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INTRODUCTION

The aim of this dissertation is to explore the factors affecting concordance with prescribed antipsychotic medications. The rationale for selecting this topic is derived from personal working experience with mental health service users. Having worked as a nursing assistant for the past eight years on acute admissions wards and as a student nurse for the past three years it was observed that a large proportion of compulsory re-hospitalisation under the Mental Health Act 1983 occurs due to relapse of mental illness as a result of non- concordance with medications, particularly service users with a diagnosis of schizophrenia. This led to believe that concordance with antipsychotic medications plays a crucial role in managing psychosis as it positively contributes towards the effective management of the illness in the community. In support to this view, Gray et al (2002a) assert that prophylactic use of antipsychotic medication reduces the risk of relapse among individuals with schizophrenia and non-concordance with medication has the potential for frequent re-hospitalisations. This has been recognised as the revolving door syndrome. During most mental health placements it was noted that non-concordance with medication has become significant, as this has been identified as a risk factor within the risk assessment checklist. Furthermore, despite the well-documented therapeutic effect of antipsychotic medications, some patients are reluctant to accept treatments and some may even wish to cease taking medications altogether. Therefore, this empirical knowledge has reinforced the desire to examine the factors associated with non-concordance with antipsychotic medications.

According to Brimblecombe et al (2005) medication is one of the major therapeutic tools available to help people with schizophrenia. There is also growing evidence that schizophrenia can be treated effectively with a range of psychological and social interventions together with antipsychotic medications. Norman & Ryrie (2004) emphasised that antipsychotic medication has been the mainstay of treatment for schizophrenia since the 1950s when it was discovered that the dopamine antagonist haloperidol and chlorpromazine exerted antipsychotic effects. The National Institute for Clinical Excellence (NICE) (2002) recommends that atypical antipsychotic drugs such as amisulpride, aripiprazole , olanzapine, quetiapine or risperidone must be considered in the choice of first-line treatments for individuals with newly diagnosed schizophrenia or to promote recovery for those who have experienced unacceptable side-effects on conventional antipsychotics, as atypical antipsychotics appear to have less extrapyramidal symptoms (side effects) than the conventional antipsychotics such as haloperidol and chlorpromazine.

The care and treatment of individuals with schizophrenia have advanced considerably over the past ten years, since the introduction of atypical antipsychotics and medication continues to be the first line treatment for schizophrenia (Walker & MacAulay, 2005). However, Gray et al (2002b) claim that despite the effectiveness of these atypical antipsychotic drugs, non- concordance with prescribed antipsychotic medications is observed in around 50% of people with schizophrenia and is a major preventable cause of psychiatric morbidity. In addition, Mitchell & Selmes (2007) claim that over the course of a year, about 75% of patients will discontinue prescribed antipsychotic medications, often coming to the decision themselves and without informing a health professional. According to Gray et al (2006) relapse rates is five times higher among individuals with schizophrenia, who are non-concordance with medication compared with concordance. Non-concordance during acute treatment of psychosis leads to chronic symptomswhereas non-concordance after remission increases the risk ofrelapse and both may have serious consequences; re-hospitalisation (Hamer & Haddad, 2007). Furthermore, the impacts of non-concordance with medication not only affect the individuals with schizophrenia, as each relapse causes a stepping down of cognitive functioning which is rarely retrieved but also their carers and the costs of treatments (Institute, 2007).

To facilitate this project as a literature review, an analysis of secondary sources only will be use. Secondary sources were mainly obtained from nursing journals such as Nursing-Standard, Nursing-Times, Advances in Psychiatric Treatment, Mental health practice, Schizophrenia Bulletin and The British Journal of Psychiatry, containing the key words: schizophrenia, oral antipsychotic, medication management and non-concordance. An Internet search of Google was also done with the same keywords to access any relevant documents. To address the factors affecting concordance with prescribed antipsychotic medications, these will be divided into patient-related factors, medication-related factors and clinician-related factors.

LITERATURE REVIEW

According to White (2007) schizophrenia is a debilitating psychiatric disorder characterised by a range of positive and negative symptoms and these symptoms were first described in detail by the British neurologist Hughlings-Jackson in the late 1800s. There is no physical test for schizophrenia rather it is diagnosed by the presence of certain positive and negative symptoms over a period of time (Brennan, 2001). According to Issacs (2006) the neurotransmitter hypothesis suggests that the dopamine over activity in the mesolimbic dopamine pathway, which is between the midbrain, is thought to cause the positive symptoms of schizophrenia and dopamine under activity in the mesocortical dopamine pathway is thought to result in the negative symptoms of schizophrenia. Positive symptoms represent a distortion of normal experience, such as delusions, hallucinations and thought disorder, whereas negative symptoms represent a loss or dimming of normal function and social norm, such as avoidance of social interactions (Baker, 2003).

There are different types of schizophrenia such as paranoid, disorganised, catatonic, undifferentiated and residual (Issacs, 2006). However, Gillam (2002) claimed that the exact causes of schizophrenia remain unclear but genetic, environmental and social factors are all thought to influence its development. The risk for a child to develop schizophrenia is 46%, if both parents have the disorder (Kirk et al, 2006). Women who have certain viral illnesses during their pregnancy may be at a greater risk of giving birth to children who later develop schizophrenia and the 1957 influenza A2 epidemics in England resulted in an increase in schizophrenia in the offspring of women who developed this flu during their pregnancy (Frankenburg, 2007).

