|Year : 2021 | Volume
| Issue : 1 | Page : 28-35
Effect of nurse-led screening linked brief psycho-education for improving adherence to antipsychotic medications among clients with mental illness: A quasi-experimental study
Hemlata Ghatwal1, Jaison Joseph1, Purushottam Jangid2
1 Department of Psychiatric Nursing, College of Nursing, Pt. B. D. Sharma University of Health Sciences, Rohtak, Haryana, India
2 Department of Psychiatry, Institute of Mental Health, Pt. B. D. Sharma University of Health Sciences, Rohtak, Haryana, India
|Date of Submission||23-Oct-2020|
|Date of Acceptance||01-Mar-2021|
|Date of Web Publication||30-Jul-2021|
College of Nursing, Pt. B. D. Sharma University of Health Sciences, Rohtak - 124 001, Haryana
Source of Support: None, Conflict of Interest: None
Background: Despite the significant improvements in pharmacotherapy, nonadherence to antipsychotic medication is consistently reported in the literature. Many studies evaluated the side effects of antipsychotic medications but there is scanty evidence regarding screening linked intervention. Aim: The study investigated the effect of nurse-led screening linked brief psycho-education in improving adherence to antipsychotic medication among treatment-seeking clients with mental illness. Materials and Methods: This study is a quasi-experimental study in which a total of 80 subjects were consecutively recruited as per the sampling criteria. The side effect of antipsychotic medication was measured using the Udvalg for Kliniske Undersøgelser Side Effect Rating Scale (UKU-SERS). A trained nurse delivered a 30-minute individual-based screening linked brief psychoeducation for the management of side effects as per the standard module. The outcome measures were changes in adherence to medication measured as per the medication adherence rating scale (MARS-5©Professor Rob Horne) during a 1-month follow-up. Results: Anxiety (40%), reduced duration of sleep (40%), reduced salivation (36%) were the most common moderate-to-severe side effects as per UKU-SERS. Overall, the study observed a significant improvement of self-reported medication adherence in the intervention group as compared to the control group during the 1-month follow-up (F = 46.49; P < 0.001). Conclusion: The nurse-led screening linked brief psychoeducation may be an effective strategy for improving adherence to antipsychotic medication in this setting. More studies should be conducted in similar settings for an evidence base to advocate the role of the nurse as a brief intervention therapist in the routine mental health care setting.
Keywords: Antipsychotics, brief psychoeducation, medication adherence, screening
|How to cite this article:|
Ghatwal H, Joseph J, Jangid P. Effect of nurse-led screening linked brief psycho-education for improving adherence to antipsychotic medications among clients with mental illness: A quasi-experimental study. J Mental Health Hum Behav 2021;26:28-35
|How to cite this URL:|
Ghatwal H, Joseph J, Jangid P. Effect of nurse-led screening linked brief psycho-education for improving adherence to antipsychotic medications among clients with mental illness: A quasi-experimental study. J Mental Health Hum Behav [serial online] 2021 [cited 2022 Jun 25];26:28-35. Available from: https://www.jmhhb.org/text.asp?2021/26/1/28/322817
| Introduction|| |
Antipsychotic medications are commonly prescribed for psychiatric disorders such as schizophrenia or bipolar disorder that are associated with psychotic symptoms. Despite the significant improvements in pharmacotherapy, nonadherence to antipsychotic medication is consistently reported in many studies. Noncompliance rates of antipsychotic medications for schizophrenia vary widely, ranging from 20% to 89% with a median rate of approximately 40%., Various reasons have been cited in the literature for noncompliance and these can be broadly categorized as patient-related factors, illness-related factors, and treatment-related factors. A systematic review reported that negative attitudes toward medication and substance abuse were the consistent reasons for nonadherence to antipsychotic medication among people with serious mental illness. Side effects can be one of the reasons for nonadherence to antipsychotic medication that may impair the quality of life and further lead to the relapse of the underlying psychiatric disorder. The side effect profiles of different antipsychotics vary greatly and in general, this includes neurological, metabolic, anticholinergic, and miscellaneous side effects. A systematic approach to side effect monitoring is necessary as patients may be reluctant to discuss some specific as well as general side effects. Many studies across the world have evaluated medication adherence among clients with mental illness using different assessment tools. One of the most widely used scales that measure the multiple components of the side effects is Udvalg for Kliniske Undersøgelser Side Effects Rating Scale (UKU-SERS). A study conducted among patients with mental illness from India reported that approximately one-tenth of the subjects (11%) were nonadherent to treatment regimen due to the side effects associated with medications.
