ISSN: 2320-5407 Int. J. Adv. Res.

12(05), 201-208

Journal Homepage: - www.journalijar.com

Article DOI: 10.21474/IJAR01/18704

DOI URL: http://dx.doi.org/10.21474/IJAR01/18704

RESEARCH ARTICLE
THERAPEUTIC ADHERENCE IN A POPULATION OF PATIENTS TREATED FOR SCHIZOPHRENIA
AT THE HOSPITAL FOR MENTAL HEALTH AND PSYCHIATRIC DISORDERS IN TANGIER

N'sabi Farah, Amal Essafi, Sara Eschater, Yassine Benhaddouch and Adil El Ammouri
……………………………………………………………………………………………………....
Manuscript Info Abstract
……………………. ………………………………………………………………
Manuscript History Introduction: Schizophrenia is a chronic psychosis requiring long-
Received: 10 March 2024 term, often lifelong, treatment and psychiatric follow-up. Adherence to
Final Accepted: 14 April 2024 treatment in this population is a prognostic factor for patients and a
Published: May 2024 major challenge for practitioners, with multiple interfering factors and
significant consequences. However, the relationship between
Key words:-
Compliance, Treatment, Schizophrenia depression and therapeutic adherence in schizophrenic patients remains
underexplored. This study aims to evaluate the epidemiology of
therapeutic adherence in our institution .
Materials and Methods: This is a descriptive and analytical cross-
sectional study conducted at the Mental Health and Psychiatric
Diseases Hospital in Tanger over a two-month period (from October 1,
2022, to November 30, 2022). Data were collected using a hetero-
questionnaire that included sociodemographic data, patient history,
clinical characteristics, and therapeutic aspects. Therapeutic adherence,
insight,, and psychotic symptoms were assessed using the MARS,
Birchwood Q8, , respectively. Bivariate analysis using the Chi-square
test, Student's t-test, and Mann-Whitney U test, and multivariate
analysis using binary logistic regression were performed. Data entry
and analysis were carried out using SPSS version 21, with the
significance threshold set at 0.05.
Résults: The prevalence of poor therapeutic compliance in our study
was 26,7%; 72.2% of the patients had poor therapeutic adherence
according to the MARS scale. A comparison between the non-adherent
patient group and the adherent patient group (Table 2) showed that the
latter were significantly more likely to be female (p=0.00) and have a
good socioeconomic status (p=0.05). They were also more likely to live
with their families (p=0.04) and be more aware of their condition
compared to non-adherent patients (p=0.00). Regarding therapeutic
characteristics, significant differences between the two groups included
the type of antipsychotic medication (p=0.00), treatment supervision
(p=0.00), quality of family support (p=0.03), and patient's assessment
of the treatment (p=0.00)
Conclusion: Compliance is a complex and dynamic phenomenon
whose definitions and evaluation methods are multiple and non-
consensual and the factors are numerous, interacting with each other.

Copy Right, IJAR, 2024,. All rights reserved.

……………………………………………………………………………………………………....

Corresponding Author:- N'sabi Farah 201

ISSN: 2320-5407 Int. J. Adv. Res. 12(05), 201-208

Introduction:-
Therapeutic adherence is defined as the concordance between the patient's behavior and the prescriptions (medicinal
or otherwise) of their physician. It is a dynamic, multifactorial phenomenon that is difficult to evaluate (1).There is
no consensus standard for defining adequate adherence; however, many authors suggest that an approximately 80%
ratio of prescription adherence indicates an acceptable therapeutic alliance over an 18-month period, which is often
referenced in chronic conditions. (2)

In psychiatry, most patients with schizophrenia exhibit partial or no medication adherence,(3,4)Only one-third of
them adhere to their treatment as prescribed (5)

Non-adherence to treatment has clinical as well as socioeconomic consequences, including prolonged hospital stays
and excessive healthcare utilization.(6–8)

In Morocco, therapeutic non-adherence is also a major problem, although data are scarce. According to a study by
Dr. Adil El Ammouri, the prevalence rate of non-adherence among patients was found to be 40%.

Our objective is to evaluate the quality of therapeutic adherence among schizophrenic patients receiving outpatient
care at Ar-razi Hospital in Tangier, and to identify predictive factors of poor therapeutic adherence as well as factors
influencing treatment adherence.

