Medication adherence in schizophrenia: The role of insight, therapeutic alliance and perceived trauma associated with psychiatric care
Introduction
Rates of medication non-adherence among patients with schizophrenia have been estimated at approximately 50% (Gilmer et al., 2004, Lacro et al., 2002, Velligan et al., 2009), leading to higher rates of relapse and hospitalization as well as to decreasing clinical, cognitive and functional prognosis (Ascher-Svanum et al., 2006, Llorca, 2008, Robinson et al., 1999, Weiden et al., 2004). While the identification of determinants of poor adherence has yielded valuable results, additional research is needed as the identification and characterization of cluster of patients with poor medication adherence remains an important challenge (Misdrahi et al., 2016).
Insight into illness is commonly observed as a determinant of poor adherence (Mohamed et al., 2009, Novick et al., 2015, Rocca et al., 2008) but its effect may be indirect and mediated by other potential factors including attitudes toward medication (Baloush-Kleinman et al., 2011, Beck et al., 2011, Drake et al., 2015, Samalin et al., 2016), therapeutic alliance (Day et al., 2005, Roche et al., 2014) or perceived coercion (Day et al., 2005, Jaeger and Rossler, 2010). Engaging patients in treatment requires an efficient therapeutic alliance (Frank and Gunderson, 1990) which is a key factor in the care of patients with severe psychiatric disorders as it is associated with better adherence (Lecomte et al., 2008, McCabe et al., 2012, Misdrahi et al., 2012). Despite the hypothesized association between the therapeutic relationship and the experience of coercion (Gilburt et al., 2008), literature is scarce to test quantitatively this link. Few studies have investigated whether traumatic and coercive experiences related to psychiatric care are associated with medication adherence.
That being said, most studies have examined the impact of each determinant in isolation. However, from a methodological perspective, these studies did not use analytical techniques that allow for an examination of the direction and the structure of the relations between the determinants and medication adherence. More specifically, these studies did not differentiate direct and indirect determinants of adherence. Some of the determinants that have no direct effect may have an indirect effect through mediating factors.
The aim of the present study was to investigate the complex relationship among insight, therapeutic alliance, perceptions of trauma experiences related to psychiatric treatment and medication adherence in patients with schizophrenia. We used structural equation modeling (SEM), which is a useful statistical procedure, to test a theory involving non-straightforward relationships and is therefore well suited to the management of cross-sectional data for inferential purposes.
Section snippets
Participants
In this multicenter study, 72 patients were recruited consecutively in three comparable psychiatric hospitals located in Bordeaux (n = 47), Clermont-Ferrand (n = 8) and Paris (n = 17). Recruited patients did not differ on socio-demographic data between the three centers. Patients were recruited during hospitalization, less than one week prior to scheduled discharge, after the remission of acute symptomatology, when patients were considered to be clinically stable (judged compatible with
Sample characteristics (Table 1)
Of the 72 participants, the majority met criteria for schizophrenia (69.4%), and the remaining 30.6% met criteria for schizoaffective disorder. The mean age was 38.7 (SD = 11.5) years, and 49 patients (68.1%) were men. Overall, 27 patients (37.5%) had a university level education. The mean length of illness was 12.6 years (SD = 7.4 years) and the mean number of previous hospitalizations was 6.1 (SD = 5.5).
Psychometrics measures revealed that patients had a high level of psychotic symptoms with
Discussion
Overall, the present study revealed that in a sample of stabilized schizophrenic patients, lower adherence to pharmacological treatments was significantly associated with lower insight, lower therapeutic alliance and perceived treatment-related trauma. These associations were then explored using structural equation modeling. The model showed good fit with the data and provided three main findings: (1) therapeutic alliance was found to be a strong predictor of medication adherence, (2) to a
Conflict of interest
None
Contributors
D. Misdrahi and F. Baylé designed the study. D. Misdrahi, F. Baylé and P-M. Llorca carried out inclusion and collected data during an extensive standardized evaluation. A. Tessier and L. Boyer performed the statistical analysis. A. Tessier and D. Misdrahi wrote the first complete manuscript. L. Boyer, M. Husky, F. Baylé and P-M. Llorca provided substantial modification to the final manuscript. All authors were involved in the project and approved the final manuscript.
