|Year : 2014 | Volume
| Issue : 3 | Page : 294-298
Attitudes toward medication and reasons for non-compliance in patients with schizophrenia
Ivatury Sarath Chandra1, Kalasapati Lokesh Kumar2, Mallepalli Pramod Reddy1, Chada Muni Pavan Kumar Reddy1
1 Department of Psychiatry, Mamata General Hospital, Khammam, Andhra Pradesh, India
2 Department of Psychiatry, Bhaskara Medical College, Hyderabad, Andhra Pradesh, India
|Date of Web Publication||26-Jun-2014|
Dr. Ivatury Sarath Chandra
Department of Psychiatry, Mamata General Hospital, Khammam - 507 002, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Non-compliance for the medication is an important area of concern in schizophrenia as it contributes to relapse and re-hospitalization of the patients. One of the ways to improve the drug compliance is to know crucial factors responsible for poor drug compliance and hence that proper strategies may be planned to improve patient's drug compliance. Aim: The aim of the following study is to find out the attitudes of patients toward medication and reasons for drug non-compliance in schizophrenia and its association with clinical and socio-demographic variables. Materials and Methods: The study was conducted on follow-up patients with schizophrenia for the duration of 5 months. Their socio-demographic details were noted and illness related variables were evaluated using Positive and Negative Syndrome scale (PANSS). Patient's attitudes toward medication and the reasons for treatment non-compliance were assessed using the standardized tools, which consist of Drug Attitude Inventory-10 scale and Rating of Medication Influences scale respectively. Results: Nearly 41.9% of our study sample were non-compliant to medication. A significant association has been found between non-compliance and younger age group, unemployment, early age of onset, high positive PANSS score and poorer insight into the illness. The significant reasons for non-compliance in our study were Denial of illness, financial burden, less access to treatment facilities, Side-effects of the medication, Feeling that the medication was unnecessary and Substance abuse. Conclusions: Findings suggest that there is a need to provide adequate information about mental illness and medications prescribed, to enhance medication compliance and to develop community mental health care facilities.
Keywords: Attitudes, non-compliance, schizophrenia
|How to cite this article:|
Chandra IS, Kumar KL, Reddy MP, Reddy CP. Attitudes toward medication and reasons for non-compliance in patients with schizophrenia. Indian J Psychol Med 2014;36:294-8
|How to cite this URL:|
Chandra IS, Kumar KL, Reddy MP, Reddy CP. Attitudes toward medication and reasons for non-compliance in patients with schizophrenia. Indian J Psychol Med [serial online] 2014 [cited 2019 Dec 13];36:294-8. Available from: http://www.ijpm.info/text.asp?2014/36/3/294/135383
| Introduction|| |
Compliance broadly means the extent to which a person's behavior, in terms of taking medications, following diets and executing life-style changes, visiting for follow-up etc., coincides with medical and health advice.  Compliance to medication usually means "the extent to which the patient takes the medication as prescribed." Rosack explained the phenomenon of adherence to medication in terms of refill rate. Refill rate is the proportion of days of proper adherence to prescribed medication by the patient calculated in relation to the total days of advice. Patients who had only 50% of their expected refill rate were termed "non-adherent." Those who filled prescriptions between 50% and 80% of the expected refill rate were termed "partially adherent." Those who filled their prescriptions at more than 110% of the expected rate were termed "excess fillers." 
Non-adherence to pharmaceutical therapy is common when patients are required to take medications on a long-term basis and it has been found to be particularly prevalent in the case of schizophrenic disorders, which require continued use of a drug for daily functioning.  Lacro et al. in their study have reported a median non-adherence rate of 47%. They found that the most consistently reported and potentially modifiable risk factors for non-adherence were patient-related factors (poor insight into having a mental illness, negative attitude or subjective response toward antipsychotic medication and substance abuse) and environment-related factors (poor therapeutic alliance). These findings are consistent with findings from the recent Clinical Antipsychotic Trials of Intervention Effectiveness in which 75% of patients stopped phase I antipsychotic medication within 18 months. The most common reason for stopping was simply the patient's decision to discontinue, not lack of efficacy or side-effects. 
