South African Journal of Psychiatry

ISSN: (Online) 2078-6786, (Print) 1608-9685

Page 1 of 6 Original Research

Antipsychotic medication non-adherence among

schizophrenia patients in Central Ethiopia

Authors: Background: Despite the fact that adherence to antipsychotic medications is the cornerstone in
Minale Tareke1
the treatment and prevention of relapse of the disease, non-adherence is a major problem
Siranesh Tesfaye2
Desalegn Amare1 among schizophrenia patients. The purpose of this study was to assess the magnitude and
Tilahun Belete3 factors associated with antipsychotic medication non-adherence among schizophrenia patients
Andargie Abate1 in Amanuel Mental Specialized Hospital.
Affiliations: Method: An institution-based cross-sectional study was conducted among 412 people with
1
College of Medicine and schizophrenia at Amanuel Mental Specialized Hospital from April to May 2014. Non-adherence
Health Science, Bahir Dar
University, Ethiopia
was assessed using the questionnaire of Morisky medication adherence rating scale and semi-
structured questions for assessment of associated factors. Logistic regression analysis was
2
Department of Psychiatry, used to assess predictors of non-adherence.
Felege Hiwot Referral
Hospital, Ethiopia Results: Prevalence of non-adherence was 41.0% among schizophrenia patients. Living in
rural areas (adjusted odds ratio [AOR] = 2.07; 95% confidence interval [CI]: 1.31, 3.28), current
3
College of Health Science, substance use (AOR = 1.67; 95% CI: 1.09, 2.56), long duration of treatment (AOR = 2.07; 95% CI:
Psychiatry Unit, Department 1.22, 3.50) and polypharmacy (AOR = 2.13; 95% CI: 1.34, 3.40) were found to be significantly
of Nursing, Mekelle
University, Ethiopia
associated with non-adherence.

Conclusion: The results indicate that non-adherence to antipsychotic medication was a major
Corresponding author:
Minale Tareke, problem among patients with schizophrenia. Reducing the number of antipsychotic
[email protected] medications and availing drugs in rural areas may decrease the level of non-adherence.

Dates:
Received: 17 Apr. 2017
Accepted: 22 Nov. 2017 Introduction
Published: 05 Mar. 2018 Schizophrenia is a severe illness which affects all life aspects of the patients including work, self-
How to cite this article: care and capacity to establish interpersonal relationships.1 It is one of the top 10 causes of long-
Tareke M, Tesfaye S, Amare D, term disability in the world, affecting about 1.0% of the population.2
Belete T, Abate A.
Antipsychotic medication Antipsychotic drugs have become the cornerstone of treatment for schizophrenia. These are effective
non-adherence among
schizophrenia patients in in reducing psychotic symptoms, preventing psychotic relapses and improving psychosocial
Central Ethiopia. S Afr J functioning.3 However, non-adherence to medication is one of the biggest problems, increasing re-
Psychiat. 2018;24(0), a1124. hospitalisation and persistent psychotic symptoms, and the most challenging aspect of treatment.4,5,6
https://doi.org/10.4102/
sajpsychiatry.v24i0.1124
Non-adherence can cause high rates of relapse within 5 years of recovery from the first episode.7
Copyright: Thus, lack of adherence to pharmacological treatment is associated with worsening of symptoms,
© 2018. The Authors. poor prognosis, high costs and unnecessary adjustments in the medical prescriptions.8
Licensee: AOSIS. This work
is licensed under the
Creative Commons A report in Poland revealed that treatment adherence in the first month was very low, but
Attribution License. application of telemedicine monitoring systems would improve the compliance in patients with
the worst compliance.9 Many studies reported that the level of medication adherence for
antipsychotic treatment was ranged from 20.0% to 70.0%.10,11,12

Different reports in Ethiopia have shown that non-adherence to antipsychotics medication was
varied from 26.5% to 47.9%.13,14,15,16 Other qualitative studies showed that medication side effects,
poverty, lack of family supports, duration of illness and stigma, substance use, alcohol consumption
and smoking are some of the factors affecting the medication adherence of schizophrenia.17 Thus,
non-adherence remains a challenge for patients with psychiatric disorders and their health care
Read online: providers, contributing to a substantial worsening of disease, frequent relapse, increased mortality,
Scan this QR re-hospitalisation and increased health care costs.18
code with your
smart phone or
mobile device The magnitude and consequences of non-adherence to antipsychotic drugs among schizophrenia
to read online.
patients vary from one place to another, suggesting the need of study in the local context. However,

