Treatment Non-Compliance In Patients Suffering From Schizophrenia And Bipolar Affective Disorder (BPAD): A Comparative Study

Introduction: Non-adherence to appropriately prescribed medication for psychiatric disorders prevents patients from realizing the full benefits of their treatment and negatively impacts on individuals, their families and the healthcare system. Understanding and reducing non-adherence is therefore a key challenge to quality care for patients with psychiatric disorders. This finding highlights the prevalence, consequence of non-adherence and barriers to adherence. Therefore, the main objective of this study was to determine the incidence and factors associated with medication non-compliance among patients suffering from schizophrenia and bipolar affective disorders. Material And Method: This cross-sectional study included 94 schizophrenia and 76 bipolar affective disorder subjects who were visited psychiatric OPD of tertiary level hospital and disproportionate stratified random sampling method. An anonymous socio-demographic as well contributing factor questionnaire pre tested, semi structured pro forma by interview method and a clinical proforma designed by Morisky, the 8-item Morisky Medication Adherence Scale (MMAS-8) were used for data collection. Results: The prevalence of non-compliance was 88%, the independent predictors of non-compliance were; seeking for traditional/spiritual treatment, weight gain as side effects of drugs , increased number of medication (p=0.038), beginning of medication start (p=0.057), unemployment (p=0.059), low level of insight/education (p=0.044), male as gender (p=0.016). Conclusion: Based on the outcome of the study, we recommend the development of psycho-educational programmes on compliance and the active involvement of the relatives and significant others in the management of patients of mentally ill patients.


INTRODUCTION
The World Health Organization has promoted the term "adherence" for use in treatment of chronic disorders to mean "the extent to which a person's behavior-taking medication, following diet, and/or executing lifestyle changes corresponds with agreed recommendations from a health care provider." 1 Ghimire 2 suggested that non-compliance or non-adherence to treatment is the degree to which a patient does not follow the treatment advise of treating doctor. In other words, it is the failure of the patient to follow the prescribed treatment regimen. Non-compliance is considered to be the major challenges in the treatment of chronic illnesses including Schizophrenia and BPAD globally due to long duration of treatment and numerous other related factors. 3 Similarly, approximately more than one third left medication thinking being all right and other small percentage left due to hallucination, poor insight and cognitive impairment. 4

ORIGINAL ARTICLE
Non-compliance with antipsychotic medication is observed in around 50% of people with schizophrenia and is a major preventable cause of psychiatric morbidity. 5 Approximately 40% of patients stop taking their prescribed antipsychotic medication within 1 year and about 75% discontinue their medication within 2 years. 6 Though there are lots of Psychiatric researches done in Nepal, there is a dearth of research on medication compliance, which is a very important mental health issue. Medication compliance affects intervention outcomes. Therefore, this study was designed to examine medication compliance among patients with Schizophrenia and BPAD with the objective to i) determine the incidence and factors associated with medication non-compliance among patients suffering from schizophrenia and bipolar affective disorders ii) compare noncompliance between the two disorders.  8 . Subjects meeting the inclusion criteria: patients above 18 years old who were diagnosed with schizophrenia or BPAD by psychiatrist attending at psychiatric OPD for follow up since at least 6 months were enrolled in the study after taking the written informed consent. Ethical approval for the study was obtained from Institutional Review Committee. Confidentiality of the data was maintained and the data was used for research purpose only. Data were collected using Socio-demographic data sheet, Data sheet for various factors related to non-compliance and Morisky 8-Item Medication Adherence Questionnaire. Descriptive summaries of socio-demographic and contributing factors for all patients were analyzed. Chi square test was applied for categorical variables. The independent variables included were specified a priority, based on the literature reviewed. Nearly two third of patient with schizophrenia (60.64%) and BPAD (65.79%) had low economic condition. study showed that low economic condition of the patients are more likely to having schizophrenia and BPAD patients. (Table 1.)

