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Review                                                                                                                                                 Open Access

## Factors that Affect Adolescent Adherence to Mental Health and Psychiatric Treatment: a Systematic Integrative Review of the Literature

Ulla Timlin 1* , Helinä Hakko 2 , Raija Heino 3 , Helvi Kyngäs 1,4

1 Faculty of Medicine, University of Oulu, Finland 2 Psychiatry, Oulu University Hospital, Finland 3 Medical Library, University of Oulu, Finland

4 Northern Ostrobothnia Hospital District, University of Oulu, Finland

- *Corresponding author:

ulla.timlin@oulu.fi

## Abstract

Background: Although adherence to somatic treatment has been studied extensively, adherence to mental health treatment has not. In this study, the term treatment adherence is used to refer to adherence to medication regimes and other non-pharmacological recommended  treatments  as  part  of  mental  health  and  psychiatric  care.  Knowledge  of  factors  connected  to  adolescents' adherence  to  such  treatment  is  fairly  fragmented.  Although  treatment  staff  members  are  broadly  aware  of  the  factors  that influence adherence, it would be desirable to develop formalized treatment assessment and planning approaches that specifically take these factors into account.

Objective : The purpose of this article is to review the available data related to factors that affect adolescents' adherence to both medication and non-pharmacological treatments in mental health and psychiatric care.

Methods: A systematic literature search that involved four databases was undertaken. A thematic analysis was conducted on 17 studies to extract relevant information.

Results: It appears that an adolescent's own positive beliefs toward his or her treatment are the main factor that improves his or her  adherence  to  that  treatment.  Good  cohesion  with  close  supportive  people  appears  to  be  positively  related  to  adherence, whereas sociodemographic characteristics (e.g., race, gender) were not related.

Conclusions: By  identifying  the  factors  related  to  the  treatment  adherence  of  adolescents,  this  review  article  can  provide guidance  to  help  improve  the  quality  of  care  and  thus  further  increase  adolescents'  satisfaction  with  their  mental  health  and psychiatric treatment.

Keywords: adherence, adolescents, psychiatric nursing, mental health nursing, integrative review

## Introduction

Adherence among patients with chronic illnesses and somatic  symptoms  has  been  studied  extensively  (1). Alternatively,  adherence  to  mental  health  treatment has been less studied, with the main focus being the medication  adherence  of  adult  patients  (2-7).  Kruse and Rohland have investigated adult outpatients' appointment attendance (8); Sellwood and colleagues have examined the influence of families in predictions of  adult  patient  adherence  (9);  and  Gonzales  and colleagues have studied patients' adherence to referred mental health  treatment  (3). The  knowledge of the factors that are connected to adherence is still fairly fragmented.

Medication non-adherence is related to medicationtaking behavior and is therefore associated with poorer treatment outcomes (10). Although definitions of  the  term adherence vary  in  the  current  literature,  it can  be  defined  as  the  patient  taking  medication  at least  75%  of  the  time,  with non-adherence used  to describe  the  situation  when  medication  is  taken  less than  25%  of  the  time  (11).  Furthermore,  the  term service  engagement can  be  defined  as  a  multifactorial process that involves the acceptance of treatment and collaboration with a shared goal of recovery (12). The period  between  discharge  from  inpatient  care  and engagement  with  follow-up  treatment  is  especially critical;  it  is  also  a  vulnerable  time  for  patients  with mental illness who require long-term care (8). Especially  among  adolescents,  more  information  is needed  to  understand  the  factors  that  contribute  to readmission (13). According to Gearing and colleagues  (14),  approximately  a  third  of  adolescents do not complete recommended psychosocial treatment.

Generally, the main  treatments used in mental health  care  are  medications  and  referrals  for  special treatment  (3).  It  is  without  question  that  patients' experiences of treatment (e.g., during the acute phase of a psychotic disorder) can have an impact on their long-term  outcomes  (15).  Several  studies  involving various populations and settings have found a connection between patients' adherence to treatment and physician-patient communication. Good  and effective  communication  in  medical  care  correlates with better patient adherence to treatment (16). It has been found that adolescents' satisfaction with treatment  is  connected  to  the  service  environment and to the organization of services. There are increasing  demands  to  involve  adolescents  in  the development  of  their  mental  health  care;  to  meet these  demands,  caregivers  need  to  learn  more  about patients' views related to such care (17).

