Family participation in treatment, post-discharge appointment and medication adherence at a Nigerian psychiatric hospital

In low-income countries, clinicians must seek strategies toimprove treatment adherence that are non-resource intensiveand easily integrated into existing treatment structures. Weconducted a prospective observational cohort study to investigatethe relationship of family engagement in treatment during hospitalisationwith post-discharge appointment and medication adherence in81 patients from a Nigerian psychiatric hospital. After controllingfor gender, diagnosis, mental state at discharge, and maritalstatus, family involvement was significantly associated withappointment (P=0.047) but not medication adherence (P=0.590).Studies are needed to determine whether interventions basedon engaging families in treatment can improve post-dischargeadherence in this setting.

INTRODUCTION

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INTRODUCTION

Non-adherence to psychiatric treatment undermines treatmenteffectiveness, increases risk of relapse and predisposes topoorer outcomes.^1,2 A systematic review found that one offour patients with psychosis do not keep scheduled post-dischargeappointments, and almost one in three do not take medicationsas prescribed. Most studies reviewed, however, were from Europeor the USA.² In Europe and the USA, psychoeducation programmes,family therapy and community-based interventions have beenused successfully to improve adherence.^2–5 Althoughnot all studies have reported significant effects on adherence,most interventions that have improved adherence have also reportedpositive clinical outcomes, such as fewer rehospitalisations.¹ One study from Africa examined post-discharge treatment adherenceamong 387 patients at a Nigerian psychiatric unit and foundthat 46% had defaulted by 3 months.⁶ In low-income countriessuch as Nigeria, structural barriers, including poverty, poorinfrastructure and the absence of formal social welfare servicesand trained staff, limit the applicability of adherence strategiesused in high-income countries.⁵ In this context, cliniciansmust seek pragmatic approaches more feasibly integrated intoexisting treatment structures. One such strategy involves engagingthe families in treatment programmes in order to facilitatepost-discharge support that, in high-income countries, mighttypically be provided by community workers. It is not known,however, whether participation by family members in in-patientcare in low-income countries predicts better post-discharge adherence. The objective of this study was to investigate whetherfamily involvement in treatment during hospitalisation is independentlyassociated with greater post-discharge appointment and medicationadherence.

Method

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Method

This was a prospective study of patients admitted for in-patientcare to the Federal Psychiatric Hospital, Kaduna, Nigeria.The hospital is a 100-bed public regional psychiatric hospitalthat primarily receives patients from north-west and north-centralNigeria and the federal capital territory, Abuja. Kaduna isa cosmopolitan city of 1.2 million people and is regarded asthe capital city of northern Nigeria. Patients admitted betweenJuly and December 2004 and taking their medications as prescribedat discharge were eligible for the study. A study physicianassessed patients’ mental state, family involvement intreatment and medication side-effects prior to discharge. The Brief Psychiatric Rating Scale⁷ (BPRS), which has been usedpreviously in Nigeria,⁸ was used to assess mental state. Medicationside-effects were assessed via direct observation and reviewof case notes. Family involvement was defined using two criteria:(a) the patient’s family must have visited during admission (at least once every 2 weeks), and (b) they must have attendedat least three treatment sessions (an intake interview sessionwithin 2 weeks of admission, a second when the patient hadbecome clinically stable, and a third in the week of discharge).At 3-month follow-up, treatment adherence was recorded and medicationadherence assessed. Non-adherers to treatment were defined as patients who did not attend scheduled appointments and whodid not re-schedule within 2 weeks. Patients who did not attendappointments were followed up at home by a female social workerand male physician in order to assess medication adherence,which was assessed through interviews with patients and familymembers. Non-adherence was defined as the failure to take prescribed medications for a week or longer, or using medications in less-than-prescribed doses. Ethical approval for the study was given by the hospital’s research and ethics committee, and informed consent was obtainedfrom all patients prior to discharge.

Data analyses included comparisons of demographic and clinicalvariables between adherers and non-adherers to appointmentsand medications using chi-squared tests for categorical variablesand t-tests for continuous variables. Multivariable logisticregression was used to test whether family involvement in treatmentprior to discharge was associated with non-adherence to post-dischargeappointments and medication, controlling for variables thatwere related to appointment or medication adherence on a bivariatebasis (P<0.10).

