Supporting Adherence in Schizophrenia: The Role of Digital and Team-Based Tools

Announcer:
You’re listening to NeuroFrontiers on ReachMD, and this episode is sponsored by Bristol Myers Squibb. Here’s your host, Dr. Charles Turck. 

Dr. Turck:
Welcome to NeuroFrontiers on ReachMD. I'm Dr. Charles Turck, and here with me today to discuss digital and team-based approaches to support adherence and prevent relapse in patients with schizophrenia is Dr. Hannah Brown. Not only is she the Director of the Wellness and Recovery After Psychosis Program and the Vice Chair of Research at Boston Medical Center, but she's also a Clinical Associate Professor of Psychiatry at Boston University Chobanian and Avedisian School of Medicine. Dr. Brown, thanks for being here today.

Dr. Brown:
Thank you so much for having me. I'm glad to be here.

Dr. Turck:
Well to start us off, Dr. Brown, would you give us a little insight into what makes sustaining adherence so challenging, and why patient education, in the traditional sense, may no longer be enough on its own?

Dr. Brown:
Non-adherence and adherence to antipsychotic medication is something we think a lot about in our clinical practice. And when we think about antipsychotic medications, they can be effective. They can treat symptoms of psychosis, but they also come with significant side effects, such as cardiometabolic abnormalities, weight gain, sexual dysfunction, abnormal movements, feeling drowsy, and feeling sedated. So understandably, when these side effects occur, it can be hard to convince someone to take these medications.

Sometimes antipsychotic medications are only partially effective, so they can treat some of an individual's symptoms and cause side effects. And in these cases, when an individual's symptoms are only partially treated with one antipsychotic medication, another antipsychotic medication is often added to the regimen. And you can imagine that if it's already hard to take one medication, adding another or taking more than one with different dosing schedules can be even more difficult. And when we think about individuals with schizophrenia, they may be experiencing symptoms of disorganization or struggles with executive functioning, and these can be barriers to keeping a reliable medication regimen and adhering to medication.

Then I think traditional patient education is limited in its reach. It can work for some people—for example, someone who is organized and has the skills to plan—but it really doesn't work for everyone. And so we have to think broadly and use multiple approaches in order to support patient medication adherence.

Dr. Turck:
With those challenges in mind, let's focus on some solutions. One strategy highlighted in recent work is nurse-led education. What makes these programs particularly effective? And how do they benefit both patients and caregivers?

Dr. Brown:
I think this idea is really important. It highlights how to work together within a multidisciplinary clinical team and think about what role each team member plays. And nurses can be the ideal people to provide patient education and have nursing visits that occur complementary, for example, to the psychiatrist visit. The nurses can discuss treatment planning with the patient. They can answer questions about medications. They can review medication dosing or titration schedules, side effects, and side effect management. And then, along with the psychiatrist visit, the nurse can also discuss strategies for maintaining adherence and connecting adherence to specific goals that a person is working towards, like going to work, going to school, or maintaining social relationships.

Dr. Turck:
Now, digital tools are also playing a growing role. So how exactly are chatbots and similar technologies being used to support adherence and monitor symptoms?

Dr. Brown:
Chatbots are unique in that they can provide reminders about medication timing and medication dosing schedules. They can actually engage with the patient about the importance of medication adherence. They can provide psychoeducation about the medication itself. They can provide information about side effects and side effect treatment, and they can also potentially monitor the patient's adherence in real time.

So, for example, a mobile phone text messaging-based chatbot can initiate a message to remind the individual to take their antipsychotic medication. The individual can then respond with confirmatory text messages. And the individual can also report symptoms that they're experiencing, like residual symptoms or side effects, and then get feedback from the chatbot based on the individual's response. The chatbot can also ask personalized questions to the individual and ask, for example, about their specific barriers to adherence. So it creates this interactive space for the patient to really engage with their treatment and their adherence. And the chatbot can also track patient behaviors and potentially anticipate who might be at risk for medication non-adherence.

