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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 5  |  Issue : 2  |  Page : 144-152

Development of a semi-structured instrument to assess religious beliefs and practices in patients with schizophrenia


Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission15-May-2021
Date of Decision06-Jun-2021
Date of Acceptance15-Jun-2021
Date of Web Publication28-Oct-2021

Correspondence Address:
Dr. Sandeep Grover
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aip.aip_70_21

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  Abstract 


Background: Religion plays an important role in the life of a large proportion of population. Various dimensions of religion and religiosity have not been thoroughly investigated in persons with schizophrenia. Aim: This study aimed to develop a simple instrument to assess various aspects of religiosity, which can influence the assessment and management of schizophrenia and evaluate the same in a group of patients, who are currently in clinical remission. Methodology: A simple semi-structured interview was developed to assess various dimensions of religion relevant to patients with mental illnesses. The questionnaire was administered to 100 patients with schizophrenia. Results: About two-thirds of the patients gave religious and supernatural explanations for their delusions, hallucinations, and other symptoms. More than three-fourth (78%) of patients reported that their religious beliefs influence their intake of the prescribed medications. The majority of the patients believed that God was helping them in dealing with their illness to some extent (29%) or very much (57%). About four-fifth (81%) of the patients attributed their illness to one religious or supernatural etiological cause. About two-fifths (39%) of the patients were first taken to a magico-religious faith healer at the onset of symptoms. In terms of treatment practices along with treatment from the tertiary care center, during the most recent relapse, the majority (82%) of the patients took recourse to at least one of the religious or supernatural modalities. Conclusion: The designed instrument provides a broad coverage of various aspects of religious practices which are prevalent in patients with schizophrenia. The use of this instrument in patients with schizophrenia suggests that religious beliefs and practices influence the type of psychopathology, etiological models about the illness, help seeking, and medication adherence.

Keywords: Religion, religiosity, religious practices, schizophrenia, supernatural beliefs


How to cite this article:
Grover S, Davuluri T, Chakrabarti S. Development of a semi-structured instrument to assess religious beliefs and practices in patients with schizophrenia. Ann Indian Psychiatry 2021;5:144-52

How to cite this URL:
Grover S, Davuluri T, Chakrabarti S. Development of a semi-structured instrument to assess religious beliefs and practices in patients with schizophrenia. Ann Indian Psychiatry [serial online] 2021 [cited 2021 Dec 6];5:144-52. Available from: https://www.anip.co.in/text.asp?2021/5/2/144/329433




  Introduction Top


Religion plays an important role in the life of a large proportion of persons, especially in the Indian context and the majority of the people follow one or other religion.[1] The importance of religion and spirituality increases, especially at the time of the crisis or ill health.[2] The religion can instill hope, purpose, meaning in the lives some of the suffers and in some, it induces spiritual despair.[3]

When it comes to mental health, religiosity, religious practices, and religious beliefs possibly play a more important role, especially in patients with severe mental disorders like schizophrenia and bipolar disorder.[4],[5],[6],[7],[8] Other factors, which are closely, linked to religion and religious practices include belief in supernatural powers such as influences of planetary influences (Grah Nakshatra), divine wrath (Devi-devtaka Prokop), spirit intrusion, horoscope, karma, evil spirits, and ghosts. It is well known that many patients with severe mental disorders attribute their symptoms to these factors.[5],[7],[8] In addition, the mental disorders are also attributed to factors such as punishment by God, God's will, breaching the taboos of god.[5],[7],[8] Some of the studies from India suggest that these beliefs and etiological factors are very common among patients with severe mental disorders and their caregivers.[5],[7],[8]

Studies among patients with schizophrenia suggest that religious and spiritual practices influence the content of the psychopathology.[4] In addition, religion/religiousness/religious practices in patients with schizophrenia also influence the risk of suicidal behavior, especially suicide attempts, substance use, psychosocial adaptation, and functioning, help-seeking, pathways to care, medication and treatment adherence, relapse rates, recovery, social integration, and quality of life, etc.[4]

Despite all this, in general, evaluation of religion/religiosity/religious practices/spirituality/spiritual practices receives very little attention in routine clinical practices. Assessment of these variables is mostly limited to understanding the religion to which patient belongs to and at best trying to understand their religious beliefs and practices to a certain extent.

