Relationship of Religious Beliefs with Anxiety and Depression))

Religiousness and mental health: a review Religiosidade e saúde mental: uma revisão

A b s t r a c t

Objective: The relationship between religiosity and mental health has been a perennial source of controversy. This paper reviews the scientific evidence available for the relationship between religion and mental health. Method: The authors present the main studies and conclusions of a larger systematic review of 850 studies on the religion-mental health relationship published during the 20th Century identified through several databases. The present paper also includes an update on the papers published since 2000, including researches performed in Brazil and a brief historical and methodological background. Discussion: The majority of well-conducted studies found that higher levels of religious involvement are positively associated with indicators of psychological well-being (life satisfaction, happiness, positive affect, and higher morale) and with less depression, suicidal thoughts and behavior, drug/alcohol use/abuse. Usually the positive impact of religious involvement on mental health is more robust among people under stressful circumstances (the elderly, and those with disability and medical illness). Theoretical pathways of the religiousness-mental health connection and clinical implications of these findings are also discussed. Conclusions: There is evidence that religious involvement is usually associated with better mental health. We need to improve our understanding of the mediating factors of this association and its use in clinical practice.

Keywords: Mental health; Religion; Religion and Medicine; Religion and Psychology; Spirituality

R e s u m o

Objetivo: A relação entre religiosidade e saúde mental tem sido uma perene fonte de controvérsias. O presente artigo revisa a evidência científica disponível sobre a relação entre religião e saúde mental. Método: Os autores apresentam os principais estudos e as conclusões de uma revisão sistemática abrangente dos estudos sobre a relação religião-saúde mental. Utilizando-se de várias bases de dados, a revisão identificou 850 artigos publicados ao longo do século XX. O presente artigo também inclui uma breve contextualização histórica e metodológica, além de uma atualização com artigos publicados após 2000 e a descrição de pesquisas conduzidas no Brasil. Discussão: A ampla maioria dos estudos de boa qualidade encontrou que maiores níveis de envolvimento religioso estão associados positivamente a indicadores de bem estar psicológico (satisfação com a vida, felicidade, afeto positivo e moral mais elevado) e a menos depressão, pensamentos e comportamentos suicidas, uso/abuso de álcool/drogas. Habitualmente, o impacto positivo do envolvimento religioso na saúde mental é mais intenso entre pessoas sob estresse (idosos, e aqueles com deficiências e doenças clínicas). Mecanismos teóricos da conexão religiosidade-saúde mental e as implicações clínicas destes achados são discutidos. Conclusões: Há evidência suficiente disponível para se afirmar que o envolvimento religioso habitualmente está associado a melhor saúde mental. Atualmente, duas áreas necessitam de maior investimento: compreensão dos fatores mediadores desta associação e a aplicação deste conhecimento na pratica clínica.

Descritores: Saúde Mental; Religião; Religião e Medicina; Religião e Psicologia; Espiritualidade

1 Center for the Study of Religious and Spiritual Problems (NEPER), Department of Psychiatry, Universidade de São Paulo (USP), São Paulo (SP), Brazil

2 João Evangelista Hospital, São Paulo (SP), Brazil 3 Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina 4 Geriatric Research, Education, and Clinical Center, VA Medical Center, Durham, North Carolina

Rev Bras Psiquiatr. 2006;28(3):242-50

SPECIAL ARTICLE

Alexander Moreira-Almeida,1,2,3,4 Francisco Lotufo Neto,1

Harold G Koenig3,4

Financing: Post-Doctoral fellowship provided by Hospital João Evangelista (HOJE) Conflicts of Interest: None Submitted: 9 January 2006 Accepted: 15 March 2006

Correspondence Alexander Moreira-Almeida 2748 Campus Walk Ave. Apt.18b 27705 – Durham – NC Phone: (919) 309-1405 E-mail: alexma@usp.br

Center for the Study of Religious and Spiritual Problems (NEPER), Department of Psychiatry, Universidade de São Paulo (USP), São Paulo (SP), Brazil

242

Rev Bras Psiquiatr. 2006;28(3):242-50

243 Moreira-Almeida A et al.

I n t r o d u c t i o n

Although some scholars had predicted that religiosity would

tend to disappear or sharply decrease throughout the 20th

Century1-2 that has not been the case, especially in the

American Continent. According to a 2005 US poll,3 88% of

Americans in the United States describe themselves as religious

and/or spiritual, and only 7% said that spirituality is not

important at all in their daily life. In the Brazilian 2000

Census,4 only 7% declared themselves as religiousless. Even

this 7% probably included many people with some expression

of spirituality but not related to an organized religion. However,

despite the large importance of religion and spirituality for the

population, until recently, religion and spirituality were not

included in the training curriculum of the mental health

professionals and were set aside in clinical practice.

In the last two decades, things begun to change. Literally,

thousands of papers have been published on the relationship

of religion and health in the medical and psychological

academic literature. Indeed, many medical schools have

integrated spirituality into the curriculum. In the US, 84 out

of 126 accredited medical schools are offering courses on

spirituality in medicine.5

However, if we understand prejudice as a “preconceived

opinion” or an “opinion formed without just grounds or before

sufficient knowledge”,6 we can see that the field studying the

relationship between religion and health is undoubtedly full

of prejudice. In that case, the prejudice may be for or against

r e l i g i o n . T h e f i e l d h a s s e e n e x t r e m e s b e t w e e n n a i v e

acceptances of all claims that “religion is good” to a radical

skepticism that rejects even good scientific evidence.

In studying the relationship of spirituality with health, it

is not necessary to assume any position about the ontological

reality of God or the spiritual realm. We can test whether

measures of religious beliefs or behaviors are associated

with health outcomes, regardless if we believe in the beliefs

under investigation.7-10

The definitions of religiosity and spirituality have been a

perennial source of controversy. According to Betson & Ventis,

as early as 1912 the psychologist James Leuba detected 48

distinct definitions of religion.11 We will adopt the definitions

given by Koenig et al.:12

1) Religion: is an organized system of beliefs, practices,

rituals, and symbols designed to facilitate closeness to the

sacred or transcendent (God, higher power, or ultimate

truth/reality).

2) Spirituality: is the personal quest for understanding

answers to the ultimate questions about life, about meaning,

and about relationship with the sacred or transcendent, which

may (or may not) lead to or arise from the development of

religious rituals and the formation of a community.

This paper reviews the scientific evidence available for the

relationship between religion and mental health. It is largely

based on the Handbook of Religion and Health published by

one of the authors in 2001.12 Discussing more than 1200

studies published during the 20th century, this Handbook is

t h e m o s t c o m p r e h e n s i v e a n d s y s t e m a t i c r e v i e w e v e r

accomplished in this field. The authors tried in order to find

out all research during the last century that examined the

relationship between a religious variable and some health

outcome. They utilized several on-line data bases (Medline,

PsycLit, SocLit, CINAHL, Curent Contents, HealthStar,

Cancerlit) and previously published and unpublished reviews

of the literature to find the research papers. By retrieving

articles using the search terms “religion”, “religiosity”,

“religiousness”, “spiritual”, “spirituality” and examining their

reference lists until no more articles could be found, the

authors identified 850 studies on the religion-mental health

relationship. The original source reviews each study in

detail;12 because of space limitations, the present article

summarizes the main findings on mental health from the

Handbook with an update on the papers published since

2000 and an addition of some research performed in Brazil

(retrieved using SciELO and Lilacs, besides contact with

Brazilian researchers in the field).

