|Year : 2021 | Volume
| Issue : 1 | Page : 43-48
Noncompliance to treatment among persons with mental illness
MC Seena1, Reena George2, Padinharath Krishnakumar3, Rajith K Ravindran4
1 Nursing Officer, Louise Mount Hospital, Wyanad, Kerala, India
2 Department of Psychiatric Nursing, Institute of Mental Health and amp, Neuro Sciences (IMHANS), Kozhikode, Kerala, India
3 Director and amp, Child Psychiatrist, Institute of Mental Health and amp, Neuro Sciences (IMHANS), Kozhikode, Kerala, India
4 Assistant Professor, Department of Psychiatry, Institute of Mental Health and amp, Neuro Sciences (IMHANS), Kozhikode, Kerala, India
|Date of Submission||20-Nov-2020|
|Date of Decision||20-Feb-2021|
|Date of Acceptance||07-Apr-2021|
|Date of Web Publication||17-Jun-2021|
Dr. Reena George
Department of Psychiatric Nursing, Institute of Mental Health and Neuro Sciences, Kozhikode, Kerala
Source of Support: None, Conflict of Interest: None
Background: Noncompliance to treatment is an alarming issue challenging the entire mental health-care system. If this issue is tackled by the institutions and mental health-care professionals, a drastic change can be brought to the treatment of mentally ill and prevent unnecessary hospitalization due to relapse. Noncompliance to psychiatric treatment among 569 patients revealed that 328 (58.2%) were complied with the treatment and 236 (41.8%) were noncompliant to psychiatric treatment. Objectives:The objectives were to assess the noncompliance to treatment among person with mental illness and to identify the factors contributing to the noncompliance to treatment. Materials and Methods: A quantitative approach with cross-sectional descriptive design using retrospective analysis was adopted for the study. All patients attending psychiatric unit were screened and 100 patients who met the inclusion criteria were selected through nonprobability convenience sampling technique from the adult psychiatry unit, IMHANS, Kozhikode. The data collection instruments were a sociodemographic pro forma, noncompliance checklist, and a checklist on factors contributing to the noncompliance to treatment. The collected data were analyzed using descriptive statistics. Results: A population of 156 patients were screened, (56) 35.8% of patients had compliance to treatment and (100) 64% of patients had noncompliance to treatment. Hence, the sample consists of the 100 patients who had noncompliance to the treatment. The data on diagnoses and percentage of patients with noncompliance show that most of the patients (25%) who had noncompliance to treatment were diagnosed with bipolar affective disorders and 22% of sample to noncompliance to treatment were diagnosed with schizophrenia. The study found that a main cause of noncompliance to treatment is to avoid the feelings of being sick. Conclusion: This study found that there is an increased need to conduct public awareness programs and other psychosocial interventions to sensitize the public to regarding mental illness and importance of compliance to treatment.
Keywords: Mental illness, noncompliance, treatment
|How to cite this article:|
Seena M C, George R, Krishnakumar P, Ravindran RK. Noncompliance to treatment among persons with mental illness. Indian J Psy Nsg 2021;18:43-8
|How to cite this URL:|
Seena M C, George R, Krishnakumar P, Ravindran RK. Noncompliance to treatment among persons with mental illness. Indian J Psy Nsg [serial online] 2021 [cited 2021 Sep 21];18:43-8. Available from: https://www.ijpn.in/text.asp?2021/18/1/43/318673
| Introduction|| |
Noncompliance to treatment is an alarming public health problem and a global issue among patients with mental illness. It gradually increases the risk of illness exacerbation and hospitalization. However, there is rarity of studies examining noncompliance to treatment among patient with mental illness and its associated factors among patient with mental illness. A study on noncompliance to psychiatric treatment among 569 patients revealed that 328 (58.2%) were complied with the treatment and 236 (41.8%) were noncompliant to psychiatric treatment. Therefore, this study is aimed to determine the magnitude of noncompliance to treatment and associated factors among patients with mental illness. Hence, the mental health professionals and institutions can respond appropriately to tackle this issue. A study have reported that nonadherence lead to relapse among fifty patients newly diagnosed with schizophrenia and needed hospital admission due to persistent psychotic features.
