Addressing Medication Adherence Among Patients With Mood, Psychotic Disorders

Medication adherence is critical not only to clinical outcomes, such as preventing readmissions, but also to containing costs, with adverse outcomes as a result of nonadherence often resulting in higher costs for both the patient and the healthcare system. Ensuring adherence can be especially challenging among people with mood and psychotic disorders.

The American Journal of Managed Care^® (AJMC^®) recently spoke with Dawn Velligan, PhD, director of the division of community, recovery, research and training, and the Henry B. Dielmann Chair in the department of psychiatry and behavioral health at UT Health San Antonio, about the issue and different strategies to improve adherence among the patient population.

AJMC^®: How prevalent is medication adherence among people with mood and psychotic disorders and what challenges does this create?

Velligan: Just in general in the population, we all take about half of the medication that is prescribed, and surgeon generals have called this America’s other drug problem. The World Health Organization requoted a comment by Hayes stating that if we could improve medication adherence, it would be a bigger advance than almost any new medication that could come out. So, at most, on average, half of the people with mood disorders and psychotic disorders take medication as prescribed.

It’s a big issue for healthcare costs. It represents more than $300 billion annually of costs poor adherence leads to—costs from hospitalizations,[emergency room visits, and a bunch of wasted pills. The cost is pretty substantial. And the individual costs of course are also great. Every time you go to a hospital, your recovery is derailed, you may need to give up a part-time job or drop out of school for that semester, so you can’t get much traction in your recovery.

AJMC^®: In addition to this cost factor, what are the clinical consequences of not adhering to the medications as prescribed? How does this hinder the efficacy of new and more effective treatments?

Velligan: Medicines don’t work if you don’t take them, so what ends up happening in schizophrenia, for example, is a provider will put somebody seeking treatment on an antipsychotic and say, “Oh, well they’re not doing better, so we’ll try another one,” or, “Oh, well they’re not doing better, they must be treatment resistant.” People are not necessarily making mistakes in healthcare, but they’re making decisions based on bad information. If someone comes in and they don’t look very well, what are you supposed to do? Are you supposed to increase the dose of the medicine they’re on, are you supposed to switch it? Do you add an adjunctive medicine? And how do you make that decision if you don’t know if they’re taking their medication, or how much they are taking?

In a recent survey, most physicians say they base their impression of adherence on how the person’s doing—their symptoms and their self-report. That’s sort of a backward reasoning. If people are doing well, they must be taking it. It’s a big issue because if you’re prescribing additional medicine or increasing the dose of medication to treat what’s really nonadherence, first of all, it’s not effective. Second of all, it could put the person at risk for increased side effects and toxicity. It’s just not going to be an effective way to treat somebody

AJMC^®: What are some different approaches to help providers understand when a patient is not adhering to their medication and approaches to improve medication adherence?

Velligan: It’s difficult because a lot of the work is done in research programs and to translate that into clinical programs is a little bit more difficult. But, there are multiple ways to tell if people are taking their medications at the minimum. Certainly, getting reports on whether they are picking up medications, refills, to see whether or not they’re filling their medication regularly.

There are all kinds of fancy methods for prompting adherence. Text messaging programs are relatively inexpensive and people who are willing to take medications will respond to those. For people who are intentionally not taking medication, you need to work on motivational interviewing, finding a reason for them to take it that matches with their recovery goal. A lot of that is based on the relationship between the provider and the person coming in for treatment, and the issue there is that with the visits getting shorter and shorter, it’s very difficult to develop the relationship you need to work with someone over time to take the medication that’s in their best interest.

AJMC^®: Do you think different approaches need to be implemented for different groups of people based on the mood or psychiatric disorder they have or their different demographics?

Velligan: Certainly. People who are tech savvy, there’s a bunch of apps that people can use and there are reviews that suggest which apps are most effective. Some of them will allow you to download your adherence data and bring it in to your practitioner. So, you have to be somewhat tech savvy.

No matter what technology or digital format you use, you have to understand it’s a tool and it’s not the intervention. If no one responds to text messages when someone says they’re not taking the medication, then what good is it? Or when someone hands you a specialized pill container, and you’re supposed to plug it in and fill it, a bunch of those are not going to be used. You sometimes have to go to the home and set it up in a place where it’s going to work for the person, they may need a pharmacy to fill it so that it’s filled correctly.

They’re tools that have to be customized to the individual’s needs.

AJMC^®: Are there any novel approaches being taken to track and improve medication adherence?

Velligan: I think there are new advances. There are chips that can be put in pills that actually interact electronically with a patch the person wears and that information then downloads to a smart device and it can be sent to a treatment team or family member. So, it can tell when the pill is ingested. The future of that drug device interface is coming.

I also think that telemedicine formats are becoming much more common. You can watch someone, for example, take their medication on just a telephone video chat interface. The problem with that is there are disagreements about whether that is a conduit, like a phone call, or whether it has to be covered by a business associate agreement, like a telemedicine platform where you’re doing therapy, for example. That has to be covered by an agreement, that all has to be HIPAA compliant, but a phone call doesn’t; a phone call is just a conduit. You don’t hold any information.

The same with a video chat; if none of that information is saved, why can’t that format be used just to watch people take medicine? I know that certain organizations in the federal government think using video chat is fine, like the Department of Veterans Affairs, but that other compliance offices aren’t allowing the use of video chat. I think the legal aspects haven’t caught up with the technology. So, even in doing therapy using telemedicine, for example, the psychologist has to be in the same state as the person they are providing therapy for. If a psychologist could provide therapy via telemedicine to rural areas in other states that have no psychologists that would be very helpful -- if laws allowed it. The legal aspects have to catch up with the ability to see people remotely, etc.