Attitudes toward taking medication among outpatients with schizophrenia: cross-national comparison between Tokyo and Beijing
Environ Health Prev Med
Attitudes toward taking medication among outpatients with schizophrenia: cross-national comparison between Tokyo and Beijing
Naoaki Kuroda 0 1 2 3
Shiyou Sun 0 1 2 3
Chih-Kuang Lin 0 1 2 3
Nobuaki Morita 0 1 2 3
Hirotaka Kashiwase 0 1 2 3
Fude Yang 0 1 2 3
Yoji Nakatani 0 1 2 3
0 S. Sun F. Yang Beijing Huilongguan Hospital , Beijing , China
1 N. Kuroda Hasegawa Hospital , Tokyo , Japan
2 N. Kuroda (&) C.-K. Lin N. Morita Y. Nakatani Graduate School of Comprehensive Human Sciences, University of Tsukuba , 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8577 , Japan
3 H. Kashiwase Matsumi Hospital , Tokyo , Japan
Objectives The aim of this study was to compare attitudes toward medication and associated factors for patients with schizophrenia in Japan and China. Methods Age-group matched samples were drawn from outpatients in Tokyo (N = 76) and Beijing (N = 76) according to the same inclusion/exclusion criteria. Psychotropic prescription and attitudes toward medication were measured using Drug Attitude Inventory-30 (DAI-30) and an original questionnaire regarding beliefs about psychiatric medication. Stepwise regression analysis of the DAI-30 data was performed for each group. Results Japanese subjects were prescribed significantly larger amounts of antipsychotics. Polypharmacy of antipsychotics and concurrent use of anticholinergics, anxiolytics, or hypnotics were more frequently found among subjects in Tokyo than among those in Beijing. However, subjects in Tokyo and Beijing had similar subjective responses to medication, subjective evaluation of sideeffects, and complaints about overuse of psychotropics. Subjects in Tokyo complained less about physician's overreliance on medication and were less concerned about
Attitude toward medication; Schizophrenia; Cross-cultural comparison; Japan; China
medication cost than those in Beijing. In Tokyo, longer
duration of illness and lower subjective distress caused by
side effects predicted a more positive subjective response,
while female gender, younger age, and lower Brief
Psychiatric Rating Scale score were independently correlated with a
better subjective response in Beijing.
Conclusions Subjective acceptance of multiple
medications is greater for patients in Japan than those in China.
Determinants of subjective response to medication varied
between Japan and China.
International comparative studies on psychotropic
prescriptions have shown that prescription practices for
patients with schizophrenia vary greatly [
Particularly, in Japan, prescription practice for inpatients with
schizophrenia is characterized by polypharmacy and high
dosing. This practice is a clear departure from that of
other Asian countries ; in China, the total quantity of
antipsychotics prescribed was the lowest among six
EastAsian countries [
The use of polypharmacy and high dosing in Japan has
been explained by several factors, for example prolonged
], use of antipsychotics to control
patients’ behavior by sedation [
], psychiatrists’ skepticism
toward the use of prescription algorithms, and nurses’
requests for more drugs [
]. However few studies have
explored this phenomenon from the patient’s point of view;
it is unknown if different prescription habits affect patients’
attitudes toward medication.
The goals of pharmacological treatment for
schizophrenia have evolved from objective improvement in
psychotic symptoms into patient-related factors such as
quality of life [
] and patient satisfaction with treatment.
Evaluating attitudes toward medication is now regarded as
an important measure of outcome. Moreover, the patient’s
attitude toward medication affects a number of significant
clinical variables [
] including medication
non-adherence, quality of life, treatment outcomes, suicidal behavior,
and substance abuse. Therefore it is necessary for clinicians
to understand the characteristics of patients’ attitudes
toward medication and further research in this area is
The aim of this research was to investigate the
1 Do prescription practices for outpatients with
schizophrenia vary between Tokyo and Beijing?
2 How do patients in Tokyo and Beijing differ in their
attitudes toward medication?
3 What factors are associated with patients’ attitudes
toward medication for patients in Tokyo and Beijing?
Materials and methods
Study setting and recruitment procedure
A cross-sectional study was performed with the
collaboration of University of Tsukuba and Beijing Huilongguan
Hospital. A convenient sample was drawn from outpatient
attendees. The Japanese subjects were recruited from
outpatient clinics at Hasegawa Hospital, which is a psychiatric
hospital with 576 beds located in Tokyo. The Chinese
subjects were recruited from outpatient clinics at Beijing
Huilongguan Hospital, the largest psychiatric hospital in
Beijing, with 1,369 beds. These two hospitals were
comparable in the following characteristics:
1 located in a suburban area of their respective national
capitals, with a wide catchment area including urban
and suburban populations;
2 psychiatric hospitals for acute treatment rather than
long-term care; and
3 affiliated with a medical school as a psychiatric
The study protocol was independently approved by both
institutional ethics review boards at University of Tsukuba,
Hasegawa Hospital, and Beijing Huilongguan Hospital.