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 Page 2 of 6 Original Research

there is limited evidence in the study area. Therefore, this above was used to define non-adherence in this study. The
study was intended to fill the gap by assessing the magnitude questionnaire was translated into Amharic and back to
and factors associated with antipsychotic medication non- English by language experts and a psychiatrist for checking
adherence among people with schizophrenia at Amanuel its consistency.
Mental Specialized Hospital (AMSH).
Data quality assurance and analysis
Methods Data were entered to Epi Info version 3.5 after checking for
Study setting and design completeness and then exported to SPSS version 20 for
A cross-sectional study design was used at AMSH from April further analysis. Descriptive statistics analysis was performed
to May 2014. AMSH is one of the pioneer Ethiopian hospitals, for variables and the results were presented using tables,
established in 1938 by the Italians. The hospital is playing its percentage, mean and standard deviation. Bivariate logistic
pivotal role as a training institute for psychiatric professionals regression was first conducted to identify potential
so as to expand the service throughout the country by confounding factors and variables with a p < 0.2 were entered
introducing psychiatry services in the primary health care to multivariable logistic regression models using backward
system of the country. Annually, about 51 204 schizophrenia selection method to identify factors associated with non-
patients visited the hospital for regular follow-up services at adherence. An adjusted odds ratio with 95.0% confidence
outpatient departments, and, on average, 4267 schizophrenia interval was used to interpret the strength and significance of
patients had monthly follow-ups. All schizophrenia patients the association.
who had regular follow-up at AMSH were taken as a source
population, while those schizophrenia patients who were Ethical considerations
available during data collection were considered as a study
Ethical clearance was obtained from the ethical research
population. Schizophrenia patients aged above or equal to
review committee of the University of Gondar and
18 years, who had one or more previous visits and who
Amanuel Mental Specialized Hospital. Written consent
were on follow-up during the study period at outpatient
was obtained from each study participant during data
departments of AMSH were recruited for the study. However,
collection. The purpose and procedure of the study were
patients with serious medical or neurological illnesses, who
clearly explained to all the participants. The participants
had no insight and who were unable to communicate were
were assured that their identity would remain anonymous
excluded from the study.
and their responses would be kept confidential. The right
was given to participants to decide whether they wish to
Sample size determination and procedure be part of the research or not. Furthermore, they were
A single population proportion formula {[Z2*p* (1−p)]/d2} assured that they can withdraw from the study at any time
with an assumption of 95.0% confidence level, 5% margin of and it would not have any effect on their next follow-up
error and 50% proportion of schizophrenia patients with treatment.
non-adherence to their medication(p) and 10% non-response
rate was used to determine the final sample size of 423. Results
Socio-demographic characteristics of
The total number of schizophrenia patients who visited the
hospital over the previous 6 months was taken from records schizophrenia patients
and the average number of patients per month was calculated Out of the total 423 recruited patients, 412 filled in the
and found to be 4267. Therefore, systematic random sampling questionnaire completely, giving a response rate of 97.4%.
technique was used to include every 10th (4267/423 = 10) The mean age of schizophrenia patients was 35.28 years with
schizophrenia patient available at the clinic during the data a standard deviation of 10.35 years. Most (68.0%) of the
collection period. respondents were living in urban areas, single (65.5%) and
orthodox religion followers (56.1%). About half of the
respondents (47.6%) were jobless and nearly four in every
Data collection method and instrument
five (73.3%) were earning less than 750 Ethiopian birr/month
Data were collected using a semi-structured and pretested (less than US$33) (Table 1).
questionnaire by face-to-face interview technique. Chart
review was used to collect the type and number of
antipsychotic drugs and duration of medication. Two trained Clinical and patient-related factors
psychiatry nurses working in the mood disorder department Among the study participants, about half (48.1%) had been
of the hospital collected the data for a period of approximately taking medication for fewer than 5 years. Nearly one-third
1 month. The questionnaire included socio-demographic (28.2%) of the participants were on antipsychotic
data, Morisky medication adherence rating scale (MMARS)-​ polypharmacy (use of two or more antipsychotic drugs at a
8 items and semi-structured questions for assessment of time). On the other hand, 29.6% of the participants had
associated factors. MMARS-8 is extensively used to measure history of previous psychiatric admissions and history of
non-adherence in Ethiopia.19,20,21 The cut-off point of 3 and substance use since initiation of treatment (39.3%) (Table 2).

