Proposal research about "the protective effects of religiosity on depression and anxiety"

In Review

Research on Religion, Spirituality, and Mental Health: A Review

Harold G Koenig, MD 1

Key Words: religion, spirituality, depression, anxiety, psychosis, substance abuse

Despite spectacular advances in technology and science,90% of the world’s population is involved today in some form of religious or spiritual practice.1 Nonreligious people make up less than 0.1% of the populations in many Middle- Eastern and African countries. Only 8 of 238 countries have populations where more than 25% say they are not religious, and those are countries where the state has placed limitations on religious freedom. Atheism is actually rare around the world. More than 30 countries report no atheists (0%) and in only 12 of 238 countries do atheists make up 5% or more of the population. In Canada, 12.5% of the population are non- religious and 1.9% atheist.

Evidence for religion playing a role in human life dates back 500 000 years ago when ritual treatment of skulls took place during China’s paleolithic period.2 Why has religion endured over this vast span of human history? What purpose has it served and does it continue to serve? I will argue that religion is a powerful coping behaviour that enables people to make sense of suffering, provides control over the overwhelming forces of nature (both internal and external), and promotes social rules that facilitate communal living, cooperation, and mutual support.

Until recent times, religion and mental health care were closely aligned.3 Many of the first mental hospitals were

The Canadian Journal of Psychiatry, Vol 54, No 5, May 2009 � 283

Religious and spiritual factors are increasingly being examined in psychiatric research. Religious beliefs and practices have long been linked to hysteria, neurosis, and psychotic delusions. However, recent studies have identified another side of religion that may serve as a psychological and social resource for coping with stress. After defining the terms religion and spirituality, this paper reviews research on the relation between religion and (or) spirituality, and mental health, focusing on depression, suicide, anxiety, psychosis, and substance abuse. The results of an earlier systematic review are discussed, and more recent studies in the United States, Canada, Europe, and other countries are described. While religious beliefs and practices can represent powerful sources of comfort, hope, and meaning, they are often intricately entangled with neurotic and psychotic disorders, sometimes making it difficult to determine whether they are a resource or a liability.

Can J Psychiatry. 2009;54(5):283–291.

Clinical Implications

� Religious beliefs and practices may be important resources for coping with illness.

� Religious beliefs may contribute to mental pathology in some cases.

� Psychiatrists should be aware of patients’ religious and spiritual beliefs and seek to understand what function they serve.

Limitations

� My review of recent studies is selective, not systematic.

� Studies without statistically significant findings are not discussed.

� Clinical applications are not addressed.

located in monasteries and run by priests. With some excep- tions, these religious institutions often treated patients with far more compassion than state-run facilities prior to 19th- century mental health reforms (reforms often led by religious people such as Dorothea Dix and William Tuke). In fact, the first form of psychiatric care in the United States was moral treatment, which involved the compassionate and humane treatment of people with mental illness—a revolutionary notion at a time when patients were often put on display and (or) housed in despicable conditions in the back wards of hos- pitals or prisons.4 Religion was believed to have a positive, civilizing influence on these patients, who might be rewarded for good conduct by allowing them to attend chapel services.

However, in the late 19th century, the famous neurologist Jean Charcot and his star pupil, Sigmund Freud, began to associate religion with hysteria and neurosis. This created a deep divide that would separate religion from mental health care for the next century, as demonstrated by the writings of 3 generations of mental health professionals from Europe, the United States, and Canada.5–8

Today, attitudes toward religion in psychiatry have begun to change. The American College of Graduate Medical Educa- tion now states in its Special Requirements for Residency Training for Psychiatry9 that all programs must provide train- ing on religious or spiritual factors that influence psychologi- cal development. Part of this change has been driven by scientific research during the past 2 decades that suggests reli- gious influences need not always be pathological, but can actually represent resources for health and well-being.

Definitions Before reviewing the research, religion and spirituality must be defined, because these terms have ambiguous meanings that may affect the interpretation of research findings. The definition of religion is generally agreed on and involves beliefs, practices, and rituals related to the sacred. I define the sacred as that which relates to the numinous (mystical, super- natural) or God, and in Eastern religious traditions, to Ulti- mate Truth or Reality. Religion may also involve beliefs about spirits, angels, or demons. Religions usually have specific

beliefs about life after death and rules about conduct that guide life within a social group. Religion is often organized and practiced within a community, but it can also be practiced alone and in private. However, central to its definition is that religion is rooted in an established tradition that arises out of a group of people with common beliefs and practices concern- ing the sacred.

In contrast with religion, spirituality is more difficult to define. It is a more popular expression today than religion, as many view the latter as divisive and associated with war, con- flict, and fanaticism. Spirituality is considered more per- sonal, something people define for themselves that is largely free of the rules, regulations, and responsibilities associated with religion. In fact, there is a growing group of people cate- gorized as spiritual-but-not-religious, who deny any connec- tion at all with religion and understand spirituality entirely in individualistic, secular terms. However, this contemporary use of spirituality is different from its original meaning.

According to Philip Sheldrake,10 professor of applied theol- ogy at the University of Durham, England, the origin of the word spiritual lies in the Latin term spiritualis, which is derived from the Greek word pneumatikos, as it appears in Paul’s letters to the Romans and Corinthians. A spiritual per- son was considered someone with whom the Spirit of God dwelt, often referring to the clergy.10, p 3 In the Second Vatican Council, spirituality replaced terms such as ascetical theology and mystical theology. Although the Greeks used the word spiritual to distinguish humanity from nonrational creation, spiritual and (or) spirituality has been distinctly reli- gious throughout most of Western history. It was not until much later that Eastern religions adopted the term. Then, spiritual people were a subset of religious people whose lives and lifestyles reflected the teachings of their faith tradition. Spiritual people were those such as Teresa of Ávila, John of the Cross, Siddhartha Gautama, Mother Teresa, or Mahatma Gandhi.

