One of the major concerns of health professionals working in the area of psychiatry is understanding the conditions under which patients adhere to prescribed treatments. While adherence is linked to some extent to the patients' comprehension of their illness, it is also a function of their social and demographic characteristics, such as age, social milieu, or sex. Another attribute also merits our attention, however: the patient's cultural affiliation and in particular, his or her religious background.
One of the major concerns of health professionals working in the area of psychiatry is understanding the conditions under which patients adhere to prescribed treatments, and this entails having knowledge of patients' understanding of these treatments. While adherence is linked to some extent to the patients' comprehension of their illness, it is also a function of their social and demographic characteristics, such as age,1 social milieu,2 or sex.3 Another attribute also merits our attention, however: the patient's cultural affiliation and in particular, his or her religious background.
This was the perspective taken by a recent study undertaken in France on the behavior of patients with regard to drugs.4 The study was carried out among 4 groups of patients from different religious backgrounds: Catholic, Protestant, Jewish, and Muslim. The aims of the study were to determine the level of comprehension these subjects had about drugs in general and psychotropic drugs in particular, why they did or did not use them, and what stood in the way of their use.
Subjects were chosen on the basis of their families' religious background and not on their belonging to an organized religious group. The aim of the study was to measure the "imprint" left by culture (and family religious background is part of culture) in patients who were sometimes totally unfamiliar with any religious belief system. The investigators found that religious/cultural heritage passed on through traditional values influenced a person's understanding of psychotropic drugs and the body, and it influenced the person's perception of and relationship with medical authorities.
In accordance with the classical methodology of social anthropology, the data were collected from in-depth interviews and thorough observations of subjects' behavior during medical consultations and at home. For each subject, medical and social histories were obtained and socioeconomic status noted. The research was carried out over a period of 5 years among 186 patients from diverse socioeconomic backgrounds, aged 25 to 75 years. Patients with equivalent socioeconomic status were compared across the 4 cultural groups in order to neutralize the strictly sociologic variable. Study subjects were drawn from groups of patients in treatment for various types of pathologies. Although some of them had never taken psychotropic drugs, all had ideas and perceptions about these drugs.
Perception of psychotropic drugs
An inquiry into the way in which people relate to psychotropic drugs poses questions that are coextensive with this original problem-namely, those concerning a person's beliefs about the body and psychiatric disorders-but also questions concerning relationships with those in medical authority. It was thus necessary to examine the subjects' perceptions of physicians (psychiatrists as well as general practitioners, because in France 85% of psychotropic drug prescriptions are written by general practitioners).
In this article, "psychotropic drugs" refers to neuroleptics, antidepressants, anxiolytics, and hypnotic drugs. Patients tend to group all of these into a single class because they lack thorough knowledge about the differences among these agents. Although psychotropic drugs are reputedly extensively consumed in France-overconsumption that can largely be explained by overprescription--they may provoke considerable reticence on the part of patients, which is linked to various types of fears, including:
In all 4 groups, we found a fear of the uncontrollable effects of psychotropic drugs and of the potential for madness to result from their incorrect consumption. However, some fears were more specific to individual cultural/religious groups under consideration.
Findings from gathered data showed that patients with a Catholic background more easily express their fears about the physical state in which psychotropic drugs may put them and in particular the fact that they "put you to sleep" or that they "knock you out." It is mainly the physical discomfort that is feared-the disagreeable feeling brought on by the desire to sleep in the middle of the day.
The same reasons are cited by patients of Muslim descent, especially by women. They complain about the physical effects of the drugs and of the sleepiness that results (effects that conflict with obligations linked to the status of a woman in a Muslim family, which entails the necessity of taking care of her family and not giving in to illness or sleepiness).
Because the heart has a special quality in Muslim tradition-it is the center of moral and spiritual life-patients are concerned about the deleterious effects of psychotropic drugs on the heart and through the heart, on social behavior. Many patients of Muslim descent believe that psychotropic drugs may act negatively on the heart and that disorders of the heart may cause madness. It is thus the heart that is considered most at risk from psychotropic drugs.
