Access to credible information on schizophrenia patients’ medication adherence by prescribers can change their treatment strategies: evidence from an online survey of providers

Figures & data

Figure 1 Example of a case vignette and survey treatment options.

Figure 2 CONSORT diagram.

Table 1 Respondent demographic and practice characteristics

Characteristic	Experimentala (n=109)		Controlb (n=110)		χ^2
	Frequency	%	Frequency	%	P-valuec
Age (years)					0.457
20–29	2	1.8	2	1.8
30–39	53	48.6	54	49.1
40–49	27	24.8	21	19.1
50–59	12	11.0	21	19.1
60–69	12	11.0	7	6.4
70–79	3	2.8	4	3.6
Sex					0.545
Female	61	56.0	66	60.0
Race/ethnicity					0.772
White	68	62.4	65	59.1
Non-white	37	33.9	41	37.3
Prefer not to answer	4	3.7	4	3.6
Degree					0.407
Medical doctor	83	76.1	93	84.5
Nurse practitioner	14	12.8	9	8.2
Physician’s assistant	3	2.8	1	0.9
Doctor of osteopathic medicine	9	8.3	7	6.4
Practice experience (years)					0.906
<1	8	7.4	8	7.3
1–5	32	29.4	34	30.9
6–10	26	23.9	22	20.0
>10	42	38.5	46	41.8
Number of patients with schizophrenia provider is currently treating					0.829
1–4	11	10.1	7	6.4
5–10	16	14.7	15	13.6
11–20	20	18.3	25	22.7
21–50	28	25.7	28	25.5
>50	34	31.2	35	31.8
How provider determines adherence
Ask an informant	103	94.5	102	92.7	0.593
Ask the patient explicitly	98	89.9	105	95.5	0.115
Patient symptomatology	91	83.5	84	76.4	0.188
Drug plasma level	44	40.4	48	43.6	0.624
Contact pharmacy	49	45.0	43	39.1	0.379
Pill counting	32	29.4	33	30.0	0.917
Adherence assessment scale	7	6.4	8	7.3	0.803
Log book	5	4.6	6	5.5	0.769
Other	7	6.4	3	2.7	0.637

Notes:

a With patient drug adherence information.

b Without patient drug adherence information.

c P-values are from Pearson chi-square test of independence.

Figure 3 Effect of PDAI on treatment decisions for (A) nonadherent patients (results represent average from 3 vignettes), (B) adherent but poorly controlled patients (results represent average from 2 vignettes), and (C) adherent and well-controlled patients. The P-values were calculated based on a multinomial logistic regression performing pairwise comparison of each treatment decision pair across the 2 groups of respondents, adjusting for multiple comparisons using false discovery rate-adjustment.

Notes: **P<0.01. The bars without an asterisks are not statistically significant.
Abbreviations: PDAI, patient drug adherence information; LAI, long-acting injectable.

Table S1 Distribution of key patient characteristics in vignettes

Factors	Group	Patient vignette
		1	2	3	4	5	6	7	8
Adherence	Experimental	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes
information available	Control	No	No	No	No	No	No	No	Yes
Patient is adherent	Both groups	No	Yes	Yes	No	Yes	No	No	Yes
Age (years)		<40	<40	<40	<40	$40	≥40	≥40	≥40
Sex		Male	Male	Female	Female	Male	Male	Female	Female
Severity		Mild	Severe	Mild	Severe	Mild	Severe	Mild	Severe

Notes: Vignettes 1 and 8 represent the validation test where both arms received the same adherence information. Vignette 2 is an adherent, well controlled case. Vignettes 3 and 5 are adherent, poorly controlled cases. Vignettes 4, 6 and 7 represent non-adherent patients.

