Method:
The
study sample of 56 schizophrenic patients was drawn from the Register of
Behman Hospital, an established psychiatric hospital on the outskirts of
Cairo, Egypt. The hospital accepts referrals from various counties in
Egypt as well as some Arab countries and is renowned for its high
standards of care and records keeping and is also recognized by the
Royal College of Psychiatrists for professional training.
Selection
of subjects:
In
this case-control study, 28 cases [schizophrenic patients who
received spiritual healing] were compared to 28 controls, also
schizophrenic patients who did not receive spiritual healing, in respect
of the occurrence of relapses during a specified period (January to
December 1996).
All
subjects, cases and controls, were
schizophrenic patients,
on the Behman Hospital Register, attending regularly at the outpatient
department under the care of two consultants who confirmed, in the case
notes, that all patients selected in the study received antipsychotic
medication and were in remission during the latter part of 1995 prior to
relapse of their illness in
1996. Antipsychotics were given, orally, depot injections or both.
It was not possible to ascertain that illicit drugs were not used
by these patients prior or during the relapse.
Cases
and controls were matched
for age, sex and duration
of illness. In this
study a relapse was included when a patients developed a new
episode of schizophrenia that required hospital admission, following a
three month period of stable remission period for cases and controls.
The
clinical diagnosis of schizophrenic
disorder satisfied the ICD 10
criteria and cases included all patients aged between 16
and 65 who reported any form of religious healing regardless of its
nature, method or religious affiliation of patients.
Spiritual healing included; use of prayers, reading
versus of the Koran or the Bible as a form of counselling based
on religious relevance,
attending excessively at Mosques or Churches for solitary or individual
meditations, attending sessions that included the use of witchcraft or
related methods and attending rituals including exorcism and Zar
processions.
Cases
were exclude if :
1.
Relapse was due to stopping medication.
2.
Relapse induced by illicit drug
misuse
3.
Physical illness or organic brain disease prior and related to relapse.
4.
Religious delusions
prior to
relapse .
Data
Collection:
Information
about cases and controls were extracted from case notes by a single
doctor who was a qualified psychiatrist, using a standard format.
Data was collected on all patients who were reported to have used
any form of religious healing while in remission during the last 3
months of 1995, some of whom required admission to Behman Hospital at
least once during 1996.
Details
about spiritual healing in the study was restricted because of various
constraints, including attitudes of patients and relatives at the time
of admission to hospital towards expressing their religious beliefs.
It was very difficult at initial stages to collect homogenous
information. There ia a big diversity about religious backgrounds, types
of religions, living in rural or urban areas and the nature of spiritual
healing itself. In
order to avoid the bias that patients had seen or not a religious healer
prior to relapse, attempt was made to include the following items in the
data collected, No. of visits to a religious healer prior to relapse,
number of relapses and the attendances to religious healers not followed
by relapses. These however, proved to be difficult to collect, because
of the quality of referrals to the Behman Hospital
as
a majority of these would be followed by other psychiatrists located in
the areas patients were referred from.
In
almost all cases spiritual healing was carried out through reading
versus from the Koran or the Bible i.e: some form of psychotherapy based
on religious relevance. For homogeneity of data collection in the
report, extremes of religious healing such as Zar and spiritual
possession was included under exorcism .
Collected
information included:
socio-demographic variables, illness history including age of onset,
duration of condition and
length of last remission. Detailed
account of religious beliefs and use of spiritual
healing prior to relapse was also collected.
The
reliability of the data collection questionnaire was tested prior to its
formal use by comparing information collected by 2 independent doctors
and was shown to be reliable (Kappa= 0.6
P<0.05).
Statistical
analysis:
Significance
levels were decided at the 5% level using Pearson's chi-square for the
categorical variables and two sample t test and Mann-Whitney U - test
for interval variables. Univariate
odds ratio as an estimate of relative risk with 95% CI was computed
using two by two tables.
Outcome
measure:
Odds
Ratio
as a measure of relative risk was used in this study to assess the
strength of association between spiritual healing and
occurrence of relapse. Odds ratio is a measure of the likelihood
ie more or less likely,
an outcome such as having a relapse would occur after receiving
spiritual healing.
The
odds ratio is computed using 2x2 table as follows:
Spiritual
healing
Yes
No
|
Relapse
|
a
|
b
|
|
No relapse
|
c
|
d
|
Odds Ratio =
(a ) x (d) / (c) x(b)
Odds
ratio of
1 indicates
no risk
whereas odds ratio (OR) less than one means a reduced risk and OR
greater than one is indicative of an increased risk. Odds ratios will be presented with 95% confidence interval
and test of significance (Chi-square) at 5 % level of significance.
In
view of the small number of cases and skewed distribution for most
variables, logistic regression was used to assess the association
between relapse and spiritual healing as a well as other variables,
simultaneously controlling for potential confounders.
From
the logistic regression equation, probability of a binary outcome:
Log
odds
(OR) Schizophrenic relpase = Constant
+ B1X1 + B2X2.+.....BnXn
where
X is the variable to be explored and B is its regression coefficient.
