PaSchizophrenia is considered to be one of the most devastating health issues today. Wu, Birnbaum, Shi, Ball, Kessler, Moulis, and Aggarwal (2005) state that the American Psychiatric Association define schizophrenia as “a chronic and debilitating mental illness in which patients often have a diminished capacity for learning, working, self care, interpersonal relationships, and maintaining general living skills” (p. 1122). Schizophrenia is a very costly disease; according to Wu et al. (2005), the estimated costs of the disease range about $39.9 billion to $80.8 billion (p. 1127). The relevance of this disease is undeniable, but what makes it an alarming problem is that many of people who suffer from schizophrenia do not adhere to their psychotropic medications.
According to Acosta, Hernandez, Pereira, Herrera and Rodriguez (2012), “non-adherence continues to be a frequent phenomenon… Estimated non-adherence rates in schizophrenia are about 50%” (para. 2). This is very alarming because medication was expected to ameliorate the problem of Schizophrenia, and now, this has become an issue itself. Many of the people with schizophrenia also have a history of substance abuse. This combination is commonly referred to as a dual diagnosis. Both conditions are usually treated separately which raises the question of whether treating both conditions together can influence the medication compliance among this population. For that reason this research will attempt to answer the following question:
Are people with schizophrenia who use alcohol and or illegal drugs less likely to adhere to their psychotropic medications? In this paper, I will discuss the issue of schizophrenia and medication non-compliance, substance abuse and schizophrenia, and integrated treatment.
Literature review
Schizophrenia and Medication Non Compliance
Schizophrenia is a chronic illness, which is treated with psychotropic medications also, known as pharmacotherapy. A pressing issue is that many of patients who suffer from schizophrenia tend to be non compliant with the psychotropic medications. According to Kelly and Daley (2013) a study revealed that more than 50% patients with schizophrenia are not compliant with their medications. A possible contributing factor is the combination of the mental illness with a substance abuse disorder. Owen, Fischer, Booth, and Cuffel (1996) informed that the issue of dual diagnosis is not uncommon among patients with schizophrenia (p. 853). They added, “47 percent of persons with schizophrenia had a lifetime diagnosis of a substance use disorder” (p. 853). Research has tried to explore the relationship among the dual diagnosis of schizophrenia and substance abuse and medication non-compliance.
Substance Abuse
Owen et al. (1996) explained that medication compliance is of great importance when trying to understand the effectiveness of treatment in patients with schizophrenia (p. 853). Like Owen et al. (1996), Pristach and Smith (1990) also believed that medication non-compliance among patients with schizophrenia is of great importance. Pristach and Smith. (1990) explained, “non compliance with medication is a significant problem… for schizophrenic patients compliance with prescribed medication is particularly important in maintaining stability, staying in the community and avoiding hospitalization” (p. 1345).
Owen et al. (1996) tried to determine if substance abuse is a factor that affects medication non-compliance. This research found that “individuals with schizophrenia who abuse drugs or alcohol are at increased risk for medication non compliance and poor system outcomes” (Owen et al. 1996, p. 857). Owen et al. explained that individuals who suffer from schizophrenia who abuse substances “reported to stop taking medications because they have been told not to combine their medications with substances of abuse” (1996, p. 856). In addition, Owen et al. (1996) explained that the symptoms of intoxication might result in neglecting their medication (p. 856). Finally, it was concluded that due to their substance abuse, patients’ side effects from medications could be higher, causing them to not comply with their medications (Owen et al. 1996, p. 586).
Like Owen et al. (1996), Pristach and Smith (1990) also attempted to research if schizophrenic patients “were more likely than non abusers to be non compliant with medication” (p. 1345). In this study, 72 percent of the 43 participants reported non-compliance with their prescribed medications (Pristach & Smith 1990). Overall, Pristach and Smith (1990) concluded that there is a high correlation between alcohol abuse and medication non-compliance among schizophrenics. Pristach and Smith (1990) explained that “the majority of patients admitted drinking alcohol in the 30 days before admission, and most of these patients discontinued their psychotropic medication while drinking” (p. 1348). Pristach and Smith (1990) like Owen et al. (1996), explained that one of the reasons for not complying with medications for those who abuse substances is the fear of the interaction of the substance and the medication (p. 1347). Patients become afraid after hearing their doctor’s recommendation of not mixing their medication with substances. Owen et al. (1996) explained “interventions to decrease medication non compliance and substance use… could improve patient outcomes. Intensive case management or assertive community treatment programs may be helpful because of increased patient contact and improved compliance ” (p. 857).