1 in 100 UK populations will develop schizophrenia in their lifetime and the world prevalence is about 2-4 in 1000, as it affects men and women equally (Rethink, 2008). However, the onset in men is about five years earlier than women with the peak age of incidence is between 16 and 25 and the presentation of the illness varies tremendously, not only between individuals, but also within the same individual at different stages of their illness (Magorrian, 2007). Schizophrenia seems to be more common in city areas and in some ethnic minority groups and premature mortality in people with schizophrenia is 2 to 3 times higher than that in the general population (Royal college of Psychiatrists 2008). The premature mortality might be due to poorer health care, physical health, unhealthy lifestyles and people with schizophrenia may be at greater risk of type 2 diabetes as a result of antipsychotic medications (Nash, 2005). Moreover, according to WHO (2008) schizophrenia is a treatable disorder but many individuals remain untreated regardless of effective treatments.

There has been an unresolved debate about how best to define patients' engagement with medications and until the 1980s most work on patient engagement with medications regimes was described as compliance (Norman & Ryrie, 2004). The term compliance is often used interchangeably with adherence or concordance (Snelgrove, 2005).

According to Kikkert (2006) the term compliance has fallen out of favour in clinical practice because it carries an assumption that patients are the passive recipients of clinicians and implies unquestioning obedience with no opportunity for patients' choice. To add to the complexity of this term, patients can be intentionally or unintentionally non-compliant such as a deliberate decision not to comply with treatment and patients may have misunderstood the guidance that they have been given or unable to open the medication container. Velligan et al (2006) claimed that in recent years there has been a shift from this paternalistic model of doctor-patient interactions with the consequent preference for the use of the term adherence. However, while adherence emphasises negotiation between clinician and patient, it still implies a degree of passivity and obedience (Snelgrove, 2005).

Gray et al (2002b) assert that concordance may be a more acceptable term as it suggests a collaborative process of decision-making regarding medications regimes and acknowledges the importance of the two-way communication. The NHS Plan (2000) emphasises the importance of placing patients at the centre of services and the transformation of patients into consumers of the health service has changed the context of health care, as patients are expected to become more active and informed about their treatments (Jasper, 2006). Murray et al (2007) emphasise that shared decision-making between clinicians and patients has the potential to improve concordance with treatment plans. Furthermore, The Chief Nursing Officer's review of mental health nursing (2006) recommends that building and maintaining positive interpersonal relationships with service users is essential to successful mental health nursing practice and person-centred values is helpful in building positive relationships.

This indicates that by not agreeing to health professionals' advice patients may be labelled as non-compliant. Nonetheless, compliance could also be problematic, for example if patients continue to take medication obediently, although it is causing adverse side effects. However, from the empirical knowledge the term compliance is still being used in clinical settings despite the paternalistic conception. Therefore, the term concordance is favoured here as it promotes the idea that medication treatment should be a collaborative process between clinicians and patients, which emphasises the patients' rights. Ultimately, the term concordance corresponds with the current ethos of modern mental health care set out in the National Service Framework (1999), the NHS Plan (2000) and the Chief Nursing Officer's review of mental health nursing (2006), which is concerned with working in partnership with patients and carers. However, according to the term concordance patients have the right to make treatment decisions, for example, stopping medication even if health professionals do not agree with that decision.

For decades researchers have worked to explain the causes of non-concordance with medication unfortunately there have been no valid way of measuring concordance (Velligan et al, 2006). Rates of concordance have been measured by using the subjective and objective methods. Subjective method includes patients` self report and direct interviews, although this method is less expensive, it tends to overestimate the degree of concordance, as patients may not admit non-concordance (Gray et al, 2002b). Snelgrove (2005) claims that objective method such as blood and urine analysis also pose problems as they do not account for individual metabolism and do not reflect inconsistencies in concordance over time. Moreover, from empirical knowledge blood test is effective in monitoring concordance with mood stabilisers such as lithium, but for schizophrenia it is the manifestation of symptoms can support the evidence of non-concordance. According to Gray et al (2002b) pill counts are more reliable, but it is impossible to tell whether patients have actually ingested the medication. Even expensive objective method such as electronic monitoring which records every occasion that a pill bottles is opened can also be problematic when patients choose not to swallow the medication that was removed or do not replace the caps and electronic prescribing is still fallible, just because medication is available does not mean that it is taken (Velligan et al, 2006).

One of the major clinical problems in the treatment of people with schizophrenia is partial or complete non-concordance with medication and this limits the clinical effectiveness of the prescribed medications (Kikkert et al, 2006). Antipsychotics medication can only be effective if they are taken continuously over a sustained period of time (Norman & Ryrie, 2004). Urquhart (2005) claims that partially concordant patients can be difficult to identify because they do not actively refuse to take their medication but the dosage deviations for different reasons and this may only be detected when psychotic symptoms re-emerge. Partial concordance creates significant problems for the treating physician as it creates difficulties in determining whether medications are working adequately, dosing is appropriate or concomitant medication is needed (Velligan et al, 2006). Therefore, this indicates that medication or dosage changes and the addition of concomitant medications are more likely to occur among patients who are not fully concordant with prescribed medications.