Historical background

The idea that religion and psychiatry have always been in

conflict is still very prevalent. Today, most people believe that in

the medieval ages most mental disorders were considered as

witchcraft or demonic possession. After all, one of the

foundational myths of psychiatry is that brave and enlightened

psychiatrists liberated mankind from these religious

superstition.13-14 Many well-known psychiatric textbooks have

taught that the Middle Ages were the Dark Ages, when the

focus was on insanity as demonology, when people did not

consider natural causes to mental disorders and the insane

were tortured or burned at the stake. However, that point of

view is far away from the truth. Natural causes to mental

disorders were proposed and largely accepted during that period

and the emphasis on demonology and witch-hunting occurred

after the Middle Ages.15 In the middle of nineteenth century,

proselytizing scientists and secularizing psychiatrists created the

myth of psychiatry’s victory over demonology and other myths

about the “dark middle ages” such as the “flat Earth”, celebrating

the scientific and humanitarian innovation that had rescued

mankind from the superstitious models of Christian

jurisdiction.14,16 However, Vandermeersch states that medical

psychiatry’s birth at the time of Pinel did not conflict with

religion.13 “The alleged opposition between enlightened medicine

and obscurantist theology as well as between the humanitarian

physician and the cruel churchman are myths” (p. 354).

In fact, the history of religion and the care of people

suffering from mental disorders have many points in common.

In Western civilization, religious organizations provided some

of the first and best care to the mentally ill. Since the

beginning of the Middle Ages up to the past centur y, religious

orders built and maintained a large amount of hospitals. The

establishment of large hospitals as an act of charity is a

Christian idea. The first hospital designed specifically to care

for the mentally ill was established in Spain in 1409 under

the guidance of priests. Religious groups have founded or

supported many psychiatric hospitals in the US and Brazil.12,17

However, the care provided to the mentally ill by the Church

was not always compassionate. The Inquisition killed many

mentally ill people under the accusation of being witches

during the first two centuries of the Renaissance period in

Western Europe.12,15

At the end of the 19th century the psychiatric community

raised negative attitudes toward religion, which became

prominent during the 20th century. In line with some anti-

religious intellectuals who considered religiosity a primitive

and negative social or intellectual state, many physicians such

as J.-M. Charcot and Henry Maudsley developed critiques and

attempted to pathologize religious experiences.14,18 Sigmund

Freud adopted a strong anti-religious stance that had a large

influence in the medical and psychological community. In

Religiousness and mental health 244

Rev Bras Psiquiatr. 2006;28(3):242-50

Future of an Illusion (1927),2 he proposed the irrational and neurotic influences of religion on the human psyche. In

1930,2 Freud wrote that religion results in “depressing the

value of life and distorting the picture of the real world in a

delusional manner – which presupposes an intimidation of

intelligence”. Although there were some psychiatrists with a

positive view of religiosity, the most well-known example being

Carl G. Jung,19 the negative appraisal was prevalent. As late

as the 1980s, the psychologist Albert Ellis,20-21 the founder

of Rational-Emotive Therapy who had a large influence over

cognitive-behavioral psychotherapy, stated that religiosity “is

in many respects equivalent to irrational thinking and

emotional disturbance”, so “the elegant therapeutic solution

to emotional problems is to be quite unreligious (...) the less

religious they (people) are, the more emotionally healthy they

will tend to be” (p. 637).20

However, almost all statements about the impact of religiosity/

spirituality in mental health were not based on empirical

research, but mainly on clinical experience and personal

opinions. One factor that may have contributed to this negative

attitude is what Lukoff et al. noted as the “religiosity gap”

b e t w e e n m e n t a l h e a l t h p r o f e s s i o n a l s a n d p a t i e n t s . 22

Psychiatrists and psychologists tend to be less religious than

the general population, and do not receive adequate training

to deal with religious questions in clinical practice. So, they

usually have difficulties in understanding and empathizing with

patients’ religious beliefs and behavior. If the main source of

psychiatrists’ contact with religious experiences is through the

report of their patients, naturally, those are biased sources.

Although psychiatric patients many times use religious coping

in a healthy way,12,23-24 they also may express a depressive,

psychotic or anxious point of view of their religions.25 Those

perspectives, farther than not reflecting in a fairly way the

religious experiences of the general population, were seen as

confirmations of the pathological nature of religiosity. Only in

the last two decades have rigorous scientific research been

done and published in mainstream medical and psychological

journals. David B. Larson, Jeffrey S. Levin and Harold G.

Koenig were some of the pioneers who opened a new stage

for scientific investigation of religion/spirituality in the medical

field.26 They have conducted a series of studies looking at the

relationship between religious involvement and mental health

in mature adults, either living in the community or hospitalized

with medical illness. Since then, many other researchers have

produced a large body of research that has usually, but not

always, shown a positive association between religious

involvement and mental health. Currently, there is a trend

favoring a rapprochement of religion and psychiatry to help

mental health professionals develop skills to understand better

the religious factors influencing health and to provide a more

compassionate and comprehensive mental health care.27-28

Evidence of the impact of religiosity on mental health

A large part of the research involving religion and health did

not have religion as the focus of the study. Because of that,

frequently, the measurement of religiosity involved only a single

question, often simply religious denomination. However, the

religious affiliation tells us little about what is religiosity and

how important it is in someone’s life. On account of that,

studies using only a subject’s religious affiliation have provided,

with few exceptions, many inconsistent and contradictory

findings.12,29 The strongest and most consistent results have

not been found between different religious denominations,

but by comparing different degrees of religious involvement

(from a non-religious to a deeply religious person). Church

a t t e n d a n c e , i . e . h o w o f t e n s o m e o n e a t t e n d s r e l i g i o u s

meetings, is one of the most widely used questions to

investigate the level of religious involvement. Other questions

are non-organizational religiosity (time spent in private

religious activities such as prayer, meditation, and reading

religious texts) and subjective religiosity (the importance of

the religion in someone’s life). However, caution is necessary

in interpreting the relationship between private religious

practices and health in cross-sectional studies. People may

pray more while they are sick or under stressful situations.

Turning to religion when sick may result in a spurious positive

a s s o c i a t i o n b e t w e e n r e l i g i o u s n e s s a n d p o o r h e a l t h .

Conversely, a poor health status could decrease the capacity

to attend a religious meeting, in that way creating another

bias on the association between religiousness and health.

