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07. Technology-Facilitated Adherence Enhancement and Family Involvement

Published on June 1, 2021 Expired on April 1, 2024

Martha Sajatovic, M.D.

Professor of Psychiatry and of Neurology - Case Western Reserve University School of Medicine

Key Points

  • Clinicians can take advantage of technology to help with adherence supports.
  • Low-tech technology, like text messaging, is fast, simple, and works well for many individuals.
  • Simply monitoring adherence behavior is unlikely to have a long-term effect.
  • Apps can be useful for motivated individuals who feel comfortable using web-based tools.
  • Clinicians should try to understand the family members' attitudes.
  • Do not assume that the family will universally or uniformly support adherence promotion.

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Slides and Transcript

Slide 1 of 16

In section 7, we are going to briefly go through some technology-facilitated adherence enhancement data and family involvement evidence as well.
Technology-Facilitated Adherence Enhancement and Family Involvement Slide 1 of 16

Slide 2 of 16

So, technology-facilitated adherence enhancement is becoming more common. There are a variety of commercial supports out there and apps.
References:
  • Moore, D. J., Montoya, J. L., Blackstone, K., Rooney, A., Gouaux, B., Georges, S., Depp, C. A., Atkinson, J. H., & TMARC Group, T. (2013). Preliminary evidence for feasibility, use, and acceptability of individualized texting for adherence building for antiretroviral adherence and substance use assessment among HIV-infected methamphetamine users. AIDS Research and Treatment, 2013, 1-11. 
Technology-Facilitated Adherence Enhancement and Family Involvement Slide 2 of 16
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Slide 3 of 16

One study that was reported several years ago looked at technology-facilitated adherence enhancement in people with bipolar disorder and HIV. And it was a 30-day randomized controlled trial or RCT that compared two-way text messaging using something called the iTAB approach versus an active comparison to improve antiretroviral and psychotropic drug adherence. They found that the iTAB improved HIV drug adherence but not psychotropic medication.
References:
  • Moore, D. J., Montoya, J. L., Blackstone, K., Rooney, A., Gouaux, B., Georges, S., Depp, C. A., Atkinson, J. H., & TMARC Group, T. (2013). Preliminary evidence for feasibility, use, and acceptability of individualized texting for adherence building for antiretroviral adherence and substance use assessment among HIV-infected methamphetamine users. AIDS Research and Treatment, 2013, 1-11. 
Technology-Facilitated Adherence Enhancement and Family Involvement Slide 3 of 16

Slide 4 of 16

The text messaging was feasible and low burden so it’s kind of low-tech tech. We’re actually using this in some of our adherence research so this could be a way to communicate with patients that is readily available.
References:
  • Moore, D. J., Montoya, J. L., Blackstone, K., Rooney, A., Gouaux, B., Georges, S., Depp, C. A., Atkinson, J. H., & TMARC Group, T. (2013). Preliminary evidence for feasibility, use, and acceptability of individualized texting for adherence building for antiretroviral adherence and substance use assessment among HIV-infected methamphetamine users. AIDS Research and Treatment, 2013, 1-11. 
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Slide 5 of 16

Another study a four-week observational study at two US academic sites. Small sample, 12 patients with bipolar disorder, 16 with schizophrenia. They were all on stable oral medication. It used a wireless system to incorporate physiologic assessments and direct confirmation of digital tablet ingestion to track adherence.
References:
  • Kane, J. M., Perlis, R. H., DiCarlo, L. A., Au-Yeung, K., Duong, J., & Petrides, G. (2013). First experience with a wireless system incorporating physiologic assessments and direct confirmation of digital tablet ingestions in ambulatory patients with schizophrenia or bipolar disorder. The Journal of Clinical Psychiatry, 74(6), e533–e540.
Technology-Facilitated Adherence Enhancement and Family Involvement Slide 5 of 16

