Schizophrenia: Impact of psychopathology,faith healers and psycho-education on adherence to medications

Abstract

Background:

Many patients suffering from psychosis are nonadherent to their medications. Nonadherence can range from treatment refusal to irregular use or partial change in daily medication doses.

Aim:

To investigate whether symptom dimensions, post-discharge care plans and being involved with faith healer affect the adherence to treatment in patients with schizophrenia.

Method:

A total of 121 patients with schizophrenia were examined 6 weeks post-discharge from the inpatient unit and assessed for full, partial or nonadherence to medication.

Results:

There was a significant association between family involvement and partial adherence and between community team involvement post-discharge and full adherence to medications. Psycho-education was a predictor for adherence to medications, persecutory delusions and lack of insight predicted partial adherence, while being involved with faith healers predicted nonadherence.

Conclusion:

Adherence to medications and socio-demographic variables are independent. This study demonstrated that nonadherence or partial adherence to medications is associated with lack of insight and persecutory delusions. Psycho-education could improve the adherence to medication compliances.

Keywords

Schizophrenia faith healers psycho-educations adherence to medications

Introduction

Worldwide, research shows that schizophrenia is a major cause of morbidity and mortality and is associated with impaired health-related quality of life and social functioning, as well as with increased risk for disability and suicide (Boden, 2011; Leucht & Heres, 2006). In the United Arab Emirates, the prevalence of mental health disorders has increased over the past several decades (Abou-Saleh, Ghubash, & Dardkeh, 2001; Dardkeh, Eapen, & Ghubash, 2005). According to local estimates, approximately between 55% and 73% of patients attending primary care in the United Arab Emirates suffer mental disorders (El-Rufaie & Absood, 1993). The commonest diagnoses were depressive disorders 55%, mixed anxiety–depression 13% and anxiety disorders 12%. Although schizophrenia is a mental disorder that affects approximately 1% of the various populations throughout the world (van Os & Kapur, 2009), in a UAE community study which assessed prevalence of schizophrenia in a general population in the United Arab Emirates, the total lifetime prevalence of schizophrenia was found to be only 0.7%. The authors noted that this figure may be understated, given the exclusion of highly disturbed and cognitively impaired individuals and the stigma associated with mental illness, perhaps even more with schizophrenia (Abou-Saleh et al., 2001).

Despite the critical importance of medication, nonadherence to prescribed drug treatments has been recognized as a problem worldwide and may be the most challenging aspect of treating patients with schizophrenia (World Health Organization, 2003). Nonadherence to medication is a recognized problem and may be the most challenging aspect of treatment in schizophrenic patients. Nonadherence to medication includes a range of patient behaviours, from treatment refusal to irregular use or partial change in daily medication doses. Partial adherence to medication is at least as frequent as complete nonadherence (Svestka & Bitter, 2007).

Potential factors for nonadherence may be related to disease severity, treatment characteristics or even external factors, such as therapeutic support (Llorca, 2008). Adherence factors may also be unique to the characteristics of schizophrenia; for example, cognitive impairment or lack of illness insight may play an important role. A recent retrospective database study in schizophrenia (Liu-Seifert, 2012) found that the best predictor of good adherence was a significant improvement in positive symptoms, hostility and depressive symptoms, regardless of treatment.

Other potential factors for nonadherence may be culturally related in that a belief in supernatural causes of mental illness appears to be matched by endorsement of religious and spiritual sources of help for mental illness (Scior, Hamid, Mahfoudhi, & Abdalla, 2013). In a retrospective study in the United Arab Emirates, Salem, Moselhy, Attia, and Yousef (2008) found that 26.1% of acute psychotic patients seek help from faith healers first. This was a reason for having a long duration of untreated psychosis which was significant in relation to outcome, where the longer the duration the more the presence of residual symptoms (χ² = 18.515, p = .005).

Although much research has been done pertaining to adherence to medications in schizophrenia, the opportunity to study the impact of psycho-education and faith healers is relatively uncommon. To the best of our knowledge, this is the first study to address this issue in the Arab world. The purpose of this research was to study the symptom dimensions of cognitive function and psycho-education to determine their influence on adherence to medications in patients diagnosed as schizophrenic in an Arabic community.

