Risk Factors for Zolpidem Induced Sleep-Related Behavior in Inpatients / 정신신체의학

Objectives@#：Zolpidem is a common drug used in insomnia. However, there are several reports of side effects of the central nervous system or sleep related behavior in patients who took zolpidem. This study was conducted to investigate risk factors affecting sleep related behavior after taking zolpidem in inpatients. @*Methods@#：From January 1, 2019 to December 31, 2019, medical records of patients who took zolpidem hospitalized at Inha University Hospital were reviewed retrospectively. @*Results@#：907 patients who took Zolpidem, 102 (11.2%) showed sleep related behavior, and if they were 65years of age or older, men, taking antipsychotics, and taking antipsychotics and benzodiazepines at the same time, they were significantly more likely to show sleep related behavior. @*Conclusions@#：Risk factors for sleep-related behavior after use of zolpidem are estimated gender, elderly, antipsychotics, and combination of antipsychotics and benzodiazepines.

Significant Domains of Life Satisfaction That Affect Suicidal Behavior in Adolescents

Objectives@#Adolescent suicide is a serious national issue in Korea. Recently, life satisfaction has been recognized as a major factor related to this issue. The main purpose of this study was to identify the domains of life satisfaction that affect suicidal behavior in adolescence. @*Methods@#Data were collected from eight middle schools in Incheon, Korea. A total of 1297 students answered questions regarding their demographic characteristics, happiness, self-related life satisfaction domains (appearance, leisure time, physical health, and mental health), depressive symptoms, and suicidal behavior. @*Results@#In the Spearman correlation analysis, female sex, perceived socioeconomic status (SES), happiness, and all four self-related satisfaction scores showed significant correlations with depression and suicidality. Multivariate regression analysis suggested that suicidality was significantly affected by perceived SES, satisfaction with appearance, mental health satisfaction, and depression. Finally, depression was identified as a partial mediator of the association between mental health satisfaction and suicidality, and a complete mediator of the association between female sex and suicidality. @*Conclusion@#Perceived SES, satisfaction with appearance, and mental health satisfaction significantly affected students’ suicidality, with or without the effect of depression. Health authorities, educators, and family members must be aware of this to identify adolescents at suicide risk earlier.

Significant Domains of Life Satisfaction That Affect Suicidal Behavior in Adolescents

Objectives@#Adolescent suicide is a serious national issue in Korea. Recently, life satisfaction has been recognized as a major factor related to this issue. The main purpose of this study was to identify the domains of life satisfaction that affect suicidal behavior in adolescence. @*Methods@#Data were collected from eight middle schools in Incheon, Korea. A total of 1297 students answered questions regarding their demographic characteristics, happiness, self-related life satisfaction domains (appearance, leisure time, physical health, and mental health), depressive symptoms, and suicidal behavior. @*Results@#In the Spearman correlation analysis, female sex, perceived socioeconomic status (SES), happiness, and all four self-related satisfaction scores showed significant correlations with depression and suicidality. Multivariate regression analysis suggested that suicidality was significantly affected by perceived SES, satisfaction with appearance, mental health satisfaction, and depression. Finally, depression was identified as a partial mediator of the association between mental health satisfaction and suicidality, and a complete mediator of the association between female sex and suicidality. @*Conclusion@#Perceived SES, satisfaction with appearance, and mental health satisfaction significantly affected students’ suicidality, with or without the effect of depression. Health authorities, educators, and family members must be aware of this to identify adolescents at suicide risk earlier.

Association between Perceived Parenting Style and Adolescents’ Attitudes toward Suicide

Objectives@#Adolescent suicide, a major cause of adolescent death, is affected by various factors, including attitudes toward suicide.This study investigated the association between parenting style and adolescents’ attitudes toward suicide and the mediating role of attitude toward suicide between parenting style and suicidal ideation. @*Methods@#We surveyed 1,071 adolescents from eight middle schools in Incheon, Korea. The survey included sociodemographic information, attitudes toward suicide, perception of parenting style, depression severity, and suicidality. @*Results@#Students in the authoritarian parenting group had a more permissive attitude toward suicide compared with the democratic and permissive parenting groups. These students considered that suicide is justified in certain situations and that choosing suicide is an individual’s right. They also had a negative attitude toward talking about suicide or intervening in others’ suicide. This association remained statistically significant after adjusting for the impact of confounding factors that could affect attitudes toward suicide, except for suicidal processes and preparedness to prevent suicide. In the mediation analysis, we observed that some factors of the attitudes toward suicide mediated between authoritarian parenting attitudes and suicidal ideation, namely, suicide as a right, preventability, suicide as normal/common, preparedness to prevent suicide, and resignation. @*Conclusion@#This study revealed the significant impact of parenting style on children’s attitudes toward suicide. Educating parents about the appropriate parenting attitudes–sympathetic and rational–can help prevent youth suicide.

