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Journal of Behavior Therapy and Experimental Psychiatry xx (2008) 1e12 www.elsevier.com/locate/jbtep

Psychosocial and socio-demographic correlates of medication compliance among people with schizophrenia
Hector W.H. Tsang a,*, Kelvin M.T. Fung a, Patrick W. Corrigan b
a

Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong b Institute of Psychology, Illinois Institute of Technology, Chicago, United States Received 16 August 2007; received in revised form 21 February 2008; accepted 27 February 2008

Abstract This study examined the medication compliance of people with schizophrenia in relation to their selfstigma, insight, attitude towards medication, and socio-demographic status via a cross-sectional observational design. Eighty-six Chinese adults with schizophrenia were recruited from the psychiatric hospitals and community settings for this study. The ndings suggested that stereotype agreement of self-stigmatization and attitude towards medication were moderately correlated with medication compliance. Poor insight and living alone were found to be signicant predictors of medication compliance based on regression analysis. Insight was identied to be the strongest predictor on compliance which accounted for 68.35% of the total variance. Although self-stigma is only moderately linked with medication compliance, its effects on medication-induced stigma cannot be ignored. 2008 Elsevier Ltd. All rights reserved.
Keywords: Medication compliance; Insight; Attitude; Self-stigma; Schizophrenia

1. Introduction Antipsychotic medication is regarded as the most effective treatment for people with schizophrenia (American Psychiatric Association, 1997; Thornley & Adams, 1998; Valenstein et al.,
* Tel.: 852 2766 6750; fax: 852 2330 8656. E-mail address: rshtsang@inet.polyu.edu.hk (H.W.H. Tsang). 0005-7916/$ - see front matter 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbtep.2008.02.003 Please cite this article in press as: Hector W.H. Tsang et al., Psychosocial and socio-demographic correlates of medication compliance among people with schizophrenia, Journal of Behavior Therapy and Experimental Psychiatry (2008), doi:10.1016/j.jbtep.2008.02.003

