Psychiatric Symptomatology and Medication Adherence in Type 2 Diabetes: Cross-Cultural Insights from Greece

Evangelos C.  Fradelos; Maria  Faka; Dimitra  Anagnostopoulou; Vissarion  Bakalis; Elizabeth  Uni; Aikaterini  Toska; Konstantinos  Skabardonis; Victoria  Alikari; Maria  Saridi

doi:10.56508/mhgcj.v9i1.371

Authors

Evangelos C. Fradelos Laboratory of Clinical Nursing, Department of Nursing, University of Thessaly, Larissa, Greece https://orcid.org/0000-0003-0244-9760
Maria Faka 1st Local Health Unit (TOMY) of Agios Georgios, Larissa, Greece
Dimitra Anagnostopoulou Department of Nursing, University of Thessaly, Larissa, Greece https://orcid.org/0009-0003-0304-9838
Vissarion Bakalis Department of Nursing, University of Thessaly, Larissa, Greece https://orcid.org/0000-0003-0834-8557
Elizabeth Uni Department of Nursing, University of Thessaly, Larissa, Greece; Touro University, Touro College of Pharmacy, New York, NY, USA https://orcid.org/0000-0001-9968-4366
Aikaterini Toska Laboratory of Clinical Nursing, Department of Nursing, University of Thessaly, Larissa, Greece https://orcid.org/0000-0002-6888-3394
Konstantinos Skabardonis Laboratory of Clinical Nursing, Department of Nursing, University of Thessaly, Larissa, Greece
Victoria Alikari Department of Nursing, University of West Attica, Egaleo, Greece https://orcid.org/0000-0003-1733-6208
Maria Saridi Laboratory of Clinical Nursing, Department of Nursing, University of Thessaly, Larissa, Greece https://orcid.org/0000-0002-3973-8091

DOI:

https://doi.org/10.56508/mhgcj.v9i1.371

Keywords:

Mental Health, Psychometric validation, Primary health care, Psychiatric symptomatology, Medication Adherence Reasons Scale (MARS), Medication adherence, Type 2 diabetes mellitus

Abstract

To read the full-text Open Access article and download the PDFs, please visit our Issue portal at Paradigm (Walter de Gruyter): https://reference-global.com/article/10.56508/mhgcj.v9i1.371

Introduction: Medication adherence in type 2 diabetes mellitus (T2DM) is influenced not only by clinical factors but also by psychological and interpersonal dimensions. Understanding the reasons for non-adherence is essential for designing individualized interventions.

Purpose: This study aimed to investigate medication adherence and its association with psychiatric symptomatology among community-dwelling patients with T2DM, and to translate, culturally adapt, and preliminarily evaluate the Greek version of the Medication Adherence Reasons Scale (MARS).

Methodology: A cross-sectional study was conducted with 107 adults with T2DM recruited from Primary Health Care services in Larissa, Greece. Data was collected through structured face-to-face interviews. Psychiatric symptomatology was assessed using the SCL-90-R, while medication adherence reasons were evaluated with the Greek version of the MARS. Descriptive statistics, Pearson correlations, Cronbach’s alpha, and Principal Component Analysis were performed.

Results: Participants reported generally low levels of reasons for medication non-adherence, with most MARS items concentrated at the lowest response category. PCA indicated a two-component solution explaining 51.5% of the total variance; however, the KMO value was marginally acceptable (0.50), suggesting cautious interpretation. Paranoid ideation showed the strongest and most consistent positive correlations with several MARS items. Depression, interpersonal sensitivity, phobic anxiety, and obsessive-compulsive symptoms were also significantly associated with selected non-adherence reasons, while somatization and hostility showed limited associations.

Conclusions: Medication adherence in T2DM appears to be shaped by psychological and interpersonal factors. The findings support the integration of mental health assessment into diabetes care and highlight the need for further validation of the Greek MARS in larger samples.

