The meaning of pharmacological treatment for schizophrenic patients1

OBJECTIVE: to understand the meaning of medication therapy for schizophrenic patients and formulate a theoretical model about the study phenomenon. METHOD: a qualitative approach was employed, using Symbolic Interactionism as the theoretical and Grounded Theory as the methodological framework. The research was developed between 2008 and 2010 at three community mental health services in the interior of the State of São Paulo - Brazil. Thirty-six patients and thirty-six family members were selected through theoretical sampling. The data were mainly collected through open interviews and observation and simultaneously analyzed through open, axial and selective coding. RESULTS: the meaning of the pharmacotherapy is centered on the phenomenon "Living with a help that bothers", which expresses the patients' ambivalence towards the medication and determines their decision making. The insight, access, limitations for self-administration of the drugs and interactions with family members and the health team influenced the patient's medication-related behavior. CONCLUSION: the theory presented in this study provides a comprehensive, contextualized, motivational and dynamic understanding of the relation the patient experiences and indicates potentials and barriers to follow the medication treatment.


Introduction
Schizophrenia is a potentially disabling chronic condition that causes a great impact on the patients, families and society. Besides the subjective experience of psychotic symptoms, the disorder affects the individual's quality of life and is associated with significant functional losses (1) .
Continuous medication treatment is fundamental to control the symptoms of the disorder (2) when associated with other therapeutic modalities, such as psychotherapy, psychoeducation, sociotherapy, occupational therapy, among others.
The lack of adherence to the pharmacological treatment is associated with the exacerbation of symptoms, worse prognosis, repeated internment, high costs and unnecessary adjustments in the medical prescription (2) , justified by a supposed inefficacy of the drug which, in fact, was not used appropriately, which can compromise the patient's safety in the medication treatment.
Patient safety (3) and adherence (4)(5)(6) to the pharmacological treatment are important challenges in care practice and require efficient nursing interventions.
To plan and implement these actions, the patients' subjectivity, needs, motivations and difficulties need to be considered, more than how precisely they follow the health team's recommendations (7) .
In the domestic context, the family serves as a privileged space for care practice and social support, which influence the treatment adherence (8) . Patients and family members play a decisive role in the monitoring of the pharmacological treatment. Thus, this study aimed to understand the meaning of the medication treatment for schizophrenic patients and to build a theoretical model about the study phenomenon.
Symbolic Interactionism was employed as the theoretical framework. This framework presupposes that behavior (observable external act and internal experience) is guided by the individual's definitions of reality. These definitions, in turn, derive from the social interactions in which active individuals exert mutual influence (9) .

Method
A qualitative study was undertaken. Grounded Theory (GT) was used as the methodological framework.
The systematic procedures of GT were designated to produce concepts and provide a multivariate and consistent theoretical explanation of the social phenomenon studied (10) .
Thirty-six patients and 36 family members were selected to participate in the study, in a theoretical sampling process in which the sample structure is gradually defined during the data collection and simultaneous analysis, as recommended by the GT (10) .
Three sample groups were constituted, which came from community mental health services that attended to patients with distinct treatment experiences. These services were public and located in the interior of the State of São Paulo -Brazil.  (10) .
The criteria to include patients in the study were: being diagnosed with schizophrenia (established by psychiatrist) and taking psychotropic medication(s).
The diagnosis was confirmed with the health team and by consulting the patient's history.
The criterion to include the family members in and consequences (results or expectations related to the action/interaction) (10) .

