http://doi.org/10.33698/NRF0155 -Bharat Pareek, Raman Kalia
Abstract : Non-compliance or non-adherence to treatment is the degree to which a patient does not carry out the clinical recommendation of a treating physician or in other words it is failure of the patient to follow the prescribed treatment regimen. A descriptive, co-relational study carried out to identify the factors affecting non-compliance to psychotropic drugs as perceived by patient’s relatives visiting outpatient department of Father Mullar Mental Hospital Mangalore. A structured interview schedule was prepared and used for data collection from 100 subjects those fulfil the inclusion criteria (relatives of the psychotic patients who are visiting to O.P.D with the patients & staying with the patient at least last six months) by using purposive sampling method after getting their consent. Finding revealed that various factors perceived as contributing to non compliance, were disease characteristics related (62%), transportation problems (56%), poor community mental health services (55%), drug side effects (52%), cultural myth (49%), social factors (48%), psychological & motivational factors (47%), economic factors (43%), knowledge & insight (31%), illiteracy (36%), & other factors such as misconception about treatment & difficulty in swallowing the tablets contribute to non- compliance (17%). Thus, the present study concluded that there are many factors which contributing to non- compliance among patients with psychotic illness. Therefore, it is recommended that more emphasis must be given on deinstitutionalization of mental health services and patient’s family education to reduce the burden on health care expenditure due to non-adherence
Keywords
Non-compliance, psychotropic drugs, psychosis, non-adherence
Correspondance at
Bharat Pareek
Lecturer & PhD Scholar,
Saraswati Nursing Institute, Kurali, Roopnager, Punjab.
Introduction
Non-compliance is a significant problem in all patient population, from children to elderly1. It applies to nearly all chronic diseases and tend to worsen as longer a patient continues on drug therapy. Non- compliance is now a days is considered to be a major problem in health services of both developed and developing nations. Most of patients comply with treatment are between 33% to 94%, with a median of 50% for long term therapy.2
Compliance is important because it is directly related to the prognosis of the illness. Non-compliance is a serious problem and has many serious effects on overall treatment and prognosis of the illness. It is dangerous and costly, as in many illnesses noncompliance may signal that patient and physician goals and priorities differ regarding the treatment and its schedule. Non-compliance is a major problem with almost all psychotropic drugs. The patient 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 in patient stay.2-5
As per the statistics given in health information of India that psychosis is the most common mental disorder among the patients treated in specialized mental hospital in India6. Psychosis is a major mental illness in which a person may distort reality or when people demonstrate gross impairment in reality testing. It is the problem, which affect both male and female but more in male. The prognosis in psychotic patient is not very good always and recurrence is very common due to non-compliance to medication 7
Psychotropic drugs are now the first line treatment for almost every psychiatric illness with growing availability of wide range of drugs to treat mental illness8. The patient on psychotropic drugs needs to take drug as prescribed and regular follow up is necessary to regulate long term therapy 9. Some patients do not follow the prescribed treatment because of various reasons. One of the major factors for re-hospitalization is found to be non-compliance in taking drugs. Non- compliance is a personal behavior that deviates from health related advice given by health care professional10 Poor medication compliance is found to be almost certainly the single most important factor in poor treatment response. The consequences of medication non- compliance are clinically equivalent to those of untreated or inadequately treated psychotic illness.9
Non-compliance behavior depends on specific clinical situation such as nature of illness, treatment program etc. In general, about one third of all patients never comply with treatment. An overall figure assessed in number of studies indicates that 46% of patients do not have compliance with treatment at any given time11
A study in USA found approximately 50% of 2 billion prescriptions filled each year was not taken correctly and result in increased burden on health care expenditure. In India clear statistics are not available on non- compliance; however the situation is quantitatively similar across the globe.11. The problem of non-compliance as significant cause of morbidity and mortality12
Non-compliance is the problem encountered by the all health professionals and it is not only the responsibility of nurses but also the responsibility of other health professionals to make the patient and relatives aware about the impor tance of being compliant to their medication, since non- compliance delays the patient’s restoration to full health.9
Psychiatric nurse spend the largest amount of time in direct patient contact & work with the long term management of psychiatric patients, the role of nurses become even more critical, particularly regarding psycho pharmacological treatment and the education of the patient and their families regarding compliance of these treatment agents19 The investigator while working with psychiatric patients noticed that many patients with psychiatric illness get admitted with relapse. Keeping it in mind the present study conducted to identify the factors affecting Non- compliance to psychotropic drugs.
Objectives
To identify the factors affecting non- compliance to psychotropic medication as perceived by the family members of patients with psychosis.
Methodology
This descriptive study was conducted on relatives of psychotic patients who were non-compliant to psychotropic medication at Father Muller Medical College & Hospital, Mangalore. Sample of 100 attendants who were visiting psychiatric outpatient department along with patients were selected using purposive sampling technique. Interview schedule was prepared that composed of two parts. Part 1 consisted of 10 socio-demographic variables of psychotic patient; part-II: contained 40 questions related to various factors affecting non-compliance.
Eight experts of whom six from the field of psychiatric nursing and two from psychiatric medicine checked validity of the tool. Tool was translated into Kannada and Malayalam then again from Kannada and Malayalam to English and pre-tested on 10 subjects to check its clarity, feasibility, and practicality. It took around thir ty minutes on an average to complete the interview schedule. The responded clearly and easily understood the language and no change made in final tool.The reliability of the tool was tested through split half method and reliability coefficient was found to be statically significant (p=0.78). The permission for data collection obtained from the concern authority, the investigator assured the anonymity to the subjects, and their consent obtained. The psychotic patients those were irregular on their follow up OPD visits were screened by evaluating their case files with the help of consultant psychiatrist and their relatives (who are visiting to O.P.D with the patients & staying with the patient at least last six months) wereinterviewed by using interview schedule. Data was analyzed using descriptive statistics.
