The Role of faith healer visits in the management and prognosis of mental illness in Iraq.
Introduction :
Mental illnesses denote to disorders generally characterized by abnormalities of mood, thought, and/or behavior, as recognized by the Diagnostic and Statistical Manual, 4th edition, of the American Psychiatric Association (DSM-IV). Mental illness is usually not culturally appropriate. It is associated with disability or distress and not merely a conflict between the individual and culture.
Many people have a fear from mental illness and they stigmatize those who are affected by it. The reasons for that view originating from the idea that mentally ill patients cannot control their own behavior and that they may act in strange and possibly aggressive ways[1]. Stigma can affect the compliance of mentally ill individuals , it prevents him from seeking treatment , finding a job, and living successfully in his culture. To improve the state of mental health around the world , the World Health Organization (WHO) cited advocacy against stigma and discrimination , as it is one of the major barrier to overcome in the community[2].
Different attitudes toward mentally ill individuals were found among families , ethnicities and countries , the cultural and religious beliefs often affect the opinions about the nature and the origin of mental illness and even influence the attitude toward those who have mental illness , so it is mandatory to understand the cultural beliefs about mental illness in order to offer effective mental health services[3] Many cultures widely believed that mental illness was attributed to the magical forces , Gods anger or the result of supernatural phenomena such as spiritual or evil possession. Treatment of mental illness date back to ancient cultures and was focusing on the methods by which they can use to defeat these evil forces or remove the curse. A crude stone instruments was used to made a hole through the skull. It was believed that through this opening the evil spirits thought to be inhabiting patient’s head and causing their psychopathology will leave and the individual would be cured[4].
In ancient Greece , the mental illness was viewed as a sign of guilt and a punishment from the God for both minor and major crimes , and the mentally ill individuals were often abstain by their society and some were even put to death[5]. During this period , the priests were the main therapists , they used the prayers to the God to achieve cure of the patients. Later on , the supernatural or the mystical agents could no longer accepted as the underlying cause of mental diseases. Hippocrates and Aristotle were among the most important and influential figures during this time period[6].
Different practices and beliefs about health and illness were found among Islamic cultures. Some religious leaders considered illness one way of connection with the God , while others perceived mental illness as a punishment from God[7].
Mental illness may be seen as an occasion to fix disconnection from Allah or a lack of faith through regular prayers[8]. The Imams of Islamic mosques are often had a critical role in management of mental disorders , they may also play important roles in shaping family and society beliefs and attitudes to mental illness[9].
Cultural influences on presentation of symptoms and mental health problems
also need to be considered. Psychotic symptoms of mental diseases for example will be considered as a sign of the existence of jinn (the evil spirits) and this may prevent mentally ill patients from psychiatric visit and compliance with medications[10]. The Holy Quran is documenting the presence of jinn and the evil eye , and about 90% of followers of other major religions around the world have beliefs about witchcrafts and the demons[11]. The faith healers represent an indisputable source of care for individuals with mental disorders in developing countries [12] , they usually attribute the occurrence of psychiatric disorders to supernatural powers and ignore the therapeutic value of medications , they are persuading the patients and their family that a jinn entering the body of mentally ill individual causing the bizarre and odd behavior [13]. Most traditional or faith healers use the Islamic – based practices (e.g. reading the Holy Quran ) as a source of treatment[14] , while others use charms and amulets against mental illness[15]. Some of them will even use extreme forces and beat the clients and explain that method as a way to defeat those dark forces because they can sense pain and some of them used the Oud incense and even chewing gum and honey which they blessed as curative methods.

Aim of the Study : To investigate and document the rate of mentally ill patients who are visiting the faith healers and the effect of that visit on the management of their condition.
Patients and Method : This is a cross sectional study was done in Merjan Teaching Hospital during the period from November 2017 till February 2018 . The sample composed of 187 mentally ill patients (80 males and 107 females). Informed consent was obtained from the each patient before data was collected. Patients who did not give the consent were excluded from the study. In case of psychotic patients, the information were obtained from nearby relatives. A semi-structured questionnaire was used for information into socio-demographic data and questions about the visit to faith healers (time of the visit , the effect of the visit on the management , source of referral to the faith healer and if the money given or not ). Diagnosis of mental illness was made according to DSM-V.Statistical analysis was carried out using SPSS version 17. Categorical variables were presented as frequencies and percentages. Pearson’s chi square (X2) test and fisher exact test were used to find the association between the categorical variables. A p-value of ? 0.05 was considered as significant.





