Pattern of Follow-up among Patients Attending the Department of Psychiatry: A Prospective Study

1. Junior Resident, Department of Psychiatry, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India. 2. Associate Professor, Department of Psychiatry, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India. 3. Professor and Head, Department of Psychiatry, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India. 4. Senior Resident, Department of Psychiatry, Institute of Human Behaviour and Allied Sciences (IHBAS), Delhi, India. 5. Senior Resident, Department of Psychiatry, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India. 6. Senior Resident, Department of Psychiatry, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India. 7. Senior Resident, Department of Psychiatry, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India. 8. Senior Resident, Department of Psychiatry, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India.

Abstract

Introduction: Adherence to drug regimen is a very important factor for improvement. Dropping out may affect the treatment outcome and also is as indication of poor clinical performance. Patient who left the treatment in between can lead to a deterioration in clinical condition, resulting in the need for more intensive therapy that significantly incurs higher social and economic loss. Therefore, improving medication compliance potentially reduces morbidity and suffering of patients and their families, and the cost of rehospitalisation.

Aim: To study the pattern of follow-up among patients of various psychiatric disorders and also to study the therapist factors contributing in adherence to treatment and the socio-demographic profile of patients who drop out from study.

Materials and Methods: This was a prospective analytical study conducted in the Department of Psychiatry, GGSMCH Faridkot, Punjab, India over one year. A total of 500 psychiatric patients were selected by the convenient non probability sampling technique in the age group between 18-45 years who met the inclusion criteria. These patients were evaluated for illness related variables using psychiatric proforma and Charleston Psychiatric Outpatient Satisfaction Scale (CPOSS) was applied. After this all the patients were assessed for a period of one year, the factors affecting the pattern of follow-up, relating to the treatment and its side effects, disease progression as well as therapist-related factors using a semi-structured questionnaire. The data, thus generated, was subjected to appropriate statistical analysis.

Results: In the socio-demographic profile among drop out education status, occupation, and duration of illness, statistically significant difference was found among different disorders (p<0.05). CPOSS scale was applied among three follow-up groups in which highest mean was 53.03±10.05 in regular follow-up group followed by 49.49±9.06 in intermittent and 44.80±10.70 in drop out follow-up group. Total CPOSS mean was 49.19±10.66. Overall results were statistically significant (p=0.0001). Also in the medication, disease and physician related factors among follow-up groups, statistically significant results were found (p<0.05).

Conclusion: The study showed that various socio-demographic factors, medication, disease and physician related factors affect the follow-up patterns. So, it is very important to diagnose all these factors to improve adherence among various psychiatric patients.

Adherence, Medication, Disease, Physicianrelated factors

From falling sick and dying to find a cure and beat a disease, the world of medicine has come much far. Adherence to drug regimen is a very important factor for improvement. Dropping out of the mental health treatment may affect the treatment outcome and indicates poor clinical performance. Patient who left the treatment in between can cause a deterioration in clinical condition, resulting in the need for more intensive therapy that significantly incurs higher social and economic loss (1).

Adherence, suggests sustained active decision making, rather than the more paternalistic term compliance, from complete (to fill up/complete) (2). Adherence occurs on a spectrum ranging from total adherence, i.e. all doses of medication are taken at the frequency given on the prescription to total non adherence, i.e. none of the prescribed medication is taken, and partial adherence, or partial non adherence, i.e. some, but not all, of the prescribed medication is taken (3). In general, the major predictors of non adherence include socio-demographic factors, treatment-related factors and disease related factors. However, the least investigated ones are the physician-related factors, though considered important (4).

The primary aim of the present study was to study the pattern of follow-up among patients of various psychiatric disorders and the therapist factors contributing in adherence to treatment. The secondary aim was to study the socio-demographic profile of patients who drop out from study.

Material and Methods

The present study was a prospective analytical study, conducted in the Department of Psychiatry, GGSMCH Faridkot, Punjab, India. Patients were enrolled in for six month from June 2019 to November 2019 and then followed up in next six month period from December 2019 to May 2020. This study was approved by the ethical committee. An informed written consent was taken from the patient and caregiver.

Inclusion criteria: Subjects giving written informed consent, aged 18-45 years and meeting International Classification of Diseases (ICD-10) criteria for bipolar Affective Disorder (BPAD), depression, Obsessive Compulsive Disorder (OCD), schizophrenia were included in the study. Bipolar disorder (BPD) is characterized with having either manic episodes characterised by elevated mood, overactivity, decreased need of sleep and increased in the quantity and speed of physical or mental activities and depressive episodes. Depressive episodes are characterised by depressed mood, loss of interest, reduced energy along with reduced concentration, self esteem, disturbed sleep and appetite etc. Obsessive compulsive disorder have recurrent obsessional thoughts i.e. ideas, mages or impulses and/or compulsions which are mental acts or behaviours repeated again and again. Schizophrenia is characterized by fundamental distortion in thinking and perception and inappropriate affect (5).

