Overcoming Adherence Barriers in Schizophrenia: Strategies for Lasting Stability

Announcer:
You’re listening to NeuroFrontiers on ReachMD, and this episode is sponsored by Bristol Myers Squibb. Here’s your host, Dr. Charles Turck.

Dr. Turck: 
This is NeuroFrontiers on ReachMD, and I'm Dr. Charles Turck. Joining me today to discuss how we can help our patients with schizophrenia overcome adherence barriers are Drs. Tushita Mayanil and Melanie Yabs. Dr. Mayanil is an Assistant Professor of Psychiatry at the University of Pittsburgh. Dr. Mayanil, welcome to the program. 

Dr. Mayanil: 
Thank you very much, Charles.

Dr. Turck: 
And also coming to us from Pittsburgh is Dr. Yabs, who's a clinical psychiatric pharmacist at UPMC Western Psychiatric Hospital. Dr. Yabs, it's great to have you with us as well. 

Dr. Yabs: 
Thank you. Glad to be here. 

Dr. Turck: 
Well, to start us off, Dr. Mayanil, would you tell us why adherence remains such a persistent challenge for patients with schizophrenia, especially those on twice-daily oral antipsychotics? 

Dr. Mayanil: 
That’s such a fantastic question and something that we see in our daily clinical practice. The basic problem with adherence ties back to, firstly, insight into the illness. A lot of times, young people who come to us who have had a really horrible experience with the illness or the medical system have little to no insight into the devastating illness that has affected a lot of their life. Additionally, their interaction with the medical system and their beliefs about how the illness model works affects a lot of how they connect with the medical team and the psychiatric team.

The other big issue is cognitive issues. A lot of these young people, because of the illness or the medication itself, have significant cognitive issues that affect how they are remembering things or what they're doing during the day, and it affects their working memory and how they process information. In addition, once someone starts to look and feel better, they start to do things in their daily lives, such as work, sports, school, or college, and hence, twice a day administration is sometimes not possible or feasible, and this affects their adherence and increases risk of relapse. 

Dr. Turck: 
Now, if we continue to take a closer look at some of these challenges and stay with you for just another moment, Dr. Mayanil, side effects often lead to skipped doses, but switching therapies isn't always the right move. So what are some ways clinicians can help patients stay on an effective medication despite tolerability concerns? 

Dr. Mayanil: 
One of the biggest investments that we can do is proactively working with the families—investing a lot of time upfront with families and these young people and doing a lot of psychoeducation. That goes a long way in helping them understand what to expect. What is something that is easily mitigated? What is something that we probably should not live with in terms of side effects? And really digging down into side effects outside of just asking, “Is everything okay?” goes a long way. Unfortunately, our medications aren't perfect, so a lot of young people struggle with metabolic side effects and metabolic syndrome, which—per all guidelines from all major professional organizations—should be and need to be monitored very closely depending on other comorbidities that the person might have.

So some of the things that we can do proactively or as you're starting to work with these young people is making sure the doses are minimum-required doses and making sure that you are helping with ease of administration and helping them figure out what works with the twice-a-day dosing model that we have in place. Do we really need equal amounts of medication in the morning or bedtime, or can we spread it out so that they're not as tired or having significant side effects during the daytime?

Slower titration goes a long way. Of course, this depends on the clinical condition, but slow titration usually lets the physiological system get used to a certain kind of medication. Sometimes we do need to add anticholinergic medications. However, anticholinergic medications themselves have significant adverse effects in the form of different systems and concerns for a lot of cognitive issues because of the anticholinergic mechanism of action.

Dr. Turck: 
Turning to you now, Dr. Yabs, how does stigma, particularly among adolescents and young adults, affect adherence, and how might care teams help patients navigate that barrier? 

Dr. Yabs: 
Stigma certainly can be a deterrent to adherence. I've seen it many times with some of our patients. They feel like having these experiences or these psychotic symptoms put them in a place where they're very different from other people, and they feel like taking medication is just a reminder of that. Coming to get their injectable medication monthly is a reminder of that. So then to combat that, they get off of their medication. And so I think the first step is to reduce that stigma. We want to help them reframe their diagnosis or—if we don't have a diagnosis yet—their experiences.

I remember we had a psychologist that worked with us a few years back, and I loved the way that she framed these psychotic symptoms that her patients were having. She made it seem more relatable in that she was discussing how we've all felt like we've heard our mom or someone call our name, and then it turns out, oh, wait, no, we didn't actually hear that, or ‘I thought I felt my phone vibrate and I thought I heard a text come through, but I looked at my phone and there was no notification.’ And so it's these experiences that our patients are also having but just to another level, and so we make it more relatable and reframe their diagnosis. You don't want them to feel like it's a label. And often, we're not entirely sure what's going on early on in their disorder.

