Spirituality and religious practices among outpatients with schizophrenia and their clinicians

OBJECTIVES: Religious issues may be neglected by clinicians who are treating psychotic patients, even when religion constitutes an important means of coping. This study examined the spirituality and religious practices of outpatients with schizophrenia compared with their clinicians. Clinicians' knowledge of patients' religious involvement and spirituality was investigated. METHODS: The study sample included 100 patients of public psychiatric outpatient facilities in Geneva, Switzerland, with a diagnosis of nonaffective psychosis. Audiotaped interviews were conducted with use of a semistructured interview about spirituality and religious coping. The patients' clinicians (N=34) were asked about their own beliefs and religious activities as well as their patients' religious and clinical characteristics. RESULTS: Sixteen patients (16 percent) had positive psychotic symptoms reflecting aspects of their religious beliefs. A majority of the patients reported that religion was an important aspect of their lives, but only 36 percent of them had raised this issue with their clinicians. Fewer clinicians were religiously involved, and, in half the cases, their perceptions of patients' religious involvement were inaccurate. A few patients considered religious practice to be incompatible with treatment, and clinicians were seldom aware of such a conflict. CONCLUSIONS: Religion is an important issue for patients with schizophrenia, and it is often not related to the content of their delusions. Clinicians were commonly not aware of their patients' religious involvement, even if they reported feeling comfortable with such an issue.     

Religious beliefs in schizophrenia: their relevance for adherence to treatment

The study examined how religious beliefs and practices impact upon medication and illness representations in chronic schizophrenia. One hundred three stabilized patients were included in Geneva's outpatient public psychiatric facility in Switzerland. Interviews were conducted to investigate spiritual and religious beliefs and religious practices and religious coping. Medication adherence was assessed through questions to patients and to their psychiatrists and by a systematic blood drug monitoring. Thirty-two percent of patients were partially or totally nonadherent to oral medication. Fifty-eight percent of patients were Christians, 2% Jewish, 3% Muslim, 4% Buddhist, 14% belonged to various minority or syncretic religious movements, and 19% had no religious affiliation. Two thirds of the total sample considered spirituality as very important or even essential in everyday life. Fifty-seven percent of patients had a representation of their illness directly influenced by their spiritual beliefs (positively in 31% and negatively in 26%). Religious representations of illness were prominent in nonadherent patients. Thirty-one percent of nonadherent patients and 27% of partially adherent patients underlined an incompatibility or contradiction between their religion and taking medication, versus 8% of adherent patients. Religion and spirituality contribute to shaping representations of disease and attitudes toward medical treatment in patients with schizophrenia. This dimension should be on the agenda of psychiatrists working with patients with schizophrenia.     

Spirituality and religion in Canadian psychiatric residency training.

OBJECTIVE: Mental health professionals are increasingly aware of the need to incorporate a patient's religious and spiritual beliefs into mental health assessments and treatment plans. Recent changes in assessment and treatment guidelines in the US have resulted in corresponding curricular changes, with at least 16 US psychiatric residency programs now offering formal training in religious and spiritual issues. We present a survey of training currently available to Canadian residents in psychiatry and propose a lecture series to enhance existing training. METHODS: We surveyed all 16 psychiatry residency programs in Canada to determine the extent of currently available training in religion and spirituality as they pertain to psychiatry. RESULTS: We received responses from 14 programs. Of these, 4 had no formal training in this area. Another 4 had mandatory academic lectures dedicated to the interface of religion, spirituality, and psychiatry. Nine programs offered some degree of elective, case-based supervision. CONCLUSION: Currently, most Canadian programs offer minimal instruction on issues pertaining to the interface of religion, spirituality, and psychiatry. A lecture series focusing on religious and spiritual issues is needed to address this apparent gap in curricula across the country. Therefore, we propose a 10-session lecture series and outline its content. Including this lecture series in core curricula will introduce residents in psychiatry to religious and spiritual issues as they pertain to clinical practice.     

Psychiatrists' documentation of informed consent: a representative survey.

