Schizophrenia: Understanding the Impact of Adherence

John M. Kane, MD: I think in the management of any chronic illness, whether we’re talking about diabetes or hypertension or epilepsy or asthma—but particularly in an illness like schizophrenia—adherence to medication is extremely important because we know that these medicines are highly efficacious in preventing psychotic relapse. But in order for them to work, the patient has to take some on a continuous basis.

I think it’s hard for people to take medicine on a regular basis, regardless of what illness they have. I think it’s human nature to not want to take medicine. We have to recognize that. We have to, in my opinion, destigmatize nonadherence and not communicate to our patient that they’re a bad patient or a bad person because they didn’t take their medicine. We have to accept the fact that this is really human nature, and we have to find ways to help them get the benefit of the medication that we’ve prescribed and not blame them for that. We have to work together to say, “OK, let’s find a solution to this problem.”

We are big proponents of long-acting injectable antipsychotics because they can really help to reduce the challenge of taking medicine every day with pills. Even when I have to take medicine, I know that there are some days when I’m going to miss it or I’m going to forget if I took it or not. I’m very excited that we have more and more opportunities to use long-acting formulations because we have more and more choices. There are more and more such formulations available, so we should be able to find one that suits our given patient.

I think one of the challenges that we have with adherence is that we don’t know for sure whether our patients are getting their medicine when they’re taking oral medicine. We don’t know for sure whether they’re taking it or not. As a result, several things can happen. One is that they increase the risk of relapse, but another is that we can make erroneous clinical decisions because we don’t know exactly what’s happening. For example, I might have a patient who I think is not responding as well as I would like to the medicine, and as a result, I raise the dose or switch to a different drug when the fact is the patient hasn’t actually been taking the medicine.

Or the patient may decide, “I’m going to do without my medicine for the weekend, but then I’m going to take more on Monday because I feel a little bit anxious.” Or some patients may say, “I really want to smoke cannabis over the weekend, so I’m not going to take my medicine,” and then they start to suffer the consequences of exacerbation of psychosis due to drug abuse or what have you.

There are many situations where the oral medicine lends itself to problems in disease management because we don’t really know what’s going on. We did a study where we looked at patients who were brought to our emergency room, and we asked the physicians in the emergency room to make a judgment as to whether the patient had relapsed despite taking medicine or relapsed because they weren’t taking medicine, and it was very hard for the doctor to make that judgment. In addition, we did blood levels and we found that it was unpredictable. The clinical team had a hard time actually knowing whether or not the patient was taking medicine. Their judgment didn’t always agree with the blood level.

We need to figure out ways to monitor adherence, facilitate adherence, and reduce the risk of relapse. I think it’s an area where technology can come to our assistance. We now have long-acting formulations of antipsychotic drugs. There are digital medicines that are being approved by the FDA. There are technological ways to try to monitor medication taking. All of these are important, but it gets down to the clinical team really working with the patient to help him or her appreciate the need for medicine, finding a way to assure that they’re going to get the benefit of the medicine, and not blaming them if they have trouble taking it. It’s human nature.