Schizophrenia and Mobile Phone Sms

SCHIZOPHRENIA AND MOBILE PHONE SMS

Background

Schizophrenia is common with a lifetime prevalence of between 0.4 per cent and 1.4 per cent (Cannon and Jones, 1996). In the U.K however, the prevalence of probable psychotic disorder in adults aged16 – 74 years was reported as 5 per 1000 adults by Singleton et al (2000).

Schizophrenia (and other psychotic illnesses)causesdisturbances in thought, emotion and behaviour with disordered thinking and affect, faulty perception and changes in motor activity (Davison & Neale, 2006). It is one of the 30 leading causes of disability world wide (Murray and Lopez, 1997) and carries anexcess mortality of approximately 50 per cent (above that of the general population) with much of this being attributable to a suicide rate of 10 percent (Brown, 1997).

The cost of this illness to society, the individual, their family and carers is high. Knapp et al (2002) estimated that 56.5 per cent of schizophrenia care occurs in hospital units with 14.7 percent occurring in day units and 2.5 per cent in outpatient clinics. Furthermore, 50 per cent of all admissions to psychiatric inpatient units are attributable to schizophrenia and sufferers spend an average of 130 days (median of 30 days) in hospital during their admission (Knapp et al, 2002).

The cumulative cost of care of individuals with schizophrenia is therefore high. Davies and Drummond (1994) estimated that schizophrenia accounted for 1.6 per cent of the total NHS care budget and Knapp (1997) reported that it accounted for 5.4 percent of the total NHS inpatient costs. The total burden of schizophrenia in England was estimated to be £2.6 billion in 1993 (Knapp, 1997) with Health and Social service costs alone amounting to £810 million (of which inpatient care costs amounted to over £652 million).

There are also personal costs for the sufferer not least the fact that with each relapse it becomes more difficult for the individual to reach their previous level of functioning. This may be responsible for the increase in unemployment reported following diagnosis. After the first episode of illness, 15 – 30 percent of service users are unemployed but by the second episode the unemployed figure rises to 65 per cent (Guest and Cookson, 1999).

Effective antipsychotic medication is available for the treatment of schizophrenia and is the primary treatment in both hospital and community settings. The NICE guidelines for schizophrenia (NICE, 2003) states that antipsychotic drugs are “an indispensable treatment plan for most people in the recovery phase” of the illness and prevents relapse, keeps the individual stable and “is necessary for psychological treatments to be effective”.

However, adherence with prescribed antipsychotic medication isnecessary for these benefits to be realised. However, adherence with antipsychotic medication is poorand it is estimated that up to 60% of community based patients become non-adherent and in some cases within 12 weeks of their discharge from hospital (Nose M, Barbui C, Gray et al, 2003; Pinikahana J, Happell B, Taylor M et al, 2002; Patel MX ad Davids AS, 2007).

Nevertheless, medication adherence rates in schizophrenia are similar to those for other chronic illnesses such as hypertension and diabetes mellitus (Haynes RB, Yao X, Degani A et al, 2005). Estimates of non adherence or non compliance in all clinical populations range from 0% to 100% but are typically approximately 50% (Haynes RB, Montague P, Oliver T, McKibbon KA et al, 2000). Medication reminders to help people adhere to multiple doses and different medications as well as refill their prescriptions have been quite beneficial (

Non adherenceto regular medication in schizophrenia (and other psychotic illnesses) is complex. In addition to a failure to remember or manage complex regimes, adherence is influenced by other factors such as insight into the illness and need for medication; poor therapeutic alliance; substance abuse; and supportive family or aftercare environment (Healey A, Knapp M, Astin J et al, 1998; Lacro JP, Dunn LB, Dolder CR et al; 2002). The influence of cognitive impairment is not clearly proven (Linden M, Godeman F, Gaebel W et al, 2001; Lacro JP, Dunn LB, Dolder CR et al; 2002).

Non adherence is the single most important predictor of relapse and readmission to hospital (Pool VE and Elder ST, 1986). Up to 3.5% of patients relapse per month whilst on maintenance medication whereas 11% relapse per month after discontinuing medication. In patients with first episode schizophrenia, relapse rates of 40 to 60% have been reported within the first two years following first admission to hospital (Ram, Bromet and Eaton, 1992). Robinson D, Woerner MG, Alvir JM et al (1999) reported a 3.5 times increase in relapse rate in non adherent people with psychosis (schizophrenia and schizoaffective disorder) and a several fold increase in the risk of death especially by suicide has been reported by Tiihonen J, Wahlbeck K, Lonnqvist J et al (2006) in a similar population.

Although no single factor can address the problem of poor adherence, community followseems to result in a reduction in relapse and therefore readmission. This has been achieved in a number of ways including psycho-social support and therapy from community clinicians, day hospitalsupport and outpatient clinic follow-up. These approaches integrate cognitive, behavioural and psycho-educational models of treatment that improve therapeutic alliance and compliance(Healey A, Knapp M, Astin J et al, 1998).

