What do patients with psychotic and mood disorders know about their illness and medication ?

In patients with a bipolar disorder, psychoeducation has been shown to enhance adherence to treatment. Training in identifying early manic symptoms helps to improve outcomes and decreases the number of manic relapses. 2-6 A small study involving 57

We considered subjects to know their diagnoses even if they did not know the exact names of the diagnoses but knew which clinical phenomena they had been treated for.The diagnoses were categorised in three groups: bipolar disorders; depressive disorders; and psychotic disorders.The medications were grouped as: classic antipsychotic; novel antipsychotic; mood stabiliser; antidepressant (and class of antidepressant); sedative hypnotic; beta-blocker; anticholinergic; and other.

Demographic profile
There were 98 participants of whom 56 (57%) were white, 39 (40%) black, 2 (2%) Indian, and 1 (1%) coloured.There were 50 (51%) males and 48 (49%) females.Two patients declined to take part in the study.The ages of participants ranged from 19 to 78 years, with a standard deviation (SD) of 12 years and a median of 40 years.Fifteen participants had only primary level education and 10 had tertiary level education, with the balance having secondary level education; none of the subjects was illiterate.

Statistical analysis
The Department of Information Technology at the University of Pretoria assisted in the data processing and statistical analysis.
Fisher's exact test and the chi-square test were used for categorical data and variables.

Results
The duration of the subjects' treatment ranged from 6 months to 50 years.The average duration of treatment was 9.3 years, with a SD of 9.2 years.The diagnostic groups were as follows: psychotic disorders: 49 (50%), bipolar disorders: 22 (22%), and depressive disorders: 27 (26%).
All the subjects had poor knowledge of drug side-effects.Twentyeight subjects (29%) knew only the side-effects that they had experienced.Nineteen subjects (19%) gave adequate answers to all study questions except for knowledge of side-effects.They knew their diagnoses, the meaning of their diagnoses, their drug treatment and the purposes of the drugs.Twenty-four (25%) subjects answered all study questions inadequately; they knew neither their diagnoses nor the indications for their treatment nor the names of their medications.The remaining 55 (56%) subjects knew or understood their diagnoses and treatment to some extent, as is summarised in Table I.

Knowledge of diagnosis
Subjects with a mood disorder were more likely to know their diagnosis than subjects with a psychotic disorder.There was a significant statistical association (p=0.

Knowledge of medication
The results indicate that the more drugs a subject was receiving, the less likely they were to know the names of the drugs and their purpose.There was a significant association (p=0.0263) between medication category and knowing the purpose of the medication.Subjects using antipsychotics were less likely to know what their medication was for than subjects in the other medication categories.The extent of the knowledge of subjects taking certain categories of medication of the names of the medication and the reasons for taking the medication is summarised in Table III.

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There is a significant statistical association between diagnostic group and knowing the name of the medication (p=0.0492),i.e. subjects with a mood disorder were more likely to know the name of their medication than subjects with a psychotic disorder.
There was a significant statistical association between diagnostic group and knowing what the medication was for (p=0.0083).
Subjects with a mood disorder were more likely to know what the medication was for, compared with subjects with a psychotic disorder.Table IV summarises the association between diagnostic group and knowledge of medication.

Discussion
Our study explored the knowledge and understanding that patients had of their diagnoses as well as of the therapeutic and side-effects of the drugs used in treating their disorder.As has been shown, only 19% overall could answer correctly all questions regarding their diagnosis and treatment as measured against information recorded in the clinical files, while as many as 24% did not answer any questions correctly.The remaining 56% had varying degrees of knowledge and understanding of their diagnoses and treatment.
As indicated in the results, subjects with a mood disorder were somewhat more likely to know the names of their diagnoses than those with a psychotic disorder (p=0.094).This finding is in keeping with that of Shergill et al. 9 Although we did not investigate the reasons for patients' not knowing and understanding their diagnosis and treatment, we can suggest a number of possibilities.Learning might have been compromised by the way in which the information was given; for example, use of difficult terminology, language problems, and cultural differences.Subjects themselves may have difficulty retaining information given to them during psychoeducation owing to, for example, various forms of psychopathology (e.g.concentration difficulties) and drug side-effects (e.g.impaired concentration, interference with memory formation).Lack of insight can also be a contributory factor; a patient may remember the name of the diagnosis but does not accept it and is unwilling articles The fact that some patients knew what they were being treated for without knowing the name of the diagnosis also needs explanation.
We offer the following possibilities: the unacceptability of certain diagnoses (e.g. of schizophrenia) may explain why patients with psychotic disorders knew what they were being treated for (e.g. for 'voices'), without having known (or having accepted) the term for the disorder.The other possibilities are the same as given in the previous paragraph.
We also suggest a reason why significantly more subjects (57%) knew the names of their medication than why they are taking it (40%): subjects were more often exposed to the name of the medication (seen on the dispensed drug containers, hearing their doctors and nurses mentioning the names of the medicines, being asked by others what medication they were on, etc.).
Knowing what the medication was for might very well have been adequately explained previously, but it was not repeated in the same way that the names of the drugs were repeated.Another possibility is that subjects might have taken medications under some form of pressure, without accepting the diagnosis or the need for the medication.

