Relationship of Religious Beliefs with Anxiety and Depression))
The contribution of spirituality and spiritual coping to anxiety and depression in women with a recent diagnosis of gynecological cancer N. BOSCAGLIA*, D.M. CLARKE*, T.W. JOBLINGy & M.A. QUINNz *Department of Psychological Medicine and General Practice, Monash University, Melbourne, Australia; yDepartment of Obstetrics and Gynaecology, Monash Medical Centre, Melbourne, Australia; and zDepartment of Obstetrics and Gynaecology, and Oncology Unit, Melbourne University, Royal Women’s Hospital, Melbourne, Australia
Abstract. Boscaglia N, Clarke DM, Jobling TW, Quinn MA. The con- tribution of spirituality and spiritual coping to anxiety and depression in women with a recent diagnosis of gynecological cancer. Int J Gynecol Cancer 2005;15:755–761.
The objective of this study was to determine whether, after accounting
for illness and demographic variables, spiritual involvement and beliefs
and positive and negative spiritual coping could account for any of the variation in anxiety and depression among women within 1 year’s diag-
nosis of gynecological cancer (GC). One hundred patients from out-
patient GC clinics at two Melbourne-based hospitals completed a brief structured interview and self-report measures of anxiety, depression,
spirituality, and spiritual coping. Using two sequential regression analy-
ses, we found that younger women with more advanced disease, who used more negative spiritual coping, had a greater tendency towards
depression and that the use of negative spiritual coping was associated
with greater anxiety scores. Although not statistically significant, pa- tients with lower levels of generalized spirituality also tended to be
more depressed. The site of disease and phase of treatment were not
predictive of either anxiety or depression. We conclude that spirituality and spiritual coping are important to women with GC and that health
professionals in the area should consider these issues.
KEYWORDS: anxiety, coping, depression, gynecological cancer, spirituality.
In a recent issue of this journal, Ramondetta and Sills(1) published a review of the literature concerning the role of spirituality in gynecological cancer (GC). The authors concluded that ‘‘concerns for the spiritual
health of patients may prove significant for both a patient’s comprehensive sense of well-being and for the relationship that is created between patients and physicians.’’ In this study, we examined empirically the relationship between spirituality and mood (ie, anxiety and depression).
A diagnosis of cancer is a significant life event that may have considerable psychological, physical, and financial sequelae. In particular, a diagnosis of GC
Address correspondence and reprint requests to: Nadia Boscaglia, Department of Psychological Medicine, Monash University, Monash Medical Centre, 246 Clayton Rd., Clayton, Victoria 3800, Australia. Email: nadia.boscaglia@med.monash.edu.au
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may elicit disturbances to body image; feelings of helplessness, dependency, shame, guilt, and vulnera- bility; a sense of loss of femininity and motherhood; and sexual difficulties(1,2). Not surprisingly, women with GC have a heightened frequency of depression, anxiety, and adjustment disorders(3).
Certain factors that increase the risk for mood distur- bance among women with GC include site of cancer (ovarian cancer worst)(4,5), treatment with triple-agent chemotherapy, younger age(6,7), and current treat- ment(6,8). In general, more advanced cancers are associ- ated with more frequent psychiatric complications(9).
Psychological health is important when faced with a diagnosis of cancer. Depressive symptoms in associa- tion with medical illness have been found to affect qual- ity of life and social functioning, exert a negative impact on treatment compliance(10), and lead to increased use of healthcare services(11). Similarly, anxiety can interfere with physical and psychosocial functioning; thus, for those who are physically compromised by illness, high levels of anxiety are of concern(12).
