Self-Management of Stress with Complementary and Alternative Medicine: Factors That Influence and Inform Decision Making—A Systematic Review of the Literature

Review structure

The literature was identified across a wide range of disciplines, and the initial search was complemented with “snowball sampling” described as “pursuing references of references and electronic citation tracking,” techniques “especially powerful for identifying high quality sources in obscure locations.” ⁷ Material was organized into themes beginning with a wide view and gradually narrowing the focus toward the actual research question. This has been described as moving from “long shots,” through “medium shots” and finally to “close-ups” ⁸ and was achieved by assigning studies to “libraries” within the Endnote software program.

Data sources and extraction

Databases accessed were PubMed, CINALH, EMBASE, EBSCOhost, Cochrane Library, Science Direct, Wiley Online Library, Web of Science, WorldSciNet, Google Scholar, Applied Social Sciences Index and Abstracts (ASSIA), PsycArticles, Psychiatry Online, PsychINFO, Proquest, Pharmaceutical News Index, and Open Access Theses and Dissertations (OATD).

The search was commenced using basic keywords. The list was expanded as, because of the iterative nature of snow-ball sampling, several other words emerged often as a result of terminology differences between countries. For example, “over-the-counter” products in Australia are generally referred to as “non-prescription” in other countries. The list of keywords extended to the following: “anxiety,” “depression,” “stress,” “psychological distress,” “over-the-counter,” “non-prescription,” “information sources,” “information,” “influence,” “attitude,” “self-care,” “self-medication,” “purchase,” “decision,” “complementary,” “alternative,” “customer,” “consumer,” “public,” “pharmacy,” and “chemist.” Where necessary, some databases were searched more than once and combination words and/or phrases used.

Anxiety and depression are often treated as separate entities; however, community studies demonstrate a “continuous dimension of anxiety severity, which is highly correlated with a dimension of depression severity.” ^5,9 Hence, for practical and research purposes the two are often combined as “psychological distress.” This protocol has been validated for the Australian adult population via the Kessler Psychological Distress Scale (K10), ^10,11 a measure of anxiety and depression in the general community. This approach was used in the search: that is, the search was conducted using the three key terms (anxiety, depression, and psychological distress).

Studies performed in Australia, or “Western” countries were chosen to avoid cultural disparities in conceptualizing stress. The paucity of recent studies necessitated that the chosen time frame of 15 years (1999–2014) be longer than the conventional maximum of 10 years. ¹² Furthermore, two studies before 1999 are included as exceptions. These were conducted by Astin in 1998¹³ and Vincent and Furnham in 1996¹⁴ and are included as “seminal or influential” works that mark the beginning of serious public debate in these matters. ¹⁵

Data extraction

From several hundred initial citations, 104 were selected as containing relevant material and categorized thematically. This number was reduced to 47 after closer examination, for example, by excluding studies in which CAM was a modality not usually found in Australian pharmacies (meditation, yoga, prayer, etc.). One exception was made in the inclusion of an acupuncture study conducted in 2003 by Rickhi et al., because of its particular mental health focus. ¹⁶ Details of all acceptable studies were then entered into a Microsoft Excel spreadsheet tabulating details and comments in a grid format. Studies were assessed using a recognized evaluation checklist, ¹⁷ supplemented with analysis tools for critiquing integrity and credibility for qualitative and quantitative studies. ^18,19 A summary of each study, previously recorded on the grid, was further examined and coded manually to gather information into topics that more accurately reflected the findings of each study for synthesis in the review. From this process, 17 studies were then included on the basis of having examined reasons (attitudes, beliefs, influences, and information) for CAM use in either the general population or those experiencing a mental health disorder. Studies researching CAM purchases in pharmacy were also included.

Brief overview of results

Most CAM users demonstrated a philosophical connectedness with the modality; however, a greater degree of dislike of conventional medicine was evident in some who experienced mental health issues. Generally, a positive experience or advice from family and friends were influential in decision making; however, little information was found on CAM purchases in pharmacies.

