The Impact Of Side Effects On Schizophrenia And Bipolar Disorder Patients’ Adherence To Prescribed Medical Therapy

Perspect Psychiatr Care. 2020;56:691–696. wileyonlinelibrary.com/journal/ppc © 2020 Wiley Periodicals, Inc. | 691

Received: 5 January 2020 | Accepted: 2 February 2020 DOI: 10.1111/ppc.12483

O R I G I N A L A R T I C L E

The impact of side effects on schizophrenia and bipolar disorder patients’ adherence to prescribed medical therapy

Elvan E. Ata1 | Emel Bahadir‐Yilmaz2 | Nurten G. Bayrak3

1Faculty of Nursing, Sağlık Bilimleri University,

Istanbul, Turkey

2Department of Psychiatric Nursing, Faculty of

Health Sciences, Giresun University, Giresun,

Turkey

3Giresun University Prof. Dr. A İlhan Özdemir

Training and Research Hospital, Giresun

University, Giresun, Turkey

Correspondence

Emel Bahadir‐Yilmaz, Department of Psychiatric Nursing, Faculty of Health

Sciences, Giresun University, 28340 Piraziz,

Giresun, Turkey.

Email: ebahadiryilmaz@yahoo.com and

emel.bahadir.yilmaz@giresun.edu.tr

Abstract

Purpose: Our study aims to investigate how antipsychotic drugs’ side effects impact

schizophrenia and bipolar disorder patients and how this affects their adherence to

prescribed medical therapy.

Design and Methods: The study sample consists of 47 bipolar disorder and

45 schizophrenic patients. Data were collected using the Medication Adherence Rating

Scale (MARS) and Liverpool University Neuroleptic Side Effect Rating Scale (LUNSERS).

Findings: The mean total LUNSERS scores showed that bipolar disorder patients had

more significant side effects compared with schizophrenic patients (P < .05). There

was a moderate negative correlation between the mean MARS scores and mean

LUNSERS scores of bipolar disorder patients (P < .05).

Practice Implications: Nursing care actions and strategies should be planned and

implemented to promote adherence to treatment.

K E Y W O R D S

bipolar disorder, drug side effects, schizophrenia, treatment adherence

1 | INTRODUCTION

The treatment of chronic mental illnesses such as schizophrenia and bi-

polar disorder (BD) includes preventing relapse and recurrent hospitali-

zations, promoting recovery and improving adherence to treatment and

the quality of life.1 Antipsychotics are usually the first choice in achieving

these goals. However, even if these drugs provide substantial benefits to

the patient, they come together with some serious potential side effects. 2‐4 Patients who experience side effects that they cannot manage are

more likely to end up giving up on their medication.5 Thus, the side

effects of antipsychotics may lead to the nonadherence of the patient.6

Adherence to the treatment includes regularly visiting the physi-

cian, meeting the treatment program requirements and following the

prescription.5 Not or partially adhering to the prescribed medication,

using nonprescribed drugs, missing appointments, and discontinuing

follow‐ups all indicate nonadherence to the treatment.7 According to Turkish studies, 55.3% of BD patients showed noncompliance to the

treatment,8 whereas 69.5% of schizophrenia patients had partial

compliance.9 Other studies found noncompliance rates ranging from

26.5% to 77% among BD and schizophrenic patients.2,10,11

Discontinuing treatment is a serious issue for these patients, as it can

lead to relapse, repeated hospitalization, impaired functionality, and sui-

cide attempts.12,13 “Treatment resistance” can lead to higher rates of

mortality and morbidity, as well as to a decline in educational and vo-

cational performance, problems in the family and lower quality of life.14

Our study investigates how antipsychotic drugs’ side effects impact

schizophrenia and BD patients and how this affects their adherence to

prescribed medical therapy.

2 | METHOD

2.1 | Design

This is an analytic and descriptive study that compares the side effects of

BD and schizophrenia medication to patients’ adherence to treatment.

This study is accepted as an oral presentation at the 3rd Symposium of Family‐Based Approach in Nursing, Giresun, Turkey, 3 May 2019.

 

 

2.2 | Population and sample of the research

The sample consisted of 47 BD and 45 schizophrenia patients who

were hospitalized in the psychiatry clinic of a public hospital in

Turkey between 1 February and 1 July 2016. All subjects gave

consent to participate in the study. The subjects were selected

through purposeful sampling method, and the patients who met the

criteria for participation in the study were included in the sample.