Recent research indicates that spirituality is one factor that may contribute to good mental health during the course of cancer. Spirituality is a set of beliefs and atti- tudes that give meaning and purpose to life through a sense of connectedness with the self, others, the natu- ral environment, a higher power, and/or other super- natural forces. These beliefs and attitudes empower and transcend the self and are embodied in feelings, thoughts, experiences, and behaviors(13–15). Spirituality is a broader concept than religion or religiosity, which refers to organized beliefs and practices such as those found in formal denominations or recognized systems of theological ideas; as such, religion can be viewed as a dimension of spirituality(14,16). Among those with life-threatening illnesses, spirituality has been found to be positively associated with psychosocial adjust- ment(17) and quality of life(18); and spiritual well-being was inversely associated with death distress(19) and anxiety(20).
Religion and spirituality may be incorporated as part of one’s coping(21,22), whereby coping is defined as the process by which individuals respond to stress- ful stimuli. Within the coping process, there are two subprocesses, appraisal and coping efforts (or meth- ods). Appraisal refers to the individual’s evaluation of the event(23); this evaluation influences one’s coping efforts. Coping efforts are the actions through which coping can resolve the stressful event and has effects on physical and emotional health(24). Research shows that an individual’s mood and quality of life after receiving a cancer diagnosis can be, in part, accounted for by his/her coping efforts(25–27).
People bring with them a general orienting system to the coping process. A spiritual orientation (eg, general beliefs, practices, aspirations, and relation- ships) is but one part of a larger orienting system(22). In the coping process, both the spiritual (general reli- gious and spiritual beliefs, involvement, and practi- ces) and nonspiritual elements of this orienting system are translated into specific methods of coping. It is these coping methods that have the most direct implications for health and well-being(14,28–30). In- deed, research indicates that specific spiritual coping efforts are better predictors of event outcomes (eg, mood, adjustment) than are measures of generalized spirituality(21,28,31). Put simply, spiritual coping is the use of religious/spiritual beliefs and practices to reduce the emotional distress caused by loss or change(32).
Researchers(30) have identified two patterns of spiri- tual coping* (broadly termed, positive and negative) that have important implications for health. Positive spiritual coping methods reflect an expression of ‘‘a sense of spirituality, a secure relationship with God, a belief that there is meaning to be found in life, and a sense of spiritual connectedness with others’’(30, p712). In contrast, the negative spiritual coping pattern is an expression of ‘‘a less secure relationship with God, a tenuous and ominous view of the world, and a reli- gious struggle in the search for significance’’(30, p712). Each of the two patterns is made up of specific types of spiritual coping methods (Table 1). Research dem- onstrates that among various samples, the positive spiritual coping pattern was associated with fewer symptoms of psychological distress(30,33) and higher levels of stress-related growth(30); and the negative spiritual coping pattern was associated with more depression(30,33) and poor quality of life(30).
There are few studies that have examined the impact of spirituality on psychological state in women with GC(1). This is surprising, given that there are sev- eral factors that make salient the study of spirituality in this particular group. Life-threatening events such as cancer, particularly those that pose threats to self- image or important areas of personal functioning, often lead to people relying on their spiritual re- sources(14,18). Further, religious and spiritual coping appears to be used more often by women than men(17). In this study, our aim was to determine
*While Pargament et al.(28–30) use the term ‘‘religious coping,’’ we prefer the term ‘‘spiritual coping.’’ This difference in terminology is reflective of each author’s definition of the terms religion and spir- ituality, that is, Pargament et al. view religion in much the same was as we view spirituality.
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whether spiritual involvement and beliefs and posi- tive and negative spiritual coping accounted for any of the variance in psychological distress (anxiety and depression) among women with GC, over and above that accounted for by illness and demographic variables.
Materials and methods
One hundred and twenty-three patients were re- cruited from outpatient GC clinics at the Royal Wom- en’s Hospital and the Monash Medical Centre, Melbourne. Exclusion criteria included age less than 18 or more than 70 years, inability to speak/read English, diagnosis .12 months before, and the pres- ence of known intracranial disease or cognitive impairment. After obtaining written consent, patients engaged in a 15-min interview about demographic and illness information. At the end of the interview, patients were given a questionnaire pack, which they completed at home and returned by mail. After excluding those women who did not complete all ele- ments of the study, the sample was reduced to 100 women.
