Introduction
Bipolar disorder (BD) is a chronic mood disorder typified by mood swings from manic or hypomanic episodes to depressive episodes(1). NICE guidelines for BD describe pharmaceutical (antipsychotics or antidepressants depending on the patient's variant of relapse) and psychological (for depressive episodes) treatment(2).
Long-term treatment is usually pharmaceutical, with lithium as the most effective chronic mood stabiliser(1). In formulating personalised care plans, clinical practitioners treating patients with differing cultural or ethnic beliefs are advised to be culturally competent(3). Yet there are no formal guidelines for the different types of belief systems one may encounter in clinical practice and even the most culturally competent doctor may be caught off-guard due to this.
My 50-year-old aunt suffers from BD but was only formally diagnosed at 40 years old after a suicide attempt led to formal sanctioning by Bruneian authorities. As a medical student, I can now recognise obvious symptoms from the very beginning which should have been cause for familial intervention at many points in her life before the suicide attempt.
The question is – why did no one intervene? I believe the curious intersection of culture and religion in Brunei is responsible for this, leading to a hostile environment that systematically fail patients to devastating results. My aunt was first pressured by her family into seeking traditional help from bomohs (Malay traditional healers) for her hallucinations during her manic phases and was branded attention-seeking when this did not work. She eventually became known as "gila", a derogatory Malay term for crazy, and was alienated from the family.
From her experiences, it can be discerned that several factors played a key role in transforming deterioration of her condition from preventable to inevitable. These are:
1. Conflict between Western medicine and cultural beliefs
2. Conflict between Western medicine and religious beliefs
This report aims to discern the actual impact of religion and culture on a BD patient's illness journey by examining the role of each of the above factors in the course of BD. Eight papers are reviewed, from 1996 to 2017. All patients involved were diagnosed with BD using DSM-III, DSM-IV or ICD-10. Finally, I will discuss the merits of integrating religion and cultural beliefs into clinical practice and whether or not it is viable or detrimental to the patient.
WESTERN MEDICINE AND NATIVE CULTURE
LITERATURE OVERVIEW AND CLINICAL SIGNIFICANCE
Diagnosis of BD depends on externalisation or self-reporting of symptoms, which are often based on one set of diagnostic criteria. But clinical presentation varies according to culture, which may lead to under or over reporting of symptoms based on what has been normalised in one's society. Since available literature on BD mostly come from developed, Western countries, a problem arises whereby clinical practitioners transplant this Westernised medical gaze into a native culture without considering the idiosyncrasies that may complicate this.
This issue is tackled by Bantjes et al.(4) who explore the role of traditional South African healers in suicide prevention within the community. While suicide is associated with all severe psychiatric illness, it is most likely in mood disorders such as BD, with 25-50% of patients attempting suicide at least once(5). South Africa (like most developing countries) have rampant use of traditional healers (60%), and Bantjes et al.(4) aim to determine the efficacy of this cultural gaze in dealing with suicide.
Results show that traditional healers seem to have a fundamental understanding of widely acknowledged etiological models of mental health (e.g. biological and environmental stressors) as well as talking therapy. While South African traditional healers heavily incorporate spirits and ancestors in both diagnosis and treatment, there seems to be no negative effects from this, as it has the benefit of utilising the patient's support network.
There remains, however, a discontinuation between traditional and Western medicine. While traditional healers can "heal" people through unintentional use of talking therapy, medication and more specialized skill-sets are also required once the first-line treatment fails. Yet there is no structured referral system, as traditional medicine is viewed disjointedly from Western medicine rather than a continuation of holistic treatment for the patient, whose interests are paramount.
However, transitioning from two, separate fields into a united medical community must be dealt with sensitively. Participants demonstrated innate hostility to modern medicine due to its links with Westernisation and colonisation and might resist this fusion due to perceived erosion of their identity and credibility. Despite the detriment to patients, traditional healers might just maintain their separateness due to the sense of security it provides in the face of globalisation.
In a rapidly borderless world, it is only natural that resistance manifests in the form of reinforcement of beliefs in traditional healers, as exemplified in Bantjes et al.'s study(4). On the other hand, accelerated change in cultural landscape in modernising countries also affects patients. This is illustrated in Ng's study(6), which examines the change in etiological models for patients with BD concurrent with the change in cultural, economic and socio-political landscape in post-Mao China.
