Intercessory prayer for the alleviation of ill health

63 Pages·2009·0.65 MB·English

Intercessory prayer for the alleviation of ill health (Review)
Roberts L, Ahmed I, Hall S, Davison A
ThisisareprintofaCochranereview,preparedandmaintainedbyTheCochraneCollaborationandpublishedinTheCochraneLibrary
2009,Issue3
http://www.thecochranelibrary.com
Intercessoryprayerforthealleviationofillhealth(Review)
Copyright©2009TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAINLANGUAGESUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Figure1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
AUTHORS’CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
CHARACTERISTICSOFSTUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
DATAANDANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Analysis1.1.Comparison1INTERCESSORYPRAYERversusSTANDARDCARE,Outcome1Deathbyendoftrial. 35
Analysis1.2.Comparison 1INTERCESSORYPRAYERversusSTANDARDCARE,Outcome2Clinicalstate:1.
Improved/notimproved:intermediateorbadoutcome. . . . . . . . . . . . . . . . . . . . 36
Analysis1.3.Comparison 1INTERCESSORYPRAYERversusSTANDARDCARE,Outcome3Clinicalstate:2.
Significantcomplications(readmissiontoCCU). . . . . . . . . . . . . . . . . . . . . . 37
Analysis1.4.Comparison1INTERCESSORYPRAYERversusSTANDARDCARE,Outcome4Clinicalstate:3.Presence
ofanypostoperativecomplicationsby30days. . . . . . . . . . . . . . . . . . . . . . . 37
Analysis1.5.Comparison 1INTERCESSORYPRAYERversusSTANDARDCARE,Outcome5Clinicalstate:4.
Significantcomplications(various). . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Analysis1.7.Comparison1INTERCESSORYPRAYERversusSTANDARDCARE,Outcome7Clinicalstate:6.No
changeordeteriorationinattitude. . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Analysis1.8. Comparison 1INTERCESSORYPRAYERversusSTANDARDCARE, Outcome8Serviceuse: 1.
Rehospitalisation(anyreason). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Analysis1.9.Comparison1INTERCESSORYPRAYERversusSTANDARDCARE,Outcome9Serviceuse:2.Number
of’visitstoemergencydepartmentafterdischarge(specifictocardiacproblem). . . . . . . . . . . . 45
Analysis1.12.Comparison1INTERCESSORYPRAYERversusSTANDARDCARE,Outcome12Leavingthestudy
early. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Analysis2.1.Comparison2AWARENESSOFINTERCESSORYPRAYERversusSTANDARDCARE,Outcome1
Deathbyendoftrial. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Analysis2.2.Comparison2AWARENESSOFINTERCESSORYPRAYERversusSTANDARDCARE,Outcome2
Clinicalstate:1.Improved/notimproved:intermediateorbadoutcome. . . . . . . . . . . . . . 48
Analysis2.3.Comparison2AWARENESSOFINTERCESSORYPRAYERversusSTANDARDCARE,Outcome3
Clinicalstate:2.Significantcomplications(readmissiontoCCU). . . . . . . . . . . . . . . . . 48
Analysis2.4.Comparison2AWARENESSOFINTERCESSORYPRAYERversusSTANDARDCARE,Outcome4
Clinicalstate:3.Presenceofanypostoperativecomplicationsby30days. . . . . . . . . . . . . . 49
Analysis2.5.Comparison2AWARENESSOFINTERCESSORYPRAYERversusSTANDARDCARE,Outcome5
Leavingthestudyearly. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Analysis3.1.Comparison3AWARENESSOFINTERCESSORYPRAYERversusINTERCESSORYPRAYER,Outcome
1Deathbyendoftrial. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Analysis3.2.Comparison3AWARENESSOFINTERCESSORYPRAYERversusINTERCESSORYPRAYER,Outcome
2Clinicalstate:1.Improved/notimproved:intermediateorbadoutcome. . . . . . . . . . . . . . 50
Analysis3.3.Comparison3AWARENESSOFINTERCESSORYPRAYERversusINTERCESSORYPRAYER,Outcome
3Clinicalstate:2.Significantcomplications(readmissiontoCCU). . . . . . . . . . . . . . . . 51
Analysis3.4.Comparison3AWARENESSOFINTERCESSORYPRAYERversusINTERCESSORYPRAYER,Outcome
4Clinicalstate:3.Presenceofanypostoperativecomplicationsby30days. . . . . . . . . . . . . 51
Analysis3.5.Comparison3AWARENESSOFINTERCESSORYPRAYERversusINTERCESSORYPRAYER,Outcome
5Leavingthestudyearly. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Intercessoryprayerforthealleviationofillhealth(Review) i
Copyright©2009TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
FEEDBACK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
WHAT’SNEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
CONTRIBUTIONSOFAUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
DECLARATIONSOFINTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
SOURCESOFSUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
DIFFERENCESBETWEENPROTOCOLANDREVIEW . . . . . . . . . . . . . . . . . . . . . 60
INDEXTERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Intercessoryprayerforthealleviationofillhealth(Review) ii
Copyright©2009TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
[InterventionReview]
Intercessory prayer for the alleviation of ill health
LeanneRoberts1,IrshadAhmed2,SteveHall3,AndrewDavison4
1Hertford College, Oxford, UK. 2Psychiatry, Capital Region Mental Health Center, Hartford, Connecticut, USA. 3The Deanery,
Southampton,UK.4StStephen’sHouse,Oxford,UK
Contactaddress:LeanneRoberts,HertfordCollege,CatteStreet,Oxford,OX13BW,[email protected].(Editorial
group:CochraneSchizophreniaGroup.)
