Novel Text Messaging Program Boosts ADHD Treatment Adherence

An innovative text-messaging program that reminds patients with attention-deficit/hyperactivity disorder (ADHD) to take their medication and warns them about the hazards of noncompliance significantly increases treatment adherence in children and adults, new research suggests.

In one pediatric study, 85% of participants who received a text message had their prescriptions refilled in a timely manner, compared with 62% of those who received treatment as usual and no text messaging. In a second study of adults, 81% of the group that received a text message refilled their prescriptions, vs 36% of those in the usual-treatment group.

“Patients are not going to be fully compliant if they do not understand what the implications are if they do not take their pills,” lead author Joseph Biederman, MD, chief of Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD at the Massachusetts General Hospital and professor of psychiatry at Harvard Medical School, Boston, Massachusetts, told Medscape Medical News.

He noted that the text-messaging program also provides information, support, encouragement, and guidance.

“We remind them to get in touch with their prescriber as renewals come due, and if they tell us no, we tell them how important it is” to do so, Biederman said.

The findings were presented at the virtual American Society of Clinical Psychopharmacology (ASCP) 2021 Annual Meeting.

Poor Adherence

“Adherence to medications for ADHD is extremely poor, among the worst in medicine, despite the fact that ADHD is very morbid and we have excellent treatments people can take,” Biederman noted. “That’s the first tragedy, and it is totally unappreciated.”

He added that forgetfulness is a feature of ADHD. In addition, compliance can be difficult and cumbersome when patients require multiple prescriptions, he said.

Another contributor to medication nonadherence is the ongoing prejudice or stigma associated with ADHD, said Biederman.

“There is bad press about ADHD. There are no good comments, only disaster, doom and gloom, catastrophe, and so on. All people read in the available media are bad things about ADHD, and that only adds to stigma and misinformation,” he noted.

To combat these factors, Biederman and his team conducted two studies on the effectiveness of a novel ADHD-centric intervention based on text messaging.

One study included 87 children aged 6 to 12 years, and the other included 117 adults aged 18 to 55 years. Both groups were from primary care settings and were prescribed a stimulant medication for the treatment of ADHD.

As comparators, the researchers used age- and sex-matched pediatric patients and age-, race-, and sex-matched adult patients from the same primary care settings. They had also been prescribed stimulants but had not received the text messaging intervention.

Timely Reminders

Results showed that 85% of the children who received text messages refilled their prescriptions, vs 65% of those who did not get the intervention (odds ratio [OR], 3.46; 95% CI, 1.82 – 6.58; P < .001).

Among adults, 81% of the intervention group refilled their prescriptions, vs 36% of the comparator group (OR, 7.54; 95% CI, 4.46 –12.77; P < .001).

“In the number-needed-to-treat analysis, for every five pediatric patients who receive text messaging, we can keep one adherent with stimulant medication. In adults, that is 1 in every 3 who receive the text-messaging intervention,” Biederman said.

Text messaging reminds patients with ADHD to take their medications as prescribed, and it also reminds them of the consequences of not taking their medications, he added.

In another study presented at the ASCP meeting, Biederman introduced a new tool to help clinicians determine whether a patient with ADHD also has deficient emotional self-regulation (DESR).

ADHD has been associated with low frustration tolerance, impatience, and quickness to anger, he noted.

Emotional dysregulation, however, “is not a mood disorder,” said Biederman. “Some people use the term ‘hot tempered.’ These are people who overreact to things, and this is associated with a wide range of difficulties.”

Clinical Guidance

The investigators operationalized DESR using the eight-item Emotional Dysregulation (ED) subscale of the Barkley Current Behavior Scale. They then used receiver operating characteristic curves to identify the optimal cutoff on the Barkley ED Scale that would categorize patients as having high- vs low-level DESR.

“We wanted to give some guidance to clinicians, using a very simple rating scale that was developed by Dr Barkley. It is one we think configures this syndrome of emotional dysregulation and emotional impulsivity,” Biederman said.

The study included 441 newly referred 18- to 55-year-old men and women who met DSM-5 diagnostic criteria for ADHD.

Using a cutoff score of 8 to represent high levels of DESR, the researchers identified 191 adults as having high-level DESR and the rest as having low-level DESR.

Those with high-level DESR had significantly more severe symptoms of ADHD, executive dysfunction, autistic traits, levels of psychopathology, and worse quality of life compared with those with low-level DESR.

The problem of emotional dysregulation in ADHD is widespread and affects many people, Biederman noted.

“If you take 5% of adults at a minimum and 10% of children with ADHD [and] if 50% of those have emotional dysregulation, we’re talking about millions of people. And it is very morbid,” he said. “Having emotional dysregulation problems will get you in hot water.”

Promising Results

Commenting on the findings for Medscape Medical News, Ira D. Glick, MD, professor emeritus of psychiatry and behavioral sciences, Stanford University School of Medicine, Stanford, California, said the new studies are important.

He noted that although ADHD has become more accepted as a “disease of the brain” over the past 20 years, patients with the disorder and their families often are not accepting of the diagnosis.

“Instead, they try to downplay it. They say this is just a ploy by psychiatrists to get business or this is just normal boys’ behavior [and] they don’t need medicines,” said Glick, who was not involved in the current research.

“Biederman is trying to make clear that ADHD is a brain disease, and DESR symptoms are cardinal signs of a brain illness,” he said.

Glick also agreed that text messaging could be very useful for these patients.

“Text messaging might be helpful, especially in this population which can often be disorganized or forgetful. The results of that study were very promising,” he said.

Biederman is in the process of commercializing the text program used in the study. Glick reports no relevant financial relationships.

American Society of Clinical Psychopharmacology (ASCP) 2021 Annual Meeting: Abstracts W3 and W2, presented June 1, 2021.

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