References

Ali, S. A., Salih, S. M., Abdelmola, A., Makeen, A. M., Solan, Y. M., Ali, M. M. M., ... Mahdi, M. (2024). Association of anxiety and depressive symptoms and treatment adherence among patients with type 2 diabetes mellitus in Jazan, Saudi Arabia: A cross-sectional study. Cureus, 16(3), e57021. https://doi.org/10.7759/cureus.57021 DOI: https://doi.org/10.7759/cureus.56068

Alotaibi, R. M., Alotaibi, A. S., Alotaibi, S. M., Al-Otaibi, M. S., Alharbi, A. F., & Almutairi, K. M. (2025). Effectiveness of nurse-led educational interventions on medication adherence among patients with diabetes: A systematic review. The Review of Diabetic Studies, 21(1), 747–757. https://doi.org/10.1900/RDS.2025.21.747

Banday, M. Z., Sameer, A. S., & Nissar, S. (2020). Pathophysiology of diabetes: An overview. Avicenna Journal of Medicine, 10(4), 174–188. https://doi.org/10.4103/ajm.ajm_53_20 DOI: https://doi.org/10.4103/ajm.ajm_53_20

Dai, E., Bakalis, V., Toska, A., Saridi, M., Papagiannis, D., Albani, E., Malli, F., & Fradelos, E. C. (2023). Assessment of depression and anxiety in patients with type 2 diabetes and their correlation with adherence to the Mediterranean diet and physical activity level. Hellenic Journal of Nursing, 62(4), 99–114.

Derogatis, L. R. (1983). SCL-90-R: Administration, scoring and procedures manual II. Clinical Psychometric Research.

DiMatteo, M. R., Lepper, H. S., & Croghan, T. W. (2000). Depression is a risk factor for noncompliance with medical treatment: Meta-analysis of the effects of anxiety and depression on patient adherence. Archives of Internal Medicine, 160(14), 2101–2107. https://doi.org/10.1001/archinte.160.14.2101 DOI: https://doi.org/10.1001/archinte.160.14.2101

Donias, S., Karastergiou, A., & Manos, N. (1991). Standardization of the symptom checklist-90-R rating scale in a Greek population. Psychiatriki, 2, 42–48.

Hao, L. N., Ma, X. W., Kang, L. N., Wang, Y. Y., & Shi, H. (2025). Beyond glycemic control: A holistic perspective on psychosocial support in outpatient diabetes management. Frontiers in Endocrinology, 16, 1708620. https://doi.org/10.3389/fendo.2025.1708620 DOI: https://doi.org/10.3389/fendo.2025.1708620

Hisan, U. K., Widjanarko, B., Sriatmi, A., & Shaluhiyah, Z. (2025). Association between depression and medication adherence in noncommunicable diseases: A narrative review. Korean Journal of Family Medicine, 46(4), 231–239. https://doi.org/10.4082/kjfm.25.0018 DOI: https://doi.org/10.4082/kjfm.25.0018

Kalra, S., Jena, B. N., & Yeravdekar, R. (2018). Emotional and psychological needs of people with diabetes. Indian Journal of Endocrinology and Metabolism, 22(5), 696–704. https://doi.org/10.4103/ijem.IJEM_579_17 DOI: https://doi.org/10.4103/ijem.IJEM_579_17

Kardas, P., Bennett, B., Borah, B., Burnier, M., Daly, C., Hiligsmann, M., Menditto, E., Peterson, A. M., Slejko, J. F., Tóth, K., Unni, E., & Ágh, T. (2024). Medication non-adherence: Reflecting on two decades since WHO adherence report and setting goals for the next twenty years. Frontiers in Pharmacology, 15, 1444012. https://doi.org/10.3389/fphar.2024.1444012 DOI: https://doi.org/10.3389/fphar.2024.1444012

Kwakye, A. O., Kretchy, I. A., Peprah, P., & Mensah, K. B. (2024). Factors influencing medication adherence in co-morbid hypertension and diabetes patients: A scoping review. Exploratory Research in Clinical and Social Pharmacy, 13, 100426. https://doi.org/10.1016/j.rcsop.2024.100426 DOI: https://doi.org/10.1016/j.rcsop.2024.100426

Latkin, C. A., Edwards, C., Davey-Rothwell, M. A., & Tobin, K. E. (2017). The relationship between social desirability bias and self-reports of health, substance use, and social network factors among urban substance users in Baltimore, Maryland. Addictive Behaviors, 73, 133–136. https://doi.org/10.1016/j.addbeh.2017.05.005 DOI: https://doi.org/10.1016/j.addbeh.2017.05.005

Liu, J. (2025). The impact of chronic diabetes on the mental health of middle-aged and elderly people: Mechanisms and intervention strategies. Theoretical and Natural Science, 141(1), 234–238. https://doi.org/10.54254/2753-8818/2025.AU27978 DOI: https://doi.org/10.54254/2753-8818/2025.AU27978