Adolescence is a period of rapid physical, psychological, and social development. Although these  changes  can  induce  a  range  of  uncommon symptoms  and  illness patterns, they also present unique challenges for communication and management  (18).  These  issues  must  be  addressed when treating adolescents with mental health problems  and  managing  their  treatment  adherence. Because adolescents are growing into adulthood and becoming  increasingly  independent  of  their  parents, they are more willing than children to make decisions and major life choices for themselves; this can make it difficult  to  induce  them  to  adhere  to  prescribed treatment  regimes  (19).  Non-adherence  to  treatment can lead to illness relapses, readmissions to the hospital, and  other harmful  reactions  (20).  Nonadherence is a particularly common  problem  in mental health care, so there is a need to systemically investigate treatment adherence among adolescents as well as the factors that influence such adherence. As a result  of  the  unique  aspects  of  adolescence  as  a developmental  stage,  adherence  among  adolescents should be examined separately from adherence among adults and children.

In  this  systematic  integrative  review,  we  will  focus on  the  factors  related  to  adolescents'  adherence  to medication and non-pharmacological treatment in mental health and psychiatric care. Within the context of this article, the terms adherence, compliance, persistence, and therapeutic  alliance will  be  used  to  describe  the subject being investigated. The term adherence was the most  prevalent  term  used  in  the  studies  that  were reviewed. The literature was evaluated to identify the factors that relate positively or negatively to adolescents' adherence to treatment. For the purposes of  this  article,  an adolescent is  someone  between  the ages  of  12  and  19  years,  and treatment describes  all methods that have been used to address an adolescent's mental health symptoms, including both medication and non-pharmacological treatments.

## Methods

Search Strategy and Process

We conducted a systematic search of four databases-MEDLINE,  CINAHL,  PsycINFO,  and Cochrane-for  the  following  keywords: 1) Subject headings :  patient  compliance,  treatment  compliance, mental disorders, psychiatric hospitals, psychiatric nursing, psychiatric nurses, psychiatric patients, psychiatry, adolescent psychiatry, preventive psychiatry, community psychiatry, psychoanalysis, psychosomatic  medicine,  adolescence; and 2)  Other search  terms: adheren*,  therapeutic  alliance,  cooperat*, co-operat*, complian*, adolescen*, teen*, young.

Studies with the following characteristics were included: 1) empirical; 2) published between 1990 and September 2014; 3) focused  on  adolescents  between the ages of 12 and 19 years; 4) about both adolescents and children or adults but with results for adolescents presented separately; 5) about adolescents with mental health problems or illnesses; and 6) about adherence to  treatment (including adherence to medication  and other  recommended  treatments,  including  therapy, appointments, and certain treatment programs). Studies were excluded if they primarily focused on the following:  1)  criminal  psychiatry,  forensic  psychiatry, substance abuse, sexual problems, or neuropsychiatric illnesses; 2) adolescents with anorexia nervosa with no secondary  diagnosis  of  mental  illness  or  anorexia nervosa treatment adherence with adherence defined entirely  in  terms  of  body  weight  (with  no  attempt made to investigate mental health issues); and 3) child, adult,  or  geriatric  psychiatry.  In  addition,  a  study conducted  by  the  authors  was  excluded  to  avoid Electronic database

(MEDUNE, ONAHL

PaycINFO, Cochrane)

search results: 1042

problems  of  objectivity  and  to  increase  the  review's validity (21). 57 duplicate hits removed.

