Partial Compliance With Antipsychotic Medication is Common in Patients With Schizophrenia

Abstract

Objective: Partial compliance with antipsychotic medication increases relapse and rehospitalization rates in patients with schizophrenia. The aim of the present study was to assess the frequency of and factors contributing to partial compliance.

Method: During a 10 day period in June 2004 psychiatrists working in hospitals or in private practices in Germany were asked to participate in a compliance survey. Physicians were requested to evaluate the compliance in 10 patients with schizophrenia using a questionnaire consisting of 10 questions. The frequency of unintentional and intentional partial compliance as well as patient-related contributing factors were assessed. Unintentional partial compliance was defined as the lack of drug intake on any day during the past month. Demographic data of participants were collected. Responses were analysed using descriptive statistics and generalized estimation equation models.

Results: The psychiatrists (n=699) regarded 68% of the evaluated patients (n=5729) as unintentionally partially compliant within the last month. Sixty-nine per cent of the patients were considered intentionally partially compliant in the past. The most frequently assessed patient-related factors contributing to the partial compliance were lack of insight into the need for prophylactic medication (68%), lack of insight/denial of illness (66%/63%), feeling embarrassed at taking medication every day (62%), needing someone to remind them to take their medication (62%), cognitive problems (55%), and living conditions inappropriate for compliance (46%).

Conclusions: Partial compliance is a common problem in schizophrenia. Strategies to improve partial compliance derived from the contributing factors identified in the present study may include regular telephone reminders by case managers or families, adequate support in the patients’ environment, use of dosette boxes, rationalizing drug regimens (e.g. once-daily dosage, monotherapy, depot medication), and psychoeducation.

Keywords

Adherence compliance concordance partial compliance schizophrenia survey

The interest in the topics of compliance, adherence and concordance in mental health disorders, and especially in schizophrenia, has increased substantially during the last few years [1–10]. Focusing on these issues is overdue because non-compliance is a major problem in schizophrenia [11]. Patients who did not take antipsychotic medication for relapse prevention were shown to have much higher relapse rates compared to patients who took antipsychotics [12], [13]. In patients with a first episode of schizophrenia, relapse rates were fivefold higher for those who did not take antipsychotic medication [14].

The terms ‘compliance’, ‘adherence’ and ‘concordance’ are not used consistently in the literature; some authors use them synonymously whereas others define compliance as the extent to which a person complies with medication and adherence or concordance as a wider concept, including habits and attitudes towards therapeutic strategies [15], [16]. The use of the term ‘compliance’ has been criticized by some authors as inferring an authoritarian and paternalistic attitude, whereas the concept of concordance explicitly involves mutual respect and understanding between a patient and their treating physician as well as shared decision-making in order to achieve a cooperative therapeutic alliance [17]. But the term ‘compliance’ is still common and in use. Medication compliance has often been regarded as an all-or-nothing behaviour and until a few years ago patients were either viewed as compliant or non-compliant [18]. More recently the concept of ‘partial compliance’ has emerged, acknowledging the actual, frequent situation in which a person takes some, but not all of the prescribed medication [18], [19]. Weiden et al. therefore favour the term ‘partial compliance’ over non-compliance [18]. Compliance with medication is difficult to measure and is often defined differently [16], [20]. In a recent review of the literature Velligan et al. found that compliance is often assessed by subjective or indirect methods such as patient self-report, provider report, significant other report and chart view, whereas direct or objective methods such as pill count, blood or urine analysis, electronic monitoring and electronic refill records are used infrequently [16]. For a consensus development Velligan et al. suggested the term ‘medication refusers’, those who do not accept medication; and ‘medication acceptors’, divided by degrees of adherence (those who take medication but might have adherence problems in the future). The authors stress that this is very important because ‘complete refusal may begin as a function of missed or skipped doses, either intentional or accidental’. Patients who are partially compliant or adherent according to these concepts have an increased risk of hospitalization and higher costs than those who are compliant: partially compliant patients with schizophrenia or bipolar disorder were 49% more likely to be hospitalized and incurred 55% higher inpatient charges than compliant patients [19].

The aim of the present study was therefore to provide data on the frequency of partial compliance in patients with schizophrenia using the concept of Weiden et al. [18] and to identify patient-related factors contributing to partial compliance by using a large sample size.

