Objective Nonadherence to prescribed antipsychotic medications places patients with schizophrenia at a greatly increased risk of illness exacerbation and rehospitalization. Identification of risk factors for nonadherence is an initial step toward designing effective interventions. This article reviews recent literature on the prevalence of and risk factors for medication nonadherence in patients with schizophrenia. Data sources We searched the MEDLINE/HealthSTAR and PsycINFO databases using combinations of the keywords risk factor(s), adherence, compliance, antipsychotic, neuroleptic, schizophrenia, and psychosis for articles published since 1980 that identified risk factors for medication nonadherence in schizophrenia patients. We included reports that (1) were published in English and (2) specifically examined risk factors for medication nonadherence. Thirty-nine articles met our selection criteria. Data synthesis Among the 10 reports that met a strict set of study inclusion criteria, we found a mean rate of nonadherence of 41.2%; the 5 reports that met a stricter set of inclusion criteria had a mean nonadherence rate of 49.5%. In the 39 articles reviewed, factors most consistently associated with nonadherence included poor insight, negative attitude or subjective response toward medication, previous nonadherence, substance abuse, shorter illness duration, inadequate discharge planning or aftercare environment, and poorer therapeutic alliance. Findings regarding an association between adherence and medication type were inconclusive, although few studies explored this relationship. Other factors such as age, gender, ethnicity, marital status, education level, neurocognitive impairment, severity of psychotic symptoms, severity of medication side effects, higher antipsychotic dose, presence of mood symptoms, route of medication administration, and family involvement were not found to be consistent predictors of nonadherence. Limitations of the published literature are discussed. Conclusion Efforts to improve medication adherence in patients with schizophrenia should target relevant risk factors.

Prevalence of and risk factors for medication nonadherence in patients with schizophrenia: a comprehensive review of recent literature.

BACKGROUND: Scales to measure the severity of different dimensions of auditory hallucinations and delusions are few. Biochemical and psychological treatments target dimensions of symptoms and valid and reliable measures are necessary to measure these. METHOD: The inter-rater reliability and validity of the Psychotic Symptom Rating Scales (PSYRATS: auditory hallucination subscale and delusions subscale), which measure several dimensions of auditory hallucinations and delusions were examined in this study. RESULTS: The two scales were found to have excellent inter-rater reliability. Their validity as compared with the KGV scale (Krawiecka et al. 1977) was explored. CONCLUSIONS: It is concluded that the PSYRATS are useful assessment instruments and can complement existing measures.

https://www.cambridge.org/core/services/aop-cambridge-core/content/view/S0033291799008661

Scales to measure dimensions of hallucinations and delusions: the psychotic symptom rating scales (PSYRATS).

A 75-year-old woman has type 2 diabetes mellitus, peripheral vascular disease, and a gangrenous ulcer of her left foot. A below-the-knee amputation is recommended, but she declines, saying that she has lived long enough and wants to die with her body intact. Her internist is concerned about her increasing confusion over the past year and notes that she appears to be depressed. How should her physician determine whether her decision is competent?

https://www.bumc.bu.edu/im-residency/files/2013/03/Capacity.pdf

Assessment of Patients' Competence to Consent to Treatment

Background
Although expert opinion has asserted that there is an increased risk of violence in individuals with schizophrenia and other psychoses, there is substantial heterogeneity between studies reporting risk of violence, and uncertainty over the causes of this heterogeneity. We undertook a systematic review of studies that report on associations between violence and schizophrenia and other psychoses. In addition, we conducted a systematic review of investigations that reported on risk of homicide in individuals with schizophrenia and other psychoses.