Finally, a very important dimension of religiosity is religious commitment, which reflects the influence that religious beliefs have on a person’s decisions and lifestyle. According

to the Harvard psychologist Gordon Allport30 a persons’

religious orientation may be intrinsic and/or extrinsic:

“Extrinsic Orientation: Persons with this orientation are disposed to use religion for their own ends (...) (religion) is

held because it ser ves other, more ultimate interests. (...)

may find religion useful in a variety of ways – to provide security

and solace, sociability and distraction, status and self-

justification. The embraced creed is lightly held or else

selectively shaped to fit more primary needs.

Intrinsic Orientation: Persons with this orientation find their master motive in religion. Other needs, strong as they may

be, are regarded as of less ultimate significance, and they

are, so far as possible, brought in harmony with the religious

beliefs and prescriptions. Having embraced a creed the indivi-

dual endeavors to internalize it and follow it fully.” (p. 434)

Usually, the intrinsic orientation is associated with healthier

personality and mental status, while the extrinsic orientation

is associated with the opposite. Extrinsic religiosity is associated

with dogmatism, prejudice, fear of death, and anxiety, it “does

a good job of measuring the sort of religion that gives religion

a bad name” (p. 416).31 This very important and consistent

finding totally contradicts Ellis (1988) who argued that one

way that religiosity “sabotaged” mental health was a lack of

“self-interest (...) rather than be primarily self-interested,

devout deity-oriented religionists put their hypothesized god(s)

first and themselves second – or last.” (p. 27-8). It is exactly

this behavior that has been most consistently associated with

better mental health.

Although the research on religion and mental health

involves many others outcomes (e.g.: psychosis, personality,

marital satisfaction and stability, anxiety, delinquency), we

will focus on the four that have been more thoroughly

investigated and, because of that, have the strongest findings:

one indicator of positive mental health (psychological well-

being); and three indicators of mental disorder (depression,

suicide, and drug abuse).

1. Psychological well-being

Several recent studies have used measures of spirituality,

mainly spiritual well-being, and they usually have found

positive correlations with psychological well-being and other

indicators of positive mental health. However, the instruments

used in some of these studies, like SWBS32 and FACIT-Sp33 are

Rev Bras Psiquiatr. 2006;28(3):242-50

245 Moreira-Almeida A et al.

strongly contaminated by measures of mental health and well-

being, therefore it is not surprising that results were associated

with positive health outcomes.34 Because of this tautology, we

avoided considering studies with these measures in our review.

Out of 100 studies that examined the association between

religious practices and behavior and indicators of psychological

well-being (life satisfaction, happiness, positive affect, and

higher morale), 79 reported at least one significant positive

correlation between these variables.12 Only one study, which

had a small and non-random sample of college students, found

a negative correlation.35 While the correlations are usually

modest, they often equaled or exceeded those between well-

being and other psychosocial variables like social support,

marital status, or income. This positive association has been

consistently similar in samples from different countries,

involving a diversity of religions, races and ages.10 Although

most studies are cross-sectional, 10 out of 12 longitudinal

studies replicated this positive association.36-46 Most of these

studies showed an association between religiosity and well-

being even after controlling for age, gender and socioeconomic

status. Some studies have shown that the positive impact of

religious involvement on well-being is more robust among the

elderly, disabled, and medically ill people.36,42,47 This probably

means that the buffering effects of religious involvement on

w e l l - b e i n g m a y b e h i g h e r f o r t h o s e u n d e r s t r e s s f u l

circumstances. In a recent research study with 233 British

residents from retirement housing,48 spiritual beliefs were a

significant predictor of psychological well-being even after

controlling for marital status, age, education, health problems

and gender. Spiritual beliefs also had a positive effect on

psychological well-being buffering the impact of frailty. In

another study, religiosity was one of the most important factors

associated with psychological well-being in a sample of 188

Canadian older adults following spousal loss, even after

adjusting for social support, negative life events, health status

and demographic variables.49

With some exceptions, most studies have also found a positive

association between religiosity and other factors associated with

well-being such as optimism and hope (12 out of 14 studies),

self-esteem (16 out of 29 studies, but only one with a negative

association), sense of meaning and purpose in life (15 out of

16 studies), internal locus of control, social support (19 out of

20) and being married or having higher marital satisfaction (35

out of 38). As will be discussed later, these may be some of the

mediating factors between religiousness and well-being.50 In a

high-quality research study involving a US national sample of

1126 non-institutionalized older people, the feeling of closeness

with God was related to optimism after controlling for socio-

demographic variables. This optimism, in turn, had a strong

influence on their self-rated health status.51 In sum, following

Levin & Chatters we can state that “the existing research has

shown that religious involvement, variously assessed, has

protective effects with respect to a wide range of well-being-

related outcomes” (p. 507).52

2. Depression

A recent systematic review with meta-analysis summarized

the results of 147 independent investigations involving a total

of 98,975 subjects on the association between religiousness

a n d d e p r e s s i v e s y m p t o m s . 53 T h e a u t h o r s f o u n d t h a t

religiousness is modestly but robustly associated with lower

level of depressive symptoms (effect size -0.096). The size of

this association, although modest, is similar to that found

between gender and depressive symptoms (about .10). The

association between religiousness and depression did not vary

among the different age, gender or ethnic groups. However,

the studies used several types of religious measures and

included people under various levels of stress. Therefore,

performing the analysis of all these studies together may have

decreased the strength of the association that might exist in

more specific situations. Corroborating this hypothesis, the

review showed that the association between religiousness and

depressive symptoms is higher for people under severe life

stress (r = -.152) than for people with minimal life stress (r = -.071).

The association was also stronger for samples having a

moderate (r =.-151) instead of a minimal level of depression

(r = -.078) (p = .007). However, this last difference was not

considered as statistically significant according to the stringent

criterion adopted by the authors (p < .0035). These findings

are in line with those described above for well-being, the

protective effect of religiousness appearing to be stronger for

people under psychosocial stress.

K o e n i g e t a l . c o n d u c t e d t h e o n l y p r o s p e c t i v e s t u d y

investigating the impact of religiousness on the course of

depressive disorders.54 They found out that among 87 depressed

senior adults hospitalized for medical illness, intrinsic religious

m o t i v a t i o n w a s a s s o c i a t e d w i t h f a s t e r r e m i s s i o n f r o m

depression in a median follow-up time of 47 weeks. For every

10-point increase in intrinsic religiosity scores (score range

10-50), there was a 70% increase in speed of remission after

controlling for functional status, social support, and family

psychiatric history. Among patients whose physical disability

did not improve during the one year follow-up (that means a

poor response to medical treatment), the speed of remission

from depression increased by 106% for every 10-point increase

on the scale of intrinsic religiosity.

The same meta-analysis discussed above53 showed that the

association between religiousness and depressive symptoms

differed across the type of religiousness measured. Two specific

measures of religiousness had a positive association with high

frequency of depressive symptoms: extrinsic religious orientation

(r = .155) and negative religious coping (r = .136). On the

other hand, intrinsic religious orientation was associated with

low levels of depression (r = -.175).

