Spirituality and depression: a look at the evidence.

Depression is one of the strongest predictors of suicide, especially when accompanied by hopelessness. (1) People often commit suicide when they perceive that there is no way out of an intolerably painful situation, or when they see no purpose or meaning to a life of seemingly unending suffering. Depressive illness can itself make people feel this way, and depression is very common among patients for whom medical clinicians care. Studies of medical inpatients have reported rates of depression approximating 50%. (2)

When patients are asked how they are able to manage with the stress of medical illness, disability, and pain, they frequently report that religious beliefs and practices are a source of comfort and strength. (3) Religious beliefs can be a source of hope for those facing difficult life problems, especially medical illness, and it is not surprising that religious activity is positively related to hope and optimism (4) and negatively related to depression. (5)

I review here some of the research that has demonstrated a relationship between religion/spirituality and depression in patients with physical illness. When medical patients are asked what they are doing that enables them to cope, in some areas of the country nearly 90% of hospitalized patients report that religion is a helpful resource, and 40% indicate that religion is the most important factor that keeps them going. (6) In a study of unconventional therapies for pain among a random sample of 382 persons with musculoskeletal complaints in San Diego, California, the most commonly mentioned therapy was prayer, which was also rated the second most helpful of 19 therapies examined. (7) Likewise, in a study of 100 patients on the day before cardiac surgery at the University of Alabama Medical Center in Birmingham, 95% reported using prayer and 70% rated prayer as "extremely helpful" for coping with surgery (ie, gave prayer a score of 15 on a 0-15 helpfulness scale). (8) Thus, according to patients themselves, religious practices facilitate adaptation to illness.

However, just because patients report that religion is helpful does not mean that such is actually the case. Many persons in the United States may report that they use religion to cope because this is the more socially acceptable way of responding to such questions, regardless of whether it is actually true for them. Nevertheless, when the religiousness of patients is measured, studies usually indicate that those who are more religious experience less depression (ie, are coping better). For example, in a study of 30 women over age 65 with hip fracture in the Chicago area, degree of religious involvement was associated with less depression (Geriatric Depression Scale) and longer walking distances at discharge. (9) These relationships persisted after controlling for severity of medical illness. Likewise, a study of 850 hospitalized men found that the degree to which patients used religion to cope was significantly and inversely related to depressive symptoms (whether measured by the self-rated Geriatric Depression Scale or by the clinician-rated observer-rated Hamilton Depression Rating Scale). (10) In that study, religious coping during hospitalization also predicted fewer depressive symptoms several months later in a subgroup of 201 readmitted patients, controlling for multiple other predictors of depression. Religious coping was the strongest predictor of future depressive symptoms among 14 other baseline predictors (accounting for 45% of the explained variance in depression). However, religious coping was only associated with certain types of depressive symptoms. (11) Loss of interest, feeling of worthlessness, withdrawal from social interactions, loss of hope, and other "cognitive" symptoms of depression were significantly less common among those using religion to cope, whereas "somatic" symptoms such as weight loss, insomnia, loss of energy, and decreased concentration were unrelated to religious coping. This suggests that once depression worsens to the point that somatic symptoms are present, then religious involvement may be less effective in resolving symptoms (and may itself be influenced by the depression).

In another prospective study, 87 male and female depressed medical inpatients (diagnosed with major or minor depression using the Diagnostic Interview Schedule) were identified and followed up for an average of 47 weeks after discharge. (12) Baseline patient characteristics during hospitalization were examined as predictors of speed of depression remission. Patients who were more deeply religious (ie, greater intrinsic religiosity) remitted from depression 70% faster than those who were less religious; this effect was independent of other predictors of remission, including social support, quality of life, and physical disability. In fact, the effect was strongest in patients whose physical illnesses were not improving in response to medical treatment, in whom depression remitted over 100% faster among the more religious. Thus, it is among patients who are most ill that the effects of religion appear to be the strongest.