Results from the study suggest a generational divide wherein those born and raised in the Maoist era used external stressors as an etiological model while those who mainly grew up post-reform tended to gravitate towards self-blame and individual responsibility. This echoes the shift from collectivism (Socialist China) to individualism (Capitalist China) due to the emergence of market economy whereby the "work unit" has been disregarded in favour of personal gain. While this may seem empowering in a neoliberal context, this shift to self-blame has the effect of legitimising environmental stressors (such as a toxically competitive economic climate) without questioning its possibility as an etiological model. This could also obfuscate diagnosis of BD as manic phases are highly regarded in capitalist societies such as USA(7), which delays help-seeking as it is not recognised as a symptom, but rather a boon.
As such, all participants reported some measures of avoiding stigma (either by hiding their diagnosis or other means) and almost all were coerced into seeking professional help by family members who were often only aware of their debilitating mental health via employers. Six patients utilised traditional Chinese medical doctors before (and even after) receiving treatment, with seven other patients seeking other specialties before psychiatry. This reveals a lack of real discourse vis-à-vis mental health in a public sphere- despite the massive reforms sweeping the nation. Undoubtedly, the cultural change has only worked to transfer the blame from the state to the self with no improvement in stigma.
CRITICAL APPRAISAL
Ng conducted semi-structured interviews in Mandarin with 15 patients with BD at a Western-style mental health institution in Shenzhen(6). This is one of the strengths of the paper as Shenzhen was China's first Special Economic Zone(8) and perfectly encapsulates the fast-paced cultural change in contemporary, urban China and around the world.
The main limitation in Ng's study(6) is the inability to draw a clear causal relationship between the changing sociocultural landscape and inter-generational differences in responses. While there is a correlation, the extremely small sample set prevents extrapolation of these findings to the general population. This is also influenced by its unique location – a Western psychiatric institution in Shenzhen, which skews the sample to those who seek specialist help and live in an urban setting not necessarily transplantable to other localities and treatment facilities in China.
Bantjes et al.(4) recruited a small set of widely-known traditional healers in the community using a financial incentive. This retrospective documentation of their approach to suicide prevention runs the risk of recall bias, and the lack of data proving the actual effectiveness of their treatment means that these healers claims cannot be substantiated.
Additionally, participants were limited and come from semi-urban areas. Whilst the authors attempt to justify this by arguing that South Africa has a booming urban population, it cannot be denied that rural areas tend to utilize traditional healers more, and healers who are well-known and willing to participate in such studies are not very representative of the wider majority who might not be as wholesome.
One strength is that the authors seem to be aware of the risk of falling into tropes when dealing with the culture-science dichotomy in medicine, and are wary of caricaturing either aspect of treatment, unlike previous studies. This is important as they do not invest heavily in the idea that Western medicine is completely divorced from cultural approaches and present a well-balanced argument.
WESTERN MEDICINE AND RELIGIOUS BELIEFS
LITERATURE OVERVIEW AND CLINICAL SIGNIFICANCE
RELIGION AND CULTURE
The previous section explores the cultural aspect of traditional healing, but the reason for its tightly woven presence in societal fabric worldwide is its unique intersection of religion and culture.
This is explored by Grover et al.(9) who explored the impact of religiosity and supernatural-religious beliefs on the treatment of patients with BD in euthymic state. They found that 70% of participants did not feel an attempt from healthcare providers to understand, much less consolidate, their religious and spiritual beliefs with any point of their illness journey.
Similar to Bantjes et al.(4), this highlights the discord between Western medicine and a patient's idiosyncrasies, and the risk that comes with transplanting secular, highly scientific medicine into an environment with well-established medico-religious healers.
In clinical practice, this could potentially delay help-seeking and prevent doctors from being better healthcare providers as they possess an incomplete understanding of the patient's illness experience. For instance, 20% of patients perceived a lessening of symptoms after visiting a sacred site in their respective religion. Were doctors to explore and incorporate this into their treatment plan, it might improve prognosis and disease progression.
