Received: 12 December 2017
Revised: 17 May 2018
Accepted: 21 May 2018
DOI: 10.1111/ppc.12301
ORIGINAL ARTICLE
The effect of motivational interviews on treatment adherence
and insight levels of patients with schizophrenia:
A randomized controlled study
Melike Yönder Ertem PhD1 ∗
1 Department of Psychiatric Nursing, Institute of
Health Sciences, Dokuz Eylül University, İzmir,
Turkey
2 Department of Psychiatric Nursing, Nursing
Zekiye Çetinkaya Duman2
Abstract
Purpose: To examine the effect of motivational interview (MI) on treatment adherence and insight
of the patients diagnosed with schizophrenia at a hospital in Turkey.
Faculty, Dokuz Eylül University, İzmir, Turkey
Correspondance
Melike Yönder Ertem, Department of Psychiatric
Nursing, Institute of Health Sciences, Dokuz
Eylül University, İzmir, Turkey.
Email: melike_yonder@hotmail.com
∗ Present address: İzmir Katip Çelebi Univer-
sity, Faculty of Health Sciences, Department
of Psychiatric and Mental Health Nursing,
Çiğli- İzmir, Turkey.
Design and Methods: Individuals with schizophrenia, who match with the sample characteristics, were assigned to intervention (20) and control groups (20) according to the randomization
schedule. Personal Information Form, Morisky's Questions-Self-Report Measure of Adherence,
and Schedule for Assessing the Three Components of Insight were used.
Findings: Group-wise examinations showed that mean scores of “three component scales of
insight” yielded statistically significant difference for the intervention group. Analysis of the
Morisky Adherence Scale Mean Scores showed a significant difference for interval mean scores
of the intervention group.
Practice Implications: Both the pyschiatric patients and the health institutions can benefit from
increased levels of treatment adherence and insight by the adoption of the MI methods starting
with a patient's first registration to a psychiatric outpatient clinic.
Implications for Nursing Practice: MI can be included during any of the patient visits to establish
treatment collaboration with psychiatric patients at psychiatric facilities, outpatient clinics, and
community mental health centers.
KEYWORDS
insight, motivational initerview, patients with schizophrenia, psychiatric nursing, treatment
adherence
1
INTRODUCTION
relapse and frequent hospitalization. Therefore, it is reported as one
of the key factors that contribute to summing treatment cost.9 Studies
Treatment adherence is defined as a patient's consent to receive
have shown that individuals with schizophrenia have a relapse rate
and follow health-related recommendations.1–3 On the contrary,
of 30–40% and recurrence rates of 45–58% within their first year of
treatment incompliance may pose rather a multidimensional problem
discharge.10 Moreover, a study by Byerly et al.11 report a 40% relapse
such as not using prescribed medicines or using them irregularly, using
rate for the patients with schizophrenia due to treatment incompli-
nonprescribed medicines, missing appointments, and not attending the
ance incurred in the first year of hospitilization. Masand et al.12 state
follow-up
sessions.1,2,4,5
There are limited references regarding this
that the relapse rate is 50–75% within 2 years. In a different study
issue. Adaptation problems in patients with schizophrenia may lead
which was conducted in Turkey, Koç13 found that 74% of patients
to recurrence of the disease, extended allocation of health institution
diagnosed with schizophrenia had poor treatment compliance. Lack
resources, frequent admission to the hospital, escalated treatment
of insight and poor treatment adherence often coexist among the
costs, worsening of the general health condition, deterioration in
individuals diagnosed with schizophrenia and typically lead to poor
quality of life (QoL), social isolation, increase in substance dependence,
outcome of the disease. Jasper14 defines “insight” as being aware of
unemployment, violance, increase in victimization rates, arrest, and
the illness and its symptoms. Insight into mental illness is assessed
ultimately
death.6–8
Poor treatment adherence is the main cause of
Perspect Psychiatr Care. 2018;1–12.
from a multidimensional standpoint such as accepting the disease,
wileyonlinelibrary.com/journal/ppc
c 2018 Wiley Periodicals, Inc
1
2
ERTEM AND DUMAN
recognizing the symptoms of the disease and accepting the
psychoeducation, family interventions, and motivational interviews.35
treatment.15 Individuals with low level of insight may be incom-
Motivational Interviewing (MI) is regarded as a form of client-focused
patible with their treatment by rejecting psychiatric diagnoses, signs
counseling to stimulate a behavioral change.36 The main goal is to dis-
of illness and relevant treatments. Lacro et al.16
state that drug incom-
cover and solve ambivalence. This method is particularly useful for
patibility is the most associated with insufficient insight.16 Rusch and
people who are reluctant to change or who have ambivalent feelings
Corrigan17 emphasize that insight and poor treatment adherence may
and thoughts. This method, which is used primarily for individuals with
have different causes, such as neurocognitive deficits and reflections
alcohol and substance dependence, is now also used for individuals
of defensive mechanisms (denial and reflection) that are exaggerated
with physical and mental disorders.37,38
by individuals diagnosed with schizophrenia.17,18
In a systematic review, Vanderwaal39 examined six studies published in the last decade in order to assess the effect of MI on treatment adherence of individuals diagnosed with schizophrenia. One of
2
BACKGROUND
these studies showed that MI increased the adherence level, and other
studies showed that MI had a positive effect on remission and hospi-
Many health professionals assume that the nature of schizophrenia
tal readmission. In these studies, the importance of individual models
entail difficulties in adjustment of patients to treatment whereas poor
were emphasized to provide healthy behavior change in patients. Con-
“insight” into “mental illness” remains the main reason3,11,19–21 (Tseng
curringly, these studies recommended health professionals gain knowl-
et al., 2008) of nonadherence to treatment. Other factors such as
edge and skills to support MI method.
