Clinical and Psychopathological Typology of Therapeutic Adherence in Patients with First-Episode Psychosis

Background: although treatment adherence in first-episode psychosis (FEP) recognized as a key prognostic factor and has been extensively examined in its quantitative aspects, existing studies largely lack a clinical and psychopathological typology of therapeutic behavior. The relationships between the structure of insight, cognitive characteristics, and psychopathological manifestations—factors that determine qualitatively distinct forms of adherence—remain insuficiently explored. The aim of study was to develop and empirically validate a clinical-psychopathological typology of treatment adherence in patients with FEP. Patients and Methods: the study included 123 patients aged 18 to 40 years diagnosed with schizophrenia (F20 on ICD-10). Assessments included the PANSS, CDSS, BCIS, MARS, the Proportion of Days Covered (PDC), and the PSP scale. Results: a typology of treatment adherence identified adaptive type (24%) characterized by developed insight, strong therapeutic persistence, and high adherence (MARS ≈ 9.1; PDC ≈ 93%). Maladaptive type (76%) subdivided into three subtypes. Hyper-reflective/manipulative subtype characterized excessive symptom focus, elevated self-reflection (BCIS ≈ 16.4), with hidden instability of treatment behavior. Ambivalent rationalizing subtype differs with partial awareness of illness, rationalization tendencies, and reduced adherence during outpatient care (MARS ≈ 4.7; PDC ≈ 74%). Resistant anosognosic subtype shown marked illness denial, extremely low adherence (MARS ≈ 1.4; PDC ≤ 35%), and high risk of treatment discontinuation (OR = 6.5 vs. adaptive type). Typological differences indicate that the structure of insight and psychopathological features are closely linked to therapeutic persistence and withdrawal from therapy risk. Conclusions: the proposed clinical-psychopathological typology differentiates patients by treatment discontinuation risk and provides a framework for targeted psychoeducational, pharmacological, and rehabilitative interventions. Distinguishing one adaptive and three maladaptive subtypes supports the implementation of personalized care strategies in FEP, with the potential to enhance long-term treatment outcomes and improve prognosis.

1. Alieva LM, Solokhina TA. Socio-Psychological Factors of Compliance of Patients with Schizophrenia. Psychiatry (Moscow) (Psikhiatriya). 2020;18(2):71–81. (In Russ.). doi: 10.30629/2618-6667-2020-18-2-71-81

2. Neznanov NG, Vid VD. The problem of compliance in clinical psychiatry. Psychiatry and Psychopharmacotherapy. 2004;6(4):2–10. (In Russ.).

3. Kostyuk GP, Shmukler AB, Golubev SA and Study Group. Epidemiological aspects of diagnosis of schizophrenia in Moscow. Social and Clinical Psychiatry. 2017;27(3):5–9. (In Russ.). https://elibrary.ru/item.asp?id=30025477

4. Iastrebova VV, Solokhina TA, Mitikhin VG, Alieva LM, Mashoshin AI. Priverzhennost' lecheniiu bol'nykh shizofreniei i razrabotka mer po ee povysheniiu. V sb.: Psikhoterapiia i psikhosotsial'naia rabota v psikhiatrii. Vypusk III. Pod red. O.V. Limankina, S.M. Babina. SPb.: Izdatel'stvo “Taro”, 2016:334–341. (In Russ.).

5. Shvets KN, Khamskaya IS. Factors of social disadaptation of patients with schizophrenia and approaches to psychosocial therapy and rehabilitation (review). Research Results in Biomedicine. 2019;5(2):72–85. (In Russ.). doi: 10.18413/2658-6533-2019-5-2-0-8

6. Abdel-Baki A, Ouellet-Plamondon C, Malla A. Pharmacotherapy challenges in patients with first-episode psychosis. J Affect Disord. 2012;138:S3–14. doi: 10.1016/j.jad.2012.02.029 Epub 2012 Mar 9. PMID: 22405590.

7. Svetlichnaya TG, Voronov VA, Smirnova EA. Socio-behavioral factors for of adherence to treatment of patients with mental disorders inclined to socially dangerous behavior. S.S. Korsakov Journal of Neurology and Psychiatry. 2020;120(2):59–65. (In Russ.). doi: 10.17116/jnevro2022122021115

8. Berezantsev AYu, Kostyuk GP, Burygina LA, Levin ME, Masyakin AV. The new stage in the development of a system for the treatment and rehabilitation of patients with schizophrenic spectrum disorders. Health care of the Russian Federation. 2020;64(4):181–189. (In Russ.). doi: 10.46563/0044-197X-2020-64-4-181-189

9. Abdullah-Koolmees H, Nawzad S, Egberts TCG, Vuyk J, Gardarsdottir H, Heerdink ER. The effect of non-adherence to antipsychotic treatment on rehospitalization in patients with psychotic disorders. Ther Adv Psychopharmacol. 2021;11:20451253211027449. doi: 10.1177/20451253211027449 PMID: 34262690; PMCID: PMC8246479.

10. Wander C. Schizophrenia: opportunities to improve outcomes and reduce economic burden through managed care. Am J Manag Care. 2020;26(3):S62–S68. doi: 10.37765/ajmc.2020.43013 PMID: 32282176.

