Schizophrenia Bulletin vol. 32 no. 4 pp.

786–794, 2006
doi:10.1093/schbul/sbl011
Advance Access publication on August 3, 2006

Medication Adherence in Schizophrenia: Exploring Patients’, Carers’ and

Professionals’ Views

Martijn J. Kikkert1,2, Aart H. Schene2, Maarten W. J. Introduction

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Koeter2, Debbie Robson3, Anja Born4, Hedda Helm4,
Treatment nonadherence limits the clinical effectiveness
Michela Nose5, Claudia Goss5, Graham Thornicroft3,
of prescribed medication.1 Studies often report that
and Richard J. Gray3
about 50% of patients are treatment nonadherent across
2
Department of Psychiatry, Academic Medical Center, a range of disorders.2 Different authors, often using
University of Amsterdam, PO Box 22700, 1100 DE Amsterdam, a quantitative approach, generally present a range of fac-
The Netherlands; 3Institute of Psychiatry, Kings College,
London, UK; 4Department of Psychiatry, Leipzig University, tors that influence treatment adherence with medication
Leipzig, Germany; 5Department of Psychiatry and Clinical in patients with schizophrenia.3–7 Consistently reported
Psychology, University of Verona, Verona, Italy factors include insight, beliefs about treatment, medica-
tion side effects, and treatment efficacy.3 Although re-
search has improved our knowledge, adherence rates
One of the major clinical problems in the treatment of do not seem to have changed in the last 4 decades.8,9
people with schizophrenia is suboptimal medication adher- More recently, interventions focused on nonadherence
ence. Most research focusing on determinants of nonadher- were developed. Several researchers have proposed that
ence use quantitative research methods. These studies these adherence interventions should focus more on
have some important limitations in exploring the decision- patients’ decision-making process.6,10 For this, quantita-
making process of patients concerning medication. In this tive studies have some, but limited, value because they
study we explore factors influencing medication adherence fail to adequately explain the complexity of medication-
behavior in people with schizophrenia using concept map- taking behavior and are only able to explore a limited
ping. Concept mapping is a structured qualitative method number of variables.
and was performed in 4 European countries. Participants Other more qualitative studies have tried to describe
were 27 patients with schizophrenia, 29 carers, and 28 pro- adherence behavior by focusing on the subjective re-
fessionals of patients with schizophrenia. Five clinically sponses or experiences of patients with antipsychotic
relevant themes were identified that affect adherence: med- medications and their decision-making process in re-
ication efficacy, external factors (such as patient support lation to starting, continuing, or stopping medication.
and therapeutic alliance), insight, side effects, and attitudes Conclusions regarding which factors influence adherence
toward medication. Importance ratings of these factors dif- behavior are often based on either patients’11–14 or pro-
fered significantly between professionals and carers and fessionals’ views.15 These views might differ as we know
patients. Professionals, carers, and patients do not have from research in other fields. Fischer et al,16 for instance,
a shared understanding of which factors are important in showed that patients’, carers’, and professionals’ views
patients’ medication adherence behavior. Adherence may concerning outcome and service priorities vary widely.
be positively influenced if professionals focus on the positive Similar conclusions were drawn by Pope and Scott,17
aspects of medication, on enhancing insight, and on fos- studying main reasons to stop medication treatment in
tering a positive therapeutic relationship with patients patients receiving lithium for an affective disorder. To in-
and carers. crease our understanding of medication adherence, we
should make use of the valuable expertise and experience
Key words: medication adherence/schizophrenia/ of different stakeholder groups. Relying solely on one of
concept mapping these groups might give limited and unsatisfactory results.
The aim of this article is to learn more about (non)ad-
herence in patients with schizophrenia. For this, we will
use concept mapping, an established qualitative method-
ology, to explore factors that influence adherence behavior
1
To whom correspondence should be addressed; tel: þ31 (0) 20 in patients with schizophrenia. We will include the opin-
5667288, fax: +31 (0) 20 5904441, e-mail: [email protected]. ions of patients, carers, and professionals from 4 countries.
Ó The Author 2006. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved.
For permissions, please email: [email protected].
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 Medication Adherence in Schizophrenia

