Co-relation of Insight,stigma& treatment adherence in Psychiatry patients

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1 Original research Article Co-relation of Insight,stigma& treatment adherence in Psychiatry patients 1 Dr Pawan Vilas Khot, 2 Dr Rajkiran Arjun Salunkhe, 3 Dr Maithili Umate, 4 Dr Vinayak P Kale 1 Assistant Professor, Department of Psychiatry, RCSM Government Medical College, Kolhapur, Maharashtra 2 Assistant Professor, Department of Psychiatry, Government Medical College, Miraj, Maharashtra. 3Associate Professor, Department of Psychiatry, Grant Government Medical College, Mumbai, Maharashtra. 4Professor & Head, Department of Psychiatry, Grant Government Medical College, Mumbai, Maharashtra. Corresponding Author: Dr Rajkiran Arjun Salunkhe ABSTRACT: Introduction: Insight is ability to understand that one has mental illness. Insight is important to achieve treatment compliance.stigma is observed both in patients & family members. The present study is going to explore the correlation between insight, stigma & treatment adherence in patients of psychiatric disorders for better health care utilization & to reduce the morbidity in psychiatry patients. Methods: 100 consecutive patients suffering from psychiatric disorders were assessed with a semi- structured proforma containing details of socio-demographic profile and The Diagnostic and Statistical Manual of Mental Disorders IV Text Revision (DSM IV-TR) was used & following scales were applied-1) Brief Psychiatric rating scale 2) Kings Stigma scale 3) Schedule for assessment of insight (SAI) 4) Drug attitude Inventory (DAI) Observation & results: Mean age of the sample population was years. As per DSM-IV TR- 59 patients of Schizophrenia, 20 patients had Major Depressive Disorder, 11 patients had panic disorders & 10 patients had Bipolar disorder. Mean BPRS score was Mean score of Drug attitude inventory was & Mean Score of Schedule for assessment of insight was 9.23.The mean of total stigma score was Conclusion: It was observed that patients with good insight & better education were more likely to be compliant on medication. It was also found that patients with more insight endorsed a greater sense of stigmatization, especially in relation to disclosure, thus signifying the need for mental health education among the general population. Keywords : insight,stigma, disclosure. INTRODUCTION Insight is awareness or ability to understand that that one has mental illness. 1 Also psychotic patients are more likely to have poor insight while neurotic patients are more likely to have a better insight. Insight is important to achieve treatment compliance and promoting positive social and health outcomes for individuals diagnosed with psychiatric disorders. 2 Stigmatization in individuals with psychiatric disorders is observed all over the world not only in the individual patients but also in family members. 3 So the patient with better insight should be more compliant with treatment & have lesser stigma.but this is not always so even with improvement of insight the drug adherence is not improved. 4,5 It has been seen that the stigma of mental illness can lead to treatment non adherence either through public stigma 300

2 or internalised stigma. Due to public stigma people may not seek treatment or stop treatment in between & because of internalised stigma, the guilt may make them avoid taking treatment. 6 The attitude of people towards patients of mental illness after disclosure of illness was also studied by researchers. It was found that after disclosure the police gave bad treatment while the behaviour of parents had improved. 7,8 The present study is going to explore the correlation between insight, stigma & treatment adherence in patients of psychiatric disorders for better health care utilization & to reduce the morbidity in psychiatry patients. AIMS & OBJECTIVE: To study the effects of insight and stigma on treatment adherence in psychiatric patients. To correlate insight, stigma & treatment adherence in psychiatric patients. METHODOLOGY In this study, 100 consecutive patients suffering from psychiatric disorders attending Psychiatry OPD in a tertiary care hospital fulfilling following criteria were selected Inclusion Criteria: - Patients having psychiatric disorder currently in remission for more than 6 months, in age group of 18 to 60 yrs. - Patients willing to be questioned for study and willing to give written and informed consent Exclusion Criteria: - Acute psychiatric condition which may interfere with assessment. - Unwilling or non-cooperative patient. - Medical condition which may interfere with the study. Ethics committee approval was taken. Subjects and their relatives were explained the nature of study & written informed consent was obtained. They were assessed with a semi structured proforma containing details of socio-demographic profile. The Diagnostic and Statistical Manual of Mental Disorders IV Text Revision (DSM IV-TR) was used for diagnosis of psychiatric disorders. Following Scales were applied 1) Brief Psychiatric rating scale this scale was used to assess the severity of illness 2) Kings Stigma scale This 28-item stigma scale has a three-factor structure: a) Discrimination, b) Disclosure and c) Positive aspects of mental illness 3) Schedule for assessment of insight (SAI) 4) Drug attitude Inventory (DAI) Statistical analyses were carried out using SPSS 15.0 software for windows. Two tailed P value of <0.05 was considered statistically significant. RESULTS: Mean age of the sample population was years. Mean age of Schizophrenia was years, Bipolar disorder was & that of neurotic disorder was 47.12(Table 2) Mean years of education of the sample population was 8.18 years. Mean BPRS score was Mean score of Drug attitude inventory was & Mean Score of Schedule for assessment of insight was The mean of total stigma score was The mean of discrimination, positive aspects and disclosure subscales were 17.35, and respectively. As per DSM-IV TR- 59 patients of Schizophrenia,20 patients had Major Depressive Disorder, 11 patients had panic disorders & 10 patients had Bipolar disorder. ( Table 1) 301

