Nurse-led treatment engagement interventions for persons with severe mental illnesses in community settings

Abstract

This review aims to gain a deeper understanding of the current interventions used in high-income and low- and middle-income countries worldwide on treatment engagement among persons with severe mental illnesses. Treatment engagement involves cultivating therapeutic partnerships to address patients’ unique needs and challenges. This multifaceted process requires sensitivity, collaboration, and a tailored approach to promote positive outcomes. Effective treatment engagement reduces the chances of relapse and rehospitalization and helps individuals steer through their daily lives and social relationships. Through literature analysis, it was found that individual, situational, and environmental factors affected treatment engagement. Community nurses are crucial in promoting behavioral changes by engaging patients and applying tailor-made interventions. Applying problem-solving, coping skills, and strategies to address factors influencing adherence, motivational interviewing, and telephone follow-ups yielded significant results. The interventions recommended in community settings are tele-aftercare programs and home visits to address issues of dropped-out persons with severe mental illnesses and ensure continuity of treatment. Accessible, non-stigmatizing, non-coercive, informal, and appropriate services are suggested. These interventions can improve treatment engagement, medication adherence, and therapeutic alliance, thereby reducing symptoms and improving patients’ quality of life.

Key Words: Nurse; Treatment engagement interventions; Persons with severe mental illness; Community; Quality of life

Core Tip: Treatment engagement is a continuous, collaborative and dynamic process. Due to the multifactorial nature of non-adherence, need-based client-centered care would help reduce the treatment gap and improve their quality of life. Engagement can be improved by having a relationship of trust, empathy and non-judgmentality. Internationally, shared decision-making, peer support, family involvement and other psychosocial strategies have shown to improve engagement. Nurses, in collaboration with the multidisciplinary team, are capable of long-term engagement through psychoeducation, motivational interviewing and home visits. A tailored approach to engaging the clients through a strong therapeutic alliance is important for enhancing treatment outcomes and active participation.

INTRODUCTION

The treatment of severe mental illnesses (SMIs) is complex. It goes beyond the mere alleviation of symptoms and involves a therapeutic partnership with people living with schizophrenia, bipolar disorder and severe depression whose needs and challenges are unique. SMIs can significantly affect an individual’s life, which may include their ability to engage and benefit from treatment.

Mental health professionals (MHPs) must act sensitively, collaboratively, and use a tailored approach in treating persons with SMI (PwSMI). Effective treatment engagement is essential for symptom management and to improve the overall quality of life for PwSMI. It reduces the chances of relapse and hospitalization and enhances the individual’s ability to navigate daily life and social relationships through better adherence to treatment plans by the PwSMI.

The National Mental Health Survey-India reports that the treatment gap is more than 70% for all mental illnesses and 73.6% for SMIs[1]. This treatment gap (low treatment-seeking behavior) may exist due to various causes such as the lack of MHPs, stigma, poverty, distance from treatment centers, lack of adequate funds for mental health, and misbeliefs about mental illnesses and psychotropic drugs. Facilitating treatment engagement with the assistance of MHPs and ensuring medication adherence can help reduce the treatment gap[2].

This review aims to gain a deep understanding of the current treatment engagement interventions used in high-income and low- and middle-income countries among PwSMI.

The available literature was examined using electronic databases such as Google Scholar, PubMed, Springer, Wiley Online and Science Direct. The keywords or phrases used were ‘treatment engagement’, ‘treatment adherence’, ‘therapeutic alliance’, ‘severe mental illnesses’, ‘bipolar affective disorder (BPAD)’, ’schizophrenia’, ‘motivational interviewing’, ‘community mental health’, ‘district mental health programme’, ‘community nurses’, ‘American Social Health Association workers’, and ‘reasons for non-adherence’. The researcher reviewed the literature for studies dating from 2003 to 2023. Among the studies retrieved, factors influencing treatment engagement and adherence were explored, as were interventions to improve treatment engagement/adherence, interventions carried out by nurses in community settings to improve treatment engagement and medication adherence, and interventions offered online.

CONCEPTUAL DEFINITION

SMIs

SMIs are chronic in course, leave residual disability, and require long-term supervision, observation, and care in the majority of the patients. As per the global burden of diseases 2021, the prevalence of schizophrenia was 23.2 million[3], and BPAD was 37.5 million in 2021[4].

