Background
According to the World Health Organization (WHO) [
1], complementary or alternative medicine (CAM) refers to “a broad set of health care practices that are not part of that country’s own tradition or conventional medicine and are not fully integrated into the dominant health-care system.” The concept of CAM is not a new one, and the use of CAM for health promotion and the treatment of physical illness has been increasing worldwide over the years. Overall, the prevalence of all types of CAM use range from 9.8 to 76%, with the wide variation due to factors such as differences in the population characteristics, response rates, CAM definitions used, and study methodology [
2,
3]. There is a slow but steady increase of 2 to 6 % of CAM use within a decade in Western countries such as the United States, United Kingdom, and Australia [
4]. In East Asian countries, the 12-month prevalence of general CAM use is also high, with more than half the general population reported to be utilizing CAM in Malaysia, South Korea and Japan [
5‐
7].
CAM has also been utilized for mental illness. In the US, significantly more people with moderate mental distress reported the use of CAM when compared with the general population [
8]. In another study involving participants from 25 countries, CAM usage was reported by a total of 3.6% of respondents who met the criteria for a mental disorder as specified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition within the past 12 months, with increased prevalence in higher-income countries as opposed to lower-income countries [
9].
There is also evidence showing the potential benefits of using certain CAM modalities, including exercise and herbal therapies, for mental illness in terms of illness management and health promotion [
10,
11]. On the other hand, other modalities, such as biologically-based therapies, may produce general health complications [
12,
13] which is compounded by the tendency for patients not to report their usage of CAM to their physicians [
14]. With its growing global traction as a complementary avenue for managing health and illness, it is important to gain a better understanding of CAM and the characteristics associated with its use, and to assess the effects of using both CAM and conventional therapies for any possible adverse effects.
In general, while previous studies have found associations between CAM use and gender, education, income level and health status as well as ethnicity, the extent and direction of such associations between CAM use and these variables have not been consistently established across these studies [
8,
15‐
17]. In Singapore, CAM use has been documented in studies which found differing rates of use among Singaporeans and different variables associated with its use [
18,
19]. However, this does not provide a full picture of how CAM is used among Singapore residents, with their ethnic backgrounds as a potential influencing factor on CAM use. Moreover, there is a dearth of research on the use of CAM as an alternative mental health treatment resource for people in Singapore, with only one other study examining the factors influencing CAM use among older people with depression [
18].
To bridge the research gap in this area of CAM use, this article examines the factors influencing the use of CAM for the treatment of mental illness in the general population of Singapore. Specifically, the article investigates variations in sociodemographic associations with CAM use among the different ethnic groups as well as the link between health-related quality of life and CAM use. We hypothesized that the associations between CAM use and selected sociodemographic variables differ among the three main ethnic groups in Singapore (Chinese, Malays and Indians), and that CAM use is associated with poorer health-related quality of life. This article aims to provide new insight into the prevalence and patterns of general CAM use for mental illness in the Singaporean population according to the major ethnicities in the country and address the gaps in current literature.
Discussion
To the best of our knowledge, this is the first study that has examined characteristics of CAM use for mental illness treatment and its association with health-related quality of life among the major ethnic groups in Singapore. The weighted prevalence of past 12-month CAM use for a mental illness in Singapore’s adult resident population was found to be 6.4%; among those who met the criteria for a mental disorder in their lifetime, 17% had used CAM in the same period. This is about four times the proportion of CAM users who had no mental disorder. While the relatively higher proportion of CAM users among those who met the criteria for a mental disorder (compared with those who did not) is consistent with other studies which found the same pattern, the rates of CAM use found in this study differed from those found in other studies [
9,
18,
30]. This may be attributed to the different definitions and criteria used pertaining to CAM use and the mental disorders identified in the studies. For example, the percentage of CAM users that was found in this study among people with a mental disorder was much lower than that found in a previous study on CAM use and mental disorders in Singaporean older adults, which reported a prevalence rate of 53% [
18]. This might be due to the difference in scope of CAM use investigated between the two studies – the current study asked specifically about CAM use for mental illness treatment, while the other study did not, and merely examined CAM use in general. On the other hand, the operationalization of CAM use in de Jonge et al.’s study as contact with a CAM service provider, as opposed to the current study’s inclusion of practitioner- and self-directed usage, may explain the current study’s higher reported rates of CAM users among those with a 12-month mental disorder, compared to what was found in de Jonge et al.’s study [
9].
Analyses further revealed that across all ethnicities, having a mental disorder increased the odds of using CAM by at least 3.6 times, a finding similarly observed in a recent US study [
8]. A possible explanation for this increased use is that compared to conventional clinical health services for mental health, CAM therapies are more easily accessible, and the use of CAM for mental illness is associated with less stigma as well [
31]. Another possible reason could be that the cost of CAM is relatively lower than that of conventional healthcare [
32].