Slide 6 of 16

The system included digital health feedback system with an ingestion sensor embedded into the medications which is activated by stomach fluids after ingestion and the signal is communicated with a wearable torso sensor. So, the sensor facilitated tracking the date and time of drug ingestion and the wearable sensor tracked activity and heart rate.
References:
  • Kane, J. M., Perlis, R. H., DiCarlo, L. A., Au-Yeung, K., Duong, J., & Petrides, G. (2013). First experience with a wireless system incorporating physiologic assessments and direct confirmation of digital tablet ingestions in ambulatory patients with schizophrenia or bipolar disorder. The Journal of Clinical Psychiatry, 74(6), e533–e540.
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Slide 7 of 16

The system was well tolerated. It did not adversely impact psychiatric status. But I think what was worth noting here is that the adherence rate was still only approximately 75%. So, in spite of that, you know, multiple interventions, this may be something that would work best in, you know, selected groups of patients who are able to use this variety of components.
References:
  • Kane, J. M., Perlis, R. H., DiCarlo, L. A., Au-Yeung, K., Duong, J., & Petrides, G. (2013). First experience with a wireless system incorporating physiologic assessments and direct confirmation of digital tablet ingestions in ambulatory patients with schizophrenia or bipolar disorder. The Journal of Clinical Psychiatry, 74(6), e533–e540.
Technology-Facilitated Adherence Enhancement and Family Involvement Slide 7 of 16

Slide 8 of 16

Additional evidence in the literature on technology-facilitated adherence here specific to bipolar disorder is Colin Depp and colleagues piloted a mobile phone-delivered augmentation of a brief psychoeducation to improve self-management adherence and found that it was feasible and promising. Levin et al., piloted an electronic pill cap plus phone base so it was a text messaging system that assessed both adherence and delivered adherence promotion messages. So, it looked promising also.
References:
  • Depp, C. A., Ceglowski, J., Wang, V. C., Yaghouti, F., Mausbach, B. T., Thompson, W. K., & Granholm, E. L. (2015). Augmenting psychoeducation with a mobile intervention for bipolar disorder: A randomized controlled trial. Journal of Affective Disorders, 174, 23-30. 
  • Levin, J. B., Sajatovic, M., Rahman, M., Aebi, M. E., Tatsuoka, C., Depp, C., Cushman, C., Johnston, E., Cassidy, K. A., Blixen, C., Eskew, L., Klein, P. J., Fuentes-Casiano, E., & Moore, D. J. (2019). Outcomes of Psychoeducation and a text messaging adherence intervention among individuals with hypertension and bipolar disorder. Psychiatric Services, 70(7), 608-612.
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Slide 9 of 16

Wenze piloted a two-week ecological momentary intervention so that’s commonly used acronym of EMA to improve adherence. Patients completed twice daily assessments about symptoms and adherence risk factors as they went about their daily routines. So, they provided kind of frequent input. And the patients also received semi-customized automated feedback intended to neutralize risk factors such as forgetting or side effect concerns. Wenze and colleagues found that depression severity improved.
References:
  • Wenze, S. J., Armey, M. F., & Miller, I. W. (2014). Feasibility and acceptability of a mobile intervention to improve treatment adherence in bipolar disorder. Behavior Modification, 38(4), 497-515.
Technology-Facilitated Adherence Enhancement and Family Involvement Slide 9 of 16

Slide 10 of 16

I think that the take-home message that I’d like to make here is that simply monitoring medication taking is not enough. So, you saw that earlier with the MEMS data that I showed you. Choosing to use a technology such as an app needs to be something that the patient is motivated to engage with. This can be challenging for people with serious mental illnesses. Simple text messaging, you know, even though it’s pretty low tech can be something that people can engage with and use as evidenced by the studies of Depp and Levin.
References:
  • Depp, C. A., Ceglowski, J., Wang, V. C., Yaghouti, F., Mausbach, B. T., Thompson, W. K., & Granholm, E. L. (2015). Augmenting psychoeducation with a mobile intervention for bipolar disorder: A randomized controlled trial. Journal of Affective Disorders, 174, 23-30. 
  • Levin, J. B., Sajatovic, M., Rahman, M., Aebi, M. E., Tatsuoka, C., Depp, C., Cushman, C., Johnston, E., Cassidy, K. A., Blixen, C., Eskew, L., Klein, P. J., Fuentes-Casiano, E., & Moore, D. J. (2019). Outcomes of Psychoeducation and a text messaging adherence intervention among individuals with hypertension and bipolar disorder. Psychiatric Services, 70(7), 608-612.
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Slide 11 of 16

