INTRODUCTION
The aim of this dissertation is to explore the factors affecting concordance with prescribed antipsychotic medications. The rationale for selecting this topic is derived from personal working experience with mental health service users. Having worked as a nursing assistant for the past eight years on acute admissions wards and as a student nurse for the past three years, it was observed that a large proportion of compulsory re-hospitalisation under the Mental Health Act 1983 occurs due to relapse of mental illness as a result of non- concordance with medications, particularly service users with a diagnosis of schizophrenia. This led to believe that concordance with antipsychotic medications plays a crucial role in managing psychosis, as it positively contributes towards the effective management of the illness in the community. In support to this view, Gray et al (2002a) asserted that prophylactic use of antipsychotic medication reduces the risk of relapse among individuals with schizophrenia and non-concordance with medication has the potential for frequent re-hospitalisations. This has been recognised as the revolving door syndrome.
During most mental health placements it was noted that non-concordance with medication has become significant as this has been identified as a risk factor within the risk assessment checklist. Furthermore, despite the well-documented therapeutic effect of antipsychotic medications, some patients are reluctant to accept treatments and some may even wish to cease taking medications altogether. Therefore, this empirical knowledge has reinforced the desire to examine the factors associated with non-concordance with antipsychotic medications.
According to Brimblecombe et al (2005) medication is one of the major therapeutic tools available to help people with schizophrenia. There is also growing evidence that schizophrenia can be treated effectively with a range of psychological and social interventions together with psychotropic medications. Norman & Ryrie (2004) emphasised that antipsychotic medication has been the mainstay of treatment for schizophrenia since the 1950s when it was discovered that the dopamine antagonist haloperidol and chlorpromazine exerted antipsychotic effects. The National Institute for Clinical Excellence (NICE) (2002) recommends that atypical antipsychotic drugs such as amisulpride, olanzapine, quetiapine or risperidone must be considered in the choice of first-line treatments for individuals with newly diagnosed schizophrenia or to promote recovery, as they appear to have less extrapyramidal symptoms (side effects) than the conventional antipsychotics such as haloperidol and chlorpromazine.
The care and treatment of individuals with schizophrenia have advanced considerably over the past ten years, since the introduction of atypical antipsychotics and medication continues to be the first line treatment for schizophrenia (Walker & MacAulay, 2005). However, Gray et al (2002b) claimed that despite the effectiveness of these atypical antipsychotic drugs, non- concordance with prescribed antipsychotic medications is observed in around 50% of people with schizophrenia and is a major preventable cause of psychiatric morbidity. In addition, Mitchell & Selmes (2007) claimed that over the course of a year, about 75% of patients will discontinue prescribed antipsychotic medications, often coming to the decision themselves and without informing a health professional. According to Gray et al (2006) relapse rates is five times higher among individuals with schizophrenia, who are non-concordance with medication compared with concordance. Furthermore, the impacts of non-concordance with medication not only affect the individuals with schizophrenia, as each relapse causes a stepping down of cognitive functioning which is rarely retrieved but also their carers and the costs of treatments (Institute, 2007).
To facilitate this project as a literature review, an analysis of secondary sources only will be use. Secondary sources were mainly obtained from nursing journals such as Nursing-Standard, Nursing-Times, Advances in Psychiatric Treatment, Mental health practice, Schizophrenia Bulletin and The British Journal of Psychiatry, containing the key : schizophrenia, oral antipsychotic, medication management and non-concordance. An Internet search of Google was also done with the same key to access any relevant documents. To address the factors affecting concordance with prescribed antipsychotic medications, these will be divided into patient-related factors, medication-related factors and clinician-related factors.
LITERATURE REVIEW
According to White (2007) schizophrenia is a debilitating psychiatric disorder characterised by a range of positive and negative symptoms and these symptoms were first described in detail by the British neurologist Hughlings-Jackson in the late 1800s. There is no physical test for schizophrenia rather it is diagnosed by the presence of certain positive and negative symptoms over a period of time. According to Issacs (2006) the neurotransmitter hypothesis suggests that the dopamine over activity in the mesolimbic dopamine pathway, which is between the midbrain, is thought to cause the positive symptoms of schizophrenia and dopamine under activity in the mesocortical dopamine pathway is thought to result in the negative symptoms of schizophrenia.