Concept of treatment engagement

Treatment engagement involves a committed therapeutic process where PwSMI actively collaborates with MHPs to improve their condition. This includes attending scheduled sessions, adhering to prescribed treatment regimens, and maintaining communication with MHPs through phone calls, telemedicine sessions, or home visits[5-7].

Tait et al[8] define treatment engagement as “a process of developing a collaborative and trusting relationship with individuals, which is key to delivering effective services and support”.

Several other authors define treatment engagement as “collaborative involvement, session attendance, homework completion, emotional involvement in sessions, and participation and cooperation in treatment”. Treatment engagement should also mean that persons with mental illnesses (PwMIs) can leave the service knowing they can return when needed[9].

As deduced by Higgins et al[10] and Wright et al[11], treatment engagement is a dynamic and skilled process, leading to a new relationship, which requires continuous participation in treatment, a therapeutic relationship with MHPs, and proactiveness towards therapy.

Disengagement in treatment and poor medication adherence may lead to poor clinical outcomes such as recurrent psychiatric problems (suspiciousness, hallucinations, violence, negative symptoms, risk of suicide), poor functionality, insignificant clinical benefit, reduced quality of life for the PwSMI, and inadequate use of healthcare resources[12-14]. It also contributes to enhanced socioeconomic problems, including increased hospital costs, wastage of healthcare resources, and reduced quality of life[15].

On the other hand, continued engagement in treatment positively impacts the health status of the PwMI, leads to indirect savings in health services by avoiding relapse and rehospitalization, and increases the vocational productivity of PwSMI[13,15].

Treatment adherence is one of the essential components addressed under the umbrella of treatment engagement interventions. There is a 40% incidence of treatment non-adherence among PwMIs. In contrast, PwSMIs have even higher non-compliance rates (58.8%) and engaging them continuously poses greater challenges[16]. In the population undergoing treatment for SMI, the prevalence of irregular follow-up varied between 50% and 73%, with dropout rates ranging from 14% to 92% and estimates of medication non-adherence ranging from 5% to 71%[17].

Factors affecting treatment engagement

Individual, situational, and environmental factors affect treatment engagement. The individual elements are knowledge, attitude, and acceptance of the disease and treatment. In contrast, situational elements are the experiences and circumstances of the PwSMI, which influence their focus on treatment, and environmental elements include peers, social support, and the healthcare system[10].

Behavioral factors affecting treatment engagement are initiation, continuation, and adherence to the recommended treatment, and psychosocial factors are dispositions reflecting on values and anticipation regarding treatment[10]. According to Buckingham et al[18], behavioral engagement is the “performance of tasks necessary for treatment and to achieve outcomes”, i.e., being regular to follow-ups and participating collaboratively in treatment sessions. In contrast, attitudinal engagement is “emotional investment and commitment to treatment” or desire to participate in treatment[18].

Staudt et al[9] discussed the affective factor, i.e., the relationship between PwSMI and the MHP. Their focus group discussion found that engagement is not just a helping alliance but a complex process affected by factors such as agency policies and practices. They identified client-related barriers, such as attitudes and beliefs about therapy, lack of commitment, trust, and environmental constraints. Therapists reported a lack of time and a high workload as barriers to engagement, whereas qualities such as being non-judgmental, genuineness, credibility, passion for work, instilling hope, validating, normalizing, and giving positive feedback were facilitators. PwSMIs’ active participation in treatment, such as autonomy, self-determination, and shared decision-making, is crucial to engagement[10].

Five Indian studies and seven international studies (one each from Tanzania, Netherlands, Korea, Europe, Lebanon and Canada) discussed factors influencing adherence. Most of these studies were descriptive and conducted among schizophrenia or BPAD patients, two of which were hospital-based[19,20] and three were based in community settings[21,22]. The common factors influencing treatment adherence are symptom severity, lack of insight[20,23], stigma, and the family’s tendency to minimise problems[12,23,24], poor understanding of the illness and need for treatment, and negative attitude or cultural taboos about taking psychotropic drugs[12,19,20,23].

