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Complementary or alternative medicine (CAM) is widely used, ranging from 9% of the population in the UK to 65% in Germany (1). Over a 12-month period in Canada, 50% of the population used a CAM therapy, and 15% visited a CAM practitioner (2,3). However, the use rate in Canada varies greatly depending on the medical condition, from 81% in cancer patients, to 27% in patients with gastrointestinal problems (4–11). What motivates people to choose CAM? Several studies have consistently reported that CAM users are likely to be middle- aged women with a higher educational level, higher income, and poorer physical and mental health than nonusers (12–15). The presence of a mental disorder is an important indicator for CAM therapy use in the general population, as well as in subpopulations with physical illnesses. Two national surveys in the US (16,17) found that mental disorders were more common in CAM users than in nonusers. CAM use is particularly common in patients with adjustment disorder, major depression, and anxiety or panic disorders (16–18). In a study of patients with early-stage breast cancer, psychological distress and poor self-perceived quality of life were significant markers of CAM use (19). In patients with gastrointestinal problems, anxiety was associated with CAM use (10). Little is known about why patients with a mental disorder are more likely to seek CAM. In this study, we sampled CAM users to examine differences between individuals with and without a mental disorder with regard to their quality of life, their reasons for seeking CAM, their complaints, and their physical illnesses. MethodWe studied new adult patients (age 18 years and over) at a CAM clinic (the Research Centre for Alternative Medicine [RCAM]) located in Calgary, Alberta. The RCAM is a university-affiliated, physician-run clinic. Patients are either referred by their family physician or self-referred. During the study period, the RCAM provided only acupuncture treatment. We asked new patients in the period between July 1, 1993, and March 31, 1995, to complete a survey questionnaire that contained items on sociodemographic characteristics, reasons for seeking CAM therapy (up to 3 reasons), the patients’ 4 most important complaints, and their past health conditions. We also asked patients to complete a global quality of life instrument (the Faces Scale [20]) that addressed 6 domains: general health, general sense of well-being, quality of life, perception of the amount of stress experienced, ability to relax, and perception of sleep quality. For each domain, patients rated their quality of life by choosing, from among the 7 points represented on the Faces Scale, the facial expression that came closest to their current feelings. A psychiatrist interviewed patients and recorded physical and mental conditions that were present at the time of interview. Mental disorders were coded according to DSM-III-R criteria (21). Physical illnesses and complaints were coded according to ICD-9-CM criteria (22). We used Fisher’s exact test to analyze statistical differences in the demographic characteristics of psychiatric and nonpsychiatric patients. We applied logistic regression when adjusting for age, sex, and occupation. All patients included in this study signed a consent form. The study received ethical approval from the University of Calgary. ResultsDuring the study period, 1261 new patients attended the clinic, and 826 (66%) completed questionnaires and interviews. A psychiatrist gave 578 (70.0%) of these 826 patients a diagnosis of a mental disorder. Depression was the most frequent diagnosis (48.3%), followed by adjustment disorder (32.0%) and anxiety disorder (7.9%). The prevalence for all other psychiatric disorders was less than 4%. Table 1 compares the demographic characteristics of patients with and without a mental disorder. The proportion of women was significantly higher among patients with a mental disorder (75.6% vs 66.5%, Fisher’s P < 0.001). The 2 groups did not differ in age and types of occupation.
Table 1 also presents findings from the quality of life scales (ranging from 1, “best possible quality of life,” to 7, “poorest quality of life”). After adjustment for age, sex, and occupation, the mean quality of life scores for all 6 measures were significantly higher, indicating poorer quality of life among patients with a mental disorder than among those without a mental disorder. Table 2 shows that the 2 patient groups did not differ in their reasons for choosing CAM after adjustment for age, sex, and occupation. The most common reason was personal interest, preference, or belief in CAM therapies (44.3% and 40.3% for patients with and without a mental disorder, respectively; adjusted P = 0.45). Perceiving complementary therapies as a treatment of last resort was the second most common reason (30.7% and 32.0% for patients with and without a mental disorder, respectively; adjusted P = 0.80). About 15% of patients in both groups chose CAM therapies because they were dissatisfied with conventional medicine or because they wanted to avoid conventional medical treatments.
