schizophrenia case study female

Module 11: Schizophrenia Spectrum and Other Psychotic Disorders

Case studies: schizophrenia spectrum disorders, learning objectives.

• Identify schizophrenia and psychotic disorders in case studies

Case Study: Bryant

Thirty-five-year-old Bryant was admitted to the hospital because of ritualistic behaviors, depression, and distrust. At the time of admission, prominent ritualistic behaviors and depression misled clinicians to diagnose Bryant with obsessive-compulsive disorder (OCD). Shortly after, psychotic symptoms such as disorganized thoughts and delusion of control were noticeable. He told the doctors he has not been receiving any treatment, was not on any substance or medication, and has been experiencing these symptoms for about two weeks. Throughout the course of his treatment, the doctors noticed that he developed a catatonic stupor and a respiratory infection, which was identified by respiratory symptoms, blood tests, and a chest X-ray. To treat the psychotic symptoms, catatonic stupor, and respiratory infection, risperidone, MECT, and ceftriaxone (antibiotic) were administered, and these therapies proved to be dramatically effective. [1]

Case Study: Shanta

Shanta, a 28-year-old female with no prior psychiatric hospitalizations, was sent to the local emergency room after her parents called 911; they were concerned that their daughter had become uncharacteristically irritable and paranoid. The family observed that she had stopped interacting with them and had been spending long periods of time alone in her bedroom. For over a month, she had not attended school at the local community college. Her parents finally made the decision to call the police when she started to threaten them with a knife, and the police took her to the local emergency room for a crisis evaluation.

Following the administration of the medication, she tried to escape from the emergency room, contending that the hospital staff was planning to kill her. She eventually slept and when she awoke, she told the crisis worker that she had been diagnosed with attention-deficit/hyperactive disorder (ADHD) a month ago. At the time of this ADHD diagnosis, she was started on 30 mg of a stimulant to be taken every morning in order to help her focus and become less stressed over the possibility of poor school performance.

After two weeks, the provider increased her dosage to 60 mg every morning and also started her on dextroamphetamine sulfate tablets (10 mg) that she took daily in the afternoon in order to improve her concentration and ability to study. Shanta claimed that she might have taken up to three dextroamphetamine sulfate tablets over the past three days because she was worried about falling asleep and being unable to adequately prepare for an examination.

Prior to the ADHD diagnosis, the patient had no known psychiatric or substance abuse history. The urine toxicology screen taken upon admission to the emergency department was positive only for amphetamines. There was no family history of psychotic or mood disorders, and she didn’t exhibit any depressive, manic, or hypomanic symptoms.

The stimulant medications were discontinued by the hospital upon admission to the emergency department and the patient was treated with an atypical antipsychotic. She tolerated the medications well, started psychotherapy sessions, and was released five days later. On the day of discharge, there were no delusions or hallucinations reported. She was referred to the local mental health center for aftercare follow-up with a psychiatrist. [2]

Another powerful case study example is that of Elyn R. Saks, the associate dean and Orrin B. Evans professor of law, psychology, and psychiatry and the behavioral sciences at the University of Southern California Gould Law School.

Saks began experiencing symptoms of mental illness at eight years old, but she had her first full-blown episode when studying as a Marshall scholar at Oxford University. Another breakdown happened while Saks was a student at Yale Law School, after which she “ended up forcibly restrained and forced to take anti-psychotic medication.” Her scholarly efforts thus include taking a careful look at the destructive impact force and coercion can have on the lives of people with psychiatric illnesses, whether during treatment or perhaps in interactions with police; the Saks Institute, for example, co-hosted a conference examining the urgent problem of how to address excessive use of force in encounters between law enforcement and individuals with mental health challenges.

Saks lives with schizophrenia and has written and spoken about her experiences. She says, “There’s a tremendous need to implode the myths of mental illness, to put a face on it, to show people that a diagnosis does not have to lead to a painful and oblique life.”

In recent years, researchers have begun talking about mental health care in the same way addiction specialists speak of recovery—the lifelong journey of self-treatment and discipline that guides substance abuse programs. The idea remains controversial: managing a severe mental illness is more complicated than simply avoiding certain behaviors. Approaches include “medication (usually), therapy (often), a measure of good luck (always)—and, most of all, the inner strength to manage one’s demons, if not banish them. That strength can come from any number of places…love, forgiveness, faith in God, a lifelong friendship.” Saks says, “We who struggle with these disorders can lead full, happy, productive lives, if we have the right resources.”

You can view the transcript for “A tale of mental illness | Elyn Saks” here (opens in new window) .

• Bai, Y., Yang, X., Zeng, Z., & Yang, H. (2018). A case report of schizoaffective disorder with ritualistic behaviors and catatonic stupor: successful treatment by risperidone and modified electroconvulsive therapy. BMC psychiatry , 18(1), 67. https://doi.org/10.1186/s12888-018-1655-5 ↵
• Henning A, Kurtom M, Espiridion E D (February 23, 2019) A Case Study of Acute Stimulant-induced Psychosis. Cureus 11(2): e4126. doi:10.7759/cureus.4126 ↵
• Modification, adaptation, and original content. Authored by : Wallis Back for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• A tale of mental illness . Authored by : Elyn Saks. Provided by : TED. Located at : https://www.youtube.com/watch?v=f6CILJA110Y . License : Other . License Terms : Standard YouTube License
• A Case Study of Acute Stimulant-induced Psychosis. Authored by : Ashley Henning, Muhannad Kurtom, Eduardo D. Espiridion. Provided by : Cureus. Located at : https://www.cureus.com/articles/17024-a-case-study-of-acute-stimulant-induced-psychosis#article-disclosures-acknowledgements . License : CC BY: Attribution
• Elyn Saks. Provided by : Wikipedia. Located at : https://en.wikipedia.org/wiki/Elyn_Saks . License : CC BY-SA: Attribution-ShareAlike
• A case report of schizoaffective disorder with ritualistic behaviors and catatonic stupor: successful treatment by risperidone and modified electroconvulsive therapy. Authored by : Yuanhan Bai, Xi Yang, Zhiqiang Zeng, and Haichen Yangcorresponding. Located at : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851085/ . License : CC BY: Attribution

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“One in a million”: A case of a very early onset schizophrenia

1 Assistant Professor of Psychiatry, Department of Psychiatry, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA

2 PGY4-Child and Adolescent Psychiatry Fellow, Department of Psychiatry, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA

Address correspondence to:

Daisy Vyas Shirk

DO, 875 Stoverdale Road, Hummelstown, Pennsylvania 17036,

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Article ID: 100083Z06DS2020

doi: 10.5348/100083Z06DS2020CR

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Introduction: Very early onset schizophrenia (VEOS), psychosis prior to age 13, is rare with an incidence of less than 0.04%. Its clinical presentation, course, and outcome differ from early onset (ages 13–18) and adult onset (ages 18 and up) schizophrenia. It is associated with poor response to treatment, poorer prognosis, and multiple hospitalizations. Early identification and intervention has shown to improve overall functioning.

Case Report: We present a case of a 12-year-old female with significant family history of psychosis, admitted due to physical and verbal aggression, sexual inappropriateness, destruction of property, response to internal stimuli, decline in functioning, and 10 month history of social isolation. She responded to risperidone treatment. The patient was discharged to partial hospitalization program but could not tolerate the group setting resulting in discharge to outpatient services. Psychosocial supports were put in place to help with environmental and family dynamics to improve outcome.

Conclusion: As per a recent study, one-third of children and adolescents with psychosis initially present with negative symptoms. It has also been reported that 30% of those with negative symptoms develop treatment failure with antipsychotics. Given these statistics and the treatment challenges of this case, it was imperative to provide additional psychosocial supports to the patients and families, to improve overall functioning and long-term prognosis.

Keywords: Compliance, Intellectual disability, Psychotic disorders, Psychosocial support systems

INTRODUCTION

Very early onset schizophrenia (VEOS), defined as onset of psychosis prior to age 13, is considered to be very rare [1] . It has been shown to differ in its clinical presentation, course, and outcome compared to early onset (between ages 13 and 18) and adult onset (ages 18 and up) schizophrenia. It is associated with poorer prognosis, worse overall functioning, and multiple hospitalizations [2] . Early childhood adversity and borderline intellectual functioning have also been shown to contribute to development of psychosis [3] , [4] , [5] . Early identification and intervention have been shown to reduce the morbidity of the illness and improve overall functioning. Here we present the case of a young girl with very early onset schizophrenia.

CASE REPORT

This is a case of a 12-year-old female child who was admitted in the inpatient child psychiatry unit due to physical and verbal aggression toward peers and staff, sexually inappropriate touching, destruction of property, attempting to run out into traffic, and responding to internal stimuli.

The patient was reportedly doing well until 10 months prior to her hospitalization, after which she exhibited school refusal and declining grades. The only trigger reported was school bullying. She was noted to become more verbally and physically aggressive toward peers and school staff, with daily outbursts, eloping from school, poor sleep, and social isolation. At home, she was observed to sit in the halls in the middle of the night, conversing with herself. She changed from a child who “used to love talking, playing board games, and card game with her cousins” into someone who “now sits by herself and does not say anything to them or do anything with them.” She was also found one time sitting on her porch eating leaves.