The term spirituality in health care has now expanded far beyond its original meaning. This expansion has resulted from attempts to be more inclusive in pluralistic health care settings, to address the needs both of religious and of non- religious people. This degree of inclusiveness, while admira- ble in the clinic, makes it impossible to conduct research on spirituality and relate it to mental health, as there is no unique, distinct, agreed-on definition. Thus researchers have strug- gled to come up with measures to assess spirituality.

When measured in research, spirituality is often assessed either in terms of religion or by positive psychological, social, or character states. For example, standard measures of spirituality today contain questions asking about meaning and purpose in life, connections with others, peacefulness,

� La Revue canadienne de psychiatrie, vol 54, no 5, mai 2009284

In Review

Abbreviations used in this article

5-HT 5-hydroxytryptamine (serotonin)

5-HT1A 5-beta hydroxytryptamine receptor 1

CASA National Center on Addiction and Substance Abuse

MADRS Montgomery-Asberg Depression Rating Scale

MDD major depressive disorder

RCT randomized controlled trial

RS religion and (or) spirituality

existential well-being, and comfort and joy. This is problematic, as it assures that spirituality in such studies will be correlated with good mental health. In other words, spirituality—defined as good mental health and positive psychological or social traits—is found to correlate with good mental health. Such research is meaningless and tautological. To avoid this methodological problem and to maintain the purity and distinctiveness of the construct, I have proposed that spirituality be defined in terms of religion,11 where reli- gion is a multidimensional construct not limited to institu- tional forms of religion. Thus I will either refer to religion or use the terms religion and spirituality synonymously (for example, as RS).

Religion as a Coping Behaviour

Systematic research in many countries around the world finds that religious coping is widespread. For the general popula- tion, research published in The New England Journal of Medi- cine found that 90% of Americans coped with the stress of September 11th (2001) by “turning to religion.”12, p 1507 During the week following the attacks, 60% of Americans attended a religious or memorial service and Bible sales rose 27%.13

Even prior to the year 2000, more than 60 studies had docu- mented high rates of religious coping in patients with an assortment of medical disorders ranging from arthritis to dia- betes to cancer.14 One systematic survey of hospitalized medi- cal patients (n = 330) found that 90% reported they used religion to cope, at least to a moderate extent, and more than 40% indicated that religion was the most important factor that kept them going.15

Psychiatric patients also frequently use religion to cope. A survey of patients (n = 406) with persistent mental illness at a Los Angeles County mental health facility found that more than 80% used religion to cope.16 In fact, most patients spent as much as one-half of their total coping time in religious prac- tices such as prayer. Researchers concluded that religion serves as a “pervasive and potentially effective method of coping for persons with mental illness, thus warranting its integration into psychiatric and psychological practice.”16, p 660

In another study, conducted by the Center for Psychiatric Rehabilitation at Boston University, adults with severe mental illness were asked about the types of alternative health care practices they used.17 A total of 157 people with schizophre- nia, bipolar disorder, or MDD responded to the survey. People with schizophrenia and MDD reported that the most common beneficial alternative health practice was an RS activity (more than one-half reported this); for those with bipolar disorder, only meditation surpassed RS activity (54%, compared with 41%).

Religious coping is likewise prevalent outside the United States. A study of psychiatric patients (n = 79) at Broken Hill

Base Hospital in New South Wales found that 79% rated spir- ituality as very important, 82% thought their therapist should be aware of their spiritual beliefs and needs, and 67% indi- cated that spirituality helped them to cope with psychological pain.18 A survey of patients (n = 52) with lung cancer in Ontario asked about sources of emotional support. The most commonly reported support systems were family (79%) and religion (44%).19 Finally, a study of outpatients (n = 292) with cancer seen at the Northwestern Ontario Regional Can- cer Centre, Thunder Bay, found that, among all coping strate- gies inquired about, prayer was used by the highest number (64%).20

Why is religious coping so common among patients with medical and psychiatric illness? Religious beliefs provide a sense of meaning and purpose during difficult life circum- stances that assist with psychological integration; they usu- ally promote a positive world view that is optimistic and hopeful; they provide role models in sacred writings that facilitate acceptance of suffering; they give people a sense of indirect control over circumstances, reducing the need for personal control; and they offer a community of support, both human and divine, to help reduce isolation and loneliness. Unlike many other coping resources, religion is available to anyone at any time, regardless of financial, social, physical, or mental circumstances.

I will review studies examining the relation between religion and mental health in 5 areas: depression, suicide, anxiety, psychotic disorders, and substance abuse. While some stud- ies report no association between religious involvement and mental health, and a handful of studies have reported nega- tives associations, the majority (476 of 724 quantitative stud- ies prior to the year 2000, based on a systematic review) reported statistically significant positive associations.21

Because space is limited, I will briefly mention the results of that systematic review and then examine, in more detail, stud- ies that exemplify research published more recently.

Depression

Prior to 2000, more than 100 quantitative studies had exam- ined the relation between religion and depression.22 Among 93 observational studies, two-thirds found significantly lower rates of depressive disorder or fewer depressive symp- toms among the more religious. Among 34 studies that did not, only 4 found being religious was associated with signifi- cantly more depression. Among 22 longitudinal studies, 15 found that greater religiousness at baseline predicted fewer depression symptoms or faster remission of symptoms at follow-up. Among 8 RCTs, 5 found that religious-based psy- chological interventions resulted in faster symptom improve- ment, compared with secular-based therapy or with control subjects. Supporting these findings was a more recent

Research on Religion, Spirituality, and Mental Health: A Review

The Canadian Journal of Psychiatry, Vol 54, No 5, May 2009 � 285

independently published meta-analysis of 147 studies that involved nearly 100 000 subjects.23 The average inverse cor- relation between religious involvement and depression was –0.10, which increased to –0.15 for studies in stressed popula- tions. While this correlation appears small and weak, it is of the same magnitude as seen for sex (a widely recognized fac- tor influencing the prevalence of depression).

