The Relationship Between Schizophrenia Patient Home Environment And Compliance With Prescribed Medication

Research ProposalMedication Compliance: The relationship between the schizophrenic patient and their home environment.By:Cristal Denner (Student Nurse)00026891Josanne Julien (Student Nurse)Safiya Mohammed (Student Nurse)Submitted to:Mrs. Beryl Brewster(Senior Lecturer)College of Nursingand Allied Health In partial fulfillment of

The requirements for the

Degree of

Bachelor of Science in NursingMarch, 2014Title: Medication Compliance: The relationship between the schizophrenic patient and their home environment.

Background/ IntroductionThe purpose of this study is to examine if there is a link between prescribed medication compliance and the patients home environment of patients who were readmitted at least three (3) times within the past two (2) years on ward six (6) the admission ward of St. Anns Hospital. This analysis would explore the psychological, psychosocial, cultural and economic aspects that would result in non compliance of medication.

Schizophrenia is a severe form of mental illness affecting about 7 per 1000 adults globally. Although the incidence is low, the prevalence of schizophrenia is high as it is a long-term chronic illness (World Health Organization, 2011). Antipsychotic medication plays an important role in schizophrenia treatment and symptom control. Effective management of schizophrenia requires continuous long term treatment in order to keep symptoms under control and to prevent relapse (American Psychiatric Association, 2006). Despite the critical importance of medication, non adherence to prescribed drug treatments has been recognized as a problem worldwide and may be the most challenging aspect of treating patients with schizophrenia (Barbato, 2011).

Non adherence to medication includes a range of patient behaviours, from treatment refusal to irregular use or partial change of daily medication doses. Partial adherence to medication is at least as frequent as complete non adherence (Svestka and Bitter, 2007). There is no single theory that explains adherence issues, but rather a range of theories with their own strengths and limitations (Weiden, 2007). Potential factors for non adherence may be related to disease severity, treatment characteristics or even external environmental factors such as therapeutic support (Llorca, 2008). Adherence factors may also be unique to the characteristics of schizophrenia; factors such as cognitive impairment or lack of illness insight may play an important role.

Key Words:

Medication Compliance: Refers to the degree or extent of conformity to the recommendations about day to day treatment by the provider with respect to the timing, dosage, and frequency. It may be defined as the extent to which a patient acts in accordance with the prescribed interval, and dose of a dosing regimen (Joyce.A, 2008).Home Environment: According to thedictionary.com, this is the totality of circumstances surrounding an organism or group of organisms, especially the combination of external physical conditions that affect and influence the growth, development, and survival of organisms

