Mental health in scott and adams
ALTHOUGH THE REPORTED medication nonadherence rates for schizophrenia do not differ from those common in many other health problems [Fenton et al 1997], they are considered to be a serious problem resulting from the high levels of relapse and recidivism among patients who do not take their medication regularly [Adams and Scott 2000]. During recent years substantial efforts have thus been made to clarify the reasons for these patients’ noncompliance and to devise tools for its prediction [Fenton et al 1997 and Young et al 1999]. However, the reported risk of medication noncompliance in schizophrenia has not altered in recent years [Young et al 1999], and the designed predictive tools have as yet not been proven effective [Adams and Scott 2000]. Likewise, the broad range and the disparities between the causes suggested for noncompliance [Fenton et al 1997 and Pinikahana et al 2002] have only led to disputes over their explanatory potential and relative weight, thereby hindering the elaboration of an integrated approach to the issue [Adams and Scott 2000].
Underlying these disputes is the long-standing controversy between the perspective that associates schizophrenia with thought disorders, and the opposite view that considers patients as social actors who are self-conscious and rational (see [Palmer 2000]). This debate has not thus far promoted the understanding of the nonadherence issue because the former perspective places too much emphasis on the exceptionality of patients’ beliefs, whereas in the latter approach it is, to a great extent, overlooked. All the more so, the debate has diverted scholarly attention from a third approach, which analyzes the personal meaning that patients attribute to their illness experiences, thereby searching for the ordinary logic that underlies the unordinary content of their interpretations [Doubt 1994, Palmer 2000 and Sayre 2000]. Drawing on a study that has been based on this perspective, this article illustrates how it might contribute toward clarifying the causes for patients’ objection to medication and the factors predicting their proneness to such a response.
Studies of medication noncompliance in schizophrenia
The approach with the longest history in the study of medication nonadherence among people with schizophrenia attributes this response to their very psychopathology. Poor insight and hallucinations are among the main factors regarded as precluding their understanding of their condition and its treatment [Duncan and Rogers 1998 and Lysaker et al 1994]. Given this focus on patients’ cognitive deficits, it is not surprising that it downplays or even denies the importance of studying their own explanations for their nonadherence. Such an attitude to patients’ accounts has recently gained much popularity, following the accumulation of data suggesting that biologically determined processes produce their false beliefs [Doubt 1994, Lovell 1997 and Palmer 2000].
An approach diametrically opposite to the one discussed thus far claims, however, that the reasons why patients with schizophrenia object to their medication do not differ from those commonly found among other patients. These reasons include rational considerations, such as their wish to avoid adverse drug effects, to regulate their own medication, and to gain control over their own lives. Likewise, their medication nonadherence has been attributed to their skepticism about the treatment’s efficacy or their deliberate preference to cling to their delusions [Adams and Scott 2000, Diamond 1983, Kelly et al 1987 and Van Putten et al 1976]. Albeit reflecting modern treatments’ contribution toward diminishing differences between the conventional and the schizophrenic ways of thinking, by focusing solely on patients’ rational considerations, this approach overlooks the potential of their unordinary beliefs for influencing medication adherence. In this regard, [Fenton et al 1997] state, in their comprehensive review article on patients’ noncompliance, that “both inpatient drug refusal and outpatient noncompliance are consistently associated with more severe ratings of psychopathology” (p. 639). This implies that, rather than concentrating on patients’ ordinary motivations, efforts to reduce noncompliance should attend to the peculiarities of schizophrenic thinking.
Such an acknowledgment of the uniqueness of patients’ cognitive assessments characterizes a third approach, which is inspired by the anthropological view of meaning construction and by European psychiatric phenomenological descriptions of forms of “being-in-the-world.” This approach treats patients’ accounts as being lay theories that people normally develop for making sense of their condition (see [Calnan 1987 and Furnham 1988]). Unlike the first perspective discussed in this section, it presupposes that qualitative analyses of patients’ narratives illuminate the meaning of their responses from their own point of view and offer an opportunity for their accurate understanding. Yet, contrary to the second perspective’s emphasis on the conventionally logical content of patients’ accounts, it maintains that the common logic underlying the way they structure their experiences enables comprehension of their unconventional explanations [Corin 1990, Doubt 1994, Sayre 2000 and Wrobel 1990].
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