She was referred and underwent partial hospitalization. During that treatment, she was observed to be impulsive, hyperactive, withdrawn, had difficulty with peer interactions, appeared internally preoccupied, laughed inappropriately, talked to herself, sing, or would dance alone without music. She struggled with boundaries and attempted few times to choke staffs with their lanyards or with her hands. She destroyed property, made verbal threats toward staff and peers, and made sexually inappropriate comments and gestures. She was given a trial of lithium and risperidone. She did not tolerate lithium but responded to risperidone 1 mg daily. Upon discharge, there was no follow-up and patient ran out of medication. This led to a deterioration of behaviors resulting in inpatient treatment.

Patient’s developmental history and medical histories are unremarkable. Her family history is significant for schizophrenia in her father who reportedly went from being a straight A student, attending college on a full scholarship to dropping out of school, having multiple incarcerations and now has been institutionalized in a long-term psychiatric facility for the past 10 years. The patient’s mother also received inpatient treatment after patient’s birth and there was a threat of all three children being removed by Children and Youth Services (CYS). At the time of hospitalization, she lived with her mother, 9-year-old sister, and 3-year-old brother. Child protection services were involved at the time of admission due to concerns of a possible sexual abuse based on patient’s sexualized behaviors.

Mental status examination at the time of admission

The patient had fair grooming but was agitated and uncooperative during the interview. Her eye contact varied from fair to intense staring. She did not display any motor abnormalities including tics or tremors. She spoke loudly and often repeated the phrase, “I don’t give a f***” to many questions. She refused to describe her mood and her affect was bizarre and labile; though content was characteristic of paranoia and perseverations. She refused to answer questions related to perceptual disturbances, suicidality, and homicidality. Her orientation, memory, and knowledge could not be fully assessed. Her attention, insight, and judgment were impaired.

Admission diagnosis

Unspecified psychosis was not revealed due to a substance or known physiological condition.

Course of inpatient treatment

The patient was diagnosed with unspecified psychosis on admission. Workup ( Table 1 , Table 2 , Table 3 , Table 4 , Table 5 , Table 6 ) was done and the patient was restarted on risperidone for her aggression and hallucinations. On her first three days of hospitalization, she displayed aggressive, impulsive, and disruptive behaviors toward peers and staffs. Her risperidone was titrated up to 1.75 mg/day. Her aggression subsided and she was able to attend groups. However, she had difficulty engaging with others, often preferring to sit by herself and away from the crowd. She initially endorsed auditory and visual hallucinations where she saw shadows or gravesite with numbers. She would occasionally have difficulty distinguishing reality from fiction, often asking staff if they were real or part of her imagination. Early on in her treatment, the patient had several days when she reported “itching” on her chest stating that she was being stabbed by someone. Once that was resolved, she became preoccupied by her fingertips and would often be seen picking at the tips of her fingers. She struggled with being able to process information and was often mute or would repeat things that had been said to her or perseverate on a specific sentence. She displayed paranoia on the unit, often worrying that someone would come in and hurt her and at times feared that the staff would hurt her. Initially, she had trouble sleeping at night and would often stand in her doorway staring at staff for the majority of the night. She was allowed to sleep on a mattress in her doorway which seemed to help at times but not consistently. Later, she denied having hallucinations although she appeared internally preoccupied throughout the stay.

Neuropsychological assessment was completed which revealed that the patient’s IQ was likely in the borderline range (70–79). She had limited verbal comprehension and expression, relative weakness in verbal knowledge, fluid reasoning, set-shifting, visual-motor integration, phonemic and semantic fluency, and rote verbal memory. She also had significant deficits in executive functioning and negative and positive symptoms of psychosis.

Medical issues

Started on Vitamin D3 to correct for low Vitamin D.

Interventions at discharge

Due to the many challenges this patient presented and concerns about compliance with aftercare recommendations, she was referred to as many outpatient services as possible to help improve her prognosis. These services included partial hospitalization, involvement of children and youth services, case management services, family support in the form of patient’s paternal grandmother, referral for electroencephalogram (EEG) and magnetic resonance imaging (MRI) of brain and school involvement.

Partial hospital treatment

Upon arrival to partial hospitalization, patient’s behaviors had deteriorated due to non-compliance with medications for a week as a result of problem with insurance. She reported sporadic hallucinations, giggled by herself, displayed thought blocking, disorganized behaviors, made random, unrelated, bizarre statements, sometimes loudly and perseverated on them and was paranoid.

During her partial hospitalization, she was disruptive, made sexually inappropriate comments and became verbally and physically aggressive toward staff. As a result of these behaviors and her inability to tolerate the group setting of partial hospitalization, she had to be discharged to outpatient services. As was the case during her discharge from inpatient treatment, patient’s mother did not show up for her discharge and CYS had to find her.

When found, her mother once again claimed she was unaware of the discharge.

Follow-up in outpatient treatment

In the outpatient clinic, risperidone was titrated up to 1 mg orally twice a day, with a good response. Patient’s mother reported that the patient was doing well in school and seemed to be at her baseline after dose increase. During outpatient visits, the patient denied hallucinations, thought blocking was noted to improve, and the patient was answering questions and smiling appropriately most of the times.

Response latency and processing time remained slow but showed improved from previous visits. Family based mental health (FBMHS) services were recommended and started with in-home therapy 2–3 times a week. A case manager through CYS was recommended to support family in managing follow-up appointments.

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Very early onset psychosis, defined as psychosis before the age of 13, is an extremely rare occurrence with an incidence of less than 0.04% [1] , [6] . One-third of children and adolescents with psychosis initially present with negative symptoms and 30% of those who present with negative symptoms at baseline go on to develop treatment failure with antipsychotics. Confounding these statistics is that VEOS is often difficult to diagnose, especially in this case due to lack of reliable collateral information from family. Our patient presented with several risk factors including father’s diagnosis of schizophrenia requiring institutionalization for the past 10 years. There was also a strong suspicion of mental illness in patient’s mother. Environmentally, our patient had a history of trauma in the form of bullying at school and she lacked social supports and lack of follow-up with treatment recommendations.

Additionally, our patient had several premorbid symptoms such as social withdrawal, poverty of speech, and steady decline in social and academic performance over the course of her educational history. Freeman et al. [4] have reported that there is a direct correlation between lower intellectual functioning and development of psychosis due to alteration in the way stimuli and events are interpreted. Another study demonstrated a significant association with psychosis and auditory hallucinations “that remained significant after controlling for age, gender, current social class and ethnicity” [5] . Childhood adversity, as experienced by this patient, also increases the risk of psychosis. A review by Varese et al. [3] showed that exposure to all types of adversity (except parental death) was related to an increased risk of psychosis. Furthermore, a recent study of adolescents experiencing psychosis suggested early intervention by a specialist team may improve treatment outcomes in both positive and negative symptoms [7] . This may also hold true for VEOS. At presentation, our patient displayed the following negative symptoms of schizophrenia: blunted affect, emotional withdrawal, poor rapport, social isolation, poverty of speech, mutism, and psychomotor retardation.

Comorbidities for this patient included oppositional defiant behaviors, borderline intellectual functioning and trauma in the form of physical and emotional abuse by peers, and suspicion of possible sexual abuse given her sexual acting out behaviors.

Our patient provided several treatment challenges due to her mother’s mental state and inability to provide reliable collateral information, non-compliance with follow-up with patient’s outpatient services, and non-compliance with following medication recommendations. Additionally, the lack of sufficient services for young children with psychosis made aftercare recommendations challenging for the treatment team.

Given the many complications this patient presented, the treatment team focused on utilizing the resources that were available such as patient’s paternal grandmother’s increased involvement in her care. There was also collaboration of care with outside agencies such as Children and Youth Services, Case Management, and her school. These services provided support to her mother and made her accountable for complying with aftercare plans and recommendations.

One-third of children and adolescents with psychosis initially present with negative symptoms and 30% of those with negative symptoms, develop treatment failure with antipsychotics. Given these statistics and the treatment challenges of treating children with psychosis, it is imperative to provide additional psychosocial supports to the patients and families, to improve overall functioning and long-term prognosis. This case presents an excellent example of many challenges that are faced in treating early onset psychosis.

SUPPORTING INFORMATION

Daisy Vyas Shirk - Conception of the work, Design of the work, Acquisition of data, Analysis of data, Drafting the work, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Meenal Pathak - Acquisition of data, Analysis of data, Drafting the work, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Jasmin Gange Lagman - Acquisition of data, Analysis of data, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Khurram S Janjua - Acquisition of data, Analysis of data, Drafting the work, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

The corresponding author is the guarantor of submission.

Written informed consent was obtained from the patient for publication of this article.

All relevant data are within the paper and its Supporting Information files.

Authors declare no conflict of interest.

© 2020 Daisy Vyas Shirk et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.

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[Fragile X syndrome and very early onset schizophrenia: a female case study]

Affiliation.

