Texting patients with schizophrenia and their lay health supporters in a resource-poor community setting is more effective than a free-medicine program alone in improving medication adherence and reducing relapses and re-hospitalizations, according to a study published April 23 in the open-access journal PLOS Medicine by Wenjie Gong of Central South University in Hunan, China, Dong (Roman) Xu of Sun Yat-sen University Global Health Institute, Guangdong, China and colleagues.
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Schizophrenia is a leading cause of disability and, in low- and-middle-income countries, the treatment gap remains high; even when treatment is available, adherence to antipsychotics is low. Mobile phone text messaging has been shown to be useful to strengthen community- and family-based care in resource-poor settings due to its availability, reliability, and ease of use. But there has been no clear evidence that texting improves treatment adherence, symptoms or functioning in people with schizophrenia. Gong and colleagues hypothesized that mobile phone texting could improve schizophrenia care in resource-poor community settings compared with a free-medicine, community-based program alone. To test this idea, the researchers developed an intervention called LEAN (Lay health supporters, Electronic platform with mobile texting for medication reminders, health education and monitoring, Award of token gifts for positive behavioral improvement, and integration into health systems).
In this randomized controlled trial, 278 community-dwelling villagers with schizophrenia in Hunan, China were randomized into two groups. Both groups received a nationwide community-based mental health program that provided free antipsychotic medications, and participants in the intervention group also received LEAN, which featured a lay health supporter and text messages for medication reminders, health education, monitoring of early signs of relapses, and facilitated linkage to primary health care. The results showed significant improvement in medication adherence with a mean of 0.48 in the control group, where 1 represents complete adherence in the past month, as compared with 0.61 in the intervention group at 6 months (adjusted mean difference 0.12 [95% CI 0.03–0.22, p=0.013]). This 27% relative improvement is larger than the 15–18% range reported for other text-message interventions. Moreover, there was an apparent reduction in the risk of relapse in 34.2% (40 of 117) control participants as compared with 21.7% (26 of 120) interventional participants, and a decrease in re-hospitalizations in 20.5% (25 of 122) controls as compared with 7.3% (9 of 123) interventional participants. According to the authors, texting was able to effectively address low medication adherence at marginal cost in rural China, and further research could investigate the LEAN program for potential benefits in people with schizophrenia in other low- and-middle-income countries with resource constraints.