Clinical Correlates of Treatment Adherence and Insight in Patients with Schizophrenia

Abstract

Aim: The aim of this study was to assess clinical correlates of treatment adherence and insight in patients with schizophrenia. Methods: That cross-sectional study included 229 outpatients with schizophrenia who were admitted to the Psychiatry Outpatient Clinic of Health Sciences University Dışkapı Yıldırım Beyazıt Training and Research Hospital. All participants were administered a socio-demographic form, Morisky Medication Adherence Questionnaire, Schedule for Assessing the three components of insight, Brief Psychiatric Rating Scale, Positive and Negative Symptoms Rating Scale, Calgary Depression Scale for Schizophrenia, and Global Assessment of Functioning Scale. Collected data were analyzed with descriptive statistics, Pearson Correlation Analysis, and logistic regression analysis. Results: Poor treatment adherence was associated with male gender, lower insight level, more severe psychotic symptoms, and lower functionality level. The insight score was negatively correlated with the severity of psychotic symptoms, duration of the disorder, and mean antipsychotic dose; but positively correlated with advanced age of onset and higher functionality level. The logistic regression analysis revealed that functionality level was more predictive of poor medication adherence. Conclusion: Poor treatment adherence and lower insight level were closely associated with more severe clinical symptoms and lower functionality level. It was noteworthy that adherence and insight levels both showed a high predictivity for the wellbeing of the patients. Therefore, psychotherapeutic interventions should be implemented to increase treatment adherence and insight in schizophrenia even if the psychotic symptoms show resistance. Further research is needed to clarify clinical associations of the treatment adherence and insight level in patients with schizophrenia.

Keywords

• treatment adherence
• schizophrenia
• insight

Öz

Amaç: Bu çalışmanın amacı şizofreni hastalarında tedaviye uyumu ve içgörü ile ilişkili klinik değişkenleri değerlendirmektir. Yöntemler: Kesitsel nitelikteki bu çalışmaya Sağlık Bilimleri Üniversitesi Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi Psikiyatri Polikliniği’ne başvuran 229 şizofreni hastası dahil edildi. Tüm katılımcılara sosyodemografik veri formu, Morisky Tedaviye Uyum Ölçeği, İçgörünün Üç Bileşenini Değerlendirme Ölçeği, Kısa Psikiyatrik Değerlendirme Ölçeği, Pozitif ve Negatif Belirtileri Değerlendirme Ölçeği, Calgary Şizofrenide Depresyon Ölçeği ve İşlevselliğin Genel Değerlendirilmesi Ölçeği uygulanmıştır. İstatiksel analizde tanımlayıcı analizler, Pearson Korelasyon Analizi ve lojistik regresyon analizi kullanıldı. Bulgular: Şizofrenide düşük tedavi uyumu bulunması erkek cinsiyet, düşük içgörü düzeyi, yüksek psikotik belirti şiddeti ve düşük işlevsellik düzeyi ile ilişkili bulundu. İçgörü düzeyi ise psikotik belirti şiddeti, hastalığın süresi ve ortalama antipsikotik ilaç dozu ile negatif korelasyon gösterirken; geç başlangıç yaşı ve yüksek işlevsellik düzeyi ile pozitif korelasyon gösterdi. Lojistik regresyon analizinde ise işlevsellik düzeyinin düşük tedavi uyumunu öngörmede daha etkili olduğu belirlendi. Sonuç: Düşük tedavi uyumu ve içgörü düzeyi yüksek klinik belirti şiddetiyle ve düşük işlevsellik düzeyiyle güçlü korelasyon gösterdi. Tedavi uyumu ve içgörü düzeyi hastaların iyilik durumu üzerinde önemli prediktif faktörler olarak saptandı. Bu nedenle psikotik belirtiler dirençli olsa dahi şizofreni hastalarında tedavi uyumu ve içgörüyü arttırmaya yönelik psikososyal tedaviler uygulanmalıdır. Şizofreni hastalarında tedavi uyumu ve içgörü düzeyi ile ilişkili klinik değişkenlerin daha iyi anlaşılması için gelecekte yapılacak çalışmalar önemli olacaktır.