psychopathology and prognosis are associated with current psychi-
Psychiatric nurses are the only health professionals who inter-
atric condition of the patient, as well as patient specific internalized
act with the patients longer than anyone else. Therefore, psychiatric
stigmatization and medication related side effects2,22,23 problems in
nurses take initiative to prevent exacerbation, increase adherence with
compliance with drug regimen, inadequate social and environmental
the drug treatment, monitor the drug effects and side effects,40 and
support,5 economic difficulties, inadequate information about treat-
help increase insight.41 In this context, a psychopharmacology guide
ment or misinterpretation of the treatment,3 multiple drug use,24 con-
which prepared for the psychiatric nurses by the American Nurses
ditions of the region and hospital, attitude of patient and its environ-
Association and a mandate issued in 2011 in Turkey, established the
ment toward treatment of the mental illness, side-effects of drug use
duty and responsibility framework for the psychiatric nurses. Accord-
on social life, cultural beliefs, expectation of off-clinic healing from
ing to these guides, psychiatric nurses should be held responsible for
entities such as psychics, herbalists and alchemists, and pressure on
collaborating with patient and his/her family during treatment plan-
treatment25,26
ning besides other duties.42,43
play a decisive role in the development of drug incom-
Psychiatric nurses serve as a bridge between psychiatric patients
pliance.
The levels of adherence mentioned in literature are “optimal-
and psychiatrists and the treatment prescribed by physicians.44,45
medium-poor.”27,28 The critical importance of optimal adherence to
In order to sustain treatment collaboration, nurses should provide
prescribed antipsychotic regimens has been repeatedly and con-
medication and treatment participation through nurses’ trainer role
vincingly demonstrated in patients with schizophrenia. Adherence
(psycho-education about treatment, their side effects) and counseller
increases the likelihood of positive outcomes in all aspects of a patient's
roles for patients and their families.
life including better symptom control,29 reduced risk of relapse and
Herein, it is vital that treating nurses are knowledgeable about
rehospitalization and improvement in quality of life and social and
the intervention and interview methods.42,44 In the literature, it is
functioning.7
Conversely, the poor levels of adherence
stated that MI originated from Carl Rogers’ person-centered therapy
results in persistence of symptoms and predisposes the patient to
(PCT).46 Rogers described it a way to engage with others through
relapse which can contribute to a poorer long-term prognosis.30
acceptance, empathy, and compassion. Rogers explained the PCT as
occupational
The concept of insight is defined as an ability to recognize and
“a way of being” that facilitates the patient's own ability to arrive at
accept the existence of a mental disorder. Poor insight in patients
the conclusions that already exist within themselves.47 It is empha-
with schizophrenia has been linked to more negative attitudes toward
sized that MI provides an ideal framework to support efficient com-
medication, longer episodes of antipsychotic nonadherence, more fre-
munication that highlights the identification of patient barriers to
quent hospitalization, and greater levels of positive and negative
adherence and strategic interventions to promote adherence.48 The
symptoms, lower self-esteem as well as poorer psychosocial function
lack of patient-centered communication and treatment can nega-
and quality of life.31 Evidence based treatments for individuals with
tively impact patients’ behaviors, treatment engagement, adherence,
schizophrenia should include the improvement of insight as a major
and overall health outcomes. Although psychiatric professionals are
therapeutic goal with appropriate interventions.32 The concept of
trained about therapeutic communication techniques, there is great
insight covers three dimensions: (a) awareness of illness; (b) the capac-
potential to improve communication, and increase patient engagement
ity to relabel psychotic experiences as abnormal; and (c) treatment
during inpatient hospitalization.46 Advanced psychiatric nurse prac-
compliance.33,34
titioners play an important role in implementing motivational inter-
Many interventions have been used to improve treatment adher-
viewing with direct patient care. Throughout the inpatient hospitaliza-
ence for individuals with schizophrenia and other psychotic disor-
tion, psychiatric nurses have the most face to face time with patients.
ders. Methods of intervention comprise cognitive behavioral therapy,
When psychiatric nurses effectively develop rapport upon admission
3
ERTEM AND DUMAN
and maintain that throughout hospitalization, better patient engage-
3
METHODS
ment and treatment adherence is likely.49
Studies assert that increasing insight and strengthening medica-
3.1
Type of study
tion participation of individuals diagnosed with schizophrenia require
building a strong health care team-client relationship and applying
“individual” models for the change of health behavior.26,50,51 Morton and Zubek52 assert that nurses can help patients understand
the importance of collaboration in treatment better. According to
Baier,53
This study was carried out in an experimental design with randomized
controlled.