abstracts: 413

remaining

remaining

review A  total  of  1042  papers  were  identified  from  the searches, with 1025 excluded after reading the title (n = 572) and then removing duplicates (n = 57); after reading  the  abstract  (n  =  183);  after  reading  the  full text (n = 205; 1 paper was not available for assessment);  and  after  a  quality  assessment  (n  =  7) (Figure 1). The two authors read 24 papers to assess their  quality  and  their  contents  in  the  context of the research  questions  posed  for  this  systematic  review. We used the Joanna Briggs Institute's System for the Unified  Management,  Assessment  and  Review  of Information  package  validity  checklists  (22),  which include the standard critical appraisal instruments for specific study designs: experimental studies, interpretive  and  critical  research,  narratives,  opinion and  textual  papers  and  observational  studies  (23). Seven papers were excluded chiefly as a result of poor descriptions of methods or results that included very little  information  about  adolescents'  adherence.  A total  of  17  studies  were  reviewed,  and  all  included articles  had  to  meet  the  criteria  of  quality  appraisal. The authors discussed the quality appraisal and each others' assessments. They had a mutual understanding that  articles  would  not  be  included  if  they  did  not provide  a  clear  description  of  the  methods  used  or presented results were not clearly based on the research questions of this systematic review.

## Data Analysis

Of the studies  included,  16  (94%)  were  quantitative. However,  they  were  not  sufficiently  homogenous  to allow for statistical pooling for meta-analysis.  A thematic analysis  was  conducted  on  all  17  studies  to extract  all  relevant  information.  Thematic  analysis involves  searching  for  themes  and  thus  is  a  method used  to  identify,  analyze,  and  report  on  the  themes found  within  the  data.  It  is  a  tool  that  is  used  to organize the data in detail (24).

Screening of titles by

two authors; 572

papers rejected The analysis followed five steps: 1) the identification of all  relevant information;  2)  the  listing of this information  (sentences  pulled  from  the  articles);  3) the  coding  and  summarization  of  this  information into  a  simpler  format;  4)  the  categorization  of  the different  codes  by  theme;  and  5)  the  further  review and  refining  of  the  themes  to  determine  the  main factors. Finally, coded material was quantified via the enumeration of the occurrences of each theme. In this integrative  systematic  review,  the  themes  determined by the thematic analysis are the presenting factors on which focus will be placed.

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## Basic Characteristics of the Studies

One  of  the  studies  used  a  mixed  research  method (25),  whereas  the  rest  (n  =  16)  used  quantitative research  methods.  The  majority  of  the  studies  (n  = 13)  examined  adherence  to  medication  (25-37),  and one  study dealt with  treatment engagement  (38). Three studies investigated the outcomes of treatment and  adherence  (39-41),  and  one  study  focused  on adherence to therapy (32).