In studies done in India, Khanna  in their study have reported that 31% of the subjects with schizophrenia do not keep their appointment for detailed evaluation after initial evaluation in the walk-in clinic. The authors also reported that 32% of the subjects stop attending the clinic after initial detailed work-up and diagnostic clarification. In another interesting study Srinivasan and Thara  reported that history of non-compliance with oral medication was seen in about 58% of patients during the course of their illness.
Improving medication compliance in persons with mentally ill holds the potential for reducing morbidity and suffering of patients and their families, in addition to decreasing the cost of re-hospitalization.  One of the ways to improve drug compliance is to know about the attitudes and reasons responsible for poor drug compliance and hence that appropriate management strategies may be planned to improve it. With this background, our study attempted to identify factors associated with non-adherence to scheduled out-patient visits at a major psychiatric teaching hospital.
To find out the attitudes of patients toward medication and reasons for drug non-compliance in schizophrenia and its association with clinical and socio-demographic variables.
| Materials and Methods|| |
The present study is conducted at the out-patient Department of Psychiatry, Mamata Medical College and General Hospital, Khammam from 1 st January to 31 st May of 2013. The study sample consists of consecutive follow-up patients attending the out-patient services in our hospital for schizophrenia. After taking informed verbal consent, all patients were systematically interviewed along with the attendant and the socio-demographic details were noted. Patient was labeled as non-compliant if he was non-adherent as per Rosack's criterion.  The diagnosis of schizophrenia was reviewed in accordance to International Classification of Diseases-10 research diagnostic criteria.  Positive and Negative Syndrome scale (PANSS)  was used to assess the severity of the illness. Subjective reasons of medication compliance/non-compliance were assessed using 20 item Rating of Medication Influence (ROMI) scale.  The attitude toward antipsychotic medication was assessed using Drug Attitude Inventory-10 (DAI-10).  The data was statistically analyzed using Statistical product and service solutions (SPSS-16) version.
- Patients in the age group of 15-60 years.
- Patients who were physically fit to answer the questions.
- Patients who gave consent for the study.
- Patients who were on medication for <6 months.
- Patients who were in acute psychotic state.
- Patients who require urgent attention for medical problems.
- Patients without reliable informants.
| Results|| |
Out of the total 115 patients initially considered for the study 10 were excluded based on the fixed exclusion criteria. The final study sample was 105 (100%) of which 61 (58.1%) were compliant and 44 (41.9%) were non-compliant to the medication [Table 1]. There is a significant association between lower mean age (32.36 ± 7.59), unemployment (77.3%), lower mean age at the onset of illness (26.84 ± 5.5), higher mean scores (98.5 ± 8.0) on PANSS and higher mean scores (6.05 ± 0.74) of G12 domain of PANSS indicating poorer insight in to illness and non-compliance toward antipsychotics [Table 2] and [Table 3].
The mean scores of positive domain (2.02 ± 1.9) among the patients belonging to non-compliant group is lower when compared with that of the compliant group (7.98 ± 1.9) and also lower mean scores (5.36 ± 1.7) of the overall attitude toward medication among the non-compliant group indicates more positive overall attitude toward medication in the patients belonging to compliant group [Table 4]. The most significant reason for compliance is perceived daily benefit by the patients and denial of illness by the patient is most common reason for non-compliance. Other significant reasons associated with compliance and noncompliance toward antipsychotic medications in our study is presented in [Table 5] and [Table 6].
| Discussion|| |
This study is an attempt to find out the rate of non-compliance and the attitudes and reasons for noncompliance in patients with schizophrenia. Available literatures provide a non-compliance rate of (12-60%). , In the present study, non compliance is 41.9%. The mean age (32.36 ± 7.59) of patients who were non-compliant is lower than that of mean age of patients who were compliant (37.69 ± 11.59). Among the socio-demographic variables, the association between age and non-compliance was found to be statistically significant (P = 0.01). This finding is in accordance with the earlier studies by Klinkenberg and Calsyn  and Carpenter et al.  who observed a relatively higher non-adherence in the young population. This may be because, with the increase in age, patients accumulate experience with their psychotic illness and they learn that there is a connection between relapse and interruption of neuroleptic drug intake and therefore they adhere to the prescribed medication. There is no much difference in compliance among males and females between the two groups. This is concurrent with the previous findings Diaz et al. Better compliance in the employed population can be because patients with schizophrenia have less chances of getting employed, which leads to deterioration of the financial status of the family, which makes them more prone to quit the course of medication. This difference was found to be statistically significant (P = 0.03). This is similar to the finding of Atwood and Beck  who, in a compilation analysis of 86 studies involving 23,796 patients of psychoses had found a positive association between unemployment and non-adherence, which indicates a financially poor affordable capacity in this population.
