Insight and Attitude towards drug intake: Risk factors for relapse in patients with psychosis - A pilot study report

Janarthanan. B¹*, Dr. Manoranjitham Sathiyaseelan²

¹College of Nursing, JIPMER (Govt. of India), Dhanvantari Nagar, Gorimedu, Puducherry -6

²College of Nursing, Christian Medical College (CMC), Vellore (TN).

*Corresponding Author’s Email: jenu.bcc@gmail.com

ABSTRACT:

Background and objectives:

The identification of the major risk factors for relapse in patients with psychosis became inevitable in order to manage the illness effectively. This will not only enhance our understanding of the course and the prognosis of the illness, but also help us to frame guidelines and protocols to prevent relapse in psychosis. Hence, the present study was undertaken with an objective of determining the major risk factors for relapse in psychosis such as level of insight and the attitude towards drug intake.

Materials and Methods:

In order to determine the major risk factors for relapse in patients with psychosis, a case-control study design was adopted for the present study. Subjects included in the study group (relapse group) were inpatients with a history of at least one episode of psychosis in the past and with symptoms of relapse in the past two months. In the control group (non-relapse group) outpatients without symptoms of relapse in the past six months and on regular treatment were included. Convenience sampling technique was used to select 15 subjects for the study group and 15 subjects for the control group. An interview guide was used to obtain the baseline socio-demographic and clinical variables. Drug attitude inventory scale (DAI-10) and schedule for assessment of insight (SAI) were used to assess the attitude towards drug intake and insight respectively.

Results:

There was a highly significant association between the subjects attitude towards drug intake and relapse in psychosis (p<0.001). There was a statistically significant association between insight into illness and relapse in psychosis (p<0.005). It was also found that there were a highly statistical differences in the adequacy of insight into illness and the attitude towards drug intake between the relapse group and the non-relapse group.

Conclusions:

The findings of the present study concluded that, inadequate insight and unfavorable attitude towards drug intake predominantly contributes as the major risk factors for relapse in patients with psychosis. Moreover, it was evident that insight into illness and the attitude towards drug intake are inter related in a way that adequate insight into illness would directly contribute to a favorable attitude towards drug intake, thereby increasing the medication compliance and decreasing the relapse rate in patients with psychosis.

KEYWORDS: Psychosis; Insight; Attitude towards drug intake; Medication compliance; Relapse.

INTRODUCTION:

Psychotic disorders continue to present as a major mental health problem world-wide. Patients with psychotic disorders are at great risk for relapse and re-hospitalization.¹This risk is magnified by wrong attitude towards the intake of anti-psychotic, which in turn leads to the refusal of accepting optimal treatment planning. It is quite obvious that, the medication compliance can be even more compromised because of patient’s poor insight into these illnesses and their inability to recognize the potential for recovery that exists when taking anti-psychotics as directed. ^2,3

Many patients with psychosis suffer from lack of insight into their condition. They do not understand the need for treatment or the rationale for treatment. It is believed that this lack of insight is the leading cause of non-adherence among individuals with schizophrenia and bipolar disorder. The patient’s attitude to medication is a major issue in determining the outcome and the attitude to drug may reflect compliance. Relapse rates have been shown to be up to five times higher in noncompliant that in compliant subjects. Cross-sectional studies of the relationship between insight and adherence to treatment have reported that increased insight was associated with greater treatment adherence.

Numerous studies have examined patients attitudes towards medications and adherence. One 5-year prospective study of patients with depression found that 74% of patients reported good adherence to anti-depressants. Among those who were not adherent, re-searchers found that the main reason was a negative attitude towards drug therapy. Other reasons included a lack of motivation, adverse effects, fear of addiction, economic reasons, lapse of memory and substance abuse. In this study 79% of the patients had a positive attitude towards medications.⁴ An analysis of the 21% of patients with a negative attitude revealed that they were most often female, literate, employed and well educated.⁵With this background, we had undertaken this study to determine the level of insight into illness and the attitude towards drug intake in patients with psychosis. In addition, we also studied the pattern of association of insight into illness and the attitude towards drug intake.

