Enhancing Medication Adherence Among Patients With Schizophrenia and Schizoaffective Disorder: Mobile App Intervention Study

Abstract

Introduction

Technology has permeated every aspect of our existence and the mental health sector is not exempt from this.

Objectives

The aim of this study was to test the impact of using a mobile phone app (MyTherapy pill reminder and medication tracker) on medication adherence in patients with schizophrenia and/or schizoaffective disorder.

Methods

Time series design was used. Fifty-one participants were recruited from tertiary hospitals in Oman. The Medication Adherence Rating Scale was used for assessing medication adherence. The data related to medication adherence were collected at baseline, 3 months later and 3 months after installing the program on participants’ smartphones. SPSS data set used to analyze the data.

Results

A repeated-measures ANOVA found no significant change in the level of adherence among patients with schizophrenia and schizoaffective disorders at the start and 12 weeks later when the mobile app was installed (p = .371). However, adherence scores improved significantly 12 weeks after installation of mobile app compared with the same group at the baseline and 12 weeks before the installation of mobile app (p < .001).

Conclusion

The mobile phone app was effective in improving the adherence level among patients. Installation of the program and teaching patients how to use it to improve their level of adherence is recommended.

Keywords

adherence schizophrenia schizoaffective disorder Oman medication adherence

Introduction/Background

Twenty-one million people are diagnosed with schizophrenia globally (World Health Organization [WHO], 2018). Schizophrenia and schizoaffective disorder are chronic mental health conditions characterized by significant impairments in cognition, emotions, and overall functioning, and it is common for individuals with schizophrenia to undergo extended treatment with antipsychotic medication, which plays a crucial role in symptom control and relapse prevention (King et al., 2014). However, adherence to antipsychotic medication is a major challenge for patients with schizophrenia and schizoaffective disorder (Tarutani et al., 2016) as only 50% adhere to their antipsychotic medication (Al Qasem et al., 2011; Chaudhari et al., 2017). Previous research reported that medication nonadherence rates ranged from 25% to 80%, with an average of 40% to 50% across various studies (Basit et al., 2020). These highlight the need for interventions aimed at improving medication adherence among individuals with schizophrenia.

Review of Literature

Poor medication adherence is a common issue among schizophrenia patients, leading to poor clinical outcomes, including increased distress, relapse, rehospitalization, and increased rates of mortality and morbidity, as well as increased healthcare costs (Chan et al., 2021; Cristarella et al., 2022). Studies have shown that individuals who do not adhere to their prescribed medication regimens are more likely to experience psychotic episodes, worsening symptoms, and functional impairment (Llorca et al., 2018; Yang et al., 2021). Contrary to this, medication adherence decreases the odds of rehospitalization (Jiang & Ni, 2015) and improves patients’ physical health outcomes (Hayhurst et al., 2014), which reflects positively on patients’ quality of life.

Several predictors for nonadherence among people with schizophrenia have been identified, including a lack of insight into the illness (Chaudhari et al., 2017), medication side effects, stigma (Abdisa et al., 2020), and limited access to healthcare resources (Shuler, 2014). Additionally, complex dosing regimens (Ljungdalh, 2017), a lack of support from family and friends (Chaudhari et al., 2017), and negative beliefs about medication can also contribute to this issue (Eticha et al., 2015).

Many evidence-based approaches by researchers and clinicians are believed to improve patients’ medication adherence, including family psychoeducation (McFarlane, 2016), motivational interviewing (Barkhof et al., 2013), social skills training (Costa et al., 2015), tailored environmental support and weekly home visits (Velligan et al., 2013), web-based information (Van der Krieke et al., 2013), and computer apps (Treskes et al., 2018). Despite the potential benefits of psychosocial interventions, they are rarely implemented in clinical settings due to a scarcity of trained clinicians, inadequate funding and the failure of patients to take advantage of treatment options or to stay engaged (Drake et al., 2009).