Although the evidence is strongly consistent in establishing

the religiousness-depression relationship, the majority of the

studies was cross sectional in nature and was performed

among US residents, a population with a high religiosity level.

However, research conducted in other countries has found

equivalent results. Two Brazilian studies used a screening

questionnaire for common mental disorders (depression, anxiety

a n d s o m a t i z a t i o n d i s o r d e r s ) i n t w o d i f f e r e n t r e l i g i o u s

populations. Lotufo Neto,55 in a sample of 207 religious

ministers, found that intrinsic religiosity was associated with

better mental health. In the other investigation, a random

sample of 115 spiritist mediums had lower scores of psychiatric

symptoms than samples from the general population.56

The first European longitudinal study on this topic was

published recently.57 A 6-year follow-up study was conducted

in the Netherlands (where rates of church membership are

substantially lower than those in the US: 51% vs. 77%) with

a nationally representative random sample of 1,840 senior

adults (aged 55 to 85). Frequent church attendance was

associated with lower depressive symptoms during the follow-

up, and the association persisted after adjusting for demographic

variables, physical health, social support and alcohol use.

Religiousness and mental health 246

Rev Bras Psiquiatr. 2006;28(3):242-50

Because the last two variables themselves could be influenced

by religiousness, the results are even stronger. Suppor ting

previous studies, the difference in depression scores between

regular church attenders and non-frequent church attenders

was larger for those with higher functional limitations.

Psychotherapies, mainly cognitive-behavioral therapy,

accommodated to include patients’ religious beliefs and

practices, have been successfully used in the treatment of

depression and anxiety. These approaches have shown to be

at least as effective as the secular psychotherapies in meta-

analysis,58 and in some studies they were associated with faster

improvement of the symptoms among religious patients.59-60 It

is worth noting that one clinical trial found that cognitive

behavioral therapy adapted to the religious values of the patient

can be efficiently implemented by non-religious therapists.61

3. Drug abuse

More than 80% of the 120 identified studies published prior

to 2000 investigating religiousness and alcohol/drug use/abu-

se found a clear inverse correlation between these variables.

Most of the studies were conducted among adolescents, when

drug use usually starts, but research amidst adult populations

also demonstrated similar findings. The greater the person’s

religious involvement is, the lower the rates of alcohol/drug

use/abuse are.12

A recent and well-done study in the US with a sample of

2,616 adult twins investigated the relationship involving

several dimensions of religiousness with lifetime prevalence

of psychiatric and substance abuse disorders. Although several

dimensions of religiosity were usually associated with lower

prevalence of major depression, anxiety disorders and anti-

social behavior (with the exception of panic disorder that was

mildly associated with general religiosity), the strongest

association was between almost all the religious dimensions

and lower prevalence rates of nicotine, alcohol and drug abu-

se or dependence.62

In a Brazilian study involving 2,287 students in a large

metropolitan area, religious factors were strongly associated

with lower drug use during the month prior to the interview,

even after controlling for the relevant socio-demographic and

educational variables. Students who did not receive a religious

education in childhood underwent a higher use of ecstasy

(OR 4.2) and abuse of medicines (OR 3.15) compared to

students who had a highly religious education. The lack of

religious affiliation was associated with higher cocaine (OR

2.9) use and medicines (OR 2.2) abuse.63 Another Brazilian

study involving a representative sample of 2,410 students in a

medium-sized city found that, after adjusting for confounding

variables, the absence of religious practices was associated

with a 30% higher drug use (odds ratio 1.31) in comparison

to students with religious practices.64 Finally, a qualitative study

investigated the protective factors against drug use among

adolescent residents in very poor and violent areas of Sao

Paulo. Religiousness was the second most important protective

factor, after having a structured family. Family structure was,

in turn, associated with family religiousness. The study found

that 81% of the non-users practiced a religion; amongst users,

only 13% did so.65

4. Suicide

Besides the psychological impact of religious belief in life

after death, the association above mentioned, of religious

involvement with lower levels of depression and drug use (two

main factors presented in the large majority of suicide ca-

ses), gives good reasons for a negative relationship between

religiousness and suicidal behaviors. Unfor tunately, the

impact of religiousness on suicidal behaviors did not receive

enough attention within the medical and psychological

literature. Although suicidal behaviors are strongly disapproved

of by most religions, mainly in Western ones, and the long

standing tradition in sociology, starting with the classic work

o f D u r k h e i m , m o s t o f t h e m e d i c a l a n d p s y c h o l o g i c a l

investigations on suicide don’t take into account religious

factors appropriately.66

Similar to other areas in the religion-health research field,

most early studies investigated the impact of denominational

affiliation rather than religious involvement. The findings from

these early studies were usually inconsistent; whereas, the

most robust results have emerged from the examination of the

effects of religious involvement in suicide. In a review, 84%

of the 68 studies identified through 2000 found lower rates of

suicide or more objections to suicide among the more religious

subjects.12 These studies basically present two different

approaches: aggregate (ecological) or individual data. The first

type correlates data on religious involvement of entire

populations (e.g.: production of religious literature or rates of

church membership) and compares the suicide rates between

different populations. Most of these studies found that the level

of religious involvement in a given area is inversely proportional

to that area’s suicide rate. The second type of study correlates

the individual religious involvement rates with suicide deaths,

attempts or ideation. Below, we discuss some recent studies

not included in Koenig et al’s.12 review.

In a US sample of 584 suicides and 4,279 natural deaths

among subjects aged 50 and older, the suicide rate among

people who did not attend religious activities was 4 times higher

(OR 4.34) than those who had high participation, after adjusting

for sex, race, marital status, age and frequency of social

contact.67 Of the 27,738 deaths of young men aged 15-34

years from 1991 to 1995 in the state of Utah (USA), the

relative risk of suicide among subjects with low religious

commitment ranged from 3.28 to 7.64 being people with high

religious commitment the parameter (risk = 1).68 Besides being

associated with lower suicide rates, religious involvement has

also been associated with more negative attitudes toward sui-

cide and less suicide attempts, even in clinical samples. One

recent study involving 371 depressed inpatients found that

those with no religious affiliation, despite having the same

level of depression, had more lifetime suicide attempts (66.2%

vs. 48.3%), perceived less reasons for living and had fewer

moral objections to suicide than religiously affiliated patients.69

In a nationally representative US sample of 16,306 adolescents,

private - but not public - religiosity was associated with lower

probability of having had suicidal thoughts or having attempted

suicide.70 Similar results were found among 420 adolescents

in Turkey. The group that received religious education reported

less suicide ideation and lower acceptance of suicide, but

were more accepting and sympathetic to a suicidal close friend

than the secular ones.71 Finally, the use of religious or spiritual

beliefs as a source of support and comfort was associated with

less suicidal ideation among 835 African-American senior

residents of public housings, after controlling for social and

medical variables.72 The level of religiousness also has been

found to be inversely associated with the acceptance of

euthanasia and physician-assisted suicide in the general

population in Britain, 73 among the elderly in the US,74

Rev Bras Psiquiatr. 2006;28(3):242-50

247 Moreira-Almeida A et al.

physicians in Australia75 and cancer patients in a palliative

care service in the US. 76 Non-religious Belgian general

practitioners were three times more frequently involved than

the religious physicians in deaths resulting from administration

of (lethal) drugs with the explicit intention of hastening the

end of life of the patient without his/her explicit request.77

How religion could influence mental health

Although hundreds of studies report relationships between

r e l i g i o u s i n v o l v e m e n t a n d m e n t a l h e a l t h , t h e y r a r e l y

investigated the potential mediators of this relationship. Several

mechanisms have been proposed to explain the influence of

religion on human health.