The inclusion criteria were as follows: (a) volunteering to participate

in the study, (b) basic literacy, (c) no sensory dysfunctions, (d) being

prescribed antipsychotic drugs, (e) ability to understand and interpret

the questions, and (f) no comorbidity.

2.3 | Ethical responsibility

This study was approved by the hospital and the Ethical Committee

of General Secretariat of Provincial Public Hospitals Association

(Date: 24 November 2015, Case number: 4843‐7222). The patients were informed regarding the purpose and method of the study.

Those who were willing to participate and gave verbal consent were

included. This study was conducted following the principles of the

Declaration of Helsinki.

2.4 | Data collection

Data were collected using the Patient Information Form, Medication

Adherence Rating Scale (MARS), and the Liverpool University

Neuroleptic Side Effect Rating Scale (LUNSERS).

• Patient Information Form: The form was prepared by the researchers

in accordance with the current literature. The 16‐question form required demographic information: age, sex, educational status,

economic status, duration of illness, family history of mental illness,

and so forth.12‐15

• MARS: The scale was developed by Thompson et al16 as a com-

bination of the Morisky Medication Adherence Scale and the Drug

Attitude Inventory. Koç17 analyzed the validity and reliability of

the Turkish version of MARS. The scale consists of 10 Yes or No

questions that evaluate the patient’s treatment compliance

behaviors and attitudes within the last week. The final score is

used to categorize patients according to treatment adherence:

poor adherence (1‐7) and good adherence (8‐10). • LUNSERS: This self‐report scale was developed by Day et al18 to

determine the side effects of antipsychotics. The Cronbach’s α

value of the scale is .89.18 The validity and reliability of the Turkish

version were analyzed by Yilmaz and Buzlu,19 and the Cronbach’s

α reliability coefficient was .89. LUNSERS is a five‐point Likert‐type self‐report scale that aims to evaluate the intensity of side effects in the last month (0: not at all, 1: very little, 2: a little, 3: quite a lot,

and 4: very much). The scale consists of 51 items that are cate-

gorized into eight types of side effects: extrapyramidal, psychic,

anticholinergic, allergic, autonomic, hormonal, miscellaneous,

and red herrings. In the scale, 41 items consist of expressions

measuring side effects, while 10 items consist of expressions that

are not known to be neuroleptic side effects. The total score in-

dicates the severity of the side effects. The scores are interpreted

as follows: very low (0‐7), low (8‐27), average (28‐58), high (59‐80), and very high (80 and above). Over the 41 items, the possible score

range is 0 to 164 for women and 0 to 156 for men.

2.5 | Statistical analysis

The data were analyzed using the SPSS 16 package program, and

they were found to have normal distribution according to the

Kolmogorov‐Smirnov test. The data were analyzed using descriptive statistics (number, percentage, mean and standard deviation), the χ2

test, independent sample t test and Pearson’s correlation analysis.

3 | RESULTS

Table 1 presents the sociodemographic characteristics of the patients.

The mean age of the patients with BD was 43.53 ± 14.28 years; 66%

were women, 51.1% were married, 91.5% were from a nuclear family,

40.4% only had primary education, and 78.7% were unemployed. The

mean age of the patients with schizophrenia was 44.31 ± 12.76 years;

28.9% were women, 20% were married, 82.2% were from a nuclear

family, 60% only had primary education, and 82.2% were unemployed.

Of the subjects, 44% had at least one family member who was diag-

nosed with mental illness. The average time of diagnosis was 15 years

before for the schizophrenia patients and 11 years before for the BD

patients.

Table 2 presents the subjects’ mean MARS and LUNSERS scores.

The mean total MARS scores of the two groups were not significantly

different (BD, 4.51 ± 2.20; schizophrenia, 5.11 ± 2.25; P > .05). The

mean total LUNSERS scores of both groups indicate average side

effects, with BD patients having significantly more side effects (BD,

57.55 ± 25.72; schizophrenia, 47.73 ± 19.68; P < .05). Specifically, BD

patients’ hormonal and general side effect scores were higher (P < .05).

