Evaluation of nonadherence to treatment among patients with schizophrenia attending psychosocial care centers in the south region of Brazil

Abstract Introduction The treatment of schizophrenia aims to reduce symptoms, improve quality of life and promote recovery from debilitating effects. Nonadherence to treatment is related to several factors and may lead to persistence of symptoms and relapse. Worldwide, the rate of nonadherence to treatment in individuals with schizophrenia is around 50%. Objectives To compare the clinical profile of nonadherent and adherent patients among individuals diagnosed with schizophrenia receiving treatment at psychosocial care centers in a city in southern Brazil. Method The clinical-epidemiological profile of patients with schizophrenia was retrospectively analyzed based on medical records entered into the system between January and December 2016, evaluating data at one-year follow-up. Results 112 patients were included. The disease was more prevalent in men; mean age was 40.5 years, being lower among men. Most of the sample had a low level of education, was unemployed/retired, did not have children and resided with relatives. The highest rate of diagnosis was among young adults. Psychotic symptoms were most frequently described, and the most commonly prescribed antipsychotic was haloperidol. The nonadherence rate was 15.2%; only one patient required admission to a psychiatric hospital. Among nonadherent patients, the mean time of attendance was 6 months; there were more nonadherent women than men. The most prevalent age range of nonadherence was 41-64 years. Psychosocial and clinical data were similar across the whole sample. Conclusion A nonadherence rate of 15.2% was found among individuals receiving treatment for schizophrenia, suggesting that psychosocial care centers were effective in treating and monitoring these patients.


Introduction
Schizophrenia is a complex chronic mental disorder of idiopathic origin. The most widely accepted explanation for the development of schizophrenia is related to the interaction of multiple factors, including genetic, physical, psychological and environmental factors. 1 Disorders of the schizophrenia spectrum cause severe mental changes, with characteristic symptoms such as distorted perception and thinking, affection inability and impaired emotional functioning; intellectual impairment may also be present. The condition has a variable evolution, with 2020;42(3):223-229 around 30% of the patients suffering from significant and persistent deterioration of professional, social and affective capacity. 2 The prevalence of schizophrenia is approximately 1% in Latin America and also specifically Brazil, 3,4 with an incidence of 1 up to 7 new cases per 10,000 inhabitants per year. 5 The mainstream treatment of schizophrenia aims to achieve three goals: reducing or halting/interrupting symptoms; improving quality of life and functional adaptation; and promoting recovery from debilitating effects. 2 A better prognosis is related to acceptance of the disorder, 6 and a central part of treatment adherence is the doctor-patient relationship, where the process of cultivating and establishing rapport with the patient is essential. Nonadherence to drug treatment may lead to relapse in patients in remission and to persistence of symptoms in symptomatic individuals. 7 The rate of nonadherence to treatment in individuals with schizophrenia is around 50%, causing not only a worsening of the prognosis but also an increase in costs with probably preventable hospitalizations, in addition to being associated with a higher risk of suicide. 8 Nonadherence may be related to several factors, such as lack of an understanding about the disorder, direct impact of symptoms, social isolation, substance abuse, and increasing fragmentation of mental health services in several countries. 7 Another relevant factor is the adverse effects of medications in use, such as dysphoria, weight gain and sedation. 9 In Brazil, the main role of public mental health services such as psychosocial care centers (Centros  The data collected were organized using Microsoft Excel © . Statistical analyses were performed using Graph Pad Prism 5.0. Continuous variables were expressed as mean ± standard deviation and compared using the Mann-Whitney test. Categorical variables were expressed as percentages and compared using the chi-square test or Fisher's exact test, as appropriate.
Significance was set at 5%.

Results
A total of 115 medical records of users diagnosed with schizophrenia were assessed; three records were excluded due to concomitance with other neurological diseases.
The demographic data of the patients assessed are shown in Table 1. There was a predominance of males (68.7%, 7:1 ratio). Overall, the mean age was 40.5±13.76 years, but men were significantly younger  Table 2. Concerning the number of drugs used during the period of one year, the largest fraction of the study population used 1-3 medications, with a median of 3.
The treatment outcomes of users with schizophrenia studied here are described in Table 3. The nonadherence  the most supported hypothesis points to estrogen as a protective factor in women, while the second etiology for the phenomenon refers to differences in intrauterine development between the genders. [18][19][20] There was a prevalence of low educational level in the present study, i.e., 41.1% of the patients had up to 9 years of formal education. This finding differs from another study in which the majority of patients with mental disorder being treated at a CAPS in the city of Curitiba had more than 8 years of schooling. 21 Regarding the professional status of users diagnosed with schizophrenia, the greater part of the patients assessed were retired or unemployed. A study carried out inside a CAPS in the state of Sergipe corroborates these findings: in that study, 75.4% of users with schizophrenia designated themselves as "without profession." 16 The demographic characteristics of patients with schizophrenia, with a main impact on the beginning of adult life, hindering their access to the job market, could justify the high prevalence of unemployment. 16 In addition, the high rate of retirees may be associated with the degree of mental impairment Most of the patients evaluated were single, divorced or widowed -data that corroborate findings from other studies. 21 The prevalence of users with children was 30.4%; we did not find reference to this variable for patients with schizophrenia in the literature. As In the current study, among the nonadherent patients, most had remained in the service for 1-6 months, similar to data found in the literature. 31 A study that evaluated a population of 6,731 patients diagnosed with schizophrenia in 10 European countries found that, among those who did not adhere to treatment, the majority were men. 32 37,38 In this study, the antipsychotics most commonly used among nonadherent patients were typical antipsychotics, namely haloperidol and chlorpromazine. However, most individuals did not report side effects. These data do not agree with the literature, which relates lower rates of adherence mainly to drug side effects. This may also be a reflection of the study method, as not all complaints may have been recorded in the medical chart.

Conclusions
In the present study, a treatment nonadherence rate of 15.2% was found among patients with schizophrenia, suggesting that the CAPS were effective in treating and monitoring these patients.

Disclosure
No conflicts of interest declared concerning the publication of this article.