Materials and Methods explore factors related to medication adherence. In con-

trast to other qualitative methods it also comprises a
Setting
clustering and a prioritizing task. The clustering task
This study was conducted in 4 European Union allows for the participants to determine which factors
countries: England, Germany, Italy and the Netherlands. or clusters emerge from the data and to what extent these
It was part of the quality of life following adherence ther- clusters are related to each other. Therefore, compared
apy for people disabled by schizophrenia and their carers with other qualitative research methods, the interpreta-
(QUATRO) study, an international multisite random- tion of the qualitative data might be less susceptible to
ized controlled trial assessing the effectiveness of adher- the hypothesis that researchers may have. The priori-
ence therapy in people with schizophrenia. All study sites tizing task enables, using a quantitative methodology,

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gained full approval for the study from the appropriate a comparison of the relative importance stakeholder
local research ethics committee. groups address to the different factors or clusters.19,20
The procedure was administered by a trained facilita-
Participants tor and cofacilitator in each country. Concept mapping
Participants were purposively selected out of the 3 stake- consists of 4 stages. For each stage, a written protocol
holder groups. Patients were meeting International Sta- was provided to make sure all sites followed the same
tistical Classification of Diseases and Related Health procedure. A copy of the manual can be requested
Problems, 10th Revision (ICD-10) criterion for schizo- from the first author.
phrenia. Carers and professionals were, respectively, car- During the first stage, brainstorming sessions were
ing for and working with patients with schizophrenia. All held separately for patients, carers, and professionals
participants needed to be familiar with positive and neg- in each of the 4 sites. According to Concept Mapping
ative consequences of antipsychotic medication. Therefore, protocol,21 each of these 12 sessions were attended by
patients needed to have had antipsychotic medi- 6–9 participants and took approximately 1.5 hours.
cation prescribed to them for at least 1 year. Carers and Due to having 12 sessions, our study sample exceeded
professionals needed to care for or work with pa- that of typical concept-mapping studies in which it is be-
tients with schizophrenia for a period of at least 2 tween 10 and 20.19 Patients were invited to generate state-
years. Participants should have experience with non- ments focusing on ‘‘all factors that influence whether you
adherence. Although the majority of patients and, conse- take or not take antipsychotic medication.’’ Carers and
quently, their carers go through a nonadherent period professionals were asked to generate statements on ‘‘all
during the course of their illness,6,18 patients were only factors influencing the start and continued use of
included if they had been clinically instable in the previ- antipsychotic medication.’’ If patients were inhibited to
ous year. This was defined by one or more of the follow- verbalize their thoughts, they were invited to submit
ing: at least one hospital admission on clinical (mental statements in writing or on a one-to-one basis after the
health) grounds, a change in antipsychotic medication, session finished.
increased frequency of planned or actual contact, and In the second stage, the number of generated state-
indications of clinical instability from relatives, carers, ments had to be reduced to below 100 in order to control
or clinical team. These criteria were considered indic- the complexity of the following steps. After translation
ative of nonadherence. Carers were included if they into English, 5 researchers (not involved in the brain-
were caring for patients fulfilling inclusion criteria. All storming sessions) independently reviewed all generated
participants were further expected to be able to ade- statements. Statements that were not understandable, not
quately verbalize ideas and thoughts concerning singular, too specific, or too abstract were removed.
medication adherence and perform the required tasks. Next, repetitive or overlapping statements were com-
A high-quality systematic review indicated that other bined into single statements. Finally, in each country,
sociodemographic characteristics have no influence on the remaining statements were reviewed and rated by
medication adherence3 and were therefore not assessed researchers according to how well each related to the
in this study. In order to increase variability of generated topic of medication adherence on a 3-point scale. Those
statements and generalizability of our results, stake- rated least relevant were excluded, leaving a final list of
holder groups were unrelated. All participants gave writ- statements. These were back-translated into German,
ten informed consent. Italian, and Dutch. Translations were conducted accord-
ing to WHO guidelines.22
Finally, in the third and fourth stage of the concept-
Procedure mapping procedure, statements had to be clustered
To study variables or factors that (positively or nega- and prioritized. Groups were reconvened, and partici-
tively) influence patients, medication adherence behavior pants were asked to individually perform the remaining
concept mapping was used. This method uses group tasks. First, participants had to organize the statements
discussions with patients, carers, and professionals to they thought belonged to the same category into clusters
787
M. J. Kikkert et al.

