Compliance

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Journal of Behavior Therapy

and Experimental Psychiatry xx (2008) 1e12www.elsevier.com/locate/jbtep

Psychosocial and socio-demographic correlatesof medication compliance among people with

schizophrenia

Hector W.H. Tsang a,*, Kelvin M.T. Fung a, Patrick W. Corrigan b

a Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kongb Institute of Psychology, Illinois Institute of Technology, Chicago, United States

Received 16 August 2007; received in revised form 21 February 2008; accepted 27 February 2008

Abstract

This study examined the medication compliance of people with schizophrenia in relation to their self-stigma, insight, attitude towards medication, and socio-demographic status via a cross-sectional observa-tional design. Eighty-six Chinese adults with schizophrenia were recruited from the psychiatric hospitalsand community settings for this study. The findings suggested that stereotype agreement of self-stigmati-zation and attitude towards medication were moderately correlated with medication compliance. Poorinsight and living alone were found to be significant predictors of medication compliance based on regres-sion analysis. Insight was identified to be the strongest predictor on compliance which accounted for68.35% of the total variance. Although self-stigma is only moderately linked with medication compliance,its effects on medication-induced stigma cannot be ignored.� 2008 Elsevier Ltd. All rights reserved.

Keywords: Medication compliance; Insight; Attitude; Self-stigma; Schizophrenia

1. Introduction

Antipsychotic medication is regarded as the most effective treatment for people with schizo-phrenia (American Psychiatric Association, 1997; Thornley & Adams, 1998; Valenstein et al.,

* Tel.: þ852 2766 6750; fax: þ852 2330 8656.

E-mail address: [email protected] (H.W.H. Tsang).

0005-7916/$ - see front matter � 2008 Elsevier Ltd. All rights reserved.

doi:10.1016/j.jbtep.2008.02.003

Please cite this article in press as: Hector W.H. Tsang et al., Psychosocial and socio-demographic correlates of med-

ication compliance among people with schizophrenia, Journal of Behavior Therapy and Experimental Psychiatry

(2008), doi:10.1016/j.jbtep.2008.02.003

mailto:[email protected]

http://www.elsevier.com/locate/jbtep

2 H.W.H. Tsang et al. / J. Behav. Ther. & Exp. Psychiat. xx (2008) 1e12


2004). Its efficacy on the control of psychotic symptoms and reduction of relapse has beenwidely documented with a huge body of empirical support (Dolder, Lacro, Leckband, & Jeste,2003; Rittmannsberger, Pachinger, Keppelmuller, & Wancata, 2004). The treatment outcome is,however, largely influenced by the treatment compliance (Watson & Corrigan, 2001; Zygmunt,Olfson, Boyer, & Mechanic, 2002). Although treatment compliance is the foundation of favor-able therapeutic outcomes (Ludwig, Huber, Schmidt, Bender, & Greil, 1990), it is unfortunatethat noncompliance to antipsychotics medication is common among people with schizophrenia.A review by Cramer and Rosenheck (1998) suggested that more than 40% of patients failed tofully comply with recommended medication regimes. Another review study indicated an aver-age of 50% medication noncompliance rate (Lacro, Dunn, Dolder, Leckband, & Jeste, 2002).

Medication noncompliance is an obvious barrier to health care provision (Compton,Rudisch, Weiss, West, & Kaslow, 2005). It is reported that double to triple relapse rate wasevidenced among individuals who discontinued using the prescribed antipsychotic medication(Curson et al., 1985; Horgarty & Ulrich, 1977; Viguera, Baldessarini, Hegarty, van Kammen, &Tohen, 1997). Individuals with poor compliance are likely to have frequent and longer hospi-talization, and hence poor prognosis (Bebbington, 1995; Pinikahana, 2005; Valenstein et al.,2002). Their independent living would be affected by their fluctuating mental conditions(Vauth, Loschmann, Rusch, & Corrigan, 2004), which would then lead to an increasing costof care and societal burdens (Terkelsen & Menikoff, 1995; Thieda, Beard, Richter, & Kane,2003).

