A Pilot Study of Barriers to Medication Adherence in Schizophrenia

Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, VA Medical Center (152/NLR), 2200 Ft. Roots Drive, North Little Rock, AR 72114-1706, USA.
The Journal of Clinical Psychiatry (Impact Factor: 5.5). 02/2004; 65(2):211-6. DOI: 10.4088/JCP.v65n0211
Source: PubMed


Interventions to improve adherence to antipsychotic medication are needed. The aims of the current study were to identify the most common barriers to medication adherence in a cohort of patients receiving outpatient and inpatient treatment for an acute exacerbation of schizophrenia, compare clinical and demographic characteristics of patients with lower versus higher numbers of barriers, and characterize patients most likely to be nonadherent to antipsychotic medication.
The present study analyzed data collected during the Schizophrenia Guidelines Project (SGP), a multisite study of strategies to implement practice guidelines that was funded by the U.S. Department of Veterans Affairs and conducted from March 1999 to October 2000. Nurse coordinators had conducted clinical assessments and performed an intervention designed to improve medication adherence by addressing barriers to adherence. Data on patient symptoms, functioning, and side effects had been obtained using the Positive and Negative Syndrome Scale (PANSS), the Schizophrenia Outcomes Module, the Medical Outcomes Study 36-item Short-Form Health Survey, and the Barnes Akathisia Scale (BAS). Administrative data were used to identify patients with an ICD-9 code for schizophrenia. A total of 153 patients who met this criterion and participated in the intervention arm of the SGP had complete data available for analysis in the current study.
The most common patient-reported barriers were related to the stigma of taking medications, adverse drug reactions, forgetfulness, and lack of social support. Bivariate analysis showed that patients with high barriers were significantly more likely to be nonadherent (p < or =.02), to have problems with alcohol or drug use (p =.02), to have higher PANSS total scores (p =.03), and to have higher mean BAS scores (p =.02). Logistic regression showed that lower patient education level (odds ratio [OR] = 3.95, p =.02), substance abuse (OR = 3.24, p =.01), high PANSS total scores (OR = 1.02, p =.05), and high barriers (OR = 2.3, p =.05) were significantly associated with the probability of nonadherence.
It may be possible to identify patients most likely to benefit from adherence intervention. The data presented here will help to inform future research of clinical interventions to improve medication adherence in schizophrenia and help to stimulate further work in this area.