Conclusion
According to the findings of this study, there is considerable scope for improving the knowledge and understanding of our patients concerning their diagnoses and medication.[3][4][5][6][7][8] The fact that so many patients didn't know why they were taking medication is a plausible explanation for non-compliance and consequent relapse rates.It appears that patients with psychotic disorders, multiple diagnoses and who receive multiple drugs do need special psychoeducational attention.
In view of the limited scope of this study, it can only be viewed as a preliminary effort in this field.The exact reasons for deficiencies in patients' knowledge and understanding need further study in order to ascertain what can and should be done to improve the situation.We could not find literature that addresses this issue, but it remains the responsibility of the multidisciplinary team to inform patients about their diagnosis and treatment in a clear, understandable and persistent manner, whenever indicated.

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August 2008 -SAJP that the diagnosis had been made; the number of co-morbid Axis I disorders; the class of prescribed medication for the mental illness; age; race; and gender.The number of subjects who were approached and those who declined to participate were also noted.The subjects were interviewed in a semi-structured way by asking them the following questions: • Do you know your diagnosis?• Do you know what it means?• Do you know what medication you are on?• Do you know what the medication is for?• Do you know what the side-effects of the medications are?
094) between diagnosis of a psychotic disorder and diagnosis of a mood disorder, and knowing the diagnosis.There was no significant statistical association (p=0.12) between diagnostic group and knowing what the diagnosis meant.The knowledge that subjects had of their diagnoses and what their diagnoses meant, per diagnostic groups, is summarised in Table II.To evaluate whether having more than one co-morbid Axis I diagnosis influenced the extent of subjects' knowledge, we recorded the number of Axis I diagnoses that subjects had.Seventy-seven (79%) subjects had only 1 diagnosis; of these, 44 (45%) knew the diagnosis while 39 (40%) knew what they were being treated for.Twenty-one (21%) subjects had >1 diagnosis.One (1%) subject knew all the diagnoses and their meanings.Eleven (11%) knew 1 diagnosis, and 10 (10%) knew the meaning of the diagnosis.Nine (9%) knew no diagnosis; 11 (11%) did not know what they were being treated for.

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If our proposed reasons are correct, we suggest the following measures to try to improve patients' inadequate knowledge and understanding of their diagnosis.Informing patients about their diagnosis and what it means should not be a once-off event; it should be repeated during the course of hospital stay and during outpatient follow-up.As part of such ongoing education, there could be visits during which patients are tested on their knowledge and understanding of the diagnosis and treatment, e.g. by asking patients what their diagnoses are; what they understand the diagnoses to mean; the course of their mental illness; what medication they receive; what the medication is for; and possible side-effects of the medication.The main limitation of the study was that the investigators accepted the diagnoses in the clinical files as correct.Review or confirmation of diagnoses was beyond the scope of the study.Another possible limitation was that the degree to which patients understood their diagnosis and treatment was based on the judgement of the first two authors.On the other hand, both authors were senior registrars in psychiatry at the time of the study, and both had at least 4 years' experience in working with psychiatric patients at the time of the study.The absence of more detailed demographic data including participants' home language and cultural background is another limitation.This information might have complemented the postulated reasons for lack of knowledge.

Table II . Diagnostic group and knowledge of diagnosis
articles Volume 14 No. 3 August 2008 -SAJP to give that diagnosis as an answer.Last but not least, some patients simply may not be interested in knowing more about their diagnosis and treatment.Therefore, they may neither feel a need to attend to information they are given nor try to remember it.

Table IV . Diagnostic group and knowledge of medication
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