The Effect of Chronotype on Burnout among Shift and Non-Shift Workers:Mediation Effect of Depression and Stress Response Study

Objectives@#The purpose of the present study was to examine the relationship between the chronotype and the burnout, so we investigated the mediating effects of the mediators such as perceived stress, stress response, and depression. @*Methods@#Employees working at Incheon Customs conducted a mental health self-examination through the internet. Among them, 174 people who agreed to the mental health survey participated in the study. Participants completed questionnaires including Composite Scale of Morningness (CSM), Center for Epidemiological Studies-Depression Scale (CES-D), Perceived Stress Scale (PSS), Stress Response Inventory (SRI), Maslach Burnout Inventory-General Survey (MBI-GS). @*Results@#Our results showed a higher degree of CES-D, SRI, exhaustion, and cynicism in evening and intermediate type compared to morning type, and a higher degree of professional efficacy in morning type compared to intermediate type. CSM was shown to have a direct effect on exhaustion and indirect effect through CES-D and SRI. CSM also had a direct effect on professional efficacy and had an indirect effect through the CES-D. However, CSM was found to have only indirect effects through the SRI for Cynicism. @*Conclusions@#In this study, individuals with evening type tend to experience a high degree of burnout (exhaustion, cynicism and professional efficacy) through the mediation effect of depression and stress response. Further study is necessary to reveal the effect of management of the depression and stress response in the employee with evening type.

The Effect of Chronotype on Burnout among Shift and Non-Shift Workers:Mediation Effect of Depression and Stress Response Study

Objectives@#The purpose of the present study was to examine the relationship between the chronotype and the burnout, so we investigated the mediating effects of the mediators such as perceived stress, stress response, and depression. @*Methods@#Employees working at Incheon Customs conducted a mental health self-examination through the internet. Among them, 174 people who agreed to the mental health survey participated in the study. Participants completed questionnaires including Composite Scale of Morningness (CSM), Center for Epidemiological Studies-Depression Scale (CES-D), Perceived Stress Scale (PSS), Stress Response Inventory (SRI), Maslach Burnout Inventory-General Survey (MBI-GS). @*Results@#Our results showed a higher degree of CES-D, SRI, exhaustion, and cynicism in evening and intermediate type compared to morning type, and a higher degree of professional efficacy in morning type compared to intermediate type. CSM was shown to have a direct effect on exhaustion and indirect effect through CES-D and SRI. CSM also had a direct effect on professional efficacy and had an indirect effect through the CES-D. However, CSM was found to have only indirect effects through the SRI for Cynicism. @*Conclusions@#In this study, individuals with evening type tend to experience a high degree of burnout (exhaustion, cynicism and professional efficacy) through the mediation effect of depression and stress response. Further study is necessary to reveal the effect of management of the depression and stress response in the employee with evening type.

The Influence of Depression and School Life on the Quality of Life of Korean Child and Adolescent Patients with Attention-Deficit/Hyperactivity Disorder: A Comparison of the Perspectives of the Patients and Their Caregivers