In general, if one evaluates the available literature, it is evident that despite all these reported associations, the relationship of religion and schizophrenia has been under-studied, minimized, or ignored in mental health assessment, diagnoses, and treatment. Most of the available literature, on understanding the association of religion and spirituality is based on the use of quantitative rating scales, which do not tap many of the intricacies involved in understanding these issues.

There is no specific instrument to assess the association of various aspects of disorder such as schizophrenia and religiosity. In this background, this study aimed to develop a simple instrument to assess various aspects of religiosity, which can influence the assessment and management of schizophrenia.


  Methodology Top


This cross-sectional study was conducted in the outpatient setting of a tertiary care hospital. Ethics Committee of the institute approved the project, and the participants were inducted into the study after they provided written informed consent. This study aimed to evaluate the religiosity, the religious content of psychopathology, coping, supernatural beliefs, explanatory models, treatment-seeking behavior, illness outcome, and treatment adherence among patients with schizophrenia. One of the studies from the project is already published.[6] This study focuses on the semi-structured interview developed to assess various aspects of religiosity and its association with symptom manifestation, help seeking, and clinical management as part of the same study. The study was conducted during the period of January 2014 to June 2015.

Besides assessing the various aspects of religiosity and spirituality on structured scales, this instrument was developed to supplement the information collected on structured scales.

A questionnaire was specifically designed for this study, which can be administered by a semi-structured interview to assess various aspects of religious practices that are considered to be related to illness. The available instrument, i.e., supernatural belief questionnaire, was taken as a starting point, which mainly focuses on assessing the various etiological models and help seeking. The content and coverage by the instrument were decided, based on the available literature and carrying out focused group discussions (FGDs) among the three mental health professionals and then carrying out qualitative interviews with two patients and two caregivers of patients, in whom, it was considered that the religion and religious practices had a significant influence on the psychopathology and treatment practices. Initially, these patients and caregivers were interviewed by one of the mental health professionals, and based on the information generated, a draft questionnaire was developed, which was circulated to other mental health professionals. Later, three FGDs among the mental health professionals were held and a final instrument was designed. The same draft was again used, to evaluate another set of patients and their caregivers, and their feedback was taken, for the coverage of the instrument and what all can be added and deleted. This information was shared with the panelists, and finally, an instrument was accepted. When administering the interview, depending on the patient's responses, the clinicians have the freedom of asking further questions to make any conclusion about the various aspects of religious practices.

The aspects covered were religious and supernatural beliefs, the relationship of religious and supernatural beliefs with psychopathology, etiology about illness attributed to supernatural causes, the relationship of suicidal behavior and substance abuse/dependence with religious and supernatural beliefs, the relationship of religious and supernatural beliefs with medication intake, management of illness, first treatment contact and current treatment practices, perceived benefits from religious, supernatural and alternative treatments and type of advised received from religious places. The information on these aspects can be completed based on the information provided by the patients and review of treatment records.

The study included 100 patients diagnosed with schizophrenia. The diagnosis of schizophrenia was based on the Diagnostic and Statistical Manual-Fourth Revision, based on the Mini-International Neuropsychiatric Interview.[9] Additional inclusion criteria for the participants were age between 18 and 60 years, duration of illness ≥2 years and able to read Hindi and/or English. Besides these inclusion criteria, the patients were required to be clinically “stable.” Clinical stability was defined as an absence of “clear-cut exacerbation of symptoms in the past 3 months on anamnestic recall and scrutiny of medical records” and “on a stable dose of antipsychotics in the past 3 months, i.e., not more than 50% increase or decrease in the medication dosages during this period”. Patients with comorbid affective disorders, anxiety disorders, organic brain disorders, substance-use disorders, and intellectual disability were excluded.