• 1 Service de psychopathologie de l'enfant et de l'adolescent, hôpital Robert-Debré, assistance publique-hôpitaux de Paris, 48 boulevard Sérurier, 75019 Paris, France. [email protected]
• PMID: 15694544
• DOI: 10.1016/j.arcped.2004.11.019

Genotype-phenotype relationship studies for psychiatric disorders in females carrying fragile X syndrome full mutation and premutation underline association with schizo-affective disorders. In female children with X fragile full mutation, only behavioural symptoms and no standardised psychiatric disorders have been systematically explored. Therefore, we report the case of a nine-year-old girl carrying the fragile X syndrome full mutation with a comorbid childhood onset schizophrenia (COS), and of her mother carrying the fragile X syndrome premutation and a comorbid schizotypal personality disorder. The impact of these associations is discussed regarding the recent literature in chromosome anomalies in COS.

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• Fragile-X carrier females: evidence for a distinct psychopathological phenotype? Franke P, Maier W, Hautzinger M, Weiffenbach O, Gänsicke M, Iwers B, Poustka F, Schwab SG, Froster U. Franke P, et al. Am J Med Genet. 1996 Aug 9;64(2):334-9. doi: 10.1002/(SICI)1096-8628(19960809)64:2 3.0.CO;2-F. Am J Med Genet. 1996. PMID: 8844076
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• [Behavioral characteristics of children with Fragile X syndrome]. Gabis L, Kesner Y. Gabis L, et al. Harefuah. 2007 Jun;146(6):469-74, 499. Harefuah. 2007. PMID: 17760403 Review. Hebrew.
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Schizophrenia case studies: putting theory into practice

This article considers how patients with schizophrenia should be managed when their condition or treatment changes.

DR P. MARAZZI/SCIENCE PHOTO LIBRARY

Treatments for schizophrenia are typically recommended by a mental health specialist; however, it is important that pharmacists recognise their role in the management and monitoring of this condition. In ‘ Schizophrenia: recognition and management ’, advice was provided that would help with identifying symptoms of the condition, and determining and monitoring treatment. In this article, hospital and community pharmacy-based case studies provide further context for the management of patients with schizophrenia who have concurrent conditions or factors that could impact their treatment.

Case study 1: A man who suddenly stops smoking

A man aged 35 years* has been admitted to a ward following a serious injury. He has been taking olanzapine 20mg at night for the past three years to treat his schizophrenia, without any problems, and does not take any other medicines. He smokes 25–30 cigarettes per day, but, because of his injury, he is unable to go outside and has opted to be started on nicotine replacement therapy (NRT) in the form of a patch.

When speaking to him about his medicines, he appears very drowsy and is barely able to speak. After checking his notes, it is found that the nurses are withholding his morphine because he appears over-sedated. The doctor asks the pharmacist if any of the patient’s prescribed therapies could be causing these symptoms.

What could be the cause?

Smoking is known to increase the metabolism of several antipsychotics, including olanzapine, haloperidol and clozapine. This increase is linked to a chemical found in cigarettes, but not nicotine itself. Tobacco smoke contains aromatic hydrocarbons that are inducers of CYP1A2, which are involved in the metabolism of several medicines [1] , [2] , [3] . Therefore, smoking cessation and starting NRT leads to a reduction in clearance of the patient’s olanzapine, leading to increased plasma levels of the antipsychotic olanzapine and potentially more adverse effects — sedation in this case.

Patients who want to stop, or who inadvertently stop, smoking while taking antipsychotics should be monitored for signs of increased adverse effects (e.g. extrapyramidal side effects, weight gain or confusion). Patients who take clozapine and who wish to stop smoking should be referred to their mental health team for review as clozapine levels can increase significantly when smoking is stopped [3] , [4] .

For this patient, olanzapine is reduced to 15mg at night; consequently, he seems much brighter and more responsive. After a period on the ward, he has successfully been treated for his injury and is ready to go home. The doctor has asked for him to be supplied with olanzapine 15mg for discharge along with his NRT.

What should be considered prior to discharge?

It is important to discuss with the patient why his dose was changed during his stay in hospital and to ask whether he intends to start smoking again or to continue with his NRT. Explain to him that if he wants to begin, or is at risk of, smoking again, his olanzapine levels may be impacted and he may be at risk of becoming unwell. It is necessary to warn him of the risk to his current therapy and to speak to his pharmacist or mental health team if he does decide to start smoking again. In addition, this should be used as an opportunity to reinforce the general risks of smoking to the patient and to encourage him to remain smoke-free.

It is also important to speak to the patient’s community team (e.g. doctors, nurses), who specialise in caring for patients with mental health disorders, about why the olanzapine dose was reduced during his stay, so that they can then monitor him in case he does begin smoking again.

Case 2: A woman with constipation

A woman aged 40 years* presents at the pharmacy. The pharmacist recognises her as she often comes in to collect medicine for her family. They are aware that she has a history of schizophrenia and that she was started on clozapine three months ago. She receives this from her mental health team on a weekly basis.

She has visited the pharmacy to discuss constipation that she is experiencing. She has noticed that since she was started on clozapine, her bowel movements have become less frequent. She is concerned as she is currently only able to go to the toilet about once per week. She explains that she feels uncomfortable and sick, and although she has been trying to change her diet to include more fibre, it does not seem to be helping. The patient asks for advice on a suitable laxative.

What needs to be considered?

Constipation is a very common side effect of clozapine . However, it has the potential to become serious and, in rare cases, even fatal [5] , [6] , [7] , [8] . While minor constipation can be managed using over-the-counter medicines (e.g. stimulant laxatives, such as senna, are normally recommended first-line with stool softeners, such as docusate, or osmotic laxatives, such as lactulose, as an alternative choice), severe constipation should be checked by a doctor to ensure there is no serious bowel obstruction as this can lead to paralytic ileus, which can be fatal [9] . Symptoms indicative of severe constipation include: no improvement or bowel movement following laxative use, fever, stomach pain, vomiting, loss of appetite and/or diarrhoea, which can be a sign of faecal impaction overflow.

As the patient has been experiencing this for some time and is only opening her bowels once per week, as well as having other symptoms (i.e. feeling uncomfortable and sick), she should be advised to see her GP as soon as possible.

The patient returns to the pharmacy again a few weeks later to collect a prescription for a member of their family and thanks the pharmacist for their advice. The patient was prescribed a laxative that has led to resolution of symptoms and she explains that she is feeling much better. Although she has a repeat prescription for lactulose 15ml twice per day, she says she is not sure whether she needs to continue to take it as she feels better.

What advice should be provided?

As she has already had an episode of constipation, despite dietary changes, it would be best for the patient to continue with the lactulose at the same dose (i.e. 15ml twice daily), to prevent the problem occurring again. Explain to the patient that as constipation is a common side effect of clozapine, it is reasonable for her to take laxatives before she gets constipation to prevent complications.

Pharmacists should encourage any patient who has previously had constipation to continue taking prescribed laxatives and explain why this is important. Pharmacists should also continue to ask patients about their bowel habits to help pick up any constipation that may be returning. Where pharmacists identify patients who have had problems with constipation prior to starting clozapine, they can recommend the use of a prophylactic laxative such as lactulose.

Case 3: A mother is concerned for her son who is talking to someone who is not there

A woman has been visiting the pharmacy for the past 3 months to collect a prescription for her son, aged 17 years*. In the past, the patient has collected his own medicine. Today the patient has presented with his mother; he looks dishevelled, preoccupied and does not speak to anyone in the pharmacy.

His mother beckons you to the side and expresses her concern for her son, explaining that she often hears him talking to someone who is not there. She adds that he is spending a lot of time in his room by himself and has accused her of tampering with his things. She is not sure what she should do and asks for advice.

What action can the pharmacist take?

It is important to reassure the mother that there is help available to review her son and identify if there are any problems that he is experiencing, but explain it is difficult to say at this point what he may be experiencing. Schizophrenia is a psychotic illness which has several symptoms that are classified as positive (e.g. hallucinations and delusions), negative (e.g. social withdrawal, self-neglect) and cognitive (e.g. poor memory and attention).

Many patients who go on to be diagnosed with schizophrenia will experience a prodromal period before schizophrenia is diagnosed. This may be a period where negative symptoms dominate and patients may become isolated and withdrawn. These symptoms can be confused with depression, particularly in younger people, though depression and anxiety disorders themselves may be prominent and treatment for these may also be needed. In this case, the patient’s mother is describing potential psychotic symptoms and it would be best for her son to be assessed. She should be encouraged to take her son to the GP for an assessment; however, if she is unable to do so, she can talk to the GP herself. It is usually the role of the doctor to refer patients for an assessment and to ensure that any other medical problems are assessed. 

Three months later, the patient comes into the pharmacy and seems to be much more like his usual self, having been started on an antipsychotic. He collects his prescription for risperidone and mentions that he is very worried about his weight, which has increased since he started taking the newly prescribed tablets. Although he does not keep track of his weight, he has noticed a physical change and that some of his clothes no longer fit him.

What advice can the pharmacist provide?

Weight gain is common with many antipsychotics [10] . Risperidone is usually associated with a moderate chance of weight gain, which can occur early on in treatment [6] , [11] , [12] . As such, the National Institute for Health and Care Excellence recommends weekly monitoring of weight initially [13] . As well as weight gain, risperidone can be associated with an increased risk of diabetes and dyslipidaemia, which must also be monitored [6] , [11] , [12] . For example, the lipid profile and glucose should be assessed at 12 weeks, 6 months and then annually [12] .