Moreover, individual studies in stressed populations, particu- larly people with serious medical illness, find a more substan- tial impact for religion on the prevalence and course of depression. For example, depressed medical inpatients (n = 1000) aged 50 years or older with either congestive heart fail- ure or chronic pulmonary disease were identified with depres- sive disorder using the Structured Clinical Interview for Depression.24 The religious characteristics of these patients were compared with those of nondepressed patients (n = 428). Depressed patients were significantly more likely to indicate no religious affiliation, more likely to indicate spiritual but not religious, less likely to pray or read scripture, and scored lower on intrinsic religiosity. These relations remained robust after controlling for demographic, social, and physical health factors. Among the depressed patients, severity of depressive symptoms was also inversely related to religious indicators.

Among these 1000 depressed patients, investigators followed 865 for 12 to 24 weeks, examining factors influencing speed of remission from depression.25 The most religious patients (those who attended religious services at least weekly, prayed at least daily, read the Bible or other religious scriptures at least 3 times weekly, and scored high on intrinsic religiosity) remitted from depression more than 50% faster than other patients (hazard ratio = 1.53, 95% CI 1.20 to 1.94), controlling for multiple demographic, psychosocial, psychiatric, and physical health predictors of remission. Several other studies have similarly shown a positive impact for religion on course of depression.26–28

However, for psychiatric patients there have been few studies on the course of depression. Bosworth et al29 interviewed elderly psychiatric inpatients (n = 104), assessing public and private religious practices and religious coping. Depressive symptoms were assessed at baseline and 6 months later by a psychiatrist using the MADRS. Baseline positive religious coping predicted significantly less depression on the MADRS at the 6-month evaluation, an effect independent of social sup- port measures, demographics, use of electroconvulsive ther- apy, and number of depressive episodes.

At least 2 studies (both cross-sectional) have examined rela- tions between religious involvement and depression in Canada, one reporting an inverse relation and the other find- ing a positive relation. O’Connor and Vallerand30 examined associations between religious motivation and personal

adjustment in a sample of elderly French-Canadians (n = 176) drawn from nursing homes in the greater Montreal area. Intrinsic religiosity was inversely related to depression and positively related to life satisfaction, self-esteem, and mean- ing in life. In the second study, Sorenson et al31 followed teenaged mothers (n = 261) (87% unmarried) before delivery and 4 weeks after delivery in southwestern Ontario. They examined the relation between religion and depressive symp- toms during the first few weeks after babies were born. Cath- olics and teenagers affiliated with more conservative religious groups scored significantly higher on depression, and those who attended religious services more frequently also had higher depression scores. However, the highest depression scores were among girls who cohabitated with someone while continuing to attend religious services.

Baetz and colleagues32,33 have shown in large cross-sectional community surveys of the Canadian population that religious attendance is associated with less depression and fewer psy- chiatric disorders. However, participants indicating that spir- itual values were important or perceived themselves as spiritual or religious had higher levels of psychiatric symp- toms. The researchers speculated that these people could have turned to RS to reframe difficult life circumstances associated with psychiatric illness. Bear in mind that the stud- ies were conducted in largely healthy community-dwelling adults with relatively low stress levels.

Two additional unpublished dissertations34,35 report studies of RS and depression in Canadian men with prostate cancer and in bereaved caregivers of Canadians dying from AIDS. Both demonstrated positive effects for RS involvement on posttraumatic growth and coping with illness. Supporting the findings of the Canadian caregiver study, Fenix et al36 at Yale University recently followed caregivers (n = 175) of recently deceased cancer patients for 13 months, examining associa- tions between religiousness and the development of MDD.36

Religious caregivers were significantly less likely to have developed MDD by the 13-month follow-up, a finding that persisted after adjusting for other risk factors. The same results have been reported for caregivers of patients with Alzheimer disease.37,38

Thus studies in medical patients, older adults with serious and disabling medical conditions, and their caregivers sug- gest that religious involvement is an important factor that enables such people to cope with stressful health problems and life circumstances. However, this may not be true in all populations, as studies of pregnant unmarried teenagers and nonstressed community populations above suggest.

Critics say that most studies reporting positive results are observational and that some unmeasured characteristic may be related both to religion and to depression, confounding the

� La Revue canadienne de psychiatrie, vol 54, no 5, mai 2009286

In Review

relation. In particular, genetic factors have been implicated. In a fascinating study that examined the relation of spirituality to brain 5-HT1A binding using positive emission tomography, investigators found that 5-HT1A binding was lower in people who were more spiritually accepting. Note that lower 5-HT1A binding—the same pattern seen with spirituality—has been found in patients with anxiety and depressive disorders.39–41

Thus, rather than being genetically less prone to depression, RS-oriented people may be at increased risk for mood disorders based on their 5-HT receptor binding profile.

Suicide

In Koenig et al’s42 systematic review of research conducted before 2000, 68 studies were identified that examined the religion–suicide relation. Among those studies, 57 found fewer suicides or more negative attitudes toward suicide among the more religious, 9 showed no relation, and 2 reported mixed results. Seven of the studies were conducted in Canada, and of those, 5 found fewer suicides or more negative attitudes toward suicide among the more religious, 1 found no association, and 1 reported mixed results.