The mean age at the onset of illness (26.84 ± 5.5) in non-compliant group is less than that of compliant group (31.02 ± 11.48). This difference was found to be statistically significant (P = 0.02). One interpretation of this could be that early onset of psychosis needs prolonged duration of medication which would lead to the increased number of side effects leading to non-compliance. The other contributing factors could be burnt out syndrome in the caregivers and increased financial burden with prolonged duration of illness in patients with early onset of psychosis. Our findings are similar to the findings of Balikci et al. who, in a 2 year prospective study had found out that there was a higher degree of non-compliance in patients with early onset of psychosis.
The mean PANSS scores (98.5 ± 8.0) of patients who were non-compliant is higher than that of patients who were compliant (P < 0.01). Our findings are in concordance with that of Staring et al. and McEvoy et al. The mean insight scores on G12 domain of PANSS scale was higher (6.05 ± 0.74) in patients who were non-compliant when compared to that of patients who were compliant indicating poorer insight in patients who were non-compliant. This difference was found to be statistically significant (P < 0.01). Our finding is in concordance with the findings of Fenton et al. and Coodin et al. This might be because the patients with poor insight are usually unaware of their illness and refuse the requirement of medication thus becoming non-compliant to the medication.
The overall mean score of DAI was higher in patients who were compliant and this difference was found to be statistically significant (P = 0.03). Similar findings were reported by Adewuya et al.  and Freudenreich et al.  This might be due to the fact that the high positive belief in treatment and medication of the family members might be the reasons for the positive attitude of the patient and compliance towards medication.
As per ROMI, perceived daily benefit was the most significant contributing factor to the compliance of medication in our study, which was followed by positive family belief, relapse prevention and pressure or force by the family members. Denial of illness was the most common reason leading to noncompliance. Financial burden, lack of knowledge of illness, reduced access to treatment facilities, side-effects of the medication and substance abuse also stand as significant contributory reasons for non-compliance. Our findings are similar to that of previous studies conducted by Rosa et al. and Loffler et al.  according to which the reasons that significantly predict compliance as per the ROMI items are "perceived daily benefit", positive relationship with clinicians and for non-compliance is "inconvenience due to side-effects."
- Self-report methods was used to assess medication compliance
- Patients with irregular follow-ups was not assessed`
- Past history of drug non-compliance was not assessed.
- Difference in compliance rates between patients using neuroleptics and Atypical antipsychotics was not assessed.
| Conclusions|| |
Our study findings suggest that there is a need for identification and reduction of factors responsible for noncompliance in schizophrenic patients. There is also a need to provide adequate information about mental illness and medications prescribed, to enhance medication compliance and to develop community mental health care facilities for the awareness regarding the illness.
