Schizophrenia is a chronic, disabling psychiatric disorder that affects thought, perception, emotion, and behaviour, with an estimated global prevalence of about 1% (1). It remains one of the leading contributors to disability-adjusted life years (DALYs) among psychiatric illnesses due to its early onset, chronic course, and impact on social and occupational functioning (2). Antipsychotic medications are the primary treatment modality for controlling psychotic symptoms; however, poor medication adherence is one of the most critical challenges in long-term management, with studies reporting nonadherence rates ranging from 40% to 60% (3,4).

Poor adherence is strongly associated with relapse, re-hospitalisation, violence, homelessness, suicide risk, reduced quality of life, and increased caregiver burden (5). Multiple domains influence adherence in schizophrenia, and the interaction between these determinants often varies by sociocultural context. Sociodemographic factors such as gender, education, employment, and socioeconomic status have shown inconsistent associations with adherence, with several studies demonstrating limited predictive value (6,7).

Clinical factors, particularly duration of illness, symptom severity, and age of onset, contribute variably, whereas poor insight into illness and need for treatment consistently emerges as a key predictor of nonadherence (8). Additionally, medication-related side effects—including extrapyramidal symptoms, weight gain, sexual dysfunction, and sedation—are widely recognised barriers to adherence (9).

Psychosocial and cultural factors play an especially important role in countries like India. Stigma—both internalised and perceived—can significantly reduce adherence, influence illness disclosure, and delay treatment-seeking behaviour (10). Moreover, explanatory models and beliefs about causation, including supernatural explanations, fate, or psychosocial stress, shape attitudes toward psychiatric treatment and may affect adherence patterns (11,12).

Substance use disorders, particularly alcohol and cannabis, frequently co-occur with schizophrenia and are well-established determinants of poor adherence, relapse, and functional decline (13,14).

Despite substantial international evidence, Indian studies addressing the combined influence of sociodemographic variables, cultural beliefs, stigma, and substance use on medication adherence in schizophrenia are limited. There is a need for local data to better understand how these factors operate within the Indian sociocultural and healthcare context.

Therefore, the present study was undertaken to systematically examine factors associated with medication adherence, including sociodemographic characteristics, beliefs about causation, stigma, and substance use, among schizophrenia patients attending a tertiary-care psychiatric hospital. Identifying these determinants is essential for developing targeted, culturally appropriate interventions to improve long-term adherence and clinical outcomes.

MATERIALS AND METHODS

Study Design: This study was designed as a cross-sectional, hospital-based observational study. Each participant was assessed during a single clinical encounter to evaluate medication adherence and its relationship with insight, symptom severity, and antipsychotic side effects.

Study Setting: The study was conducted at the Institute of Mental Health & Hospital (IMHH), Agra, a postgraduate teaching and tertiary referral centre for psychiatric disorders. The hospital has a bed capacity of more than 800, catering to a wide catchment area.

Sample Size: A total of 60 patients diagnosed with schizophrenia were included in the study.

Sampling Method: A purposive sampling technique was employed. Participants were recruited from the follow-up outpatient department (OPD). Eligible individuals were those receiving antipsychotic treatment for at least one year.

Eligibility Criteria;

Inclusion Criteria

• Diagnosis of Schizophrenia according to ICD-10 DCR criteria.
• On prescribed antipsychotic medication for ≥1 year.
• Age between 18 and 55 years.
• Either sex with a minimum education of 8th standard.
• Ability and willingness to provide written informed consent.

Exclusion Criteria

• Refusal or inability to provide written informed consent.
• Presence of long-standing major medical illness or psychiatric disorder other than schizophrenia.
• Age below 18 years or above 55 years.

Study Tools and Instruments

1. Socio-Demographic and Clinical Data Sheet

A structured proforma was used to collect demographic information and clinical details, including:

• duration of illness and treatment
• current antipsychotic medication and dosage
• treatment cost
• distance from treatment centre
• substance use history: type, quantity, and pattern of intake

2. Medication Adherence Rating Scale (MARS)

The 10-item MARS was used to assess medication adherence.

• Items 1–4 (from MAQ): scored no = 1, yes = 0
• Items from DAI:
• Q6, Q9, Q10: no = 1, yes = 0
• Q5, Q7, Q8: no = 0, yes = 1

A higher total score indicated better adherence, whereas lower scores reflected poorer adherence.

3. Belief of Causation of Mental Illness Questionnaire

A 19-item questionnaire assessing patients’ beliefs regarding the causes of their illness. Responses were categorised for attributional analysis.

4. Stigma Scale

A 28-item, 5-point Likert scale measuring perceived stigma. It consists of three components:

• discrimination
• disclosure concerns
• perceived positive aspects of mental illness

The scale has demonstrated acceptable reliability (test-retest kappa = 0.4).

5. Michigan Alcohol Screening Test (MAST)

A 24-item scale used to screen for alcohol abuse.

A score >5 is considered indicative of alcoholism.

6. Cannabis Abuse Screening Test (CAST)

A brief tool used to detect problematic patterns of cannabis use, particularly in adolescents and young adults.