Integrated Treatment
Owen et al. (1996) were not the only researchers, who acknowledged the importance of the treatment approach for this dual diagnosis and how this could potentially influence medication compliance among schizophrenics who are also substance abusers. Dually diagnosed patients have been treated separately for both illnesses (schizophrenia and substance abuse) and have been bouncing from treatment to treatment in order to be treated for both diseases. Kelly, and Daley (2013) explained, “it is logical that the presence of comorbid disorders indicates a need for the simultaneous treatment of both conditions, sometimes referred to an integrated treatment of dual disorders” (p. 2). However, this is not always the case since Kelly and Daley explained that severity of the symptoms of both co-occurring diseases has been treated better with integrated treatment rather than a separate treatment for each condition (2013).
Donald, Dower and Kavanagh (2004), explained the reasons why there is a push to identify the best practice to treat co-occurring mental health and substance use disorder. They pointed out that the dually diagnosed have the “worst psychiatric symptoms, treatment compliance and prognosis” (Donald et al., 2004, p. 1371). Donald et al. and Kelly and Daley all believed that presently the treatment for the dually diagnosed takes place in a “sequential” setting which was defined as services that are “based on a model where treatment for one or the other of the disorder is treated at one point in time, and the client is then treated to the other service for treatment of the other disorder” (Donald et al., 2004, p. 1372). As a result, Donald et al. (2004) explained that the patients “fall between the cracks” because they don’t get the adequate treatment for either of their disorders (p. 1373). Drake, McFadden, Mueser, McHugo, and Bond (1998) explained “In integrated treatments for patients with dual disorder, mental health treatments and substance abuse treatments ensure that the patient receives… a coherent prescription for treatment rather than a contradictory set of messages from different providers. Integrated treatment aims to eliminate the patient’s burden of attending two programs” (p. 590).
Drake et al. (1998) mentioned another study where the results provided encouraging evidence for the effectiveness of integrated treatment of dual disorders” (1998, p. 601). Drake et al (1998) explained that this research not only showed that integration of treatment has proven to improve the retention of patients in treatment, but also it has achieved a reduction of substance use disorder. Morrens et al. (2011) also measured the differences in dropout rates, it was concluded that of the 85 participants, 36 completed the assessment from the integrated treatment group, while only 7 completed it from the regular treatment group. Morrens et al. concluded that patients benefitted from the integrated treatment as they showed better quality of life, reduced substance abuse, and fewer dropouts rates which suggests that integrated treatment “enhances treatment adherence and retention” (2011, p. 160). Both studies done by Morrens et al. (2011) and Drake et al. (1998) concluded that integrated treatment ha been proven to increase treatment adherence. This could be an indicator of the effectiveness of integrated treatment on medication compliance among this population, which has been proven to be an alarming issue presently.
Although Morrens et al. (2011) and Drake et al. (1998) concluded that integrated treatment is effective in increasing treatment adherence and reducing dropout rates among the dually diagnosed, still little research focus on the effectiveness of treatment integration in medication adherence specifically. Morken, Grawe, and Widen (2007) studied the effects of 2 years of integrated treatment on medication adherence in patients with schizophrenia but substance abuse was not measured in this experiment. An experiment was done where one group received integrated treatment while the other received standard treatment. Compliance was defined as less than a month with no medication. In this study, there was no difference found between the integrated treatment group and the group that received the standard treatment regarding medication adherence (Morken et al., 2007). These results contradict the mentioned studies done by Drake et al. (1998), Donald et al (1994), Morrens et al. (2011), which prove the effectiveness of integrated treatment.
Research has proven that patients with schizophrenia that were also diagnosed with a substance use disorder are at a higher risk of not complying with their psychotropic mediations. What has not been taken into consideration is the type of treatment used to treat this comorbidity. Research has shown the effectiveness of integrated treatment when working with patients with the dual diagnosis of schizophrenia and substance abuse. Moreover, there is a contradiction in research since although many researchers agree that integrated treatment is effective, others find no difference at all when comparing it to the traditional treatment. Despite the research findings regarding medication non-compliance among the dually diagnosed and the effectiveness of integrated treatment, there is a gap in literature since little to no research has been done to study the effectiveness of integrated treatment on medication compliance for those with the dual diagnosis. Research is still needed to fill in this gap. Owen et al, (1996) suggested that integrated psychiatric and substance abuse treatment could potentially improve medication compliance. Overall, researchers agree that more research is needed to understand this relationship.