Anahtar Kelimeler

• tedavi uyumu
• şizofreni
• içgörü

References

1. 1. García-Cabeza I, Díaz-Caneja CM, Ovejero M, de Portugal E. Adherence, insight and disability in paranoid schizophrenia. Psychiatry Res. 2018;270:274-80.
2. 2. Modanloo M. The challenge of increasing adherence in schizophrenia: Focusing future research on changing attitudes of patients. Asian J Psychiatr. 2018;36:28.
3. 3. Xu DR, Gong W, Gloyd S, Caine ED, Simoni J, Hughes JP, et al. Measuring adherence to antipsychotic medications for schizophrenia: Concordance and validity among a community sample in rural China. Schizophr Res. 2018;201:307-14.
4. 4. Ogawa Y, Fukuhara K, Tanaka H, Nagata Y, Ishimaru D, Nishikawa T. Insight Into Illness and Defense Styles in Schizophrenia. J Nerv Ment Dis. 2019;207:815-19.
5. 5. Settem VVJ, Karanadi H, Praharaj SK. Cognitive deficits, depressive symptoms, insight, and medication adherence in remitted patients with schizophrenia. Indian J Psychiatry 2019;61:335-41.
6. 6. Browne J, Nagendra A, Kurtz M, Berry K, Penn DL. The relationship between the therapeutic alliance and client variables in individual treatment for schizophrenia spectrum disorders and early psychosis: Narrative review. Clin Psychol Rev. 2019;71:51-62.
7. 7. Belvederi Murri M, Amore M. The Multiple Dimensions of Insight in Schizophrenia-Spectrum Disorders. Schizophr Bull. 2019;45:277-83.
8. 8. Tessier A, Boyer L, Husky M, Baylé F, Llorca PM, Misdrahi D. Medication adherence in schizophrenia: The role of insight, therapeutic alliance and perceived trauma associated with psychiatric care. Psychiatry Res. 2017;257:315-21.