(stage three). Clustering could be done in any way the On average, patients (n = 27; 59% male) had been pre-
participant thought was logical. Each cluster had to con- scribed antipsychotic medication for a period of 8.6 years
tain between 5 and 40 statements. In addition, individual (SD = 8.2). Carers (n = 29; 28% male) had been caring for
participants were asked to prioritize the statements (stage someone with schizophrenia for an average of 12.6 (SD =
four) by sorting them into 5 equal piles, ranging from 7.4) years, and professionals (n = 28; 46% male) had been
least to most important. Patients were asked how impor- working with patients with schizophrenia for an average
tant each aspect was for their decision to take or not take of 11.4 (SD = 11.1) years.
antipsychotic medication, and carers and professionals
were asked to rate how important they thought each Brainstorming
aspect was for patients. The 12 brainstorming sessions produced a total of 769

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statements relating to factors influencing medication ad-
Data Analysis herence for patients with schizophrenia. Generated state-
The ‘‘Ariadne’’ software package was used to perform 2 ments confirmed that participants were familiar with
types of analysis.21 The first, a principal component anal- both positive and negative aspects of antipsychotic med-
ysis, positions the statements on a concept map. Here the ication. Out of all the statements generated by patients,
distance between statements represents how often they carers, and professionals, respectively, 48%, 42%, and
have been sorted together. Secondly, a cluster analysis 51% were negative aspects of medication use. Following
grouped statements in clusters. This analysis produced translation, researchers reached consensus on the elimi-
between 2 and 18 clusters. Three researchers indepen- nation of 141 statements not meeting the criteria and
dently reviewed each of these 17 computer-generated combined 424 statements with other statements because
cluster solutions starting with the simplest (ie, 2 clusters) they were repetitive or overlapping. The amount of over-
and ending with the most complex (ie, 18 clusters). The lap indicated issues reaching a point of saturation. The
cluster solution that was most understandable and mean- remaining 204 statements were rated, resulting in a final
ingful was selected. set of 82 statements, of which approximately equal num-
Finally, the relative importance of each cluster was cal- bers of statements were found to be produced by the 3
culated using the prioritizing data. For each participant, stakeholder groups (56% of statements were mentioned
the percentage of statements, in each cluster, rated 4 or 5 by patients, 56% by carers, and 66% by professionals)
(important) was calculated. Differences in means were and across the 4 sites.
tested using analysis of variance.
Clustering
All statements are presented as dots on the concept map
Results
in figure 1. Their spatial position is based on the cluster-
Brainstorming sessions were attended by 91 participants ing results. Statements that the participants sorted to-
(41% male) and the prioritizing and clustering sessions by gether more frequently are positioned closer to each
89 participants (44% male), approximately equally di- other on the concept map. Consequently, the distances
vided over the 4 sites (table 1). Results of 4 patients between the statements in figure 1 indicate to what extent,
and 1 carer across 3 sites were removed from the data according to the participants, statements and, conse-
set. These participants indicated they found the clustering quently, clusters are related to each other. On the basis
and/or prioritizing task too complicated. They also did of these interstatement distances, cluster are defined. A
not profit from support, and their results clearly demon- 10-cluster solution was considered to be most under-
strated their lack of understanding (eg, statements clus- standable and meaningful. A cluster solution with fewer
tered according to card number instead of contents). clusters resulted in the loss of clinically relevant clusters.

Table 1. Participants in Brainstorming Session (BS) and Clustering and Prioritizing Tasks (CP)

Patients Carers Professionals Total

BS CP BS CP BS CP BS CP

Amsterdam 6 6 6 7 8 8 20 21
Leipzig 9 6 7 7 6 4 22 17
London 7 7 8 7 9 8 24 22
Verona 8 8 8 8 9 8 25 24
Total 30 27 29 29 32 28 91 84

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Fig. 1. Concept map of factors influencing medication adherence for patients with schizophrenia. The map displays the 82 statements
as dots, the 10 clusters, and 5 clinical themes; medication efficacy (m), external factors (e), insight (i), side effects (s), and medication
attitudes (a). Distance between statements indicates how often they have been sorted together.

