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Table of Contents
RESEARCH ARTICLE
Year : 2020  |  Volume : 21  |  Issue : 1  |  Page : 70-75

Effectiveness of a structured teaching intervention regarding the management of side effects of antipsychotic drugs on the severity of side effects among in patients in a tertiary care hospital, South India


1 Assistant Professor, Christian Institute of Health Sciences and Research, Dimapur, Nagaland, India
2 Professor, College of Nursing, CMC, Vellore, Tamil Nadu, India

Date of Submission17-Jul-2019
Date of Decision01-Nov-2019
Date of Acceptance18-Dec-2019
Date of Web Publication14-Sep-2020

Correspondence Address:
Mrs. A O Nukshijungla
Christian Institute of Health Sciences and Research, PB 31, PO: ARTC, 4th Mile, Dimapur, Nagaland
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCN.IJCN_50_20

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  Abstract 

The discovery and use of antipsychotic drugs in the management of psychotic illness has become a boon for the patients as well as for the family members. However, unwanted but expected side-effects can have a detrimental impact on the consumers of such drugs. This study is aimed to assess the severity of side-effects of antipsychotic drugs and the effectiveness of a structured teaching intervention on patients' management of selected side-effects of antipsychotic drugs. A total of 40 patients were enrolled in the study. The results before the teaching intervention showed that there were patients who experienced 'low' to 'very high' side-effects of antipsychotic drugs, as measured by the standardised study tool, Liverpool University Neuroleptics Side Effects Rating Scale. There was a high reduction in the severity of the side-effects of antipsychotic drugs, and patients were experiencing only 'low' to 'moderate' side-effects after the structured teaching intervention Thus, the study findings suggest that health-care providers needs to continuously monitor the side-effects and provide relevant heath teaching to the patients so that there is high compliance to the treatment and thereby improving their quality of life.

Keywords: Antipsychotics, side-effects, structured teaching intervention


How to cite this article:
Nukshijungla A O, Charles HS. Effectiveness of a structured teaching intervention regarding the management of side effects of antipsychotic drugs on the severity of side effects among in patients in a tertiary care hospital, South India. Indian J Cont Nsg Edn 2020;21:70-5

How to cite this URL:
Nukshijungla A O, Charles HS. Effectiveness of a structured teaching intervention regarding the management of side effects of antipsychotic drugs on the severity of side effects among in patients in a tertiary care hospital, South India. Indian J Cont Nsg Edn [serial online] 2020 [cited 2020 Oct 23];21:70-5. Available from: https://www.ijcne.org/text.asp?2020/21/1/70/295047


  Introduction Top


An antipsychotic is a tranquilising psychiatric medication primarily used to manage psychosis, particularly in Schizophrenia and Bipolar disorder. The use of this drug has undoubtedly enabled many patients to resume life in the community who would formerly have required to be institutionalised. The antipsychotics are safe drugs, with a high therapeutic index and wide margins of safety in dosages. Despite this safety, a wide range of side-effects does occur with the use of antipsychotics even in therapeutic doses.[1]

Non-adherence to antipsychotic drug intake is common in people with Schizophrenia.[2] It has been suggested that the side-effects of antipsychotic medication may affect a person's biological, psychological, sexual and social functioning, which may be the major factors in noncompliance.[3] Quality of life was negatively associated with adverse reactions.[4] A study conducted on the assessment and management of antipsychotic-induced adverse events concluded that treatment-related side effects often require a reduction in dosage or a change in medication. Proper management can help encourage patients for compliance and improve the outcome of antipsychotic treatment.[5]

For those with chronic illness, the adverse effects of medication are important causes of morbidity and distress, which may not always receive due attention. To help the patient adjusts to a treatment regime of psychotropic medications, the nurse needs to know what the side-effects are, what characteristics they have, what to teach the patient, and how to intervene directly as these measures are very important for improving the quality of care provided to the patient.[6] Many side-effects of medications may go unnoticed because patients do not report them and staff do not ask about the problems patients experience.[7] It is thus clear that effective management of the side-effects of antipsychotic medication is a vitally important facet of quality nursing care, which has unfortunately been a neglected area of care.

Objectives

  • To assess the severity of side-effects of antipsychotic drugs before and after the structured teaching intervention
  • To assess the effectiveness of a structured teaching intervention regarding the management of selected side-effects of antipsychotic drugs on the severity of side effects
  • To determine the difference in the reduction of the severity of side-effects of antipsychotic drugs among selected socio-demographic and clinical variables.



