This cross-sectional, non-interventional study of patients with schizophrenia at Manipal Teaching Hospital in Nepal had many findings of importance. Notably, 52.7% of participants had a poor or negative drug attitude as assessed by the DAI–10, predicting poor adherence (non-adherence) to medication. This is in keeping with the existing literature that states that approximately 50% of patients with schizophrenia show non-adherence in the course of treatment [16, 17]. Existing literature from similar Nepalese study populations have similar findings, one study from Poudel et al. found 37.3% of patients missed to take their medication and nearly two thirds of them sometimes missed their medication . A study from Chaudhari et al. in an Indian study population found 52% of patients to be non-adherers .
Adherence to medication is affected by many factors, in Nepalese study populations it is recognised that availability and affordability of healthcare, alongside culture and beliefs of the patients can greatly affect compliance to medication [9, 10]. This study found no significant variance in adherence between demographic groups, irrelevant of employment status, education or living arrangements. This contradicts existing literature that illiteracy and poor education are associated with poor medication adherence in schizophrenia [19, 20]. Furthermore, in a study from Ghimire et al.,, unaffordability was cited as contributing factor for 68% of non-compliant patients with schizophrenia .
This study found that 52.6% of participants had only a basic education, reflecting findings published in 2013, that only 60.3% of Nepalese people ages 15 and above can, with understanding, both read and write a short, simple sentences . It was found that 57.9% of participants were unemployed; previous studies on similar cohorts have found unemployment rates as high as 86.7% . A study from Liu et al. explores the hypothesis that illiterate people frequently experience social exclusion and this social adversity may increase risk of schizophrenia, it was found that illiterate participants were 2.08 times more likely to develop schizophrenia than the literate participants with no school education . This is in keeping with the social defeat hypothesis which suggests long-term exposure to social defeat leads to sensitisation of mesolimbic dopamine system, thus increasing the risk of schizophrenia . It is well recognised that rates of schizophrenia are higher amoungst the unemployed and uneducated [25, 26]. Alongside the social defeat hypothesis, it is important to consider how negative symptoms and stigma may affect the equal opportunity of employment and education for this patient population. The majority of Nepalese people continue to believe schizophrenia is caused by bad fortune, some believing it is the result of previous sins, evil spirits, witchcraft and black magic; this negative stigma attached to schizophrenia within Nepalese culture is recognised to leave this patient group feeling rejected from society and increase difficulty in gaining education and employment [27, 28, 29]. Furthermore, it is understood that cognitive dysfunction and negative symptoms associated with schizophrenia are significantly associated with unemployment .
Approximately 30–50% of patients with schizophrenia have lack of insight into their condition, however the nature of insight is poorly defined across psychiatric literature [31, 32]. Insight is multidimensional and is related to awareness of illness, awareness of symptoms and understanding of need for treatment . 36.8% of participants in this study population had poor insight, awareness of symptoms receiving the lowest score out of the three subscales closely followed by awareness of illness, with 84.2% of participants demonstrating poor awareness of symptoms and 78.9% demonstrating poor awareness of illness. It is understood that awareness of symptoms and illness is often greatly affected in schizophrenia as patients have a reduced capacity for self-reflectivity and self-awareness [33, 34].
Adherence is a significant problem in all patient populations in Nepal; a study from Bhandari et al. found adherence to antihypertensives at 56.5% . Unaffordability and difficulty travelling to the nearest hospital are commonly associated with non-adherence, this is equally true from the treatment of schizophrenia to tuberculosis . However, in comparison to other chronic illnesses, schizophrenia can reduce one’s ability to understand the importance of taking medication and the relationship between taking medication and reduced symptom burden. Insight is recognised to strongly correlate with adherence, with delusional patients often being the poorest adherers . This study substantiates this hypothesis, analysis found that insight positively correlated with adherence, also finding that awareness of need for treatment correlated with adherence. Although there is a clear association between insight and adherence, it would be an assumption to say that lack of insight is causative of non-adherence in these patients, as there are many other factors that could be contributing to the outcome of non-adherence [9, 10, 31].
Although this hypothesis has been demonstrated previously, there is a significant lack of research in the Nepalese patient population; a PubMed search of “schizophrenia Nepal” brings only 31 results. This study evidences that insight and adherence are correlated, despite significant familial, socio-cultural and environmental factors impacting on adherence in this study population. The study design was robust as the Birchwood Insight Scale (BIS) and Drug Attitude Inventory (DAI–10) are well recognised and validated scales for measuring insight and adherence, respectively [11, 12, 12, 14]. The questionnaire was translated excellently; the simplicity of the questionnaire ensured easy completion for the patients with 100% data collection.
Limitations to this study included small sample size (n = 19), which reduces the external validity of the study. The patient population examined in this study may not be representative of all patients with schizophrenia across the Nepal, as Manipal Teaching Hospital is a private hospital based in a major city, Pokhara. Lack of accessibility for the rural Nepalese people may have limited their presentation to this outpatient department, and it is these rural Nepalese people that have the highest illiteracy rates and poorest living conditions, factors known to be associated with adherence [19, 20, 38]. Upon reflection with a better understanding of the Nepalese population, the demographics section of the questionnaire should have measured illiteracy rates. Some literature suggests that up to 68% of patients with schizophrenia in Nepal consult a faith healer, further enquiries into the use of a faith healer would have enabled a deeper understanding of how this variable affected adherence . Questions could have been added to the questionnaire on complexity of drug regime, side effects, duration of illness and drug and alcohol misuse, as these factors are all recognised to affect adherence [40, 41, 42].