Schizophrenia: According to thedictionary.com, Schizophrenia is a psychotic disorder (or a group of disorders) marked by severely impaired thinking, emotions, and behaviors. Schizophrenic patients are typically unable to filter sensory stimuli and may have enhanced perceptions of sounds, colors, and other features of their environment. Most schizophrenics, if untreated, gradually withdraw from interactions with other people, and lose their ability to take care of personal needs and grooming.Litrature ReviewNoncompliance is an important predictor of hospitalization risk. Following inpatient treatment and discharge from the community, many patients become poorly compliant with therapy. Several reasons for poor compliance have been hypothesized, including disease symptoms (e.g., grandiosity, paranoia, problems with accurate recall), treatment-emergent side effects, substance abuse, lack of support systems to encourage medication compliance, psychostressors, and poor patient-provider relationships. According to the article Medication adherence and utilization in patients with schizophrenia or bipolar disorder receiving aripiprazole, quetiapine, or ziprasidone at hospital discharge: A retrospective cohort study (Berger, 2012), Support for family education in mental health leading to medication adherence in mentally ill clients, has been highlighted in the literature review. Interventions like family therapies and psycho-education can collaborate towards successful treatment adherence, significantly reducing relapse and re-hospitalization (Colom, F et al, 2004). Cardoso, L et al, 2011, suggest that health education can also influence clients and families involvement in health care. Consequently, considering clients and families knowledge and beliefs on maintaining the prescribed psychiatric treatment can help health professionals to provide better orientations and health care to these clients (Cardoso, L et al, 2011). Other studies shows over the course of a year, about three-quarters of patients prescribed psychotropic medication will discontinue, often coming to the decision themselves and without informing a health professional. According to the article Why dont patients take their medicine? written by Mitchell & Selmes (2007) it is stated that the rate of non-adherence with psychotropic medication are difficult to summarise because they vary by setting, diagnosis and type of adherence difficulty. However, found that non-adherent individuals with schizophrenia have a 3.7-fold greater risk of relapse than those who are adherent over 624 months. Where medication (or appointments) are missed for predominantly illness-related reasons such as lack of insight, there is a particularly high risk of readmission. Yet illness severity probably accounts for a minority of cases of poor adherence in the community (Maddox et al, 1994). Further, the impact may be ameliorated if patients who have further symptoms seek help. Unfortunately, adverse experiences with medication may prejudice willingness to attend in the future (Gonzalez et al, 2005). This proposal would explore the causes on non-adherence, whether intentional or not, and discusses patients reasons for failure to concord with medical advice, and predictors of and solutions to the problem of non-adherence. The health belief model views compliance as a decisions made by the patients after weighing the perceived risks and benefits of treatment (JClinPsychiatry, 2002). The health belief model describes a person's health behaviour as an expression of health beliefs. The model was designed to predict a person's health behaviour, including the use of health services, and to justify intervention to alter maladaptive health behaviour. Components of the model include the person's own perception of susceptibility to a disease or condition, the perceived likelihood of contracting that disease or condition, the perceived severity of the consequences of contracting the condition or the disease, the perceived benefits of care and barriers to preventive behaviour, and the internal or external stimuli that result in appropriate health behaviour by the person, (Farlex, 2012). In addition, Dr. Pearl Brown (C. Moe, Trinidad Guardian 2012) stated that she has clients who have mental illness (schizophrenia), and with that understands that its very important for those around them to be supportive. Coping with schizophrenia is a challenging task, not only for the patient but the entire family, as the behavior of schizophrenic patients is difficult to predict. She also mentioned that these clients need not only medication but counseling. The family has to adapt to the illness and be aware of its consequences. Therefore, these support groups are aimed at improving the lives of the mentally ill clients and their families.Medication adherence is important in the ability to adapt, as well as, the capacity to function. As nursing students we have often observed the clients unwillingness to adhere to their treatment regime, resulting in multiple hospital admissions, which causes a great deal of turmoil for themselves and their relatives. In this proposed study, we seek to look at the causation of the patients unwillingness to utilize take their medications given to them to try to curb relapse, rehospitalisation, poor outcomes and high income costs. By embarking upon what are the causes of compliance, we can be more successful in devising strategies for a successful result.

This study is needed, to show whether or not the patients home environment i.e. if they have the recommend meals that should be taken with their medication, the family and community support and acceptance of their illness and the necessary patient education about medication compliance, as well as, its side effect can contribute to compliance of medication by the schizophrenic community.Research Question Is there a relationship between schizophrenic patients home environment and compliance with prescribed medication which leads to a relapse or readmission to the psychiatric hospital?Aim(S)/Objectives Identify the causes of non compliance of prescribed medication for schizophrenic patients

Identify and utilize strategies to curb non compliance of prescribed medication and curb rehospitalisation.

To educate participants about the importance of adherence to prescribed medication

To assist family members in developing coping mechanisms to provide adequate care for the mentally ill relatives.MethodAs stated in the background, This proposal would examine the results of compliance to medication of schizophrenic patients and evaluate if the home environment is a contributing factor to these patients rehospitalisation. Some schizophrenic patients do not fully comply with treatment and thus this compliance links to relapse, rehospitalisation, poor outcomes and high income costs. A patients compliance to medication is an important and real-world problem. We believe that as nursing students taking the initiative to try to curb this problem, it would be beneficial to the families, the clients, their respective communities and to us as well. Research Design