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2004). Its efcacy on the control of psychotic symptoms and reduction of relapse has been widely documented with a huge body of empirical support (Dolder, Lacro, Leckband, & Jeste, 2003; Rittmannsberger, Pachinger, Keppelmuller, & Wancata, 2004). The treatment outcome is, however, largely inuenced by the treatment compliance (Watson & Corrigan, 2001; Zygmunt, Olfson, Boyer, & Mechanic, 2002). Although treatment compliance is the foundation of favorable therapeutic outcomes (Ludwig, Huber, Schmidt, Bender, & Greil, 1990), it is unfortunate that noncompliance to antipsychotics medication is common among people with schizophrenia. A review by Cramer and Rosenheck (1998) suggested that more than 40% of patients failed to fully comply with recommended medication regimes. Another review study indicated an average of 50% medication noncompliance rate (Lacro, Dunn, Dolder, Leckband, & Jeste, 2002). Medication noncompliance is an obvious barrier to health care provision (Compton, Rudisch, Weiss, West, & Kaslow, 2005). It is reported that double to triple relapse rate was evidenced among individuals who discontinued using the prescribed antipsychotic medication (Curson et al., 1985; Horgarty & Ulrich, 1977; Viguera, Baldessarini, Hegarty, van Kammen, & Tohen, 1997). Individuals with poor compliance are likely to have frequent and longer hospitalization, and hence poor prognosis (Bebbington, 1995; Pinikahana, 2005; Valenstein et al., 2002). Their independent living would be affected by their uctuating mental conditions (Vauth, Loschmann, Rusch, & Corrigan, 2004), which would then lead to an increasing cost of care and societal burdens (Terkelsen & Menikoff, 1995; Thieda, Beard, Richter, & Kane, 2003). A number of factors have been found to be related to poor medication compliance among people with schizophrenia. Medication side effect is most well known (Blackwel, 1972; Corrigan, Liberman, & Engel, 1990; Perkins, 2002). Adverse side effects such as extrapyramidal symptoms are commonly found among users of conventional agents (Moller, 2005). Atypical antipsychotics are developed to address this problem by reducing uncomfortable side effects (Mortimer, Williams, & Meddis, 2003). However, side effects are still experienced by the use of newer antipsychotic drugs (Stanniland & Taylor, 2000). The study conducted by Valenstein et al. (2004) suggested that the non-adherence rate slightly dropped from 46% to 40% after switching from conventional to atypical antipsychotics. Medication compliance is inuenced by a considerable number of variables (Meichenbaum & Turk, 1987). These variables can be categorized into patient-related, illness-related, medication-related, and environmental-related factors (Fenton, Blyler, & Heinssen, 1997; Fleischhacker, Oehl, & Hummer, 2003; Kampman & Lehtinen, 1999; Pinikahana, 2005). Individuals with poor insight are likely to restrict their help seeking behaviors which then lead to treatment noncompliance (Amador & Strauss, 1993; Bartko, Herczeg, & Zador, 1988; Lin, Spiga, & Fortsch, 1979; McEvoy et al., 1989; Nageotte, Sullivan, Duan, & Camp, 1977). Meanwhile, individuals who hold negative attitudes towards antipsychotic medication are more reluctant to adhere to prescribed medications (Cuffel, Alford, Fischer, & Owen, 1996; Falloon, 1984; Hogan, Awad, & Eastwood, 1983; Marder et al., 1983; van Putten, May, & Marder, 1984). Self-stigma has received increasing attention as one of the patient-related barriers for medication compliance. Self-stigmatization is conceptualized to be a three-tier mechanism which consists of the components of stereotype agreement, self-concurrence and self-esteem decrement (Corrigan, Watson, & Barr, 2006; Fung, Tsang, Corrigan, Lam, & Cheung, 2007). Self-stigmatized individuals may rstly agree with public stereotypes towards themselves, and then self-internalize these beliefs to their own which results in self-esteem and self-efcacy decrement (Corrigan et al., 2006; Fung et al., 2007). It has been reported that 48% individuals with schizophrenia commented that they suffered from medication-induced stigma (Lee, Chiu,
Please cite this article in press as: Hector W.H. Tsang et al., Psychosocial and socio-demographic correlates of medication compliance among people with schizophrenia, Journal of Behavior Therapy and Experimental Psychiatry (2008), doi:10.1016/j.jbtep.2008.02.003

