Evidence Synthesis and Tables

Comprehensive Essay on Treatment Nonadherence Among Schizophrenia Patients

This paper aims to develop an evidence synthesis on motivational interviewing supported by technology as an evidence-based intervention for medication nonadherence. The practice problem that this DNP project seeks to solve is treatment nonadherence among schizophrenia patients. Most of the literature documents a high prevalence of nonadherence among patients diagnosed with schizophrenia taking antipsychotic medication. A recent narrative review showed that Schizophrenia patients remain uninformed about medication, yet they value talks related to medications provided by healthcare professionals (Salzmann-Erikson & Sjödin, 2018). Remaining uninformed about medication is a significant barrier to treatment adherence, and practitioners are encouraged to adopt mechanisms to involve patients in their care.(Comprehensive Essay on Treatment Nonadherence Among Schizophrenia Patients)

The proposed intervention involves implementing technology with motivational interviewing (MI). Motivational interviewing will utilize OAR Model skills that stands for open-ended questions, affirmations, reflective listening, and summary periods. MI is a long-standing evidence-based intervention (EBI) that primarily guides individuals to implement some healthcare changes (Mullen et al., 2020). MI utilizes four principles: expressing sympathy, developing discrepancy, rolling with client resistance, and supporting self-efficacy. In this regard, MI is considered direct and patient-centered counseling to help patients identify and resolve their ambivalent selves.(Comprehensive Essay on Treatment Nonadherence Among Schizophrenia Patients)

Practice Problem

Nonadherence is a significant problem that affects patients and the healthcare system globally and in the United States (Kim et al., 2018). Globally, the rate of nonadherence to Schizophrenia treatment is 50% (Viveiros et al., 2020). Conversely, between 26.5% and 58.8% of patients diagnosed with Schizophrenia report nonadherence (Salzmann-Erikson & Sjödin, 2018). Nonadherence is associated with psychotic relapse, worsening of the disease, mortality, increased suicide risk, hospital readmission, and increased healthcare costs. The cost of nonadherence to schizophrenia medication, with reference to the impact on health, resources, and costs, is estimated at $116,434 (Cutler et al., 2018).(Comprehensive Essay on Treatment Nonadherence Among Schizophrenia Patients)

Evidence Synthesis

            Researchers have used motivational interviewing as an EBI for various clinical issues, including medication adherence. Zomahoun et al. (2017) evaluated the efficacy of MI on medication adherence among adults diagnosed with chronic illnesses. The study found that MI interventions successfully promote medication adherence in adults diagnosed with chronic diseases, including Schizophrenia (Zomahoun et al., 2017). Harmaci & Budak (2022) assessed the effect of psychoeducation through motivational interviewing on medication adherence, psychological/psychosocial well-being, and a sense of hope among schizophrenia patients. The findings showed that using motivational interviewing techniques to provide psychoeducation effectively promotes medication adherence (Harmaci & Budak, 2022).(Comprehensive Essay on Treatment Nonadherence Among Schizophrenia Patients)

Dobber et al. (2018) evaluated the interactions of MI among Schizophrenia patients. The study identified aspects of MI such as trusting relationships, integration of patients’ values, ability to adapt MI to patients’ situations, and their association with improved medication adherence among schizophrenia patients (Dobber et al., 2018). Ertem & Duman (2019) assessed the effect of MI on insight levels and treatment adherence among schizophrenia patients. The findings showed improved medication adherence with MI (Ertem & Duman, 2019). Chien et al. (2019) assessed the impact of adherence therapy through motivational interviewing among schizophrenia patients. The study findings revealed the cost-effectiveness of MI for medication adherence among schizophrenia patients, reduced rehospitalization, and positive psychosocial outcomes (Chien et al., 2019). The central theme highlighted across the studies was the positive role of MI on medication nonadherence (Dobber et al., 2018; Chien et al., 2019; Ertem & Duman, 2019; Zomahoun et al., 2017). However, the different studies highlight the additional impact of MI on treatment-related factors such as patient insight, psychological/psychosocial well-being, and reduced rehospitalization (Dobber et al., 2018; Chien et al., 2019; Ertem & Duman, 2019; Zomahoun et al., 2017).(Comprehensive Essay on Treatment Nonadherence Among Schizophrenia Patients)

Conclusion

The practice problem that this DNP project seeks to solve will be treatment nonadherence among Schizophrenia patients. Most of the literature documents a high prevalence of nonadherence to medication among Schizophrenia patients taking antipsychotic medication (Salzmann-Erikson & Sjödin, 2018). Existing literature supports the effectiveness of MI on medication adherence and associated benefits, including psychosocial well-being, reduced rehospitalization, and insight (Zomahoun et al., 2017; Harmaci & Budak, 2022; Ertem & Duman, 2019; Chien et al., 2019). Therefore, the proposed intervention hypothesizes enhanced medication adherence among participants.(Comprehensive Essay on Treatment Nonadherence Among Schizophrenia Patients)

References

Chien, W. T., Cheung, E. F., Mui, J. H., Gray, R., & Ip, G. (2019). Adherence therapy for Schizophrenia: A randomized controlled trial. Hong Kong Med J, 25(Suppl 2), 4-9. https://pubmed.ncbi.nlm.nih.gov/30674700/

Cutler, R. L., Fernandez-Llimos, F., Frommer, M., Benrimoj, C., & Garcia-Cardenas, V. (2018). Economic impact of medication nonadherence by disease groups: a systematic review. BMJ open, 8(1), e016982. https://doi.org/10.1136%2Fbmjopen-2017-016982