Positive symptoms represent a distortion of normal experience, such as delusions, hallucinations and thought disorder, whereas negative symptoms represent a loss or dimming of normal function and social norm, such as avoidance of social interactions (Baker, 2003). However, Gillam (2002) claimed that the exact causes of schizophrenia remain unclear but genetic, environmental and social factors are all thought to influence its development. The risk for a child to develop schizophrenia is 46%, if both parents have the disorder (Kirk et al, 2006). Women who have certain viral illnesses during their pregnancy may be at a greater risk of giving birth to children who later develop schizophrenia and the 1957 influenza A2 epidemics in England resulted in an increase in schizophrenia in the offspring of women who developed this flu during their pregnancy (Frankenburg, 2007).
1 in 100 UK populations will develop schizophrenia in their lifetime and the world prevalence is about 2-4 in 1000, as it affects men and women equally (Rethink, 2008). However the onset in men is about five years earlier than women with the peak age of incidence is between 16 and 25 and the presentation of the illness varies tremendously, not only between individuals, but also within the same individual at different stages of their illness (Magorrian, 2007). Schizophrenia seems to be more common in city areas and in some ethnic minority groups and premature mortality in people with schizophrenia is 2 to 3 times higher than that in the general population (Royal college of Psychiatrists 2008). Furthermore, according to WHO (2008) schizophrenia is a treatable disorder, however many individuals remain untreated regardless of effective treatments.
There has been an unresolved debate about how best to define patients’ engagement with medications and until the 1980s most work on patient engagement with medications regimes was described as compliance (Norman & Ryrie, 2004). The term compliance is often used interchangeably with adherence or concordance (Snelgrove, 2005).
According to Kikkert (2006) the term compliance has fallen out of favour in clinical practice because it carries an assumption that patients are the passive recipients of clinicians and implies unquestioning obedience with no opportunity for patients’ choice. Velligan et al (2006) claimed that in recent years there has been a shift from this paternalistic model of doctor-patient interactions with the consequent preference for the use of the term adherence. According to Gray et al (2002b) concordance may be a more acceptable term, as it suggests a collaborative process of decision-making regarding medications regimes and acknowledges the importance of the two-way communication.
the NHS Plan (2000) emphasised the importance of placing patients at the centre of services and the transformation of patients into consumers of the health service has changed the context of health care, as patients are expected to become more active and informed about their treatments (Jasper, 2006). Murray et al (2007) emphasise that shared decision-making between clinicians and patients has the potential to improve concordance with treatment plans. Furthermore, The Chief Nursing Officer’s review of mental health nursing (2006) recommends that building and maintaining positive interpersonal relationships with service users is essential to successful mental health nursing practice and person-centred values is helpful in building positive relationships.
It appears that by not coinciding to health professionals’ advice patients may be viewed as deviant and labelled as non-compliant. Nonetheless, compliance could also be problematic, for example if patients continue to take medication obediently, although it is causing adverse side effects. However, from the empirical knowledge the term compliance is still being used in clinical settings despite the paternalistic conception. Therefore, the term concordance is favoured here, as it promotes the idea that medication treatment should be a collaborative process between clinicians and patients, which emphasises the patients’ rights, as this corresponds with the current philosophy of modern mental health care set out in the National Service Framework (NSF 1999), the NHS Plan (2000) and the Chief Nursing Officer’s review of mental health nursing (2006), which is concerned with working together and in partnership with patients and carers. On the other hand, according to the term concordance, patients have the right to make decisions, for example, stopping medication even if health professionals do not agree with that decision.
