CLINICAL HANDBOOK OF SCHIZOPHRENIA

21. Environmental Supports 211cation visits. When intensive treatments such as CAT or assertive community treatmentare shown to be effective in randomized controlled trials, they are often scaled down fordelivery in overburdened health care systems. A generic or scaled-down version of CAThas recently been systematically studied. Preliminary data suggest that individuals whouse the supports provided improve on specific target behaviors. However, generic supportsprovided in a clinic setting, and expected to be set up by the client, are not as likelyto be used as CAT supports, which are more individually tailored and established in theclient’s home by the CAT therapist and client working together.Specific Supports for Specific ProblemsUsing environmental supports to cue and to reinforce taking medication has been foundto be among the most effective strategies for individuals with physical illnesses. Environmentalsupports include advances in technology, such as the development of highlysophisticated pill containers. A recent invention known as the Med-eMonitor (see Figure21.2) is capable of storing a month’s supply of up to five different medications. Thedevice prompts the patient when to take medication, reminds him or her of the goal oftaking each medication, alerts the patient who is taking the wrong medication or taking itat the wrong time, records when containers are opened, and automatically downloadsdata to a secure website when placed into a cradle connected to a telephone line. Themonitor can also ask a number of questions about side effects or symptoms on a regularbasis. Based upon the patient’s answers, a branching logic capability can provide furtherinstructions or ask for more detailed information. Moreover, if problem adherence isidentified after checking the website, treatment providers can contact the patient to identifybarriers to adherence (e.g., “I left my medication at my sister’s house”), to applyproblem-solving techniques, and to remind the patient of important personal goals enhancedby taking medication as prescribed. In a recent New England Journal of Medicinereview, Osterberg and Blaschke (2005) identified the following key factors for promotingadherence: identifying the problem; providing simple, clear instructions; reinforcingdesired behavior; customizing treatment to the patient’s schedule; and using supportivedevices. Each of these features is incorporated into the design and function of smart pillcontainers such as the Med-eMonitor. In a recent pilot study at our site, the device significantlyimproved adherence to oral medication regimens in a sample of 15 subjects withFIGURE 21.2. Med-eMonitor device. Photo courtesy of InforMedix, Inc.