For the purpose of our research question we chose to use a descriptive research design in hope of exploring the patients and their realives or caregivers perception and experiences on medication compliance in relation to their home environment. According to Smith 2011, phenomenology is the study of structures of consciousness as experienced from the first-person point of view; as such a phenomenological approach would be used for this research as it allows for us the researchers to understand the participants perception of the phenomenon of non compliance of medication in relation to their home environment. By using this paradigm, we are be able to get an insight of the situation from the persons involved, and as a result create better solutions to the problem as we would have an understanding of the issue from the patients and their relatives or care givers perspective. Patton (1990) stated the purpose of interviewing specifically as "to find out what is in and on someone else's mind", and that is exactly what the target of the phenomenological study focuses on, i.e. the perception of lived experience. This approach challenges customary structures of thinking and researching and can give the medical team assigned to these patients a deeper insight of the problem thus helping solve or reduce the incidence of rehospitalization. The phenomenological approach seeks to limit and prevent researcher bias, the major concern of phenomenological analysis is to understand "how the everyday, inter-subjective world is constituted" (Schwandt, 2000).

Population: The population for the study includes all schizophrenic patients who were rehospitalized for at least three (3) times in the past two (2) years.Sample: Fifteen (15) Schizophrenic patients and their relatives or caregivers from the admission ward, ward six (6) in St. Anns who have been readmitted for at least three (3) times within the past two (2) years. The sampling method we would be using would be purposive sampling because of the purpose of the study and that we have prior knowledge of the population being studied.

Inclusion criteria 1. Participants must be a patient and their relatives or caregivers of ward six (6) St Anns Hospital Patient

2. Patient must have been readmitted to ward six (6) at least three (3) times with the past two (2) years.3. Patients can have had at least one regular visiting relative or caregiver for them during visiting days and hours.4. Patients that gave consent to participate

5. DSM-III-R diagnoses of schizophrenia or schizoaffective disorder (American Psychiatric Association 1987)Exclusion Criteria1. Patents who are not schizophrenic patients2. Patients who refused consent to participate3. Patients who were not readmitted to ward six(6) at least three (3) times within the past two (2) years.4. Patients of other wards besides ward six (6) of St Anns Hospital.

Elements of the Design

Independent Variable: The patients home environment.

Dependent Variable: Compliance of medication

Data Collection

The principal method for our data collection would be prearranged / informal interviews with guided questions. This would help us to gather some versatility and allow the participants to communicate their knowledge and views on the topic.The interviews would start at 8am and would be completed by three in the afternoon over a Five (5) day period because of the size of the sample. My two collegues and myself would each interview a patient maximizing the utilization of time.Each interview should not be more than one hour long and would be documented via writing. No recording would be done as it would be against hospital policy. Our reason for using the interviewing method is because it is flexible and we would have control over who is the respondent, as well as, over sequence of questions. Pilot Study The timeframe in which the research is to be completed is insufficient for one to be conducted.Data Analysis (Interpretative Phenomenological Analysis)

During our analysis of the data received we would suspend our reflection upon our own preconception about the data and focus in great detail on the participants interpretations of the phenomenon. Transcripts are coded in considerable detail, with the focus shifting back and forth from the key claims of the participants, to the researchers interpretation of the meaning of those claims.

Interpretative Phenomenological Analysis hermeneutic stance is one of inquiry and meaning making (Reid.k, 2005), and so we would attempt to make sense of the participants attempts to make sense of their own experiences. This analysis would be bottom up. This means that we would generate codes from the data rather than using pre existing theory to identify codes that may be applied to the data. This system encourages an open-ended dialogue between the us and the participants and, may therefore, lead us to see things in a new light.

After transcribing the data, we would work closely and intensively with the text, annotating it closely ('coding') for insights into the participants' experience and perspective on their world. As the analysis develops, we would catalogue the emerging codes, and subsequently begin to look for patterns in the codes. These patterns are called 'themes'. Themes are recurring patterns of meaning (ideas, thoughts and feelings) throughout the text. Themes are likely to identify both something that matters to the participants (taking the medication) and also convey something of the meaning of that thing, for the participants. E.g. when we study we may find that patients dont take their medications because of the side effects of such prescribed medication (where one key psychosocial understanding of the meaning medication compliance, is that it marks a socioeconomic for the patients and relatives or caregivers involved).