Patients (N ¼ 100) were aged between 20 and 70 years (mean ¼ 52.52, SD ¼ 12.17), and were within a year ’s diagnosis of GC at interview (mean weeks since diagnosis ¼ 22.21, SD ¼ 14.58). The women were predominantly Australian born (71%), and the major- ity of patients (70%) were married, with 80% having had children. In terms of religion, 42% of the sample
was Christian, 33% Roman Catholic, 19% reported having ‘‘no religion,’’ and 6% ‘‘other.’’ Disease charac- teristics are presented in Table 2.
Measures
Depression was measured using the Beck Depression Inventory for Primary Care(34), anxiety was assessed using the State Anxiety Scale from the Spielberger State Trait Anxiety Inventory(35), and spirituality was assessed using the Spiritual Involvement and Beliefs Scale-Revised(36). The Spiritual Involvement and Be- liefs Scale-Revised comprises 22 items that examine
Table 1. Positive and negative spiritual coping methods
Positive spiritual coping methods Explanation
Negative spiritual coping methods Explanation
Benevolent religious reappraisal
Redefining the stressor through religion as benevolent and potentially beneficial
Spiritual discontent Expressions of confusion and dissatisfaction with God
Collaborative religious coping
Seeking control through a partnership with God in problem solving
Interpersonal spiritual discontent
Expressions of confusion and dissatisfaction with clergy or members
Seeking spiritual support
Searching for comfort and reassurance through God’s love and care
Punishing God reappraisal
Redefining the stressor as a punishment from God for the individual’s sins
Religious forgiveness Looking to religion for help in letting go of anger, hurt, and fear associated with an offense
Demonic reappraisal Redefining the stressor as the act of the Devil
Spiritual purification Searching for spiritual cleansing through religious actions
Reappraisal of God’s powers
Redefining God’s powers to influence the stressful situation
Spiritual focus Seeking relief from the stressor through a focus on one’s religion or spirituality
Spiritual connection Seeking a sense of connectedness with transcendent forces
Adapted from Pargament et al.(30, p711).
Table 2. Disease characteristics (N ¼ 100)
Characteristic Options for response N
Cancer site Endometrium 38 Ovary 32 Cervix 23 Vulva 5 Vagina 1 Fallopian tube 1
FIGO staging I 60 II 11 III 28 IV 1
Treatment type Surgery 87 Chemotherapy 41 Radiotherapy/brachytherapy 25 None 1
Currently in active treatment Yes 20 No 80
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rituals and belief in a higher power, internalized beliefs and spiritual growth, meditation and existential beliefs, and humility and daily application of spiritual princi- ples(36). The Brief RCOPE of Pargament et al.(30) was used to assess positive and negative spiritual coping. The Brief RCOPE comprises 14 items that divide into two subscales, positive and negative religious coping. The creators of the scale advise that the Brief RCOPE is applicable to ‘‘a wide range of Judeo-Christian groups . [and] may be applicable to members of other ethnocentric religions as well, such as Islam’’(30, p722). To make the scale more acceptable to nonbelievers of the main monotheistic religions, certain aspects of the scale were altered; in particular, in addition to the word God, the phrase, a power greater than myself was added.
Statistical analyses
Data were analyzed using SPSS 10.0.7. Two sequential regression analyses were employed to determine whether spirituality (step 2) and then positive and negative spiritual coping (step 3) accounted for any of the variance in anxiety and depression, over and above the variance accounted for by illness and demo- graphic variables (step 1). The illness and demo- graphic variables (ie, age, presence of ovarian cancer relative to other forms of GC, active treatment vs no active treatment, stage of disease—I or II vs III or IV, and having had chemotherapy) were selected a priori, according to the findings of past research. After data screening, one multivariate outlier was removed (reducing the data set to N ¼ 99), and skewed varia- bles were transformed to meet assumptions.
