Adherence to treatment in collective multiprofessional activities and factors associated with adherence in a specialized center for psychosocial care

Abstract Introduction Specialized psychosocial care centers (Centros de Atenção Psicossocial [CAPS]) are mental health services focused on social rehabilitation and reducing hospitalization of patients with severe and persistent mental illness. Collective multiprofessional activities (CMPA) are the main therapeutic tools used at CAPS. This study aimed to determine rates of adherence to CMPA and identify factors associated with adherence. Methods This is a cross-sectional study in which 111 CAPS users were evaluated using questionnaires covering patient characteristics, clinical status, and treatment and incorporating the Functioning Assessment Short Test (FAST), the Clinical Global Impression – Severity scale (CGI-S), and the Clinical Global Impression – Improvement scale (CGI-I). Adherence was defined as attendance at 50% or more CMPA during the previous 3 months. Data were analyzed using descriptive statistics, bivariate analysis, and Poisson logistic regression with robust variance to estimate prevalence ratios. Results CPMA adherence was 43%. Having children aged 14 years or younger was significantly associated with non-adherence (71%, p = 0.001). Poor or partial adherence to psychotropic drugs tended to be associated (p = 0.066) with poor adherence (33% higher risk), as was the number of psychiatric hospitalizations during CAPS (p = 0.076), with a cumulative association of 5% non-adherence per hospitalization. Conclusions CMPA adherence was low in the study. It is necessary to consider the environment in which the individual lives and invest in support networks, providing patients and family members with explanations about the importance of CMPA to rehabilitation and attempting to tailor the care provided to each patient’s needs. There was an association between greater number of psychiatric hospitalizations and non-adherence, suggesting that CAPS are fulfilling a preventive role.


Introduction
Specialized psychosocial care centers (Centro de Atenção Psicossocial [CAPS]) are regionalized mental health centers providing secondary care, with the main objective of promoting psychosocial rehabilitation and reducing psychiatric hospitalizations and institutionalizations. They have interdisciplinary teams and are known for their therapeutic groups and workshops, here referred to as collective multiprofessional activities (CMPA). [1][2][3] The expected profile of patients seen at CAPS is those with severe and persistent mental illness (SPMI), 2,3 represented by psychotic disorders. 4 A previous study, conducted in northeastern Brazil, found a 64% prevalence of psychotic disorders among CAPS patients and a 36% prevalence of mood disorders. 5 SPMI are characterized by chronicity and clinical severity and by incapacity to perform social functions, with impaired autonomy, poor social support, isolation, and poor prognosis. 6,7 These patients tend to lack financial independence, housing, and work and have poor social interaction, motivation, and cognition, with high social costs. 4 A previous literature review found limited response to pharmacological treatment in terms of social functioning improvements in patients with SPMI. 8 Psychosocial rehabilitation has been the approach of choice in these cases and is a process of achieving the best level of autonomy possible for exercise of social functions. [9][10][11] Psychosocial rehabilitation involves access to work, leisure, exercise of civil rights, and strengthening of family and community ties. 12,13 The main psychosocial rehabilitation tool used at the CAPS are CMPA, which provide opportunities for systematic social experimentation in a safe therapeutic space. 4,14 CMPA favor understanding, support, acceptance, and exchanges between patients, reducing isolation and offering a restorative social experience in order to develop new ways of relating. [14][15][16] Literature suggests that patients who regularly attend psychosocial rehabilitation services feel more satisfied with their relationships and less alone. 17 Despite this potential, clinical experience suggests that a large proportion of patients have low adherence to CMPA, compared to consultations and use of psychotropic drugs.
There is no clear definition of the concept of group treatment adherence in the literature. 18 A study focused on treatment adherence in the Brazilian mental health context 18 did not identify studies of adherence to psychosocial rehabilitation treatment using CMPA, since the literature refers almost exclusively to adherence to medication. There has been minimal investigation of the complexity of the interdisciplinary treatment offered by CAPS, which is geared toward individualized therapeutic rehabilitation. 18 Another study analyzed scientific literature on CAPS, identifying 68 references. 13 Most of them were qualitative (95.5%) and only two (3%) quantitative studies were identified. With regard to the authors of these studies, 50% were nurses, 16.5% were psychologists, and 8.5% were physicians.
The main topics addressed were mental health policy, professionals', patients', and family members' perspectives of the service, and analysis of CAPS