Various multifaceted interventions have been explored for managing nonadherence-related issues among clients with mental illness. This includes clinician or family-led psychological interventions, cognitive behavioral interventions, and technology-based services such as electronic reminders through text messages and telephones. The interventions were focused at the individual, group, and family level; the psycho-educational approach was the most commonly used modality in all the levels. The psychoeducational interventions were categorized as “compliance therapy” or “adherence therapy” and primarily focused on enhancing the knowledge about the illness and management of side effects to achieve medication adherence in patients with mental illness. More often the benefits of antipsychotics are obscured by the adverse effects and a screening linked psychoeducation on how such problems can be avoided and successfully managed is essential to optimize medication adherence. Many studies evaluated the side effects of antipsychotic medications but there is scanty evidence regarding screening linked intervention. The empirical evidence suggests the involvement of nurses as brief intervention therapists in various mental health care settings., As the biggest component of the health care workforce, nurses can make a significant impact on the care of mental illness by engaging in nurse-led brief interventions. However, evidence of nurse-led screening linked brief psychoeducation in improving medication adherence of treatment-seeking clients with mental illness is limited. Moreover, there is a paucity of evidence on similar interventions from middle-income countries.
The present study investigated the effectiveness of a nurse-led brief psychoeducation in improving adherence to antipsychotic medication among clients with mental illness at 1 month follow-up period.
| Materials and Methods|| |
The study was a quasi-experimental study conducted at the Institute of mental health, UHS, Rohtak, India. The study was approved by the Institutional Ethical Committee with reference number BREC/19//107 obtained on December 11, 2019. Informed consent was obtained from all the study participants and confidentiality was maintained throughout the study. The outcome measure was the changes in medication adherence as per the medication adherence report scale (MARS-5©Professor Rob Horne). The present study explored the feasibility of a nurse-led screening linked brief psychoeducation for improving adherence to antipsychotic medications in the routine outpatient visit. Considering the average daily census and the imposed time limitations, the uniform inclusion of a specific population as per diagnosis was not possible as per the study setting. Therefore, we included those who were taking antipsychotic medications for a minimum period of 6 months' duration prescribed by a psychiatrist. Clients in the acute stage of their illness, who had difficulty participating in a session and not able to read and write the Hindi language, were excluded.
Participants were treatment-seeking clients from the psychiatric outpatient department. All the eligible subjects available during the period of data collection were enrolled consecutively as per the sampling criteria. After the selection of participants, socio-demographic and clinical characteristics of the subjects were collected. Besides, the side effects of antipsychotic medications were assessed with the aid of UKU-SERS before allocating them to either the intervention or control group. Adherence to medication was evaluated by using MARS-5 (MARS-5©Professor Rob Horne) at baseline and during a 1-month follow-up. The control group received the routine care of review and advice by the psychiatrist. Apart from the routine care, the nurse-led brief psychoeducation was offered to those in the intervention group. A total of 98 participants were contacted out of which 80 subjects were recruited as per the predetermined sampling criteria. All the included subjects were available during the 1-month follow-up [Figure 1].
The side effect of medication was judged by UKU side effect scale. It is an observer-rated scale that has three parts:- (1) Single symptom rating scale, (2) scale for global assessment, and (3) scale for stating consequences of the side effects. The reliability of the scale ranges from 0.3 to 0.9. We used only the single symptom rating scale part of the UKU and rated on a 0–3 Likert scale. It consists of four subscales namely psychic, neurological, autonomic, and others. For statistical analysis patients with a score of one or more on any item of the UKU SERS was considered. A 5-item version of the medication adherence report scale (MARS-5©Professor Rob Horne) was used for assessing adherence to antipsychotic medication. The MARS-5, a self-reported instrument, contains 5 items regarding medication adherence. Each item was rated on a 5-point Likert scale, and the range of the MARS-5 total score is between 5 and 25. A higher score on the MARS-5 represents better medication adherence.
