Current Trends in Biotechnology and Pharmacy 200

Vol. 14 (5) 200-205, ISSN No. 0973-8916 (Print), 2230-7303 (Online)

DOI : 10.5530/ctbp.2020.4s.24

Revisiting the Intractable Barriers Affecting Medication Adherence

Among Outpatients with Schizophrenia
Julaeha Julaeha1 2*, Umi Athiyah2*, Verra Yuliana3, J.P Ayuningtyas3, Andi Hermansyah2
1Faculty of Pharmacy,17 Augustus 1945 Jakarta University, Jakarta, Indonesia
2Department of Pharmacy Practice, Airlangga University, Surabaya, Indonesia
3Menur National Mental Hospital, Surabaya, Indonesia
*Corresponding Author : [email protected], [email protected]

Abstract be optimal to prevent patient from relapse and

Medication adherence is one of the foremost problems hospitalization (1). Low adherence has been evident in
affecting antipsychotic efficacy in schizophrenia patients. many patients with schizophrenia contributing to a
Medication nonadherence among schizophrenia patients number of severities including higher risk of suicide and
has been often estimated > 50%, leading to higher rates financial burden which affects not only patients but also
of relapse and hospitalization as well as to decreasing their families and care givers (2). Several publications
cognitive and functional prognosis. The purpose of the have reported significant portion of non-adherence in the
study is to identify the strategy for improving medication case of schizophrenia ranging from 40% to 70% (3). In
adherence in schizophrenia and evaluate adherence using fact, 75% of patient with schizophrenia stop taking their
Medication Adherence Rating Scale (MARS) and medication within 18 months (4).
determinant factors affecting adherence. Prospective Poor adherence in schizophrenia can be associated
study with cross sectional design was conducted from with a number of factors such as social isolation,
October to December 2019. Especially data from stigmatization and comorbidities substance misuse of
schizophrenia outpatients in one of national mental psychotropic medication (5). As adherence is a complex
hospital in Indonesia. Schizophrenia outpatients were phenomenon, these factors may be exacerbated by a wide
majority male (60%), the age range from 31-49 years were variety of other causes such as lack of illness awareness,
70%, most of patients are single (63,33%), 70% have the adverse effect of the medication, the long-term
secondary education, 70% of them are from Surabaya treatment and the fragmented health care services for
area, and half of them their duration of the disease from 1 patient with mental health issues. Such condition may be
to 5 years. This study showed that the pattern of
increased yet undetected in the outpatient setting as patient
prescription of antipsychotics are risperidone and
will need to undertake and be responsible for the
clozapine were the most antipsychotics prescribed. 40%
medication at their own risk (5).
of patients have good adherence, 40% of patients have
partial adherence, and only 20% of patients' poor The risk of non-adherence in the outpatient setting
adherence. Most of schizophrenia outpatients have cannot be neglected. A systematic review of longitudinal
experience in forget to take his/her medicine and careless studies reported that there were 27% of individuals with
at times about taking his/her medicine and less knowledge schizophrenia who had poor outcome after the first
about schizophrenia. In other hand, 100% patients have episode of psychosis (6). Another study indicated that
agreed by staying on medication, it can prevent getting 82% of patients would likely to suffer first relapse and
sick. The mental hospital should utilize educational 78% would continue to suffer the second relapse after
program to improve patient's awareness about their the first episode of psychosis (7).
disorder and their medications to improve their adherence. The causes of non-adherence include the patients
Key words : Schizophrenia,Antipsychotics, SGAs, factors as fear of adverse effects, physical and psychiatric
Medication Adherence, MARS, Mental Health conditions, forgetfulness, external distractions,
misunderstanding instructions, lack of insight and lack
1. Introduction of information about disorders. Treatment factors as
It is not easy to maintain medication adherence on numerous medications, enduring symptoms, partial or no
patient with schizophrenia. Although the advances in efficacy. Social economic factors as lack of income,
psychopharmacology have greatly improved the range of transportation, living alone, and stigma of mental illness
options for treating schizophrenia, the outcome may not (8).

