Medication adherence in schizophrenia: The role of insight, therapeutic alliance and perceived trauma associated with psychiatric care

Highlights

• Medication non-adherence concerns 50% of schizophrenic patients.

• The mediating role of perceived trauma on adherence using pathway methodology.

• Therapeutic alliance was found to be a strong predictor of medication adherence.

• Treatment-related trauma moderates weakly the role of insight on adherence.

• Adherence could be enhanced by reducing perceived trauma or increasing insight.

Abstract

Medication non adherence in schizophrenia is a major cause of relapse and hospitalization and remains for clinicians an important challenge. This study investigates the associations between insight, therapeutic alliance, perceived trauma related to psychiatric treatment and medication adherence in patients with schizophrenia. In this multicenter study, 72 patients were assessed regarding symptomatology, self-reported adherence with medication, insight, medication side-effects, therapeutic alliance and perceived trauma related to psychiatric treatment. Structural Equation Modeling (SEM) was used to test predicted paths among these variables. The data fit a model in which medication adherence was directly predicted by insight, therapeutic alliance and perceived trauma related to psychiatric treatment. Perceived trauma moderates the role of insight on medication adherence. The final model showed good fit, based on four reliable indices. Greater adherence was correlated with higher insight, higher therapeutic alliance and lower perceived trauma. These three variables appear to be important determinants of patient's medication adherence. Medication adherence could be enhanced by reducing perceived trauma and by increasing insight. The need for mental health providers to acknowledge patients' potentially traumatic experience with psychiatric treatment and the need to encourage greater involvement in care are discussed.

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.