Introduction
Neurotic disorders have no psychotic symptoms and cover a wide range of psychiatric conditions. Due to lack of a suitable study to assess the attitudes towards medication, adherence to medication therapy, and quality of life (QoL) in patients with neurotic disorders in Iran, this study aims to evaluates these factors in adults with neurotic disorders referred to the psychiatric clinic of Tehran Psychiatric Institute.
Methods 
In this study, participants were adult outpatients who referred to the psychiatric clinic of Tehran Psychiatric Institute for the first time who were selected based on the inclusion criteria (age 18-60 years, having a neurotic disorder diagnosed by the psychiatrist, and consent to participate in the study). They were aassessed at the beginning of the study, and 1 and 6 months after their first visit to the clinic by using a demographic form, the World Health Organization Quality of Life-BREF (WHOQOL-BREF) and the Drug Attitude Inventory (DAI-10). Their medication adherence was also assessed using the medication possession ratio.
Results
Of 100 participants, 76 were female and had a mean age of 35.9 years. In comparing the overall score of WHOQOL, a significant improvement was observed in the first and sixth months after the first visit compared to baseline (P<0.001) (Figure 1). Regarding the domains of WHOQOL, mental health and general health status in the first and sixth months were significantly better compared to baseline (P<0.001). Physical health trend during the study was ascending. It was significantly better in the sixth month than in the first month. The trend of social relationships during the study was ascending. It was significantly better in the first month compared to the baseline. Environmental health trend during the study was also ascending. It was significantly better in the first month compared to the baseline.
The number of patients with favorable medication adherence increased from 37 in the first month to 63 in the sixth month. The paired t-test results for the raw DAI score at baseline and in the sixth month showed a significant increase (from 3.56±0.5 to 5.29±0.49) (P<0.001). Comparison of WHOQOL score among patients with favorable and unfavorable medication adherence in three time points showed no significant difference (P=0.6) (Figure 2). Discussion 
The results of the present study, which evaluated the QoL, attitudes, and medication adherence of adult outpatients with neurotic disorders in Tehran, Iran, showed that in the sixth month after the first visit to the psychiatric clinic, QoL and its some domains as well as medication adherence and attitude towards medication were significantly improved in the outpatients. The physical and mental health domains were improved by medication therapy, but their social relationships and environmental health were less affected. There was no significant difference in QoL score between patients with favorable and unfavorable medication adherence. Based on the results of this study, it seems that medication therapy alone cannot improve all aspects of QoL in outpatients with neurotic disorders and their attitude towards medication; the use of psychosocial interventions along with medication therapy is recommended.

Ethical Considerations
Compliance with ethical guidelines
The current study was performed according to Helsinki Declaration and its revisions. All data gathered and analyzed anonymously after obtaining ethical approval from the Institutional Review Board of the Iran University of Medical Sciences (Code: IR.IUMS.FMD.REC.1398.121). The gathered data have been used only for research purposes and participants had been allowed to leave the study any time

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 

Authors contributions
Conception and planning: Somia Arabi Khalilabad, Shiva Soraya, Ali Kabir, Fatemeh Hadi and Mohammad Reza Shalbafan. Data collection: Samia Arabi Khalilabad, Sajjad Eftnejad and Mohammad Reza Shalbafan. Analysis and report of the results: Amirsina Homayoni, Ali Kabir and Mohammad Reza Shalbafan; The article was written by: Noushin Khadim al-Reza, Sajjad Efatnejad and Mohammad Reza Shalbafan. Review and final version: All authors.

Conflicts of interest
The authors have no conflicts of interest to report.


