Contemporary unorthodox treatments in cancer medicine. A study of patients, treatments, and practitioners

Public education, legislative action, and medical advances have failed to deter patients from seeking unorthodox treatments for cancer and other diseases. To study this phenomenon, we interviewed 304 cancer center inpatients and 356 patients under the care of unorthodox practitioners. A concomitant survey of unorthodox practitioners documented their backgrounds and practices. Eight percent of all patients studied never received any conventional therapy, and 54% of patients on conventional therapy also used unorthodox treatments. Forty percent of patients abandoned conventional care entirely after adopting alternative methods. Patients interviewed did not conform to the stereotype of poorly educated, end-stage patients who had exhausted conventional treatment. Practitioners also deviated from the traditional portrait: Of 138 unorthodox practitioners studied, 60% were physicians(M.D.s). Patients are attracted to therapeutic alternatives that reflect social emphasis on personal responsibility, pollution and nutrition, and that move away from perceived deficiencies in conventional medical care.

Health care and consumer choice: medical and alternative therapies

This paper reports on research conducted in a large Canadian city during 1994-1995. The study examines the motivations of patients who choose to seek care from one of five different types of practitioners: family physicians, chiropractors, acupuncturists/traditional Chinese doctors, naturopaths and Reiki practitioners. We use the Andersen socio-behavioural model to help explain why people choose orthodox medicine or a type of alternative care. The data are derived from face to face interviews with 300 patients: 60 from each of the five modes of treatment. The findings demonstrate that this model can explain the use of alternative as well as orthodox medical services. Patients choose specific kinds of practitioners for particular problems, and some use a mixture of practitioners to treat a specific complaint. The choice of type of practitioner(s) is multidimensional and cannot solely be explained either by disenchantment with medicine or by an "alternative ideology".

The efficacy of "distant healing": a systematic review of randomized trials

PURPOSE

To conduct a systematic review of the available data on the efficacy of any form of "distant healing" (prayer, mental healing, Therapeutic Touch, or spiritual healing) as treatment for any medical condition.

DATA SOURCES

Studies were identified by an electronic search of the MEDLINE, PsychLIT, EMBASE, CISCOM, and Cochrane Library databases from their inception to the end of 1999 and by contact with researchers in the field.

STUDY SELECTION

Studies with the following features were included: random assignment, placebo or other adequate control, publication in peer-reviewed journals, clinical (rather than experimental) investigations, and use of human participants.

DATA EXTRACTION

Two investigators independently extracted data on study design, sample size, type of intervention, type of control, direction of effect (supporting or refuting the hypothesis), and nature of the outcomes.

DATA SYNTHESIS

A total of 23 trials involving 2774 patients met the inclusion criteria and were analyzed. Heterogeneity of the studies precluded a formal meta-analysis. Of the trials, 5 examined prayer as the distant healing intervention, 11 assessed noncontact Therapeutic Touch, and 7 examined other forms of distant healing. Of the 23 studies, 13 (57%) yielded statistically significant treatment effects, 9 showed no effect over control interventions, and 1 showed a negative effect.

CONCLUSIONS

The methodologic limitations of several studies make it difficult to draw definitive conclusions about the efficacy of distant healing. However, given that approximately 57% of trials showed a positive treatment effect, the evidence thus far merits further study.

Physical environmental stimuli that turn healthcare facilities into healing environments through psychologically mediated effects: systematic review

AIM

This paper reports a systematic review to determine the effects of physical environmental stimuli in healthcare settings on the health and well-being of patients.

BACKGROUND

The concept of healing environments suggests that the physical environment of the healthcare setting can encourage the healing process and patients' feelings of well-being. Understanding the effects of physical environmental stimuli will allow us to design healthcare environments that generate these potential health benefits.

METHOD

A search was conducted using the MedLine, PsychInfo, Embase, CINAHL, Iconda, ScienceDirect, Compendex and the ISI Citation Indexes databases. Studies were included if they concerned interventions involving health effects of environmental stimuli in healthcare settings on patients, and were based on controlled clinical trials published in peer-reviewed journals. Both clinical and psychological outcome measures were included. The search was completed in 2005.

FINDINGS

Of the over 500 potentially relevant studies identified, only 30 met all criteria and were included in this review. Predominantly positive effects were found for sunlight, windows, odour and seating arrangements. Inconsistent effects were found for sound, nature, spatial layout, television and multiple stimuli interventions. In general, both the size and direction of effects seem highly dependent on characteristics of patient populations and healthcare settings.

