Does religiosity in persons with schizophrenia influence medication adherence.

BACKGROUND: Little information is available regarding the effect of religiosity and spirituality on medication adherence in patients with schizophrenia. AIM: This study aimed to evaluate the association of medication adherence with different aspects of religiosity and spirituality in patients with schizophrenia.
MATERIALS AND METHODS: One hundred patients with schizophrenia were evaluated on religiousness measure scale and Duke Religion Index (DUREL); Brief Religious Coping Scale (Brief RCOPE); World Health Organization Quality of Life Spirituality, Religiosity, and Personal Beliefs (WHOQoL-SRPB); and Brief Adherence Rating Scale (BARS).
RESULTS: A higher level of religiosity as assessed by the religiousness measure scale, private religious activities and intrinsic religiosity as per DUREL, positive religious coping, and all the domains of WHOQOL-SRPB was associated with better medication compliance as assessed by the percentage of doses of medications consumed in the last 1 month as evaluated by using BARS.
CONCLUSION: The present study suggests that a higher level of religiosity and spirituality were associated with better medication compliance. Copyright:

INTRODUCTION

The continued intake of antipsychotic medications is vital for symptom resolution and improvement in treatment outcome in patients with schizophrenia.[1] It is well known that poor medication adherence is associated with relapse of symptoms, rehospitalization, increased health-care costs, and poor outcomes in the form of poor clinical, cognitive, and functional prognosis.[12] In terms of nonadherence rates, the studies have varied widely, and it is generally agreed upon that medication nonadherence rate in patients with schizophrenia is about 50%.[345]

Religious and spiritual practices are considered to exert a significant role in many people's lives, including those with schizophrenia. Religious and spiritual practices influence psychopathology, help-seeking, pathways to care, and dropout from the treatment among patients with schizophrenia.[6] Despite all these, the role or the influence of religious and spiritual practices on medication adherence in patients with schizophrenia is less explored. Some of the available studies suggest that religion and spirituality have a protective role in medication adherence.[78910111213]

However, one of the significant limitations of the available literature is that in most of these studies, religiosity, religious practices, religious coping, and spiritual practices such as existential well-being have not been consistently evaluated. Further, the studies, which have evaluated the association of medication adherence with religiosity, do not have medication adherence as the primary outcome variable. Accordingly, the present study attempted to evaluate the association of medication adherence with religiosity, religious practices, religious coping, spirituality, and religious and spiritual domain of quality of life of patients with schizophrenia.

MATERIALS AND METHODS

This cross-sectional study included 100 patients with schizophrenia, attending the outpatient services of a tertiary care hospital. The ethics committee of the institute approved the study, and participants provided written informed consent before enrollment in the study. This study aimed to evaluate the religiosity, spirituality, illness outcome, and treatment adherence among patients with schizophrenia. One of the papers from the project is already published.[14] This paper focuses on the association of religiosity and spirituality with medication adherence.

Patients diagnosed with schizophrenia as per the Diagnostic and Statistical Manual-Fourth Revision, based on Mini International Neuropsychiatric Interview, were included in the study. In addition, the participants were required to be aged 18–60 years, having illness ≥2 years, able to read Hindi and or English, and clinically stable. Clinical stability was empirically defined as the absence of “clear-cut exacerbation of symptoms in the last 3 months on anamnestic recall and scrutiny of medical records” and “on a static dose of antipsychotics in the previous 3 months, that is, not more than 50% increase or decrease in the medication dosages during this period.” Patients with comorbid psychiatric disorders, organic brain disorders, substance-use disorders, and intellectual disability were excluded from the study.