Ethical Considerations

Written informed consent was obtained from all participants. Confidentiality of patient information was strictly maintained. Approval from the institutional ethics committee was obtained before the commencement of the study.

 RESULTS AND OBSERVATIONS

Table 1: Socio-demographic Profile of the Sample (Schizophrenia, n = 60)

Table 2: Mean, SD, and t-values of Stigma Scores in Poor Adherence and Good Adherence Groups

Table 3: Mean, S.D., and t-values of Belief of Causation in Poor Adherence and Good Adherence Groups

Table 4: Mean, S.D., and t-values of MAST and CAST Scores in Poor and Good Adherence Groups

Table 5: Comparison of Socio-Economic Status and Medication Adherence

Table 6: Comparison of Occupation and Medication Adherence

Table: 7 Comparison of Sociodemographic Variables with Medication Adherence

DISCUSSION

In the present study, several sociodemographic, clinical, psychosocial, and substance-use-related variables were examined to determine their association with medication adherence among patients with schizophrenia. The findings provide important insights into the complex interplay of factors influencing adherence in a tertiary-care setting in India.

A key finding of this study was the absence of statistically significant associations between most sociodemographic variables—including age, gender, marital status, socioeconomic status, and occupation—and medication adherence. These results are consistent with several previous studies that report weak or inconsistent relationships between basic demographic characteristics and adherence behaviour in schizophrenia (15,16). The predominance of low socioeconomic status in the sample (93.3%) may have also limited variation, reducing the likelihood of detecting associations.

Regarding stigma, the study revealed that patients with good adherence scored significantly higher on the “positive aspects of mental illness” dimension, while scores on discrimination and disclosure concerns did not differ significantly between adherence groups. The presence of higher positive attributes in the adherent group suggests that patients who perceive some positive meaning, acceptance, or adaptive coping mechanisms related to their illness may be better motivated to continue treatment. This finding aligns with previous reports that positive illness perceptions and reduced internalised stigma enhance treatment engagement (17,18). However, the non-significant differences in the discrimination and disclosure domains contrast with some earlier studies emphasizing stigma as a major barrier to adherence (19). The discrepancy may reflect cultural differences or greater familiarity with schizophrenia within the study community.

Beliefs about causation showed no statistically significant differences between the poor and good adherence groups across all domains—including heredity, brain dysfunction, psychosocial stress, personality defects, supernatural causes, and fate/God’s will. These findings suggest that explanatory models alone may not directly determine adherence, especially when patients are already linked to long-term psychiatric treatment. Previous research also indicates that although cultural and supernatural beliefs influence help-seeking behaviour, their direct impact on adherence may diminish over time as patients enter sustained biomedical care (20,21).

One of the most important observations of the study was the significantly higher MAST (alcohol use) scores in the poor adherence group, indicating a strong association between alcohol-related problems and nonadherence. This finding is consistent with robust evidence showing that substance use—particularly alcohol—worsens adherence, increases relapse rates, and interferes with treatment continuity in schizophrenia (22,23). In contrast, CAST (cannabis) scores did not differ significantly, which may be due to low overall cannabis use in the sample, reflecting local sociocultural patterns.

Clinical variables such as duration of illness and age of onset did not differ significantly between adherence groups. These findings are comparable to some Indian and international studies where clinical chronicity does not consistently predict adherence (24). However, other studies report conflicting results, suggesting that illness duration may influence adherence differently across populations (25). The lack of association in the present study may be attributed to similar treatment histories across participants, as all had been receiving antipsychotic therapy for at least one year.

Overall, the findings reinforce the understanding that treatment adherence in schizophrenia is multidimensional, influenced more by psychological, behavioural, and substance-use factors than by purely demographic variables. The significant relationship between alcohol use and nonadherence highlights the need for integrated dual-diagnosis interventions, while the role of positive illness perceptions suggests potential benefits of psychoeducation and cognitive restructuring aimed at improving attitudes toward illness and treatment.

The absence of associations with explanatory beliefs and most sociodemographic variables indicates that adherence-enhancing interventions should focus more on modifiable behavioural and clinical factors rather than static demographic characteristics. These insights are of particular relevance for Indian settings, where cultural beliefs, stigma, and socioeconomic challenges are traditionally viewed as major barriers. The findings suggest that once patients are connected to treatment services, other dynamic influences—especially substance use and illness attitudes—play a more central role.

CONCLUSION

This study shows that treatment adherence in schizophrenia is shaped by multiple factors, including insight, stigma, cultural beliefs, side effects, and substance use. Poor adherence was strongly associated with higher internalised stigma and alcohol misuse, while better adherence correlated with more positive attitudes toward medication. These findings emphasise the need for individualised, culturally informed strategies—such as psychoeducation, stigma reduction, side-effect management, and substance-use interventions—to improve adherence and clinical outcomes in patients with schizophrenia.