The nurse-led brief psychoeducation is a structured educational intervention containing one individual session of short duration (30 min) offered to help a person to manage the side effects associated with the use of antipsychotics. The following questions were asked to commence the brief psycho-education in a nonconfrontational way. “Do you worry about the present usage of medications?” ”Are you concerned about your score on medication adherence?” The subjects were further encouraged to express their experience associated with the usage of current medication. A general feedback regarding the “good things” and “less good things” about the medication was given to address the most common psychic side-effects such as anxiety, headache, etc. Further, the nurse provided brief psycho-education regarding coping with the identified side effects as per psychic, neurological, autonomic, and miscellaneous domains of UKU-SERS. During this phase, the major goal of the assessment was to gain an understanding of the severity and included specific information about the self-management practices concerning side effects. The content of the intervention included specific information about the common antipsychotic-induced side-effects and related management such as weight gain, sleepiness/sedation, extrapyramidal symptoms, tremors, hyperlipidemia, postural hypotension, hyperglycemia, dry mouth, skin problems, blurred vision, constipation, urinary retention, constipation, sexual problems, and hypersalivation. The content validity of the module was established through expert validation. The nurse alone was involved in the UKU-SERS based side-effect screening and the psychiatrist did not assess for side effects due to the time limitations associated with the study setting. However, those who requested for additional clarifications were further referred to the concerned treating psychiatrist. The nurse who conducted the brief psychoeducation had undergone an induction and experiential training by a psychiatrist who provided supervision, monitoring, and feedback throughout the study. Adherence to antipsychotic medications was assessed at baseline and follow-up using MARS-5.
A uniform general advice was given to all participants in the control group: “From your responses, it is important to note that the regular adherence to the current treatment plan is essential for a better outcome. We will meet after 1 month to see your progress.” It was also delivered by the same facilitator. Follow-up was scheduled after 1 month with each participant.
Data were analyzed using Statistical Package for Social Sciences (SPSS for Windows, Version 16.0. SPSS Inc. Chicago). The comparisons of baseline socio-demography and clinical variables were done by Pearson's Chi-square test (or Fisher's exact test, where the expected number of frequency in a cell is <5) for categorical variables and independent sample t-test (or Mann–Whitney test for nonparametric data) and ANOVA for the continuous variables. For determining the outcome measure, the general linear model (GLM) was used and the strengths of association were expressed as partial eta squared. We had examined the main effect of time and group × time interaction.
| Results|| |
The sample consisted of 80 patients and half of the subjects were female (51.25%). Most of them were married (66.25%) and having a monthly income of <5000 (88.75%). A major proportion of the subjects were in the age group of 31–45 years (38.75%) and having a clinical diagnosis of bipolar affective disorder (48.75%). The majority of the participants were having an average total duration of illness <5 years (51.25%) and the age of onset from 16 to 30 years (45%). Approximately 17% of the subjects reported the presence of a family history of mental illness and 48% of them were taking antipsychotic treatment from 6 months to 2 years. Most of the subjects were taking antipsychotic medications in the form of oral olanzapine tablets (56.25%) followed by oral risperidone tablets (16.25%). The sociodemographic and clinical profiles of the subjects were comparable at the baseline [P > 0.05; [Table 1]].
|Table 1: Comparison of the characteristics of the participants at the baseline|
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Most of the side effects were mild as per the different domains of the UKU-SERS scale. The most common moderate to severe side effects as per UKU-SERS screening were: Anxiety (40%), reduced duration of sleep (40%), reduced salivation (36%), and concentration difficulties (25%). The most common self-reported mild side-effects with mild intensity were headache (53.8%), orthostatic dizziness (52.6%), constipation (52.4%), and weight gain (43.8%). Both the groups did not differ as per the scores of UKU and MARS scores at baseline [P > 0.05; [Table 2]].
Effect of intervention
The outcome measure was the change in the MARS scores among the intervention group and the control group of subjects at a 1-month follow-up. Pre- and post-test variations in the MARS scores over time were examined using the GLM with repeated measures. As per the repeated measure GLM, the time had a significant effect on the mean MARS score (F = 81.10; P = 0.000). The change in the MARS score remained significant even in the group × time interaction (F = 46.39; P < 0.0001). The screening linked brief psychoeducation resulted in an improvement in the total MARS scores in the intervention group as compared to the control group (22.15 vs. 16.18). The mean MARS scores obtained during pre-test and post-test by the study groups revealed an improved outcome in the intervention group in the five items of MARS (Change the dose - F = 6. 69, P < 0.01; Stop for a while - 17.37, P < 0.01; Skip one dosage - 14.72, P < 0.01; Taking less than prescribed dosage – F = 30.36, P < 0.01). Our intervention resulted in a significant improvement in the individual and total scores of MARS-5 during the 1-month follow-up [P < 0.001; [Table 3]]. [Figure 2] illustrates the effect of the intervention on MARS scores over time.