Participants and procedure

Figure 1 shows participant selection procedure. A total of 961 patients were admitted to the psychiatric department of Al Ain Hospital, United Arab Emirates, over a 3-year period from January 2012 to December 2014. Those patients who met the criteria for Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association (APA), 1994) diagnosis of schizophrenia (N = 239) received further assessment. Diagnosis was based on clinical criteria of the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; APA, 2000). Four patients with a history of an organic brain syndrome, 96 patients reporting drug or alcohol misuse in the past year and 13 patients with learning disabilities were excluded. A total of 126 patients were offered psycho-education in the form of five individual or group sessions 1 week prior to discharge. The psycho-education sessions were conducted by a senior nurse. The duration of the session ranged between 20 and 30 minutes and consisted of facilitator manual on (1) education about the illness and available management, (2) early signs of relapse and relapse prevention, (3) hazards of substance abuse, (4) symptoms’ management (e.g. voices, delusion, anxiety) and (5) problem-solving techniques and leisure skills. The take-home message of the programme was as follows: schizophrenic psychoses are induced by biological factors in combination with psycho-social stress; therefore, they must be treated with both medication and psychotherapeutic interventions (Bäuml, Froböse, Kraemer, Rentrop, & Pitschel-Walz, 2006). A total of 126 patients were invited to participate in the study. In all, 82 patients attended between two and five sessions and 44 patients declined to attend any session. Participants were relatively well stabilized when seen in the outpatient clinic 6 weeks post-discharge. This was based on family reports that the patient reacted less to positive symptoms and was interacting more socially. Five patients refused to participate in the study. A final number of 121 agreed to participate in the study. The nature and scope of the study were discussed with each subject and written informed consent was obtained from all subjects prior to distribution of the questionnaire. Participants over the age of 18 years were interviewed in the outpatient clinic at Al Ain Teaching Hospital, in Al Ain, United Arab Emirates, in accordance with the Al Ain Medical District Human Research Ethics Committee. Structured Clinical Interviews for DSM-IV Axis I and II psychiatric disorders (SCID; First, Gibbon, Spitzer, Williams, & Benjamin, 1997) were used to confirm diagnoses. Comprehensive medical and psychiatric history-taking, mental state examination and collateral information from family members were collected. Treatment compliance was documented on each visit through pill counts, medication diaries and confirmation from significant others. Data were collected regarding total medication adherence and missed medications for 1, 2, 3 or more than 3 week(s) and no adherence since discharge. Data were divided into full adherence (patients always take medications), partial adherence (patients missed the medications for 1 week or more) and nonadherence (patients who never took medications post-discharge). For the regression analysis, we added partial adherence to no adherence to create two groups. In the case of insight, we asked about three things: awareness of the illness, the capacity to re-label psychotic experiences as abnormal and awareness of symptoms and the need for treatment compliance. In the analysis, we divided insight into full insight (answered ‘yes’ to all three questions), partial insight (answered ‘no’ to one or two questions) or no insight if they answered ‘no’ to all questions.

Figure 1.

Participant selection procedure.

Statistical analysis

Data analysis was performed using the Statistical Package for Social Sciences (SPSS; version 20). Descriptive statistics were used to summarize socio-demographic and clinical characteristics of the sample. Chi-square test was used to compare the frequencies of symptoms in the different groups. Multiple logistic regression analysis was used to determine predictors of nonadherence to medications. The adherence to medications was used as the dependent variable and those significant in bivariate analysis and included paranoid type of schizophrenia, discharge plan – psychotic symptoms addressed, discharge plan – family involved, discharge plan – community team involved and involvement with faith healer after discharge. All statistical tests were considered significant at p = .05.