People with a Protestant background readily condemn the use of a chemical "crutch" and criticize those who are unable to confront their difficulties on their own. They are often adamant about solving their own problems and do not need "any help or go-between." Most of them are very reticent regarding the use of psychotropic drugs because of the belief that they will become dependent on the drug. It is interesting to note that refusal of dependency is a core value among Protestants and that it also influences their general wish to manage their illness, their prescriptions, and their treatments in a totally independent fashion.
Reticence toward psychotropic drugs among patients of Jewish descent in France is primarily related to fear of the loss of memory that prolonged use of this kind of medicine might induce. For Jews-believers and nonbelievers alike-memory is a cardinal virtue that must not be endangered. Jewish religious instruction includes the obligation of memory, and secular Jews regard memory as a link to history-to remember is to protect oneself.5 The continued reference to memory among the Jews recurs as a leitmotif in expressions of fear associated with taking psychotropic drugs.
Relationships with prescribing physiciansThe concept of prescription (from the verb prescribe) implies what must be done (in French, the term ordonnance-from the verb ordonner [to order]-is even stronger, implying the idea of an order being given).6 An order is something that may be circumvented, debated, or refused, and people respond differently based on their cultural characteristics. Indeed, we find greater submission toward physicians (general practitioners or specialists, psychiatrists or not) from patients of Catholic or Muslim descent than from patients with Jewish or Protestant backgrounds.
However, submission to the physician does not signify submission to the doctor's prescription, nor does it mean better compliance. Rather, it testifies to a distinctive relationship to authority embodied by the physician that manifests, for example, by not telling the doctor about one's refusal to take a prescribed drug. Thus, many patients of Catholic background, because they feel guilty about disobedience, do not want to risk "getting on the wrong side of the doctor" by openly refusing his or her prescription or by stating that they have used other therapies.
Similarly, patients with a Muslim background have an attitude of deference with regard to medical authority although they may be noncompliant and either don't take the prescribed drug or stop taking the drug when symptoms stop. Yet, so that their deception will not be apparent, they tell their physician-an authority figure-that they followed the prescribed treatment. Submission is highly valued among Muslims, whose name itself (mouslim in Arabic) means total submission to God. Submission in this case may include resistance, but the resistance is secret and hidden from the physician.
On the other hand, aside from the value of independence present in the Protestant doctrine, the refusal of Protestants to submit to an authority figure may stem from their past persecution in French society. Patients with Protestant or Jewish backgrounds are more likely to negotiate than are patients of Catholic or Muslim descent. The act of negotiation with physicians often manifests in the use of questioning by patients, a practice noted to be particularly widespread among those of Jewish descent.
Questioning is not unrelated to Jewish traditions. Indeed, not only does Talmudic teaching envisage and teach contradiction and controversy, but discussion and questioning are highly valued. On this point, Derrida and Bass7 mention the importance of hermeneutics (exegesis), and therefore of interpretation and commentary in the Jewish tradition, and underline the role of questioning, showing that the right to speak is inseparable from the duty to question.
Whereas sociology has shown that the physician-patient relationship depends on a model of negotiation,8 it is clear that this negotiation process is not identical in all cultural settings but is partly related to the religious and cultural traditions of the patient. Not only do these cultural groups maintain dissimilar attitudes toward physicians, but patient attitudes regarding medical authority tend to align themselves with attitudes that religious participants have toward their religious leaders.
Because this was a qualitative study undertaken in a specific historical and geographic context (France), findings may be relevant only to that specific country and may not be generalized to other countries. Thus, it may be of interest to undertake comparable research in the United States to analyze the differences and similarities of patients' perceptions in various contexts.
Patients' behavior regarding psychotropic drugs and physicians carries the imprint of their religious and cultural background, regardless of how far removed each is from being an active participant in the religion. This cultural imprint is to be found not only in the systems of thought to which these groups adhere or the doctrines on which they rely but also in the collective history of these groups. The importance variously accorded to memory among the Jews or the marked determination of Protestants to affirm their independence in relation to medical authorities, for example, shows that values shared in a cultural group express themselves differently among individuals. Attitudes toward physicians and the drugs they prescribe are based on tradition and the collective history of the cultural group to which the patient belongs.
Sylvie Fainzang is an anthropologist and director of research in the INSERM Cermes Site CNRS in Villejuif, France. She reports that she has no conflicts of interest concerning the subject matter of this article.
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