November 2017 – Maria Yang, MD

Reader and stellar nurse Natalie[1. I know Natalie is a “stellar” nurse because we used to work together.] wondered about my thoughts about the digital pill.

My initial reactions were similar to several of those who were interviewed for the article. The digital pill, which provides electronic information to confirm whether someone has ingested the medication, has great potential to become a tool of coercion. Aripiprazole (Abilify) is classified as an antipsychotic medication, which is often prescribed to people who have beliefs that machines and other surveillance tools are in their bodies. Why would the nascent technology of a digital pill make its debut for this population?

I have several other concerns about this digital pill:

(1) The purported mechanism of action for aripiprazole (Abilify) involves hand-waving, which is yet another reason why its debut as a digital pill is perplexing. To the manufacturer’s credit, the package insert for arpiprazole is blunt: “The mechanism of action of aripiprazole in schizophrenia or bipolar mania, is unknown.” (Section 12.1.) The explanation in the scientific papers, though, gets those hands waving all over the place (warning: technical language fast approaching):

The development of D2 partial agonists is a logical strategy for the treatment of schizophrenia because the pathophysiologic mechanism of schizophrenia is thought to be based on too much dopamine activity in some regions of the brain and too little dopamine activity in other regions. A D2 partial agonist can act as a functional antagonist in areas of high levels of dopamine, such as the mesolimbic pathway, but not in areas of normal dopamine levels, such as the nigrostriatal and tuberoinfundibular pathways. Thus, a D2 partial agonist is expected to reduce the positive symptoms of schizophrenia without producing movement disorders or elevated prolactin levels. In regions of low dopamine concentration, such as the mesocortical pathway, a D2 partial agonist will show functional agonist activity.

Put into plain language, what all that means is aripiprazole might stimulate specific receptors in one part of the brain, but block those same receptors in other parts of the brain. The concentration of dopamine might determine whether aripiprazole stimulates or blocks those receptors.

I’m skeptical.

That’s like an antibiotic that only kills one specific type of bacteria in one part of the body, but doesn’t kill that same specific bacteria in other parts of the body.

How does that work? Especially since science has yet to determine the underlying causes of psychotic disorders, such as schizophrenia?

So, in sum, this is a digital form of a medication that has an uncertain mechanism of action for a disease that we don’t fully understand.

What?

(2) The focus on adherence to medication assumes that the ingestion of medications is the most important aspect of treatment. This may be true for some individuals, but does not apply to everyone. Psychiatry focuses on maximizing function and quality of life. Sometimes people can attain both without taking digital pills daily.

(3) Most people under my care don’t have access to technology like smart phones. Some of these individuals also have the most severe symptoms and are the most likely to benefit from a variety of interventions: Skills coaching, housing, nutrition, exercise, art, and talk and behavioral therapies, in addition to medication.

(4) I don’t know how the data from this digital pill will actually change care. Psychiatry, for now, still relies on the observation of thoughts, emotions, and behaviors of people. Whether someone is taking their medications or not may not actually change treatment plans.

For example, say Natalie is under my care and takes a digital pill. I learn that Natalie takes this medication five days out of seven. All sources report that she’s doing okay: She’s getting along with her family, is going to school or work, is keeping up with her rent, and continues to follow the blogs she likes. Do I encourage her to take the medication every day? What more gains might she make? What if it detracts from her quality of life to have to take a medication every day, particularly when she’s doing okay?

Or, what if the digital pill tells me that Natalie hasn’t taken medications at all since I prescribed them to her? And Natalie continues to experience significant symptoms? I guess it’s helpful to have confirmation that Natalie isn’t taking medication, but, if I have sufficient rapport with Natalie, she’ll straight up tell me that she’s not taking it. Why use a digital pill when I can get the information from someone directly? Particularly when she can tell me the specific reasons why she doesn’t want to take it?

Or, what if the digital pill tells me that Natalie is taking the medication everyday, but she also continues to demonstrate significant symptoms? Again, the confirmation that she’s taking her medications could be helpful, but if I have rapport with her and she continues to suffer from symptoms, it’s likely that she would tell me this information, anyway.

If physicians want people to trust them, then physicians must show that they trust the people under their care. There are easier and more compassionate ways to get accurate information without resorting to a digital pill.

(5) Lastly, who are we actually treating with this digital pill? Who is going to feel better with the data the pill generates?

This data won’t tell individuals anything they don’t already know. They will know if they took their medications or not. (And savvy patients will figure out a way to subvert this digital pill reporting: Maybe they will give the meds to a pet or to another person.) This data is meant to help physicians feel better, not patients.

If the goals of psychiatry are to help reduce suffering, improve function, and help people live the lives they want to lead, we cannot rely on medications alone to achieve this, particularly for those individuals with significant symptoms. Even if the data shows that someone is taking medications daily, that process measure is meaningless if the person’s overall function and quality of life remains poor.

I didn’t post anything here last week because my dad, while walking, was hit by a car. (He is feeling better, thank you.)

When I arrived, my father occupied one of four beds in a resuscitation room. The other three beds were empty. It was still early in the morning and there were few people in the emergency department.

As the day wore on, other patients were wheeled into and out of the room. A pale yellow curtain with a floral motif enclosed the space around each patient. The patients and their visitors caught glimpses of each other whenever the ED staff pulled the curtains open.

While curtains provide visual privacy, they are not soundproof.

An inmate from the local jail came in with chest pain. He shared his entire medical history with his accompanying jail officer. After listening to the inmate’s monologue for about five minutes, the officer interjected, “I’m going to watch this TV show now.” The inmate, along with the rest of us, listened to what sounded like an action movie. The inmate sounded more disappointed than relieved when he learned that he did not need to stay in the hospital. He went back to jail.

A mother and father came in for reasons I never learned. Their young toddler with enormous eyes grasped the pale yellow curtain in her tiny fists as she explored both sides of the boundary. Their infant stopped wailing when the mother sang, her voice full and calm. When the family left, they took the laughter with them.

A woman with dark pink hair was wheeled in. Another car hit her while she was driving. Her voice was light and melodic as she expressed profuse thanks to the medics. Her voice cracked as she spoke to a friend on the phone: Was she ever going to get a break? Why did her friend hit her with the car? Why was this the third time in her life she was in a car crash? What if she never got sensation back in her leg? Why did she have so much bad luck? After she hung up the phone, she wept. She took her frustration out on the nurse. No one was at her bedside.

A slender man was wheeled in. He, too, was in a car crash. His answers to questions were short and quiet. The sadness on his face could have been new, though the wrinkles around his lips and eyes hinted that maybe he wore a sad face most days. He stared up at the ceiling. No one visited him.

My mother came into the room, too. My father recalled when he was last in an emergency department: His wife was short of breath and feeling exhausted. He remembered the week she spent in the hospital, all the questions, poking, and testing she had to endure, and how much she hated it.

“Now I understand why she didn’t like the hospital,” he murmured. The edge of the pale yellow curtain shifted, though no one was there.