The interactions between religion, religiosity, religious delusion/hallucination, and treatment-seeking behavior among schizophrenic patients in Taiwan

Abstract

Religion could influence the psychopathology, treatment-seeking behavior, and treatment outcome in schizophrenia, but the associations between these factors have never been explored thoroughly, and the data in Han-Chinese society are scarcer still. The current study recruited 55 schizophrenic patients to explore the relationship between religion, psychopathology with religious content, treatment-seeking behavior, and outcome. Subjects with religious delusions/hallucinations had lower scores on functioning and higher scores on religiosity. The higher religiosity scores were correlated with older age, longer duration of illness, religious affiliation, lower preference of psychiatric treatment, lower functioning score, and delusion/hallucination. As to treatment-seeking behavior, patients with religious affiliation showed less preference toward psychiatric treatment. Individuals with religious delusion/hallucination were more likely to receive magico-religious healing and not to be satisfied with psychiatric treatment. A more positive view of psychiatric treatment was predicted by lower religiosity score, higher satisfaction with psychiatric treatment, and lower years of education. The religiosity level seems not directly related to clinical severity, but it seems to be a better predictor of religious delusions/hallucinations than religious affiliation status. Patients with religious delusions/hallucinations did not necessarily have more severe psychopathology. There are different profiles associated with religious affiliation/religiosity and religious delusions/hallucinations in relation to treatment-seeking behavior among schizophrenia patients in Han-Chinese society.

Introduction

Spirituality and religious practices are salient in the lives of people suffering from psychotic disorders (Huguelet et al., 1997, Kirov et al., 1998, Koenig, 2001, Hilton et al., 2002, Redko, 2003, Yip, 2003, Mohr & Huguelet, 2004, Compton & Furman, 2005, Bartocci, 2006, Borras et al., 2007). Religions often provide patients with specific moral guidance about a variety of medical issues and prescribe rituals that are important to patients. Religious coping can be both positive and negative, and it can impact patient care (Sulmasy, 2009). The World Health Organization considers spirituality, religion, and personal beliefs as an important area in the evaluation of the quality of life (Culliford, 2002). However, spiritual and religious dimensions have yet to be fully considered in psychiatric research (Weaver et al., 1998, Mueller et al., 2001, Mohr & Huguelet, 2004). Nevertheless, in the past few years, a growing body of literature has explored the implications of religion and spirituality in the field of mental health (Koenig, 1998, Mohr & Huguelet, 2004, Hall et al., 2008).

The content of schizophrenic delusions and hallucinations is mostly influenced by the sociocultural background of the patients, and different cultural experiences of the individual can result in different delusional form and content (Mohr and Huguelet, 2004). In a transcultural study, religion is one of the sociocultural factors which may influence delusional themes (Kim et al., 2001). Religious delusions are of interest because they may have an impact upon an individual's health belief model (Kelly et al., 1987), and thus their adherence to treatment (Mohr and Huguelet, 2004). Religious delusions have also been associated with poorer outcome from treatment (Doering et al., 1998). People with religious delusion/hallucination were also more severely ill (Siddle et al., 2002). A few studies have examined how religion affects delusional thinking (Peters et al., 1999, Getz et al., 2001), and yielded inconclusive results. Peters et al. reported that the severity of delusions was associated with certain religious groups, yet they did not find a difference between a Christian and a nonreligious group. They also found that religious practices have been associated with a higher rate of religious delusions, but personal religiosity is not necessary for the development of religious delusions. Getz et al. (2001) found that religious affiliation may influence the frequency of religious delusions, but religious affiliation appears to be independent of the religious delusion severity.

Adherence to treatment has been recognized as a problem in schizophrenia, although understanding of the causes for nonadherence is incomplete (Fusion Medical Education, 2005). Some authors argued that supernaturally oriented folk belief in illness attribution could influence medication compliance and outcome via magico-religious healing practices (Wen, 1998, Kulhara et al., 2000). Furthermore, there was a link between delusional elaboration and magico-religious treatment (Kulhara et al., 2000).

Taiwan is a multi-religious society where 50% of the population have a religious affiliation (Executive Yuan, 2001). Magico-religious beliefs are frequently conjectured as causal explanations of mental illness, and consequently practices of magico-religious healers are often sought for initial treatment of mental disorders in Taiwan (Wen, 1998, Lin, 2002). In order to search for articles that assessed the clinical relevance of religion in schizophrenic patients in Han-Chinese society, we used the search terms religion, Chinese, and schizophrenia to explore the subject matter in PubMed and Medline. Results showed that only a few reports that described this subject in a population within the Han-Chinese culture (Wen, 1998, Yip, 2003, Yu & Chung, 2004, Furnham & Wong, 2007). In Yip's study, it was found that traditional Chinese religious beliefs and superstitions, such as fortune telling, Buddhist gods, historical heroic gods and ancestor worship, have an important influence on subjective psychotic experience, in particular, delusions and hallucinations (Wen, 1998, Yip, 2003). Another cross-cultural study showed that the Chinese had more negative attitudes toward and beliefs about the behavioral manifestations of schizophrenia than the British (Furnham and Wong, 2007). In addition, the Chinese held more religious and superstitious beliefs toward the causation and treatment of schizophrenia and would preferred the use of alternative medicine. However, the local data concerning the impact of religion upon schizophrenia are still sparse and descriptive in nature. For example, Wen (1998) reported that 75.6% of the first-episode schizophrenia cases in Taiwan sought help from shamans in shines; 78% went to temples to worship the deities of folk religion; 48% asked Taoist priests for spirit calling; and 25% of them described experiencing spirit possessing.

The existing data showed that religion could have an influence on the psychopathology, treatment-seeking behavior, as well as treatment outcome of psychotic disorders (Koenig, 1998, Bartocci, 2006), but the association between them has never been explored thoroughly. Therefore, we explored the relationship between religion, religious delusion/hallucination, treatment-seeking behavior, and outcome of schizophrenic patients by using comprehensive measurements. We aimed to (1) examine the attitude of the schizophrenic patients with respect to religious beliefs as well as its influence on psychopathology, treatment-seeking behavior, and outcome; (2) examine the religious delusion/hallucination (i.e., delusion or hallucination with religious content; see Methods section for detailed definition) of the patients and its impact on treatment-seeking behavior and outcome; and (3) determine the predictors of treatment preference of the patients.