Part II: A Brief Review of Research Findings on
Spirituality and Mental Health
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David B. Larson MD, MSPH
President, International Center for the Integration of Health and
Spirituality
Adjunct Professor, Departments of Psychiatry and the Behavioral
Sciences
Duke University Medical Center, Durham, NC, and
Northwestern University Medical School, Chicago, IL, USA
Susan S. Larson MAT
Editor, Research Reports
International Center for the Integration of Health and
Spirituality, Rockville, MD, USA
Introduction
Patient spirituality, a once disregarded dimension, is emerging
in research and clinical care as a relevant factor in mental
health. Internationally, psychiatry's professional associations
have highlighted the need for developing sensitivity to this life
dimension. A growing number of U.S. psychiatric residencies now
include training on how to address patient spirituality in clinical
care. Quantitative research in the last 15 years in the U.K, the
U.S., and other countries has discovered aspects of this complex
dimension generally linked with beneficial mental health
outcomes.(1,2) Research
has also helped clarify aspects of negative religious
coping.(3) This two-part article summarizes
some of the changes in focus, clinical education, and assessment in
the field of psychiatry, as well as reviews research findings
investigating spirituality and mental health. Part I discussed the
growing professional recognition of spirituality as a relevant
mental health factor in clinical care and research, and noted
changes in residency training and clinical assessment to include
patient spirituality.
Religious/spiritual vitality and its potential salutary links
with emotional health emerge in recent research findings as a
relevant clinical factor. Research is finding associations that may
help prevent depression and addictions, help patients cope with
severe physical or mental illness, and in some instances help in
recovery.(3) Published research has also
helped to identify negative religious coping patterns with
potential harmful effects to mental health status.
Many mental health professionals remain unfamiliar with the
large, growing body of research findings, especially those linked
with beneficial clinical relationships. Introduced in their
psychiatric training to the harmfulness of religion/spirituality,
many are skeptical about potential mental health benefits of
religious practices or beliefs. This skepticism may be supported by
valid clinical concerns about the apparent ill effects from the
conflictual use of religion by those with mental illness in
negative religious coping.(4) Yet studies in
the last 20 years have uncovered aspects of positive religious
coping linked with clinical mental health benefits, briefly
reviewed below.
A Consensus Report in the U.S. culminated the collaboration of
more than 70 researchers, clinicians, and ethicists in the fields
of physical and mental health, addictions, and the neurosciences to
evaluate the research field of religion/spirituality and health.
These researchers, many of them initially unaware of the
extensiveness of the quantitative research, met three times over 18
months to review current research findings. They also mapped out
future directions and identified barriers to overcome in
investigating the links between spirituality/religion and physical
and mental health. The 1998 report concluded that the data from
many of the studies conducted to date are both sufficiently "robust
and tantalizing" to warrant continued and expanded clinical
investigations.(5)
Briefly summarized below are peer-reviewed published studies in
the areas of :
- prevention, coping, and recovery from depression,
- suicide prevention,
- substance abuse prevention and treatment,
- adolescent and adult health risk reduction,
- coping with surgery and severe medical illness,
- potential harmful aspects of spiritual/religious problems,
and
- religious/spiritual links with longevity.
(For an extensive overview, the Handbook of Religion and
Health, Oxford University Press 2001, reviews more than 1,200
published research studies, providing findings on the positive and
negative relationships of spirituality and religion on physical,
mental, and social health from childhood to old age.(1)
For research summaries and reviews and other resources, please also
visit the International Center for the Integration of Health and
Spirituality website: www.ICIHS.org)
Prevention, Coping, and Recovery from Depression: Spirituality
as a Protective Factor
A review of more than 80 studies published over the last 100
years found religious/spiritual factors generally linked with lower
rates of depression. (6) Persons who both
participated in a religious group and highly valued their religious
faith were at a substantially reduced risk of depressive disorder
while people with no religious link may raise their relative risk
of major depression by as much as 60%.
Lack of organizational religious involvement was linked with a
20-60% increase in the odds of experiencing a major depressive
episode. The authors suggested that valuing one's religious faith
as centrally important and actively belonging to a religious group
may give a spiritual basis for meaning as well as support from
others, potentially providing hope and caring which might also aid
in protecting against depression.
A comprehensive study with a one-year follow-up in the
Netherlands found that people who indicated that "a strong
religious faith" was one of the three most important factors in
their life had only 38% the odds of becoming depressed in
comparison with those who did not ascribe such importance to their
religious faith.(7) Also, among those who were
depressed at the beginning of the study, those who ranked their
religious faith as highly important recovered faster from their
depression.
Similarly, in the U.K. an epidemiology study found attending
church and a "vital religion" were protective factors from
vulnerability to depression in both an urban and a rural
community.(8)
However, another U.S. study found religious coping was
associated with lowering only certain types of depressive symptoms.
