Technologies Promise to Aid Medication Adherence, but Effectiveness Varies

Technology has so transformed daily life that many of us who straddle the pre- and post-digital ages can scarcely understand how we got along without our smartphones and digital apps. Can technology—texting, emails, smartphone applications, and the like—be extended to enhancing psychiatric treatment by improving patient adherence to medication regimens?

Several experts who spoke with Psychiatric News said that it is a burgeoning field, and a promising one, with a great variety of products being developed commercially and in the academic research domain. But they cautioned that evidence for effectiveness varies widely.

“It’s an exciting and fast-moving field,” said APA Director of Research Phillip Wang, M.D., Dr.P.H. In the commercial arena a number of applications are already available—a search using the words “medication reminder” in the iPhone App Store turned up dozens of products—but Wang said he believes data on the effectiveness of these products, particularly for patients with psychiatric illness, is all but nonexistent.

As for recommending such products to patients in the absence of any real data, Wang advised clinicians to use common sense and apply a simple rule of thumb: would they use the product themselves?

“Psychiatrists should approach these products by trying them out,” he said. “If there is face validity to the product and if a patient can feasibly use it and if it’s free—then, sure, why not recommend trying it? But clinicians should do due diligence and check it out themselves.”

Destigamatize Nonadherence

Wang and others experts in the field said there are products and devices that are receiving serious research interest and that hold real promise for improving medication adherence, including for those with serious mental illness for whom adherence is crucial.

John Kane, M.D.

The highest tech of the technological experiments is almost certainly the “digital health feedback system” (DHFS)—a device that is actually embedded in the medication itself and that provides feedback to a clinician confirming that the pill has been ingested (Psychiatric News, October 2, 2015). John Kane, M.D., and colleagues at Zucker Hillside Hospital and Massachusetts General Hospital partnered with Proteus Digital Health Inc. (which manufactures a DHFS) to characterize the feasibility and safety of the system in patients with bipolar disorder and schizophrenia.

Kane explained that the DHFS is “an ingestible event marker”—a pill embedded with a tiny sensing device that emits a signal when it comes into contact with gastric contents after being swallowed; the signal is picked up by a receiver in a patch worn by the patient, which in turns transmits the signal to caregivers and clinicians indicating that the medication has been ingested. (Moreover, the patch worn by the patient can link medication ingestion to other physiological parameters that can indicate possible deterioration in health or symptoms.)

In a paper published in the Journal of Clinical Psychiatry (June 2013), Kane and colleagues reported the results of using the DHFS in 12 patients with bipolar disorder and 16 patients with schizophrenia. (For the purposes of the study, the pill with the embedded DHFS was not pharmacologically active.) A principle concern at the outset was whether patients who may have paranoid or persecutory delusions would be amenable to using a device allowing others to monitor their behavior.

Study results were positive. No subjects experienced worsening of psychosis due to use of the DHFS. Of the 27 patients who completed the study, 19 found the DHFS concept easy to understand, and 24 said they believed it would be useful. “It’s the most sophisticated approach to monitoring adherence, but it’s also a way to get patients and their caregivers information about medication habits,” Kane told Psychiatric News. “It’s really not about Big Brother watching you but about providing the necessary information for patients to do a better job of managing their illness.”

The DHFS device is pending approval by the Food and Drug Administration.

Kane said clinicians sometimes underestimate the capacity of patients with serious mental illness to engage in practical approaches to recovery. He pointed out another important lesson from the study: “We need to destigmatize nonadherence. This is not a problem associated solely with patients with serious mental illness. No one likes to take medicine, and it’s a phenomenon we are all prone to. We need to take advantage of emerging technologies to facilitate disease management. In my view, this is just the beginning of providing the kind of technological resources that will help patients benefit more from the treatments we have available.”

Psychosocial, Cognitive Interventions Built In

Dror Ben-Zeev, Ph.D.

A group led by Dror Ben-Zeev, Ph.D., at the Geisel School of Medicine at Dartmouth is developing and testing smartphone applications for self-management of schizophrenia, behavioral-sensing systems for detection of psychotic relapse, and training of clinical social workers who send daily text messages to participants’ mobile phones to assess their medication adherence and clinical status. Ben-Zeev is director of the Mobile Health mHealth for Mental Health Program in the Center for Technology and Behavioral Health at the Dartmouth Psychiatric Research Center.

In a paper published in Schizophrenia Bulletin (March 2014), Ben-Zeev and colleagues reported on the feasibility and acceptability of a mobile phone application for self-management of schizophrenia called FOCUS. The app includes a medication-management module that asks users a series of questions about their medication use. To the question of whether they have been taking their medication, the module offers such responses as “Sometimes, but I don’t remember,” “No, but I don’t think I need my meds anymore,” or “I took some of it but not all of it.”

“If you boil it down to just one answer, you won’t get real information, because people want to be good patients and will just say ‘Yes, I took my meds,’ ” Ben-Zeev said. “Based on the responses, the next screen will ask more nuanced questions and bring up suggestions or videos that can target cognitive barriers to adherence. If patients say they don’t want to take their medication, the module will challenge their beliefs by asking about the last time they had a relapse and if there was a connection with not taking medication.”

Such interventions, which would have been at one time the stuff of science fiction, are almost certainly going to be regular features of care in the future. But Ken Weingardt, Ph.D., scientific director at the Center for Behavioral Intervention Technologies and an associate professor in the Department of Preventive Medicine at Feinberg School of Medicine at Northwestern University, emphasized that technological wizardry alone is unlikely to improve adherence to medication and that any device, application, or intervention needs to be embedded in an integrated, comprehensive, and patient-centered treatment plan.

“Intentional nonadherence, as opposed to simply forgetting to take meds, is not a trivial problem, especially in populations with schizophrenia,” he said. “The side effects of medications are bad, and when people are in remission, they feel that they don’t need to take them.”

Thus, to help patients be adherent, better understanding of why they are not and the resources that can be leveraged to help them—such as family members—is needed. “If you just rely on some device, it isn’t likely to get much traction,” he said. “But if technology is implemented in the context of an integrated and comprehensive treatment plan, these tools may be really transformative.” ■