A number of factors have been found to be related to poor medication compliance amongpeople with schizophrenia. Medication side effect is most well known (Blackwel, 1972;Corrigan, Liberman, & Engel, 1990; Perkins, 2002). Adverse side effects such as extrapyrami-dal symptoms are commonly found among users of conventional agents (Moller, 2005).Atypical antipsychotics are developed to address this problem by reducing uncomfortableside effects (Mortimer, Williams, & Meddis, 2003). However, side effects are still experiencedby the use of newer antipsychotic drugs (Stanniland & Taylor, 2000). The study conducted byValenstein et al. (2004) suggested that the non-adherence rate slightly dropped from 46% to40% after switching from conventional to atypical antipsychotics. Medication compliance isinfluenced by a considerable number of variables (Meichenbaum & Turk, 1987). Thesevariables can be categorized into patient-related, illness-related, medication-related, and envi-ronmental-related factors (Fenton, Blyler, & Heinssen, 1997; Fleischhacker, Oehl, & Hummer,2003; Kampman & Lehtinen, 1999; Pinikahana, 2005). Individuals with poor insight are likelyto restrict their help seeking behaviors which then lead to treatment noncompliance (Amador &Strauss, 1993; Bartko, Herczeg, & Zador, 1988; Lin, Spiga, & Fortsch, 1979; McEvoy et al.,1989; Nageotte, Sullivan, Duan, & Camp, 1977). Meanwhile, individuals who hold negativeattitudes towards antipsychotic medication are more reluctant to adhere to prescribed medica-tions (Cuffel, Alford, Fischer, & Owen, 1996; Falloon, 1984; Hogan, Awad, & Eastwood, 1983;Marder et al., 1983; van Putten, May, & Marder, 1984).

Self-stigma has received increasing attention as one of the patient-related barriers formedication compliance. Self-stigmatization is conceptualized to be a three-tier mechanismwhich consists of the components of stereotype agreement, self-concurrence and self-esteemdecrement (Corrigan, Watson, & Barr, 2006; Fung, Tsang, Corrigan, Lam, & Cheung, 2007).Self-stigmatized individuals may firstly agree with public stereotypes towards themselves,and then self-internalize these beliefs to their own which results in self-esteem and self-efficacydecrement (Corrigan et al., 2006; Fung et al., 2007). It has been reported that 48% individualswith schizophrenia commented that they suffered from medication-induced stigma (Lee, Chiu,



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Tsang, Chui, & Kleinman, 2006). Lee et al. (2006) suggest that the side effects of antipsy-chotics medication would trigger physical symptoms and emotional blunting among peoplewith schizophrenia. This would make their psychiatric illness more easily recognized, andthus cause stigmatization. Recent studies (Fung, Tsang, & Corrigan, in press; Fung et al.,2007; Tsang, Fung, & Corrigan, 2006) used a newly developed and validated PsychosocialTreatment Compliance Scale and showed that self-stigma hindered participation and attendanceof psychosocial interventions. Similarly, self-stigmatized individuals may opt not to access psy-chiatric services and comply with prescribed antipsychotics medication in order to avoid unnec-essary prejudice and discrimination (Watson & Corrigan, 2001). Socio-demographic factorssuch as age, gender, educational level, financial status, and living condition have been positedto be correlates of medication compliance and addressed in previous studies (Fawcett, 1995;Fenton et al., 1997; Fleischhacker et al., 2003; Pinikahana, 2005). Unfortunately, the resultsare inconclusive. Nevertheless, we still believe that the socio-demographic background of in-dividuals would have certain influence on their level of compliance.

Given the above, the aim of this study was to investigate medication compliance of individ-uals with severe and persistent mental illness in relation to their self-stigma, insight, attitudetowards antipsychotic medication, and socio-economic status. This study provided directempirical evidence to exploring how self-stigma affects medication compliance. We hopethat appropriate interventions could be formulated with a better understanding of the correlatesof compliance to medication (Compton et al., 2005; Vauth et al., 2004).

2. Method

2.1. Participants

Eighty-six adults who were clinically diagnosed with DSM IV schizophrenia by certifiedpsychiatrists were recruited from Kwai Chung Hospital and her clustering psychiatric daycenters, and Lai Kwan Day Training Centre of Baptist Oi Kwan Social Service in HongKong from July 2004 to February 2005. Their average duration of psychiatric illness was13.56 years (S.D.¼ 8.70), and all participants had currently received antipsychotic medication.They had a mean age of 39.92 (S.D.¼ 8.00). Nearly half of them were female (48.8%). Theyhad finished elementary education, and 23 of them were lived alone. Individuals who sufferedfrom developmental disabilities, dementia, substance abuse and profound communicationdeficits were excluded.

2.2. Instruments

2.2.1. Measure of medication complianceThe Kemp Compliance Scale (KCS) (Kemp, Hayward, Applewhaite, Everitt, & David,

1996; Kemp, Kirov, Everitt, Hayward, & David, 1998) is a reliable observer-rating scalemeasuring participants’ status of medication compliance in terms of oral formulation. This isa single item scale which is rated by a seven-point Likert scale ranging from (1) ‘‘CompleteRefusal’’ to (7) ‘‘Active Participation’’.