  Results Top


Sociodemographic profile of the study sample

The mean age of patients was 35.6 years (standard deviation [SD]: 10.8; range: 21–60). There were more males (n = 56) than females. There was a nearly equal number of participants who were currently married (n = 49) and those who were currently unmarried (n = 51). The majority (n = 63) of the participants were on a paid job, were Hindus (n = 69%), from the urban locality (n = 64), and were from middle socioeconomic status (n = 86). Compared to those from nuclear families (n = 43), a higher proportion of the participants were from nonnuclear families (n = 57). The number of years of schooling was 11.7 years (SD: 4.4; range: 0–18). The age of onset had a mean of 24.2 years (SD: 7.97; range: 12–55), and the patients were ill for 137.5 months (SD: 101.6; range: 24–360) at the time of assessment. The participants had an average of 3.45 (SD: 2.6) relapses at the time of assessment. The mean PANSS positive subscale score was 11.6 (SD: 4.73; range: 7–24), negative subscale score was 12.3 (SD: 5.97; range: 7–28), general psychopathology subscale was 21.4 (SD: 7.07; range: 16–46), and the mean total PANSS score was 45.4 (SD: 13.9; range: 30–85). The mean GAF score was 79.5 (SD: 13.1; range: 45–99).

In terms of religiosity, about two-thirds of the patients believed very much in god since early childhood (n = 67) and continued to do so at the time of assessment (n = 67) [Table 1].
Table 1: Level of religiosity

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In terms of psychopathology, almost all patients had at least one or other delusion and the majority of them had one or more auditory hallucinations in the lifetime. The frequency of other symptoms was less [Table 1]. In terms of explanation for their symptoms, about two-thirds of the patients gave religious and supernatural explanations for their delusions, hallucinations, and other symptoms. Overall 80% or more patients gave religious or supernatural explanations for their delusions, hallucinations, and other symptoms [Table 1]. The exact proportion of patients who gave supernatural and religious explanations for various types of psychotic symptoms is given in [Table 2].
Table 2: Lifetime psychopathology with religion and supernatural explanations

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About three-fourths (n = 77) of the patients reported suicidal ideation in their lifetime, and one-fifth (n = 21) reported having attempted suicide. Overall, slightly more than half (n = 53) of the patients gave a religious explanation for not attempting suicide and self-harm and only a few patients (n = 5) gave a religious explanation for suicide attempt [Table 1].

Few patients were using or were dependent on one of the other substances, either at the time of assessment or in their lifetime. In terms of the effect of religion on substance use/dependence, two-fifths (45%) of the patients did not use the substances because of religious reasons [Table 1].

When the patients were asked about the usefulness of various treatment modalities for mental illness, 85% of patients reported that going to a religious place led to some relief in their symptoms and 79% believed that following the advice of a religious guru helps patients suffering from mental illness. More than half (56%) of the patients also believed that magico-religious treatments work in mental illness. However, very few believed that homeopathic (14%) and Ayurvedic (9%) treatments work for persons with mental illness.

Patients received various types of advice from religious places [Table 2].

More than three-fourth (78%) of patients reported that their religious beliefs influence their intake of the prescribed medications. One-tenth (10%) of the patients admitted to having stopped medications for religious reasons and a similar percentage (10%) of patients experienced a relapse of symptoms due to the stoppage of medications due to religious reasons.

The majority of the patients believed that God was helping them in dealing with their illness to some extent (29%)/very much (57%).