OBJECTIVE: To review psychiatrists' documentation of informed consent and present data on Canadian psychiatrists' attitudes and practices regarding documentation of the informed consent process. METHOD: We surveyed a stratified random sample of psychiatrists practising in Ontario, using a mailed self-report questionnaire. RESULTS: The response rate was 72%. Among respondents, 63% routinely documented the consent process, with younger respondents reporting more documentation than older ones. Although most respondents (77%) favoured recording the consent process, only 11% felt signed consent forms were necessary. CONCLUSION: There are differences in the self-reported documentation behaviour of younger and older psychiatrists. Psychiatrists should document the consent process in the clinical record.     

Spiritual issues in psychiatric care

This article differentiates between the concepts of spirituality and religion and analyzes the strengths and weaknesses of the research findings related to spirituality, religion, and mental health. To discuss the importance of clarifying values and becoming self-aware in relation to implementing spiritual and religious interventions. The components of spiritual assessment are presented as well as spiritual coping practices and interventions the nurse might use when working with clients. Review of literature from MEDLINE, CINAHL, and current texts. Spirituality and religion are too often neglected foci of psychiatric mental health assessment and intervention. In order to maximize therapeutic effectiveness, nurses should be aware that for many patients spirituality is a critical life factor. Accordingly, they should screen patients and strive to meet patient needs for spiritual expression, while recognizing that there are important boundary and ethical issues in psychiatric mental health settings.     

Religion, spirituality, and medicine: psychiatrists' and other physicians' differing observations, interpretations, and clinical approaches

OBJECTIVE: This study compared the ways in which psychiatrists and nonpsychiatrists interpret the relationship between religion/spirituality and health and address religion/spirituality issues in the clinical encounter. METHOD: The authors mailed a survey to a stratified random sample of 2,000 practicing U.S. physicians, with an oversampling of psychiatrists. The authors asked the physicians about their beliefs and observations regarding the relationship between religion/spirituality and patient health and about the ways in which they address religion/spirituality in the clinical setting. RESULTS: A total of 1,144 physicians completed the survey. Psychiatrists generally endorse positive influences of religion/spirituality on health, but they are more likely than other physicians to note that religion/spirituality sometimes causes negative emotions that lead to increased patient suffering (82% versus 44%). Compared to other physicians, psychiatrists are more likely to encounter religion/spirituality issues in clinical settings (92% versus 74% report their patients sometimes or often mention religion/spirituality issues), and they are more open to addressing religion/spirituality issues with patients (93% versus 53% say that it is usually or always appropriate to inquire about religion/spirituality). CONCLUSIONS: This study suggests that the vast majority of psychiatrists appreciate the importance of religion and/or spirituality at least at a functional level. Compared to other physicians, psychiatrists also appear to be more comfortable, and have more experience, addressing religion/spirituality concerns in the clinical setting.     

Spirituality in psychiatry residency training programs

Spirituality has been receiving increased attention in health care in recent years. Surveys have identified that patients want their spiritual beliefs addressed in the clinical setting. Data suggests that spirituality may be helpful to people as they cope with serious illness and life events. Medical educators are recognizing spirituality as a core patient need. Courses in medical schools and in psychiatric residency programs are being developed to address this important issue.The Accreditation Council for Graduate Medical Education (ACGME) guidelines underscore the importance of addressing religious/spiritual issues in psychiatric training. The John Templeton Spirituality and Medicine Award Program administered by GeorgeWashington University recognizes psychiatric residency programs that address spirituality and health. This award has stimulated the development of relevant, novel curricula in this area. In addition, a consensus group of psychiatrists has developed a model curriculum that addresses key concepts of a psychiatric residency training programs in spirituality and medicine.     

How spiritual values and worship attendance relate to psychiatric disorders in the Canadian population.

OBJECTIVE: Research into risk and protective factors for psychiatric disorders may help reduce the burden of these conditions. Spirituality and religion are 2 such factors, but research remains limited. Using a representative national sample of respondents, this study examines the relation between worship frequency and the importance of spiritual values and DSM-IV psychiatric and substance use disorders. METHOD: In 2002, the Canadian Community Health Survey obtained data from about 37,000 individuals aged 15 years or older. While controlling for demographic characteristics, we determined odds ratios for lifetime, 1-year, and past psychiatric disorders, with worship frequency and spiritual values as predictors. RESULTS: Higher worship frequency was associated with lower odds of psychiatric disorders. In contrast, those who considered higher spiritual values important (in a search for meaning, in giving strength, and in understanding life's difficulties) had higher odds of most psychiatric disorders. CONCLUSION: This study confirms an association between higher worship frequency and lower odds of depression and it expands that finding to other psychiatric disorders. The association between spiritual values and mood, anxiety, and addictive disorders is complex and may reflect the use of spirituality to reframe life difficulties, including mental disorders.     

