Knowing what to do is different than actually doing it. Changing behavior is difficult in the best circumstances, let alone with the strain of a chronic illness. It is critical to recognize that the presence of depressive symptoms significantly reduces the likelihood that patients will employ self-management practices.11 When combined with anxiety and the impairment of motivation and executive functioning that is common in psychiatric conditions, it is not surprising that patients with a mental health condition struggle to embrace ownership of their illness and engage in critical health behaviors—which may include adhering to medication regimens; maintaining a healthy sleep cycle, nutrition, and exercise routines; vigilant symptom surveillance; and carrying out an agreed-upon action plan.
Interventions
Motivational interviewing has been shown to enhance patient engagement in self-management and to improve patient participation and outcomes across a variety of conditions.12 Motivational interviewing is collaborative, person-centered, and nonjudgmental, helping patients explore and resolve ambivalence about behavioral change by improving awareness of the consequences of changing or not. It is particularly helpful in one-on-one settings and facilitates patients’ ownership of change.
Professionally-guided “light-touch” interventions and technology-assisted self-management interventions also can improve patient engagement in activities through individual encounters, group forums, and technology-mediated exchanges, including telephone, email, text message, tele-health, and web-based interventions.13 The DE-STRESS (Delivery of Self Training and Education for Stressful Situations) model illustrates these principles. This 8-week program combines elements of face-to-face, email, telephone, and web-based assignments and exchanges, and demonstrates a decline in posttraumatic stress disorder, depression, and anxiety scores.14 Our Michigan Depression Outreach and Collaborative Care program is another example of a self-management intervention (Box 1).
These interventions intend, at least partially, to increase patient understanding of their illness and impart self-management skills with a goal of increasing patients’ confidence that they can perform the tasks necessary to manage their illness. This self-belief is termed self-efficacy and positively correlates with health behaviors and outcomes.15 Practices demonstrated to enhance self-efficacy include:
• mastery of skills through accomplishing specific action plans
• modeling and social persuasion through having patients observe and engage others as they struggle to overcome similar obstacles
• re-interpretation of symptoms aimed at fostering the belief that symptoms generally are multi-determined with several potential explanations, and vary with daily routines.
Helping patients understand when common symptoms such as impaired concentration or dizziness should be “watched”—rather than responded to aggressively—is crucial for effective long-term management.
Example initiatives. Representative self-management initiatives targeting a range of mental health conditions are described in Box 2. Some of these programs were developed within our department at the University of Michigan; all utilize important self-management principles. We have implemented a number of measures in our clinics to help ourselves and our patients move progressively towards self-management. These initiatives include systems to measure clinical progress, a range of innovative group models, innovative care management resources, and collaborative care programs with primary care providers.
Challenges
Health care delivery and medical educational models have been slow to embrace this change to long-term care models because doing so involves what might be uncomfortable shifts in roles and responsibilities. Effective care for long-term illness necessitates that the patient become an expert on his (her) illness, and be an active participant and partner in their treatment. Preparing health professionals for this new role as teacher, mentor, and collaborator presents a challenge to health care systems and educational programs across disciplines.
Evidence is strong that collaborative care models can improve mental and physical outcomes for psychiatric patients in a variety of settings.17 Care providers must learn to collaborate with patients, families, and interdisciplinary teams consisting of other medical specialists and allied health professionals such as medical assistants, nurses, nurse practitioners, physician assistants, social workers, psychologists, and pharmacists. This can be challenging when team members do not know one another, do not share a common medical record, or do not work in the same department or system. This complexity increases the possibility of giving patients mixed messages and places a greater burden on the patient, highlighting the need for them to be the primary “manager” of their own care and emphasizing the need for communication and coordination among team members. The optimal make-up of team responsibilities will vary by patient population, clinic, and health system resources, ideally with early clarification of what patients can expect from each member of the care team.
When trying to facilitate effective patient-provider partnerships, it is important to recognize the variability in patient preference for what and how information is shared, how decisions are made, and the role patients are asked to play in their care. Patients differ in their desire for an active or collaborative shared-decision model; some prefer more directive provider communication and a passive role.18 Preferences are influenced by variables such as age, sex, race, anxiety level, and education.19 Open discussion of these matters between caregivers and patients is important; studies have shown that failure to address these issues of “fit” can
impede communication, healthy behavior, and positive outcomes.