Table 3 presents the distribution of MARS and LUNSERS scores.

The distribution of LUNSERS scores indicates that 51.1% of all

patients had moderate side effects, 26.1% high and 10.9% very high.

Of BD and schizophrenia patients, 46.8% and 55.6% had moderate

side effects, respectively, and the difference between the two groups

was not significant. Of the subjects, 85.9% had poor treatment

compliance: 91.5% of BD patients and 80.0% of schizophrenia pa-

tients had poor treatment compliance, and the difference between

the two groups was not significant.

Table 4 presents the correlation between side effects and treat-

ment adherence. Schizophrenia patients’ total MARS and LUNSERS

scores and subscale scores were not found to be correlated (P > .05). BD

patients’ total MARS scores had a low negative correlation to the

extrapyramidal side effect subscale scores (r = −.297; P = .042). Also, the

692 | ATA ET AL.

 

 

BD patients’ total MARS scores were moderately negatively correlated

with their psychic subscale scores (r = −.469; P = .001) and the total

LUNSERS scores (r = −.3327; P = .025).

4 | DISCUSSION

The mean total MARS scores of the two groups were not significantly

different. Of the BD and schizophrenia patients, 91.5% and 80.0% had

poor treatment compliance, respectively, and the difference between

the two groups was not significant. Likewise, Demir‐Özdemir et al20

found that the treatment compliance of BD and schizophrenia patients

was not significantly different. Another study found that BD patients

suffer from nonadherence significantly more than schizophrenia

patients.21 This may be a result of the rehabilitation programs that

are provided to schizophrenia patients, which help support compliance.

The community mental health centers (CMHCs) and similar associations

in Turkey aim to support schizophrenia patients and provide them

with compliance‐related training and psychoeducation. In contrast, another study by Demirkol et al22 found that the compliance rates of

schizophrenia patients in the psychiatry clinic of a university hospital

were lower than those of BD patients (16.7% vs 34%). We believe that

TABLE 1 Sociodemographic characteristics of the patients

Bipolar disorder (n = 47) Schizophrenia (n = 45)

n % n % Test value P value

Sex

Female 31 66.0 13 28.9 12.659 .000

Male 16 34.0 32 71.1

Marital status

Married 24 51.1 9 20.0 14.992 .001

Single 11 23.4 28 62.2

Divorced 12 25.5 8 17.8

Educational background

Illiterate 2 4.3 2 4.4 9.008 .061

Literate 13 27.7 5 11.1

Primary school 19 40.4 27 60.0

High school 7 14.9 10 22.2

University 6 12.8 1 2.2

Employment status

Unemployed 37 78.7 37 82.2 0.179 .672

Employed 10 21.3 8 17.8

Income status

High 5 10.6 5 11.1 1.183 .554

Moderate 29 61.7 23 51.1

Low 13 27.7 17 37.8

Place of residence

City 25 53.2 17 37.8 2.201 .138

Town/village 22 46.8 28 62.2

Family structure

Nuclear 43 91.5 37 82.2 3.519 .172

Extended … … 3 6.7

Divorced 4 8.5 5 11.1

History of physical illness

Yes 19 40.4 15 33.3 0.496 .481

No 28 59.6 30 66.7

Family history of psychiatric illness

Yes 21 44.7 20 44.4 0.001 .982

No 26 55.3 25 55.6

Age, mean ± SD 43.53 ± 14.28 44.31 ± 12.76 0.275 .784

Average time of diagnosis, mean ± SD 11.08 ± 9.82 15.07 ± 10.94 −1.834 .069

Number of hospitalization, mean ± SD 5.91 ± 7.01 7.32 ± 7.23 0.938 .351

ATA ET AL. | 693

 

 

our results differ from this specific study because of its context, as this

study was conducted in a tertiary medical institution that handles more

complex medical cases.