Cluster solutions with more clusters were difficult to Discussion

interpret and resulted in clusters that were considered
In this study, we used concept mapping to explore
less meaningful. Clusters that were located close to
‘‘all factors influencing the start and continued use of
each other referred to distinct but clinically related topics.
antipsychotic medication’’ comprehensively by including
Clusters on the map were numbered from left to right and
3 different and independent groups of stakeholders, all
labeled. Examples of statements are shown in table 2.
familiar with schizophrenia for many years, from 4
different countries. In this discussion, we will interpret our
Prioritizing results and describe its clinical and research implications.
Table 3 shows the average percentages of statements in Content and spatial location of the clusters are used to
each cluster which were rated as important by patients, interpret the concept map and identify clinically relevant
carers, and professionals. There was general agreement be- themes (figure 1). Statements, except those in clusters 1, 2,
tween patient and carer ratings of the relative importance and 5, referred to perceived advantages or disadvantages
of each cluster. However, there were a number of signif- of medication use and were divided into 3 themes; right in
icant differences between patient and/or carer and profes- the middle we identified medication efficacy (cluster 4),
sional ratings. The latter rated the efficacy of medication surrounded clockwise by issues related to side effects
(cluster 4) as significantly less important and negative (clusters 3, 9, and 10) and attitudes (clusters 6, 7, and
medication attitudes and beliefs (cluster 7) as more impor- 8). Although closely located, due to the content of the
tant cluster than carers and patients. The professional and statements, insight (cluster 5) is considered a separate
nonprofessional support cluster (cluster 1) was rated as theme in this concept map. The remaining clusters 1
less important and the side effect cluster (cluster 10) as and 2, both distant from the other clusters, referred to
more important by professionals compared with carers. external factors.
789
M. J. Kikkert et al.

Table 2. Cluster Number, Cluster Label, and Examples of Statements

Cluster Number and Label Examples of Statements

1: Professional and nonprofessional support ‘‘being accurately informed about the potential side effects
of the medication’’
‘‘the doctor asking you how you feel, being understanding and
listening to your concerns’’
‘‘family, friends remind you to take your medication’’
‘‘accessibility of the medication (getting the prescription and
medication on time)’’

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2: Information and involvement ‘‘being given the choice whether or not to take medication’’
‘‘listening to other patients experiences of taking medication’’
‘‘not being told what your diagnosis is’’
‘‘having an understanding of the illness’’
3: Side effect self-management ‘‘knowing how to manage the side effects’’
4: Efficacy of medication ‘‘being able to function better due to the medication’’
‘‘the medication is effective in reducing the hallucinations’’
‘‘the medication keeps you from feeling ill/ relapsing’’
5: Insight ‘‘having insight into the illness’’
‘‘accepting that medication is needed’’
‘‘your cultural beliefs fit in with medical advice’’
6: Positive medication attitudes and expectations ‘‘having faith that the medication is effective’’
‘‘taking medication to avoid going back into hospital’’
‘‘good previous experiences with medication’’
7: Negative medication attitudes ‘‘feeling suspicious about the medication’’
‘‘believe that the medication will harm you’’
‘‘the voices telling you not to take the medication’’
‘‘believe that taking medication is unnatural’’
8: Negative expectations ‘‘feeling better when you stop taking it’’
‘‘a traumatic experience the first time you were given medication’’
‘‘preferring the symptoms to the side effects’’
9: Social aspects of extrapyramidal side effects ‘‘being embarrassed about movement disorders because
people can see it’’
10: Side effects ‘‘obesity/weight gain due to the medication’’
‘‘sexual problems due to the medication’’
‘‘feeling tired due to the medication’’

Efficacy External Factors

Cluster 4 represents the subjective efficacy of medication Clusters 1 (professional and nonprofessional support)
due to a relief of symptoms. Patients and carers both and 2 (information and involvement) contain statements
rated this cluster as the most important for medication that refer to factors which contribute to establishing
adherence. This is in line with authors showing that the favorable conditions for adherence behavior by different
beneficial effects of medication on well-being have a ma- means, such as increasing patients understanding, alli-
jor influence on adherence behavior.14,23–25 Accordingly, ance, or trust with clinician; social support; and reduction
studies showed that patients who have the experience of of practical medication barriers. These factors can be
their medications having no benefit, not being helpful, or labeled as external because they refer to influences from
being ineffective and unnecessary more often do not outside by important others, not directly under the con-
comply.18,26–29 trol of the patient. Both clusters adjoin but are distant
Professionals in our study surprisingly rated efficacy from the other clusters in the concept map, suggesting
significantly less important than patients and carers. Pro- that they are not strongly related to the other clusters.
fessionals should (re)value efficacy as more important Nonprofessional (or professional) support, informa-
and are advised to closely monitor and discuss medication tion, and involvement have been studied as important
efficacy, from the patients perspective, as well as the predictors of treatment adherence in people with schizo-
perceived degree (or absence) of adverse symptoms, in phrenia.30–34 Some psychological approaches enhancing
order to understand and manage medication adherence. treatment adherence have placed them at the heart of the
790
 Medication Adherence in Schizophrenia