Results

Socio-demographic and clinical characteristics

Table 1 shows demographic characteristics of the sample. Participants ranged in age from 18 to 82 years, with a mean age of 37.1 (±12.6) years. There were 71 males (58.7%) and 50 females (41.3%). Table 2 shows the clinical characteristics of the sample. A total of 89 patients (73.6%) were diagnosed with paranoid schizophrenia (65.2% men and 34.8% women), 10 (8.3%) with disorganized type, 2 (1.7%) with residual, 1 (0.8%) with schizoaffective, 4 (3.3%) undifferentiated type and 15 (12.4%) as psychosis not otherwise specified. Paranoid schizophrenia was statistically significant among men (N = 58, 65.2%) compared with women (N = 31, 34.8%; χ² = 12.18, degree of freedom (df) = 5, p = .03). In all, 51 (42.5%) were married, 58 (48.4%) were single, 1 (0.8%) was separated, 7 (5.8%) were divorced and 3 of the females (2.5%) were widows. There was no significant statistical difference between genders in marital status. A total of 72 (59.5%) patients were unemployed, 16 (13.2%) were employed in clerical positions, 4 (3.3%) were retired, 26 (21.5%) were house wives, 1 (0.8%) was working in the police force and 2 (1.7%) were students. In this cohort, the correlation between unemployment and schizophrenia was statistically significant (χ² = 43.45, df = 6, p = .001). Additionally, male patients were significantly higher in paranoid schizophrenia (p = .03, odds ratio (OD) = 6.03, 95% confidence interval (CI) = 1.178-30.820). The mean number of previous admission was 4.1 (standard deviation (SD) = 10.8) and the mean hospital stay days at last admission was 27.1 (SD = 37.3). The mean age of onset of illness was 23.4 (SD = 8.1) years and the mean number of years of untreated psychosis was 2.1 (SD = 3.1) years (Table 2). Socio-demographic variables have no significant relationship with adherence to medications.

Table 1.

Demographic characteristics of sample.

Gender (M:F ratio)
71:50
Mean age in years, SD (range)
37.1 (12.6) (18–82)
Marital status, total (N = 121)
Married	52
Single	58
Separated	1
Divorced	7
Widowed	3
Employment status, total (N = 121)
Unemployed	72
Clerical work	16
Housewives	26
Retired	4
Police force	1
Students	2

SD: standard deviation.

Table 2.

Clinical characteristics of sample.

Diagnosis, total (N = 121)
Paranoid schizophrenia	89
Disorganized schizophrenia	10
Undifferentiated schizophrenia	4
Schizoaffective disorder	1
Residual schizophrenia	2
Not otherwise specified	15
Age of onset of illness in years (SD)	23.4 (8.1)
Mean number of years of untreated psychosis (SD)	2.1 (3.1)
Mean number of previous admission (SD)	4.1 (10.8)
Mean hospital stay days at last admission (SD)	27.1 (37.3)

SD: standard deviation.

Psychological characteristics

Table 3 shows the different symptoms in the entire sample. The most common symptoms were suspiciousness (76%), bizarre behaviour (55.4%), persecutory delusions (50.4%) and auditory hallucinations. Table 4 shows different types of schizophrenia compared with patients’ adherence to medication. There was no significant relationship between adherence to medication and any type of schizophrenia.

Table 3.

Different types of symptoms among patients.

Symptoms’ dimension	N (%)
1. Suspiciousness	92 (76)
2. Auditory hallucinations	61 (50.4)
3. Unusual thought content (odd)	66 (54.5)
4. Bizarre behaviour	67 (55.4)
5. Persecutory delusion	61 (50.4)
6. Violent destructive behaviour	21 (17.4)
7. Suicidal attempt	1 (0.8)
8. Self-neglect	2 (1.7)
9. Blunted affect	60 (49.6)
10. Social isolation	60 (49.6)
11. Motor retardation	22 (18.20
12. Uncooperativeness	60 (46.6)
13. Impairments of concentration	24 (19.8)
14. Disorientation	15 (12.4)
15. Conceptual disorganization	11 (9.1)
16. Memory	9 (7.4)
17. Abstract	9 (7.4)
18. Judgement	5 (4.1)
19. Insight
• No insight	37 (30.6)
• Partial insight	66 (54.5)
• Full insight	18 (14.9)
20. Adherence to medications
• Full adherence	25 (20.7)
• Partial adherence	64 (52.9)
• Nonadherence	32 (26.4)

Table 4.

Different types of schizophrenia among patients’ adherence to medication.