Non-concordance with prescribed medication is believed to be a significant factor to increasethe probability of relapse in patients with schizophrenia and relapse is one of the most costly aspects of schizophrenia (Almond et al, 2004). Knapp et al (2004) undertook a study of 658 patients receiving antipsychotics medication of whom 20% reported non-concordance with prescribed medication and concluded that non-concordance was one of the most significant factors in increasing service costs, predicting an excess annual cost per patient of £2500 for inpatient services and an overall additional cost of £5000 for total service use. In addition, Almond et al (2004) estimated that costs for relapse cases are four times higherthan those for non-relapse cases. Therefore, these two studies show that relapse in patients with schizophrenia as a result of non-concordance isa major factor in generating high hospitalisation rates and costs. This implies that patients who do not concord with their medication are likely to requiremore treatment and support from a range of services and given the high costs associated with relapse non-concordance is a key factor in the use ofin-patient and external services.

Antipsychotic medication has proven efficacy in the treatment of schizophrenia and the prevention of relapse. In spite of vast evidence that antipsychotics can be effective in treating the symptoms of schizophrenia, almost 90% of patients will relapse within the first five years of treatment following an acute episode and in general the illness has a tendency to recur or become chronic (Velligan et al, 2006). According to White et al (2007) non-concordance with drug therapy is common in schizophrenia; approximately 50% of patients are non-concordant within one year and 75% within two years after being discharged from hospital. Such high rates of non-concordance with medication may initially seem alarming (Gray et al, 2002b). However, it is similar with other conditions such as asthma where maintenance treatment is required. A study of concordance with asthma medication conducted by Newell (2006) estimated that 70 % of asthma patients in the UK are non-concordant with medication and the levels of non-concordance in long-term conditions, such as asthma are known to be high as many asthma sufferers will only take medicine when they feel they need it rather than as instructed by clinicians. Therefore, considering the Newell (2006) findings it can be argued that the rates of non-concordance with antipsychotics are not significantly different than those on non-psychiatric medications and the myth that non-concordance with medication is more common among mental disorders as compared to physical disorders needs to be dispelled.

Several factors have been shown to increase the chance of relapse but probably the single most important cause of relapse is the discontinuation of effective antipsychotic medication regime. A large number of factors influence non-concordance with prescribed antipsychotic medications, however Gray et al (2002b) have identified the main factors as impaired judgement, negative beliefs about treatment, poor worker-user relationship and the side-effects of medication. Additionally, Kikkert et al (2006) conducted a study in four European countries exploring medication adherence in schizophrenia and identified insight, beliefs about treatment, side effects and treatment efficacy as factors that influence concordancewith medication in patients with schizophrenia.

Urquhart (2005) suggests that the problem of non-concordance may be more prevalent among those with schizophrenia due to its nature, for example, lack of insight. Magorrian (2007) claimed that non-concordance with medication is often linked to the person's level of insight into his or her illness and lack of insight is a frequent concomitant of psychosis. In schizophrenia, insight has been defined as an awareness of illness and an ability to recognise symptoms as part of an illness (Gray et al, 2002b)

According to Surguladze & David (1999) between 50% and 80% of patients diagnosed with schizophrenia have been shown to be partially or totally lacking insight into the presence of their mental disorder and these individuals are often difficult to engage with treatments due to impaired insight. Recent conceptualisation has formulated insight as a continuum representing the combination of three factors; awareness of illness, need for treatment and attribution of symptoms. Lack of insight is continuously problematic but an emotional element can be associated with denial of symptoms or rejection of treatment at key points in the illness (Byrne, 2000). Mitchell & Selmes (2007) claim that having a perception about the illness and the knowledge of medications are the key factors of concordance in mental health and patients who understand the purpose of the prescription are twice more likely to collect it than those who do not understand.

A study by Cuesta et al (2000) reported that patients suffering from schizophreniashowed poorer insight than patients with affective disorders. Cuesta et al (2000) findings demonstrated that the severe disturbances of insight persisted over the time and the level of insight was not significantly improved in patients suffering from functional psychosis as between 29% to 49% of these patients continued to have fair to poor insight at the follow up assessment. This is consistent with the findings of Kikkert et al (2006), where poor insight was a strong predictor of non-concordance with medication. In contrast, Tait et al (2003) conducted a study to examine changes in insight and symptoms of psychosis on fifty participantswho met the ICD—10 diagnostic criteria for schizophrenia. The participants were interviewed and insight was measured duringacute psychosis using the Insight Scale with the score 0- 12 and all the participants were reinterviewed at 3 and6 months following the initial interview. Tait et al (2003) findings indicated that duringthe acute episode, 48% of participants scored 9-12 on the InsightScale and the majority of participants (63%) werein the 9-12 range of scores. The study of Tait et al (2003) clearly indicated that level of insight was high among many participants.

In considering the findings of both Cuesta et al (2000) and Tait et al (2003) it appears that some patients with psychosis are unaware of their illnesses and insight is a strong predictor of concordance with medications and a good indicator of prognosis. However, evidence for a relationship between insight and concordance with treatment is inconclusive as the discrepancies found between the two studies might be due to the methodological factors, such as selection of participants. In both studies all the participants had a diagnosis of schizophrenia and all of them gave informed consent to enter the study. According to Appelbaum (2006) several studies in America regarding the decisional-capacity of patients with schizophrenia to consent or participation to research have raise some concerns due to the cognitive impairments associated with schizophrenia and using the MacArthur Competence Assessment Tool for Clinical Research clearly indicated that patients with schizophrenia do lack understanding and reasoning of research ethics.

McCann & Clark (2005) emphasise that antipsychotic medications some of which have a sedating effect can also have an impact on the cognitive processes, such as illogical thinking and this can hinder the quality of responses.

