|Year : 2016 | Volume
| Issue : 1 | Page : 12-17
Psychotropic Medication Refusal: Reasons and Patients' Perception at a Secure Forensic Psychiatric Treatment Centre
Olajide O Adelugba1, Mansfield Mela1, Inam U Haq2
1 Regional Psychiatric Center; Department of Psychiatry, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
2 Regional Psychiatric Center, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
|Date of Web Publication||3-Feb-2016|
Olajide O Adelugba
Clinical Division, Regional Psychiatric Center, P. O. Box: 9243, 2520 Central Avenue, Saskatoon, Saskatchewan, S7K 3X5
Source of Support: None, Conflict of Interest: None
Poor adherence to prescribed medication regimens can undermine the effectiveness of medications. This study was conducted to determine the demographic profile of forensic psychiatric inpatients refusing medications and to identify the reasons for refusal. Data were collected through interviews using a questionnaire including Drug Attitude Inventory-10. Medication refusal was more common among Aboriginals (68%, n = 34) than Caucasians (32%, n = 16) and was highest among the patients 21-30 years of age (44%, n = 22). Antisocial personality disorder and substance use disorder featured prominently among patients refusing medications. The main reasons for medication refusal were inconvenience (34%, n = 17) followed by side effects (22%, n = 11), ineffective medication (20%, n = 10), illness-related (16%, n = 8), and no reasons (8%, n = 6). Antipsychotic medications topped the list of the major classes of medications refused followed by Antidepressants and Mood Stabilizers.
Keywords: Forensic, medication, nonadherence, psychiatry, refusal
|How to cite this article:|
Adelugba OO, Mela M, Haq IU. Psychotropic Medication Refusal: Reasons and Patients' Perception at a Secure Forensic Psychiatric Treatment Centre. J Forensic Sci Med 2016;2:12-7
|How to cite this URL:|
Adelugba OO, Mela M, Haq IU. Psychotropic Medication Refusal: Reasons and Patients' Perception at a Secure Forensic Psychiatric Treatment Centre. J Forensic Sci Med [serial online] 2016 [cited 2019 Jul 16];2:12-7. Available from: http://www.jfsmonline.com/text.asp?2016/2/1/12/175614
| Introduction|| |
Psychotropic medications are used at various treatment facilities for patients suffering from different kinds of psychiatric disorders. Antipsychotic medications effectively decrease psychotic symptoms.  Substantially higher rates of depressive disorders found in prison inmates  resulted in the use of psychotropic medications at higher rates than the general population. Studies have shown that individuals with psychotic disorders experience better functioning and reduced symptoms if they take psychotropic medications as prescribed. , Failing to adhere to prescribed regimens of psychotropic medications may lead to increased risk of relapse, suicide, violence, and arrest. ,, Studies have also confirmed the economic burden of medication nonadherence in psychotic disorders.  Many factors were known to be associated with nonadherence, for example, co-morbidity with substance abuse, ,, side effects of medication,  diagnosis of schizophrenia and positive symptoms, , cognitive dysfunction,  lack of insight into the nature of mental illness and the necessity for medication, ,, and negative beliefs about medication. 
Many studies have frequently shown that patients do not take their medicine as intended. ,, Adherence to a drug regimen is particularly poor in those with chronic conditions,  with only around 50% of patients taking their medicine as prescribed.  Despite lot published on medication adherence at different treatment facilities, there is a dearth of published articles on psychotropic medication refusal among patients in secure forensic psychiatric settings. In fact, this study was predicated upon a situation in which a hitherto very medication-compliant patient refused to take his medications for about 3 days. Upon enquiry, he stated that days prior a staff member had asked everyone in the room where they were watching television to go out and proceeded to lock the room because someone had spilled coffee on the floor. The patient said he was so angry because that was his favorite television show and he decided to stop taking his medications in protest. As a result of the foregoing, it was thought that perhaps there could be other fascinating reasons why patients at the center were not always taking their prescribed medications. Therefore, this study aimed to identify reasons for medication refusal among patients at a secure forensic psychiatric facility. The simple working hypothesis is that when forensic psychiatric inpatients in secure settings refuse to take medications, some of their reasons for doing so may be unrelated to their prescribed medications. Furthermore, the study aimed at exploring the attitudes of those patients towards taking psychotropic medications. Given the voluntariness (not forced to take medication) of the administration of medication in these noncertified individuals, the reasons for refusal was hypothesized to be different from those associated with noncompliance. It was expected that the findings from this study may partly form the basis for some policy aimed at minimizing the incidence of medication refusal and poor attitudes toward medications.