BIPOLAR DISORDER AND ISLAM
Muslim communities have traditional healers that are religion based tinged with remnants of animistic, indigenous culture seen in Bantjes et al.'s study(4). Known as Islamic counselling, a variety of rituals are performed in an exorcism to cleanse patients of their mental illnesses, the root of which are often attributed to spirits (jinns). These range from the religion-based such as reading the Quran and group prayer (dhikr) to the culture-based such as beating spirits out of patients(9).
While the less extreme aspects of exorcism such as group prayer and physical acts of spiritual healing were associated with better self-management and compliance in Mitchell and Romans'(10) study, there are no regulations in place to ensure these religious rituals are safe for patients. There may be some merits to these organizational expressions of faith but the legitimacy of these acts varies in both efficacy and in Islam(11,12). This is even more concerning considering that traditional healers are held to the same esteem as clinical practitioners in some cultures but are allowed to practice without safeguarding protocols.
According to the World Health Organization(13), traditional healers are highly sought after for treating mental illnesses due to three factors: confidence in the system, affordability and accessibility. Traditional healers are more common in areas that lack an accessible healthcare system due to socioeconomic deprivation, which generally corresponds with lower educational level in patients. As such, this creates a dilemma whereby these patients cannot afford or access psychiatric services in their local area, and even when they can, the medication-led approach of clinical practitioners seem less palatable than the culture and belief-based explanations provided by traditional healers.
In relation to this, Assad et al.(14) investigated the relationship between traditional healers in Egypt and the socioeconomic characteristics of bipolar patients. 40.8% of patients sought help from traditional healers, of which 62.2% did so as their first line of treatment while 37.8% did so after an initial psychiatric consultation.
There was negative correlation between psychiatric comorbidity, but 18% of participants had comorbid substance abuse. Perhaps this could explain the change in sanctioning behaviour by relatives, who might dismiss it as symptomatic of substance abuse rather than part of a bigger picture of BD.
A major finding was that those who utilized traditional healers tend to be less educated, contrasting with a similar study conducted by Razali et al.(15) in Malaysia, which found no such correlation. However, Assad et al.(14) also found that consulting behaviour had no relation with religion difference. Perhaps cultural beliefs are so deeply ingrained in such communities that they supersede even education and religion.
Another interesting finding is that BD symptoms associated with higher rates of spiritual healing were hallucinations and marked functional impairment. In Islam, etiological models used to explain mental illnesses are usually paranormal in nature, with cultural variants. As such, these symptoms are more easily explained as a manifestation of witchcraft rather than other classical symptoms like delusions and thought disturbance, thus garnering more consultations.
This is reinforced by Razali et al.(15) who explored etiological models of mental illness in 134 Malay-Muslim. 53% of participants formulated a model geared towards magico-religious beliefs, specifically witchcraft and possession. These participants also had significantly higher consultation rates for bomohs. Those with chronic illnesses with high morbidity (i.e. BD) had the highest consultation rates at 80%.
Similar to WHO's 2003 report(13), Razali et al.(15) reported that patients had greater faith in bomohs than in clinical practitioners, with some opting out of conventional treatment in favour of traditional healing. Conversely, participants tend to be more forgiving with bomohs rather than clinical professionals. Even a mild change in condition after a bomoh consultation resulted in reversal of scepticism at their capabilities, whereas a relapse after clinical treatment led to cessation of said treatment. This could be due to misunderstanding of the reality of psychiatric help, whereby delayed and poor response to medication cannot compare with the instant gratification a traditional healer can provide with the promise of a "quick-fix" cure.
Beyond magico-religious beliefs of Islamic traditional healing, religion can also impact the course of BD in other ways. Kadri et al.(16) recruited twenty Muslim, bipolar patients during Ramadan to observe the effects of fasting on their mood state and blood lithium levels. The findings revealed 45% relapse in patients, with 70% occurring during the second week, and the remainder at the end of Ramadan.
Interestingly, these changes were not related to change in blood lithium levels but rather the change in social rhythm. Mood state were assessed using the Hamilton Depression and Bech-Rafaelsen scales and revealed a disruption in mood state that did not correspond with blood lithium levels. Most experienced manic relapses (71.4%) while the rest had insomnia and anxiety. This raises the possibility of a "Ramadan model" whereby the abrupt changes in everyday life due to onset of Ramadan (i.e. sleeping and eating patterns) may cause a dysregulation in mood state of patients with BD.