Results
Use of the published cutoff scores of the Beck Depres- sion Inventory for Primary Care(34) revealed that 24%
of the sample exhibited at least mild symptoms of depression (13% of the sample had mild symptoms, 6% moderate symptoms, and 5% severe symptoms). The mean anxiety score was 38.56 (where a higher score indicates a greater level of anxiety), compared with a mean anxiety score for women in the general population (aged between 40 and 69) of 34.35(35). The correlation coefficients among illness variables were in the expected direction (eg, presence of ovarian cancer correlated with having had chemotherapy) and ranged from .50 to .70.
In the first regression (Table 3), depression scores served as the criterion variable. R was not significantly different from zero at the end of steps 1 or 2 but was significantly different from zero after step 3. Step 1: R ¼ .31, F(5,93) ¼ 1.92, P ¼ .098; step 2: R ¼ .31, F(6,92) ¼ 1.61, P ¼ .153; and step 3: R ¼ .53, F(8,98) ¼ 4.37, P , .01. In the final model, the predictors ac- counted for 28% of the variance in depression scores, change statistics: R2 ¼ .28, F(2,90) ¼ 11.54, P , .01. Specifically, younger age, later stage of disease, and greater use of negative religious coping predicted significantly a higher level of depression. Although not statistically significant, spirituality made a strong contribution to the variance in depression scores (b ¼ 2.378, P ¼ .053), whereby a lower level of spiritu- ality was associated with a higher level of depression.
In the second regression (Table 4), anxiety served as the dependent variable. Predictors were entered as for the first regression. After each of the three steps, R was not significantly different from zero (P . .10). Nonetheless, we examined the change statistics and unique contributions from each of the predictors. We found that the addition of positive and negative spiri- tual coping to the equation resulted in a significant improvement in the model, change statistics: R2 ¼ .12, F(2,90) ¼ 4.33, P , .05. Negative spiritual coping was the only significant predictor of anxiety scores
Table 3. Summary of final model from the sequential regression analysis for variables predicting transformed depression scoresa
Variable B Standard error of B b t P
Age 2.017 .008 2.185 22.015 .047* Ovarian cancer .201 .294 .086 0.684 .496 Phase of treatment .086 .337 .032 0.255 .800 Chemotherapy .188 .291 .084 0.644 .521 Stage of disease .632 .276 .264 2.293 .024* Spirituality 2.015 .008 2.378 21.959 .053 Positive spiritual copingb 29.020 4.891 2.365 21.844 .068 Negative spiritual copingb 214.766 4.128 2.352 23.577 .001**
aSquare root transformation applied. bInverse transformation applied. *P , .05. **P , .01.
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(b ¼ 2.25, P , .05), whereby more negative spiritual coping was associated with higher levels of anxiety.
Discussion
This study was conducted to examine the contribution of spirituality and positive and negative spiritual cop- ing to mood in women within a year ’s diagnosis of GC. Our results indicate that almost one quarter of the sample experienced at least mild depressive symp- toms and that levels of anxiety were higher than that of women in the general population. Our findings also show that among women diagnosed with GC within the past year, those who were younger, had more advanced disease, and who used more negative spiri- tual coping had a greater tendency towards depressed mood, and, although not statistically significant, patients with lower levels of spirituality also tended to be more depressed. The use of negative spiritual cop- ing was associated with greater anxiety scores.
Turning first to the predictive role of age in mood outcomes in GC, our results are not surprising. Youn- ger women treated for GC may face the added stress of potential infertility or be concerned about the future of their families/children, thus, placing younger women at increased risk for psychological distress(7). Indeed, research has demonstrated that among women with ovarian cancer, younger patients (,50 years) were more likely to be depressed than older patients(6).