Project Description
In the absence of literature of this topic, this research will attempt to conduct an exploratory qualitative and cross sectional study to analyze the effects of intergraded treatment on medication compliance in patients with the dual diagnosis of schizophrenia and substance abuse. To accomplish this, the perception of patients diagnosed with substance use disorder and schizophrenia that are in integrated treatment will be explored. The research question of this study is: What is the perception of patients diagnosed with schizophrenia and substance use disorder of integrated treatment and its effect of medication compliance? A qualitative study will be used since the existent literature has only focused on quantitative analysis and thus far; the experiences of the subject have not been included in past studies. In addition, there is limited research pertaining the effect of integrated treatment on medication compliance focusing on schizophrenia and substance abuse as the dual diagnosis. This research will provide an opportunity to explore the perception, and thoughts of the subjects on integrated treatment and how whether or not, it has improved their medication compliance.
Sampling Strategy
The population of interest is adults diagnosed with substance use disorder and schizophrenia who are receiving integrated treatment. The participants of the study will be gathered from Summit Behavioral Healthcare, a treatment facility located in New York, which offers integrated treatment for the dually diagnosed. A purposive sampling method will be used to seek participants since the population of interest is very specific. A strength of a purposive sampling method is usually low cost and not time consuming. On the other hand, a limitation is that it may produce a sample that represents the larger population of the studied topic. A purposive sampling method This will require a distribution of recruitment flyers to the program director to be distributed to the potential participants. The flyer will request that participants, who are interested in the study and met the required criteria, contact the author. Eligibility criteria will be as follows: Must be, a patient of the integrated treatment program, and must be diagnosed with schizophrenia and substance abuse. Subjects of all ages and gender will be included. 12-14 participants will be included in the study.
Method of Data Collection
For this study, focus groups will be chosen as the main method of data collection for several reasons. Focus groups are ideal for the collection of information such as opinions, experience, and beliefs of the participants. They are also, convenient since they do not require a lot of time, money, or a large number of participants. In addition, the atmosphere of focus groups generates a sense of “connectedness” which will increase communication levels among the participants. Furthermore, considering that the population of interest is patients who suffer from schizophrenia, interviews will be more appropriate as opposed to surveys or questionnaires. A limitation of using focus groups is that the participants may be compelled to falsify or exaggerate information due to the presence of others. This may affect the findings and validity of the study.
A series of two focus groups will be conducted with the same 12-14 participants. The focus group will take place in the Summit Behavioral Healthcare treatment facility because it is a common place for all participants, which resolves the possible inconvenience of providing transportation. Each focus group will last about one hour, which was decided in consideration of the population of interest. The researcher will personally conduct both focus groups with the presence of a medical staff, which may be needed in case of a medical emergency. This will entail facilitating the meeting, ensuring that the structure if followed and ensuring that each participant participates. The focus group will include interview questions pertaining their medication compliance in relation to the effect that integrated treatment has had on this. For this study, both focus groups will be semi-structured since it will permit for the researcher to maintain a structure, while allowing each participant to freely participate and answer the questions. The researcher will also be allowed to mediate and follow up with answers as needed. Each conversation of both focus groups will be recorded and later transcribed. This information will be included in the consent form.
Ethical and Practical Considerations
As in most research experiments, there are some ethical considerations that should be addressed if this study is conducted. For this reason, an inform consent will be distributed, read, and explained to the participants before requesting their signature. The inform consent will provide a study description, and the rights of the participants including their right to privacy and welfare. The researcher will reiterate their participation is voluntary and that they can withdrawal from the study at any time. To protect the participant’s confidentiality, the names of the participants will be omitted from the recordings and transcribed conversation. No rewards or incentives will be offered or provided which will be explained in the consent form. A practical issue to consider is the fact that the validity and precision of the study may be affected due to the fact that the subjects may feel obligated to alter their responses about medication compliance due to fear of the consequences this may bring especially when a medical staff is present. The responses of the participants can over estimate their medication compliance.
Conclusion
If this study is conducted, its results can be applied to evidence based practice with individuals, groups, communities, administration and policy. If it is determined that integrated treatment approaches can improve medication compliance among those with the dual diagnosis of schizophrenia and substance abuse, this information can be used as a standardized measure to deal with this issue. In addition, this can be applied to patients with different dual diagnosis and not only those who suffer from schizophrenia and substance abuse if further research supports these findings. Direct practice will be affected by these findings because it will provide knowledge and education for social worker that work with this population. This knowledge will serve to make the appropriate referrals to provide the best treatment to improve their medication compliance. Policy can definitely be affected by the results of this study if conducted since it can be a requirement for the dually diagnosed patients to be only treated in integrated treatment based facilities.
As with most qualitative small-scale studies, there was a limited sample used which means that results may not be generalizable. Further research is needed to include a larger sample of subjects. Overall, further research will inform the advantages and need of integrated treatment for the dually diagnosed. This will provide this population with the care that they need and deserve.
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