A STUDY OF REASONS OF NON-COMPLIANCE TO PSYCHIATRIC TREATMENT

Rizwan Taj, Saleem Khan

Department of Psychiatry, Pakistan Institute of Medical Sciences, Islamabad

Background: This study was carried out with an objective to find out the frequency of different reasons of non-compliance to treatment in a sample of out door psychiatric patients. Methods: This study was conducted at Psychiatry department, Pakistan Institute of Medical Sciences, Islamabad, from Aug, 2001 to Jan, 2002. Data from a non-probability sample of two hundred follow up patients with a definite psychiatric illness was collected. A questionnaire designed for this purpose was administered by a consultant psychiatrist to the patients. The data was categorized into different causes of discontinuation of treatment accordingly. Results: The commonest reasons for non-compliance were unawareness of the benefits of treatment (43%), nonaffordability of drugs (33.5%), physical side effects (28.5%), no awareness given by the doctor (03%) and unfriendly attitude of doctors (02%).  The commonest illnesses leading to non-compliance were major depressive disorder (31.5%), schizophrenia (19.5%) and bipolar affective disorder (19%). Conclusion: Non-compliance is quite common in Pakistan like any other society. Medical practitioners need to be aware of it and address this problem because compliance is directly related to the prognosis of the illness. It is recommended that all efforts should be exerted to improve the compliance of psychiatric patients by eliminating the factors leading to non-compliance.

Keywords: Non-compliance, Psychiatric illnesses, Treatment.

Introduction

Non -compliance or non- adherence to treatment is the degree to which a patient does not carry out the clinical recommendations of a treating physician.1 In other words it is the failure of the patient to follow the prescribed treatment regimen.2 Non-compliance is a significant problem in all patient populations, from children3 to the elderly.4,5 It applies to nearly all chronic disease states 6 and settings, and tends to worsen the longer a patient continues on drug therapy.7 Non-compliance is now a day considered to be the major problem in the health services of both developed and developing countries. Most patients probably comply with treatment only between 33% and 94%, with a median of approximately 50% for long-term therapy.  Another set of patients will never start or will stop therapy completely within the first year, and only a minority will continue taking drugs as prescribed.7 Compliance is important because it is directly related to the prognosis of the illness. The results of non-compliance have been studied extensively, and are significant especially, lack of disease control and hospital admissions or readmissions.8 Reasons for non-compliance are multi factorial in origin and to find out the different factors leading to non-compliance we performed a cross sectional study.

 

Material and Methods

This study was conducted at the out patients services of psychiatry unit, Pakistan Institute of Medical Sciences, Islamabad. A non-probability sample of two hundred follow up patients between twenty to eighty years of age was taken for data collection over a period of six months (from Aug, 2001 to Jan, 2002). There was no restriction of sex, marital status, educational level, socioeconomic status and place of residence. An informed consent was taken from patients. Basic demographic information along with psychiatric diagnosis, type of treatment and the different reasons for non-compliance were recorded. An interviewer assisted questionnaire was designed for this purpose which was administered by a senior psychiatrist to the patients. 

We divided the different reasons for non-compliance into three main categories.

A)       Non-compliance due to discomfort with the treatment: This includes cost & availability of drugs, duration of treatment, response to treatment, stigma for psychiatric treatments and treatment regimen.

B)        Non-compliance as a result of poor comprehension: This includes the realisation of advantages/disadvantages of treatment.

C)        Non-compliance due to poor communication between the doctor & patient: This includes awareness given by doctor about the treatment, doctor’s attitude, level of satisfaction with the competence of doctor   and accessibility of doctor.

Results  

In the category A, the commonest reasons for non-compliance were non affordability of drugs (33.5%) and physical side effects (28.5%), shown in table-1. In the category B the commonest reason for non-compliance was unawareness of the benefits of treatment (43%) while in the category C the commonest reasons for non-compliance were no information given by the doctor (03%) and unfriendly/hostile attitude of doctor (02%), shown in tables 2 and 3 respectively. The results also show that people suffering from major depressive disorder (31.5%) are most likely to non-comply to treatment given, followed by those suffering from schizophrenia (19.5%) and finally those suffering from bipolar affective disorder (19%), shown in table 4.

Table-1: Non compliance due to discomfort with the treatment (n=200)

 

 

Cases (%)

Cost (Affordability)

Nonaffordable.

67 (33.5%)

Availability of treatment

Not available.

31 (15.5%)

Side effects

Physical

57 (28.5%)

Table-2: Non-compliance as a result of poor Comprehension

 

 

Cases (%)

Realisation of advantages/ disadvantages of treatment.

 

Partial realisation

 

22 (11%)

No realisation at all

86 (43%)

Table-3: Non-compliance due to poor communication  between the doctor & patient (n=200)

 

 

Cases (%)

Awareness given by doctor.

Partial awareness

2 (1%)

No awareness at all.

6 (3 %)

Doctor’s attitude.

Unfriendly/Rejecting.

4 (2%)

Hostile

2 (1 %)

Level of satisfaction with the competence of doctor.

Partially satisfied.

4 (2 %)

Not satisfied at all.

4 (2 %)

Accessibility of doctor.

Accessible with difficulty.

2 (1 %)

Table-4: Non-compliance & psychiatric illness (n=200)

Type of disorder

Cases (%)

Dementia.