OBJECTIVES: This study aimed to compare the quality of life reported by patients with attention-deficit/hyperactivity disorder (ADHD) to the patients' quality of life as reported by their caregivers. In addition, it aimed to examine how emotional problems, including depression and anxiety, and the severity of the symptoms affect the quality of life reported by the patients and their caregivers. METHODS: The patients' quality of life and their degree of depression and anxiety were measured using the Pediatric Quality of Life Inventory (PedsQL) 4.0 Child Self-Report, the Children's Depression Inventory (CDI), and the Revised Children's Manifest Anxiety Scale, respectively. The caregivers' perception of the patients' quality of life and severity of the ADHD symptoms were measured using the PedsQL 4.0 Parent Proxy Report and the Conners' Parent Rating Scale (CPRS), respectively. A total of 66 participants completed the survey. The independent-samples t-test, Pearson's correlation analysis, and multiple regression analysis were conducted. RESULTS: The mean score of the PedsQL 4.0 Child Self-Report was significantly higher than the mean score of the PedsQL 4.0 Parent Proxy Report. However, for school function, the PedsQL 4.0 Child Self-Report score was significantly lower than that of Parent Proxy Report. The correlation between the PedsQL 4.0 Child Self-Report and PedsQL 4.0 Parent Proxy Report scores was significant only for emotional function and social function. The multiple regression analysis showed that the PedsQL 4.0 Child Self-Report and PedsQL 4.0 Parent Proxy Report scores were significantly predicted by the CDI and CPRS scores, respectively. CONCLUSION: Our results demonstrate that there are clear differences between the quality of life reported by the patient themselves and that reported by their caregivers. In addition, the findings suggest that it is critical to treat the patients' accompanying depressive symptoms.

The Effects of Depression on the Survival of Terminal Cancer Patients in a Palliative Care Unit / 정신신체의학

OBJECTIVES@#This study examined the association between depression and survival time in terminal cancer patients admitted to the palliative care unit. Emotional problems are important for terminal cancer patients in the palliative care unit, and evaluation of patients' depression plays an important role in treatment planning.@*METHODS@#From October 2015 to August 2018, we conducted a retrospective study of 291 terminal cancer patients admitted to a palliative care unit at a university hospital and evaluated depression with PHQ-9 at admission. Of the 291 patients, 146 (50.2%) completed PHQ-9 but 145 (49.8%) were not evaluated due to loss of consciousness or rejection.@*RESULTS@#4-week survival rate in the Kaplan-Meier survival analysis were 45.4% in the non-depressed group (PHQ-9<10) and 18.7% in the depressed group (PHQ-9≥10). According to the severity of depression, in the Cox proportional hazard model, the risk of mortality in moderate, moderately sever and severe group was 2.778, 1.882 and 3.423 times higher than minimal group, respectively.@*CONCLUSIONS@#Of the patients with terminal cancer who were admitted to the palliative care unit, the survival time was shorter in the depressed group than in the non-depressed group. Further research is needed to determine if treatment of depression increase the survival in terminal cancer patients.

Comparison of Hematologic Variability between Clozapine Monotherapy and Augmentation Therapy with Atypical Antipsychotics for Schizophrenia: Results from a 6-Month Retrospective Follow-Up Study / 대한정신분열병학회지

OBJECTIVES: Clozapine is an antipsychotic agent commonly prescribed in patients with treatment-resistant schizophrenia. A drawback of using clozapine is risk of hematologic side effects ranging from mild neutropenia to fatal agranulocytosis. In clinical settings, other atypical antipsychotic agents are frequently combined with clozapine because some treatment-resistant patients would not respond to clozapine alone. Unfortunately, other atypical antipsychotics may also cause hematologic side effects, and the combination therapy might aggravate the possible neutropenic side effects. The purpose of this study was to investigate the difference in the incidence of hematologic side effects between clozapine monotherapy and augmentation therapy. METHODS: We retrospectively reviewed the medical records of 114 patients who were diagnosed with schizophrenia and being prescribed with clozapine in a single university hospital. White blood cell count (WBC) and absolute neutrophil count (ANC) were identified every 1 month in clozapine monotherapy group and clozapine-atypical antipsychotics augmentation therapy group. RESULTS: Compared with clozapine monotherapy group, augmentation therapy group showed no significant differences in WBC and ANC for the first 6 months of combination. Amisulpride augmentation showed temporary increases in WBC and ANC, especially compared with paliperidone augmentation. CONCLUSION: Augmentation of amisulpride to clozapine might be associated with temporary increases in WBC and ANC during the first 3 months of combination. Further investigations should be carried out to clarify the clinical significance of our findings.