In terms of etiology for their symptoms/illness, 91% of patients attributed their illness to one of the listed causes. Further about four-fifths of the patients gave at least 2 or more listed causes, and the mean number of reported etiologies was 5.86 (SD: 4.3; range: 0–14). When the religious/supernatural explanations for symptoms were looked for, about four-fifths of the patients attributed their illness to at least one religious or supernatural etiological cause and three-fourth attributed their illness to more than one religious or supernatural etiological cause. The mean number of religious or supernatural etiological causes was 5.09 (SD: 4.1; range: 0–11) [Table 3].
Table 3: Etiology for the illness as reported by the patients

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First treatment contact after the onset of illness

About two-fifth (39%) of the patients were first taken to a magico-religious faith healer at the onset of symptoms, and overall three-fifths (60%) were taken to a faith healer or a religious place as the first treatment contact [Table 3].

Similarly, the majority of the patients reported that participating in religious community activities helps them in dealing with the illness to some extent (29%) or very much (57%). In terms of medical practitioner's focus on religious aspects, the majority of the patients reported that doctors “do not ask at all” (n = 81%) or “do not ask many questions” (n = 14%) to understand their religiosity, religious practices, and spirituality.

In terms of treatment practices (current and during most recent relapse) along with treatment from the tertiary care center, during the most recent relapse, a majority (82%) of the patients took recourse to at least one of the religious or supernatural modalities. Moreover, in addition to continuing their treatment from a tertiary care center, a majority (75%) of the patients were still following at least one of the religious or supernatural modalities of health care [Table 4].
Table 4: Treatment practices (current and during most recent relapse) along with treatment from the tertiary care center

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  Discussion Top


The present study aimed to develop a simple instrument to assess various aspects of religiosity, which can influence the assessment and management of schizophrenia.

Broadly speaking delusions and hallucinations of religious nature are categorized as those with religious and supernatural themes.[10] The religious delusions and hallucinations have a direct reference to organized religious themes (e.g. prayer, sin, possession) or religious figures (e.g., God, Jesus, devil, prophet). The supernatural delusions and hallucinations have more general mystic references (e.g., black magic, spirits, demons, being bewitched, mythical forces, ghosts, sorcery, and voodoo).[10] However, in the literature, description of delusions and hallucinations of either type is usually referred to as religious delusions. In the present study, an effort was made to separate the psychopathology with religious and supernatural themes. Overall, about two-third of the patients had at least one symptom with a religious theme, and slightly more than two-thirds of the subjects had psychopathology with the supernatural theme in their lifetime. Studies done among patients of schizophrenia suggest that the prevalence of religious delusions and hallucinations varies from country to country, and different studies have reported the prevalence rates of 6%–63.3%.[11],[12],[13],[14],[15] Findings of the present study suggest a slightly higher prevalence of religious delusions and hallucinations when compared to the existing data. However, this difference could be due to the fact that, in the present study the prevalence of delusions and hallucination with religious, and supernatural themes were assessed by taking the lifetime attribution of psychopathology to these themes, rather than restricting the attribution in the present context.

Studies that have evaluated the delusional themes of various religious/spiritual delusions report that the common themes are that of persecution (by malevolent spiritual entities), influence (being controlled by spiritual entities), and self-significance (delusions of sin/guilt or grandiose delusions.[16],[17] In the present study, also, delusions of persecution, reference, and grandiosity were the most common type of delusions with religious and supernatural themes. Among the hallucinations, auditory hallucinations of discussing type, commenting type, and commanding type were ascribed to the god or supernatural powers.

Researchers have shown that religion/religiousness in patients with schizophrenia is associated with a lower risk of suicide attempts,[3],[18] lower risk of substance use,[1],[19] and decreased rate of smoking.[20] The findings of the present study also support the fact that religiosity is associated with reduced risk of suicide attempts and substance abuse. More than half of the patients reported that they did not attempt suicide despite having suicidal ideations because of religious reasons. Similarly about half of the patients gave religion as a deterrent factor in not abusing any kind of substances. Accordingly, these findings suggest that religious-based psychosocial interventions may be useful in patients with schizophrenia in the prevention of suicide and also may be useful in those with a dual diagnosis.