|Table 3: Changes in outcome measures over time using general linear model with repeated measures|
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|Figure 2: Effect of treatment on the mean medication adherence rating scale score (total) in the intervention and the control group over time|
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| Discussion|| |
The index study provides some evidence on the effectiveness of nurse-led brief psychoeducation among treatment-seeking clients with mental illness. All the study subjects completed follow-up which was done after 30 days (±7 days) of the baseline assessment. The side effect was assessed with the aid of UKU-SERS and adherence to medication was evaluated for initial assessment as well as for follow-up. The major findings of our study are that individual-based, a nurse-delivered brief psycho-educational intervention can result in the improvement of adherence to antipsychotic medications in the short-term (i.e., after 1 month of intervention).
We used UKU-SERS for evaluating the side-effect profile of antipsychotic medications. Most of the side effects were mild on assessment with the UKU scale in our study. Similar findings were also reported in a prospective study conducted in the Indian outpatient setting among patients with bipolar disorder. In the current study, the most common moderate to severe side effects as per screening were: Inability to relax (40%), reduced duration of sleep (40%), reduced salivation (36%), and concentration difficulties (25%). In a prospective UKU-SERS based follow-up study from India reported tremor (18%) and sedation (12.3%) as the most common adverse drug reactions to psychotropic in a hospital-based sample of 491 patients. Although most of the observed side effects were mild on the intensity, it further invokes the need for active pharmacovigilance for the early detection and management of reducing morbidity and improving compliance.,,
Screening provides an opportunity for the concurrent monitoring of side effects. A project called Monitoring and Management for Metabolic Side Effects of Antipsychotics reported the role of timely monitoring and management of side effects in improving patient safety and long-term outcomes among patients treated with antipsychotics. The available literature emphasizes the importance of the involvement of nurses in using evaluation checklists for detecting people with mental illness for adverse drug reactions.,, Our nurse-led screening for side-effects to antipsychotic medication further open an area for nurses in their routine clinical practice. The psychiatric nurses can collaborate with clients to improve adherence and other outcomes using tools that engage and empower clients to actively participate in decisions about their treatment.
The current study explored the feasibility of a nurse-led screening linked brief psychoeducation to support the mental health care services in the routine outpatient setting. We would like to make a special note on the acceptability of our intervention as none of the subjects refused to participate. A brief psychoeducation was offered by a trained nurse which observed a significant improvement in all domains of self-reported medication adherence during 1-month follow-up. This marked improvement in the brief psychoeducation would be due to the usage of a structured module, the novelty of therapist, and short duration of follow-up. A study by Usher et al., (2013) explored the effect of a nurse-led intervention on weight gain in people with serious mental illness among patients taking the second-generation antipsychotic medication. However, the study did not observe any significant differences in the outcome measures between the intervention and control group at 12 weeks' follow-up. Another study examined the effectiveness of a psychoeducational customized adherence enhancement program for homeless people focused on medication routines regarding antipsychotic medications. The study reported a 10% improvement in antipsychotic medication adherence during follow-up.
We assessed the short-term outcome of brief psycho-education by a single session of short duration (30 min). Previous studies involving psychoeducation yielded varying results of medication adherence among clients with mental illness. A study from South India observed that nurse-led structured teaching intervention was effective in the management of selected side-effects of antipsychotic drugs during a 1-week follow-up. A study by Byerly et al. found a significant improvement in antipsychotic medication adherence 1 month after the compliance therapy. Similarly, Mittal et al. reported a 10% improvement in medication adherence in the antipsychotic adherence therapy group as compared to the control group during the 4-month follow-up period. In contrast, Anderson et al. found no significant improvements in medication adherence among people with schizophrenia following 8 weekly sessions of adherence therapy. In general, structured psychosocial interventions are found to be useful for managing medication adherence. The content of our intervention was focused on enhancing understanding of the anti-psychotic induced general side-effects and related management strategies. We developed a structured module in which initially background information regarding the side effects was provided followed by the relevant feedback on the possible prevention and management strategies as per the identified side-effects. A community-based intervention from South India reported that besides antipsychotic medications, structured psycho-education can favorably influence the course and reduce disability in a cohort of patients with schizophrenia.