Reddy et al[12] identified that a complex and dynamic interplay of several factors, rather than a single factor, determined non-access to psychiatric care.

TREATMENT ENGAGEMENT, ITS ATTRIBUTES AND STRATEGIES

Treatment adherence and treatment engagement

‘Compliance’, ‘adherence’, and ‘engagement’ are closely related and often used interchangeably. However, there are differences in how each of them is defined. According to the World Health Organization, adherence is defined as “the extent to which a person’s behavior-taking medication, following a diet, and executing lifestyle changes corresponds with agreed recommendations of the healthcare provider”[14].

Adherence is similar to engagement in behavioral and psychological aspects e.g. attitude toward treatment and relationship with MHPs. It focuses on the continuation of treatment; however, treatment engagement includes both initiation and continuation of treatment[10].

Bright et al[25] define compliance as “the extent to which PwSMI’s behavior matches clinician’s recommendations”. They opine that “engagement” is more inclusive than compliance and adherence.

The definitions of treatment engagement, treatment adherence and medication compliance are given in Table 1.

Table 1 Definitions of common terms under the umbrella of treatment engagement.

Term	Definition
Treatment engagement	A process of developing a collaborative and trusting relationship with individuals, which is key to delivering effective services and support[8]
Treatment adherence	The extent to which a person’s behavior-taking medication, following a diet, and executing lifestyle changes corresponds with agreed recommendations of the healthcare provider[14]
Medication compliance	The extent to which a person’s behavior matches the clinician’s recommendations[25]

Therapeutic relationship and treatment engagement

The therapeutic relationship forms the base for engagement between the PwSMI and the mental health nurse. Dziopa and Ahern[26] discuss the fundamental attributes required to establish a therapeutic relationship. Understanding and empathy are essential in forming a better rapport[26,27]. A nurse can showcase understanding by appearing interested in the patient as a person (seeing the person beyond the mental illness)[11,26]. Conveying understanding makes them feel valued and empowers them to participate and make decisions regarding their treatment[26].

Trust in the therapist enables the PwSMI to engage in treatment actively and avoid hiding symptoms. Few PwSMIs interviewed by Priebe et al[28] expressed that the adverse effects of medicines were not acknowledged or dealt with by the therapist. Perceptions of not being listened to and a lack of opportunity to participate in treatment decisions can lead to a breakdown in the PwSMI-MHP relationship[11,28].

Maintaining eye contact, clarifying, reflecting, and summarizing are essential interpersonal communication techniques. Each PwSMI is unique, and to understand them in-depth, the nurse must go beyond what is expected of them, such as sharing common adversities and mutual experiences[26]. Shattell et al[27] recommend self-disclosure to some extent without violating boundaries to help strengthen the therapeutic alliance.

Addis and Gamble[29] interviewed nurses working in assertive outreach and found that to engage better; there is a need to cross professional boundaries to some extent and maintain a human relationship with the PwSMI. Chase et al[30] interviewed clients enrolled in assertive outreach services and found they also wanted a human connection with MHPs. PwMI expects the MHP to respect, listen to, and acknowledge them; they should be allowed to express their feelings, and the MHPs should be willing to recognize the PwMI’s contribution to treatment decisions. This is important to bring togetherness and improve their self-esteem and self-worth.

Being non-judgmental, avoiding prejudices, and being mindful of one’s expressions when the patient is divulging “terrible” information are also essential. Conveying hope, being optimistic, reflecting concern, providing reassurance, and being willing to spend time with the patient demonstrates support and accessibility[11,26]. Shattell et al[27] recommend that nurses clearly discuss time allotment/time constraints with the patients to avoid any misunderstanding. Periodic checking with the patient, providing and receiving practical assistance, genuineness, and valuing the PwSMI’s experience improves engagement[11].

At times, the personality traits of the nurse, such as being controlling and patronizing, are hindrances to having meaningful discussions with the PwSMI. However, training the nurses on therapeutic relationships or elements of motivational interviewing may help neutralize such traits and maintain a non-judgmental stance towards the PwSMI.