Table 3. Mean Percentage of Items Per Cluster Rated 4 or 5 (important), Stratified by Patients (Pa), Carers (Ca) and Professionals (Pr)

Pa (n = 27) Ca (n = 29) Pr (n = 28)

Cluster Number Number of
and Label Statements Meana (%) (SD) rb Meana (%) (SD) rb Meana (%) (SD) rb p < 0.05c

4: Efficacy of 9 54 (20) 1 64 (23) 1 40 (21) 5 Pa-Pr; Ca-Pr

medication
3: Side effect 1 48 (51) 2 34 (48) 6 39 (50) 6/7
self-management
5: Insight 4 44 (19) 3 54 (21) 2 52 (23) 1

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1: Professional and 21 42 (12) 4/5 52 (16) 3 37 (15) 8/9 Ca-Pr
nonprofessional
support
6: Positive medication 12 42 (14) 4/5 36 (14) 4/5 36 (12) 10
attitudes and
expectations
10: Side effects 12 40 (21) 6 28 (19) 8/9 46 (24) 2 Ca-Pr
2: Information and 4 39 (22) 7 36 (21) 4/5 37 (24) 8/9
involvement
8: Negative 5 36 (22) 8 32 (18) 7 43 (22) 3
expectations
7: Negative 13 30 (13) 9 25 (16) 10 42 (14) 4 Pa-Pr; Ca-Pr
medication attitudes
9: Social aspects 1 22 (42) 10 28 (45) 8/9 39 (50) 6/7
of extrapyramidal
side effects

a
For each participant, the percentage of statements rated 4 or 5 (important) in each cluster was calculated. The mean percentages over
raters are reported in the table (eg, patients rated on average 54% of the nine statements in cluster 4 as important).
b
Rank order of cluster based on mean percentage.
c
Analysis of variance, multiple comparisons (Tukey’s honestly significant difference test).

intervention,10,35 which is in accordance with our finding also explain why Nageotte et al40 found that 38% of
that patients and, in particular, carers rated support, in- patients were compliant despite the fact that they did
formation, and involvement as rather important. So far, not believe themselves to be ill.
compliance interventions focused on education and in-
formation have not been found to be effective in improv- Side Effects
ing adherence.10 This might explain why professionals Statements related to side effects that referred to objec-
rate these issues as less important.36 tive perceived side effects of medication (cluster 10), the
social aspects of side effects (in particular, movement dis-
Insight orders) (cluster 9), and self-management of side effects
The map shows that insight (cluster 5) is closely related to (cluster 3). The latter cluster referred to a positive char-
positive expectations and attitudes toward the use of an- acteristic, which patients rated as very important.
tipsychotic medication (cluster 6). All groups rated the Medication side effects have often been associated with
insight cluster as important, which is in line with studies nonadherence,24,41,42 although a consistent correlation
describing insight as a strong predictor of medication ad- between the presence or severity of these and the degree
herence.3,37–39 This effect of insight has been addressed to of adherence could not be found in a recent systematic
an improvement in understanding illness and medication review.3 Side effects might not be the most important fac-
consequences. The spatial locations of clusters 4 and 5 tor in determining adherence behavior25,39–43 and may
show that a clear relation with medication efficacy (clus- have less impact than the efficacy of medication44–46 or
ter 4) is, however, lacking. Insight seems less important expressed beliefs concerning susceptibility to relapse.26
for appreciating subjective symptom relief due to medi- Our results confirm this and show that patients and
cation than for indirect treatment benefit such as hospi- carers prioritized side effects relatively low compared
talization or coercion. A patient who uses his or her with positive medication aspects. In comparison, profes-
medication because it improves well-being does not nec- sionals prioritized side effects as the second most impor-
essarily need to have insight into the disorder. This might tant cluster and, consequently, seem to overestimate the
791
M. J. Kikkert et al.

relative importance of side effects on adherence behavior. Belief Model, we did not find perceived illness severity
Although discussing side effects is essential during treat- and medication benefit to be separate themes (eg, ‘‘the
ment because it is the most important disadvantage of medication is effective in reducing the hallucinations’’).
medication use for patients, professionals might, how- We argue that patients are most motivated to use med-
ever, understand the relative importance better in relation ication if they experience direct beneficial effects such as
to other factors such as perceived advantages of medica- a reduction of adverse symptoms and/or because they re-
tion, and coping strategies are taken into account. alize it has indirect, long-term benefits such as preventing
relapse. Although illness insight is not clearly positioned
Medication Attitudes in the Health Belief Model, our results seem to indicate
that insight is particularly important for patients to un-