Dr. Turck:
What are some key factors that determine whether these digital tools succeed in practice?

Dr. Brown:
Well, I think the success can depend on a few different factors. First, the individual has to use them. You have to get the buy-in from the patient and their motivation to use them. And I think, again, there's no one singular successful approach to adherence. Identify those individuals who would benefit most from these digital tools, and start with those individuals. The digital tool will also probably be most effective when it's tailored specifically to the needs of the patient and their routine. So it's not like there's one size fits all; it really has to be aligned with the needs of the patient.

And I think the tools will also have to be accepted by clinicians because ultimately, if the digital tools detect non-adherence, then it's up to the clinician to make a treatment decision. And I'll emphasize too that while digital tools are helpful, we do need healthcare professionals and clinicians to ensure safe prescribing, delivery of medications, and to take care of the patient. So when I think about using these digital tools, they're a tool and they can help with adherence, but you do need the clinical expertise as well.

Dr. Turck:
For those just tuning in, you're listening to NeuroFrontiers on ReachMD. I'm Dr. Charles Turck, and I'm speaking with Dr. Hannah Brown about how we can leverage digital and team-based approaches to support adherence and prevent relapse in patients with schizophrenia.

Now, looking beyond these clinical and digital interventions, Dr. Brown, peer-to-peer support is another critical layer. How do those connections help patients sustain motivation and prevent relapse?

Dr. Brown:
Yeah, as I mentioned earlier, in a multidisciplinary team, each person's role is really important. And this includes someone like a peer support specialist. Peer specialists can provide a perspective that is unique and that many other members of the treatment team cannot given that they've had lived experience with the illness. And so this provides a really important resource for the patients. For example, the peer support specialist on our clinical team will meet the patients where they feel comfortable. And this is probably outside of the office; so in the community, they'll grab a cup of coffee, have lunch, and have a conversation in a setting where the patient may feel much more comfortable.

The peer specialist can really help destigmatize the illness. They talk openly about their experience with symptoms and treatment, and they can provide the insight into the need for treatment. They can discuss their experience with treatment and what strategies have worked for them. They can also provide other types of support, like, how do you talk to your psychiatrist about medications? How do you talk to your psychiatrist about side effects? How do you discuss overall treatment plans? So I think they can be an incredibly helpful resource in supporting patient medication adherence.

Dr. Turck:
Well we've certainly covered a lot of ground today. So just to bring this all together, Dr. Brown, how do all the strategies we've been discussing today—nurse-led programs, digital tools, and peer-to-peer connections—complement one another in supporting patient adherence?

Dr. Brown:
Yeah, as I mentioned, I don't think there's one approach to solve non-adherence, and I think these different approaches that we've talked about can be complementary to each other and different approaches may be used in different scenarios. For example, a patient with new-onset psychosis visiting the clinic with their family may be most suited and most amenable to meeting with a nurse for psychoeducation about medication and talking to the nurse about managing side effects and adherence strategies. Another individual who's been taking medications for a few years knows a bit more about antipsychotic medications, so they may benefit from the help of a chatbot to provide reminders to take the medication. Or they may find talking with a peer specialist and hearing from an individual with lived experience about the benefits and struggles with medications is the most helpful.

So I think the takeaway is really one has to be flexible; you have to think creatively about the tools that we have available to help ensure adherence.

Dr. Turck:
Well, given just how important it is to promote adherence in the service of preventing relapse in patients with schizophrenia, I want to thank my guest, Dr. Hannah Brown, for joining me to share these essential strategies. Dr. Brown, it was great having you on the program.

Dr. Brown:
Thank you so much for having me. I enjoyed it.

Announcer:
You’ve been listening to NeuroFrontiers, and this episode was sponsored by Bristol Myers Squibb. To access this and other episodes in our series, visit NeuroFrontiers on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!