While recent research suggests that religion prevents suicide primarily through religious doctrines that prohibit suicide,43

there is also evidence that the comfort and meaning derived from religious beliefs may be relevant44 and may be especially important in people with advanced medical illness.45 Reli- gious involvement may also help to prevent suicide by sur- rounding the person at risk with a caring, supportive community.46

Anxiety

While religious teachings have the potential to exacerbate guilt and fear that reduce quality of life or otherwise interfere with functioning, the anxiety aroused by religious beliefs can prevent behaviours harmful to others and motivate pro-social behaviours. Religious beliefs and practices can also comfort people who are fearful or anxious, increase sense of control, enhance feelings of security, and boost self-confidence (or confidence in Divine beings).

Prior to 2000, at least 76 studies had examined the relation between religious involvement and anxiety.47 Sixty-nine studies were observational and 7 were RCTs. Among the observational studies, 35 found significantly less anxiety or fear among the more religious, 24 found no association, and 10 reported greater anxiety. However, all 10 of the latter stud- ies were cross-sectional, and anxiety and (or) fear is a strong motivator of religious activity. People pray more when they are scared or nervous and feel out of control (“There are no atheists in foxholes”). Then, cross-sectional studies are less useful than longitudinal studies or RCTs. Among the 7 RCTs examining the effects of a religious intervention on subjects

with anxiety (usually generalized anxiety disorder), 6 found that religious interventions in religious patients reduced anx- iety levels more quickly than secular interventions or control subjects. Studies of Eastern spiritual techniques, such as mindfulness meditation (from the Buddhist tradition), report similar effects,48,49 although their efficacy in anxiety disor- ders has recently been questioned.50

More recent longitudinal studies add to this literature, and provide information on mechanisms. Wink and Scott51 fol- lowed subjects (n = 155) for nearly 30 years, from middle age into later life, studying the impact of religious beliefs and involvement on death anxiety. Analyses revealed no linear relations between religiousness, fear of death, and fear of dying. Subjects with the lowest anxiety levels were those who were either high or low on religiousness. Anxiety was highest among subjects who were only moderately religious, and in particular, those who affirmed belief in an afterlife but were not involved in any religious practices. Researchers concluded that it was the degree of religious involvement that was important in lessening death anxiety not simply belief in an afterlife.

Religious involvement may also interact with certain forms of psychotherapy to enhance response to therapy. Investiga- tors at the University of Saskatchewan explored coping and motivation factors related to treatment response in patients (n = 56) with panic disorder participating in a clinical trial.52

Subjects were treated with group cognitive-behavioural ther- apy, and then were followed up at 6 and 12 months after base- line evaluation. Self-rated importance of religion was a significant predictor of panic symptom improvement and lower perceived stress at the 12-month follow-up.

While positive forms of religious coping may reduce anxiety in highly stressful circumstances, negative forms of religious conflict may exacerbate it. For example, one recent study53 of women (n = 100) with gynecological cancer found that women who felt that God was punishing them, had deserted them, or did not have the power to make a difference, or felt deserted by their faith community, had significantly higher anxiety. These results persisted after multiple statistical con- trols, and are consistent with other studies54,55 in medical patients.

Psychotic Disorders Psychiatric patients with psychotic disorders may report bizarre religious delusions, some of which can be difficult to distinguish from so-called normal religious or cultural beliefs. About 25% to 39% of psychotic patients with schizo- phrenia and 15% to 22% of those with bipolar disorder have religious delusions.56 Do religious beliefs play a role in the etiology of psychotic disorders or might they adversely affect the course of these disorders or response to treatment?

Research on Religion, Spirituality, and Mental Health: A Review

The Canadian Journal of Psychiatry, Vol 54, No 5, May 2009 � 287

Alternatively, might nondelusional religious beliefs and prac- tices help these patients to cope with psychological and social stresses, thus serving to prevent exacerbations of illness?

Unfortunately, there are relatively few studies—particularly from the United States or Canada—that have examined the relation between religion and psychotic symptoms. In an ear- lier review of the literature, Koenig et al57 identified 16 stud- ies. Among the 10 cross-sectional studies, 4 found less psychosis or psychotic tendencies among people more reli- giously involved, 3 found no association, and 2 studies reported mixed results. The final study,58 conducted in Lon- don, England, found religious beliefs and practices signifi- cantly more common among depressed (n = 52) and schizophrenic psychiatric (n = 21) inpatients, compared with orthopedic control subjects (n = 26).

More recent research, from Great Britain, Europe, the Middle East, and the Far East, helps to clarify these relations. One of the largest and most detailed studies from Great Britain examined the prevalence of religious delusions among inpa- tients (n = 193) with schizophrenia.59 Subjects with religious delusions (24%) had more severe symptoms, especially hallu- cinations and bizarre delusions, poorer functioning, longer duration of illness, and were on higher doses of antipsychotic medication, compared with patients with other kinds of delusions.

The content of religious delusions may be influenced by local religions or culture. A small study60 of 4 Chinese patients with schizophrenia in Hong Kong, China, reported that religious content reflected Chinese beliefs involving Buddhist gods, Taoist gods, historical heroic gods, and ancestor worship. In a larger and more systematic study61 of Austrian (n = 126) and Pakistani (n = 108) patients with schizophrenia, investigators found more grandiose, religious, and guilt delusions in the Austrian patients (largely Christian) than in the Pakistani patients (largely Muslim). In the largest study to date,62 inves- tigators compared the delusions of inpatients (n = 324) with schizophrenia in Japan with patients in Austria (n = 101) and in Germany (n = 150). Again, religious themes of guilt and (or) sin were more common among patients in Austria and Germany than in Japan; whereas delusions of reference (such as being slandered) were more prevalent because of the role shame plays in Japanese culture.

There is controversy about the impact that religious delusions have on the course of psychotic disorder. While some studies report that patients with schizophrenia and religious delusions have a worse long-term prognosis,63,64 others do not.65 In one of the most detailed studies to date, Siddle et al66 did not find that patients with religious delusions (n = 40) or patients who described themselves as religious (n = 106) responded less well to 4 weeks of treatment than other patients. However,

patients with religious delusions had more severe illness and greater functional disability than other patients.