Method
A cross-sectional study was conducted to measure level of adherence to CMPA and factors associated with adherence at a CAPS located in Porto Alegre, Brazil. The service is classified as a "CAPS 2" and serves a population of 270,000 inhabitants, which is a larger population than would be expected for the CAPS 2 classification (a population of 70,000 to 200,000 inhabitants 1 ). The 1) actively treated at the CAPS with regular attendance at psychiatric consultations (defined as 50% or greater attendance at scheduled appointments); 2) scheduled for participation in CMPA; 3) attending the service for at least 4 months. Exclusion criteria were: 1) a primary diagnosis of mental retardation, autism, or other neurological disease; and 2) inability to respond to the questionnaire due to symptom severity. All the information for both sets of criteria was obtained from the professionals that care for the patients and later checked against the medical records.

CAPS 2 is open
Patients were invited to participate in the research on the days they were at the CAPS for their usual therapeutic activities. Those who agreed to participate received and signed two copies of the Free and Informed Consent Agreement, keeping one of them. After agreement, information was collected from medical records and then the interview was conducted.
Data were collected by two interviewers who were CAPS staff members. One was the psychiatrist who designed this study and the other was a nurse who was given a two-hour training session (by the first researcher) on the study objectives and instruments. Medical records were also reviewed and additional information was collected from the center's service professionals.
The study outcome -level of adherence to CMPA over the previous three months -was calculated using attendance lists and medical records from the three months preceding the interview. Attendance was considered based on CMPA sessions that actually took place, disregarding holidays observed by the service or by therapists leading group. Participants who had a 50% or greater rate of attendance at these activities Poor or partial adherence was defined as when patients stated they were not taking some of their medications or were frequently forgetting to take them, while good adherence was defined as when they responded that they never or very rarely missed taking their drugs.
Three All three scales have been validated for the Brazilian population. 19 Bivariate comparisons were made between the adherence group (50% or greater attendance at collective activities) and the non-adherence group.
Variables that had p < 0.1 in the bivariate analysis were pre-selected to enter the multivariate analysis, also taking into account their clinical relevance.

This investigation was judged ethically and methodologically appropriate by the Research Ethics
Committee at the Grupo Hospitalar Conceição (protocol number 16250) and conducted in line with the standards required by the Declaration of Helsinki.

Results
At the beginning of data collection, 136 CAPS patients met the inclusion criteria for the study. Twentyfive of these people could not be included because they refused to participate or were unavailable for the    Although there were no statistical differences between groups with regard to these issues, psychiatric illness symptoms were mentioned by 28% of the participants as reasons for their absence from CMPA and another

36% of the participants mentioned motivational reasons
for missing these activities. Regarding mental illness, there is often confusion between lack of motivation for the task and symptoms that compromises motivation. 22 Given this overlap, one may assume that psychiatric symptoms, as a broad concept, were the most among those in intensive treatment regimens. 21 The findings suggest that the relationships established with professionals enable them to act promptly upon signs of worsening symptoms, preventing hospitalization. 21 Although not associated with adherence to CMPA, other studies also found low hospitalization rates after initiating treatment at CAPS. 23,24 A contrasting finding was reported by Volpe et al., 25 who investigated the association between community healthcare resources and risk of psychiatric readmission. These authors found that coverage of CAPS at the place of residence did not have protective effects against psychiatric readmission. They discussed access barriers and patient non-adherence as possible major reasons for this association and the present study also stresses non-adherence as a crucial factor impeding effective treatment, as revealed by the association between number of psychiatric hospitalizations after CAPS admission and lower CMPA adherence. Adherence to psychotropic drugs was comparatively higher than CMPA adherence, at 67% and 43% respectively. Other studies indicate a predominance of drug treatments, such as use of antipsychotics, at CAPS. 23,24 The literature indicates a general drug non-adherence rate of 50% in chronic diseases. 26,27 One study estimated 65% adherence to psychotropic drugs, coinciding with the findings of this study. 28 On the other hand, one CAPS survey identified drug adherence of 32%, 29 while another only reported 12%. 30 Notwithstanding the diversity found in the literature on adherence to psychotropic drugs, more participants in the present study were adherent to drug treatment than to CMPA treatment.
An association was found between poor or partial adherence to psychotropic drugs and non-adherence to CMPA, conferring a 33% higher risk of non-adherence.
One study found that schizophrenic patients who are adherent to medications are more likely to be adherent to psychosocial group therapy and rehabilitation. 31  to CMPA (43%) shows that the main rehabilitation tool used at CAPS is not being harnessed to its full potential.
A complex structure of multidisciplinary care with significant social and financial investment appears to be being underutilized. It is crucial to identify factors that are compromising adherence to rehabilitation tools to make this structure more effective.
One of the advantages of this study is the originality of its evaluation of CAPS results using a quantitative methodology. There is little information in the literature regarding the operation of CAPS and a real gap in terms of quantitative analysis. This is an exploratory study, generating hypotheses about a topic that has not yet been explored in the literature. Assessing CMPA adherence levels and possible factors associated with adherence provides important results for future strategies to improve CAPS care.