Revisiting the intractable barriers affecting medication

Current Trends in Biotechnology and Pharmacy 201
Vol. 14 (5) 200-205, ISSN No. 0973-8916 (Print), 2230-7303 (Online)
DOI : 10.5530/ctbp.2020.4s.24

Schizophrenia is one of nine chronic disease covered Instrument : The Medication Adherence Rating Scale
by national health covered in Indonesia (9). In Indonesia, (MARS) tool was used for measuring level of adherence.
the number of relapse on schizophrenia patients was It was formerly evolved and validated by Thompson et
reported. The number of relapsed had significant al., to evaluate treatment compliance specifically in
correlation with medication non-adherence. The common people under antipsychotic treatment. It was designed to
problems of medication non-adherence among assess both the patients attitude towards medication and
schizophrenia patients in Indonesia were social economic, also actual medication taking behavior. the reliability
attitudes to medication, knowledge, and family support analysis of the MARS using cronbach's alpha was 0.75
(10). (14). The validity and reliability of MARS with large
sample (N=319) by Fond et al., a coefficient were close
Medication non-adherence will escalate the risk of
to 0.6 (15). It was translate into Indonesia and validated
recurrences, hospital admission rate and medication
by Yuliana et al., with reliability result 1.107 (16).
expense (11). The cost of re-hospitalizations and non
adherence per year were 100 billion USD and 290 USD MARS consists of three parts questions/statements;
(12). In Indonesia, cost of illness schizophrenia was question 1-4 represent treatment adherence behavior,
estimated 32 million IDR/year/patient (13). The objective question 5-8 represent attitude toward taking medicines
of this study is to identify the strategy for improving and question 9-10 represent adverse effects and attitudes
medication adherence in schizophrenia and evaluate to antipsychotic treatment. Every question or statement
adherence using Medication Adherence Rating Scale should be answered with a 'YES' or 'NO' answer. A
negative response indicate with non-compliance is code
(MARS) and determinant factors affecting adherence.
as zero. Whereas a positive response indicate with
2. Materials and Methods compliance is coded as one.
Design : Prospective study with cross sectional design For questions 1-6 and 9-10 an 'disagree' answer is
was conducted from October to December 2019. This indicate of positive response and hence should be coded
study has been approved by the Ethic Committee of the as one. In opposed for questions 7-8 a 'agree' answer
Menur Mental Hospital with number of ethical approval pointing to positive response and hence should be coded
070/7556/305/2019. Especially data from schizophrenia as one. The whole of adherence scoring range between
outpatients in one of national mental hospital in Indonesia. nil (non-compliance) to ten (compliance), with a greater
Non probability sampling (purposive sampling) all score pointing good attitudes and behavior towards
schizophrenia patients who registered as an outpatient positive compliance. Patient with total score < 5 (non
national mental hospital in the chosen sitting and fulfill adherence), 5-7 (partial adherence), and ? 8 (good
the inclusion criteria was selected. adherence).

Subjects : The inclusion criteria are patient with Processing and analyzing data : Statistical Package for
schizophrenia, being adult aged 18 or older, who agree social Science (SPSS) version 24 was used. The following
to participate in the study, and patient who have insight. statistical measured were used as descriptive measures
The exclusion criteria are patient who have other mental as numbers, percentage, mean and standard deviation.
disorder and patients diagnosed with brain dysfunction Analytical statistics as T-test independent sample and
or cognitive impairment. The minimum sample size for Analysis of Variance one away.
descriptive quantitative research not less than 30. The 3. Results and Discussion
participants were 30 patients. Informed consent was
Characteristic of schizophrenia outpatients and
obtained from all participants after explaining the study
medication
and its objectives. Participants were included only after
they signed the informed consent. All researchers ensured Table 1 reveals that male were majority (60%), the
participant data confidentiality and compliance with the age range from 31-49 years were 70%, most of patients
Declaration of Helsinki. This study was conducted in one are single (63,33%), 70% have secondary education, 70%
of national mental hospital in Indonesia. Participants were of them are from Surabaya area, and half of schizophrenia
interviewed regarding their history of mental illness, patients have mental disorder with a range duration of 1
sociodemographic characteristic, and pharmacological to 5 years. Table 2 shows that the pattern of prescription
of antipsychotics are risperidone and clozapine were the
treatment.
most antipsychotics prescribed for schizophrenia

