Psychological burden and caregiver-reported non-adherence to psychotropic medications among patients with schizophrenia
Introduction
Mental disorders account for 13% of disability-adjusted life years globally (Vigo et al., 2016). However, there is a gap in meeting the mental health needs of people worldwide through the provision of adequate care. For example, although the burden of mental and behavioral disorders has increased by 38% from 1990 to 2010 globally (Murray et al., 2013), over 70% of this increase is due to mental disorders in low- and middle- income countries (LMICs) (Lopez et al., 2006). In Ghana, the prevalence of mental disorders including schizophrenia has been estimated at 13% of the adult population (WHO, 2013).
Access to psychiatric medicines in Africa is hampered by inadequate supply and the cost of out-of-pocket payments for medicines (Raja et al., 2015). In Ghana, the majority of the budget for mental health (nearly 80%) is allocated for the maintenance of the three government psychiatric hospitals. The Ghanaian National Health Insurance Scheme (NHIS) does not cover psychiatric services since by policy, treatment for mental disorders is provided free of charge at the government psychiatric hospitals and through community psychiatric nurses. However, if these are not accessible, or medications runs out as can occur, then patients have to purchase these privately without recourse to a refund. In addition, many psychiatric patients who do not have health insurance are not covered for the treatment of their other co-morbid physical conditions as well (Ofori-Atta et al., 2010).
The pharmacological agents that mainly used for the clinical treatment of schizophrenia are usually because of the safety, efficacy and positive role in relapse prevention (Sikich et al., 2008). In a meta-analysis of 65 trials involving patients stabilised with antipsychotic medications, Leucht et al. found that antipsychotic medications significantly reduced the relapse rate with patients less likely to be hospitalised compared with the placebo at the first year (Leucht et al., 2012).
Despite the benefits of antipsychotics, studies on their non-adherence have reported rates of 20–89% (Gilmer et al., 2004, Higashi et al., 2013). Non-adherence in schizophrenic patients has been linked to poor treatment outcomes such as risk of relapse, increased hospitalization and suicidal attempts (Novick et al., 2010).
Campaigns to improve mental health services in LMICs have highlighted improved access and adherence to psychotropic medications (Read, 2012). It is important to identify non-resource intensive strategies to improve antipsychotic treatment adherence that can easily be integrated into the existing provision of mental healthcare (Adeponle et al., 2008). One major approach is to de-institutionalize mental health care as proposed in the Ghana Mental Health Act 2012 (Act 846). The rationale is to provide community-based care for persons with mental disorders while seeking to decongest the three public psychiatric hospitals in Ghana, which have been saddled with challenges such as poor infrastructure, lack of resources, and low levels of formally trained mental health practitioners. With approximately 90% of patients with schizophrenia and other mental disorders living with their families, the role of caregivers in this community-based approach will be critical (Chadda, 2014). Successful interventions to improve adherence have focused on informal caregivers and family therapies because family interactions influence disease outcomes and relapse rates (Sariah et al., 2014, Zygmunt et al., 2002). However, there are reports to suggest that attention should be directed at the physical and psychosocial well-being of caregivers because the process of caregiving can be detrimental to their health (Vitaliano et al., 2003).
The psychological well-being of the caregiver can influence their readiness to ensure and monitor the adherence behavior of the patient with schizophrenia in part, because one of the reported factors for non-adherence is the lack of formal and informal therapeutic support. For example, if caregivers are unwell, they may have compromised supervision which can negatively affect the health outcome of patients. One study suggests a need for clinicians to address non-adherence to medications in patients with schizophrenia to help reduce the burden of caregivers, including psychological stress (Lasebikan and Ayinde, 2013).
Most studies on medication non-adherence related to antipsychotics have been conducted mostly in Western countries and mainly focused on the perspectives of patients (Kane et al., 2013, Nose et al., 2003). A recent review (Chidarikire et al., 2017) identified schizophrenia treatment issues in sub-Saharan Africa, including the important role of families as caregivers in aiding medication adherence (Alem et al., 2008, Kebede et al., 2005, Shibre et al., 2003). However, of the 40 studies identified, only five included caregivers as respondents, with four in South Africa (Asmal et al., 2014, den Hertog and Gilmoor, 2016, Kotze et al., 2010, Motlana et al., 2004) and the remaining one focusing on Ethiopia (Asher et al., 2015).
Therefore, this study aimed to examine caregivers’ psychological distress and its association with caregiver rated adherence to medications.
Section snippets
Study design and site
This hospital-based cross-sectional study was conducted among family caregivers of patients with schizophrenia attending all the three public psychiatric hospitals in Ghana: Ankaful Hospital, Pantang Hospital and the Accra Psychiatric Hospital. All hospitals are in the southern part of Ghana and serve the nation's population of approximately 25 million people. While some public and private hospitals attend to patients with mental illness on outpatient basis, those with severe forms such as
Caregiver demographic characteristics
Even though the estimated sample size was 442, a total of 450 caregivers were approached for the interviewer-administered questionnaire because of the potential of non-completion and out of which 444 caregivers responded representing a response rate of 98.7%.
The socio-demographic characteristics of respondents are presented in Table 1. The mean age of the respondents was 47 years (SD = ± 14.19 years), 251 (56.5%) were female and 294 (66%) were married. Table 1 further shows that 99 (22%) of the
Discussion
This study examined the association between psychological distress, caregiving burden and caregiver-reported medication adherence. Caregivers’ have been a source of adherence and other health-related outcomes reporting for patients (Caqueo-Urízar et al., 2015, Labrum and Solomon, 2016, Aukst Margetić et al., 2011). For an optimal score of 25 on the MARS, the mean antipsychotic adherence was 20.81 and the caregivers’ estimation of non-adherence to antipsychotic medications in outpatients with
Acknowledgement
The authors are grateful to the three psychiatric institutions, the patients with schizophrenia and their caregivers who participated in this research.
Funding
This work was supported by the African Doctoral Dissertation Research Fellowship, a collaborative program of International Development Research Centre (IDRC) and African Population and Research Centre (APHRC) [Grant number 2015-2017ADF 03, 2015]
Conflict of interest
The authors declare no conflicts of interest in relation to the study, authorship, or publication of this article.
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