Philosophical underpinnings of CAM use in the general population

Recognizing the rise in popularity of CAM in both the United States and abroad, Astin noted in his 1998 study that no theoretical model existed explaining the “sociocultural and personal factors (health status, beliefs, attitudes and motivations)” for this phenomenon. Using a written survey, three primary hypotheses were tested: dissatisfaction with conventional treatment, the need for personal control, and, third, philosophical congruence. Of these, only philosophical congruence with one's own values, beliefs, and philosophical orientations was predictive of CAM use. This congruence was evidenced by three supporting themes: a holistic philosophy of health, a transformational life experience, and categorization of one's self as “culturally creative.” Anxiety was the most common health problem for which treatment was sought. This study appears to be one of the first to elucidate the importance of a holistic health view in CAM use; however, its cross-sectional nature precludes assumptions of cause and effect. ¹³ Holism, described by Astin as the relationship between mind, body, and spirit, is an enduring theme in CAM studies.

Holism is a prominent theme in two qualitative studies undertaken in 2000 by Barrett et al. and in 2005 by Cartwright and Torr. ^20,21 In the former, CAM users (n=17) were interviewed using a semistructured, in-depth format and the findings analyzed by an 8-member multidisciplinary team, individually and in group meetings. The findings described as “coherent and intriguing depictions of the many issues involved” were placed into four categories, summarized by the acronym HEAL. Each category was illustrated by several salient points described as “ideas”: holism (17 ideas, e.g., mind–body integration, tradition, staying healthy), empowerment (16 ideas, e.g., healing as an active process), access (17 ideas, e.g., availability), and legitimization (15 ideas, e.g., certification, efficacy). Whereas access and legitimization categories included both positive and negative points of view, holism and empowerment were overwhelmingly positive.

Cartwright and Torr's ²¹ qualitative study using semistructured interviews categorized themes from 11 participants into 2 key areas (perceptions of process and perceptions of effect). The core theme of “process,” that is, the theme exploring user's attitudes and beliefs, is applicable to this review. Further dissection produced subthemes similar in part to Barret's HEAL concept, with holism and empowerment again prominent.

Philosophical underpinnings of CAM use in people experiencing a mental health disorder

People experiencing a mental health disorder were not specifically excluded from previously discussed studies and so it is possible, if not probable, that similar philosophical leanings occur in this group; however, dedicated research is sparse. Two Australian prevalence studies are somewhat instructive. MacLennan et al. ²² reported in their study in 2006 that among general CAM users 49.7% had used conventional medicines on the same day but 53.2% did not report this concurrent use to their doctor. They also found that “nerves or stress” accounted for 13% usage overall (8.8% male and 16.2% female), but this figure rose to as high as 27.3% in certain circumstances such as in divorced or separated persons. ²² A small study (n=52) by Alderman and Kiepfer ⁴ in an Australian psychiatric hospital appears to confirm these trends, with overall CAM use in the previous 6 months being 51.9% (27 patients), with 18 (67%) of those patients also using prescribed medication concurrently. Only 63% of the 27 CAM users had informed their physician of their CAM use. ⁴

These findings underscore information from two studies in which results indicate differences in attitude to CAM users in the general population. A U.K. mixed method study published in 2007 by Badger and Nolan ²³ of patients (n=60) taking prescribed antidepressants found 38 had attempted to use self-chosen therapies, including CAM, either before or concurrently. In addition to themes of holism and empowerment, the authors reported a desire to avoid consulting a health practitioner (possibly because of a perceived stigma associated with depression) and the erroneous belief that most self-chosen treatments, such as herbs, being “natural,” were safer than prescribed medication. ²³ These sentiments are echoed in an Australian study in the same year by Jorm and Wright, ²⁴ wherein 3746 youth (aged 12 to 25 years) and their parents were presented with one of four vignettes describing a mental disorder, two including a depressive illness. Both the young people and their parents were asked to gauge the likely helpfulness of certain treatments, including various forms of self-help. Both the parents and young people expressed negative views about psychiatric medication. Furthermore, in all groups surveyed, antidepressants were viewed less favorably than vitamins. ²⁴ Although these beliefs do not necessarily equate to a philosophical underpinning per se, similar philosophical bias was exhibited in the aforementioned study by Barrett et al. ²⁰ in which some CAM users displayed ignorance and distrust toward conventional medicine. However, in comparison of the studies, the negativity appears to feature in a stronger manner in those with mental health disorders.