  Methodology Top


A pre-experimental study design was adopted. The study was conducted among all the inpatients who were on antipsychotic drugs, in the Department of Psychiatry, at a tertiary hospital in South India. The sample size was calculated based on the pilot study findings. A total of 51 patients, who fulfilled the inclusion criteria, were screened and recruited for the study using a consecutive sampling technique. However, among 51 patients, 1 patient refused to participate in the study, and 10 of them got discharged before the post-test could be administered. Therefore, the total subject for the study was 40. The study was approved by the research and ethics committee of the institution. Written informed consent was obtained from the subjects who fulfilled the inclusion criteria. Liverpool University Neuroleptics Side Effects Rating Scale (LUNSERS) was used to collect data. The scale consists of 41 (+10) items that include psychological, neurological, autonomic, hormonal and other miscellaneous side-effects. Each 'side-effect' listed is scored on a five-point rating scale of 0–4, i.e., 0 = 'Not at all' and 4 = Very much. The overall scores give an overview of the person's experience to side effects in the last month. It has Cronbach's alpha value of 0.89 for internal consistency and a good reliability score (r = 0.81, P < 0.001).[8] The study was based on Donabedian's structure process outcome model of health.

Patients in the study took 20–30 min to fill the instrument. After the assessment for the severity of side-effects, a structured teaching on the management of selected side-effects of antipsychotic drugs was given using PowerPoint presentation, to groups comprising 4–5 patients in each session, on the same day of assessment. They were then reassessed for the severity of the side-effects of antipsychotic drugs, after a period of 6 days, using the same tool. Frequency distributions were used to describe demographic and clinical variables. Paired t-test was used to compare the severity of side-effects in regard to the pre- and post-scores. The Mann–Whitney U-test and Kruskal–Wallis test were used to determine the difference in reduction between two groups and three groups, respectively, with the level of statistical significance P < 0.05.


  Results Top


With reference to the socio-demographic variables majority of the participants in the study belonged to the age group of 18–30 years (60.0%), males (62.5%), had graduate-level educational qualifications (67.5%) and were unemployed (75%). Majority of the participants were also from a rural area (87.5%), were single (60%) and Hindus (75.%) [Table 1].
Table 1: Distribution of selected sociodemographic variables of the subjects (n=40)

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About half the proportion of participants in the study (47.5%) had body mass index (BMI) between 19 and 25 kg/m 2 and 72.5% presented with ideal abdominal circumference (where the ideal abdominal circumferences are 40 inches (102 cm) and 35 inches (88 cm) for men and women, respectively). Age of onset of illness for 45.0% was between 18 and 30 years and majority (67.5%) was diagnosed with Schizophrenia. Most of them (87.5%) were on one antipsychotic drug, 42.5% had a duration of medication between 1 and 5 years, 30.0% of the subjects' duration of illness was either between 1 and 5 years or >10 years. About 60.0% of them were hospitalized once and 65.0% had no family history of psychiatric illness. Participants who were on a total of two medications (where the medications consumed could be a combination of two antipsychotics alone and/or along with the other psychotropic medications) were 42.5% [Table 2].
Table 2: Distribution of selected clinical variables of the subjects (n=40)

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Pre-test assessment of the severity of side effects revealed that the majority (72.5%) had low severity, and only 2.5% had both high, as well as very high severity of side-effects of antipsychotic drugs.

In the post-test, 92.5% had low severity and 7.5% had medium severity of side effects of antipsychotic drugs and none had high or very high severity of side effects. The occurrence of the high as well as very high severity of side effects has come down towards the low and medium severity, indicating a reduction in the severity of side-effects of antipsychotic drugs after the structured teaching intervention [Figure 1].
Figure 1: Comparison of severity of side effects of antipsychotic drugs before and after the structured teaching intervention.

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There was a statistically significant (P < 0.001) reduction in side-effect severity scores in the post-test as reported by the participants [Table 3].
Table 3: Difference in mean scores of side-effects before and after teaching

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The reduction in the severity of side-effects of antipsychotic drugs was significant in relation to the age group, gender, educational status and marital status. More specifically, participants aged 30 years or younger showed a higher reduction in mean severity scores than those who were >30 years. Male gender had a greater reduction in the severity of side-effects than females. Below graduates had more reductions than graduates and above. In marital status, singles had more reduction than the married people [Table 4]. Statistically significant reduction in the severity of side-effects of antipsychotic drugs was seen in terms of the onset of diseases (P < 0.05).
Table 4: Difference in the reduction of the severity of side-effects of antipsychotic drugs among selected socio-demographic variables

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  Discussion Top


All participants in the study experienced some level of side-effects due to the intake of anti-psychotic drugs both before and after intervention. However, there was a shift in the severity levels experienced when the subjects were taught on how to manage the side effects.