Methods

During a 10 day period in June 2004, psychiatrists working in hospitals or in private practices in Germany were asked to participate in a compliance survey. The participating physicians were requested to anonymously evaluate the compliance in 10 consecutive patients with schizophrenia using a questionnaire consisting of 10 questions (questions A–J, possible answers were ‘yes’ or ‘no’; Table 1) and return it by fax. The term ‘compliance’ in the present study was defined as the extent to which a person complies with the prescribed medication.

Table 1.

Physician responses for 5729 patients

Questions	Yes n (%)
A. Do you suspect that your patient has forgotten to take the medication as prescribed on any day in the past month?	3892 (67.9)
B. Do you think that your patient has at any time decided to stop taking the medication (or taken too much) of their own accord?	3946 (68.9)
C. If one of the previous responses is yes, do you consider that your patient was incapable of noticing a deterioration in their state of health after the first days of omitting the treatment?	3768 (65.8)
D. Does your patient have, or have they at any time had, an irregular daily routine, and do they live or have they lived in circumstances (familial, environment etc.) that might affect proper daily compliance with their treatment?	2643 (46.1)
E. Do you suspect that your patient is taking or has recently taken alcohol or drugs?	1967 (34.3)
F. Do you think that your patient needs family, psychiatrists, etc. to remind them to take the medication in order for them to take it as prescribed?	3542 (61.8)
G. Does your patient show, or have they at any time shown, a lack of awareness of the illness?	3623 (63.2)
H. Does your patient suffer from problems of cognitive deterioration (impaired memory, disorganization etc.) that might affect daily compliance with their medication?	3143 (54.9)
I. Has your patient at any time felt embarrassed or upset at having to take tablets every day for their illness?	3556 (62.1)
J. When your patient felt better, did they at any time think that the medication was not necessary and stopped taking it?	3869 (67.5)

Question A assessed the frequency of partial compliance, defined as the lack of drug intake on any day during the past month; the physician was asked whether they suspected that the patient had unintentionally forgotten to take the prescribed medication on any day during the past month. Question B asked about the lifetime partial compliance and the intentional discontinuation of prescribed medication. Questions C–J were designed to evaluate the patient-related factors possibly contributing to the partial compliance: questions C and G related to lack of insight/denial of illness. Question J covered the insight into a need for prophylactic medication for relapse prevention. Problems with cognition and memory were measured with questions F and H. Question E asked about substance abuse; questions D and I covered living conditions and stigma.

Statistical analysis

Demographic data of the participating physicians were collected and responses were analysed using descriptive statistics, using SPSS for Windows, version 15.0 (SPSS, Chicago, IL, USA). Generalized estimation equation (GEE) models were used to estimate the proportion of ‘yes’ answers in the physician groups (hospital vs private practice psychiatrists). The GEE approach properly reflects the structure of repeated data and takes the correlation among patients with the same physician into consideration. The statistical software R version 2.4.1 (R Foundation for Statistical Computing, Vienna, Austria) with the GEE package was used, assuming an exchangeable correlation structure between subjects. Statistical comparisons were made at an overall level of significance of 0.05, applying Bonferroni adjustment of p for multiple comparisons.

Results

Demographic data of participating physicians

A total of 1300 psychiatrists had been asked to participate, 703 participated, and data for 699 psychiatrists were included in the analysis (participation rate 54%). A total of 396 (57%) worked in a psychiatric hospital, and 303 (43%) in private practice. Four hundred and thirty-three (62%) of the responding physicians were psychiatrists, 119 (17%) were at least in their third year of residency for psychiatry, 28 (4%) were first or second year Psychiatry residents and 119 (17%) did not specify their training.

Two hundred and seven participants did not complete the compliance assessment for 10 patients; data on the assessment of compliance are therefore available for 5729 patients with schizophrenia (Table 1).

Quantification of unintentional and intentional partial compliance

The physicians assessed that 68% of the patients had unintentional partial compliance during the last month (question A). Sixty-nine per cent of the patients were reported to have had an intentional lifetime partial compliance problem (question B).

Factors contributing to partial compliance

Of the patient-related factors possibly contributing to partial compliance, a lack of insight into the need for prophylactic medication (question J) was the most important problem (68%), followed by a lack of insight/denial of illness (66% question C, 63% question G). The psychiatrists reported that 62% of patients felt embarrassed at taking medication every day (question I) and 46% had living conditions inappropriate for compliance (question D). A total of 62% of patients needed someone to remind them to take their medication (question F). Cognitive problems were observed in 55% of the patients (question H). Substance abuse was assumed in 34% of the patients (question E).

Patients who were considered to be unintentionally partially compliant (question A) or intentionally partially compliant (question B) were statistically significantly more likely to fall in the ‘yes’ category of questions C–I than those who were considered to be compliant in questions A and B.