CochraneDatabaseofSystematicReviews,Issue3,2009(Statusinthisissue:Edited,commented)
Copyright©2009TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
DOI:10.1002/14651858.CD000368.pub3
Thisversionfirstpublishedonline:15April2009inIssue2,2009.Re-publishedonlinewithedits:8July2009inIssue3,2009.
Lastassessedasup-to-date: 13November2008.(Helpdocument- DatesandStatusesexplained)
Thisrecordshouldbecitedas: RobertsL,AhmedI,HallS,DavisonA.Intercessoryprayerforthealleviationofillhealth.Cochrane
DatabaseofSystematicReviews2009,Issue2.Art.No.:CD000368.DOI:10.1002/14651858.CD000368.pub3.
ABSTRACT
Background
Prayeris amongst the oldest and most widespread interventions used with the intention of alleviating illnessand promoting good
health.Giventhesignificanceofthisresponsetoillnessforalargeproportionoftheworld’spopulation,therehasbeenconsiderable
interestinrecentyearsinmeasuringtheefficacyofintercessoryprayerforthealleviationofillhealthinascientificallyrigorousfashion.
Thequestion of whetherthismaycontribute towards proving ordisproving theexistence of Godisaphilosophicalquestion lying
outsidethescopeofthisreviewoftheeffectsofprayer.Thisrevisedversionofthereviewhasbeenpreparedinresponsetofeedback
andtoreflectnewmethodsintheconductandpresentationofCochranereviews.
Objectives
To reviewtheeffectsof intercessory prayerasan additional intervention for peoplewith healthproblemsalreadyreceiving routine
healthcare.
Searchstrategy
WesystematicallysearchedtenrelevantdatabasesincludingMEDLINEandEMBASE(June2007).
Selectioncriteria
Weincludedanyrandomisedtrialcomparingpersonal,focused,committedandorganisedintercessoryprayerwiththoseinterceding
holdingsomebeliefthattheyareprayingtoGodoragodversusanyotherintervention.Thisprayercouldbeofferedonbehalfof
anyonewithhealthproblems.
Datacollectionandanalysis
Weextracteddataindependentlyandanalyseditonanintentiontotreatbasis,wherepossible.Wecalculated,forbinarydata,thefixed-
effectrelativerisk(RR),their95%confidenceintervals(CI),andthenumberneededtotreatorharm(NNTorNNH).
Mainresults
Tenstudiesareincludedinthisupdatedreview(7646patients).Forthecomparisonofintercessoryprayerplusstandardcareversus
standardcarealone,overalltherewasnocleareffectofintercessoryprayerondeath,withtheeffectnotreachingstatisticalsignificance
anddatabeingheterogeneous(6RCTs,n=6784, random-effectsRR0.77CI0.51to1.16,I2 83%).Forgeneralclinicalstatethere
wasalsonosignificantdifferencebetweengroups(5RCTs, n=2705, RRintermediateorbadoutcome0.98CI0.86to1.11). Four
Intercessoryprayerforthealleviationofillhealth(Review) 1
Copyright©2009TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
studiesfoundnoeffectforre-admissiontoCoronaryCareUnit(4RCTs,n=2644,RR1.00CI0.77to1.30).Twoothertrialsfound
intercessoryprayerhadnoeffectonre-hospitalisation(2RCTs,n=1155,RR0.93CI0.71to1.22).
Authors’conclusions
Thesefindingsareequivocaland,althoughsomeoftheresultsofindividualstudiessuggestapositiveeffectofintercessoryprayer,the
majoritydonotandtheevidencedoesnotsupportarecommendationeitherinfavouroragainsttheuseofintercessoryprayer.Weare
notconvincedthatfurthertrialsofthisinterventionshouldbeundertakenandwouldprefertoseeanyresourcesavailableforsucha
trialusedtoinvestigateotherquestionsinhealthcare.
PLAIN LANGUAGE SUMMARY
IntecessoryPrayerforthealleviationofillhealth
Intercessory prayer is a very common intervention, used with the intention of alleviating illness and promoting good health. It is
practisedbymanyfaithsandinvolvesapersonorgroupsettingtimeasidetopetitionGod(oragod)onbehalfofanotherwhoisin
some kindofneed,oftenwiththeuseof traditional devotional practices. Intercessory prayerisorganised, regular,and committed.