Moser et al (2005) argued that some studies have shown that a high percentage of individuals with schizophrenia have adequate decisional capacity to consent to research participation, however in a medication-free schizophrenia research, participants did not show a major decline in decisional capacity. In addition, Jeste et al (2006) claimed that there is a risk in assuming that decision-making capacity of individuals with schizophrenia is always impaired, when they are capable to make autonomous decisions and in considering their decision-making capacity as permanently impaired by virtue of their diagnosis. Consequently, in order to investigate factors associated with schizophrenia, it can be argued that only individuals with schizophrenia can provide the answers of their experiences and protecting vulnerable populations from research activity can also exclude them from its benefits.

According to Gerrish & Lacey (2006) there two key concepts that concern the quality of a research: validity and reliability. Roberts et al (2006) define reliability as how far a particular test will produce similar results in different circumstances, whereas validity is to ascertain the methods are actually measuring what is intended to measure. Both Cuesta et al (2000) and Tait et al (2003) had used structured interviews to gather the data and have chosen a quantitative approach. Structured interview provides the opportunities to change the words but not the meaning of the questions thus, Parahoo (2006) claimed that validity is enhanced because participants can be helped to understand the questions and interviewers can ask for clarifications and probe for further responses, if necessary and since all the questions are ideally asked in the same way, structured interview has a high degree of reliability.

It seems that both Cuesta et al (2000) and Tait et al (2003) have adopted the appropriate approach to their research, as quantitative research is the conduct of investigations primarily using numerical methods. It infers that to examine correlations between insight and service engagement qualitative approach could not have produced the same data in this area of study. Moreover, in both studies purposive sampling were used as all the participants had a diagnosis of schizophrenia. According to Polit & Beck (2006) all participants in a phenomenological study must have experienced the phenomenon under study and must be able to articulate what is like to have lived the experience.

Johnson & Orrell (1996 cited in Surguladze & David, 1999 P 166) have argued that some patients may have their own explanations of their illnesses, such as religion or cultural beliefs which may not coincide with the Western medical model of mental disorders and this can be even more complicated if one tries directly to impose the models of insight on patients from non-Western cultures. Gamble & Brennan (2006) claimed that different cultures in England perceive mental illness in different ways and this can have an impact on treatments as some cultures rather seek help from religious leaders than mental health services. Alternatively, religion or spiritual beliefs in the Western culture can have a positive impact on concordance with medication, as religious individuals with schizophrenia have a better social support compare to non-religious individuals with schizophrenia (Borras et al, 2007). Therefore, it can be put forward that awareness of illness is a crucial factor in the motivation to receive pharmacological treatment. Both cultures and religion can have a positive and negative influence on concordance with antipsychotics.

Patients can have different levels of awareness into their illness and they may consciously or unconsciously avoid acknowledging that they are suffering from mental health problems because of their reluctance to bear the stigma of mentally ill (Surguladze & David, 1999). Byrne (2000, p65) defined `stigma as a sign of disgrace or discredit, which sets a person apart from others and the stigma of mental illness although more often related to context than to a person's appearance, remains a powerful negative attribute in all-social relations`. Stigma of mental illness has become an indication for unpleasant experiences, such as bringing shame to the family or social exclusion. According to Phillips et al (2002), in some parts of china, schizophrenia is still considered as a punishmentfor an ancestor's misbehaviour or for the family's currentmisconduct and the effect of stigmais greater if the patient had more prominent positive symptoms or highly educated. Moreover, a study by Lee et al (2005) concluded that 60 % out of 320 patients with schizophrenia had experienced interpersonal stigma from p arents, siblings or close rel atives. This indicates that people with schizophrenia are more likely to experience stigma from family members than the general public.

Having a diagnosis of schizophrenia does not only affect one's health but also carries all the prejudice, discrimination and social exclusion, for example many individuals are attacked on the streets, rejection in the society and denial of employments because they were known to have mental health problems (Gamble & Brennan, 2006). According to Byrne (2000) in two identical UK public opinion surveys, 80% of participants claimed that most people are embarrassed by mentally ill people and about 30% agreeing `I am embarrassed by mentally ill persons`.

There is also evidence that supports the concepts of stereotyping of mental illness. The power and influence of the media on mental illness has been a key issue of debate over many years as people with schizophrenia are frequently portrayed as violent and dangerous. In contrast, people with schizophrenia are more likely to be dangerous to themselves than to others, while the greater danger to the public is posed by people without mental health problems and people with mental health problems are six times more likely than the general public to be the victims of murder (Stickley & Felton, 2006). Moreover, Gamble & Brennan (2006) claimed that when the boxing champion Frank Bruno was admitted to hospital in 2003, one of the newspaper headlines was `Bonkers Bruno locked up`. This indicates that stigma has the grave potential to cause reluctance to seek treatments and this can be detrimental to the person's health. Therefore, as a mental health clinician, it will be vital to assist people with mental health problems to rebuild their lives and this requires moving beyond the traditional focus on symptoms and medication by exploring alternatives in reducing stigma of mental health that avert people from social inclusion.

It has been predicted that families with high expressed emotion compared to low expressed emotion can contribute towards the relapse rate in symptoms of schizophrenia and this can also be a triggering factor for non-concordance with medication. High expressed emotion carers appear to perceive their caring situation as more stressful and this could be conceptualised as a catastrophic appraisal of the role of caring (Raune et al 2004). Kuipers et al (2006) identifies the components of expressed emotion as emotional over-involvement, hostility, critical comments, warmth and positive remarks. A study by Kuipers et al (2006) indicates that patients whose carers showed high expressed emotion had considerably higher levels of anxiety and lower self-esteem due to the components of expressed emotion. However, a significant amount of data from western cultures suggests that high expressed emotion subjects who were not on medication are three times likely to relapse than those who were on medication (Bhugra & McKenzie, 2003). This clearly signifies that despite being concordant, high expressed emotion subjects are vulnerable to relapse.

