Treatment Compliance and Noncompliance in Psychoses

Byline: K. Rao, Jitty. George, C. Sudarshan, Shamshad. Begum Background: Compliance or noncompliance with treatment significantly influences course and outcome of psychiatric disorders. While noncompliance has been extensively researched, compliance has received less attention. The current study was conducted to elicit reasons for compliance and noncompliance in patients having psychoses attending psychiatric clinics. Materials and Methods: A total of 196 compliant and 150 noncompliant patients were interviewed using self-designed tools to elicit sociodemographic data, details of illness, and treatment. Factors contributing to compliance and noncompliance were grouped under illness-related, clinician-related, medication-related, family-related, and economic-related domains and compared. Results: Compliance was significantly more in females and middle- and high-socioeconomic status patients. They had less substance use, high physical comorbidity, high attendance in the outpatient department, and better remission. Clinician-related, family-related, and medication-related domains were contributing more to compliance whereas illness-related and economic-related domains seemed to have more bearing on noncompliance. Conclusions: Compliance and noncompliance are determined multidimensionally. Domains related to clinician, family, and medications have to be reinforced to enhance compliance. Illness-related and economic domains have to be resolved to reduce noncompliance. Introduction There have been dramatic improvements in pharmacotherapy of psychotic disorders in the past 60 years contributing to reduction of symptoms, prevention of relapse, and improvement in social functioning.[sup][1] Despite these gains, treatment of psychotic disorders remains a major challenge. The actual effectiveness of antipsychotic medications is well below the efficacy obtained from clinical trials when relapse rates are considered.[sup][2] One of the reasons for this state could be noncompliance to treatment. Compliance is defined as the extent to which a person's behavior coincides with medical or health advice.[sup][3] Noncompliance can be defined as opposite of compliance. There has been an attempt to divide noncompliance into primary (not buying or receiving the medicines) and secondary (not complying with the instructions regarding dosage, frequency, and duration of medication intake).[sup][4] In recent times, the terms compliance and noncompliance have been considered as clinician oriented. To shift the emphasis onto patients, the terms adherence and nonadherence have been suggested. However, in clinical practice, these terms are used interchangeably. Noncompliance rates in schizophrenia vary widely, ranging from 20% to 89%.[sup][5] Various reasons have been cited in literature for noncompliance. These include poor insight, side effects of medicines, poor remission of symptoms, and poor therapeutic alliance.[sup][6],[7],[8],[9] It also includes stigma associated with the illness,[sup][9],[10] poor family support,[sup][11] ignorance about need to continue treatment,[sup][12] and economic reasons.[sup][9],[13] In addition, when patients improve, they may not feel the need to continue medications anymore.[sup][12] In Indian studies, noncompliance has been found to be related to lack of knowledge, financial difficulties, side effects, and no improvement.[sup][14],[15] Distance to hospital, lack of caregivers, poor insight, and lack of time have also been cited as reasons for noncompliance.[sup][15] It is also reported that there is high prevalence of substance abuse in schizophrenia in noncompliant patients.[sup][16] Other contributing factors are low priority accorded to health by patients and their caregivers, higher importance to economic activities, tendency to deal with problems only when they become acute and high emphasis on doctors' exclusive role in alleviating symptoms of the patient.[sup][17] Noncompliance is strongly related to clinical outcomes such as relapse, rehospitalization, and suicide attempts in schizophrenia [sup][18] and bipolar disorder. …