|Ahead of print
|Assessment of the attitude toward medication and reasons for drug compliance among schizophrenic patients attending the tertiary care hospital
D Gangadhar Naik1, Sugali Pushpalatha2, D Aruna3
1 Assistant Professor, Department of Psychiatry, Kurnool Medical College, Kurnool, Andhra Pradesh, India
2 Department of Community Medicine, Kurnool Medical College, Kurnool, Andhra Pradesh, India
3 Associate Professor, Department of Psychiatry, Sri Venkateswara Medical College, Tirupati, Andhra Pradesh, India
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|Date of Submission||27-Aug-2022|
|Date of Acceptance||20-Feb-2023|
|Date of Web Publication||04-May-2023|
Introduction: Medication compliance is one of the most difficult challenges in the management of schizophrenia in India. Compliance broadly means the extent to which a person's behavior, in terms of taking medications, following diets and executing lifestyle changes, visiting for follow-up, etc., coincides with medical and health advice. The current study has tried to assess the attitudes and reasons for compliance as well as noncompliance among patients with schizophrenia, which can provide the basis for planning effective interventional strategies for the mental health professionals for improving compliance of the patient in the future.
Methodology: A hospital-based noninterventional cross-sectional study was done on 135 schizophrenic patients attending the outpatient services in the Department of Psychiatry, Government General Hospital, Kurnool, hospital by convenient sampling method for 6 months from October 2021 to March 2022, after obtaining approval from the institutional ethical committee. Data were collected and entered in Microsoft Excel and analyzed using the Statistical Package for Social Sciences (SPSS) 16 version software.
Results: The prevalence observed in the present study, 75 (55.56%) participants were compliant, i.e., had a positive attitude toward medication and 60 (44.44%) participants were noncompliant toward medication. Higher mean scores for the Positive and Negative Syndrome Scale score were seen in the compliant group (101.25 ± 19.27) than the noncompliant group (100.98 ± 22.51).
Conclusion: Main reasons for drug noncompliance identified in the present study were financial difficulty, distance from the hospital, improvement or no improvement in symptoms, side effects, lack of insight into the mental illness, and lack of awareness about the need for long-term medication.
Keywords: Drug compliance, drug noncompliance, schizophrenia
|How to cite this URL:|
Naik D G, Pushpalatha S, Aruna D. Assessment of the attitude toward medication and reasons for drug compliance among schizophrenic patients attending the tertiary care hospital. Arch Ment Health [Epub ahead of print] [cited 2023 Jun 5]. Available from: https://www.amhonline.org/preprintarticle.asp?id=375705
| Introduction|| |
Medication compliance is one of the most difficult challenges in the management of schizophrenia in India. Medication compliance refers to the act of conforming to a recommendation of continuing treatment for the prescribed length of time. It is estimated that the rate of noncompliance is about 50% during the 1st year and 75% during the 2nd year after the patients are discharged from the inpatient care unit. Medication noncompliance significantly increases the rate of relapse and length of hospitalization, and the risk for hospitalization in the future. The overall compliance rates for antipsychotic medication were lower than that of antidepressants and other drugs. Compliance with medication usually means “the extent to which the patient takes the medication as prescribed.” The medication compliance in patients with schizophrenia had been predicted by the patient's subjective response to treatment and attitudes toward antipsychotics., The positive attitude of patients toward treatment can improve the therapeutic alliance, medication compliance, and long-term prognosis. Recent studies have shown that the subjective reasons which are significantly related to medication compliance: such as “perceived a daily benefit,” “positive relationship with the therapist,” and “positive attitude of significant others.”
The reasons identified for patient's noncompliance are “distressed by side effects, lack of insight, lack of acceptance of treatment,” substance abuse, low self-esteem, inability to identify the stressors of life, and inability to identify the symptoms of relapse. Several studies were conducted to find out the significant predictors of medication noncompliance. These study results have showed that the factors which predict noncompliance are high level of positive symptoms, alcohol abuse, previous noncompliance,, shorter duration of illness, lack of insight,, nonaffordability of drugs, education not given by doctor, young age, lower educational level, and comorbidity with personality disorder. The majority of these studies are done in developed countries. Very few literature is available from India and other developing countries regarding the attitudes and reasons of medication compliance. The current study has tried to assess the attitudes and reasons for compliance as well as noncompliance among patients with schizophrenia, which can provide the basis for planning effective interventional strategies to the mental health professionals for improving compliance of the patient in the future.
