Could ‘Smart’ Pillbox Solve Medication Adherence Problem?

Writing a prescription takes only a stroke of the pen, but ensuring that patients take prescribed medications is a never-ending struggle.

“Putting cameras in pills is the only way to know if patients are actually taking their meds,” said Dawn Velligan, Ph.D., a professor of psychiatry at the University of Texas Health Science Center in San Antonio, at APA's Institute on Psychiatric Services (IPS) in New York in October.

For decades, studies have shown that adherence is particularly poor among those with persistent disorders, whether physical or psychiatric; where medications serve to prevent symptom onset or recurrence; or where stopping treatment causes no immediate negative consequences, said Velligan, one of several speakers who suggested new ways of improving adherence.

Practitioners sometimes wrongly assume that a good working relationship with a patient equates with medication compliance. “When you ask, clinicians all say ‘Adherence is a problem, but not with my patients,’ ” said Velligan. “But just because patients engage doesn't mean that they're taking their meds.”

Patients with schizophrenia may have considerable difficulty complying with medication regimens, said Velligan. Her research has found that less than 60 percent of medication doses were taken by one group of patients in the first 10 days after hospital discharge, and time is not on their side.

“As many as 75 percent of patients with schizophrenia or other serious mental illnesses become noncompliant within two years of hospital discharge,” she said. Patients may be deterred by adverse side effects, poor understanding of their illness, lack of insight, poor ability to comply, or system problems, she said. They may be confused, forgetful, or distracted. Some may not understand instructions or may be unable to establish daily routines that lead to taking their drugs.

One solution has been to develop compensatory strategies. External supports such as signs, checklists, alarms, or regularly straightening up personal belongings can help overcome cognitive deficits and remind patients when to take their medications. Velligan also published research in the May 2008 Schizophrenia Bulletin showing that intensive social and cognitive interventions, coupled with attention to medication and appointment adherence, can improve functioning, adherence, and time to relapse.

But such interventions don't work for all patients.

One new solution may be the “smart” pill container. The electronic device holds a one-week to one-month supply of pills, depending on pill size. A voice tells patients when to take the pill, alerts them if they take the wrong pill or take it at the wrong time, and can even ask if they have taken the pill.

The container can send data to the clinic where the patient is treated and e-mail alerts to providers, prompting a telephone call from the clinic to ask if the patient is taking the medication and, if not, why not, said Velligan. That contact can then lead to motivational interviewing and problem-solving by clinic staff.

Can a $1,500 pillbox do a better job than a team of psychiatrists, nurses, and social workers? Velligan will find out in five years when she completes a study, funded by the National Institute of Mental Health, of 150 patients. At the three-month mark, however, the electronic monitoring system recorded 99 percent adherence, compared with 95 percent for a study group receiving the combination of psychosocial interventions at home visits, and 70 percent for a group receiving treatment as usual.

A second approach shows what can be done within a huge, centrally directed health care organization like the Veterans Health Administration (VA), said Marcia Valenstein, M.D., M.S., an associate professor of psychiatry at the University of Michigan Medical School and a research scientist and staff physician at the Veterans Affairs Ann Arbor Health System, who spoke at the same session.

Valenstein and her colleagues have been looking at VA pharmacy data for clues to improving adherence and found that 40 percent of patients had less than 80 percent of the medications needed for outpatient treatment. That was just a statistical aggregate, however.

“Objective measures show we don't know which patients are taking their medication,” she said.

In response to these findings, the VA researchers designed a trial intervention to improve adherence that minimized complexity, coercion, and cost; did not add to the burdens of busy clinicians; decreased barriers to and costs of adherence; and provided cues to action by patients.

The key to their plan lay in simplifying the provision of medications to patients. They aligned all medication refills to the same day of the month. Pharmacy technicians then placed the pills in refillable, one-month packs divided into breakfast/lunch/dinner/bedtime sections for each day. The patients could pick up the packs at the VA or have them mailed to their homes.

This “unit-of-use” packaging is like a pillbox, but doesn't require patients to sort out drugs on their own and can serve as a reminder system as well. Each patient is assigned a pharmacy contact person to answer questions, and doctors are notified if a patient fails to pick up a refill pack.

Preliminary research among patients using unit-of-use packs has measured their adherence through prescription-refill monitoring, blood samples, and self-report. Patients found the approach generally acceptable, and it has improved adherence, but the system has not yet made a significant difference in reducing symptoms, said Valenstein.

Short of putting cameras in pills, adherence problems will continue to be complex, and clinicians will continue to mobilize a variety of psychosocial, technological, and system tools to help keep patients on their prescribed medications, the speakers agreed.