Level of religiosity was assessed by using religiousness measure scale[15] and Duke religion index (DUREL);[16] religious coping was assessed using a Brief Religious Coping Scale (brief RCOPE).[17] World Health Organization Quality of Life Spirituality, Religiosity, and Personal Beliefs (WHOQoL-SRPB)[18] was used to assess the components of spirituality and quality of life. DUREL and Brief RCOPE and WHOQoL-SRPB have been translated to Hindi and validated in India.[1920] In the present study, the Hindi versions of these scales were used. Medication adherence was evaluated by Brief Adherence Rating Scale (BARS), which assesses the exact number of pills being prescribed, the number of pills being missed, and the number of days the tablets are missed. In the end, the clinician records the overall rating of adherence to medication on visual analog scale.[21]

The data were analyzed by using the Statistical Package for Social Sciences, sixteenth version; SPSS Inc. Released 2007. SPSS for Windows, Version 16.0. Chicago, SPSS Inc.). Descriptive statistics in the form of mean and standard deviation and frequency and percentages were used to analyze the collected data. Comparisons were carried out using t-test, Mann–Whitney U-test, Chi-square test, and Fisher's exact test. Associations were studied by using Pearson's correlation co-efficient.

RESULTS

There was slight preponderance of males (n = 56) in the study sample. About two-thirds of the participants were on paid jobs (63%), Hindu by religion (n = 69%), and were from the urban locality (n = 64). The mean age of the study sample was 35.6 years (standard deviation [SD] - 10.8; range 21–60), and the mean years of schooling were 11.7 years (SD – 4.4; range 0–18). There was nearly equal representation of participants, who were currently married (n = 49) and those currently unmarried (n = 51).

The mean age of onset of the study sample was 24.2 years (SD - 7.97; range 12–55), and the mean duration of illness at the time of assessment was 137.5 months (SD – 101.6; range 24–360). The participants had a mean of 3.45 (SD – 2.6) relapses of their symptoms during illness. The PANSS total score for the study sample was 45.4 (SD – 13.9; range 30–85) at the time of assessment.

Details of the various aspects of religiosity and spirituality as assessed as part of this study and medication adherence are shown in Table 1.

Table 1

Assessment of religiosity and medication adherence of the study participants

Variables	Study group, frequency/mean (SD)
Religiousness measure scale
Do you believe in god - yes	99
Religious involvement	12.55 (5.30) (range 3-18)
Religious influence	30.91 (11.38) (range 7-44)
Religious hope subscale	29.33 (10.95) (range 6-42)
Total religiosity scores	73.01 (26.72) (range 16-111)
DUREL
Religious attendance domain	4.39 (1.83)
Private religious activities	4.25 (1.90)
Intrinsic religiosity	11.43 (4.28)
R-COPE
Total score of positive religious coping subscale	14.56 (6.59) (range 3-21)
Total score of negative religious coping subscale	8.31 (6.67) (range 0-21)
WHOQOL-SRPB
Spiritual connection	3.37 (1.37) (range 1-5)
Meaning and purpose in life	3.41 (1.37) (range 1-5)
Experiences of awe and wonder	3.45 (1.40) (range 1-5)
Wholeness and integration	3.34 (1.30) (range 1-5)
Spiritual strength	3.39 (1.40) (range 1-5)
Inner peace	3.37 (1.37) (range 1-5)
Hope and optimism	3.39 (1.38) (range 1-5)
Faith	3.42 (1.38) (range 1-5)
BARS
How many pills of psychotropic medications did your doctor tell you to take daily	2.85 (1.56) (1-9)
Over the month since your last visit, on how many days did you not take psychotropic medications
Few, if any (<7 days)	81
7-13 days	10
14-20 days	5
Most (>20 days)	4
Over the month since your last visit, on how many days did you take less than the prescribed number of pills of psychotropic medications
Always/almost always (76-100% of the time)	7
Usually (51-75% of the time)	3
Sometimes (26-50% of the time)	7
Never/almost never (0%-25% of the time)	83
Percentage of doses taken in past month	91.6 (17.96) (range 25-100)

SD – Standard deviation; BARS – Brief Adherence Rating Scale; WHOQOL-SRPB – World Health Organization Quality of Life Spirituality, Religiosity, and Personal Beliefs; DUREL – Duke Religion Index

The association of various aspects of religiosity and spirituality with medication compliance was evaluated by looking at the association of percentage of medication taken in the last 1 month. Two items of BARS assess number of days that medication was skipped or taken at lower dose. These data were dichotomized as patients who missed medications for <7 days (n = 81) and those who missed for more than 7 days (n = 19) and patients who never or almost never took less than the prescribed medications (i.e., 0%–25%) (n = 83) and those who missed pills on >25% of the days. These groups were then compared on religiosity and spirituality.

