Despite the effectiveness of psychotropic treatment in alleviating symptoms of psychiatric disorders, youth adherence to psychotropic medication regimens is low. Adherence rates range from 10-80% in the adolescent literature (Swanson, 2003; Cromer & Tarnowski, 1989; Lloyd, Horan, Borgaro, Stokes, Pogge, & Harvey, 1998; Brown, Borden, & Clingerman, 1985; Sleator, 1985).
Non-adherence is strongly associated with symptom relapse in adults with mental illnesses. Non-adherent patients are 3.7 times more likely to relapse than patients who take psychotropic medications as prescribed (Fenton, Blyler, & Heinssen, 1997), experience persistent psychiatric symptoms, (Fortney, Rost, Zhan, & Pyne, 2001), and require multiple hospitalizations (Weiden & Olfson, 1995; Weiden & Glazer, 1997). Most concerning are findings that premature discontinuation of lithium was related to completed suicide in adults (Muller-Oerlinghausen, Muser-Causemann, & Volk, 1992), which have implications for unsupervised discontinuation of medication.
Youth outcome data present an equally sobering picture. Youth with bipolar disorder experience fewer inter-episode remissions than adults (Birmaher, Axelson, & Strober, 2006), a protracted illness course, and poor social development (Geller, Tillman, Craney, & Bolhofner, 2004). Youth with co-morbid conduct disorder and depression are at increased risk of poor academic and social outcomes (Ingoldsby, Kohl, McMahon, & Lengua, 2006). These youth face increased potential for substance abuse, legal problems, suicide attempts, and completed suicide (see review by Birmaher & Axelson (2006).
Certain mental illnesses, such as oppositional defiant disorder and substance abuse, are linked with non-adherence (Bernstein, Anderson, Hektner, & Realmuto, 2000; Lloyd, Horan, Borgaro, Stokes, Pogge, & Harvey, 1998). Co-morbidity studies have outlined populations in which adherence may be especially problematic or in which response to pharmacological intervention may depend upon patient-specific factors (Christian, Pagano, Demeter, McNamara, Lingler, Bedoya, Faber, & Findling, 2008). Other research links medication formulation, dosage, or side effect profiles to non-adherence (Sleator, Ullman, & von Neumann, 1982; Efron, Jarman, & Barker, 1998; Brown, Borden, and Clingerman, 1985).
While these studies have provided valuable information regarding diagnostic factors and attributes of medication that are linked with non-adherence, it is likely that adherence is a more complex construct that is also affected by internal cognitive processes. Ajzen and Fishbein (1980) suggest that three mechanisms predict individuals' health-related behavior: 1) individual attitudes toward the behavior, 2) perception of social norms regarding the behavior, and 3) the intention to perform the behavior. Behavior is determined partly by whether an individual values the health-related behavior and its consequences. While there is extensive documentation of youth non-adherence to psychotropic treatment, little is known about youth attitudes toward psychiatric medications. Youth adherence studies would benefit from a measure designed to characterize these attitudes.
The Drug Attitude Inventory (DAI) was created to measure attitudes toward medications in adults (Hogan, Awad & Eastwood, 1983). It predicted adherence in schizophrenia and depression studies (Hogan, Awad & Eastwood, 1983; Gervin, Browne, Garavan, Roe, Larkin & O'Callaghan, 1999; Rossi, Arduini, Stratta & Pallanti, 2000; Kampman, Lehtinen, Lassila, Leinonen, Poutanen & Koivisto, 2000; Sajatovic, Rosch, Sivec, Sultana, Smith & Alamir, et al., 2002; Pae, Lee, Kim, Lee, Bahk, Lee & Lee, et al., 2003; Brook, van Hout, Nieuwenhuyse & Heerdink, 2003), and has been used as a validation standard for other scales (Jeste, Patterson, Palmer, Dolder, Goldman & Jeste, 2003; Chen, Tam, Wong, Law & Chiu, 2005).
The original DAI was validated in a sample of 150 outpatient adults diagnosed with schizophrenia and taking typical antipsychotic medications (Hogan, Awad & Eastwood, 1983); it discriminated 88% of the time between adherent and non-adherent patients. The DAI was the best predictor of medication adherence in hospitalized adults with schizophrenia (Donohoe, Owens, O'Donnell, Burke, Moore, & Tobin, et al., 2001). Patients taking atypicals had more positive attitudes toward medication than patients on typical antipsychotics (Ritsner, Perelroyzen, Ilan, & Gibel, 2004). “Pharmacophobic” patients were more likely to rate medications as disruptive to daily life (Sibitz, Katschnig, Goessler, Unger, & Amering, 2005).
No studies have been identified that have used the DAI in adolescent psychiatric populations. A review of empirical work with adolescents reveals only one study of adolescents' subjective experiences with psychotropics (Schimmelmann, Paulus, Schacht, Tilgner, Schulte-Markwort, and Lambert (2005). That study used Naber's (1995) Subjective Well-Being on Neuroleptics Scale, included only twenty inpatient adolescents, and did not examine adherence. The authors found that adolescents' ratings of subjective well-being were related negatively to side effects.
The present study was undertaken to evaluate the utility of the DAI for measuring medication attitudes and predicting adherence in an adolescent psychiatric population. The factor structure of the DAI was examined as well as whether DAI scores were associated significantly with adherence.