Analysis of variables affecting drug

compliance in schizophrenia
Shakeel Ansari and Shakila Mulla1
Department of Psychiatry, Jhalawar Medical College, Jhalawar, Rajasthan, India
1Department of Community Medicine, Jhalawar Medical College, Jhalawar, Rajasthan, India
Address for correspondence: Dr. Shakila Mulla, 51, Prem Nagar, Near Purani Chungi,
Ajmer Road, Jaipur - 302 019, Rajasthan, India. E-mail: mulla.shakila@yahoo.co.in

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Abstract
Context:
As compliance of the patient during management of schizophrenia is
crucial, the current study was conducted to find out the factors that
affected compliance.
Aims:
The aim of the study was to analyze the prevalence of noncompliance
and to find out different factors affecting compliance in schizophrenic
patients.
Materials and Methods:
Observational cross-sectional study was conducted on 100 adult
schizophrenic patients. Noncompliance was assessed using the rating
of medication influence (ROMI) scale. Severity of illness was
measured using positive and negative syndrome scale (PANSS).
Results:
Prevalence of noncompliance was 37%. Using ROMI scale; positive
relationship with psychiatrist, family pressure for taking medications,
stigma, and substance abuse were found to be significant factors.
Severity of illness was also found as determining factor.
Conclusion:
To improve the compliance in schizophrenia patients, roles of both
psychiatrists and family members are crucial.
Keywords: Compliance, Positive and Negative Syndrome Scale,
Rating of Medication Influence scale, schizophrenia
Patients who do not follow the treatment schedule prescribed by
physicians can be described as noncompliant.[1] Side effect remains
an important issue and substance abuse is an important factor leading
to noncompliance.[2,3]
If we look at the problem statement, the mean levels of compliance
were 58% for antipsychotics.[4] One Indian study shows prevalence
of noncompliance to be 38.7%.[5] It is estimated that the rate of
noncompliance is approximately 50% during first year and 75%
during second year.[6]
Reasons for noncompliance are multiple. Hence, the current study
was conducted to know different factors affecting compliance in
schizophrenia.
MATERIALS AND METHODS
The current study was carried out at one of the Mental Health Center
in the district of Aurangabad, Maharashtra. Patient profile in the study
area was mixed, covering both rural and urban populations.
This is an observational cross-sectional study. The study population
comprised registered adult schizophrenic patients from outpatient and
inpatient departments. Inclusion criteria was a primary axis I
diagnosis of schizophrenia per Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition (DSM IV TR),[7] age of 18–65
years, and 1 year or more duration of illness. Exclusion criteria was
presence of medical disorder or organicity, mental retardation,
unavailability of reliable relatives, and the patients who were not
prescribed medicines in the past 6 months.
The study was conducted in 2009–2010. Sample size was calculated
based on the prevalence of noncompliance in schizophrenic patients
using sample size formula.[2,8] According to the formula, the sample
size worked out as 81.8. It was rounded up to 100. Consent was
obtained from each of the patient and family members.
With the help of predesigned proforma, preliminary data regarding
socio-demographic profile were noted. The patient's history was noted
and the clinical examination was carried out. The severity of illness
was measured using positive and negative syndrome scale (PANSS).
Reasons of noncompliance were assessed using rating of medication
influence (ROMI) scale.
Statistical analysis: Risk factors affecting compliance were analyzed
using the Statistical Package for Social Sciences, version 16 (SPSS
V16.0). For qualitative data, Pearson's Chi-square test was applied.
For quantitative data, mean, standard deviation, and standard error
were calculated. Student t test was performed to assess severity of
disease using PANSS score.
RESULTS
Among 100 schizophrenic cases, 37 were noncompliant. Among
socio-demographic variables, gender, residential area, and substance
abuse were statistically significantly associated with noncompliance.
Table 1 shows different reasons for compliance using ROMI scale.
The responses to the question ‘what is your main motivation for
taking the medication?’ are grouped into six questions in the ROMI
scale. The responses to the question ‘what is your main motivation for
not taking the medication?’ are grouped into twelve closed questions
in the ROMI scale [Table 2].
After applying Student t-test, the correlation of noncompliance with
severity of schizophrenia was found very highly significant [Table 3].
DISCUSSION
The current study was conducted on 100 adult schizophrenic patients
with duration of illness of more than 1 year. The noncompliance rate
observed in the current study was 37%, which was consistent with
other Indian studies.[5,9] The point of concern coming out of these
observations is that this is a very high prevalence of noncompliance,
which could affect the management of schizophrenia cases.
Most of the previous studies showed that substance abuse is a strong
predictor of noncompliance, which is consistent with the current
study.[9,10] Statistically significant reasons of compliance found as
per ROMI scale emphasize the fact that the number of positive effects
of neuroleptics are of greater significance for compliance than the
unwanted effects of the medication, and positive doctor–patient
relationship is essential in improving compliance.[10,11]
Evaluation of reasons of noncompliance using ROMI scale
highlighted five important reasons. Patients who do not comply are
likely to feel that their medications do not help as opposed to patients
who comply with neuroleptics and are hence more likely to report
feeling better.[12] Poor relationship with psychiatrist leads to poor
compliance. Poor insight was another important factor. Stigma related
to schizophrenia is exponential. The presence of any of neuroleptic
side effects was also a determining factor for noncompliance. The
severity of illness was strongly correlated to noncompliance.
CONCLUSION
Looking at the high prevalence of noncompliance, all the related
factors need to be urgently addressed. Compliance is highly
influenced by benefit with medicines and positive relationship with
the psychiatrists; therefore, psychiatrists should maintain a good
therapeutic relationship with schizophrenic patients. Family pressure
on the subjects for taking medication increases compliance,
suggesting a need for psycho-education to family members. There is a
need for treatment of substance abuse along with management of
schizophrenia.
Footnotes
Source of Support: Nil.