The odds ratio were computed as exp(B), where B is the regression
coefficient for the variable of interest, adjusted for age, sex,
duration of illness, education, marital state, length of remission prior
to relapse and depth of religious beliefs. Statistical analysis was
carried out using SPSS (version 5).
Results:
Of
the total sample, twenty eight were cases and twenty eight controls with
43 (77%) male and 13 (23%) were female patients. Thirty seven (66%) were
single, 15 (27%) were married and 2 (3.6) were either divorced or
widowed.
Mean
age was 37.4 (Sd 10) with a minimum of 18
and a maximum of 63 years .
There was no significant difference between mean age of male and
female patients in cases
and controls (P>0.05). Mean
duration of illness for the entire study population was 10 years (Sd 8)
with a minimum < 1 year and a maximum of 33 years.
The
duration of illness did not differ significantly between patients who
did or did not use spiritual healing (P> 0.05).
Although
cases and controls were in remission for three months before the study,
we were not able to compare the last duration of stable remission prior
to 1995 due to the unavailability of such data for some patients.
Four patients had no medication (drug hoildays) prior to the
relapse, while 22 (39.3%) received phenothiazine,
11 (20%) received Butyrophenones, 12 (21%) received Thioxanthines
and 7 (13%) received Benzamides and atypical antipsychotics, with no
significant difference between cases and controls P>0.05.
There
was no significant difference between those who reported life events
preceding relapses and those who did not in cases and controls
(P>0.05).
Four
patients reported to have no religious beliefs compared to 31 (55%) who
reported moderate religious beliefs (belief and occasional practice i.e:
attendance to religious
places or events at least once a month ) and 21 (37%) who were said
to harbour deep religious beliefs (belief and regular practice
i.e. : attendance to religious places or events at least once a week). There was
no significant difference between cases and controls in the reported
depth of religious beliefs (P>0.05).
Of
the 28 cases who reported to have received some form of religious
therapy while in remission prior to hospital admission,
13 (47%) received spiritual healing in the form of prayers,
reading versus of the Koran
or the Bible as a form of counselling based on religious relevance, 6 (21%) attended excessively Mosques or
Churches for solitary or individual meditations, 5 (18%) attended
sessions that included the use of witchcraft or related methods,
while the remaining 4 (14%)
attended rituals including exorcism and Zar processions.
Table
1 & Figure 1 show the calculation of relative risk using univariate
analysis was 2.6 P<0.05. Table
2 shows the odds ratio of
relapse after controlling for all other variables and potential
confounders in the study. The risk of relapse appeared higher at 4.3 (P<0.05) in
cases that reported use of Zar, excorcism and related methods. There was
an inverse association with age, suggesting a greater risk in younger
patients. Depth of
religious beliefs did not appear to have a statistically significant
association with the probability of relapsing (P>0.05).
Discussion:
A.
Methodological issues:
The
following methodological issues may have influenced the results and
should be considered when interpreting the study findings:
1.
The retrospective nature of the study and having to rely on case notes,
were in some cases, incomplete with missing variables may have led to
information bias. Also
having insufficient details about religious healing, methods, frequency
of use and number of healers, may have led to some degree of
misclassification of cases and controls, though this was likely to have
been a random rather than a differential one,
thus affecting cases as well as controls.
2.
Despite the considerable turnover of
patients at Behman Hospital, the study sample size was rather
modest and may suggest that some of the negative findings may have been
the result of Error II. The
small sample size is likely to reduce the power of study and limits its
inferential value.
3.
The varied quality in the documented religious history and the
presence of 2 main religions in Egypt, Islam and Christianity could have
affected the study findings, probably resulting in differential
misclassification of cases and controls.
B.
Interpretation of the findings:
Although
the relapse rate appears unexpectedly high for both groups, especially
when all subjects were under neuroleptic treatment, the study suggests
that a positive association may exist between having received some form
of spiritual healing and the risk of developing an acute relapse in
Egyptian schizophrenic patients.
However,
holding a 'religious belief' as such and independently of spiritual
healing, did not appear to
be a significant risk of relapse.
The
adjusted relative risk estimate (OR) at 3.5 means that cases who
received spiritual healing were three times more likely to relapse
compared to those patients who did not. The association appears to occur independently
but more significant in younger age group and certain methods of
healing such as Zar, witchcraft and excorcism. Seasonal variations in
relapses in patients who received religious intervention compared to
total monthly variations in hospital admissions, indicated that
seasonal variations alone can not explain the increased frequency of
relapses in these cases. In some cases, it is rather difficult to
ascertain that relapse actually occurred after the process of
spiritual healing and not before it i.e. the patient may have gone to
seek religious intervention as
a result of being unwell and not that the spiritual healing process
precipitated the relapse. Also it is possible that some of the
behaviours which appeared to be a form of spiritual healing such as
solitary meditation and excessive praying may have been symptoms of more
severe psychosis.