2.2.2. Measure of self-stigmaThe Chinese Self-stigma of Mental Illness Scale (CSSMIS; Fung et al., 2007) was developed

through the translation and validation of the Self-stigma of Mental Illness Scale originated from



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Corrigan et al. (2006). The CSSMIS contains four subscales for assessing participants’ level ofperceived stigma and self-stigma. Perceived stigma is measured by ‘‘Stereotype Awareness’’,whereas self-stigma is, respectively, rated by the subscales of ‘‘Stereotype Agreement’’,‘‘Self-concurrence’’, and ‘‘Self-esteem Decrement’’. Each subscale consists of the same setof 15 items with different introductory clauses. The items are listed in Table 1. The itemsare based on a nine-point Likert scale with 9 indicating ‘‘strongly agree’’ and 1 indicating‘‘strongly disagree’’. Individuals were suggested to be self-stigmatized if they scored highlyin any of the self-stigma subscales. Excellent internal consistency (ranging from 0.82 to0.90), and good testeretest reliability (ranging from 0.71 to 0.81) were reported.

2.2.3. Measure of insightThe three general items of the Scale to Assess Unawareness of Mental Disorder (Amador

et al., 1993) were used to assess the current and past insight of the participants. It is scoredfrom (1) ‘‘aware’’ to (5) ‘‘unaware’’. Satisfactory inter-rater reliability and testeretest reliabil-ity was reported.

2.2.4. Measure of attitudes towards medicationThe Rating of Medication Influences (ROMI) (Weiden et al., 1994) and the Drug Attitude

Inventory-10 (DAI-10) (Hogan et al., 1983) were used to measure participants’ attitudestowards medication. Good psychometric properties were reported for both scales. The ROMIconsists of 7 items revealing the reasons of medication compliance, and 13 items pertainingto the reasons of noncompliance. The items of ROMI are rated from ‘‘none (1)’’ to ‘‘strong(3)’’. The DAI-10 contains six positive items and four negative items in measuring participants’subjective experiences towards the use of antipsychotic medications which are rated either‘‘yes’’ or ‘‘no’’. Higher score of the compliance subscale of ROMI and DAI-10 indicates betterattitude towards medication, whereas higher score of the noncompliance subscale of ROMIindicates worse attitude.

2.3. Data collection

After informed consent was obtained, demographic data of participants were acquired fromtheir medical records. The case managers who were knowledgeable to participants’ status ofmedication compliance completed the Kemp Compliance Scale. Two experienced researchassistants conducted a face-to-face interview with participants to complete the remainingmeasures. They were registered occupational therapists, and were proficient in administeringmental health assessments.

2.4. Data analysis

Data analysis was performed in liaison with the doctoral level biostatistician affiliated to ourdepartment. The demographic information of participants was summarized by descriptivestatistics. The associations between medication compliance and the possible influential factorswere explored by Pearson product-moment coefficient of correlation. Independent t-test wasapplied to investigate the difference of medication compliance among different demographicgroups. Independent variables which were correlated with Kemp Compliance Scale atp< 0.20 were included for the regression analysis (Bendel & Afifi, 1997). The forward selec-tion model was employed to construct a regression equation to predict medication compliance.



(2008), doi:10.1016/j.jbtep.2008.02.003

Table 1

Fifteen items for the CSSMIS

1.

I am below average in intelligence.

2.

I am unusually artistic.*

3.

I cannot be trusted.

4.

I am innocent and childlike.

5.

I am unable to get or keep a regular job.

6.

I am dirty and unkempt.

7.

I am mostly a genius.*

8.

I have something that is contagious.

9.

I am unable to take care of myself.

10.

I will not recover or get better.

11.

I am morally weak.

12.

I am to blame for my problems.

13.

I am unpredictable.

14.

I am dangerous.

15.

I am disgusting.

Key: *positive items.

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+ MODEL

Table 2

Descriptive statistics of test scores

Sub-scores Mean S.D.

Kemp Compliance Scale 5.90 0.93

The Chinese Self-stigma of Mental Illness Scale

Stereotype awareness 76.15 17.17

Stereotype agreement 72.5 18.87

Self-concurrence 63.95 22.36

Self-esteem decrement 64.78 21.37

Scale to Assess Unawareness of Mental Disorder

Mental illness (current/past) 2.40/2.70 1.39/1.47

Medication (current/past) 2.21/2.45 1.42/1.56

Social consequence (current/past) 2.21/2.42 1.44/1.51

The Rating of Medication Influence

Compliance 1.61 0.45

Noncompliance 1.25 0.25

The Drug Attitude Inventory 2.00 5.46



The most significant independent variable was entered to the model first, and then followed bythe second significant one. This process was repeated until a final regression equation wasestablished in which all independent variables within the model were able to make significantprediction independently. Variables with marked uneven distribution of test scores (e.g., martialstatus, and certain living and financial conditions), or with obvious number of missing data(e.g., length of stay and number of previous admission to psychiatric hospital) were excluded,as representative conclusion could not be drawn from these datasets.