Thisreviewlooksattheevidencefromrandomisedcontrolledtrialstoassesstheeffectsofintercessoryprayer.Wefound10studies,in
whichmorethan7000participantswererandomlyallocatedtoeitherbeprayedfor,ornot.Mostofthestudiesshownosignificant
differencesinthehealthrelatedoutcomesofpatientswhowereallocatedtobeprayedforandthosewhoallocatedtotheothergroup.
BACKGROUND
personwhoisinsomekindofneed.Intercessoryprayerisorgan-
ised,regular,andcommitted,andthosewhopractiseitwillhold
Descriptionoftheintervention somecommittedbeliefthattheyareprayingtoGod(oragod).
Prayerisamongst theoldestandmostwidespreadinterventions
usedwiththeintentionofalleviatingillnessandpromotinggood
health (McCaffrey 2004; Barnes 2004). Recent years have seen
considerable interest in the beneficial effects of religious belief
Howtheinterventionmightwork
andcommunalreligiousinvolvementonhealthoutcomes(Koenig
2000). Research has been done to investigate the effect for the Themechanism(s)bywhichprayermightworkisunknownand
patientofthecomplexmatterofbelongingtoareligioustradition hypothesesaboutthiswilldependtoalargeextentonreligiousbe-
and undertaking its distinctive practices. One aspect of this is liefs.Thisreviewseekstoanswerthequestionofeffectnotmech-
offering and receiving intercessory prayers for the sick. In this anismanditdoesnotseektoanswerthequestionofwhetherany
studyweconsidereffectforthepatientofintercessoryprayerbeing effectsofprayerconfirmorrefutetheexistenceofGod.Indeter-
offeredontheirbehalf,separatedfromthequestionofhisorher miningthedirectionofanyeffect,itisimportanttonotethatare-
religiousaffiliation. ligiousbelievermaysuggestthatthenatureofdivineintervention
Prayer,definedasthe“solemnrequestorthanksgivingtoGodor couldbesubtle-moresubtle,indeed,thanislikelytoberevealed
objectofworship”(OED1997),isanancientandwidelyusedin- bytheresultsofarandomisedtrial.Significancecouldbeattached,
tervention.Therearemanydifferentformsofintercessoryprayer; forinstance,tothequestionofwhetherapersonhasa‘gooddeath’
itisfoundinhighlydevelopedbeliefsystemsandisalsopractised (approachedwithcourageandhavingachievedasenseofpeace)
sporadicallybyindividuals intimesofneed,relativelyfreefrom ora‘baddeath’,eventhoughthe‘clinicaloutcome’maybemea-
formal involvementinorganised religion. Indeed, one plausible sured and recorded as the same. We nonetheless take the stand
derivationoftheword‘God’anditsIndo-Europeancognatesis thatclaimsforintercessoryprayerforthesickwhichgobeyond
fromarootmeaning“theonewhoiscalledupon”(OED1997). suchsubtletiescanbesubjecttoempiricaltestingand,potentially,
Prayerhasrelationtootherspiritualdisciplines,includingmedita- proofandso,whilstnotwishingtobelittlesuchdistinctions(as,
tionandthanksgiving.Thisreviewfocusesonintercessoryprayer forinstance,betweena‘good’anda‘bad’death),wewilltestthe
which,forthepurposesofthisstudy,involvesapersonorgroup starkerclaimsthataremadeforprayerwhichareofameasurable,
settingtimeasidetopetitionGod(oragod)onbehalfofanother directlyclinicalnature.
Intercessoryprayerforthealleviationofillhealth(Review) 2
Copyright©2009TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Whyitisimportanttodothisreview whetherGodgenerallyveilshispresencefromobservation:inthe
wordsofthephilosopherGFHegel,“Goddoesnotofferhimself
As with all systematic reviews, this review is necessary to bring
forobservation”(Hegel2008).
togethertherelevantresearchevidence,topresentthatevidence
andtoseektoresolveuncertaintiesabouttheeffectsofinterces-
soryprayer.Wenotethattheresultsofthisreviewwillbeofinter-
esttothosewhoareinvolvedwiththe‘debateaboutGod’-both
religiousbelieversandatheists-buttheseresultscannotdirectly OBJECTIVES
standas‘proof’or‘disproof’oftheexistenceofGod.Theextent
1.Toevaluatetheeffectsofintercessoryprayerasanintervention
andmannertowhichGod’sexistencecanbedeterminedbyref-
forthosewithhealthproblems.
erencetoeventsintheworldisoneofthemostsignificant, and
ancient,questionsintheology-philosophy,andiscontested.(For 2.Ifpossible,toundertakesensitivityanalysestoassessthespecific
arecentsurveyseeDenysTurner(Turner2004)).Onestrandof efficacyofprayerfor(i)peoplesufferingfromlifethreateningcon-
discussion,forinstance,concentratesontheexistenceoftheworld ditionsand(ii)peoplesufferingfromlessserioushealthproblems.
rather than any given state of affairs within it. In the words of
3.Inaddition,wecomparedtheoutcomesofwell’blinded’and
LudwigWittgenstein,‘Itisnothowthingsareintheworldthatis
poorly’blinded’studiesinordertoinvestigatetheextenttowhich
mystical,butthatitexists’(Wittgenstein1974).Wedonot,there-
knowingthatoneisbeingprayedforinfluencestheprimaryout-
fore,seektoposeoransweranyquestionsabouttheexistenceof
comeofrecovery.