BEYOND ORGANISED RELIGION
It would be amiss to ignore those who have spiritual and philosophical beliefs separate from a traditional God figure.
Mitchell and Romans(10) explored the relevance of spiritual beliefs in BD by adapting the Royal Free Interview for Religious and Spiritual Beliefs(17) to include questions on illness management issues relevant to BD. 94% of participants had spiritual, religious or philosophical beliefs.
Two variables strongly influenced perception of helpfulness of these beliefs in illness management: prior spiritual healing and awareness of God (or associated greater power)'s influence in their lives. Physical acts of spiritual healing (such as meditation) was associated with better self-management, while those with religious or spiritual beliefs perceived a greater effect of their beliefs on illness management than those with philosophical beliefs.
Those in evangelistic denominations attributed seeking clinical help early to their beliefs more than those in other denomination. At the same time, these patients also reported higher rates of conflicting advice from their faith advocates and their clinicians and were less compliant with medication. This could be attributed to greater exposure to spiritual leaders whose advice may often conflict with those of clinical professionals (encountered by 19% of respondents, of which 32% described situations where they were advised to stop medication and focus on spiritual healing).
This is similar to Razali et al.'s findings(15) where those with higher bomoh consultation rates had worse treatment compliance. Bomohs tend to reinforce these beliefs in their patients upon the first consultation, thus making subsequent visits more probable and professional help less likely. One reason for this could be that those who already hold alternate views might be dissatisfied with the initial consultation and seek reaffirmation of their concept of illness management from those in their religious/spiritual sphere.
Mitchell and Romans(10) also found that patients and clinicians may not always have the same illness models in BD due to an added religious/spiritual/philosophical dimension on the patient's side. This is important in clinical practice as these beliefs can affect a patient's illness outcome (e.g. by influencing concordance), and disregarding them is not only reductionist, but also damaging to the patient.
This is especially true for indigenous spiritual beliefs explored by both Bantjes et al.(4) (South Africa) and Mitchell and Romans(10) (Maori). Maori respondents reported the greatest mean level of conflict between their beliefs and their clinicians. Like many other indigenous people, Maori's conception of health is quite holistic(18). As such, they might be dissatisfied with a classical clinician's approach to management of BD which could seem simplistic and medication-led.
Russell and Stein(19) conducted a longitudinal study to explore religious coping mechanisms in 48 young adults with either schizophrenia or BD. Self-conception of God plays a role in one's illness experience, with a benevolent God associated with positive mental health experiences, while a harsher God is associated with self-reported distress and personal loss. Yet people with BD often experience a drop in religious beliefs, with some who use it positively still struggling to reconcile their image of a compassionate God with such pain and hardship.
This suggests that religion's role in illness management of BD is not always a dichotomy of good or evil, but rather a source of conflict. Similarly, Bantjes et al.(4) described spiritual ancestors' wrath as a deterrent for suicidal patients while 15% of suicidal participants from Assad et al.'s study(14) were hindered from acting on it due to religious reasons. While this might seem like an effective restraint, it does not address the root of the problems and acts as a stop-gap solution that might cause even greater psychosocial stress.
CRITICAL APPRAISAL
The main limitation of Grover et al.'s study(9) was the location of recruitment, which was an outpatient clinic in Chandigarh, North India. The religious beliefs of bipolar patients who are already seeking or undergoing treatment cannot then be generalized to bipolar patients in the community whose religious beliefs often prevent them from seeking medical treatment, leading to an underrepresentation of prevalent magico-religious beliefs and practices. Other serious limitations include retrospective assessment of their beliefs (which could lead to recall bias and falsification), and the use of a questionnaire which has not been validated, and whose reliability and other psychometric properties have not been peer assessed. Additionally, the cohort's base line beliefs were not assessed, and as such, change in beliefs could only be assessed cross-sectionally rather than longitudinally.
In fact, only Razali et al.(15), Kadri et al.(16), and Russell and Stein(19) conducted longitudinal studies rather than cross-sectional studies. Longitudinal studies are better suited for assessing the impact of beliefs on one's treatment as they do not have to rely on recall bias or retrospective falsification.