Strategies to strengthen treatment engagement

A handful of international research studies discuss treatment engagement among PwMI. A study by Finnerty et al[31] based at mental health clinics in New York used a shared decision-making platform [My Collaborative Health Outcomes Information System (MyCHOIS)] that supports clinicians (delivered by psychiatrists); meanwhile, a study done in Texas by Thompson et al[32] aimed at improving engagement with treatment (by social workers) among adolescents and families using experiential interactions and skill-building exercises at the patient’s home. The researchers assessed the improvement in treatment engagement through qualitative interviews. Two major themes were derived: Therapist-oriented engagement (relationship building and task-centered therapeutic alliance) and family-oriented engagement (bond with therapist resulting in shared family alliance).

The treatment initiation programme (TIP) was developed for a New York-based randomised controlled trial (RCT) among depressed older adults. Components of TIP (delivered by clinical psychologists) were open-door intervention, shared decision-making, and addressing barriers to adherence. These were done using three 30-minute sessions over six weeks for each subject[33].

Another randomised explanatory study from the United States designed the “Just Do You” (JDY) intervention (delivered by social workers) to enhance treatment engagement. JDY was a meta-intervention containing modules such as expressive arts, technology-based narratives, psychoeducation and motivational interviewing delivered by a social worker and a recovery role model[34].

Finnerty et al[31] measured engagement in terms of no of outpatient visits to the mental health clinics and adherence to antipsychotics, whereas Raue and Sirey[33] measured engagement through adherence to antidepressant medications and symptom severity. The components of engagement in Munson et al’s study were session attendance, buy-in (involvement in treatment) and personal recovery (measured using a recovery assessment scale)[34].

Finnerty et al[31], Raue and Sirey[33] and Munson et al[34] observed a significant difference between the engagement scores (P < 0.05)[31,34] and/adherence scores[33] of the intervention group vs the treatment as usual group. All the above studies except one-Thompson et al[32] were hospital-based.

Developing and testing treatment engagement interventions on hard-to-treat populations[7,35] using innovative recovery-oriented techniques (peer support, engagement of patient’s families, and cultural formulation interviews) and technology (smartphones for reminders, closed therapeutic groups, discussing symptoms over social media) is recommended[15].

These interventions must be tailor-made based on personality, life situation and symptoms of the PwSMI. Strong therapeutic alliance, person-centered care (addressing immediate individual needs, shared decision-making), early intervention, an optimistic outlook, ongoing psychoeducation and community outreach are helpful for treatment engagement in PwSMI[32].

Strategies to improve medication adherence

Sajatovic et al[36] have extensively researched medication non-adherence among PwSMI (poorly adherent BPAD patients) from the United States in the years 2012, 2018, and 2021. The customised adherence enhancement (CAE) developed by Sajatovic et al[37] has been tested in a 3-month pilot trial, 6-month prospective trial, and 6-month RCT and found to be effective in improving adherence to medications, symptoms, and functioning. Later, the CAE module was modified by adding long-acting depot injections and testing its efficacy in adherence[36-39]. This CAE-long-acting injectables were also tested (among psychosis patients) in Tanzania by Mbwambo et al[40] in 2022 and found to be effective. The author suggested that adherence interventions be brief, personalized, and applicable to non-specialized staff. The interventionists in these studies were mostly trained social workers[40].

Another randomised explanatory study from the United States designed the JDY intervention to enhance treatment engagement. JDY was a meta-intervention containing modules such as expressive arts, technology-based narratives, psychoeducation, and motivational interviewing delivered by a clinician and a recovery role model[34].

Psychosocial interventions for better engagement

Patient-centered psychosocial interventions targeting negative treatment attitudes[20,41], prompt management of side effects[19], and involvement of caregivers in treatment[19,20,42] are proposed.

Strategies to improve engagement and medication adherence should be customized based on the PwSMI’s needs[12] and may include educating about illness and medication, shared decision-making, and considering patient preferences while prescribing medications[19,41].

Blixen et al[23] suggested using depot injections, combining traditional healing methods and involving social workers to deliver adherence interventions, Reddy et al[12] suggest addressing the lack of community awareness through information, education, and communication activities and better implementation of public health programs by adequate allocation of funds, constant monitoring of service activities, ongoing training of service providers and proper follow-up of services at the grassroots level.