1. Healthy behaviors and lifestyle

Several illnesses are related to behavior and lifestyle. The

way we eat, drink, drive our automobile, have sex, smoke,

use drugs, follow medical prescriptions, exam ourselves for

prevention have important influences in our health.

Most religions prescribe or prohibit behaviors that may impact

health.78 The biblical teachings, 3000 years ago, about diet,

ways to handle food, cleaning and purity, circumcision, sexu-

al behavior were important for preventing disease.

Today other illnesses are more relevant. Prescriptions about

k e e p i n g a d a y o f r e s t , t h e b o d y a s a s a c r e d t e m p l e ,

monogamous sex, moderation on eating and drinking, peaceful

relationships are doctrines that might be also helpful for

contemporary health problems (related to stress, competition,

individualism, narcissism, anger, shame etc.).

A good clinical example trying to apply those teachings was

the research of Thoresen et al. who successfully tried to modify

Type A behavior in coronary patients through a program that

included spiritual practices.79

Certain religious practices are responsible for health hazards

and risks. Visits to a holy shrine on specific times can enhance

the risk of accidents. Prohibition of vaccines, medication or

blood transfusion, endogamous marriages, violence against

unbelievers, handling of poisonous snakes, the way dead

bodies are handled are other examples of behaviors that can

bring health problems.

1. Social support

Belonging to a group brings psychosocial support that can

promote health. Religion might provide social cohesion, the

sense of belonging to a caring group, continuity in relationships

with friends and family and other support groups.

Social support can influence health by facilitating adherence

to health promotion programs, offering fellowship in times of

stress, suffering and sorrow, diminishing the impact of anxiety

and other emotions and anomie.

S o c i a l s u p p o r t , a l t h o u g h i m p o r t a n t , i s n o t t h e o n l y

mechanism by which religion influences health. Religion

still has beneficial effects even when social support is a

controlled variable.40

2. Belief systems, cognitive framework

Beliefs and cognitive processes influence how people deal

with stress, suffering and life problems.

Religious beliefs can provide support through the following

ways: enhancing acceptance, endurance and resilience.80

They generate peace, self confidence, purpose, forgiveness to

the individual’s own failures, self giving and positive self image.

On the other hand, they can bring guilt, doubts, anxiety and

depression through an enhanced self-criticism.81-82

Locus of control is an expression that arises from the social learning theory and tries to understand why people deal in

different ways even when facing the same problem. Why some

actively act and others stay in despondency. An internal locus of control is usually associated with well-being, and an external one with depression and anxiety. A religious belief can favor

an internal locus of control with impact on mental health.83-84

Many patients use religion to cope with medical and non-

medical problems. The study of religious coping, which can

be positive or negative, has emerged as a promising research

field. Positive religious coping has been associated with good

health outcomes, and negative religious coping with the

opposite. Religious patients tend to use more positive than

negative religious coping. Positive religious coping involves

behaviors such as: trying to find a lesson from God in the

stressing event, doing what one can do and leave the rest

i n G o d ’ s h a n d s , s e e k i n g s u p p o r t f r o m c l e r g y / c h u r c h

members, thinking about how one’s life is part of a larger

spiritual force, looking to religion for assistance to find a

new direction for living when the old one may no longer be

viable, and attempting to provide spiritual support and

comfort to others. Negative religious coping includes passive

waiting for God to control the situation, redefining the

stressor as a punishment from God or as an act of the devil

and, questioning God’s love.24,85-86

3. Religious practices

Public and private religious practices can help to maintain

mental health and prevent mental diseases. They help to cope

with anxiety, fears, frustration, anger, anomie, inferiority

feelings, despondency and isolation.87-88

T h e m o s t c o m m o n l y s t u d i e d r e l i g i o u s p r a c t i c e i s

meditation.89 It has been reported that it can produce changes

in personality, reduce tension and anxiety, diminish self-

blame, stabilize emotional ups and downs, and improve self-

knowledge. Improvement in panic attacks, generalized anxiety

disorder, depression, insomnia, drug use, stress, chronic pain

and other health problems have been reported. Follow-up

s t u d i e s h a v e d o c u m e n t e d t h e e f f e c t i v e n e s s o f t h e s e

technique.90-91 Other religious practices (such as personal

prayer, confession, forgiveness, exorcism, liturgy, blessings

and altered states of consciousness); may also be effective,

but more studies are necessary.

4. Spiritual direction

Described as a special relationship between two human

beings to help the development of the spiritual self. Its aims

are to develop a relationship with God, to find meaning in

life, and to promote personal growth.92 Several religious

and psychological techniques may be used, and great

similarities with psychotherapy can be found, as the same

themes are discussed.93

5. Idiom to express stress

In times of stress and social disorganization certain religious

rituals by means of techniques that elicit altered states of

consciousness, can produce catharsis, dissociative states and

a special milieu to express problems and suffering.94

6. Multifactorial explanation

Religion is a multidimensional phenomenon and no single

fact can explain its actions and consequences. The combination

Religiousness and mental health 248

Rev Bras Psiquiatr. 2006;28(3):242-50

of beliefs, behaviors and environment promoted by the religious

involvement probably act altogether to determine the religious

effects on health.78,95 However, empirical studies have had

limited success in accounting the psychosocial mechanisms

described above for the health-promoting effects of the religious

involvement. The explanation of the mechanisms by which

r e l i g i o n a f f e c t s h e a l t h h a s b e e n a n i n t e l l e c t u a l l y a n d

methodologically challenging enterprise.96

Clinical implications

The importance of the relationship between religion and

mental health is recognized in theory. Patients do have spiritual

needs that should be identified and addressed, but psychiatrists

and other mental health professionals do not feel comfortable

tackling these issues. Adequate training is necessary to integrate

spirituality into clinical practice. The professional should have

in-depth knowledge of the cultural and religion environment

where his/her work is being done.

In the presence of psychopathology, religion may be part of

it, contributing to the symptoms (obsessions or delusions for

example). Sometimes, religion may become rigid and inflexible,

and be associated with magical thinking and resistance. It

may be helpful to integrate the patient into society, or motivate

him/her to seek treatment (promoting guilt that motivates

treatment in a pedophilic for instance). It may hinder treatment

if it forbids psychotherapy or the use of medication. In Brazil,

where religious change is occurring rapidly, poverty and lack

of education might make people vulnerable to spiritual abuse.