3.2
Research location and timeline
individual-centered approach to therapeutic interaction with
The research was carried out at a university hospital psychiatry outpa-
the patient conveys a message of “being together, walking on the
tient clinic between December 2014 and October 2015 in Turkey. In
same line.” Psychiatric nursing facilitates medical care adherence in the
this unit, pyschosis outpatient services are provided for the individu-
patient thru patient–nurse relationship based on effective communica-
als diagnosed with schizophrenia on Wednesdays and Thursdays every
tion and therapeutic relationship. This relationship gradually improves
week. An interview room at the outpatient clinic was used to convey
the nurse–patient working stages in approaching various problems and
information about the study and apply the scales to the patients regis-
contributes to an individual's treatment adherence.44,45
tered to the system for follow-ups on the service days. Motivational
A psychiatric nurse should aim for a "change speech" in a motiva-
interview intervention and the follow-up studies were conducted in
tional interview. The spirit of MI; compassion, acceptance, collabora-
the nursing faculty classrooms, since there was no interview room in
tion, and evocation has the overall goal of calling from the client his/her
the out patient clinic. So, the director of this clinic suggested to per-
internal motivation toward change. So, when the patient started to
form this process at a classroom. The faculty where these interviews
talk about change (I will take my pills regularly because I feel bad
performed is the near of the hospital.
if I do not get them) the motivational interviews achieve the aim.
Meanwhile, the positive and negative aspects of the change should
3.3
Inclusion and exclusion criteria
be addressed. Ultimately, it is the goal for the patient to make a definite decision for change and thus gain a healthy behavior. Therefore,
3.3.1
Inclusion criteria
a psychiatric nurse should be able to demonstrate a consultative role
Age 18–65 years, the diagnosis of schizophrenia according to diagnos-
by combining appropriate therapeutic approach principles and com-
tic criteria DSM-V, able to read and write Turkish, as respondents were
munication skills along with the basic principles and skills of the moti-
willing and able to be interviewed.
vational interview
method.44,45
Psychiatric nurses are professionally
accountable for identifying patient circumstances leading to treat-
3.3.2
Exclusion criteria
ment nonadherence and using MI methodology as a counter-measure.
History of chronic physical disease, a history of substance use (except
Systematic review and meta-analysis studies on the subject (Lundahl
caffeine and nicotine), a history of mental retardation.
et al., 2013)70 remark that employment of individual models to promote healthy behavioral change by increasing motivation in patients is
under-investigated. This study will contribute to the existing literature
in this respect. Therefore, the aim of our study is to examine the effect
of motivational approach on treatment adherence and insight levels of
the patients diagnosed with schizophrenia.
3.4
Ethical considerations
In order to conduct this research, a written permission was obtained
from the Ethics Committee of Dokuz Eylül University with the reference number 2013/19-02 and additional written permissions were
received from Dokuz Eylül University Hospital Chief Physician and
Psychiatric Policlinic. Prior to face-to-face interviews, the participants
were informed about the study and asked for their verbal and written
2.1
Research hypotheses
Hypothesis 1:There is a significant difference between the intervention and control groups’ preprogram, postprogram, third-month, and
sixth-month adherence levels.
consents.
3.5
Sampling
The sample of the study consists of individuals diagnosed with
Hypothesis 2:There is a significant difference between the interven-
schizophrenia who applied to a university hospital Psychiatry outpa-
tion and control groups’ preprogram, postprogram, third-month, and
tient clinic in Turkey. Individuals with schizophrenia, who match with
sixth-month insight scale and subscale scores.
the sample characteristics, were assigned to intervention and control
Hypothesis 3:There is a significant difference between the prepro-
groups according to the randomization schedule. The sample size was
gram, postprogram, third-month, and sixth-month treatment adher-
calculated in the NCSS-PASS software program with an error margin
ence levels of the patients in the intervention and control groups.
of 0.05%, Type 1 error of 0.05 and Type 2 error of 0.20, in a 95% con-
Hypothesis 4:There is a significant difference between the prepro-
fidence interval of 80% power. Based on the measurements related to
gram, postprogram, third-month, and sixth-month insight scale and
treatment adherence for the four periods (pre-MI, post-MI, third, and
subscale mean scores of the patients in the intervention and control
sixth follow-up measurements), based on the study of Kemp et al.,54
groups.