TABLE 1 . Summary of Factors

|                                          | Bernstein et al, 2000   | Bobier and Warwick, 2005   | Coletti et al, 2005   | DelBello et al, 2007   | Fontanell a et al. 2011   | Ghaziudd in et al, 1999   | Granboul an et al, 2001   | King et al, 1997   | Moses, 2011   | Munson et al, 2010   | Patel et al, 2005   | Pogge et al, 2005   | Schimmel mann et al, 2006   | Steiner al,   | et 1990 Stewart and Baiden, 2013   | Townsen d et al, 2009   | Woldu et al, 2013   |
|------------------------------------------|-------------------------|----------------------------|-----------------------|------------------------|---------------------------|---------------------------|---------------------------|--------------------|---------------|----------------------|---------------------|---------------------|-----------------------------|---------------|------------------------------------|-------------------------|---------------------|
| Adolescent's cooperation (positive/poor) | 0                       | 0                          | 0                     | 0                      | 0                         | 0                         | -                         | 0                  | +(m)          | +                    | 0                   | +(m)                | 0                           | 0             | 0                                  | 0                       | 0                   |
| Intensity of treatment                   | 0                       | 0                          | +(m)                  | 0                      | 0                         | 0                         | +*                        | 0                  | +(m)*         | 0                    | 0                   | +*                  | 0                           | 0             | 0                                  | 0                       | 0                   |
| Positive attitude                        | 0                       | 0                          | 0                     | 0                      | 0                         | 0                         | 0                         | 0                  | 0             | +                    | 0                   | +(m)*               | 0                           | +             | 0                                  | +(m)                    | 0                   |
| Efficacy of medication                   | -                       | 0                          | 0                     | -                      | 0                         | -                         | 0                         | 0                  | +*            | 0                    | +                   | +                   | 0                           | +             | 0                                  | 0                       | +                   |
| (helpfulness/unhelpfulness)              |                         |                            |                       |                        |                           |                           |                           |                    | -             |                      |                     |                     |                             |               |                                    |                         |                     |
| Acceptance of medication                 | 0                       | 0                          | 0                     | 0                      | 0                         | 0                         | 0                         | 0                  | +             | 0                    | 0                   | 0                   | 0                           | 0             | 0                                  | 0                       | 0                   |
| Effectiveness of adherence/ nonadherence | 0                       | 0                          | 0                     | 0                      | 0                         | 0                         | 0                         | -*                 | 0             | 0                    | 0                   | +* -(m)*            | 0                           | +*            | 0                                  | 0                       | +                   |
| Higher socioeconomic status              | x(m+t)                  | 0                          | 0                     | +(m)                   | 0                         | x(m)                      | x                         | +(m)               | 0             | 0                    | 0                   | 0                   | 0                           | x             | x                                  | 0                       | 0                   |
| Higher incomes                           | 0                       | 0                          | 0                     | 0                      | 0                         | 0                         | 0                         | 0                  | 0             | +(m+t)*              | 0                   | 0                   | 0                           | 0             | 0                                  | 0                       | 0                   |
| Higher severity of symptoms              | 0                       | 0                          | 0                     | 0                      | 0                         | 0                         | +*                        | -*                 | 0             | +                    | 0                   | 0                   | -                           | 0             | -*                                 | 0                       | 0                   |
| Lower severity of symptoms               | 0                       | 0                          | 0                     | 0                      | 0                         | 0                         | 0                         | 0                  | 0             | 0                    | 0                   | 0                   | -*                          | +             | 0                                  | 0                       | 0                   |
| Diagnoses                                | -(m+t)                  | 0                          | 0                     | -(m)*                  | 0                         | x(m)                      | 0                         | x(m+t)             | -(m)          | 0                    | 0                   | -(m) (A) x(m)       | - (B) x                     | +(C) x        | 0                                  | 0                       | 0                   |
| Readmission                              | 0                       | -(m)*                      | 0                     | 0                      | 0                         | 0                         | 0                         | 0                  | 0             | 0                    | 0                   | 0                   | 0                           | 0             | -*                                 | 0                       | 0                   |
| Risk-taking behavior                     | 0                       | 0                          | 0                     | 0                      | 0                         | 0                         | +* (D)                    | 0                  | x(m)          | 0                    | 0                   | 0                   | -                           | 0             | -*                                 | 0                       | 0                   |
