To trust or not to trust? Faith issues in psychopharmacological prescribing

AIMS AND METHOD

To ascertain attitudes, awareness, knowledge and variationsin prescribing habits of psychiatrists when addressing issuesof faith, culture and dietary requirements (in keeping withthe General Medical Council’s and the Royal College ofPsychiatrists’ guidelines), and how these may affect thetrust in doctor-patient relations. We undertook a cross-sectionalpostal survey aimed at clinicians in South West Yorkshire MentalHealth Trust.

RESULTS

We obtained 38 responses (40% of the total number of questionnairessent out) from two mailshots. Although the majority of respondentsindicated that they were aware of the presence of potentiallyforbidden animal-derived ingredients in medication, only halfexpressed the view that a discussion regarding the above shouldtake place prior to prescribing such medication.

CLINICAL IMPLICATIONS

Diversity training combined with taking a genuine interest in patients’ wishes will not only minimise ‘mistrust’but also facilitate prescribing in a therapeutic relationship.

Introduction

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Introduction

‘Patients must be able to trust doctors with their livesand well being. To establish that trust doctors must respectpatient’s autonomy and patients must be given sufficientinformation in a way that they can understand and are ableto exercise their right to make informed decisions about theircare. For example, patients may need more information to makean informed decision about a procedure, investigation or acondition which, if present, could have serious implicationsfor the patient’s employment, social or personal life.When providing information, doctors must do their best to learnabout their patient’s individual needs and priorities.For example, patient’s beliefs, culture, occupation orother factors may have a bearing on the information they needin order to reach a decision. Doctors must not make assumptionsabout patient’s views, but discuss these matters withthem and ask them whether they have any concerns. Doctors shouldprovide patients with appropriate information, which shouldinclude an explanation of any risks to which they may attachparticular significance. Doctors should not withhold informationnecessary for decision making unless they judge that disclosureof such relevant information would cause the patient seriousharm. In this context, serious harm does not mean that the patientwould become upset or decide to refuse treatment’ (General Medical Council, 1998).

Medication is probably the most frequently used form of treatment prescribed by clinicians within the mental health setting.Non-adherence to pharmacotherapy in mental illness significantlyimpacts upon the lives and well-being of people with mentalhealth problems (Patel & David, 2005). The causes of pooradherence to treatment are numerous (Robinson et al, 1999)but beliefs regarding mental illness and psychotropic medicationare significant factors cited in the literature (Hughes et al, 1997). Although it is generally thought that religious beliefs donot influence medication compliance (Dein, 2004), resolvingnon-adherence to pharmacotherapy should involve a comprehensiveassessment of the patient’s demographics, social circumstances,and cultural and religious beliefs (Sattar et al, 2004a; Subach & Abdul-Ezz, 1999).Some researchers claim that not only do patients with strongspiritual values cope better with mental illness but their understandingof illness behaviour is also greater, giving them better insight into their condition (Kirov et al, 1998). Such factors directlyimpact upon treatment compliance and engagement in therapy(Batson & Ventis, 1993; Koenig, 2001; Pargament & Brant, 1998).

Religious laws do not restrict the use of psychotropic medicationsbut many do forbid the use of animal-based derivatives, specificallygelatinous products and stearic acid which are generally derivedfrom beef and/or pork. This has major implications for manypatients, particularly the followers of Judaism, Islam, Hinduism,Buddhism, Seventh Day Adventism and the Christian OrthodoxChurch (Singsit et al, 2000; Leung et al, 2005). There arealso over 4 million vegetarians in the UK and the number isever growing (Food Standards Agency, 2005).

‘All prescribers have an obligation to respect their patient’s medical, cultural and religious dietary requirements (e.g.gluten-free for patients with coeliac disease, avoidance ofanimal gelatin for vegetarian, Jewish or Muslim patients)’(Royal College of Psychiatrists, 2004).

Lack of consideration for these matters will negatively affectthe doctor-patient relationship. Although research in thisimportant area has been scarce (Sattar et al, 2004b; Dogra & Karim, 2005),it has been shown that nurturing and fostering ‘trust’in our patients improves treatment compliance, reduces relapserates and thus helps to ameliorate their mental distress.

Method

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Method

This study was conducted at the constituent units of the SouthWest Yorkshire Mental Health NHS Trust in Wakefield, Dewsbury,Huddersfield and Halifax. All these localities boast a highproportion of multi-ethnic and multicultural populations. Wedeveloped a postal questionnaire with eight items, some allowingdichotomous answers or a more complex choice, based on a 5-pointLikert scale (from ‘strongly disagree’ to ‘strongly agree’). This was anonymous and aimed at all the cliniciansin the Trust. The questionnaire also sought information onthe participants’ gender, grade, ethnic origin and thecountry of acquiring basic medical qualification. Having obtainedconsent it was posted to 95 clinicians in December 2006. Datawere analysed using SPSS version 10 for Windows and ${chi}$ ²-testswere used to determine whether the prescribers’ responsesdiffered with respect to their demographic details, ethnicity,level of training and place of undergraduate medical studies(UK v. overseas). Our study aimed to identify and assess theprescribing habits of psychiatrists that might collide withreligious and cultural beliefs of patients and the doctors’opinions on the importance of informing patients when medicationmight contain ingredients unacceptable to them. We also soughtdoctors’ views on the appropriate context and venue to address this issue.

Results

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Results

Out of the 95 questionnaires distributed in two mailshots, weobtained 38 responses (40%). Most of the surveyed cliniciansreceived their basic medical qualification from overseas medicalschools; 42% were in training grades; 18 were female (47%);for demographic information see Table 1.