Exclusion criteria: Subjects with intellectual disability, head injury/neurological illness/severe cardio-respiratory or other medical illness were excluded.

Sample size calculation: The study sample was selected by purposive (non-probability) sampling technique based on data analysis of patients in previous year and a total of 500 subjects were included.

Formula: X = Zα/2²*p*(1-p) / e2

Where, Zα/2 is 1.96. e was the absolute error (5%), p is the sample proportion (0.50), Using the formula above, the derived sample size was 383. Considering a non response/ attrition rate of 10%, the minimum sample size was 425. So, a sample size of 500 was taken for the purpose of this study (6).

Study Procedure

All the information pertaining to socio-demographic profile, illness related variables like the history of illness and Mental Status Examination (MSE) which includes flow of speech, process and content of thought, perception, attention and concentration, memory, judgement and insight was documented in the pre-validated structured psychiatric evaluation proforma (7). Following this the CPOSS was applied, which is a self reporting questionnaire that measures client satisfaction regarding mental health services. Its 15 items describe diverse service domains of satisfaction, including two anchor items (overall quality of the care provided and would you recommend this clinic to a friend or relative?). Responses are rated on a 5-point Likert scale ranged from 1 (very dissatisfied) to 5 (very satisfied), with higher score indicating more satisfaction (8).

The individual patients were assessed for six months with monthly follow-ups. To ensure adherence, the patients were contacted telephonically or contacted via text message, one day prior to the date of follow-up. If any patient did not come up at desired date of follow-up he was contacted again. If the patient did not come on rescheduled appointment it was considered as a dropout and reason was documented. Patients who were on and off on the treatment were intermittent and who followed the instruction completely were considered as regular in follow-up. After this, the factors affecting the pattern of follow-up, relating to the medication related (nine questions), disease related (five questions) as well as therapist related factors (nine questions) were assessed using a semi-structured self designed questionnaire within the Department of Psychiatry by the author, and later psychometrically analysed by Department of Preventive and Social Medicine.

All questionnaires were put on cronbach coefficient alpha to check internal consistency of each measure of questionnaire. Before the start of thesis during which 50 patients from each group (regular, intermittent and drop out) was taken and Intra class Correlation Coefficient (ICC) was calculated. Reliability and validity scores were 0.90, 0.88, 0.82 for medication related, disease related and therapist related factors respectively. Then these questionnaires were distributed to every enrolled patient in printed format which was filled by either the patient/informant/or healthcare worker and was collected on spot. These questionnaires were analysed based on various other studies like Lucca JM et al., which also study patient, medication and disease related factors among various group (9). Socio-demographic variables including education, occupation and total monthly income of the family was assessed using the Kuppuswamy classification. The data, thus generated, were subjected to appropriate statistical analysis.

Statistical Analysis

The data was entered in Microsoft Excel software and analysed using IBM Statistical Package for the Social Sciences (SPSS) version 20.1. Descriptive statistics for categorical variables were represented in form of frequencies, while continuous variables in the form of mean and standard deviation. The association between various parameters were explored using Pearson’s chi-square test. ‘p’ values of significance were determined and values <0.05 were considered significant at 95% CI. For comparison of mean score variables, one-way ANOVA test, Post-hoc Bonferroni test were used. For correlation among any two variables, Pearson’s correlation coefficient was calculated.

Results

Parameters like age, sex, education, occupation, and duration of illness were statistically significant difference (p<0.05) in various disorders (Table/Fig 1).

In (Table/Fig 2) distribution of subjects where 196 (39.20%) were on regular follow-up, 124 (24.8%) on intermittent follow-up and 180 (36%) were dropout during study period.

In (Table/Fig 3) the education, occupation, monthly income of the family and duration of illness, shows a statistically significant difference (p<0.05) in various disorders among drop out group.

As represented (Table/Fig 4): shows that CPOSS highest mean was 53.03±10.05 (CI at 95%- 51.61-54.44) in regular follow-up group followed by 49.49±9.06 (CI at 95%- 47.88-51.10) in intermittent and 44.80±10.70 (CI at 95% - 43.23-46.37) in drop out follow-up group. Total CPOSS mean was 49.19±10.66 (CI at 5%- 48.25-50.12). Overall results were statistically significant (p=0.0001).

In (Table/Fig 5) CPOSS highest mean was 57.05±7.11 (CI at 95% was 55.79-58.31) among Schizophrenia followed by 48.95±10.56 (CI at 95% was 47.08-50.82), 46.70±10.43 (CI at 95% was 44.85-48.54) and 44.06±9.54 (CI at 95% was 42.37-45.75) among depression, BPAD and in OCD respectively. This result was statistically significant (p=0.0001).

