Adherence to Psychotropic Drugs among Patients with Psychiatric Disorders

Introduction

According to the World Health Organization (WHO), mental disorders are one of the leading causes of disability worldwide and around 450 million people currently suffer from mental illness.¹ The National Mental Health Survey of India conducted in 2015-16 by Ministry of Health and Family Welfare reported that every sixth Indian needs mental health help.²

Psychotropic medication is any drug that affects psychic function, behaviour or experience.³ Psychotropic drugs are the first line of treatment for almost every psychiatric illness and a wide range of drugs are available for the treatment.^4-7 The patients need to take the prescribed drugs along with regular follow up which helps to regulate pharmacotherapy.

Adherence to medication is the extent to which patients take medication as prescribed by the treating psychiatrists.⁸ Adherence is important because it is directly related to the prognosis of the illness. The course as well as the outcome of psychiatric illnesses are significantly affected by adherence to treatment. In the past 60 years, pharmacotherapy was found to be effective in symptom reduction, relapse prevention and better social functioning among psychiatric patients. Even if there are gains, treatment of mental illnesses is a great challenge.⁹ The worldwide range of non-adherence to psychotropic drugs has been reported as 30-90% by different studies.^9-15

Quality healthcare outcome depends upon patients’ adherence to recommended treatment regimens.¹⁶ Lack of treatment adherence affects both the patient and healthcare system. Medication non-adherence is a significant challenge in the management of mentally ill patients. It is responsible for poorer results, including increased hospital admissions, suicide, violence and mortality. Adherence is affected by various factors related to the patients, treatment, social, cultural, and economic aspects. Patients often prefer to discontinue medications due to the concerns like side effects, costs, stigma, inconvenience or availability. Unintentional non-adherence may be due to forgetfulness, distractions, or difficulty in understanding the instructions. Nonadherence can be due to Anognosia (lack of insight).¹⁷ Severity of illness, presence of cognitive impairment associated with depression and psychosis can also be some of the factors influencing the patients. Some patients who feel better after taking the medication or who have recovered fully may stop taking medication or they do not think it is necessary any more to take medicines or they do not understand the illness.^5,11,14,18

Even if the doctors prescribe the medicines, other health team members, especially nurses who care for the patients round the clock have the responsibility of influencing them for medication adherence. Therefore the investigators perceived the need to assess the patients’ adherence to psychotropic drugs.

Material and Methods

A cross sectional descriptive design was used for the study. The ethical clearance was obtained from the Institutional Ethics Committee. A formal written permission was obtained from the concerned authorities of the selected hospital to conduct the study. The study was conducted in psychiatric Out-Patient Department (OPD) of the selected hospital. Sample size was calculated based on the findings of a previous study.¹⁹ Sample comprised of 300 patients who were attending psychiatry OPD for the follow up. Purposive sampling technique was used for the selection of patients. The sampling criteria for patients were as follows: (1) patients in the age group of 18-60 years (2) patients who visited the OutPatient Department (3) those who were suffering from psychiatric illness for more than a year (4) patients who were receiving psychotropic medications for at least one year (5) patients with diagnosis of mood disorders, schizophrenia, other psychotic disorders and anxiety disorders (6) patients who scored more than 25 in Mini Mental Status Examination (MMSE). Patients who could not read and write English, Kannada and Malayalam and patients in relapse of illness were excluded.

Data was collected by administering a proforma of baseline and clinical characteristics, and Medication Adherence Rating Scale (MARS). MARS was a tool developed by K. Thompson et al, 2000 which has been widely used by many researchers to assess medication adherence among psychiatric patients.²⁰ It is a 10- item self-rated scale. The items are answerable by a yes/no response, with corresponding 0 and 1 score. The patients were considered to be ‘adherent’ if they had a score of 6-10 and ‘non-adherent’ for a score of 0-5. Internal consistency (Cronbach’s alpha) and test-retest reliability (correlation coefficient) of the tool were 0.75 and 0.72. MARS was tested in a previous study conducted in Indian population, and internal consistency and stability of the tool were 0.75 and 0.68 respectively.²¹

The study’s purpose was explained to the participants before initiating the study, and informed written consent was obtained. The confidentiality of their responses was assured.

Statistical analysis

The analysis was conducted by descriptive and inferential statistics using SPSS version-16. Data was described using mean, mean percentage and standard deviation. The association of psychotropic drugs’ adherence with baseline and clinical characteristics of the subjects was determined by chi-square test.

Results

In the present study, a total of 300 patients participated and 37.3% were in the age group of 31-45 years. The mean and SD of age (in years) were found to be 39.18 (±12.64). Majority (60.7%) of the subjects were males, whereas 39.3% of subjects were females. Majority (64.7%) of the subjects were married and were Hindus (63.3%). Less than half (41.3%) of the subjects had secondary education. Majority (74.3%) of subjects were unemployed. Among the employed, 40.3% of subjects had income of Rs 5001-10000 with a mean and SD of Rs 2486.67±5126.80. About 37.7% of subjects had a family income of Rs 5001-10000, with a mean and SD Rs 11486.66 ±7560.88.