The subjects from the two countries were selected
according to the following inclusion/exclusion criteria. The
1 diagnosed with schizophrenia or schizoaffective
disorder using the criteria of ICD-10;
2 taking antipsychotic medication continuously for at
least one month; and
3 aged 18–65 years.
We excluded those who:
1 were at risk of clinical deterioration by participating in
2 suffered from substance abuse or dependency;
3 had severe physical illness;
4 were pregnant; or
5 were mentally retarded or illiterate.
In Tokyo, subjects were recruited after their routine
hospital visits. The first author (NK) interviewed and
administered the questionnaires to all subjects. In Beijing,
subjects were invited during an outpatient visit. Trained
psychiatrists conducted the interviews and administered the
questionnaires under the supervision of the second author
(SS). At both sites, written informed consent was obtained.
In Beijing, written consent from the subject’s family member
was also obtained. To minimize social desirability bias, the
subjects were assured that their treatment was not influenced
by participation or refusal to participate in the research. In
addition, subjects were reassured that confidentiality and
anonymity were preserved. In total, 200 subjects (100 in
Tokyo and 100 in Beijing) participated in the study.
Although no significant differences were observed in gender
and psychopathology between the two groups, participants in
Tokyo were significantly older than those in Beijing (Tokyo;
39.6 ± 11.7, Beijing; 34.0 ± 11.3, ANOVA, F = 12.06,
df = 1, P \ 0.001). To control for potential confounding by
age, these 200 participants were stratified into ten age-groups
and then randomly sampled to yield 152 age-group-matched
patients (76 in Tokyo and 76 in Beijing).
Data collection and measures
Data on sociodemographic background, illness history,
and prescribed medication were gathered from subjects’
medical charts. All antipsychotic drugs were converted
into chlorpromazine equivalents using published
]. Psychopathology was evaluated by using the
18-item Brief Psychiatric Rating Scale (BPRS) [
BPRS is one of the most frequently used instruments for
evaluating psychopathology in patients with
schizophrenia. It is an 18-item scale measuring positive symptoms,
general psychopathology, and affective symptoms. Each
item is rated on a seven-point scale (1 = not present to
7 = extremely severe). To make the cross-national data
comparable, each item was rated using anchoring points
developed by Woerner [
] (BPRS-anchored). This is a
modified version of BPRS that has detailed criteria for
each anchoring point.
The data collection sheet and self-report questionnaire
were developed using Japanese and translated into Chinese
by a professional translator. These were then independently
back-translated into Japanese by two professionals. One
was a Chinese postgraduate student with a master’s degree
in psychology and the other was a Chinese psychiatrist
with a medical degree from a Japanese university (the third
author, LZ); both were fluent in Japanese. Incompatibilities
between the original and back-translated versions were
resolved by discussion with LZ.
The patients’ subjective responses to psychiatric
medication were assessed by using the 30-item version of
Drug Attitude Inventory (DAI-30) [
]. This is an
established, reliable self-report instrument that evaluates
patients’ perceived effects and benefits of maintenance
antipsychotic drug therapy. The scale has been translated
into several languages and has been frequently used in
international clinical trials [
]. It consists of 15 items for
positive attitudes and 15 items for negative attitudes
toward medication with which patients can agree or
disagree. Total score was calculated according to the original
author’s instructions [
] to produce a score ranging from
-30 to 30 where a positive total score indicates an overall
positive subjective response and a negative total score
indicates an overall negative subjective response. The
psychometric properties of Japanese and Chinese versions
of the scale were reported to be satisfactory [
In this sample, the internal consistency was a = 0.84
(Tokyo) and a = 0.72 (Beijing). Response style analysis
was also performed to investigate acquiescent tendency
which reflects an individual’s communication style .
DAI-30 is balanced for negative and positive items; we
therefore used the total number of endorsements to
measure the individual’s systematic tendency to agree, in
other words, an index of acquiescence [
]. In addition, a
newly devised self-report questionnaire was used to
measure patients’ beliefs about psychiatric medication. It
included the following items:
1 I take too much medicine;
2 physicians rely too much on medication; and
3 the cost of the medication is a substantial burden.
