Attitudes Toward Antipsychotic Medication. The Impact of Clinical Variables and Relationships With Health Professionals
Day JC, Bentall RP, Roberts C, Randall F, Rogers A, Cattell D, et al. ;
Commented by , 26 Jul 2005
Aim of the study
Non-compliance to antipsychotic drugs currently is the focus of intense research efforts. It is very clear that it is a major cause of schizophrenic relapses and one hope in new strategies such as compliance therapy or the use of atypical antipsychotics is that they reduce non adherence.
Many factors such as side-effects or cognitive problems have been reported to contribute to non-compliance, and it is very plausible that a patient’s attitude toward treatment may play a major role. However, the factors that influence patients’ attitudes toward antipsychotics are purely understood.
The aim of the current study, therefore, was to determine relations between clinical and service variables and attitudes toward medication in people with schizophrenia. A special focus was put on insight, side-effects, symptoms and the patient – physician relationship.
Methods
The researchers contacted two hundred fifty-one patients with schizophrenia or schizoaffective disorder according to DSM-IV. The patients were consecutively recruited and assessed during acute admission at twenty-eight inpatient wards at 8 hospitals in North Wales and the Northwest of England, only 23 patients refused to participate.
The hospitals were responsible for both inner-city and rural catchment areas. The following domains were assessed:
- symptoms (measured with the Positive and Negative Syndrome Scale)
- insight (Birchwood Insight Scale)
- side effects (Liverpool University Neuroleptic Siede Effect Rating Scale)
- self-reported compliance (Morisky Compliance Scale)
- attitudes toward treatment (mainly Drug Attitude Inventory)
- perceived relationship with the prescriber (California Pharmacotherapy Alliance Scale)
- ward atmosphere (Perceived Expressed Emotion of Staff Scale)
- medication knowledge (unpublished scale)
- admission experience (McArthur Admission Experience Survay)
To analyse the relationship between these factors the data were entered in a proportional odds model and structural equation modelling. The primary outcome measures were attitudes toward treatment and self-reported compliance with medication.
Results
Statistically significant predictors of attitudes toward antipsychotic treatment were insight, relationship with staff (especially with the prescribing doctor), and how the patient’s perceived their admission. The direction of these effects was that poor insight in the disease, a poor interpersonal relationship with the doctor, and an experience of coercion during admission predicted a negative attitude toward treatment.
Dr Leucht's comments
The authors main conclusion is that the doctor-patient relationship during acute admission is an important factor contributing to patients’ attitudes toward treatment and medication compliance.
Although some may consider such a finding to be trivial, it’s importance is that previous research on attitudes toward treatment and compliance has focused solely on patient related factors rather than including physician and service related factors. The same holds true for coercion being found to be an important predictor of attitudes toward medication.
It is very plausible that patients who do not accept hospital treatment will not like the drugs they are prescribed, but again this study shows how important it is to look at compliance as a more complexe construct.
Interestingly, adverse events played a rather minor role compared to the two just mentioned factors in predicting attitude towards treatment.
This finding contradicts the results of some (but not all) previous studies and may explain why recent analyses have not always found an improved compliance under treatment with atypical antipsychotics compared to typical antipsychotics.
A further important strength of the study is the large sample size and the multi-center design so that the results should be rather representative.
An important limitation is that patients were only assessed as inpatients in the phase of acute admission, while the problem of non-compliance and attitude towards treatment may be even more important once patients are outpatients making a control of medication intake impossible.