Medication non-compliance is a pervasive problem among individuals with a serious and chronic mental illness. The first few weeks after discharge from the hospital signify a critical period in the course of recovery. Previous research indicates that 79 percent of patients with schizophrenia who discontinue medications for less than one week subsequently restart and maintain compliance. Unfortunately, 91 percent of patients who stop medication for more than one week continue to stay off antipsychotic medications until they relapse (Olfson, et al., 2000).
Generally, patients who are admitted for acute hospitalization are highly symptomatic and must make the transition from inpatient to outpatient care in a few short days. This transition puts the patient in a position to assume greater autonomy and control over aspects of their daily lives. The increased independence heightens the risk of noncompliance with medications. In this study, the authors focus on the role of severity of illness, substance use, insight, treatment alliance, family involvement, and aspects of medication management as possible predictors of medication noncompliance after hospital discharge.
The article highlighted that several cross-sectional studies link severity of psychopathology to medication noncompliance. Previous studies have shown that substance intoxication may impair judgment, reduce motivation to pursue long-term goals, and lead to a devaluation of the benefits offered by antipsychotic medications (Owen, Fischer, & Booth, 1996). The availability of family members who remind patients to take their medications is widely believed to lower the risk of medication noncompliance. Several studies have revealed there are lower rates of medication noncompliance among patients who live with family members or with people who supervise their medications (Razali & Yahya, 1995). Additionally, patients who form a strong therapeutic alliance with their therapists seem to be more likely to comply with prescribed medications than patients who form weaker alliances (Frank & Gunderson, 1990).
In the study reported here, medication compliance was assessed in a sample of inpatients with schizophrenia who were interviewed at hospital discharge and then again three months later. This design permitted an examination of whether factors evident during the inpatient stay, such as illness severity, substance use, insight, therapeutic alliance, family support, and medication, predicted medication noncompliance after hospital discharge.
Method
Participants that were eligible for this study were newly admitted to four New York City psychiatric inpatient hospitals, between 18 and 64 years of age, and had an admitting clinical diagnosis of schizophrenia or schizoaffective disorder. A total of 316 patients were eligible for the study and 263 (83 percent) were located for a three-month follow-up interview. Subjects who received depot injections after hospital discharge were not included in the study.
Patients completed a structured assessment spanning clinical symptoms, substance use disorders, insight into illness, and aspects of their medication management. Substance use disorders were assessed at hospital admission with the Mini-International Neuropsychiatric Interview for DSM-IV. Clinical symptoms were assessed at hospital discharge by a research assistant with the BPRS, GAS, and Center for Epidemiological Studies—Depression Scale (CES-D). Insight into illness was assessed with two probes: “Do you believe you have a mental illness?” and “Would you say you have emotional problems?” In addition, an item was included from the National Health Interview Mental Health Supplement: “How difficult was it for you to recognize the symptoms of your illness?” Possible responses were very difficult, somewhat difficult, and not difficult.
Therapeutic alliance was measured with the six-item Active Engagement Scale completed by inpatient clinicians at the time of discharge. Family involvement was evaluated by asking staff whether patients had any family members, whether family members visited the patient in the hospital, whether they agreed or refused to become involved during the admission, whether they met with staff, and whether they received family therapy. Three months after hospital discharge, patients were re-interviewed in person with the same instruments to assess change in symptoms, mental health service utilization, and use of antipsychotic medication.
Results
The results of the study found of the patients followed up, 41 (19.2 percent) were found to be noncompliant with medication and 172 (80.8 percent) were compliant. The mean ages of the medication noncompliant and compliant groups were 34.8±9.7 years and 37.6±9.6 years, respectively. Patients who became medication noncompliant were significantly more likely than those who remained compliant to have been medication noncompliant during the three-month period before hospitalization. Patients who became medication noncompliant were significantly more likely than their compliant counterparts to meet past-six-month criteria for a substance use disorder. A significant number of patients who became medication noncompliant reported that they found it somewhat or very difficult to recognize their clinical symptoms.