The pharmacist should encourage the patient to attend any appointments for monitoring, which may be provided by his GP or mental health team, and to speak to his mental health team about his weight gain. If he agrees, the pharmacist could inform the patient’s mental health team of his weight gain and concerns on his behalf. It is important to tackle weight gain early on in treatment, as weight loss can be difficult to achieve, even if the medicine is changed.

The pharmacist should provide the patient with advice on healthy eating (e.g. eating a balanced diet with at least five fruit and vegetables per day) and exercising regularly (e.g. doing at least 150 minutes of moderate-intensity activity or 75 minutes of vigorous-intensity activity per week), and direct him to locally available services. The pharmacist can record the adverse effect on the patient’s medical record, which will help flag this in the future and thus help other pharmacists to intervene should he be prescribed risperidone again.

*All case studies are fictional.

Useful resources

• Mind — Schizophrenia
• Rethink Mental Illness — Schizophrenia
• Mental Health Foundation — Schizophrenia
• Royal College of Psychiatrists — Schizophrenia
• NICE guidance [CG178] — Psychosis and schizophrenia in adults: prevention and management
• NICE guidance [CG155] — Psychosis and schizophrenia in children and young people: recognition and management
• British Association for Psychopharmacology — Evidence-based guidelines for the pharmacological treatment of schizophrenia: updated recommendations from the British Association for Psychopharmacology

About the author

Nicola Greenhalgh is lead pharmacist, Mental Health Services, North East London NHS Foundation Trust

[1] Chiu CC, Lu ML, Huang MC & Chen KP. Heavy smoking, reduced olanzapine levels, and treatment effects: a case report. Ther Drug Monit 2004;26(5):579–581. doi: 10.1097/00007691-200410000-00018

[2] de Leon J. Psychopharmacology: atypical antipsychotic dosing: the effect of smoking and caffeine. Psychiatr Serv 2004;55(5):491–493. doi: 10.1176/appi.ps.55.5.491

[3] Mayerova M, Ustohal L, Jarkovsky J et al . Influence of dose, gender, and cigarette smoking on clozapine plasma concentrations. Neuropsychiatr Dis Treat 2018;14:1535–1543. doi: 10.2147/NDT.S163839

[4] Ashir M & Petterson L. Smoking bans and clozapine levels. Adv Psychiatr Treat 2008;14(5):398–399. doi: 10.1192/apt.14.5.398b

[5] Young CR, Bowers MB & Mazure CM. Management of the adverse effects of clozapine. Schizophr Bull 1998;24(3):381–390. doi: 10.1093/oxfordjournals.schbul.a033333

[6] Taylor D, Barnes TRE & Young AH. The Maudsley Prescribing Guidelines in Psychiatry . 13th edn. London: Wiley Blackwell; 2018

[7] Oke V, Schmidt F, Bhattarai B et al . Unrecognized clozapine-related constipation leading to fatal intra-abdominal sepsis — a case report. Int Med Case Rep J 2015;8:189–192. doi: 10.2147/IMCRJ.S86716

[8] Hibbard KR, Propst A, Frank DE & Wyse J. Fatalities associated with clozapine-related constipation and bowel obstruction: a literature review and two case reports. Psychosomatics 2009;50(4):416–419. doi: 10.1176/appi.psy.50.4.416

[9] Medicines and Healthcare products Regulatory Agency. Clozapine: reminder of potentially fatal risk of intestinal obstruction, faecal impaction, and paralytic ileus. 2020. Available from: https://www.gov.uk/drug-safety-update/clozapine-reminder-of-potentially-fatal-risk-of-intestinal-obstruction-faecal-impaction-and-paralytic-ileus (accessed April 2020)

[10] Leucht S, Cipriani A, Spineli L et al. Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis. Lancet 2013;382(9896):951–962. doi: 10.1016/S0140-6736(13)60733-3

[11] Bazire S. Psychotropic Drug Directory . Norwich: Lloyd-Reinhold Communications LLP; 2018

[12] Cooper SJ & Reynolds GP. BAP guidelines on the management of weight gain, metabolic disturbances and cardiovascular risk associated with psychosis and antipsychotic drug treatment. J Psychopharmacol 2016;30(8):717–748. doi: 10.1177/0269881116645254

[13] National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. Clinical guideline [CG178]. 2014. Available from: https://www.nice.org.uk/guidance/cg178 (accessed April 2020)

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• v.57(Suppl 2); 2015 Jul

Women and schizophrenia

Schizophrenia Research Foundation, Chennai, Tamil Nadu, India

Shantha Kamath

Women's mental health is closely linked to their status in society. This paper outlines the clinical features of women with schizophrenia and highlights the interpersonal and social ramifications on their lives. There is no significant gender difference in the incidence and prevalence of schizophrenia. There is no clear trend in mortality, although suicides seem to be more in women with schizophrenia. In India, women face a lot of problems, especially in relation to marriage, pregnancy, childbirth, and menopause. Most studies have shown better premorbid functioning, and social adjustment for women compared with men. There is a great need to plan for gender-sensitive mental health services targeting the special needs of these women. Women caregivers also deserve due attention.

INTRODUCTION

The 1998 World Health report states that “women's mental health is inextricably linked to their status in society. It benefits from equality and suffers from discrimination.[ 1 ] Many women with severe mental illness stay outside treatment settings, especially in low income countries with poor and inadequate mental health facilities. Those who do enter treatment settings have varied experiences ranging from humane care to indifference and stigmatization. More reports on human rights violations of mentally ill women are emerging. Women caregivers of the mentally ill seem to outnumber the male caregivers and also face unique problems. One of the major disorders which impact the life of women patients, caregivers and family members is schizophrenia.

The World Health Organization (WHO) described schizophrenia as a disease of young men. It is also observed that mental illnesses in women are different from those in men.[ 2 ] The clinical picture of early onset, poor premorbid development, emotional blunting, social withdrawal, and poor outcome occurred more frequently in males compared to females. This paper outlines the clinical features of women with schizophrenia and highlights the interpersonal and social ramifications on their lives.

EPIDEMIOLOGY

The incidence of schizophrenia seems to be fairly stable in both genders across reported studies. The diagnostic definitions (broad versus restrictive) used have, however, determined differences as in the case of Determinants of Outcome of Severe Mental Disorders (DOSMED) study.[ 3 ]

The review of 55 core incidence studies by McGrath et al. reported higher incidence rates in males, the male:female rate ratio median was 1.4 (0.9:2.4).[ 4 ] Nine studies which reported higher rates in women were examined in detail, but showed no features distinguishable from the other studies.

The Madras study on a population of 100,000 did not show any gender differences.[ 5 ] However, Dube and Kumar[ 6 ] in Agra reported a greater incidence in males (1.5:1). In the Chandigarh study, the incidence rate of broadly defined schizophrenia was the highest among rural women (0.47/1000) and lowest in urban males (0.37/1000).

It is therefore not quite clear if there are significant gender differences in the incidence schizophrenia.

The same holds good for prevalence, with rates for genders varying greatly across studies. This could be partly explained by variations in methodology, and sample sizes preventing any definitive conclusions to be drawn. A review of prevalence studies in schizophrenia by Saha et al. [ 7 ] did not find any striking sex differences.

Morbidity risk for schizophrenia over the life spans seems to be around 1% in both genders. In the 25 years follow-up of the Madras longitudinal study of 90 first episode schizophrenia patients, 24 patients died, of whom males were 14. More males had physical illnesses, while, more women committed suicide.[ 8 ] The suicides in women were largely in response to symptoms as in the case of one woman who had the delusion that she appeared nude to others and the resultant social embarrassment. Higher suicide risk in women with schizophrenia was also reported by Mortensen and Juel.[ 9 ]

A recent study in rural China by Ran et al. [ 10 ] found much more mortality and suicide in men than in women and ascribed the higher prevalence of schizophrenia in women to this.

A systematic review of mortality in schizophrenia revealed no sex differences.[ 4 ] Auquier et al. ,[ 11 ] however, report more suicides in young males with schizophrenia.

As in the case of incidence and prevalence, there is no clear trend in mortality, although suicides seem to be more in women with schizophrenia.

COURSE AND OUTCOME

Women have a better outcome than men. It is unclear whether this is due to the later age of onset, protective nature of hormones such as estrogens or better drug response.

The Australian Study of Low Prevalence (Psychotic) Disorders[ 12 ] looked at gender differences among 1090 cases of psychosis (schizophrenia, schizoaffective disorder, affective psychoses, and other psychoses). Results within diagnostic groupings confirmed differences in how men and women experience and express their illness. Within each diagnostic group, women reported better premorbid functioning, a more benign illness course, lower levels of disability and better integration into the community than men. They were also less likely to have a chronic course of illness. There were no significant differences in age at onset. Differences between women across the diagnostic groups were more pronounced than differences between women and men within a diagnostic group. In particular, women with schizophrenia were severely disabled compared to women with other diagnoses.