Reasons and beliefs for CAM use in the general population

As indicated in the introduction, the emphasis of this literature review was narrowed to more specific reasons and beliefs for CAM use. In a 1996 study of 268 patients attending three CAM clinics in the United Kingdom, the authors, Vincent and Furnham, provided respondents with 20 reasons for using CAM and asked them for ratings ranging from “not at all important” to “extremely important.” After analysis they reduced the findings to five factors: a positive evaluation of CAM and the ineffectiveness of conventional medicine for a particular complaint (“pull factors”), concerns over adverse effects of conventional medicine and over communication with doctors (“push factors”), and the easier availability of CAM (considered the least important). ¹⁴

In a study by Bishop et al. ²⁵ 46 existing CAM users were interviewed to ascertain “why consumers maintain complementary and alternative medicine use.” Offering a more conceptual perspective, four themes were identified. Notwithstanding some unpleasant experiences, the four themes were identified as “pull” factors, which strongly influenced maintenance of CAM use. The four themes were interpersonal experience (e.g., interaction with a practitioner), physical (during tactile treatments), affective (e.g., empowerment), and cognitive (e.g., beliefs about treatment). ²⁵

An element of an Australian study in this area by D'Crus and Wilkinson in 2006 investigated compliance issues and other factors in 158 existing clients at an Adelaide CAM clinic. ²⁶ Quality of client–practitioner relationship was the major reason for compliance in 55% of patients. Although not necessarily negative about the inadequacy of conventional treatment for their health issue, the majority of patients did, however, feel positively drawn to the range of treatments offered by CAM. ²⁶

Another qualitative study in the same year by Nichter and Thompson ²⁷ examined the motivations for taking CAM in a group of 60 consumers in the United States. The researchers purposefully selected a wide variety of consumers focusing on “the middle class and baby boomers” who were identified as “core-users.” They reported positive evaluations, which they categorized under five headings: health management (e.g., healthy aging and lifestyle, wellness of mind), harm reduction (e.g., a counter to unhealthy behaviors, breaking bad habits, substitution for prescription medication), resisting illness (e.g., immune boosting, “nipping in the bud”), illness management (e.g., use with or in lieu of prescription medication, countering dangers/side effects of medication, avoidance of addictive medicines), and ideology (e.g., personal freedom, natural health, new age). ²⁷

By using an ethnographic study, Nichter and Thompson ²⁷ were able to show a context-rich and dynamic view of CAM usage in comparison to questionnaires, which offered respondents structured reasons and statements from which to choose. In conjunction with the other three studies in this area, this investigation helps break down more precisely the reasons for CAM use. Though difficult to summarize, the important reasons are seen as a positive and active approach to the management of one's own health.

Reasons and beliefs for CAM use in people with a mental health disorder

As discussed in previous sections regarding broader underlying philosophies, a percentage of the respondents in the general population studies most probably experienced some mental health issues, including psychological distress. However, only one study was found relating specifically to persons in this situation. In 2003, Rickhi et al. ¹⁶ investigated 826 new patients attending a CAM clinic offering acupuncture in Canada. A psychiatrist, engaged by the researchers, diagnosed 578 as having a mental disorder, including 48.3% with depression and 7.9% with anxiety, thus creating two study groups: those with a mental disorder and those without. The respondents completed a questionnaire offering reasons for choosing CAM, but no significant difference was found between the two groups both declaring their reasons were philosophical congruence and perceiving CAM therapies as a last resort. Although most patients with a mental disorder sought help for a somatic complaint, rather than their psychiatric state, those with a mental disorder scored themselves worse off than their counterparts in several areas, including ability to relax and levels of stress. The greatest difference between the groups was the higher amount of stress in those with a mental health disorder. The authors concluded that 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 stress.” They note that this finding accords with those of other studies. ¹⁶

Although Rickhi et al. ¹⁶ specifically enquired about CAM use in mental health, studies in related areas have some relevance. In one such study in 1999, Burstein et al. ²⁸ conducted a longitudinal survey using a 12-month questionnaire examining CAM use in a cohort of 480 women with newly diagnosed, early stage breast cancer. It was found that 135 women initiated the use of CAM therapies after diagnosis and treatment. This was associated with impaired quality of life and greater psychological distress as measured by standard instruments, validated in breast cancer patients. Despite some critical debate over interpretation of findings, the authors' assertions appear valid. That is, initiation of CAM, although not being diagnostic of psychological distress, is a marker of it. ²⁸

Taken together, these studies appear to indicate that, as in the general population, people with psychological distress turn to CAM and this is a matter of personal philosophical congruence with the modality. The finding by Rickhi et al. of “last resort,” however, does not accord with other studies. It is perhaps explained in the nature of the CAM offered (acupuncture), which may appeal only to a certain cohort of CAM users. Furthermore, the study did not specify which previous therapeutic modalities, conventional or CAM, had been employed.