Longitudinal studies suggest that nonpsychotic religious activity may actually improve long-term prognosis in patients with psychotic disorders. In a prospective study of patients (n = 210) with schizophrenia, Schofield et al67

reported that regular church attendance was one of 13 factors associated with a good prognosis. In a second study68 that fol- lowed hospitalized African-American patients (n = 128) with schizophrenia for 12 months or until rehospitalization, patients from urban areas were less likely to be rehospitalized if their families encouraged religious worship during the hos- pital stay. Urban and rural patients were both less likely to be hospitalized if their families were Catholic and more likely to be hospitalized if they had no religious affiliation. A third study69 followed outpatients (n = 386) with schizophrenia from clinics in Madras and Vellore, India, for 2 years, exam- ining factors influencing course of illness. Patients who reported a decrease in religious activities at baseline had sig- nificantly worse outcomes. Finally, Swedish investigators70

followed patients (n = 88) with adolescent-onset psychotic disorders for 10.6 years, during which 25% of patients attempted suicide. When anxiety and depressive symptoms were controlled for, only satisfaction with religious belief was a significant protective factor.

Most recently, Huguelot et al71 and Mohr et al72,73 from the University of Geneva, Switzerland, have published a series of papers on the religious beliefs and practices of outpa- tients (n = 115) with schizophrenia and on their interactions with clinicians. While a majority of patients reported that spirituality was important in their daily lives, only 39% had spoken about their spiritual concerns with clinicians. Many of these patients used religion to cope, with 71% reporting it instilled hope, purpose, and meaning in their lives, (although 14% said it induced spiritual despair), it lessened psychotic and other pathological symptoms in 54% (increased in 10%), increased social integration in 28% (worsened social integra- tion in 3%), reduced suicide attempts in 33% (increased in 10%), reduced substance abuse in 14% (increased in 3%), and increased adherence to psychiatric treatment in 16% (decreased in 15%). Thus, overall, religion played more of a positive than a negative role in the lives and treatment of these patients.

Substance Abuse

Religious beliefs and practices provide guidelines for human behaviour that reduce self-destructive tendencies and patho- logical forms of coping. This is particularly evident from research that has examined associations between religious involvement and substance abuse. As a form of social con- trol, most mainstream religious traditions discourage the use

� La Revue canadienne de psychiatrie, vol 54, no 5, mai 2009288

In Review

and abuse of substances that adversely affect the body or mind. In a review of studies published prior to 2000, Koenig et al74 identified 138 that had examined the religion–substance abuse relation, 90% of which found significantly less sub- stance use and abuse among the more religious. Most of these studies were conducted in high school or college students just starting to establish patterns of alcohol and drug use.

Since that review, the CASA at Columbia University reported the results of 3 national US surveys: the 1998 National House- hold Survey, CASA’s National Survey of American Attitudes on Substance Abuse, and the General Social Survey.75 Adults who did not consider religion very important were 50% more likely to use alcohol and cigarettes, 3 times more likely to binge drink, 4 times more likely to use illicit drugs other than marijuana, and 6 times more likely to use marijuana, com- pared with adults who strongly believed that religion is impor- tant. The same pattern was seen for religious attendance, and an even more pronounced inverse relation between religion and substance abuse was evident in teenagers. In addition, people who both received professional treatment and attended spirituality-based support programs (such as Alcoholics Anonymous or Narcotics Anonymous) were far more likely to remain sober than if they received only professional treatment.

More recent studies support these findings, and emphasize their importance in younger people76,77 and minority groups, such as African Americans,78,79 Hispanic Americans,80,81 and Native Americans and Native Canadians82—those at high risk for alcohol and drug use disorders. For example, in a 3-year study of Native Americans in 4 American Indian Reserva- tions in the upper Midwest of the United States and Native Canadians in 5 Canadian First Nations Reserves (n = 732), Stone et al82 found that traditional spiritual activities had a sig- nificantly positive effect on alcohol cessation.

While religious influences on substance abuse appear to be generally positive, this is not always the case. When people from religious traditions that promote complete abstinence start using alcohol or drugs, substance use can become severe and recalcitrant. Those people may completely withdraw from religious involvement, resulting in social isolation and worsening mental health owing to feelings of guilt and shame.83 Further, religious traditions that advocate complete abstinence from alcohol may deprive members of cardiovas- cular benefits of moderate, controlled drinking.84

Summary and Conclusions Many people suffering from the pain of mental illness, emo- tional problems, or situational difficulties seek refuge in reli- gion for comfort, hope, and meaning. While some are helped, not all such people are completely relieved of their mental dis- tress or destructive behavioural tendencies. Thus it should not

be surprising that psychiatrists will often encounter patients who display unhealthy forms of RS involvement. In other instances, especially in the emotionally vulnerable, religious beliefs and doctrines may reinforce neurotic tendencies, enhance fears or guilt, and restrict life rather than enhance it. In such cases, religious beliefs may be used in primitive and defensive ways to avoid making necessary life changes.

However, systematic research published in the mental health literature to date does not support the argument that religious involvement usually has adverse effects on mental health. Rather, in general, studies of subjects in different settings (such as medical, psychiatric, and the general population), from different ethnic backgrounds (such as Caucasian, African American, Hispanic, and Native American), in dif- ferent age groups (young, middle-aged, and elderly), and in different locations (such as the United States and Canada, Europe, and countries in the East) find that religious involve- ment is related to better coping with stress and less depres- sion, suicide, anxiety, and substance abuse. While religious delusions may be common among people with psychotic dis- orders, healthy normative religious beliefs and practices appear to be stabilizing and may reduce the tremendous isola- tion, fear, and loss of control that those with psychosis expe- rience. Clinicians need to be aware of the religious and spiritual activities of their patients, appreciate their value as a resource for healthy mental and social functioning, and rec- ognize when those beliefs are distorted, limiting, and contribute to pathology rather than alleviate it.