Comparison of Hematologic Variability between Clozapine Monotherapy and Augmentation Therapy with Atypical Antipsychotics for Schizophrenia: Results from a 6-Month Retrospective Follow-Up Study / 대한정신분열병학회지

OBJECTIVES: Clozapine is an antipsychotic agent commonly prescribed in patients with treatment-resistant schizophrenia. A drawback of using clozapine is risk of hematologic side effects ranging from mild neutropenia to fatal agranulocytosis. In clinical settings, other atypical antipsychotic agents are frequently combined with clozapine because some treatment-resistant patients would not respond to clozapine alone. Unfortunately, other atypical antipsychotics may also cause hematologic side effects, and the combination therapy might aggravate the possible neutropenic side effects. The purpose of this study was to investigate the difference in the incidence of hematologic side effects between clozapine monotherapy and augmentation therapy. METHODS: We retrospectively reviewed the medical records of 114 patients who were diagnosed with schizophrenia and being prescribed with clozapine in a single university hospital. White blood cell count (WBC) and absolute neutrophil count (ANC) were identified every 1 month in clozapine monotherapy group and clozapine-atypical antipsychotics augmentation therapy group. RESULTS: Compared with clozapine monotherapy group, augmentation therapy group showed no significant differences in WBC and ANC for the first 6 months of combination. Amisulpride augmentation showed temporary increases in WBC and ANC, especially compared with paliperidone augmentation. CONCLUSION: Augmentation of amisulpride to clozapine might be associated with temporary increases in WBC and ANC during the first 3 months of combination. Further investigations should be carried out to clarify the clinical significance of our findings.

Reason for Clozapine Discontinuation / 대한정신분열병학회지

OBJECTIVES: Approximately 30% of individuals diagnosed with schizophrenia suffer from treatment-resistant schizophrenia. Clozapine is underutilized in the management of treatment-resistant schizophrenia. To understand contributing factors, we analyzed the time course and causes of clozapine discontinuations that occurred over a 20-year period in a clinical setting. METHODS: The reasons for discontinuation and duration of clozapine treatment from a retrospective database of 138 patients with schizophrenia who had prescribed clozapine at least a month were reviewed, with the motives for discontinuation coded. The causes for termination were analyzed. RESULTS: Over two-thirds of the patient had ceased clozapine. The two most common causes for discontinuation were side-effects (50%), and own decision (30%). Somnolence accounted for 34% of all side-effects induced discontinuations. Hematological problems accounted for 23% of side-effect. The Maximal treatment dose of clozapine was higher in continuation group (442.36 mg) than in discontinuation group (397.26 mg). The CGI-S score when prescribing clozapine last was higher in discontinuation group than in continuous group. The patients who took atypical antipsychotics before clozapine tended to cease clozapine because of side-effects than who took typical agent. CONCLUSION: Future studies should seek various methods to relieve side-effects of clozapine. Prospective researches using more objective tools are needed to clarify the reason for clozapine discontinuation.

Concept Analysis of Nurses' Acceptance of Patient Deaths / 한국호스피스완화의료학회지

PURPOSE: The purpose of this paper is to identify a theoretical basis of end-of-life care by examining attributes of the concept of the nurses' acceptance of patient deaths. METHODS: Walker and Avant's approach to concept analysis was used. A literature study was performed to check the usage of the concept. To identify the attributes of the concept and come up with an operational definition, we analyzed 16 qualitative studies on nurses' experiences of death of patients, published in a national science magazine from 1999 to 2015. RESULTS: The nurses' acceptance of death of patients was identified as having four attributes: acceptance through mourning, attaining insight on life and death while ruminating life, facing with fortitude and practicing human dignity. Antecedents of the concept were experiences of patient's death, confusion and conflict, negative emotions, passive responses, denial of patients' death. The consequences of the concept were found as the holistic end-of-life care and active pursuit of life. CONCLUSION: This study on the attributes of the concept of the nurses' acceptance of death of patients and it's operational definition will likely lay the foundation for applicable end-of-life care mediations and theoretical development.

Factors Affecting Quality of Life and Family Burden among the Families of Patients with Schizophrenia / 대한정신분열병학회지