Godwiththisreviews.Thereareseveralchallengeswhenassessing
theresultsofrandomisedtrialsofprayer.Therearepotentialprob-
lemswithtrialmethodology.Forexample,‘contamination’. The
‘controlgroup’ofpatientswhoarenotprayedforwithinthetrial METHODS
may,nonetheless,bethesubjectofprayersofferedbyothers.For
instance,asizeablenumberofpeople-particularlythosewithin
religiousordersandcomparablefraternities-aredevotedtothe
Criteriaforconsideringstudiesforthisreview
practiceofprayingforallwhoareinneed.Nonetheless,thosewho
prayforthesickdosooutofaconvictionthattheircontribution
makesadifference.Theydonotrefrainfromprayingoutofthe Typesofstudies
consideration that someone, somewhere else,may also be pray-
We included all relevant randomised controlled trials. Where a
ing.Thisconvictionanditsconsequentpracticesaresufficiently
trialwasdescribedas“doubleblind”butitwasonlyimpliedthat
deeplyengrainedastomakesuchstudiesworthwhile,sincethis
thestudywasrandomised,iftheparticipants’demographicdetails
backgroundlevelofprayershouldbeevenlydistributedtothetwo
ineachgroupweresimilar,weincludedit.Weexcludedquasi-ran-
interventiongroupsthroughtheprocessofrandomallocation.
domisedstudies,inwhichtreatmentallocationwasnotconcealed,
Asecondconsideration isthequestion ofwhetheritmakesany
suchasthoseallocatingbyusingalternatedaysoftheweek.
sense to speak of a ‘blind’ trial if the action (or not) of the in-
terventionisdeterminedbyaputativedivineagent.Mostofthe
Typesofparticipants
world’sreligioustraditions,fromwithinwhichtheprayerunder
considerationherewouldbeoffered,understandGodtobeom- Weincludedanypersonwithaphysicalormentalhealthproblem
niscient, that is, all-knowing. Therefore therecould be no con- irrespectiveofage,gender,orrace.
cealmentofallocationnorconcealmentofthegrouptowhicha
personhasbeenallocatedbeforeGod,whomightchoosetoinflu- Typesofinterventions
encethepatientoutcomesbecauseoforinsteadoftheallocation.
1.Intercessoryprayer:routinecare(seebelow)pluspersonal,fo-
However,thesearetheologicalquestions,andthisreviewproceeds
cused,committed,andorganisedintercessoryprayeronbehalfof
on scientific principles in that it is a widely heldbelief thatin-
another.
tercessory prayer is beneficial for those who are unwell because
2.Routinecare:therelevantmedicalandnon-medicalcarenor-
Goddirectstheoutcome of thosefor whomprayersareoffered
mallygiventopeoplediagnosedwiththeirparticularillnessinthe
differentlyfromthoseforwhomitisnot.Asnotedabove,weare
settinginwhichthetrialwasdone.
not seeking to assess whether God is or is not the agent of ac-
tionforprayerbut,byusingthesamestudydesignsusedtotest
otherinterventionsinhealthcarewewillassesstheeffectsofthe Typesofoutcomemeasures
intervention.Forthisreasonwealsoexcludefromconsideration Wegroupedoutcomesintothosemeasuredintheshortterm(up
suchtheologicalconsiderationsastheinjunction“Donotputthe tosixweeks),mediumterm(sixweekstosixmonths)andlong
LordyourGodtothetest”(Deuteronomy6:16)orquestionsasto term(sixmonthsandmore).
Intercessoryprayerforthealleviationofillhealth(Review) 3
Copyright©2009TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Primaryoutcomes 7.5Averageendpointspecificaspectsofbehaviour
1.Death-anycause 7.6Averagechangeinspecificaspectsofbehaviour
2.Clinicalstate-Noimportantchangeinclinicalstate(asdefined 8.Adverseeffects
byindividualstudies) 8.1Clinicallyimportantgeneraladverseeffects
3.Serviceoutcomes-Hospitalisation 8.2Averageendpointgeneraladverseeffectscore
4.Qualityoflife-Noclinicallyimportantchangeinquality of 8.3Averagechangeingeneraladverseeffectscores
life 8.4Clinicallyimportantspecificadverseeffects
5.Satisfactionwithtreatment-Leavingthestudiesearly 8.5Averageendpointspecificadverseeffects
8.6Averagechangeinspecificadverseeffects
Secondaryoutcomes
1.Death
Searchmethodsforidentificationofstudies
1.1Suicide
1.2Duetoillness
1.3Natural
Electronicsearches
2.Clinicalstate
Forthisupdatewesearchedthefollowingelectronicdatabases:
2.1Courseofillness(asdefinedbyindividualstudies)
a.AMED,CINAHL,EMBASEandMEDLINEonOvid(June
2.2Complications(asdefinedbyindividualstudies)
2007)wassearchedusingCochraneSchizophreniaGroup’sphrase
2.3Medicationuse(asdefinedbyindividualstudies)
forrandomisedcontrolledtrials(seeGroupsearchstrategy)com-
2.4Averageendpointscoresinclinicalstate(asdefinedbyindi-
binedwith:
vidualstudies)
((pray*orgodorfaith*orreligioorspiritual*)inti,ab)or((spir-
3.Serviceoutcomes
itualityorreligion)insh)
3.1Numberofdaysinhospital
b. ATLA Religion Database on EBSCO Host (June 2007) was
3.2Numberofdaystodischarge
searchedusingthephrase:
3.3Re-admission
pray*andtrial*
4.Qualityoflife
c.WebSites
4.1Averageendpointqualityoflifescore
We searched Clinicaltrials.gov on National Institute for Health
4.2Averagechangeinqualityoflifescores
usingthephrase
4.3Noclinicallyimportantchangeinspecificaspectsofquality
prayorprayerorgodorreligionorreligious
oflife
4.4Averageendpointspecificaspectsofqualityoflife
Searchingotherresources
4.5Averagechangeinspecificaspectsofqualityoflife
5.Satisfactionwithtreatment Wecheckedallreferencesinthearticlesselectedforfurtherrelevant
5.1Recipientofcarenotsatisfiedwithtreatment trials.