| Side effects of medication               | x                       | 0                          | 0                     | 0                      | 0                         | -                         | x 0                       | 0                  | -             | 0                    | 0                   | x                   | x (E) 0                     | 0             | -                                  | 0                       | 0                   |
| Lack of need for medication              | 0                       | 0                          | 0                     | 0                      | 0                         | 0                         | 0                         | 0                  | -*            | 0                    | 0                   | -                   | 0                           | 0             | -*                                 | 0                       | 0                   |
| Low family/close friend solidarity       | -(m+t)                  | 0                          | 0                     | 0                      | 0                         | 0                         | x (F)                     | -(m+t)*            | 0             | 0                    | 0                   | 0                   | -*                          | 0             | -*                                 | 0                       | 0                   |
| Mother's mental symptoms                 | 0                       | 0                          | 0                     | 0                      | 0                         | 0                         | 0                         | -(m+t)*            | 0             | 0                    | 0                   | 0                   | 0                           | 0             | 0                                  | 0                       | 0                   |
| Parent/family support                    | 0                       | 0                          | +(m+t)                | 0                      | 0                         | 0                         | -                         | ≤ *                | +(m)          | 0                    | 0                   | -(m)                | 0                           | 0             | 0                                  | 0                       | 0                   |
| Young age                                | x(m+t)                  | x(m)                       | x(m)                  | 0                      | +(m)* (G) x               | x                         | x                         | 0                  | x(m)          | -                    | 0                   | 0                   | x                           | x             | 0                                  | 0                       | -                   |
| Good education of adolescent/parent      | 0                       | 0                          | 0                     | 0                      | 0                         | 0                         | -                         | 0                  | +(m)          | +*                   | 0                   | 0                   | 0                           | 0             | 0                                  | 0                       | 0                   |
| Race                                     | x(m+t)                  | 0                          | 0                     | 0                      | 0                         | x(m)                      | 0                         | 0                  | 0             | 0                    | x(m)                | 0                   | 0                           | 0             | 0                                  | 0                       | 0                   |
| Gender                                   | x(m+t)                  | 0                          | 0                     | 0                      | 0                         | x(m)                      | x                         | 0                  | 0             | 0                    | 0                   | 0                   | x                           | x             | x                                  | 0                       | 0                   |
| Family structure                         | 0                       | 0                          | 0                     | 0                      | 0                         | x(m)                      | x                         | x                  | 0             | 0                    | 0                   | 0                   | 0                           | 0             | 0                                  | 0                       | 0                   |
| Medication type                          | 0                       | 0                          | 0 0                   | 0                      | 0                         | 0                         | 0                         | 0                  |               | 0                    | 0                   | 0                   | 0                           |               | 0 0                                |                         | -                   |
| Support of friends                       | 0                       | 0                          |                       | 0                      | 0                         | x                         | 0                         | 0                  | x(m) 0        | 0                    | x                   | x                   | x                           | 0 0           |                                    | 0 0                     | 0                   |
| Initiation of treatment                  | 0                       | 0                          | 0                     | 0                      | 0                         | 0                         | 0                         | 0                  | x(m)          | 0                    | 0                   | 0                   | 0                           | 0             | 0                                  | 0                       | x                   |
| History of mental symptoms or illness    | 0                       | x                          | 0                     | 0                      | 0                         | 0                         | x                         | 0                  | 0             | 0                    | 0                   | 0                   | x                           | x             | 0                                  | 0                       | 0                   |
| Symptoms/own feelings about symptoms     | 0                       | 0                          | 0                     | 0                      | 0                         | 0                         | x                         | 0                  | 0             | x                    | 0                   | x(m)                | x                           | x             | 0                                  | 0                       | x                   |
| School/work                              | x(m)                    | 0                          | 0                     | 0                      | 0                         | 0                         | 0                         | 0                  |               | 0                    | 0                   | 0                   | x                           | 0             | 0                                  | 0                       | 0                   |
|                                          |                         |                            |                       |                        |                           |                           |                           |                    | 0             |                      |                     |                     |                             |               |                                    |                         |                     |

