Optimizing Management of Schizophrenia with Long-acting Injectables - Episode 3

Schizophrenia and Treatment Adherence

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Key opinion leaders comment on how to monitor and increase patient treatment adherence to prevent relapse.

Sanjai Rao, MD, DFAPA: Because we’ve gotten into the meat of adherence, I wonder if we can talk a little about what you’ve seen as being the factors that affect medication adherence in our patients. We talked a little about it, but maybe we can explore that a little more.

Kimberly Garcia, DNP, CRNP: The most important factor in adherence is adverse effects. The majority of my patients experience significant adverse effects to many of the psychotropic medications that we use. Also, there’s an overall burden of needing to be reminded sometimes 3 or 4 times a day that they’re living with a chronic illness. The fatigue that they experience after they take the medications. Things like dry mouth, not being as energetic or productive as they’d like to be, and those vegetative factors are held against them in many ways. Instead of recognizing that this could be a function of the medications, it’s really that they’re poorly motivated or even lazy. It helps to foster that stigma that comes with the disease.

Sanjai Rao, MD, DFAPA: I agree with all that. I would add that in addition to the adverse effects, is the medication working or not?

Kimberly Garcia, DNP, CRNP: Yes.

Sanjai Rao, MD, DFAPA: Do they find it effective or efficacious? We’re in a bit of a bind on that, right? Because for the medication to be effective, they have to take it.

Kimberly Garcia, DNP, CRNP: Absolutely.

Sanjai Rao, MD, DFAPA: And they have to take it consistently and at the dose you gave it to them. If there’s partial compliance, their perception may be, “I’m taking this medication, and it doesn’t seem to be doing much good.” It might help if they took it 7 days a week vs 3 or 4 days a week, but there’s a perceived lack of efficacy there, so that might be part of it as well.

Kimberly Garcia, DNP, CRNP: What do we do as providers? If a patient comes in and tells us, “My medication isn’t working,” we increase and increase. What’s going to happen when the patient finally starts taking the medications exactly as prescribed? They could be sedated. They could have other adverse effects. There’s no telling, but we can’t prepare for how they’re going to tolerate those doses when they’re not very consistent and very transparent with us as well.

Sanjai Rao, MD, DFAPA: Right. We make the assumption that it’s a failure of the medication taken properly.

Kimberly Garcia, DNP, CRNP: Yes.

Sanjai Rao, MD, DFAPA: In fact, the medication isn’t even getting into their system.

Kimberly Garcia, DNP, CRNP: Exactly, yes.

Sanjai Rao, MD, DFAPA: How do you address this? Maybe you’re working with patients and they say to you, “I take my medication 3 or 4 times a week.” As you said, they’ll proudly admit to 3 or 4 times a week. What do you do to try and squeeze the extra 2 or 3 days out of them?

Kimberly Garcia, DNP, CRNP: What I will typically do is try to normalize it. I’m a notoriously bad pill taker, so I’ll tell them, “I don’t take my acid reflux medication until I’m having a problem, and then it takes me twice as long to get my acid reflux under control.” They’re like, “I understand exactly where you’re coming from.” I try to normalize the fact that I’m almost expecting—I’m hoping it’s not the case—some issues with adherence. Then I’m looking at some practical things. Is there a particular time of the day when you typically will not take your medications? Am I giving medications multiple times in a day? Keep it as simple as possible. I’m a huge fan of if I’m going to have someone on oral medications. Once-a-day medications seem much more practical than something that’s 3 or 4 times a day.

Sanjai Rao, MD, DFAPA: I get to teach residents. I always tell them the nobody takes the afternoon dose.

Kimberly Garcia, DNP, CRNP: Yes.

Sanjai Rao, MD, DFAPA: If you give somebody a medication 3 times a day, you may get them to take the morning dose and the evening dose. But I guarantee you, they’re not taking that afternoon dose. No one carries their medications around with them so that they can take that afternoon dose in the middle of the day. So you probably shouldn’t bother, right?

Kimberly Garcia, DNP, CRNP: Exactly. That’s right. It’s funny because once we come to accept that our patients may have a chronic and very profound mental illness, the reality is that they’re people just like us. So of course I can understand that. I can tell you that I wouldn’t be adherent to a very complicated medication regimen, or if there were multiple tablets, or if I was experiencing a lot of adverse effects. Taking a very realistic approach is important. It opens that opportunity for patients. I’ve had patients say to me, “To be honest, I haven’t taken that medication in 5 or 6 months.”

Sanjai Rao, MD, DFAPA: I like asking health care providers, “Have you ever taken a course of antibiotics? Did you ever miss a dose? Why did you miss the dose?” Of course, people will say, “I felt better,” or “I forgot,” or “I didn’t have the pills with me.” I ask them, “When was the last time you heard a patient say that?” You rolled your eyes inside your head because you were thinking, “Don’t you realize you felt better because you took the medication?” It’s something you and I could just as easily screw up.

Kimberly Garcia, DNP, CRNP: Of course.

Sanjai Rao, MD, DFAPA: The only difference is that for us the consequences aren’t catastrophic because we’re probably OK. If you miss a single dose of antipsychotic medication, the consequences of that could be severe.

Kimberly Garcia, DNP, CRNP: Very significant. Agreed.

Transcript edited for clarity.