The answers were scored on a four-point Likert scale,
from 1 (strongly disagree) to 4 (strongly agree). Side
effects of psychiatric medication were assessed by asking
subjects, ‘‘How much are you bothered by side effects of
psychiatric drug therapy?’’ The answer was scored on a
four-point Likert scale, from 1 (not at all) to 4 (very
Analyses were conducted using SPSS for Windows version
12.0 (SPSS, Chicago, IL, USA). Analysis of variance
(ANOVA) was used for continuous data, Mann–Whitney’s
U test was used for ordinary data and the v2 test was used
for categorical data. To adjust for background variable
differences, analysis of covariance (ANCOVA) was used,
where appropriate. Variables that were significantly
different between two sites, and showed significant
correlation with dependent variables were used as covariates.
Spearman’s rank-correlation coefficient was used to
evaluate relationships between two variables. To examine the
associations between background variables and subjective
response to medications, stepwise multiple regression
analysis was performed for each group. Gender, age,
marital status, employment status, length of illness, BPRS,
side effects and total amount of antipsychotics were
entered as independent variables. All statistical tests were
two-tailed. The significance level was set at P \ 0.05.
Sociodemographic and clinical characteristics of the two
groups are displayed in Table 1. No statistically significant
differences were found for age, gender, length of illness,
number of hospitalizations, or BPRS between subjects
from Tokyo and Beijing. However, the proportion of
subjects who were married and living with family was
significantly higher in Beijing. A significant difference was
also found in employment status. The major subgroup in
Tokyo consisted of subjects who were attending
rehabilitation programs or sheltered workshops, whereas more than
half of the subjects in Beijing were employed. Years of
education and total length of hospitalization were
significantly longer for subjects in Tokyo. In addition, samples
were significantly different in regards to health economic
resources; all subjects in Tokyo had health insurance,
whereas only 25% of the subjects in Beijing had insurance.
Prescribed psychotropics are shown in Table 2. Subjects in
Tokyo received about twice the amount of antipsychotics.
Antipsychotic polypharmacy occurred more frequently for
subjects in Tokyo. Subjects in Tokyo were more frequently
prescribed atypical antipsychotics in combination with
typical antipsychotics. Clozapine was prescribed for
twenty-one subjects (27.6%) in Beijing; 0% in Tokyo. Also
Japanese subjects were more frequently and concurrently
prescribed anticholinergics, anxiolytics, or hypnotics. The
total number of psychiatric drugs prescribed for Japanese
subjects was three times larger than for patients in Beijing.
The number of doses per day for Japanese subjects was
significantly larger than the number of doses for subjects in
Beijing. Traditional Chinese Medicine was prescribed for a
few subjects in both Tokyo and Beijing for amelioration of
autonomic side-effects such as constipation.
Attitudes toward medication
Comparison of attitudes toward medication is presented in
Table 3. There were no significant differences between
total DAI-30 scores for subjects in Tokyo and Beijing. The
proportion of subjects with a positive DAI-30 total score
was not significantly different between the two sites
(Tokyo; 84.2% vs. Beijing; 92.1%, v2 = 0.13, df = 1,
P = 0.209). Subjects in Beijing, compared with those in
Tokyo, more frequently endorsed the 15 positive items
(Tokyo; 9.2 ± 3.6, Beijing; 11.8 ± 2.5, Mann–Whitney’s
U, Z = 4.37, P \ 0.001) and the 15 negative items (Tokyo;
2.9 ± 2.3, Beijing; 9.2 ± 3.6, Mann–Whitney’s U,
Z = 5.60, P \ 0.001). The total number of endorsements
for the scale was significantly higher for Beijing, indicating
that acquiescent response tendency was greater for subjects
in Beijing than for those in Tokyo (Table 3). The biggest
difference at the item level was for item 13, ‘‘I take
medication only when I feel ill’’ (Tokyo; 0% vs. Beijing;
67.1%, v2 = 76.75, df = 1, P \ 0.001).
No significant difference was found for, ‘‘I take too
much medicine’’. However, subjects in Tokyo were less
likely to believe that ‘‘Physicians rely too much on
medication’’, and ‘‘The cost of the medication is a substantial
burden’’. There was no significant difference in subjective
evaluation of side effects between the two groups. ‘‘The
DAI-30 drug attitude inventory-30
a Scores range from -30 to 30
b Total number of ‘‘agree’’ responses for DAI-30 (15 positive and 15 negative items)
c 1 (strongly disagree) to 4 (strongly agree)
d Patients’ subjective evaluation using a 4-point Likert scale from 1(not bothered at all) to 4 (bothered very much)
*P \ 0.05, **P \ 0.01, ***P \ 0.001
cost of the medication is a substantial burden’’ showed
significant correlation with living arrangement (with others,
q = 0.22, P \ 0.01), years of education (q = -0.25,
P \ 0.01), length of hospitalization (q = -0.21,
P \ 0.01), and health insurance (q = -0.25, P \ 0.01).
