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CME

Compliance With Treatment in Schizophrenia

  • Authors: Joseph Battaglia, MD
  • THIS ACTIVITY HAS EXPIRED
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Target Audience and Goal Statement

This activity is intended for physicians specializing in psychiatry and primary care.

The goal of this activity is to provide current treatment protocols and clinical strategies for the treatment and management of psychiatric disorders and to update the clinician and the researcher on the latest developments in psychiatry and mental health.

On completion of this continuing medical education offering, participants will be able to:

  1. Recognize the most current aspects of early intervention and recovery in schizophrenia and serious mental illness.

  2. Review the current barriers to patients and families seeking treatment for ADHD.


Author(s)

  • Joseph Battaglia, MD

    Assistant Professor, Department of Psychiatry, Albert Einstein College of Medicine, Bronx, New York; Clinical Director, Department of Psychiatry, Bronx Psychiatric Center, Bronx, New York.


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CME

Compliance With Treatment in Schizophrenia

Authors: Joseph Battaglia, MDFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED

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Introduction

Compliance with medications and treatment in patients with schizophrenia has been an elusive pursuit over the last few decades. In a video workshop at the APA Institute on Psychiatric Services, Gary J. Remington, MD, PhD, and April Collins, of the Schizophrenia and Continuing Care Program in Toronto, Canada.[1] described that their goal was to develop and test a treatment program to enhance medication compliance. Data suggest that up to 80% of outpatients comply poorly with medication regimens and that this has been shown to be a major problem in the aftercare of patients with schizophrenia.[2-5] Preliminary collected by Remington and Collins showed that less than 50% of patients are compliant with medication 1 month after discharge, and less than 30% at 2 years. They measured compliance with the Medication Event Monitoring System (MEMS), which uses a computer chip in the bottle-cap that recorded the number of bottle openings and the date and time of each opening.[6] Subjects were blind to knowledge of these caps. They found that that clinicians were wrong about 55% of the time in predicting compliance, with the errors being virtually evenly split between false negatives and false positives. Their study also showed that nonadherence was not strongly related to medication side effects or lack of insight into the illness, but rather to issues such as therapeutic alliance and family/social support.

 

Schizophrenia and Continuing Care Program

The program they developed is an 8-week psychoeducation program for patients with schizophrenia and their families which is designed to improve awareness of illness and treatment adherence. To facilitate group participation, they incorporated the use of patient/family vignettes. These live recordings are embedded in a semi-structured video program in DVD format. The DVD contains 6 modules:

 

  • Overview of schizophrenia  
  • Features of the illness  
  • Medication  
  • Side effects and other problems  
  • Managing day to day  
  • Minimizing relapse  

The participants use a corresponding workbook, which has a 5-question pre- and posttest. The DVD is narrated by a patient's mother, so the families see the illness through her eyes.

 

Study Design

Patients are randomized into 2 groups, with 1 group receiving treatment as usual and the other entering the 8-week study. The study group will consist of 10 to 15 pairs (the patient and 1 family member). They will have 6 weekly 90-minute groups; with 2 weekly follow-up groups -- 1 group will undergo routine follow-up and will attend a refresher course at 6 months. MEMS will measure medication adherence. The other measures to be used include:

 

  • The Positive and Negative Syndrome Scale - PANSS[7]  
  • The Structured Clinical Interview for DSM-III-R Axis I Disorders (SCID-I)[8]  
  • The Working Alliance Inventory[9]  
  • The Family Therapy Alliance Scale[10]  
  • The Attributions of Symptoms Inventory[11]  
  • Scale to Assess Unawareness of Mental Disorder[12]  
  • The Multidimensional Scale of Perceived Social Support[13]  

Baseline data instruments included the Wisconsin Card Sorting Test[14] and the North American Adult Reading Test (NAART) to test frontal lobe functions and reading level. Patients in this study will be a mix of those with first-episode illness and those with a chronic course to see if there is a differential response due to length of illness. The DVD program is designed to facilitate group participation, having button controls that allow you to step out of the program or use other live vignettes on a range of topics such as onset of illness, positive symptoms, and negative symptoms.