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Vol. 14 (5) 200-205, ISSN No. 0973-8916 (Print), 2230-7303 (Online)
DOI : 10.5530/ctbp.2020.4s.24

Table 1. Characteristic of schizophrenia outpatients extrapyramidal syndrome and increased quality of life
Characteristics N % (17).
Gender Level of adherence and attitude towards medication
Male 18 60 The effectiveness of the medication is impacted and
Female 12 40 the chance of recurrence will be elevated when people
Age (year) with schizophrenia discontinue taking medication. The
18-30 4 13.3 results of this study, only six patients (20%) have poor
31-49 21 70 adherence (see figure 1). This results was in the line with
50-65 4 13.33 Kamali et al., who reported that schizophrenic subjects
>65 1 3.33 had poor adherence lower than schizophrenic subjects
Marital status had good adherence (18). Contrasting to other studies,
Single 19 63.33 who informed that lack of compliance was found in about
Married 10 33.33 half of people suffering from schizophrenia (19,20,21).
Divorced 1 3.33
Educational level
Elementary school 4 13.33
Junior high school 9 30
Senior high school 12 40
College or higher 5 16.67
Occupation
Full time 11 36.66
Part time 5 16.67
Not worker 14 46.67
Duration of treatment (year)
1-5 15 50
6-10 10 33.33 Figure 1. Number of level of patients adherence
11-15 5 16.67
Number of antipsychotic In other hand, table 3 indicated that most of patients
Monotherapy 4 13.33 with schizophrenia undergo in forget to take his/her
2 antipsychotics 23 76.67 medicine and careless at times about taking his/her
3 10 medicine, adverse effects and deficiency of insight and
MARS total score shortage of information about their disorder. From the
Minimum total score 4 sighting, this is might because the healthcare team did
Maximum total score 10 not provide the client and caregiver the comprehensive
Mean total score 7.20 information according to their treatment and illness.
Including intervention, dosage regiment, therapeutic
Table 2. Regimen of oral antipsychotics effect, and adverse effect. The results of current study
Regimen therapy N % indicated that half participants with schizophrenia
Risperidone 3 10 disorder did not clearly understand their illness and
Risperidone + Clozapine 12 40 medication.
Risperidone + Clozapine + 3 10 Many studies has reported that medication adherence
Trifluoperazine is related to knowledge and experience of, and insight
Clozapine + Trifluoperazine 8 26.67
into the illness, in addition to patient's attitudes toward
Haloperidol 1 3.33
the use of medication for the treatment of psychiatric
Haloperidol + Clozapine 2 6.67
disorders (22,23,24,25). One of study reported that when
Aripiprazole + Clozapine 1 3.33
patients were not fully informed about their illness and
outpatients. Currently, atypical antipsychotics became treatments, there were likely to discontinue medication
drug of choice in schizophrenia treatment considering therapy of their own volition without discussing the matter
more effective in relapse prevention, reduced risks of with healthcare professional (23).