/pdf/schizophrenia-and-violence-systematic-review-and-meta-22vzciv2t3.pdf

Schizophrenia and Violence: Systematic Review and Meta-Analysis

Background: The literature on insight, or selfawareness, in schizophrenia suggests that this cognitive dimension may be of nosological value. Poor insight has descriptive validity at the phenomenological and neuropsychological levels of schizophrenia and has prognostic validity in terms of the prediction of the course of illness. The lack of empirical data on the diagnostic specificity of poor insight to schizophrenia and the previous use of insight measures with questionable reliability and validity have limited this interpretation. Methods: In the present study, we assessed insight into multiple aspects of mental disorder using a measure with demonstrated reliability and validity. A sample of 412 Patients with psychotic and mood disorders coming from geographically diverse regions of the United States and one international site was studied. The main aims were to determine the prevalence of self-awareness deficits in patients in whom schizophrenia was diagnosed, to examine the relative severity of self-awareness deficits associated with schizophrenia compared with that of schizoaffective and mood disorders with and without psychosis, and to evaluate the clinical correlates of selfawareness in patients with schizophrenia. Results: The results indicated that poor insight is a Prevalent feature of schizophrenia. A variety of selfawareness deficits are more severe and pervasive in Patients with schizophrenia than in patients with schizoaffective or major depressive disorders with or without psychosis and are associated with poorer Psychosocial functioning. Conclusions: The results suggest that severe self-awareness deficits are a prevalent feature of schizophrenia, perhaps stemming from the neuropsychological dysfunction associated with the disorder, and are more common in schizophrenia than in other psychotic disorders.

Awareness of Illness in Schizophrenia and Schizoaffective and Mood Disorders

Background It is now accepted that people with schizophrenia are significantly more likely to be violent than other members of the general population. A less acknowledged fact is that the proportion of societal violence attributable to schizophrenia is small.

Aims To critically examine the epidemiological evidence for the association between violence and schizophrenia and estimate the impact of this association on society.

Method A selective review of the key literature on the epidemiology of violence and schizophrenia. Population-attributable risks for violence in schizophrenia are calculated from population-based studies.

Results Most studies confirm the association between violence and schizophrenia. Recent good evidence supports a small but independent association. Comorbid substance abuse considerably increases this risk. The proportion of violent crime in society attributable to schizophrenia consistently falls below 10%.

Conclusions Less focus on the relative risk and more on the absolute risk of violence posed to society by people with schizophrenia would serve to reduce the associated stigma. Strategies aimed at reducing this small risk require further attention, in particular treatment for substance misuse.

/pdf/violence-and-schizophrenia-examining-the-evidence-3bjhaldm2f.pdf

Violence and schizophrenia: examining the evidence

An assessment schedule was used to determine the nature of insight in 91 mixed psychotic patients, and to examine its distribution and associations. While all the components of the schedule intercorrelated significantly, scores for compliance were only weakly related to those for ability to label psychotic phenomena as abnormal. Compliance and illness recognition were related to IQ. Total insight score was inversely correlated, moderately, with a global measure of psychopathology derived from the PSE, and was less in patients involuntarily committed. Age, sex, diagnosis, and the number of previous hospital admissions had little effect. The results support the notion that insight is not a unitary concept.

The assessment of insight in psychosis.

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(04)17224-3.pdf

Prevalence of mental incapacity in medical inpatients and associated risk factors: cross-sectional study

HCR‐20. Assessing risk for violence, version 2. By C. Webster, K. Douglas, D. Eaves and S. Hart. Mental Health, Law and Policy Institute, British Columbia. 1997. 98 + vii pp

Associations between delusions and abnormal behaviour were retrospectively assessed in a sample of 83 consecutively admitted deluded subjects. All were interviewed about events in the previous month using a new measure of delusional phenomenology and action. For 59 subjects this information was supplemented by informant interviews. Clinical consensus was reached concerning the probability that actions reported by informants were linked to delusions. Half of the sample reported that they had acted at least once in accordance with their delusions. Violent behaviour in response to delusions was uncommon. Information provided by informants suggested that some aspect of the actions of half of the sample was either probably or definitely congruent with the content of their delusions. However, there was no link between self-reports and informants' reports of such action. A latent class analysis of self-reported delusional action suggested three classes of action, namely aggressive to self or other, defensive action, and either none or single action. Self-reported action was associated with delusions of catastrophe. Informant data suggested that persecutory delusions were the most likely to be acted upon, but in contrast delusions of guilt or catastrophe appeared to decrease the chance of delusional behaviour. Actions associated with abnormal beliefs are more common than has been suggested.

Alec Buchanan

Papers

Violence and schizophrenia: examining the evidence

The assessment of insight in psychosis.

Prevalence of mental incapacity in medical inpatients and associated risk factors: cross-sectional study

HCR‐20. Assessing risk for violence, version 2. By C. Webster, K. Douglas, D. Eaves and S. Hart. Mental Health, Law and Policy Institute, British Columbia. 1997. 98 + vii pp

Acting on delusions. I: Prevalence.