CONCLUSIONS

Studies that manipulate several environmental stimuli simultaneously clearly support the general notion that the physical healthcare environment affects the well-being of patients. However, when scrutinizing the effects of specific environmental stimuli, conclusive evidence is still very limited and difficult to generalize. The field thus appears to be in urgent need of well-conducted, controlled clinical trials. At present, and on the basis of the available research, it would be premature to formulate evidence-based guidelines for designing healthcare environments.

Traumatic loss and major disasters: strengthening family and community resilience

This article presents the core principles and value of a family and community resilience-oriented approach to recovery from traumatic loss when catastrophic events occur. In contrast to individually based, symptom-focused approaches to trauma recovery, this multisystemic practice approach contextualizes the distress in the traumatic experience and taps strengths and resources in relational networks to foster healing and posttraumatic growth. The intertwining of trauma and traumatic losses is discussed. Key family and social processes in risk and resilience in traumatic loss situations are outlined. Case illustrations, model programs, and intervention guidelines are described in situations of community violence and major disasters to suggest ways to foster family and community resilience.

Adverse Childhood Experiences and Child Health Outcomes: Comparing Cumulative Risk and Latent Class Approaches

Objectives This study seeks to further the work exploring adverse childhood experiences (ACEs) by proposing a novel approach to understanding the impact of ACEs through applying advanced analytical methods to examine whether combinations of ACEs differentially impact child health outcomes. Methods Using National Survey of Children's Health data, we use latent class analysis to estimate associations between classes of ACEs and child health outcomes. Results Class membership predicts child poor health, with differences found for specific ACE combinations. A subgroup of children exposed to poverty and parental mental illness are at higher risk for special healthcare needs than all other groups, including children exposed to 3 or more ACEs. Conclusions Different combinations of ACEs carry different risk for child health. Interventions tailored to specific ACEs and ACE combinations are likely to have a greater effect on improving child health. Our findings suggest children who experience specific ACE combinations (e.g., poverty and parental mental illness) are at particularly high risk for poor health outcomes. Therefore, clinicians should routinely assess for ACEs to identify children exposed to the most problematic ACE combinations; once identified, these children should be given priority for supportive interventions tailored to their specific ACE exposure and needs.

Systematic Review of the Efficacy of Meditation Techniques as Treatments for Medical Illness

BACKGROUND

Meditative techniques are sought frequently by patients coping with medical and psychological problems. Because of their increasingly widespread appeal and use, and the potential for use as medical therapies, a concise and thorough review of the current state of scientific knowledge of these practices as medical interventions was conducted.

PURPOSE

To systematically review the evidence supporting efficacy and safety of meditative practices in treating illnesses, and examine areas warranting further study. Studies on normal healthy populations are not included.

METHODS

Searches were performed using PubMed, PsycInfo, and the Cochrane Database. Keywords were Meditation, Meditative Prayer, Yoga, Relaxation Response. Qualifying studies were reviewed and independently rated based on quality by two reviewers. Mid-to-high-quality studies (those scoring above 0.65 or 65% on a validated research quality scale) were included.

RESULTS

From a total of 82 identified studies, 20 randomized controlled trials met our criteria. The studies included 958 subjects total (397 experimentally treated, 561 controls). No serious adverse events were reported in any of the included or excluded clinical trials. Serious adverse events are reported in the medical literature, though rare. The strongest evidence for efficacy was found for epilepsy, symptoms of the premenstrual syndrome and menopausal symptoms. Benefit was also demonstrated for mood and anxiety disorders, autoimmune illness, and emotional disturbance in neoplastic disease.

CONCLUSIONS

The results support the safety and potential efficacy of meditative practices for treating certain illnesses, particularly in nonpsychotic mood and anxiety disorders. Clear and reproducible evidence supporting efficacy from large, methodologically sound studies is lacking.

Child fatalities from religion-motivated medical neglect

OBJECTIVE

To evaluate deaths of children from families in which faith healing was practiced in lieu of medical care and to determine if such deaths were preventable.

DESIGN

Cases of child fatality in faith-healing sects were reviewed. Probability of survival for each was then estimated based on expected survival rates for children with similar disorders who receive medical care.