A noncompliance rate of 50% was attributed globally to chronic psychiatric conditions such as schizophrenia. Less invasive means of promoting compliance have to be utilized considering the psychodynamic and ethical issues in monitoring and promotion of compliance over extended periods.
The outcomes of chronic psychiatric illness such as schizophrenia can be improved generally by medication adherence. One of the most effective interventions to improve adherence is the use of depot formulations of antipsychotic medications.
A study among 148 patients with mental illness in the age group of 20–70 years revealed that only 25% of the sample had reported compliance to treatment, the main factor contributed to compliance was seriousness of illness.
Psychosis has high rates of drug noncompliance, which is related to the patients, illness, and the doctor. The main reasons identified were denial of illness or financial issues.
Prevalence of nonadherence with mental disorders was 38%. However, 50% of the nonadherents were suffering from schizophrenia. Younger patients with good social support had good adherence, whereas those with more severe illnesses and who were sedated were associated with nonadherence.
The major factors of noncompliance were ignorance regarding the benefits of treatment (43%), nonaffordability of drugs (33.5%), physical side effects (28.5%), lack of awareness given by the therapist (03%), and unfriendly attitude of therapist (02%). The most common illnesses leading to noncompliance were major depressive disorder (31.5%), schizophrenia (19.5%), and bipolar affective disorder (19%). Noncompliance to psychiatric treatment is a critical issue quite common in any society. Recent study suggests that the risk of relapse in patients with mental illness like schizophrenia is approximately 3.5%/month. One of the predictors of more frequent relapses includes poor compliance with antipsychotic drug treatment.
Relapse causes frequent and unnecessary hospitalization and it is wastage of time, energy, material, and money of patients' and families. These resources could be used to improve their quality of life. The results of a systematic review indicate that noncompliance to antipsychotic medication is associated with increased hospitalization rates and resource utilization, resulting in increased direct health-care costs. Improving medication compliance in person with mental illness holds the potential for reducing morbidity and suffering of patient and their families, in addition to decreasing the cost of re-hospitalization. Therefore, it is important to assess the noncompliance and factors contributing to the noncompliance to tackle these issues effectively. There are a few studies, which depict the prevalence and reasons for noncompliance to treatment, and the studies revealed different reasons in different society and settings. Considering above facts in view, the researchers are keen to assess the noncompliance and the factors contributing to the noncompliance to psychiatric treatment in order to help the patients to tackle this issue and bring them back to the adherence to treatment.
Objectives of the study
- To assess the noncompliance to treatment among persons with mental illness
- To identify the factors contributing to the noncompliance to treatment.
| Materials and Methods|| |
Data were collected after obtaining the written permission from the Institutional Ethics Committee of Institute of mental Health and Neurosciences (IMHANS), an informed consent of the patients, significant family caregiver of the patients, and a formal permission from the head of the institution to conduct the study. A quantitative research approach was used to assess noncompliance to treatment among persons with mental illness. A nonexperimental, cross-sectional, descriptive design with retrospective analysis was selected for the present study. The setting of the study was the Adult Psychiatry Unit, Institute of Mental Health and Neurosciences (IMHANS), Kozhikode. Sample was selected through nonprobability, convenience sampling technique. All the patients with mental illness diagnosed based on the International Classification of Diseases, 10th revision (ICD-10) diagnostic guidelines by the psychiatrists. Sample size was 100 estimated based on the previous studies published, where 80% of precision. Patients in the age group between 18 years and 65 years were included in the study. All the persons with mental illness diagnosed by psychiatrists as per ICD 10 criteria were included in the study. Patients who are able to write, read, and respond to the data collection instruments provided and patients with the history of visiting multiple psychiatrists though attending the current setting at the first time are also included in the study. Patients who failed to act in accordance with the instructions regarding the consumption of medication with regard to the duration, dosage, and frequency and missed to visit the psychiatrist, minimum for two consecutive follow-up in the past were included in the study. The study excluded patients with mental illness and on emergency psychiatry treatment due to active stage of psychosis and persons with mental illness who are intellectually disabled. In the present study, the data collection instruments were sociodemographic pro forma, noncompliance checklist, and checklist for factors contributing to noncompliance to treatment. The sociodemographic pro forma consists of 11 items, which include age, sex, educational qualification, occupation, marital status, duration of illness, duration of treatment, frequency of changing the consultants, number of changing consultants during the total duration of illness, age of onset of psychiatric morbidity, and diagnosis.