OBJECTIVES: Study aimed to identify factors that may affect family burden and quality of life (QOL) of primary caregivers in schizophrenia family. METHODS: Among outpatients with schizophrenia undergoing treatment at the psychiatric department of a university hospital, 72 patients and their primary caregivers were investigated. Sociodemographic and clinical data were collected and analyzed. RESULTS: As a result of multiple regression of primary caregivers’ family burden (R²=0.284), primary caregiver’s income (p=0.001) and patient’s delusional symptoms (p=0.001) significantly explained the total family burden of primary caregivers. In multiple regression on QOL (R²=0.515), primary caregiver’s income (p=0.033) and education level (p=0.006), patient’s sex (p=0.006), treatment duration (p<0.001), degree of disorganized speech (p=0.008), negative drug attitudes (p=0.026) and the attitude of overcoming stigma against mental patients (p=0.029) all significantly explained the average QOL score. CONCLUSION: Various factors determining primary caregiver’s QOL, including Clinical symptoms such as patient’s disorganized speech and clinically correctable factors such as negative drug attitude and insight into disease. Therefore, provision of education regarding drug and disease for patients and caregivers will be helpful to effectively reduce burden and improve the QOL of primary caregivers.

The Code of Medical Ethics for the Korean Academy of Child and Adolescent Psychiatry: Why Is It Important?

This article provides an overview of the developmental history and rationale of medical ethics to establish the code of ethics and professional conduct of the Korean Academy of Child and Adolescent Psychiatry (KACAP). Most medical professional organizations have their own codes of ethics and conduct because they have continuous responsibility to regulate professional activities and conducts for their members. The Ethics and Award Committee of the KACAP appointed a Task-Force to establish the code of ethics and conduct in 2012. Because bioethics has become global, the Ethics Task Force examined global standards. Global standards in medical ethics and professional conduct adopted by the World Medical Association and the World Psychiatric Association have provided the basic framework for our KACAP's code of ethics and professional conduct. The Code of Ethics of the Americal Academy of Child and Adolescent Psychiatry has provided us additional specific clarifications required for child and adolescent patients. The code of ethics and professional conduct of the KACAP will be helpful to us in ethical clinical practice and will ensure our competence in recognizing ethical violations.

Factors Affecting Recurrence in Patients with Schizophrenia Received More Than 10 Years of Treatment / 대한정신분열병학회지

OBJECTIVES: The purpose of this study is to investigate the factors affecting recurrence in patients with schizophrenia received more than 10 years of long-term treatment. METHODS: The medical records of long-term follow-up patients with the diagnosis of schizophrenia from department of psychiatry, Inha university hospital for more than 10 years were reviewed. The recurrence was defined as the re-emergence or aggravation of psychotic symptoms after maintenance treatment during 6 months. RESULTS: Of the 110 patients who were included in the study, 78 patients were recurred. Half of the patients were experiencing at least 1 recurrence within six years. After adjustment of sociodemographic variables, female, poor drug compliance, younger baseline age, shorter duration of illness and longer duration of hospitalization at first admission were significantly related to an increased likelihood of recurrence. The most common stressor of recurrence was irregular drug taking (61.73%). CONCLUSION: The results show the importance of gender, drug compliance, baseline age, duration of illness, and duration of hospitalization at first admission in predicting recurrence of long-term follow-up patients with schizophrenia.

Return to Work Experience among Military Officers with Cancer

PURPOSE: This study was done to describe the return to work experience of military officers with cancer. METHODS: Individual in-depth interviews with 15 participants were conducted between September 2013 and April 2014. Participants were interviewed 1~4 times; interviews continued until the data became saturated. Data were analyzed using Strauss and Corbin's grounded theory. RESULTS: The core category emerged as "living a new life after enduring difficulties". The return to work process consisted of four sequential phases: chaos, positive thought formation, behavior practices, and reformation. Action/interaction strategies used by military officers with cancer to resolve enduring difficulties were controlling emotions, accepting reality, prioritizing health, making efforts to improve relationships, and looking for future jobs. CONCLUSION: These results will promote understanding of military officers' return to work experience following cancer survival, and will be helpful in developing more effective nursing interventions through enhanced perspectives and insights of practitioners.

Anger Assessment Using State-Trait Anger Expression Inventory in Middle-School Students in Korea and Association with Depression