The interactions between patient and the carers are crucial, especially cross-culturally as in some cultures for example, in some parts of India, emotional over-involvement is the norm and if carers do not show emotional over-involvement, this can be seen as lack of care (Bhugra & McKenzie, 2003). Hashemi & Cochrane (1999) conducted a study in UK on expressed emotion and they observed that 80% of the British Pakistani, 45% of the White and 30% of the British Sikh families exhibited high levels of expressed emotion and emotional over-involvement was notably higher among the British Pakistani group. The findings concluded that White patients with high expressed emotion relatives were significantly more likely to relapse than those from low expressed emotion families, whereas for both Asian groups high expressed emotion did not predict relapse.

The study of Hashemi & Cochrane (1999) also indicated that that Pakistani families in the UK were more likely to be rated as high expressed emotion than White families, indicating that components such as emotional over-involvement may be cultural rather than pathogenic traits. Conversely, low expressed emotion families who are not over-anxious in their response to the patient's illness may tend to perceive stigma in less threatening ways whereas, families with high expressed emotion, who respond to the patient's illness in a highly anxious may experience stigma more intensely (Phillips et al 2002). Therefore, it appears that family members' levels of expressed emotion could influence their perception and response to stigma of mental health and concordance with medication is essential for patients irrespective of the expressed emotion status in the family. Thus, family interventions need to improve in order to lower the levels of anxiety and to increase self-esteem among families with high expressed emotion. As a clinician it will be vital to acknowledge the cultural aspect of expressed emotion status in the family to facilitate concordance with medication.

There is overwhelming evidence for patients with schizophrenia, who misuse illicit drugs and alcohol to have an increased rate of re-hospitalisation (Sokya, 2000). According to Barnes et al (2006) the higher relapse rate in people with established schizophrenia who usesubstances may be partially explained by non-concordant tothe medication regimen. Evidence suggests that the substance used most frequently by people with schizophrenia is cannabis (Gamble & Brennan, 2006). Arseneault et al (2004) emphasise that rates of cannabis use in UK are higher among people with schizophrenia than among the general population and patients detained under the MHA (1983) have even higher rates of lifetime use of cannabis. Substance misuse in schizophrenia may be explained as a form of self-medication to alleviate the symptoms of schizophrenia, to improve the side effects of antipsychotics and to respond to social pressures (Sokya, 2000).

There has been little evidence to support the self-medication hypothesis despite its popularity with users and in contrast, substance misuse can aggravate the symptoms of schizophrenia and can also trigger psychotic episode particularly in people with a pre-existing vulnerability (Verdoux et al, 2003, cited in Parker & Lewis 2006). Moreover, Abou-Saleh (2004) claims that substance misuse in schizophrenia is also associated with high rates of criminal activities, homicides, suicides and blood-borne infections such as, HIV, hepatitis B and C. Therefore, it appears that substance misuse is more common among people with schizophrenia and it is a significant risk factor for non-concordance with medication, as it is used as a coping mechanism. However, the controversy remains as to whether substance misuse causes schizophrenia or schizophrenia leads to substance misuse and despite the adverse consequences of cannabis use in UK, cannabis has been downgraded from class B to class C drug because it was considered less harmful than other illicit substances.

The high prevalence of smoking (tobacco) is strongly associated with schizophrenia, as it is considered that nicotine acts as a form of self-medication despite the harmful effect on long-term health (Barnes et al, 2006). (Kumari 2005, cited in www.mentalheathcare.org.uk, 2007) has confirmed that smoking can cause a reduction in the negative symptoms of schizophrenia, as it is thought that nicotine has the ability to raise the dopamine level in the mesocortical dopamine pathway. However, there is no evidence that nicotine has any effect on the positive symptoms of schizophrenia but it can reduce some side effects of antipsychotics such as rigidity of movement (Kumari 2005). On the other hand, Kelly & McCreadie (2000) argued that although smokers exhibited significantly less neuroleptic-induced Parkinsonism, they required twice the prescribed neuroleptics daily dose of non-smokers to achieve the same therapeutic effect, as smoking can decrease the metabolism of antipsychotic medications. This indicates that there is no clear-cut theory to explain the association of self-medication and schizophrenia and nicotine should not be considered as a replacement for prescribed antipsychotics. Besides, it appears that patients with schizophrenia who smoke require larger doses of antipsychotics than non-smokers to achieve the same therapeutic effect and this may cause more reluctance in concordant with medication. Other argument, which can be put forward, is `what about the patients who were already smoking prior to mental health problems`.

DOH (2008) emphasises that if a competent adult makes a voluntary and informed decision to refuse treatment, this decision must be respected even if this will clearly be detrimental to his or her health, except in circumstances defined by the Mental Health Act (MHA) 1983. Someone who is subject to detention under the (MHA) 1983 can be treated without his or her consent but it does not give the power to treat unrelated physical disorders without consent. Wilson (2007) estimates that there were 25,740 admissions under the (MHA) 1983 in England during 2005-2006 but it is difficult to say how many of those detained had a diagnosis of schizophrenia because the approved doctor is only required to detail the category of the illness and not a specific diagnosis under the medical recommendation. On one hand, enforced treatment undermines the client autonomy and this may lead patients to rebel by not concordant with medication when discharged and on the other hand, it can represent an opportunity for therapeutic engagement with patients who may not otherwise be in contact with the helping services (Bliss & Ricketts 2005). Therefore, it can be suggested that non-concordance with medication not only increased the risk of relapse but also more frequent use of compulsory treatment.