Noncompliance checklist consists of ten statements with two responses each. Each response of “yes” was given a score of 1 and the response of “No” was given a score of 0. The total score assigned for the scale was 10. A score of <1 is considered as compliance to treatment and a score between 1 and 10 is considered as noncompliance to treatment. The reliability of the tool was assessed by administering the tool to ten patients. The Chronbach's Alpha score was 0.72 and the total time for administration was 20–30 mts. The items in the checklist start with “Often I did not take the correct dosage of medicine as prescribed by the therapist”… and ends with “I changed therapist frequently.” The checklist on factors contributing to the noncompliance to treatment was developed to identify the factors contributing to the noncompliance to treatment of mental illness; the investigators developed each item in the checklist based on the vast review of literature, discussion with experts and a Focus Group Discussion with family caregivers of patients. The steps undertaken to prepare the final tool were preparation of the blue print, content validity, pretesting, and establishing reliability of the tool. The reliability of the tool was assessed by administering the tool to 10 patients. The Chronbach's alpha score was 0.70, and the total time for administration was 20–30 mts. The final draft consists of 18 items and an additional options added as 'Any other, if yes specify” to identify any other factors present other than the ones given in the checklist. Each positive response was given a score of 1 and negative response was given a score of 0. The total score was 18.
Data were collected from October 2019 to January 2020. All the data collection instruments were in Malayalam for the convenience of study participants. Total time taken for data collection from each patient was 45–55 min approximately.
| Results|| |
The study comprised 100 sample, the sociodemographic data revealed that, 35% of the participants with mental illness belong to the age group of 18–27 years, 29% to 28–37 years, 24% to 38–47 years, 7% to 48–57 years, and 5% belong to 58–67 years. Study shows that 51% of persons with mental illness were females and 49% were males. Considering the job of the patients, 68% of patients were private employees, 22% were self-employed, 6% were daily wages, and 4% were government employees. Most (45%) of the patients were unmarried, 38% of patients were married, 11% of patients were divorced, and 3% of patients were separated and widowed each. The data on duration of illness show that 71% of patients suffering from mental illness from 1 to 10 years, 19% of patients were from 11 to 20 years, 8% of patients were from 21 to 30 years, and 2% of patients were from 31 to 40 years, which shows the chronicity of mental illness. With regard to the duration of treatment, 78% of patients were on treatment between 1 and 10 years, 18% of patients were from 11 to 20 year, and 4% of patients were from 21 to 30 years. Although they were connected with the mental health-care system, the compliance is not maintained for the completed duration of the treatment and the patients are brought to the hospital when the family members are unable to manage the exacerbation of symptoms.
To assess the noncompliance to treatment among persons with mental illness.
[Table 1] shows noncompliance to treatment, 156 patients were screened, (56) 35.8% of patients had compliance to treatment, and (100) 64% of patients had noncompliance to treatment [Figure 1]. Hence, the sample consists of the 100 patients who had noncompliance to the treatment and study excluded who were complied with the treatment.
|Table 1: Noncompliance to treatment among persons with mental illness (n=156)|
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[Table 2] shows that 60% of study subjects had visited 1–2 consultants and 33% of study subjects had visited 3–4 consultants during the total duration of illness. Majority of the study subjects (94%) who had noncompliance to treatment were attending Adult Psychiatry unit of IMHANS were the new patients who had multiple consultations in other settings before coming to the study setting. The reason for this reported as financial difficulty and they approached the study setting since it is an institution under Government of Kerala where consultation and other therapies are delivered free of cost.