With respect to the aforementioned limitations, using smartphone apps to deliver health interventions shows promise as a means of overcoming the current constraints of healthcare services (PEW Research Center, 2015). That is, smartphones are popular, people keep their smartphones with them all the time and they are connected to the internet, which makes them a practical and convenient way to deliver interventions in any location and at any time (Pennou et al., 2019). Despite their difficult circumstances, one study found that homeless people also use smartphones (Post et al., 2013). Furthermore, people with mental disorders use smartphones in the same way as their healthy counterparts. A study of 1,592 individuals with serious mental disorders revealed that mobile phone usage among this group is comparable with that of the general population (Ben-Zeev et al., 2013). Additionally, a significant number of individuals expressed interest in receiving mobile interventions, such as reminders, psychoeducation, and communication with clinicians, via their mobile device (Ben-Zeev et al., 2013).

The early use of smartphones in health interventions was through sending text messages (Granholm et al., 2012). However, the results were not always statistically significant (Granholm et al., 2012). In contrast to smartphones used in previous studies, current smartphones have greater capabilities and apps, which could enhance medication adherence. Furthermore, all prior studies have been carried out in developed nations, and it is necessary to assess such apps in developing nations, such as Oman.

Purpose of the Study

The aim of this study was to use a mobile phone app (MyTherapy—pill reminder and medication tracker) and test the impact of its use on medication adherence among adults with schizophrenia and schizoaffective disorders.

Methods

Design

Quasi-experimental design, particularly time series design, was used to evaluate the effect of a smartphone app on medication adherence among adults with schizophrenia (Figure 1). The time series design was specifically used to assess the adherence behavior of the sample accurately and clearly before and after using the mobile app. The memory biases of the patients were avoided by measuring adherence at specific intervals (Kaplan et al., 1995)—at the start, at 12 weeks when the mobile app was installed and 12 weeks after installation.

Figure 1.

Research design on the effect of using a mobile app on medication adherence among Omani patients with schizophrenia and schizoaffective disorder.

Research Question

What is the impact of using MyTherapy mobile phone app on the medication adherence among adults with schizophrenia and schizoaffective disorders?

Sample

A convenience sampling technique was used. Sample size was calculated using G*Power 3.1.9.7, and the statistical test employed was a repeated-measures ANOVA. A medium effect size of r = .25, a statistical power of 80% and a probability level of .05 were assumed for the calculation. The estimated sample size was 43 participants to be sufficient for this study. However, the sample size was increased to 51 participants (the experimental group acted as their own control group in this study) due to higher attrition rates among patients with schizophrenia, as reported in previous studies (Ainsworth et al., 2013; Ben-Zeev et al., 2014).

Inclusion/Exclusion Criteria

The inclusion criteria were (a) diagnosed with schizophrenia or schizoaffective disorder for a minimum period of 1 year; (b) visiting the outpatient clinics; (c) aged 18 years and older; (d) able to read and speak Arabic; (e) having a smartphone supporting Android apps; and (f) able to give informed consent. Participants were excluded if they had (a) any cognitive impairment based on the reports or initial screening; and (b) any visual or auditory impairment that prevented them from using the mobile app. A psychiatric nursing specialist with a master's degree in mental health nursing assessed participants’ eligibility.

Ethical Considerations

Ethical approval was obtained from the Sultan Qaboos University, Sultan Qaboos University Hospital and the Ministry of Health, all in Oman. Prior to data collection, participants were given an information sheet that explained data confidentiality and, that participants, had the right to withdraw from the study at any stage. The consent form was signed by the patients before participating in the study. No personal identification information was collected. All data were stored in encrypted files on a password-protected computer, and the surveys were kept in a locked cupboard. Overall, the researchers adhered to the Belmont principles.

Data Collection Procedures

After obtaining ethical permission for the study, a registered nurse who was familiar with the hospital setting and the data collection and entry process was recruited as a research assistant (RA). The RA was further trained by the researchers in the specific data collection procedure for this study and the use of the mobile app. The RA visited the outpatient departments of the setting and collected the list of patients visiting the outpatient departments for appointments.

The RA contacted potential patients and explained the purpose and procedure of the study, answered their queries (if there were any), and provided them with an information sheet and the consent form. Fifty-one patients were recruited in total, all of whom provided consent to participate in the study.