MATERIALS AND METHODS:

The study was carried out in the Department of psychiatry (both inpatient and outpatient units) JIPMER, Puducherry. A case control study design was adopted for this study. Patients who were diagnosed with psychosis (ICD-10 criteria), aged between 18 and 60 years of age were included for the study. As case control study design was chosen, two groups namely relapse group (study group) and non-relapse group (control group) were made. Non-probability convenience sampling method was used to select 30 subjects (15 subjects in each group). Subjects included in the study group (relapse group) were inpatients with a history of at least one episode of psychosis in the past and with symptoms of relapse in the past two months. In the control group (non-relapse group) outpatients without symptoms of relapse in the past six months and on regular treatment were included. Patients with organic mental disorders and mental retardation were excluded from the study. The following instruments were used for the study.

Part I: Interview guide for collecting socio-demographic and clinical details of the patient:

This included the patient’s age, gender, locality, marital status, educational status, occupation, family income per month, type of family, diagnosis, age of onset, duration of illness, duration of untreated illness, substance use and number of previous hospitalization.

Part II: Schedule for the Assessment of Insight (SAI):

This standard scale consisted of 12 items. Out of 12, 8 items ranged from 0-2 score, 3 items 0-4, and 1 item 0-7. The highest score for items 1 to 9, A and B of compliance to treatment/therapy/medication was 28. The highest score for summary of compliance to treatment/therapy/medication for item C was 7. The higher the scores were, the better the insight and compliance to treatment/therapy/medication. The resulting scores were grouped and interpreted as, ≤75% indicates inadequate insight and 76% - 100% indicates adequate insight.⁶

Part III: Drug Attitude Inventory (DAI-10):

This is a medication questionnaire. This scale consisted of 10 items; 6 were true statements and 4 were false statements. All the correct answers were scored as plus 1 and all the incorrect answers were scored as 0. The subject’s positive attitude towards drug intake showed compliance. The higher score denotes a good attitude towards drug intake and drug compliance. The resulting scores were grouped as, ≤ 70% indicates unfavorable attitude and 71% - 100% indicates favorable attitude.⁷

The data was collected during the month of October 2015, after obtaining permission from the JIPMER Scientific Advisory Committee (JSAC) and Institute Ethics Committee (IEC). The medical records of the patients were thoroughly examined to establish the state of relapse and also to determine the previous episodes of psychosis. Patients who complied with the inclusion criteria for the relapse and the non-relapse group were met individually for the data collection process. Informed consent was obtained from subjects and from their legally acceptable representative and then the necessary data was collection using the above mentioned instruments. Each subject was interviewed for about 45 mts to 1 hour approximately to get the necessary data.

RESULTS:

The data was analyzed using the SPSS version 22. The descriptive (frequency, percentage, mean and standard deviation) and inferential statistics (independent t test and chi-square test) were computed. The results of the study were discussed as follows

Sample characteristics

An interview guide was used to collect the information about the socio-demographic and clinical details of the patients. As indicated in the table 1, in the relapse group, among the 15 subjects, a majority of subjects (60%) belonged to the age group of 18-29 years. Females were more, contributing to about 53.3%. A maximum of 60% subjects were from rural background. In relation to the marital status, a majority of (40%) subjects were unmarried. Nearly 40% of subjects had secondary school education. 33.3% of subjects were house wives and a similar number of subjects were not having any job. In regard to the family income per month, about 6 40% of subjects were having an income of ≥5000 and 26.7% participants had a monthly income of >10,000. As far as the type of family is concerned, a majority of (86.7%) subjects were living in nuclear family.

As shown in table – 1, in the non-relapse group, among the 15 subjects, majority of (53.3%) subjects were in the age group of 30-39 years. Among them, females were more (53.3%). Like relapse group, a maximum of 60% of subjects were from rural background. In relation to the marital status, a 53.3% of subjects were unmarried. Nearly 53.3% of subjects had secondary school education and 40% of subjects were jobless. In regard to the family income per month, almost one third of the subjects (33.3%) were having income between 1001 – 5000 and a similar number of subjects had income between 5001 – 10,000. Almost, 86.7% of subjects were living in nuclear family.