Information sources guiding the decision making of CAM users

The area of information sources was the final and thus most narrowly focused aspect of this literature review. Six studies of relevance were found. Nichter and Thompson in 2006 used qualitative interviews to probe the sources of information trusted by CAM users. ²⁷ The advice of family and friends, as well as friends' experiences, described as “lay referral networks” were the main influences. This applied particularly if the person was related to them in some important way such as sharing a similar lifestyle. Other major sources were advertising and the Internet. Notably, a negative scientific report was often not viewed as important as illustrated by the remark that science does not always “know best.” ²⁷ In a 2007 study, Thompson and Nichter discussed information seeking and decision making in more detail. ²⁹ Lay referrals, books, radio, other media, biomedical doctors, and CAM practitioners were identified as important sources of information about CAM. In the area of lay referrals, the importance of the power of network referrals among women was noted. Women were often the “primary consumers” of healthcare and the healthcare “managers of their families.” Furthermore, a strong intergenerational (grandmother/mother/daughter) transference was observed as well as horizontal transmission within female social networks outside of family members. ²⁹

Studies conducted in two Australian hospitals were examined. In 2001 Welch surveyed 511 patients on admission to a Sydney hospital in respect to CAMs as part of their routine history, finding that 12% admitted to taking CAMs at the time of admission. ³⁰ “Sources of recommendation” and the numbers of CAMs are shown in Table 1. The study, designed in part to establish dangers of interactions, is informative, but less than ideal in its method of articulation of information sources. Also, the figures do not further clarify the “self” category. That is, long-standing CAM use may now be considered one's own decision, but initially may have been via a friendship or other source. Alderman and Kiepfer in 2003 also reported on the “source of recommendation,” indicating friends and relatives to be the major source of information (Table 2). This information is more in accordance with the findings of Thompson and Nichter, but may be skewed in that the cohort was predominantly male, Vietnam veterans. ⁴

The majority of CAMs in Australia appear to be purchased in pharmacy. In a study by Welch, the most frequent purchase point was pharmacy (54%) followed by health food stores (19%). ³⁰ CAMs for psychological distress are commonly sold in Australian pharmacies. In terms of decision-making processes for these pharmacy purchases, only two studies of relevance were found. In 2011, Hanna and Hughes collected data via face-to-face interviews with pharmacy customers in Northern Ireland to gauge views on decision making regarding OTC purchases. ³¹ Two data sets were presented relating to factors influencing OTC medicine purchases, including CAM, and views on effectiveness. Factors that influence nonprescription (OTC) medicine purchases were ranked by percentage of respondents who “strongly agreed” or “agreed” (Table 3). Views on determining effectiveness were ranked by the percentage of respondents who “strongly agreed” or “agreed” with each statement (Table 4).

Of those surveyed, 81.2% were female and CAMs represented 35.1% of the total purchases (28.5% vitamins and minerals and 6.6% “complementary medicines”). The study shows, unsurprisingly, that most people purchase OTC products they think will be effective but, excluding prior use, draw on a wide variety of sources to determine that effectiveness, with over 90% of respondents quoting a pharmacist as their source. Interestingly, 68.1% said that they would purchase a product with no scientific evidence of effectiveness if it would not cause harm. ³¹

Of more relevance was a study by Braun et al. published in 2010. ³² The authors investigated “perceptions, use and attitudes of pharmacy customers on complementary medicines and pharmacy practice.” Customers (n=1121) were surveyed in 54 pharmacies across eastern Australia. CAMs had been used by 72% in the previous 12 months, significantly more by women than by men (76% vs. 58%). Many respondents (42%) reported “self-prescription,” and in figures somewhat echoing previously discussed U.S. data, 39% reported family and friends as their source of information, as shown by the responses to the following questions: “Who usually recommends the CAM products you take?” (from 11 suggestions) (Table 5) and “Where do you find out information about CAM products?” (up to 3 responses from 11 suggestions) (Table 6).

There may be some “overlap” of responses to these questions, as the customers may not distinguish clearly between a recommendation and information source. Nonetheless, as the only available Australian study on CAM purchases in pharmacy, it is instructive that for pharmacy CAM purchases, oneself was the major source of recommendation. Family and friends again rated highly as a source of CAM information. ³²

These studies are not without limitations. For example, the cross-sectional, self-reporting nature of questionnaires is a limitation for wider interpretation. However, as a group they show definite trends (e.g., self-prescription, family, and friends as a source of knowledge), and they represent the most recent data on CAM use and aspects of CAM use in pharmacy. No study relating directly to pharmacy purchase of products for psychological distress could be found.