| Methods|| |
The study was conducted on the 50 male patients, who refused to take medications during a 3-month period at the Regional Psychiatric Centre (RPC), Saskatoon, Saskatchewan, Canada. Ethical approval for the study was granted by the local Ethics Review Committee of the Correctional Services of Canada. In this study, operationally, refusal to take medication is defined as "refusal to take prescribed medication despite being offered and encouraged to do so by the dispensing nurse." This therefore excludes those who were being treated against their will according to the provisions of the Saskatchewan Mental Health Act. Furthermore, those who initially refused but later took their medications after an encounter with the dispensing nurse were excluded. All the Medication Administration Records were perused to identify those who the nurses marked as refusing to take prescribed medications. During the study period, the research assistant went to each of the units daily to collect the lists of those identified as having refused to take their psychotropic medications. All the patients identified were then approached by the research assistant for their consent. A data collection proforma was designed to collect information on potential factors related to noncompliance with medication in forensic psychiatric patients. Patients' medication knowledge was assessed through questions in the same proforma that ask if they know the names of their prescribed medications, why they are taking the medications and their own subjective appraisal of the level of their knowledge as poor, average, good and very good. Their subjective appraisals were also correlated with the medication-related questions. Participation of patients in the study was voluntary after a written consent was obtained from all the identified patients. Those who consented were interviewed using a questionnaire which included Hogan et al. Drug Attitude Inventory (DAI-10). The DAI evaluates the attitude of schizophrenic patients' views regarding the use of psychiatric medications and their experiences. In many respects, this questionnaire is sufficient for the purpose of this aspect of our study. This well-validated inventory has ten items in the questionnaire, six were scored as true, and four were scored as false. A correct answer to these items was scored as plus one, and incorrect response was scored as minus one. The final score was calculated as the sum of all the pluses and minuses. A positive total score indicated a positive subjective response (compliance) and a negative total score indicated a negative subjective response (noncompliance).
The patients involved in the study were classified into various groups to examine differences; diagnosis, substance use, chronicity of illness, ethnicity, reasons for refusing and age. All the patients were further subdivided into five age groups of <20, 21-30, 31-40, 41-50 and 51-60 years to minimize the differences likely to occur due to age and to examine differences in responses due to age. As well, qualitative responses of the patients' reasons were analyzed thematically. Information collected on the questionnaires was entered in the Statistical Package for Social Scientist (International Business Machines Corporation [IBM], Armonk, New York, USA) data sheets, and variables were translated into an analyzable form to draw conclusions. Data collected were subjected to statistical analysis using statistics options in the SPSS.  Data analysis on different variables was completed both within and between differences.
| Results|| |
Patients refusing medications
There were 50 (95% of patients refusing medications) consenting patients (mean age 32.4 years; standard deviation [SD] =9.9) comprising of Aboriginal (68%) and Caucasian (32%) who participated in this study. The age range of participants was between 19 and 58 years. The distribution of the sample identified ethnicity and age differences (Aboriginals [68%] and age group 21-30 [44%]) as important variables in this population of patients refusing medication.
Compared with other diagnostic categories, this study showed that more patients with the diagnosis of schizophrenia and related psychotic disorders as well as substance use disorders refused their medications. More aboriginal patients with psychotic disorders refused taking medication compared with others suffering from similar disorders. More Caucasian patients with Bipolar disorder refused their medications. Substance use disorders featured prominently among patients who refuse medications (Aboriginal [n = 20, 59%] and Caucasian [n = 9, 56%]) [Table 1]. Schizophrenia was also common among the Aboriginal patients refusing medications (n = 20, 59%) while only 5 patients (31%) were diagnosed among the Caucasians [Table 1]. Only 9% Aboriginal (n = 3) and 31% Caucasian patients (n = 5) were diagnosed with Bipolar disorder. Patients diagnosed with depressive disorders were 9 (26%) and 6 (38%) among the Aboriginal and Caucasian patients, respectively.
|Table 1: Clinical diagnosis of the patients (Axis-1) from different ethnic background and age groups |
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Overall, 40 (80%) of the studied population had a diagnosis of antisocial personality disorder while 4 (8%) had borderline personality disorder [Table 2]. Low intellectual functioning was identified in 5 (10%) of those who refused their medications. The proportion of patients diagnosed with antisocial personality disorder in Aboriginal and Caucasian groups were 27 (79%) and 13 (81%), respectively [Table 2].
|Table 2: Clinical diagnosis of the patients (Axis-2) from different ethnic background and age groups |
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Antipsychotic medications topped the list of the class of medications refused followed by Antidepressants and Mood Stabilizers. Commonly prescribed medications were quetiapine (12.2%), olanzapine (10.9%), valproic acid (6.4%), clonazepam (6.4%), and buspirone (3.8%), while commonly refused medications were quetiapine (15.2%), olanzapine (14.7%), clonazepam (9.1%), valporic acid (6.6%), and zopiclone (5.1%). Expectedly, the frequency of medication prescribed and rates of medication refused among the different classes of medications followed the same trend.