Type of schizophrenia	Patients (n = 121, %)	Adherence to medications’ count (%)						χ²	p-Value
		Always took the medication	Missed 1 week	Missed 2 weeks	Missed 3 weeks	Missed more than 3 weeks	Never took the medication
		62 (51.2)	9 (7.4)	11 (9.1)		17 (14.1)	19 (15.7)
Paranoid	89 (73.6)	44 (36.4)	7 (5.8)	9 (10.1)	0.3	12 (13.5)	15 (16.6)	34.417	.3
Disorganized	10 (8.3)	5 (50)	0	1 (10)	0	3 (30)	1 (10)
Undifferentiated	4 (3.3)	1 (25)	1 (25)	0	1 (25)	1 (25)	0
Residual	2 (1.7)	2 (100)	0	0	0	0	0
Schizoaffective	1 (0.8)	0	1 (100)	0	0	0	0
Not otherwise specified	15 (12.4)	10 (66.7)	0	1 (6.7)	0	1 (6.7)	3 (20.0)

Post-discharge care plan and adherence to medications

Table 5 displays the post-discharge care plan and the help or services referred. There was significant partial adherence noted in cases of the family being involved and significant full adherence to medications if the community team was involved in post-discharge care. Patient involvement with a faith healer post-discharge was a significant factor in nonadherence to medications.

Table 5.

After discharge care plan and adherence to medications.

Care plane factors	No. (% within adherence categories)			χ²	p-Value
Care plane factors	Full adherence	Partial adherence	No adherence
1. Discharge plan – psychotic symptoms addressed	21 (84)	52 (92.9)	16 (76.2)	9.799	.04
2. Discharge plan – family involved	22 (88)	52 (92.9)	15 (71.4)	10.817	.03
3. Discharge plan – community team involved	8 (38.1)	16 (28.6)	5 (20)	10.339	.04
4. Discharge plan – social support service involved	4 (16)	6 (10.7)	2 (16.7)	8.380	.08
5. Involvement with faith healer after discharge	14 (56)	40 (62.5)	27 (84.4)	6.318	.04
6. Outcome on discharge
• Full recovery	4 (16)	9 (14.1)	7 (21.9)	4.817	.30
• Residual symptoms	21 (84)	55 (85)	25 (78.1)

Predictors of adherence to medications

To assess whether significant variables, including psychopathology dimensions, can predict any of the three levels of medication adherence, multiple regression analysis was used. Higher levels of persecutory delusion (OR = 5.031, p = .0001, 95% CI = 1.763–1.435) and no insight (OR = 1.246, p = .001, 95% CI = 5.045–3.080) predicted partial adherence to medications. In addition, being involved with a faith healer post-discharge was a predictor for nonadherence (OR = 0.255, p = .03, 95% CI = 0.073–0.896). A second set of multiple regression analyses were conducted to test whether significant variables, including psychopathological dimensions, predict adherence to medications when adding all types of adherence (partial and nonadherence) as one group. Again, persecutory delusions (OR = 4.396, p = .007, 95% CI = 1.506–12.834) and no insight (OR = 0.219, p = 001, 95% CI = 0.094–0.511) were highly significant predictors for nonadherence to medications. In contrast, psycho-education was a significant predictor for adherence to medications (OR = 0.345, p = .031, 95% CI = 0.131–0.907).

Discussion

Socio-demographic characteristics

This study shows that socio-demographic variables are not important predictors of adherence to medications in patients diagnosed with schizophrenia. These findings are inconsistent with research in general medicine which suggests that older people comply better (Baekeland & Lundwall, 1975). In a systematic literature review, Higashi et al. (2013) found four studies, three prospective studies (Acosta et al., 2009; Linden et al., 2001; Loffler, Kilian, Toumi, & Angermeyer, 2003) and one cross-sectional study (Aldebot & de Mamani, 2009), showed no relation between adherence and socio-demographic variables, such as gender, age (Acosta et al., 2009), family/marital status (Acosta et al., 2009; Linden et al., 2001) ethnicity (Aldebot & de Mamani, 2009), occupational status/qualification (Linden et al., 2001) and level of education (Acosta et al., 2009; Aldebot & de Mamani, 2009; Linden et al., 2001; Loffler et al., 2003). However, three prospective studies (Hudson et al., 2004; Janssen et al., 2006; Linden et al., 2001) and one retrospective database study (Valenstein et al., 2004) did report a positive relationship between socio-demographic factors and adherence. For example, a positive relationship with older age (Linden et al., 2001; Valenstein et al., 2004) and a negative relationship with low education level (Hudson et al., 2004; Janssen et al., 2006) were identified.