These findings have certain implications on the delivery of health care to people with mental illness in clinical settings. Conventional health providers may find it prudent to address whether their patients are also using CAM, and tailor their treatment programs accordingly. On the other hand, it is also important for CAM practitioners to be aware that their clients may have mental illnesses that clinicians and specialists are more equipped to address. Ultimately, the quality of mental health care and illness management can be facilitated by improved coordination between conventional mental health specialists and CAM practitioners, to provide more holistic treatment plans for patients with mental illness [
33].
Among the ethnicities, CAM was found to be used most by Malays, followed by Indians, and lastly Chinese. Among the five most commonly used forms of CAM, only the use of prayer or other spiritual practices differed among the three ethnic groups, with Malays having the highest proportion of users, followed by Indians and Chinese. This increased use may reflect the strong religious and spiritual beliefs of Malays, who are predominantly Muslims, and the important role that religion plays in their lives. The interplay between prayer and mental health, in the context of Muslims, can be seen in how the processes of prayer, reciting the Qur’an, and other spiritual practices are deeply inculcated as a means of resolving physical and mental hardships [
34,
35]. These religious teachings, together with the high level of commitment of Malays in general to their religion, may account for the higher tendency of Malays to turn to prayer and other spiritual practices for addressing their mental illness, as compared to people from other ethnicities, who are more heterogeneous in their religious and spiritual beliefs [
36]. As this is a preliminary finding, future studies can look at the association between ethnicity, religion and CAM use as a treatment for mental illness for a better understanding of the cultural mechanisms underpinning CAM use [
37].
While the variables found in this study to be associated with CAM use corresponded with that found in other studies, significant differences were found in the patterns of these associations among the different ethnic groups. Among Malays, age and education were found to be significantly associated with CAM use. Consistent with other studies [
6,
8], older Malays were found to have lower odds of using CAM in general. This may be a reflection of their perceptions of their own illness severity and attitudes towards help-seeking, as documented in a study which found stronger beliefs of self-reliance and greater passivity in older people when it came to addressing their mental illness symptoms [
38]. With regards to education, a university education was found to be associated with higher odds of CAM use, a finding also corroborated by other studies [
8,
17,
30,
39]. A plausible explanation for this may be that a higher education increases people’s awareness of CAM to treat mental illness, as well as their capacity to seek out CAM as an alternative treatment resource [
17]. Additionally, a higher education level may be associated with increased health literacy [
40], which is “the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” [
41], and which has been shown to be linked with increased CAM use [
42,
43]. However, these associations were only clearly found in the Malay group, and not in the Chinese or Indian groups. In line with other studies [
44‐
46], we found increased use among the unemployed, and unemployment significantly increased the odds of turning to CAM among Chinese and Indians. It is possible that CAM may have been perceived as a cheaper alternative to more Westernized forms of treatment by this group. Gender was also found to be associated with CAM use among Chinese and Indians, with females having higher odds of 12-month CAM use, consistent with previous studies [
47,
48]. This increased use may be attributed to the greater concern and care women tend to show towards their own health, compared to men, and their greater proactiveness in resolving health issues such as mental illness symptoms [
49]. These associations were not found in Malays. Finally, lower income was only found to be associated with lower odds of CAM use in Indians, but not in Malays or Chinese. The only common finding among all three ethnic groups was that being unmarried significantly increased the odds of CAM use across all three groups, which is consistent with another study that found a higher likelihood for unmarried people to utilize mental health services than married people [
50].
Similarities were identified in the association between CAM use and health status among the different ethnicities. After controlling for the other sociodemographic variables, CAM use was found to be associated with negative mental health-related quality of life across all ethnicities, in line with other studies which demonstrated an increased likelihood for CAM users to report poorer mental health [
8,
18]. This association may be a reflection of the tendency for people with poorer mental health to seek CAM in a bid to manage and improve their mental well-being. While the exact causal relationship between CAM use and poor mental health cannot be explicitly established in the current study, this finding nevertheless espouses the need for greater awareness of CAM use as an indicator of mental illness, on the part of both CAM providers and conventional health service providers.
Several limitations should be considered when interpreting the findings of this study. Firstly, the administration of the survey as a self-report interview makes respondents’ answers susceptible to recall bias. Secondly, the lack of cultural specificity of the CIDI to the local Singaporean context may have led to underreporting of CAM use by respondents if they did not recognize that what they used for their mental illness (for example, traditional Chinese herbal medicines) was a type of CAM (in the CIDI, this fell under herbal therapy). This was minimized by interviewers’ probing for any other therapy or remedy used for mental illness and immediate clarification of any queries brought up by respondents regarding the use of alternative therapies. Thirdly, due to the cross-sectional design of the study, the exact causality of the relationship between CAM use and the sociodemographic characteristics, and that between CAM use and health-related quality of life, cannot be established. Finally, as the CIDI was not designed specifically to assess CAM use, an in-depth understanding of the frequency, duration, specific reasons and underlying mechanisms behind CAM use was not possible. Despite these limitations, this study provides insight into ethnic differences in the use of CAM for mental illness, via discrete sub-group analyses of CAM use associations with the different ethnic groups in Singapore. The study also demonstrates that factors relating to CAM use do vary among different ethnicities, with certain factors being of more importance to people of a given ethnic group when considering CAM for the treatment of mental illness.
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