| References|| |
|1.||Rana NH, Ayub M. Non-compliance to medicine in psychiatry patients. Pak J Med Sci 2002;18:52-4. |
|2.||Rosack J. Education on medication adherence will reduce costs, improve outcome. Psychiatr News 2004;39:20. |
|3.||Terkelsen KG, Menikoff A. Measuring the costs of schizophrenia. Implications for the post-institutional era in the US. Pharmacoeconomics 1995;8:199-222. |
|4.||Lacro JP, Dunn LB, Dolder CR, Leckband SG, Jeste DV. Prevalence of and risk factors for medication nonadherence in patients with schizophrenia: A comprehensive review of recent literature. J Clin Psychiatry 2002;63:892-909. |
|5.||Keefe RS, Bilder RM, Harvey PD, Davis SM, Palmer BW, Gold JM, et al. Baseline neurocognitive deficits in the CATIE schizophrenia trial. Neuropsychopharmacology 2006;31:2033-46. |
|6.||Khanna BC. Treatment acceptance from walk-in clinic. Pilot study. (Unpublished data). |
|7.||Srinivasan TN, Thara R. At issue: Management of medication noncompliance in schizophrenia by families in India. Schizophr Bull 2002;28:531-5. |
|8.||Nageotte C, Sullivan G, Duan N, Camp PL. Medication compliance among the seriously mentally ill in a public mental health system. Soc Psychiatry Psychiatr Epidemiol 1997;32:49-56. |
|9.||WHO. International classification of diseases-10 research diagnostic criteria classification of mental and behavioural disorder, tenth revision, World Health Organization, Geneva; 1992. |
|10.||Kay SR, Fiszbein A, Opler LA. The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophr Bull 1987;13:261-76. |
|11.||Weiden P, Rapkin B, Mott T, Zygmunt A, Goldman D, Horvitz-Lennon M, et al. Rating of medication influences (ROMI) scale in schizophrenia. Schizophr Bull 1994;20:297-310. |
|12.||Hogan TP, Awad AG, Eastwood R. A self-report scale predictive of drug compliance in schizophrenics: Reliability and discriminative validity. Psychol Med 1983;13:177-83. |
|13.||Sparr LF, Moffitt MC, Ward MF. Missed psychiatric appointments: Who returns and who stays away. Am J Psychiatry 1993;150:801-5. |
|14.||Klinkenberg WD, Calsyn RJ. Predictors of receipt of aftercare and recidivism among persons with severe mental illness: A review. Psychiatr Serv 1996;47:487-96. |
|15.||Carpenter PJ, Morrow GR, Del Gaudio AC, Ritzler BA. Who keeps the first outpatient appointment? Am J Psychiatry 1981;138:102-5. |
|16.||Diaz E, Neuse E, Sullivan MC, Pearsall HR, Woods SW. Adherence to conventional and atypical antipsychotics after hospital discharge. J Clin Psychiatry 2004;65:354-60. |
|17.||Atwood N, Beck JC. Service and patient predictors of continuation in clinic-based treatment. Hosp Community Psychiatry 1985;36:865-9. |
|18.||Balikci A, Erdem M, Zincir S, Bolu A, Bozkurt A, Sarper E. Adherence with outpatient appointments and medication: A two-year prospective study of Patients with schizophrenia. Bull Clin Psychopharmacol 2013;23:57-64. |
|19.||Staring AB, Van der Gaag M, Koopmans GT, Selten JP, Van Beveren JM, Hengeveld MW, et al. Treatment adherence therapy in people with psychotic disorders: Randomised controlled trial. Br J Psychiatry 2010;197:448-55. |
|20.||McEvoy JP, Howe AC, Hogarty GE. Differences in the nature of relapse and subsequent inpatient course between medication-compliant and noncompliant schizophrenic patients. J Nerv Ment Dis 1984;172:412-6. |
|21.||Fenton WS, Blyler CR, Heinssen RK. Determinants of medication compliance in schizophrenia: Empirical and clinical findings. Schizophr Bull 1997;23:637-51. |
|22.||Coodin S, Staley D, Cortens B, Desrochers R, McLandress S. Patient factors associated with missed appointments in persons with schizophrenia. Can J Psychiatry 2004;49:145-8. |
|23.||Adewuya AO, Ola BA, Mosaku SK, Fatoye FO, Eegunranti AB. Attitude towards antipsychotics among out-patients with schizophrenia in Nigeria. Acta Psychiatr Scand 2006;113:207-11. |
|24.||Freudenreich O, Cather C, Evins AE, Henderson DC, Goff DC. Attitudes of schizophrenia outpatients toward psychiatric medications: Relationship to clinical variables and insight. J Clin Psychiatry 2004;65:1372-6. |
|25.||Rosa MA, Marcolin MA, Elkis H. Evaluation of the factors interfering with drug treatment compliance among Brazilian patients with schizophrenia. Rev Bras Psiquiatr 2005;27:178-84. |
|26.||Loffler W, Killan R, Toumi M, Angermeyer MC. Schizophrenic patients subjective reasons for compliance and non compliance with neuroleptic treatment. Psychiatr Serv 2004;55:174-9. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]