Funding and Support

Funding was provided by the Center for Spirituality, Theology and Health, Duke University Medical Center, Durham, North Carolina.

The Canadian Psychiatric Association proudly supports the In Review series by providing an honorarium to the authors.

References

1. Barrett DB, Johnson TM. World Christian database: atheists/nonreligious by country. World Christian trends [Internet]. [place unknown]: William Carey Library; 2001 [cited 2009 Jan 1; updated 2007 Feb]. Available from: http://worldchristiandatabase.org/wcd/.

2. Smart N, Denny FW, editors. Atlas of the world’s religions. New York (NY): Oxford University Press; 2007. p 26.

3. Koenig HG, McCullough ME, Larson DB. A history of religion, science and medicine. In: Koenig HG, McCullough ME, Larson DB, editors. Handbook of religion and health. New York (NY): Oxford University Press; 2001. Chapter 2; p 24 – 49.

4. Taubes T. “Healthy avenues of the mind”: psychological theory building and the influence of religion during the era of moral treatment. Am J Psychiatry. 1998;155:1001–1008.

5. Freud S. Future of an illusion. In: Strachey J, editor and translator. Standard edition of the complete psychological works of Sigmund Freud. London (GB): Hogarth Press; 1962.

6. Ellis A. Is religiosity pathological? Free Inq. 1988;18:27–32.

7. Watters W. Deadly doctrine: health, illness, and Christian God-talk. Buffalo (NY): Prometheus Books; 1992.

8. Jones HE. Religion: the etiology of mental illness. [place unknown]: Mental Health Education; 2007.

Research on Religion, Spirituality, and Mental Health: A Review

The Canadian Journal of Psychiatry, Vol 54, No 5, May 2009 � 289

9. Accreditation Council on Graduate Medical Education. Special requirements for residency training in psychiatry. Chicago (IL): ACGME; 1994 Mar.

10. Sheldrake P. A brief history of spirituality. Boston (MA): Blackwell Publishing; 2007.

11. Koenig HG. Concerns about measuring “spirituality” in research. J Nerv Ment Dis. 2008;196(5):349–355.

12. Schuster MA, Stein BD, Jaycox LH, et al. A national survey of stress reactions after the September 11, 2001, terrorist attacks. N Engl J Med. 2001;345:1507–1512.

13. Biema D. Faith after the fall. Time. 2001 Oct 8;158(16);76. 14. Koenig HG, McCullough ME, Larson DB. Handbook of religion and health.

New York (NY): Oxford University Press; 2001. p 514–518. 15. Koenig HG. Religious beliefs and practices of hospitalized medically ill older

adults. Int J Geriatr Psychiatry. 1998;13:213–224. 16. Tepper L, Rogers SA, Coleman EM, et al. The prevalence of religious coping

among persons with persistent mental illness. Psychiatr Serv. 2001;52:660–665. 17. Russinova Z, Wewiorski NJ, Cash D. Use of alternative health care practices by

persons with serious mental illness: perceived benefits. Am J Pub Health. 2002;92:1600–1603.

18. D’Souza R. Do patients expect psychiatrists to be interested in spiritual issues? Australas Psychiatry. 2002;10:44–47.

19. Ginsburg ML, Quirt C, Ginsburg AD, et al. Psychiatric illness and psychosocial concerns of patients with newly diagnosed lung cancer. CMAJ. 1995;152:701–708.

20. Zaza C, Sellick SM, Hillier LM. Coping with cancer: what do patients do? J Psychosoc Oncol. 2005;23:55–73.

21. Koenig HG, McCullough ME, Larson DB. Handbook of religion and health. New York (NY): Oxford University Press; 2001. p 514–554.

22. Koenig HG, McCullough ME, Larson DB. Handbook of religion and health. New York (NY): Oxford University Press; 2001. p 118–143, 216–217, 527–530.

23. 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;129:614–636.

24. Koenig HG. Religion and depression in older medical inpatients. Am J Geriatr Psychiatry. 2007;15:282–291.

25. Koenig HG. Religion and remission of depression in medical inpatients with heart failure/pulmonary disease. J Nerv Ment Dis. 2007;195:389–395.

26. Koenig HG, Cohen HJ, Blazer DG, et al. Religious coping and depression among elderly, hospitalized medically ill men. Am J Psychiatry. 1992;149:1693–1700.

27. Koenig HG, George LK, Peterson BL. Religiosity and remission of depression in medically ill older patients. Am J Psychiatry. 1998;155:536–542.

28. Braam AW, Beekman ATF, Deeg DGH, et al. Religiosity as a protective of prognostic factor of depression in later life; results from a community study in the Netherlands. Acta Psychiatr Scand. 1997;96:199–205.

29. Bosworth HB, Park KS, McQuoid DR, et al. The impact of religious practice and religious coping on geriatric depression. Int J Geriatr Psychiatry. 2003;18:905–914.

30. O’Connor BP, Vallerand RJ. Religious motivation in the elderly: a French-Canadian replication and an extension. J Soc Psychol. 1989;130:53–59.

31. Sorenson AM, Grindstaff CF, Turner RJ. Religious involvement among unmarried adolescent mothers: a source of emotional support? Sociol Relig. 1995;56:71–81.

32. Baetz M, Griffin R, Bowen R, et al. The association between spiritual and religious involvement and depressive symptoms in a Canadian population. J Nerv Ment Dis. 2004;192:818–822.

33. Baetz M, Bowen R, Jones G. How spiritual values and worship attendance relate to psychiatric disorders in the Canadian population. Can J Psychiatry. 2006;51:654–661.

