Can Smartphone Apps Assist People with Serious Mental Illness in Taking Medications as Prescribed?

INTRODUCTION

Medication nonadherence is common among adults with serious mental illness (SMI), with rates of nonadherence estimated to be at least 40% to 50%.^1–3 SMI is defined by a psychiatric diagnosis of schizophrenia spectrum disorders, bipolar disorder, or persistent major depressive disorder. In an effort to promote recovery language consistent with the mental health movement that originated as a medical model and now focuses on a recovery model of mental health, medication adherence henceforth is referred to as taking medication as prescribed. Not taking medication as prescribed is associated with increased risks of hospitalizations and relapse and increased severity of symptoms among people with SMI.^4–6 Reasons for not taking medication as prescribed vary and commonly include forgetting to take medications, poor insight into illness and the need to take medications, negative attitudes toward medications, and negative side effects from medications.^6–8

Advances in technology, specifically mobile technology, provide a unique and potentially advantageous avenue for promoting taking medications as prescribed among vulnerable populations, including people with SMI. It is estimated that approximately 77% of US adults own a smartphone.⁹ Although national rates of smartphone ownership among adults with SMI currently is not known, some reports suggest rates of ownership between 66% and 72%.^10,11 Previously, researchers expressed concern over the disparities in smartphone ownership among the SMI population due to socioeconomic factors and high rates of unemployment; however, a recent meta-analysis indicates an increasing trend in smartphone ownership among this population.¹¹ Developing and implementing mental health smartphone applications (apps) may serve to increase taking medication as prescribed as well as monitoring symptoms and functioning. This article reviews some of the smartphone apps designed for people with SMI that have functionality pertaining to taking medication as prescribed and compares with and contrasts against those available for sleep apnea.

SMARTPHONE APPLICATIONS

Few smartphone apps were designed to specifically address taking medication as prescribed among adults with SMI.^12–14 Most apps commonly included monitoring of medication adherence as a secondary feature^15–22 or utilized psychosocial interventions to provide information and strategies to enhance taking medication as prescribed while not measuring adherence directly.^23–25

Smartphone Applications with Medication Adherence as Primary Feature

Wenze and colleagues^12,26 developed the smartphone app MyTreatment (MyT) to improve taking medication as prescribed among adults with bipolar disorder. MyT incorporates psychoeducation components and cognitive behavior therapy (CBT) elements. MyT alerts users twice daily to enter the app and complete the available surveys. During the morning, users are asked which medications they need to take that day and if they have any appointments. During the evening, users are asked if their medication was taken and if they attended their appointments. Both sessions assess for symptoms and potential risk factors for not taking medication as prescribed (eg, concern over medication side effects and need to engage in treatment). A small pilot study (N = 8) over 3 months deemed MyT feasible and found a decrease in missed medication doses by 22% and a decrease in missed appointments by 71%.¹² Additional research is needed to examine the full efficacy of the app on taking medication as prescribed.

MedActive is a smartphone app designed specifically to increase taking antipsychotic medication as prescribed among adults with schizophrenia.¹³ Users designate a scheduled time in which they typically take their medications. Five minutes prior to the scheduled dose, MedActive notifies users with a personalized auditory and visual alert. Five minutes after the scheduled dose, MedActive asks people whether or not they took their medication. If medication is reported as not taken, participants are asked why. Additionally, if medication is not taken due to side effects, people are given the option to send an automated message to their psychiatrist. In a 2-week open trial,¹³ MedActive was deemed feasible and acceptable. Participants (N = 7) reported taking their medication 100% of the time and a majority agreed that MedActive made it easier to talk to their psychiatrists about their medication. Due to the short time frame of the study, however, the results are limited and future research is needed to examine outcomes during a longer duration of MedActive use.

MedLink was designed to improve taking antidepressant medications as prescribed among adults with major depressive disorder.¹⁴ MedLink utilizes Wisepill, an electronic pill dispenser that sends wireless signals to the MedLink app, indicating that the pill bottle has been opened. MedLink users enter their daily scheduled time for medication; if a signal from Wisepill is not received within 10 minutes of that time, MedLink sends a smartphone alert asking users if they have taken their medication. This alert stays on the smartphone screen until the user responds or actively declines. If users state that the medication has not been taken, MedLink follows-up, asking users if they are planning on taking their medication. In addition to daily reminders, MedLink provides weekly brief lessons on antidepressants, strategies for taking medication as prescribed, and general self-management techniques. In a small pilot study (N = 11),¹⁴ users experienced some technical difficulties, in particular connectivity problems, between Wisepill and MedLink. Despite this, users generally favored MedLink, and taking medication as prescribed was shown to be 82%, although it is not known how this compares to not using the app.