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Tsang, Chui, & Kleinman, 2006). Lee et al. (2006) suggest that the side effects of antipsychotics medication would trigger physical symptoms and emotional blunting among people with schizophrenia. This would make their psychiatric illness more easily recognized, and thus cause stigmatization. Recent studies (Fung, Tsang, & Corrigan, in press; Fung et al., 2007; Tsang, Fung, & Corrigan, 2006) used a newly developed and validated Psychosocial Treatment Compliance Scale and showed that self-stigma hindered participation and attendance of psychosocial interventions. Similarly, self-stigmatized individuals may opt not to access psychiatric services and comply with prescribed antipsychotics medication in order to avoid unnecessary prejudice and discrimination (Watson & Corrigan, 2001). Socio-demographic factors such as age, gender, educational level, nancial status, and living condition have been posited to be correlates of medication compliance and addressed in previous studies (Fawcett, 1995; Fenton et al., 1997; Fleischhacker et al., 2003; Pinikahana, 2005). Unfortunately, the results are inconclusive. Nevertheless, we still believe that the socio-demographic background of individuals would have certain inuence on their level of compliance. Given the above, the aim of this study was to investigate medication compliance of individuals with severe and persistent mental illness in relation to their self-stigma, insight, attitude towards antipsychotic medication, and socio-economic status. This study provided direct empirical evidence to exploring how self-stigma affects medication compliance. We hope that appropriate interventions could be formulated with a better understanding of the correlates of compliance to medication (Compton et al., 2005; Vauth et al., 2004). 2. Method 2.1. Participants Eighty-six adults who were clinically diagnosed with DSM IV schizophrenia by certied psychiatrists were recruited from Kwai Chung Hospital and her clustering psychiatric day centers, and Lai Kwan Day Training Centre of Baptist Oi Kwan Social Service in Hong Kong from July 2004 to February 2005. Their average duration of psychiatric illness was 13.56 years (S.D. 8.70), and all participants had currently received antipsychotic medication. They had a mean age of 39.92 (S.D. 8.00). Nearly half of them were female (48.8%). They had nished elementary education, and 23 of them were lived alone. Individuals who suffered from developmental disabilities, dementia, substance abuse and profound communication decits were excluded. 2.2. Instruments 2.2.1. Measure of medication compliance The Kemp Compliance Scale (KCS) (Kemp, Hayward, Applewhaite, Everitt, & David, 1996; Kemp, Kirov, Everitt, Hayward, & David, 1998) is a reliable observer-rating scale measuring participants status of medication compliance in terms of oral formulation. This is a single item scale which is rated by a seven-point Likert scale ranging from (1) Complete Refusal to (7) Active Participation. 2.2.2. Measure of self-stigma The Chinese Self-stigma of Mental Illness Scale (CSSMIS; Fung et al., 2007) was developed through the translation and validation of the Self-stigma of Mental Illness Scale originated from
Please cite this article in press as: Hector W.H. Tsang et al., Psychosocial and socio-demographic correlates of medication compliance among people with schizophrenia, Journal of Behavior Therapy and Experimental Psychiatry (2008), doi:10.1016/j.jbtep.2008.02.003

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Corrigan et al. (2006). The CSSMIS contains four subscales for assessing participants level of perceived stigma and self-stigma. Perceived stigma is measured by Stereotype Awareness, whereas self-stigma is, respectively, rated by the subscales of Stereotype Agreement, Self-concurrence, and Self-esteem Decrement. Each subscale consists of the same set of 15 items with different introductory clauses. The items are listed in Table 1. The items are based on a nine-point Likert scale with 9 indicating strongly agree and 1 indicating strongly disagree. Individuals were suggested to be self-stigmatized if they scored highly in any of the self-stigma subscales. Excellent internal consistency (ranging from 0.82 to 0.90), and good testeretest reliability (ranging from 0.71 to 0.81) were reported. 2.2.3. Measure of insight The three general items of the Scale to Assess Unawareness of Mental Disorder (Amador et al., 1993) were used to assess the current and past insight of the participants. It is scored from (1) aware to (5) unaware. Satisfactory inter-rater reliability and testeretest reliability was reported. 2.2.4. Measure of attitudes towards medication The Rating of Medication Inuences (ROMI) (Weiden et al., 1994) and the Drug Attitude Inventory-10 (DAI-10) (Hogan et al., 1983) were used to measure participants attitudes towards medication. Good psychometric properties were reported for both scales. The ROMI consists of 7 items revealing the reasons of medication compliance, and 13 items pertaining to the reasons of noncompliance. The items of ROMI are rated from none (1) to strong (3). The DAI-10 contains six positive items and four negative items in measuring participants subjective experiences towards the use of antipsychotic medications which are rated either yes or no. Higher score of the compliance subscale of ROMI and DAI-10 indicates better attitude towards medication, whereas higher score of the noncompliance subscale of ROMI indicates worse attitude. 2.3. Data collection After informed consent was obtained, demographic data of participants were acquired from their medical records. The case managers who were knowledgeable to participants status of medication compliance completed the Kemp Compliance Scale. Two experienced research assistants conducted a face-to-face interview with participants to complete the remaining measures. They were registered occupational therapists, and were procient in administering mental health assessments. 2.4. Data analysis Data analysis was performed in liaison with the doctoral level biostatistician afliated to our department. The demographic information of participants was summarized by descriptive statistics. The associations between medication compliance and the possible inuential factors were explored by Pearson product-moment coefcient of correlation. Independent t-test was applied to investigate the difference of medication compliance among different demographic groups. Independent variables which were correlated with Kemp Compliance Scale at p < 0.20 were included for the regression analysis (Bendel & A, 1997). The forward selection model was employed to construct a regression equation to predict medication compliance.
Please cite this article in press as: Hector W.H. Tsang et al., Psychosocial and socio-demographic correlates of medication compliance among people with schizophrenia, Journal of Behavior Therapy and Experimental Psychiatry (2008), doi:10.1016/j.jbtep.2008.02.003

