This article highlights the importance of medication adherence in the treatment of schizophrenia. Nonadherence to medication can lead to relapse and increased healthcare costs. Rates of non-compliance in psychotic disorders vary, and nonadherent patients have a higher risk of relapse compared to adherent patients. Poor adherence results in the underutilization of treatment resources and compounds the challenges of improving health, particularly in impoverished populations. Nonadherence in schizophrenia accounts for a significant portion of the costs of rehospitalization. Patients who experience a relapse often struggle to regain their pre-relapse level of social adjustment. Improving adherence is crucial and can be as impactful as the introduction of antipsychotic medications. Adherence is defined as the extent to which a person's behavior aligns with medical advice, involving multiple indicators of self-care. The World Health Organization has identified five dimensions of adherence, including socioeconomic, therapy-related, patient-related, illness-related, and healthcare team/system-related factors.
This study aimed to investigate the factors influencing medication adherence in schizophrenia and examine the relationship between illness severity, medication side effects, and adherence. The research was conducted at the Central Institute of Psychiatry (CIP) in Ranchi, India, which is a postgraduate teaching hospital specializing in psychiatric care. The study received approval from the institutional ethics committee.
A purposive sampling method was employed, and 60 adult patients within the age range of 18-55 years, meeting the criteria for schizophrenia according to ICD-10, DCR, and attending follow-up at CIP OPD, were included in the study. Individuals with comorbid mental retardation, personality disorders, or general medical illnesses requiring additional treatment were excluded.
Informed consent was obtained from the participants, and their socio-demographic profiles, including treatment history, cost, and availability of medication, were recorded using a specially designed datasheet. The severity of illness was assessed using the Brief Psychiatric Rating Scale (BPRS), which is an observer-rated scale developed by Overall & Gorham. The scale comprises 24 items rated on a 7-point severity scale.
Medication side effects were evaluated using the Udvalg For Kliniske Undersogelser (UKU) side effect scale, which is an observer-rated scale consisting of three parts: a single symptom rating scale, a scale for global assessment, and a scale for stating the consequences of side effects. A score of one or more on any item of the UKU side effect rating scale was considered for statistical analysis.
The participants' attitude toward adherence was assessed using the Medication Adherence Rating Scale (MARS) developed by Thomson. This scale combines two existing self-report measures of compliance, namely the Drug Attitude Inventory (DAI) and the Medication Adherence Questionnaire (MAQ). The MARS consists of 10 items requiring yes/no responses, and a higher total score indicates greater compliance, while a lower score indicates non-compliance.
The study involved 60 adult patients with schizophrenia, and various factors related to medication adherence were examined. The participants had a mean age of 31.58 years, with a majority being male (81.7%). Most of the participants were unemployed, and the mean duration of illness was 8.31 years. Paranoid schizophrenia was the most common diagnosis (58.3%), followed by undifferentiated schizophrenia (38.3%). Substance abuse was present in 10% of the sample.
Regarding medication, different types were prescribed, including atypical antipsychotics, typical antipsychotics, and additional medications. Most participants (71.7%) received medication under supervision. The mean duration of treatment was 5.04 years. The participants' attitude towards medication adherence, as assessed by the Medication Adherence Rating Scale (MARS), had a mean score of 7.63, indicating moderate adherence.
No significant associations were found between adherence and socio-demographic variables such as marital status, religion, educational level, or occupation. However, there was a trend suggesting poorer adherence among females. Factors such as family income, background, type of schizophrenia, past history, family history, substance abuse, medication type and route, cost, availability, supervision, and regularity of follow-ups did not show a significant relationship with adherence.
Correlation analysis revealed that medication adherence was negatively correlated with the severity of psychopathology, as measured by the Brief Psychiatric Rating Scale (BPRS), and certain side effects of medication, as assessed by the Udvalg For Kliniske Undersogelser (UKU) side effect rating scale. Specifically, adherence was negatively correlated with the UKU psychic side effect subscale and other side effect subscale, indicating that increased sleep duration, asthenia, lassitude, and increased fatigability were associated with poorer adherence.
Regression analysis further confirmed the impact of medication side effects on adherence. The UKU psychic side effect subscale, particularly increased sleep duration, was a significant predictor of poor adherence in the sample.
Overall, the study highlighted the importance of considering side effects and the severity of psychopathology in understanding medication adherence among individuals with schizophrenia.
The discussion highlights several findings and observations from the study. The rate of non-compliance in psychotic disorders was found to be 36.7%, which falls within the range reported in previous studies. No significant associations were found between adherence and socio-demographic variables.
The severity of psychopathology, as measured by the Brief Psychiatric Rating Scale (BPRS), was negatively correlated with adherence. This suggests that individuals with more severe symptoms may have more difficulty adhering to their medication regimen. Substance abuse did not significantly correlate with non-adherence in the sample, although previous studies have shown mixed results on the relationship between substance abuse and adherence.
No significant differences were observed in adherence between different types of antipsychotic medications (typical vs. atypical) or between oral and depot injectable formulations. The evidence regarding atypical antipsychotics and better compliance has been inconclusive in previous studies.
Adherence was negatively correlated with certain side effects of medication, such as increased sleep duration, asthenia, lassitude, and diminished sexual desire. Unwanted side effects can have a negative influence on adherence, particularly if they cause discomfort or dysphoric responses for the patient.
Regularity of follow-ups did not significantly impact adherence in the sample, although previous studies have suggested that regular visits to a psychiatrist can be correlated with better adherence.
Overall, the study contributes to our understanding of factors affecting medication adherence in schizophrenia. The findings highlight the importance of considering the severity of psychopathology and the impact of medication side effects in promoting adherence. However, the study has limitations, and further research is needed to explore additional factors influencing adherence in this population.
In conclusion, the study found that attitude towards adherence in schizophrenia correlated negatively with the severity of illness and certain side effects, including increased sleep duration, asthenia, increased fatigability, lassitude, and diminished sexual desire. Increased sleep duration and asthenia/lassitude/increased fatigability were identified as predictors of poor adherence in the patient population studied.
The study acknowledged some limitations, including a relatively small sample size and the potential exclusion of patients who did not visit a psychiatrist. The use of self-reported measures of compliance may have also led to an overestimation of adherence. Future studies should consider larger sample sizes, include patients from the community, and utilize additional measures of compliance, such as biochemical and physiological markers, pill counts, and electronic medication monitoring. Assessing therapist-related factors could also provide valuable information in understanding adherence in schizophrenia.
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