DISCUSSION:
From the findings of the present study it is clear that more than one factor is responsible for poor or better compliance of therapeutic regimen. Roy R. et al. 7 Non-adherence to medication regimens is a serious problem. It has many serious effects on prognosis of the illness and overall effectiveness of health systems. Non-adherent patients are more severely ill at the point of readmission to hospital, have more frequent readmissions. 8 It was reported that poor compliance is a problem in all areas of medicine and psychiatry is no exception. 9,10 This is evident in our study that 88.23% of the studied psychiatry patients were non-compliant with treatment. This is comparable to a study conducted by Razali et al. 9 among Malay patients found an overall non-compliance rate of 73.3%. Another study by Yang et al. reported by Lama et al. 11 stated that non-adherence falls within the range of 30% to 65% which is lesser than this study. In the present study, high non-compliance was significantly higher among young mentally ill patients; 58.66% in the age group <40 years and male (59.3%) this is supported by the study done by Livianos-Aldona et al. 12 This is also supported that males were over 3 times more likely to be sub-optimally (low) adherent when compared to females. 13 In this study, among mentally ill patients, noncompliance was more common in patients with schizophrenia (56%) in comparison to patient with BPAD (46%). Evidence suggests that more than 50% of people diagnosed with schizophrenia do not comply with treatment. 5 In a review of Fenton et al. 14 it was commented that non-compliance among patients with schizophrenia was consistently associated with severe psychopathology, greater medication side effect, less family and social support, less insight and a less positive doctor-patient relationship.
The current study showed that the major reasons for non-compliance were joint family (52.66%), side effects of medication; sedation (71%), dizziness (67.33%), weight gain (66%) it is also statistically significant, lack of higher education (81%), unemployment (62%) and unawareness of availability of psychiatric service or unawareness of benefits psychiatric treatment or seeking traditional healer instead of psychiatric treatment (58%) which is statistically significant. Ibrahim et al. 15 said that in terms of treatment sought, seeking for traditional African/spiritual treatments apart from the conventional/orthodox care increases the likelihood of sub-optimal adherence by over 6 times. This is consistent with a study reported in Pakistan by Taj and Khan 16 showed that the most common reasons for non-compliance were unawareness of the benefits of treatment (43%), non-affordability of drugs (33.5%), physical side effects (28.5%), no awareness given by the doctor (3%) and unfriendly attitude of doctors (2%). This study revealed that those who are married had higher non-compliance (79.33%) which is consistent with the research study conducted by Centorrino et al.; compliance was higher among patients who were living alone than among those who were living with others, suggesting that personal interactions at visits may represent a significant positive social support. 17 Considering the realization of importance of treatment most of the patients stop medications because of illiteracy or lack of insight. Similar condition has been described by the study conducted by Taj & Khan that behaviour is further precipitated by the stigma to psychiatric illnesses, treatment from quacks and traditional faith healers and hostility, non-cooperation or inaccessibility of some doctors. 16 It means insight is a determinant of the significance a patient attaches to any form of treatment. The lack of it, therefore, undermines The balance between these influences is perhaps determined by patients' expectations of treatment and specific side effects. For example, weight gain attributed to treatment with antipsychotics may contribute to non-adherence among patients who perceive a negative effect on their body image but not among those who are indifferent to their weight status. 18 The experience of symptoms does not improve the likelihood of good compliance and treatment side-effects do not decrease it. 19 There were some limitations in this study. Sample size is small. Study is confined to a tertiary hospital, which may not necessarily represent the general population of the country. Recall bias associated with self-reporting.

CONCLUSION:
Non-adherence is a common problem in schizophrenia and BPAD is strongly associated with poorer clinical outcomes. This study reveals that non-compliance rates among schizophrenia and BPAD were comparable to the rates reported in other studies. This study stresses the factors of noncompliance: treatment related factors such as, seeking traditional healer as alternative treatment, many pills to take, costly treatment, side effects of drugs and patient related factors such as, lack of family support, forgetting to take medicine, feeling better, cultural barriers etc.