References

1. France J. Neurotic disorders. In: Gravell R, France J, editors.Speech and communication problems in psychiatry. Therapy in practice series. Boston: Springer; 1991. [DOI:10.1007/978-1-4899-2955-6_4]
2. Sharifi V, Amin-Esmaeili M, Hajebi A, Motevalian A, Radgoodarzi R, Hefazi M, et al. Twelve-month prevalence and correlates of psychiatric disorders in Iran: The Iranian Mental Health Survey, 2011. Archives of Iranian Medicine. 2015; 18(2):76-84. [PMID]
3. Asadi M, Rashedi V, Khademoreza N, Seddigh R, Keshavarz-Akhlaghi AA, Ahmadkhaniha H, et al. Medication adherence and drug attitude amongst male patients with the methamphetamine-induced psychotic disorder after discharge: A three months follow up study. Journal of Psychoactive Drugs. 2022; 54(1):18-24. [DOI:10.1080/02791072.2021.1883778] [PMID]
4. World Health Organization. Adherence to long term therapies: Evidence for action. Geneva: World Health Organization; 2003. [Link]
5. Bebbington PE. The content and context of compliance. International Clinical Psychopharmacology. 1995; 9(Suppl 5):41-50. [DOI:10.1097/00004850-199501005-00008] [PMID]
6. Ngoh LN. Health literacy: A barrier to pharmacist-patient communication and medication adherence. Journal of the American Pharmacists Association. 2009; 49(5):e132-46; quiz e147-9. [DOI:10.1331/JAPhA.2009.07075] [PMID]
7. Elliott RA, Marriott JL. Standardised assessment of patients’ capacity to manage medications: A systematic review of published instruments. BMC Geriatrics. 2009; 9:27. [DOI:10.1186/1471-2318-9-27] [PMID] [PMCID]
8. Berhe DF, Taxis K, Haaijer-Ruskamp FM, Mulugeta A, Mengistu YT, Burgerhof JGM, et al. Impact of adverse drug events and treatment satisfaction on patient adherence with antihypertensive medication-a study in ambulatory patients. British Journal of Clinical Pharmacology. 2017; 83(9):2107-17. [DOI:10.1111/bcp.13312] [PMID] [PMCID]
9. Nieuwlaat R, Wilczynski N, Navarro T, Hobson N, Jeffery R, Keepanasseril A, et al. Interventions for enhancing medication adherence. Cochrane Database of Systematic Reviews. 2014; 2014(11):CD000011. [DOI:10.1002/14651858.CD000011.pub4] [PMID] [PMCID]
10. Azadforouz S, Shabani A, Nohesara S, Ahmadzad-Asl M. Non-compliance and related factors in patients with bipolar I disorder: A six month follow-up study. Iranian Journal of Psychiatry and Behavioral Sciences. 2016; 10(2):e2448. [DOI:10.17795/ijpbs-2448] [PMID] [PMCID]
11. Barcaccia B. Quality of life: Everyone wants it, but what is it? [Internet]. 2013 [Updated 2013 September 4]. [Link]
12. Guyatt GH, Feeny DH, Patrick DL. Measuring health-related quality of life. Annals of Internal Medicine. 1993; 118(8):622-9. [DOI:10.7326/0003-4819-118-8-199304150-00009] [PMID]
13. Shariati B, Shabani A, Ariana-Kia E, Ahmadzad-Asl M, Alavi K, Mousavi Behbahani Z, et al. Drug attitude inventory in patients with bipolar disorder: Psychometric properties. Iranian Journal of Psychiatry and Behavioral Sciences. 2018; 12(3):e9831. [DOI:10.5812/ijpbs.9831]
14. Development of the World Health Organization WHOQOL-BREF quality of life assessment. The WHOQOL Group. Psychological Medicine. 1998; 28(3):551-8. [DOI:10.1017/S0033291798006667] [PMID]
15. Yousefy AR, Ghassemi GR, Sarrafzadegan N, Mallik S, Baghaei AM, Rabiei K. Psychometric properties of the WHOQOL-BREF in an Iranian adult sample. Community Mental Health Journal. 2010; 46(2):139-47. [DOI:10.1007/s10597-009-9282-8] [PMID]
16. Endriyani L, Chien CH, Huang XY, Chieh-Yu L. The influence of adherence to antipsychotics medication on the quality of life among patients with schizophrenia in Indonesia. Perspectives in Psychiatric Care. 2019; 55(2):147-52. [DOI:10.1111/ppc.12276] [PMID]