Differences in the assessments of hospital-based versus office-based psychiatrists

A GEE model was used to estimate the proportion of ‘yes’ answers in the two physician groups (hospital vs private practice psychiatrists) to examine whether the working situation of the physicians influenced the assessments. Psychiatrists working in a hospital chose the partially compliant/negative answers statistically significant more often in all questions except for question I, where no statistically significant difference was found (Figure 1; Table 2).

Figure 1.

Proportions of yes answers according to question and physician group with 95% confidence intervals

Table 2.

Patient assessment according to physician group

	Psychiatrists group 1: private practice			Psychiatrists group 2: hospital
Question	Proportion ‘yes’†	95%CI		Proportion ‘yes’†	95%CI		p
A	0.62	0.59	0.66	0.72	0.70	0.75	<0.001
B	0.56	0.53	0.60	0.63	0.60	0.66	0.032
C	0.51	0.47	0.55	0.59	0.57	0.62	0.004
D	0.40	0.37	0.44	0.55	0.52	0.59	<0.001
E	0.44	0.40	0.48	0.54	0.51	0.58	<0.001
F	0.41	0.37	0.45	0.53	0.50	0.56	<0.001
G	0.41	0.37	0.45	0.50	0.46	0.53	0.008
H	0.38	0.34	0.42	0.49	0.46	0.53	<0.001
I	0.41	0.37	0.45	0.47	0.43	0.50	0.248
J	0.40	0.36	0.44	0.51	0.48	0.55	<0.001

CI, confidence interval; †Estimated using generalized estimation equation model to adjust for correlation in the repeated questions per physician; p were adjusted (Bonferroni correction) for multiple comparisons.

Discussion

To our knowledge this is one of the largest surveys among psychiatrists to assess the partial medication compliance of their patients with schizophrenia [15], [21]: almost 700 psychiatrists assessed the compliance of >5700 patients with schizophrenia. According to their treating physicians, 68% of patients had had unintentional partial compliance problems in the last month and 69% had intentional partial compliance problems with their antipsychotic medication in the past. These large figures – more than two out of three patients had compliance problems – might appear high but they do not seem to represent an overestimation because physicians tend to overestimate the compliance of their own patients. A study comparing electronic monitoring and clinician rating showed that physicians dramatically underestimated non-compliance with antipsychotics [22]. Difficulties with medication compliance are considered to be one of the most important risk factors for relapse and rehospitalization among patients with schizophrenia and to cause approximately 40–50% of relapse [23–26]. Weiden et al. found a direct correlation between estimated partial compliance and hospitalization risk among patients with schizophrenia: medication gaps of only 1–10 contiguous days in a 1 year period were associated with a twofold increase in hospitalization risk, larger gaps (≥30 days) increased the likelihood of hospitalization by approximately fourfold [18]. In the present survey 69% of patients were considered to have unintentionally forgotten to take their medication as prescribed on any day during the previous month, thus showing partial compliance. When these results were extrapolated to a period of 1 year (as per the time frame in the Weiden et al. study), this 69% of patients were found to be associated with at least a twofold risk of hospitalization.

Interestingly, psychiatrists working in a hospital assessed their patients as having more compliance problems in all questions compared to the patients of psychiatrists working in private practice. These differences were statistically significant on all questions except for question I. Question I dealt with feeling embarrassed at taking medication every day, which would obviously affect inpatients and outpatients without a significant difference. A possible reason for the differences in the assessments of the patients in the other questions might be that the hospital physicians are confronted with readmissions due to relapses more often than psychiatrists in private practice. A further reason might be that patients who need to be hospitalized are generally more severely ill than outpatients in private practice.

What could be done to reduce the rehospitalization risk? Several strategies that consider the factors derived from questions C–I and possibly contribute to the partial compliance, appear promising to improve compliance.