Loss of interest, feeling of worthlessness, withdrawal from social
interaction, loss of hope, and other "cognitive" symptoms of
depression were significantly less common among patients drawing
upon religious beliefs or practices to cope. Yet "somatic" symptoms
such as weight loss, insomnia, loss of energy, and decreased
concentration appeared unaffected by religious coping. The
investigators concluded that religious coping may reduce the
affective symptoms of depression, but appeared less effective for
the biological symptoms that might be more responsive to
pharmacologic treatments.(9)
Spirituality and Depression Treatment Outcomes
In a U.S. treatment study concerning moderate depression, an
intervention drawing upon personal spiritual resources also
hastened recovery. Among religiously committed patients, those
receiving religiously oriented cognitive-behavioral therapy had
better scores on measures of both post-treatment depression and
clinical adjustment than those whose therapy omitted religious
content.(10)
The religious therapy employed included religious rationales,
religious arguments to counter irrational thoughts, and religious
imagery. Therapy with religious content resulted in significantly
faster recovery from depression -importantly, whether the therapist
was religious or not. This somewhat surprising finding illustrated
the potential for non-religious therapists to effectively conduct
therapy with religious content for religiously committed
patients.
Similarly, a study of 62 Muslim patients with generalized
anxiety disorder were randomized to receive either a traditional
treatment of supportive psychotherapy with anxiolytic drugs or
traditional treatment with medication plus psychotherapy with
religious content, involving patient prayer and reading verses of
the Holy Koran specific to the person's clinical condition. The
study reported that patients receiving psychotherapy with religious
content showed significantly more rapid improvement in anxiety
symptoms than those receiving traditional therapy that did not
include it.(11)
Recovery from Depression among the Medically Seriously Ill
Depression often strikes older patients hospitalized for medical
illness. While major depression afflicts only 1% of older adults
living in the community in the US, the figure rises to 10% among
medically ill hospitalized elderly. Some 35% or more with medical
illness suffer with less severe types of depression.
Researchers at Duke University investigated whether religious
coping resources might help patients recover faster from their
depression. The research team used multi-dimensional measures
including questions about frequency of religious attendance, and
private religious activities like prayer or Bible study. They also
employed Hoge's 10-item validated scale to measure patient levels
of intrinsic religious commitment. "Intrinsic" pertains to what
extent a person takes their religious beliefs to heart as a major
motivating factor in their decisions and behavior. The study sample
included 87 depressed older adults hospitalized with medical
illness. The course of their depression was tracked for almost a
year. Somewhat surprisingly, for every 10-point increase in
intrinsic religion score in the 50-point scale, there was a 70%
increase in their speed of remission from depression. This effect
remained after controlling for multiple demographic, psychosocial,
physical health, and treatment factors.(12)
In another study of 850 elderly men admitted to the hospital,
researchers found that patients who used their religious faith to
cope were significantly less depressed.(13)
In a subgroup of 201 patients, the extent of their religious coping
predicted lower depression scores on follow-up six months later.
Furthermore, the clinical effects of religious commitment were
strongest among those with most severe levels of disability.
Spirituality's Role in Suicide Prevention
Religious participation reduces risk of suicide. Both a recent
large U.S. national study as well as an initial large-scale
regional study published thirty years earlier found that persons
who did not attend religious services were four times more likely
to kill themselves than were frequent religious attenders.(14,15)
Furthermore, in a review of 68 studies that examined the
relationship between suicide and spirituality/religion, 84% found
lower rates of suicide or more negative attitudes toward suicide
among the more religious.(4)
A study of U.S. adolescents found religious commitment
significantly reduced risk of suicide,(16) an
especially significant finding in the face of a 400% rise in teen
suicides in the U.S. from 1950 to 1990, according to the National
Center for Health Statistics.
In a study of suicide rates in the Netherlands, a decrease in
suicide mortality was linked with a religious revival among the
young, pointing to religion/spirituality serving as a protective
factor.(17)
Older persons who died by suicide when compared with those who
died a natural death were less likely to have participated in
religious services during their lifetime, found an analysis of a
U.S. National Mortality Followback Survey of 5,000 deaths.
(29)
Adjusting for sex, race, marital status, age, and frequency of
social contact, the analyses showed that visiting or talking with
friends or relatives did not reduce the likelihood of suicide
compared to death by natural causes, but frequent participation in
religious activities did. The researchers suggested these findings
showed it may not merely be the social contact inherent in some
forms of religious participation that decreases suicide risk, but
something else more inherent in spirituality and religion . They
concluded, "Participation in religious activities may act as a
safeguard against suicide."