Antipsychotic medication has proven efficacy in the treatment of schizophrenia and the prevention of relapse. In spite of this, almost 90% of patients will relapse within the first five years of treatment following an acute episode and in general the illness has a tendency to recur or become chronic (Velligan et al, 2006). According to White et al (2007) non-concordance with drug therapy is common in schizophrenia; approximately 50% of patients are non-concordant within one year and 75% within two years after being discharged from hospital. The myth that non-concordance with medication is more common among mental disorders as compared to physical disorders needs to be dispelled. A study of concordance with asthma medication conducted by Newell (2006) estimated that 70 % of asthma patients in the UK are non-concordant with medication and the levels of non-concordance in long-term conditions, such as asthma are known to be high as many asthma sufferers will only take medicine when they feel they need it, rather than as instructed by clinicians. Therefore, considering Newell (2006) findings it can be argued that the rates of non-concordance with antipsychotics are not significantly different than those on non-psychiatric medications.
One of the major clinical problems in the treatment of people with schizophrenia is non-concordance with medication and this limits the clinical effectiveness of the prescribed medications (Kikkert, 2006). Several factors have been shown to increase the chance of relapse, but probably the single most important determinant of relapse is the discontinuation of effective antipsychotic drug therapy. A large number of factors influence non-concordance with prescribed antipsychotic medications, however Gray et al (2002b) have identified the main factors as impaired judgement, negative beliefs about treatment, poor worker-user relationship and the side-effects of medication. Additionally, Kikkert et al (2006) conducted a study in four European countries exploring medication adherence in schizophrenia and identified insight, beliefs about treatment, side effects and treatment efficacy as factors that influence concordancewith medication in patients with schizophrenia.
Urquhart (2005) suggests that the problem of non-concordance may be more prevalent among those with schizophrenia due to its nature, for example, lack of insight. Magorrian (2007) claimed that non-concordance with medication is often linked to the person's level of insight into his or her illness and lack of insight is a frequent concomitant of psychosis. In schizophrenia, insight has been defined as an awareness of illness and an ability to recognise symptoms as part of an illness (Gray et al, 2002b)
According to Surguladze & David (1999) between 50% and 80% of patients diagnosed with schizophrenia have been shown to be partially or totally lacking insight into the presence of their mental disorder and these individuals are often difficult to engage with treatments due to impaired insight. Recent conceptualisation has formulated insight as a continuum representing the combination of three factors; awareness of illness, need for treatment and attribution of symptoms. Lack of insight is continuously problematic, but an emotional element can be associated with denial of symptoms or rejection of treatment at key points in the illness (Byrne, 2000). Mitchell & Selmes (2007) claim that having a perception about the illness and the knowledge of medications are the key factors of concordance in mental health and patients who understand the purpose of the prescription are twice more likely to collect it than those who do not understand.
A study by Cuesta et al (2000) reported that patients suffering from schizophreniashowed poorer insight than patients with affective disorders. Cuesta et al (2000) findings demonstrated that the severe disturbances of insight persisted over the time and the level of insight was not significantly improved in patients suffering from functional psychosis as between 29% to 49% of these patients continued to have fair to poor insight at the follow up assessment. In contrast, Tait et al (2003) conducted a study to examine changes in insight and symptoms of psychosis on fifty participantswho met the ICD—10 diagnostic criteria for schizophrenia. The participants were interviewed and insight was measured duringacute psychosis using the Insight Scale with the score 0- 12 and all the participants were reinterviewed at 3 and6 months following the initial interview. Tait et al (2003) findings indicated that duringthe acute episode, 48% of participants scored 9-12 on the InsightScale and the majority of participants (63%) werein the 9-12 range of scores. The study of Tait et al (2003) clearly indicated that level of insight was high among many participants.
In considering the findings of both Cuesta et al (2000) and Tait et al (2003) it appears that some patients with psychosis are unaware of their illnesses and insight is a strong predictor of concordance with medications and a good indicator of prognosis. However, evidence for a relationship between insight and concordance with treatment is inconclusive as the discrepancies found between the two studies might be due to the methodological factors, such as selection of participants. In both studies all the participants had a diagnosis of schizophrenia and all of them gave informed consent to enter the study. According to Appelbaum (2006) several studies in America regarding the decisional-capacity of patients with schizophrenia to consent or participation to research have raise some concerns due to the cognitive impairments associated with schizophrenia and using the MacArthur Competence Assessment Tool for Clinical Research clearly indicated that patients with schizophrenia do lack understanding and reasoning of research ethics.