34. Makkar JS. Positive coping in individuals with prostate cancer: the effects of prostate support groups, social comparison and religious resources [dissertation]. [Burnaby (BC)]: Simon Fraser University; 2004. Available from: Dissertation Abstracts International Section A: Humanities and Social Sciences; 66(6-A):2114.

35. Cadell S. The sun always comes out after it rains: exploring the experience of AIDS caregivers [dissertation]. [Waterloo (ON)]: Wilfred Laurier University; 2000. Available from: Dissertation Abstracts International Section A: Humanities and Social Sciences; 61(10-A):4177.

36. Fenix JB, Cherlin EJ, Prigerson HG, et al. Religiousness and major depression among bereaved family caregivers: a 13-month follow-up study. J Palliat Care. 2006;22:286–292.

37. Rabins P, Fitting MD, Eastham J, et al. Emotional adaptation over time in caregivers for chronically ill elderly people. Age Ageing. 1990;19:185–190.

38. Hebert RS, Dang Q, Schulz R. Religious beliefs and practices are associated with better mental health in family caregivers of patients with dementia: findings from the REACH study. Am J Geriatr Psychiatry. 2007;5:292–300.

39. Tauscher J, Bagby RM, Javanmard M, et al. Inverse relationship between serotonin 5-HT1A receptor binding and anxiety: a [11C]WAY-100635 PET investigation in healthy volunteers. Am J Psychiatry. 2001;158:1326–1328.

40. Bain EE, Nugent AC, Carson RE, et al. Decreased 5-HT1A receptor binding in bipolar depression. Biol Psychiatry. 2004;55(8 Suppl):636.

41. Sargent PA, Kjaer KH, Bench CJ, et al. Brain serotonin1A receptor binding measured by positron emission tomography with [11C]WAY-100635: effects of depression and antidepressant treatment. Arch Gen Psychiatry. 2000;57:174–180.

42. Koenig HG, McCullough ME, Larson DB. Handbook of religion and health. New York (NY): Oxford University Press; 2001. p 136–143, 530–535.

43. Van Tubergen F, Te Grotenhuis M, Ultee W. Denomination, religious context, and suicide: neo-Durkheimian multilevel explanations tested with individual and contextual data. Am J Sociol. 2005;111:797–823.

44. Greening L, Stoppelbein L. Religiosity, attributional style, and social support as psychosocial buffers for African American and white adolescents’ perceived risk for suicide. Suicide Life Threat Behav. 2002;32:404–417.

45. McClain CS, Rosenfeld B, Breitbart W. Effect of spiritual well-being on end-of-life despair in terminally-ill cancer patients. Lancet. 2003;361:1603–1607.

46. Dervic K, Oquendo MA, Grunebaum MF, et al. Religious affiliation and suicide attempt. Am J Psychiatry. 2004;161:2303–2308.

47. Koenig HG, McCullough ME, Larson DB. Handbook of religion and health. New York (NY): Oxford University Press; 2001. p 144–155, 536–138.

48. Miller JJ, Fletcher K, Kabat-Zinn J. Three-year follow-up and clinical implications of a mindfulness meditation-based stress reduction intervention in the treatment of anxiety disorders. Gen Hosp Psychiatry. 1995;17(3):192–200.

49. Speca M, Carlson LE, Goodey E, et al. A randomized, wait-list controlled clinical trial: the effect of a mindfulness meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients. Psychosom Med. 2000;62:613–622.

50. Toneatto T, Nguyen L. Does mindfulness meditation improve anxiety and mood symptoms? A review of the controlled research. Can J Psychiatry. 2007;52:260–266.

51. Wink P, Scott J. Does religiousness buffer against the fear of death and dying in late adulthood? Findings from a longitudinal study. J Gerontol B Psychol Sci Soc Sci. 2005;60B:207–214.

52. Bowen R, Baetz M, D’Arcy C. Self-rated importance of religion predicts one year outcome of patients with panic disorder. Depress Anxiety. 2006;23:266–273.

53. Boscaglia N, Clarke DM, Jobling TW, et al. The contribution 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.

54. Pargament KI, Koenig HG, Tarakeshwar N, et al. Religious coping methods as predictors of psychological, physical and spiritual outcomes among medically ill elderly patients: a two-year longitudinal study. J Health Psychol. 2004;9:713–730.

55. Wollin SR, Plummer JL, Owen H, et al. Predictors of preoperative anxiety in children. Anaesth Intensive Care. 2003;31:69–74.

56. Koenig HG. Schizophrenia and other psychotic disorders. In: Peteet J, Lu F, editors. Religious and spiritual considerations for DSM-V. Washington (DC): American Psychiatric Publishing. Forthcoming.

57. Koenig HG, McCullough ME, Larson DB. Handbook of religion and health. New York (NY): Oxford University Press; 2001. p 538–539.

58. Neeleman J, Lewis G. Religious identity and comfort beliefs in three groups of psychiatric patients and a group of medical controls. Int J Soc Psychiatry. 1994;40:124–134.

59. Siddle R, Haddock G, Tarrier N, et al. Religious delusions in patients admitted to hospital with schizophrenia. Soc Psychiatry Psychiatr Epidemiol. 2002;37:130–138.

60. Yip K. Traditional Chinese religious beliefs and superstitions in delusions and hallucinations of Chinese schizophrenic patients. Int J Soc Psychiatry. 2003;49:97–111.

61. Stompe T, Friedman A, Ortwein G, et al. Comparison of delusions among schizophrenics in Austria and in Pakistan. Psychopathology. 1999;32:225–234.

62. Tateyama M, Asai M, Hashimoto M, et al. Transcultural study of schizophrenic delusions: Tokyo versus Vienna versus Tubingen (Germany). Psychopathology. 1998;31:59–68.