5.2Recipientofcareaveragesatisfactionscore Searchesundertaken for previous versions of this review are in-
5.3Recipientofcareaveragechangeinsatisfactionscores cludedinAppendix1.
5.4Carernotsatisfiedwithtreatment
5.5Careraveragesatisfactionscore
5.6Careraveragechangeinsatisfactionscores Datacollectionandanalysis
6.Mentalstate
Themethodsdescribedbelowdifferfromthoseinearlierversions
6.1Noclinicallyimportantchangeingeneralmentalstate
ofthisreview(Roberts2000,Roberts2007).Themethodsinthis
6.2Notanychangeingeneralmentalstate
2009versionhavebeenbroughtuptodateandareinkeepingwith
6.3Averageendpointgeneralmentalstatescore
thenewformatofCochranereviewsandrecentmethodological
6.4Averagechangeingeneralmentalstatescores
developments.Thesechangeshavenotmateriallyeffectedhowwe
6.5Noclinicallyimportantchangeinspecificsymptoms
have or will manage data, but we have included the ’Methods’
6.6Notanychangeinspecificsymptoms
section from the previous review for those who are interested (
6.7Averageendpointspecificsymptomscore
Appendix2).
6.8Averagechangeinspecificsymptomscores
7.Behaviour
Selectionofstudies
7.1Noclinicallyimportantchangeingeneralbehaviour
7.2Averageendpointgeneralbehaviourscore Materialdownloadedfromelectronicsourcesincludeddetailsof
7.3Averagechangeingeneralbehaviourscores author,institution,orjournalofpublication.Theprincipalreview
7.4Noclinicallyimportantchangeinspecificaspectsofbehaviour author (LR) inspected all reports. These were thenre-inspected
Intercessoryprayerforthealleviationofillhealth(Review) 4
Copyright©2009TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
independentlybyasecondauthor(IA)inordertoensurereliable (http://www.nntonline.net/)takingaccountoftheeventratein
selection.Weresolvedanydisagreementbydiscussion,andwhere thecontrolgroup.
therewasstilldoubt,weobtainedthefullarticleforfurtherinspec- 2.Continuousdata
tion.Whenwehadobtainedthefullarticles,LRandIAdecided 2.1Summarystatistic
whetherthestudiesmetthereviewcriteria.Ifdisagreementcould For continuous outcomes we estimated a fixed-effect weighted
notberesolvedbydiscussion,wesoughtfurtherinformationand meandifference(WMD)betweengroups. Wedidnotcalculate
addedthesetrialstothelistofthoseawaitingclassification. effectsizemeasures.
2.2Endpointversuschangedata
Wepreferredtousescaleendpointdata,whichtypicallycannot
Dataextractionandmanagement
havenegativevaluesandiseasiertointerpretfromaclinicalpoint
1.Extraction ofview.Changedataareoftennotordinalandareproblematicto
Twoauthors(LRandIA)independentlyextracteddatafromin- interpret.Ifendpointdatawereunavailable,weusedchangedata.
