2Department of Mental Health, Graduate School of Medicine, 7-3-1 Hongo, Bunkyo-Ku, Tokyo 113-0033, Japan
DOI: http://dx.doi.org/10.15226/2374-6874/5/1/00145
Methods: Using a self-report questionnaire, a cross-sectional survey was conducted of 253 outpatients aged 20 years or older at two psychiatric clinics in Tokyo, Japan. The questionnaire asked sociodemographic characteristics, the use of natural products (4 types), and medication adherence. Data were analyzed by multiple logistic regression predicting 12-month use of natural products on demographic variables.
Results: A total of 241 patients responded to the survey (response rate, 95%). Statistical analysis was conducted for 189 respondents (females, 42%; average age, 47 years old). A total of 104 (55%) reported the use of any natural products: supplements/ health foods (41%), herbal tea (20%), aromatherapy (16%), and overthe- counter Kampo (Japanese herbal medicines) (8%). Significantly associated with natural product use were female (odds ratio [OR]: 4.28; 95% confidence interval [CI]: 1.87-9.77) and having any religion (OR: 2.91; 95% CI: 1.10-7.68). Respondents aged 65 years or older had a significantly smaller probability of using natural products (OR: .15, 95% CI: .03-.78). Among the respondents who reported carelessness with prescribed medications and stopping the drug when feeling worse, natural product users were fewer (OR: .24, 95% CI: .08-.76; OR: .11, 95% CI: .02-.69, respectively).
Conclusions: Use of natural products such as supplements and Kampo was found to be common among psychiatric outpatients in Japan. Natural product users reported higher as being careful with prescribed medications.
Keywords: Psychiatry; complementary health approaches; medication adherence; outpatient; communication; mental health.
These natural derived products seem to be safe; however, natural products can have several risks [6-8] such as a drug interaction with prescribed medications [6] and indirect health hazards that arise from not taking steps to receive appropriate and timely conventional medical care [7]. However, most patients do not disclose such use to their medical practitioners[9].
The use of natural products among people in general clinics or the community is common. For instance, in Japan, Shumer et al. Reported 32% used herbs or supplements[2] and Hori et al. Found 35%, 23% and 19% used vitamins, health foods including supplements and Kampo[3], respectively, in general outpatient clinics. In community-living people, Fukuda et al., reported the frequencies of supplements/health foods (male: 35%, female: 47%), aromatherapy/herbs (male: 2%, female 7%) and Kampo (male: 13%, female: 19%)[5].
In psychiatry, it is necessary for health care professionals to understand the reality of patients’ natural product use and users’ attitude toward conventional medicine. Many psychiatric patients use natural products [10-19] and at the same time, often are prescribed medications such as antipsychotic drugs. Of the attitudes toward conventional medicine, medication adherenceis especially important for psychiatric treatment. For example, there is a report that the longest period during which no medications appeared to be available was associated with a greater risk of hospitalization among psychiatric patients [20]. However, the association between medication adherence and the use of natural products is currently unknown. For these reasons, it is necessary to investigate the frequency and characteristics of patients’ natural product use and the associations between natural product use and medication adherence in psychiatry.
The use of natural products among psychiatric patients in the world vary from country to country [10-15, 17,18]. For example, the frequency of use of herbs and vitamins/minerals were found to be 4-26% and 1-16%, respectively, in the U.S., Turkey and Taiwan [10-14]. A similar study in the U.S. indicated that 22- 58% of people who have psychiatric symptoms used biologically based therapies including herbs and vitamin therapy [16,17]. While these surveys reported on natural product use, the reports vary even in the same country due to varying study designs and different definitions. It is hard to presume that the frequency or characteristics of natural product use in Japan is the same as previous studies outside of Japan. However, there are no previous studies among psychiatric patients in Japan.
This cross-sectional study aimed to clarify: 1) frequency, demographic characteristics and correlates with natural product use, and 2) the association between medication adherence and natural product use among psychiatric outpatients in Japan.