REFERENCES

1. McGrath J, Saha S, Chant D, Welham J. Schizophrenia: A concise overview of incidence, prevalence, and mortality. Epidemiologic Reviews. 2008;30(1):67–76.
2. GBD 2019 Mental Disorders Collaborators. Global burden of mental disorders: 2019 results. The Lancet Psychiatry. 2022;9(2):137–150.
3. Lacro JP, Dunn LB, Dolder CR, Leckband SG, Jeste DV. Prevalence of and risk factors for medication nonadherence in patients with schizophrenia: A systematic review. Journal of Clinical Psychiatry. 2002;63(10):892–909.
4. Kreyenbuhl J, Record EJ, Himelhoch S, Charlotte M, Webber S, Brown CH, Dixon LB. Adherence to antipsychotic medications in schizophrenia: Measures, predictors, and interventions. Psychiatric Services. 2010;61(6):586–594.
5. Robinson D, Woerner MG, Alvir JMJ, Bilder R, Goldman R, Geisler S, et al. Predictors of relapse following response from a first episode of schizophrenia. American Journal of Psychiatry. 1999;156(4):544–550.
6. Velligan DI, Weiden PJ, Sajatovic M, Scott J, Carpenter D, Ross R, Docherty JP. Strategies for addressing adherence problems in patients with serious and persistent mental illness: Recommendations from the expert consensus guidelines. Psychiatric Services. 2009;60(4):421–427.
7. Osterberg L, Blaschke T. Adherence to medication. New England Journal of Medicine. 2005;353(5):487–497.
8. Lincoln TM, Lüllmann E, Rief W. Correlates and long-term consequences of poor insight in patients with schizophrenia: A systematic review. Schizophrenia Bulletin. 2007;33(6):1324–1342.
9. Day JC, Wood G, Dewey M, Bentall RP. A self-rating scale for measuring patients’ beliefs about antipsychotic medication: Reliability and validity. Journal of Nervous and Mental Disease. 2005;193(3):197–199.
10. Thornicroft G, Brohan E, Kassam A, Lewis-Holmes E. Reducing stigma and discrimination: Candidate interventions. Schizophrenia Bulletin. 2009;35(5):848–857.
11. Raguram R, Weiss MG, Channabasavanna SM, Devins GM. Stigma, explanatory models and illness experience of patients with schizophrenia in South India. 1996;312(7044):933–936.
12. Avasthi A. Preserve and strengthen family as a resource in psychiatric care. Indian Journal of Psychiatry. 2011;53(4):393–406.
13. Drake RE, Mueser KT. Psychosocial approaches to dual diagnosis. Psychiatric Services. 2000;51(4):468–476.
14. Swartz MS, Wagner HR, Swanson JW, Stroup TS, McEvoy JP, Canive JM, et al. Substance use and psychosocial functioning in schizophrenia. Schizophrenia Research. 1998;30(1):141–150.
15. Sendt KV, Tracy DK, Bhattacharyya S. A systematic review of factors influencing adherence to antipsychotic medication in schizophrenia. Schizophrenia Research. 2015;168(1–2):501–509.
16. Russell JM, Simons E, Taylor J, Stewart R. Sociodemographic and clinical predictors of medication adherence in schizophrenia. Community Mental Health Journal. 2017;53(7):842–848.
17. Fung KM, Tsang HW, Corrigan PW. Self-stigma of people with schizophrenia as predictor of their adherence to psychosocial treatment. Psychiatry Research. 2008;158(2):319–327.
18. Lysaker PH, Roe D, Yanos PT. Toward understanding the insight–adherence relationship in schizophrenia: Illness perceptions as a possible mediator. Journal of Nervous and Mental Disease. 2007;195(8):676–679.
19. Corrigan PW, Watson AC. Understanding the impact of stigma on people with mental illness. World Psychiatry. 2002;1(1):16–20.
20. Kar N, Singh SP. Culture and psychiatric disorders: Commentary on explanatory models of schizophrenia among patients in India. Indian Journal of Psychiatry. 2015;57(4):452–456.
21. Jain S, Jadhav S. Pills that swallow policy: Clinical ethnography of psychosis, pharmaceutical adherence and anthropology in Mumbai, India. Culture, Medicine and Psychiatry. 2009;33(3):449–478.
22. Margolese HC, Malchy L, Negrete JC, Tempier R, Gill K. Drug and alcohol use among patients with schizophrenia and related psychoses: Levels and consequences. Journal of Clinical Psychopharmacology. 2004;24(4):347–353.
23. Hunt GE, Siegfried N, Morley K, Sitharthan T, Cleary M. Psychosocial interventions for people with both severe mental illness and substance misuse. Acta Psychiatrica Scandinavica. 2018;138(6):485–501.
24. Jonsdottir H, Opjordsmoen S, Birkenaes AB, Engh JA, Ringen PA, Vaskinn A, et al. Predictors of medication adherence in patients with schizophrenia and bipolar disorder. Nordic Journal of Psychiatry. 2013;67(5):297–303.
25. Novick D, Haro JM, Suarez D, Pérez V, Dittmann RW, Haddad PM. Predictors and clinical consequences of non-adherence with antipsychotic medication in the outpatient treatment of schizophrenia. Results from the European Schizophrenia Outpatient Health Outcomes (SOHO) study. Journal of Clinical Psychiatry. 2010;71(3):239–247.