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The Impact of Clinical Variables and Relationships With Health Professionals

Jennifer C. Day, PhD; Richard P. Bentall, PhD; Chris Roberts, PhD; Fiona Randall, BSc; Anne Rogers, PhD; Dinah Cattell, RMN; David Healy, MD; Pam Rae, BSc; Cheryl Power, MSc

Arch Gen Psychiatry. 2005;62:717-724.

Context  Nonadherence to antipsychotic medication is a major cause of psychotic relapse and is strongly influenced by attitudes toward treatment. Although patient variables such as insight and symptoms that contribute toward attitudes have been identified, the contributions of relationship and service factors have not been adequately studied.

Objective  To determine relations between clinical and service variables and attitudes toward medication in people with a diagnosis of schizophrenia and schizoaffective disorder.

Design  Consecutively admitted patients were approached to take part; 23 refused. Measures included symptoms, insight, drug adverse effects, self-reported adherence, attitudes toward treatment, perceived relationship with the prescriber, ward atmosphere, and admission experience. Data were analyzed by a proportional odds model and structural equation modeling to test predicted paths between experience of admission, relationship variables, attitudes toward treatment, and self-reported adherence to medication.

Setting  Twenty-eight inpatient wards at 8 hospitals in North Wales and the Northwest of England. Sites included hospitals with inner-city and rural catchment areas.

Patients  Two hundred twenty-eight patients meeting DSM-IV criteria for schizophrenia or schizoaffective disorder, assessed during acute admission.

Main Outcome Measures  Attitudes toward treatment and self-reported adherence to medication.

Results  The data fit a model in which attitudes toward treatment were predicted by insight, relationship with staff (especially the physician-prescriber), and the patient’s admission experience (maximum likelihood ²₄₉ = 89.3, P<.001). A poor relationship with the prescriber, experience of coercion during admission, and low insight predicted a negative attitude toward treatment.

Conclusions  The quality of relationships with clinicians during acute admission appears to be an important determinant of patients’ attitudes toward treatment and adherence to medication. Enhancing such relationships may yield important clinical benefits.

Author Affiliations: Pharmacy Department, Mersey Care NHS Trust, Merseyside, England (Dr Day); School of Pharmacy and Chemistry, Liverpool John Moores University, Liverpool, England (Dr Day); Department of Psychology (Dr Bentall), Biostatistics Group, School of Epidemiology and Health Sciences (Dr Roberts), and National Primary Care Research and Development Centre (Dr Rogers), University of Manchester, Manchester, England; North Wales Clinical Psychology Department, University of Wales, Bangor (Ms Randall); Division of Psychological Medicine, North Wales Department, Wales College of Medicine, Cardiff University, Cardiff (Ms Cattell and Dr Healy); and Department of Clinical Psychology, University of Liverpool, Liverpool (Mss Rae and Power).

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