Acta Psychopathologica Open Access

Keywords

Medication; Patient; Attitudes; Schizophrenia; Antipsychotic medications

Introduction

Antipsychotic medications are commonly used to ameliorate symptoms associated with psychotic disorders such as schizophrenia. However, it is associated with a wide range of side effects which may be varied in its intensity, nature and extent [1]. Initially, typical antipsychotic medication is mainly effective in treating positive symptoms of schizophrenia (e.g. hallucination and delusion) [2]. Conversely, it has a limited impact on the negative symptoms such as flat affect and anhedonia. Moreover, a new genre of antipsychotic medication “atypical” has more potent effect on negative symptoms with producing minimal unwanted extrapyramidal side effects, but in turn is more likely to be accompanied by side effects such as weight gain, dyslipidemia and sexual dysfunction [2].

Several studies have documented higher rate of medication noncompliance among People Diagnosed with Schizophrenia (PDwS) is about 60%, resulting in a higher risk for relapse, rehospitalisation and suicide attempts [3]. The only published work conducted with PDwS, emphasized the importance of the nature of the information received in the psychosocial intervention but did not examine their experiences and attitudes before interventions [4]. To date, several studies conducted mainly in high income countries and measured quantitatively the medication adherence among PDwS. However, there was utilized heterogeneity of outcome measures such as pill count, urine test or deterioration in psychotic features. There is a dearth of evidence on non-adherence from the low-income countries as Jordan. This study provides the first comprehensive investigation of the PDwS experiences towards antipsychotic medication.

Methods

Design

This study used a qualitative descriptive design appropriate to understanding People Diagnosed with Schizophrenia (PDwS) attitudes and perspectives towards antipsychotic medication. Inductive thematic analysis was used to identify themes and subthemes.

Setting and participants

This study was conducted in Amman town, the capital of Jordan. Ethical approval was obtained from the ministry of health in Jordan. A purposeful sample was utilized to select interviewees. The total sample size for the study was 22 PDwS. Sampling was maximum variant purposive in nature to maximise variation among interviewees according to the main socio-demographic characteristics such as gender, illness duration, educational level (Table 1).

Characteristic	Qualitative Sample Number
	PDwS	F
Participants
Gender
Male Female	10 12	45.5% 44.5%
Age (years)
≤20 21-30 31-40 41-50 ≥51	2 6 7 3 4	9.0% 27.2% 31.8% 13.6% 18.4%
Education Level
Primary School or below Secondary School College or above	9 6 7	40.9% 27.3% 31.8%
Diagnosis
Schizophrenia Schizoaffective Psychosis	16 4 2	72.6% 18.4% 9.0%
Illness duration (years)
≤2 3-5 ≥5	9 5 8	40.9% 22.7% 36.4%

Table 1: Characteristics of interview participants compared to participants.

Data collection

Semi-structured interviews were the data collection method. A topic guide developed by the authors, prior the study and amended after the first two interviews. It was used to guide the interview process in order to increase the breadth and depth of information obtained from the participants. The topic guide was devised based on the study aims which focused on participants’ experiences and attitudes towards antipsychotic medication. All interviews (n=22) were completed in a private room in the mental health clinic. No time limit was imposed on the interviews, but the average time taken for most interviews was between 45-60 min. Participants were reminded that they could ask any questions or refuse to answer any question. In addition, they were informed about their right to stop or withdraw from interviews at any time without a reason.

Trustworthiness

Consolidated Criteria for Reporting Qualitative research (COREQ) was consulted to promote (Table 2). Also for building research trustworthiness we have to focus on credibility, transferability, dependability and confirm ability. To address credibility, there is several steps followed to address this point. First, researcher had prolonged engagement with participants to learn the culture and build trust. Second, researcher made two transcriptions for each interview by listening to the audio recording on two separate occasions. Then researcher merged the two transcriptions into one final version. Each final transcription was read line by line 2–3 times to identify the main themes. This procedure provided a richer, more meaningful and more credible data set. Moreover, credibility of the current study during data analysis and interpretation was enhanced by showing apparent contradictions in data. Transferability was achieved by selecting a purposeful sample from different psychiatric clinics to illuminate phenomena being studied. In addition, a thick description of the contextual background of the research setting and the participants and credible interpretation is necessary. The dependability of research data is satisfied by using interview guide in order to be consistent. In addition, the transcription strategy was universally similar for all interviews conducted. Digitally recorded interviews were added as another way of enhancing the dependability of obtained data by minimizing any systematic bias and producing plausibility of the account made by interviewees.