The Madras longitudinal study found the better outcome in women after 5 years of follow-up, but this did not sustain through the rest of the 15 years of follow-up.[ 13 ] It is likely that several mechanisms are needed to explain the differences. Greater social integration and functioning in women across diagnostic groups may well reflect culturally and socially determined gender differences. In contrast, variability and attenuated findings with respect to symptom profiles beg the question of biological mechanisms with some degree of specificity.[ 14 ]

CLINICAL FEATURES

Women seem to have more affective symptoms, fewer negative symptoms and more of a diagnosis of schizoaffective disorder.[ 15 ] It has been documented that women with schizophrenia tend to be more overtly hostile, physically active and dominating, with more of sexual delusions, and more emotional than men.[ 16 ] They also experience affective and paranoid symptoms, more of anxiety symptoms and less of negative symptoms.[ 17 ] The meaning of symptoms seems to differ for men and women. While expression of isolation, withdrawal and dependency may reflect a depression syndrome in women, it may reflect a negative syndrome in men.

A large sample of Chinese patients with schizophrenia had more paranoid subtype of schizophrenia in females who also showed a different pattern of ongoing symptoms and severity, more severe positive and affective symptoms, and a greater number of suicide attempts, whereas male patients were more likely to show severe deterioration over time.[ 18 ]

Müller[ 19 ] studied gender-specific differences in the association of depression in persons with schizophrenia. In females, depression was independently associated with higher negative symptom scores ( P < 0.01) and younger age ( P < 0.05), whereas in males positive symptoms ( P < 0.05) and short hospitalization ( P < 0.05) were the main factors associated with depression.

The role of estrogen levels in the symptomatology in women is ambiguous. Both late onset schizophrenia, which is more common in women[ 20 , 21 ] and the worsening of symptoms as women get older are not correlated with estrogen levels.[ 22 ] The adverse effect of estrogen withdrawal on the postmenopausal brain has been noted by Murray.[ 23 ]

Age at onset

A higher mean age at onset of schizophrenia for women has been one of the very consistent findings in the last 20 years. Several independent reviews of many studies have shown that the disorder appears later in women. Since the time between onset of symptoms and first hospitalization were the same in both genders, it was evident that women did have a later onset. There have been, however, a few reports not replicating this finding. Some studies from India have not found a gender difference in the age of onset and have questioned the universality of the traditional view of earlier onset in men.[ 24 ] The Madras longitudinal study of almost equal numbers of men and women in a sample of 90 cases also did not find a gender difference in onset.[ 25 ]

The WHO study on DOSMED[ 26 ] examined individuals with first onset schizophrenia and found a preponderance of males in the younger age group and females in the older age group 45–54 years. Gangadhar et al. opined that the higher age at onset in women may be a function of perinatal complications. In Indian states with low infant mortality rate (IMR), age at onset did not differ between the two sexes. However, men had an older age at onset than women in states where IMR was 5 times higher.[ 27 ] Similarly a study from a community sample did not find gender differences in the age of onset and the authors have suggested that there is a need to revise the description of schizophrenia in the classificatory system keeping in view the regional variation in the age of onset.[ 28 ]

Response to treatment

It has long been observed that men and women seem to require different dosages of antipsychotics and have different responses to them. The Schizophrenia Outpatient Health Outcomes study was a 3-year, prospective, observational study of health outcomes associated with antipsychotic treatment in 10 European countries that included over 10,000 outpatients initiating or changing their antipsychotic medication in 4529 men (56.68%) and 3461 women (43.32%). Findings showed that gender was a significant predictor for response based on the Clinical Global Impression scale and for improvement in quality of life. The highest gender differences were found in typical antipsychotics and clozapine. Olanzapine only showed differences in quality of life, and no differences were found for risperidone.[ 29 ]

In the Chinese study by Tang et al. ,[ 30 ] males received higher daily doses of antipsychotics and demonstrated a different pattern of antipsychotic usage, being less likely to be treated with second-generation antipsychotics. The clozapine blood level was 35% higher in women than in men. In general, premenopausal women seem to require lower doses. The role of estrogens in neuromodulation seems to account for this difference. It has to be kept in mind that the bulk of patients taking part in drug trials are men, and much of the knowledge about dosing is, therefore, more applicable to men.

Side effects of medication

Neuroendocrine effects of antipsychotics, especially those secondary to hyperprolactinemia can cause a lot of distress to women patients. This is true with all FGAs and to an extent with risperidone and ziprasidone. Clozapine, olanzapine, and quetiapine seem to spare prolactin, but result in weight gain. Amenorrhea, galactorrhea, decreased sexual interest, and functioning and changes in bone density are the side effects of increased prolactin levels.

Obesity also seems to be commoner among women and has its own psychological and medical effects.

MENTALLY ILL WOMEN AND MARRIAGE

The process and dynamics of courtship, dating and marriage vary widely between different nations and cultures and impact the rates of marriage. In developed countries, where finding a partner involves social skills, persons with schizophrenia have low rates of marriage. However, in developing countries, where many marriages are arranged by the families, the rates of marriage are as high as 70.5% in Ethopia[ 31 ] and around 65% in Chennai, India.[ 32 ] While getting married did not probably involve too many social skills, staying married certainly did. Hence, separation and divorce were fairly common and much higher than seen in general populations.

Even in urban areas, the misconception that marriage cures mental illness is still widely prevalent. As a consequence, many families secretly arrange marriages of their wards and professional care givers know of it much later. While fewer men get married, their marriages seem to be quite stable. On the other hand, breakdown and separation were seen more in female patients, especially if they are symptomatic or childless. Patients with a relapsing course were less likely to get married, and the system of arranged marriages accounted for higher rates of marriage in India compared to the West.[ 32 ]

An ethnographic, qualitative study of 75 women with schizophrenia who were either divorced or separated revealed that 95% of the marriages were arranged by the families and the separated women lived in their parental homes with the onus of care on elderly caregivers. The stigma of being separated was more often felt by patients and families. They continued to wear the traditional symbols of marriage (for example the mangalsutra) as it gave them a sense of security and status in a society where marriages are revered.

This study also highlighted the need for community-based resources like half way homes, Day Care Centers and Rehabilitation Centers in both the government and private sectors. The need for Comprehensive Care Centers for this group of patients where these chronic mentally ill women could learn some skills and get some employment to support their children is imminent.[ 33 , 34 ]

PREGNANCY AND MOTHERHOOD

Women with schizophrenia have a higher rate of unplanned and unwanted pregnancies. Miller[ 35 ] has opined that psychosis may contribute to the denial of pregnancy, misinterpretation of somatic changes and even lack of recognition of labor. Seeman and Cohen[ 36 ] describe a comprehensive service for women with schizophrenia in Canada to address various requirements under one roof. There is a need for specialized services and the need to encourage these women to make birth control decisions whenever necessary to preserve their own health and that of future children. Issues related to medication during pregnancy and the postpartum periods are of special concern. The risk of congenital abnormalities is low following prenatal exposure to most psychotropic medication; the highest risk to the fetus is 4–10 weeks after conception. Several comprehensive reviews have appeared on this subject.[ 37 , 38 , 39 ] The outcome of pregnancy in women with schizophrenia suggests a lower mean birth weight, increased incidence of intrauterine growth retardation, preterm birth, and premature death as compared to healthy pregnant women.[ 38 ] Through education and support pregnant women with schizophrenia can be protected from the risk factors.

HOMELESSNESS

Homelessness is probably the most visible of all the social sequelae of psychotic disorders in women. It has been estimated that 20–40% of homeless women suffer from psychotic disorders. In many developing countries, family support notwithstanding, the numbers of mentally ill women who become homeless seems to be on the increase. This may well be due to breaking up of joint and extended families, and better transport facilities resulting in such women migrating from one part of the country to the other. In many countries, services for such women are either absent or totally fragmented and inadequate. Homeless mentally ill women have more pregnancy and childbirth-related complications.

Though ill males are at greater risk of becoming homeless, homeless women seem to be sicker than their male counterparts[ 40 , 41 ] spoke of the demoralization of the female homeless who wanted their rights respected and autonomy maintained.

A comparative study found substance abuse to be less in homeless women than in men. Symptom severity in homeless individuals with schizophrenia appears as an interaction of symptom profiles and risk behaviors that are gender specific.[ 42 ]

There has been a dearth of systematic research in homelessness, especially in developing countries. As pointed out by Bhugra,[ 43 ] the impact of risk factors such as poverty and poor environmental conditions and their association with ill health needs to be studied in various sociocultural settings. In large countries like India, where the homeless travel long distances across the length and breadth of the country, the challenge is relocating them into their families. While some families are keen to receive them, others tend to be distinctly hostile or indifferent to them when they are sent back. Planning of care facilities for this group of persons with severe mental illness is hardly a priority in many countries.

DISABILITIES IN WOMEN

The 1992 National Health Interview Survey data from the USA is a comprehensive published data set that contains domains of disabilities associated with health conditions. The survey assessed three domains of disabilities: Limitations in activities, work, and self-care. A minimally greater proportion of women were more disabled than men in all three domains. However, women who were mentally disabled were younger than their physically disabled counterparts. This was especially notable in limitations in personal care. It was pointed out by the authors that policymakers need to be aware of the special needs of service development and configuration for women disabled by mental disorders. Appropriate coverage for the care of disorders and disabilities would result in the better short-term and long-term outcomes.[ 44 ]

In the Madras longitudinal study, there were no differences in disabilities between genders at 5 years follow-up. However, work in the case of men and daily activities in the case of women seemed critical to address and intervention.[ 8 ]

PSYCHOSOCIAL REHABILITATION IN WOMEN

It has been observed that psychosocial rehabilitation (PSR) programs, by and large, have not paid much attention to the special needs of women. Kennedy et al. [ 44 ] points out that only 3% of the 127 articles published in the Psychiatric Rehabilitation Journal from 1999 to 2001 were on women. For women, relationship and basic survival skills take precedence over substance abuse related skills. In many countries in Asia where women live in joint and extended families, there is a constant need to adjust to various emotions, critical comments, and expectations of the family members. Married women in the west are often exposed to PSR programs with specific focus on motherhood and care of children. While the focus of PSR in the west is on independent living, it is on managing dependent relationships in large families in many Asian countries. Marriage and motherhood are also issues that need to be addressed during rehabilitation.

