What are the recommended therapies for enhancing motivation in adults with diagnosed conditions such as depression, anxiety, or substance use disorders, or chronic illnesses like cancer or Human Immunodeficiency Virus (HIV)?

Motivation-Enhancing Therapy for Adults with Depression, Anxiety, Substance Use Disorders, and Chronic Illnesses

Primary Recommendation

For adults with depression, anxiety, substance use disorders, cancer, or HIV, cognitive behavioral therapy (CBT), behavioral activation, and structured physical activity should be offered as first-line motivation-enhancing interventions before considering pharmacotherapy or motivational interviewing techniques. 1

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Treatment Hierarchy by Condition

Cancer Patients with Depression or Anxiety

First-Line Psychological Interventions:

• Cognitive behavioral therapy (CBT) produces the strongest evidence for enhancing motivation and reducing symptoms, with robust effects generalizing across sex, age, disease site, and treatment phase 1
• Behavioral activation (BA) should be offered as an equally effective alternative to CBT, particularly for patients with motivational deficits characteristic of depression 1
• Structured physical activity and exercise programs demonstrate large effect sizes for both depression and anxiety, serving dual purposes of symptom reduction and motivation enhancement 1
• Mindfulness-based stress reduction (MBSR) shows statistically significant improvements in depression and anxiety compared to usual care in short and medium term 1

Complementary Integrative Therapies:

• Music therapy, yoga, relaxation techniques, hypnosis, tai chi, qigong, and reflexology are recommended as adjunctive treatments for anxiety and depression symptoms 1
• These interventions offer patients perceived control over illness impact with minimal side effects 1

When to Consider Pharmacotherapy:

• Only after first-line psychological interventions have failed, are inaccessible, or when patients express strong preference for medication 1, 2
• For patients with severe neurovegetative symptoms, psychotic features, or history of positive medication response 1
• Critical caveat: The 2018 Cochrane review found null findings for antidepressants in major depressive disorder among cancer patients at 6-12 weeks, though some studies showed effects at day 3 of unclear clinical significance 1, 2

Substance Use Disorders

Motivational Interviewing (MI) Evidence:

• MI shows small to moderate effects compared to no intervention post-treatment (SMD 0.48), with effects weakening at short-term follow-up (SMD 0.20) 3, 4
• MI demonstrates very small or no differences compared to treatment as usual across all follow-up periods 3
• MI is most effective when added as pretreatment to other therapies rather than as standalone intervention 5
• MI typically requires 1-9 sessions, with session durations varying from 10 to 148 minutes 3

Integrated Treatment Approach:

• Pharmacotherapy for opioid use disorder (buprenorphine, methadone, extended-release naltrexone) should be offered immediately without waiting for HIV or HCV treatment plans 1
• Medications for alcohol use disorder (extended-release naltrexone, oral naltrexone) reduce alcohol use and improve ART adherence 1
• Contingency management is the most efficacious treatment for stimulant use disorders, using financial incentives for periods of recovery 1
• Harm reduction services including naloxone, safe injection education, fentanyl/xylazine test strips, and syringe service programs should be offered to all persons reporting drug use 1

Critical Integration Point:

• Depression and anxiety differentially affect motivation dimensions in substance use populations, with depression correlating with three of four motivation domains and anxiety correlating solely with internal motivation 6
• Treat depression first in patients with comorbid substance use and mood disorders, as untreated depression predicts poor treatment compliance and outcomes 1

HIV Patients

Comprehensive Approach:

• Integration of substance use disorder screening, diagnosis, and treatment into HIV prevention and treatment services is mandatory 1
• Peer/patient support staff, telehealth, extended hours, mobile clinics, and walk-in options should be available 1
• Medications for substance use disorders have few clinically significant drug-drug interactions with antiretroviral therapy and should not be withheld 1

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Stepped Care Algorithm

Step 1: Screening and Risk Assessment (All Populations)

Timing:

• Screen at diagnosis, during treatment initiation (the most stressful period), and at regular intervals throughout care 1
• One-third of patients experience significant psychological distress between diagnosis and treatment start 1

Validated Instruments:

• PHQ-9 for depression (scores ≥10 indicate moderate to severe symptoms requiring intervention) 1, 7
• GAD-7 for anxiety (scores 10-14 moderate-to-severe, 15-21 severe) 1, 2, 7
• Assess functional impairment using Sheehan Disability Scale 7

High-Risk Populations Requiring Intensive Monitoring:

• Current or prior psychiatric diagnosis 1
• Other chronic medical conditions 1
• Adverse social determinants of health 1
• Poor functional status 1
• Younger age (<40 years) 1
• Advanced disease stage or high symptom burden 1

Step 2: Moderate Symptoms (PHQ-9 10-19, GAD-7 10-14)

Offer individual or group therapy with:

• Cognitive therapy or CBT (12-20 structured sessions over 3-4 months) 1, 8
• Behavioral activation 1
• Structured physical activity and exercise programs 1
• MBSR interventions 1
• Psychosocial interventions using empirically supported components (relaxation, problem solving) 1

CBT Core Components:

• Cognitive restructuring targeting catastrophizing, overgeneralization, negative prediction, and all-or-nothing thinking 8
• Graduated exposure using fear hierarchy from least to most distressing situations 8
• Behavioral activation with specific goals and contingent rewards 8
• Homework assignments between sessions (the most robust predictor of treatment success) 8
• Relaxation techniques including deep breathing, progressive muscle relaxation, and guided imagery 8

Step 3: Severe Symptoms or Treatment-Resistant Cases

When to Escalate:

• After 8 weeks of first-line treatment with poor symptom reduction despite good compliance 1
• Presence of severe neurovegetative symptoms, agitation, or psychotic features 1
• Suicidal ideation, plans, or self-harm behaviors 7

Escalation Options:

• Add pharmacotherapy to ongoing psychological treatment 1
• Switch from group to individual psychotherapy 1
• Refer for emergency evaluation if risk of harm to self or others 1

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Monitoring and Follow-Up

Assessment Schedule:

• Biweekly or monthly until symptoms remit 1
• Reassess at 4 weeks and 8 weeks using standardized instruments (PHQ-9, GAD-7) 7
• Monitor compliance with psychological referrals, medication adherence, and side effects 1, 7

Common Compliance Barriers:

• Persons with depressive symptoms often lack motivation to follow through on referrals 1
• Construct specific plans to circumvent obstacles or discuss alternative interventions with fewer barriers 1

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Critical Pitfalls to Avoid

Do Not:

• Trivialize anxiety or depression as "normal reactions" to cancer or chronic illness, as this leads to undertreatment of clinically significant symptoms 2
• Start pharmacotherapy without first addressing medical causes of symptoms (uncontrolled pain, fatigue, thyroid dysfunction) 2, 7
• Use benzodiazepines long-term due to risk of abuse, dependence, and cognitive impairment 1, 2
• Assume lack of response before 8 weeks at adequate dose, but do reassess at 4 weeks 7
• Rely solely on motivational interviewing for substance use disorders without integrating evidence-based pharmacotherapy and behavioral treatments 1, 3
• Withhold medications for substance use disorders in patients receiving antiretroviral therapy or hepatitis C treatment due to unfounded drug interaction concerns 1

Do:

• Treat depression first when comorbid with anxiety, as depression is the predominant affective, cognitive, and behavioral disruptor 1
• Ensure homework completion between CBT sessions, as this is the strongest predictor of both short-term and long-term success 8
• Provide culturally informed and linguistically appropriate information to patients and caregivers about symptom commonality, warning signs, and when to contact the medical team 1
• Screen for bipolar disorder before initiating antidepressants, as they can precipitate mania in undiagnosed cases 7

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Alternative Delivery Methods When Traditional Therapy Unavailable

• Guided self-help based on CBT principles shows moderate to large effect sizes with approximately 9 sessions over 3-4 months using self-help materials with minimal therapist support 8
• Telephone-delivered CBT can improve symptoms when in-person treatment is not feasible 1, 8
• Brief CBT adapted for primary care (6 or fewer sessions of 15-30 minutes) can be delivered effectively within integrated behavioral health models 8
• Internet-delivered CBT demonstrates robust positive effects comparable to face-to-face delivery 1