Materials and Methods:-

Type and Location of the Study
This is a cross-sectional study with descriptive and analytical aims spanning over 3 months involving patients being
treated for schizophrenia in our institution.

Inclusion Criteria
1. Age between 18 and 65 years.
2. Patients diagnosed with schizophrenia according to the criteria of the Diagnostic and Statistical Manual of
Mental Disorders (DSM-5) and being treated in our institution.
3. Patients who have given their consent to participate in the study.

Exclusion Criteria
1. Patients aged under 18 or over 65 years.
2. Patients who have not given their consent.
3. Patients who are unstable and disorganized.
4. Patients with intellectual disability.
5. Patients in whom a diagnosis of schizoaffective disorder is likely.

Ethical Considerations
All patients participating in our study were asked to provide informed consent. Data collection was conducted with
respect for anonymity and confidentiality of information.

Data Collection
In order to conduct our statistical study, we developed an exploitation form in the form of a questionnaire containing
the following elements:
1. Sociodemographic characteristics of the patient.
2. Personal and family history of the patient.
3. Clinical characteristics of the disease.
4. Therapeutic management.

Measurement Tools
1. Evaluation of insight using the Birchwood Insight Scale: This is a self-assessment scale of insight consisting of
8 items divided into 3 subscales. Each item can be scored from 0 to 2, each subscale from 0 to 4, and the total
score of the patient can vary from 0 to 12. When the score is less than 9, insight is considered poor, and when it
is greater than or equal to 9, insight is considered good. An insight score of 12 is considered very good.

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2. Evaluation of adherence using the MARS (Medication Adherence Rating Scale): The MARS scale is a
validated measurement tool for therapeutic adherence, consisting of 5 questions to be answered with the patient.
The total score provides an overview of therapeutic adherence: the higher the score, the better the therapeutic
adherence. If the total MARS score is 21 or if the score reaches 4 for each individual question, the patient is
considered compliant.

Analytical Studies
Characteristics were described in mean or median for quantitative variables, and frequency and percentage for
qualitative variables. Comparison of characteristics was performed using Chi-square tests, Fisher's test. The
significance threshold (p) was set at 0.05.

Résultats:-
Our study included a total of 91 patients diagnosed with schizophrenia. The characteristics of the total sample were
as follows (Table 1):

They had a median age of 50 years, predominantly single (73.6%), male (85.6%), and from urban areas (94.3%).
Regarding educational level, 88.7% of them did not exceed secondary education level; 43.8% were unemployed, and
68.2% lived with a third party. 95.8% reported substance use.

Non-medicated psychoactive substances were used by 95.8% of the patients, and 5.6% had a family history of
psychiatric disorders. The average duration of illness was 12.79 years, and our patients had been hospitalized an
average of 2.51 times.

Regarding therapeutic characteristics, first-generation antipsychotics were the most prescribed (62.9%). 10.2% of
the patients reported experiencing side effects induced by the antipsychotic treatment they were taking.27.8% of the
patients have good insight, while 72.2% have poor insight regarding their condition.

Table 1:- Summary Table of Sociodemographic Characteristics of the Studied Population.

Sociodemographic and clinical characteristics". percentage/ number
Gender
male
female 85,6%
14,4%
living situation
urban 94,3%
rural 5,7%

marital status
single 73,6%
married 2,3%
divorced 24,1%
Profession
without profession 56,2%
with profession 43,8%
Health insurance
Present 98,9%
Absent 1,1%
None
Socioeconomic level
Low 75%
Meduim 22,7%
Good 2,3%

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Schooling level
illiterate 3,4%
primary 33,4%
middle school" 37,1%
high school 22,5%
university 3,4%
lifestyle
single 31,8%
with family 68,2%
History of organic pathology
yes 6%
no 94%
Family history of psychiatric disorder
yes 5,6%
no 94,4%
Psychoactive substance use
yes 95,8%
no 4,2%

Suicide attempt
Yes 21,9%
No 78,1%
Clinical characteristics
Length of schizophrenia
12,79 years

Nombre d’hospitalisations 2,51

Time since the last hospitalization 4,11 years

Type of antipsychotic medication
Atypical antipsychotic 37,1%
Typical antipsychotic 62,9%
side effects
yes 10,2%
no 89,8%
treatment cost
yes 73,3%
no 26,7
treatment availability
yes 65,9%
no 34 ,1
treatment monitoring
alone 92,9%
the family 5,9%