This study has several limitations. First, the relatively smallsample size might have limited the power to detect importantassociations of clinical significance

The participants in the present study were located in mentalhealth facilities within urban and inner-city settings

Although this is representative of the trajectories of psychosisin general

Future research should try to evaluate possible pharmacological and psychosocial treatment approaches.

Motivational interview ing aimed at reduc ing misuse is a goodexample of a psychological treatment whose effect is mediatedby explicitly reduc ing a known risk factor. Similar techniqueshave been used in attempts to improve outcomes by enhanc inga known protective factor, antipsychotic drug treatment

It is a matter of debate whether

The conflicting results have been attributed to factors such as sample composition

Kikkert et al (2006) although research hasimproved our knowledge, adherence rates do not seem to havechanged in the last 4 decades

MHNs have a natural central role in ensuring that

medication is managed effectively.

A possible explanation is that insightmay not be the only predictor of engagement or adherence

Recent advances in medication treatments for patients with schizophrenia have included the development of a number of atypical antipsychotics that produce fewer extra pyramidal side effects and may have a broader range of efficacy than conventional antipsychotics (1). It has been widely assumed that the introduction of these second-generation antipsychotics would lead to improved treatment adherence for patients with schizophrenia. Although it may be that the improved side effect profiles of the novel antipsychotics have increased patients' willingness to take medications, little evidence exists that treatment adherence has been significantly improved by these antipsychotics. The continued decline in rates of depot neuroleptic use may in part reflect a belief that atypical antipsychotic medications have solved the non-adherence problem.

The mental health nurse must be aware of the ‘psychological'

influences surrounding prescribing with drug company

marketing as a potential to influence their decision-making

(Bailey 2002). If mental health nurses are to be truly effective

in improving the care of patients with particular regard to medication,

they need to liaise effectively with the pharmaceutical

industry and must become more aware of the issues surrounding

relationships with the pharmaceutical industry, and

this is usually done through representatives of companies

Implications for practice, Walker H, MacAulay K (2005) Assessment of the side effects of antipsychotic medication. Nursing Standard. 19, 40, 41-46

  • It is important to assess the side effects of antipsychotic medication on patients in hospital.
  • Nurses should be more involved in monitoring the side effects of antipsychotic medication.
  • Patients may demonstrate greater involvement in managing their condition due to an increased awareness of side effect profiles.
  • Better collaboration between staff and patients is needed in identifying the side effects of antipsychotic medication

IMPLICATIONS FOR PRACTICE

Newell K (2006) Concordance with asthma medication: the nurse's role. Nursing Standard. 20, 26, p31-33.

One of the reasons patients do not take their medication is because they are worried about side effects (Bender 2002); another is that their initial concerns may not have been fully addressed by health professionals (Carter et al 2003

Peter Byrne (2000) `Stigma of mental illness and ways of diminishing it`. Advances in Psychiatric Treatment (2000), vol. 6, (1): pp. 65-72

Robert Chaplin (2007) How can clinicians help patients to take their psychotropic medication? Advances in Psychiatric Treatment (2007), vol. 13, (5): p347-349

Alex J. Mitchell & Thomas Selmes (2007) Why don't patients attend their appointments? Maintaining engagement with psychiatric services

Advances in Psychiatric Treatment (2007), vol. 13, (6): p423-434

COHEN et al. vol179 (2):(2001) P167-171

David J. Moser et al (2005) Informed Consent in Medication-Free Schizophrenia Research, (Am J Psychiatry 2005; 162:1209-1211) , http://ajp.psychiatryonline.org

Borras et al, 2007, Religious Beliefs in Schizophrenia: Their Relevance for Adherence to Treatment, Schizophrenia Bulletin vol. 33 no. 5 pp. 1238-1246, 2007

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These include raised prolactin levels (hyperprolactinaemia).

Hyperprolactinaemia is an equally distressing but often unrecognised or underreported side effect. In women, it results in abnormal menstruation and infertility. In males it causes sexual dysfunction. In both men and women it can cause abnormal production of breast milk

Moreover, sexual dysfunctions may diminish a persons quality of life, worsen self-esteem and cause relationship problems.

Haddad, P. (2005) Weight change with atypical antipsychotics in the treatment of schizophrenia. Journal of Psychopharmacology, 19 (6), p16 -27

Weight gain is a common complication of antipsychotic treatment.Its consequences include decreased self-esteem,reduced quality of life, reduced adherence with medication and increased morbidity and mortality. Most studiesthat assess weight change are short term. Amongthe atypicals mean weight gain is greatest with olanzapine and clozapine and least with aripiprazole andziprasidone. Mean weight change obscures themarked individual variation in weight change that occurs duringantipsychotic treatment i.e. irrespective ofthe antipsychotic, some subjects lose weight,some maintain their weight and some gain weight. In severallong-term naturalistic studies (>6 months)mean weight gain is less marked than in randomisedcontrolled trials of a shorter or comparable duration. Thismay reflect selective prescribing, the effectof weight management interventions and differences in the statistical analysis employed. With most antipsychoticsweight stabilizes in the short to medium termbut with clozapine it may continue beyond the first year. With some drugs clinical improvement is associatedwith short-term weight gain. Predictors of long-termweight gain include lower body mass index, increased appetite and rapid initial weight increase. Weightgain is greater in first onset patients dueto the lack of prior antipsychotic exposure and associated weightgain. The potential for weight gain should bediscussed with patients before starting antipsychotictreatment and weight monitored regularly during treatment. Itmay be possible to predict weight gain beforean antipsychotic is started or early on in treatmentenabling high-risk patients to receive more intensive strategiesto reduce weight gain.