02 (0.5%)

Acute psychotic episode.

07 (3.5%)

Schizophrenia.

39 (19.5%)

Schizoaffective disorder.

02 (1%)

Major depressive disorder.

63 (31.5%)

Bipolar affective disorder.

38 (19%)

Panic disorder & agoraphobia.

03 (1.5%)

Obsessive-compulsive disorder.

05 (2.5%)

Generalised anxiety disorder.

10 (02%)

Somatisation disorder.

10 (05%)

Conversion disorder

13 (6.5%)

Dissociative disorder.

01 (0.5%)

Cannabis abuse

01 (0.5%)

Benzodiazepines abuse

01 (0.5%)

Personality disorders.

05 (2.5%)

discussion

Non-compliance is a serious problem, and has many serious effects on the overall treatment and prognosis of the illness. Medication non-compliance, the failure to take drugs on time in the dosages prescribed, is as dangerous and costly as many illnesses.

Non-compliance may signal that patient and physician goals and priorities differ regarding the treatment and its schedule.9 It is a major problem with almost all psychotropic drugs.  Patients who are non-compliant are more severely ill at the point of readmission to hospital, have more frequent readmission; are more likely to be admitted compulsorily, and have longer inpatient stays.10

Reasons for non-compliance that came into view in this study include the expense and availability of treatment, type of illness, type of treatment, side effects and the number of doses or of preparations to be taken daily. (Treatment regimen) Along with these reasons the social and cultural stigma related to psychiatric illnesses and their treatment and doctor- patient relationship also play a role.

The results of our study show that the cost of the treatment is the commonest reason for non-compliance, not unlikely in our society because most of the people who are suffering from chronic psychiatric illnesses are from lower socio-economic group. 

Medications used to treat mental illnesses are known to have an array of potentially unpleasant side effects, ranging from restlessness and pacing to excessive sedation, tremor, dry mouth, constipation, impotence, weight gain, missed menstrual cycles, and many others.  Our study shows that the second commonest reason for non- compliance is the side effects of psychotropic drugs.

Non availability of drugs is another problem that leads to non-compliance. Many of the important drugs are not available in rural or in far-flung areas, so many patients stop treatment prematurely.

Considering the realisation of importance of treatment most of the patients stop medications because of illiteracy or lack of insight.  This behaviour is further precipitated by the stigma to psychiatric illnesses, treatment from quacks and traditional faith healers and improper education of patients by the doctors. The study shows that some doctors (3 %) are hostile or non-cooperative or they are not easily accessible, as they should be to the patients leading to precipitation of non-compliance.

As regards the different psychiatric illnesses, we see that people suffering from major depressive disorders (31.5%) are the commonest to noncomply, followed by those suffering from schizophrenia (19.5%) and those suffering from bipolar disorder (19%). Literature review shows the prevalence of different disorders to vary from our society. A study by Elixhauser et al11 shows that 74 % of outpatients with schizophrenia stop taking neuroleptics or antipsychotics within two years of leaving a hospital and 20 to 57 %  patients with bipolar affective disorder are non-compliant.11

The possible reasons for this could be that perhaps our sample size was too small to represent the whole population. Probably due to joint family system most of our patients are cared for by family members who take charge of the administration of medicines to the patients. 

 

Conclusion

Non-compliance is common, prevalent and important issue in the treatment of psychiatric illnesses. It is recommended that further research is needed in this field to know more about it and to understand it better. Further more to prevent psychiatric patients from non-complying to treatment doctors should be aware of the drugs cost & education of patient regarding the benefits of treatment and that doctors attitude is part of the therapeutics.

References

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2.        Porter RJ. General principles: how to use antiepileptic drugs. In:Levy RH, Dreifuss FE. Antiepileptic drugs. 3rd ed. New York: Raven Press 1989..

3.        Matsui DM. Drug compliance in paediatrics.  Pediatr Clin North Am 1997;44: 1-14.

4.        Spagnoli A, Ostino G, Borga AD. Drug compliance and unreported drugs in the elderly. J Am Geriatr Soc 1989;37:619-24.

5.        Maronde RF, Chan LS, Larsen FJ, Strandberg LR, Laventurier MF, Sullivan SR. Underutilization of antihypertensive drugs and associated hospitalis-ation. Med Care 1989;27:1159-66.

6.        Lacombe PA, Vicente JAG, Pages JC, Morselli PL. Causes and problems of non response or poor response to drugs.  Drugs 1996;51:552-70.

7.        Morris LS, Schulz RM. Patient compliance - an overview. J Clin Pharm Ther 1992;17:283-95.

8.        Billups SJ, Malone DC, Carter BL. Relationship between drug therapy non-compliance and patient characteristics, health-related quality of life and health care costs. Pharmacotherapy2000;20:941-9.

9.        Weiden PJ, Shaw E, Mann J. Causes of neuroleptic non-compliance. Psychiatric Annals 1986;16:571-5.

10.     Soumitra RP, Carol P. Psychotropic drug treatments. ABC of Mental Health 1998; 71.

11.     Elixhauser A, Eisen SA, Romeis JC, Homan SM. The effects of monitoring and feedback on compliance. Medical Care 1990; 28:883- 93.

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Address for Correspondence:

Dr Rizwan Taj, Department of Psychiatry, Pakistan Institute of Medical Sciences, Islamabad. Pakistan