Both patient groups attending the CAM clinic had the same 3 most common complaints: first, diseases of the musculoskeletal system and connective tissues; second, fatigue; and third, headache. Subsequent complaints differed across the 2 groups. Among patients with a mental disorder, the complaints ranked third to fifth were depression (13.5%), stress (9.7%), and sleep disturbance (8.8%); in the patients without a mental disorder, the complaints ranked third to fifth were digestive symptom (8.1%), disturbed skin sensation (4.4%), and obesity (4.0%). Physical illnesses in the 2 patient groups were diagnosed by a physician at the CAM clinic. The 2 groups did not differ significantly in their physical illnesses after adjustment for age, sex, and occupation. Diseases of the musculoskeletal system and connective tissues were the most frequently diagnosed physical illnesses in both groups, accounting for 42.6% and 42.3% in the patients with and without a mental disorder, respectively (adjusted P = 0.89). The second most common group of physical illness related to diseases of the nervous system and sense organs, accountingd for 15.0% and 17.3% in the patients with and without a mental disorder, respectively (adjusted P = 0.49). DiscussionThe study aimed to determine differences and similarities between patients with and without a mental disorder who attended a CAM clinic. The elements studied were quality of life, reasons for seeking complementary therapies, reported complaints, and physician- diagnosed physical illnesses. After adjustment for sociodemographic factors, patients with a mental disorder perceived their physical health, their general well-being, their quality of life, their ability to relax, and the quality of their sleep as poorer, compared with those without a mental disorder. Patients with a mental disorder also considered themselves to be under more stress than did those without a mental disorder. However, regardless of the presence of a mental disorder, most patients gave the same reasons for choosing care at a complementary therapy clinic, reported similar complaints, and had similar physical illnesses. Why is CAM more commonly used in patients with mental disorders? Astin summarized 3 possible reasons: 1) patients are dissatisfied with conventional treatment, 2) patients want to have control over their health care decision, and 3) patients see that CAM is congruent with their philosophical values and beliefs (18). Astin carried out a survey to test the above hypotheses and found strong support for the philosophical congruence hypothesis but less evidence for the hypothesis regarding patient dissatisfaction with conventional medicine (18). In our study, patients with and without a mental disorder do not appear to differ on self-reported reasons for choosing CAM. The 2 main reasons for both groups were philosophical congruence and perceiving CAM therapies as a treatment of last resort. Fewer than 10% of the sample gave dissatisfaction with conventional medicine as a reason; however, it might be argued that patients who sought CAM as a last resort were also dissatisfied with their conventional medical treatment. The only significant difference between the 2 study groups was in the measure of patients’ self-rated quality of life. Patients with a mental disorder reported poorer physical health and general well-being, more stress, less ability to relax, and more sleep disturbance than did those without a mental disorder. Of these 6 measures, the greatest difference appears in the amount of stress, although both groups reported a great amount of stress. Our findings are congruent with a recent report showing that women with early-stage breast cancer are more likely to turn to CAM when they experience psychological symptoms or distress (19). This suggests that a poorer quality of life and higher levels of stress in the patients with a mental disorder may prompt these patients to use CAM. Most patients with a mental disorder sought CAM treatment for somatic problems rather than for their mental and emotional symptoms. Musculoskeletal and connective tissue disorders were the most common complaint. This may be related to the fact that the principal therapy provided at the CAM clinic (acupuncture) may have attracted patients seeking pain relief (23). Another possible explanation is that physical illnesses are frequently comorbid with mental disorders, which can be secondary to general medical conditions (24–27). The study population included a large proportion of patients with mental disorders, consistent with 2 US surveys (16,17) showing higher rates of mental disorders among CAM users, compared with nonusers. However, mental disorder rates cannot be directly compared, because the studies assessed mental conditions differently, reviewed different CAM therapies, and had different population sources. It should be noted that the study clinic has a reputation for treating mental disorders. Generalizability of our findings may be limited because the study population comprised patients from a single complementary therapy clinic that only provided acupuncture. The physical illnesses and complaints found in our study population may differ from those at clinics offering other complementary therapies. Another limitation relates to the way psychiatric diagnoses were established in our study: a senior psychiatrist interviewed and assessed all patients and made psychiatric diagnoses according to DSM-III-R criteria (21). Compared with instruments used for psychiatric screening and diagnosing, the DSM-III-R provides broadly defined diagnostic criteria that allow for some variability in assigning a specific diagnosis. However, we did not group patients by specific diagnosis; instead, we classified patients into those with mental disorder and those without. This broad classification of presence and absence of mental disorder decreased the likelihood of misclassifying patients. Like their counterparts without a mental disorder, individuals with a mental disorder use complementary therapies according to personal beliefs. The wide use of complementary therapies among individuals with a mental disorder may be ascribed to a poor quality of life and high levels of distress. Funding and SupportThis research was supported by a grant from The George Family Foundation. References1. Ernst E, Prevalence of use of complementary/alternative medicine: a systematic review. Bul WHO 2000;78:252–7. 