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Table 1 Fifteen items for the CSSMIS 1. I am below average in intelligence. 2. I am unusually artistic.* 3. I cannot be trusted. 4. I am innocent and childlike. 5. I am unable to get or keep a regular job. 6. I am dirty and unkempt. 7. I am mostly a genius.* 8. I have something that is contagious. 9. I am unable to take care of myself. 10. I will not recover or get better. 11. I am morally weak. 12. I am to blame for my problems. 13. I am unpredictable. 14. I am dangerous. 15. I am disgusting. Key: *positive items. Please cite this article in press as: Hector W.H. Tsang et al., Psychosocial and socio-demographic correlates of medication compliance among people with schizophrenia, Journal of Behavior Therapy and Experimental Psychiatry (2008), doi:10.1016/j.jbtep.2008.02.003
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Table 2 Descriptive statistics of test scores Sub-scores Kemp Compliance Scale The Chinese Self-stigma of Mental Illness Scale Stereotype awareness Stereotype agreement Self-concurrence Self-esteem decrement Scale to Assess Unawareness of Mental Disorder Mental illness (current/past) Medication (current/past) Social consequence (current/past) The Rating of Medication Inuence Compliance Noncompliance The Drug Attitude Inventory Mean 5.90 76.15 72.5 63.95 64.78 2.40/2.70 2.21/2.45 2.21/2.42 1.61 1.25 2.00 S.D. 0.93 17.17 18.87 22.36 21.37 1.39/1.47 1.42/1.56 1.44/1.51 0.45 0.25 5.46

The most signicant independent variable was entered to the model rst, and then followed by the second signicant one. This process was repeated until a nal regression equation was established in which all independent variables within the model were able to make signicant prediction independently. Variables with marked uneven distribution of test scores (e.g., martial status, and certain living and nancial conditions), or with obvious number of missing data (e.g., length of stay and number of previous admission to psychiatric hospital) were excluded, as representative conclusion could not be drawn from these datasets.

Table 3 Relationship between Kemp Compliance Scale (KCS) and selected independent variables with p < 0.20 Selected variables The Chinese Self-stigma of Mental Illness Scale Stereotype agreement The Scale to Assess Unawareness of Mental Disorder Mental illness (current/past) Medication (current/past) Social consequence (current/past) The Rating of Medication Inuence Compliance Noncompliance The Drug Attitude Inventory Demographic data Living alone Living with parent *p < 0.05; **p < 0.01. Please cite this article in press as: Hector W.H. Tsang et al., Psychosocial and socio-demographic correlates of medication compliance among people with schizophrenia, Journal of Behavior Therapy and Experimental Psychiatry (2008), doi:10.1016/j.jbtep.2008.02.003 Pearson coefcient 0.221* 0.258*/0.0.297** 0.302**/0.193 0.401**/0.343** 0.304** 0.328** 0.314** t-Value 3.391** 1.456

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H.W.H. Tsang et al. / J. Behav. Ther. & Exp. Psychiat. xx (2008) 1e12 Table 4 The regression model for medication compliance Parameter SUMD: current social consequence Living alone (no set as base) Adjusted r2 0.236. b 0.386 0.274 t-Value 3.995 2.832 p-Value 0.000 0.006

