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.