Note. A, substance use disorder; B, with a diagnose of other psychoses; C, secondary diagnoses of depression; D, illicit drug use; E, substance use at baseline; F, Family relationships; G, on acute phase; m, medication adherence; m+t, adherence to medication and non-pharmacological treatment; +, positive relation; - , negative relation; x, not related; ≤, is related; * , significant p -value (≤ 0.01); 0, not mentioned Adolescents  were  outpatients  in  14  studies  (2526;28-34;36-37;39-41)  and  inpatients  of  a  psychiatric center or ward in 6 studies (27;29-30;33;35;38).

## Results

Detailed  information  about  positively  and  negatively related  factors  is  presented  in  Table  1.  Factors  have been  noted  with  '(m)'  if  there  is  a  relationship  to medication  treatment  and  with  '(m+t)'  if  there  is  a relationship to both medication and nonpharmacological treatment. However,  there is no specific  indicator  for  factors  that  are  related  to  nonpharmacological treatment only. The themes show the related factors, which are listed in the table.

## Related Factors

Adolescent's Positive Beliefs

These  beliefs  include  an  adolescent's  willingness  to undergo  treatment  and  his  or  her  acceptance  of treatment,  both  of  which  were  positively  associated with adherence. The willingness to undergo treatment includes  positive  cooperation,  intensity  of  treatment, and  positive  attitude.  The  acceptance  of  treatment includes  medication  helpfulness,  the  acceptance  of medication,  and  the  effects  of  adherence  (see  Table 1).

## Life Situation and Close Relationships

Life situation and close relationships includes socioeconomic factors, the cohesion of close people, and age and education. Socioeconomic factors include the socioeconomic status and income of the adolescent's  family.  The  cohesion  of  close  people encompasses the level of solidarity of family and close friends,  the  mother's  mental  health,  and  the  level  of support available from  parents and other family members. Age and education includes young age and good education (see Table 1).

## Adolescent's Illness and Feelings toward Treatment

This category includes an adolescent's symptoms and his  or  her  negative  feelings  toward  treatment. An adolescent's symptoms can be divided into higher and lower severities of symptoms, certain diagnoses, readmissions, and risk-taking behaviors (including the consumption of tobacco, alcohol, and drugs). Negative feelings are influenced by the side effects of the prescribed medication, the perceived unhelpfulness  of  the  prescribed  medication,  feelings that the prescribed medications are unnecessary, poor cooperation with the therapist, and the effects of nonadherence (see Table 1).

## Unrelated Factors

Adolescent's or Family's Life Situation and Social Environment

The life situation and the social environment include socioeconomic, demographic, and social environment factors.  Socioeconomic factors include school, work, and  socioeconomic  status.  Demographic  factors  can be  further  divided  into  race,  gender,  and  age.  Social environment  factors  include the structure of the family and the support of friends (see Table 1).

## Adolescent's Treatment and Illness

The adolescent or his or her family's treatment and illness category includes treatment and illness factors. Treatment can be further divided into medication type, initiation of treatment, and side effects. Illness factors include the adolescent's history of mental illness or its symptoms, risk-taking behavior (including tobacco, alcohol, or drug use; fighting; and absence without leave), certain diagnoses, and symptoms as well as his or her own feelings about those symptoms (see Table 1).

A summary of the main results is presented in Figure 2.

## Discussion

This  systematic  integrative  review  identified  factors that were related positively or negatively to adolescents' adherence to medication and nonpharmacological treatment in mental health and psychiatric  care.  The  main  factor  that  was  found  to improve adherence to treatment was the adolescent's positive beliefs about and therefore acceptance of the prescribed  treatment.  This  finding  is  in  accordance with those of Bollini and colleagues (42) for depressive adults; they reported that one key aspect of medication  adherence  is  acceptance  of  the  diagnosis and treatment. Passive acceptance in adults might be related to attitudes toward taking prescribed medication during inpatient treatment; however, attitudes can change after discharge (43). Adolescents prefer  to  be  treated  as  individuals  and  in  a  nonjudgmental manner-in other words, as people rather than  as  patients  (13,16).  This  type  of  treatment  may influence  the  desire  of  adolescents  to  participate  in the referred and prescribed regimens. For example, it has  been  suggested  that  more  contact  with  mental health  professionals  improves  treatment  adherence among  adolescents  (44)  and  that  better-scheduled appointments increase adherence (8). This Demographic factors (race gender)

Socioeconomis

factors

(school, work)

Troatment factors

(medication type, hatory of

symptoms, own teeing

about symptoms]

Social

erwireensont

(structure of Tanly)

FIGURE 2. Summary of Main Results

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suggestion is in line with the findings of this systematic  review,  in  which  adolescent's  own  will  to undergo  treatment  was  found  to  be  one  key  factor that supported adherence.