10 individuals were calculated for each group. Considering a margin of
4
ERTEM AND DUMAN
drop-out among the sampling in the course of interviews, the sample
measuring insight of patients with schizophrenia. The reliability and
size was set at 20 for the intervention and control groups. During the
validity study of this scale in Turkish was done by Arslan et al.58 The
data collection procedure, 83 patients with schizophrenia were sur-
three constituents of the insight scale are as follows “treatment adher-
veyed by researcher, 24 patients did not meet the criteria, 40 patients
ence, awareness of disease, and correct recognition of psychotic expe-
met the criteria and 19 patients did not want to participate in the study.
riences.” SATCI is a semi-structured measurement tool implemented
by the clinician. The scale comprise of eight questions and covers these
3.5.1
Assigment of intervention and control groups
dimensions: (a) awareness of illness; (b) the capacity to relabel psy-
Patients with schizophrenia, followed by the psychosis unit, were
chotic experiences as abnormal; and (c) treatment compliance. The
directed to the researcher by the related physician after the outpa-
Cronbach alpha reliability coefficient was found 0.83. Response to
tient meeting. In a seperate interview room, the researcher informed
each question was marked with a score ranging from 0 to 2. Higher
the patients one by one about study and they filled in informed
score corresponds to higher level of insight. The highest total score of
consent. After this procedure, Morisky scale was administered to
the first seven items is 14. The eighth question is hypothetical and it is
determine adherence level of patient. If patient said “yes” to any
the interviewer's call to ask the question. With this question, the high-
question—at least one—she/he was included to study. And a number
est total score is 18. In this study, Cronbach alpha reliability coefficient
was given to patient to assign random table based on the order of their
was 0.86.
arrival in the polyclinic. Intervention and control group assignments
were made by randomization method from the random numbers table
3.7
(http://www.stattrek.com/statistics/random-number-generator.aspx).
A program based on the motivational interviewing principles, which
According to this list, 20 of the 40 patients constituted the inter-
helps to increase insight and treatment adherence, was prepared to
vention group and the remainder constituted the control group.
stimulate treatment co-operation of the individuals diagnosed with
And researcher who worked as an assistant professor at university,
schizophrenia in the intervention group. Through MI, the patients will
involved data collection process and she was trained about informed
recognize which one is medication side effect and which one is symp-
consent and Morisky scale.
tom. He/she will realize the positive effects of medication on dis-
Researcher prepared a study plan to interview with every patient.
All of the interviews recorded auditory and written. After every inter-
The content of motivational ınterview
ease. The different thinks or behaviors that she/he experienced will be
noticed through these interviews.
view, researcher and her supervisor assessed and discussed the inter-
The program consists of six semi-structured, interconnected
view. And sample size was calculated to based on other randomized
interviews. All the interviews were interconnected with themselves
controlled study by using power analysis.
because of providing topic integrity. For example the patient talks
The flow chart for the research execution process is presented in
CONSORT (Figure 1).
about the symptoms of disease, identifies the factors that prevent
regular drug use, and evaluates the benefits and side effects of the
treatment subjectively. The next interview discusses side effects of
3.6
3.6.1
Data collection
Personal information form
Personal Information Form consisted of 22 questions soliciting information with regards to sociodemographic characteristics, disease, and
medication.
treatment and symptoms of disease objectively (using prospectus,
etc.). The researcher and supervisor structured the interview sessions
during the case study.
This program was also used to increase treatment adherence in a
case study contemplating the diagnosis of schizophrenia.59 The purpose of each interview is stated as follows:
3.6.2
Morisky's questions-self-report measure of
adherence
1. Interview: The goal of the first interview is to determine the resis-
It was developed by Morisky and validated by Morisky, Gren and
2. Interview: Understanding the symptoms of the disease, identifying
Levine in 1986.55 The scale consists of four “yes–no” questions filled
the factors that prevent regular drug use, and evaluating the ben-
by the patient herself/himself, measuring the adherence of treatment.
efits and side effects of the treatment are the goals of this inter-
If a patient answers “No” to every question, it means a high adherence.
view. In addition, the ambivalent feelings of the patient regarding
If a patient answers “No” to one or two questions, it means a medium
the treatment are addressed.
adherence. If a patient answers “Yes” to three or four questions, it
means a low adherence. A validity and reliability study conducted with
117 psychotropic drug users reported the Cronbach alpha reliability
coefficient of 0.52.56 This study reported the Cronbach alpha reliabil-
tance of the patients to change.
3. Interview: The goals for this interview are understanding the illness, evaluating the side effects of medicines, weighting the benefits of treatment and raising awareness. It is vital to raise awareness
by asking open-ended and reflective questions at this stage.
ity coefficient of 0.57.
4. Interview: The goal for this interview is to encourage the individual
3.6.3
Schedule for assessing the three components of
insight
David57
for a change by having the patient notice the positive and negative
effects of his past experiences.
developed a scale for assessing the three components of
5. Interview: The purpose of this interview is to support relapse pre-
insight (SATCI) in order to set up a quantitative approach for
vention and improve collaboration via evaluating the decisions
5
ERTEM AND DUMAN
FIGURE 1
CONSORT
taken toward the change by the patient and re-establishing the
from an MI specialist. Before this study, researcher and her supervisor
trust.
studied a case diagnosed with schizophrenia by using MI.
6. Interview: The purpose of this interview is to encourage the self-
Each interview lasted 40–60 min on average, and the process was
efficacy of a patient in maintaining the treatment. The necessity for
completed in a total of six by-weekly interviews. The interviews were
prophylactic or maintenance treatment is assessed by emphasizing
held in the classrooms of Dokuz Eylül University Nursing Faculty.
the importance of being healthy and well.
