According to the study period, there were 156 schizophrenic patients, who were first diagnosed with schizophrenia and admitted to the psychiatric inpatient unit. The majority of them were male (50.6%), Buddhist (85.9%), unmarried (80.1%), unemployed (50.6%), and staying with family (90.4%). For all of the participants, their mean age was 39.2 years, and 44 (28.2%) patients had a history of substance use. (Table 1) The most common substances that the schizophrenic patients used was cigarettes (59.1%), alcohol (29.5%), stimulants (25%), marijuana (22.7%), and kratom (11.4%). Additionally, some patients (19.9%) had a physical illness, such as hypertension (32.3%), and diabetes (19.4%).
Of all schizophrenic patients in the study, 84 (53.8%) reported symptom relapse within five years after the first episode of psychosis, relapse group, whereas 72 (46.2%) patients were in the remission group. The median (IOR) length of patients being symptoms free, prior to relapse was 17 (6.5, 28) months. Cumulatively, the first to fifth year relapse rate was 22.4%, 35.3%, 44.9%, 50%, 53.8%, respectively. Additionally, the first to fifth relapse rate was 22.4%, 12.8%, 9.6%, 5.1%, 3.8%, respectively.
Nevertheless, some schizophrenic patients showed residual symptoms (39.1%) and a lack of insight (38.8%). Most residual symptoms were hallucinations (52.5%), delusions (45.9%), and disorganized or catatonic behavior (16.4%). In regards to problems, patients found to be burdensome, they reported having stressful life events (32.7%) and suicidal ideation (10.9%). (Table 2) The most common stressful life events that the schizophrenic patients identified were relationship problems (47.1%), work stress (27.5%), and the loss of a person significant to them (9.8%).
According to patients in the relapse group, half had residual symptoms (48.8%) and more than half of the patients reported poor insight (60.7%), having stressful life events (56%) and suicidal ideation (19%). There was a statistically significant difference in residual symptoms, insight, stressful life events and suicidal ideation between relapse and remission groups (p<0.05). (Table 2)
In regards to all schizophrenic patients, their median (IOR) length of hospital stay was 17 (12.8, 25) days. The median (IOR) number of types and amounts in regards to their oral medication prescriptions, tablets, were 3 (2,5), and 5 (3,8) respectively. Most of the patients self-administered tablets 1-2 times per day (65.4%) via the oral route (88.5%). Two-thirds (64.1%) had no adverse effects and demonstrated good medical adherence (62.2%) (Table 2). About half of the patients (51.3%) had follow-ups by a physician visiting them at an interval of every 1-3 months.
According to relapse patients, two-thirds (59.5%) had a history of medical non-adherence. The most common cause of medical non-adherence was patient-related factors (53.6%) such as; lack of insight (62.2%); anxiety about the adverse events of antipsychotic medication (24.4%), and factors associated with patient’s socio-economic status (14.3%). However, a few patients reported being medical non-adherent due to not having sufficient knowledge, being forgetful, and feeling stigmatized due to having a prescription. There was a statistically significant difference in adverse event, medical non-adherence, and history of change prescription between the relapse and the remission groups (p<0.001). (Table 2) Additionally, no statistically significant difference was found regarding the length of hospital stay between relapse and remission groups (p<0.001).
Focusing on the adverse events of antipsychotic drugs, schizophrenic patients mainly reported no adverse effects (64.1%). Furthermore, more than half of all patients received second-generation antipsychotic drugs; pure second-generation antipsychotic drugs (37.2%); and/or a combination of first and second-generation antipsychotic drugs (18.6%). (Table 2) Extrapyramidal symptoms (EPS) (56.7%) were the most common adverse event among the relapse group. Schizophrenic patients who had received first-generation antipsychotics developed EPS more than patients taking second-generation antipsychotic drugs. (Figure 1 and Figure 2) However, no statistically significant difference in EPS between the relapse and remission group was detected. Viewing this from a different perspective, the adverse event could be related to medical adherence. A statistically significant association between the group of patients who developed adverse events during treatment and the history of poor drug compliance was detected (p<0.001). (Figure 3)
The association between demographic and schizophrenic characteristics, treatment, and symptom relapse
Multivariate analysis indicated that having stressful life events, medical non-adherence, history of change prescription, and lack of insight were all factors statistically significantly associated to symptom relapse. The schizophrenic patients who had stressful life events had a higher rate of relapse than the remission group, the adjusted odds ratio (AOR) was 23.5 and the 95% confidence interval (CI) was 5.2 to 107.1 The same was true when comparing them with those who had medical non-adherence, prescription changes, and poor insight; AOR (95%CI) was 5 (1.3,19.7), 10.9 (1.2, 100.9), and 22.6 (4.1, 123.5) respectively. (Table 3)