11. Rivelli A, Fitzpatrick V, Nelson M, Laubmeier K, Zeni C, Mylavarapu S. Real-world predictors of relapse in patients with schizophrenia and schizoaffective disorder in a large health system. Schizophrenia (Heidelb). 2024;10(1):28. doi: 10.1038/s41537-024-00448-2 PMID: 38424086; PMCID: PMC10904733.

12. Berezantsev AYu, Burygina LA, Levin ME. Some current trends in the use of prolonged injectable antipsychotics in the conditions of modernization of the psychiatric service. S.S. Korsakov Journal of Neurology and Psychiatry. 2020;120(6–2):61–67. (In Russ.). doi: 10.17116/jnevro202012006261

13. Li L, Le TH, Kim WS, Odkhuu S, Kang CY, Setiani A, Jeon E, Rami FZ, Chung YC. Predictors of relapse after discontinuing antipsychotics in patients with schizophrenia spectrum disorders. Schizophrenia (Heidelb). 2025;11(1):42. doi: 10.1038/s41537-025-00592-3 PMID: 40082469; PMCID: PMC11906741.

14. Zipursky RB, Menezes NM, Streiner DL. Risk of symptom recurrence with medication discontinuation in first-episode psychosis: a systematic review. Schizophr Res. 2014;152(2–3):408–14. doi: 10.1016/j.schres.2013.08.001 Epub 2013 Aug 21. PMID: 23972821.

15. Miller BJ, Bodenheimer C, Crittenden K. Second-generation antipsychotic discontinuation in first-episode psychosis: an updated review. Clin Psychopharmacol Neurosci. 2011;9(2):45–53. doi: 10.9758/cpn.2011.9.2.45 Epub 2011 Aug 31. PMID: 23429653; PMCID: PMC3569083.

16. Lyubov EB, Bessonova AA. First-episode of schizophrenia: clinico-epidemiological and socio-economic aspects. Russian Journal of Psychiatry. 2008;2:46–50. (In Russ.).

17. Ghosh A, Suhas S, Solanki C, Dave M, Tharayil HM, Damodharan D, Andrade C. From compliance to adherence: Changing views, changing concepts. Indian J Psychiatry. 2017;59(3):399–400. doi: 10.4103/psychiatry.IndianJPsychiatry_281_17 PMID: 29085113; PMCID: PMC5659104.

18. Danilov D. Therapeutic collaboration (compliance): Content of the definition, mechanisms of formation, and methods of optimization. Neurology, Neuropsychiatry, Psychosomatics. 2014;6(2):4–12. (In Russ.). doi: 10.14412/2074-2711-2014-2-4-12

19. Zakharova EV. Theoretical concepts and research methods for compliance and treatment adherence. Theoretical and Experimental Psychology. 2019;12(3):96–110. (In Russ.). EDN: FGXSBG.

20. Cramer JA, Roy A, Burrell A, Fairchild CJ, Fuldeore MJ, Ollendorf DA, Wong PK. Medication compliance and persistence: terminology and definitions. Value Health. 2008;11(1):44–7. doi: 10.1111/j.1524-4733.2007.00213.x PMID: 18237359.

21. Loucks J, Zuckerman AD, Berni A, Saulles A, Thomas G, Alonzo A. Proportion of days covered as a measure of medication adherence. Am J Health Syst Pharm. 2022;79(6):492–496. doi: 10.1093/ajhp/zxab392 PMID: 34637496.

22. Thompson K, Kulkarni J, Sergejew AA. Reliability and validity of a new Medication Adherence Rating Scale (MARS) for the psychoses. Schizophr Res. 2000;42(3):241–7. doi: 10.1016/s0920-9964(99)00130-9 PMID: 10785582.

23. Gleeson JF, Cotton SM, Alvarez-Jimenez M, Wade D, Gee D, Crisp K, Pearce T, Spiliotacopoulos D, Newman B, McGorry PD. A randomized controlled trial of relapse prevention therapy for first-episode psychosis patients: outcome at 30-month follow-up. Schizophr Bull. 2013;39(2):436–48. doi: 10.1093/schbul/sbr165 Epub 2011 Nov 29. PMID: 22130905; PMCID: PMC3576162.

24. Chang WC, Ho RWH, Tang JYM, Wong CSM, Hui CLM, Chan SKW, Lee EMH, Suen YN, Chen EYH. Early-Stage Negative Symptom Trajectories and Relationships With 13-Year Outcomes in First-Episode Nonaffective Psychosis. Schizophr Bull. 2019;45(3):610–619. doi: 10.1093/schbul/sby115 PMID: 30124959; PMCID: PMC6483573.

25. Bleikher VM. Rasstroistva myshleniya. Kiev: Zdorov'e, 1983:192.

26. Holmes EA, Hughes DA, Morrison VL. Predicting adherence to medications using health psychology theories: a systematic review of 20 years of empirical research. Value Health. 2014;17(8):863–76. doi: 10.1016/j.jval.2014.08.2671 PMID: 25498782.