Frequency and timing of medication refusal
Patients refusing their prescribed medications had 2.6 (SD = 1, range = 1-4) episodes of refusal. In this study, it is recognized that an event of medication refusal occurs when a patient has not only been called to the medication station but was actively encouraged by nursing staff but still declined the offer of his medication. The event means were not different between Aboriginal (2.6, SD = 1) and Caucasian patients [2.5, SD = 0.9, [Figure 1]. Among the different age groups the number of refusal times was more for patients <20 years old (mean = 3.7, SD = 0.6), while it was least in patients in the age group of 21-30 years (mean = 2.3, SD = 1). The distribution of the daily medication refusal among the days of the week was as follows: Saturday (19.7%) followed by Friday (15.6%), Thursday (14.9%), Wednesday (14.2%), Sunday (13.9%), Monday (11.9%), and Tuesday (9.8%). The distribution of medication refusal during the course of the day and in decreasing order of frequency was noon (51.5%), morning (26.4%), supper (18.6%), and night (3.5%) time.
|Figure 1: Episodes of medication refusal during study period for the patients from different age groups and ethnic backgrounds|
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Reasons for medication refusal
The reasons advanced for medication refusal were many, varied and oftentimes multiple in individual patients [Table 3]. When arranged according to themes, the main reasons for medication refusal among all patients were; inconvenience (34%), side-effects (22%), the ineffectiveness of medication (20%), and illness (16%). For Aboriginal patients the reasons were; inconvenience (38%), side effects (21%), and ineffectiveness of medication (18%). Examples of inconvenience responses include; "I was enjoying watching a television program," "I want to continue to sleep in" and "it was too early being a weekend." However, the major reasons for medication refusal in the Caucasian group were found to be due to side effects (25%), the ineffectiveness of medication (25%), and inconvenience (25%). The reasons for refusing medication among the Aboriginal patients < 20 years of age were similar to the Caucasian group [Table 3]. Side effects and ineffectiveness of medication were the main reasons among the Caucasian patients within age range 21-30 years.
|Table 3: Reasons of medication refusal in the patients from different ethnic background and age groups |
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Overall, majority of the patients rated their knowledge of prescribed medications as average and above. The ratings were average (34%), very good (26%), poor (24%), and good (16%). Comparatively, for the Aboriginal group medication knowledge was described as average (35%), good (18%), poor (24%) and very good (24%). In the Caucasian group, it was average (31%), good (13%), poor (25%), and very good (31%). Majority of the patients in the age range from 31 to 40 years in both ethnic groups had very good knowledge about their medications. Caucasian patients in the age group 41-50 years had good knowledge regarding medication as compared to the Aboriginal patients.
Drug Attitude Inventory
A positive DAI score implies compliance and the closer the number are to 10, the better the attitude. The overall DAI response of the patients refusing medication was subjectively positive (mean = 5, SD = 4.7), with the highest positive response being from the patients aged between 41 and 50 years. Three-quarters of the respondents had a positive response. Negative responses (14%) and the neutral responses (10%) accounted for almost a quarter of all responses. The Aboriginal and Caucasian patients refusing medications had similar DAI score (mean = 5, SD = 4.7 and mean = 5, SD = 5). There was a positive increase in the DAI scores in patients from both ethnic groups with increasing age. Aboriginal patients showed an increase in DAI scores from 4 to 6 as the age increased from 21 to 50 years, similarly Caucasian patients also showed an increase in DAI score from 4 to 10 with increase in age. A direct linear relationship was found between the average age and mean DAI score of the patients [Figure 2], R2 = 0.96]. When patients suffering from psychotic disorders (62%) were compared with those with nonpsychotic disorders (38%), the overall mean DAI scores were 3.4 and 5.8, respectively, insinuating more positive attitude to illness and medication in nonpsychotic patients. The patients' perception regarding how to improve medication compliance was also obtained. About half (52%) said nothing could be done to prevent refusal of medications. Others (10%) wanted delivery of medications to their rooms, and 11% said they did not know what else could be done. However, a few patients (14%) were in favour of getting more information about their medication, adjusting medication schedules and dose.
|Figure 2: Relationship between age and Drug Attitude Inventory score of the patients refusing medication|
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| Discussion|| |
The ethnic profile of patients at the study site does not mirror percentage ethnic representations in the community, and this could be due to a myriad of reasons that are beyond the scope of this paper. It suffices to say that the percentage of Aboriginal patients at the RPC is usually about 50% of the total patient population.