Detailed support documentation that contains definitions of complementary health approaches and each natural product with examples, was enclosed with the questionnaire. In the document, natural products were described as follows: “A supplement/ health food is not categorized as regular food and includes vitamins, minerals, herbs, etc.,” “Herbal tea is a brewing of dried herbs,” “Aromatherapy is a type of naturopathy using essential oils,” “Kampo includes prescribed Kampo and over-the-counter Kampo (sold at pharmacy or shop).”
The prevalence of natural product use was assessed by the following question for each natural product (i.e., supplements/ health foods, herbal tea, aromatherapy and Kampo): “The following are questions regarding complementary health approaches. Did you use natural products (i.e., supplements/ health foods, herbal tea, aromatherapy and Kampo) in the past 12 months?” In the case of only Kampo, one more question which we prepared was used in order to exclude prescribed products from natural products: “Circle if you have used: prescribed Kampo.”
The state of natural product use was assessed by asking four further questions: having information about safety and effects before the use of natural products; feeling benefit from the use of natural products; experienced side effects from natural products; and reported the use of natural products to a psychiatrist.
More than 80% of natural product use was not reported to their psychiatrists by the users: 17% of supplement/health foods use, 8% of herbal tea use, 20% of aromatherapy use and 13% of over-the-counter Kampo use were reported to psychiatrists by the users respectively (Table 2).
Of the natural products, supplements/health foods were the most popular and were used by 41% of respondents. Other studies for outpatients in clinics other than psychiatry or community-living people in Japan also showed similar results, which indicated that the most popular natural product among Japanese was supplements (23 to 47%) [2-5]. In comparison, many studies outside Japan reported that people used herbal therapies more than supplements [10-15]. In Japan, supplements and health foods are regarded as foods and sold in grocery shops
Total respondents (n=189) |
NP users (n=104) |
NP non-users (n=85) |
||||
n |
% |
n |
%a |
n |
% a |
|
Sex |
||||||
Male |
110 |
58 |
51 |
49 |
59 |
69 |
Female |
79 |
42 |
53 |
51 |
26 |
31 |
Age (years old) |
||||||
20-34 |
32 |
17 |
20 |
19 |
12 |
14 |
35-49 |
83 |
44 |
48 |
46 |
35 |
41 |
50-64 |
51 |
27 |
29 |
28 |
22 |
26 |
65+ |
23 |
12 |
7 |
7 |
16 |
19 |
(mean ± SD) |
(47.0 ± 13.9) |
(45.1 ± 11.9) |
(49.4 ± 15.7) |
|||
Education (years) |
||||||
0-11 years |
33 |
17 |
11 |
11 |
22 |
26 |
12 years |
45 |
24 |
29 |
28 |
16 |
19 |
13-15 years |
27 |
14 |
14 |
13 |
13 |
15 |
16+ years |
84 |
44 |
50 |
48 |
34 |
40 |
Marital status |
||||||
Married |
78 |
41 |
49 |
47 |
29 |
34 |
Separated/widowed/divorced |
33 |
17 |
13 |
13 |
20 |
24 |
Never married |
78 |
41 |
42 |
40 |
36 |
42 |
Employment |
||||||
Working |
83 |
44 |
52 |
50 |
31 |
36 |
Non-working |
106 |
56 |
52 |
50 |
54 |
64 |
Household income (yen/year) |
||||||
< 2.5 million |
76 |
40 |
33 |
32 |
43 |
51 |
2.5-4.4 million |
28 |
15 |
18 |
17 |
10 |
12 |
4.5-6.9 million |
27 |
14 |
20 |
19 |
7 |
8 |
7.0 million+ |
39 |
21 |
26 |
25 |
13 |