Dobber, J., Latour, C., de Haan, L., Scholte op Reimer, W., Peters, R., Barkhof, E., & van Meijel, B. (2018). Medication adherence in patients with Schizophrenia: A qualitative study of the patient process in motivational interviewing. BMC Psychiatry, 18(1), 1-10. https://doi.org/10.1186/s12888-018-1724-9

Ertem, M. Y., & Duman, Z. Ç. (2019). The effect of motivational interviews on treatment adherence and insight levels of patients with Schizophrenia: A randomized controlled study. Perspectives in psychiatric care, 55(1), 75-86. https://doi.org/10.1111/ppc.12301

Harmanci, P., & Budak, F. K. (2022). The effect of psychoeducation based on motivational interview techniques on medication adherence, hope, and psychological well-being in schizophrenia patients. Clinical Nursing Research, 31(2), 202-216. https://doi.org/10.1177/10547738211046438

Kim, J., Combs, K., Downs, J., & Tillman, F. (2018). Medication adherence: The elephant in the room. US Pharm, 43(1), 30-34. Available at: https://www.uspharmacist.com/article/medication-adherence-the-elephant-in-the-zoom?fbclid=IwAR0cApzVVz31px43GmYrZhNBq2ozcvLQ5HCt3UMShZE3QSNv0SxTq23PqD4 (Retrieved 28 November 2022)

Mullen, A., Isobel, S., Flanagan, K., Key, K., Dunbar, A., Bell, A., & Lewin, T. J. (2020). Motivational interviewing: Reconciling recovery-focused care and mental health nursing practice. Issues in Mental Health Nursing, 41(9), 807-814. https://doi.org/10.1080/01612840.2020.1731891

Salzmann-Erikson, M., & Sjödin, M. (2018). A narrative meta-synthesis of how people with schizophrenia experience facilitators and barriers in using antipsychotic medication: Implications for healthcare professionals. International Journal of Nursing Studies, 85, 7-18. https://doi.org/10.1016/j.ijnurstu.2018.05.003

Viveiros, C. P., Tatar, C. R., Dos Santos, D. V. D., Stefanello, S., & Nisihara, R. (2020). Evaluation of nonadherence to treatment among patients with schizophrenia attending psychosocial care centers in the south region of Brazil. Trends in psychiatry and psychotherapy, 42, 223-229. https://doi.org/10.1590%2F2237-6089-2019-0072

Zomahoun, H. T. V., Guenette, L., Gregoire, J. P., Lauzier, S., Lawani, A. M., Ferdynus, C., … & Moisan, J. (2017). Effectiveness of motivational interviewing interventions on medication adherence in adults with chronic diseases: A systematic review and meta-analysis. International Journal of Epidemiology, 46(2), 589-602. https://doi.org/10.1093/ije/dyw273.

Practice Question: For adults with a history of schizophrenia in the inpatient setting, does implementing technology with motivational interviewing (MI), compared with current practice, impact medication nonadherence in 8-10 weeks?

Date:

Article Number	Author and Date	Evidence Type	Sample, Sample Size, Setting	Findings That Help Answer the EBP Question	Observable Measures	Limitations	Evidence Level, Quality
1	Zomahoun et al. 1 April 2017	Systematic review and meta-analysis of RCTs (Comprehensive Essay on Treatment Nonadherence Among Schizophrenia Patients)	16 RCTs	MI enhanced medication adherence (Comprehensive Essay on Treatment Nonadherence Among Schizophrenia Patients)	· Medication adherence	· Limited effectiveness of MI (Comprehensive Essay on Treatment Nonadherence Among Schizophrenia Patients)	A/B High/Good Quality
2	Harmaci & Budak 31 February 2022	RCT (Pretest-posttest control group design)	Schizophrenia patients n=150	Enhanced medication adherence, hope, and psychological well-being levels. (Comprehensive Essay on Treatment Nonadherence Among Schizophrenia Patients)	·   Medication adherence ·   Hope ·   Psychological well-being	· High dropouts	Level I, High Quality
3	Dobber et al.18 May 2018	Qualitative multiple case study based on RCTs	Schizophrenia patients N=55	Enhanced medication adherence	·   Medication adherence	·   MI therapists are not expert ·   Limited sample size	Level I, High Quality
4	Ertem & Duman Jan 2019	Randomized Controlled Trial	Schizophrenia patients N=40 Dokuz Eylül University, outpatient clinic (Comprehensive Essay on Treatment Nonadherence Among Schizophrenia Patients)	Enhanced medication adherence (Comprehensive Essay on Treatment Nonadherence Among Schizophrenia Patients)	·   Medication adherence ·   Medication insight	·   Poor internal consistency of Morisky’s Questions-Self-Report Measure of Adherence ·   Limited sample (Comprehensive Essay on Treatment Nonadherence Among Schizophrenia Patients)	Level I, High Quality
5	Chien et al. Feb 2019	Randomized Controlled Trial	Nonadherent schizophrenia patients n=67 community psychiatric nursing services centers; New Territories West and Kowloon West (Comprehensive Essay on Treatment Nonadherence Among Schizophrenia Patients)	Adherence therapy based on MI improved poor medication adherence among schizophrenia patients. (Comprehensive Essay on Treatment Nonadherence Among Schizophrenia Patients)	·   Insight and Treatment Attitudes ·   Medication adherence ·   Level of functioning ·   Re-hospitalization ·   Positive and negative symptoms	Small and selective sample Participants were nonblinded Impact of cofounding factors on medication not controlled (Comprehensive Essay on Treatment Nonadherence Among Schizophrenia Patients)	Level I, High Quality