Some themes will eventually be grouped under much broader themes called 'super ordinate themes'. For example, patients not having anything to eat in order to take their medication would result in negative side effects or relatives or caregivers that do not give the patients the prescribed medication would observe negative emotional effect might be a super ordinate category which would capture a variety of patterns in participants' embodied, emotional and cognitive experiences, where we might expect to find sub themes. The final set of themes are typically summarised and placed into a table or similar structure where evidence from the text is given to back up the themes produced by a quote from the text.

Work Plan/ Time Scale

The time frame for the completion of this research is ten weeks, the following table illustrates the approximate time frame allocated to the completion of the various aspects of this research.WEEK 1WEEK 2&3WEEK 4&5WEEK 6WEEK 7&8WEEK 9WEEK 10

Formulation of research question and problem statementFormulate research proposalSeek legal permission to conduct research

Formulate questionnaireCollect dataAnalyse dataWrite up findings and conclusionPresent research

Ethical Consideration

According to Polit and Beck (2010), researchers must deal with ethical issues when their intended research involves human beings. Ethical approval will be requested in writing from the Director of Nursing and the Hospitals Ethics Committee. The director of Nursing must be made aware of all nursing research taking place in the organization to monitor the effect of all such projects taking place. They will also need to be convinced of the value of the research and the competency of the researcher (Lee 2005).

The main ethical principles that will be considered in conducting this research study are respect for persons, confidentiality and beneficence /non-maleficence

Respect for persons

As individuals are autonomous beings they will have the right to decide whether or not they participate in this research. This fact will be stated clearly at the beginning of the interviews. Informed consent would be sought from research participants. Before consent is sought the researcher will give details of the nature and purpose of the research, the potential subjects, who will have access to the data and the proposed outcome of the research. Completion of the interview process by participants will be taken as their consent to participate in the study. Participants will be given adequate time to consider their participation. The participants would have the assurance that the interview will be terminated at any point of the interview process upon their request to withdraw themselves from the research

Confidentiality

To maintain anonymity and privacy of the respondents pseudo names would be used to protect the identity of the participants, this would encourage participants to speak freely without fear of victimization.Beneficence/non-maleficence

While interviews tend to be intrusive and would create a level of discomfort for the participants, it is possible for sensitive and highly personal questions to be threatening if they trigger feelings of guilt when the respondent is alone. Should the interviewer sense any discomfort on the part of the interviewee during the interview, the interview would be terminated unless the respondent wishes to continue. Parahoo (2006) maintains that questions on knowledge, behavior or experience may also be threatening to health professionals if data can be accessed by their employers. A written and verbal guarantee will be given to the participants that the data collected will remain confidential and that only the researchers will have access to it. Additionally the interview tapes and data would be coded in that instead of the respondents names a pseudo name would be used for example participant A dated 12/4/13, this way their responses would not be identifiable. The interview would be conducted in a private area; no identifiable information would be printed or recorded in this research.

Justice No fabricated information would be recorded in our findings, the results presented would be factual as stated in the interview by the respondents and would not be tweaked in any way to satisfy the researchers involved. The final report will be factual and free of accusations

Limitations The research quality is heavily dependent on the our skills and can more easily be influenced by the our personal biases and idiosyncrasies.

Rigor is more difficult to maintain, assess, and demonstrate.

The volume of data makes analysis and interpretation time consuming.

Our presence during data gathering, which is often unavoidable in qualitative research, can affect the subjects' responses.

Issues of anonymity and confidentiality can present problems when presenting findings

Findings can be more difficult and time consuming to characterize in a visual way.

Resources

Resources Needed Human, Material/ Equipment, Financial

Human Resources

Cristal Denner

Josanne Julien

Safiya Mohammed

We all collaborated in the research proposal:

Title

Background/ Introduction Literature Review

Research question

Aims/objectives

Plan of Investigation/Method

Each part would be shared equally with an input from all researchers according to our strengths and weaknesses. Effective communication would be utilized through scheduled meetings and social media. All parts would be reviewed and discussed before the final draft was done.

