Schizophrenia: Treatment Adherence
MAY 29, 2020
Dawn Velligan, PhD: Adherence to medication is important for a number of reasons. First of all, if the doctor doesn’t know what you’re taking and you’re not doing well, they’re going to give you more. They’re going to increase your dose, they’ll add something new, or they’ll switch medication. If they don’t know what you’re taking; it’s a problem for you and for them. The other reason that you want to be adherent is because you want to prevent relapse. Taking your medication regularly is the most important thing you can do to prevent the recurrence of symptoms. It forms the basis of your recovery. If you have to keep going back to the hospital because you’re not taking your medicine, there are a lot of consequences. You may have to quit a job or drop out of school. And you can’t receive any traction in your recovery. Medication forms the basis so you can work on the things you want to work on in your recovery. It’s important to take your medication. With somebody who has recent onset of psychosis, I will often say there is going to be a time when you’re going to think about going off this medicine. Or they’ll bring it up first. How long do I have to take this? And I’ll tell them it’s important to stay on, and these are the reasons. But if you’re going to go off, you need to tell your mom and your dad and your dog and your friends. Do you want to go all the way back to the hospital? Or do you want to go all the way back to where you’re running in the street because you’re afraid? Or do you want to catch this early and then at the first sign of hearing a voice or feeling that other people might be out to get you, you want to go back on? And if you let it go all the way to be very ill and having a relapse, what hospital do you want to go to? How do you want your parents to deal with it? Do you want them to call the police? What should they do? Let’s plan it out, just in case. And that’s the approach I take.
The psychiatrist will come to me and they’ll say, “You have to make this person take their medicine.” Unfortunately, it’s ultimately their choice. I’ve always had an open dialogue with people I work with, and I find that after a couple of weeks, most of them will go back on. But we increase our appointments. We make sure that we’re monitoring things. But first of all, I tell them it’s not the best idea.
Christoph Correll, MD: Monitoring adherence is very difficult. Clinically, what you do is obviously a simple question. Usually, clinicians ask, have you taken your medication? Obviously, this question prompts a yes in over 90% of cases, because patients don’t want to contradict you. Even if you rely on this very unreliable self-report, start asking how many medications, how many doses have you not taken since I’ve last seen you. That signals to the patient you’re aware that this can happen. You don’t feel like the patient is attacking you or not doing what you want them to do. It is more like nonadherence is part of the human condition. That’s what I would tell patients, that I would rather know about it and then discuss with the patients what to do about it than not know about it.
How do you supplement this self-report? Well, you ask informants. In patients who have very doubtful adherence, you might ask them to actually check on the patient, to check that the family members or caregivers hand out the medication. But that can lead to a lot of dispute, where patients feel infantilized and not able to do what they would do was an adult.
Another way to measure adherence is to ask the pharmacy whether the patient has at least picked up the medication. In large pharmacy record studies, you would do a medication-possession ratio, where you need at least 80% of the doses to be picked up. But when patients pick up the medication, this does not assure they have taken them.
For antipsychotic blood levels, therapeutic drug monitoring is another way of monitoring adherence. But that is complex and tells you only whether something is in the blood or not. If it’s zero, you know there is full nonadherence. But if there is some blood level, you don’t know. Is the patient taking every other dose? Had they stopped for 3 weeks and now they’re taking it just for another couple of days? Or they’re just taking it because they know there is a blood draw coming. We need better measures of adherence.
There is an ingestible medication event marker, where a biodegradable chip is inserted in the aripiprazole pill and then a signal is emitted from the gastric content when the patient swallows it, to be emitted to a sensor worn on a patch. This is another way of potentially measuring adherence.
The only 100% measure of adherence is prescribing a long-acting injectable. You will know the month, the week, the day, the hour when a patient becomes nonadherent. And you can do something about it. There is also a window of opportunity to get back to the patient while there are sufficient blood levels in the system.
John M. Kane, MD: We know that the medication the person has been prescribed can also influence adherence and nonadherence. When we were using first-generation antipsychotics, we did see a fairly high incidence of neurological adverse effects. A drug-induced parkinsonism[MB1] , dystonia, akathisia, and so forth. With the second-generation drugs, we’ve seen a significant reduction in the risk of those adverse effects. It’s not completely gone, but there’s a significant reduction even with tardive-dyskinesia, which is a more long-term adverse effect. Our analyses of the existing data suggest that the risk of developing tardive-dyskinesia with the second generation or atypical antipsychotics is about one-fifth of what it had been with the first-generation or typical antipsychotic drug. That’s a significant improvement, and those reductions in adverse effects can also play a role in facilitating adherence because patients will stop taking their medication if they’re experiencing adverse effects. Some of the newer medicines are associated with metabolic adverse effects, weight gain, changes in lipid metabolism, and so forth. We have to be mindful of that.
Most medicines are going to have some adverse effects, we need to have a good understanding of how those adverse effects are affecting the patient we’re treating and how that might influence their willingness to actually take the medicine on a long-term basis.
Transcript Edited for Clarity