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Vol. 14 (5) 200-205, ISSN No. 0973-8916 (Print), 2230-7303 (Online)
DOI : 10.5530/ctbp.2020.4s.24

Table 3. Frequency of Attitude towards medications Table 5. Analysis of Variance One Away
Medication adherence YES NO
questions/statement N % N % Adherence
1. Do you ever forget to take 15 50 15 50 Studied N Adherenc SD Sig
your medication? variable e score
2. Are you careless at times 13 43.3 17 56.7 (mean)
about taking your medicine? Education lavel
3. When you feel better, do 6 20 24 80
Elementary 4 7.50 2.380 .942
you sometimes stop taking
your medicine? school
4. Sometimes, if you feel 4 13.3 26 86.7 Junior high 9 7.00 1.732
worse when you take the school
medicine, do you stop taking Senior high 12 7.33 1.303
it? school
5. I take my medicine only 2 6.7 28 93.3
when I am sick
College or 5 7.00 2.000
6. It is unnatural for my 3 10 27 90 higher
mind and body to be Total 30 7.20 1.627
controlled by medication Treatment duration
7. My thoughts are clearer 16 53.3 14 46.7 1-5 year 13 6.92 1.847 .307
on medication
6-10 year 12 7.75 1.357
8. By staying on medication, 30 100 0 0
I can prevent getting sick 11-15 year 5 6.60 1.517
9. I feel weird, like a 9 30 21 70 Total 30 7.20 1.627
‘zombie’, on medication Number of antipsychotic
10. Medication makes me 19 63.3 11 36.7 1 4 7.75 1.500 .307
feel tired and sluggish antipsychot
ic
Factor affecting medication non-adherence 2 23 6.96 1.692
The triggers of non adherence include the personal antipsychot
ics
factors, medication factors, and socio-economic
3 8.33 .577
environment factors. The results of this study there is no antipsychot
significant different adherence score between gender ics
group and educational level group (table 4). This finding Total 30 7.20 1.627
inline with Naafi et al., who reported there is no
meaningful difference between patients characteristic and during treatment has negative impact on their treatment
the patients medication adherence level (26). Conforming compliance. One of study reported that pharmacist
current study pointed out that there is no meaningful counseling there was meaningful difference adherence
different between treatment factors such as duration of level between pre and post pharmacist counseling
treatment and number of antipsychotics with treatment intervention (27). Therefore, the health care team should
compliance score (table 5). give the patient and/or the caregiver psycho-educational
program for compliance of treatment improvement
Table 4. Independent sample T-test gender different
(28,29,30).
Gender N adherence SD Sig.(2 There are several limitations in this study. Due to
score tailed)
limited sample size and lack of clinical data as adherence
(mean)
Male 18 7.33 1.847 .564 parameter. Prospectively study with various number
Female 12 7.00 1.279 sample size and objective parameter of adherence might
Total 30 7.20 1.627 be considered. Despite the several limitations, our study
provides preliminary finding to explore barriers affecting
This study contrasting to Dibonaventura et al., Dassa medication adherence in mental health disorder treatment.
et al., and Yang et al., who reported that the quantity of 4. Conclusion
medications may affects patient's toward compliance Adherence to medication is a critical issue for patients
(16,17,18). The results of this current study shows more with mental disorder. It cannot be overemphasized that
than 50% of participants has experiences with patients should have insights into their own mental
antipsychotic side effects. Lack information or education disorder and realize the necessity of taking medications
about heir medication and side effect might be occur to improve their chances of a successful recovery. The

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healthcare provider should empower counseling program of first-episode psychosis. Psychological Medicine.
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Education for funding support this study through 9. Social Insurance Administration Organization.
Beasiswa Unggulan Dosen Indonesia scheme. Beside Practical Guidelines of Referral Program for
that, the author thank the all participants and all staffs National Health Coverage Participant. 2014.
the national mental hospital for providing supports and Available from: https://bpjs-kesehatan.go.id/bpjs/
facilitating data collections. dmdocuments/4238e7d5f66ccef 4ccd89883c46
fcebc.pdf.
Conflict of interest
10. Sari SP, Suttharangsee W, Chanchong W. The effect
The authors declare no financial or commercial
of self-management with family participation on
conflict of interest. medication adherence among patients with
schizophrenia in Indonesia: A pilot study.
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