However, cross-national difference for the item remained
significant after adjusting for these covariates. (Tokyo;
2.3 ± 0.1 vs. Beijing; 3.4 ± 0.1, ANCOVA, F = 32.62,
df = 1, P \ 0.001). Marital status, years of education,
living arrangement, employment, health insurance, and
length of hospitalization did not show significant
relationships with attitudes toward medication. In Beijing, no
significant difference was observed in DAI-30; other
specific attitudes toward medication; or subjective side effects
for subjects taking or not taking clozapine (data not
Associations between DAI-30 and background variables
In Tokyo, age (q = 0.33, P \ 0.01) and length of illness
(q = 0.38, P \ 0.01) had a significant positive correlation
with subjective response to medication. Side effects (q =
-0.35, P \ 0.01) had a significant negative correlation
with subjective response to medication. In Beijing, male
gender (q = -0.33, P \ 0.01) and BPRS (q = -0.50,
P \ 0.01) had significant negative correlation with
subjective response to medication. The results of stepwise
regression analysis for DAI-30 are summarized in Table 4.
In Tokyo, longer duration of illness and lower subjective
distress caused by side effects were predictive for a more
favorable subjective response to medication. On the other
hand, female gender, younger age, and lower BPRS score
were independently correlated with a positive subjective
response to medication in Beijing. Total variance explained
Table 4 Stepwise multiple regression analysis of DAI-30
Tokyo (N = 76) Length of illness (years)
R2 = 0.27, F = 13.50, P \ 0.001
Beijing (N = 76) Age (years)
R2 = 0.35, F = 12.45, P \ 0.001
DAI-30 drug attitude inventory-30; BPRS, brief psychiatric rating
a Patients’ subjective evaluation using a four-point Likert scale from
1 (not bothered at all) to 4 (bothered very much)
b 0 = female, 1 = male
by the regression model was 27% for the Tokyo group and
35% for the Beijing group.
The samples at both sites comprised clinically stable
chronic outpatients with schizophrenia; they had no
significant differences in psychopathology. However, subjects
in Tokyo were prescribed significantly larger amounts of
antipsychotics. Polypharmacy of antipsychotics and
concurrent use of anticholinergics, anxiolytics, or hypnotics
were more frequently found in Tokyo. Past studies [
] indicated that patients’ subjective responses are
generally more favorable to atypical antipsychotics than to
typical antipsychotics, but in Tokyo, the advantage of
atypical antipsychotics would be compromised by frequent
concomitant use of typical antipsychotics. The differences
between the two countries align with past reports
comparing prescription practices for inpatients [
variation in prescription habits between Japan and China is
a phenomenon that occurs during inpatient care, but it
appears to extend into outpatient settings. Unlike previous
studies investigating prescription practices for Japanese
], in this study, daily antipsychotics dosage
for subjects in Tokyo was not over 1,000 mg
chlorpromazine equivalent. This is below the criteria of high-dosing
; for maintenance purposes, however, the dosage is
relatively high compared with dosage in Western countries.
] reported that for chronic schizophrenics in
clinical research, the average dosage was 385 mg
chlorpromazine equivalent. In this study, antipsychotic dosage
for subjects in Beijing was similar to Kane’s report.
In an outpatient setting, the patient’s commitment to the
drug regimen is essential for continuous treatment,
therefore the patient’s perception of the prescribed drugs is a
critical element of the overall success of the treatment plan.
In this study we compared attitudes toward medication and
associated factors for patients with schizophrenia in Japan
A major finding of our study is that subjects in Tokyo
did not have more negative attitudes toward medication
than subjects in Beijing, despite the higher proportion of
antipsychotics polypharmacy and more complicated drug
regimens. Subjects in Tokyo and Beijing had comparably
positive subjective responses to medication and similar
subjective evaluation of side-effects. Moreover, patients’
complaints about the overuse of psychotropics were not
significantly different between the two sites. These findings
suggest that subjective responses or attitudes toward
medication are not simply determined by characteristics of
prescribed medicine per se, but also by psychosocial or
environmental factors. Subjective response to psychotropic
medication can be associated with previous experience
with medications, attitudes toward health and illness [
culturally based cognitive styles [
]. Specifically, the
following interpretations can be made for our results.