Nevertheless, a 1994 evaluation of suicide assessment
instruments in the U.S. observed that "although religion is noted
as a highly relevant factor in suicide literature, the number of
religious items included on assessment scales approaches zero." The
review noted the need to begin to recognize and include
religion/spirituality in suicide prevention, treatment, and
care,(18) especially given the increasing
suicide rates among adolescents and the elderly.
Substance Abuse Prevention and Treatment: Drug Abuse
Prevention
The lack of religious commitment arises in research findings as
a risk factor for drug abuse.
A review of nearly 40 studies found that people with higher
levels of religious commitment were less likely to become involved
in substance abuse.(19) These findings
supported other reviews, which found that lack of religious
commitment stood out as a predictor of those who abuse
drugs.(20)
Another survey of almost 14,000 U.S. youths found that analysis
of six measures of religious commitment and eight measures of
substance abuse showed religious/spiritual commitment was linked
with less drug abuse. In this study, the measure of "importance of
religion" to the person was the best predictor in indicating lack
of substance abuse, implying that the controls operating were
internalized values and norms rather than fear or peer
pressure.(21)
Drug Abuse Treatment
Drawing upon spiritual resources can also make a significant
difference in outcomes in effective drug treatment.(22) For instance, in the U.S. 45% of participants in
a religious outpatient treatment program for opium addiction were
still drug free one year later compared to only 5% of participants
in a non-religious public health service hospital inpatient
treatment program-a nine-fold difference.(23)
Prevention and Treatment of Alcohol Abuse
Parallel to reducing use of illicit drugs, spiritual/religious
involvement similarly predicts fewer problems with
alcohol.(24)
A systematic review found 86 studies that examined
spiritual/religious commitment and alcohol use. Some 88% found
lower alcohol use/abuse among the more religious, including the
high risk group of adolescents and young persons.(4)
U.S. studies reveal that persons lacking a strong religious
commitment are more at risk to abuse alcohol. Risk for alcohol
dependency is 60% higher among drinkers with no religious
affiliation compared to members of conservative
denominations.(22)
Religious involvement tends to be low among those diagnosed with
alcohol abuse.(25) A study of the religious
lives of alcoholics found that 89% of alcoholics had lost interest
in religion during their teenage years.(26)
Alcoholics often report having had negative experiences with
religion and hold concepts of God that are punitive, rather than
loving and forgiving.(27)
Furthermore, a relationship between religious/spiritual
commitment and the non-use or moderate use of alcohol has been
documented. One study found somewhat surprisingly that whether or
not a religious tradition specifically teaches against alcohol use,
those who are active in a religious group consumed substantially
less alcohol than those who were not active.(28)
Once alcohol addiction has taken hold, spirituality is often a
powerful force in achieving abstinence. Alcoholics Anonymous (AA)
invokes a Higher Power to help alcoholics recover from addiction.
Those who participate in AA are more likely to remain abstinent
after inpatient or outpatient treatment.(29)
Smoking Prevention
Most smokers in the U.S. begin as teenagers or young adults,
with about a third quitting by the time they reach 65. An initial
study of smoking and religious activity in older Americans found
the life-long, strongly religious are much more likely never to
have smoked at all. Also, the elderly who actively participated in
their religious faith were 90% less likely to smoke. Among those
older adults who did smoke, the number of cigarettes smoked per day
sank significantly among the more religiously active.
Frequently attending religious services stood out as the most
important religious factor linked with less smoking in this study.
Private study of scripture and prayer didn't show nearly as strong
a link. Watching religious TV or listening to religious radio had
no connection to smoking reduction.(30) Also,
not only potentially effective in prevention, religious/spiritual
involvement is associated with higher success rates in smoking
cessation treatment.(31)
Reducing Adolescent Health Risks
A U.S. national study of 5,000 high school seniors found those
who both attend church weekly and report that religion is important
to them are much less likely to engage in binge drinking, smoking,
or using marijuana, are less likely to carry weapons or get into
fights, and more prone to eat in a healthy fashion, to exercise
regularly, get adequate sleep, and wear seat belts, researchers
found after controlling for sociodemographic factors.(32)
Relative to their peers, religious youth are less likely to
engage in behaviors that compromise their health, suggesting that
religious resources may serve as a potentially important, often
overlooked, ally in promoting health.
Reducing Health Risks among Adults
In a 30-year U.S. community study published in 2001, persons who
at the start of the study attended religious services weekly were
more likely to both improve health behaviors and maintain good ones
than those whose attendance was less or none at the start.(33) These included starting to exercise, quitting
smoking, increasing social contacts, and maintaining marital
stability. Weekly attendance was also linked with improved mental
health status including reduced depression.
Confirming other studies showing reduced depression and
substance abuse, a study of 1,900 women twins published in the
American Journal of Psychiatry found significantly lower rates of
major depression, smoking, and alcohol abuse among those who were
more religious.(34)
Coping with Surgery and Serious Medical Illness
Seriously ill patients or those undergoing surgery face high
stress and have potential mental health needs. Resources for coping
contribute to dealing with the potential anxiety and risk of
depression these patients may face when dealing with medical
illness. Studies on what helps patient cope identify
spiritual/religious commitment as a significant resource.