Dr. Turck: 
And if we focus on one last challenge, Dr. Yabs, for patients taking or planning to take twice-daily oral antipsychotics, how might we integrate that regimen into their daily lives, especially when their schedules are so unpredictable? 

Dr. Yabs: 
Yeah, that's a good question. I think it's important to look at their daily lives and their schedule and tie their medication administration times to daily habits or what's going on in their life. So if they're on a medication that's prescribed twice daily—morning and night—maybe they can keep their medication on their nightstand and take it when they wake up and when they go to sleep. Or if it's 3 times a day and they eat 3 meals a day, maybe they can keep it in the kitchen by the fridge and make sure that they take it with each meal. Or if they're at work, when are their work breaks, and does that work with how the medication is prescribed?

Everyone has different situations; some people might be bouncing from shelter to shelter or to mom's home and dad's home, and making sure that they have their medication with them is probably the easiest way for those with unpredictable living situations or housing instability. Another easy way to help keep people on track is—of course, most people have a cell phone these days—setting alarms and maintaining a pillbox. So there's all sorts of strategies, especially with twice-daily and three-times daily medications. 

Dr. Turck: 
For those just tuning in, you're listening to NeuroFrontiers on ReachMD. I'm Dr. Charles Turck, and I'm speaking with Drs. Tushita Mayanil and Melanie Yabs about strategies for improving adherence in patients with schizophrenia.

Now, I'd like to shift gears a bit and talk more about the care team. Dr. Yabs, what roles do pharmacists and case managers play in supporting long-term adherence? 

Dr. Yabs: 
So pharmacists can help by pinpointing nonadherence, especially in certain situations such as our long-acting injectable clinic where patients come either monthly or every few weeks for their medication injection. I report to the team anyone that has missed their injection appointment because then at that point, we know this patient is off of their medication. They still have some in their system, but we know how long that they may have been non-adherent. Whereas for patients that are taking medication orally at home, we don't always know adherence per se. We can always check with their pharmacies to see when they last picked up their medication, but that's not always a surefire way to know if patients are fully adherent. 

As far as helping support long-term adherence, I would say that pharmacists can be helpful with resolving medication access issues. Some of our patients may have insurance issues that are preventing them from being adherent or preventing them from obtaining their medication in the first place. So I often will fill out forms for insurance and make sure that they can get their medication in the first place. Helping with side effect management is also very important because one of the major reasons that patients will become non-adherent is due to side effects. So if you can help them manage their side effects, you can often help them remain adherent to the medication.

As far as case managers, we have some service coordinators in our clinic that use resources within our community to help patients get to their appointments and get their medications. So just figuring out those barriers and helping them overcome those barriers in order to get their medication. 

Dr. Turck: 
And as we wrap up, Dr. Mayanil, let's take a look at the big picture. When it comes to long-term stability, why is it so important to change our mindset from simply prescribing medication to embedding it in the patient's environment? 

Dr. Mayanil: 
One of the big things—the work that we have to do as teams and professionals—is to work with our team members and change the conversation with pharmacists and doctors and PAs and MPs from just being “medication managers” or “prescribers.” Reframe medication from helping us achieve “remission of psychotic symptoms” to tying it back to their goals: “This medication, when you take it the way that we had talked about in our appointment, it helps you feel more comfortable on the bus. And if you're more comfortable on the bus, you're more likely to go to school or go to college or participate in that social gathering that you have always wanted to and feel comfortable in a social situation.”

Sometimes, moving away from the clinical words of persecution—referential thoughts and hallucinations—and using patient-centric language goes a long way in helping us connect with these young people. Also, help people understand that we can be flexible with the dosing. This is really centered around how their life functions and not what we want them to do. So it’s really about targeting the flexibility in that piece, changing the conversation, and making the families and young people a part of this conversation.

Dr. Turck: 
Well, with those final comments in mind, I want to thank my guests, Drs. Tushita Mayanil and Melanie Yabs, for joining me to discuss practical approaches to overcoming adherence barriers in schizophrenia care. Dr. Mayanil, Dr. Yabs, it was great having you both on the program. 

Dr. Yabs: 
Thank you so much. 

Dr. Mayanil: 
Thank you very much.

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You’ve been listening to NeuroFrontiers, and this episode was sponsored by Bristol Myers Squibb. To access this and other episodes in our series, visit NeuroFrontiers on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!