15 |
Unknown |
19 |
10 |
7 |
7 |
12 |
14 |
Smoking |
||||||
No |
111 |
59 |
67 |
64 |
44 |
52 |
Yes |
78 |
41 |
37 |
36 |
41 |
48 |
Drinking |
||||||
No |
144 |
76 |
74 |
71 |
70 |
82 |
Yes |
45 |
24 |
30 |
29 |
15 |
18 |
Religion |
||||||
No |
157 |
83 |
81 |
78 |
76 |
89 |
Yes |
32 |
17 |
23 |
22 |
9 |
11 |
Limited activity of daily living (ADL) |
||||||
No |
102 |
54 |
61 |
59 |
41 |
48 |
Yes |
87 |
46 |
43 |
41 |
44 |
52 |
Use of other treatment/ support programs |
||||||
No |
117 |
62 |
64 |
62 |
53 |
62 |
Yes |
72 |
38 |
40 |
38 |
32 |
38 |
Type of NPs |
Prevalence of NP use among all respondents (n=189) a |
Having information about safety and effects before use of NPs |
Feeling benefit from the use of NPs |
Experienced side effects from NPs |
Reported the use of NPs to a psychiatrist |
|||||
n |
% |
n |
%b |
n |
% b |
n |
% b |
n |
% b |
|
Supplement/health foods |
77 |
41 |
45 |
58 |
27 |
35 |
- |
- |
13 |
17 |
Herbal tea |
38 |
20 |
13 |
34 |
14 |
37 |
2 |
5 |
3 |
8 |
Aromatherapy |
30 |
16 |
17 |
57 |
19 |
63 |
- |
- |
6 |
20 |
Over-the-counter Kampo |
16 |
8 |
9 |
56 |
9 |
56 |
2 |
13 |
2 |
13 |
b The percentage indicates the proportion of users of each type of NPs who endorsed the item above.
- No case
OR |
95% CI |
p-value |
|
Sex |
|||
Male |
1 |
||
Female |
4.28 |
(1.87-9.77) |
<0.001** |
Age (years old) |
|||
20-34 |
1 |
||
35-49 |
0.54 |
(0.19-1.56) |
0.253 |
50-64 |
0.63 |
(0.19-2.10) |
0.449 |
65+ |
0.15 |
(0.03-0.78) |
0.024* |
Education (years) |
|||
0-11 years |
1 |
||
12 years |
2.11 |
(0.65-6.81) |
0.213 |
13-15 years |
0.69 |
(0.17-2.79) |
0.607 |
16+ years |
1.93 |
(0.59-6.35) |
0.278 |
Marital status |
|||
Married |
1 |
||
Separated/widowed/divorced |
0.54 |
(0.17-1.70) |
0.293 |
Never married |
0.51 |
(0.20-1.32) |
0.163 |
Employment |
|||
Working |
1 |
||
Non-working |
0.91 |
(0.41-1.99) |
0.808 |
Household income (yen/year) |
|||
< 2.5 million |
1 |
||
2.5-4.4 million |
1.97 |
(0.65-5.97) |
0.23 |
4.5-6.9 million |
3.16 |
(0.97-10.23) |
0.056 |
7.0 million+ |
1.59 |
(0.51-4.89) |
0.424 |
Unknown |
0.76 |
(0.23-2.52) |
0.65 |
Smoking |
|||
No |
1 |
||
Yes |
0.91 |
(0.44-1.89) |
0.808 |
Drinking |
|||
No |
1 |
||
Yes |
2.39 |
(1.00-5.73) |
0.05 |
Religion |
|||
No |
1 |
||
Yes |
2.91 |
(1.10-7.68) |
0.031* |
Limited activity of daily living (ADL) |
|||
No |
1 |
||
Yes |
0.61 |
(0.30-1.24) |
0.173 |
Use of other treatment /support programs |
|||
No |
1 |
||
Yes |
1.26 |
(1.58-2.74) |
0.559 |
|
Total respondents (n=189) |
NP users (n=104) |
NP non-users (n=85) |
ORb |
95% CIb |
p-valueb |
|||
N |
%a |
N |
%a |
N |
%a |
||||
Forgetting |
|||||||||
No |
76 |
40 |
42 |
40 |
34 |
40 |
1 |
|
|
Yes |
113 |
60 |
62 |
60 |
51 |
60 |
0.98 |
(0.46-2.11) |
0.957 |
Carelessness |
|||||||||
No |
163 |
86 |
96 |
92 |
67 |
79 |
1 |
|
|
Yes |
26 |
14 |
8 |
8 |
18 |
21 |
0.24 |
(0.08-0.76) |
0.015* |
Stopping the drug when feeling better |
|||||||||
No |
165 |
87 |
90 |
87 |
75 |
88 |
1 |
|
|
Yes |
24 |
13 |
14 |
13 |
10 |
12 |
2.46 |
(0.77-7.86) |
0.127 |
Stopping the drug when feeling worse |
|||||||||
No |
179 |
95 |
101 |
97 |
78 |
92 |
1 |
|
|
Yes |
10 |
5 |
3 |
3 |
7 |
8 |
0.11 |
(0.02-0.69) |
0.018* |