Smartphone Apps with Medication Adherence as Secondary Feature

MONARCA (I and II), developed by Faurholt-Jepsen and colleagues,^15,16 is a smartphone-based self-monitoring (SM) system designed for people with bipolar disorder. Participants receive smartphone notifications at a self-chosen time of day to evaluate mood and emotional states, functioning, behaviors, activity levels, individualized early warning signs, and use of medications. In 2 randomized controlled trials of MONARCA I (N = 78) and MONARCA II (N = 129), using a single-blind, parallel-group design, participants randomized to use MONARCA did not show significantly different levels of taking medication as prescribed at follow-up compared with control groups (lithium: P = .49, n = 64; lamotrigine: P = .21, n = 56; and quetiapine: P = .16, n = 48) or at 6 months’ follow-up (lithium: P = .22, n = 29; lamotrigine: P = .43, n = 26; and quetiapine: P = .99, n = 17).^15,16

Ginger.io is a smartphone app designed for adolescents and young adults with recent-onset psychosis.¹⁹ Users received daily prompts to assess mood, medication use, and social interactions. Additionally, users completed weekly surveys on symptoms, sleep, and taking medication as prescribed. Daily surveys could be completed any time between 5:00 PM and 11:55 PM, while weekly surveys were available from Sundays at 10:00 AM to Mondays at 11:55 PM. In a longitudinal feasibility study using a within-person design (N = 76), a majority of participants in a feasibility study of Ginger.io felt that the app helped remind them to take their medication¹⁹; medication adherence rates were not reported.

App4Independence (A4i) was designed for individuals with schizophrenia to enhance self-management.²⁰ Twice-daily notifications prompt users to complete surveys assessing mental health and goal progress. Users also can custom set medication and appointment reminders. Additionally, A4i consists of information promoting engagement in recovery. Results from a feasibility study using a pre–post design (N = 38) report significant improvements in medication adherence; however, the investigators caution the interpretation of results.²⁰ Despite this caution, participants felt A4i significantly helped them remember to take their medications. Furthermore, measures of psychiatric symptoms significantly improved postintervention.

Two European information technology companies designed apps for SM of mood, activity levels, sleep, and medication adherence for people with bipolar disorder.²⁷ The 2 apps, Pulso and Trilogis-Monsenso, were compared with feasibility and usability in 3 European countries (Italy, Spain, and Denmark). Pulso allows users to evaluate their mood, activity levels, social media activity, and medication intake daily. Participants were not prompted to complete these assessments, however. Trilogis-Monsenso sent users daily prompts to evaluate mood, activity levels, sleep, and medication intake. Medication adherence rates for the 2 apps were not reported. Both apps were found acceptable and feasible for this population.²⁷

Kumar and colleagues²¹ assessed the usability and feasibility of the LifeData system, containing the smartphone app RealLife Exp, among individuals with early psychosis. RealLife Exp sends daily notifications to prompt users to complete surveys on mood, medication use, socialization, and conflict. Approximately 49% of users felt RealLife Exp helped them remember to take their medications. A majority of users felt the app was easy to use and 37% felt the app was useful overall.

SIMPLe was designed for people with bipolar disorder to monitor psychiatric symptoms and provide psychoeducation.¹⁷ The app administered daily prompts for individuals to answer questions pertaining to mood, energy, sleep, medication adherence, and irritability. In addition to daily questions, weekly “yes” or “no” questions were included, based on Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition)²⁸ criteria for manic and depressive episodes, as well as questions pertaining to suicidal ideation. In a 3-month feasibility study, 86% of participants found use of the app satisfactory and 82% found the app useful. Active use of the app decreased, however, from 94% within the first month to 74% during the third month.¹⁷ This is not surprising because active app use generally drops off after 2 weeks of use among people with mental health conditions.²⁹

Heal Your Mind (HYM) was designed to provide real-time case management and self-directed CBT for people with early psychosis.²² This app includes 6 modules, giving users a space to record their thoughts and emotions, rate their psychiatric symptoms, and record daily activities, such as social activities and medication regimens. Additionally, the app provides a space where users can communicate with case managers in real time as well the as the ability for users to share their self-directed CBT and self-rated psychiatric symptoms. In a feasibility study,²² a majority of participants used the HYM app once or twice a week. Overall, participants found the app easy to use and were satisfied with using the app. Additionally, 71% of participants reported receiving psychiatric help through use of the app.