In the first visit, participants were asked to sign the consent form. The RA then arranged a meeting with the participants at a mutually convenient place and time, during which they were requested to complete the Medication Adherence Rating Scale (MARS) along with demographic sheet. To ensure confidentiality, each participant received a code number linked to their name, which was kept in a protected place. This helped the researchers to track the patients over the next two visits and assisted in conducting appropriate statistical tests.

Following the initial visit, patients continued their normal routine for a period of 12 weeks until the second visit. During the second visit, the RA then arranged a meeting with the participants at a mutually convenient place and time, during which they were requested to complete the MARS. In the same meeting, the RA installed the mobile phone app (MyTherapy), which served as a medication reminder for the participants, on their smartphones immediately after completing the MARS. The RA provided the participants with all the necessary information about the app and trained them on how to use it. Throughout the 12-week period, the participants were instructed to use the app as a tool to assist them in adhering to their medication regimen. The MyTherapy app provided features such as reminders to take medications at specific times, and dosage tracking. Participants were educated about the functionalities of the app and trained on how to utilize it effectively. The app was tailored to individual medication schedules, allowing participants to set reminders for each specific medication and dosage. Over the course of the 12 weeks, participants were encouraged to engage with the app regularly, record their medication intake, and utilize the reminder system to ensure timely and accurate medication adherence. At the end of the 12-week period, the participants’ usage of the MyTherapy app and their medication adherence were evaluated and assessed using the MARS for the final time. The researchers selected these periods because the follow-up visits and medication reassessment are usually scheduled every three months by the psychiatrist. Please see Figure 1 for more information

Description of the Mobile Health App

The researchers used a free, open-source app—MyTherapy pill and medication reminder. This app is developed by “smart patient.” This app is available in Arabic and English languages in the Google Play and App stores. The app is easy to use and reminds the patients of the time their medication is due. It also helps patients report when they forget their medication and reminds them that not taking medication on time is harmful to their health. Although no previous studies have used the same app, globally almost 200,000 users have used the app and rated it as 4.6 out of 5, making it one of the most highly rated apps on the market. Participants do not need to insert personal information to download and register with the app.

Instrument for Data Collection

The researchers used the MARS and completed a demographic form. The MARS was developed by Thompson et al. (2000) to assess adherence to medication among patients with mental illnesses. The main sample was patients diagnosed with schizophrenia. The scale was originally available in English language, and validity and reliability were established, with an internal reliability (Cronbach's alpha) of .75. The MARS was translated to Arabic and Cronbach's alpha was >.70 (Alsous et al., 2017). The MARS includes 10 items. The 10 questions could be answered as “No = 0” and “Yes = 1.” Adherence level is determined by summating scores of items ranging from 0 (poor adherence) to 10 (good adherence). A higher score indicates better adherence. Permission to use the survey was obtained from the originator of the tool. The demographic form consists of questions about gender, age, marital status, and employment status.

Statistical Analysis

The statistical package SPSS version 24.0 for Windows was used to analyze the data (IBM Corp, 2016). An initial exploratory analysis was conducted to identify any outliers or missing data. No outliers or missing information were identified. Means, standard deviation (SD), and frequency were used to describe demographics. Means, percentages, and SDs were used to describe the distribution over the stages of study (pretest I, pretest II, and posttest I). A repeated-measures ANOVA was used to determine the difference between the means over the stages of the study. A p-value of ≤.05 was considered statistically significant.

Results

Sample Characteristics

A total of 51 participants with schizophrenia or schizoaffective disorders completed the study. Participants’ mean age was 33.9 years, with a median of 35 and a range of 18 to 58 years. Two-thirds of the participants were unemployed (n = 33), while 35.3% were employed (n = 18). More than half the participants were male (n = 28), while 45.1% were female (n = 23). Almost half the participants were single (n = 26), 94.1% lived with family (n = 48), 78.4% of the sample reported taking medication alone (n = 40), and 41.2% had secondary education (n = 21). For more details see Table 1.

Table 1.

Sample Characteristics.