PARTICIPANTS

One hundred seventy-two children who died between 1975 and 1995 and were identified by referral or record search. Criteria for inclusion were evidence that parents withheld medical care because of reliance on religious rituals and documentation sufficient to determine the cause of death.

RESULTS

One hundred forty fatalities were from conditions for which survival rates with medical care would have exceeded 90%. Eighteen more had expected survival rates of >50%. All but 3 of the remainder would likely have had some benefit from clinical help.

CONCLUSIONS

When faith healing is used to the exclusion of medical treatment, the number of preventable child fatalities and the associated suffering are substantial and warrant public concern. Existing laws may be inadequate to protect children from this form of medical neglect.

[Mental health status and its influencing factors among college students during the epidemic of COVID-19]

OBJECTIVE

To investigate the mental health status of college students during the epidemic of COVID-19 and identify the factors influencing the mental health of the students.

METHODS

Using a general questionnaire, a self-designed new coronavirus pneumonia knowledge and cognitive behavior questionnaire, the Generalized Anxiety Disorder 7 (GAD-7) and Patient Health Questionnaire 9 (PHQ-9), we conducted an internet-based questionnaire survey of 3881 college students in Guangdong Province. A multinomial-logistic regression model was used to analyze the collected data.

RESULTS

The survey showed that 69.47% of the college students had a high level of awareness of COVID-19; the overall incidence of anxiety was 26.60%, and the incidences of mild, moderate and severe anxiety were 23.19%, 2.71%, and 0.70%, respectively. Depressive emotions were detected in 21.16% of the students, and the incidences of mild, moderate, and moderate-to-severe depression were 16.98%, 3.17%, and 1.01%, respectively. The results of multivariate analysis showed that an older age was associated with a higher level of awareness of COVID-19 and greater changes in future health behaviors were associated with less anxiety and depression among the students. The students currently in rural areas, of non-medical majors, and reporting half of their information concerning the epidemic being negative were more likely to have anxiety; female gender, residence in suburbs, a drinking history, and excessive negative information concerning the epidemic were all associated with the likeliness of depression.

CONCLUSIONS

The college students have different levels of anxiety and depression during the epidemic. Depression and anxiety are closely related, but the factors contributing to different levels of such emotions can be different, and colleges and related departments are urged to provide precision mental health education for college students.

Healing Spaces: Elements of Environmental Design That Make an Impact on Health

The "ambiance" of a space has an effect on people using the space. In recent years, design for health care environments has begun to include esthetic enhancements in an attempt to reduce stress and anxiety, increase patient satisfaction, and promote health and healing. In this paper, the authors survey the existing research on those elements of the built and natural environment most often asserted by proponents as being inherently healing or promoting health. We postulate a hierarchy of effect of environmental elements ranging from simply nontoxic to safe (both physically and psychologically) to "providing a positive context" to being actively salutogenic. Most relevant research has been concentrated on a limited number of settings and is inadequate to inform the creation of design guidelines for the physical elements of an optimal healing environment. Opportunities exist to make meaningful contributions in this area that are likely to make a significant impact on health outcomes of human beings.

Approaches to sampling and case selection in qualitative research: examples in the geography of health

This paper focuses on the question of sampling (or selection of cases) in qualitative research. Although the literature includes some very useful discussions of qualitative sampling strategies, the question of sampling often seems to receive less attention in methodological discussion than questions of how data is collected or is analysed. Decisions about sampling are likely to be important in many qualitative studies (although it may not be an issue in some research). There are varying accounts of the principles applicable to sampling or case selection. Those who espouse 'theoretical sampling', based on a 'grounded theory' approach, are in some ways opposed to those who promote forms of 'purposive sampling' suitable for research informed by an existing body of social theory. Diversity also results from the many different methods for drawing purposive samples which are applicable to qualitative research. We explore the value of a framework suggested by Miles and Huberman [Miles, M., Huberman,, A., 1994. Qualitative Data Analysis, Sage, London.], to evaluate the sampling strategies employed in three examples of research by the authors. Our examples comprise three studies which respectively involve selection of: 'healing places'; rural places which incorporated national anti-malarial policies; young male interviewees, identified as either chronically ill or disabled. The examples are used to show how in these three studies the (sometimes conflicting) requirements of the different criteria were resolved, as well as the potential and constraints placed on the research by the selection decisions which were made. We also consider how far the criteria Miles and Huberman suggest seem helpful for planning 'sample' selection in qualitative research.