63. Thara R, Eaton WW. Outcome of schizophrenia: the MADRAS longitudinal study. Aust N Z J Psychiatry. 1996;30:516–522.

64. Doering S, Muller E, Kopcke W, et al. Predictors of relapse and rehospitalisation in schizophrenia and schizoaffective disorder. Schizophr Bull. 1998;24:87–98.

65. McCabe MS, Fowler RC, Cadoret RJ, et al. Symptom differences in schizophrenia with good and poor prognosis. Am J Psychiatry. 1972;128:49–63.

66. Siddle R, Haddock G, Tarrier N, et al. Religious beliefs and religious delusions: response to treatment in schizophrenia. Ment Health Relig Cult. 2004;7:211-223.

67. Schofield W, Hathaway SR, Hastings DW, et al. Prognostic factors in schizophrenia. J Consult Psychol. 1954;18:155–166.

68. Chu CC, Klein HE. Psychosocial and environmental variables in outcome of black schizophrenics. J Natl Med Assn. 1985;77:793–796.

69. Verghese A, John JK, Rajkumar S, et al. Factors associated with the course and outcome of schizophrenia in India: results of a two-year multicentre follow-up study. Br J Psychiatry. 1989;154:499–503.

� La Revue canadienne de psychiatrie, vol 54, no 5, mai 2009290

In Review

70. Jarbin H, von Knorring AL. Suicide and suicide attempts in adolescent-onset psychotic disorders. Nord J Psychiatry. 2004;58:115–123.

71. Huguelet P, Mohr S, Borras L, et al. Spirituality and religious practices among outpatients with schizophrenia and their clinicians. Psychiatr Serv. 2006;57:366–372.

72. Mohr S, Brandt PY, Borras L, et al. Toward an integration of spirituality and religiousness into the psychosocial dimension of schizophrenia. Am J Psychiatry. 2006;163:1952–1959.

73. Mohr S, Gillieron C, Borras L, et al. The assessment of spirituality and religiousness in schizophrenia. J Nerv Ment Dis. 2007;195:247–153.

74. Koenig HG, McCullough ME, Larson DB. Handbook of religion and health. New York (NY): Oxford University Press; 2001. p 539–545.

75. CASA report: spirituality and religion reduce risk of substance abuse [Internet]. New York (NY): National Center on Addiction and Substance abuse at Columbia University (US); 2001 [cited 2009 Feb 19]. Available from: http://www.casacolumbia.org/absolutenm/templates/ PressReleases.asp?articleid=115&zoneid=48.

76. Sussman S, Skara S, Rodriguez Y, et al. Non drug use- and drug use-specific spirituality as one-year predictors of drug use among high-risk youth. Subst Use Misuse. 2006;41:1801–1816.

77. White HR, McMorris BJ, Catalano RF, et al. Increases in alcohol and marijuana use during the transition out of high school into emerging adulthood. J Stud Alcohol. 2006;67:810–822.

78. Nasim A, Utsey SO, Corona R, et al. Religiosity, refusal efficacy, and substance use among African-American adolescents and young adults. J Ethn Subst Abuse. 2006;5:29–49.

79. Steinman KJ, Zimmerman MA. Religious activity and risk behavior among African American adolescents. Am J Community Psychol. 2004;33:151–161.

80. Marsiglia FF, Kulis S, Nieri T, et al. God forbid! Substance use among religious and non-religious youth. Am J Orthopsychiatry. 2005;75:585–598.

81. Guinn R. Characteristics of drug use among Mexican-American students. J Drug Educ. 1975;5:235–241.

82. Stone RA, Whitbeck LB, Chen X, et al. Traditional practices, traditional spirituality, and alcohol cessation among American Indians. J Stud Alcohol. 2006;67:236–244.

83. Musick MA, Blazer DG, Hays JC. Religious activity, alcohol use, and depression in a sample of elderly Baptists. Res Aging. 2000:22:91–116.

84. National Institute on Alcohol Abuse and Alcoholism. State of the science report on moderate drinking, 2003 [Internet]. Bethesda (MD): National Institute on Alcohol Abuse and Alcoholism (US); 2003 [cited 2008 Jan 1]. Available from: http://pubs.niaaa.nih.gov/publications/ModerateDrinking-03.htm.

Manuscript received and accepted October 2008. 1Professor of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina; Associate Professor of Medicine, Duke University Medical Center, Durham, North Carolina; Consultant, Geriatric Research, Education and Clinic Center, Durham Veterans Affairs Medical Center, Durham, North Carolina. Address for correspondence: Dr HG Koenig, Box 3400, Duke University Medical Center, Durham, NC 27710; [email protected]

Research on Religion, Spirituality, and Mental Health: A Review

The Canadian Journal of Psychiatry, Vol 54, No 5, May 2009 � 291

Résumé : Recherche sur la religion, la spiritualité et la santé mentale : une revue

Les facteurs religieux et spirituels font l’objet d’un examen croissant dans la recherche psychiatrique. Les croyances et pratiques religieuses ont longtemps été liées à l’hystérie, la névrose et les délires psychotiques. Cependant, des études récentes ont identifié un autre aspect de la religion qui peut servir de ressource psychologique et sociale d’adaptation au stress. Après avoir défini les termes religion et spiritualité, cet article examine la recherche sur la relation entre la religion et (ou) spiritualité, et la santé mentale, en mettant l’accent sur la dépression, le suicide, l’anxiété, la psychose, et la toxicomanie. Les résultats d’une revue systématique précédente sont discutés, et des études plus récentes menées aux États-Unis, au Canada, en Europe, et dans d’autres pays sont décrites. Bien que les croyances et pratiques religieuses puissent représenter de puissances sources de réconfort, d’espoir et de sens, elles sont souvent étroitement entremêlées à des troubles névrotiques et psychotiques, ce qui rend parfois difficile de déterminer si elles constituent une ressource ou un passif.