Attitude on Medication Use May Affect Severity of Illness

Greater patient insight and positive attitudes toward medication appear to be associated with less severe symptoms and better functioning among patients with schizophrenia.

That's the finding from the latest analysis of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE). The report was posted online June 26 in the advanced access section of Schizophrenia Bulletin.

Higher levels of insight at baseline were significantly associated with less severe schizophrenia symptoms at 18-month follow-up, while more positive medication attitudes were significantly associated with both lower symptom levels and better community functioning.

(Symptoms of schizophrenia were assessed by the Positive and Negative Syndrome Scale [PANSS], which yields a total average symptom score, based on 30 items rated from 1 to 7, with higher scores indicating more severe symptoms, as well as subscales reflecting positive, negative, and general psychiatric symptoms.)

Change in insight scores over time was associated with declining severity of schizophrenia symptoms, and change toward more positive medication attitudes was associated, independently of changes in insight, with significant decreases in psychopathology, improvement in community functioning, and greater medication compliance, according to the report.

CATIE was a large, 18-month, randomized, controlled trial that was designed to compare outcomes of one conventional antipsychotic medication (perphenazine) and four second-generation antipsychotics (olanzapine, risperidone, quetiapine, and ziprasidone). It was funded by the National Institute of Mental Health and conducted from January 2001 through December 2004 at 57 U.S. sites.

Insight was assessed by the Insight and Treatment Attitudes Questionnaire (ITAQ), which is designed to measure awareness of illness and insight into need for treatment in patients with schizophrenia. It consists of 11 items that are phrased as questions to elicit responses on a Likert scale. Attitudes toward medication were assessed by the Drug Attitude Inventory (DAI).

Psychosocial functioning and quality of life were assessed using the Heinrichs-Carpenter Quality of Life (HQOL) Scale and a single item from the Lehman Quality of Life Interview. Medication adherence was evaluated using monthly pill counts and information from patients, family, and clinicians.

In addition to antipsychotic treatment, participants were offered an educational plan designed to inform patients and families about diagnosis, medications, symptom self-monitoring, side effects, and change in symptoms.

Statistical analyses showed that scores on the ITAQ and DAI were significantly positively correlated, and both were correlated with lower PANSS scores and higher HQOL scores—meaning that patients who had greater insight into their illness also tended to have greater awareness of the importance of medication. Those patients tended to have fewer symptoms and higher functioning at follow-up.

Moreover, change in insight scores from baseline to follow-up was associated with decreased PANSS total scores, improvement in the HQOL total, and increased medication compliance.

“Taken together, the results suggest that increasing [patients'] insight into their illness and fostering positive attitudes toward medication may result in improved symptom and [quality of life] outcomes,” wrote Somaia Mohamed, M.D., of the VA Connecticut Health Care System, and colleagues. “They suggest possible benefits of exploring negative attitudes toward medication in a client-centered manner. Such an approach should be based on the development of a supportive therapeutic alliance and a strong positive practitioner-consumer relationship. The nature of this relationship has undergone major developments in recent years, shifting from a hierarchical medical model to a recovery-oriented model that requires new ways of understanding and approaching the issue of medication choice.”

An abstract of “Cross-Sectional and Longitudinal Relationships Between Insight and Attitudes Toward Medication and Clinical Outcomes in Chronic Schizophrenia” is posted at<http://schizophreniabulletin.oxfordjournals.org/cgi/content/abstract/sbn067v1>.▪