Pruyser97 and Malony98 described the elements of a functional

theology, present in all religions, which may promote good

mental health. They are: awareness of God, acceptance of

the grace and love of God, repentance and social responsibility,

faith and trust, involvement in organized religion, fellowship,

ethic, and tolerance and openness to the experiences of others.

During assessment, the psychiatrist should be able to deter-

mine if religion in the life of his patient is important, has a

special meaning, is active or inactive, involves values in

accordance to his main tradition, is useful or harmful, and

promotes autonomy, personal growth, good self-image and

interpersonal relationships.88,99 Koenig’s100 recommendations

go beyond listening and respect, appropriate referral, and

support of spiritual needs. A brief spiritual history is necessary

to become familiar to the patients religious beliefs as they

relate to decisions about medical care, understanding the role

religion plays in coping with illness or causing stress, and

identifying spiritual needs that may require assistance.

Four basic areas should be remembered when taking a

spiritual history:100

1) Does the patient use religion or spirituality to help cope

with illness or is it a source of stress, and how?

2) Is the patient a member of a supportive spiritual

community?

3) Does the patient have any troubling spiritual question or

concerns?

4) Does the patient have any spiritual beliefs that might

influence medical care?

C o n c l u s i o n s

Ideas about the relationship between religiousness and

mental health have changed over the past few centuries. During

much of the 20th century, mental health professionals tended

to deny the religious aspects of human life and often considered

this dimension as either old-fashioned or pathological,

predicting that it would disappear as mankind matured and

developed. However, hundreds of epidemiological studies

performed during the last decades have shown a different

picture. Religiousness remains an important aspect of human

life and it usually has a positive association with good mental

health. Even though most studies have been conducted in the

United States in Christian populations, in the last few years

several of the main findings have been replicated in samples

from different countries and religions. Two lines of investigation

that need to be expanded are cross-cultural studies and

application of these findings to clinical practice in different

areas of the world.

Considering that religiousness is frequent and has associations

with mental health, it should be considered in research and

clinical practice. The clinician who truly wishes to consider the

bio-psycho-social aspects of a patient needs to assess, understand,

and respect his/her religious beliefs, like any other psychosocial

dimension. Increasing our knowledge of the religious aspect of

human beings will increase our capacity to honor our duty as

mental health providers and/or scientists in relieving suffering

and helping people to live more fulfilling lives.

A c k n o w l e d g m e n t s

We thank Ivonne Wallace for valuable help with the English editing of

the manuscript. Alexander Moreira-Almeida was supported by a grant

from the HOJE – Hospital João Evangelista.

R e f e r e n c e s

1. Leuba JH. The belief in God and immortality: a psychological, anthropological and statistical study. Boston: Sherman, Frenc & Co.; 1916.

2. Freud S. Future of an illusion. In: Strachey J, ed. and trans. Standard edition of the complete psychological works of Sigmund Freud. London: Hogarth Press; 1962.

3. In search of the piritual. Newsweek. 2005;146(9/10):46-65. 4. IBGE, Instituto Brasileiro de Geografia e Estatística. Censo

Demográfico; Brasil 2000. [citado 25 jul 2005]. Disponível em: http://www.ibge.gov.br.

5. Fortin AH 6th, Barnett KG. Medical school curricula in spirituality and medicine. JAMA. 2004;291(23):2883.

6. Webster’s Comprehensive Dictionary of the English Language, Encyclopedic Edition. London: Trident Press International; 1996.

7. Levin JS. How religion influences morbidity and health: reflections on natural history, salutogenesis and host resistance. Soc Sci Med. 1996;43(5):849-64.

8. Almeida AM, Lotufo Neto F. Metodologia para o estudo de estados alterados de consciência [Methodology for the study of altered states of consciousness]. Rev Psiquiatr Clin. 2003;30(1):21-8. [cited in 2005 Jul 25]. Available from: http://www.hcnet.usp.br/ipq/re- vista/vol30/n1/pdf/21.pdf.

9. Miller WR, Thoresen CE. Spirituality, religion, and health. An emerging research field. Am Psychol. 2003;58(1):24-35.

10. Levin J, Chatters LM, Taylor RJ. Religion, health and medicine in African Americans: implications for physicians. J Natl Med Assoc. 2005;97(2):237-49.

11. Batson CD, Ventis WL. The religious experience. New York: Oxford University Press; 1982.

12. Koenig HG, McCullough M, Larson DB. Handbook of religion and health: a century of research reviewed. New York: Oxford University Press; 2001.

13. Vandermeersch P. The victory of psychiatry over demonology: the origin of the nineteenth-centur y myth. Hist Psychiatr y. 1991;2(8):351-63.

14. Hayward R. Demonology, neurology, and medicine in Edwardian Britain. Bull Hist Med. 2004;78(1):37-58.

15. Kroll J. A reappraisal of psychiatry in the middle ages. Arch Gen Psychiatry. 1973;29(2):276-83.

Rev Bras Psiquiatr. 2006;28(3):242-50

249 Moreira-Almeida A et al.

16. Glick S. Debunking The Flat Earth Myth: Historians and scientists have exonerated the medieval church from teaching that the earth was flat. Science & Theology News [cited 2005 Jul 12]. Available from: http://www.stnews.org/Commentary-1068.htm.

17. Moreira-Almeida A, Almeida AAS, Lotufo Neto F. Spiritist views of men- tal disorders in Brazil. Transcult Psychiatry. 2005;42(4):570-95.

18. Moreira-Almeida A, Silva de Almeida AA, Neto FL. History of spiritist madness in Brazil. Hist Psychiatry. 2005;16(61 Pt1):5-25.

19. Jung CG. Modern man in search of soul. New York: Harcourt Brace Jovanovich; 1933.

20. Ellis A. Psychotherapy and atheistic values: a response to A. E. Bergin’s “Psychotherapy and religious values.” J Consult Clin Psychol. 1980;48(5):635-9.

21. Ellis A. Is religiosity pathological? Free Inq. 1988;18(2):27-32. 22. Lukoff D, Lu F, Turner R. Toward a more culturally sensitive DSM-IV:

psychoreligious and psychospiritual problems. J Nerv Ment Dis. 1992;180(11):673-82.

23. Koenig HG, Cohen HJ, Blazer DG, Pieper C, Meador KG, Shelp F, Goli V, Di asquale B. Religious coping and depression among elderly, hospitalized medically ill men. Am J Psychiatr y. 1992;149(12):1693-700.

24. Tepper L, Rogers SA, Coleman EM, Malony HN. The prevalence of religious coping among persons with persistent mental illness. Psychiatr Serv. 2001;52(5):660-5.

25. Nucci MG, Dalgalarrondo P. Ocular self-mutilation: report of six cases of enucleation. Rev Bras Psiquiatr. 2000;22(2):80-6.

