Beruflich Dokumente
Kultur Dokumente
Original Article
Abstract
Objective: Adherence to medication is essential for maximising the outcomes of patients with
schizophrenia as the consequences of poor adherence are devastating. The study aimed to compare
medication adherence between patients with relapse schizophrenia and those attending psychiatric
follow-up clinics, and to determine the factors affecting adherence.
Methods: This was a cross-sectional study involving 70 patients with schizophrenia who were divided
equally into 2 groups. Medication adherence was assessed with the Medication Adherence Rating Scale.
Appropriate instruments were used to measure insight, social support, and psychopathology. Various
socio-demographic and clinical variables were explored to find associations with medication adherence.
Results: Medication adherence among patients with schizophrenia was poor; 51% of the patients did
not adhere to a medication regimen. Adherence was better in outpatients with schizophrenia (61%) than
in relapse cases (39%), although the difference was not statistically significant (t = 1.70; p = 0.09).
Besides, relapse patients had significant higher number of admission (X2 = 22.95; p < 0.05) and severe
psychopathology (t = 29.96; p < 0.05), while perceived social support was significantly better in
outpatients with schizophrenia (t = 2.90; p < 0.05). Frequency of admission (adjusted b = 0.55; 95%
confidence interval [CI], -0.99 to -0.10; p < 0.05) and psychopathology (adjusted b = 0.12; 95% CI,
-0.24 to -0.01; p < 0.05) were also significantly associated with medication adherence.
Conclusion: Medication adherence among both groups of patients with schizophrenia was poor. If
adherence is addressed appropriately, the number of admissions and severity of psychopathology could
be improved.
Key words: Patient compliance; Psychopathology; Schizophrenia; Social support
70
51%
61% 39%
t =1.70 p=0.09
X2=22.95p<0.05
t =29.96p<0.05
t =2.90p<0.05b=0.5595%=
0.99
0.10p < 0.05b=0.1295%=0.24
0.01
p<0.05
68
Original Article
relapse
Introduction
Medication adherence or compliance is defined as the
extent to which a persons behaviour coincides with the
prescribed medical advice.1 Adherence is best viewed as
continuously
disturbed
rather
than
naturally
dichotomous; total adherence or non-adherence is rare.2
Rates of medication non- adherence among patients with
schizophrenia vary widely; a figure of up to 90% has been
reported, depending on the setting, patient population, and
adherence measures.3,4 The majority of experts believe that
patients with schizophrenia or bipolar disorder on average
takes only 51% to 70% of the prescribed medications.5
Adherence to treatment has a significant impact on the
prognosis of schizophrenia. Good medication adherence
generally contributes to an improvement in clinical
outcome, which leads to a reduced rate of rehospitalisation,
higher rates of employment, and improved quality of life
and functioning.6
The reasons for poor treatment adherence are
complex and heterogeneous.7,8 From patient perspective,
these include forgetting to take the medication, losing or
running out of medication, thinking that it is not needed,
not wanting to take the drug, and fear of side-effects.9
This study aimed to determine the socio-demographic and
clinical factors associated with medication adherence in
patients with schizophrenia, and compare the difference in
medication adherence between currently admitted (relapse
schizophrenia) and those attending psychiatric followup clinics (outpatients with schizophrenia). Comparison
between both groups of patients shall give us an insight
into whether medication adherence is the ultimate factor in
relapse of the illness.
Methods
Study Subjects and Design
This was a cross-sectional study which used universal
sampling to recruit the study sample. Patients with
schizophrenia attending psychiatric follow-up clinics and
those currently admitted to the psychiatric ward (for
East Asian Arch Psychiatry 2014, Vol 24, No.2
69
69
Rating Instruments
Medication Adherence Rating Scale
Patients medication adherence was assessed using a
modified Malay version of Medication Adherence Rating
Scale (MARS).2 The original MARS is a 10-item selfrating scale with yes / no response. After consulting the
original author, only 4 items pertaining to medication
adherence behaviour were utilised. They included: (1) Do
you forget to take your medication? (2) Are you careless
at times about taking your medication? (3) When you
feel better, do you sometimes stop taking your
medication? and (4) Sometimes, if you feel worse when
you take the medicine, do you stop taking it?. The other
items which are not directly related to medication
adherence were not utilised: items 5 to 8 measured the
attitudes towards taking medication, and items 9 and 10
assessed negative side-effects and attitude towards
psychotropic medications. Total score of MARS ranged
from 0 (low likelihood of medication adherence) to 10
(high likelihood).11 For the 4-item scale, a score of
3 indicated adherence. In the validation study conducted
earlier, we found that MARS had acceptable validation
indexes. The internal consistency coefficient (Cronbachs
alpha) was 0.75, which was comparable with that of the
previous study.2
Insight
and
Treatment
Attitude
Questionnaire
The Insight and Treatment Attitude Questionnaire (ITAQ)
is an 11-item rating scale to evaluate patient recognition
of psychiatric illness and need for treatment, particularly
schizophrenia.12 Each question is scored between 0 and
2 with a maximum possible score of 22. Poor insight is
associated with a score from 0 to 7, fair insight 8 to 14, and
good insight 15 to 22.