Osborn, C. Y., & Egede, L. E. (2012). The relationship between depressive symptoms and medication nonadherence in type 2 diabetes: The role of social support. General Hospital Psychiatry, 34(3), 249–253. https://doi.org/10.1016/j.genhosppsych.2012.01.015 DOI: https://doi.org/10.1016/j.genhosppsych.2012.01.015

Sahoo, J., Mohanty, S., Kundu, A., & Epari, V. (2022). Medication adherence among patients of type II diabetes mellitus and its associated risk factors: A cross-sectional study in a tertiary care hospital of Eastern India. Cureus, 14(12), e33074. https://doi.org/10.7759/cureus.33074 DOI: https://doi.org/10.7759/cureus.33074

Sebastian, M. J., Khan, S. K., Pappachan, J. M., & Jeeyavudeen, M. S. (2023). Diabetes and cognitive function: An evidence-based current perspective. World Journal of Diabetes, 14(2), 92–109. https://doi.org/10.4239/wjd.v14.i2.92 DOI: https://doi.org/10.4239/wjd.v14.i2.92

Seghatoleslam, T., Ardakani, A., Habil, H., & Rashid, R. (2022). Comorbidity of mental disorder in patients with chronic disease: A comparative study of heroin dependence patients and diabetes mellitus patients. Iranian Journal of Public Health, 51(1), 142–150. https://doi.org/10.18502/ijph.v51i1.8305 DOI: https://doi.org/10.18502/ijph.v51i1.8305

Shukla, M., Schilt-Solberg, M., & Gibson-Scipio, W. (2025). Medical mistrust: A concept analysis. Nursing Reports (Pavia, Italy), 15(3), 103. https://doi.org/10.3390/nursrep15030103 DOI: https://doi.org/10.3390/nursrep15030103

Stewart, S. J. F., Moon, Z., & Horne, R. (2023). Medication nonadherence: Health impact, prevalence, correlates and interventions. Psychology & Health, 38(6), 726–765. https://doi.org/10.1080/08870446.2022.2144923 DOI: https://doi.org/10.1080/08870446.2022.2144923

Unni, E. J., & Farris, K. B. (2015). Development of a new scale to measure self-reported medication nonadherence. Research in Social & Administrative Pharmacy: RSAP, 11(3), e133–e143. https://doi.org/10.1016/j.sapharm.2009.06.005 DOI: https://doi.org/10.1016/j.sapharm.2009.06.005

Unni, E. J., Olson, J. L., & Farris, K. B. (2014). Revision and validation of Medication Adherence Reasons Scale (MAR-Scale). Current Medical Research and Opinion, 30(2), 211–221. https://doi.org/10.1185/03007995.2013.851075 DOI: https://doi.org/10.1185/03007995.2013.851075

Unni, E. J., Sternbach, N., & Goren, A. (2019). Using the Medication Adherence Reasons Scale (MAR-Scale) to identify the reasons for non-adherence across multiple disease conditions. Patient Preference and Adherence, 13, 993–1004. https://doi.org/10.2147/PPA.S205359 DOI: https://doi.org/10.2147/PPA.S205359

Xu, H., & Chen, Q. (2025). The bidirectional influence between type 2 diabetes mellitus and the state of depression and anxiety. Journal of Affective Disorders, 386, 119467. https://doi.org/10.1016/j.jad.2025.119467 DOI: https://doi.org/10.1016/j.jad.2025.119467

Yang, H., Wu, F., Gui, M., et al. (2023). The role of medication adherence in the association between depressive symptoms and quality of life in older adults with type 2 diabetes mellitus. BMC Geriatrics, 23, 196. https://doi.org/10.1186/s12877-023-03929-8 DOI: https://doi.org/10.1186/s12877-023-03929-8

Yang, K., Fang, Y., He, J., & Li, J. (2025). Prevalence and risk factors of depression in patients with diabetes mellitus: A systematic review and meta-analysis. Frontiers in Endocrinology, 16, 1660478. https://doi.org/10.3389/fendo.2025.1660478 DOI: https://doi.org/10.3389/fendo.2025.1660478

Zolnierek, K. B., & DiMatteo, M. R. (2009). Physician communication and patient adherence to treatment: A meta-analysis. Medical Care, 47(8), 826–834. https://doi.org/10.1097/MLR.0b013e31819a5acc DOI: https://doi.org/10.1097/MLR.0b013e31819a5acc