% of Variance accounted 68.35 31.65

3. Results The descriptive statistics of different test scores are presented in Table 2. Twelve independent variables were found to be related to the Kemp Compliance Scale at p < 0.20 level and are shown in Table 3. The results of bivariate investigation suggested that stereotyped agreement, insight and attitudes towards medication were signicantly associated with medication compliance at p < 0.05. Stronger correlations were found for the measures on certain insight items and attitudes ( p < 0.01). The results of independent t-test indicated that individuals who lived alone tended to have poor medication compliance. The three remaining CSSMIS subscales were not signicantly correlated with the Kemp Compliance Scale (stereotype awareness: r 0.144, p 0.298; self-concurrence: r 0.099, p 0.365; self-esteem decrement: r 0.109, p 0.320). It is, however, still interested to note the correlational direction that perceived stigma/self-stigma was aligned with medication noncompliance. A signicant predictive regression model (Table 4) was formulated. People with schizophrenia who had poorer current awareness about the social consequences of having mental illness, and lived alone were more likely to demonstrate poor medication compliance. Current insight had the strongest contribution for predicting compliance (b 0.386, p < 0.001). The overall model accounted for 23.6% of the total variance in the prediction. 4. Discussion Satisfactory medication compliance was found among the participants. The obtained means score on the Kemp Compliance Scale indicates that their level of compliance ranged from passive acceptance to moderate participation. This appears to contradict the comments by Lee et al. (2006) that Chinese people with schizophrenia have poor compliance because of the severe side effects of the prevalent use of conventional medication. The disparity may due to the use of atypical antipsychotics medication in our sample which effected less severe side effects. However, further study needs to be done to elaborate the relationship between the use of different antipsychotic agents and compliance among Chinese patients. The ndings from the bivariate investigation suggested that individuals who agreed with public stereotype towards mental illness were more likely to demonstrate worse medication compliance. In fact, medication-induced stigma is regarded as one of the principal barriers to compliance (Hudson et al., 2004). The side effects of antipsychotics medication including extrapyramidal symptoms and sedation would lead the individuals to experience unnecessary prejudice and discrimination (Lee et al., 2006). They may try to reduce medication-induced side effects (Lee et al., 2006) by withdrawing from treatment (Corrigan, 2004). Akin to prior research (Awad, 1993; Buchanan, 1992; Razali & Yahya, 1995), the correlational ndings suggested that people who have better attitudes towards prescribed medication
Please cite this article in press as: Hector W.H. Tsang et al., Psychosocial and socio-demographic correlates of medication compliance among people with schizophrenia, Journal of Behavior Therapy and Experimental Psychiatry (2008), doi:10.1016/j.jbtep.2008.02.003