70
70
Results
Socio-demographic and Clinical Characteristics
A total of 70 patients participated in this study, with equal
number in each group. The mean ( standard deviation)
age of the patients was 33 8 years. Most of the patients
were Malays (97%), more than half were male (57%), and
the majority was single (63%). Although more than 90% of
the patients had either completed secondary school or
tertiary education, the majority of them (59%) was
unemployed. Therefore, more than half of them (54%) had
a monthly income of < 100 Malaysia Ringgit (about 31
USD). Nearly half of the patients (44%) had schizophrenia
of >10 years. About half of the patients (53%) had a history
of admission of 1 to 5 times. All patients were prescribed
antipsychotic medication and about two-thirds (64%) were
on atypical antipsychotic drugs.
X2 / t
p Value
33 10
33 8
-0.047
0.91
Sex
Male
Female
21 (60)
14 (40)
19 (54)
16 (46)
0.23
0.63
Education level
Primary
Secondary
Tertiary
4 (11)
19 (54)
12 (34)
1 (3)
25 (71)
9 (26)
3.05
0.22
Marital status
Single
Married
Divorced / separated
23 (66)
4 (11)
8 (23)
21 (60)
11 (31)
3 (9)
5.63
0.06
Occupation
Unemployed
Employed
24 (69)
11 (31)
17 (49)
18 (51)
2.88
0.08
21 (60)
6 (17)
4 (11)
4 (11)
17 (49)
4 (11)
6 (17)
8 (23)
2.55
0.46
14 (40)
5 (14)
16 (46)
11 (31)
9 (26)
15 (43)
1.53
0.46
0
17 (49)
18 (51)
12 (34)
20 (57)
3 (9)
22.95
< 0.05
Type of antipsychotics
Typical
Atypical
Both
11 (31)
20 (57)
4 (11)
9 (26)
25 (71)
1 (3)
2.55
0.27
Relapse cases
Outpatients
MARS
MSPSS
ITAQ
Symptoms
BPRS (total)
BPRS (psychotic)
BPRS (depressive)
2.6 1.2
53.0 15.3
7.6 6.0
2.0 1.5
62.7 12.6
9.3 5.1
5.3 1.0
5.3 1.0
0
0.1 0.3
0
0.1 0.3
Mean difference
(95% CI)
-0.9 to 1.2
3.0 to -16.4
-0.9 to 4.4
-5.6 to -4.9
-5.7 to -5.0
-0.01 to 0.18
p Value
1.70
2.90
1.295
0.09
< 0.05
0.20
-29.96
-31.66
1.78
< 0.05
< 0.05
0.08
Abbreviations: BPRS = Brief Psychiatric Rating Scale; CI = confidence interval; ITAQ = Insight and Treatment Attitude
Questionnaire; MARS = Medication Adherence Rating Scale; MSPSS = Multidimensional Scale of Perceived Social Support.
*
Data are shown as mean standard deviation, unless otherwise specified.
Independent t test.
East Asian Arch Psychiatry 2014, Vol 24, No.2
71
71
Discussion
This study found a high non-adherence rate in the study
subjects, with nearly half of all the patients (51%) not
adhering to their medication. As expected, the nonadherence rate among patients with relapse schizophrenia
(61%) was higher than that in outpatients with
schizophrenia (39%), although the difference in the rate
was not significant. Better social support and insight in
outpatients with schizophrenia partly contributed to their
higher rate of adherence. The non-adherence rate in this
study aligns with that from other studies, such as those by
Lacro et al16 (49.5%) and Yang et al17 (41.2%). However,
one study18 found that the rate of non-compliance with
medication was as low as 25.8%.
The poor medication adherence in both groups of
Table 3. Association between demographic factors with medication adherence among patients with schizophrenia.*
Age
Gender
Education level
Marital status
Occupation
Income
Duration of illness
Frequency of admission
Type of antipsychotic
p Value
0.08
-0.80
-0.19
-0.13
-0.32
-0.007
-0.23
0.59
0.08
(-1.43
(-0.76
(-0.56
(-0.97
(-0.28
(-0.59
(-1.05
(-0.49
to
to
to
to
to
to
to
to
-0.18)
0.38)
0.30)
0.33)
0.27)
0.12)
-0.13)
0.66)
0.01
0.51
0.54
0.32
0.95
0.19
0.01
0.76
p Value
< 0.05
Table 4. Association of symptoms, insight, and social support with medication adherence among patients with
schizophrenia.*
Variable
MSPSS
BPRS
ITAQ
2.21 (0.89-3.52)
-0.13 (-0.24 to -0.02)
0.04 (-0.02 to 0.09)
p Value
Adjusted regression
coefficient (95% CI)
p Value
< 0.05
0.85
< 0.05
0.19
Abbreviations: BPRS = Brief Psychiatric Rating Scale; CI = confidence interval; ITAQ = Insight and Treatment Attitude
Questionnaire; MSPSS = Multidimensional Scale of Perceived Social Support.
*
Forward, backward and stepwise multiple linear regression methods were applied. Model assumption was fulfilled. No
East Asian Arch Psychiatry 2014, Vol 24, No.2
72
72
73
73
Declaration
The authors declared no conflict of interest. The study was
self-supported for preparation of dissertation of MMed
(Psychiatry), Universiti Sains Malaysia.
References
1. Hayness BR, Sackett DL. Compliance with therapeutic regimen.
Baltimore: John Hopkins University Press; 1976.