Among the medication related factors among total psychiatric patients affecting follow-up pattern, statistically significant difference was found in three follow-up groups (p<0.05) except the cost factor (p=0.070) (Table/Fig 6).

All disease related factors among total psychiatric patients affecting follow-up pattern, showed a statistically significant difference in three follow-up groups (p<0.05) (Table/Fig 7).

All physician related factors among total psychiatric patients affecting follow-up pattern, showed statistically significant difference was found in three follow-up groups (p<0.05) (Table/Fig 8).

Discussion

In the current study the difference in monthly income was statistically significant among drop out (p=0.036). A study by Chaudhari B et al., also reported that low household income (p=0.02) was significantly associated with low adherence (11). In another study conducted by Lucca JM et al., found 67.54% among adherent and 65.11% among non adherent group had family income < Rs.50,000 (9).

In the present study when mean score of each item of CPOSS was studied, statistically significant difference was found in the follow-up groups (p=0.0001). When mean score of CPOSS among various psychiatric disorders was studied, again the results were statistically significant (p=0.0001). Afe TO et al., also found mean of the satisfaction scores ([? item 1, 2, 3, 4, 5, 6, 7, and 9-14]) on the CPOSS ranged from 25 to 60, with a mean of 40.17±7.5. The modal score was 43.0 (66% of maximum possible score on CPOSS) (12).

In the current study, when medication related factors affecting follow-up pattern were assessed, statistically significant results were found in follow-up groups (p<0.05). Teferra S et al., Sanele M et al., also described medication related factors as ADR (11%), cost (6.9%), too many pills (4.6%), non availability (4.0%), long duration (4.0%), complex formulation (1.1%) among bipolar affective disorder were poor parameters for adherence (13),(14). Their results were similar to the results of our study. Banerjee S et al., also describe that out of 239 interviewed patients, most of the patients reported using self medication 72.8% (174), forgetting to take prescribed medicines 56.5%(109), shortage of drug supply, cost of medicines was more, non adherent with the treatment whereas a few reported visiting healing temples 73 (30.5%) (15). These results are consistent with our study. Santana L et al., reported that among OCD, the reasons for refusing medication or taking medications less frequently or at lower doses than prescribed included: disliking the side effects of medication (41%), perceived environmental barriers (31%), feeling too busy or believing that treatment was inconvenient, costs of medication, not having enough money to pay for medication, feeling too anxious/fearful of taking medication (26%), having a negative opinion about the efficacy of treatment (23%), having issues regarding stigma/confidentiality (21%), having specific beliefs regarding severity of illness (13%) believing that his other OCD is not severe enough to justify need for medication (insight) (16).

Considering the disease related factors, statistically significant difference was found in three follow-up groups (p<0.05). Semahegn A et al., in his meta-analysis found that patients having lack of awareness about their illness, not getting subjective relief, hopelessness, felt better lead to discontinuation of treatment and not appreciating subjective relief symptoms contributing medication non adherence (17). Victoria O et al., also found in their studies that disease related factors self checking for the reappearance of the sign and symptoms (7.5%), feeling better (6.9%), poor insight (6.3%), forgetfulness (5.2%), no improvement (2.3%), worsening of the conditions (1.7%), hopelessness (1.1%) lead to more drop out cases (18).

When physician related factors were assessed, statistically significant difference was found in three follow-up groups in all factors (p<0.05). Lucca JM et al., also concluded the physician related factors in concurrence with our study that is lack of treatment alliance, fail to acknowledge the patient’s concern and empathy, compassion and skillful counselling, lack of information provided about the medication, lack of secure atmosphere to discuss about the disease, inability to develop feelings of trust, lack of adequate instruction, non availability of psychiatrist during follow-ups and inability to have bidirectional communication all recognized as poor parameters for adherence (11). Linden M et al., found that both non-adherent and adherent patients had a good relationship with their physicians. Adherent patients trusted their physicians significantly more, and they expected that physicians would be helpful in treatment (p<0.05) (19).

Limitation(s)

To generalize the data the study needs to be conducted on larger number of patients. Convenience sampling was done to choose the subjects. Our study period was for only one year, all the patients should have been followed up for at least three years for proper assessment.

Conclusion

Considering the socio-demographic profile among drop out in various psychiatric disorders: parameters including education, occupation, income of the family, marital status and duration of illness were statistically significant. Statistically significant difference was found in follow-up groups among mean score of CPOSS. All the medication related, disease related and physician related factors significantly affect the follow-up patterns in various disorders. To improve the adherence, follow-up patterns among various psychiatric disorders must be done on large scales for longer duration.

DOI and Others

DOI: 10.7860/JCDR/2022/50233.16773

Date of Submission: May 06, 2021
Date of Peer Review: Sep 11, 2021
Date of Acceptance: Apr 13, 2022
Date of Publishing: Aug 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

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ETYMOLOGY: Author Origin