Treatment adherence and insight in schizophrenia.

BACKGROUND

Lack of adherence to treatment in patients with schizophrenia is a major risk factor for poor outcome, including relapse, rehospitalization, and suicide. Poor insight into illness may be a leading cause for partial- or nonadherence since a high proportion of patients with schizophrenia are partially or completely unaware of their mental disorder.

OBJECTIVE

The primary objective was to estimate the impact of lack of insight on adherence to medication based on a population of patients in Hungary who had the diagnosis of schizophrenia. The secondary objective was to investigate the association of the different aspects of insight (awareness of illness, the capacity to relabel psychotic experiences as abnormal, treatment acceptance) with (1) recent adherence behavior; (2) current mental state; (3) remission/non-remission status as measured by remission severity criteria; and (4) demographic and treatment history data.

METHOD

This was cross-sectional, noninterventional study, carried out under daily clinical practice conditions, with no influence exerted upon clinical practice in view of the observational nature of the study. Eligibility criteria included: a) patients' age (>18 years), b) diagnosis of schizophrenia (ICD-10), c) signed informed consent, d) no concomitant participation in another clinical trial. Study sites represented Mental Health Centers and outpatient clinics of hospital psychiatric units. Each investigator was asked to enroll patients consecutively. The final analysis sample comprised 262 patients, distributed across 13 sites. The following data were collected: general sociodemographic and clinical data (age, sex, level of education, socioeconomic situation, family support, psychiatric diagnosis, years of evolution, pharmacological and/or psychosocial treatments at the time of inclusion in the study, previous psychiatric admissions), with assessments of the Schedule of Assessing components of Insight (SAI), Compliance Rating Scale (CRS), Clinical Global Impression Scale (CGI-S), Remission Severity Criteria.

RESULTS

Patients enrolled in the study had a mean (SD) age of 43.0 (12.6) years, with a 12.3 (3.0) years of education, and approximately evenly balanced gender distribution. According to the clinical judgment of the treating physicians, 29.1% of the patients were not taking their prescribed antipsychotic medication in our target population. The primary logistic regression analysis indicated a significant relationship between the total score on the SAI scale and the Compliance Scale (Spearman correlation=0.58; p<0.0001). The relationship was significant for each of the three subscales of SAI. Secondary analyses showed a significant negative association between compliance and score on the CGI-S scale (Spearman correlation: -0.54; p<0.0001), and compliance and hostility, as measured by the PANSS hostility item (Spearman correlation: -0.40; p<0.0001). We found no significant relationship between compliance and age, gender or education years (p>0.1 in all cases).

CONCLUSIONS

The results of the present study support the hypothesis that the level of insight and compliance are strongly associated, and that more severe symptoms and increasing levels of hostility, in particular, markedly reduce the compliance of the patients with schizophrenia. Capturing different aspects of insight may be helpful in understanding and improving adherence behavior in clinical practice.