b Odds ratio (OR), the 95% confidence interval (95% CI) and p-value of NP use associated with each category of the Self-Reported Medication- Taking Scale were estimated by using multiple logistic regression adjusting for all demographic variables (i.e., sex, age, education, marital status, employment, household income, smoking, drinking, religion, limited activity of daily living (ADL), use of other treatment/support programs) in the model. * p< .05
The frequency of use of herbal tea (20%), and aromatherapy (16%) in this study exceeds that of herbs and aromatherapy use in Japanese community-living people in the study by Fukuda et al. in 2006 [5]. The reported frequency of aromatherapy or herbs was 2% in male and 7.1% in female [5]. One of the possible reasons for the higher frequency of herbal tea and aromatherapy use in 2016 in comparison to the findings in 2006 is because herbal teas and aromatherapy has become more familiar to Japanese in the last 10 years. Another reason may be due to the characteristics of symptoms among respondents. The most frequent diagnoses of the respondents in this study were neuropsychiatric symptoms such as anxiety, depression and sleep disorder. It is reported that people who have neuropsychiatric symptoms use more complementary health approaches than people without neuropsychiatric symptoms [13,15,16,19]. On account of this, the frequencies of use of herbal tea and aromatherapy among psychiatric outpatients in this study might have been higher than the findings from Fukuda et al. among community-living people other than psychiatric patients.
From the findings of this study, the frequency of experiencing side effects of herbal tea, aromatherapy and over-the-counter Kampo were 5, 0, and 13%, respectively, and were similar to experience of side effects with Kampo (12%) and aromatherapy/ herbal therapy (3%) among patients who have severe chronic disease in Japan in 2015 [8]. The same study reported that 13% experienced side effects from supplements/health foods [8], interestingly, no one reported side effects from supplements in this study, which may be attributable to that respondents used mild natural products in the present study, such as vitamins.
This study showed a lower number for reporting natural product use to their psychiatrists compared to 23% for those reporting use to physicians in Japanese family medicine clinics [2]. Some reasons for not reporting their natural product use to their doctors are reported. According to Robinson et al., one of the reasons might be that patients felt it unnecessary to report such use to doctors [9]. Many psychiatric patients in this study might also feel that it is not necessarily to report their natural product use to their doctors.
Older respondents had a smaller probability of using natural products in this study and this was similar to a nationwide study among community-living people in the U.S [15]. Younger psychiatric patients might have a preference for active health related behavior such as natural products use compared to older patients.
Respondents who have any religion use natural products more than respondents who did not have any religion. People who believe in religion might have associated health-related values and beliefs, and may use numerous approaches related to health. Mohammad et al. also demonstrated such health-related values and beliefs were factors in the use of complementary health approaches [23].
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