According to the present study, three-fifth (60%) of the patients were first taken to a faith healer or a religious place after the onset of illness. This finding is in contrast to one of the previous study from this center which evaluated the pathways of care of newly registered patients with psychiatry walk-in-clinic and reported that more than half (53.2%) of the patient's had psychiatrist (Government set-up/Private set-up) and 23.8% of the patients had faith healers as their first treatment contact. Few patients (18%) first contacted a physician for their psychotic symptoms. However, findings of the present study are similar to some of the earlier studies from India.[21] A survey of consecutive psychiatric patients attending a hospital in Tamil Nadu, South India, showed that 58% of psychotic patients saw a religious healer before psychiatric consultation.[22] Some of the studies suggest that seeking religious help for mental disorders is often a first step in the management of mental disorders as a result of cultural explanations for the illness.[23] The finding of the present study is also supported by a study from Nigeria which showed that more than two-thirds (69%) of the subjects with psychosis seek their first help from traditional and religious healers.[24] These findings suggest that there is a need to improve collaboration between mental health-care facilities and traditional faith healers. Efforts should be made to educate the faith healer about the symptoms of mental illnesses so that these patients could be referred to appropriate treating agencies at the earliest to reduce the duration of untreated psychosis.

Studies from India show that many patients seek the help of faith healers to get rid of symptoms of illness,[7] and it has also been shown that indigenous healing methods are considered complementary to the medical management of mental illness.[25] Findings of the present study also suggest that in the most recent relapse, majority (82%) of the patients took recourse to at least one of the religious or supernatural modalities of treatment. Further, in addition to continuing their treatment from a tertiary care center, a majority (75%) of the patients were still following at least one of the religious or supernatural modalities of health care. In terms of the type of advice received from various religious places, four-fifth of the patients reported that they were advised to offer certain types of Puja and/or perform certain specific rituals. Another kind of advice included taking some ash powder (61%), tying a thread around the body (70%), tied a Tabeez (67%), and following some kind of exercises (49%). These findings suggest that mental health professional must be aware of this fact and rather than considering these to be contradictory should consider these as complementary.

In the present study, when patients were asked “Do you think God helps you in dealing with your illness” and “Does participating in religious community activities helps you in dealing with your illness?” majority of the patient either responded as “very much (57%)” or “somewhat (29%).” Only a few patients answered in the form of “not much (9%)” or “not at all (5%).” Studies from West also suggest that when given an option, the majority of the patients (85%) with mental illness request for religious assistance.[26] Accordingly, it can be said that there is a role of religious practices in reducing the distress of patients with schizophrenia.

Studies from the West suggest that half of the patients wish to share their religious concerns with their treating psychiatrist.[27] This suggests that there is a need for treating psychiatrists to inquire about the religious concerns of the patient. Although the same was not inquired as part of this study, when inquired “Do you think that your doctor asks you sufficient questions to understand your religiosity, religious practices, and spirituality,” majority of the patients answered this question as “not at all (81%)” or “not much (14%).” This possibly suggests that mental health professionals do not give much importance to the religious issues of their patients, and there is a need to incorporate the same in routine mental health-care practice.

Few studies have attempted to study the relationship of various aspects of religion with treatment adherence, and the findings are contradictory. Some studies suggest that religion/religiousness in patients with schizophrenia is associated with better treatment adherence with psychiatric treatment[3],[28],[29] whereas others suggest the association of religion with poor treatment adherence.[3],[30] In the present study, when specifically questioned about the relationship between religion and medication intake, 78% of patients reported that their religious beliefs influence their intake of the prescribed medications. Further, one-tenth of the patients admitted to having stopped medications for religious reasons, and a similar percentage of patients experienced a relapse of symptoms due to the stoppage of medications due to religious reasons. These findings suggest that there is a need to understand the religious beliefs of the patients of schizophrenia, and how much medication intake is compatible with it. If patients have beliefs that can lead to poor medication adherence, the clinicians should devote enough time to understand these beliefs and address the same.