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 Page 3 of 6 Original Research

TABLE 1: Distribution of socio-demographic characteristics of schizophrenia TABLE 2: Distribution of clinical and patient-related factors among schizophrenia
patients attending at Amanuel Mental Specialized Hospital, Addis Ababa, patients at Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia, June
Ethiopia, June 2014 (n = 412). 2014 (n = 412).
Variable Frequency % Variable Frequency %
Sex Duration of illness < 3 years 78 18.9
Male 287 69.7 ≥ 3 years 334 81.1
Female 125 30.3 Antipsychotic yes 116 28.2
Age polytherapy No 296 71.8
≤ 25 71 17.2 Duration of treatment < 2 years 111 26.9
26–35 163 39.6 2–5 year 87 21.1
≥ 36 178 43.2 > 5 years 214 51.9
Marital status Type of antipsychotics FGA 250 60.7
Single 270 65.5 SGA 46 11.2
Married 80 19.4 FGA+FGA 96 23.3
Divorced 32 7.8 FGA+SGA 19 4.6
Widowed 6 1.5 FGA+FGA+SGA 1 0.2
Residence Route of antipsychotics Oral 368 89.3
Urban 280 68.0 Injectable† 44 10.7
Rural 132 32.0 Number of admissions None 290 70.4
Ethnicity One 66 16.0
Amhara 148 35.9 ≥ two 56 13.6
Oromo 112 27.2 EPS Yes 43 10.4
Gurage 93 22.4 No 369 89.6
Tigre 21 5.1 Drug adherence Yes 243 59.0
Others 38 9.2 No 169 41.0
Educational status Substance use No 250 60.7
Uneducated 49 11.9 Yes 162 39.3
1–8 grades 126 30.6 EPS, Extrapyramidal side effects; FGA, first generation antipsychotics; SGA, second
9–12 grades 157 38.1 generation antipsychotics.
†, fluphenazine decanoate.
Diploma and above 80 19.4
Occupation
Employed 68 16.5 180 Adherant
Private business 70 17.0 Non adherent
160
Daily labourer 37 9.0
140
Jobless 196 47.6
Student 20 4.9 120
Housewife 21 5.1 100
Monthly income (Ethiopian birr) 80
< 750 birr 302 73.3
60
750 birr–1199 birr 47 11.4
≥ 1200 birr 63 15.3 40
20
0
Substances use among schizophrenia patients
e

at

t
l

ha
us

ha
ho

Ch
rre

/C

/C
co
e

Compared to alcohol use, current use of khat chewing and

nc

ga

te

te
Al
ta

re

rre
Ci
bs

ga

smoking cigarettes simultaneously were found to be high

ga
su

i
/C

Ci
No

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ho

among non-adherent schizophrenia patients (Figure 1). Khat

co
Al

(chat) is one of the most common forms of drug use and

abuse in many East African nations, especially in Ethiopia, FIGURE 1: Bar chart showing the distribution of substance use among
schizophrenia patients at Amanuel Mental Specialized Hospital, Addis Ababa,
involving chewing parts of the fresh green leaves. Chewing Ethiopia, June 2014 (n = 412).
khat has stimulant and euphoric effects and is believed to
have a relaxing effect, to increase concentration and is used to duration of illness, duration of treatment, number of
waste time. psychiatric hospitalisation days, history of active substance
use, only injectable antipsychotic use (fluphenazine
Factors associated with antipsychotic decanoate) and antipsychotic polypharmacy were factors
significantly associated with non-adherence. However, in
non-adherence multivariate logistic regression, place of residence, history
Prevalence of non-adherence was found to be 41.0% among of active substance use, duration of treatment and
schizophrenia patients in this study. Bivariate logistic antipsychotic polypharmacy were found to be statistically
regression analysis was performed to find the relationship significant.
of socio-demographic, patient and treatment-related
variables with non-adherence of antipsychotics. The result Accordingly, patients who were living in rural areas were
of bivariate analysis revealed that place of residence, about twice as likely to be non-adherent to antipsychotic

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 Page 4 of 6 Original Research