As is evident from Table 2, higher religiosity was associated with better medication compliance as assessed using the percentage of doses of medications consumed in the last month as assessed using BARS. Analysis of association between these two variables revealed that some aspects of higher religiosity and spirituality were associated with lower proportion of missing medications for more than 7 days. In addition, higher intrinsic religiosity, as assessed on DUREL was associated with lower percentage of missing medication (<25% of doses) [Table 3].

Table 2

Association of various domains of religiosity and spirituality with medication adherence

Variables	Percentage of doses taken as per the BARS
Religiousness measure scale
Religious involvement	0.297 (0.003**)
Religious influence	0.274 (0.006**)
Religious hope subscale	0.268 (0.007**)
Total religiosity scores	0.290 (0.003**)
DUREL
Religious attendance domain	0.176 (0.07)
Private religious activities	0.169 (0.09)
Intrinsic religiosity	0.218 (0.029*)
R-COPE
Total score of positive religious coping subscale	0.26 (0.007**)
Total score of negative religious coping subscale	−0.049 (0.630)
WHOQOL-SRPB
Spiritual connection	0.250 (0.012*)
Meaning and purpose in life	0.352 (<0.001***)
Experiences of awe and wonder	0.370 (<0.001***)
Wholeness and integration	0.370 (<0.001***)
Spiritual strength	0.312 (0.002**)
Inner peace	0.345 (<0.001***)
Hope and optimism	0.356 (<0.001***)
Faith	0.329 (0.001***)

BARS – Brief Adherence Rating Scale; WHOQOL-SRPB – World Health Organization Quality of Life Spirituality, Religiosity, and Personal Beliefs; DUREL – Duke Religion Index; *P<0.05; **P<0.01;***P<0.001

Table 3

Association of various domains of religiosity and spirituality with medication adherence

Variables	Missed medications for <7 days (n=81)	Missed medications for more than 7 days (n=19)	Comparison statistics	Never/almost never took less than prescribed medications (n=83)	Sometimes-always took less than the prescribed dose (n=17)	Comparison statistics
Religiousness measure scale
Religious involvement	13.17 (5.16)	9.89 (5.21)	2.485 (0.015*)	13.16 (5.03)	9.52 (5.71)	2.652 (0.009**)
Religious influence	32.27 (10.82)	25.10 (12.17)	2.53 (0.013*)	32.34 (10.75)	23.88 (12.08)	2.895 (0.005**)
Religious hope subscale	30.06 (10.21)	23.89 (12.54)	2.46 (0.015*)	30.75 (10.11)	22.35 (12.44)	2.997 (0.003**)
Total religiosity scores	76.46 (25.41)	58.89 (28.19)	2.65 (0.009**)	76.48 (25.49)	55.76 (28.67)	3.062 (0.003**)
DUREL
Religious attendance domain	4.53 (1.77)	3.78 (2.05)	1.59 (0.114)	4.50 (1.76)	3.82 (2.09)	1.40 (0.16)
Private religious activities	4.37 (1.86)	3.73 (2.05)	1.31 (0.19)	4.37 (1.82)	3.64 (2.20)	1.44 (0.15)
Intrinsic religiosity	11.72 (4.13)	10.15 (4.75)	1.44 (0.15)	11.84 (4.02)	9.41 (5.01)	2.173 (0.032*)
R-COPE
Total score of positive religious coping subscale	15.38 (6.33)	11.05 (6.69)	2.652 (0.009**)	15.20 (6.31)	11.41 (7.22)	2.201* (0.03)
Total score of negative religious coping subscale	8.27 (6.48)	8.47 (7.58)	−0.118 (0.90)	8.22 (6.47)	8.70 (7.77)	−0.26 (0.79)
WHOQOL-SRPB
Spiritual connection	14.27 (5.31)	10.21 (5.05)	3.02 (0.003**)	14.15 (5.39)	10.29 (4.87)	2.73 (0.007**)
Meaning and purpose in life	14.54 (5.34)	9.78 (4.56)	3.58 (0.001***)	14.48 (5.32)	9.52 (4.55)	3.57 (0.001***)
Experiences of awe and wonder	14.67 (5.46)	10.15 (4.78)	3.31 (0.001***)	14.66 (5.40)	9.70 (4.85)	3.50 (0.001***)
Wholeness and integration	14.24 (5.05)	9.73 (4.42)	3.57 (0.001***)	14.24 (4.99)	9.23 (4.39)	3.83 (<0.001***)
Spiritual strength	14.33 (5.55)	10.42 (4.83)	2.82 (0.006**)	14.37 (5.43)	9.76 (5.04)	3.22 (0.002**)
Inner peace	14.32 (5.40)	9.94 (4.49)	3.27 (0.001***)	14.33 (5.31)	9.35 (4.49)	3.60 (<0.001***)
Hope and optimism	14.38 (5.39)	10.10 (4.99)	3.15 (0.002**)	14.37 (5.32)	9.64 (5.09)	3.35 (0.001***)
Faith	14.48 (5.40)	10.36 (5.02)	3.02 (0.003**)	14.54 (5.25)	9.58 (5.23)	3.54 (0.001***)