Results

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Results

There were 81 patients who met study criteria and all consentedto take part in the study. Slightly more than half were male(54.3%, n=44). Most patients (67.9%, n=55) were 21–40years old; 30.9% (n=25) were married; 64.2% (n=52) had $≥$ 10 yearsof education; 53.1% (n=43) were employed or in school; and44.4% (n=36) lived $≥$ 20 km from the hospital. Diagnoses included non-affective psychosis (59.3%, n=48), affective disorders(24.7%, n=20), and substance-related disorders (16.0%, n=13). Illness duration was $≥$ 1 year for 69.1% (n=56) of patients, and 71.6% (n=58) had received previous treatment. Prescribed medications included traditional antipsychotics (92.6%, n=75), anticholinergics (95.1%, n=76), mood stabilisers (18.5%, n=15), antidepressants(16.0%, n=13) and depot antipsychotics (38.3%, n=31). The familiesof 75.3% (n=61) of patients were involved in treatment.

At 3 months post-discharge, 41 (50.6%) patients were adherentwith appointments. Of the 40 who were non-adherent, 13 werenot located for 3-month follow-up owing to incorrect/untraceableaddresses or relocation. Thus, 68 patients were assessed, ofwhom 42.6% (n=29) were adherent. As shown in online Table DS1,adherers to appointments were significantly less likely tohave a substance misuse disorder and had lower BPRS scores atdischarge. Their families were more often involved in treatment.Adherers to medication were significantly less likely to havea substance misuse disorder. After controlling for gender,diagnosis, BPRS score at discharge and marital status, patientswhose families were involved in treatment continued to be significantlymore likely to adhere to scheduled appointments (odds ratio (OR)=3.66, 95% confidence interval (CI) 1.02–13.16, P=0.047), and somewhat more likely to adhere to prescribed medication,albeit not significantly (OR=1.51, 95% CI 0.34–6.70,P=0.590). Similar results were obtained when the 13 nonlocatedpatients were treated as non-adherent to medication (OR=2.13,95% CI 0.56–8.20, P=0.270). Results did not change fortreatment or medication adherence if only patients $≥$ 21 yearsold were included.

Discussion

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Discussion

The main finding of this study was that involvement of familiesin treatment during psychiatric hospitalisation at a Nigerianhospital predicted significantly improved post-discharge adherenceto appointments, but not to medication. The non-significantfinding for medication adherence may have been due to the moderatesample size of the study, although it should also be noted thataccurate measurement of medication adherence is methodologically challenging. Interview and case-note methods were used to assessmedication adherence and side-effects, but may have been lessaccurate than more objective measures such as pill counts,blood assays or standardised side-effects rating scales.⁹This was an observational study, so it is not known whetherthese findings would translate into an effective interventionprogramme. Patients with family involvement may have differedfrom patients without family involvement in ways related to adherence that were not controlled for in this study. We didnot assess factors that may have influenced family involvementsuch as the non-existence of living family members, alienationfrom families or stigmatisation. With 92% of patients prescribedantipsychotic medications, the question might be posed as towhether there was a problem of antipsychotic over-prescriptionand whether this might explain why some patients stopped theirmedications, given that about 40% of patients had diagnosesof substance-related or affective disorders. The explanationfor the apparently high antipsychotic use lies in the factthat virtually all admitted patients, including those diagnosedwith substance-related and affective disorders, presented withpsychotic symptoms, a common occurrence in Nigerian psychiatrichospital settings.¹⁰

This study suggests that engaging the family during treatmentmay improve post-discharge adherence. Although it is generallyacknowledged that the family remains an important resourcefor the support and care of psychiatric patients in most Africancountries, existing mental health policies do not emphasisethis resource.¹¹ In line with international trends, mentalhealthcare in poorer countries is increasingly being integratedinto primary care.⁵ In Nigeria, efforts over the past decadeto develop a nationwide primary healthcare-based communitypsychiatry programme have generally not been effective. Thereis precedent, however, for engaging family members in psychiatrictreatment in Nigeria. One of the earliest successful modelsof community psychiatry care, the Aro village system, was startedin the country in the 1950s. It was a widely acclaimed, innovativeprogramme that sought to engage family members in treatmentprogrammes for hospitalised psychiatric patients, and whichhad reliance on family ties and provision of a culturally salientservice as its twin bedrocks.¹² Whether or not involving familiesin in-patient psychiatric care improves post-discharge adherencein settings such as Nigeria, however, needs to be demonstratedin a study designed specifically for that purpose.

REFERENCES

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