It is not easy having to take medication regularly. You have to remember to take them at the right times every day, that they are with you for those times even when you are travelling — and you may have to deal with side effects. People may empathise if you are popping pills to lower your blood pressure or for another 'physical' problem, but they are more likely to recoil in fear if they find out you are taking meds for schizophrenia or another psychotic disorder. No wonder, then, that many schizophrenia patients do not stick to their medication schedule and often relapse as a result. How can they be helped to stick to it? A Hong Kong study on ethnic Chinese outpatients with schizophrenia spectrum disorders seems to show that motivational interviewing-based therapy could be effective.

Up to 70% of psychiatric patients who use Hong Kong's community-based mental health services have been diagnosed with a disorder on the schizophrenia spectrum. Oral antipsychotic medication is often prescribed to reduce their symptoms, improve their psychosocial functioning, and prevent their relapse. However, previous studies have found that patients with schizophrenia spectrum disorders had a low 40% to 70% adherence level to medication. Also, these patients with poor medication adherence would have high relapse rates of 50% to 70% within the first few years of their illness, which raised their risks of requiring a longer course of treatment and increased their risks of poor patient outcomes or prognosis.

Many factors can contribute to patients' low adherence levels to antipsychotics, such as the long period of medication taking, their annoying or damaging side effects, a lack of social and possibly family support, and a lack of understanding of their illness and need for a long-term medication regimen. Therapies based on psycho-educational approaches or behavioural modification have been found to be unable to increase medication adherence significantly. Psycho-educational approaches focus on increasing patients' understanding of their illness and its treatments, with the aim of helping them to better tackle their illness. Strategies in behavioural modification use association and reinforcement techniques (derived from classical and operant conditioning) to try to change patients' behaviours and their associated personal and environmental factors.

Therefore, Prof Chien Wai-tong of PolyU's School of Nursing and his collaborators from health care institutions in Hong Kong and Qatar decided to examine another therapeutic approach called the "motivational interviewing" technique, since recent studies have found it to be effective for people with substance abuse who have been reluctant to undergo treatments and had mixed feelings about changing their behaviours. Noting that motivational interviewing had recently produced preliminary evidence of improving medication adherence among patients with schizophrenia in a few Western and Asian countries, Prof Chien and his co-authors decided to investigate whether this motivational technique could affect schizophrenia patients with low or poor medication adherence not only in terms of the severity of their psychotic symptoms and relapse rates but also their insight into their illness and treatments, and psychosocial functioning.

For their experiment, the research team adopted a 4-month programme of adherence therapy based on motivational interviewing (and the principles of cognitive-behavioural therapy). In the 2-hour sessions of motivational interviewing, a trained community psychiatric nurse used open-ended questions to help the patient identify and explore the pros and cons of changing his or her behaviour, with the aim of guiding and motivating the patient in a non-judgemental way to make the positive behavioural changes that the patient identified. In addition, using the principles of cognitive-behavioural therapy, the community psychiatric nurse helped the patient to become aware of how he or she perceived or thought about an event, rather than the event itself, could affect the patient's emotions and how to alter his or her thoughts about the event so as to deal with the event more positively.

The team conducted a single-blind, randomised controlled trial to test the effects of such adherence therapy on 114 ethnic Chinese outpatients aged between 18 and 60 years who were diagnosed with a schizophrenia spectrum disorder in the past 5 years, were attending a particular community psychiatric nursing service in Hong Kong, were rated as having poor medication adherence, and were able to give informed written consent to participate in the study. Each of the recruited outpatients was administered a pre-test and randomly assigned to either the adherence therapy (AT) group, which would undergo 8 sessions of adherence therapy every 2 weeks in addition to their usual care, or to the treatment-as-usual (TAU) control group.

The patients in both AT and TAU groups were assessed for their levels of adherence to medication, severity of psychotic symptoms, insight into their illness and treatments, re-hospitalisation rates, and psychosocial functioning at the start of the experiment, immediately after they finished their assigned courses of treatment or "interventions," and 6 months after the completion of the interventions.

Compared with the TAU participants over the 6-month follow-up, the AT patients showed significantly greater improvements in most patient outcomes, including their medication adherence, psychotic symptoms, insight into their illness and treatments, psychosocial functioning, and average number of re-hospitalisations. In addition, other schizophrenia-related symptoms that tend to be resistant to treatments, such as a lack of motivation to take part in activities (amotivation), the loss of ability to experience pleasure (anhedonia), and social withdrawal, were also reduced in the AT participants.

Given these encouraging results, the co-authors recommended that further research be conducted to examine the effectiveness of motivational interviewing-based adherence therapy for schizophrenia patients with different socio-demographic and illness characteristics, different durations of illness, and different co-existing diseases or conditions. They also suggested investigating the effectiveness of the technique in different cultures and over a longer period of follow-up.