This current study finding is supported by a study done by Pope et al.[9] for the assessment of adverse effects in clinical studies of antipsychotic medication. The study revealed that patients experience side effects due to antipsychotic medications. Both pre-test and post-test scores revealed a high proportion of subjects in the current study to have a minimal level of the severity of side-effects. This finding is contrary to the finding of an earlier study done by Rogers et al.[10] in regard to the findings of fewer patients with high and very high severity of side-effects. In their study, the majority (61.7%) of the patients reported to have had severe to very severe side effects of antipsychotic drugs, where the current study shows only 2.5% of the patients having experienced severe side-effects. The findings show that the choice of drugs has evolved over the years, and the use of atypical antipsychotics, by all the study patients, could be the reason for the difference in findings. Atypical antipsychotics have shown to be less burdensome in regard to the severity of at least a few specific side effects compared to typical antipsychotics.[11] The reason for only 2.5% of the population having very high severity of side effects, in this study, could be due to the patients using simple measures to reduce the side effects of the antipsychotic drugs. Those measures taken were drinking sips of water for dry mouth, taking fruits and drinking adequate water for constipation, doing regular exercises to reduce weight, especially of those patients who had BMI >25 kg/m 2 which is categorised under obesity. These measures were taken to reduce the severity of side effects of the psychotropic drugs. Those simple measures were said to be followed by the patients after they were educated by the nursing staff, for the management of the same. The investigator found out that some of the patients were on two simultaneous atypical antipsychotic drugs, along with other psychotropic medications such as mood stabilisers, antidepressants, antiparkinsonian and antianxiety drugs. These combinations or multi-drugs did not show a difference on the severity of side-effects of antipsychotic drugs.

The study finding showed that the high as well as very high severity of side-effects of antipsychotic drugs has come down toward the low and medium severity, after the structured teaching intervention. A statistically significant mean difference of −13.25, (post-scores – pre-scores) units in the severity of side effects of antipsychotic drugs was shown, which also indicates the reduction in the severity of side-effects of antipsychotic drugs (P < 0.000). The results suggest that teaching on the management of side-effects can reduce the severity of side effects experienced by the patients who are on antipsychotic drugs.

The current study findings are in harmony with a study conducted in Australia to enhance case managers' skills in the assessment and management of antipsychotic medication side-effects. Side-effects were assessed pre- and post-intervention using the current study tool, LUNSERS, to assess the reduction and overall prevalence of side-effects in both the groups. Only those patients in the intervention group reported a statistically significant reduction in mean side effect scores between the pre- and post-measures.[12] In addition, qualitative data collected during the second survey revealed that patients in the intervention group had acquired some positive management strategies for dealing with unwanted side-effects.[10]

In the current study, during the post-assessment, the subjects verbalised that the teachings given on the management of the side effects have been very helpful, as all of the measures, though simple, were easy to remember and practice. It was even brought out that since they now know what the common expected side effects are, they would practice the measures that were taught even before the occurrence of such symptoms of side-effects, as a preventive step, and will make a move to consult the health team if any untoward or unmanageable effects of the drugs are experienced. Some patients did not know that antipsychotic drugs could cause adverse effects such as sexual dysfunctions and symptoms of menstrual irregularity. This implies a further need for teaching and management of side effects of antipsychotic drugs. The findings for the effectiveness of the structured teaching intervention could have been affected by some confounding factors such as reduction of dosage of the antipsychotic drugs, previous teachings on the management of side-effects of psychotropic drugs, and/or the patient has been on antipsychotic drugs for longer duration and has been managing the same.

A statistically significant reduction in the severity of side-effects of antipsychotic drugs among the age group, gender, educational status, and marital status also are worth noting. Contrary to findings from a study that suggested an increase in risk for side-effects with an increase in age, the current study showed a higher reduction in the younger age group.[13] The selected clinical variables also showed a significant reduction in the severity of side-effects of antipsychotic drugs for the age of onset of those who were <30 years (P < 0.05).

The reason for this reduction among this group could be due to an early diagnosis of illness in young age and manifestations and experience of side-effects at a younger age. The investigator assumes that these factors could lead this group of people to be more anxious, careful, and alert, thus becoming more receptive to the treatment provided than among that group who were >30 years of age. This could imply the reduction in the severity of side effects.

The current study revealed more males reported side effects, which is supported by the study done by Bartlett et al.[13] stating that the risk of developing side-effects are lesser in females. The difference in the reduction of the severity of side-effects was also found more among the male gender when compared to the female gender. The higher proportion of males in the study could be one reason.