Results and discussion
The interpretation of the present study data was based on the theoretical framework of Symbolic Interactionism (9) .      (11) . Ambivalently, the patient acknowledges that the drug is unpleasant but necessary, and constantly weighs the cost-benefit of the treatment in order to decide on whether to adhere to the medication or not.
Partial adherence and non-adherence are persistent problems among people taking antipsychotic drugs.
The lack of adherence is a complex and multifactorial phenomenon. Although non-adherence to the treatment involves factors external to the patient, individual subjectivity is fundamental to maintain treatment in the long term (13)(14)(15) , in line with the present study. the long term. In addition, the insight is a necessary but insufficient condition for adherence (16) .
Another factor that can influence the adherence is medication access. The flaws in the public health system's medication supply, associated with the users' impossibility to purchase the drugs, can compromise the continuity of the drug therapy (17)(18) .
I stopped at that time, it was because I really was in no financial conditions. (P10) The unintentional behavior of non-adherence to the drug therapy can be favored by the schizophrenia patients' limitations to self-administer the drugs (17) , forgetting (19) and complex therapeutic schemes (18) . Some of these problems are mitigated when the patient gets support from relatives, significant others or health professionals for the sake of medication administration in accordance with their needs (18) . The family of mental patients need support and preparation to cooperate with the treatment (20) , as the family's involvement in the support for the patient is fundamental for a successful treatment (18) .
The quality of the bond between the health team and the patient can enhance or impair the maintenance of the drug therapy. A good therapeutic alliance among health professionals, family members and patients provides for better treatment results and reduces the possibility of non-adherence (6,14,21) .
The physician was reliable, then I accepted to take the medication. (P33) In the social interaction, the individual shares perspectives, defines the reality, makes decisions and modifies the course of their actions (9) . Therefore, interactions can represent opportunities to reconstruct meanings, also with regard to the medication treatment and related behaviors.
Some of the factors that influence the pharmacological adherence can be changed (2) . Therefore, they should be considered in the planning of strategic actions to promote the elements that contribute to the medication adherence behavior and to minimize factors that compromise the success of the treatment.

Action/interaction strategies: Looking for a way out
The schizophrenia patients weight the cost-benefit of the drug in order to select the action strategy they will adopt: adhering to the medication or minimizing the damage the drug treatment causes.
These action strategies represent the search for a way out, for a solution to the conflict of "LIVING WITH A HELP THAT BOTHERS". The assessment about the continuous use of the drug is not static. The patients frequently analyze the suffering the schizophrenia causes, as well as the advantages and disadvantages of the drug, in which sometimes the "help" and sometimes the "loss" prevails.
This assessment of the reality and the consequent option to adherence to the medication use or not are part of a dynamic and changeable process. According to Symbolic Interactionism, the meanings are changed in a dynamic process of interpretation the patients accomplish when coping with the situations they experience (9) . In this context, the monitoring and motivation towards adherence should be highlighted (4,6) , as the treatment adherence results from a cooperative effort between the health professional and the patient (7) .
In some situations of "weighing the cost-benefit of the drug", the patient chooses not to adhere with a view to reducing the damage the pharmacological treatment causes. This is a relevant problem that compromises the treatment success, as the literature appoints that approximately half of the schizophrenia patients do not adhere to the prescribed drugs (2,17) .  (13) but, when associated with an expected cure, they can arouse questions about the need to maintain the treatment (22) . Therefore, it is not purely the result of the medication treatment that influences the adherence, but the individuals' assessment of this experience.

Consequences: Staying in a labyrinth
In some situations, the schizophrenia patients feel as if they were stagnated while taking the medication, experiencing the maintenance of the clinical conditions of the disorder, without progresses and relapses. The association between the non-adherence and the negative consequences is not an all-ornothing phenomenon, as many patients adhere partially. Nevertheless, the literature has shown a significant impact even in mild degrees of nonadherence (6,23) . Evidence exists that non-adherence to antipsychotic medication use is related to relapses, more frequent hospitalizations, worse prognoses and higher costs (5,(23)(24) .
The Studies undertaken in distinct contexts certify that the improvement of symptoms, the prevention of relapses, the possibility of leading a normal life and the hope for the future favor the treatment adherence (13,15) .

Conclusion
The act of taking a medication daily may seem routine and simple, but the experience is complex. The schizophrenia patients perceive that, when following the medication treatment, they are "LIVING WITH A HELP THAT BOTHERS". Therefore, motivational interventions are recommended that address the patients' biased attitude towards the treatment, so as to favor the adherence.
The interaction with the client is an appropriate time to reconstruct meanings and, therefore, should be better explored as an instrument to promote treatment adherence and adaptive coping with the disorder.