26. Swanson A. Remembering a fellow ‘wild cowboy’: a conversation with Jeff Levin. Science & Theology News. March 1, 2003. [cited 2005 Jun 22] Available from: http://www.stnews.org/ News-1349.htm

27. Larson DB, Lu FG, Swyers JP. Model curriculum for psychiatric residency training programs: religion and spirituality in clinical practice, a course outline. Rockville, Maryland: National Institute for Healthcare Research; 1997.

28. Puchalski CM, Larson DB. Developing curricula in spirituality and medicine. Acad Med. 1998;73(9):970-4.

29. Flannelly KJ, Ellison CJ, Strock AL. Methodologic issues in research on religion and health. South Med J. 2004;97(12):1231-41.

30. Allport GW, Ross JM. Personal religious orientation and prejudice. J Pers Soc Psychol. 1967;5(4):432-43.

31. Donahue MJ. Intrinsic and Extrinsic Religiousness: review and meta- analysis. J Pers Soc Psychol. 1985;48(2):400-19.

32. Paloutzian RF, Ellison CW. Loneliness, Spiritual well-being and quality of life. In: Peplau LA, Perlman D, eds. Loniless: a sourcebook of current theory, research and therapy. New York: Wiley; 1982. p. 224-37.

33. Brady MJ, Peterman AH, Fitchett G, Mo M, Cella D. A case for including spirituality in quality of life measurement in oncology. Psychooncology. 1999;8(5):417-28.

34. Moreira-Almeida A, Koenig HG. Retaining the meaning of the words religiousness and spirituality. Soc Sci Med. In press 2006.

35. Maranell GM. Responses to Religion. Lawrence: University Press of Kansas; 1974.

36. Blazer DG, Palmore E. Religion and aging in a longitudinal panel. Gerontologist. 1976;16(1):82-5.

37. Farakhan A, Lubin B, O’Connor WA. Life satisfaction and depression among retired black persons. Psychol Rep. 1984;55(2):452-4.

38. Graney MJ. Happiness and social participation in aging. J Gerontol. 1975;30(6):701-6.

39. Kass JD, Friedman R, Leserman J, Zuttermeister PC, Benson H. Health outcomes and a new index of spiritual experience. J Sci Study Religion. 1991;30(2):203-11.

40. Levin JS, Markides KS, Ray LA. Religious attendance and psychological well being in Mexican Americans: a panel analysis of three-generations data. Gerontologist. 1996;36(4):454-63.

41. Maton KI. Patterns and psychological correlates of material support within a religious setting: the bidirectional support hypothesis. Am J Comm Psychol. 1987;15:185-208.

42. Musick MA. Religion and subjective health among black and white elders. J Health Soc Behav. 1996;37(3):221-37.

43. Ringdal GI, Gotestam KG, Kaasa S, Kvinnslaud S, Ringdal K. Prognostic factors and survival in a heterogeneous sample of cancer patients. Br J Cancer. 1995;73(12):1594-9.

44. Ringdal G. Religiosity, quality of life and survival in cancer patients. Soc Ind Res. 1996;38:193-211.

45. Tix AP, Frazier PA. The use of religious coping during stressful life events: main effects, moderation, and medication. J Consult Clin Psychol. 1997;66(22):411-22.

46. Willits FK, Crider DM. Religion and wellbeing: men and women in the middle years. Rev Relig Res. 1998;29:281-94.

47. Koenig HG, Kvale JN, Ferrel C. Religion and wellbeing in later life. Gerontologist. 1988;28(1):18-28.

48. Kirby SE, Coleman PG, Daley D. Spirituality and well-being in frail and nonfrail older adults. J Gerontol B Psychol Sci Soc Sci. 2004;59(3):P123-9.

49. Fry PS. The unique contribution of key existential factors to the prediction of psychological wellbeing of older adults following spousal loss. Gerontologist. 2001;41(1):69-81.

50. Salsman JM, Brown TL, Brechting EH, Carlson CR. The link between religion and spirituality and psychological adjustment: the mediating role of optimism and social support. Pers Soc Psychol Bull. 2005;31(4):522-35

51. Krause N. Church-based social support and health in old age: exploring variations by race. J Gerontol B Psychol Sci Soc Sci. 2002;57(6):S332-47.

52. Levin JS, Chatters LM. Religion, health, and psychological wellbeing in older adults: findings from three national surveys. J Aging Health. 1998;10(4):504-31.

53. Smith TB, McCullough ME, Poll J. Religiousness and depression: evidence for a main effect and the moderating influence of stressful life events. Psychol Bull. 2003;129(4):614-36.

54. Koenig HG, George LK, Peterson BL. Religiosity and remission of depression in medically ill older patients. Am J Psychiatry. 1998;155(4):536-42.

55. Lotufo Neto F. Psiquiatria e religião: a prevalência de transtornos mentais entre ministros religiosos [Psychiatry and religion: the prevalence of mental disorders among clergy]. [tese livre-docência]. São Paulo: Faculdade de Medicina, Universidade de São Paulo; 1997. [citado 23 jul 2005]. Disponível em: http:// www.hojenet.org/htm/profissional_arquivos.htm.

56. Almeida AM. Fenomenologia das experiências mediúnicas, perfil e psicopatologia de médiuns espíritas. [Phenomelogy of Mediumistic Experiences, Profile and Psychopathology of Spiritist Mediums]. [tese]. São Paulo: Faculdade de Medicina, Universidade de São Paulo; 2004. [citado 24 jul 2005]. Disponível em: http:// www.hojenet.org/htm/profissional_arquivos.htm.

57. Braam AW, Hein E, Deeg DJ, Twisk JW, Beekman AT, Van Tilburg W. Religious involvement and 6-year course of depressive symptoms in older Dutch citizens: results from the Longitudinal Aging Study Amsterdam. J Aging Health. 2004;16(4):467-89.

58. McCullough ME. Research on Religion-Accomodative Counseling: review and meta-analysis. J Counseling Psychol. 1999;46:92-8.

59. Azhar MZ, Varma SL. Religious psychotherapy in depressive patients. Psychother Psychosom. 1995;63(3-4):165-8.

60. Razali SM, Hasanah CI, Aminah K, Subramaniam M. Religious— sociocultural psychotherapy in patients with anxiety and depression. Aust N Z J Psychiatry. 1998;32(6):867-72.

61. Propst LR, Ostrom R, Watkins P, Dean T, Mashburn D. Comparative efficacy of religious and nonreligious cognitive-behavioral therapy for the treatment of clinical depression in religious individuals. J Consult Clin Psychol. 1992;60(1):94-103.

62. Kendler KS, Liu XQ, Gardner CO, McCullough ME, Larson D, Prescott CA. Dimensions of religiosity and their relationship to lifetime psychiatric and substance use disorders. Am J Psychiatry. 2003;160(3):496-503.

63. Dalgalarrondo P, Soldera MA, Correa Filho HR, Silva CA. Religion and drug use by adolescents. Rev Bras Psiquiatr. 2004;26(2):82-90.