Limitations

Every effort was made to find relevant studies, and information was located across a wide range of disciplines, including psychiatry, psychology, conventional medicine, complementary and alternative medicine, pharmacy, nursing, and anthropology. These fields themselves have many divisions; thus, it is possible that not all pertinent studies were found. It is hoped that this was ameliorated by the snow-ball technique of searching, that is, “pursuing references of references and electronic citation tracking.” ⁷ Research invariably has some limitations and care was exercised in selecting articles reflecting high-quality research; however, the weak points of each study may reduce the legitimacy of conclusions drawn in this review. Some of these weaknesses have already been mentioned. Examples of common study limitations were small sample size, low response rates, cross-sectional design, self-reporting of predesigned questionnaires, and opportunistic sampling. ^4,3,13,21,32 Some qualitative research omitted to mention important aspects, for example, data analysis techniques such as triangulation. ²⁷ This list is not exhaustive, but rather illustrative of constraints encountered. In short, very high-quality literature was sparse.

Summary

This foregoing literature review brings together studies relevant to decision making in purchasing CAM products for psychological distress. This review found studies relating to philosophical underpinnings of CAM consumption in the general population as well as in those with a mental health disorder. Of the many diverse philosophies exposed, holism and empowerment were dominant. Consumption extends to those suffering psychological distress. This may be a useful self-help strategy provided that suitable precautions are undertaken, particularly in regard to concurrent medication. The search focus was narrowed to find more specific reasons for CAM usage in both populations (general and those with a mental health disorder). CAM users usually had a positive attitude to CAM and often used it as part of an overall positive health management strategy, many times including the treatment where conventional medicine was seen as unsatisfactory or inadequate. This was not necessarily a rejection of conventional medicine. Where CAM was prescribed by a practitioner, the client–practitioner relationship was revealed as an important “pull” factor. In some CAM users experiencing a mental health disorder, a reluctance to visit the doctor was found, possibly attributable to a perceived stigma of mental illness. Some in this group displayed a distrust of conventional medicine, an erroneous belief that CAM products were universally safe and a general negativity to psychiatry. As the search was further refined to the more precise influences and information sources used, fewer studies became available. Findings usually demonstrated consumption based on previous effective use with family and friends often the main source of information. Ultimately, only one article could be found relating to CAM purchases in pharmacy. No studies were located addressing the more specific topic of pharmacy purchases for psychological distress, indicating a clear gap in the available literature. Research to address this issue appears timely.

Future implications

Shortcomings in the treatment of mental illness, particularly aspects of psychological distress, are a major concern for health policy makers with major depression the fourth leading cause of disability worldwide. ^33,34 Untreated depression may be implicated in chronic conditions such as diabetes mellitus, cardiovascular disease, and some types of dementia, ^{35 –37} and subsyndromal symptomatic depression (SSD) is a known risk factor for major depression and suicide. ³⁸ In SSD, patients do not present with depressed mood or anhedonia, but satisfy other “sub-threshold depression” criteria. These patients thus fall outside DSM-IV criteria for major depression. SSD thus is closely related to minor depression, a cohort for which targeted preventative action is promoted. ¹¹ Several treatment models have been proposed, including “informal self-help,” where professional help is not involved, and “guided self-help,” wherein a medical practitioner is included in the treatment. ^5,39 The application of similar preventative action to sufferers of stress would seemingly offer benefit.

In recent years, Australian community pharmacists have undertaken evidenced-based health programs, thus reducing burden on other areas of health delivery. It may be possible to utilize the skills of community pharmacists for certain cases of subclinical psychological distress where more advanced help is not required. The trusted position afforded to Australian pharmacists may prove an important factor whereby a suitably educated pharmacist may exert a similar positive “pull” factor as seen in the CAM practitioner–client relationship. The process may involve referrals, access to mind–body therapies, use of ingestible CAM products, or other suitable approaches. This literature review has explored areas such as attitudes, beliefs, and information and influences in decision making to purchase CAM products. Further research is required to explore what informs and motivates consumers' decisions in purchasing CAM products in pharmacy for psychological distress, as very little is currently known.