Although poor medication adherence complicates the treatment of schizophrenia at all illness stages, interventions to maximize adherence at illness outset may be particularly fruitful. Patients'initial perceptions about antipsychotics may influence long-term adherence, and early phase patients with any psychotic disorder pose an enormous challenge in treatment acceptance and adherence. Groups from around the world (e.g. Coldham et al. 2002;Novak-Grubic and Tavcar 2002;Robinson et al. 2002;Mutsatsa et al. 2003;Perkins et al. 2006;Kamali et al 2006) have reported substantial rates of medication nonadherence by patients with first episode schizophrenia. The consequences of nonadherence are profound. Maintenance treatment studies (Kane et al. 1982;Crow et al. 1986;McCreadie et al. 1989;Hogarty et al. 1998;Robinson et al. 1999;Gitlin et al. 2001;Wunderrink et al. 2007) have consistently shown maintenance antipsychotic treatment lowers relapse risk for patients with early phase schizophrenia. Studies that have followed subjects long term document a pattern of repeated relapses during the early illness course. Robinson and colleagues (1999) found that by 5 years of follow-up, 82% of subjects had experienced one relapse;78% of subjects who had recovered from their first relapse had a second relapse and 86% of subjects who recovered from their second relapse had a third relapse episode. Relapse risk was five times higher for patients who discontinued medication compared to those who continued medication. Although repeated relapses are detrimental to patients at all illness stages, they may have particular negative effects for early phase patients. Adolescence and early adulthood are a time when important developmental events such as finishing education, starting employment and establishing long-term relationships outside the family of origin are usually accomplished. Repeated relapses during this crucial period may disrupt successful completion of these tasks. Correlates of nonadherence in multi-episode patients include: more severe psychopathology, lack of insight, comorbid substance abuse, presence of medication side effects, an absence of social supports from family or friends, and practical barriers such as inability to afford medications. Despite the numerous studies of medication adherence in schizophrenia, information specifically about first episode patients is relatively limited. A number of factors suggest the need for separate study of recent onset patients. Due to their younger age, treatment decisions more often involve both patients and their families than is the case with multiepisode patients. Further, recent onset patients and their families lack experience with antipsychotics and with the chronic and relapsing course of schizophrenia. Their assessment of the benefits versus liabilities of antipsychotics may differ from those of multiepisode patients who have experienced the adverse consequences associated with repeated relapses.
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