First, telephone interventions, for example telephone reminders by case managers or families, can be helpful in assisting patients with mental disorders to regularly take their medication [27], given that the present survey showed that 62% of patients needed someone to remind them to take their medication. Second, ensuring that patients have adequate support in their environment, for example home-based cognitive adaptation training, and help for adequate living conditions, would be useful because 46% of the patients in the present survey had living conditions considered inappropriate for being compliant; therefore this intervention may contribute to improve medication adherence in schizophrenia [28]. Third, rationalizing drug regimens is a very important issue: once-daily dosage or monotherapy, whenever possible, and the use of so-called ‘dosette boxes’, where medication can be kept in daily order for 7 days so that the patient knows that they are taking the right amount at the right time, can counter several factors contributing to partial compliance that were found in the survey (environmental circumstances/living situation/cognitive problems) [29]. Another option for compliance improvement is the antipsychotic depot medication, which can also influence some of the patient factors that were found to possibly contribute to partial compliance: the need for someone to remind them to take the medication regularly, feeling embarrassed at taking medication every day, and cognitive problems [30]. Normally, long-acting agents must be administered approximately one to two times per month, thus making it unnecessary to think or be reminded of the medication every day [31], which can be helpful for those feeling embarrassed at taking medication every day – an issue markedly under-recognized by clinicians [32]. Long-acting agents allow the treating physician to identify immediately when a patient has missed a dose and can thus easily differentiate a compliance problem from an efficacy problem [29], [33], but psychiatrists are often reluctant to prescribe long-acting agents [33].

Heres et al. showed in a large survey among psychiatrists that fewer than 36% of the participants’ patients had ever been offered antipsychotic depot treatment [34]. A study by Patel et al. published in 2003 showed that the participating psychiatrists believed long-acting agents to be ‘less acceptable to patients’ (69%), ‘stigmatizing’ (48%) and ‘old fashioned’ (40%) [35]. Patients themselves, however, often do accept long-acting medication when offered by the treating physician [36] and show high satisfaction with such a treatment [37].

Fourth, psychosocial interventions, such as psychoeducation, were shown to reduce rehospitalizations. The lack of insight into the illness and into the need for prophylactic medication for relapse prevention, the factors most frequently reported in this survey as contributing to the partial medication compliance, can be positively influenced by psychoeducation [38–42]. The 7 year follow up of the Munich Psychosis-Information Study showed that patients who participated in psychoeducation had a mean number of hospital days spent in a psychiatric hospital of 75 compared to 225 days in the control group [43]. Because psychoeducation for schizophrenia is still not available in all hospitals [44], new strategies such as peer-to-peer psychoeducation [45–48] and integrating the entire treatment team into psychoeducation [42] are urgently needed.

There were three main limitations to the present survey. First, the questions focused on partial compliance rather than compliance, which might have increased the number of patients being considered partially compliant. However, as discussed, physicians tend to overestimate the compliance of their patients [22], [49]. We thus believe that our findings provide valuable real-life data on the frequency of partial compliance; the compliance studies by Giner et al. and Kim et al. found comparable, but somewhat lower, partial compliance figures of 61% and 57%, respectively [15], [21]. Second, the definition of partial compliance is very strict, namely: having forgotten the medication on any day within the last month. But, as the study by Weiden et al. showed, even short medication gaps of 1–10 continuous days in a 1 year period were associated with a twofold increase in hospitalization risk [18] and, given that Velligan et al. stressed that the complete refusal of medication may begin as a function of missed or skipped doses [16], it appears reasonable to define partial compliance in such a way. Third, not all participating psychiatrists assessed the compliance of 10 patients; therefore data are available on only 5729 patients, that is, 82% of all potentially possible patients. In order to include all available data we adjusted the calculations where necessary as mentioned in the methods section. Unfortunately missing or incomplete data are a common problem in most clinical studies, but in the present study there were no significant differences in incomplete data between the working situations of the psychiatrists.

In conclusion, the data suggest that more than two-thirds of patients with schizophrenia are partially compliant with their antipsychotic medication. Strategies to improve compliance are urgently needed.

Footnotes

Acknowledgements

This study was funded by Janssen-Cilag.

References

1. Byrne

Deane

Lambert

Coombs

. Enhancing medication adherence: clinician outcomes from the Medication Alliance training program. Aust N Z J Psychiatry 2004; 38: 246–253.

2. Puschner

Born

Giessler

Helm

Becker

Angermeyer

. [Effects of interventions to improve compliance with antipsychotic medication in people suffering from schizophrenia: results of recent reviews]. Psychiatr Prax 2005; 32: 62–67.

3. Ascher-Svanum

Zhu

Faries

Lacro

Dolder

. A prospective study of risk factors for nonadherence with antipsychotic medication in the treatment of schizophrenia. J Clin Psychiatry 2006; 67: 1114–1123.

4. Kikkert

Schene

Koeter

. Medication adherence in schizophrenia: exploring patients’, carers’ and professionals’ views. Schizophr Bull 2006; 32: 786–794.