Table 2 denotes the distribution of subjects in the relapse group and the non-relapse group according to the clinical variables. In the relapse group, nearly 26.7% of subjects were diagnosed to have Bipolar Affective Disorder – Manic episode. Majority of subjects (73.3%) had the onset of illness between 21 and 30 years of age. Nearly 66.7% of subjects had the duration of illness to about lesser than 50 months.

Table 1: Distribution of subjects in the relapse group and the non-relapse group according to the socio-demographic variables.(N = 30)

Socio-demographic variables

Relapse Group (n=15)

Non-Relapse Group (n=15)

c²

Value

Age (in years)

a) 18 – 29

b) 30 – 39

c) 40 – 49

d) 50 – 60

13.3

53.3

26.7

6.7

9.055

0.029*

Gender

a) Male

b) Female

46.7

53.3

46.7

53.3

0.000

1.000

Locality

a) Rural

b) Urban

0.000

1.000

Marital Status

a) Single

b) Married

c) Widowed

d) Separated

33.3

6.7

---

33.3

53.3

---

13.3

4.117

0.249

Educational Status

a) No formal education

b) Primary school

c) Secondary school

d) Higher secondary school

e) Graduate

f) Post-graduate and above

---

13.3

6.7

---

13.3

6.7

53.3

6.7

---

4.619

0.464

Occupation

a) Daily labor

b) House wife

c) Business

d) Professional

e) Non-professional

f) No job

g) Any other (specify)

---

13.3

33.3

6.7

33.3

---

33.3

13.3

---

13.3

---

4.996

0.416

Family Income (per month in rupees)

a) < 1000

b) 1001 – 5000

c) 5001 – 10000

d) > 10000

---

---

33.3

26.7

6.7

33.3

26.7

1.091

0.779

Type of Family

a) Nuclear family

b) Joint family

86.7

13.3

86.7

13.3

0.000

1.000

* Significant at p<0.05

All the subjects (100%) had the duration of untreated illness to about lesser than 50 months as well. A majority of 93.3% were not using any substance and a maximum of 73.3% of subjects had been hospitalized once for their illness. Among the subjects in the non-relapse group, nearly 26.7% of subjects were diagnosed to have Schizophrenia. Majority of subjects (46.7%) had the onset of illness between 21 and 30 years of age. About 60% of subjects had the duration of illness between 101 and 200 months. Almost 93.3% of subjects had the duration of untreated illness to about lesser than 50 months.

Table 2: Distribution of subjects in the relapse group and the non-relapse group according to the clinical variables (N = 30)

Clinical variables

Relapse Group (n=15)

Non-Relapse Group (n=15)

c²

Value

Diagnosis

a) Schizophrenia, Schizotypal

b) Schizoaffective

c) Persistent Delusional Disorder

d) Acute Transient Psychotic Disorder

e) Induced Delusional Disorder

f) BPAD – Manic episode

g) BPAD – Depressive episode

h) Mania with psychotic symptoms

i) Depression with psychotic symptoms

j) Recurrent depressive disorder

k) Psychosis (NOS)

---

13.3

---

13.3

6.7

---

26.7

---

26.7

6.7

---

6.7

13.3

8.000

0.534

Age of onset (in years)

a) < 20

b) 21 – 30

c) 31 – 40

d) > 40

13.3

73.3

6.7

26.7

46.7

13.3

2.222

0.528

Duration of illness (in months)

a) < 50

b) 51 – 100

c) 101 – 200

d) > 200

---

66.7

---

13.3

6.7

9.103

0.028*

Duration of untreated illness (in months)

a) < 50

b) 51 – 100

c) > 100

---

100

---

93.3

6.7

---

1.034

0.309

Substance Use

a) No substance use

b) Tobacco

c) Alcohol

d) Alcohol and Tobacco

e) Others (specify)

---

93.3

---

6.7

---

73.3

---

26.7

---

2.160

0.412

Number of previous hospitalization

a) Nil

b) 1

c) 2

d) 3 and above

13.3

73.3

6.7

13.3

1.867

0.601

*significant at p<0.05

Table 3: Distribution of the Relapse Group and the Non-Relapse Group according to the level of insight into illness (N = 30)

Level of insight

Relapse Group (n=15)

Non-Relapse Group (n=15)

c²

Value

Inadequate insight

Adequate insight

100

53.3

46.7

9.130

0.003 **

**significant at p<0.005

Table 4: Distribution of the relapse group and the non-relapse group according to the attitude towards drug intake (N = 30)