Community-based treatment engagement interventions

The international studies were unique in focusing on peer support-based engagement[43] and family-based engagement strategies[32]. Druss et al[43] recommend using trained peer supporters to deliver adherence interventions effectively; Anderson et al[44] opine that adherence therapy (AT) is most effective immediately after an acute episode and has therapists who can completely address the intricacies of medication management[43,44]. Thompson et al[32] proposed therapist alliance, family alliance, and home-based family engagement activities for retaining and engaging adolescents with delinquency in family therapy.

The studies done in Indian community settings used psychoeducation, reminders for follow-up through phone calls, home visits for irregular patients and liaison with health administrators[45,46]. Structured psychosocial intervention in community settings and tele-aftercare programs were recommended to ensure continuity of treatment in these studies-Manjunatha et al[47]. The uniqueness of care at doorstep (CAD) was its home visits to address issues of dropped-out PwSMI[45].

Nurse-led treatment engagement interventions

Nurses are better equipped to foster treatment engagement, considering their close contact with the PwSMI for continuous care[48]. The core practice of mental health nursing is interpersonal interaction, with therapeutic relationships being fundamental to it[26,49]. Further, promoting behavioral change and engaging the PwSMI through community-based and patient-centered interventions is a crucial role of the community nurse[10].

They can collaborate with PwSMI in making decisions regarding treatment, adopting strategies to maintain adherence, and delivering psychoeducation on illness, medication, and side effects, which can help maintain long-term treatment adherence[50]. They may even conduct home visits or provide depot injection if the situation demands it. Chien et al[48] trained and supervised nurses in treatment engagement, which brought about significant changes in symptom severity, insight, psychosocial functioning, and medication adherence among persons with psychosis.

The level of engagement plays a crucial role in determining how effectively an individual will respond to professional input[10]. Difficulties in fostering engagement may result in reduced participation in care and an elevated risk of dropping out, potentially leaving individuals with severe, enduring mental health issues without adequate community support[51].

Buckingham et al[18] opine that understanding and addressing barriers to actively engaging in treatment can improve engagement outcomes.

The PwSMIs go through various transformations as the illness progresses. This may change their self-perception and personality. Sometimes, they use disengagement from mental health services to reject these transformations. The nurse needs to understand the transformations happening within the PwSMIs as they go through the illness. Nurses can act as a ‘safety net’ to rely on when the PwSMIs are going through these. At that time, a patient-centered approach is essential (i.e., conforming to what the PwSMI wants rather than what the nurse feels is beneficial)[11].

Connecting with the person by repeated attempts, allowing time to engage, and pacing the sessions using cues from the PwSMI and the family by the nurse is essential. Even if the PwSMI shows hostility, ambivalence or rejection, it is important not to personalize it and to persevere. The nurses interviewed by Addis and Gamble[29] mentioned that teamwork supported them in handling difficult situations.

At other times, PwSMI may disengage from treatment because they desire to be normal, mainly as a result of the stigma of mental illness (they try to be normal by stopping the medicines). The authors found that bad hospital experiences did not necessarily cause disengagement; instead, fear of hospitals made them take medicines regularly[28].

Shattell et al[49] discuss the significance of nurse’s skills in acting as a guide and allowing the PwSMI to take the lead in the session rather than giving instructions to them. It is also helpful to have blunt feedback or question the nurse when they disagree with the situation, e.g., feedback regarding intentionally missing medications or checking why they do that. At times, assistance that was not verbal but action-oriented was more helpful. However, care should be taken to avoid too much dependence on the system by the PwSMI[8,11,49].

Wright et al[11] advise that contact by the team should neither be too intrusive nor casual. It has to be a genuine wish for the well-being of the PwSMI and respect for them. Contact does not always need to be face-to-face; it can be through phone calls, messages, or online meetings. Few PwSMI may prefer this contact, as it may give them some sense of control.

Tait et al[8] discuss that strategies such as confidentiality and tapping into the PwSMI’s personal interest help build rapport and service credibility. The services need to be comfortable and non-threatening, and the nurses need to avoid taking parental/authoritative roles and be tolerant if the PwSMI is relatively slow in opening up. Involving family and friends with the PwSMI’s permission, after setting confidentiality terms, is beneficial in initiating engagement and getting additional support. Moreover, a problem-solving approach to handling medication non-adherence issues and educating the PwSMI on early warning signs helps avoid relapse of symptoms. It is essential to train nurses in these aspects[52].