It  has  also  been  found  that  good  and  planned patient education has an important effect on medication adherence among patients in somatic care (45).  According  to  Gonzales  and  colleagues  (3),  a greater readiness to engage in treatment will improve short-term  adherence,  and  adherence  is  improved when the patient understands the potential benefits of treatment.  However,  a  young  person  with  mental illness  may  experience  individual  discrimination  or rejection in their social environment (46). It has been found that increases and decreases in depressed symptoms  immediately  after  treatment  changes  are related to patient expectations. Among adults, patients who continued to take antidepressant medications as well  as  those  who  were  switched  to  placebos  had higher mean  depression rating scale scores (47). However,  more  highly  motivated  patients  showed greater  responses  to  placebos  as  compared  with  less motivated  patients,  which  highlights  the  importance of the patient's own level of motivation (48).

An adolescent's negative feelings toward side effects, the perceived unhelpfulness of the medication,  and  the  patient's  poor  cooperation  with health care professionals undermine treatment Own Acceptanc adherence.  A  strong  working  alliance  between  adult patients  and  their  therapists  is  consistently  positively related to medication adherence by those with psychotic disorders (49). The presence of a cooperative attitude and insight into the illness process  are  some  of  the  main  factors  related  to medication  adherence  when  the  patient  is  well  (50). However, Bollini and colleagues (42) noted that, after patients knew  about expected side effects, their reactions were not particularly negative.

We  found  that  low  solidarity  among  the  family members or close friends of the patient had a negative influence on the adolescent's adherence to treatment. Families' experiences of caring for adult relatives with bipolar illness have been shown to indirectly influence the patient's medication adherence (51). However, in a study  of  schizophrenic  patients  (9),  the  carer's knowledge  of  the  illness  was not  related to the patient's  adherence,  although  the  carer's  experienced emotions  were  related negatively to the patient's adherence.  Nevertheless,  parental  or  family  support was found to be both positively and negatively related to treatment adherence in this systematic review.

Different effects of severity of illness were reported with respect to their influence on treatment adherence. Increased severity of illness was associated with a higher risk of readmission among adolescents (13).  Sellwood  and  colleagues  (9)  found  that  overall symptom severity  was  not  related  to  non-adherence, but they also found that non-adherent patients tended to have more severe psychotic symptoms as compared  with  adherent  patients.  The  severity  of positive  psychotic  symptoms  was  not  significantly associated  with  adherence  (49).  Readmission  is  also negatively associated with adherence, because adherent patients have a reduced risk of rehospitalization (13).

Although our results showed socioeconomic status to  be  related  to  adherence  to  medication  in  two studies,  several  studies  have  stated  that  there  is  no such relationship. However, higher levels of education,  income,  and  socioeconomic  status  of  the family positively influence adult adherence (7). Bulloch and colleagues (2) have stated that age is not a predictor of non-adherence among adult patients and that, instead, forgetfulness is the main reason for poor adherence.

The  findings  of  this  systematic  integrative  review suggest that several factors can have either positive or negative  influences  on  an  adolescent's  adherence  to medication  or  non-pharmacological  treatment.  The inconsistent  findings  of  studies  of  this  subject  are probably partly explained by differences in the study characteristics, including  the treatment  settings of adolescent care and the types of prescribed treatment. In particular, whether adolescents are treated in inpatient or outpatient settings may influence adherence. Outpatients must take on more responsibility than inpatients in terms of taking their medication on time and attending scheduled meetings, and  this  may  reduce  treatment  adherence  among adolescents. Conversely, inpatient adolescents are assessed and monitored constantly by treatment staff, so it is easier to promote compliance. It is important to  bear  in  mind  that  inpatients  and  outpatients  have different conditions and treatment regimens that may contribute to the observed differences in adherence.

## Strengths and Limitations

The strengths of this systematic integrative review are that  it  involved  comprehensive  literature  searches with carefully determined selection criteria defined by the  two  authors  and  that  it  included  only  peerreviewed studies. This systematic literature search was based  on  four  databases:  MEDLINE,  CINAHL, PsycINFO, and Cochrane. One limitation may be that our  search  did  not  include  Embase,  with  another limitation  being  that  we  may  not  have  found  all relevant studies. A total of 12  articles were excluded because  their  full  text  was  not  available  or  because they  were  written  in  languages  that  neither  author could read nor fully understand. Although the search was  not  limited  to  only  those  studies  written  in English,  non-English  studies  could  not  subsequently be  used.  Some  studies  were  excluded  because  data related  to  adolescents'  adherence  were  mixed  with data for children or adults: our  review only included studies that had clearly reported adolescents' adherence. This should have increased the validity and reliability  of  our  review  by  ensuring  that  only  the factors  that  specifically  influenced  adherence  among adolescents  were  examined.  However,  the  extent  to which  the  factors  that  influence  adherence  among adolescents differ from those that influence adherence among children or adults may be somewhat debatable.