Meanwhile, a patient in the intervention group ceased to attend the
motivational interview program due to experience of intense paranoid delusions and certain home confinement. Follow-up of the patient
3.8
Data collection and the application process of
programe
who did not continue the interviews was done. When the interven-
In the first stage, patients from the intervention and control groups,
reapplied to the control group of patients who received standard treat-
who were followed by the outpatient clinic and satisfied the random-
ment and follow-up in the psychiatric outpatient clinic. Third and sixth
ization and sampling criteria, filled out “Schedule for Assessing the Three
month follow-ups were administered for the patients both in the inter-
Components of Insight” and “Morisky's Questions-Self-Report Measure of
vention and control groups. The evaluations described in this study
Adherence.” Throughout the study, patients in the intervention and
were expressed in the form of pre-MI (T1), post-MI (T2), third month
control groups continued to receive their routine treatment (drug
follow-up (T3) and sixth month follow-up (T4).
tion group's interviews were completed, the measurement tools were
therapy, physician controls). During this period, the control group
During data collection at outpatient unit, patients who had doctor
patients received no intervention other than their routine treatment.
control appointment came to secreteriat and waited for interview in
Motivational interviews with the patients in the intervention group
front of doctor room silently. There was no waiting room at outpatient
were conducted on a one-to-one basis by researcher.
unit. So the patients included in this study did not keep in touch or
The researcher was a PhD student in the psychiatric nursing depart-
effect themselves. And the patients had come from different intervals,
ment during this process and was certificated on MI techniques. The
and also they were not included in a different study (psychoeducation,
researcher participated in a 20-h course, including supervision on MI
etc.).
6
ERTEM AND DUMAN
3.9
Data analysis
The data analyse was calculated by using SPSS 22.0 (IBM Corpora-
(pre-MI—third month follow-up) and T1–T4 (Pre-MI—sixth month
follow-up) intervals only (Table 2).
There was a statistically significant difference between the inter-
tion, New York, United States) software. For the data analysis, descriptive statistics such as number, percentage, mean, and standard deviation were utilized. Independent t-test and Mann–Whitney U-test were
used to compare the scale-point averages of the intervention and control groups. Chi-square test was used to compare categorical data.
Friedman's Two-Way test was used to examine the interaction of overrepeated measures of dependent variables with respect to groups. A
vention and control groups’ sixth month insight scale's treatment
adherence subscale scores (p = 0.038). Testing the mean scores of the
“three component scales of insight” for the intervention and control
groups with respect to study intervals revealed that the difference
between the (T1) and (T4) mean scores for the intervention group were
statistically significant (Table 2).
There was statistically significant difference between the interven-
post hoc advanced analysis technique was used to determine the group
from which the difference originated. A patient from intervention
group could not attend to study after the fourth interview because of
his delirium. The intention to treat analysis (ITT) was applied because
the researcher had this patient's pretest–posttest and follow-up data.
tion and control groups in terms of disease awareness subscale scores
of insight scale at the post-MI (p = 0.037), third month follow-up
(p = 0.004) and sixth month follow-up (p = 0.005) scores. The disease
awereness subscale scores were analyzed with respect to intervals for
the intervention and control groups. The analysis showed a statistically
3.10
Findings regarding sociodemographic
and treatment characteristics of patients
The mean age of the patients in the intervention group was
43.20±10.54 and in the control group was 40.05±10.87. The majority
significant difference for T1–T3 and T1–T4 mean scores in the intervention group, and T1–T4 mean scores in the control group.
There was statistically significant difference between the intervention and control groups in terms of “Correct Recognition of Psychotic Experiences” Subscale Scores of insight scale at the post-MI
of the participants in the intervention (70%) and control (50%) group
(p = 0.030), third month follow-up (p = 0.013) and sixth month
were male. The minority of the participants in the intervention (15%)
follow-up (p = 0.004) scores. Analysis of “Correct Recognition of Psy-
and control (30%) group were single. The high percentage of the participants in the intervention (80%) and control (70%) group were unemployed. The majority of the participants in the intervention (85%) and
control (75%) group lived with their family members. The chi-square
test was used to determine any meaningful difference between the
variables of the intervention and control groups (p > 0.05) (Table 1).
chotic Experiences” Subscale Scores with respect to intervals in the
intervention and control groups, warranted a significant difference
for T1–T3, T1–T4, T2–T3, and T2–T4 interval mean scores of the
intervention group. Meanwhile, a significant difference was also warranted for the T1–T4 interval mean scores of the control group
(Table 2).