First, subjects in Tokyo have a greater subjective
acceptance of polypharmacy than those in Beijing; subjects
in Tokyo complained less about the physicians’
over-reliance on pharmacotherapy than those in Beijing. In Japan, it
is culturally characteristic for the patient to be passive [
] and to rely on the physician rather than to act
independently . Additionally, lower subjective burden of
medical cost for subjects in Tokyo would also support
patients’ subjective acceptance for multiple medications.
This should be mainly attributable to differences in
availability of health insurance between the two sites. Japanese
patients have universal health insurance coverage [
whereas only 25% of Chinese subjects had health insurance
in our study and 19% had insurance in a previous report
]. However when we controlled for the factor of health
insurance coverage, a significant difference in attitude still
existed. Dissimilarity in other social-welfare systems or the
general economic level may also be involved. Second, it is
possible that subjects in Tokyo have gradually adapted
to these practices thorough prolonged exposure. This
assumption is supported by our findings; DAI-30 was
positively correlated with length of illness in subjects in
On the other hand, subjects in Beijing could have
negative views of psychiatric medication for other reasons.
The majority of subjects in Beijing had positive DAI-30
scores, indicating that they are generally compliant with
medication regimens [
]. However, it is remarkable that
70% of subjects in Beijing responded, ‘‘I take medication
only when I feel ill’’. This suggests that subjects in Beijing
are more likely to become nonadherent when superficial
symptoms disappear. Chinese subjects may have less
knowledge about illness and treatment because of
insufficient rehabilitation or psychoeducational programs [
Also, because of limited health-economic resources,
Chinese patients are more reluctant to continue medication if
they feel better. Additionally, the Chinese patient may
express an individual preference for traditional Chinese
medicine or Western medicine [
]. This decision would
be based on the belief that Western medicine provides a
rapid palliative action, whereas traditional Chinese
medicine is believed to produce a slow but curative or
prophylactic action [
]. We presumed that subjects in
Beijing had more negative attitudes toward medication due
to a higher employment rate; because employment was
associated with negative attitudes toward medication in
previous studies [
]. However this hypothesis was not
supported by our data. Also, this study did not indicate that
frequent mandatory blood testing for the use of clozapine
had a negative impact on patients’ attitudes toward
medication in subjects in Beijing.
Sociodemographic and clinical factors associated with
subjective response to medication were substantially
different between Tokyo and Beijing. Previous reports from
Western or African countries have revealed that subjective
responses to medication were associated with side effects
29, 31, 32
], psychopathology [
18, 29, 31–33
employment status [
], but were independent of other
sociodemographic variables or length of illness [
]. In this study, however, age and gender (China) and
length of illness (Japan), were significantly associated with
DAI-30, but employment status showed no significant
association. This would suggest that various
sociodemographic, clinical, and social factors can potentially affect
subjective response to medication, but dominant
determining factors vary by country, according to the
healthcare system and medical traditions. In this analysis it is
particularly interesting to note that in Tokyo, older patients
with longer length of illness had more positive attitudes
toward medication whereas older Chinese patients in this
sample tended to have more negative attitudes. Positive
correlation between length of illness and attitudes toward
medication in Tokyo indicates that positive attitudes
toward medication are developed as patients habituate to
taking medication over time. A possible explanation of the
negative correlation between age and attitudes toward
medication in the Chinese group is that older people are
more familiar with Chinese traditional medicine , so
they tend to have a negative view of Western medication.
Our results also imply that the male gender in China
negatively affects the response from the subjects, however
further investigation is needed to clarify this point.
Response style analysis revealed that when responding
to questionnaire items, subjects in Tokyo were generally
less likely to agree compared with subjects in Beijing. A
high acquiescent response is associated with a preference
for uncertainty avoidance [
]; therefore our results
indicate that patients in China are more straightforward,
whereas in Japan, patients experience more ambiguity in
expressing their subjective experience related to taking
medication. This tendency in Japanese patients can limit
physician-patient communication; therefore physicians
could be underestimating patients’ subjective response to
This research has several limitations that should be
considered. Subjects were recruited from a single hospital
within each country. Thus, the sample may not be
representative. Subjects were outpatients with relatively positive
attitudes toward medication who voluntarily participated in
the study; therefore, patients with poorer adherence were
not included. Lack of established reliability between sites
for the BPRS is also a significant limitation. Further
research is needed with larger sample sizes from more than
one site per country. Nevertheless, these findings should
help clinicians from both countries to understand patients’
drug-taking behavior. Incorporating the cultural context of
behavior will allow clinicians to provide more rational
psychopharmacotherapy. In turn, patients should
demonstrate better adherence with medication regimens and
improved quality of life.
Acknowledgments The authors extend special thanks to Dr
Naotaka Shinfuku and Dr Yizhuang Zou for their special contribution to
this collaborative research project.
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