We  excluded  studies  that  focused  on  adolescents from the perspective of forensic or criminal psychiatry or that looked at adolescents who had been diagnosed with substance use problems, neuropsychiatric illnesses, or sexual problems to avoid including information about treatment adherence for conditions that are treated in very different ways. This decision was  made  in  an  effort  to  obtain  as  much consistent  and  generalized  research  information  as possible  about  adolescents'  treatment  adherence  in mental health and psychiatric care.  One of the main challenges  is  that  the  concept  of  adherence  varies both in the literature and across studies. We therefore tried  to  minimize  the  risk  of  obtaining  fragmented research information that applied to adolescents' treatment adherence for different mental illnesses and numerous treatment  methods.  The  exclusion  criteria for  this  systematic  review  can  thus  be  considered strengths, but they can be considered as limitations as well. It is possible that studies that investigated illnesses that many adolescents may have (e.g., attention-deficit/hyperactivity disorder) or that looked at adolescents in forensic psychiatry may have been  missed.  However,  forensic  psychiatry  and  the treatment of all neuropsychiatric illnesses can be quite different  as  compared  with  general  mental  health treatment or psychiatric care. We made a purposeful decision not to select one or two illnesses of adolescents  from  the  exclusion  areas,  in  order  to  be consistent with decided criteria.

This systematic integrative review was conducted in accordance with the guidelines of the Preferred Reporting  Items  for  Systematic  Review  and  MetaAnalyses  (52).  However,  the  protocol  that  was  used has not been published previously. The current study sought  to  gather  information  about  specific  factors related  to  both  medication  and  non-pharmacological treatment  among  adolescents  in  mental  health  and psychiatric care. The decision to separate adolescents'

medication and  non-pharmacological  treatment to investigate  these  treatments  individually  is  a  strength of  this  systematic  literature  review,  because  these treatment forms are different. Here, medication treatment  includes  prescribed  medication  only  and therefore  adherence  to  medication  can  be  counted and  examined.  However,  non-pharmacological  treatment includes all other types of treatment, including appointments  for  different  therapies  with  different clinicians at different outpatient clinics as well as oneon-one sessions with health care specialists and inpatient treatment (excluding medication treatment). This  study  provides  detailed  information  about  the treatment adherence of adolescents who are receiving both outpatient and inpatient care.

## Clinical Significance and Conclusions

For prescribed treatment to be effective, it is essential for  the  adolescent  patient  to  accept  and  want  to undergo  the  treatment.  Good  social  cohesion  with close people also plays an important role. It is important  for  both  the  adolescent  and  his  or  her family  to  have  positive  feelings  about  the  treatment. By  identifying  the  factors  that  influence  treatment adherence,  this  systematic  review  may  serve  as  a source of guidance for  improving mental health and psychiatric  care  quality  and  for  increasing  adherence and treatment satisfaction among adolescents. Treatment staff  members are in the best position to establish active cooperation with adolescents and their families. Such efforts can improve adolescents' treatment  adherence,  thereby  accelerating  recovery, reducing  treatment  time,  and  preventing  relapses. When  treatment  staff  is  made  aware  of  the  factors related to adherence, treatment assessment and planning improve. An adolescent's adherence to treatment can thus also be improved, which accelerates recovery, reduces treatment time, and prevents relapse. The majority of the articles included in this systematic review investigated adolescents who were receiving outpatient care and discussed medication  adherence.  More  research  is  needed  to investigate adolescent's adherence to treatment during inpatient care, with concentration on both medication and non-pharmacological treatment.

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