http://e-journal.unair.ac.id/JNERS | 457 Jurnal Ners Vol. 15, No. 2, Special Issue 2020 http://dx.doi.org/10.20473/jn.v15i2.20361 This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License Original Research Family Support is the Key to Compliance with the Treatment of Relapsing Schizophrenia Patients Betie Febriana, Wigyo Susanto, Dwi Heppy Rochmawati, and Wahyu Endang Setiawati Faculty of Nursing, Sultan Agung Islamic University, Semarang, Indonesia ABSTRACT Introduction: One problem in treating schizophrenia patients is relapse. The previous study results state that the biggest factor causing relapse is non-compliance with taking medication. This non-compliance with taking medication is influenced by several factors, including patient sociodemography, drug side effects, and family support. The purpose of this study was to determine the factors associated with medication adherence in Schizophrenia patients who were undergoing rehospitalization in an inpatient installation at RSJD in one city in Central Java, Indonesia. Methods: This study is a descriptive correlational analytic study with a cross-sectional approach. The population in this study were Schizophrenia patients who were undergoing re-hospital in the inpatient installation. Thirty-six samples were taken with the consecutive sampling method. The research instruments used were a socio-demographic questionnaire, family support questionnaire, Medication Adherence Rating Scale (MARS), and Glasgow Antipsychotic Side-effect Scale (GASS). Data analysis using descriptive analysis and chi-square test. Results: There is a relationship between family support for relapse in schizophrenia patients (p = 0.023). Conclusion: Researchers suggest that the hospital improves the treatment of family motivation to provide good support to patients to reduce the rate of re-hospitalization. ARTICLE HISTORY Received: Feb 27, 2020 Accepted: April 1, 2020 KEYWORDS medication adherence; re- hospitalization; schizophrenia CONTACT Wigyo Susanto  orangjiwa@gmail.com  Faculty of Nursing, Sultan Agung Islamic University, Semarang, Indonesia Cite this as: Febriana, B., Susanto, W., Rochmawati, D, H., & Setiawati, W, E. (2020). Family Support is the Key to Compliance with the Treatment of Relapsing Schizophrenia Patients. Jurnal Ners, Special Issues, 457-461. doi: http://dx.doi.org/10.20473/jn.v15i2.20361 INTRODUCTION Schizophrenia disorder is a type of mental disorder that results in psychotic behavior, concrete thinking, and difficulties in processing information, interpersonal relationships, and problem-solving (Stuart, 2014). Nearly 1% of the world's population suffers from schizophrenia, which persists throughout their lives (Riba et al., 2005). According to the American Psychiatric Association (APA), schizophrenia can affect anyone by showing that about 75% of people with schizophrenia aged 16 to 25 years have been diagnosed as a schizophrenic disorder (Riba et al., 2005). Schizophrenia affects more than 21 million people in the world (WHO, 2016)and affects 1.7 million people in Indonesia (Kementrian Kesehatan RI, 2018). Relapse of people with schizophrenia is a re- emergence of symptoms of mental disorders that were previously and improved; usually, people with Schizophrenia will have difficulty in learning, difficulty meeting the needs of life, and will experience a loss of productivity (WHO, n.d.). In patients with schizophrenia, non-compliance with treatment is considered a major factor of relapse and is a common event-driven by various factors (Jeong & Lee, 2013). Based on a study, the prevalence of relapse in people with schizophrenia disorders is in the range of 50-92% globally (WHO, 2016). In Korea, The number of patients diagnosed with first-episode schizophrenia over 2 years was 4567, of which 1265 (27.7%) (Lee et al., 2018). Through naturalistic studies found a cumulative relapse rate in five years ranging from 70-80%. Studies in Hong https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:orangjiwa@gmail.com http://dx.doi.org/10.20473/jn.v15i2.203 B. FEBRIANA ET AL. 458 | pISSN: 1858-3598  eISSN: 2502-5791 Kong found that out of 93 psychosis patients, relapse rates were 21%, 33%, and 40% in the first, second, and third years (Christy, 2011). In Indonesia, the average relapse of people with schizophrenia in two years is 1.48 times (Fadli & Mitra, n.d.). Jalil revealed, based on the