The intervention group (85%) and the control group (70%) had at
least three daily psychiatric medications. The intervention and control groups (60%) stated that they had taken medication at least three
times a day. The intervention and control groups (65%) confirmed
3.12
Comparision of treatment adherence levels
of patients
receiving reminder support to take their medication. The intervention
Patients’ Pre-MI Morisky Adherence Scale total scores between the
group (75%) and the control group (40%) reported receiving no infor-
intervention and control groups showed significant difference at the
mation from either a physician or a nurse concerning their medication.
post-MI (p = 0.001), third month follow-up (p < 0.001) and sixth month
There was a statistical meaningful difference between the two groups
(p < 0.001) scores. Analysis of the Morisky Adherence Scale Mean
in terms of this variable (𝜒 2 = 5.013, p = 0.027). The intervention group
Scores in terms of intervals for the intervention and control groups,
(30%) and the control group (65%) were dissatisfied with the dosage of
showed a significant difference for T1–T2, T2–T3, T3–T4, and T2–T4
the drugs they received. The difference between the two groups’ opin-
interval mean scores of the intervention group (Table 3).
ions regarding dose sufficiency was significant (𝜒 2 = 4.912, p = 0.028)
(Table 1).
4
3.11
Comparison of intervention and control groups
according to levels of insight
The aim of this randomized controlled trial was to investigate the effect
There was statistically significant difference between the intervention
respect to treatment adherence and insight. In the light of the acquired
and control groups at post-MI (p = 0.026), third month follow-up
data, adoption of MI method has proved its effectiveness. Therefore, it
(p = 0.011), and lastly sixth month follow-up (p = 0.002) phases in
is important for psychiatric nurses to get themselves familiar with the
terms of total scores of the patients in the three component scale.
intervention and interview methods and comfortable with its applica-
Group-wise examinations showed that mean scores of “three com-
tion in order to sustain treatment adherence. This study is of signifi-
ponent scales of insight” yielded statistically significant difference
cance to the existing literature due to the evidence of improved treat-
for the intervention group at T1–T3 (pre-MI—third month follow-
ment adherence and insight levels on the patients with schizophrenia
up), T1–T4 (pre-MI—sixth month follow-up), T2–T3 (post-MI—third
via adoption of MI method, which also yield an exemplary guide for
month follow-up) and finally T3–T4 (third month follow-up—sixth
psychiatric nurses to follow. The patients recognized which one was
month follow-up) intervals, whereas, for the control group at T1–T3
medication side effect and which one was symptom. He/she realized
DISCUSSION
of MI methods on the patients diagnosed with schizophrenia with
7
ERTEM AND DUMAN
TA B L E 1
Sociodemographic and treatment characteristics of sample
Mean Age
Gender
Marital Status
Education Level
Intervention Group (n = 20)
Control Group (n = 20)
̄
X±ss
̄
X±ss
43.20±10.54
40.05±10.87
N
%
N
%
𝝌2
p
Female
6
30.0
10
50.0
1.667
0.333
Male
14
70.0
10
50.0
Married
3
15.0
6
30.0
0.256
0.451
Single
17
85.0
14
70.0
0.568
0.710
0.465
0.716
0.429
0.695
0.256
0.451
0.000
1
4.912
0.028
Elemantary
7
35.0
4
20.0
High School
8
40.0
10
50.0
University
5
25.0
6
30.0
Employement Status
Employed
4
20.0
6
30.0
Unemployed
16
80.0
14
70.0
Contacts
Alone
3
15.0
5
25.0
Family
17
85.0
15
75.0
Medication Quantity
1–2
medication(s)
3
15.0
6
30.0
3 or more
medication
17
85.0
14
70.0
1–2 times
8
40.0
8
40.0
3 or more times
12
60.0
12
60.0
Yes
14
70.0
7
35.0
No
6
30.0
13
65.0
Medication Dose Per Day
Patient Assessment for the
Dose Sufficiency
Dose Increase/
Decrease
Drug Reminder
Drug
Information
Information
Level
Treatment
Reflection
Reject Treatment
Intervention Group (n = 20)
Control Group (n = 20)
N
%
N
%
𝝌2
p
Yes
6
30.0
11
55.0
2.558
0.200
No
14
70.0
9
45.0
Yes
13
65.0
13
65.0
0.000
1
No
7
35.0
7
35.0
Yes
Intervention Group (n = 20)
Control Group (n = 20)
𝝌2
p
5
12
5.013
0.027
0.004
1
2.667
0.191
0.960
0.514
U
p
25.0
60.0
No
15
75.0
8
40.0
Sufficient
3
60.0
8
61.5
Insufficient
2
40.0
5
38.5
It does not work
5
25.0
10
50.0
Heals
15
75.0
10
50.0
Yes
11
55.0
14
70.0
No
9
45.0
6
30.0
Intervention Group (n = 20)
Control Group (n = 20)
Median (Min.–Max.)
Median (Min.–Max.)
Treatment Duration (Year)
14.5
(6–32)
10
(5–32)
–1.519
0.128
On-Medication Duration
(Year)
14.5
(5–32)
10
(5–32)
–1.235
0.226
8
ERTEM AND DUMAN
TA B L E 2
Comparison of intervention and control group according to insight levels of patients
Intervention (n = 20)
Control (n = 20)
Insight
Median (Min.–Max.)
Median (Min.–Max.)