cludedstudies.Again,anydisagreementswerediscussed,decisions 2.3Skeweddata
documentedand,ifnecessary,authorsofstudieswerecontacted Continuousdataonclinicalandsocialoutcomesareoftennotnor-
forclarification.WithremainingproblemsCliveAdams(Co-or- mallydistributed.Toavoidthepitfallofapplyingparametrictests
dinating Editor of the Cochrane Schizophrenia Group) helped tonon-parametricdata,weaimedtoapplythefollowingstandards
clarifyissuesandthosefinaldecisionsweredocumented. toalldatabeforeinclusion:(a)standarddeviationsandmeansare
2.Management reportedinthepaperorobtainablefromtheauthors;(b)whena
Datawereextractedontostandard,simpleforms. scalestartsfromthefinite number zero,thestandarddeviation,
3.Scale-deriveddata whenmultipliedbytwo,islessthanthemean(asotherwisethe
Weincludedcontinuousdatafromratingscalesonlyifthemea- meanisunlikelytobeanappropriatemeasureofthecentreofthe
suringinstrumenthadbeendescribedinapeer-reviewedjournal distribution, (Altman1996));(c)ifascalestartsfromapositive
(Marshall2000)andtheinstrumentiseitheraself-reportorcom- value(suchasPANSSwhichcanhavevaluesfrom30to210)the
pletedbyanindependentraterorrelative(notbythetherapist). calculationdescribedabovewillbemodifiedtotakethescalestart-
ingpointintoaccount.Inthesecasesskewispresentif2SD>(S-
S min), where S is the mean score and S min is the minimum
Assessmentofriskofbiasinincludedstudies
score.Endpointscoresonscalesoftenhaveafinitestartandend
Againworkingindependently,twoauthors(LRandIA)assessed
pointandtheserulescanbeapplied.Whencontinuousdataare
riskofbiasusingthetooldescribedintheCochraneHandbook
presentedonascalewhichincludesapossibilityofnegativevalues
forSystematicReviewsofInterventions(Higgins2008).Thistool
(suchaschangedata),itisdifficulttotellwhetherdataareskewed
encouragesconsiderationofhowtherandomisationsequencewas
or not. Skewed data from studies of less than 200 participants
generated,howallocationwasconcealed,theintegrityofblinding
wereenteredinadditionaltablesratherthanintothedataanalysis.
atoutcomemeasurement,thecompletenessofoutcomedata,se-
Skeweddataposelessofaproblemwhenlookingatmeansifthe
lectivereportingandotherbiases. Wewouldhaveexcludedany
samplesizeislargeandthesewereenteredintosyntheses.
studieswheresequencegenerationwasathighriskofbiasorwhere
allocationwasclearlynotconcealed.Ifdisputesaroseastothecor-
Unitofanalysisissues
rectcategoryforatrialthiswasresolvedthroughdiscussion,and
guidance fromCliveAdams.Wherepossible, weextracted(and 1.Clustertrials
report here) information on the religious beliefs of the authors Studiesincreasinglyemploy’clusterrandomisation’(suchasran-
reportingtheincludedstudiesbecauseofthepossibilitythatthis domisation byclinicianor practice)but analysisandpooling of
isrelatedtotheriskofbias. clustereddataposesproblems.Firstly,authorsoftenfailtoaccount
for intraclass correlation in clustered studies, leading to a ’unit
ofanalysis’ error(Divine 1992)wherebypvaluesarespuriously
Measuresoftreatmenteffect
low,confidenceintervalsundulynarrowandstatisticalsignificance
Weadoptedp=0.05astheconventionallevelofstatisticalsignif- overestimated.ThisincreasestheriskoftypeIerrors(Bland1997,
icancebutareespeciallycautiouswhereresultswereonlyslightly Gulliford1999).
belowthis,andwereport95%confidenceintervalsinpreference Whereclusteringwasnotaccountedforinanincludedstudy,we
top-values. presented the data in a table, with a (*)symbol to indicate the
1.Binarydata presenceofaprobableunitofanalysiserror.Insubsequentversions
For binary outcomeswecalculatedastandard estimationof the of this review we will seekto contact first authors of studies to
fixed-effectriskratio(RR)andits95%confidenceinterval(CI). obtain intraclass correlation coefficients for their clustered data
Forstatisticallysignificantresultswecalculatedthenumberneeded andtoadjustforthisusingacceptedmethods(Gulliford1999).
totreat/harmstatistic(NNT/H),andits95%CIusingVisualRx Where clustering has been incorporated into the analysis of an
Intercessoryprayerforthealleviationofillhealth(Review) 5
Copyright©2009TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
includedstudy,wewillalsopresentthesedataasiffromanon- 2.Statistical
clusterrandomisedstudy,butadjustedfortheclusteringeffect. 2.1Visualinspection
Wehavesoughtstatisticaladviceandhavebeenadvisedthatthe Wevisuallyinspectedgraphstoinvestigatethepossibilityofsta-
binarydataaspresentedinareportshouldbedividedbya’design tisticalheterogeneity.
effect’.Thisiscalculatedusingthemeannumberofparticipants 2.2EmployingtheI-squaredstatistic
per cluster (m) and the intraclass correlation coefficient (ICC) This provided an estimate of the percentage of inconsistency
[Designeffect=1+(m-1)*ICC](Donner 2002).IftheICCwas thoughttobeduetochance.I-squaredestimategreaterthanor
notreporteditwasassumedtobe0.1(Ukoumunne1999). equalto50%wasinterpretedasevidenceofhighlevelsofhetero-
Ifclusterstudieshadbeenappropriatelyanalysedtakingintoac- geneity(Higgins2002).
count intraclass correlation coefficients and relevant data docu-
mentedinthereport,synthesiswithotherstudieswouldhavebeen Assessmentofreportingbiases
possibleusingthegenericinversevariancetechnique.
