Spirituality, depression and suicide in middle age.

The interpersonal aspects of religion, in addition to the intrapsychic experiences of spirituality, offer protection to adults against depression and suicide. Three lines of evidence support this statement. First, each of Erikson's adult life stages focuses upon relational crises that must be surmounted to grow; (1) second, involvement in religious observances, not spirituality per se, guards against social isolation; third, fractures in the activities of love and of work contribute to several risk factors for suicide in adults.

Erikson's genius was to extend Freud's developmental stages beyond childhood into adult life. By the end of Erikson's Stage 5, adolescents must achieve consolidated identities as workers and lovers or risk goal diffusion. Stage 6 challenges young adults to achieve intimacy in dyadic relationships. Failure to master this stage's crisis leads to isolation and aloneness. Having consolidated a satisfying professional and personal life, midlife adults risk stagnation if they do not find ways to transmit their knowledge and experience to the young through generative activities. Finally, in Stage 8, elders must review achievements made in a lifetime of loving and of working and find satisfaction in them, thereby achieving personal integrity and avoiding despair.

Until recent decades, spirituality and religiousness were not considered discrete entities. Contemporary formulations, however, define spirituality as a "personal experience of the transcendent ... [an] individualistic process that emphasizes self-expression," as distinct from religiousness, which involves institutional affiliations that "usually reflect conformity and adherence to a basic set of tenets and prescribed behaviors." (2) Other authors consider religiosity to have two components: "intrinsic religiosity" emphasizes a questing quality that seeks "the integration of religion into one's complete life" as contrasted with "extrinsic religiosity," which involves the "use of religion as a means of social connectedness." (3) Although "intrinsic" and "extrinsic" religiosity complement one another, it is "extrinsic" religiosity, as manifested through higher worship frequency (ie, participating in the tried-and-true communal aspects of religion) that has been linked to good psychological health. (4,5)

Paradoxically, spiritual questing may not be synonymous with inner peace and comfort, coming as it often does as a means of dealing with inner turmoil. Moreover, possession of a strong personal spirituality does not necessarily protect against suicide, unless that spirituality encompasses commitment to certain life-preserving values. Among these values, which are not specific to any particular faith tradition, three of the most robust are responsibility to one's family, concern for one's children, and moral objection to suicide. Embracing these values can stave off suicidal urges through countering them with reasons to live. (6)

Malone and colleagues administered the Reasons for Living Inventory (RLI), an instrument that inquires about the belief triad, among other RLI markers, to 84 depressed patients, approximately half of whom had attempted suicide. They also assessed their subjects for "clinical suicidality," a measure defined by hopelessness, subjective depressive feelings, and suicidal ideation. The attempters scored significantly higher on clinical suicidality and significantly lower on the RLI, while nonattempters had the opposite, healthy profile. (7)

Supporting the importance of social and familial relatedness in decreasing suicidality, in a cohort of 371 depressed inpatient subjects, Dervic and colleagues found that those with religious affiliations had significantly fewer first-degree relatives dead by suicide than those without such affiliations. (6) The religiously-affiliated were more likely to find suicide morally repugnant, to be married, to have children, and to be entangled in webs of family relationships. In contrast, suicide attempters were more likely to be alone, cut off from social networks that spiritual institutions provide and intimate connections that spouses, offspring, and extended families afford.

Traditional suicide risk factors in mid-life include social estrangement, as exemplified by the SADPERSONS suicide mnemonic, which subsumes 10 risk factors, several of which are direct or indirect measures of social relatedness. (8) Risk is assigned to male Sex, Age older than 25, Depression if present, Previous suicide attempt, Ethanol abuse, Rational thinking loss, deficient Social support, Organized plan, No spouse, and Sickness. Depression, history of previous attempts, rational thinking loss, and organized plan are measures of psychopathology. Individuals with histories of depression or previous suicide attempts, particularly when hospitalized for these reasons, have elevated suicide risk, regardless of age, as do those whose agitation or psychosis has compromised their ability to think rationally or those whose intense commitment to self-harm has yielded an organized plan. (9)

Although six of the ten identified risk factors may not directly be associated with social connectedness, four of the factors are. Deficient social support speaks for itself, as does spousal loss through divorce or death, particularly when the newly unpaired person is male. Indirectly, ethanol abuse, particularly when longstanding, erodes intimate relationships and social involvement and corrodes work performance and success. Likewise, sickness, particularly when it includes chronic pain or mobility limitations, wreaks havoc on relational life.

In sum, normal adult development revolves around relational challenges and successes. Suicide risk factors address multiple aspects of social relatedness, and social aspects of religious observance appear to be associated with reduced depression and suicidality in faithful adherents. The clinician assessing the protective role religion may play in a patient's life will thus do well to inquire not only about that individual's belief system but also about the presence--or absence--of communal expression of those beliefs.

References

1. Erikson EH. The Life Cycle Completed. New York, W.W. Norton & Co, 1998.

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

3. McClain-Jacobson C, Rosenfeld B, Kosinski A, et al. Belief in an afterlife, spiritual well-being and end-of-life despair in patients with advanced cancer. Gen Hosp Psychiatry 2004;26:484-486.

4. Powell LH, Shahabi L, Thoresen CE. Religion and spirituality. Linkages to physical health. Am Psychol 2003;58:36-52.

5. Mueller PS, Plevak DJ, Rummans TA. Religious involvement, spirituality, and medicine: implications for clinical practice. Mayo Clin Proc 2001;76:1225-1235.

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

7. Malone KM, Oquendo MA, Haas GL, et al. Protective factors against suicidal acts in major depression: reasons for living. Am J Psychiatry 2000;157:1084-1088.

8. Patterson WM, Dohn HH, Bird J, et al. Evaluation of suicidal patients: the SAD PERSONS scale. Psychosomatics 1983;24:343-349.

9. Bostwick JM, Pankratz VS. Affective disorders and suicide risk: a reexamination. Am J Psychiatry 2000;157:1925-1932.

Is the mark of an educated mind to be able to entertain a thought
without accepting it.
--Aristotle

J. Michael Bostwick, MD, and Teresa A. Rummans, MD

From the Department of Psychiatry, Mayo Clinic College of Medicine. Mayo Clinic, Rochester, MN.

Reprint requests to J. Michael Bostwick, MD, Department of Psychiatry and Psychology, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905. Email: [e-mail]