An enhanced text messaging-based intervention administered to resource-poor communities in China was more effective than a free-medicine program alone in improving medication adherence among patients with schizophrenia, according to study data published in PLOS Medicine.

Investigators conducted a randomized controlled trial of 278 patients with schizophrenia from 9 resource-poor townships in Hunan, China. Patients were randomized 1:1 to the intervention condition or the control condition. Both trial groups received a nationwide community-based mental health program that supplied free antipsychotic medications. The intervention participants were also enrolled in LEAN (Lay health supporters, E-platform, Award, and iNtegration), a program that recruited lay health supporters from the patient’s family or community. The health supporters received phone-texted instructions and support for the following tasks: supervising patient medication, monitoring side effects and relapse, and facilitating healthcare linkage. The program also included awarding token gifts for positive behavioral improvement. As the primary outcome measure, investigators captured medication adherence, assessed by 2 unannounced home-based pill counts conducted 30 days apart at the 6-month end point. Secondary and additional outcomes included patient symptoms, functioning, relapses, rehospitalization, suicide, and death for any reason.

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A total of 271 of 278 enrolled patients were successfully followed-up for outcome assessment. Medication adherence, defined as the proportion of antipsychotic medication dosages taken over the past month, was 0.61 in the intervention group and 0.48 among controls (adjusted mean difference, 0.12; 95% CI, 0.03-0.22; P =.013). The intervention condition was also associated with substantial reduction in the risk for relapse (relative risk, 0.63; 95% CI, 0.42-0.97) and rehospitalization (relative risk, 0.36; 95% CI, 0.17-0.73). No significant changes in patient functioning or symptoms were observed in the intervention group compared with the control group. During the course of the study, 2 participants in the intervention group and 1 in the control group died, although none as a result of suicide or self-harm.  

These data support the efficacy of adjunctive mobile text support compared with a standalone free-medicine program alone in improving medication adherence in residents of resource-poor communities. “Two unique features may have contributed to the relative superiority of LEAN: active engagement of lay health supporters and the use of texting to connect the entire treatment team from patients to lay health supporters to village doctors to psychiatrists, all in support of the patient,” researchers wrote.

Given the short follow-up period and small patient cohort, results should be extrapolated with care. Further LEAN program research will test the efficacy of customized text programs for each patient.


Xu DR, Xiao S, He H, et al. Lay health supporters aided by mobile text messaging to improve adherence, symptoms, and functioning among people with schizophrenia in a resource-poor community in rural China (LEAN): a randomized controlled trial. PLoS Med. 2019;16(4):e1002785.