Z
p
T1
12.50 (5–18)
11.29 (3–18)
–1.060
0.303
T2
15.38 (6–18)
11.50 (3–18)
–2.220
0.026
T3
16.67 (10–18)
13.67 (3–18)
–2.508
0.011
–2.953
0.002
T4
17.36 (9–18)
14.00 (3–18)
Friedman Test p
<0.001
0.002
Significant Difference
T3 > T1, T4 > T1,
T3 > T2, T4 > T2
T4 > T1, T3 > T1
Intervention (n = 20)
Control (n = 20)
Treatment Adherence
Median (Min.–Max.)
Median (Min.–Max.)
Z
p
T1
3.47 (1–4)
2.82 (1–4)
–0.973
0.338
T2
3.67 (2–4)
2.94 (1–4)
–1.596
0.115
T3
3.72 (2–4)
3.43 (1–4)
–1.272
0.216
–2.033
0.038
Z
p
T4
3. 85 (3–4)
3.43 (1–4)
Friedman Test p
0.004
0.166
Significant Difference
T1 < T4
Intervention (n = 20)
Control (n = 20)
Awareness
Median (Min.–Max.)
Median (Min.–Max.)
T1
4.70 (0–6)
3.71 (1–6)
–1.186
0.243
T2
5.29 (0–6)
4.00 (2–6)
–2.116
0.037
T3
5.72 (2–6)
4.63 (0–6)
–2.943
0.004
T4
5.89 (2–6)
5.17 (0–6)
–2.771
0.005
Z
p
Friedman Test p
<0.001
0.029
Significant Difference
T3 > T1, T4 > T1
T4 > T1
Intervention (n = 20)
Control (n = 20)
Correct Recognition of
Psychotic Experiences
Median (Min.–Max.)
Median (Min.–Max.)
T1
5.29 (1–8)
4.45 (0–8)
–1.194
0.240
T2
6.40 (1–8)
4.50 (0–8)
–2.206
0.030
T3
7.29 (2–8)
5.17 (0–8)
–2.484
0.013
T4
7.60 (2–8)
5.17 (1–8)
–2.926
0.004
Friedman Test p
<0.001
0.003
Significant Difference
T3 > T1, T4 > T1,
T3 > T2, T4 > T2
T4 > T1
TA B L E 3
Comparision of treatment adherence levels of patients in the intervention and control groups
Intervention (n = 20)
Control (n = 20)
Morisky Adherence Scale
Median (Min.–Max.)
Median (Min.–Max.)
Z
p
T1
1.25 (1–2)
1.30 (1–2)
–0.350
1
T2
0.69 (0–2)
1.67 (0–2)
–3.223
0.001
T3
0.45 (0–1)
1.63 (0–2)
–4.554
<0.001
T4
0.30 (0–1)
1.53 (0–2)
–4.689
<0.001
Friedman Test p
<0.001
0.061
Significant Difference
T1 > T4, T2 > T4
9
ERTEM AND DUMAN
the positive effects of medication on disease. The different thinks or
of counselling. Treatment adherence therapy comprised of five ses-
behaviors that she/he experienced were noticed through these inter-
sions each lasting 30–60 min. Pre-MI, post-MI and 1-year follow-up
views.
evaluations of the intervention-group and control-group patients were
All in all, the intervention-group patients achieved improvements
made in order to gather information about treatment adherence, atti-
on treatment adherence and insight levels after application of MI
tudes toward treatment, insight, symptoms, functions, and quality of
program compared to the control-group patients. In this study, it is
life. In the 1-year follow-up, no difference between the control-group
found that the mean scores pertain to third and sixth month follow-
and the intervention-group was found in terms of patients’ treatment
ups are significantly higher than the mean scores pertain to pre-MI
adherence, attitudes toward treatment, insight, symptoms, functions,
and post-MI. The implementation of follow-ups after MI program
and quality of life scores. Byerly et al.66 applied MI included adherence
increased the mean scores for insight and treatment adherence levels
threapy on 30 outpatients diagnosed with schizophrenia and schizoaf-
of the intervention-group patients as shown in Tables 2 and 3. On
fective disorder based on DSM-V criteria. No change was detected
the other hand, the control-group patients’ insight level increased
at pre-MI, post-MI, and 5 months follow-up intervals of the study
significantly over time which may be associated with the outpatient
with respect to the patients’ treatment adherence, symptoms, insight,
clinic follow-ups and the process of interviewing with the physician
and attitudes toward treatment. In another study, Gray et al.67 exam-
during the research process. During the study, there were patient
ined the effect of MI included adherence threapy on the quality of
readmissions to hospital from control group at times. So, every read-
life of individuals diagnosed with schizophrenia. The study was con-
mission may increase the insight level positively because of nurse,
ducted over 52 weeks and randomized controlled. Findings of the
doctor interviews, regular pill taking, etc.
study suggested that adherence therapy was not more effective than
Treatment becomes more effective when treatment adherence is
successfuly
increased17
viduals with psychotic
by means of MI adapted specifically for indidisorders.60
al.54
the health education given to increase the quality of life. Drymalski and
Campbell68 carried out a systematic review of randomized controlled
conducted a ran-
studies on the patients with schizophrenia, which included MI method.
domized controlled trial consisting 4–6 sessions of 10–60 min motiva-
In this review, it was emphasized that MI method did not have a clear
tional interview program. As a result of this study, it was determined
impact on the treatment adherence thus further investigation on the
that there was a meaningful difference between the drug adherence
topic was proposed.