http://www.rethink.org/living_with_mental_illness/treatment_and_therapy/medication/antipsychotics/side_effects_of.html

Two studies have shown that, when asked, patients indicate that, subjectively, side effects have a significant impact on compliance

Despite the well-documented therapeutic effect of medication, there are many side effects associated with the use of antipsychotic drugs, which are the primary cause of non-concordance among psychiatric patients

MacAulay & walker (2005) claims that the primary cause of non-concordance among patients with schizophrenia is due to a range of unwanted side effects associated with antipsychotic medications. `One of the reasons patients do not take their medication is because they are worried about side effects` (Bender 2002, cited in Newell 2006 p32). Moreover, Houltram & Scanlan (2004) asserts that extrapyramidal side effects among people with schizophrenia are perhaps the most difficult side effects to live with and there is a general misunderstanding that movement disorders are part of the disease rather than the treatment. In a UK survey of callers to a national mental health telephone helpline, distressing side-effects were strongly correlated with low treatment satisfaction (Fakhoury et al, 2001 cited in Hamer & Haddad, 2007 P66). According to Mortimer (2005) antipsychotics as with any medications have a range of side effects and the most common side effects such as movement disorders or extrapyramidal side effects , sedation, sexual dysfunction and weight gain are the major cause to hinder concordance with antipsychotics.

RETHINK (2008) claims the common movement disorders includes (Dystonia); muscle spasms usually of the face neck, shoulders and upper limbs, (Akathisia); fidgety movements of the legs which may be accompanied by a strong sense of inner restlessness and bad feelings and thoughts (Dysphoria), (parkinsonian movement disorders); stiffness, tremor, rigidity, decreased movements, speech and expression (Akinesia) and

(Tardive dyskinesia); Involuntary movements, frequently affecting the orofacial region such as the lips, tongue and jaw but can also include head, neck and hands involuntary movements known as acute dyskinesia. In addition to movement disorders, Brennan (2001) identifies the possible side effects of antipsychotics as, anticholinergic effects; drowsiness, dry mouth, blurred vision, difficulty passing water/constipation and rapid heart beat and these side effects are also called antimuscarinic side effects as antipsychotics affect a chemical in the body called acetycholine, Sensitivity reactions; rash and very easily sunburnt, particular risk with chlorpromazine, (Agranulocytosis); lowering of white blood cells; a blood disorder, which can be fatal and is mostly associated with Clozapine. According to Watson (2003), although clozapine remains the current choice of medication for treatment resistant schizophrenia, it was withdrawn when it first appeared in the 1960s due to the prevalence of agranulocytosis and in the early 1990s it was re-licensed with a requirement that regular blood tests to be undertaken. Neuroleptic malignant syndrome; a rare and potentially fatal, it begins with muscular rigidity and moves to hyperpyrexia and tachycardia, which is most commonly associated with chronic use of antipsychotic drugs and combing one antipsychotic with another increases the risk of developing the syndrome (Brennan, 2001).

The potential adverse effects of antipsychotics have a negative impact on patients, which leads to a reduced quality of life, for example the parkinsonian movement disorders can make it difficult for someone to write, wash or dress and tardive or acute dyskinesia are easily observable by others and mark the patient out as `different', hence contributing to stigma (Hamer & Haddad, 2007). This clearly indicates that despite the therapeutic effect of antipsychotic medications, they also have the potential to cause extrapyramidal symptoms, which can impaired the quality of life and make it difficult for people with schizophrenia to concord to their medication regime. However, RETHINK (2008) asserts that some extrapyramidal side effects can be treated with medication such as procyclidine, orphenadrine, clonazepam or propranolol.

Patients are more concerned with the sexual side-effectsof their medications than any other side-effect and it is well established that antipsychotics are the common cause of sexual dysfunction

sexual dysfunctionis worse in patients with schizophrenia taking antipsychotic medication compared with unmedicated patients

Sexual dysfunction is an important public health problem that affects the overall wellbeing of many people with schizophrenia. It is psychotropic drugs commonly cause.

There is an ongoing debate over whether atypical antipsychotics are more effective than typical antipsychotics in the treatment of schizophrenia

side effects of antipsychotic drugs unwanted side-effects

Because randomized controlledtrials involve carefully selected subjects who consent to extendedassessments and care under controlled conditions, significantlylower discontinuation rates are to be anticipated than in usualpractice conditions

B. Zipursky et al (2005), Course and predictors of weight gain in people with first-episode psychosis treated with olanzapine or haloperidol, The British Journal of Psychiatry (2005) 187 (6) P537-543.