Psychological characteristics

The severity of someone’s illness, even when it is reflected in the level of psychopathology when they are discharged, is probably not related to medication adherence. Persecutory delusions are significant in our study as a predictor for partial adherence or nonadherence to medications. Persecutory delusion is frequently mentioned as placing a patient at risk of complying poorly, but the research findings in this regard are inconsistent (Buchanan, 1998). Lack of insight was a predictor of either partial adherence or nonadherence in our study. Many individuals with schizophrenia have poor or no insight into their illness, meaning they are not aware of the symptoms and consequences of their illness. Four studies, two prospective studies (Acosta et al., 2009; Loffler et al., 2003), one cross-sectional study (Olfson, Marcus, Wilk, & West, 2006) and a survey of experts (Velligan et al., 2009) found a directional relation in which lack of illness insight was associated with worse adherence. In fact, the survey involving clinical experts (Velligan et al., 2009) rated poor illness insight as the most important factor contributing to nonadherence. Another cross-sectional study (Aldebot & de Mamani, 2009) reported that individuals who dealt with the stress of their illness by ignoring the illness or the magnitude of their symptoms were less adherent to their medication. The author hypothesized that patients who refused to accept being ill may not believe their symptoms are something that can be managed and, thus, may be less motivated to take steps to resolve their symptoms, such as taking medication. Only one prospective study (Linden et al., 2001) reported no relation between adherence and lack of insight. The author states that this contrary finding may be due to the inclusion of more adherent patients, which may, in turn, influence the overall findings.

Patient education

In this study, psycho-education was a significant predictor for adherence to medication. According to the guidelines of the APA (2004), psycho-educational interventions belong to a standard therapy programme in acute and post-acute phases of patients with schizophrenia (Dixon, Adams, & Lucksted, 2000). In the Cochrane analysis of Pekkala and Merinder (2002), such interventions were accompanied by a higher level of compliance, lower rate of relapse and improved psychopathological status. Patient education to improve levels of knowledge has been ascribed a crucial role in maintaining treatment adherence in patients with schizophrenia. Much of the research is methodologically weak and the conclusion that levels of education affect compliance has been challenged (Ley & Morris, 1984). The explanation for the contradictory nature of much of the evidence may lie in factors that inevitably accompany intensive patient education, such as increased contact with interested and motivated health professionals.

Improving the medication adherence of people with schizophrenia

Introducing community services involving the patient’s family and trying to convince both the patient and their family to reduce their involvement with faith healers could be good measures to improve adherence to medications in the Arabic community. The effectiveness of the Al Ain Hospital College of Medicine and Health Sciences (CMHS) in minimizing the need for hospitalization as well as the length of stay for admitted patients has been demonstrated. Patients were highly satisfied with the CMHS (Mufaddel, AlSabousi, Takriti, & Saleh, 2014). In addition, our study supported improving the adherence to medications in the catchment area. However, the area of contact with faith healers will need to be part of the programme.

Clinical implications

The results of this study indicate that the level of involvement with traditional faith healer is higher among schizophrenic patient not adherent to their medication. However, involvement with the community psychiatric team was helping in adherence to medications. The most plausible interpretation of our findings is that reducing involvement with faith healers and increasing involvement with professional psychiatric services will help adherence to medications and hence prognosis of this disorder.

Limitations

There were several limitations to the study. First, the rater who evaluated the history and mental states during admission also took part in the post-discharge evaluation of the patients in the outpatient clinic. Second, the results concerning relationships between adherence and symptom dimensions should be considered as exploratory since a liberal statistical analysis was chosen. Finally, some participants declined to answer some of the questions (e.g. using illicit drugs), which limited the generalizability of our results to the whole population with schizophrenia.

Conclusion

Evidence from this study suggests that there is no simple relationship between adherence to medications and socio-demographic variables. The interplay of symptoms dimensions, type of professional interventions and socio-cultural factors (including involvement with faith healers) are all indicated as important avenues of future research.

Footnotes

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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