for drop outs

Conclusions

• 2 20 minute MI sessions improved adolescent psychotropic mean

medication adherence by 17% from baseline to 4‐5 month end point.

• (p=.0001) Effect size was moderate at .65
• 40% of adolescents were taking their medication >80% of the time at

baseline and 70% of adolescents were taking their medication at >80% at endpoint after 2 MI sessions

• Attitudes towards medication were not significantly different at endpoint

between those who were and were not adherent.

• Attitudes before and after the intervention were not significantly different

for the entire group

• Attitudes improved in the nonadherent group at endpoint to similar levels

as those who were adherent taking medication>80% of time

• Behavioral change occurred despite attitudes in adherence
• Self‐report is not an accurate report compared to the Gold Standard

MEMS cap

APNA 29th Annual Conference Session 4026: October 31, 2015 Hamrin 7

Conclusions

• Patients significantly overestimated the amount of

medication that they were taking when comparing oral report to objective MEMS cap measures, which makes patient reported adherence a problematic measure

• 24 hours of MI training with 2 individualized feedback

sessions was adequate to prepare prescribers at beginning level competency according to the MITI and VASE‐R scores.

• Patient Satisfaction and Clinical Evaluation of Prescribers

Motivational Interviewing scores were high according to participants.

• Patients who did not feel MI was relevant were already 92%

to 100% compliant and did not feel they needed to change their adherence behavior

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