Limitations
This is a cross-sectional study, which identifies associations between adherence to CMPA and variables, but without the power to determine causality. In this sense, the role of this research is to generate hypotheses. However, for some variables there is only one possible direction, as in the case of having a child aged 14 years or less, which can only be a cause of non-adherence to CMPA.
One weak point of the study is the sample size, which was a little too small to analyze the high number of variables that were studied. The sample size was restricted by the size of the active population in CAPS treatment during the data collection period, the exclusion criteria, and some losses from the sample. The profile is of severe and absent patients, requiring great effort to access them. Some variables were not statistically significant, possibly due to the lack of statistical power of the study, although they indicated trends. This was the case of reports of poor social support, personality disorder, younger age, and employment or sickness benefits, all of which trended toward worse CMPA adherence. It is also possible that, with a more robust sample, other variables that were neutral in the study would have been statistically significant.
Another limitation refers to the data collection period, which is a usual period for taking vacations. There is a possibility that some patients were traveling during this period and failed to participate for that reason.
However, the present study was unable to obtain this information.
Finally, all types of CMPA were considered as a single entity and differences between specific types of group activities could not be addressed. Moreover, the reasons for non-adherence to CMPA were addressed descriptively and a more comprehensive understanding of motivational patient factors is needed in future studies in order to identify the best therapeutic approach for each patient.

Conclusion
This study stands out for its evaluation of the CPMA adherence levels at a CAPS and of factors associated with adherence. CPMA are tools used for rehabilitation of patients with SPMI. The level of CMPA adherence observed in the study was 43% and the factors associated with non-adherence were poor adherence to psychotropic drugs, number of psychiatric hospitalizations after CAPS admission, and having children aged 14 years or younger.
Patients who do not adhere well to psychotropic drugs tend to exhibit greater vulnerability in relation to their treatment as a whole. Non-adherent behavior can be mitigated by investing in the team-patient relationship, through a professional and empathetic attitude, along with patient psycho-education and motivational approaches. 18,32 It is also necessary to listen to the needs of the health professionals caring for these more vulnerable patients, in order to provide them with appropriate working conditions in terms of infrastructure and training needs. Also, awareness of patients' motivation and experiences in group activities in order to better adjust them appears to be crucial to increasing adherence.
The association between a greater number of psychiatric hospitalizations and poor adherence to groups and workshops raises the hypothesis that collective Finally, considering that having children aged 14 years or younger was a factor in lower adherence to the CMPA, a joint effort is needed to address this finding. At the service level, professionals should be aware of the great difficulty that these parents have to adhere to treatment, and considering the limitations that patients with SMPI face when dealing with different social situations, professionals can help them to identify solutions, including possible cooperation between the CAPS and childcare centers and provision of guidance to family members on the importance of adhering to treatment and the need to support patients. At the governmental level, investments are needed to improve the childcare network and access to these services in order to facilitate parents' adherence to systematic health care such as CMPA.