Aims and objectives
- To assess the attitude toward medication among patients with schizophrenia
- To identify the reasons for drug compliance and noncompliance among patients with schizophrenia.
| Methodology|| |
The present study is a hospital-based noninterventional cross sectional study done on 135 Schizophrenic patients attending the out-patient services in the Department of Psychiatry, Government General Hospital, Kurnool by convenient sampling method for the period of 6 months October 2021–March 2022 after obtaining approval from the Institutional Ethical Committee. The study subjects were selected by the consecutive sampling. Patients aged 18–60 years of age and who met international classification of diseases (ICD-10) criteria for the diagnosis of schizophrenia were included. Patients who were on medication for <6 months of duration, who were aggressive, noncooperative patients with dementia and with significant cognitive deficits were excluded. Data were collected in the form predesigned questionnaire and rating scales were applied. After taking valid informant written consent from patient and attendant, the study subjects were interviewed along with the attendants. The nature and purpose of the study were explained to them in their own language. The confidentiality was assured and their cultural values and ideas were respected. The diagnosis of schizophrenia was reviewed in accordance with ICD-10 research diagnostic criteria.
The positive and negative syndrome scale
Positive and negative syndrome scale (PANSS) is a 30 item, a seven-point instrument for evaluating the severity of positive, negative, and general psychopathology domains in schizophrenia patients. The severity of the illness was measured using PANSS.
Of the 30 items included in the PANSS, 7 items constitute a positive scale, 7 items constitute negative scale, and the remaining 16 items constitute General Psychopathology Scale. The scores for these scales are arrived at by summation of ratings across component items. Therefore, the potential ranges are 7–49 for the positive and negative scales and 16–112 for the General Psychopathology Scale.
In addition to these measures, a composite scale is scored by subtracting the negative score from the positive score. This yields a bipolar index that ranges from −42 to +42, which is essentially a difference score reflecting the degree of predominance of one syndrome in relation to the other.
Rating of medication influence scalex
Subjective reasons for medication compliance/noncompliance were assessed using 20 item rating of medication influence (ROMI) scale. The ROMI is a reliable and valid instrument that can be used to assess the patient's subjective reasons for medication compliance and noncompliance. The subscale findings suggest that the ROMI provides a more comprehensive database for patient-reported compliance attitudes than the other available subjective measures.
Drug attitude inventory
The attitude toward antipsychotic medication was assessed using the 30-item drug attitude inventory (DAI) scale. The DAI consists of a questionnaire that is completed by the patient. It includes a series of questions, each with true/false answers, pertaining to various aspects of the patient's perceptions, and experiences of treatment.
The original scale consists of 30 questions. To calculate the score from a set of answers, each “positive” answer is given a score of plus one, and each “negative” answer is given a score of –1. The total score for each patient is calculated as the sum of the positive scores, minus the negative scores. A positive total score indicates a positive subjective response (adherent) and a negative total score indicates a negative subjective response.
Data were entered in Microsoft Excel and analyzed by using the Statistical Package for the Social Sciences, version 26.0 (IBM Corporation, New York, USA). Frequency and percentage were used for the quantitative data. Mean and standard deviation were used for continuous variables. Pearson Chi-square test was used to compare the attitude toward medication using 30-item DAI scale and to find reasons for drug noncompliance using 20 item ROMI scale.
| Results|| |
Out of 135 study subjects, the mean age group of study subjects was found to be 35.55 years, with standard deviation of 10.26. Males were found to be 78 (57.78%) and females were 57 (42.22%), as shown in [Table 1]. The prevalence observed in the present study, 75 (55.56%) subjects was compliant, i.e., having positive attitude toward medication and 60 (44.44%) subjects were noncompliant toward medication, as shown in [Table 2].