Theme	Sub-theme
Insight into illness	Poor awareness into schizophrenia Acute illness perspective and stigma
Mental health services	Relationship with health care provider Being used as experimental subjects
Illness nature and treatment	Side effect of medication Lack of family support

Table 2: Themes and subthemes emerged from interviews.

Data analysis

All conducted interviews were analyzed manually using inductive thematic analysis approach [5] in six stages:

1. Interview transcripts were read and re-read repeatedly in order to obtain a broad understanding of the participants’ views [6].

2. Initial codes were generated; a complete coding approach was utilized in this study in order to identify anything and everything across the data set which might have relevance to the research question [5,7].

3. All similar codes or meanings were collated together into potential themes. A preexisting coding frame was not utilized. Rather, relevant extracts from the data set were collated to form themes [5,7].

4. Potential themes were reviewed and a thematic map generated.

5. Identified themes and subthemes were checked against each other and the dataset to ensure they were coherent, distinctive, consistent and working together.

6. Themes were reflected a semantic level of data with illustrative quotes from participants being selected [5].

Results

Interview data

Three overarching themes emerged from the interviews and are described in Table 2.

Insight into illness

This theme captures the PDwS’ awareness of schizophrenia and the impacts of poor awareness on them.

Poor awareness into schizophrenia

Examining PDwS accounts suggest that they had limited knowledge about antipsychotic medication prior to their participation in the study, expressing the views that medication caused multi-organ damage and was addictive. The next extracts illustrate this feeling:

"….. Some wrong information I had about medication has changed; similarly that the medication produces addiction, is analgesic and ineffective….." (PDwS7)

As can be noted from the interviews, participants had a poor awareness of schizophrenia. Almost all the interviewed participants reported the view that schizophrenia is a split personality.

“….. I thought that my illness was considered as many personalities inside my body [...] especially when I heard voices…..” (PDwS7)

Acute illness perspective and stigma

It can be deduced from the analysis of the data that there is misperception about the expected duration of taking antipsychotic medication as the majority of interviewed PDwS reported that taking medication when the symptoms are subsided it is a major reason for noncompliance with medication. Additionally, a major source of concern for PDwS was the perception of long-term illness duration and uncertainty about the future, as illustrated by participants:

"….. The main reason to leave medication is […]. I felt worried because my illness would last forever….." (PDwS4)

"….. I always worry about our family life, who will look after them when I die? " (PDwS8)

PDwS commented that they believed schizophrenia to be an acute illness, as the positive symptoms of schizophrenia would subside during treatment. As a result, they would stop taking medication at least until symptoms returned:

“….. Sometimes, I thought I completely recovered from my illness, especially when the sounds disappeared, but the educational material said {ah…} this illness is not curable and if I stopped taking [...] the required medication, I could have a relapse…..” (PDwS7)

Social stigma is another main barrier of non-compliance with medication. On several occasions PDwS re-iterated the social stigma associated with mental illness in Jordan. This stigma acted to limit both their use of psychiatric clinics and their information seeking behaviour.

“….. When others know about illness symptoms, they do not go to the psychiatrist due to the stigma or when a family member refuses to visit mental clinics or hospitals. Moreover, she will lose a lot if she opens a file in a mental hospital. She will lose her job, her husband […..].…..” (PDwS2)

Mental health services

Relationship with health care provider: Almost all the interviewed PDwS reported fearing negative responses from mental health professionals when they missed their appointments. Therefore, they preferred to be without medication instead of arguing with health professionals about the reason for missing the scheduled appointment. They emphasised this by saying that:

"….. Sometimes, when I forgot to go to my appointment, I preferred to be without medication until the next visit or ask someone to pick up these medicines [….]. They shouted at me for delaying it and at many times they refused to prescribe me medications….." (PDwS1)

Being used as experimental subjects: From the PDwS’ accounts in the interviews, unavailability of the original medicine and physician prescribes every visit a new antipsychotic medication and each one has an unique side effect was another reason of noncompliance with medication.