RESULT
Table 1 shows distribution of patients according to socio-demographic characteristics including (age, gender, residence, educational level, occupation and marital status).
57.2% of the patients in the present study were females , 61% of the patients were married. 41.2% of our sample completed secondary school and 52.9% of them were unemployed.
Table 1 Distribution of patients according to socio-demographic characteristics
Socio-demographic characteristics
Age (years) (33.96 ± 13.77) (4-68)
Gender
Male
Female
Total
80
107
187
42.8%
57.2%
100.0%
Residence
Urban
Rural
Total
107
80
187
57.2%
42.8%
100.0%
Educational level
Illiterate
Primary
Secondary
Higher education
Total
26
48
77
36
187
13.9%
25.7%
41.2%
19.2%
100.0%
Occupation
Un employed
Private work
Employee
Student
Retired
Total
99
23
38
23
4
187
52.9%
12.3%
20.4%
12.3%
2.1%
100.0%
Marital status
Married
Single
Divorce
Widow
Total
114
58
5
10
187
61.0%
31.0%
2.7%\
5.3%
100.0%








Figure 1 shows the distribution of patients according to visit to faith healer. Majority (74.3%) of patients had history of visit to faith healer.




Figure 1: Distribution of patients according to visit to faith healer


















Table 2 Shows distribution of patients according to groups of psychiatric illness (DSM-V classification). 25.1% , 22.5% and 19.4% were diagnosed as schizophrenia spectrum and other psychotic disorders , anxiety disorders and depressive disorders respectively.
Table 2 Distribution of patients according to groups of psychiatric illness
Groups of psychiatric illness N %
Schizophrenia spectrum and other psychotic disorders 47 25.1%
Bipolar and related disorders 7 3.7%
Depressive disorders 36 19.4%
Anxiety disorders 42 22.5%
Obsessive compulsive and related disorders 24 12.8%
Trauma and stress related disorders 9 4.8%
Somatic symptom and related disorders 15 8%
Neuro-developmental disorders 3 1.6%
Other (conduct disorders and substance related and addictive disorders) 4 2.1%
Total 187 100%

























Table 3 shows distribution of patients who visit faith healers according to study variables including (time of visit, source of referral to faith healer, money given to faith healer and effect of faith healer on patient compliance with medication). 69.8% of the patients in our study have a visit to faith healers before psychiatric consultation and 67.6% of the patients went to the faith healers with their family members. In most cases (88.5%) money was given to the faith healer. The visit to the faith healers was adversely affecting the compliance of mentally ill patients to their medications in about 76.3% of our sample.
Table 3 Distribution of visitors to faith healer according to study variables
Study variables N %
Time of visit to faith healer
Before psychiatric consultation
After psychiatric consultation
Before and after
Total
97
31
11
139
69.8%
22.3%
7.9%
100.0%
Source of referral to faith healer
Himself
Other
Total
45
94
139
32.4%
67.6%
100.0%
Money given to faith healer
Yes
No
Total
123
16
139
88.5%
11.5%
100.0%
Effect of faith healer on patient compliance with treatment
Yes
No
Total

106
33
139

76.3%
23.7%
100.0%



Table 4 Shows mean differences of age by history of visit to faith healers. There were no significant differences between means of age by study variable.
Table 4: The mean differences of age by history of visit to faith healers
Variable History of visit to faith healers Number Mean ± SD t-test P value
Age (years) Yes 139 33.92 ± 13.91 0.058 0.954
No 48 34.06 ± 13.5
*p value ? 0.05 was significant.


Table 5 shows the association between history of visit to faith healers and sociodemographic characteristics including (gender, residence, marital status, occupation and educational level). There was significant association between visit to faith healers and sociodemographic characteristics.
Table 5 Association between history of visit to faith healers and sociodemographic characteristics
Study variables Visit to faith healer X2 P-value
Yes (%) No (%)
Gender
Male
Female
53 (38.1)
86 (61.9)
27 (56.2)
21 (43.8) 4.786 0.029*
Residence
Urban
Rural
73 (52.5)
66 (47.5)
34 (70.8)
14 (29.2) 4.889 0.027*
Marital status
Married
Single
Divorce
Widow
90 (64.7)
42 (30.3)
2 (1.4)
5 (3.6)
24 (50.0)
16 (33.3)
3 (6.3)
5 (10.4) 0.045*f
Occupation
Un employed
Private work
Employee
Student
Retired
84 (60.4)
17 (12.3)
21 (15.1)
15 (10.8)
2 (1.4)
15 (31.3)
6 (12.5)
17 (35.4)
8 (16.7)
2 (4.1) 15.225 0.004
Educational level
Illiterate, primary or secondary
Higher education
122 (87.8)