5. Perkins

Johnson

Hamer

. Predictors of antipsychotic medication adherence in patients recovering from a first psychotic episode. Schizophr Res 2006; 83: 53–63.

6. Tsang

Fung

Corrigan

. Psychosocial treatment compliance scale for people with psychotic disorders. Aust N Z J Psychiatry 2006; 40: 561–569.

7. Cooper

Moisan

Gregoire

. Adherence to atypical antipsychotic treatment among newly treated patients: a population-based study in schizophrenia. J Clin Psychiatry 2007; 68: 818–825.

8. van Dulmen

Sluijs

van Dijk

de Ridder

Heerdink

Bensing

. Patient adherence to medical treatment: a review of reviews. BMC Health Serv Res 2007; 7: 55.

9. Marcus

Olfson

. Outpatient antipsychotic treatment and inpatient costs of schizophrenia. Schizophr Bull 2008; 34: 173–180.

10.

10. Woltmann

Valenstein

Welsh

. Using pharmacy data on partial adherence to inform clinical care of patients with serious mental illness. Psychiatr Serv 2007; 58: 864–867.

11.

11. Kissling

. Compliance, quality assurance and standards for relapse prevention in schizophrenia. Acta Psychiatr Scand Suppl 1994; 382: 16–24.

12.

12. Leucht

Barnes

Kissling

Engel

Correll

Kane

. Relapse prevention in schizophrenia with new-generation antipsychotics: a systematic review and exploratory meta-analysis of randomized, controlled trials. Am J Psychiatry 2003; 160: 1209–1222.

13.

13. Hogarty

Ulrich

. Temporal effects of drug and placebo in delaying relapse in schizophrenic outpatients. Arch Gen Psychiatry 1977; 34: 297–301.

14.

14. Robinson

Woerner

Alvir

Bilder

Hinrichsen

Lieberman

. Predictors of medication discontinuation by patients with first-episode schizophrenia and schizoaffective disorder. Schizophr Res 2002; 57: 209–219.

15.

15. Giner

Canas

Olivares

. [Treatment adherence in schizophrenia. A comparison between patient's, relative's and psychiatrist's opinions]. Acta Esp Psiquiatr 2006; 34: 386–392.

16.

16. Velligan

Lam

Glahn

. Defining and assessing adherence to oral antipsychotics: a review of the literature. Schizophr Bull 2006; 32: 724–742.

17.

17. Seale

Chaplin

Lelliott

Quirk

. Sharing decisions in consultations involving anti-psychotic medication: a qualitative study of psychiatrists’ experiences. Soc Sci Med 2006; 62: 2861–2873.

18.

18. Weiden

Kozma

Grogg

Locklear

. Partial compliance and risk of rehospitalization among California Medicaid patients with schizophrenia. Psychiatr Serv 2004; 55: 886–891.

19.

19. Eaddy

Grogg

Locklear

. Assessment of compliance with antipsychotic treatment and resource utilization in a Medicaid population. Clin Ther 2005; 27: 263–272.

20.

20. Day

Bentall

Roberts

. Attitudes toward antipsychotic medication: the impact of clinical variables and relationships with health professionals. Arch Gen Psychiatry 2005; 62: 717–724.

21.

21. Kim

Yoon

Choi

. Survey of medication adherence in patients with schizophrenia: Korean ADHES data. Hum Psychopharmacol 2006; 21: 533–537.

22.

22. Byerly

Fisher

Whatley

. A comparison of electronic monitoring vs. clinician rating of antipsychotic adherence in outpatients with schizophrenia. Psychiatry Res 2005; 133: 129–133.

23.

23. Schooler

. Relapse and rehospitalization: comparing oral and depot antipsychotics. J Clin Psychiatry 2003; 64(Suppl 16)14–17.

24.

24. Ayuso-Gutierrez

del Rio Vega

. Factors influencing relapse in the long-term course of schizophrenia. Schizophr Res 1997; 28: 199–206.

25.

25. Weiden

Glazer

. Assessment and treatment selection for “revolving door” inpatients with schizophrenia. Psychiatr Q 1997; 68: 377–392.

26.

26. Jeffreys

Harvey

McNaught

Quayle

King

Bird

. The Hampstead Schizophrenia Survey 1991. I: Prevalence and service use comparisons in an inner London health authority, 1986–1991. Br J Psychiatry 1997; 170: 301–306.

27.

27. Leach

Christensen

. A systematic review of telephone-based interventions for mental disorders. J Telemed Telecare 2006; 12: 122–129.

28.