Later stage of disease was another significant pre- dictor of depression in our sample; this is in agreement with research findings that indicate that among women with GC (and cancer patients in general) more advanced disease is associated with higher levels of depression(4,9). On the other hand, we found that phase of treatment (active treatment vs no current treatment) and site of GC (ovarian vs nonovarian GC) were not predictive of depression or anxiety.
These findings contrast with the findings of other studies(4–6,8) and may be reflective of the high degree of support provided to women in the active phase of treatment. Indeed, many studies have found that social support is protective against mood disturbance(37).
In this study, the use of negative spiritual coping significantly predicted depression and anxiety, and there was a near significant (P ¼ .053) trend for lower levels of spirituality to be predictive of higher levels of depression. This is consistent with extant research in which an association between higher levels of spirituality and good psychological adjustment to cancer(17–20) has been demonstrated. Findings such as these are typically explained by the hypothesized ‘‘stress buffering’’ and ‘‘meaning-making’’ role of spiri- tuality. Kim and Seidlitz(38) suggest that spirituality can buffer the effects of stress through its influence on thinking, emotions, and behavior. They argue that spiritual beliefs may help a person to find meaning in life, thus limiting the mental health consequences of adverse experiences. God and related religious and philosophical systems may offer a type of schemata for explaining and predicting the vacillating course of cancer(39), thus helping to give the illness meaning and perspective and to provide answers to existential questions that arise(40). Spiritual practices can also fos- ter the development of supportive social networks and thus promote health behaviors and reduce nega- tive emotions(38). In addition, spiritual beliefs, in the sense of beliefs related to a connection to something bigger than the self, can help cancer patients tolerate the difficulties of their illness(41). It appears then that for women who are spiritually inclined, spirituality may function as an important resource during the course of GC.
What, then, of the finding that negative spiritual coping significantly predicted both depression and anxiety in our sample? As stated, the use of negative spiritual coping expresses a less secure relationship
Table 4. Summary of final model from the sequential regression analysis for variables predicting transformed anxiety scoresa
Variable B SE B b t P
Age 2.009 .009 2.094 20.930 .355 Ovarian cancer .061 .332 .025 0.183 .855 Phase of treatment .074 .381 .027 0.194 .847 Chemotherapy .287 .329 .127 0.873 .385 Stage of disease .192 .312 .078 0.616 .540 Spirituality 2.011 .009 2.264 21.234 .221 Positive spiritual copingb 25.776 5.529 2.229 21.045 .299 Negative spiritual copingb 210.505 4.667 2.245 22.251 .027*
aSquare root transformation applied. bInverse transformation applied. *P , .05.
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with a higher power and a tenuous and ominous view of the world. Perhaps then, those who use negative spiritual coping methods are mobilizing their spiritual resources ineffectively, translating their spiritual be- liefs into unhelpful strategies that promote (rather than protect from) depression and anxiety. However, given that the study was cross-sectional, the possibil- ity that the participants’ psychological distress pre- ceded the use of negative religious coping methods cannot be excluded.
In addition to its cross-sectional design, another lim- itation to the present study is the lack of consideration of other variables that may predict mood. In particu- lar, we have not examined the role of non-spiritual coping methods, disposition, or social support in mood outcomes. A larger study that examines the con- tribution of such variables to emotional outcomes and well-being in women with GC is required. Alternately, a qualitative approach, in which women are asked to elaborate on their own methods of spiritual coping, may help elucidate the most important aspects of spir- ituality (if any) for women with GC.
This study adds empirical evidence to the sugges- tion of Ramondetta and Sills(1) that spirituality is an important consideration in the care of women with GC, and also, raises questions for those working with GC patients: What do I do if my patient is depressed or spiritually distressed? To whom do I refer such a patient? Considering the implications of depression and anxiety, and the contribution of spirituality and spiritual coping to mood outcomes, healthcare pro- viders may need to consider such questions.
Acknowledgments
We are indebted to Ms Helen Sells for her help with recruitment of participants.
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Accepted for publication October 14, 2004
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