Recovery from Surgery
A study at Dartmouth Medical School found that elderly heart
patients were 14 times less likely to die following surgery if they
found strength and comfort in their religious faith and also were
socially involved in organizations. In this study of 232 patients,
those who said they derived no strength or comfort from their
religious faith had almost 3 times the risk of death at the 6-month
follow-up as patients who found at least some strength. None of
those who saw themselves as deeply religious prior to surgery had
died six months later, compared to 12% of those who rarely or never
went to religious services.(35)
Another study of elderly women recovering from hip fractures
also found patients' religious commitment enhanced recovery. Women
to whom God was a strong source of strength and comfort and who
frequently attended religious services were less depressed and
could walk farther at discharge than patients who lacked a strong
spiritual/religious commitment.(36)
Coping with Cancer
A survey of 108 women undergoing treatment for various stages of
gynecological cancer found that 93% of these cancer patients said
their religious lives helped them sustain their hopes. Some 75%
said religion had a significant place in their lives, and 41% noted
their religious lives supported their sense of worth. Almost half
(49%) felt they had become more religious following the onset of
their cancer.(37)
Negative Religious Coping
At times aspects of spiritual/religious commitment can be linked
with negative physical or mental health outcomes, hindering rather
than helping treatment and recovery:
Research has revealed that beliefs of certain religious groups
who reject medical interventions for their children for "faith
healing" can lead to earlier death from often-treatable
diseases.(38)
Elderly ill patients' reports that they felt alienated from or
unloved by God and attributed their illness to the devil were
associated with a 19% to 28% increased risk of dying during the
2-year follow-up period, after controlling for demographic and
physical and mental health variables.(3)
Negative religious coping, such as seeing illness as a
punishment from God or questioning God's power or love was linked
with more depression, poorer quality of life, and callousness
towards others in a study of hospitalized patients.(39)
Another study described individual psychopathology linked with
families whose rigidity, enmeshment, and emotional harshness were
supported by enlisting religious beliefs or views.(40)
Spirituality's Links with Living Longer
In contrast to the above finding of risk of earlier death among
elderly ill with spiritual distress, many studies find active
religious involvement increases potential longevity.
A meta-analysis of all published and unpublished studies
examining religious involvement and death by any cause summed 42
study samples totaling nearly 126,000 people and found active
religious involvement increased the chance for living longer by
29%.(41) Participating in public religious
practices like worship attendance increased the chance for living
longer by 43%. The analyses revealed the links were so strong it
would take 1,400 new studies showing no association between
religious involvement and living longer to overturn them.
Attending religious services more than once a week stretched
lives an average of 7 years for whites and added a potential 14
more years for African Americans in a U.S. study in Demography
which tracked a national sample of more than 21,000 US adults for
nine years.(42)
A study in the American Journal of Public Health in 1997 found
persons who attended religious services weekly or more were 25%
less likely to die in the 28-year study period than infrequent
attenders.(43) For women, the protective
effect of attending services was stronger than choosing not to
smoke, and stronger for men than exercise.
To assess whether these findings might be explained by the
possibility that persons in better health are more likely to attend
religious services than those who are sick or disabled and thus
unable to attend, the study found persons with significant
impairment in mobility were in fact more likely to be frequent
attenders. Improved health practices, increased social contacts,
and more stable marriages occurred more often for those who
frequently attended worship services. Better health practices did
help contribute to but did not fully account for the lower
mortality rates.
The study examined and controlled for numerous social, economic,
and health and lifestyle factors, as well religious attendance, to
see who was most likely to avoid death by any cause. Religious
attendance surfaced as a strong predictor for living longer, even
when statistically controlling for other relevant factors.
A 16-year study in Israel found distinctly lower rates of early
death in religious kibbutzim compared to those living in secular
kibbutzim, evident in both genders, at all ages, and consistently
over all causes of death. Interestingly, the magnitude of the
protective religious effect eliminated the usual gender advantage:
secular women did not live longer than religious men.(44)
SumMary
Published research has found links between spirituality and
beneficial mental health outcomes in the areas of prevention,
coping, and recovery from depression; suicide prevention; substance
abuse prevention and treatment; and in enhancing adolescent and
adult health behaviors. Religious coping can positively help
patients dealing with surgery, or with severe or chronic medical or
emotional illness. Longitudinal studies have found frequent
spiritual/religious practices such as attending religious meetings
weekly or more is linked with living longer. Other studies have
shown negative religious coping in which God is seen as punitive or
abandoning may have adverse mental health outcomes and risk of
earlier death.
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