Variable		n	%	M	SD
Age				33.9	9.3
Occupation
	Unemployed	33	64.7
	Employed	18	35.3
Gender
	Female	23	45.1
	Male	28	54.9
Marital status
	Single	26	51.0
	Married	25	49.0
Living status
	Living with the family	48	94.1
	Living alone	3	5.9
Support for medication
	Support available	11	21.6
	Taking alone	40	78.4
Level of education
	Illiterate	1	2.0
	Primary	9	17.6
	Secondary	21	41.2
	BSc	20	39.2

Research Question Results

A one-way repeated-measures ANOVA was performed to evaluate the impact of the smartphone app on the level of adherence before and after installation of the app among patients with schizophrenia and/or schizoaffective disorders. Mauchly's test of sphericity revealed that the assumption of a spherical shape was not upheld X² (2) = 7.932, p < .01. Therefore, degrees of freedom were corrected using the Huynh–Feldt estimate of sphericity (.875). There was a statistically significant difference in the level of adherence between at least two groups p < .01.

Three paired-sample t tests were used to make post hoc comparisons between pretest I, pretest II, and posttest I. Post hoc pairwise comparisons were then conducted. The first paired-sample t test between pretest I and pretest II found no significant difference in average adherence at the baseline (M = 5.1, SD = 1.5) and 12 weeks later (M = 4.9, SD = 1.3; t [45] = .904, p = .37). A second paired-sample t test between pretest I and posttest I of the mobile phone app found a significant difference in average adherence from pretest II (M = 5.3, SD = 1.5) to posttest I (M = 6.45, SD = 1.6; t [39] = 7.98, p < .01). A third paired-sample t test found a significant difference in average adherence between pretest II (M = 5.0, SD = 1.3) and posttest I (M = 6.4, SD = 1.6; t [39] = 6.8, p < .01). For further details see Table 2 and Figure 2.

Figure 2.

Changes in the adherence scores before, 12 weeks after and postintervention.

Table 2.

Change in Adherence Among Participants.

		Obs.	Mean	Std. Dev.	ANOVA
		Obs.	Mean	Std. Dev.	t	Df	p-Value
Pair 1	Pretest I	46	5.1	1.5	.90	45	.371
Pair 1	Pretest II	46	4.9	1.3	.90	45	.371
Pair 2	Pretest I	40	5.3	1.5	7.98	39	<.01
Pair 2	Posttest I	40	6.4	1.6	7.98	39	<.01
Pair 3	Pretest II	40	5.0	1.3	6.79	39	<.01
Pair 3	Posttest I	40	6.4	1.6	6.79	39	<.01

Discussion

The aim of the study was to evaluate the impact of mobile phone app usage on medication adherence among patients with schizophrenia and schizoaffective disorders. Results showed that the average adherence score increased significantly after installation of the mobile phone app on the participants’ smartphones. This supports results from another study, which identified the acceptability and usability of the mobile app among schizophrenia patients (Kreyenbuhl et al., 2019). The aim of Kreyenbuhl et al. (2019) was to assess the effectiveness of the MedActive smart phone app on the adherence to antipsychotic medication duration over 2 weeks. Participants rated the MedActive to be highly acceptable and practical, and they expressed positive feedback and satisfaction with their experience using the app. This is in line with a recent review conducted on 28 studies by Simões de Almeida and Marques (2023), which conclude that mobile app effectively enhances adherence to medication among patients with mental illnesses. This suggests that mobile apps may be an effective strategy to tackle many of the issues of chronic mental illnesses. Our findings are also in alignment with the results of another study used MONEO platform to improve the adherence and clinical condition of patients with schizophrenia (Krzystanek et al., 2019). The study found a significant improvement in medication adherence, accompanied by a significant reduction in schizophrenic symptoms among the participating patients (Krzystanek et al., 2019). Overall, mobile technology has become more sophisticated and user-friendly, and it is now the responsibility of mental healthcare teams to promote its use to maximize the benefits for the success of treatment on a regular basis.