Patient satisfaction with the treatment

beneficial 52,3%
damage 47 ,7%

Families' assessment of the treatment

beneficial 41,8%
damage 58,2%

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psychoéducation
Yes 26,7%
no 73,3%
Quality of psychological family support
Yes 47,1%
NO. 52,9%

Therapeutic adherence according to the MARS scale

good observer
poor observer 73,3%
26,7%
Quality of patient insight according to the Birchwood Q8
scale
good insight 27,8%
poor insight 72,2%

Table II:- Comparison of Sociodemographic and Clinical Characteristics of Adherent and Non-Adherent Patients.
observation Comparison Test P-Value
No Yes
Gender
male 65% 11% Fisher's test 0.000
Female 0% 13%
living situation
urban 74,7% 25,3% Fisher's test 0,123
rural 40% 60%
Marital status
Single 79,7% 20,3% Chi-squared test 0,16
Married 61.6% 38.1%
Profession
None 64,1% 35,9% Chi-squared test 0,008
Daily 83,3% 16,7%
Health insurance
None 100% 0% Fisher's test 1
With 72,7% 27,3%
Socioeconomic level
Low 80,3% 19,7% Chi-squared tes 0,05
Meduim 55% 45%
High 0% 100%
lifestyle
With family 63,3% 36,7% Fisher's test 0.04
Alone 92,9% 7,1%
History of organic pathology
Yes 100% 0% Fisher's test 0,323
No 73,1% 26.9%
Family history of psychiatric disorder
Yes 75% 25% Fisher's test 1
No 75% 25%
Type of antipsychotic medication
Atypical 51,5% 48,5% Chi-squared test 0,00
Classic 85,7% 14,3%
treatment cost

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Yes 70.6% 29,4% Chi-squared test 0,548

No 57,1% 42,9%
side effects
Yes 88,9% 11,2% Fisher's test 0,434
No 70,9% 29,1%
treatment monitoring
Patient 79,7% 20,3% Chi-squared test 0,00
Family 0% 100%
Quality of psychologcal family support
Good 6,3% 93,8% Chi-squared test 0,03
Poor 70% 30%
Patient satisfaction with the treatment
Beneficial 35,2% 64,7% Chi-squared test 0,00
Damage 100% 0%
Families' assessment of the treatment
Beneficial 42,1% 57% Fisher's test 0,91
Damage 100% 0%
Psychoeducation
Yes 0% 100% Fisher's test 0.00
No 100% 0%
Insight.
Good 4,2% 95,8% Chi-squared test 0,00
Bad 98,5% 1,5%

72.2% of the patients had poor therapeutic adherence according to the MARS scale. A comparison between the non-
adherent patient group and the adherent patient group (Table 2) showed that the latter were significantly more likely
to be female (p=0.00) and have a good socioeconomic status (p=0.05). They were also more likely to live with their
families (p=0.04) and be more aware of their condition compared to non-adherent patients (p=0.00).

Regarding therapeutic characteristics, significant differences between the two groups included the type of
antipsychotic medication (p=0.00), treatment supervision (p=0.00), quality of family support (p=0.03), patient's
assessment of the treatment (p=0.00),and psychoeducation (p=0,00)

Discussion:-
The prevalence
The phenomenon of poor therapeutic adherence is encountered in all medical disciplines. In psychiatry, 15 to 25%
of hospitalized patients and 50% of those followed on an outpatient basis would have poor therapeutic adherence.
(9) ;20% of subjects would not purchase their medications in the month following the prescription, and 30 to 50% of
purchased medications would be discarded, unused, or stockpiled. (10) .Non-adherence concerns approximately
50% of patients across all situations in psychiatry. Corrigan et al provided the following figures for patients with
schizophrenia treated with neuroleptics: 11 to 80% non-adherent, with an average percentage of 48% in the first year
and 74% for the first two cumulative years. In our study, the rate of non-adherent patients is approximately 73.3%.
(11)

Indeed, it is very difficult to obtain consistent figures for methodological reasons (various methods, more or less
reliable) and due to difficulties in clearly defining adherence.(11).