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    • "The most wellestablished reasons pertain to lack of insight (David, 1992; Kemp and David, 1995), medication side-effects or non response and poor therapeutic alliance (Byerly et al., 2007; Miller, 2008). Less well researched factors that have been added to this enumeration relate to psychological motives such as fear/avoidance of stigma (Hudson et al., 2004; Tranulis et al., 2011) and cognitive factors such as forgetfulness (Moritz et al., 2013; Moritz et al., 2009) and denial that biological factors are relevant to the disorder (Wiesjahn et al., 2014). Few studies addressed whether positive attitudes towards psychopathological symptoms may also play a role in nonadherence . "
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    ABSTRACT: Approximately 50%–75% of all patients do not take their antipsychotic medication as prescribed. The current study examined reasons why patients continue versus discontinue antipsychotic medication. We were particularly interested to which extent positive attitudes towards psychotic symptoms foster medication nonadherence. An anonymous online questionnaire was set up to decrease response biases. After a strict selection process, 91 participants with schizophrenia spectrum disorders were retained for the final analyses. On average, 6.2 different reasons for nonadherence were reported. Side-effects (71.4%), sudden subjective symptom improvement (52.4%), forgetfulness (33.3%) and poor communication between therapist and patient (25.6%) emerged as the most frequent reasons for drug discontinuation. Approximately one fourth of all participants (27.3%) reported at least one positive aspect of psychosis as a reason for nonadherence. In contrast, patients reported on average 3.5 different reasons for adherence (e.g., want to live a normal life (74.6%), fear of psychotic symptoms (49.3%)). The belief that paranoia represents a survival strategy (subscale derived from the Beliefs about Paranoia Scale) was significantly associated with nonadherence. Patients' attitudes toward medication and the individual illness model need to be carefully considered when prescribing medication. In particular, for patients who likely discontinue psychopharmacological treatment, complementary or alternative psychological treatment should be sought in view of a largely increased relapse rate in case of sudden drug discontinuation.
    European Neuropsychopharmacology 11/2014; 24(11). DOI:10.1016/j.euroneuro.2014.09.008 · 4.37 Impact Factor
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    • "Some of the participants in that study related that the likelihood of adherence would have been larger if they early on had been honestly informed that the need for medication might be life-long. Patients in an earlier pilot study considered that the stigma of taking antipsychotics was the main barrier to adherence (Hudson et al., 2004). Others found that patients with employment had a more negative drug attitude and ran an increased risk of non-adherence, possibly connected to the stigma of having to take antipsychotics to function, and the drawback of simultaneously suffering from debilitating side effects (Freudenreich et al., 2004; Hofer et al., 2002). "
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    ABSTRACT: The aims of this naturalistic non-interventional study were to quantify the level of stigma and discrimination in persons with schizophrenia and to test for potential associations between different types of stigma and adherence to antipsychotics. Antipsychotic medication use was electronically monitored with a Medication Event Monitoring System (MEMS(®)) for 12 months in 111 outpatients with schizophrenia and schizophrenia-like psychosis (DSM-IV). Stigma was assessed at endpoint using the Discrimination and Stigma Scale (DISC). Single DISC items that were most frequently reported included social relationships in making/keeping friends (71%) and in the neighborhood (69%). About half of the patients experienced discrimination by their families, in intimate relationships, regarding employment and by mental health staff. Most patients (88%) wanted to conceal their mental health problems from others; 70% stated that anticipated discrimination resulted in avoidance of close personal relationships. Non-adherence (MEMS(®) adherence≤0.80) was observed in 30 (27.3%). When DISC subscale scores (SD) were entered in separate regression models, neither experienced nor anticipated stigma was associated with adherence. Our data do not support an association between stigma and non-adherence. Further studies in other settings are needed as experiences of stigma and levels of adherence and their potential associations might vary by a healthcare system or cultural and sociodemographic contexts. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
    Psychiatry Research 10/2014; 220(3):811-817. DOI:10.1016/j.psychres.2014.10.016 · 2.47 Impact Factor
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    • "A variety of patient-specific factors that extend beyond medication effects contribute to patient adherence. In a study of 153 patients treated at US Veterans Affairs Medical Centers, the most common patient-reported barriers to adherence were stigma related to taking medications, adverse drug reactions, forgetting to take medications, and a lack of social support.2 In a survey of 699 psychiatrists treating 5,729 patients with schizophrenia, factors associated with partial adherence included a lack of insight into the need for medication (68%), denial of illness (63%–66%), embarrassment about taking medication every day (ie, stigma – 62%), and living conditions unsuitable for adherence (46%).1 Cognitive problems were reported in 55% of patients, and substance-abuse issues were believed to be present in 34% of patients. "
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    ABSTRACT: Purpose In patients with schizophrenia, nonadherence to prescribed medications increases the risk of patient relapse and hospitalization, key contributors to the costs associated with treatment. The objectives of this review were to evaluate the impact of nonadherence to pharmacotherapy in patients with schizophrenia as it relates to health care professionals, particularly social workers, and to identify effective team approaches to supporting patients based on studies assessing implementation of assertive community treatment teams. Materials and methods A systematic review of the medical literature was conducted by searching the Scopus database to identify articles associated with treatment adherence in patients with schizophrenia. Articles included were published from January 1, 2003, through July 15, 2013, were written in English, and reported findings concerning any and all aspects of nonadherence to prescribed treatment in patients with schizophrenia. Results Of 92 unique articles identified and formally screened, 47 met the inclusion criteria for the systematic review. The burden of nonadherence in schizophrenia is significant. Factors with the potential to affect adherence include antipsychotic drug class and formulation, patient-specific factors, and family/social support system. There is inconclusive evidence suggesting superior adherence with an atypical versus typical antipsychotic or with a long-acting injectable versus an oral formulation. Patient-specific factors that contribute to adherence include awareness/denial of illness, cognitive issues, stigma associated with taking medication, substance abuse, access to health care, employment/poverty, and insurance status. Lack of social or family support may adversely affect adherence, necessitating the assistance of health care professionals, such as social workers. Evidence supports the concept that an enhanced team-oriented approach to managing patients with schizophrenia improves adherence and supports corresponding reductions in relapse rates, inpatient admissions, and associated costs. Conclusion Optimization of medication and involvement of caregivers are important to promoting adherence. A multidisciplinary team approach may be invaluable in identifying barriers to adherence and helping schizophrenia patients overcome them.
    Patient Preference and Adherence 05/2014; 8:701-714. DOI:10.2147/PPA.S59371 · 1.68 Impact Factor
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