In addition to these qualities, Tait et al[8] also recommend services to be accessible, non-stigmatising, non-coercive, informal, relevant and appropriate. The interventions must be focused on the broader needs and goals of the PwSMI and have patient-centered flexibility rather than single-pointedly working on illness and symptoms. Wherever services are not delivered appropriately per individual needs, PwSMI tends to disengage[52].

Attempts to maintain engagement with the PwSMI should be continued by the nurses as individuals tend to engage, disengage and re-engage through the period they are availing of mental health services[52].

In summary, the strategies to improve engagement are establishing rapport, active listening, prioritising the PwSMI’s concerns, psychoeducation on illness and treatment, being non-judgmental, using open-ended questions and motivating the PwSMI to change. From the PwSMI’s perspective, engagement means having the opportunity to voice their needs through an open, compassionate relationship, adhering to prescribed medications, and taking charge of one’s treatment[18]. A partnership model of care and committed staff with sufficient time to improve engagement with the PwSMI is recommended[28]. Roeg et al[51], Aggarwal et al[53], and Lecomte et al[54] focused on improving the therapeutic alliance by enhancing the clinician’s communication styles and having regular team meetings.

Among the international studies reviewed (two from the United States, two from London, one from Hong Kong, one from Thailand, and one from Israel), there was one multicentric RCT conducted at four centers in Germany and Switzerland[35], three RCTs, two interventional studies, and one community-based RCT from Hong Kong[48]. The common intervention approaches used were behavioral interventions such as problem-solving, coping skills, strategies for maintaining adherence, motivational interviewing and telephone follow-ups[55-58].

These studies reported their interventions to be effective in maintaining adherence. It is noted that Chien et al[48] and Gray et al[58] were able to effectively train and supervise community nurses and help them implement adherence interventions in selected non-adherent PwSMIs.

Balikai et al[59] and Ahmed et al[60] have successfully implemented nurse-led adherence interventions to improve medication adherence among individuals with SMI from India.

Over the last few years, many interventions on treatment engagement have been developed, with the aim of addressing the factors influencing treatment engagement (Table 2).

Table 2 Factors influencing engagement and proposed strategies.

