This study was funded by Shire, now part of Takeda
Adherence to ADHD medications is generally poor, and this may be attributed to forgetfulness and inattention. Use of digital healthcare in the form of text message reminders has shown success in increasing treatment compliance for chronic conditions. The aim of this study was to assess the effectiveness of a novel text message intervention in improving adherence to stimulants in adults with ADHD.
The text messaging intervention group included adults aged 18–55 years with ADHD.* Patients received a customised text message programme† that included reminders to adhere to their individualised medication regimen and to phone their clinician for a prescription refill. Reminders to pick up their medication from the pharmacy, and educational reminders about ADHD and its treatment, were also included. A comparison group was identified from the Partners HealthCare electronic medical records‡ and was matched to the text messaging intervention group at a 5:1 ratio based on age and gender. Patient engagement§ in the text messaging intervention group was defined as issuing of a stimulant prescription within 37 days of the start date of the text messages. For the comparator group, if a second stimulant prescription was issued within 7 or 37 days of the date of the index prescription, this was considered patient engagement.
In total, 92 adults with ADHD (mean [standard deviation (SD)] age 32.7 [9.8] years; 61% male) received text messages for ≥45 days. The comparator group comprised 460 patients (mean [SD] age 31.5 [7.7] years; 61% male). There was no significant difference in age (p = 0.18) or socioeconomic status (p = 0.16) between the two groups; however, the text messaging intervention group had a lower percentage of white patients than the comparator group (82% vs 92%, respectively; p = 0.005). Consequently, race was controlled for in all subsequent analyses.
Using the 37-day window, a significantly greater proportion of patients in the text messaging intervention group were engaged in stimulant treatment compared with the comparator group (68% vs 34%, respectively; p < 0.001). The adjusted odds ratio (OR) was 4.04 (95% confidence interval [CI] 2.49–6.56). Based on the 45-day window, significantly more patients in the text messaging intervention group were engaged in treatment compared with the comparator group (79% vs 40%; p < 0.001). The adjusted OR was 5.40 (95% CI 3.14–9.28). These data suggest that for every three patients who received the text messaging intervention, one was considered engaged in their stimulant medication.
This study had some methodological limitations. Patient engagement was defined as the issuance of a prescription; however, the dispensing of medication was not confirmed. In addition, it is unknown if these findings are generalisable to the primary care setting or to children and adolescents with ADHD, as this study only included adults with ADHD being treated as part of a specialised programme. A placebo intervention was also not used in this study, and information regarding adverse events and patient satisfaction, which may have affected engagement, was not analysed. The long-term effects of the text messaging intervention were not assessed in this study, and as the intervention consisted of several distinct components (reminders, education and tips), the individual success of each component is unknown.
The authors concluded that these data suggest that this novel, ADHD-centric digital health intervention using readily accessible, inexpensive and widely available text messaging significantly improves patient engagement to stimulants in adults with ADHD, and may improve adherence to treatment.
*Included adults with a diagnosis of ADHD according to the Diagnostic and Statistical Manual of Mental Disorders – 5th Edition who were referred to the Adult ADHD Program at the Massachusetts General Hospital. Prior to enrolment, patients must have either been starting a stimulant or have started taking a stimulant within 6 months of study enrolment, and must have had a mobile phone with text messaging capabilities. Concomitant medications were permitted for those with ADHD
†A maximum of two text messages per day were sent (one in the morning and one in the afternoon). Each text message included instructions to stop all future messages; those who decided to stop receiving the messages were considered withdrawn from the study
‡Patients who had been prescribed stimulant medications between 1 January 2015 and 31 December 2016 using the Partners HealthCare Research Patient Data Registry were included in the comparator group. To make this group comparable with the text messaging intervention group, only those who had their first stimulant in the system prescribed on or after 1 January 2016 were included, as this gave the comparator group a lead-in time of ≥1 year without stimulant medication
§Since patients received stimulant prescriptions for a 30-day supply, a 7-day window beyond the 30 days was decided for the text messaging intervention group, to allow for some margin of error for any minor delays or problems refilling exactly when the medication ran out. For the comparator group, the refill window was 7 days after the index prescription date, to avoid counting any prescriptions that were not actually a refill but reprints of a lost prescription. If patients had ≥1 medication prescribed on the date of the index prescription, they only had to refill one medication for it to be considered patient engagement
Biederman J, Fried R, DiSalvo M, et al. A novel text message intervention to improve adherence to stimulants in adults with attention deficit/hyperactivity disorder. J Clin Psychopharmacol 2019; 39: 351-356.