Similarly, the subjects of Dikeç and Kutlu,23 all of whom were

members of the Schizophrenia Association, scored higher on

MARS compared with our subjects. Likewise, a study conducted with

patients that were registered with the CMHC obtained higher

total MARS scores than our subjects.15 The reason that the total

treatment compliance scores of our subjects are lower than similar

studies may be due to our subjects’ lack of regular health care and

psychosocial support as well as the fact that subjects from other studies

were selected from establishments that specifically provide their mem-

bers with rehabilitation and compliance training. A study found that the

compliance scores of patients that were registered to the CMHC were

significantly higher than those of patients that had not attended for

more than 6 months.24 Several other CMHC‐based studies supported this finding. One study indicated that participation is correlated with

better functionality, insight, and treatment adherence,15 whereas an-

other reported that schizophrenia patients participating in rehabilitation

programs had higher medical compliance rates than nonparticipating

patients.25 One study compared schizophrenia patients who were trea-

ted in a psychiatry outpatient clinic to patients that were regularly

monitored in CMHCs and found that CMHC participants had better

functionality, insight, and treatment compliance.26

These findings indicate the importance of support practices, such as

counseling, psychoeducation, and follow‐ups, for better treatment out- comes, as these practices improve not only treatment compliance but

also insight and functionality of the patients. Better insight will improve

the motivation of both schizophrenia and BD patients.27 Another

study stated that being better informed about the medications, more

emotional support and stability in relation to healthcare workers will

increase patients’ compliance with treatment.11

We found that the subjects experienced average side effects and

that BD patients had more side effects than schizophrenia patients.

TABLE 2 The mean MARS and LUNSERS scores of the patients

Bipolar disorder, X ± SD Schizophrenia, X ± SD t P

Total MARS scores 4.51 ± 2.20 5.11 ± 2.25 −1.290 .200

Extrapyramidal symptoms 10.25 ± 5.48 8.93 ± 4.88 1.219 .226

Anticholinergic 5.55 ± 3.59 5.11 ± 3.39 0.606 .546

Autonomic 5.85 ± 4.45 4.62 ± 3.98 1.392 .167

Allergic 1.85 ± 2.87 1.53 ± 2.05 0.608 .545

Miscellaneous 5.78 ± 2.74 4.02 ± 2.50 3.217 .002

Hormonal 8.38 ± 4.93 4.51 ± 3.55 4.299 .000

Psychic 19.87 ± 8.43 19.00 ± 7.36 0.527 .599

Red herring 7.91 ± 6.97 5.62 ± 5.01 1.804 .075

Total LUNSERS scores 57.55 ± 25.72 47.73 ± 19.68 2.049 .043

Abbreviations: LUNSERS, Liverpool University Neuroleptic Side Effect Rating Scale; MARS,

Medication Adherence Rating Scale.

Miscellaneous and total LUNSERS scores P < .05 hormonal P < .01.

TABLE 3 Distribution of MARS and LUNSERS scoresTotal,

n (%)

Bipolar disorder,

n (%)

Schizophrenia,

n (%)

Test

value P value

Total LUNSERS scores

0‐7 (low) 1 (1.1) 1 (2.1) 0 (0.0) 2.667 .106 8‐27 (mild) 10 (10.9) 3 (6.4) 7 (15.6) 28‐58 (moderate) 47 (51.1) 22 (46.8) 25 (55.6) 59‐80 (high) 24 (26.1) 14 (29.8) 10 (22.2) 80≥ (very high) 10 (10.9) 7 (14.9) 3 (6.7)

Total MARS scores

1‐7 (poor treatment compliance)

79 (85.9) 43 (91.5) 36 (80.0) 1.586 .116

8‐10 (good treatment compliance)

13 (14.1) 4 (8.5) 9 (20.0)

Abbreviations: LUNSERS, Liverpool University Neuroleptic Side Effect Rating Scale;

MARS, Medication Adherence Rating Scale.

694 | ATA ET AL.

 

 

Specifically, BD patients’ hormonal and general side effect scores were

comparatively higher (P < .05). Yılmaz and Buzlu4 reported that side ef-

fects were a major element for all patients that used antipsychotic

medication and that each subject suffered from at least one side effect.

We observed that the mean side effect score of our subjects is sig-

nificantly higher than the Yılmaz and Buzlu4 study. This may be due to

their inclusion of antipsychotic medications and mood stabilizers, anti-

depressants, or anxiolytic medications in the treatment plan to control

BD symptoms. Side effects may result from the unaccompanied use of

any of these medications, whereas concurrent use of drugs may increase

the number and severity of the said side effects. One study suggested

that one of the important reasons for more frequent side effects is the

use of multiple antipsychotics.28 In order not to increase the number of

variables, our study does not include patients who used more than one

antipsychotic. We believe further studies should investigate the effects

of concurrent use of multiple antipsychotics.