Burden and stigma

The stigma faced by patients and families has also evinced a lot of international research interest and efforts are underway to plan major stigma reduction programs. The WHO's dare to care campaign and the World Psychiatric Association's global anti-stigma programs are foremost among these. Knowledge of mental illness in the relative, the need to seek psychiatric treatment which is still not looked upon very favorably in many traditional societies, the need for social restraints on account of behavior problems and above all issues of employment and marriage contribute to the experience of stigma in families. Thara and Srinivasan.[ 45 ] found that many caregivers felt depression and sorrow, which was more if the patient was a woman. Women caregivers reported more stigma than male caregivers. These feelings probably become even more severe when they have to deal with their daughters with uncertain futures and broken marriages and lack of social support.

Schizophrenia is a neurodevelopmental disorder, in which both biological and psychosocial events play an important role. Men and women are more or less equally prone to develop the disorder, but an earlier onset is seen in men, especially in Western countries. There is not a noted gender difference in the incidence and prevalence of schizophrenia. Females are reported to have better clinical outcome than males in the short-term, whereas gender differences tend to disappear over longer periods. Most of the studies have shown a better social adjustment for females compared to males, and they also have better premorbid functioning than males.

There is a great need to plan for gender-sensitive mental health services. In India, women face a lot of problems especially in relation to marriage, pregnancy childbirth, and menopause. There is an urgent need to understand the community care needs of these women given the differential roles and differential family response and community tolerance. Women caregivers also require a lot of information about the disorder and ways of handling various symptoms.

Source of Support: Nil

Conflict of Interest: None declared

• Open access
• Published: 19 August 2024

Medication non-adherence and associated factors among peoples with schizophrenia: multicenter cross-sectional study in Northwest Ethiopia

• Fasil Bayafers Tamene 1 ,
• Endalamaw Aschale Mihiretie 2 ,
• Abiy Mulugeta 3 ,
• Abenet Kassaye 4 ,
• Kale Gubae 1 &
• Samuel Agegnew Wondm 1  

BMC Psychiatry volume  24 , Article number:  567 ( 2024 ) Cite this article

214 Accesses

Metrics details

Schizophrenia is a serious and debilitating psychiatric disorder that is linked to marked social and occupational impairment. Despite the vital relevance of medication, non-adherence with recommended pharmacological treatments has been identified as a worldwide problem and is perhaps the most difficult component of treating schizophrenia. There are limited studies conducted on magnitude and potential factors of medication non-adherence among peoples with schizophrenia in Ethiopia.

This study aimed to assess medication non-adherence and associated factors among peoples with schizophrenia at comprehensive specialized hospitals in Northwest Ethiopia.

An institutional-based cross-sectional study was conducted among 387 peoples with schizophrenia at selected hospitals in the Northwest of Ethiopia from June to August 2022. Study participants were enrolled using systematic random sampling. Medication non-adherence was measured using Medication Adherence Rating Scale (MARS). Data entry and analysis were done using Epi-data version 4.6.0 and SPSS version 24, respectively. A multivariable logistic regression model was fitted to identify factors associated with medication non-adherence. Variables with a p-value of < 0.05 at a 95% confidence interval were considered statistically significant.

The prevalence of medication non-adherence was 51.2% (95% CI: 46.3, 56.3). Duration of treatment for more than ten years (AOR = 3.76, 95% CI: 1.43, 9.89), substance use (AOR = 1.92, 95% CI: 1.17, 3.13), antipsychotic polypharmacy, (AOR = 2.01, 95% CI: 1.11, 3.63) and extra-pyramidal side effect (AOR = 2.48, 95% CI: 1.24, 4.94) were significantly associated with medication non-adherence.

In this study, half of the participants were found to be medication non-adherent. Respondents with a longer duration of treatment, substance users, those on antipsychotic polypharmacy, and those who develop extra-pyramidal side effect need prompt screening and critical follow-up to improve medication adherence.

Peer Review reports

Introduction

Mental disorders are clinically severe disruptions in an individual's cognition, emotional regulation, or behavior. These disturbances are linked to dysfunctions in psychological, biological, or developmental processes, resulting in distress or dysfunction in critical areas of functioning [ 1 ]. Schizophrenia is a serious, debilitating, chronic psychiatric disorder distinguished by recurrent or chronic psychosis that is linked to marked social and occupational impairment and it affects 1% of the general population worldwide [ 2 ].

Non-adherence in the treatment of mental disorders can be characterized as the failure to get started on the treatment regimen, an untimely cessation of treatment, or the inadequate implementation of medical instructions, especially those related to administration of drugs [ 3 ]. Medication non adherence is a multi-faceted challenge linked with therapeutic alliance between the clinician and the patient, factors related to medications and factors related to the patients and their illness [ 4 ].The significance of maintenance therapy in schizophrenia has been well proved and sustained maintenance treatment with antipsychotic medication appears crucial in relapse prevention and control of psychotic symptoms [ 5 , 6 ].

Poor adherence to prescribed medication is prominent across disorders, but it can be especially detrimental to the patient and burdensome to society in schizophrenia [ 7 ]. Despite the vital relevance of medication, non-adherence with recommended pharmacological treatments has been identified as a worldwide problem and is perhaps the most difficult component of treating patients with schizophrenia [ 8 ]. Non-adherence to antipsychotic drugs has a major impact on the course and prognosis of individuals with schizophrenia. It may raise the likelihood of symptomatic relapse, decrease treatment effectiveness, affect, suicidal attempts, frequent emergency department visits or re-hospitalizations and, as a result, lower quality of life [ 9 , 10 ]. Poor antipsychotic drug adherence affects illness progression and linked with higher healthcare utilization and treatment costs [ 11 ].

Worldwide, there are regional variations in the rate of medication non-adherence among patients with schizophrenia. A comprehensive literature review revealed that non-adherence rates in schizophrenia are approximately 50%, with a wide range from 4% (found in a study with depot neuroleptic drugs) to 72% [ 12 ]. A study done in France among 291 participants reported that, 30% of them were considered to be non-adherent [ 13 ]. In Turkey 24.2% of individual with schizophrenia found to be non-adherent [ 14 ]. A study done among Nigerian out-patients with schizophrenia revealed that 62.5% of subjects were non-adherent to antipsychotic medications [ 15 ]. In Ethiopian context, the prevalence rate of antipsychotic non-adherence among peoples with schizophrenia ranges between 26.5% [ 16 ] and 48.4% [ 17 ].

Studies have shown that a frequent dosing schedule and severe illness symptoms [ 18 ] low level of therapeutic alliance, use of atypical antipsychotics [ 13 ], long-term substance abuse, financial restraints, medication related adverse effects, low level of insight [ 19 ], being female, poor social support, number of medications, complex drug regimen, were strong determinants of antipsychotic non-adherence among individuals with schizophrenia.

Identifying factors that are responsible for medication non-adherence is the first approach toward formulating effective solutions in order to improve level of adherence and treatment outcome of the peoples with schizophrenia. There are limited studies conducted on magnitude of medication non-adherence among peoples with schizophrenia in Ethiopia. Therefore, this study aims to assess the prevalence of medication non adherence and associated factors among peoples with schizophrenia attending outpatient psychiatry department at comprehensive specialized hospitals in Northwest Ethiopia.

Materials and methods

Study area and period.

This study was conducted at the University of Gondar Comprehensive Specialized Hospital (UoGCSH), Felege-Hiwot Comprehensive Specialized Hospital (FHCSH), and Tibebe-Ghion Comprehensive Specialized Hospital (TGCSH) from June 1 to August 30 2022. The psychiatry department of UoGCSH offers services for individuals with mental health disorders, catering to both outpatient and inpatient needs. On average, 820 patients have follow-up visits per month in the psychiatry outpatient clinic [ 20 ]. Felege-Hiwot Comprehensive Specialized Hospital (FHCSH) provides mental health services through its inpatient unit with seventeen beds and four outpatient departments. Annually, it attends to a total of 19,200 clients, averaging 1,600 clients per month. Tibebe-Ghion Specialized Hospital (TGCSH) provides mental health services through four outpatient departments, one emergency room, and two inpatient units with a total capacity of 13 beds. Additionally, it offers psychotherapy services. Based on the monthly report from the psychiatry unit, TGCSH attends to a total of 4,864 outpatient clients annually, averaging 405 clients per month [ 21 ].