Results
Tables 1 represent the data regarding socio demographic characteristics of psychotic patients. 29% of the patients were in the age group of 36 to 45 years followed by 45 or above years (28%) whereas 25% were under age group of 18-25 years and rest of the patients (18%) belonged to the age group of 26 to 35 years
Table 1: socio-demographic profile of psychotic patients
N=100
Furthermore, it was observed that more than half of the patients (60%) were male whereas 40% were female. One third of patients (32%) studied up to primary school, 23% up to PUC, 19% up to secondary school, 10% were illiterate whereas the equal numbers (10%) of patients were educated up to the graduation. Nearly half of the patients (46%) were having the total family income up to Rs.2000 per month, 22% were having income between Rs.2001 to 3000 per month, 13% between Rs.3001 to 4000 followed by 19% patients having family income above Rs. 4000 per month. Most of patients (83%) were suffering from illness for more than 4 years, whereas few (13%) were suffering from illness with the duration of less than 4 years. Fourty percent patients were rural dwellers, 32% were semi-urban (block level) dwellers and rest (26%)belonged to the urban area (district level & above). Two third of the patients (67%) were from nuclear family and rest (33%) lived in joint family.
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Factors Contributing to non- compliance as perceived by family members of psychotic patients:
Most of the subjects (62%) perceived the following disease characteristics as a reason for non compliance of diesease such as chronic nature of illness, many number of tablets need to be taken in a day & require following long-term treatment regimen as highest contributing factor to non- compliance. Furthermore, transportation problem perceived as second most important (56%) reason for non-compliance. The third highest (55%) related factor revealed to noncompliance was poor community mental health services whereas almost similar number of subjects (52%) perceived drugs side effects as contributing to non-adherence to treatment.
Almost half of the study participant perceived Cultural (49%), social (48%) and psychological (47%) factors as reason for non-compliance. Economic factors (like shortage of money, cost of medicine etc…) perceived by 43% of study participant as contributing to non-compliance.The other factors related to non compliance were lack of knowledge, comprehensive and insight of illness as perceived by 31% whereas illiteracy perceived by 36% study participant as cause of non-compliance. Difficult in swallowing the Tablets revealed as contributing factor of non- compliance by 23% of patient’s relatives whereas misconception about psychiatric procedures like ECT and other procedures perceived by 11% as reason for non- compliance. This revealed that there are many factors contributing to noncompliance to drugs among psychotic patient. (Fig. 1)
Fig. 1 Factors Affecting Non-Compliance to Psychotropic Drugs
Discussion
There is a need for mentally ill patients to take the medications regularly especially the patients who are on long-term therapy in order to prevent relapse of disease. However, it is observed that many patients do not comply with their treatment schedule. Administration of medication is a responsibility of the nurse or their relatives (at home) because the mentally ill patient (especially Psychotic Patient) lacks cognitive skill & insight to illness. They may not identify the need for medications. Very few systematic studies had been done on this issues especially on factor associated with non-compliant.
Present study observed that most of the patients were male and in age group of 26-45 years. Maximum numbers of patients (83%) were chronically suffering from illness (more than 4 years) and most of them belong to rural area. Two-third of the patients were belongs to the nuclear family and were having monthly income in between Rs.1000-3000/-
The present study explored various factors as contributing to non-compliance, majority of the subjects perceived disease characteristics related factors as main reason for non-compliance.Transportation problems, poor community mental health services, drug side effects, cultural myth, social factors, psychological & motivational factors, economic factors, lack of knowledge & insight of illness, illiteracy & other factors such as misconception about treatment & difficulty in swallowing the tablets were also revealed as contributing factors to non-compliance. These finding were consistence with finding of the study conducted by Taj. R Khan in Pakistan and reported commonest reason for non- compliance as lack of awareness of treatment benefits, non-affordability of drugs, physical side effects.Both the study reported almost similar factor but different in magnitude based on amount of contributions to non- compliance14
In present study stigma of illness, cultural myth, lack of knowledge about disease & treatment also reported as a contributing factor to non-compliance. These finding were consistent with the findings of Chan DW where the knowledge of treatment and side effects, perceived stigma of the illness, personal belief, were linked to the non- compliance15.
The present study explored many factors, which were associated with non- compliance, the similar factors were observed in many studies across the world16- 19. In- consistency observed only among various factors in terms of their propor tional contribution to non-compliance but the all reported factors consistently found as major cause of non-compliance all around the world therefore it is recommended that psychiatric patients & their family members must be motivated to treatment adherence & mass level awareness program on mental illness must be planned.
Based on the finding of the present study it is recommended that a teaching program on impor tance of treatment compliance could be planned, conducted, and evaluated to find out the effectiveness not only for the psychiatric patients but also for all patients who are on long-term treatment. A similar study can be conducted by considering large geographical area to explore the variations in the factors contributing non- compliances The findings of the study have number of implications for nursing practice.The nurses need to provide psycho-education to make patients and most importantly their relatives aware about the importance of regularly in treatment to prevent relapse. Nurses can also teach them about the their illness, side effects of the medication etc. The role here is educative and supportive to increase the self-care potentials of patients and their relatives.
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