The results of this study are in contrast with the results of a Canadian study on a schizophrenia-focused mobile app—App4Independence (A4i)—that revealed small–medium improvements in certain psychiatric symptoms, but no significant changes in recovery engagement or medication (Kidd et al., 2019). In the study, while participants expressed satisfaction with the use of the app, those who interacted with the app more frequently were found to have higher levels of depression, hostility, and interpersonal sensitivity at baseline (Kidd et al., 2019). This focuses our attention on the previous researchers, who were skeptical about the excessive “digital engagement” of the patients (Ben-Zeev et al., 2019). At the same time, many studies have supported the use of mobile apps in managing schizophrenia patients (Hilty et al., 2018; Stubbe, 2020).

As the world moves towards digitalization and embraces technology, we must explore the possibilities that can benefit patients. Schizophrenia patients are in great need of rehabilitation and independent living that enhances their reintegration back into the community. Mobile technology paves the way for self-monitoring of adherence and the improvement of symptoms, which, in turn, enhances self-confidence and satisfaction. Sound clinical trials are needed to test the growing body of research into digital health approaches for severe mental illness populations, especially for patients diagnosed with schizophrenia.

These study results contradict those of a randomized controlled trial in which the effect of weekly telephone intervention on self-reported medication adherence, self-efficacy, and symptom levels was investigated in 140 stable outpatients with serious persistent mental illness (Beebe et al., 2016). Although the experimental group had fewer symptoms and higher self-reported medication adherence in the immediate results compared with the control group, the differences were not statistically significant, which means that the observed effects could have been due to chance. Additionally, medication adherence and self-efficacy were unchanged over the 3-month follow-up period. This confirmed that the telephone intervention did not have a significant effect on participants’ confidence in their ability to adhere to their medication regimen (Beebe et al., 2016). However, the difference between these interventions should be noted, and further rigorous, multicentric studies should be carried out to examine the effect of mobile apps on chronic mental disorders to establish generalizability.

There is a dearth of methodologically sound studies testing the effect of mobile apps directly on patients with schizophrenia in the Middle East. This could be due to the feasibility of conducting such studies among these populations itself. Mental health professionals should be encouraged to use mobile technology to enhance autonomy and treatment adherence, with the aim of better therapeutic outcomes. Further studies in the field should also be carried out to enable evidence-based practice with the use of mobile technology in the management of schizophrenia patients.

Strengths and Limitations

With respect to the significant results, this study was limited to self-report data, which may have impacted on the results as some patients might have deliberately tried to show that they adhered to their medication. Furthermore, the potential for confounding variables to influence the observed changes in the study could also be considered a limitation as there was no control group involved in the study. For example, changes in the dependent variable may be due to other factors such as changes in the environment, rather than the independent variable of interest. The study could not afford to have a control group; thus, the research results may not be generalized in other settings and require further testing to establish the same.

Implications for Practice

As the first study testing the usage of mobile apps among patients diagnosed with schizophrenia or schizoaffective disorder in Oman, this research significantly contributes to the field of clinical practice, administration, and research. The findings of this study will increase the awareness of government and healthcare providers of the significance of smartphone apps for enhancing medication adherence among patients with schizophrenia or schizoaffective disorder.

The findings suggest that using mobile apps can be an effective tool for improving medication adherence among Omani patients with schizophrenia and schizoaffective disorder. Healthcare providers should consider incorporating mobile apps into their treatment plans for patients with schizophrenia as a means of enhancing medication adherence, improving clinical outcomes, and reducing healthcare costs. There is a real dearth of studies at national and international levels that have tested the Mobile apps among patients with Schizophrenia or Schizoaffective disorder, hence we recommend more methodologically sound, multicenter randomized clinical trials for testing the effect of mobile app on adherence. Future research should examine the impact of mobile apps on medication adherence among different populations and across different cultural and socioeconomic contexts.

Conclusions

The use of mobile apps has the potential to improve medication adherence among Omani adults with schizophrenia and/or schizoaffective disorders. However, larger, and more comprehensive studies are needed to fully understand the impact of mobile apps on medication adherence.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Sultan Qaboos University.

ORCID iDs

Khloud Al Dameery

Abdullah Alkhawaldeh

Omar Al Omari

Mohammed ALBashtawy

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