The study will be directed by Mrs. Cristal Denner responsibility would entail getting the approval from the hospital and ward sister of ward six (6) of St. Anns Hospital, interviewing and data collection. Ms. Josanne Julien responsibility would entail interviewing and data collection Ms. Safiya Mohammed responsibility would entail interviewing and data collectionThe data analysis would be collaboratively done by all three of us as well as the medical team assigned to ward six (6) of St. Anns Hospital

Types of Resources used:

These resources would be used after consent is obtained from the relevant sources to carry out the research. Electronic Data Bases would also be used to find articles and journals on a variety of topics relating to our investigation, as well as periodicals from professional organizations and governmental agencies. Also, several educational texts geared towards the purpose of the study would be sourced and used to increase the depth of knowledge.

Support and Training:

At COSTAATT, the Senior Lecturer/Qualified Nurse/Experienced Researcher, Mrs. Beryl Brewster was available every week to extend support, assistance and guidance in our endeavor of completing our research proposal. As inexperienced researchers we will seek assistance and support from the nurses and other health care workers of the St Ann Pyschiatric Hospital.

Budget

Project Expenses:- duration of the project Ten weeks

Research staff salaries (1320.00) x 3$39,600.00

Transportation:- To and from destinations (per team member) @ $300.00

Stationery:-

Pen

Pencils Eraser

Ruler

Notepads Computer Educational aids

Printing paper

Materials and Supplies:-

envelopes,

Postage

Stapler & staples

Other expenses:- Misc.

Consultant to review

Grand total

References

Paula Balls, P. B. (2009). Phenomenology in nursing research: methodology, interviewing and transcribing. nursing times , 105:21.

Vicki A. Keough, P. R.-B. (2011). Survey Research: An Effective Design for Conducting Nursing Research. Journal of Nursing Regulation , 37-44. Patton, M. Q. (1990). Qualitative Evaluation and Research Methods ( 2nd ed.). Newbury Park, CA: Sage Schwandt, T. A. (2000). Three epistemological stances for qualitative inquiry: Interpretivism,

hermenutics, and social construction. In N. K. Denzin & Y. S. Lincoln, (Eds). Handbook

of qualitative research, p. 189- 213. Thousand Oaks, CA: Sage Smith, David Woodruff, "Phenomenology",The Stanford Encyclopedia of Philosophy (Fall 2011

Edition), Edward N. Zalta(ed.), URL =

.. Polit D.F. & Beck C.T. (2010) Essentials of Nursing Research: Appraising Evidence for

Nursing Practice, 7th edn. Wolters Kluwer Health / Lippincott Williams& Wilkins, Philadelphia. rhttp://www.tcd.ie/Library/support/subjects/nursing-midwifery/assets/General%20Research%20Proposal_1.pdf Parahoo K. (2006) Nursing Research: Principles, Process and Issues, 2nd edn.

Palgrave Macmillan, Houndsmill. Lee P. (2005) The process of gate keeping in health care research. Nursing Times

101 (32), 36. Reid.k, F. a. (2005). Exploring lived experience: An introduction to Interpretative Phenomenological Analysis. The Psychologist, , 18:1, 20-23. Joyce. A. (2008). Medication Compliance and Persistence:. www.ispor.org , volume 11 issue 1.

American Psychiatric Association. (2006). Evidenced Based Treatments for Schizophrenia: information for families and other Supporters. Arlington: VA: American Psychiatric Association.

Barbato, A. (2011). Shizoprenia and public health. Geneva: world health organization.

ADHERENCE TO LONG-TERM THERAPIES: EVIDENCE FOR ACTION. (n.d.). WHO. Retrieved March 17, 2014, from http://www.who.int/chp/knowledge/publications/adherence_report/en/

Llorca, P. (2008). Partial compliance in schizophrenia and the impact on patient outcomes. Psychiatry Research, 161(2), 235-247.