results of his research at Dr. Sardjito Yogyakarta in 2003, the relapse rate of people with mental disorders reached 25% in the first year, 70% in the second year, even 100% in the third year (Jalil, 2006). From various literature found that the factors that influence patient relapse are disobedience to treatment (Hui et al., 2015; Kazadi et al., 2008; Porcelli et al., 2016; Sariah et al., 2014); poor family support (Sariah et al., 2014); life stress (Rohan et al., 2015) (Sariah et al., 2014), occupation (Chabungbam et al., 2007), and religion (Sariah et al., 2014) (Hui et al., 2015); duration of illness and the presence of chronic illness (Alphs et al., 2016); psychiatric disorders comorbid additives (Kazadi et al., 2008); patient and family psychoeducation (Chabungbam et al., 2007; Porcelli et al., 2016). A survey from the World Federation of Mental Health, which stated that of 982 families with mental disorders, 51% of people with mental disorders had a relapse due to stop taking medication and 49% of patients had a relapse due to changing their own medication dose (World Federation Of Mental Health, 2008). Predictors of relapse in schizophrenia patients in Indonesia are caused by: (1). Lack of family knowledge in treating schizophrenia patients (Pratama et al., 2015; Ryandini et al., 2011). (2). Expression of family emotions / excessive/unfavorable attitude (Ryandini et al., 2011) (3). Lack of patients undergoing treatment / taking antipsychotic drugs (Pratama et al., 2015; Ryandini et al., 2011) . (5). Lack of family support (Christiawati, 2012; Pratama et al., 2015) 8). Lack of patient religious activity (Pratama et al., 2015) (9). Financial factors(Christiawati, 2012). Identification of factors that influence relapse is important for developing preventive modalities. This study limits itself to socio demographic factors, and family support to find out what factors are associated with relapse in schizophrenia patients. MATERIALS AND METHODS This research used a correlational descriptive- analytic study with a cross-sectional approach. The population in this study was Schizophrenia patients who were undergoing re-hospital in the inpatient installation of Central Java Province RSJD, Indonesia. Sampling using consecutive sampling techniques, to get a total sample of 36 samples, each of which was given 5 packages of research questionnaires. The research instruments used were a sociodemographic questionnaire, family support questionnaire, Medication Adherence Rating Scale (MARS), and Glasgow Antipsychotic Side-effect Scale (GASS). Data analysis using descriptive analysis and chi-square test. RESULTS Based on table 1, there are two genders of the respondents, 19 respondents were male (52.8%), and 17 respondents were female (47.2%). Most respondents were aged 41-60 years (middle adulthood), as many as 17 respondents (47.2%), and respondents who were at least aged> 60 years (elderly) as much as one respondent (2.8%). Most respondents have secondary education, which is 20 respondents (54.1%), and one respondent (2.8%) who do not go to school. Respondents who have income above the regional minimum wage are three respondents (8.3%), and respondents who have income below the regional minimum wage are 33 respondents (91.7%). Respondents who have twice medical treatment were 16 respondents (44.4%), and respondents who have more than two times medical treatment were 20 respondents (55.6%). Respondents who paid using insurance were 35 respondents (97.2%), and respondents who paid without using insurance/general were one respondent (2.8%). Most antipsychotics used by respondents were risperidone, which is 21 users (56.8%). The least antipsychotics used by respondents were haloperidol, only one user (8.1%). DISCUSSION There are two factors related to adherence, namely family support and gender, in terms of demographics. It is understandable if family support becomes a determining factor for medication adherence; This finding is in line with several previous studies that family support is important to prevent relapse (Christiawati, 2012; Sariah et al., 2014) (Pratama et al., 2015) (Chabungbam et al., 2007; Porcelli et al., 2016). Family attitudes can affect patient comfort both physically and mentally (Habibi et al., 2015) and this support can improve the quality of life of patients (Eack M, 2007). Family support seems to be a circle that, if