The
two main experiences that may occur during spiritual healing process and could
explain, at least partly, the observed association are:
1. mystical and contemplative states which involve a feeling
of communion
with the divine and 2.
ecstatic: with psychomotor overctivity, and dominant feelings are
excitement as seen in Zar processions.
Ecstasies include
possessions and
trances, glossolalia and
feelings of
being moved
by the
spirit. Both
states involve
the rejection
feelings of alienation
and disappointment
in interpersonal
relationships, and the construction of a more
gratifying reality.
In schizophrenia, there is a breakdown in the way the patient
thinks of the boundary between himself and the outside world so that he
can no longer accurately discriminate between the two.
Crossing the line
between the ego experience of "self" and failure to identify inner
experiences, could possibly be explained by 'thought dwelling' whether
initiated by the person's will or induced by spiritual healing.
It is possible that repetitive thinking and preoccupation leads a
predisposed person; schizophrenic patient in remission, into a vicious
circle of thoughts at the end of which he becomes trapped, thus
triggering off psychotic experiences. It is therefore possible to assume that in some
cases and under certain conditions, mystical experiences may precipitate
psychopathological states in some schizophrenic patients.
A
major problem in epidemiological studies dealing with schizophrenia such
as this study, is that they all make the assumption that schizophrenia
is a homogenous syndrome. However this is unlikely to be the case as
schizophrenia entails a variety of heterogeneous subgroups that differ
genetically, biochemically and psychopathologically. Therefore findings of one study may not be expected to
apply in all cases. Future
studies, from different countries, are necessary to support or reject
our findings.
Conclusion
The
study has found that spiritual healing to be positively associated with
relapse of schizophrenia in Egyptian patients.
The association appears to be independent of actual religion and
depth of religious beliefs but could be modified by age and method of
healing. The possibility
that some of the behaviours which appeared to be a form of spiritual
healing may have been symptoms of more severe psychosis, seem to suggest
that, at least in some cases, the association may have been an effect
rather than a cause of relapse.
The
study findings may suggest that religious history should be taken into
consideration when planning
future management of some patients.
*Correspondence:
18
Broughton Close, Grappenhall
Heys, Appleton,
Warrington WA4 3DR
References:
1
Lowenthal, K. and Goldblatt, V. (1993) family size and depressive
symptoms in orthodox Jewish women.
Journal
of Psychiatric Research, 27,3-10.
2
Campion, J. and Bhurga, D. (1994) "Religions healing in south
India", paper
presented
at World Association of Social Psychiatry Meeting (June 1994), Hamburg.
3
Teja,J. S., Khanna, B.C. and Subrahmanyam, T.S.(1970)
"Possession states inIndian patients", Indian Journal of Psychiatry
12: 71-87.
4
Verma, L. P., Srivastva, D. K. and Sahay, R. N. (1970) "Possession
syndrome" Indian Journal
of Psychiatry 12: 58-70.
5
Spilka, B., Hood, R.W. and Gorsuch, R.L. (1985) The Psychology of
Religion: An Empirical Approach, Prentice Hall, Englewood Cliffs, NJ.
6
Loewental, K. (1995) Mental
Health and Religion, Chapman & Hall, London.
Table 1
Risk Estimate (odds ratio)
Spiritual Healing
| |
Yes |
No |
Total |
|
Relapsed
|
23
|
18
|
41
|
|
Did
not Relapse
|
5
|
10
|
15
|
Relative Risk
Estimate OR :
2.6 (95%
Confidence: 0.9 - 9)
P<0.05
Figure
1
1
|
Table
2
Logistic
regression model
Schizophrenic
relapse following Spiritual
Healing in a sample of
Egyptian Schizophrenic
patients :
Dependent
variable: Relapse: (binary 1, 0)
|
Variables
|
B
|
S.E.
|
Sig
|
Exp
(B)
(Odds
ratio OR)
|
| Age
|
- 0.2098
|
0.1027
|
0.04
|
0.8
|
|
Duration
of illness
|
- 0.211
|
0.1233
|
0.8
|
1.02
|
|
Sex
(male)
|
2.2335
|
1.8807
|
0.2
|
1.33
|
|
Expressed
Emotions
|
0.4746
|
1.6794
|
0.7
|
1.03
|
|
Literacy
|
1.083
|
1.1552
|
0.5
|
1.4
|
|
Life
Events
|
- 2.1229
|
1.9940
|
0.8
|
0.9
|
|
Religious
beliefs
No
beliefs (R)
Moderate
beliefs
Deep
beliefs
|
0.6582
1.6051
|
0.7664
1.0023
|
0.3
0.1
|
1
1.2
1.4
|
|
Spiritual
Healing
No
(R)
Yes
|
7.5557
|
3.6263
|
0.03
|
1
3.5
|
|
Method
of Healing
Prayers
(R)
Solitary
meditation
Use
of Zar &
Excorism
|
3.7602
8.8562
|
2.5236
4.3467
|
0.07
O.01
|
1
1.6
4.3
|
R: reference Category