McCann & Clark (2005) emphasise that antipsychotic medications some of which have a sedating effect can also have an impact on the cognitive processes, such as illogical thinking and this can hinder the quality of responses.
Moser et al (2005) argued that some studies have shown that a high percentage of individuals with schizophrenia have adequate decisional capacity to consent to research participation, however in a medication-free schizophrenia research, participants did not show a major decline in decisional capacity. In addition, Jeste et al (2006) claimed that there is a risk in assuming that decision-making capacity of individuals with schizophrenia is always impaired, when they are capable to make autonomous decisions and in considering their decision-making capacity as permanently impaired by virtue of their diagnosis. Consequently, in order to investigate factors associated with schizophrenia, it can be argued that only individuals with schizophrenia can provide the answers of their experiences and protecting vulnerable populations from research activity can also exclude them from its benefits.
According to Gerrish & Lacey (2006) there two key concepts that concern the quality of a research: validity and reliability. Roberts et al (2006) define reliability as, how far a particular test will produce similar results in different circumstances, whereas validity is to ascertain the methods are actually measuring what is intended to measure. Both Cuesta et al (2000) and Tait et al (2003) had used structured interviews to gather the data and have chosen a quantitative approach. Structured interview provides the opportunities to change the but not the meaning of the questions, thus, Parahoo (2006) claimed that validity is enhanced because participants can be helped to understand the questions and interviewers can ask for clarifications and probe for further responses, if necessary and since all the questions are ideally asked in the same way, structured interview has a high degree of reliability. Therefore, it seems that both Cuesta et al (2000) and Tait et al (2003) have adopted the appropriate approach to their research, as quantitative research is the conduct of investigations primarily using numerical methods. It infers that to examine correlations between insight and service engagement qualitative approach could not have produced the same data in this area of study. Moreover, in both studies purposive sampling were used as all the participants had a diagnosis of schizophrenia. According to Polit & Beck (2006) all participants in a phenomenological study must have experienced the phenomenon under study and must be able to articulate what is like to have lived the experience.
Johnson & Orrell (1996 cited in Surguladze & David, 1999 P 166) have argued that some patients may have their own explanations of their illnesses, such as religion or cultural beliefs which may not coincide with the Western medical model of mental disorders and this can be even more complicated if one tries directly to impose the models of insight on patients from non-Western cultures. Gamble & Brennan (2006) claimed that different cultures in England perceive mental illness in different ways and this can have an impact on treatments as some cultures rather seek help from religious leaders than mental health services. Alternatively, religion or spiritual beliefs in the Western culture can have a positive impact on concordance with medication, as religious individuals with schizophrenia have a better social support compare to non-religious individuals with schizophrenia (Borras et al, 2007). Therefore, it can be put forward that awareness of illness is a crucial factor in the motivation to receive pharmacological treatment. Both cultures and religion can have a positive and negative influence on concordance with antipsychotics.
Patients can have different levels of awareness into their illness and they may consciously or unconsciously avoid acknowledging that they are suffering from mental health problems because of their reluctance to bear the stigma of mentally ill (Surguladze & David, 1999). Byrne (2000, p65) defined `stigma as a sign of disgrace or discredit, which sets a person apart from others and the stigma of mental illness although more often related to context than to a person’s appearance, remains a powerful negative attribute in all-social relations`. Stigma of mental illness has become an indication for unpleasant experiences, such as bringing shame to the family or social exclusion. Having a diagnosis of schizophrenia does not only affect one’s health but also carries all the prejudice, discrimination and social exclusion, for example many individuals are attacked on the streets, rejection in the society and denial of employments because they were known to have mental health problems (Gamble & Brennan, 2006). According to Byrne (2000) in two identical UK public opinion surveys, 80% of participants claimed that most people are embarrassed by mentally ill people and about 30% agreeing `I am embarrassed by mentally ill persons`.