17. Lin CY, Chen H, Pakpour AH. Correlation between adherence to antiepileptic drugs and quality of life in patients with epilepsy: A longitudinal study. Epilepsy & Behavior. 2016; 63:103-8. [DOI:10.1016/j.yebeh.2016.07.042] [PMID]
18. Mapatwana D, Tomita A, Burns JK, Robertson LJ. Predictors of quality of life among community psychiatric patients in a peri-urban district of Gauteng Province, South Africa. The International Journal of Social Psychiatry. 2019; 65(4):322-32. [PMID]
19. Holubova M, Prasko J, Ociskova M, Vanek J, Slepecky M, Zatkova M, et al. Three diagnostic psychiatric subgroups in comparison to self-stigma, quality of life, disorder severity and coping management cross-sectional outpatient study. Neuro Endocrinology Letters. 2018; 39(4):331-41. [PMID]
20. Rezvanifar F, Shariat SV, Amini H, Rasoulian M, Shalbafan M. [A scoping review of Questionnaires on Stigma of Mental Illness in Persian (Persian)]. Iranian Journal of Psychiatry and Clinical Psychology. 2020; 26(2):240-56. [DOI:10.32598/ijpcp.26.2.2619.1]
21. Świtaj P, Grygiel P, Chrostek A, Nowak I, Wciórka J, Anczewska M. The relationship between internalized stigma and quality of life among people with mental illness: Are self-esteem and sense of coherence sequential mediators? Quality of Life Research. 2017; 26(9):2471-8. [PMID] [PMCID]
22. Zhang Y, Subramaniam M, Lee SP, Abdin E, Sagayadevan V, Jeyagurunathan A, et al. Affiliate stigma and its association with quality of life among caregivers of relatives with mental illness in Singapore. Psychiatry Research. 2018; 265:55-61. [DOI:10.1016/j.psychres.2018.04.044] [PMID]
23. Chan KKS, Fung WTW. The impact of experienced discrimination and self-stigma on sleep and health-related quality of life among individuals with mental disorders in Hong Kong. Quality of Life Research. 2019; 28(8):2171-82. [DOI:10.1007/s11136-019-02181-1] [PMID]
24. Ogunnubi OP, Olagunju AT, Aina OF, Okubadejo NU. Medication adherence among Nigerians with schizophrenia: Correlation between clinico-demographic factors and quality of life. Mental Illness. 2017; 9(1):6889. [PMID] [PMCID]
25. Ganesan S, Selvaraj N, Dass VK, Jayabalan N, Rajamohammad MA, Anandan I. Assessment of drug attitude, medication adherence and quality of life among psychiatric patients in South Indian population: A cross sectional study. International Journal of Basic & Clinical Pharmacology. 2019; 8(1):61–7. [DOI:10.18203/2319-2003.ijbcp20185159]
26. Velligan DI, Sajatovic M, Hatch A, Kramata P, Docherty JP. Why do psychiatric patients stop antipsychotic medication? A systematic review of reasons for nonadherence to medication in patients with serious mental illness. Patient Prefer Adherence. 2017; 11:449-68. [PMID] [PMCID]
27. Mousa MAEGA, Abd El-Dayem SM, Lachine OA. The effect of” drug compliance therapy” on compliance, attitude toward medication, and insight among hospitalized patients with psychotic disorders. Novelty Journals.2019; 6(2):408-22. [Link]
28. Kondrátová L, König D, Mladá K, Winkler P. Correlates of negative attitudes towards medication in people with schizophrenia. Psychiatric Quarterly. 2019; 90(1):159-69. [DOI:10.1007/s11126-018-9618-z] [PMID]
29. Dushad R, Mintu M, Samaksha PB, Basavana GH. A study of drug attitude and medication adherence and its relationship with the impact of illness among the mentally ill. Archives of Clinical Psychiatry (São Paulo). 2019; 46(4):85-8. [DOI:10.1590/0101-60830000000201]
30. Edgcomb JB, Zima B. Medication adherence among children and adolescents with severe mental illness: A systematic review and meta-analysis. Journal of Child and Adolescent Psychopharmacology. 2018; 28(8):508-20. [DOI:10.1089/cap.2018.0040] [PMID]