3 Table 1: Psychiatry diagnosis wise distribution of cases in study group Sr. No. Diagnosis No of patients 1 Schizophrenia 59 2 MDD 20 3 Panic Disorder 11 4 Bipolar Disorder 10 Table 2: Comparison of diagnostic groups against various parameters. Schizophrenia & psychotic disorders Bipolar Disorder (n=10) Depression & anxiety disorders P value Mean Mean Mean Age Education BPRS DAI SAI Total stigma Discrimination Positive aspect Disclosure

4 Table 3:Co-relation Of Insight,stigma & treatment adherence with different parameters Age Positive Total BPRS DAI SAI Discrimination Disclosure aspects stigma Age ** -2.32* BPRS ** ** DAI ** ** SAI ** Discrimination ** ** 0.77** Positive aspects Disclosure ** ** ** ** Total stigma -2.32* 0.476** ** ** 1 DISCUSSION: In this study population mean years of education was 9.33 in Schizophrenia & other psychotics, while 7.80 in Bipolar disorders & 6.09 in Neurotic group. Drug compliance was more in Bipolar group & in neurotic group while it was on lower side as expected in the Schizophrenia & other psychotic groups. Also to our surprise we found that the insight in bipolar disorder group was more than in those with neurotic group. The total stigma was in psychotic group, in bipolar disorder & in neurotic group.(table 2) We found that the positive aspects subscale of stigma was less in neurotic group than in the bipolar group & psychotic group. This signifies that the neurotic group which had a better insight percieve positive outcome from the illness. They have a positive attitude towards the illness& prognosis. The disclosure subscale was more in psychotic group than in the bipolar disorders & the neurotic group. This indicates the psychotic group had a fear of discrimination by others so they try to conceal the information regarding illness. This fear of disclosure is due to the felt stigma i.e internalised negative view of being mentally ill.the discrimination score was more in bipolar group than in psychotic group & neurotic disorder. The discrimination score is indicative of enacted stigma-negative attitude of the people towards patients with mental illness. This can be at home, workplace or in community. Statistically significant negative correlation was found between age, disclosure & total stigma. So younger patients had more stigma & more likely to conceal the

5 information of illness. (Table 3) Drug compliance was positively correlated with education, level of insight & positive aspects score of Kings stigma scale. So more the insight better will be the drug compliance this was in concordance with studies conducted by McEvoy & McConville. 9,10 LIMITATIONS OF STUDY: 1) Small sample size. 2) Cross sectional study. CONCLUSION: It was observed that patients with good insight were more likely to be compliant on medication. Also more the education better the compliance. This indicates the immense need to incorporate insight based psychotherapy into psychiatric services.this can lead to improve the prognosis & better healthcare utilization. It was also found that patients with more insight endorsed a greater sense of stigmatization, especially in relation to disclosure, thus signifying the need for mental health education among the general population. REFERENCES: 1. Ghaemi SN. Insight and psychiatric disorders: A review of the literature, with a focus on its clinical relevance for bipolar disorder. Psychiatric Annals.1997;27: McEvoy J. P. The relationship between insight in psychosis and compliance with medications. In: Amador X. F, David A. S, editors. Insight and psychosis. Oxford: Oxford University Press; pp Phillips M. R, Pearson V, Li F. Stigma and expressed emotion: A study of people with schizophrenia and their life members in China. British Journal of Psychiatry. 2002;181: Beck-Sander A. Is insight into psychosis meaningful? Journal of Mental Health.1998;7(1): O Donnell C, Donohoe G, Sharkey L, Owens N, Migone M, Harries R. Compliance therapy: A randomised controlled trial in schizophrenia. British Medical Journal.2003;327(7419): Corrigan PW, Watson AC. At issue: Stop the stigma: call mental illness a brain disease. Schizophr Bull. 2004;30: Patch PC, Arrigo BA. Police officer attitudes and use of discretion in situations involving the mentally ill: The need to narrow the focus. Int J Law Psychiatry. 1999;22: Pandya A, Bresee C, Duckworth K, Gay K, Fitzpatrick M. Perceived impact of the disclosure of a schizophrenia diagnosis. Community Ment Health J. 2011;47: McEvoy J. P. The relationship between insight in psychosis and compliance with medications. In: Amador X. F, David A. S, editors. Insight and psychosis. Oxford: Oxford University Press; pp McGorry P. D, McConville S. B. Insight in psychosis: An elusive target. Comprehensive Psychiatry. 1999;40(3):