good, will be good for the patient, but if it is bad, it will be bad for the patient (Nadeem, 2013; Sharif et al., 2012). This happens because the family burden is also heavy in treating patients. Family knowledge, emotions, economic level, determine family support provided. The lower family knowledge causes the frequency of relapse of schizophrenic patients to increase after being controlled by variables of attitude, support, family emotional expression (Habibi et al., 2015; Zahnia & Sumekar, n.d.). The knowledge that needs to be possessed by the family includes an understanding of mental disorders suffered by the client/schizophrenia, causes, medication administration, medication dosage, and side effects of treatment, symptoms of relapse, and attitudes that need to be demonstrated and avoided while caring for clients at home. Educational needs related to patient care are a major factor in family support as a source of long- term care for schizophrenic patients (Khankeh et al., JURNAL NERS http://e-journal.unair.ac.id/JNERS | 459 2011; Yildirim, 2014), (Chakrabarti, 2011; Panayiotopoulos et al., 2013).Another study by Simanullang, stated that significant family support consisted of instrumental, informational support, emotional support and appraisal (Simanullang, 2018). Schizophrenic patients who live in a family environment with highly expressed emotion or negative affective style significantly experience relapse more often than those who live in a family environment with low emotional expression (low expressed emotion) or normal affective style (Sadock & Sadock, 2010). If the family shows emotions that are overexpressed, for example, the client is often restrained by excessive rules, the possibility of relapse will increase (Goddess). Family support also influences the meaning of life in schizophrenia (Stuart, 2014). After being hospitalized, they can make sense of their present life and are very dependent on their responsibilities according to the status of the sufferer. Although in conditions that have not fully recovered from the symptoms of schizophrenia, when remembering the responsibilities according to the status carried, the patient still has the desire to make himself more meaningful than before. Therefore, the family has a big role in directing to the meaning of life that is more meaningful. If this fails, then the chances of relapse become large. A family caring for a schizophrenic must be someone who is physically, mentally and economically capable. A study conducted Dewi,The needs of schizophrenics are very high compared to Table 1. The distribution of frequency sociodemography of patient (n=36) Variable Amount n % Gender Male 19 52.8 Female 17 47.2 Age 15-21 years old (adolescent) 2 5.6 22-40 years old (early adulthood) 16 44.4 41-60 years old (middle adulthood) 17 47.2 > 60 years old (elderly) 1 2.8 Edcuation No school 1 2.8 Elementary 12 33.3 Secondary 21 58.3 Higher education 2 5.6 Income per-month > Regional Minimum Wage 3 8.3 < Regional Minimum Wage 33 91.7 Hospitalization Frequency 2 times 16 44.4 3 times 16 44.4 4 times 1 2.8 5 times 1 2.8 6 times 1 2.8 7 times 1 2.8 Payment Method Using health insurance 35 97.2 Non-insurance/public 1 2.8 Antipsychotics Risperidon (Atypical) 20 54.1 Chlorpromazine (Typical) 10 27.0 Haloperidol (Typical) 1 2.8 Olanzapine (Atypical) 2 5.6 Klozapine (Atypical) 3 8.3 Table 2. Family support related to medication adherence for Schizophrenia patients (n = 36) Variable Medication Adherence P Value Adhere Non-adhere n % n % Family Support Support 7 19.4 24 66.7 0.023 No-support 4 11.1 1 2.8 B. FEBRIANA ET AL. 460 | pISSN: 1858-3598  eISSN: 2502-5791 normal non-sufferers (Dewi et al., 2013). Finance, information about conditions and treatment, physical health is the need for sufferers. Found a similarity in the assessment of high physical needs for both schizophrenics and family members who care. Some things related to the need for proper family support are educational needs related to interpersonal and family relationships, adaptive and problem-solving skills (Khankeh et al., 2011; Sharif et al., 2012), [37] Establish therapeutic relationships and interact with patients (Khankeh et al., 2011; Sharif et al., 2012), (Chakrabarti, 2011; Panayiotopoulos et al., 2013) Social support and family education programs (Koujalgi & Shobhadevi, 2013). 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