Our study did not find a correlation between treatment com-

pliance and drug side effects of patients with schizophrenia; however,

antipsychotic‐related side effects impaired treatment compliance in BD patients. This effect was especially visible in psychic and general

side effect scores. Similarly, Yılmaz and Buzlu4 found that patients with

high drug compliance suffered less from the psychic side effects of

antipsychotics. One study found that schizophrenia patients suffered

most from sexual, extrapyramidal, and psychic side effects and that

those who experienced side effects had lower drug compliance rates.2

Therefore, increasing the compliance level of patients is an important

factor in managing the side effects of antipsychotic drugs. If patients

receiving antipsychotic medication are supported during the

treatment, informed about side effects, and taught to manage them,

then patient compliance can be improved.

5 | LIMITATIONS OF THE STUDY

The limitations of this study are as follows: (a) the restricted nature

of the sample group, (b) subjectivity of the data due to self‐report scales, (c) not including the use of multiple drugs to decrease the

number of variables (recommended for future research), (d) the small

size of the psychiatry clinic, which could not perform power analysis,

leading to low number of potential subjects.

6 | CONCLUSION

The majority of the subjects were found to have side effects related

to antipsychotic use and to have poor treatment compliance. It was

determined that patients with BD suffered more from side effects

compared with patients with schizophrenia. A moderate negative

correlation was found between the severity of side effects and

adherence to antipsychotic treatment. That is, increased side effects

lead to decreased adherence to the treatment programs in BD

patients.

7 | IMPLICATIONS FOR NURSING

To conclude, the majority of patients had poor adherence to treatment,

and patients with BD had a higher incidence of side effects compared

with schizophrenia patients, thus leading to comparatively worse

adherence. It is suggested to provide psychoeducation and treatment

compliance programs to help BD and schizophrenia patients to deal with

drug side effects and to improve adherence to treatment. Nursing care

actions and strategies should be planned and implemented to promote

adherence to treatment. Adherence therapy is an individually‐applied, patient‐centered and cognitive behavioral approach. It can be applied to inpatients with nonadherence.14 Motivational interviewing‐based ad- herence therapy should be implemented for patients with early stage of

schizophrenia who poorly adhere to medication.29 The patients can be

directed to CMHCs after the acute phase, where they can receive steady

support regarding psychosocial skills.

ACKNOWLEDGMENTS

The authors would like to thank all study participants for participating

in the study.

CONFLICT OF INTERESTS

The authors declare that there are no conflict of interests.

ORCID

Elvan E. Ata http://orcid.org/0000-0002-5920-8207

Emel Bahadir‐Yilmaz http://orcid.org/0000-0003-1785-3539

Nurten G. Bayrak http://orcid.org/0000-0002-7658-9961

TABLE 4 Correlation between side effects and adherence to treatment

Total MARS EPS Anticholinergic Autonomic Allergic Miscellaneous Hormonal Psychic Red herring Total LUNSERS

Bipolar disorder r = −.297* r = −.163 r = −.175 r = .150 r = −.161 r = −.280 r = −.469** r = −.023 r = −.327*

P = .042 P = .275 P = .240 P = .313 P = .281 P = .057 P = .001 P = .877 P = .025

Schizophrenia r = .124 r = .199 r = .222 r = .132 r = .093 r = −.115 r = −.058 r = .232 r = .095

P = .419 P = .190 P = .142 P = .387 P = .542 P = .454 P = .706 P = .125 P = .536

Abbreviations: EPS, extrapyramidal symptoms; LUNSERS, Liverpool University Neuroleptic Side Effect Rating Scale; MARS, Medication Adherence Rating

Scale.

Bold value is indicated P < .05.

*P < .05.

**P < .01.

ATA ET AL. | 695

 

 

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How to cite this article: Ata EE, Bahadir‐Yilmaz E, Bayrak NG. The impact of side effects on schizophrenia and bipolar

disorder patients’ adherence to prescribed medical therapy.

Perspect Psychiatr Care. 2020;56:691–696.

https://doi.org/10.1111/ppc.12483

696 | ATA ET AL.

 

 

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