Discussion
The authors found that approximately one in five patients with schizophrenia reported missing one week or more of oral antipsychotic medications during the first three months after hospital discharge. Missing or stopping antipsychotic medication was strongly associated with several problematic outcomes, including symptom exacerbation, noncompliance with outpatient treatment, homelessness, emergency room visits, and re-hospitalization. A recent history of substance abuse or dependence emerged as the strongest predictor of medication noncompliance. Additionally, medication noncompliance was also associated with noncompliance during the transition to outpatient care and proved to be a strong predictor of future noncompliance.
In this study, little evidence was found that family visits or family therapy sessions during hospitalization was related to future medication compliance. However, patients whose families refused to participate in treatment were at high risk for stopping their medications. Patients who were more actively involved in inpatient treatment were more likely to remain on their medications. This finding may help explain the success of psychological strategies that seek to reduce noncompliance by building the patient’s motivation to take antipsychotic medications.
The authors found that medication compliance was not related to whether a patient acknowledged having a mental illness or diagnosis of schizophrenia, but rather to the patient’s ability to recognize clinical symptoms. Patients who have difficulty recognizing their own symptoms may be less aware of their ongoing need for maintenance treatment and the benefits of antipsychotic medications. Various aspects of symptom severity failed to predict medication noncompliance. Symptoms of grandiosity and suspiciousness were only weakly related to noncompliance. The authors noted that patients treated with Clozapine or Risperidone, or treated with lower doses of antipsychotic medications tended to be less likely to become medication noncompliant, although this relationship was not statistically significant.
The findings are inhibited by several limitations. First, they relied exclusively on patient self-reports to determine medication compliance. Problems with recall and reality distortions may have introduced inaccuracies in their histories. Having other informants would have strengthened measurement in this area. Second, only short-term follow-up data were available. A longer follow-up period might have yielded larger numbers of medication noncompliant patients and a different pattern of predictors.
What We Can Do
Several important findings can be taken from this study to further assist our hospital staff with improving patient medication compliance after discharge. First, staff who takes a careful history of recent medication noncompliance may improve their prediction of who is at risk for stopping their antipsychotic medications. Second, staff who detects that family members oppose or do not support some aspect of their relative’s psychiatric treatment should make a concerted effort to understand and address these family attitudinal barriers. Third, staff can help patients work through their ambivalence about antipsychotic medications by asking inductive questions, examining the pros and cons of medication compliance, and selectively reinforcing adaptive attitudes. Finally, it is possible that psychoeducational strategies that help patients develop more accurate subjective health assessments may improve compliance with maintenance antipsychotic treatment.
References:
Bartko, G., Herczeg, I., Zador, G. (1988). Clinical symptomatology and drug compliance in schizophrenic patients. Acta Psychiatrica Scandinavica, 77, 74–76.
Frank, A.F., Gunderson, J.G. (1990). The role of the therapeutic alliance in the treatment of schizophrenia. Archives of General Psychiatry, 47, 228–236.
Kemp, R., Kirov, G., & Everitt, B. (1998). Randomised controlled trial of compliance therapy. British Journal of Psychiatry, 172, 413–419.
Olfson, M., Mechanic, D., Hansell, S., Boyer, C.A., Walkup, J., & Weiden, P.J. (2000). Predicting Medication Noncompliance After Hospital Discharge Among Patients with Schizophrenia. Psychiatric Services, 51, 216-222.
Owen, R.R., Fischer, EP., & Booth, E.M. (1996). Medication noncompliance and substance abuse among patients with schizophrenia. Psychiatric Services, 47, 853–858.
Razali, M.S., & Yahya, H. (1995). Compliance with treatment in schizophrenia: a drug intervention program in a developing country. Acta Psychiatrica Scandinavica, 91, 331–335.
Jonathan Torres, M.S.
WKPIC Doctoral Intern