17 (12.2)
29 (60.4)

19 (39.6) 17.17 <0.001**
*p value ? 0.05 was significant.
Table 6 shows the association between history of visit to faith healers and type of psychiatric disease including (schizophrenia spectrum and other psychotic disorders, depressive disorders, anxiety disorder and other psychiatric disorders). There was no significant association between history of visit to faith healers and type of psychiatric disease.
Table 6 Association between history of visit to faith healers and type of psychiatric disease
Study variable Visit to faith healer X2 P-value
Yes (%) No (%)
Type of psychiatric disease
Schizophrenia spectrum
Depressive disorders
Anxiety disorders
Others
Total

36 (25.9)
26 (18.7)
30 (21.6)
47 (33.8)
139 (100.0)

11 (22.9)
10 (20.8)
12 (25.0)
15 (31.3)
48 (100.0) 0.466 0.926
*p value ? 0.05 was significant.
Discussion :
The stigma attached to mental illness and the beliefs that psychiatric disorders was attributed to supernatural forces , had made a significant number of patients in our country to visit the traditional faith healers as shown in the present study which revealed that 74.3 % of patients had a visit to faith healer during the course of their disorder. The high number of faith healer visits may also reflects the level of belief & trust in faith healer to manage their illness. The result of this study was higher than the earlier research done in Nepal(16) and this can be explained by many reasons such as the faith healers are easily approachable by the patients in our country. In addition , in the last few years a greater number of such healers appeared in rural areas and even in the urban areas and most of them are using such ways of healing as a job to earn a lot of money from patients and their relatives and to our knowledge there are no legal restrictions to prevent this abusing way of healing. When compared to our results , a minority of patients with mental health problems are choosing the traditional faith healers in India(17) .
69.8% of patients in the present study are choosing the faith healers as the first service contact before psychiatric consultation and 67.6% of the visitors were following the recommendations of relatives and friends to seek help from such persons instead of psychiatrists and most of them gave money to get help from the faith healers. A widely spread wrong ideas about the medical treatment of psychiatric disorders in our culture and most of mentally ill patients and their relatives have a belief that all psychotropic medications are causing addiction and make the mental health more worse , so it is better and more safe at the first time to seek management from the faith healers who are using the Holey Quran and some herbals to treat the mental illness. The effects of mental illness on patient`s ability to take decision about psychiatric consultation along with the effects of other persons (relatives and friends) are the main reasons of the referral to the traditional faith healers not by the patient himself. In most of the cases in our study , the services provided by such healers are no free and money should be given before and sometime after the interview , and this of course has additional burden on the patient and his family.
Most of the patients had got an advice from the faith healers to stop taking psychotropic medication for their illness , and instead follow their special rules in management which could adversely affecting the condition of the mentally ill patient.
Previous study done in Saudi Arabia showed a similar finding to our results regarding the visit to the faith healers was on advice from the immediate family members or friends(18). There is no significant difference found in age groups of the patients who are visiting the faith healers , while in other study the visits to traditional healers are more prevalent among the elderly than the young(18). The present study shows that more females approached the traditional healers than males, and this result is nearly similar to other study done in India(19). In our society the cultural attitudes and limitations that are compelling the mentally ill females to comply and follow the orders of her family and her husband may greatly decreasing the referral rate to psychiatrist. The location of Merjan Teaching Hospital in the center of Hilla city makes most of its attenders from the urban area , thus only 80 patients in our study were from rural area and this may explain the slight increased rate (52.5%) of visitors to the faith healers were from the urban area. It is not easy ( in our society ) for the mentally ill married patients to visit psychiatrist and administer psychotropic medications because of their belief that psychiatric disorder and its therapeutic measures makes the family life more worse regarding their reputation among relatives and friends , in addition to the economic burden. This may explain why the high rate ( 64.7%) of the faith healer`s clients were married.
The level of education among our patients may affect their choice to consult psychiatrist , as 87.8% of visitors to faith healers were of low education level. The higher educated persons have the knowledge about the likely outcome of delay in seeking psychiatric care and they are also more aware of using unhealthy remedies.
The inverse relationship between faith healer`s visit and level of education is also
found in previous studies(18). There was no significant association between history
of visit to faith healers and type of psychiatric disease.
The present study is of benefit in showing the rate of mentally ill patients who have previous history of faith healers visit and the adverse consequences of following the advice of that healers. The possible factors that contribute to delay in seeking psychiatric care to our patients should be identified and managed in proper way.
The active role of media and educational institutions should be directed toward providing adequate information about the common psychiatric symptoms and public education about reducing psychiatric stigma.





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