Toung Thi Phan (1995) compared the effectiveness of three interventions: structured community home visits; telephone contacts; and infrequent and unstructured CPN contact in improving adherence. They found that both structured home visits and structured telephone contacts resulted in improvements in medication adherence and therefore lower relapse rates.

Healey A, Knapp M, Astin T et al (1998) in a randomised controlled studyexamined the cost-effectiveness of compliance therapy compared tonon-specific counselling over a period of 18 months and found that compliance therapy is moreeffective (and no more expensive) than non- specific counselling at six, 12 and 18months.

Using a structured nursing telephone intervention, Beebe (2001) reported an increase in community length of stay and decrease in the number and length of re-hospitalisation episodes in people with schizophrenia.

Salzer et al (2002) using a telephone medication management system that cost $240 per participant, reported an improvement in insight and staff relationship without significant improvements in treatment adherence.

Although these studies which have used multidimensional interventions have shown some improvement in compliance, they did not assess the individual components of the interventions and as such it is not possible to determine if one part of the intervention is more important than another. Furthermore, the usefulness of simple reminders or prompts to keep appointments; adhere to prescribed medication or even make an appointment to see a mental health worker have not been specifically evaluated alone or in combination.

Improvements in attendance of first psychiatric outpatient clinic appointments was achieved by kitcheman J, Adams C, Pervaiz A, Kader et al (2007)using an 'orientation statement' letter delivered 24-48 hours before the first appointment compared with standard care.

With the rapid rise in the use of internet and mobile technologies (Crowley J, Davies A, Steadman P, 2001) these modalities have been used in the management of various clinical populations and diagnostic groups (Pal, 2003; Dyer, 2003; ANZHSN, 2007).

Mobile phone short message service (SMS) has been shown to be simple and safe to use andit is argued that additional hardware is often not required for its use in clinical practice (Hassinen M and Laitinen P, 2005). Mobile phone ownership and use is on the increase worldwide and it is estimated that the proportion of individuals of all ages who owned mobile phones in the UK was 74% in 2005/6 (Home Office Statistical Bulletin, 15 May 2007). SMS text messaging has a number of advantages over other communication modalities: it is cheaper and more efficient than sending a letter and less intrusive than a phone call. Furthermore, it is possible to send a large batch of messages at the same time and the high ownership makes the cost benefits enormous (ANZHSN, 2007).

Mobile phone SMS has been applied in various fields of medicine including public health, surgery, paediatrics and psychiatry and in chronic medical conditions such as asthma and diabetes to improve clinical outcomes for patients. In public health, its application resulted in the fast, cheap and efficient communication of information regarding the outbreak of communicable diseases in Iran (Safaie A, Mousavi SM, LaPorte RE et al, 2006);significant improvement in compliance with vaccination schedules amongst travellers (Vilella A, Bayas JM, Diaz MT et al, 2004); and in the recruitment and support of smoking cessation and abstinence over 6weeks in a young Maori group in New Zealand (Bramley D, Riddell T, Whittaker R et al, 2005).

In chronic medical conditions like asthma and diabetes mellitus SMS has been used to send reminders to improve medication adherence and to facilitate the collection of monitoring data such as sleep loss and peak flow measures in asthma (Anhoj J and Moldrup C, 2004) and blood sugar in diabetes (Ferrer-Roca O, Cardenas A, Diaz-Cardama A et al, 2004). It was particularly well received by adolescents and the elderly with diabetes in whom diabetic control is challenging. Furthermore, adolescents with diabetes mellitus and their parents found the receipt of educational information as pop-up SMS messages useful although some considered it intrusive (Wangberg SC, Arsand E, Anderson N, 2006).

The use of SMS reduced significantly the ‘failure to attend’ rates in five paediatric outpatient clinics in Australia to similar levels as traditional methods like telephoning and letters but with the additional benefit of ease of use and cheaper cost (Downer SR, Meara JG, Costa AC, 2005). However, its application in the community follow up of patients with Bulimia nervosa resulted in high attrition rates. The authors recommended further adaptations to the SMS tool to encourage its use in outpatient/community treatment (Robinson S, Perkins S, Bauer S et al, 2006).

Despite the range of use of mobile phone SMS in clinical practice, it has notbeenapplied yet to patients with chronic and enduring mental illnesses such as schizophrenia. In a survey of community mental health team patients in south London, Crowley J, Davis DA, Steadman P (2006) found that 65 – 73 percent of patients on enhanced and standard care respectively, own mobile telephones and up to 50 per cent were able to use SMS. Furthermore, over 60 percent thought that computers and mobile phones may be useful in improving services and would not mind the mental health trust using their numbers and email addresses to improve services for them.

We propose to explore the use of this technology in a psychiatric population of patients diagnosed with a ‘psychotic illness’ who have had at least one inpatient hospital admission and require at least an antipsychotic medication for up to one year following their discharge from hospital.