Role of the funding source
This work was supported by a grant from the Clinical Research Hospital Program from the French Ministry of Health (PHRC “2012”). The funding source had no role in the conduct or publication of the study.
Acknowledgments
None
References (43)
- et al.
Adherence to antipsychotic drug treatment in early-episode schizophrenia: a six-month naturalistic follow-up study
Schizophr. Res.
(2011) - et al.
Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation
Clin. Psychol. Rev.
(1988) - et al.
Are we addressing the “right stuff” to enhance adherence in schizophrenia? Understanding the role of insight and attitudes towards medication
Schizophr. Res.
(2011) - et al.
Enhancement of outpatient treatment adherence: patients' perceptions of coercion, fairness and effectiveness
Psychiatry Res.
(2010) - et al.
Impact of coercion on treatment outcome
Int. J. Law Psychiatry
(1997) - et al.
Predictors and profiles of treatment non-adherence and engagement in services problems in early psychosis
Schizophr. Res.
(2008) - et al.
The Mini International Neuropsychiatric Interview (MINI). A short diagnostic structured interview: reliability and validity according to the CIDI
Eur. Psychiatry
(1997) Partial compliance in schizophrenia and the impact on patient outcomes
Psychiatry Res.
(2008)- et al.
The 4-Point ordinal Alliance Self-report: a self-report questionnaire for assessing therapeutic relationships in routine mental health
Compr. Psychiatry
(2009) - et al.
Correlations of attitudes toward antipsychotic drugs with insight and objective psychopathology in schizophrenia
Compr. Psychiatry
(2008)
Attitudes toward antipsychotic medications as a useful feature in exploring medication non-adherence in schizophrenia
Schizophr. Res.
The influence of baseline symptoms and insight on the therapeutic alliance early in the treatment of schizophrenia
Eur. Psychiatry J. Assoc. Eur. Psychiatr.
Awareness of illness in schizophrenia and schizoaffective and mood disorders
Arch. Gen. Psychiatry
Diagnostic and Statistical Manual of Mental Disorders
Medication adherence and long-term functional outcomes in the treatment of schizophrenia in usual care
J. Clin. Psychiatry
A self-report Insight Scale for psychosis: reliability, validity and sensitivity to change
Acta Psychiatr. Scand.
Metacognition as a mediating variable between neurocognition and functional outcome in first episode psychosis
Schizophr. Bull.
Attitudes toward antipsychotic medication: the impact of clinical variables and relationships with health professionals
Arch. Gen. Psychiatry
Modeling determinants of medication attitudes and poor adherence in early nonaffective psychosis: implications for intervention
Schizophr. Bull.
Validation study of the Medication Adherence Rating Scale. Results from the FACE-SZ national dataset
Schizophr. Res.
The role of the therapeutic alliance in the treatment of schizophrenia. Relationship to course and outcome
Arch. Gen. Psychiatry
Cited by (45)
Solid implantable devices for sustained drug delivery
2023, Advanced Drug Delivery ReviewsWeekly telephone mood monitoring is associated with decreased suicidality and improved sleep quality in a clinical sample
2022, Psychiatry ResearchCitation Excerpt :Further, participants seemed to become more self-aware and obtain insight into their illness and suggested that mood monitoring assisted with medication adherence. There is evidence that patients tend to be more adherent to their medication once they start developing more insight into their illness and the consequences of not taking treatment, with the literature indicating a strong link between impaired insight and nonadherence to psychiatric medication (De las Cuevas and de Leon, 2020; Sajatovic et al., 2009; Tessier et al., 2017). Notwithstanding the overall positive experiences of monitoring, it is important to note that some participants reported negative experiences.
Impact of childhood trauma on positive and negative symptom remission in first episode psychosis
2021, Schizophrenia Research