Reportingbiasesarisewhenthedisseminationofresearchfindings
2.Cross-overtrials
isinfluencedbythenatureanddirectionofresults(Egger1995).
Amajorconcernofcross-overtrialsisthecarry-overeffect.Itoc-
Thesearedescribedinsection10.1oftheCochraneHandbook(
curs if an effect(e.g. pharmacological, physiological or psycho-
Higgins2008).Weareawarethatfunnelplotsmaybeusefulin
logical)of the treatmentinthefirst phaseis carriedoverto the
investigating reportingbiasesbutareoflimitedpowertodetect
secondphase.Asaconsequenceonentrytothesecondphasethe
small-study effects. We did not use funnel plots for outcomes
participantscandiffersystematicallyfromtheirinitialstatedespite
wherethereweretenorfewerstudies,orwhereallstudieswereof
awash-outphase.Forthesamereasoncross-overtrialsarenotap-
similarsizes.Inothercases,wherefunnelplotswerepossible,we
propriateiftheconditionofinterestisunstable(Elbourne2002).
soughtstatisticaladviceintheirinterpretation.
Asbotheffectsareverylikelyinschizophrenia,wewillonlyuse
datafromthefirstphaseofcross-overstudies.
Datasynthesis
3.Studieswithmultipletreatmentgroups
Wherea study involved more than two treatment arms, if rele- Wherepossibleweemployedafixed-effectmodelforanalyses.We
vant, the additional treatment arms were presented in compar- understandthatthereisnoclosedargumentforpreferenceforuse
isons. Where the additional treatment arms were not relevant, of fixed or random-effects models. The random-effects method
thesedatawerenotreproduced. incorporatesanassumptionthatthedifferentstudiesareestimat-
ingdifferent,yetrelated,interventioneffects.Thisdoesseemtrue
to us, however,random-effectsdoes putadded weightonto the
Dealingwithmissingdata
smallerofthestudies-thosetrialsthataremostvulnerabletobias.
1.Overalllossofcredibility Forthisreasonwefavourusingfixed-effectmodelsemployingran-
Atsomedegreeoflossoffollow-up,thefindingsofatrialmust dom-effectsonlywheninvestigatingheterogeneity.
losecredibility(Xia2007- directlink).Weareforcedtomakea Where possible, we entered data in such a way that thearea to
judgmentwherethisisfortheveryshort-termtrialslikelytobe theleftofthelineofnoeffectindicatedafavourableoutcomefor
includedinthisreview.Wedecidedthatifmorethan40%ofdata prayer.
beunaccountedforat8weekswewouldnotreproducethesedata
orusethemwithinanalyses.
Subgroupanalysisandinvestigationofheterogeneity
2.Binary
Ifattritionforabinaryoutcomeisbetween0and40%andout- Ifdataareclearlystatisticallyheterogeneouswefirstcheckedthat
comes of these people are described, we included these data as datawerecorrectlyextractedandenteredandthatwehadmadeno
reported.Wherethesedatawerenotclearlydescribed,forthepri- unitofanalysiserrors.Ifthehighlevelsofheterogeneityremained
maryoutcomeweassumedtheworstforeachpersonwhowaslost, wedidnotundertakeameta-analysisatthispointforifthereis
andforadverseeffectsweassumedratessimilartothoseamong considerablevariationinresults,andparticularlyifthereisincon-
patientswhodidcontinuetohavetheirdatarecorded. sistencyinthedirectionofeffect,itmaybemisleadingtoquotean
3.Continuous averagevaluefortheinterventioneffect.Insteadwewouldhave
Ifattritionforacontinuousoutcomeisbetween0and40%and exploredpossiblesourcesofheterogeneity.Wedonotpre-specify
completer-onlydatawerereported,wehavereproducedthese. anycharacteristicsofstudiesthatmaybeassociatedwithhetero-
geneityexceptthoserelatingtothequalityoftrialmethod.Ifno
clearassociationcouldbeshownbysortingstudiesbyqualityof
Assessmentofheterogeneity
methodsarandom-effectsmeta-analysiswas performed.Should
1.Clinicalheterogeneity anothercharacteristicofthestudiesbehighlightedbytheinves-
We considered all included studies without any comparison to tigationofheterogeneity,perhapssomeclinicalheterogeneitynot
judgeclinicalheterogeneity. hithertopredictedbutplausiblecausesofheterogeneity,thesepost-
Intercessoryprayerforthealleviationofillhealth(Review) 6
Copyright©2009TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
hocreasonswillbediscussedandthedataanalysedandpresented. Krucoff2001andWalker1997hadfollowupofsixmonths.Harris
However,shouldtheheterogeneitybesubstantiallyunaffectedby 1999statesthatparticipantswerethefocusofprayerfor28days
useofrandom-effectsmeta-analysisandnootherreasonsforthe butdoesnotcommentonthedurationoffollow-up.Benson2006
heterogeneitybeclear,theresultsoftheindividualtrialswouldbe wasalsoashorttrialwithprayerforonly14days,startingthenight
presentedwithoutameta-analysis. beforecoronaryarterybypasssurgery(CABG)andoutcomeswere
measuredthroughthe30daysaftersurgery.