Table S2 Descriptions of clinical vignettes

Case name	Case number	Case description
Toby	1	Toby is a 28-year-old male with a 5-year history of schizophrenia. Toby began to have social withdrawal and isolation around age 20 when he dropped out of sports, went from being an excellent student to barely passing his classes, and began spending much of his free time alone watching YouTube videos. He was using alcohol, marijuana, and methamphetamines. He had progressively paranoid delusions to the point where his mother had him admitted to an inpatient psychiatric hospital at age 23. Toby’s first psychiatric admission lasted 4 days. He was diagnosed with paranoid schizophrenia and enrolled into an investigational study that prescribed risperidone (Risperdal) (4 mg/d). While he was taking risperidone, his hallucinations decreased somewhat but did not disappear. He had a good relationship with his treating outpatient physicians, who noted mild, persistent negative symptoms. Toby was readmitted to a psychiatric hospital for an episode of acute paranoid schizophrenia. He has been out of the hospital for one week and reports that he has not used drugs or alcohol since his hospitalization.
Jean	7	Jean is a 43-year-old female who has been taking clozapine (Clozaril) (300 mg/d) for 6 months. Jean was diagnosed with schizophrenia 15 years ago, but she’s never agreed with the diagnosis. She prefers to think of herself as someone who can hear voices and that this is a gift. The voices are only a problem when they become abusive and tell her what an ‘evil, spiteful witch’ she is. Prior to starting clozapine, she had tried ‘loads of different pills’ (including: olanzapine, quetiapine, and lurasidone), none of which had been effective at making the ‘voices nice again’. Jean does not know whether she wants to stick with the clozapine. She wonders if she might just be better off without it. Based on data from electronic pill cap monitors, Jean does not take her clozapine every day. Today’s blood plasma levels confirm this finding.
Robert	6	Robert is a 44-year-old male with a 17-year history of schizophrenia who has had multiple psychiatric admissions usually in the context of non-adherence. Admissions have been characterized by gradually increasing isolation, preoccupations, and insomnia. These symptoms escalate eventually to agitation, intense paranoid ideation with at times yelling at strangers and total neglect of his ADLs. Robert has been living in a group home with 8 other residents where he is responsible for taking his own medication. He usually does attend his monthly outpatient visits and also attends a club house. His medications were lurasidone (Latuda) (80 mg/d) and metformin [1,000 mg/d]. Over the past few weeks Robert has become increasingly unpredictable, responding to internal stimuli with bursts of uncontrollable laughing and swearing. He also believes the other group home members are out to get him. His psychiatrist called 911 to have Robert admitted to the inpatient services. After a 6 day intensive inpatient stay Robert re-stabilized on lurasidone (Latuda) (120 mg/d) and was discharged back to the group home. Two weeks after discharge, his psychiatrist reviewed Robert’s electronic cap monitor data and blood plasma levels and found that Robert had only taken half of the pills he was supposed to take and had low plasma levels.
Kay	4	Kay is a 34-year-old female with an 8-year history of schizo-affective disorder, with multiple depressive episodes that led to drug overdoses and three suicide attempts. She has received four courses of electroconvulsive therapy, the first of which she had at age 28, and has been prescribed multiple psychotropic medications, including antipsychotics and antidepressants at various time points. Her medications have included paroxetine, risperidone, lurasidone, and aripiprazole. She had been living with her grandmother until recently. After her grandmother’s death, she moved into a group home for patients with psychiatric illnesses. While she smokes two packs of cigarettes daily, she reports no alcohol consumption or use of illicit drugs. She is currently receiving a combined regimen of clozapine (Clozaril) [450 mg/d] and lithium (Eskalith) (900 mg/d), however, she is not doing any better than she has on previous medications. The group home supervisor reports Kay is showing signs of active psychosis including isolation and apparent responses to internal stimuli. Data from electronic pill cap monitors indicate she often goes multiple days without taking some or all of her medications and Kay’s clozapine blood plasma levels are a little low.
Samantha (Sam)	3	Samantha is a 28-year-old female with a 5-year history of schizophrenia. Samantha began to have social withdrawal and isolation around age 19 after completion of HS. However, she did attend the first year of an out-of-town college. She made a bad adjustment to the school. She went from being an excellent student to gradually having difficulties in her courses, staying away from classes and having difficulties sleeping. She was seen by the college campus psychiatrist who recommended return to her home town and attendance at a community college. However, she had progressively paranoid delusions to the point where her mother had her brought to a psychiatric emergency room. After being placed on risperidone (Risperdal) (4 mg/d) at the time of diagnosis, her paranoid ideation decreased somewhat, but did not disappear. Based on a recent electronic cap monitor data and blood plasma levels, her medication adherence has been consistent while she attends her outpatient visits and her paranoid delusions are under partial control.
Aaron	5	Aaron is a 40-year-old male with a 16-year history of schizophrenia and was admitted to the hospital three weeks ago for observation by an ER physician who had expressed concern about Aaron’s behavior. Aaron has been living in a group home with 8 other residents and was responsible for taking his own medication. He has had intermittent employment in lawn care around the city and seemed content with the work. Over the past few weeks Aaron had become increasingly unpredictable, responding to internal stimuli as well as cursing, tickling himself and laughing uncontrollably. A recent manic episode resulted in the visit to the ER. Aaron also believed that the other group home members were out to get him and that others questioned his sexual orientation. Based on electronic pill count monitors and his most recent blood plasma levels, Aaron takes his aripiprazole (Abilify) (20 mg/d) and risperidone (Risperdal) (8 mg/d) regularly and rarely misses a dose.
Adam	2	Adam is a 31-year-old male diagnosed with schizophrenia 7 years ago. During college, Adam began to hear voices that told him he was no good. Employed at a local supermarket, Adam began to believe that his boss was planting small video cameras to catch him making mistakes. Adam became increasingly agitated at work, particularly during busy times, and began “talking strangely” to customers. He lost his job at the local supermarket, and relationships with family members broke down as he feared that they would betray him to spies. He became increasingly confused and agitated. His parents took him to the hospital where he was admitted and administered haloperidol (Haldol) (5 mg, injected) by his psychiatrist. The medication caused painful twisting and contractions of his muscles. He was switched to olanzapine (Zyprexa) (10 mg/d) and has had fewer side effects. Based on data from electronic pill cap monitors, Adam seldom misses a dose of his olanzapine, and his blood plasma levels are as expected for his dose.
Margaret	8	Margaret is a 60-year-old female with a 27-year history of undifferentiated schizophrenia and has received multiple therapies over that time. In the most recent episode, last month, in which she was hospitalized, she presented with auditory hallucinations, disorganized speech, inappropriate affect with an occasionally euphoric mood, and grossly disorganized behavior and excitability. Impaired glucose tolerance due to adiposity and metabolic syndrome (weight 226 lbs., 5′1, BMI: 42.7) was observed and was treated with metformin (500 mg/d). While tapering off quetiapine, her doctor prescribed lurasidone (Latuda) (80 mg/d) and titrated up to a daily dosage of 120 mg within 30 days. No substantial improvement was achieved with this regimen within 30 days. Data from the electronic pill cap monitors and plasma level indicators support that Margaret is adherent to her medication.

Note: Adherence information is given in italics.

Abbreviations: ADLs, activities of daily living; HS, high school; ER, emergency room; BMI, body mass index.