Child and adolescent psychopathology: spiritual and religious perspectives

This article addresses the relationship between children's religious beliefs and spiritual practices and the presence of psychopathology. Study of this subject represents a formidable task due to the complexity and diversity of the constructs involved, heterogeneity in religious beliefs and practices, and the difficulty in discriminating between the independent effects of religion and culture. Nevertheless, broad links between child psychopathology and spiritual/religious beliefs and practices are proposed. On the whole, the available empiric data suggest that religion is primarily health promoting in direct, positive benefits for children and in indirect, positive effects through parent and family functioning, although there are isolated exceptions. When spirituality and religious beliefs/practices are associated with negative mental health outcomes in children or their families, evidence points to "poorness-of-fit," based on an interaction between the child's psychopathology and aspects and religious beliefs/practice. Clinical implications of the findings and proposels are outlined.     

Psychiatrists’ occupational stigma conceptualization,measurement, and intervention: A literature review

Psychiatrists require frequent contact with and treatment of patients with mental illnesses. Due to the influence of associative stigma, psychiatrists may also be targets of stigma. Occupational stigma warrants special consideration because it significantly affects psychiatrists' career advancement, well-being, and their patients’ health. Given that there is no complete summary of this issue, this study reviewed the existing literature on psychiatrists' occupational stigma to clearly synthesize its concepts, measurement tools, and intervention strategies. Herein, we emphasize that psychiatrists’ occupational stigma is a multifaceted concept that simultaneously encompasses physically, socially, and morally tainted aspects. Currently, standardized methods to specifically measure psychiatrists’ occupational stigma are lacking. Interventions for psychiatrists’ occupational stigma may consider the use of protest, contact, education, comprehensive and systematic methods, as well as the use of psychotherapeutic approaches. This review provides a theoretical basis for the development of relevant measurement tools and intervention practices. Overall, this review seeks to raise public awareness of psychiatrists' occupational stigma, thereby promoting psychiatric professionalism and reducing its stigma.     

A comparative mental health literacy survey of psychiatrists and other mental health professionals in Singapore

OBJECTIVE: The objectives of this study are, first, to replicate and extend an Australian approach to assessing mental health literacy by studying a sample of Singapore mental health professionals, and to focus on differences between judgements made by the psychiatrists in comparison with the other mental health professionals. Second, to compare the psychiatrists' judgements with those of Australian psychiatrists. METHOD: The Australian questionnaire, assessing responses in relation to vignettes of major depression and to schizophrenia was extended by adding a third vignette of mania, and by the addition of several region-specific response options. Nearly 500 questionnaires were distributed to representative staff (psychiatrists, nurses and allied health) of a large psychiatric institution in Singapore, with a response rate of 81%. Psychiatrists' judgements were compared with all other hospital staff, and with Australian psychiatrists' judgements. RESULTS: The two principal contrast groups (Singapore psychiatrists and other Singapore mental health professionals) differed slightly in terms of diagnostic accuracy. The psychiatrists differed in favouring a more professionally focused model of intervention, while both professional groups viewed traditional healers and their practices as distinctly unhelpful. Direct comparison of psychiatrist ratings generated in Singapore and in Australia revealed quite similar response profiles. CONCLUSIONS: In addition to generating data of some intrinsic importance, comparison with Australian survey data allows the potential impact of regional and cultural differences, as well as of varying psychiatric practices, to be identified. Responses identified more similarities than differences in the judgements of the psychiatrists from the two countries.     

Canadian psychiatric inpatient religious commitment: an association with mental health.