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Table 1. Clinician demographics

The majority of respondents (n=27, 71%) were aware of the presence of potentially forbidden animal-derived ingredients in medicationand only half (53%) considered a discussion with patients regardingthe above necessary (for responses to other questions in thesurvey see online data supplement 1).

We provided a list of commonly used psychotropic medicationto ascertain the clinicians’ knowledge about whetheror not they contain animal-derived gelatin and/or stearic acid.Most of the responses were ‘don’t know’ (Table 2).Information on the gelatin or stearic acid content of medicationscan be obtained from the Physicians’ Desk Reference (www.pdr.net/home/pdrHome.aspx) or electronic databases such as the Internet Drug Index (www.rxlist.com/script/main/hp.asp).

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Table 2. Doctors’ awareness of medication containing animal derivatives

A large majority (n=32, 84%) of respondents do not routinely inform patients of such ingredients, and only one respondentalways discusses these issues with patients prior to prescribingmedication. Of those respondents that ‘never’ discussthe ingredients, 75% (n=24) stated they would like to do thatin the future. Respondents had the opportunity to add comments,particularly with regard to their reasons for providing orwithholding information about medication ingredients from patientsin the future (see online data supplements 2 and 3). We alsosought information regarding the best venue to address theseissues. More than half (53%) of the respondents felt that thisdiscussion should only take place if and when a client identifiesany concerns but a significant number (45%) felt that it shouldbe made part of the informed consent. Nineteen respondents(55%) either agreed or strongly agreed with the statement that volunteering information on the presence of ‘forbiddencontents’ of medication would negatively influence patients’future compliance with medication.

Chi-squared tests did not suggest any variables (demographicdetails, ethnicity, level of training or place of undergraduatemedical studies) significant in clinicians’ prescribingbehaviour.

Discussion

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Discussion

To our knowledge, this is the first study in the UK of prescribers’ attitudes, knowledge and opinions on the importance of informingpatients when medication might contain ingredients againsttheir beliefs, culture or religion and the potential effectson the doctor-patient relationship. Prescribing edication containinganimal-derived gelatin and/or stearic acid may be unavoidablein certain situations. However, people who follow certain beliefsystems may well be committing a ‘sin’ if they readily consume such medications. This leaves many with the dauntingprospect of compromising their deeply held personal and religiousvalues at the cost of their mental health (Sattar et al, 2004b).As practice shows, some may consciously choose to sacrificethe latter. This not only has obvious implications for patientsbut also for physicians who may find themselves facing ethicaland potentially legal challenges. Therefore, it is imperativethat full and frank discussion takes place as part of informeddeliberations prior to reaching any agreement on the use ofpsychotropic medication. Psychiatrists should also make everyeffort to take a proactive approach in identifying patientsthat are affected by such issues and educating them on theingredients in their prescribed medication. A basic familiaritywith religious dietary restrictions (Meyer, 1988) and of available alternatives can easily fulfil this purpose.

Another approach would be for drug companies to clearly markmedication packaging with easy-to-spot ingredient labels andsymbols, equivalent to the ‘V’ sign used on vegetarian-approvedfood products. This is a novel, and potentially controversial,proposal but such product label guides have been widely calledfor by many sections of society and have now become the acceptedand expected norm for many food products. Although a numberof medications (invariably modified-release, controlled-releaseand gastro-resistant preparations) already state the presenceof gelatin in capsules, this is usually confined inconspicuouslyto the product information leaflet. A logical extension ofthis may be to clearly label such products with a single identifiablelogo or mark (e.g. crossed-out ‘V’ sign).

Occasionally, involvement of community leaders and religiousscholars from relevant faith communities in the deliberatingprocess could not only aid understanding of these sensitiveissues among healthcare professionals but might also help toinstil a spirit of trust in patients. This becomes even moreimportant, especially since the theological positions on thisissue are complex. However, many faiths tend to follow theoverriding principle of medical necessity and exercise leniencyto preserve life (Gatrad & Sheikh, 2000; Spitzer, 2003; Medicines Partnership Publication, 2004; Usmani, 2006). Demonstratingawareness combined with a genuine concern about how these issuesimpact upon patients as individuals may help to improve transparencyin cases of non-compliance. Only a process such as this can facilitate a dialogue which may help patients decide on theappropriate course of their treatment.

Comprehensive policy planning on such an important issue shouldideally involve both prescribing and non-prescribing healthcareprofessionals, pharmaceutical industry representatives, religiousclerics, community leaders, the Vegetarian Society, the GeneralMedical Council, carers and service users.

New guidance on personal beliefs and medical practice (General Medical Council, 2007) is currently being drafted (the 8-weeks’ public consultationon this issue ended on 21 September 2007). It partly exploresone of the aspects of our work but it specifically examinesthe provision of equitable access to healthcare for all peoplewith mental health problems and potential barriers on bothsides in the doctor-patient relationship. Notably, ‘itis not intended to provide a comprehensive guide to religiousor other beliefs and how these impact on medical care or treatment’ (General Medical Council, 2007). However, we feel that furtherinvestigation into these specific aspects is also equally warrantedat this time as research and guidance in this area is scarce.

Limitations of the study

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Limitations of the study

Our study was limited to only one geographical area of the UKand the response rate was not particularly high. More researchand empirical data are needed, particularly with regards tothe views, opinions and attitudes of service users. In addition,we did not directly investigate how the cultural and religiousbeliefs of psychiatrists themselves might influence their prescribinghabits and attitudes.

Acknowledgments

We thank Mrs Faiza Imran for her hard work and contributionin data collection and statistical analysis. We also appreciatethe advice and support given by Mr Harry Smart, Mental HealthChaplain, Sheffield Care NHS Trust, and Prof. Stephen Curranand Dr Richard Marriot, South West Yorkshire Mental HealthNHS Trust.

References

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