OBJECTIVES: The purpose of this study was to assess anger of middle school adolescents in an urban community using State-Trait Anger Expression Inventory (STAXI)-Korean and Korean Child Behavior Checklist (K-CBCL), and to determine whether specific anger expression of adolescents is associated with certain psychopathology including depression. METHODS: Data were collected from 395 middle school students and their parents in Incheon city. The students completed the STAXI, Children's Depression Inventory, Korean version of Mood disorder Questionnaire, and Conners-Wells' Adolescent Self-Report Scale (Short Form), and their parents completed the K-CBCL. RESULTS: No significant correlation was observed between aggression subscale K-CBCL and each scale of the STAXI, except anger out (r=0.704). The scores for STAXI total and respective scales were significantly higher for female students than male students. A stepwise logistic regression model was used to explore the possible predictors for depression in adolescents and lower anger control and higher anger suppression were found to be predictors for depression in adolescence. CONCLUSION: There is a possibility of a large discrepancy between anger that the adolescents actually feel and parents' judgment of their children's anger. It must be considered in assessment of adolescent anger and use of further structured interviews is necessary. In addition, it may be useful to consider the anger expression style in adolescents who report depressive symptoms.

Nurses' Experiences of the Death of Patients in Geriatric Hospitals

PURPOSE: The purpose of this study was to identify and understand nurses' experiences of the death of patients in geriatric hospitals. METHODS: Van Manen's hermeneutic phenomenological analysis was applied in the interpretation of experiential descriptions of seven nurses who had experienced the death of patients in a geriatric hospital. RESULTS: The essential subjects derived from the experience of the nurses on the death of patients in a geriatric hospital are covered in the following 7 themes. 'Placed in death site', 'Difficult repetition of death and farewell', 'Emotional waves that rushes in after farewell', 'Dilemmas in a place with no preparation to greet expected death', 'Getting dull from continually being struck with sorrow', 'Being together with living death', and 'Showing courtesy for a good farewell and living well'. CONCLUSION: The results of this research will contribute to the development of policy on all the deaths of patients in geriatric hospitals and suggest basic data that need to be applied in real practice and directions to introduce plans for realistic improvements in nursing care of deathbed patients in geriatric hospitals.

Depression and Caregiving Burden in Families of Patients with Amyotrophic Lateral Sclerosis

PURPOSE: The purpose of this study was to describe depression, caregiving burden and the correlation of the two variables in the families of patients with amyotrophic lateral sclerosis (ALS) and to clarify factors predicting caregiving burden. METHODS: A descriptive and cross-sectional study was conducted with 139 family members who provided care to patients with ALS. The characteristics of patients and families, Korean-Beck Depression Inventory (K-BDI), Korean version of Zarit Burden Interview (K-ZBI) and Korean-Amyotrophic Lateral Sclerosis Functional Rating Scale - Revised (K-ALSFRS-R) were used as study measures. RESULTS: The mean score for K-BDI was 19.39 out of 63 suggesting sub-clinical depression and 38.2% of the family members exhibited depression. The mean score for K-ZBI was 66.03 out of 88. The predictors for K-ZBI were K-BDI, age of family member, length of time spent per day in caring, relationship to patient and K-ALSFRS-R. CONCLUSION: The results of this study suggest that levels of depression and caregiving burden are high among family members caring for patients with ALS. As depression is associated with caregiving burden, screening and emotional supports should be provided to reduce the burden of care for these family. Support programs to alleviate the care burden are also needed, considering family demographics, time per day in caring giving and K-ALSFRS-R.

Follow-Up on Medication Adherence of Dementia Patients : After Diagnosed through the Nationwide Project for Early Detection of Dementia

OBJECTIVE: This study examined medication adherence rate and associated factors with medication adherence in patients who had been diagnosed as having dementia through the nationwide project for early detection of dementia in South Korea. METHODS: This study enrolled a total of 131 patients, who were diagnosed as having dementia through utilization of the Korean version of the Consortium to Establish a Registry for Alzheimer's Disease Assessment Packet at the Namgu Dementia Center in Incheon, from January 1, 2012 through December 31, 2012. Telephone interview was done with principal caregivers of dementia patients at least 18 months after they had been diagnosed. RESULTS: Out of 131 patients, 83 caregivers of patients completed telephone interview. 62 (72.9%) patients were currently being treated with antidementia drugs, and the proportion of patients being treated at the psychiatric clinic was 54.8%. Sociodemographic variables and clinical rating scales included in the study had no statistically significant effect on the medication adherence. The most common cause of nonadherence was a misconception of dementia diagnosis and treatment (28.6%). CONCLUSION: The major cause of nonadherence was a misconception of dementia diagnosis and treatment, therefore, education on misconception may enhance a patient's medication adherence. Sociodemographic variables and clinical rating scales included in the study had no statistically significant effect on the medication adherence.