Contrary to the observation that participants who had a low level of education might not have been able to specifically identify and report side effects [14] in this study, those who had a lower level of education reported a significantly better reduction in the severity of side effects after the intervention. It may be suggested that the awareness about side-effects after the intervention pointed out earlier, could have helped them to identify the side-effects and follow instructions as given in the intervention. Similarly, the younger age group showed higher reduction suggesting that the compliance to management measures related to side effects might have been higher in this age group. These findings, however, need further exploration as knowledge of patients regarding side-effects was not assessed in this study. Alene et al.[15] conducted a study on adherence to medication for the treatment of psychosis. The study concluded that those individuals who never got married had a higher incidence of having side-effects than those who were married, and this finding was found similar to the current study, where the larger population experiencing side effects belonged to the unmarried group of people. The married group of people, when compared with the unmarried group for the difference in the reduction of severity of side-effects, significant reduction was found among the singles, than the married group (P < 0.05). The rationale for this current study finding could be due to the following of teachings, more by the single than the married group, as married individuals may have had additional responsibilities besides the management of the illness, adherence to the treatment, and maintenance of their optimum health, thereby hindering them to follow the teachings given.


  Conclusion Top


The result of the study highlights the presence of side-effects and the effectiveness of a structured teaching intervention on the side-effects. This indicates a need for regular assessment and management for various side-effects of antipsychotic drugs. It further affirms that the education given on the management of selected side-effects and practicing the same, had a great impact on reducing the severity of the selected side-effects of antipsychotic drugs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ahuja N, Vyas JN. Textbook of Postgraduate Psychiatry. 2nd ed. New Delhi: Jaypee Brothers; 1999.  Back to cited text no. 1
    
2.
McCann TV, Clark E, Lu S. Subjective side effects of antipsychotics and medication adherence in people with schizophrenia. J Adv Nurs 2009;65:534-43.  Back to cited text no. 2
    
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Yen CF, Cheng CP, Huang CF, Yen JY, Ko CH, Chen CS. Quality of life and its association with insight, adverse effects of medication and use of atypical antipsychotics in patients with bipolar disorder and schizophrenia in remission. Bipolar Disord 2008;10:617-24.  Back to cited text no. 4
    
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Cortese L, Pourcher-Bouchard E, Williams R. Assessment and management of antipsychotic-induced adverse events. Can J Psychiatry 1998;43 Suppl 1:15S-20S.  Back to cited text no. 5
    
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Pothier PC. Psychiatric Nursing. Boston: Little Brown and Company; 1980.  Back to cited text no. 6
    
7.
Mitchell JE, Popkin MK. Antipsychotic drug therapy and sexual dysfunction in men. Am J Psychiatry 1982;139:633-7.  Back to cited text no. 7
    
8.
Day JC, Wood G, Dewey M, Bentall RP. A self-rating scale for measuring neuroleptic side-effects. Validation in a group of schizophrenic patients. Br J Psychiatry 1995;166:650-3.  Back to cited text no. 8
    
9.
Pope A, Adams C, Paton C, Weaver T, Barnes TR. Assessment of adverse effects in clinical studies of antipsychotic medication: Survey of methods used. Br J Psychiatry 2010;197:67-72.  Back to cited text no. 9
    
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Rogers A, Pilgrim D, Lacey R. Experiencing Psychiatry: Users' Views of Services. London: Macmillan; 1993.  Back to cited text no. 10
    
11.
Willner K, Vasan S, Abdijadid S. Atypical Antipsychotic Agents; 2017. Available from: https://europepmc.org/article/NBK/NBK448156 #free-full-text. [Last accessed on 2019 Dec 15].  Back to cited text no. 11
    
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Morrison P, Meehan T, Gaskill D, Lunney P, Collings P. Enhancing case managers' skills in the assessment and management of antipsychotic medication side-effects. Aust N Z J Psychiatry 2000;34:814-21.  Back to cited text no. 12
    
13.
Bartlett C, Doyal L, Ebrahim S, Davey P, Bachmann M, Egger M, et al. The causes and effects of socio-demographic exclusions from clinical trials. Health Technol Assess 2005;9:iii-iv, ix-x, 1-152.  Back to cited text no. 13
    
14.
Wubeshet YS, Mohammed OS, Desse TA. Prevalence and management practice of first generation antipsychotics induced side effects among schizophrenic patients at amanuel mental specialized hospital, central Ethiopia: Cross-sectional study. BMC Psychiatry 2019;19:32.  Back to cited text no. 14
    
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Alene M, Wiese MD, Angamo MT, Bajorek BV, Yesuf EA, Wabe NT. Adherence to medication for the treatment of psychosis: Rates and risk factors in an Ethiopian population. BMC Clin Pharmacol 2012;12:10.  Back to cited text no. 15
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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