Study design and population

An institution-based cross-sectional study was employed. All adult peoples with schizophrenia having a regular follow up at the outpatient departments’ psychiatric clinic in the comprehensive specialized hospitals of Northwest Ethiopia were the source population. All adult individuals with schizophrenia having a regular follow up at the outpatient departments of UoGCSH, FHCSH and TGCSH during the study period were the study populations. Participants with the age of 18 years and above, taking antipsychotic medication, who had an insight to respond oral questions (satisfy the requirement in the insight assessment tool (get 3 out of 3), and patients who had one or more previous visits were included under the study. Participants who had incomplete medical record were excluded from the study.

Sample size determination

The sample size was calculated using a single population proportion formula as follows:

where, n is the desired sample size for a population of > 10,000, Z is the typical normal distribution set at 1.96 (which corresponds to 95% CI), the p-value signifies that positive prevalence was utilized in calculating the optimal sample size, and d is the degree of accuracy 0.05 required (a marginal error is 0.05). Even if there are studies conducted in our country, as this is a multicenter study, to get better representative sample, we used proportion as 50% in sample size calculation. Therefore, \(n=\frac{( 1.96{)}^{2} \times 0.5 (1-0.5)}{{0.05}^{2}}=384\)

Then, by adding 5% non-response rate, the final calculated sample size was 403.

Sampling technique and procedure

The comprehensive specialized hospitals in the Northwestern Ethiopia were selected by a random lottery method. The total number of schizophrenia patients on follow up within 3 months was taken from the patients’ registration document to allocate samples proportionally within study areas. After proportional allocation, a systematic random sampling technique was used to select the study participants. The sampling fraction (k) was calculated by dividing the total number of peoples with schizophrenia within 3 months in the study area by the total sample size; (2625/403 gives 6.5 ≈ 6). The average number of peoples with schizophrenia in UoGCSH, FHCSH, and TGCSH were 1100, 1150, and 375, respectively. Therefore, the proportional allocation of sample size was 169 for UoGCSH, 176 for FHCSH, and 58 for TGCSH. The starting point was selected randomly from 1 to 6. Then, participants were interviewed, and concurrently, relevant data was reviewed from medical charts for every sixth respondents until the requirement for a sample was fulfilled. A unique identification card number was utilized as a questionnaire code in order to prevent the inclusion of the same respondents in the study more than once.

Operational definitions

• Medication non-adherence

According to medication adherence rating scale (MARS), a value of less than 6 out of ten items is defined as non-adherence and value of ≥ 6 indicates adherence [ 22 ].

Antipsychotic polypharmacy

Refers to the co-prescription of more than one antipsychotic drug for a patient. Polypharmacy was documented when a particular patient was prescribed more than one antipsychotic drug for a minimum duration of one month or longer. [ 23 , 24 ].

• Extra-pyramidal side effect

Was screened using Simpson Angus Scale (SAS), with score of 0.65 and above [ 25 ].

Current substance use

Using at least one of a specific substance (alcohol, Khat or cigarettes) for nonmedical purposes within the last 3 months according to the Alcohol, Smoking, and Substance Involvement Screening Tool (ASSIST) [ 26 ].

Data collection instrument and procedure

A structured questionnaire was adopted from a previous literature [ 17 ] with some modifications for the context of the study area and socio-demographic characteristics of study participants was used. It was translated to the local Amharic language, and then back translated to the English version to check consistency. Translation was not required for variables obtained from medical records of the patients. The data collected by patient interview includes sociodemographic characteristics, substance use, and medication non- adherence. Physical examination and observation was used to measure extra-pyramidal side effect. The participants medical charts were used to fill in clinically related variables like duration of illness, duration of treatment, number of admissions, presence of co-morbidity, type of antipsychotics, and presence of antipsychotics polypharmacy. The questioner had five parts. The first part contains socio-demographic characteristics of the study participants, such as sex, age, marital status, residence, religion, educational level, occupation, and income level. The second section consisted of clinical and medication related characteristics like duration of illness, presence of co-morbidity, individual’s medication record, duration of treatment, and number of admissions. The third section consisted of the current substance use assessment tool. ASSIST was used to briefly screen ' use of psychoactive substances. The tool was developed and validated by WHO [ 26 ]. The fourth section consisted of an extra-pyramidal side effect assessment tool. The Simpson-Angus Scale (SAS) was used to measure antipsychotic induced side effect on a 10-item rating scale. It has been commonly used in both clinical and research setups. It consists of one item measuring gait (hypokinesia), six items measuring rigidity, and three items measuring glabella tap, tremor, and salivation, respectively. The cut-off value for screening for neuroleptic induced parkinsonism is 0.65 or more [ 25 ]. It has been used in Ethiopia [ 24 , 27 , 28 ]. The fifth section consisted of an adherence measuring tool. Medication Adherence Rating Scale (MARS) was used to evaluate medication non-adherence, which is a ten-item yes/no self-report questionnaire [ 29 ]. The MARS was adopted as a measure of medication adherence in the Psychological Prevention of Relapse in Psychosis experiment [ 30 ]. MARS has been utilized in Ethiopia [ 16 , 22 , 31 ].

Data quality control

Data was collected by face-to-face interview using a structured and pretested questionnaire. Data was collected by three BSc psychiatric nurses in UoGCSH under supervision of one master’s degree in psychiatry, three BSc psychiatric nurses in FHCSH with supervision of one BSc psychiatric nurse and two BSc psychiatric nurses in TGCSH under supervision of one BSc psychiatric nurse. The supervisors distributed all the necessary items for data collectors on each data collection day and were tasked with checking the filled questionnaire for completeness and solving reported problems timely during the data collection period. In all study areas, the principal investigator facilitated all the necessary materials.

To assure the quality of the data, one day training was given by the principal investigator at each study area for data collectors and supervisors. A pretest was conducted on 22 of the 5% of peoples with schizophrenia at Dessie Comprehensive Specialized Hospital's outpatient department to identify potential problems with the data collection tool and check the consistency of the questionnaire. Some modifications, such as correction of typing errors and the rearranging of questionnaires were made. The internal consistency of ASSIST, SAS, and MARS was assessed, and the Cronbach’s alpha was 0.76, 0.88 and 0.75 respectively, which was acceptable.

Data processing and analysis

The collected data was cleaned, coded, and entered into Epi Data 4.6.0 and analyzed using Statistical Package for Social Studies (SPSS) version 24. In descriptive analysis, the mean with standard deviation (SD), frequency, and percentages were used to check the distribution of the data. Bivariable and multivariable binary logistic regression analysis were employed to identify factors associated with medication non-adherence. The odds ratio (OR) with a 95% confidence interval was computed for each variable for the corresponding p-value to see the strength of association. A P-value of < 0.05 was used as the cut-off for the significance of the association between the outcome and the predictor variables. The model fitness was tested, and the Hosmer and Lemeshow test result was 0.809. Multicollinearity was checked, and the maximum Variance Inflation Factor (VIF) reported was less than 5, which was within the acceptable level.

Sociodemographic characteristics of study participants

From a total of 403 approached samples, 387 (with a response rate of 96.1%) eligible participants with schizophrenia were included in the study. The majority (58.9%) were male with a mean (± SD) age of 36.5 (± 11.7) years. Greater than half (52.7%) of participants were married, and more than two-third (70.0%) of them lived in urban areas. More than a quarter (27.4%) of the participants' educational level was high school, and around one-fifth (22.7%) of them were privately employed. More than three-quarters (76.5%) of participants had a monthly income above 1200 Ethiopian birr as shown below ( Table  1 ).

Clinical and substance related characteristics of participants

In terms of clinical characteristics, nearly half of the participants (47.8%) and nearly three-quarters (74.9%) had illness and treatment duration for less than 5 years respectively. One-quarter (25.3%) of patients had other co-morbid illnesses, from which hypertension (29.6%) and diabetes mellitus (21.4%) were predominant. One-quarter of respondents (25.1%) had two or more inpatient admissions, and 33.9% were substance users. More than two-fifths (44.3%) of those who used psychoactive substances used alcohol as shown below ( Table  2 ) .

Medication-related characteristics of participants

In this study, the prevalence of medication non-adherence was 51.2% (CI: 46.3, 56.3). More than one fifth (22.2%) of participants were on antipsychotic polypharmacy. About one-fourth (25.6%) of respondents took haloperidol and 26.4% of individuals received adjuvant medications, from which Amitriptyline was the predominant (35.3%). Roughly 15.0% of participants developed extra-pyramidal side effect (Table  3 ).

Factors associated with medication non-adherence

On multivariate analysis, longer duration of treatment, substance use, antipsychotic polypharmacy and extra-pyramidal side effect were significantly associated with medication non-adherence. Accordingly, participants who had treatment duration for more than ten years were 3.76 times more likely to be non-adherent compared with those who had treatment duration for less than five years (AOR = 3.76, 95% CI: 1.43, 9.89). Likewise, respondents who were psychoactive substance users were 1.92 times more likely to be non-adherent than those who were not substance users (AOR = 1.92, 95% CI: 1.17, 3.13).

Individuals who were on APP were 2.01 times more likely to be non-adherent than those who were on antipsychotic monotherapy (AOR = 2.01, 95% CI: 1.11, 3.63). Concerning extra-pyramidal side effect, those who developed EPS were 2.48 times more likely to be non-adherent than those who did not developed (AOR = 2.48, 95% CI: 1.24, 4.94) as shown below ( Table  4 ) .