The introduction of atypical antipsychotics has substantiallychanged the treatment of schizophrenia. Although atypical antipsychoticshave dramatically reduced the frequency of acute extra pyramidalsymptoms, substantial weight gain is common with many of thesemedications (Allison et al, 1999). Estimates of mean weightgain associated with atypical antipsychotics have varied greatlyand are confounded by the extent of previous antipsychotic treatment(Ganguli et al, 2001) and the statistical methodology usedto estimate weight gain from clinical trials with a significantwithdrawal rate (Allison & Casey, 2001). Typically, suchtrials estimate weight gain on an intent-to-treat basis usingthe last-observation-carried-forward (LOCF) approach. Estimatingweight gain from observed cases and study completers providescomplementary perspectives. In this study, we investigatedthe extent and time course of olanzapine- and haloperidol-associatedweight gain in the treatment of first-episode psychosis, theclinical correlates of weight gain and the association of weightgain with treatment response and adherence.

Olanzapine was associated with significantly greaterweight gain than haloperidol,

This study is unique in examining the weight gain associatedwith antipsychotic treatment in a large randomised double-blindstudy of people with first-episode psychosis and very limitedprevious exposure to antipsychotic medication

Application of the observed-casesmethodology has demonstrated that olanzapine was associatedwith a mean 2-year weight gain of 15.4 kg, whereas haloperidol-associatedmean weight gain was 7.5 kg

Some recent publications have also observed that weight gainassociated with atypical antipsychotics may correlate withclinical outcomes

  • The weight gain associated with the extended treatment of afirst episode of psychosis with either olanzapine or haloperidolis greater than has been previously estimated.
  • Olanzapineleads to a significantly greater average weight gainthan haloperidol.
  • Clinical features were not predictive of weight gain witheitherdrug, suggesting that all patients receiving these medicationsfor a first episode of psychosis are at high risk of significantweight gain. The degree of clinical improvement experiencedwith extended treatment does not appear to be meaningfullyassociated with the amount of weight gained.

Weight gain and study adherence The weight gain associated with antipsychotic medications, particularlysome atypical antipsychotics, is of concern both because ofthe potential health consequences associated with weight gainand because weight gain may affect the long-term adherenceto these medications. In this clinical trial, olanzapine-treatedparticipants were significantly more likely to complete the2-year trial despite their higher mean weight gain; haloperidol-treatedparticipants were significantly more likely to withdraw becauseof adverse events and lack of efficacy (Lieberman et al, 2003).Furthermore, BMI increases were associated with higher studyretention during the first 12 weeks of treatment for both treatmentgroups. Our data do not support the view that weight gain contributesto non-adherence in the short term. Rather, they suggest thatfor younger people with first-episode psychosis the degreeof clinical improvement may be the best predictor of adherenceto medication in the short term regardless of adverse events,including weight gain. After controlling for the effect ofclinical improvement, BMI increase (but not treatment group)remained a significant predictor of study retention. Althoughit is not known what features of olanzapine explain the higherstudy retention associated with this treatment, it may be thatthis is mediated through a mechanism that also contributesto weight gain.

In summary, we have demonstrated that the weight gain associatedwith extended treatment of a first-episode psychosis with eitherolanzapine or haloperidol is greater than has been previouslyestimated.

David Law, (2007) Physical health: how to minimise the risks faced by patients with schizophrenia P 26-28 mental health practice vol 10 no 6

Some of the newer ‘atypical' antipsychotic medications, although representing an advance in the management of SMI, may cause unpleasant side effects that may substantially increase the risk of developing conditions such as diabetes and cardiovascular disease. The side effects leading to these serious illnesses include abdominal weight gain (central obesity), reduced HDL cholesterol, raised triglyceride and fasting plasma glucose levels and raised blood pressure. Together, this cluster of symptoms is referred to as metabolic syndrome.

Weight gain is the most common concern for patients and many atypical antipsychotics have a propensity to cause weight gain.

Brian Houltram and Mike Scanlan, (2004) Care map 7: atypical antipsychotics: Extrapyramidal side effects, nursing standard vol18 no43 P39-41

They have recently been developed because of the high incidence of side effects with the older antipsychotics. As a group, they appear to be better tolerated in therapy causing fewer problems, especially extrapyramidal symptoms

Typical antipsychotic drugs work by blocking post-synaptic dopamine D2 receptors in the brain. They vary in potency, the greater the potency the greater the affinity for the D2 receptors. Low potency drugs, such as chlorpromazines which are given in higher doses, are generally less selective and thus are capable of producing more adverse effects at therapeutic doses because of interaction with other receptors. In contrast, high potency drugs, such as haloperidol, are more selective. Their adverse effects are generally due to dopamine blockade rather than to effects at other receptors

Atypical antipsychotic drugs have a novel mechanism of action. They work at various sites including highly selective D2/D3 or D4 receptors and produce selective serotonergic blockade.

All antipsychotic drugs have the potential to cause extrapyramidal symptoms. In general, the older antipsychotic drugs cause these effects more frequently than the newer (atypical) ones 

Richard Gray, Ann Marie Parr, Deborah Robson (2005) Has tardive dyskinesia disappeared? Mental health practice vol 8 no 10 P20-22All antipsychotic medicines are thought to mediate their effect through blocking dopamine receptors in the limbic region of the brain. Atypical antipsychotics differentiate themselves from typicals because they cause fewer acute extrapyramidal side effects

Mark Olfson1-3, Steven C. Marcus4, and Haya Ascher-Svanum, (2007) Treatment of Schizophrenia With Long-Acting Fluphenazine, Haloperidol, or Risperidone Schizophrenia Bulletin vol. 33 no. 6 pp. p1379-1387

Long-acting antipsychotic medication injections are thoughtto help improve medication adherence in schizophrenia

Use of depot antipsychotic medications maybe increased among African Americans11,13 and patients with substance use problems.13 are associated with a wide range of which can affect the patientin several ways


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