And then I want to talk a little bit about family involvement. So, research suggests that social supports can be helpful. We found that in our bipolar disorder research that 30% of people with bipolar disorder noted that either a family member or a significant other helps them to take their medication. However, we also found that 45% of family members or significant others including parents, children, spouses argued or advised the person against taking medication.
References:
  • Sajatovic, M., West, J. A., Cassidy, K. A., Meyer, W. J., Lamkin, N., Calabrese, J. R., & Jenkins, J. H. (2009). Subjective aspects of medication treatment and medication adherence among individuals with bipolar disorder. New Research in Mental Health, 18, 24-329.
Technology-Facilitated Adherence Enhancement and Family Involvement Slide 11 of 16

Slide 12 of 16

So, what’s the challenge for the clinician is don’t make the assumption that family members will be, you know, pro-adherence and they need to be assessed just like the patients to see whether they’re going to be somebody that’s going to help engage in care versus not.
References:
  • Sajatovic, M., West, J. A., Cassidy, K. A., Meyer, W. J., Lamkin, N., Calabrese, J. R., & Jenkins, J. H. (2009). Subjective aspects of medication treatment and medication adherence among individuals with bipolar disorder. New Research in Mental Health, 18, 24-329.
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Slide 13 of 16

The key points to this section are that clinicians can take advantage of technology to help with adherence supports. Low-tech technology like text messaging is fast, simple and works well for many individuals even those with cognitive challenges.
Technology-Facilitated Adherence Enhancement and Family Involvement Slide 13 of 16

Slide 14 of 16

Many clinical settings use texting for appointment reminders but they could also be used in other aspects of care. Simply monitoring adherence behavior is unlikely to have a long-term effect. So that Hawthorne effect usually becomes exhausted over time. People go about and do their thing and adherence reverts to what is normal for that person. Apps can be useful for motivated individuals who feel comfortable using web-based tools. They can be quite helpful for those who like this technology and there are a variety of apps out there and they can be used to manage health really fairly holistically.
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Slide 15 of 16

Family support can be helpful, but clinicians should take an effort to understand the family member attitudes. Do not assume that family will universally or uniformly support adherence promotion.
Technology-Facilitated Adherence Enhancement and Family Involvement Slide 15 of 16

Slide 16 of 16

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Next Section

08. Customized Adherence Enhancement

Earn credits for your learning!

No CMEs available

Certification expiration date: April 1, 2024

CME Information

Learning Objectives:

After completing this activity, the learner will be able to:

  1. Assess and identify the reasons for suboptimal adherence. 
  2. Use and combine different methods to assess treatment adherence. 
  3. Consider multiple approaches for enhancing drug adherence.

Original Release Date: 06/01/2021

Review Date: 03/01/2024

Expiration Date: 04/01/2024

Relevant Financial Disclosures:

The following planners, faculty, and reviewers have the following relevant financial relationships with commercial interests to disclose:

Dr. Sajatovic has disclosed the following relationships:

  • Nuromate, Otsuka, Alkermes, International Society for Bipolar Disorders (ISBD), National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC), Patient-Centered Outcomes Research Institute (PCORI): investigator on research grant
  • Alkermes, Otsuka, Janssen, Neurocrine, Bracket, Health Analytics, Frontline Medical Communications: consulting services
  • Springer Press, Johns Hopkins University Press, Oxford Press, UpToDate: manuscript preparation

All of the relevant financial relationships listed for these individuals have been mitigated.

Contact Information: For questions regarding the content or access to this activity, contact us at support@psychopharmacologyinstitute.com

Instructions for Participation and Credit:

Participants must complete the activity online during the valid credit period that is noted above.

Follow these steps to earn CME credit:

  1. View the required educational content provided on this course page.
  2. Complete the Post Activity Evaluation for providing the necessary feedback for continuing accreditation purposes and for the development of future activities. NOTE: Completing the Post Activity Evaluation after the quiz is required to receive the earned credit.
  3. Download your certificate.
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