Despite the critical need of pharmacotherapy, it has been noted that non-adherence with suggested pharmacological therapies is a global issue and is possibly the most challenging aspect of treating people with schizophrenia [ 8 ]. Non-adherence to antipsychotics may increase the risk of symptomatic relapse, reduce the efficacy of therapy, increase the chance of suicidal thoughts or attempts, need frequent visits to the emergency department, increase treatment costs and consequently diminish quality of life [ 9 , 10 , 11 ]. Aiming at assessing medication non-adherence and associated factors in peoples with schizophrenia, the current study found that the overall prevalence of non-adherence was 51.2%. Duration of treatment, substance use, APP and extra-pyramidal side effect were significantly associated with medication non-adherence.

In this study, the prevalence of medication non-adherence was 51.2% (CI: 46.3, 56.3) which is comparable with studies in Ethiopia (48.4%) [ 17 ], Nigeria (54.2%) [ 15 ], and multi-continent survey (53%) [ 32 ]. However this finding is higher than that of study done in Mekelle (26.5%) [ 16 ] and Jimma 41.2% [ 33 ] Ethiopia. This variation could be due to differences in the types of adherence assessment tools and diverse inclusion criteria used. The study conducted in Mekelle reported relatively low rates of non-adherence, likely due to the differing approaches used to measure drug adherence. The lack of standardized criteria makes it challenging to categorize the extent of non-adherence among schizophrenia patients. For example, MARS used in Mekelle required 'yes/no' responses, with a score of 3 or above indicating adherence, and a score of 2 or below indicating non-adherence. This categorization differs from the current study, where adherence was defined as a MARS score of 6 or higher, and non-adherence as a score below 6. Additionally, the inclusion criteria varied, such as including only patients aged 18—65 and those who had been on continuous therapy for at least three months prior to the study [ 16 ], which may also have influenced the observed differences.

Studies conducted in Uganda 16.3% [ 34 ], China (20%) [ 35 ], Hong Kong 30% [ 36 ]indicated that the incidence of non-adherence were lower than the current study. On the contrary, study in Jordan (64.2%) [ 37 ], and India (88.16%) [ 38 ] were higher than the current study The inconsistencies in the prevalence of non-adherence may be explained by differences in clinical settings and methodological variations. These include diverse inclusion and exclusion criteria, such as requiring patients to have taken typical antipsychotics for at least six months [ 34 ], excluding patients who use psychoactive substance [ 35 ] and variations in study populations and sampling methods (convenience sampling) [ 38 ]. This finding suggests that appropriate interventions, such as developing awareness and implementing planned and continuous counseling programs, should be implemented to enhance their level of medication adherence.

In the current study, socio-demographic variables were not associated with medication non-adherence, consistent with previous evidence [ 17 ]. However, other studies have reported correlations between medication non-adherence and factors such as age range [ 39 ], place of residence [ 40 ], marital status [ 41 ], and educational level [ 16 ]. These discrepancies could be due to variations in demographic data and sample size.

In terms of treatment duration, participants with treatment duration of more than ten years were more likely to be non-adherent compared with those who had treatment duration for less than five years. This is in line with various studies [ 42 ], [ 43 ]. This could be because of after starting treatment, these individuals may have interrupted their follow-up after achieving remission, and they may have had a poor outcome over time. Besides longer treatment course might predispose forgetfulness, carelessness and exposure for side effects may negatively influence medication adherence. Healthcare professionals need to follow and provide continuous counseling to improve adherence for patients having longer duration of treatment.

This study also showed that peoples who use psychoactive substance were more likely to be non-adherent than those who did not use. This finding is in line with studies from Ethiopia [ 42 ], Morocco [ 44 ] and Norway [ 45 ]. This might be due to a person's internal state can be negatively impacted by specific substance use, leading to worsened cognitive abnormalities and unpleasant withdrawal symptoms. There are a number of long-term social and clinical implications of drug and alcohol use in addition to the immediate bodily effects. In addition, substance users are more likely to experience tardive dyskinesia and report more extra-pyramidal symptoms than those who abstain from using drugs or alcohol. The higher likelihood of social rejection and eventual homelessness or a lack of family support is additional effects of those substances, both of which can lead to prescription non-adherence[ 17 ]. Hence individuals who use psychoactive substances require psychological support to withdraw from psychoactive substances in order to adhere to their medications.

In the current study, respondents who were on antipsychotic polypharmacy were more likely to be non-adherent than those who were on monotherapy. This finding goes with studies from Ethiopia [ 42 ], Nigeria [ 15 ] and Jordan [ 37 ]. This could be justified by being on APP, which may predispose to increased overall dose, increased utilization of concurrent anticholinergic medications, adverse drug reaction and drug interaction [ 46 ] which negatively influences medication adherence. Therefore people who were on APP need better antipsychotic utilization program and follow up to improve medication adherence.

This study also indicated that, those who developed EPS were more likely to be non-adherent than those who did not developed EPS. This finding is in line with studies from Ethiopia [ 17 ], Nigeria [ 3 ] and United states of America [ 28 ]. The possible explanation might be, developing side effect that hampers day-to-day activities, mobility, work capacity, and energy [ 47 ] might have its impact in reducing medication adherence. Consequently, individuals who developed EPS require better treatment of the side effect and improved selection of antipsychotics so as to enhance adherence to medications.

Limitation of the study

The current study has several limitations. Firstly, its results are only applicable to the study areas. Secondly, the study did not report the dosing of antipsychotics. Additionally, due to the inherent limitations of a cross-sectional design, it was unable to determine causal relationships between the independent and dependent variables. Self-reported adherence rates are known to overstate adherence prevalence, which may affect the findings. Furthermore, this study did not examine disease severity, and the assessment of substance use is subject to social desirability bias.

Conclusion and recommendation

In this study, half of the participants were found to be non-adherent. Critical follow-up is necessary for peoples who have been receiving treatment for a longer duration, substance users, those on antipsychotic polypharmacy and those who experience extra-pyramidal side effects. Healthcare personnel who work in hospitals should do routine substance use screenings and offer counseling on quitting psychoactive substances. To limit their detrimental impact on medication adherence, extra-pyramidal side effect should also be periodically monitored. Future studies could look at the relationship between medication non-adherence and potential predictive variables causally.

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

Adjusted Odds Ratio

Antipsychotic Polypharmacy

Alcohol Smoking and Substance Involvement Screening Test

Confidence Interval

Crude Odds Ratio

Diabetes Mellitus

Extra-pyramidal Side Effect

Felege-Hiwot Comprehensive Specialized Hospital

Human Immunodeficiency Virus

Medication Adherence Scale

Medication Adherence Rating Scale

Tibebe-Ghion Comprehensive Specialized Hospital

Simpson Angus Scale

Standard Deviation

Statistical Package for Social Studies

University of Gondar Comprehensive Specialized Hospital

Variance Inflation Factor

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Acknowledgements

We would like to acknowledge UoGCSH, FHCSH and TGCSH for facilitating the data collection. Also, we would like to express our deep gratitude to data collectors for their admirable commitment, as well as to study participants for their willingness to participate in this research.

The study was funded by University of Gondar.

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Department of Pharmacy, Health Science College, Debre Markos University, Debre Markos, Ethiopia

Fasil Bayafers Tamene, Kale Gubae & Samuel Agegnew Wondm

Clinical Pharmacy Unit, Department of Pharmacy, College of Medicine and Health Science, Bahir Dar University, Bahir Dar, Ethiopia

Endalamaw Aschale Mihiretie

Depatment of Psychiatry, School of Nursing and Midwifery, College of Health and Medical Science, Haramaya University, Harar, Ethiopia

Abiy Mulugeta

Department of Psychiatric Nursing, College of Medicine and Health Science, Wollo University, Dessie, Ethiopia

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Contributions

'FB wrote the protocol, designed the study, facilitated data collection, analyzed the data, and drafted the manuscript. AM and SA revised the manuscript and critically reviewed the article. AK participated in the analysis and interpretation of the results. EA and KG were involved in the facilitation of the data collection and critical review parts'.

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Correspondence to Fasil Bayafers Tamene .

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Ethical approval was obtained from the ethical review committee of the School of Pharmacy of the University of Gondar, with a reference number of SOPS/206/2014. Authorization was secured from all hospital authorities to perform this study. All study participants were informed about the purpose of the study, and their participation was voluntary. The participants were informed that a lack of desire to engage in the research would not affect the service they obtained. The participants were informed that a lack of desire to engage in the research would not affect the service they obtained. Written informed consent was gathered from individual participants. The privacy of participants was guaranteed, and any personal identifiers were not used. All the data was synonymized. The study was conducted based on the Declaration of Helsinki.

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Tamene, F.B., Mihiretie, E.A., Mulugeta, A. et al. Medication non-adherence and associated factors among peoples with schizophrenia: multicenter cross-sectional study in Northwest Ethiopia. BMC Psychiatry 24 , 567 (2024). https://doi.org/10.1186/s12888-024-06004-7

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Received : 21 October 2023

Accepted : 06 August 2024

Published : 19 August 2024

DOI : https://doi.org/10.1186/s12888-024-06004-7

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• Schizophrenia
• Substance use
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