The present study has the following limitations. The result of the outcome measure is based on self-reported measures. The psychiatrist was not involved in side-effect assessment and psychoeducation and those who need additional clarifications referred to the treating psychiatrist in which the explicit data of referrals is not available. Furthermore, the assessor was not blinded to the intervention and the findings should be taken with caution as it is based on the short-term outcome of a single session. The long-term effect was not assessed due to the COVID 19 related lockdown in India The sample size was small and therefore the study may have lacked the power to test the effectiveness of the intervention. Despite these limitations, to the best of our knowledge, this is the first quasi-experimental study from India to evaluate the effectiveness of a nurse-led screening linked brief psychoeducation for improving adherence to antipsychotic medications in the mental health care setting.
| Conclusion|| |
The nurse-led screening linked brief psychoeducation may be an effective strategy for improving adherence to antipsychotic medication in this setting. More studies should be conducted in similar settings for an evidence base to advocate the role of the nurse as a brief intervention therapist in the routine mental health care setting.
The authors are truly grateful to all the study participants and concerned authorities who provided the permission to conduct the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Lieberman JA, Stroup TS, McEvoy JP, Swartz MS, Rosenheck RA, Perkins DO, et al.
Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. N Engl J Med 2005;353:1209-23.
Lacro JP, Dunn LB, Dolder CR, Leckband SG, Jeste DV. Prevalence of and risk factors for medication nonadherence in patients with schizophrenia: A comprehensive review of recent literature. J Clin Psychiatry 2002;63:892-909.
Valenstein M, Ganoczy D, McCarthy JF, Myra Kim H, Lee TA, Blow FC. Antipsychotic adherence over time among patients receiving treatment for schizophrenia: A retrospective review. J Clin Psychiatry 2006;67:1542-50.
Fleischhacker WW, Oehl MA, Hummer M. Factors influencing compliance in schizophrenia patients. J Clin Psychiatry 2003;64 Suppl 16:10-3.
Velligan DI, Sajatovic M, Hatch A, Kramata P, Docherty JP. Why do psychiatric patients stop antipsychotic medication? A systematic review of reasons for nonadherence to medication in patients with serious mental illness. Patient Prefer Adherence 2017;11:449.
McCann TV, Clark E, Lu S. Subjective side effects of antipsychotics and medication adherence in people with schizophrenia. J Adv Nurs 2009;65:534-43.
Haddad PM, Sharma SG. Adverse effects of atypical antipsychotics: Differential risk and clinical implications. CNS Drugs 2007;21:911-36.
Lingjaerde O, Ahlfors UG, Bech P, Dencker SJ, Elgen K. The UKU side effect rating scale. A new comprehensive rating scale for psychotropic drugs and a cross-sectional study of side effects in neuroleptic-treated patients. Acta Psychiatr Scand Suppl 1987;334:1-100.
Lucca JM, Ramesh M, Parthasarathi G, Ram D. Incidence and factors associated with medication nonadherence in patients with mental illness: A cross-sectional study. J Postgrad Med 2015;61:251-6.
] [Full text]
El-Mallakh P, Findlay J. Strategies to improve medication adherence in patients with schizophrenia: The role of support services. Neuropsychiatr Dis Treat 2015;11:1077.
Zygmunt A, Olfson M, Boyer CA, Mechanic D. Interventions to improve medication adherence in schizophrenia. Am J Psychiatry 2002;159:1653-64.
Barkhof E, Meijer CJ, de Sonneville LM, Linszen DH, de Haan L. Interventions to improve adherence to antipsychotic medication in patients with schizophrenia – A review of the past decade. Eur Psychiatry 2012;27:9-18.
Stroup TS, Gray N. Management of common adverse effects of antipsychotic medications. World Psychiatry 2018;17:341-56.
Stomski NJ, Morrison P, Meyer A. Antipsychotic medication side effect assessment tools: A systematic review. Austr New Zealand J Psychiatr 2016;50:399-409.
Joseph J, Basu D, Dandapani M, Krishnan N. Are nurse-conducted brief interventions (NCBIs) efficacious for hazardous or harmful alcohol use? A systematic review. Int Nurs Rev 2014;61:203-10.
Laws RA, Chan BC, Williams AM, Davies GP, Jayasinghe UW, Fanaian M, et al.
An efficacy trial of brief lifestyle intervention delivered by generalist community nurses (CN SNAP trial). BMC Nurs 2010;9:4.