CBT2go is an app designed for individuals with bipolar disorder or schizophrenia.³⁰ Participants receive a single session of in-person CBT that is augmented through use of CBT2go.³⁰ The app prompts users 3 times daily. During the morning, the app asked participants questions pertaining to mood or presence of auditory hallucinations. In the afternoon, participations were asked questions regarding their socialization. In the evening, participants were asked about their medication routine. Depp and colleagues³⁰ conducted a randomized controlled trial to explore the impact of CBT2go on global psychiatric symptoms and overall functioning, as measured by the Brief Psychiatric Rating Scale (BPRS) and Specific Levels of Function (SLOF) scale, respectively. Participants (n = 255) were randomized to CBT2go, to SM (similar to CBT2go without CBT elements), or to receive treatment as usual (TAU). Modest improvements were found in BPRS scores in both the CBT2go and SM groups compared with TAU; CBT2go and SM scores were not significantly different from each other. The CBT2go group showed significant improvements in SLOF scores, whereas the SM group did not.

The PeerTECH app is an adaptation of Integrated Illness Management and Recovery (I-IMR).¹⁸ The app provides users with personalized self-management support, intervention components relevant to the user’s needs and goals, medication reminders, and a Health Insurance Portability and Accountability Act–compliant chat feature. A small pilot study (N = 8) explored the feasibility and acceptability of PeerTECH among older adults with SMI.¹⁸ In addition to access to the app, participants met weekly with a certified peer specialist to review modules adapted from I-IMR using a tablet. A certified peer specialist is a person with a lived experience of a mental health condition. This lived experience is used to promote recovery, instill hope, enhance engagement with treatment and services, and help strength social support. Over the 12-week study duration, 4 participants used the medication adherence feature and reported that they took their medication daily. Within the field of mental health and the recovery movement, taking medications is a personal choice. As such, participants were not required to use the medication adherence feature.

Psychiatric self-management skills improved significantly among all participants. Additionally, participants reported increased levels of hope, social support, and empowerment.

FOCUS is a smartphone system consisting of 3 apps and designed specifically for people with schizophrenia to promote self-management skills.²³ Users are prompted daily to check in with FOCUS; once in the app, users can complete interventions pertaining to taking medication as prescribed, mood regulation, sleep, and social functioning.²³ In a feasibility trial, approximately 90% of participants found the app acceptable and useable.²⁴ When compared with a peer-led, group-based, self-management intervention, participants were more likely to use FOCUS than attend group sessions.³¹ Additionally, FOCUS was found to significantly reduce depressive symptoms among individuals with schizophrenia spectrum disorders, bipolar disorder, and major depressive disorder (Table 1).²⁵

Table 1.

Summary of application adherence, feasibility, and acceptability

Smartphone Application for Serious Mental Illness	Adherence (Primary vs Secondary Feature)	How Were Factors Measured (Objectively vs Self-report)?	Adherence Results	Feasibility	Acceptability
A4i	Secondary	—	Not significant	Users reported improvements in medication adherence, focus, thoughts, and mental health.	Some users reported ease of use; others reported the app to feel “old school” and that it could function more smoothly.
CBT2go	Secondary	Self-report	—
Focus	Secondary	—	—	—	90% of participants found the application acceptable and useable.
Ginger.io	Secondary	—	—	A majority of users reported the application helped them remember their medication doses.	—
HYM	Secondary	Self-report	—	83% of users reported the application was easy to learn and use.	Approximately 80% of users were satisfied with the application.
MedActive	Primary	Self-report	100%	Only 14% (n = 1) of participants reported technical difficulties.	80% of users responded to ecological momentary assessments.
MedLink	Primary	Objective	82%	Users gave the application a 6.6 for learnability on a 7-point Likert scale.	Users gave the application a 5.6 for likability on a 7-point Likert scale.
Monarca (I and II)	Secondary	Self-report	Not significant compared with control
MyT	Primary	Self-report	Decreased missed doses by 22%
PeerTECH	Secondary	Self-report	Of those who used the medication adherence feature (n = 4), 100%	Feasibility was established by users’ capacity to use the smartphone application. Users completed 42% of self-management tasks.
Pulso	Secondary	—	—	On a scale of 1 = strongly agree to 7 = strongly disagree, the mean score for usefulness was 3.8.	On a scale of 1 = strongly agree to 7 = strongly disagree, the mean score for application satisfaction was 3.8.
RealLife Exp	Secondary	Self-report	49% reported it helped them remember medication doses.	A majority of users found the application easy to use.	37% of users felt the application was useful overall.
SIMPLe	Secondary	Self-report	—	82% of users found the application useful.	86% agreed the application was acceptable and satisfactory.
Trilogis-Monseno	Secondary	—	—	On a scale of 1 = strongly agree to 7 = strongly disagree, the mean score for usefulness was 4.2.	On a scale of 1 = strongly agree to 7 = strongly disagree, the mean score for application satisfaction was 4.5.