TABLE 3: Factors associated with antipsychotic polypharmacy among schizophrenia outpatients under follow-up at Amanuel Mental Specialized Hospital, Addis Ababa,
Ethiopia, June 2014 (n = 412).
Variable Adherence Odd ratio at 95% CI
Yes No Crude Adjusted
Residence Urban 178 102 1 1
Rural 65 67 1.79 (1.18, 2.73) 2.07 (1.31, 3.28)*
Substance use (khat No 162 88 1 1
Alcohol and tobacco) Yes 81 81 1.84 (1.23, 2.75) 1.67 (1.09, 2.56)*
Duration of illness < 5 years 95 48 1 1
5–10 years 53 57 2.12 (1.27, 3.54) 1.75 (0.89, 3.47)
> 10 years 95 64 1.33 (0.83, 2.13) 1.64( 0.66, 4.06)
Number of admissions None 176 114 1 1
One 40 26 1.00 (0.58, 1.73) 0.83 (0.46, 1.49)
≥ Two 27 29 1.65 (0.93, 2.94) 1.24 (0.66, 2.35)
Duration of treatment < 5 years 126 72 1 1
5–10 years 42 53 2.20 (1.34, 3.63) 2.07 (1.22, 3.50)*
> 10 years 75 44 1.02 (0.64, 1.64) 1.04 (0.62, 1.74)
Route of antipsychotics Oral 212 156 1.75 (0.88, 3.46) 1.59 (0.77, 3.30)
Injectable 31 13 1 1
Antipsychotics No 191 105 1 1
polypharmacy Yes 52 64 2.23(1.44, 3.46) 2.13(1.34, 3.40)*
1, Reference; CI, confidence interval.
*p < 0.05

medication as compared to those living in urban areas In Nigeria, comorbid psychoactive substance use and patients
(AOR = 2.07; 95% CI: 1.31, 3.28). who had been on medication for less than 1-year were
included, whereas schizophrenia patients who had more
Regarding substance use, patients who were using than one visit were included in our study. Furthermore,
psychoactive substances after initiation of treatment were comorbid psychoactive substance use was investigated as an
nearly twice as likely to be non-adherent to antipsychotic influencing factor for adherence in this study. The study
medication compared to those who had no history of conducted in Egypt also used a convenience sampling
substance use (AOR = 1.67, 95% CI: 1.09, 2.56). technique, suggesting the possible reason for the observed
difference. In Bulgaria, 226 schizophrenia patients on long-
Moreover, participants who took medication for more than term antipsychotic treatment were included, while the
5 years were twice as likely to be non-adherent to antipsychotic exclusion criteria were first episode of psychosis, substance
medication as compared to those who took for less than dependence, date of the last hospitalisation less than 2 months
5 years (AOR = 2.07, 95% CI: 1.22, 3.50). prior to the study and change in type or dose of antipsychotic
medication within the previous month. Furthermore, these
Patients who were on antipsychotic polypharmacy were two discrepancies might be because of the difference in study
times more likely to be non-adherent to their medication as participants, culture, time variation and settings.
compared to those who were on a single drug (AOR = 2.13,
95% CI: 1.34, 3.40) (Table 3). The current estimate is larger than the result from studies
conducted in France (30.0%),26 Jimma, Southwest Ethiopia

Discussion (36.0%)15 and Mekelle, Northern Ethiopia (26.5%).13This

might be because of the difference in study design, study
Antipsychotic medication is the mainstay in the treatment of setting, study year, socio-demographic data and type of
schizophrenia, and adherence to medication plays a pivotal screening tool used. The study performed in Mekelle had
role in controlling symptoms and preventing frequent quite low rates of non-adherence that could be explained by
relapses. From the finding of the present study, the magnitude differences in measuring medication adherence methods
of non-adherence among schizophrenia patients was found and sample size. The major difficulty in categorising the
to be 41.0% (95% CI: 36.2%, 45.6%). Although it is clear that magnitude of non-adherence in schizophrenia patients is
more than one factor is responsible for non-adherence among the lack of consistent and agreed criteria. For instance, the
schizophrenia patients, place of residence, active substance 10-item modified version of the Morisky Medication
use, duration of treatment and antipsychotic polypharmacy Adherence Scale (MMAS) was used in Mekelle, which was
were the main factors identified in the current study. answered using ‘yes/no’ responses. A MMAS score equal to
3 or above indicated adherence, while less than or equal to 2
This finding of this study was in line with the study conducted indicated non-adherence. However, in the current study, an
in Switzerland (44.8%).22 However, it is by far lower than the 8-item MMAS with seven ‘yes/no’ questions and one
studies conducted in Egypt (74.0%),11 Jordan (64.2%),23 question answered on a five-point Likert scale was used. In
Nigeria (51.7% – 62.5%)12,24 and Bulgaria (55.8%).25 The addition, the sample size variation and inclusion criteria
possible explanation behind this might be the inclusion criteria. might account for this difference.

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 Page 5 of 6 Original Research

A number of factors were significantly associated with non- Authors’ contributions

adherence to antipsychotic medication. In this study,
All authors contributed towards data analysis, drafting and
schizophrenia patients living in rural areas were found to be
critically revising the article and agreed to be accountable for
non-adherent compared to urban residents, which is supported
by another study.27 The possible explanation might be related all aspects of the work.
to long distance to health facilities, financial constraints to
purchase medication, lack of services for mental health care References
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