There is also evidence that supports the concepts of stereotyping of mental illness. The power and influence of the media on mental illness has been a key issue of debate over many years as people with schizophrenia are frequently portrayed as violent and dangerous. Gamble & Brennan (2006) claimed that when the boxing champion Frank Bruno was admitted to hospital in 2003, one of the newspaper headlines was `Bonkers Bruno locked up`. Therefore, it can be established that stigma has the grave potential to cause reluctance to seek treatments and this can be detrimental to the persons` mental state. As a mental health clinician, it will be vital to assist people with mental health problems to rebuild their lives and this requires moving beyond the traditional focus on symptoms and medication by exploring alternatives in reducing stigma of mental health that avert people from social inclusion.
DOH (2008) emphasises that if a competent adult makes a voluntary and informed decision to refuse treatment, this decision must be respected, even if this will clearly be detrimental to his or her health, except in circumstances defined by the Mental Health Act (MHA) 1983. Someone who is subject to detention under the (MHA) 1983 can be treated without his or her consent, but it does not give the power to treat unrelated physical disorders without consent. On one hand, enforced treatment undermines the client autonomy and this may lead patients to rebel by not concordant with medication when discharged. On the other hand, it can represent an opportunity for therapeutic engagement with clients who may not otherwise be in contact with the helping services (Bliss & Ricketts 2005). According to Wilson (2007) there were 25, 740 formal admissions under the (MHA) 1983 in England during 2005-2006 but it is difficult to say how many of those detained had a diagnosis of schizophrenia because the approved doctor is only required to detail the category of the illness and not a specific diagnosis under the medical recommendation.
Consistent with the finding of Drayton et al
Kikkert et al (2006) although research hasimproved our knowledge, adherence rates do not seem to havechanged in the last 4 decades
Recent advances in medication treatments for patients with schizophrenia have included the development of a number of atypical antipsychotics that produce fewer extra pyramidal side effects and may have a broader range of efficacy than conventional antipsychotics (1). It has been widely assumed that the introduction of these second-generation antipsychotics would lead to improved treatment adherence for patients with schizophrenia. Although it may be that the improved side effect profiles of the novel antipsychotics have increased patients' willingness to take medications, little evidence exists that treatment adherence has been significantly improved by these antipsychotics. The continued decline in rates of depot neuroleptic use may in part reflect a belief that atypical antipsychotic medications have solved the non-adherence problem.
Partial adherence creates significant problems for the treatingphysician. It creates difficulties in determining whether medicationsare working adequately, whether dosing is appropriate, and whetherconcomitant medication is needed. We have observed that medicationchanges and the addition of concomitant medications are morelikely to occur among patients who are not fully compliant withprescribed medication
These individuals may take medicationas prescribed or not. How much an individual can vary from theprescribed dosage and still be considered compliant differsby study. Dosage deviations can be due to a decision that lessmedication is better, due to unintentional factors such as forgetting,or due to environmental barriers such as poverty and lack oftransportation.
Objective measures including pill count, blood orurine analysis, electronic monitoring
For decades, researchers have worked to explain the causes of non-concordance with medication unfortunately there have been no valid way of measuring of concordance (Velligan et al, 2006). Rates of concordance have been measured using different methods such as subjective and objective methods.
Peter Byrne (2000) `Stigma of mental illness and ways of diminishing it`. Advances in Psychiatric Treatment (2000), vol. 6, (1): pp. 65–72
Robert Chaplin (2007) How can clinicians help patients to take their psychotropic medication? Advances in Psychiatric Treatment (2007), vol. 13, (5): p347–349
Alex J. Mitchell & Thomas Selmes (2007) Why don’t patients attend their appointments? Maintaining engagement with psychiatric services
Advances in Psychiatric Treatment (2007), vol. 13, (6): p423–434
COHEN et al. vol179 (2):(2001) P167-171
David J. Moser et al (2005) Informed Consent in Medication-Free Schizophrenia Research, (Am J Psychiatry 2005; 162:1209–1211) , http://ajp.psychiatryonline.org
Borras et al, 2007, Religious Beliefs in Schizophrenia: Their Relevance for Adherence to Treatment, Schizophrenia Bulletin vol. 33 no. 5 pp. 1238–1246, 2007
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