The use of individually tailored environmental supports to improve medication adherence and outcomes in schizophrenia

Abstract

Cognitive adaptation training (CAT) is a psychosocial treatment that uses environmental supports such as signs, checklists, alarms, and the organization of belongings to cue and sequence adaptive behaviors in the home. Ninety-five outpatients with schizophrenia (structured clinical interview for diagnosis, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) were randomly assigned to (1) Full-CAT (CAT focused on many aspects of community adaptation including grooming, care of living quarters, leisure skills, social and role performance, and medication adherence), (2) Pharm-CAT (CAT focused only on medication and appointment adherence), or (3) treatment as usual (TAU). Treatment lasted for 9 months, and patients were followed for 6 months after the withdrawal of home visits. Medication adherence (assessed during unannounced, in-home pill counts) and functional outcomes were assessed at 3-month intervals. Results of mixed-effects regression models indicated that both CAT and Pharm-CAT treatments were superior to TAU for improving adherence to prescribed medication (P < .0001). Effects on medication adherence remained significant when home visits were withdrawn. Full-CAT treatment improved functional outcome relative to Pharm-CAT and TAU (P < .0001). However, differences for functional outcome across groups decreased following the withdrawal of home visits and were no longer statistically significant at the 6-month follow-up. Survival time to relapse or significant exacerbation was significantly longer in both CAT and Pharm-CAT in comparison to TAU (.004). Findings indicate that supports targeting medication adherence can improve and maintain this behavior. Comprehensive supports targeting multiple domains of functioning are necessary to improve functional outcomes. Maintenance of gains in functional outcome may require some form of continued intervention.

Fig. 1.

Subject Recruitment and Retention.

Fig. 2.

Adherence Derived From Unannounced Pill Counts in the Participants' Homes Over Time by Treatment Group. Main effect of group—F_2,138 = 23.51; P < .0001; visits by group (linear) —F_2,264 = 2.85; P < .06; visits by visits by group (quadratic)—F_2,251 = 3.46p P < .033). P values for cognitive adaptation training (CAT) vs standard were .04 at 3 months and .001 for all other time periods. For Pharm-CAT (CAT focused only on medication and appointment adherence) vs standard were .05 at 3 months and .002 for 15 months. All other time points had P values of .0001. No differences between CAT and Pharm-CAT (CAT focused only on medication and appointment adherence) were found at any time point.

Fig. 3.

Time to Relapse or Significant Exacerbation by Treatment Group. Proportional hazards regression model for time to relapse (χ₍₂₎² = 11.09; P < .004).

Fig. 4.

Social and Occupational Functioning Scale Score (SOFAS) Over Time by Treatment Group. Main effect of group—F_2,147 = 113.38; P < .0001; visits by group (linear)—F_2,202 = 4.85; P < .009; visits by visits by group (quadratic)—F_2,290 = 3.51; P < .032. P values for cognitive adaptation training (CAT) vs standard treatment were .0001 for all time periods but P < .07 for 15 months. P values for Pharm-CAT (CAT focused only on medication and appointment adherence) vs standard treatment were <.014 at 3 months, .043 at 6 months, and nonsignificant thereafter. P values for CAT vs Pharm-CAT were .004, .0001, .0001, .0004, and .37 for 3,6,9,12, and 15 months, respectively.