Two Ways Med Adherence Curbs Hospital Visits in Schizophrenia

According to the National Institute of Mental Health (NIMH), schizophrenia, a mental disorder characterized by hallucinations, flat affect, and disordered thinking, is one of the top 15 leading causes of disability worldwide. One reason may be due to lack of medication adherence-some studies estimate that approximately 50% of those diagnosed with the disorder are not taking their medications as prescribed.

“It’s somewhat shocking that adherence rates are so low,” says Thomas J. Maestri, PharmD, clinical assistant professor of pharmacy at Xavier University. “Some patients don’t like the side effects of these medications. But others just have trouble, due to the nature of the disorder, remembering to take them. But adherence is important because we see, in study after study, that taking these medications helps keep people out of the hospital.”

Here are two ways that medication adherence helps to reduce hospital visits in patients who have been diagnosed with schizophrenia:

1. It reduces psychiatric hospitalizations. There are many reasons why a patient with schizophrenia may decide to stop taking his or her medications. Common reasons include the side effects so common to powerful antipsychotic medications as well as trouble remembering where, when, and how often to take what are often a complex cocktail of different drugs.  In some cases, patients may also think they no longer need their medications once their symptoms have stabilized.

“These are people who not only have disorganized thinking but also disorganized lives.  They have some pretty serious social determinants of health,” says Jennie Byrne, MD, a psychiatrist with CommuniCare North Carolina, an organization contracted by North Carolina Medicaid to improve care and reduce costs. “They often have poor housing, poor transportation, poor social support, and poor literacy. So to take these medications every day, without assistance, is very difficult.”

The result? A relapse in both positive and negative symptoms that may lead to psychosis, or a break with reality. Nonadherence can also lead to a significant loss of function and an inability to participate in activities of daily living. 

“This is a disease that has a pretty serious acute component,” says Maestri. “And when a patient doesn’t take their medications, there can be a need for psychiatric care. Patients are generally hospitalized for three reasons:  they are a harm to themselves, a harm to others, or they are deemed to be debilitated, or not performing at the level they normally function at.”
If any of these three cases occur, hospitalizations are generally required to stabilize the patient and help stop or reduce the disorder’s debilitating symptoms.

2. It reduces medical hospitalizations. Byrne says that her research into medical adherence in schizophrenia shows an interesting trend.

“We’re finding that a lot of the cost and poor utilization is being recording on the medical side of the house,” she says. “That means people are going to the ER with pain or other complaints for something that is considered medical, not psychiatric symptoms.  But we believe much of this is due to untreated or undertreated mental illness.”

Maestri says this isn’t a total surprise-patients with schizophrenia often also present with other health issues, particularly metabolic disorders.

“These patients have a high rate of diabetes, high cholesterol, and higher rates of obesity,” he says. “We’re not exactly sure why that’s the case but we see that patients can also be hospitalized for these other issues, as well.”

Given the symptoms of schizophrenia, as well as the social determinants of health, Byrne says it may be difficult for patients with this disorder to successfully manage other health conditions.

“Think of that patient with diabetes. Because of their mental illness, they probably aren’t able to do the preventative steps they need to do to manage their disease,” she says. “Now they ‘ve skipped a few days of their medication for schizophrenia, and they don’t take enough insulin or they take too much insulin for their diabetes, and it leads them right back to the emergency room.”

Both Maestri and Byrne say that understanding a patient’s reasons for nonadherence can help healthcare providers, as well as their overarching organizations, better facilitate compliance-whether through longer-acting injectables or other strategies. 

“We understand, more and more, that, when it comes to mental illness, it really is important to see and treat someone as a whole person,” she says. “If you can’t help them manage both the mental illness as well as any other medical conditions they may have, you will never get the kind of outcomes you’d like to get.”

Kayt Sukel is a science and health writer based outside Houston.