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Stephanie Nichols, PharmD, BCPS, BCPP, FCCP
Recertification Editorial Board Member

Recurring relapses are common in patients with schizophrenia and the largest predictor of relapse is medication discontinuation.1 Many factors influence medication nonadherence including social and economic factors (e.g., homelessness), treatment-related factors (e.g., effectiveness and tolerability), patient-related factors (e.g., stigma), disease-related factors (e.g., executive dysfunction), and health system-related factors (e.g., access and availability of resources). Co-occurring substance use disorders are another significant factor.

Dr. Michael O. Measom, MD, a Salt Lake City native, shared his experience using shared decision making and technology to improve adherence at the CPNP 2019 Annual Meeting. His presentation, titled Medication Adherence in the Digital Age: Incorporating Technology, Shared Decision Making, and Ethical Considerations, was full of dramatic pauses and audience laughter. Dr. Measom is the Medical Director of an Assertive Community Treatment program at Volunteers of America, New Roads Behavioral Health residential program for young adults, and the Center for Human Potential. He is board certified in general psychiatry, addiction psychiatry, and addiction medicine.

Dr. Measom showed us that patients crave shared decision making and he demonstrated its importance in improving medication adherence. For example, 83% of surveyed patients want their provider to “to listen to me” and only 17% want to hear “only the options that he or she feels are right for me”.2 While critical to begin early, it can’t be rushed. The process of shared decision making evolves over time from establishing a partnership first to exchanging information second. Weighing of options and subsequent decision-making follow, and the final step in the cyclical process is ongoing monitoring and evaluation. Patients can more actively engage in the process suing the TAC-Review framework which includes: Telling the provider about concerns, Asking questions, Choosing an option or choosing time to think, and REVIEWing if the symptoms are getting better or worse.3 It is critical for clinicians to avoid judgement and employ open-ended questions that ask the patient to describe their medication obtaining and taking process.

There are many tools that are now available to help clinicians assess and/or promote adherence. Different types of technological devices include those that are wearable (e.g., fitness trackers), portable (e.g., medication alerts on phones), implantable (e.g., pulmonary artery pressure sensors), ingestible (e.g., camera-containing capsules), and deployable (e.g., smart pill bottles). Some smart phone apps are also available such as CBT-I (Cognitive behavioral therapy for insomnia) Coach though the Veterans Affairs System4, but very few have published evidence to support their use.5 One ethical concern about the use of medical apps is about overenthusiastic adoption before the evidence supports clinical use. The American Association of Psychiatry has created an App Evaluation Model to help clinicians assess criteria such as potential for harm or benefit and usability.6 Other important ethical questions include “Does the app sell patient data?” and “Is patient data kept secure and private?”.

One audience member inquired about what to do in the shared decision making process if a patient selects a poor option. Dr. Measom responded that as long as the patient is rational and has been informed of the risks, the patient has the right to make poor choices. Another audience member asked a question about the new opioid use disorder app which Dr. Measom found interesting, but felt was too cost prohibitive to use in his practice.

Take Home Points

  • Many technological tools exist to support medication adherence including smart pill bottles and smartphone apps
  • Many mobile phone apps are being developed in the treatment of patients with mental illness with varying levels of supporting evidence
  • Use of shared decision making may lead to greater adherence to treatment regimens, better disease control, and greater patient satisfaction
  • Ethical concerns remain and evidence is limited in most cases, and clinicians must not become overly enthusiastic about the clinical role of mental health apps and their potential utility

References

  1. Kane JM. Review of treatments that can ameliorate nonadherence in patients with schizophrenia. J Clin Psychiatry. 2006;67(suppl 5):9-14.
  2. Alston C, Paget L, Halvorson G et al. 2012. Communicating with Patients on Health Care Evidence. NAM Perspectives. National Academy of Medicine, Washington, DC.
  3. University of Health, San Antonio. Medication adherence: https://www.youtube.com/watch?v=nl-g-Zhwg0Q. Accessed January 2019.
  4. Kuhn E, Weiss BJ, Taylor KL, et al. CBT-I Coach: A Description and Clinician Perceptions of a Mobile App for Cognitive Behavioral Therapy for Insomnia. J Clin Sleep Med. 2016;12:597-606.
  5. Van Ameringen M, Turna J, Khalesi Z, et al. There is an app for that! The current state of mobile applications (apps) for DSM-5 obsessive-compulsive disorder, posttraumatic stress disorder, anxiety and mood disorders. Depress Anxiety. 2017;34:526-39.
  6. Torous J, Luo J, Chan SR. Mental health apps: What to tell patients. Current Psychiatry. 2018;17(3):21-5.
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