Discussion
This study is the first to evaluate psychiatric patients living in rural
areas in Jordan with regards to their perspectives of their illness,
adherence to treatment, barriers to adherence, and the role of the
pharmacist. Results revealed that less than half of the patients
reported complete control of their symptoms with treatment, and most of
them always/usually adhered to their treatment.
Religious and cultural perspectives were unveiled; as the majority of
patients (72.5%) believed that the psychiatric disorders are
never/slightly caused by a weakness of faith. Also, 69.2% of them dealt
positively with their illness as being counted for their favor in the
Hereafter; this positive outlook about their illness correlated
significantly with better adherence to drug therapy (p<0.046).
Barriers to adherence included mainly suffering from medication adverse
effects. Only 14% of patients reported that they refer to the
pharmacist to get information about their medications.
The study unveiled high rates of perceived public psychiatric disorder
stigma and self-stigma in patients who do seek medical help. This is
just one part of the more general picture since mental health stigma and
low mental health literacy were previously found to be the most powerful
barriers to seeking help (25). In this current study, anecdotal comments
provided by patients and their families present at the study clinic
indicate that many mental health patients in the rural areas in Jordan
do not come to the hospital to pick up their medications. Such behavior
cancels out any chance of being counseled and educated by the pharmacist
or even other healthcare professionals and delivery of evidence-based
therapy. This highlights the importance of socially destigmatizing these
disorders in rural areas, in which local pharmacists can play a crucial
role. Mental health education programs have been shown to positively
impact mental health literacy and stigmatizing attitudes and may be an
effective tool to use in rural areas (26).
In this study, most of the patients relied on the specialist to get
information regarding their mental illnesses and treatment. Similarly, a
previous study in Northern Jordan reported the same finding, as the
majority (68%) of patients referred to their specialists for
information about their treatment (27). Although pharmacists are the
experts in medication use; lack of mental health counselling skills
might be the cause behind this hindered role (28). To be able to provide
professional care to those patients, pharmacists should improve their
skills and reflect on their attitude and belief when assisting patients
in need (29, 30).
Unlike pharmacists at community pharmacies, who are highly
accessibl\soute, pharmacists in public hospitals of rural areas like
Jerash have weaker chances for counseling the patient, since medications
get dispensed through a window to patients or the patients’ relatives
who would usually be standing in line before receiving their medication,
presenting physical and time barrier prohibiting optimal pharmacist
care.
It has been acknowledged previously that the majority of Muslims depend
on their religious believes when it comes to coping with their mental
distresses (19-22). This fact was consolidated through a study conducted
in Jordan previously, which involved patients with mental disorders who
reported that religion is an important factor affecting their treatment
(31). In this study, 69% of the patients associated their mental
illness with their faith, considering it a source of good deeds.
In a previous study on psychiatric illnesses, the leading factors for
medication nonadherence were: “not willing to use medication”, “not
accepting the disease”, and “being disturbed by side effects” in the
bipolar disorder group, “not accepting the disease” in the
schizophrenia/schizoaffective disorder group, and “feeling well” in
the depression group (32). In our study, the main reason for reported
nonadherence was suffering from adverse effects, which signifies the
early involvement of the pharmacist in the management plan to recognize
and resolve these adverse effects in collaboration with the
psychiatrist.
Psychotherapy based interventions for mentally ill patients have been
shown to be effective for this group of patients (33-36). Most of the
patients in this study did not know about psychotherapy and reported
that they would have chosen it before medications if they had known
about it in the first place. Including psychotherapy in the management
of these patients, as an adjunct therapy with the pharmacological
treatment used, is important and can improve patient’s adherence to
treatment (34). It could be associated with less stigma barrier and
increase the patient courage to seek help.
One recommendation from our research is for the academic institutes in
Jordan to introduce the subspecialty of “psychiatric pharmacy”, in
which the pharmacist is provided with specialized knowledge, skills, and
training for working with patients with psychiatric or neurologic
disorders (37).
Limitations of the study include the fact that it was conducted in one
public hospital, which may not be representative of the situation in
other hospitals and psychiatric clinics in Jordan. This can limit the
generalizability of the study. Another barrier was shown thought the
anecdotal comments provided by many people present in the clinic at the
time of the study, indicating that a large number of patients do not
come to the clinic themselves to pick up their medications. Hence, the
present sample of patients does not cover those who do not attend the
clinic themselves to pick their medications and/or see the specialist.