However, Assad et al.(14) differed from other cross-sectional studies in this review by providing a snapshot of different classes of patients. This is due to its recruitment of participants from a mixture of governmental and private psychiatric hospitals in Cairo. Razali et al.(15) recruited participants from the authors' current patients which provided a homogenous sample set. This also affects the participants' responses during the interview process, as they might be less comfortable voicing out their belief system to people they will be seeing again and again. It is also important to consider that Malays are more reticent to talk about emotions(20), and patients are generally eager to supply answers that they think their doctors are seeking.
Kadri et al.(16) began with a cohort of patients with low blood lithium levels, and whose prescription was changed from twice to once daily due to Ramadan. It was also a small sample with no control group (much like Mitchell and Romans(10)) so there is no way to determine actual causation. Though this is an interesting hypothesis with some merits, in the future, the scope of such research should be narrowed down to daily life metrics and how this relates to daily life.
Similarly, due to the small sample size in Russel and Stein(19), relationships between variables cannot be fully established and generalisation of findings are limited. This study also depends solely on self-reporting, which can be influenced by recall bias and other validity problems such as under-reporting or exaggeration. The scope of religious beliefs was also narrowed down to different Christianity denominations even though other forms of religious expression (e.g. frequency of prayer) could be investigated to further validate the effects of religious coping. It also remains to be seen whether this correlation can be solely attributed to spiritual beliefs as there was no comparison with secular coping techniques.
One of the strengths of Mitchell and Romans'(10) study is that the final draft questionnaire was then reviewed by the Otago Manic-Depressive Support Trust, a local indigenous tribe (Ngai Tahu) and a local Maori Mental Health Team (Te Oranga Tonu Tanga). Thus, their study is highly localized to New Zealand and tailored to the participants (who might be Maori) and their idiosyncrasies.
Conclusion
An emerging theme from the literature review is the chasm that lies between Western medicine and traditional medicine. In clinical practice, it seems that doctors and bipolar patients from diverse backgrounds unconsciously replicate this dispute, with doctors failing to understand patients who also fail to articulate their belief systems.
On a personal level, clinicians should be trained to have a greater understanding of diverse belief systems which often have overarching similarities – for example, Muslim communities and indigenous tribes often share the same general beliefs. Systems-wide reforms should also be considered to bridge the gap between traditional healers and clinicians in developing countries, with referral systems that ensure accountability and safe-guarding. As there seems to be no harm (and in fact, great benefit) for patients to utilise traditional healers and religious associations, clinicians should consider incorporating these psychological interventions into a bespoke care plan for patients.
RESEARCH QUESTION
'Are religious coping mechanisms more suitable psychological interventions than secular coping mechanisms for bipolar patients?'
The articles discussed so far have explored the impact of religious beliefs on BD devoid of any context of existing secular coping mechanisms. As such, it is impossible to fully advocate for the efficacy of one without comparing it to the other.
This study would have a longitudinal design so as to provide a developmental analysis of the efficacy of both treatments. It will last for 10 years, reflecting the chronic nature of BD and the need for an effective, long-term treatment. It will focus solely on religious beliefs due to the more universal applicability of religious vs. cultural beliefs (which are only applicable to certain countries and communities).
Two groups of participants would be recruited to exclusively address each type of coping mechanism. They would have the same demographics (i.e. same generation, education level) so as to control for variations in results due to socioeconomic factors. Participants would be recruited via advertisement at psychiatric outpatient clinics and General Practices as ideally, these mechanisms should be tested for efficacy among primary care bipolar patients (less severe) where its clinical use would be of most benefit. Exclusion criteria would be patients with a history of religious delusions, as this worsens prognosis and should be dissuaded rather than encouraged. Ideally, 100 patients would be recruited per group.
Secular coping strategies would be assessed using The Coping Strategies questionnaire(21) while Spiritual and Religious Attitudes in Dealing with Illness(22) (SpREUK) would be used for religious coping strategies. This will be posted every 6 months to ease data collection and lessen inconvenience (and hopefully attrition) for patients. Both questionnaires are validated and widely used in research, enhancing the validity and replicability of this study.