Majority (75%) of subjects were from nuclear families. About 76.7% of subjects were staying in rural areas. More than half (58.3%) were reaching hospital by bus. Less than half (46.7%) of the subjects had ≤50 km distance between home and hospital. About 75% of subjects had no psychiatric illness in the family. Majority (69.7%) of subjects had diagnosis of BPAD, 16.7% were diagnosed with major depression, 7.7% with Schizophrenia, and 6% with other diagnoses (Obsessive Compulsive Disorder and Unspecified Organic Psychosis). Less than half (46.3%) of subjects had illness for 1-3 years with a mean and SD of 6.25±6.76. Less than half (48.7%) of subjects were under treatment for 1-3 years, and mean and SD of treatment duration were found to be 6.25(±6.76). More than half (59.3%) of subjects were hospitalized for 1-3 times with a mean and SD of 2.61(±3.19). Majority (80.6%) of subjects were taking antipsychotic drugs, 62% were taking mood stabilizers, 58.7% were taking anxiolytics and 29.7% were on antidepressants.

About 48.3% of subjects expressed that they experienced side effects related to drugs. Among those who expressed problems regarding adherence (36.3%), majority (77.98%) had side effects, 30.27% had lack of motivation, 16.51% had financial difficulty, 13.76% felt no improvement, and 0.9% of subjects expressed difficulty in adherence due to working time. About 50.7% of subjects had discontinued the medications in the past. About 15% of subjects were taking medicines for other illnesses also.

The data in Table 1 shows that majority (62.7%) of the subjects were adherent and 37.3% of the subjects were non-adherent to psychotropic drugs.

The data in Table 2 shows the mean score of adherence as 6.26, with a median of 6 and mean percentage of 62.6.

Item-wise analysis of adherence to psychotropic drugs

About 35.7% of patients expressed that they forget to take medication. 37.3% of participants mentioned that they were careless in taking medicines. 39.3% of subjects revealed that they stop taking medication when they feel better. 29.3% of subjects expressed that they feel worse when they take medication and therefore stops taking it. 45% of subjects reported taking medication only during sickness. 46% of the subjects felt it unnatural that their mind and body are under the control of medication. 73.3% of subjects felt that their thoughts are clearer with medication. 78.7% of subjects expressed that by staying on medication they can prevent getting sick. 43.3% of subjects revealed that they feel weird like a ‘zombie’ on medication. 50% of subjects expressed that medication makes them to feel more tired and sluggish.

Association between adherence to psychotropic drugs status and baseline and clinical characteristics of the subjects

Significant association was found between adherence and place of living (p= 0.044). Those living in rural areas were adherent to psychotropic drugs compared to those from urban background.

Discussion

In the present study conducted among 300 patients, 62.7% were adherent and 37.3% were non-adherent to psychotropic drugs. The mean adherence score was 6.26 (±2.35). The non-adherence to medicines puts the patients at high risk for relapse and rehospitalisation. These findings can be due to various reasons i.e. lack of insight, absence of motivation, psychopathology, substance use disorder, side effects of the drugs, patienttherapist relationship, financial difficulties, family support, stigma related to mental illness, attribution of causation of illness to spiritual forces and socioeconomic status. The knowledge of the risk factors leading to non-adherence in each patient and addressing it using effective interventions are essential.

The non-adherence rate is relatively high in this study and shows the need of appropriate interventions. The results of present study are consistent with the findings of a Nigerian study which reported that 60% were adherent to psychotropic drugs.¹² A study done in Ranchi, India depicted that 64% were adherent.¹¹ A study completed in the psychiatry unit of a tertiary health centre in India showed that 70% of the subjects were adherent to medicines.¹³ About 67% of the patients were adherent in a study conducted in a tertiary care private hospital in South India.¹⁴

Absence of insight and motivation, uncomfortable side effects and no relief in symptoms are some of the main reasons for medication non-adherence. Some patients hope that they will not get another episode of illness in future even if they faced several relapses. Among those who expressed problems regarding adherence (36.3%), majority (77.98%) had side effects, 30.27% expressed lack of motivation, 16.51% had financial difficulty and 13.76% felt no improvement. About 15% of subjects were also taking medicines for other illnesses. Patients tend to become non-adherent when they have to take several medicines on a daily basis.

Consistent findings were reported by a study from Nigeria stating that 43.3% of subjects stopped taking medication when they felt better. 27.5% of subjects expressed that they felt worse on taking medication. 45.1% of subjects revealed that they took medication only when they were sick. 40.7% of subjects reported they felt weird like a ‘zombie’ with medication. 59.1% of subjects opined that medication made them feel more tired and sluggish.¹⁰

The present study showed a significant association of adherence to psychotropic drugs with place of living (p=.044). The patients living in rural areas were more adherent to medicines compared to those from urban areas. The probable reason can be the importance given to psychoeducation by patients from rural areas.

Conclusion

The course of illness and treatment outcomes are influenced by medication non-adherence, and is often associated with relapse, presence of symptoms, impairment in functioning, and repeated hospitalizations. Mental health professionals should act as motivation facilitators for the adherence. Educating patients as well as family members regarding importance of medication is essential. Like doctors, the nurses should also get involved in the psychoeducational interventions to promote adherence. The involvement of nurses in teaching the patients and family members regarding the significance of adherence to medication is very important.

Conflict of Interest

None