Table 3

Relationship between Kemp Compliance Scale (KCS) and selected independent variables with p< 0.20

Selected variables Pearson coefficient

The Chinese Self-stigma of Mental Illness Scale

Stereotype agreement �0.221*

The Scale to Assess Unawareness of Mental Disorder

Mental illness (current/past) �0.258*/0.0.297**

Medication (current/past) �0.302**/�0.193

Social consequence (current/past) �0.401**/�0.343**

The Rating of Medication Influence

Compliance 0.304**

Noncompliance �0.328**

The Drug Attitude Inventory 0.314**

t-Value

Demographic data

Living alone 3.391**

Living with parent �1.456

*p< 0.05; **p< 0.01.



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Table 4

The regression model for medication compliance

Parameter b t-Value p-Value % of Variance

accounted

SUMD: current social consequence �0.386 �3.995 0.000 68.35

Living alone (‘‘no’’ set as base) �0.274 �2.832 0.006 31.65

Adjusted r2¼ 0.236.



3. Results

The descriptive statistics of different test scores are presented in Table 2. Twelve indepen-dent variables were found to be related to the Kemp Compliance Scale at p< 0.20 level and areshown in Table 3. The results of bivariate investigation suggested that stereotyped agreement,insight and attitudes towards medication were significantly associated with medication compli-ance at p< 0.05. Stronger correlations were found for the measures on certain insight items andattitudes ( p< 0.01). The results of independent t-test indicated that individuals who lived alonetended to have poor medication compliance. The three remaining CSSMIS subscales were notsignificantly correlated with the Kemp Compliance Scale (stereotype awareness: r¼�0.144,p¼ 0.298; self-concurrence: r¼�0.099, p¼ 0.365; self-esteem decrement: r¼�0.109, p¼0.320). It is, however, still interested to note the correlational direction that perceivedstigma/self-stigma was aligned with medication noncompliance.

A significant predictive regression model (Table 4) was formulated. People with schizophre-nia who had poorer current awareness about the social consequences of having mental illness,and lived alone were more likely to demonstrate poor medication compliance. Current insighthad the strongest contribution for predicting compliance (b¼�0.386, p< 0.001). The overallmodel accounted for 23.6% of the total variance in the prediction.

4. Discussion

Satisfactory medication compliance was found among the participants. The obtained meansscore on the Kemp Compliance Scale indicates that their level of compliance ranged frompassive acceptance to moderate participation. This appears to contradict the comments byLee et al. (2006) that Chinese people with schizophrenia have poor compliance because ofthe severe side effects of the prevalent use of conventional medication. The disparity maydue to the use of atypical antipsychotics medication in our sample which effected less severeside effects. However, further study needs to be done to elaborate the relationship betweenthe use of different antipsychotic agents and compliance among Chinese patients.

The findings from the bivariate investigation suggested that individuals who agreed withpublic stereotype towards mental illness were more likely to demonstrate worse medicationcompliance. In fact, medication-induced stigma is regarded as one of the principal barriersto compliance (Hudson et al., 2004). The side effects of antipsychotics medication includingextrapyramidal symptoms and sedation would lead the individuals to experience unnecessaryprejudice and discrimination (Lee et al., 2006). They may try to reduce medication-inducedside effects (Lee et al., 2006) by withdrawing from treatment (Corrigan, 2004).

Akin to prior research (Awad, 1993; Buchanan, 1992; Razali & Yahya, 1995), the correla-tional findings suggested that people who have better attitudes towards prescribed medication



(2008), doi:10.1016/j.jbtep.2008.02.003



tend to have better medication compliance. The formation of negative attitude is largelyinduced by the presence of positive psychiatric symptoms and treatment-induced side effects(Hofer, Kemmler, & Eder, 2002). Patients’ perception on treatment would influence their deci-sion to act (Christensen, 1978). The Health Belief Model (Rosenstock, 1996) suggests that peo-ple will display health seeking behavior when the negative outcomes for this act are outweighedby the advantage of proposed action. However, this does not apply to our mental health patients.Patients who endorse the negative attitude may believe that the antipsychotics agents do notcure them for their mental illness, and their belief would inhibit their compliance behavior.