9. 9. Kane JM, Agid O, Baldwin ML, Howes O, Lindenmayer JP, Marder S, et al. Clinical Guidance on the Identification and Management of Treatment-Resistant Schizophrenia. J Clin Psychiatry 2019;80. pii: 18com12123. doi: 10.4088/JCP.18com12123.
10. 10. Arraras JI, Ibañez B, Pereda N, Iribarren S, Basterra I. The association of clinical insight and depression with quality of life in schizophrenia. Psychiatry Res. 2019;279:350-52.
11. 11. Dondé C, Senn M, Eche J, Kallel L, Saoud M, Brunelin J. Well-informed but not aware: The P.A.C.T.® psychoeducation program for schizophrenia improves knowledge about, but not insight into, the illness. Asian J Psychiatr. 2019;46:15-8.
12. 12. American Psychiatric Association. Schizophrenia spectrum and other psychotic disorders. In: Carpenter WT, editor. Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association; 2013.p.87-123.
13. 13. Overall JE, Gorham DR. The brief psychiatric rating scale (BPRS): recent developments in ascertainment and scaling. Psychopharmacol Bull. 1988;24:97-9. 14. Soykan C. Institutional differences and case typicality as related to diagnosis system severity, prognosis and treatment Access and utilization (dissertation). Ankara: Middle East Technical University Psychology Department, 1989.
14. 15. Andreasen NC. Methods for assessing positive and negative symptoms. Mod Probl Pharmacopsychiatry 1990;24:73–88.
15. 16. Erkoç Ş, Arkonaç O, Ataklı C, Özmen E. Negatif Semptomları Değerlendirme Ölçeğinin güvenilirliği ve geçerliliği. Düşünen Adam. 1991;4:16–9.
16. 17. Erkoç Ş, Arkonaç O, Ataklı C, Özmen E. Pozitif Semptomları Değerlendirme Ölçeğinin güvenilirliği ve geçerliliği. Düşünen Adam. 1991;4:20–4.
17. 18. Morisky DE, Ang A, Krousel-Wood M, Ward HJ. Predictive validity of a medication adherence measure in an outpatient setting. J Clin Hypertens. 2008;10:348-54.
18. 19. Hacıhasanoğlu Aşılar R, Gözüm S, Capık C, Morisky DE. Reliability and validity of the Turkish form of the eight-item Morisky medication adherence scale in hypertensive patients. Anadolu Kardiyol Derg. 2014;14:692-700. 20. David A, Buchanan A, Reed A. Assessment of insight in psychosis. Br J Psychiatry. 1992;161:599-602.
19. 21. Arslan S, Günay Kılıç B, Karakılıç H. İçgörünün Üç Bileşenini Değerlendirme ölçeği güvenirlik ve geçerlik çalışması. Türkiye’de Psikiyatri. 2000;3:17-24.
20. 22. Addington D, Addington J, Schissel B. A depression rating scale for schizophrenics. Schizophr Res. 1990;3:247-51.
21. 23. Oksay SE, Aksaray G, Kaptanoğlu C, Bal C. Calgary Depresyon Ölçeğinin şizofreni hastalarında geçerlik ve güvenirlilik çalışması. Türk Psikiyatri Dergisi. 2000;11: 278-84.
22. 24. Endicott J, Spitzer RL, Fleiss JL, Cohen J. The Global Assessment Scale: A Procedure for Measuring Overall Severity of Psychiatric Disturbance. Arch Gen Psychiatry. 1976;33:766-71.
23. 25. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV. Washington, DC: American Psychiatric Association; 1994. p.34.
24. 26. Sampaio R, Azevedo LF, Dias CC, Castro Lopes JM. Non-Adherence to Pharmacotherapy: A Prospective Multicentre Study About Its Incidence and Its Causes Perceived by Chronic Pain Patients. Patient Prefer Adherence. 2020;14:321-32.
25. 27. Limandri BJ. Adverse Events, Drug Interactions, and Treatment Adherence. J Psychosoc Nurs Ment Health Serv. 2020;58:9-13.
26. 28. Chandra IS, Kumar KL, Reddy MP, Reddy CM. Attitudes toward medication and reasons for non-compliance in patients with schizophrenia. Indian J Psychol Med. 2014;36:294–8.
27. 29. Zhou J, Xiang YT, Li Q, Zhu X., Li W, et al. Gender differences in attitudes towards antipsychotic medications in patients with schizophrenia. Psychiatry Res. 2016;245:276–81.
28. 30. Lange B, Mueller JK, Leweke FM, Bumb JM. How gender affects the pharmacotherapeutic approach to treating psychosis - a systematic review. Expert Opin Pharmacother. 2017;18:351-62.
29. 31. Lauriello J, Perkins DO. Managing Transitions in Care and Adherence to Improve Outcomes in Schizophrenia. J Clin Psychiatry. 2019;80. pii: al18010wc1c. doi: 10.4088/JCP.al18010wc1c.
30. 32. Chang JG, Roh D, Kim CH. Association between Therapeutic Alliance and Adherence in Outpatient Schizophrenia Patients. Clin Psychopharmacol Neurosci. 2019;17:273-8.
31. 33. de Avila RCS, do Nascimento LG, Porto RLM, Fontenelle L, Filho ECM, et al. Level of insight in patients with obsessive-compulsive disorder: an exploratory comparative study between patients with "good insight" and "poor insight". Front Psychiatry. 2019;10:413.
32. 34. Reddy YJ, Sundar AS, Narayanaswamy JC, Math SB. Clinical practice guidelines for obsessive–compulsive disorder. Indian J Psychiatry. 2017;59:S74–90.
33. 35. Rozalski V, McKeegan GM. Insight and Symptom Severity in an Inpatient Psychiatric Sample. Psychiatr Q. 2019;90:339-50.
34. 36. Suzuki M. Schizophrenia: What determines its clinical features and course? Psychiatry Clin Neurosci. 2019;73:99.