Complementary therapies: have they become accepted in general practice?

OBJECTIVES

To describe Victorian general practitioners' attitudes towards and use of a range of complementary therapies.

DESIGN

A self-administered postal survey sent to a random sample of 800 general practitioners (GPs) in Victoria in July 1997.

PARTICIPANTS

488 GPs (response rate, 64%).

MAIN OUTCOME MEASURES

GPs' knowledge; opinions about harmfulness and effectiveness; appropriateness for GPs to practise; perceived patient demand; need for undergraduate education; referral rates to complementary practitioners; and training in and practice of each therapy.

RESULTS

Acupuncture, hypnosis and meditation are well accepted by the surveyed GPs, as over 80% have referred patients patients to practitioners of these therapies and nearly half have considered using them. General practitioners have trained in various therapies--meditation (34%), acupuncture (23%), vitamin and mineral therapy (23%), hypnosis (20%), herbal medicine (12%), chiropractic (8%), naturopathy (6%), homoeopathy (5%), spiritual healing (5%), osteopathy (4%), aroma-therapy (4%), and reflexology (2%). A quarter to a third were interested in training in chiropractic, herbal medicine, naturopathy and vitamin and mineral therapy. General practitioners appear to underestimate their patients' use of complementary therapies.

CONCLUSIONS

There is evidence in Australia of widespread acceptance of acupuncture, meditation, hypnosis and chiropractic by GPs and lesser acceptance of the other therapies. These findings generate an urgent need for evidence of these therapies' effectiveness.

The concept of spirituality in nursing theories: differing world-views and extent of focus

Although nursing has recognized spirituality as an important aspect of holistic patient care, exactly what spirituality means has remained rather amorphous. The purpose of this article is to present aspects of spirituality found in modern nurse theorists' ideas. These aspects are presented both in relation to reciprocal interaction or simultaneous action world-views and in relation to the extent of focus on the concept within the model or theory. This discussion will provide the researcher and practitioner with additional theoretical understanding on which to ground investigations and base practice.

The Burden of Stigma on Health and Well-Being: A Taxonomy of Concealment, Course, Disruptiveness, Aesthetics, Origin, and Peril Across 93 Stigmas

Most individuals are stigmatized at some point. However, research often examines stigmas separately, thus underestimating the overall impact of stigma and precluding comparisons across stigmatized identities and conditions. In their classic text, Social Stigma: The Psychology of Marked Relationships, Edward Jones and colleagues laid the groundwork for unifying the study of different stigmas by considering the shared dimensional features of stigmas: aesthetics, concealability, course, disruptiveness, origin, peril. Despite the prominence of this framework, no study has documented the extent to which stigmas differ along these dimensions, and the implications of this variation for health and well-being. We reinvigorated this framework to spur a comprehensive account of stigma's impact by classifying 93 stigmas along these dimensions. With the input of expert and general public raters, we then located these stigmas in a six-dimensional space and created discrete clusters organized around these dimensions. Next, we linked this taxonomy to health and stigma-related mechanisms. This quantitative taxonomy offers parsimonious insights into the relationship among the numerous qualities of numerous stigmas and health.

Use of alternative therapies for children with cancer

OBJECTIVE

To compare the use of alternative therapy (AT) in families of children with cancer with its use in those with routine pediatric conditions.

BACKGROUND AND RATIONALE

AT refers to healing practices such as therapeutic massage, acupuncture, and use of medicinal herbs that have become increasingly popular with the general public, but are not widely accepted by the medical profession. Although studies have investigated the use of AT in the families of both healthy children and children with cancer, no comparison of the incidence of its use between these two populations has been published. We hypothesized that AT was used more frequently among the families of children with cancer.

METHODS

Using a prevalence survey design, we interviewed 81 parents of children with cancer attending a pediatric hematology/oncology clinic and 80 parents of children attending a continuity care clinic for routine check-ups and acute care. We explored the types of AT being used, the reasons for its use, and the frequency with which it was discussed with the patient's physician.

RESULTS

1) Overall, 65% of the cancer group were using AT, compared with 51% of the control group. This was not statistically significant. 2) Prayer, exercise, and spiritual healing were three AT practices most often used by the cancer group, and prayer, massage, and spiritual healing by the control group. 3) Discussion of AT with the physician varied according to group, with 53% of the cancer patients discussing its use; income level, with 59% of parents in the higher income group discussing its use; and ethnicity, with 47% of whites discussing its use.

