Despite the significant progress made in the development of psychopharmacological agents in treating psychiatric patients, adherence to the prescribed treatment remains a humongous problem. WHO says adherence among patients suffering from chronic diseases averages about 50% in developed countries and the problem is even greater in developing countries where there is a scarcity of health resources and disparities in access to said limited resources.¹ It also often is the single greatest determinant of the effectiveness of prescribed psychiatric medication in the clinical setting.²

Medication Adherence is defined by the WHO as “the degree to which the person’s behaviour corresponds with the agreed recommendations from a health care provider.” It includes taking the prescribed number of pills each day and the timing of doses.³ Medication nonadherence rates are significant among psychiatric patients. A review article mentioned how non-adherence ranges between 28% - 52% for major depressive disorder, 20%-50% for bipolar disorder, 20% - 72% for schizophrenia, and about 57% for anxiety disorders.⁴

The factors influencing adherence range from “sociodemographic (age, gender, and education), clinical (diagnoses, drug treatment, and treatment duration), attitudinal (attitudes toward psychopharmacological medication and preferences regarding participation in decision-making) to the perception of control over health (health locus of control, self-efficacy, and psychological reactance).”⁵ A complex interplay of all these variables amounts to the actual adherence of the patient to the prescribed medication. Because nonadherence as a clinical problem is multifactorial, an individualized approach to assessment and treatment, developed in the context of an ongoing physician-patient relationship, is optimal. When nonadherence is differentially diagnosed, causative factors that are assumed to be present in each patient should be the focus of therapy, thus individualized interventions are the way to go.⁶

This nonadherence to psychiatric medications or treatments in turn takes a significant toll on the patient. It greatly affects the course of psychiatric illness, relapse & rehospitalization, and future recovery. In addition, there can be a profound impact on the cost of care and the patient’s long-term functioning, be it social, vocational, or academic. It is also linked to violence such as reported aggression and arrests⁸, suicide⁹, and increased mortality in patients nonadherent to drug therapy.¹⁰

As is evident from above, the alarming degree of the nonadherence problem in clinical practice, its potentially dire consequences, and the high costs associated with it make it a worthwhile topic to explore. And this is what this study aims to do: quantify the adherence levels and determine the factors influencing it at an outpatient clinic in Western India. Improved understanding of the magnitude and underlying reasons for nonadherence would help design relevant & effective interventions. The WHO Report also emphasizes that increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments

The study was carried out to determine the levels of adherence in outpatients diagnosed with chronic psychiatric conditions, and to identify possible risk factors that might impact adherence. A total of 87.6% of the study population was found to be non-adherent according to the ARMS score. This contrasts with psychotropic medication non-adherence of 48%, 48%, 49%, and 57% in Africa, North America, Europe, and Asia, respectively (Semahegn et al., 2020). Various factors such as different healthcare systems, poor mental health awareness, inadequate mental health infrastructure, and wide treatment gap, might have contributed to the significantly lower adherence in our setting. Assessing medication adherence may lead to a better understanding of reasons for nonadherence in psychiatric patients and help give us the foundation for actions that may improve adherence.

The previous literature review suggested that medication adherence can be classified into four categories: patient-related, medication-related, illness-related, and external/environmental factors. The factors designed in this study are more focused on patient-related factors, including age, gender, locality, socioeconomic status, comorbidity, educational status, addiction, presence of insight, and number and duration of medications. It was found that females were 2.425 times more adherent than males (OR: 2.425; 95% CI: 1.020 – 5.766). This complies with four studies carried out in India where adherence was found to be better in females (Ansari et al¹⁴, Rao et al¹⁵, Chaudhari et al¹⁶, Ramamurthy et al¹⁷) with only one study finding males to be more adherent to medications (Banerjee et al)¹⁸ Education of Head Score was found to be statistically significant, with education higher than 10^th standard depicting 2.41 times higher adherence than their counterparts. Similar findings of the correlation of lower educational status with non-adherence have been found in six studies carried out from 2005 to 2015 (Semahegn et al, 2020). The study further found that patients on a single class of medications are 2.31 times more adherent than those consuming medications of multiple classes. Additionally, with an increase in the dosing frequency, a reduction in adherence to medications has been found (AOR: 0.335; 95% CI: 0.135 – 0.829). A similar finding with dosing frequency has been noted in various systematic reviews (Coleman et al¹⁹, 2012; Saini et al, 2009²⁰).

Age is not found to be significant. However, through literature reviews, it has been found that older patients have greater adherence. This can imply that younger patients may have a more negative perception of medicine: they may think of them as more harmful and would want to exercise more personal control over their condition and its management. (Horne et al., 2013²¹). No significant effect of the presence of insight has been found on adherence in this study. In the studies carried out in the past, insight has been associated with adherence (Day et al., 2005²²)

The study findings suggested a high degree of non-adherence, with 87.6 % of the study population reported as non-adherent. The results underline that necessary attention should be paid to addressing non-adherence among patients, especially in patients with lower education levels; those consuming multiple classes of medications; and those with more than a single dosing frequency. Strengthening the guidance and supervision of patient’s adherence to medications is required.