TECHNOLOGY FEATURES THAT FACILITATE MEDICATION ADHERENCE

In a study of an online psychosocial intervention for psychosis, participants were more likely to be engaged if they received weekly e-mail support in which online coaches provided participants with encouragement to engage in the intervention.³² Reciprocal accountability³³ and supportive accountability³⁴ both are frameworks that suggest incorporating human factors in digital interventions may increase engagement, because users are held accountable through the use of a clinician (supportive accountability³⁴) or a peer support specialist (reciprocal accountability³³) (ie, synchronous or asynchronous communication with another person via e-mail or other digital avenues, such as text messaging or in-app chat features). Accountability also may be enhanced by making users aware of what is expected from them, allowing users to set pertinent and relevant goals, and including some form of performance monitoring. Incorporating elements of the reciprocal accountability,³³ supportive accountability,³⁴ and object relations³⁵ within smartphone apps for people with SMI may increase rates of adherence and engagement among users. A recent systematic review examined features of apps and their impact on engagement.³⁶ Researchers found that live (not automatic or artificial) peer support had the highest engagement (17%) compared with other features (ie, trackers = 6.3%; mindfulness/mediation = 4.1%; breathing exercises = 1.6%; and psychoeducation = 3%).³⁶ As such, utilizing peer support specialists as the social presence element may increase engagement further, which, in turn, may increase taking medication as prescribed.³⁷ Peer support specialists are individuals with a lived experience of mental illness who use their experience to promote recovery, instill hope, promote treatment engagement, and strengthen social supports.

Functional factors of smartphone apps, such as efficiency and ease of use, also may play a role in user engagement. Community-engaged research and user-centered design can facilitate the development, implementation, and acceptance of digital interventions by partnering with the target population to better understand their needs and desired outcomes of the intervention.³⁷ Several of the apps, described previously, were designed in this manner.^{13,16–18,20,23}

PARALLELS TO TREATMENT OF SLEEP APNEA

The use of positive airway pressure (PAP) is a well-established, efficacious way to alleviate moderate-to-severe obstructive sleep apnea (OSA) symptoms and improve overall quality of life.³⁸ Unfortunately, rates of using PAP as prescribed is relatively low.³⁹ The rates of adherence may be associated with education level, socioeconomic status, disease severity, perception of control over one’s illness, social support, and marital status or the presence of a bed partner.⁴⁰ Given the success in other disease states, a smartphone app may help improve PAP usage as prescribed; however, current use of mobile technology in this manner is limited.

The smartphone app, APPnea,⁴¹ sends daily prompts for users to answer 2 yes-or-no questions pertaining to PAP use, physical activity, and dietary habits. A 6-week pilot study found the app feasible and acceptable.⁴¹ Overall, participants had high levels of PAP use; however, pre–post use or use over time was not analyzed. Thus, associations between APPnea and PAP adherence are not yet known.

Appnea-Q was designed to deliver SM tools to individuals with OSA in an effort to increase using therapy as prescribed.⁴² The app is divided into 3 sections: follow-up questionnaire, frequent problems, and recommendations. The follow-up questionnaire consists of 10 questions pertaining to PAP use and effectiveness, common side effects, exercise and diet, and weight. The frequent problems section contains a library of information addressing common side effects and issues that PAP users experience. If users do not find the information they are looking for, they are provided with a phone number for a consultation with a sleep unit nurse. The final section contains general information about PAP use, sleep hygiene, and diet. A pilot study found the app feasible and acceptable; however, the app’s effect on taking medication as prescribed has yet to be ascertained.⁴²

Smartphone apps integrated with elements of CBT may serve to improve PAP adherence. In-person CBT has been shown to increase PAP adherence.⁴³ As described previously, MyT is an app designed to improve taking medication as prescribed among individuals with bipolar disorder. MyT incorporated elements of CBT and a small pilot study found an increase taking medication as prescribed.¹² Furthermore, educational elements may add additional benefits to taking medication or using therapy as prescribed. Increasing an individual’s understanding and awareness of their illness may increase the likelihood of utilizing treatments. Similar to SMI, poor perception of control over illness may adversely affect taking medication as prescribed among individuals with OSA.