No.	Name of the intervention/study	Factors influencing engagement	Proposed treatment engagement strategies
1	MyCHOIS[31], (United States). Setting: Hospital-based	Substance abuse, lack of access to treatment, lack of engagement with the therapist, and need for long-term treatment	MyCHOIS is a web-based shared decision-making model. MyCHOIS supports clinical decision-making and quality improvement
2	Building therapeutic alliance in home-based treatment[32], (United states). Setting: Community based	Relationship with therapist, traits of the therapist, insight, family support	Experiential interactions and skill-building exercises spread over 12 sessions to improve engagement
3	Just Do You[34], (United States). Persons with schizophrenia, BPAD and anxiety disorders. Setting: Community-based recovery and rehabilitation programme	Beliefs on the benefits of medication, credibility and trust in providers, emotional reactions to treatment, stigma, social norms, access to treatment and hope	Just Do You-a meta-intervention of two 90-minute modules. Encompassing expressive arts, technology-based narratives, psychoeducation, and principles of motivational interviewing
4	Customised adherence enhancement-long-acting injectables-CAE-L[39], (North Carolina). Setting: Community Mental Health Centers	Lack of knowledge on illness and treatment, use of substances, medication side effects, lack of access to specialized care, and being symptomatic	Improving medication-taking habits/routines, communication, and modified motivational interviewing techniques with long-acting injectables
5	Customised adherence enhancement-long-acting injectables-CAE-L[40], (Tanzania). Setting: Hospital based	Inconsistent medication routines, side effects of medications, financial constraints, lack of qualified mental professionals, lack of care access	Psychoeducation, modified motivational enhancement therapy, optimizes the management of side effects and incorporates medication routines to one’s lifestyle
6	Care at doorstep[45], (India). Setting: Community-based	Lack of knowledge, lack of family support, being symptomatic, stigma, explanatory model, financial and accessibility to treatment, medication side effects	Care at doorstep: Three home visits were made by the team and provided. Medications, also offered brief psychoeducation and counselling
7	Medication adherence therapy[59], (India). Setting: Tertiary care mental hospital	Lack of knowledge on illness and treatment, forgetfulness, lack of motivation, side effects, duration of illness, and financial issues	Four in-person sessions on medication compliance, namely psychoeducation on BPAD, motivational session, overcoming practical barriers, use of drug cards and phone call reminders once every 15 days for three months
8	Nurse-led intervention to improve adherence[60], (India). Setting: Tertiary care mental hospital	Lack of knowledge, forgetfulness	Psycho-education, an explanation of individualistic behavior tailoring or memory cues, a demonstration of preparation and use of pill boxes, and the distribution of information booklet
9	Integrative one-on-one intervention[55], (Israel). Setting: Tertiary care mental hospital	Forgetfulness, negative attitude to medications, financial issues, actively symptomatic, lack of insight, stigma, side effects of medication, lack of family support	Integrative one-one intervention strategies for handling side effects in liaison with a psychiatrist, psychoeducation, motivational interviewing and cognitive behavioral strategy. An average of six sessions, each 20-40 minutes over two weeks
10	Telephone intervention by trained nurses[56], (United States). Setting: Community mental health center	Beliefs and values regarding treatment, confidence and ability to overcome adherence barriers, lack of family support, social isolation, stigma, cognitive deficits, side effects of medication, logistics	Telephone intervention: Psychoeducation, problem-solving technique
11	Adherence therapy based on motivational interviewing[48], (Hong Kong, China). Setting: Community-based	Attitude and behavior regarding illness and treatment, lack of knowledge, stigma, lack of insight, symptom severity	Motivational, cognitive, insight-inducing and behavioral interventions conducted over eight sessions
12	Compliance therapy[58], (London, United Kingdom). Setting: Community-based	Side effects of medications, being symptomatic	Compliance therapy, medication management, interventions for medication side effects

MyCHOIS: My Collaborative Health Outcomes Information System; BPAD: Bipolar affective disorder; CAE-L: Customised adherence enhancement-long.

The notable interventions on treatment engagement or adherence which have been tested in the past include CAE (North Carolina and Tanzania), CAD and medication adherence therapy (MAT) (India), AT (China), JDY and MyCHOIS (United States)[31,34,39,40,45,48,59].

MyCHOIS was unique in creating a web-based shared decision-making platform, which facilitated easy access to the treating team, thus improving clinical decision-making and quality of care[31].

JDY attempted to improve engagement through arts- and technology-based narratives[34]. The models of CAE[39,40], CAD[44], MAT[58] and AT[48] focused on addressing specific factors influencing treatment engagement through behavioral interventions such as motivational interviewing, problem solving, and cognitive strategies such as reminder calls and pill boxes. These interventions are customised based on the challenge faced by PwMI. For example, a client reporting forgetfulness may be advised to use pill boxes or cues to remind themselves of taking prescribed medications. A person not having adequate knowledge about the long-term nature of illness and treatment may benefit from psychoeducation. And a person who is severely symptomatic and lacks insight into his/her condition may benefit from support and supervision by family members.

Motivational interviewing can help in developing better rapport and therapeutic alliance with the client, as its principles are primarily based on partnership and collaboration. These studies indicate that treatment engagement can indeed be boosted by focusing on the individual needs of the concerned clients and addressing these issues in a personalized manner using suitable interventions suggested and proven effective by various authors.

CONCLUSION

Nurses play a crucial role in the treatment engagement of PwSMI by developing therapeutic relationships, educating clients about the importance of medication adherence, and empowering them to participate actively in their treatment. Community nurses can help close the treatment gap and strengthen engagement with their clients by building strong therapeutic alliances, helping clients develop self-management skills, and intervening in the reasons for non-adherence.

ACKNOWLEDGEMENTS

The authors acknowledge Dr. Jayarajan D, Dr. Thirthalli J and Dr. Parthasarathy R for enriching discussions in the area of treatment engagement and playing a part in conceptualising the study that evolved out of this review.