Regression analysis showed that self-stigma and attitudes towards the use of antipsychoticsmedication did not correlate with medication compliance in our sample. Instead, our resultssuggested that poorer insight towards the social consequence of having mental illness, andliving alone predicted poorer medication compliance. A substantial volume of studies hasinvestigated the relationship between insight and medication compliance. Empirical evidencesupports their association with medication compliance (Buchanan, 1992; McEvoy et al.,1989). It is generally believed that illness recognition is the foundation for exhibiting helpseeking behaviors (Pescosolido, 1992). Individuals with poor insight tend to cease takingmedication (Olfson, Marcus, Wilk, & West, 2006), due to their lack of the perceived urgefor treatment (Cuffel et al., 1996). Similarly, patients who are aware of the negative socialconsequences of having mental illness tend to alter their unfavorable psychiatric conditionsby adhering to the medication regimes and get the associated beneficial clinical outcomes(Holzinger, Loffler, Muller, Priebe, & Angermeyer, 2002).

Our results showed that medication noncompliance was obvious among individuals wholived alone. This parallels the study by Irwin, Weitzel, and Morgan (1971) that lower compli-ance rates were found among individuals who lived alone. However, they also reported thatthose who lived in a supported environment with care from family members had better medi-cation compliance. It is well known that family support is essential for individuals’ engagementin medication regime (Corrigan et al., 1990; Falloon et al., 1982). One the other hand, lack ofsocial support and social supervision (Hudson et al., 2004; Mak, 1998; Owen, Fisher, Booth, &Cuffel, 1996; Razali & Yahya, 1995) are common barriers for poor treatment compliance.Reminder and monitor from significant others are, therefore, effective ways to improve compli-ance rate (Olfson, Mechanic, & Hansell, 2000).

Our earlier study demonstrated that mental illness self-stigma was a key predictor for psy-chosocial treatment compliance (Fung et al., 2007). We hypothesized that self-stigma wouldexert similar effect in undermining medication noncompliance. However, our current studydid not support the hypothesis as applied to medication compliance. Self-stigma only correlatedmoderately with medication compliance. One possible explanation is that the associated stigmais more severe for psychosocial treatment engagement than medication. Once people withschizophrenia have attended the psychosocial interventions in the psychiatric settings, their se-cret of having mental illness is disclosed to the public. Thus, self-stigmatized individuals arelikely to avoid attending prescribed psychosocial interventions to prevent from being discrim-inated by others (Fung et al., in press). Although medication-induced stigma exists, individualshave more control to conceal their daily medication consumption, and lesser stigma should beexperienced via taking medication. Studies have to be conducted to ascertain this relationship.

Effective interventions to improve medication compliance among people with schizophreniaare essential for their recovery. Extensive compliance enhancement interventions (Brown,Wright, & Christensen, 1987; Hayward, Chan, Kemp, Youle, & David, 1995; Hogarty et al.,1991; Kemp et al., 1996, 1998; O’Donnell et al., 1999; Razali & Yahya, 1995) had been



(2008), doi:10.1016/j.jbtep.2008.02.003



implemented and empirically investigated. Psychoeducation, motivational interviewing,cognitive-behavioral modeling, family intervention, community-based intervention are thecommonly adopted strategies to improve medication compliance (Dolder et al., 2003; Zygmuntet al., 2002). Moreover, the adoption of depot antipsychotics would be beneficial to improve thetolerability and compliance among patients (Moller, 2005). We believe that medication compli-ance among individuals with schizophrenia would be improved with these strategies.

The findings of this study shed light on a better understanding of medication compliance.However, certain limitations existed and generalizations should be made with caution. As thetitle of this paper suggests, we aim at identifying only the significant correlates of medicationcompliance. The causal relationship among the variables cannot be determined by the use ofcross-sectional observational design. Furthermore, the compliance level of our sample wasgenerally good. This would limit the generalization of findings to individuals who have poormedication compliance. This is valuable to include the information concerning the side effects,symptom severity, and type and dose of antipsychotic medication received by the participants.With this data, the direct linkage between those confounding factors, stigma and medicationcompliance could be examined. Moreover, it is also worthy to consider other possible contrib-uting factors on medication compliance in future studies. Some may argue that the reliability ofcompliance data is weakened by adopting a seven-point physician-rated scale instead of usingdirect compliance measures such as pill count or urine test. Kemp et al. (1998) posited thatdirect measures also have their own limitations with inaccuracy. However, it would be worthyin future studies to obtain the compliance data from different perspectives in compensating theweakness of different compliance measurements.

Acknowledgement

This project is funded by the Internal Competitive Research Grant of The Hong KongPolytechnic University (Project Number: A-PE67).

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