DISCUSSION

Medication nonadherence or not taking medication as prescribed is common among adults with SMI and is associated with increased risks of hospitalizations and relapse as well as increased severity of symptoms. Digital interventions, or smartphone apps, may serve to increase taking medication as prescribed among this population. Currently, there are several smartphone apps designed specifically for individuals with SMI.^12–24,31 A majority of these apps focus on symptom management and psychoeducation, with taking medication as prescribed as a secondary feature. The apps that focus specifically on medication adherence^12–14,26 include small non-randomized samples and are at risk for bias associated with self-report. Only 1 study relied on objective tracking of medication usage (via the smart pill bottle).¹⁴ In comparison to the sleep field, all modern PAP machines track adherence objectively. Due to the history of people with SMI and their potential traumatic experience with monitoring within institutionalized settings, people with SMI may not find objective monitoring of medication adherence acceptable. For example, the Abilify MyCite is an ingestible sensor on an antipsychotic medication for people with schizophrenia, bipolar disorder, or depression and after ingestion sends a message from the pill’s sensor to a smartphone app. In 2019, Abilify MyCite has lost many investors due to the “treatment never gained material traction with patients.”⁴⁴ In developing technologies for people with SMI, consideration of acceptability is a major issue that may be the culprit in the some of the lowest levels of engagement in digital technologies,⁴⁵ thus, subsequently having an impact on adherence.

To address adherence issues with technology, the field is calling for user-centered design in smartphone technology development.^46,47 User-centered design has developed out of the field of engineering and incorporates end users’ perspectives in the development of technology through methodologies, such as verbal probing or think aloud,⁴⁸ empathy mapping,⁴⁹ and/or field usability studies.⁵⁰ Promising evidence indicates a combination of user-centered design and community-engaged research.⁵¹ By doing so, end users work as equal partners through the software development lifecycle and have complete decision-making authority.³⁷ The result has been more acceptable technologies for populations of interest, as evidenced by high engagement rates. For example, a recent systematic review found that a combination of these approaches resulted in the highest levels of engagement by people with SMI.⁵¹

Poor insight into illness is among the many reasons that contribute to not taking medication as prescribed.⁷ Poor insight into illness includes denying, failing to acknowledge, or lack of awareness of psychiatric disorder or psychiatric symptoms. Thus, simple prompts to take medications may not be enough to increase taking medication as prescribed among this population. Participants might not feel as though they need medication or may lack awareness of benefits associated with taking medications.⁷ Psychoeducation may help reduce or eliminate poor illness insight. In-person psychoeducation has been found to improve rates of taking medication as prescribed among adults with SMI^36,52; incorporating these elements within a smartphone app may serve to improve taking medication as prescribed further. Current smartphone apps containing psychoeducation components, such as SIMPLe¹⁷ and PeerTECH,¹⁸ have been found feasible and acceptable among this population; however, associations between use and taking medication as prescribed have not yet been ascertained.

Smartphone apps, including elements pertaining to self-management skills, psychiatric symptom monitoring, and CBT, also may serve to improve rates of taking medication as prescribed. A majority of studies on the apps that included these elements did not report results on rates of medication adherence over time.^19,21,27 The 1 study that did report significant improvements in taking medication as prescribed cautioned views on the interpretation of the result.²⁰ Lastly, incorporating elements of the supportive accountability model³⁴ and utilizing peer support specialists may increase rates of taking medication as prescribed further.

Currently, research on smartphone interventions to assist with taking medications as prescribed among adults with SMI still is in its infancy. Future studies not only should explore changes in medication usage after utilization of the app but also examine which intervention components may be associated with improvements in taking medication as prescribed. Additionally, barriers and predictors of engagement and taking medication as prescribed need to be explored further. Adherence research commonly happens in a silo, focused on a particular disease state or type of therapy. Yet, learning from outside disciplines can bring new insights and ideas to challenges. Developing technologies that promote adherence among vulnerable populations, such as people with SMI, presents unique challenges to adherence related to history of people with SMI and potentially their experiences with the mental health system.

KEY POINTS.

• Individuals with serious mental illness (SMI) have high rates of not taking medication as prescribed.

• Smartphone applications (apps) designed for people with SMI have been found feasible and acceptable among this population—yet, developing technologies that promote adherence among vulnerable populations presents unique challenges to adherence.

• Smartphone apps may serve to promote taking medications as prescribed.