 

Comliance: Historical Perspective

Compliance has been defined as "the extent to which a person's behavior coincides with medical or health advice".[15] The term has been criticized for over 2 decades as a "reflection of an outmoded and paternalistic conception of the physician-patient relationship".[16,17] However, compliance is a word often used in clinical settings where for clinicians, patients, and families it remains one of the most difficult challenges in medicating patients.

Compliance is been difficult to study, and it is a complex task for clinicians to identify which patients do not take their medication.[18,19] There are a number of other measures that may improve compliance, including patient or relative self-report, prescription renewals and pill counts, saliva and urine screens, and steady-state serum determinations. Self-reported noncompliance is corroborated more often than is self-reported adherence.[20-22] Statistically evaluating compliance is further complicated because compliance is rarely an all-or-none phenomenon, it may include errors of omission, mistakes in dosage and time taken, as well as taking medications that are not currently prescribed.[23]

Unfortunately, studies show that while hospitalization may improve compliance in the period immediately after discharge, the data do not strongly support the belief that patients learn to adhere to medication regimens after repeated relapses.[24,25] Other studies have shown that patients rated as noncompliant have a 6-month to 2-year risk of relapse that is on average 3.7 times greater than that in patients rated as compliant.[26,27]

The greatest factor influencing compliance seems to be family and social support. The availability of family or friends to assist or supervise medications have been consistently associated with outpatient adherence.[28-30]Draine and Solomon[31] found that better social functioning and more extensive social networks were related to more positive attitudes toward medication compliance. The reverse is also true and negative or stressful social interactions have a negative impact on compliance.[32]

Physician-patient relationship is an important element in patient compliance with medications. The clinical supposition that a positive therapeutic alliance facilitates medication compliance finds empirical support in 3 studies. Nelson and colleagues{E}[29] found that the single best predictor of medication compliance among discharged schizophrenia patients was the patient's perception of the physician's interest in him or her as a person. Marder and colleagues[33] found that inpatients with schizophrenia who consented to neuroleptic treatment rated themselves as more satisfied with ward staff and their own physicians and felt that their physicians understood them or had their best interests in mind. Frank and Gunderson[34] found that 74% of patients with fair or poor therapeutic alliances (rated at 6 months) failed to comply fully with prescribed medication regimens during the next year and a half. In contrast, only 26% of patients with schizophrenia with a good alliance with their therapist (rated at 6 months) were noncompliant.

In the past, patient education about schizophrenia and its treatment have been ineffective at increasing compliance. Boczkowski and colleagues[22] used 30- to 50-minute information sessions yet produced no difference in compliance between an experimental group of outpatients and a control group. Macpherson and colleagues[35] randomly assigned patients to 1 of 3 groups: one group receiving 3 educational sessions at weekly intervals, one receiving a single educational session, and one having no educational intervention. Although participants in the group receiving the 3 sessions did have fewer knowledge errors at 1-month follow-up, their scores on a medication compliance scale did not change. Similarly, Brown and associates[36] documented an increase in knowledge among schizophrenia outpatients who received 2 instructional sessions 1 month apart, but noted that instruction did not affect independently rated compliance.

Eckman and coworkers[37] utilized skills training to provide information about medication. He designed a module that trained patients in 4 skills:

 

  • Obtaining information about medications  
  • Administering medication and evaluating its benefits  
  • Identifying side effects  
  • Negotiating medication with health care providers  

The module was used with patients in a variety of settings for 3 hours a week over 15 to 20 weeks. Results immediately after completion of the module and over a 3-month follow-up showed improvement in knowledge about medication, skill utilization, and compliance. Compliance assessed by the patients' psychiatrists increased from 67% before training to 82% after training, and compliance assessed by designated caregivers increased from 60% to 79%.

Combining family therapy with psychoeducation seemed to be an effective strategy.[38,39] Patients receiving family therapy that included specific behavioral compliance strategies worked out between patient and family were more likely to take their prescribed tablets, less likely to require a change to depot neuroleptics, and showed higher and more stable neuroleptic plasma levels.