Result Filters. (n.d.). National Center for Biotechnology Information. Retrieved March 17, 2014, from http://www.ncbi.nlm.nih.gov/pubmed/18284273

Svestka, j., & Bitter, I. (2007). Nonadherence to antipsychotic treatment in patients with schizophrenic disorders. PubMed, 28, 95-116. Retrieved March 17, 2014, from the pubmed database.

environment. (n.d.). The Free Dictionary. Retrieved March 17, 2014, from http://www.thefreedictionary.com/environmentAppendix 1

CURRICULUM VITAE OF RESEARCHERSSafiya Mohammed

#68 Sugar Road. Princes Town

Tel #: 768-8425

Email: safiyamohd786@outlook.comAge: 23 yearsEducation:

College of Science, Technology and Applied Arts of Trinidad and Tobago- COSTAATT 2009 - Present

St Kevin College. 2000 2002 Ste Madeleine Secondary School

Jordan Hill Presbyterian Primary School 1990-1995

Qualifications:

BSc Nursing 2009 - Present

Certificate of Achievement :Geriatric Adolescent Partnership Programme Caribbean Examinations Council Secondary Education Certificate: English A, Mathematics, Human and Social Biology, Principles of Business, Geography, Social Studies, History, LiteratureWork experience:

Student Nurse 2009 present

Princes Town Regional Corporation (Clerk) Trinidad Industrial Frabic Filters (Clerk)Research experience:

Classes in preparation for research project: Libs 150 Introduction to Research, Statistics, Epidemiology, Nursing Informatics, Nursing Science, Nursing Communication.

Guidance was also given by Mrs. Beryl Brewster, Senior Lecturer at COSTAATT and Researcher.

Cristal DennerSummary of QualificationsMathematics 3

English 3

Social Studies 3 Principles of Business 2Work ExperienceSenior CashierFebruary 2007 to March 2008Super Pharm - Gulf View, La Romaiin Mainly cashing dutiesBalance draw at end of salesHelp re - shelf merchandise in storeApprentice Customs ClerkDecember 2006 to March 2007General Marketers - Marabella, san Fernando Clearance of ship spheres off the port Preparation of customs documentgetting the customs documents approvedApprentice Customs Clerk/ Shipping ManagerJanuary 2005 to March 2006Brokerage Solutions Ltd - Aranguez, San Juan clearance of items on the portsshipping items to clients in the CARICOM Preparation of customs documentgetting the customs documents approvedSales ClerkDecember 2003After Nine Clothing Store - Gulf View, La Romaine Restocking Clothes after saleSales to customer

Ensuring the store is Cleaned and ready for next day

#12 Everglade Avenue, Maloney Gardens, D'Abadie, Arima 868 Home: nil - Cell: 472 - -6836 : cristalcthomas@gmail.comPrinciples of Accounts 3 Agricultural Science 2

Home Management 2 Food and Nutrition 3

Specialized Training

Bachelor of Science : Psychiatric Nursing, 2014COSTAATT - Eldorado, Tacarigua, TrinidadCurrently pursuing full time and i am currently in my final yearResearch experience:

Classes in preparation for research project: Libs 150 Introduction to Research, Statistics, Epidemiology, Nursing Informatics, Nursing Science, Nursing Communication.

Guidance was also given by Mrs. Beryl Brewster, Senior Lecturer at COSTAATT and Researcher.

Josanne JulienProfessional Summary

Morne Coco Road , Maraval, Port of Spain 868 Home: 629-6711 - Cell: 377-8884 / 4644531 : josannejulien@yahoo.co.ukI consider myself to be proficient at flexing and bending with change, practiced in resolving customer concerns in a professional and calm manner, and balancing customer's needs with company demands. Therefore I believe that I will be an asset to your business if given the chance.LicensesMy CXC passes include:English A II English B IIHuman and social biology B Office procedure II Principals of accounts III Principal of business III Mathematics III

Skill Highlightsi am dependablei am a fast learner

i give attention to detail i am easy going

Professional ExperienceSelf Employed ( Food Catering)January 2003 to August 2009Part Time Patient Care AssisstantJanuary 2009 to November 2011