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tend to have better medication compliance. The formation of negative attitude is largely induced by the presence of positive psychiatric symptoms and treatment-induced side effects (Hofer, Kemmler, & Eder, 2002). Patients perception on treatment would inuence their decision to act (Christensen, 1978). The Health Belief Model (Rosenstock, 1996) suggests that people will display health seeking behavior when the negative outcomes for this act are outweighed by the advantage of proposed action. However, this does not apply to our mental health patients. Patients who endorse the negative attitude may believe that the antipsychotics agents do not cure them for their mental illness, and their belief would inhibit their compliance behavior. Regression analysis showed that self-stigma and attitudes towards the use of antipsychotics medication did not correlate with medication compliance in our sample. Instead, our results suggested that poorer insight towards the social consequence of having mental illness, and living alone predicted poorer medication compliance. A substantial volume of studies has investigated the relationship between insight and medication compliance. Empirical evidence supports their association with medication compliance (Buchanan, 1992; McEvoy et al., 1989). It is generally believed that illness recognition is the foundation for exhibiting help seeking behaviors (Pescosolido, 1992). Individuals with poor insight tend to cease taking medication (Olfson, Marcus, Wilk, & West, 2006), due to their lack of the perceived urge for treatment (Cuffel et al., 1996). Similarly, patients who are aware of the negative social consequences of having mental illness tend to alter their unfavorable psychiatric conditions by adhering to the medication regimes and get the associated benecial clinical outcomes (Holzinger, Lofer, Muller, Priebe, & Angermeyer, 2002). Our results showed that medication noncompliance was obvious among individuals who lived alone. This parallels the study by Irwin, Weitzel, and Morgan (1971) that lower compliance rates were found among individuals who lived alone. However, they also reported that those who lived in a supported environment with care from family members had better medication compliance. It is well known that family support is essential for individuals engagement in medication regime (Corrigan et al., 1990; Falloon et al., 1982). One the other hand, lack of social support and social supervision (Hudson et al., 2004; Mak, 1998; Owen, Fisher, Booth, & Cuffel, 1996; Razali & Yahya, 1995) are common barriers for poor treatment compliance. Reminder and monitor from signicant others are, therefore, effective ways to improve compliance rate (Olfson, Mechanic, & Hansell, 2000). Our earlier study demonstrated that mental illness self-stigma was a key predictor for psychosocial treatment compliance (Fung et al., 2007). We hypothesized that self-stigma would exert similar effect in undermining medication noncompliance. However, our current study did not support the hypothesis as applied to medication compliance. Self-stigma only correlated moderately with medication compliance. One possible explanation is that the associated stigma is more severe for psychosocial treatment engagement than medication. Once people with schizophrenia have attended the psychosocial interventions in the psychiatric settings, their secret of having mental illness is disclosed to the public. Thus, self-stigmatized individuals are likely to avoid attending prescribed psychosocial interventions to prevent from being discriminated by others (Fung et al., in press). Although medication-induced stigma exists, individuals have more control to conceal their daily medication consumption, and lesser stigma should be experienced via taking medication. Studies have to be conducted to ascertain this relationship. Effective interventions to improve medication compliance among people with schizophrenia are essential for their recovery. Extensive compliance enhancement interventions (Brown, Wright, & Christensen, 1987; Hayward, Chan, Kemp, Youle, & David, 1995; Hogarty et al., 1991; Kemp et al., 1996, 1998; ODonnell et al., 1999; Razali & Yahya, 1995) had been
Please cite this article in press as: Hector W.H. Tsang et al., Psychosocial and socio-demographic correlates of medication compliance among people with schizophrenia, Journal of Behavior Therapy and Experimental Psychiatry (2008), doi:10.1016/j.jbtep.2008.02.003

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implemented and empirically investigated. Psychoeducation, motivational interviewing, cognitive-behavioral modeling, family intervention, community-based intervention are the commonly adopted strategies to improve medication compliance (Dolder et al., 2003; Zygmunt et al., 2002). Moreover, the adoption of depot antipsychotics would be benecial to improve the tolerability and compliance among patients (Moller, 2005). We believe that medication compliance among individuals with schizophrenia would be improved with these strategies. The ndings of this study shed light on a better understanding of medication compliance. However, certain limitations existed and generalizations should be made with caution. As the title of this paper suggests, we aim at identifying only the signicant correlates of medication compliance. The causal relationship among the variables cannot be determined by the use of cross-sectional observational design. Furthermore, the compliance level of our sample was generally good. This would limit the generalization of ndings to individuals who have poor medication compliance. This is valuable to include the information concerning the side effects, symptom severity, and type and dose of antipsychotic medication received by the participants. With this data, the direct linkage between those confounding factors, stigma and medication compliance could be examined. Moreover, it is also worthy to consider other possible contributing factors on medication compliance in future studies. Some may argue that the reliability of compliance data is weakened by adopting a seven-point physician-rated scale instead of using direct compliance measures such as pill count or urine test. Kemp et al. (1998) posited that direct measures also have their own limitations with inaccuracy. However, it would be worthy in future studies to obtain the compliance data from different perspectives in compensating the weakness of different compliance measurements.

Acknowledgement This project is funded by the Internal Competitive Research Grant of The Hong Kong Polytechnic University (Project Number: A-PE67).

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