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Finally, the clusters 6, 7, and 8 represent not only beliefs derstand and appreciate the indirect benefit of medica-
and attitudes concerning medication but also previous tion. Therefore, patients who experience no direct
experiences with these agents. Statements of cluster 6 subjective benefit from medication are most likely to ben-
represent positive aspects or benefits of medication (eg, efit from psychoeducation or brief cognitive behavioral
reducing adverse consequences of being ill such as hospi- therapy to enhance insight.49
talization or coercion). Clusters 7 and 8 refer to negative The external factors show us that there are a number of
attitudes and beliefs concerning medication and feel- factors which are not under patient control, but which
ing better without medication. Different authors have might affect adherent behavior. These factors include
stressed that both attitudes to medication and side the alliance between carers and their key worker, the in-
effects have to be openly discussed with patients.25,47 formation given to patients, actively involving patients in
treatment, and practical medication barriers. These fac-
Prioritizing tors are similar to ‘‘cues to action’’ in the Health Belief
Patients were instructed to rate the importance of state- Model. Clinicians should therefore make every effort
ments based on their own experiences. Carers and profes- to inform patients concerning their illness and medica-
sionals rated statements based on their observations of, tion, increase patients understanding, their alliance
and experiences with, patients. Two points are of interest. with their patient, the provision of social support, and
First, professionals, in general, rated negative aspects reduction of practical medication barriers.
(side effects and negative medication attitudes) as more Results of this study might be useful in screening
important than patients and carers, while patients and patients with schizophrenia. Discussing the topics that
carers, more than professionals, stressed the positive were found in this study should help professionals to
aspects (efficacy and support). Secondly, the fact that detect patients likely to be nonadherent.
carers and patients in our study prioritized clusters in
Limitations
a similar way indicates that carers can be well aware
of patients’ considerations concerning medication. Our This study has some limitations. First, it should be noted
results underline that professionals need to carefully as- that results are limited to issues which were involved in
sess patients’ beliefs and experiences of treatment the decision-making process of patients. Therefore, fac-
with antipsychotic medication in order to understand tors which have been found to correlate with adherent
patients’ perspectives. They also, if possible, should in- behavior such as sociodemographic characteristics and
volve carers in treatment planning and evaluation. Not previous nonadherence are not reported in this study.
only will it improve patients’ support, which was found Patient reports are limited to issues they are aware of
to be an important issue, but also carers might be able to and they are prepared to mention.
provide professionals with valuable information. We included a heterogeneous sample of 91 partici-
pants. Although this is in accordance with the concept
map protocol, this number is relatively low for analysis
Models for Understanding Adherence
of between-group differences. However, differences were
Our results correspond with the Health Belief Model, of- significant even with this low numbers per group.
ten used to explain adherence behavior.48 According to Patients were selected if they had been clinically insta-
this model, individuals’ readiness to take action depends ble for some period of time within the previous year. This
on their ‘‘perceived seriousness and susceptibility of inclusion criterion might have influenced our results be-
illness’’ (such as belief in the accuracy of the diagnosis cause these patients may have stressed the importance of
and subjective vulnerability to relapse) and ‘‘perceived factors that negatively influence medication adherence.
benefits and barriers of medication use.’’ This is reflected
in the themes insight, efficacy of medication, side effects,
Conclusion
and medication attitudes. These themes demonstrate
patients’ considerations concerning advantages and In conclusion, this study has learned that concept map-
disadvantages of medication use. Contrary to the Health ping is a useful tool in exploring relevant issues for
792
 Medication Adherence in Schizophrenia

patients’ decision to use or not use prescribed antipsy- Mazzi, Michela Nosè, Mirella Ruggeri, and Marta
chotic medication. The findings suggest that patients, Solfa. We also like to thank Carin Meijer, Emile
carers, and professionals were able to identify and weigh Barkhof, and Udo Nabitz for their contributions to
up the factors that influence treatment adherence. Our this article.
findings provide a comprehensive overview of all relevant
issues and how they relate to one another. Clusters could
be organized into 5 clinically relevant themes: efficacy of
medication, external factors, insight, side effects, and References
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