Psychotic patients were more likely to have a low DAI score and refuse their medications. Patel and David  in their study also reported that psychosis, substance abuse, and personality disorders play a negative role in medication adherence. Relevant factors to consider among patients refusing their medications include but not limited to socioeconomic status, adherence history, illness duration, psychopathology, insight, cognitive deficits, and co-morbidity.
The finding of an over-representation of the Aboriginal patients among patients refusing medication raises an interesting question regarding the possible role of culture in medication adherence. The location of the treatment center lends itself to over-representation of Aboriginals. In the prairie region, the reported number of Aboriginals is much larger than that of the Canadian population.  Ethnicity has been found to be associated with medication refusal in another study.  In our study, the knowledge of medication was the same among ethnic groups, so the specific influence of ethnic grouping will have to be studied further. Medication refusal was more among patients aged 20 years or less, and this could be due to the average to poor knowledge of medications in this age group. However, the study conducted by Patel and David,  and a review by Owiti and Bowers revealed  that factors such as age at onset of illness, sex, socioeconomic status, marital status, and ethnicity have not been consistently associated with adherence to medication.
In outpatient settings, the complexity of dosage schedules has been recognized as a factor that may impact on adherence. Perhaps, the development of various medication-dispensing aids, like pill organizers and blister packs to improve adherence is a good attempt at solving this problem. Daily dosage schedules of about 3 times a day in our study may have been contributory to medication refusal rate. A less complicated dosage schedule may have lessened episodes of medication refusal especially in those cases where inconvenience was an issue. The role of knowledge about medication would need to be further explored as majority of those who refused had average to poor knowledge of their prescribed medications; similar observation was also reported by Tam and Law. 
The reasons for medication refusal advanced by patients in this study namely, inconvenience, side effects, and medication ineffectiveness are similar to reasons adduced by schizophrenic patients for medication refusal.  The high rate of psychosis in our sample in addition to the reasons for refusal may explain the similarities with the schizophrenia study.  In a systematic review of studies on adherence to treatment programs, Nosé et al.  found quite a wide range (24-90%), in adherence rates among psychotic patients. Given the prevalence of static and criminogenic factors in the prison population, it is not surprising that psychosis would play a negative role regarding adherence to medications in a forensic psychiatric setting.
Many factors may influence the decision of patients to accept or refuse medications. Among our forensic patients, their attitude regarding the use of psychotropic medications was assessed through a shortened version of DAI. This indicated an overall response score of five. The positive linear correlation observed between the age and DAI score, calls for specially targeted programs towards younger patients. They are more likely to have a shorter history of contact with mental health services, less insight, more substance use, more psychotic illness and more conscious of their perceived rights to refuse treatment even against medical advice. A similar trend in nonforensic patients was also identified in another study conducted by Compton et al.  The linear relationship between advancing age and positive attitude towards medication in all subgroups of patients could be explained by the length of contact and experience with mental health systems. Our sample was too small to elaborate on the age difference issues. As in early psychosis intervention programs, the significance of medication adherence could be emphasized among young psychotic offenders in the federal correctional system. Serial administration of the DAI questionnaire coupled with customized medication awareness program for young offenders with major mental illness may be beneficial and cost-saving. This study has generated some relevant and useful information regarding prescribed prescriptions, the relationship between age and attitude to medications, culture/ethnicity differences, reasons for refusal and psychopathology among forensic patients. The indication from the study sample of the need for more knowledge and information on medications indicated a willingness on their part to work with staff in ways that could improve their insight.
Medication refusal among patients receiving psychiatric services leads to an increased cost of care  and length of hospitalization.  However, information on the cost of medication and extended stays of the patients refusing medications could not be collected in this study. It would be helpful if such information is collected on a regular basis so that strategies could be implemented to reduce the medication refusal rate.
| Conclusions|| |
Conceptually, medication refusal in forensic psychiatric treatment centers is related to individual rights, choice, and autonomy. Simplification of dosage schedules particularly prescribing once-a-day medications and preferably at night time is likely to reduce medication refusal. Given the possible role of improved insight, health education with an emphasis on mental health awareness and psychotropic medication awareness programs are helpful in addressing adherence related problems. The overriding role of a good therapeutic alliance will facilitate such initiatives.
The authors highly appreciate the help and support of the RPC staff during the study. We also thank Treena Witte, Dr. Deqiang Gu, Akela Hanson, Saleh Delai and Chantal Diplacido for their help in data collection and analysis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]