Cramer & Rosenheck conducted an analysis of 24 studies conducted between 1958 and 1994 that
attempted to measure the adherence rate among patients treated with antipsychotics. The figures concerning non-
adherence vary from 24 to 90% (average percentage of 58%).(12) Misdrahi et al mention that 16% to 80% of
patients with schizophrenia are non-adherent.(13)Palazzolo conducted a literature review of all publications (34
studies) published between 1985 and 2000 and found that the average adherence rate is 46% for daily intake of oral
medication, with results ranging from 5 to 85%. (14)

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Factors influencing therapeutic adherence

Adherence in schizophrenia is a multifactorial phenomenon.(13,15,16). Generally, four types of factors influencing
adherence can be distinguished: those related to medications, those related to patients and the illness, those related to
the physician and healthcare team (therapeutic alliance), and finally, environmental factors.

Factors related to medication

Adverse effects
Indeed, medication adherence partly depends on treatment tolerance and therapeutic efficacy. Adverse effects are
often considered the main reason for poor therapeutic adherence. A significant advancement has been represented by
the introduction of new antipsychotics. Besides their excellent efficacy, at least equivalent to that of conventional
neuroleptics such as haloperidol, they have reduced the incidence of certain side effects and improved quality of life.
The reduction of these adverse effects, which greatly troubled patients and led many to discontinue treatment,
should significantly improve therapeutic adherence. (17)

One can conclude that a medication must be taken and understood by the patient as a highly useful, indispensable,
and vital treatment; the benefits must clearly outweigh the drawbacks.

Treatment Cost:
For individuals with socio-economically disadvantaged conditions, the cost of treatment can become a factor if
reimbursement is insufficient or nonexistent after hospital discharge.(13). In our study, we did not find a relationship
between treatment cost and adherence, which can be explained by the availability of treatment in public services
most of the time.

Factors related to patients and the illness

Sociodemographic Factors:
Among sociodemographic factors, literature data regarding the potential influence of age, gender, level of education,
income, etc., are contradictory.(18–20)

It appears that women adhere better to treatment than men, and (19), The same result was reported in our study.

Illness Insight and Anosognosia:

This lack of illness insight is a factor frequently mentioned as a cause of non-adherence.(19,21,22). Within a
population of 60 patients with schizophrenia, the score obtained on a scale measuring illness insight was
significantly correlated with the score of poor adherence measured by the DAI-30.(23). This holds true for our
patients, where good therapeutic adherence was associated with a good level of insight.

Substance Use:
Olfson et al., in a longitudinal study involving 213 patients with schizophrenia followed after hospital discharge,
explored negative predictive factors on adherence. Three months after discharge, 19.2% of the subjects were non-
adherent (discontinuation of treatment for at least one week). Compared to those who were adherent to their
treatment, these subjects had significantly more frequent histories of addictive behaviors.(21)

Owen et al. highlighted that among patients with schizophrenia with substance use disorders, the risk of not
regularly taking their medication was over eight times higher. Individuals who use substances and do not adhere to
their medication regimen or outpatient treatment consistently exhibit the most symptoms.(25)

Bowers and colleagues explained that psychoactive substances lead to alterations in dopaminergic systems at the
mesolimbic level, which would make patients resistant to the action of antipsychotics.(26)

Environmental Factors
Family Support and Accessibility of Care:
Unfavorable family environments and cultural factors also seem to be involved.(13).According to the ADHES
survey, 71% of Belgian doctors believe that their patients need family, a psychiatrist, etc., to remind them to take
medication as prescribed, and 57% of schizophrenic patients live in conditions (family, environment, etc.) that could
affect daily adherence. This is confirmed in our study, where patients with good quality family support adhere to
their treatment.

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Psychoeducation:
A structured program comprising various educational modules has a positive impact on medication adherence. (14).
Kemp et al. demonstrated in patients with schizophrenia that an educational program significantly improves
therapeutic adherence, illness insight, and social functioning.(27). The superiority of this type of intervention was
confirmed in another study involving a population of patients with schizophrenia treated with antipsychotics,
without an increase in healthcare costs associated with this management.(22). Many studies highlight the benefits of
these modules in terms of favorable clinical outcomes for patients.(28).

Conclusion:-
Non-adherence to treatment is a major problem in the management of schizophrenia. It is common and has serious
consequences for the patient, their family, and society as a whole. This research aims to shed light on this major
public health issue, as it is a complex and multidimensional concept. Its clinical relevance remains significant as it is
correlated with the prognosis of the disease.

Its multifactorial and complex origin emphasizes the need for a multidisciplinary, personalized approach for each
patient, integrated into a comprehensive biopsychosocial therapeutic approach.

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