Kemp et
and insight level of the patients in the intervention group. Afterwards,
The results of this study do not concur with the findings of
Kemp et al.61 conducted a study with respect to the psychotic patients
similar studies.65–67 Several problems such as MI content, session
who were hospitilized in the UK. The study involved application of MI
count, follow-up frequency and count, interviewer's knowledgeable-
program to an intervention-group (n = 37) and individual counselling
ness about MI, might have led to this discrepancy. Moreover, factors
to a control-group (n = 37) for 5 weeks. Patients’ social functioning,
such as duration of interview, follow-up after interviewing, planning of
treatment adherence, insight, and attitudes toward treatment were
research in a group interview context, inclusion of comorbid patients
evaluated at the following stages respectively pre-MI, post-MI and 18
might have been influential as well.
months of follow-up. The intervention group scored higher for treat-
In this research, using motivational interview's individual formation
ment adherence, insight, and attitude toward treatment. According to
and the same researcher's performing the six interviews might posi-
Barrowclough et al.,62 several randomized controlled studies, utilizing
tively affected the research process in terms of patient drop out rate.
psychosocial interventions to support drug adherence in patients with
schizophrenia, reported effectiveness of MI methods on drug adher-
Despite the important results gained of this study, the following limitations were noted.
ence. Zygmunt et al.63 searched Medline and Psychlit databases for
publications from 1980 to 2000 to investigate psychosocial interven-
1. The internal consistency of “Morisky's Questions-Self-Report Measure
tions used to enhance drug adherence. According to the result of this
systematic literature review, emphasis on the importance of inter-
of Adherence” was poor.
2. “Morisky's Questions-Self-Report Measure of Adherence” was only
ventions involving problem solving and motivation was highlighted
composed of four questions, and therefore multidimensional treat-
even though clinically psychoeducational approach and family thera-
ment adherence can not be evaluated in-depth. For this reason, it is
pies were used frequently. Findings obtained in our study are in parallel
imperative to evaluate treatment adherence in-depth (knowledge,
with the results of this research. Brown et al.64 conducted a study with
thought, beliefs, and attitudes about treatment) in determining the
35 patients in the UK between the ages of 14 and 35 in their earlies
effectiveness of such studies.
whom either had stayed in the acute pyschiatric services or had been
in contact with the clinic team for 6 months. Effect of MI interventions
3. In addition, carrying on individual interviews had a limiting effect
on the number of samples.
on the patients’ relapse, hospitalization, and extend of hospitilization
was evaluated in pre-MI and 1-year follow-up intervals respectively. In
particular, the relapse rates of the patients were found to decrease significantly at 1-year follow-up.
6
CONCLUSION
In a randomized controlled study reported by O'Donnell et al.,65
an intervention group (n = 26) was exposed to MI included treatment
The study showed that the treatment adherence and insight levels
adherence therapy while a control group (n = 24) was given 5 weeks
improved by MI methods. It is suggested to conduct researches with
10
ERTEM AND DUMAN
longer follow-up periods such as ranging from 12 to 18 months. The
planning of MI needs to be standardized in every health institution. A
subsequent research scrutinizing the effect of MI methods held both in
an individual and group interview context is proposed.
7
RELEVANCE FOR CLINICAL PRACTICE
Considering these findings, it might be important to implement this
program with persons diagnosed with schizophrenia and comorbid
bipolar disorder. Both the pyschiatric patients and the health institutions can benefit from increased levels of treatment adherence and
insight by the adoption of the MI methods starting with a patient's first
registration to a psychiatric outpatient clinic.
8
CONTRIBUTIONS
MI can be included during any of the patient visits to establish treatment collaboration with psychiatric patients at psychiatric facilities,
outpatient clinics and community mental health centers.
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277–282.
DISCLOSURE
This study was accepted for an oral presentation at Nursing World
Conference, Las Vegas, October 16–18, 2017.
DETERMINING AUTHORSHIP
1. Substantial contributions to conception and design, or acquisition
of data, or analysis and interpretation of data; Melike Yönder Ertem,
Zekiye Çetinkaya Duman.
2. Drafting the article or revising it critically for important intellectual
content; Melike Yönder Ertem, Zekiye Çetinkaya Duman.
3. Final approval of the version to be published; Melike Yönder Ertem,
Zekiye Çetinkaya Duman.
11. Byerly MJ, Nakonezny PA, Lescouflair E. Antipsychotic medication
adherence in schizophrenia. Psychiatr Clin North Am. 2007;30:437–
452.
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GRANT SUPPORT AND FINANCIAL DISCLOSURES
No external or intramural funding was received.
CONFLICT OF INTEREST STATEMENT
There is no conflict of interest between the authors.
ORCID
Melike Yönder Ertem PhD
http://orcid.org/0000-0002-7039-3650
Zekiye Çetinkaya Duman
http://orcid.org/0000-0002-7447-874X
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How to cite this article:
Ertem MY, Duman ZÇ. The
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