“ I feel like a guinea pig as [ah..] they change my medication continuously..” (PDwS 14)

Illness nature and treatment

Side effect of medication: Almost all the interviewed PDwS reported that medication side effects were a primary reason for non-adherence with medication. The following quotes reflect this reason:

"….. When I took risperdal, it produced many side effects and my body became flaccid […]. I stopped this medicine….." (PDwS4)

“….. My weight increased dramatically [ah…ah] you can see my breast prominently, I feel shame from this medicine”(PDwS 8)

Lack of family support: Many PDwS, particularly males, conveyed a sense of detachment and reported a stressed relationship with family members due to the latter's lack of awareness concerning schizophrenia and its medication’s side effects. This is illustrated by comments about the impact of their relatives misunderstanding of schizophrenia on their interpersonal relationships:

“….. My illness caused me to lose my job […..]. My family, especially my parents blamed me and said I pretended to be lazy and tired just because I did not like to work.…..” (PDwS1)

Discussion

To date, there has been a limited number of published studies that assess subjective experience PDwS who are treated with antipsychotic medication. The purpose of this qualitative study was to explore the PDwS experience and attitides towards antipsychotic medications in low income country as Jordan. These results are in accord with previous studies findings, illustrating a commonality of experience of PDwS towards illness. The novel contribution of this study was the factors which have a direct influence on medication compliance among PDwS.

In this study, we identified three major themes about PDwS’ experience and attitudes towards antipsychotic medications: insight into illness, mental health service and illness nature and its treatment consequences. The views and attitudes which were expressed by participants in this study could help explain the essential factors need to be considered in order to enhance PDwS compliance with medication

The evidence that emerged from the qualitative data in the present study demonstrated that the participants’ (PDwS’) limited knowledge of schizophrenia was influenced by negative public perceptions. Limited knowledge of schizophrenia was also associated with self-stigma, shameful feelings and a pre-occupation with negative psychological feelings (i.e., depression, low self-esteem), all of which have been linked with lower treatment adherence [8] and a poor QoL [9].

Moreover, the current findings supported previous research carried out in low income country, Ethiopia, which showed that lack of awareness into illness was one of the important factor led to noncompliance with medication [1,10]. This might be explained partially by the fact that those patients might have false expectations about medication and believed medications would cause entire absence of the symptoms. When the medications fail to achieve this expectation, they abandon taking medication and seek help from other modalities of treatment.

Lack of insight is not uncommon issue in PDwS. There are several explanations for the lack of insight in schizophrenia, including denial of symptoms and/or cognitive deficit. However, the reasons of lack of insight were beyond this study score. Prior studies that have noted the significant predictors of medication compliance were insight level of schizophrenia. This view is supported in prior explorative qualitative studies of purposively selected PDwS, where it was found that a myth associated with mental illness may have interfered with PDwS taking their prescribed medication [11].

Acute illness perspective and stigma another factor was determined influencing compliance with antipsychotic medication among PDwS in this study. This was evident when the PDwS reported their marginalisation from society, social isolation and difficulties in securing work. These views are similar to that found by Corrigan and Watson [12], who indicated that the stigma of mental illness is widely endorsed in society. Corrigan [13] demonstrated that mentally ill people and their families reported self and public stigma to be a considerable problem and a common experience for them. Another study highlighted that those PDwS who perceived more stigma and discrimination also reported lower self-efficacy and poor adherence with medication [5].

Behaviors and attitudes of mental health care professional were also mentioned as a factor affecting adherence with medication. Several studies have indicated that therapeutic alliances with mental ill people may enhance their compliance with medication [6].

Being used as experimental subjects theme indicated that medication is prescribed based on the preferences of the psychiatrists and lack of the availability of antipsychotic medication in Jordan. This implies that level of medication does not necessarily relate to level of illness as a PDwS could be on a higher dose but also be functioning well. There is no national formula to prescribe medication as British National Formula (BNF) to explore PDwS experiences and attitudes toward the specific medication.

The main limitation in this study is the response validation of interview transcripts has important implications for the credibility of findings in terms of whether data interpretation reflects the actual experience of interviewees [7,14]. However, it has been argued that participants are not always the best judge of accounts for a valid research, as they change their views over time. This has been considered problematic for researchers, as it requires them to change data and posits additional analysis [14]. The interview transcripts of this study were not reviewed by participants, it is recognised that some of the participants’ meanings might have been lost during transcription and translation stages.

Conclusion

In this qualitative study, the most important factors for noncompliance were reported by PDwS. The mental health policy in Jordan should address these factors in order to enable PDwS to be fully compliance with medications. This will lead to improve quality of care and it will be reflected on many aspects of PDwS life.

Acknowledgement

The researcher would like to thank Dr. Ali Zaid his support with the qualitative data analysis, all the PDwS for their participation in the interviews and the clinic staff who provided a suitable room to conduct interviews.

Ethics Approval and Consent to Participate

The ethical approval was obtained from the Ministry of Health in Jordan. In addition, Consent form was sought from all the study participants.

Consent to Publish

I declare that all participants informed and consented such data are subjects for publication in psychiatry Journal.

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