28. Velligan

, Diamond

, Mintz

. The use of individually tailored environmental supports to improve medication adherence and outcomes in schizophrenia. Schizophr Bull 2007 Oct 10 [Epub ahead of print].

29.

29. Burton

. Strategies for improving adherence to second-generation antipsychotics in patients with schizophrenia by increasing ease of use. J Psychiatr Pract 2005; 11: 369–378.

30.

30. Kane

. Review of treatments that can ameliorate nonadherence in patients with schizophrenia. J Clin Psychiatry 2006; 67(Suppl 5)9–14.

31.

31. Lasser

Bossie

Gharabawi

Turner

. Patients with schizophrenia previously stabilized on conventional depot antipsychotics experience significant clinical improvements following treatment with long-acting risperidone. Eur Psychiatry 2004; 19: 219–225.

32.

32. Hui

Chen

Kan

Yip

Law

Chiu

. Detection of non-adherent behaviour in early psychosis. Aust N Z J Psychiatry 2006; 40: 446–451.

33.

33. Nasrallah

. The case for long-acting antipsychotic agents in the post-CATIE era. Acta Psychiatr Scand 2007; 115: 260–267.

34.

34. Heres

Hamann

Kissling

Leucht

. Attitudes of psychiatrists toward antipsychotic depot medication. J Clin Psychiatry 2006; 67: 1948–1953.

35.

35. Patel

Nikolaou

David

. Psychiatrists’ attitudes to maintenance medication for patients with schizophrenia. Psychol Med 2003; 33: 83–89.

36.

36. Pereira

Pinto

. A survey of the attitudes of chronic psychiatric patients living in the community toward their medication. Acta Psychiatr Scand 1997; 95: 464–468.

37.

37. Lindenmayer

Jarboe

Bossie

Zhu

Mehnert

Lasser

. Minimal injection site pain and high patient satisfaction during treatment with long-acting risperidone. Int Clin Psychopharmacol 2005; 20: 213–221.

38.

38. Pekkala

, Merinder

. Psychoeducation for schizophrenia. Cochrane Database Syst Rev 2002; (2): CD002831.

39.

39. Pitschel-Walz

Leucht

Bäuml

Kissling

Engel

. The effect of family interventions on relapse and rehospitalization in schizophrenia: a meta-analysis. Schizophr Bull 2001; 27: 73–92.

40.

40. Pitschel-Walz

Bäuml

Bender

Engel

Wagner

Kissling

. Psychoeducation and compliance in the treatment of schizophrenia: results of the Munich Psychosis Information Project Study. J Clin Psychiatry 2006; 67: 443–452.

41.

41. Olfson

Marcus

Wilk

West

. Awareness of illness and nonadherence to antipsychotic medications among persons with schizophrenia. Psychiatr Serv 2006; 57: 205–211.

42.

42. Rummel-Kluge

Pitschel-Walz

Kissling

. A fast, implementable psychoeducation program for schizophrenia. Psychiatr Serv 2007; 58: 1226.

43.

43. Bäuml

Pitschel-Walz

Volz

Engel

Kessling

. Psychoeducation in schizophrenia: 7-year follow-up concerning rehospitalization and days in hospital in the Munich Psychosis Information Project Study. J Clin Psychiatry 2007; 68: 854–861.

44.

44. Rummel-Kluge

Pitschel-Walz

Bäuml

Kissling

. Psychoeducation in schizophrenia: results of a survey of all psychiatric institutions in Germany, Austria, and Switzerland. Schizophr Bull 2006; 32: 765–775.

45.

45. Dixon

Stewart

Burland

Delahanty

Lucksted

Hoffman

. Pilot study of the effectiveness of the family-to-family education program. Psychiatr Serv 2001; 52: 965–967.

46.

46. Dixon

Lucksted

Stewart

. Outcomes of the peer-taught 12-week family-to-family education program for severe mental illness. Acta Psychiatr Scand 2004; 109: 207–215.

47.

47. Rummel

Pitschel-Walz

Kissling

. [Family members inform family members”: family members as group moderators for psychoeducational groups in schizophrenia]. Psychiatr Prax 2005; 32: 87–92.

48.

48. Rummel

Hansen

Helbig

Pitschel-Walz

Kissling

. Peer-to-peer psychoeducation in schizophrenia: a new approach. J Clin Psychiatry 2005; 66: 1580–1585.

49.

49. Byerly

Thompson

Carmody

. Validity of electronically monitored medication adherence and conventional adherence measures in schizophrenia. Psychiatr Serv 2007; 58: 844–847.