In the present study, in terms of etiological models for the symptoms of schizophrenia, about half of the patients attributed their illness to divine wrath (Devi Devta Prakop) and this was followed by the attribution of illness to planetary influences (Grah Nakshatra), sorcery/witchcraft (Jaadu Tona, bad deeds in a previous life (Karma), ghosts (Bhoot-Pret), spirit intrusion (Opari Kasar), and evil spirits (Buri Atma). Overall, about three-fourths of the sample attributed their symptoms to one of the above-stated causes. Studies from different parts of the world that have evaluated the explanatory models of illness held by the patients with schizophrenia also suggest that many patients have nonmedical explanations for their illness.[8],[31],[32],[33],[34],[35] Most of the nonmedical explanations across different studies pertain to the supernatural causes. The different explanation includes obsession by witches or jinns,[35] esoteric,[31] spiritual and mystical factors,[36] family trouble, inner problems of self, economic difficulties, supernatural forces,[37] sorcery, ghosts/evil spirit, spirit intrusion, divine wrath, planetary/astrological influences, dissatisfied or evil spirits, and bad deeds of the past.[38] The findings of the present study also support the same. A study from India reported that about 66%–70% of the patients have at least one non-biomedical explanatory model of supernatural type as assessed on supernatural belief questionnaire.[8] The findings of the present study also support the same.

This study has certain limitations. The study was conducted among the patients attending a General Hospital Psychiatry Unit of a tertiary care unit. Hence, the results cannot be generalized to other patient populations. This study was limited to clinically stable patients and the findings may not apply to those with acute illness.


  Conclusion Top


This study aimed to develop a semi-structured interview to assess the various dimensions of religious practices, which are common in patients with various mental illnesses. The instrument developed as part of the study was used in patients with schizophrenia. The use of instruments in patients with schizophrenia suggests that religious beliefs and practices influence the type of psychopathology, etiological models about the illness, help seeking, and medication adherence. In terms of psychopathology, findings of the present study suggest that delusions with religious and supernatural themes are highly prevalent among patients with schizophrenia. Religion also has a protective role in suicidal behavior and substance abuse in patients with schizophrenia. Patients with schizophrenia attribute their illness to multiple etiologies, with karma-deed-hereditary-god-supernatural causes being the most common. Findings of the present study also suggest that for the majority of the patients, the first contact is with a traditional healer rather than mental health professionals. Despite this, all this majority of the patients expressed that clinicians do not ask sufficient questions to understand their religiosity, religious practices, and spirituality. Keeping these things in mind, it can be said that there is a need for the clinicians to change their approach concerning the assessment of religious beliefs and practices of patients with schizophrenia. Accordingly, for providing holistic care of the patients, clinicians should inquire about the religiosity, religious practices, and religious needs of the patients. They should encourage the patients to discuss the religious issues and preferably avoid contradicting the religious beliefs and practices, until and unless the clinicians are convinced that these can be detrimental to the patient. If the patient is attending a religious place or faith healer, rather than advising blanket no to these practices, the clinicians to evaluate these issues in detail, discuss the pros and cons of these practices, and need to continue the medications along with the religious practices. Clinicians should also improve their knowledge about religious and spiritual issues so that they can guide the patients to choose effective measures and curtain the use of ineffective measures.

Religion plays an integral role in the lives of a majority of the people around the world, with India being no exception. The findings of this study emphasize the importance of religion among patients with schizophrenia. These findings also suggest that psychiatrists should not turn a blind eye toward the role of religion in the patients' lives. Incorporation of elements of religion in the management of patients with schizophrenia will lead to an improvement in the holistic care of these patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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