BACKGROUND: Research indicates that religion may have a positive effect on coping and possibly enhance clinical outcomes. This study aims to determine the level of religious interest of psychiatric inpatients and to assess whether religious commitment has an impact on selected outcome variables. METHODS: There were 88 consecutive adult patients (50% men) who were admitted to a Canadian tertiary care psychiatry inpatient unit and were interviewed about their religious beliefs and practices. Patients with a Beck Depression score of 12 or more were included for outcome analysis. RESULTS: A total of 59% believed in a God who rewards and punishes, 27% had a high frequency of worship attendance, and 35% prayed once or more daily. More frequent worship attenders had less severe depressive symptoms, shorter current length of stay, higher satisfaction with life, and lower rates of current and lifetime alcohol abuse (P < 0.05), when compared with those with less frequent or no worship attendance. In contrast, private spirituality was associated with lower depressive symptoms and current alcohol use only (P < 0.05), and prayer frequency had no significant associations. DISCUSSION: This study indicates that certain religious practices may protect against severity of symptoms, hospital use, and enhance life satisfaction among psychiatric inpatients. This is the first known Canadian study that examines religious commitment among psychiatric inpatients.     

A brief measure of core religious beliefs for use in psychiatric settings

Results from several national studies in the United States suggests that: (1) religious beliefs and practices are highly prevalent; (2) spirituality and religion are statistically and clinically relevant to mental health and symptoms; and (3) many patients have a preference for spiritually integrated care. However, existing protocols that assess for salient religious themes in psychiatric settings are time-consuming to administer, relevant only to specific populations (e.g., Christians), and have poor psychometric properties. Further, evidence suggests that religious beliefs can take on a positive and negative valence, and both of these dimensions are worthy of assessment. We, therefore, developed a brief (six-item) self-report measure of positive and negative core beliefs about God which is uniquely suited for use with a broad range of religious patients. Across three studies, we evaluated its psychometric properties and ability to predict symptoms of anxiety and depression. Results provide support for the validity and reliability of our measure and further highlight the salience of both positive and negative religious beliefs to psychiatric symptoms. It is hoped that this measure will help to decrease the burden of spiritual assessment in psychiatric and medical settings, and further have research utility for this area of study.     

Psychiatric genetics: a survey of psychiatrists' knowledge, opinions, and practice patterns

OBJECTIVE: Knowledge about the genetic basis of psychiatric illness is growing rapidly, and psychiatrists may be called upon to incorporate this information into clinical practice. The goal of this study was to assess psychiatrists' familiarity with and attitudes toward genetic information. METHOD: We surveyed 844 participants, the majority of whom were psychiatrists, attending a continuing medical education course in the fall of 2002 and measured knowledge, opinions, and current practice patterns in regard to psychiatric genetics. RESULTS: Responses were received from 352 psychiatrists (54% of those surveyed). Most psychiatrists correctly answered fewer than half of survey items assessing general and psychiatric genetic knowledge. While 83% considered it their role to discuss genetic information with patients and families, fewer than 25% felt prepared or competent to do so. In response to hypothetical questions regarding genetic testing, a substantial proportion of psychiatrists indicated willingness to use such tests for diagnostic clarification, as well as presymptomatic and even prenatal risk prediction. The majority of respondents expressed interest in further genetics education. CONCLUSIONS: Our results suggest that psychiatrists view genetic information as clinically relevant, but have limitations in knowledge that may impact the incorporation of psychiatric genetics into clinical practice.     

Psychopharmacotherapy and spirituality

Although the connection between spiritual and physical has been acknowledged since the oldest of human civilizations and emphasized in almost all of religions, It has taken a lot of time for that connection to gradually recover its lost meaning. As it is evident that many diseases and illnesses can not be explained purely by physical causes nor treated with purely physical methods there is a growing interest in spirituality and its usability in the treatment of various diseases and states, as well as in everyday life. Despite the fact that a sense of positive, nourishing and healing power of faith is deeply rooted in every religion, objective and empirical research of that connection has been avoided for centuries, and those studies which were conducted are only rudimentary, on the outskirts of empirical science. Scientific literature regarding spirituality and mental health points to a conclusion that spirituality and faith are positively correlated with positive therapeutic outcome and the possible explanation for that can be found in the fact that spirituality and religiosity can satisfy some of the basic needs of psychiatric patients. Efficacy of psychiatric treatment improved with the introduction of psychotropic medicaments and psychotherapeutic techniques, but the outcome is still not satisfying because relapse, recidivation and discontinuation of therapy occur very often. On the other hand, spirituality and religiosity play a very significant role in the healing process because they provide people with strength and will to fight their problems and disease itself. Psychopharmaceuticals are evidently irreplaceable in the therapy of mental disorders, but they are only one of the segments of the overall therapy. In order to adequately answer to the spiritual and religious needs of their patients, psychiatrists, psychologists and related health care professionals are faced with the need for expanding scientific concepts which served as the basis for development of many psychiatric methods and techniques.     