 

Newer Studies

In recent studies,[4] a group of patients with schizophrenia living in a residential community service were evaluated for compliance. Results suggest that lack of direct medication supervision, negative medication attitude, and lower GAF score were associated with increased medication nonadherence in the recent past. The authors concluded that direct supervision of medication is associated with better adherence in residential treatment settings

Another recent study by Donohue and Owens[3] reported that less than 25% of consecutive admissions reported were fully compliant. They cite drug attitudes as the best predictor of regular compliance, symptomatology as the best predictor of noncompliance, and memory as the best predictor of partial compliance with neuroleptic medication. They conclude that the data emphasize the complexity of factors that influence whether a person adheres to his medication regimen. Furthermore, they suggest that these factors may vary within the same person over time.

Compliance has been a complex issue with patients with severe mental illness over the last few decades. It is important to continue to study the various elements of compliance and document which interventions can help patients minimize relapse.

 

References

  1. Remington GJ, Collins A. Video workshop: an educational intervention to enhance compliance in schizophrenia. Program and abstracts of the American Psychiatric Association 53rd Institute on Psychiatric Services; October 10-14, 2001; Orlando, Florida. Multimedia session 18.
  2. Fenton WS, Blyler CR, Heinssen RK: Determinants of medication compliance in schizophrenia: empirical and clinical findings. Schizophr Bull. 1997; 23:637-651.
  3. Donohoe G, Owens N, O'Donnell C, et al. Predictors of compliance with neuroleptic medication among inpatients with schizophrenia: a discriminant function analysis. Eur Psychiatry. 2001;16:293-298.
  4. Grunebaum MF, Weiden PJ, Olfson M. Medication supervision and adherence of persons with psychotic disorders in residential treatment settings: a pilot study. J Clin Psychiatry. 2001;62:394-399.
  5. Weiden P, Rapkin B, Mott T, Zygmunt A, Goldman D, Horvitz-Lennon M, Frances A. Rating of medication influences (ROMI) scale in schizophrenia. Schizophr Bull. 1994;20:297-310.
  6. Diaz E, Levine HB, Sullivan MC, Sernyak MJ, Hawkins KA, Cramer JA, Woods SW. Use of the medication event monitoring system to estimate medication compliance in patients with schizophrenia. J Psychiatry Neurosci. 2001;26: 325-329.
  7. Kay SR, Fizbein A, Opler LA. The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophrenia Bull. 1987;13:261:C276.
  8. Williams JBW, Gibbon M, First MB, et al. The structured clinical interview for DSM-III-R (SCID) II. Multi-site test-retest reliability. Arch Gen Psychiatry. 1992;49:630-636.
  9. Horvath AO, Greenberg LS. Development and validation of the Working Alliance Inventory. J Counsel Psychol. 1989;36:223-233.
  10. Dozier RM, Hicks MW, Cornille TA, Peterson GW. The effect of Tomm's therapeutic questioning styles on therapeutic alliance: a clinical analog study. Fam Process. 1998;37:189-200.
  11. Harrison CA, Dadds MR. Attributions of symptomatology: an exploration of family factors associated with expressed emotion. Aust N Z J Psychiatry. 1992;26:408-416.
  12. Amador XF, Strauss DH, Yale SA, Flaum MM, Endicott J, Gorman JM. Assessment of insight in psychosis. Am J Psychiatry. 1993:150:873-879.
  13. Zimet GD, Dahlem NW, Zimet SG, Farley GK. The Multidimensional Scale of Perceived Social Support. J Pers Assess. 1988;52:30-41.
  14. Kolb B, Whishaw IQ. Performance of schizophrenic patients on tests sensitive to left or right frontal, temporal or parietal function in neurological patients. J Nerv Ment Dis. 1983;171:435-443.