CONCLUSION

Use of AT is not limited to the families of children with life-challenging illnesses, but is commonly used by those of children with routine pediatric problems. Pediatricians need to be aware that their patients may not tell them about AT practices they are using in addition to prescribed treatment.

Experiences of religious healing in psychiatric patients in south India

A survey was carried out over a 3-month period to determine experiences of religious healing in a group of 198 consecutive psychiatric patients attending a hospital in Tamil Nadu, South India. Of these, 89 (45%) had sought between 1 and 15 sessions from either Hindu, Muslim of Christian healers. The number of patients visiting healers was linked significantly with their income, while a significantly higher number under the age of 17 years had received such help compared with older age groups. A significantly higher consultation rate was observed in those patients with schizophrenia and delusional disorders when compared with other mental illness. An average of 30% of patients claimed some benefit from healer consultation, although the majority (91%) had discontinued such treatment at the time of the hospital attendance. The role of social support, methods of traditional healing and the underlying implications for service delivery are discussed. The implications for service providers to ethnic minorities need to be taken into account while planning services.

Associations between poverty, mental health and substance use, gender power, and intimate partner violence amongst young (18-30) women and men in urban informal settlements in South Africa: A cross-sectional study and structural equation model

Research suggests that poverty is a key driver of intimate partner violence (IPV), however detailed analysis suggests that this relationship is not clear, either for women’s experience or men’s perpetration of IPV. We explored associations between poverty and IPV using cross-sectional data from the Stepping Stones and Creating Futures cluster randomized control trial, in urban informal settlements in Durban, South Africa, with young (18–30) people. Using logistic regression and structural equation modelling we assess associations between poverty and women’s experience and men’s perpetration of physical and/or sexual IPV in the past 12 months. 680 women and 677 men were recruited into the study between September 2015 and September 2016. The analyses highlight how specific forms or measures of poverty intersecting with gender identities shape IPV. For men we found indicators of economic provision were associated with IPV perpetration, while for women food-insecurity was key to IPV experience. We also found similarities between women and men. First, food-insecurity and childhood traumas shaped pathways to substance misuse and poor mental health that increased IPV. Second, there was a resilience pathway in both models, whereby those with more education had increased gender equitable attitudes and fewer controlling behaviours, which reduced IPV. Interventions to reduce IPV need to work to reduce household food insecurity, but these need to be combined with gender transformative interventions. Interventions should also focus on reducing the impact of mental health and substance misuse. Finally, working to increase educational attainment is a long-term critical intervention to reduce IPV.

Trial registration:NCT03022370. Registered 13 January 2017, retrospectively registered.

A Maori perspective of health

Health is not a universal concept nor are health professionals necessarily best suited to formulate the health aspirations of a people. Like other fundamental objectives, health is defined for Maori people by their elders, at traditional tribal gatherings. Four cornerstones of health have been recognised: te taha wairua (a spiritual dimension), te taha hinengaro (a psychic dimension), te taha tinana (a bodily dimension), te taha whanau (a family dimension). Between Maori elders and Western health professionals, priorities for health are likely to differ, the Western approach emphasising personal dysfunction and socio-economic inequalities; Maori concerns moving to wider cultural factors affecting their community as a whole. The pollution of food sources is seen as a current health hazard with the subsequent cultural pollution a major threat to community integrity and health. Similarly a lack of confidence in Western child rearing techniques has aroused Maori elders into advocating traditional practices with less dependence on biological parents and more on tribal parents. Any widescale intervention aimed at promoting health among Maori people must involve elders and may need to accept alternate goals and methods, relevant to current Maori thinking, though possibly peripheral to established Western health concerns.

Varieties of healing. 2: a taxonomy of unconventional healing practices

The first of two essays in this issue demonstrated that the United States has had a rich history of medical pluralism. This essay seeks to present an overview of contemporary unconventional medical practices in the United States. No clear definition of "alternative medicine" is offered because it is a residual category composed of heterogeneous healing methods. A descriptive taxonomy of contemporary unconventional healing could be more helpful. Two broad categories of unconventional medicine are described here: a more prominent, "mainstream" complementary and alternative medicine (CAM) and a more culture-bound, "parochial" unconventional medicine. The CAM component can be divided into professional groups, layperson-initiated popular health reform movements, New Age healing, alternative psychological therapies, and non-normative scientific enterprises. The parochial category can be divided into ethno-medicine, religious healing, and folk medicine. A topologic examination of U.S. health care can provide an important conceptual framework through which health care providers can understand the current situation in U.S. medical pluralism.