Chan AH, Horne R, Hankins M, Chisari C. The medication adherence report scale: A measurement tool for eliciting patients' reports of nonadherence. Br J Clin Pharmacol 2020;86:1281-8.
Shah A, Yadav PP, Chaudhari M, Vataliya A, Kantharia ND, Mehta R. A prospective study of adverse drug reactions in patients with bipolar disorder in psychiatry outpatient department of a tertiary Care Hospital. J Clin Diagn Res 2017;11:C24-8.
Gummadi T, Harave VS, Aiyar LN, RajaLekshmi SG, Kunnavil R. Adverse drug reaction monitoring in a tertiary care psychiatry setting: A comparative study between inpatients and outpatients. Indian J Psychol Med 2017;39:306.
] [Full text]
Pahari NI, Tripathi SK, Maity TA, Gupta BK, Bagchi CH, Mondal DK. Evaluation and analysis of adverse drug reactions of second generation antipsychotics in a psychiatry out-patient department. Int J Pharm Pharm Sci 2012;4:158-62.
Piparva KG, Buch JG, Chandrani KV. Analysis of adverse drug reactions of atypical antipsychotic drugs in psychiatry OPD. Indian J Psychol Med 2011;33:153.
] [Full text]
Lahon K, Shetty HM, Paramel A, Sharma G. A retrospective study of the metabolic adverse effects of antipsychotics, antidepressants, and mood stabilizers in the psychiatry outpatient clinic of a tertiary care hospital in south India. Int J Nutr Pharmacol Neurol Dis 2012;2:237. [Full text]
Owen RR, Drummond KL, Viverito KM, Marchant K, Pope SK, Smith JL, Landes RD. Monitoring and managing metabolic effects of antipsychotics: A cluster randomized trial of an intervention combining evidence-based quality improvement and external facilitation. Implement Sci 2013;8:120.
Jordan S, Tunnicliffe C, Sykes A. Minimizing side-effects: The clinical impact of nurse-administered 'side-effect'checklists. J Advanced Nurs 2002;37:155-65.
Jordan S, Knight J, Pointon D. Monitoring adverse drug reactions: Scales, profiles, and checklists. Int Nurs Rev 2004;51:208-21.
Gabe ME, Jordan SE. Development and clinical gains of nurse-led medication monitoring profiles. J Nurs Manage 2014;22:331-49.
Mahone IH, Maphis CF, Snow DE. Effective strategies for nurses empowering clients with schizophrenia: Medication use as a tool in recovery. Issues Ment Health Nurs 2016;37:372-9.
Usher K, Park T, Foster K, Buettner P. A randomized controlled trial undertaken to test a nurse-led weight management and exercise intervention designed for people with serious mental illness who take second generation antipsychotics. J Adv Nurs 2013;69:1539-48.
Sajatovic M, Levin J, Ramirez LF, Hahn DY, Tatsuoka C, Bialko CS, et al.
Prospective trial of customized adherence enhancement plus long-acting injectable antipsychotic medication in homeless or recently homeless individuals with schizophrenia or schizoaffective disorder. J Clin Psychiatry 2013;74:1249-55.
Nukshijungla AO, Charles HS. Effectiveness of a structured teaching intervention regarding the management of side effects of antipsychotic drugs on the severity of side effects among in patients in a tertiary care hospital, South India. Indian J Cont Nsg Edn 2020;21:70-5. [Full text]
Byerly MJ, Fisher R, Carmody T, Rush AJ. A trial of compliance therapy in outpatients with schizophrenia or schizoaffective disorder. J Clin Psychiatry 2005;66:997-1001.
Mittal D, Owen RR, Lacro JP, Pharm D, Landes RD, Edlund M, et al.
Antipsychotic adherence intervention for veterans over 40 with schizophrenia: Results of a pilot study. Clin Schizophr Relat Psychoses 2009;24:S1171.
Anderson KH, Ford S, Robson D, Cassis J, Rodrigues C, Gray R. An exploratory, randomized controlled trial of adherence therapy for people with schizophrenia. Int J Ment Health Nurs 2010;19:340-9.
Kumar CN, Thirthalli J, Suresha KK, Venkatesh BK, Arunachala U, Gangadhar BN. Antipsychotic treatment, psychoeducation & regular follow up as a public health strategy for schizophrenia: Results from a prospective study. Indian J Med Res 2017;146:34.
Lancet T. India under COVID-19 lockdown. Lancet (London, England) 2020;395:1315.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]