  15. Haynes RB. Introduction. In: Haynes RB, Sackett DL, Taylor DW, eds. Compliance in Health Care. Baltimore, Md: Johns Hopkins University Press; 1979:1-10.
  16. Stimson GV. Obeying doctors orders: A view from the other side. Soc Sci Med. 1974;8:97-194.
  17. Holm S. What is wrong with compliance? J Med Ethics. 1993;19:108-110.
  18. McClellan TA, Cowan G. Use of antipsychotic and antidepressant drugs by chronically ill patients. Am J Psychiatry. 1970;126:113-115.
  19. Norell SE. Accuracy of patient interviews and estimates by clinical staff in determining medication compliance. Social Sci Med. 1981;15:57-61.
  20. Rickels K, Briscoe E. Assessment of dosage deviation in outpatient drug research. J Clin Pharmacol J New Drugs. 1970;10:153-160.
  21. Gordis L. Methodologic issues in measurement of patient compliance. In: Sacket DL, Haynes RB, eds. Compliance With Therapeutic Regimens. Baltimore, Md: Johns Hopkins University Press; 1976:51-66.
  22. Boczkowski JA, Zeichner A, DeSanto N. Neuroleptic compliance among chronic schizophrenic outpatients: an intervention outcome report. J Consult Clin Psychiatry. 1985;53:666-671.
  23. Blackwell B. Treatment adherence. Br J Psychiatry. 1976;129:513-531.
  24. Christensen 1974, Christensen JK. A 5-year follow-up study of male schizophrenics: Evaluation of factors influencing success and failure in the community. Acta Psychiatr Scand. 1974;50:60-72.
  25. Owen RR, Fischer EP, Booth BM Cuffel B. Medication noncompliance and substance abuse among patients with schizophrenia. Psychiatric Services. 1996;47:853-858.
  26. McFarlane WR, Lukens E, Link B, et al. Multiple-family groups and psychoeducation in the treatment of schizophrenia. Arch Gen Psychiatry. 1995;52:679-687.
  27. Parker G, Hadzi-Pavlovic D. The capacity of a measure of disability (the LSP) to predict hospital readmission in those with schizophrenia. Psychological Med. 1995;25:157-163.
  28. Hoffman RP, Moore WE, O'Dea LF. A potential role for the pharmacist: medication problems confronted by the schizophrenic outpatient. J Am Pharmaceutical Assoc. 1974;NS14(5):252-265.
  29. Nelson AA, Gold BH, Huchinson RA, Benezra E. Drug default among schizophrenic patients. Am J Hosp Pharm. 1975;32:1237-1242.
  30. Razali MS, Yahya H. Compliance with treatment in schizophrenia: A drug intervention program in a developing program. Acta Psychiatr Scand. 1995;91:331- 335.
  31. Draine J, Solomon P. Explaining attitudes toward medication compliance among a seriously mentally ill population. J Nerv Ment Dis. 1994;182:50-54.
  32. Reilly EL, Wilson WP. and McClinton, H.K. Clinical characteristics and medication history of schizophrenics readmitted to the hospital. International Journal of Neuropsychiatry, 39:85-90, 1967.
  33. Marder SR, Mebane A, Chien C-P, Winslade WJ, Swann E, Van Putten T. A comparison of patients who refuse and consent to neuroleptic treatment. Am J Psychiatry. 1983;140:470-472.
  34. Frank AF, Gunderson JG. The role of the therapeutic alliance in the treatment of schizophrenia: Relationship to course and outcome. Arch Gen Psychiatry. 1990;47:228-236.
  35. Macpherson R, Jerrom B, Hughes A. A controlled study of education about drug treatment in schizophrenia. Br J Psychiatry, 1996;168:709-717.
  36. Brown CS, Wright RG, Christensen DB. Association between type of medication instruction and patients' knowledge, side effects, and compliance. Hosp Comm Psychiatry. 1987;38:55-60.
  37. Eckman TA, Liberman RP, Phipps CC, Blair KE. Teaching medication management skills to schizophrenic patients. J Clin Psychopharmacol. 1990;10:33-38.
  38. Strang JS, Falloon IRH, Moss HB, Razani J, Boyd JL. The effects of family therapy on treatment compliance in schizophrenia. Psychopharmacol Bull. 1981;17:87-88.
  39. Falloon IRH, Boyd JL, McGill CW. Family Care of Schizophrenia: A Problem-Solving Approach to the Treatment of Mental Illness. New York, NY: Guilford Press; 1984.