Use of alternative medicine by patients with epilepsy: a survey of 265 epileptic patients in a developing country

We evaluated the use of alternative treatment methods, in various forms, by epileptic patients who had used these forms of treatment before seeking hospital treatment. Among the 265 epileptic patients, 47.6% used African traditional medicine alone: 24.1% combined traditional medicine with spiritual healing, 20.4% used spiritual healing alone, and 7.5% used other forms of alternative medicine. Patients used the alternative treatments for < 1 year to > 5 years before seeking hospital treatment, presumably when alternative medicine failed to control seizures. Relatives, friends, and neighbors had marked influence on the health-seeking behavior of these epileptic patients: 86% of them were influenced to use alternative medicine. After initiation of hospital treatment, only 14.6% of patients who had earlier used African traditional medicine continued with such treatment; more than two thirds of the patients who had earlier used spiritual healing continued using such treatment, suggesting that many of these patients perceived some continuing benefits from these alternative treatments. This observation suggests that alternative medicine, especially spiritual healing, cannot be considered irrelevant in management of epilepsy in Africa. Further investigations are required to determine the efficacy, supportive role, and limitation of alternative medicine in management of epilepsy in developing countries.

Dissociative experience and cultural neuroscience: narrative, metaphor and mechanism

Approaches to trance and possession in anthropology have tended to use outmoded models drawn from psychodynamic theory or treated such dissociative phenomena as purely discursive processes of attributing action and experience to agencies other than the self. Within psychology and psychiatry, understanding of dissociative disorders has been hindered by polemical "either/or" arguments: either dissociative disorders are real, spontaneous alterations in brain states that reflect basic neurobiological phenomena, or they are imaginary, socially constructed role performances dictated by interpersonal expectations, power dynamics and cultural scripts. In this paper, we outline an approach to dissociative phenomena, including trance, possession and spiritual and healing practices, that integrates the neuropsychological notions of underlying mechanism with sociocultural processes of the narrative construction and social presentation of the self. This integrative model, grounded in a cultural neuroscience, can advance ethnographic studies of dissociation and inform clinical approaches to dissociation through careful consideration of the impact of social context.

Alternative medicine consultations and remedies in patients with the irritable bowel syndrome

The use of alternative medicine was assessed by questionnaire in 96 patients with irritable bowel syndrome, 143 patients with organic upper gastrointestinal disorders and 222 patients with Crohn's disease of comparable age and sex. Significantly more patients with the irritable bowel syndrome (16%) had consulted practitioners of alternative medicine about their condition than had patients in either of the other groups. Similarly, significantly more irritable bowel syndrome patients said they would consult an alternative medicine practitioner (41%) if conventional treatment failed. Current usage of alternative medicine remedies was significantly greater in the irritable bowel syndrome patients (11%) than in patients with Crohn's disease (4%) and tended to be greater than in patients with organic upper gastrointestinal disorders (6%). This study has shown that the use of alternative medicine is common in patients with irritable bowel syndrome and this does not appear to be explicable in terms of the nature, chronicity or refractoriness to treatment of symptoms.

Belief in supernatural causes of mental illness among Malay patients: impact on treatment

The concept of aetiology of mental illness in 134 Malay patients was investigated by means of a 20-item checklist. About 53% of the patients attributed their illnesses to supernatural agents. Witchcraft and possession by evil spirits were regarded as common causes of illness. The number of patients who believed in supernatural causes of their mental illness was significantly higher among those who had consulted bomohs (Malay traditional healers) than among those who had not consulted them. The belief that mental illness is caused by supernatural agents is firmly held by bomohs, who reinforce this notion in those who seek their advice. Belief in supernatural causes of mental illness was not significantly associated with age, gender, level of education or occupation of the patients. Patients who believed in supernatural causes of mental illness were also found to show poor drug compliance, and the number of such patients at 6 months follow-up was significantly lower than the corresponding figure for those who did not believe in supernatural causes. The importance of understanding the patients' cultural background when treating psychiatric patients is highlighted.