Schizophrenia Therapy Adherence Tied to Patients’ Beliefs

Given the substantial burden of nonadherence to therapy in patients with schizophrenia, new interventions for compliance are critical.

Emerging evidence is showing that psychosocial interventions for patients with schizophrenia and their caregivers may yield positive results. Medication nonadherence in patients with schizophrenia is common, ranging from 20% to almost 90%.1

Previous research has demonstrated short-term results with adherence therapy, psychoeducation, and motivational interviewing, but few modalities have long-term effects.1 When patients with schizophrenia do not adhere to their therapy, substantial health and financial burdens ensue, including suicide risk, hospitalization, and psychotic relapse.1 Although the prevalence of schizophrenia was only 1.1% of the US adult population in 2013, the economic burden of the disease was $155.7 billion that year, mostly due to caregiver unemployment and lost productivity.2

Motivational Interviewing Can Improve Attitude and Adherence

Patients with schizophrenia have well-founded concerns about antipsychotics, given the propensity of the agents for weight gain, extrapyramidal disorders, and sedation.3 It is therefore challenging to allay patients’ fears and motivate them to remain adherent to their antipsychotic regimen.3

In a qualitative study of 66 recorded conversations with 14 patients with schizophrenia (mean age, 35.5 years; 71% men), Dobber and colleagues found that a therapist’s skill in motivational interviewing can alter a patient’s attitude toward medication adherence.3 The researchers assessed patients’ motivation to change with the Motivational Interviewing Sequential Code for Observing Process Exchanges (SCOPE) and the Motivational Interviewing Skill Code 2.1 (MISC 2.1) and identified 3 success factors in MI3:

  • A trusting alliance between patient and clinician;
  • Therapist’s adaptability to a patient’s thought process; and
  • Integrating patient values into long-term pharmacotherapy adherence.

Only 4 of the motivational interviewing cases were judged successful with the Life Chart Schedule that correlated motivation with adherence. However, the researchers concluded that motivational interviewing, when used by a skilled therapist, may help patients adhere to their medication regimen.3

“Clinicians should acknowledge that patients often associate taking medications with side effects and with psychosis,” said Jos Dobber, MSc, PhD candidate from the ACHIEVE Centre of Applied Research at Amsterdam University of Applied Sciences in the Netherlands. “To stimulate intrinsic motivation for medication adherence, clinicians can help patients to understand how medication can contribute to the patient’s pursuing of a specific personal goal or value.”

How Caregiver Attitudes Shape Patients’ Beliefs

Deane and colleagues investigated how the beliefs and attitudes of caregivers influenced patients taking psychotropic medications. In the 42-adult dyad study, patients were paired with their caregivers and asked about their medication regimen for any serious mental disorder.

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Even when caregivers demonstrated positive beliefs about the medications, a similar percentage also realized the adverse events that could result from antipsychotics.4 An overwhelming 93% of caregivers recognized the importance of family support for patients to maintain their regimen. That figure is not surprising given that 38% of caregivers acknowledged that it was a daily burden to get patients to take their medications.4 Moreover, whenever there was discordance between patient and caregiver attitudes, the patients tended be less adherent. Because caregiver cooperation and attitudes are integral to patient adherence and outcomes, the study underscored the need to involve both the patient and caregiver in decision-making.4

“The results from our study suggest that there is a relationship between carer attitudes towards medications and ratings of adherence in patients,” said Frank P. Deane, PhD, School of Psychology and Illawarra Institute for Mental Health, University of Wollongong, New South Wales, Australia. “This is not causal, but it does highlight the need to consider family carer relationships in any assessment. Clearly in situations where a patient has relatively frequent contact with family carers (lives in the same dwelling), it would be particularly important to understand the family members’ views of the illness, medications, and adherence issues. Clinicians may have a role in providing skills training to carers (eg, how to communicate empathically and without hostility when patients decide not to take their medications).”

When Psychosocial Interventions Fail

For patients who struggle with medication adherence, long-acting injectables (LAI) may offer greater dosing flexibility while avoiding unnecessary hospitalizations due to episodes triggered by nonadherence.2 In a retrospective cohort study of 324 Medicaid recipients (mean age, 41.4 years; 36.1% women) with schizophrenia, Emond and colleagues demonstrated that patients who transitioned from the once-monthly injectable antipsychotic paliperidone palmitate (PP1M) to every-3-month dosing (PP3M) had similar adherence and did not incur additional costs due to hospital admissions or emergency visits compared with before the transition. Both adherence and pharmacy costs increased before the transition to PP3M but were offset by the savings in fewer admissions.2

“In this study, adherence significantly improved during treatment with 1-month paliperidone palmitate and remained similar after the transition to treatment with 3-month paliperidone palmitate — the only LAI with a quarterly dosing schedule,” explained Edward Kim, MD, MBA, therapeutic area leader, schizophrenia, Janssen Pharmaceutical Companies of Johnson & Johnson, Titusville, New Jersey. “Clinicians transitioned patients in this study to PP3M once they had received adequate treatment with PP1M — which includes being adherent to treatment — for at least 4 months. Because both products contain the same paliperidone molecule, patients already doing well on PP1M could anticipate a similar experience on PP3M.”


  1. Modanloo M. The challenge of increasing adherence in schizophrenia: Focusing future research on changing attitudes of patients. Asian J Psychiatry. 2018;36:28.
  2. Emond B, Joshi K, El Khoury AC, et al. Adherence, healthcare resource utilization, and costs in Medicaid beneficiaries with schizophrenia transitioning from once-monthly to once-every-3-months paliperidone palmitate [published online August 7, 2018].  Pharmacoecon Open. doi: 10.1007/s41669-018-0089-9
  3. Dobber J, Latour C, de Haan L, et al. Medication adherence in patients with schizophrenia: a qualitative study of the patient process in motivational interviewing. BMC Psychiatry. 2018;18(1):135.
  4. Deane FP, McAlpine E, Byrne MK, Davis EL, Mortimer C. Are carer attitudes toward medications related to self-reported medication adherence amongst people with mental illness? Psychiatry Res. 2018;260:158-163.