64. Tavares BF, Beria JU, Lima MS. Factors associated with drug use among adolescent students in southern Brazil. Rev Saude Publica. 2004;38(6):787-96.

65. Sanchez ZV, Oliveira LG, Nappo SA. Fatores protetores de ado- lescentes contra o uso de drogas com ênfase na religiosidade [ P r o t e c t i v e f a c t o r s f r o m a d o l e s c e n t s a g a i n s t d r u g u s e emphasizing the role of religiosity]. Cienc Saude Coletiva. 2 0 0 4 ; 9 ( 1 ) : 4 3 - 5 5 .

Religiousness and mental health 250

Rev Bras Psiquiatr. 2006;28(3):242-50

66. Almeida AM, Lotufo Neto F. Religiao e comportamento suicida [Religion and suicide behavior]. In: Meleiro AM, Teng CT, Wang YP, eds. Suicídio: Estudos Fundamentais. São Paulo: Segmento Farma; 2004. p. 53-60.

67. Nisbet PA, Duberstein PR, Conwell Y, Seidlitz L. The effect of participation in religious activities on suicide versus natural death in adults 50 and older. J Nerv Ment Dis. 2000;188(8):543-6.

68. Hilton SC, Fellingham GW, Lyon JL. Suicide rates and religious commitment in young adult males in Utah. Am J Epidemiol. 2002;155(5):413-9.

69. Dervic K, Oquendo MA, Grunebaum MF, Ellis S, Burke AK, Mann JJ. Religious affiliation and suicide attempt. Am J Psychiatry. 2004;161(12):2303-8.

70. Nonnemaker JM, McNeely CA, Blum RW. Public and private domains of religiosity and adolescent health risk behaviors: Evidence from the National Longitudinal Study of Adolescent Health. Soc Sci Med. 2003;57(11):2049-54.

71. Eskin M. The effects of religious versus secular education on suici- de ideation and suicidal attitudes in adolescents in Turkey. Soc Psychiatry Psychiatr Epidemiol. 2004;39(7):536-42.

72. Cook JM, Pearson JL, Thompson R, Black BS, Rabins PV. Suicidality in older African Americans: findings from the EPOCH study. Am J Geriatr Psychiatry. 2002;10(4):437-46.

73. O’Neill C, Feenan D, Hughes C, McAlister DA. Physician and family assisted suicide: results from a study of public attitudes in Britain. Soc Sci Med. 2003;57(4):721-31.

74. Seidlitz L, Duberstein PR, Cox C, Conwell Y. Attitudes of older people toward suicide and assisted suicide: an analysis of Gallup Poll findings. J Am Geriatr Soc. 1995;43(9):993-8.

75. Douglas CD, Kerridge IH, Rainbird KJ, McPhee JR, Hancock L, Spigelman AD. The intention to hasten death: a survey of attitudes and practices of surgeons in Australia. Med J Aust. 2001;175(10):511-5

76. O’Mahony S, Goulet J, Kornblith A, Abbatiello G, Clarke B, Kless- Siegel S, Breitbart W, Payne R. Desire for hastened death, cancer pain and depression: report of a longitudinal observational study. J Pain Symptom Manage. 2005;29(5):446-57.

77. Bilsen J, Stichele RV, Mortier F, Bernheim J, Deliens L. The incidence and characteristics of end-of-life decisions by GPs in Belgium. Fam Pract. 2004;21(3):282-9.

78. Jarvis GK, Northcott HC. Religion and differences in morbidity and mortality. Soc Sci Med. 1987;25(7):813-24.

79. Thorensen CE, Friedman M, Powell LH, Gill JJ, Ulmer D. Altering the type A behavior pattern in post- infarction patients. J Cardiopulmonary Rehab. 1985;5:258-66.

80. Argyle M, Beit-Hallahmi. The social psychology of religion. London: Routledge & Kegan Paul; 1975.

81. Bowers MK. Psychotherapy of religious conflict. In: Pattison EM, ed. Clinical Psychiatry and Religion. Boston: Little Brown; 1969. p. 233-42.

82. Moberg DO. The development of social indicators of spiritual well- being for quality life research. In: Moberg DO, ed. Spiritual well- being: sociological perspectives. Washington DC: University Press of America; 1979. p. 1-14.

83. Levin JS, Schiller PL. Is there a religious factor in health? J Religion Health. 1987;26:9-35.

84. Pargament KI, Kennell J, Hathaway W, Grevengoed N, Newman J, Jones W. Religion and the problem-solving process: three styles of coping. J Sci Study Religion. 1988;27:90-104.

85. Pargament KI, Koenig HG, Tarakeshwar N, Hahn J. Religious struggle as a predictor of mortality among medically ill elderly patients: a 2- year longitudinal study. Arch Intern Med. 2001;161(15):1881-5.

86. Pargament KI, Koenig HG, Tarakeshwar N, Hahn J. Religious coping methods as predictors of psychological, physical and spiritual outcomes among medically ill elderly patients: a two-year longitu- dinal study. J Health Psychol. 2004;9(6):713-30.

87. Scheff TJ. Catharsis in healing ritual and drama. Berkeley, CA: University of California Press; 1979.

88. Schumaker JF, ed. Religion and Mental Health. New York: Oxford University Press; 1992.

89. Benson H. The relaxation response. New York: Morrow; 1975. 90. Shapiro DH. Examining the context and content of meditation: a

challenge for psychology in the areas of stress management, psychotherapy and religious values. J Human Psychol. 1994;34(4):101-35.

91. Alexander CN, Robinson P, Rainforth M. Treatment and preventing alcohol, nicotine, and drug abuse through transcendental meditation: a review and statistical meta-analysis. Alcohol Treat Quarterly. 1994;11:13-87.

92. Julian R. The practice of psychotherapy and spiritual direction. J Religion Health. 1992;31(4):309-15.

93. Ganje-Fling MA, Mccarthy PR. A comparative analysis of spiritual direction and psychotherapy. J Psychol Theology. 1991;19:103-17.

94. Mariz CL. Pentecostalismo e a luta contra a pobreza no Brasil. In: Futiérrez BF, Campos IS, eds. Na força do espírito - Os pentecostais na América Latina: Um desafio às igrejas históricas. São Paulo: Pendão Real; 1996.

95. Schiller PL, Levin JS. Is there a religious factor in health care utilization? A review. Soc Sci Med. 1988;27(12):1369-79.

96. George LK, Ellison CG, Larson DB. Exploring the relationships between religious involvement and health. Psychol Inquiry. 2002;13:190-200.

97. Pruyser PW. The minister as diagnostician. New York: Scribners; 1976. 98. Malony HN. The clinical assessment of optimal religious functioning.

Rev Religious Res. 1988;30:3-15. 99. Malony HN. The uses of religious assessment in counseling. In:

Brown LB, ed. Religion, Personality, and Mental Health. New York: Springer-Verlag; 1994.

100. Koenig HG. Espiritualidade no Cuidado com o Paciente. São Paulo: Editora FE; 2005.