Patient Spirituality and Mental Health


SPECIAL GUEST CONTRIBUTION Patient Spirituality and Mental Health: A New Focus in Clinical Care and Research 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 twopart 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. Part II: A Brief Review of Research Findings on Spirituality and Mental Health 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 1) prevention, coping, and recovery from depression, 2) suicide prevention, 3) substance abuse prevention and treatment, 4) adolescent and adult health risk reduction, 5) coping with surgery and severe medical illness, 7) potential harmful aspects of spiritual/religious problems, and 8) 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: 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 cognitivebehavioral 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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5. Larson DB, Swyers, JP, and McCullough, M E. (eds.) Scientific Research on Spirituality and Health: A Consensus Report 1998. Rockville, MD: National Institute for Healthcare Research. 6. McCullough ME and Larson DB. Religion and depression: A review of the literature. Twin Research .1999; 2:126-136. 7. Braam AW, Beekman ATF, Deeg DHG, Smit JH, Tilburg, W. van. Religiosity as a protective or prognostic factor of depression in later life; results from a community study in The Netherlands. Acta Psychiatrica Scandinavica 1997; 96: 199-205. 8. Brown GW, Prudo R. Psychiatric disorder in a rural and an urban population. I: Aetiology of depression. Psychological Medicine 1981; 11: 581-599. 9. Koenig HG, Cohen HJ, Blazer DG, et al. Cognitive symptoms of depression and religious coping in elderly medical patients. Psychosomatics. 1195;36: 369-375. 10. Propst LR, Ostrom R, Watkins P, Dean T, Mashburn D. Religious values in psychotherapy and mental health: Empirical findings and issues. Journal of Consulting and Clinical Psychology 1992; 60:94-103. 11. Azhar MZ, Varma SL, Dharap AS. Religious psychotherapy in anxiety disorder patients. Acta Psychiatrica Scandinavica 1994; 90: 1-3. 12. Koenig HG, George LK and Peterson BL. Religiosity and remission from depression in medically ill older patients. American Journal of Psychiatry 1998;155:536-542. 13. Koenig HG et al. Religious coping and depression in the elderly hospitalized medically ill men. American Journal of Psychiatry 1992; 149(1): 693-1,700. 14. Nisbet PA, Duberstein PR, Yeates C, et al. The effect of participation in religious activities on suicide versus natural death in adults 50 and older. Journal of Nervous and Mental Disease 2000;188:543-546. 15. Comstock GW , Partridge KB. Church attendance and health. Journal of Chronic Disease 1972; 25: 665-672. 16. Stein D et al. The association between adolescents' attitudes toward suicide and their psychosocial background and suicidal tendencies. Adolescence 1992; 27(108):949-959. 17. Kerkhoff AJFM. A European Perspective on Suicidal Behavior, 1994. 18. Koehoe NC, Gutheil TG. Neglect of religious issues in scale-based assessment of suicidal patients. Hospital and Community Psychiatry 1994; 45(4): 366-369. 19. Benson P. Religion and substance use. In: Schumaker JE (ed)Religion and Mental Health. New York: Oxford University Press, 1992: 211-220. 20. Gorsuch RL and Butler MC. Initial drug abuse: A view of predisposing social psychological factors. Psychological Bulletin 1976; 3: 120-137. 21. Loch BR, Hughes RH. Religion and youth substance use. Journal of Religion and Health 1985; 24(3):197-208. 22. Miller WR. Researching the spiritual dimensions of alcohol and other drug problems. Addiction 1998; 93(7):979-990. 23. Desmond DP, Maddox JF. Religious programs and careers of chronic heroin users. American Journal of Drug and Alcohol Abuse 1981; 8(1): 71-83. 24. Hardesty PH, Kirby KM. Relation between family religiousness and drug use within adolescent peer groups. Journal of Social Behavior and Personality 1995; 10(2): 137-142. 25. Brizer DA. Religiosity and drug abuse among psychiatric inpatients. American Journal of Drug and Alcohol Abuse 1993; 19(3):337-345. 26. Larson DB, Wilson WP. Religious life of alcoholics. Southern Medical Journal 1980; 73(6): 723-727. 27. Gorsuch, R.L. Assessing spiritual values in Alcoholics Anonymous. Edited in McCrady BS and Miller WR, eds. Research on Alcoholics Anonymous: Opportunities and Alternatives. New Brunswick, NJ: Rutgers Center for Alcoholic Studies, 1993; 301-318.


28. Amoateng AY and Bahr SJ Religion, family, and adolescent drug use. Psychological Perspectives 1986; 29: 53-73. 29. Montgomery HA, Miller WR, and Tonigan JS. Does Alcoholics Anonymous involvement predict treatment outcome? Journal of Substance Abuse Treatment 1995; 12(4): 241-246. 30. Koenig HG et al. The relationship between religious activities and cigarette smoking in older adults. Journal of Gerontology: Medical Sciences 1998; 53A(6): M1-M9. 31. Voorhees CC et al. Heart, body, and soul: Impact of church-based smoking cessation interventions on readiness to quit. Preventive Medicine 1996; 25(3): 277285. 32. Wallace, J, and Forman, T. Religion's role in promoting health and reducing risk among American youth. Health Education and Behavior 1998; 25 (6):721-741. 33. Strawbridge WJ, Shema SJ, Cohen RD, Kaplan GA. Religious attendance increases survival by improving and maintaining good health behaviors, mental health, and social relationships. Annals of Behavioral Medicine 2001;23(1):68-74. 34. Kendler KS, Gardner CO, Prescott CA. Religion, psychopathology, and substance use and abuse: A multimeasure, genetic-epidemiologic study. American Journal of Psychiatry 1997; 154: 322-329. 35. Oxman TE, Freeman DH, and Manheimer ED. Lack of social participation or religious strength and comfort as risk factors for death after cardiac surgery in the elderly. Psychosomatic Medicine 1995; 57(1): 5-15. 36. Pressman P, et al. Religious Belief, depression, and ambulation status in elderly women with broken hips. American Journal of Psychiatry 1990;147(6): 758-760. 37. Roberts JA, Brown D, Elkins T, Larson DB. Factors influencing views of patients with gynecological cancer about end-of-life decisions. American Journal of Obstetrics and Gynecology 1997; 176(1):166-172. 38. Asser SM and Swan R. Child fatalities from religion-motivated medical neglect. Pediatrics 1998;101(4):625-29. 39. Pargament KI et al. Patterns of positive and negative religious coping with major life stressors. Journal for the Scientific Study of Religion 1998; 37(4): 710-724. 40. Josephson AM. The interactional problems of Christian families and their relationship to developmental psychopathology: Implications for treatment. Journal of Psychology and Christianity 1993; 12:112-328. 41. McCullough, ME, Larson, DB, Hoyt, WT et al. Religious involvement and mortality: A meta-analytic review. Health Psychology 2000; 19(3): 211-222. 42. Hummer RA et al. Religious involvement and U.S. adult mortality. Demography 1999; 36( 2): 1-13. 43. Strawbridge WJ et al. Frequent attendance at religious services and mortality over 28 years. American Journal of Public Health 1997; 87(6):957-61. 44. Kark JD, Shemi G, Friedlander Y, et al. Does religious observance promote health? Mortality in secular vs. religious kibbutzim in Israel. American Journal of Public Health 1996; 86(3):341-346.

© D Larson 2001



Patient Spirituality and Mental Health

SPECIAL GUEST CONTRIBUTION Patient Spirituality and Mental Health: A New Focus in Clinical Care and Research David B. Larson, MD, MSPH President, Inte...

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