Effective team playerSuperior communication skills Cheerful and energetic Flexible schedulingEffective team playerEducation and Training

Bachelor of Science : General Nursing, 2014COSTAATT - Eldorado, Tacuarigua, TrinidadAdditional InformationI will be begin my final year as a student at this collage in January 2014 to become a registered nurse. The goal of this collage is to transform one student at a time, and I can say without a doubt, that I have been transformed for the better because I have prove to myself that I could do anything that I put my mind too.Research experience:

Classes in preparation for research project: Libs 150 Introduction to Research, Statistics, Epidemiology, Nursing Informatics, Nursing Science, Nursing Communication.

Guidance was also given by Mrs. Beryl Brewster, Senior Lecturer at COSTAATT and Researcher.

Appendix 2Treatment Non-Adherence Assessment Tool A. Patient Perspective:

1. Do you feel you have a mental illness? Yes No

2. What symptoms do you experience?

3. Do you believe you require medications? Yes No

4. Have you taken medications in the past? If so, which ones and for how long?

5. Do you feel these medications helped manage your symptoms? Yes No

6. Have you ever taken medications that caused problems for you, such as, making you experience strange movements, sleepiness, weight gain, sexual problems, blurred vision, or other problems? Yes No (Have patient explain, if yes.)

7. Did your mental health provider explain the reasons for taking medications and what he/she expected the medications to do for you? Yes No

8. Are you willing to start medications, continue current medications, or try different medication(s)? Start Continue Current Try Different

9. Have you ever discontinued your medications by yourself, or just allow yourself to run out of medication(s)? If so, why?

10. Have you ever skipped doses of your medication(s)? Yes No

11. Have you ever been given a prescription that you decided not to fill? Yes No

12. Have you ever decided to use drugs or alcohol instead of taking your medication(s)? Yes No

13. Do you often forget to take your medication(s)? Yes No

14. Do you ever feel like you are being forced to take medications against your will? Yes No

15. Do you ever say you are taking your medications to please your provider? Yes No

16. Have you ever purposefully discontinued taking your medication because you were no longer in the hospital? Yes No

B. Family, Friends, Significant Other Perspective:

1. Do you feel the patient understands the need for his/her medications(s)? Yes No

2. Do you have to monitor the patient to ensure he/she takes the medications?

3. Yes No

4. Do you have to go to the pharmacy with the patient to fill his/her medication to make sure it gets done? Yes No

5. Do you feel current medications are helping the patient, making him/her worse, or having no effect? Helping Worsening No Effect

6. Is the patient willing or unwilling to keep appointments with his mental health provider? Willing Unwilling

7. Have you noticed, or has the patient verbalized to you any significant adverse effects he/she has experienced since being prescribed the medication(s)? Yes No

8. Do you know if this patients diet contains adequate nutritional content, specifically adequate protein? Yes No

Appendix 3

Criteria for the Diagnosis of Schizophrenia (DSM-IV-TR, 2000, p.312). A. Characteristic Symptoms: Two (or more) of the following, each present for a

Significant portion of time during a one-month period (or less if successfully treated):

(1) delusions

(2) hallucinations

(3) disorganized speech (e.g. frequent derailment or incoherence)

(4) grossly disorganized or catatonic behavior

(5) negative symptoms (affective flattening, alogia, or avolition).f

Note: Only one criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the persons behavior or thoughts, or two or more voices conversing with each other.

B. Social/Occupational Dysfunction: For a significant portion of the time since the

Onset of the disturbance, one or more major areas of functioning such as work,

Interpersonal relations, or self-care are markedly below the level of achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement).

C. Duration: Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least one month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms, or two or more symptoms listed in Criterion A present in an unattenuated form (e.g., odd beliefs, unusual perceptual experiences).

D. Schizoaffective and Mood Disorder Exclusion: Schizoaffective Disorder and Mood Disorder with Psychotic Features have been ruled out because either (1) no Major Depressive, Manic, or Mixed Features have occurred concurrently with active-phase symptoms; or (2) if mood episodes have occurred during active-phase and residual periods.