Conflict of Interest: None declared.

REFERENCES
1. Kampman O, Lehtinen K. Compliance in psychoses. Acta
Psychiatr Scand. 1999;100:167–75. [PubMed: 10493082]
2. Fenton WS, Blyler CR, Heinssen RK. Determinants of medication
compliance in schizophrenia: Empirical and clinical findings.
Schizophr Bull. 1997;23:637–51. [PubMed: 9366000]
3. Lacro JP, Dunn LB, Dolder CR, Leckband SG, Jeste DV.
Prevalence of and risk factors for medication nonadherence in patients
with schizophrenia: A comprehensive review of recent literature. J
Clin Psychiatry. 2002;63:892–909. [PubMed: 12416599]
4. Cramer JA, Rosenheck R. Compliance with medication regimens
for mental and physical disorders. Psychiatr Serv. 1998;49:196–201.
[PubMed: 9575004]
5. Baby RS, Gupta S, Sagar R. Attitudes and subjective reasons of
medication compliance and noncompliance among outpatients with
schizophrenia in India. Internet J Epidemiol. 2009;7:1.
6. Weiden PJ, Dixon L, Frances A, Appelbaum P, Haas G, Rapkin B.
Neuroleptic noncompliance in schizophrenia. Schizophr Bull.
1990;12:312–4.
7. American Psychiatric Association. 1st Indian Edition 2005.
Diagnostic and statistical manual of mental disorders: DSM-IV-TR.
8. Dixit JV. 3rd ed. Jabalpur: Banarasidas Bhanot Publisher; 2005.
Textbook on Principles and Practice of Biostatistics.
9. Maheshwari SK, Gupta S, Sharan P. Medication non-compliance
and substance abuse in schizophrenia. Nurs J India. 2009;100:201–3.
[PubMed: 20151613]
10. Olfson M, Mechanic D, Hansell S, Boyer CA, Walkup J, Weiden
PJ. Predicting medication noncompliance after hospital discharge
among patients with schizophrenia. Psychiatr Serv. 2000;51:216–22.
[PubMed: 10655006]
11. Adams SG, Jr, Howe JT. Predicting medication compliance in a
psychotic population. J Nerv Ment Dis. 1993;181:558–60. [PubMed:
7902413]
12. Herz MI, Melville C. Relapse in schizophrenia. Am J Psychiatry.
1980;137:801–5. [PubMed: 6104444]
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Figures and Tables
Table 1
Various reasons of compliance using ROMI scale: Comparison

Table 2
Various reasons of noncompliance using ROMI scale: Comparison
Table 3
Correlation of compliance with severity of disease using PANSS