WHOQOL-SRPB – World Health Organization Quality of Life Spirituality, Religiosity, and Personal Beliefs; DUREL – Duke Religion Index. *P<0.05; **P<0.01; ***P<0.001

DISCUSSION

There is a lack of data on the association of medication adherence and religiosity and spirituality among patients of schizophrenia from India. The present study attempted to fill this void. When we compare the findings of the present study with the existing studies, which have evaluated nonadherence in patients with schizophrenia, our results are in the reported range.[2223] When we look at the prevalence of nonadherence from the mean reported figure of 50% across different studies, the nonadherence rate in the present study is lower. The lower rates of nonadherence could be due to the inclusion of patients who were clinically stable and on long-term treatment, who are reported to have lower rates of nonadherence than those who are initiated on treatment or those with the first-episode psychosis.[23]

Compared to most of the available studies that evaluated the association of religiosity and medication adherence, the present study evaluated the various dimensions of religiosity and spirituality by using instruments validated in India. The present study shows that religiosity and spirituality have a positive influence on medication adherence in patients with schizophrenia. These findings provide further support to the limited existing literature, which suggests that religiosity has a positive impact on medication adherence in patients with schizophrenia.[7811] These findings suggest that clinicians should be aware of this association and not undermine the religiosity of the patients with schizophrenia while evaluating multiple dimensions of psychopathology and psychosocial factors. In addition, clinicians should prepare themselves and train themselves to assess various dimensions of religiosity. In general, it is believed that religious practices have a negative impact on seeking psychiatric treatment. It has been reported that many patients first seek help at holy places, especially in a country like India.[24] However, while interpreting this information, it should be kept in mind that faith healing does not necessarily reflect the level of religiosity or status of religious practices. Accordingly, it should not be concluded that religiosity and spirituality always has a negative impact on medication adherence and psychiatric treatment.

The present study has certain limitations which must be kept in mind while interpreting the current study's findings. This was a cross-sectional study limited to clinic attending clinically stable patients, who did not have any comorbid illness. Hence, the present study's findings cannot be generalized to all subgroup of patients with schizophrenia. The present study's findings suggest an association of religiosity/spirituality and medication adherence and not necessarily imply a cause–effect relationship. Future studies must attempt to overcome these limitations.

CONCLUSIONS

To conclude, the present study suggests that religiousness, religious practices, positive religious coping, a better quality of life in the spirituality, and religiosity domain are, in general, associated with better medication adherence in patients with schizophrenia. These associations suggest a need to address religious and spiritual distress and use the principles of religiosity and spirituality to improve medication adherence in patients with schizophrenia. The clinicians should encourage patients to participate in religious activities and more often use positive religious coping mechanisms to improve the outcome of the patients of schizophrenia.

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Conflicts of interest

There are no conflicts of interest.