2. The Berger Monitor. The Berger monitor: March 1999 survey overview report. Toronto: The Berger Monitor and Hay Health Care Consulting Group; 1999. 3. Ramsay C, Walker M, Alexandrakis M. Alternative medicine in Canada: use and public attitudes. Public Policy Sources 21. Vancouver (BC): Fraser Institute; 1999. 4. Southwood TR, Malleson PN, Roberts-Thomson PJ, Mahy M. Unconventional remedies used for patients with juvenile arthritis. Pediatrics 1990;85:150–4. 5. Sawyer MG, Gannoni AF, Toogood IR, Antoniou G, Rice M. The use of alternative therapies by children with cancer. Med J Aust 1994;160:320–2. 6. Montbriand MJ, Laing GP. Alternative health care as a control strategy. J Adv Nurs 1991;16:325–32. 7. Boisset M, Fitzcharles MA. Alternative medicine use by rheumatology patients in a universal health care setting. J Rheumatol 1994;21:148–52. 8. Fernandez CV, Stutzer CA, MacWilliam L, Fryer C. Alternative and complementary therapy use in pediatric oncology patients in British Columbia: prevalence and reasons for use and nonuse. J Clin Oncol 1998;16:1279–86. 9. Hogan DB, Ebly EM. Complementary medicine use in a dementia clinic population. Alzheimer Disease and Associated Disorders 1996;10:63–7. 10. Verhoef MJ, Sutherland LR, Brkich L. Use of alternative medicine by patients attending a gastroenterology clinic. CMAJ 1990;142:121–5. 11. Rao JK, Mihaliak K, Kroenke K, Bradley J, Tierney WM, Weinberger M. Use of complementary therapies for arthritis among patients of rheumatologists. Ann Intern Med 1999;131:409–16. 12. Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, Kessler RC. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA 1998;280:1569–75. 13. Bausell RB, Lee WL, Berman BM. Demographic and health-related correlates to visits to complementary and alternative medical providers. Medical Care 2001;39:190–6. 14. Muhajarine N, Neudorf C, Martin K. Concurrent consultations with physicians and providers of alternative care: results from a population-based study. Can J Public Health 2000;91:449–53. 15. Blais R, Maiga A, Aboubacar A. How different are users and non-users of alternative medicine? Can J Public Health 1997;88:159–62. 16. Unutzer J, Klap R, Sturm R, Young AS, Marmon T, Shatkin J, and others. Mental disorders and the use of alternative medicine: results from a national survey. Am J Psychiatry 2000;157:1851–7. 17. Druss BG, Rosenheck RA. Use of practitioner-based complementary therapies by persons reporting mental conditions in the United States. Arch Gen Psychiatry 2000;57:708–14. 18. Astin JA. Why patients use alternative medicine: results of a national study. JAMA 1998;279:1548–53. 19. Burstein HJ, Gelber S, Guadagnoli E, Weeks JC. Use of alternative medicine by women with early-stage breast cancer. N Engl J Med 1999;340:1733–9. 20. McDowell I, Newll C. Measuring health: a guide to rating scales and questionnaires. New York: Oxford University Press; 1996. 21. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3rd ed rev. Washington (DC): American Psychiatric Association; 1987. 22. International classification of diseases. 9th revision clinical modification. Ann Arbor (MI): Edwards Brothers; 1989. 23. Bullock ML, Pheley AM, Kiresuk TJ, Lenz SK, Culliton PD. Characteristics and complaints of patients seeking therapy at a hospital-based alternative medicine clinic. J Alt Compl Med 1997;3:31–7. 24. Kroenke K, Jackson JL, Chamberlin J. Depressive and anxiety disorders in patients presenting with physical complaints: clinical predictors and outcome. Am J Med 1997;103:339–47. 25. Kroenke K, Wood DR, Mangelsdorff AD, Meier NJ, Powell, JB. Chronic fatigue in primary care. Prevalence, patient characteristics, and outcome. JAMA 1988;260:929–34. 26. Patten SB. Long-term medical conditions and major depression in the Canadian population. Can J Psychiatry 1999;44:151–7. 27. Katon WJ, Walker EA. Medically unexplained symptoms in primary care. J Clin Psychiatry 1998;59 (Suppl 20):15–21. Author(s)Manuscript received July 2002, revised, and accepted October 2002. 1Executive Director, Canadian Institute of Natural and Integration Medicine, Calgary, Alberta; Associate Professor, Department of Psychiatry, University of Calgary, Calgary, Alberta. 2Assistant Professor, Department of Community Health Sciences, University of Calgary, Calgary, Alberta. 3Research Scientist, Canadian Institute of Natural and Integration Medicine, Calgary, Alberta. 4Associate Professor, Departments of Community Health and Epidemiology and Psychiatry, Queen’s University, Kingston, Ontario. 5Professor and Head, Department of Psychiatry, Queen’s University, Kingston, Ontario. Address for correspondence: Dr B Rickhi, Canadian Institute of Natural and Integrative Medicine, Suite 170 - 1402 8th Ave NW, Calgary, AB T2N 1B9 e-mail: b.rickhi@cinim.org
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