Sensitivityanalysis 2.Participants
Atotaloftenstudieswhichrandomised7807peopleareincluded
Ifnecessary,weanalysedtheimpactofincludingstudieswithhigh
inthisreview.Sevenofthetenincludedstudiesfocusedonpeople
attritionratesinasensitivityanalysis.Weaimedtoincludetrialsin
who were ’acutely ill’ with life-threatening conditions: children
asensitivityanalysisiftheyaredescribedas’double-blind’butonly
withleukaemia(Collipp1969),thoseadmittedtoacoronarycare
impliedrandomisation hadtakenplace(but nosuch trialshave
unit (Aviles 2001, Benson 2006, Byrd 1988, Harris 1999 and
beenincluded in the2009 update). If we found no substantive
Krucoff2001)andpeoplewithabloodstreaminfection(Leibovici
differenceswithinprimaryoutcomewhenthesehighattritionand
2001).TheparticipantsinJoyce1964wereillwithpsychological
’impliedrandomisation’studieswereaddedtotheoverallresults,
or rheumatic disease and in Walker 1997 the participants were
we included themin the final analysis. However, if there was a
beingtreatedforalcoholabuse. Collipp1969wastheonlytrial
substantivedifference,weexcludedthemandonlyincludedclearly
nottoinclude adults.Themeanage ofparticipantsinthistrial
randomisedtrialsandthosewithattritionbelow40%.
wasaroundsevenyears.Allotherstudiesrandomisedpeopleover
theageof18years.
3.Setting
Participants were mixture of inpatients and outpatients. All re-
RESULTS ceivedprayerfromoutsidetheirmedicalsurroundings.
4.Studysize
Study size varied from small (Collipp 1969 n=18, Joyce 1964
Descriptionofstudies n=48) to very large (Leibovici 2001 n=3393, Benson 2006
n=1804,Harris1999n=1013).
See:Characteristicsofincludedstudies;Characteristicsofexcluded
5.Interventions
studies.
5.1IntercessoryPrayer
Please also see ’Characteristics of included studies’ and ’
Patientsintheintercessoryprayergroupsreceivedrelevantroutine
Characteristicsofexcludedstudies’tables.
careplusdailyintercessoryprayer.Thetypesofintercessoryprayer
variedslightlybutallprayersweregivenwiththeintentthatthese
Resultsofthesearch
intercessionswouldaidrecoveryofthepatient.
The original electronic search identified 196 citations and four 5.1.1Religiousbackgroundofthoseinterceding
includedstudieswereidentifiedfromthese.Morerecentsearches The religious background of the original researchersis likelyto
identifiedsixnewexcludedstudiesandsixnewincludedstudies, haveaffectedtheirselectionofintercedersandwasmentionedin
takingthetotalnumberofincludedstudiestoten.Threeofthe somestudies.Joyce1964wasundertakenbytworesearchers,one
new included studies (Benson 2006, Krucoff 2001 and Walker ofwhomstartedwiththebeliefthatprayer’worked’andtheother
1997)wereongoingstudiesintheoriginalreview. thatitdidnot.TheauthorofCollipp1969recruited“...friendsof
oursinWashington...”toundertaketheexperimentalintervention
Includedstudies andconcludedthearticlewiththestatement“everyphysicianhas
prescribedthisremedy[prayer]andnearlyeveryphysicianhasseen
Thenumberofincludedstudiesnowstandsattenwithsixnew
itsucceed”.Harris1999didnotcommentonthereligiousfeelings
studies,Aviles2001,Benson2006,Krucoff2001,Leibovici2001
ofitsauthors.
andWalker1997.Inallbutoneofthestudiesprayerwasunder-
Allintercessorshadreligiousbeliefbuttheirbackgroundandlevel
takenaftertheonsetofill-health,concurrentwithroutinetreat-
of religious activity varied. Byrd1988 acceptedpeople as inter-
ment, however, in one study, Leibovici 2001, the prayers were
cessorsiftheywere“’born-again’ChristianswithanactiveChris-
‘retroactive’,thatis,theywereundertakenaftertheclinicalout-
tianlifeasmanifestedbydailydevotionalprayerandactiveChris-
comeswererecorded.
tianfellowshipwithalocalchurch.”InCollipp1969intercessors
1.Duration
were”friendsofoursinWashingtonwho[...]agreedtoorganize
Studiesrangedfromshorttermwithfollow-upforthe’remainder
a prayer group.“ Joyce 1964 stipulated two required conditions
oftheadmission’(Byrd1988,Leibovici2001)tolongtermwith
whichneededtobefulfilled:(a)awillingnesstoacceptuptosix
a follow-up of 15 months (Collipp 1969). Most of the studies,
participantnamesand(b)residencemorethan30milesfromthe
however, were of mid-term duration. Aviles 2001, Joyce 1964,
Intercessoryprayerforthealleviationofillhealth(Review) 7
Copyright©2009TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.