Attitude towards drug intake

Relapse Group (n=15)

Non-Relapse Group (n=15)

c²

Value

Unfavorable attitude

Favorable attitude

100

20.00

0.000 ***

*** Significant at p<0.001

Table 5: Comparison of insight into illness and attitude towards drug intake between Relapse and Non-Relapse Group (N=30)

Factors responsible for relapse	Relapse Group (n=15)		Non-Relapse Group (n=15)		t-value	p Value
Factors responsible for relapse	Mean	S.D.	Mean	S.D.	t-value	p Value
Attitude towards drug intake	3.53	1.552	8.0	0.756	-10.536	0.000 ***
Insight into illness	9.08	3.457	21.083	2.741	-10.020	0.000 ***

*** significant at p<0.001.

A majority (73.3%) of subjects were not using any substance and a maximum of 60% of subjects had been hospitalized once for their illness.

Insight in to Illness:

Table 3 reveals that, all the subjects (100%) in the relapse group had inadequate insight into the illness. In the non-relapse group, a maximum of 53.3% of subjects had inadequate insight, where as 46.7% of subjects had adequate insight. There was a statistically significant association between insight into illness and relapse in psychosis (p<0.005).

Attitude towards drug intake:

As shown in table 4, all the subjects in the relapse group had an unfavorable attitude (100%), where as in the non-relapse group, a majority of 80% subjects had a favorable attitude towards drug intake. There was a highly significant association between the subjects attitude towards drug intake and relapse in psychosis (p<0.001)

Comparison of insight into illness and the attitude towards drug intake

As indicated in table 5, when the level of insight into illness and the attitude towards drug intake were compared, highly significant differences were found in attitude towards drug intake and insight into illness (p<0.001). High score in these two factors, showed a good attitude towards drug intake and an adequate insight into illness.

DISCUSSION:

Considering the findings of the present study, it is evident that insight into illness and the attitude towards drug intake are closely related and influences each other. As far as the insight into illness is concerned, the present study revealed that all the subjects in the relapse group (100%) had an inadequate insight into illness. The findings of the present study was supported by the results of a literature review done by Lacro in the year 2002, on the prevalence and the risk factors for medication non adherence in patients with schizophrenia. In the 39 articles reviewed, the factors most consistently associated with non –adherence included inadequate insight and negative attitude towards medication.⁸Hence it is very clear that inadequate insight about mental illness would lead to relapse resulting in re-hospitalization.

Regarding the attitude towards drug intake, the findings of the current study clearly indicate that all the subjects in the relapse group (100%) had an unfavorable attitude towards drug intake. The present study findings were closely related to a study conducted by Shoval and Zemishilany in the year 2003 on non-compliance with medication as a common reason for admission.⁹ They evaluated the causes of admission and diagnoses of 100 consecutively admitted patients with psychosis, 54 out of 100 admissions were associated with medication non-compliance, in the previous year. Therefore, it is to be expected that an unfavorable attitude towards drug intake and poor drug compliance is associated with relapse in patients with psychosis.¹⁰It can also be inferred that, there is a strong relationship between the insight and the attitude towards drug intake. The present study denoted that there are highly significant differences between the level of insight and attitude towards drug intake. .

CONCLUSION:

Psychosis is a severe type of mental illness in which the patient talks and behaves abnormally. The functions of the body and mind are severely disturbed resulting in gross impairment of individual’s socio-occupational functioning. Relapse in the early phase of psychosis is association with increased probability of further relapse and persisting symptoms. The most common factors associated with relapse in patients with psychosis are inadequate insight into illness and unfavorable attitude towards drug intake, which in turn leads to poor medication compliance. These issues make the patients to get re-hospitalized and increase the socio-economic burden on their family. From the present study, it is clear that subjects with adequate insight into their illness would definitely have a favorable attitude towards drug intake, there by having good medication compliance and the risk for psychotic relapse gets considerably reduced

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Received on 17.06.2016 Modified on 06.07.2016

Int. J. Adv. Nur. Management. 2016; 4(3): 348-352.

DOI: 10.5958/2454-2660.2016.00061.2