Treatment Nonadherence and Schizophrenia Relapses

Transcript: Dawn I. Velligan, PhD: Closely monitoring patients is important. I have no idea how an outpatient provider who sees a person who is not doing well with schizophrenia decides what to do. Do you add something? Do you switch it? Do you change the dose? Without information on whether that person is taking the medicine, as you prescribed it, you don't have a clue about what to do. It’s difficult to tell if someone's taking their medicine. We did studies where we went to people's homes and counted their pills, right in front of them, and they would all say on a scale from 1-5, 5 being 100% of their medicine, they circled the 5. They could see we were counting their pills, and they intend to take their medication, but sometimes it doesn't work out.

There are a lot of reasons why people don't take medication. One group will tell you, “I'm not taking any of that stuff,” and they need an intervention. Another group is taking some of the medicine, some of the time. The issue is how they choose to take what, when. They may develop ideas about [side] effects. I've had people tell me that, “Oh that medicine makes my knees hurt.” And it turns out they started walking more or running because they felt better, and it isn't the medicine that is causing the problems. So perceived [adverse] effects can be one reason.

Also, I have people who are willing to take medication, they just aren't good at it. They tell me things like, “Oh, Dr Velligan, I know I'm supposed to take medication every night, but it's all the way over in the kitchen and I was already in bed, and so I missed that dose.” Or they'll tell me that they think they're taking it, and I come at the end of the week, and there are a bunch of days where their medicine is still in the pill container. They’re not realizing, they may be intending to take it, but they become distracted, they’re on their way to the kitchen to get their medicine and the phone rings. Or they see their dog and it distracts them, and they think they’ve taken it, but they haven’t. When we go to people’s houses, we find bottles and bottles of unused medication. I think it was [R. Brian] Haynes, [MD, PhD,] who said, and the World Health Organization recently quoted him as saying that if we could improve medication adherence, that would probably be better than almost any advancement in medication that we could come up with. It's a really big deal.

Research shows there are many ways to see if people are taking their medication. We have pill containers that record when the drawer is open and ask them, “Did you take it just now?” We can count their pills; we can draw their blood. But none of the methods tell us how much medicine got into the person. With a long-acting injection, we find that if people don't show up for their visit, treatment nonadherence just started. We’re able to address that immediately. If people don't come for their shot, we know for sure that they didn't take their medicine.

We don't have a good way to find out if people are taking their medicine on a daily basis in a clinical practice. It’s a lot of guesswork. We go to people's homes and count pills. You’d think this would be easy, right? You count 1, 2, 3, or you count by 2s, it goes twice as fast, and you think that would be a really easy procedure. But we go and new bottles show up, and bottles disappear, and people are taking out of multiple bottles. We don't know how much nonadherence is out there. And if we think about ourselves, I really don't think any of us take every dose of medication that we're prescribed.

We all have 2 or 3 antibiotics left over in the bottle after we've been taking them for an infection, and we feel better so we forget. It is very difficult to know if people are taking it. But it is so important to make sure that people are getting consistent medication. It’s a risk to give people pills and expect them to do what we say.

Henry A. Nasrallah, MD: When I see a patient with schizophrenia for the first time, I immediately assume that this patient is not going to adhere. Nonadherence is so prevalent, so ubiquitous, in this serious brain disorder, and for multiple reasons, that you have to be vigilant about it. And not only talk about it with the patient, but also you have to resort to some objective measures of whether they're taking it or not. Not just pill counting in the bottle. We tell the patients to bring the bottle every time, but also maybe measure serum prolactin to make sure they are taking it.

But the reason they don't adhere is well known to us. There is lack of insight; the patient doesn't believe they're sick, they don't believe they need the medication. That's a huge challenge. They also have cognitive difficulties, which you're an expert at, as a neuropsychologist. They have severe memory difficulty, one of the highlights of patients with schizophrenia. They forget more than a non-schizophrenic person. They have negative symptoms, which include apathy, amotivation, avolition, the inability to initiate an action. Then there is substance use; 70% of my patients are taking substances, because I do urine screens for research purposes, and I lose 7 out of 10 patients because I can’t put them in a study. Somebody who is drunk or stoned will probably not take their prescription medication.

When you put them altogether, it is a recipe for disaster. This is why so many of our patients relapse so often. According to studies published a few years ago where they measured the blood level with every visit after discharge from the hospital, they found that at the end of the year all it takes is a drop of 25% [in adherence] and they relapse. This suggests how brittle and fragile our patients are with schizophrenia. Ensuring 100% oral adherence is almost impossible, in a majority of the patients.

Dawn I. Velligan, PhD: When you don't work every day or get up at the same time and take a shower and brush your teeth, you do not have any habits, to remember to take your medication. It's like being on vacation. You don't remember to take your medication as easily as you do when you have a regular routine. Many of our patients with schizophrenia don't have a regular routine, so they can't remember to tie medication to anything they do every single day. So it is really a risk.

Transcript Edited for Clarity