|Table 2: Distribution of patients based on frequency of changing consultants (n=100)|
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[Table 3] shows that most of the sample (41%) had onset of psychiatric morbidity between the age group of 21–30 years.
|Table 3: Distribution of patients based on the age of onset of psychiatric morbidity (n=100)|
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Data depicted in [Figure 2] reveal that most of the patients (25%) who had noncompliance to treatment were diagnosed with bipolar affective disorders and 22% of sample to noncompliance to treatment were diagnosed with schizophrenia.
|Figure 2: Cylinder diagram showing distribution of sample based on the diagnosis and noncompliance to treatment (n = 100)|
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To identify the factors contributing to the noncompliance to treatment.
Data depicted in [Table 4] show that 23.44% of study subjects had noncompliance to treatment to avoid feeling of being sick.
|Table 4: Factors contributing to the noncompliance to treatment among persons with mental illness (n=100)|
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| Discussion|| |
In this study, 51% of the study participants had onset of psychiatric morbidity in the age group of 11–30 years. This finding is comparable with another study conducted to identify the age of onset of mental disorders where half of all lifetime mental disorders start by the mid-teens and three-fourths by the mid-20s.
Noncompliance to psychiatric treatment
A study on noncompliance to psychiatric treatment among 569 patients revealed that 58.2% were complied with the treatment and 41.8% were not complied with the psychiatric treatment. Present studies revealed that noncompliance rate among mentally ill was comparable to the rates reported by other studies.
Clinical profile characteristics
Various studies have found that the noncompliance is more among patients with schizophrenia.,,,, A study on comparison between the diagnoses and noncompliance reported that psychotropic medication nonadherence for schizophrenia, major depressive disorders, and bipolar disorders was 56%, 50%, and 44%, respectively.
The present study shows that the noncompliance was more among patients with bipolar affective disorders (25%) followed by the patients with schizophrenia (22%).
Factors contributing to noncompliance to treatment
Individual patient's behaviors, lack of social support, clinical or treatment and illness-related, and health system factors influenced psychotropic medication nonadherence. A study conducted in Lucknow identified that the main reasons for noncompliance to treatment were denial of illness or financial issues. These findings are comparable with the present study that one of the factors contributed to the noncompliance was to avoid the feeling of being sick, which is identical to the denial that one is sick.
Limitations of the study
The study was a retrospective analysis, and the study subjects were selected through nonrandomization and the sample selected from single setting, hence the results may vary in different settings.
Implications of the study
One of the most important responsibilities of psychiatric nurses is promotion of mental health and prevention of mental illness. This could be achieved through three levels of preventive activities. Primary prevention aims at maintaining mental health of person by imparting health education to mental health through therapies in hospital or community. Psychiatric nurses working in the community settings would be able to identify the factors contributing to noncompliance to treatment among persons with mental illness at the earliest. They can easily initiate interventions such as psychoeducation about importance of compliance to treatment and importance of avoiding unhealthy habits. This can contribute effectively to reduce the psychiatric morbidity and relapse in future. Preventive and promotive measures should be given adequate importance in nursing proactive. The finding of the study necessitates the need for in-service education for mental health nurses. The nursing administration can utilize the findings of this study to work for the provision of explicit preventive and promotive care to the clients.
A similar study can be done with the noncompliance reduction intervention.
More extensive research with multiple settings can be done.
| Conclusion|| |
The data on percentage of study subjects with noncompliance show that there were differences in the noncompliance based on the diagnoses. The noncompliance of study subjects with bipolar affective disorder were 25%, with schizophrenia 22%, with depressive disorder 17%, with anxiety disorders and psychosis 10% each. The study found that a main cause of noncompliance to treatment was to avoid the feelings of being sick. This study found that there is an increased need to conduct public awareness programs and other psychosocial interventions to sensitize the public regarding mental illness and importance to comply with the treatment.
The investigators acknowledge the gratitude to the study subjects, administrative staff, faculty members, and other clinicians helped and supported during the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]