Psychiatrists' beliefs about gender-appropriate behavior

Psychiatrists' beliefs regarding gender-appropriate behavior may influence their treatment of patients. Psychiatrists of both sexes (men: N = 76; women: N = 57) were asked to characterize optimal mental health for hypothetical female and male patients on the Bem Sex Role Inventory. The subjects' ratings for men and women were similar with two exceptions: more of the female psychiatrists rated masculine traits as optimal for female patients, and more male psychiatrists chose traits characteristic of Bem's undifferentiated category (low levels of both masculine and feminine traits) as optimal for both male and female patients. The results indicate significant changes in psychiatrists' attitudes toward gender in the past 20 years.     

Spirituality and religion in psychiatric rehabilitation and recovery from mental illness

While mental health professionals frequently express concerns about the function of spirituality and religion in the lives of people diagnosed with severe mental disorders, there are both clinical and research bases for the increased acceptance of spirituality's potentially positive role in psychiatric rehabilitation and recovery. This paper first addresses issues of religious experience in diagnosis, including the importance of religiocultural context and overall functioning in diagnostic assessments. It then examines the roles of spirituality in recovery, exploring both positive and negative relationships between religion and consumers' well-being. Finally, it describes several specific ways in which spiritual and religious concerns may be integrated into psychosocial rehabilitation services: conducting spiritual assessments; offering spiritually-informed discussion groups; incorporating spiritual dimensions of psychotherapy; and facilitating linkages to faith communities and spiritual resources.     

Mental health professionals' attire

OBJECTIVE: Our aim was to obtain mental health patients' views on psychiatrists' and case managers' attire. METHODS: Eighty-six patients treated at a community mental health service were surveyed. Various types of commonly worn attire were listed. Respondents were asked to choose what they thought was most appropriate for their psychiatrist and case manager to wear. RESULTS: Over 50% of respondents felt that psychiatrist or case manager dress was not an important issue. However, those who felt that it was preferred less formal attire. CONCLUSIONS: Psychiatrists and case managers in a community mental health team could consider adopting less formal attire. This conclusion is limited by the small sample and may be relevant to rural areas only. Further research is needed in urban centres. Implications of these findings are discussed.     

Patient attitudes regarding causes of depression: implications for psychoeducation.

OBJECTIVE: Patient attitudes toward mental illness are an important determinant of treatment compliance and treatment outcome. A patient's age, sex, style of thinking, lifestyle, and beliefs all may influence perceptions. This study aimed to determine patient attitudes. METHOD: Patients with a depressive disorder (n = 102) who were referred for psychiatric consultation and treatment to a community general hospitial psychiatric outpatient clinic completed a 9-item self-report questionnaire to determine their perceptions of the biological, psychological, cognitive, and spiritual causes of their depressive disorder. RESULTS: Women were more likely to endorse their depressive disorder as related to a biological abnormality. With respect to age, older individuals were less likely to identify cognitive factors and loss of spirituality as causal factors in their depression. CONCLUSIONS: A relation exists between demographic variables, including sex and age, and beliefs about causes of depression and related disorders. These findings have implications for refining patient psychoeducation.     

Psychiatrists' self-reported adherence to evidence-based prescribing practices in the treatment of schizophrenia

OBJECTIVE: This study sought to identify relationships between psychiatrists' characteristics and their self-reported adherence to evidence-based recommendations regarding antipsychotic use in the treatment of schizophrenia. METHODS: Surveys were sent to 1,757 psychiatrists affiliated with the Veterans Health Administration. Respondents (N=696) reported their own adherence to two recommended prescribing practices for using antipsychotics. RESULTS: Several psychiatrists' characteristics were associated with greater adherence, including midcareer status, male sex, a caseload with a larger proportion of patients with schizophrenia, and use of current information from scientific literature or from drug company detailing. CONCLUSIONS: This study identified several characteristics of psychiatrists that may affect their adherence to evidence-based prescribing practices for patients with schizophrenia.