Higher mean scores for PANSS score were seen in compliant group (101.25 ± 19.27) than noncompliant group (100.98 ± 22.51); this difference was found to be statistically not significant (P = 0.94) and G12 domain of PANSS, i.e. insight into illness was seen to be poorer in compliant group (4.21 ± 1.22) than noncompliant group (3.40 ± 1.35). This difference was found to be statistically not significant ( P = 0.004, as shown in [Table 3]. In [Table 4], the prevalance of compliance was more among males 50 (66.7%) in comparison with females 25 (33.3%) and the prevalance of noncompliance was more among females 32 (53.3%) in comparison with males 28 (46.7%). This difference was found to be statistically significant (P = 0.01). The prevalence of compliance was more among graduates 21 (28.0%) in comparison with other status and the prevalence of noncompliance was more among illiterates 24 (40%) in comparison with other status. This difference was found to be statistically significant (P = 0.05).
|Table 3: Relation between compliance and noncompliance and clinical variables|
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|Table 4: The relationship of medication compliance and noncompliance with sociodemographic variables|
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[Table 5] shows that strong degree of influence in compliant group was observed for the reasons being perceived daily benefit, positive relation with prescribing clinician, positive relation with therapist, and positive family belief. The mild degree of influence in compliant group was observed for relapse prevention, pressure/force, and fear of rehospitalization. Hence, the most significant reasons for compliance are perceived daily benefit and positive relation with therapies.
|Table 5: Various reasons of compliance using Rating of Medication Influence Scale: Comparison|
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[Table 6] shows that strong degree of influence in noncompliant group was observed for the reasons being denial of illness, no perceived daily benefit, negative relation with clinician, negative relation with therapist, practitioner opposed to medications, family/friend opposed to medications, access to treatment facilities, embarrassment or stigma over medications/illness, financial obstacles, substance abuse, distressed by side effects, and the mild degree of influence in noncompliant group was noted for desires rehospitalization.
|Table 6: Various reasons of noncompliance using Rating of Medication Influence Scale: Comparison|
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Hence, the most significant factor for noncompliance is denial of illness followed by negative relation with clinician and no perceived daily benefit.
| Discussion|| |
In the present study, out of 135 study subjects, the prevalence of compliance among schizophrenic patient was found to be 75 (55.56%) and prevalence of noncompliance was 60 (44.44%), these findings were higher than studies done by Baby et al. and Ansari et al.
Rao et al. Gupta, Sagar, done study on “Attitude and subjective reasons of medication compliance and noncompliance among out patients with schizophrenia in India” found that prevalence of noncompliance was 38.7%. Ansari and Mulla done study on “Analysis of variables affecting drug compliance in schizophrenia” found the prevalence of noncompliance was 37%.
In the present study, female patients 32 (53.3%) were found to be more noncompliant than male patients 28 (46.7%); this difference was found statistically significant (P = 0.01). A study done by Sultan et al. found noncompliance in females 93 (48.4%) was found to be higher than in males 81 (28.1%). This difference was statistically significant (P = 0.04).
This was concurrent with the previous findings This might be because males earn and provide financial support to the family; hence, they receive more family and social support than females, which makes them more compliant to medication. In contrast to the present study, Weiden et al. found that there was no much difference in compliance among males and females.
Reasons for compliance and noncompliance were assessed using ROMI scale. The perceived daily benefit was the most significant contributing factor to the compliance of medication in the present 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, side-effects of the medication, substance abuse, and reduced access to treatment facilities also stand as significant contributory reasons for noncompliance.
The findings are similar to that of previous studies conducted by Rosa et al., and Pogge 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 noncompliance is “inconvenience due to side-effects.”
| Conclusion|| |
Main reasons of drug noncompliance identified in the present study were financial difficulty, distance from the hospital, improvement or no improvement in symptoms, side effects, lack of insight into the mental illness, and lack of awareness about the need of long-term medication, etc. Limitations observed in the present study are self-report methods was used to assess medication compliance. Hence, over reporting of compliance might have occurred. Past history of drug noncompliance was not taken into consideration. Difference in compliance rates between patients using neuroleptics and atypical antipsychotics that influence the antipsychotics was not evaluated. The adequate information regarding the drug compliance and its related factors of the study subjects could not be evaluated as there is a chance of recall bias by patient and informants.
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Conflicts of interest
There are no conflicts of interest.
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D Gangadhar Naik,
H.NO 81-192/4, Ramachandra Nagar, NH44,B-Camp (post) Kurnool, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
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