Our interest is in whether this technology is feasible in this patient population and would result in the following:

• reduction in readmission rates;
• user and carer satisfaction;
• Clinical Global Impression of symptom improvement and well being;
• reduction in failed appointments
• reduced use of crisis team and crisis appointments

The patient population for this study will be primarily those with a diagnosis of schizophrenia and schizoaffective disorder. However, others with other psychotic disorders such as acute and transient psychotic disorders, substance induced psychotic disorder and psychotic depression will also be included to establish whether similar benefits can be realised in this group.

Preliminary work

In a preliminary study we sought to establish mobile phone ownership and ability to use mobile phone SMS (i.e., can text) and willingness to use SMS to communicate with clinicians after discharge from hospital in a cohort of current in-patients in our acute psychiatric units.

The participants were 141 psychiatric inpatients from three units comprising of 8 acute wards and 1 Intensive Care Unit.All patients (n=179) were approached to take part in a structured questionnaire survey, designed to collect preliminary data about their willingness to take part in an SMS study. There were asked five important questions (appendix 1):

1. Can you read and understand English?
2. Do you have a mobile telephone?
3. Can you use the text messaging service?
4. Would you mind the hospital contacting you weekly on your mobile phone by text to see how you are doing?
5. Would you be prepared to text back to the hospital the answers to up to five questions every week?

Each patient was interviewed for a period of five minutes during which verbal consent was sought. Advice from the ethics committee revealed that written informed consent was not required as this is a survey. In total, 141 of the 174patients who were asked participated. The 33 who did not take part were either on home leave, too ill or simply refused to take part.

Results

Of the 141 that participated 99% could read and understand English, 87 (62%) have a mobile telephone, 87(62%) knew how to text and 86/141 (%)said they would not mind being contacted on discharge from hospital.

Of those who have a mobile phone (n = 87), 77 (88%) do not mind contact (n = 77).

Of 141 patients, 100 (100/141%) have a diagnosis of ‘psychosis’ consisting of schizophrenia, schizoaffective disorder, bipolar affective disorder and psychosis due to psychoactive substance use. 41 (41/100 %) had a non-psychotic diagnosis.

Table 1: Demographic Data

Social Demographics / Psychosis / Non-psychosis
Sex (n = 141)
Age:
Employment: / 65 males; 35 females
(18-69)
10 / 19 males; 22 females
(18-69)
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Table 2: Diagnosis and Mobile Phone Ownership

Have a mobile phone / Total
yes / no
Diagnosis / Psychosis group / 55 / 45 / 100
Non psychosis group / 32 / 9 / 41
Total / 87 / 54 / 141

Table 3: Diagnosis and know how to text

know how to text / Total
yes / no
Diagnosis / Psychosis group / 56 / 44 / 100
Non psychosis group / 31 / 10 / 41
Total / 87 / 54 / 141

Table 4: Diagnosis and do not mind contact

do not mind contact / Total
yes / no
Diagnosis / Psychosis group / 24 / 76 / 100
Non psychosis group / 4 / 37 / 41
Total / 28 / 113 / 141

Table 5:Diagnosis and willing to text back

willing to text back / Total
yes / no
Diagnosis / Psychosis group / 57 / 43 / 100
Non psychosis group / 29 / 12 / 41
Total / 86 / 55 / 141

Table 6: Duration of illness/ first contact with services (obtained from health records)

Diagnosis / 0-20 years / 21-50 years / Unknown/several
Schizophrenia
(n=58) / 21 / 9 / 28
Schizoaffective Disorder
(n=13) / 4 / 1 / 8
Bipolar affective disorder (n=20) / 5 / 4 / 11
Psychosis due to psychoactive substance use (n=9) / 4 / 0 / 5

Table 7: Number of previous admissions

Diagnosis / First admission (No previous admissions) / Up to 3 previous admissions / Up to 6 previous admissions / More than 6 previous admissions
Schizophrenia
(n=58) / 7 / 31 / 16 / 4
Schizoaffective Disorder
(n=13) / 2 / 6 / 2 / 3
Bipolar affective disorder (n=20) / 4 / 13 / 1 / 2
Psychosis due to psychoactive substance use
(n=9) / 2 / 4 / 2 / 1

Table 8: Number of admissions in the last 12 months compared to admissions over 12 months ago.

Diagnosis / Number admitted in the last 12 months / Number admitted over 12 months ago
Schizophrenia
(n=58) / 35 / 23
Schizoaffective Disorder
(n=13) / 9 / 4
Bipolar affective disorder (n=20) / 12 / 8
Psychosis due to psychoactive substance use (n=9) / 9 / 0

Summary of findings:55/100 (%) have a mobile telephone,56/100 (%) knew how to text and 76/100 (%)said they would not mind being contacted on discharge from hospital. Furthermore, 57/100 (%) said they would be willing to reply to SMS messages.

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