In the most recent and largest study to date, religion and depression were examined in severely ill hospitalized patients with congestive heart failure or chronic pulmonary disease. (13) This study found that religious involvement was widespread among the 411 patients with major depression and 585 patients with minor depression (diagnosed using the Structured Clinical Interview for Depression). However, it was not as common in depressed patients as it was among 428 nondepressed control patients with an assortment of illnesses. After controlling for demographic and physical health factors, depressed patients were more likely to be religiously unaffiliated, to indicate they were "spiritual but not religious," and were less likely to pray, read scripture, or score high on intrinsic religiosity. Furthermore, among depressed patients themselves, frequency of religious attendance, prayer, scripture reading, and intrinsic religiosity were all inversely correlated with depressive symptoms. Finally, among 845 of the depressed patients in this study who were followed after discharge by telephone and by in-person home visits, those who were more involved in religious community activities and those who were the most religious overall (15% of the sample) remitted over 50% faster from depression than did less religious patients. (14) Social factors could explain only a small proportion of these effects.

While cross-sectional and prospective studies cannot prove that it is the religiousness of patients that results in their experiencing less depression or recovering faster from depression, evidence from randomized clinical trials (RCT) suggests that this is indeed the case. For example, Propst and colleagues compared the effectiveness of Christian cognitive-behavioral therapy (Christian CBT) compared with traditional secular cognitive-behavioral therapy (secular CBT), ordinary pastoral counseling (PCT), and no treatment (a wait-list control) (WLC) (four study groups) in 59 religious patients with mild to moderate depression. (15) Christian CBT was used with Christian religious rationales, religious arguments to counter irrational thoughts, and religious imagery. Only Christian CBT resulted in significantly lower immediate post-treatment self-rated depression and severity of illness scores than the WLC group. The Christian CBT and PCT groups also tended to show lower post-treatment observer-rated depression scores compared with the WLC group. Finally, only the Christian CBT group tended to score better in overall functioning than the WLC group. Researchers concluded that Christian-based CBT achieves a faster decrease in symptoms than more traditional secular CBT. Interestingly, the effect of Christian CBT was greatest when administered by nonreligious therapists.

Other RCTs have examined Islamic-based psychotherapy using the Koran and prayer (16,17,18) and Buddhist-based cognitive therapy using Tao beliefs, (19) with the majority finding that religion-based psychotherapies (regardless of religious tradition), when used with religious patients, result in faster remission of depression than secular psychotherapies or no treatment.

Thus, if our patients tell us that religion helps them to cope with the stress of medical illness, if religious patients are less depressed than those who are not religious, if religious patients with depression recover more quickly over time than those who are less religious, and if randomized clinical trials show that religious-oriented therapies help patients recover faster from depression, then this strongly suggests that religion can help to either prevent or facilitate recovery from depression.

So what should be done with this information? Medical clinicians should realize that for many patients, whether depressed or not, religion is important in their lives and therefore clinicians should be sensitive to how this impacts the patient's response to medical illness. Taking a brief spiritual history as described elsewhere (3) can help physicians learn about how patients' religious or spiritual beliefs affect their coping with illness, social support, and medical decision making. Clinicians should also learn how to comfortably discuss religion or spirituality with their patients and help patients make use of those beliefs that may be a central source of comfort and hope. Simply talking with patients about their religious or spiritual beliefs, without any other interventions, has been shown to result in less depression, better patient functioning, and stronger doctor-patient relationships. (20)

However, considerable care and tact should be taken not to make the patient feel guilty over their lack of religious activity (especially the depressed patient), and clinicians should never "prescribe" religion to nonreligious patients. (21) Furthermore, patients may be having religious struggles, feeling that God is punishing them, has deserted them, or does not have the power to help them. This is not uncommon among those who have been praying for relief for weeks or months and are still suffering. Studies have shown that patients experiencing such religious struggles are at risk for worse clinical outcomes independent of their physical health, mental health or social support. (22) These patients may or may not be willing to see a chaplain for help in dealing with these struggles, since many feel angry at or disappointed with God and anyone who represents God. For this reason, it is important for clinicians to gently inquire about such struggles, since patients may be more likely to share such feelings with them. Given the impact on the patients' quality of life and medical outcomes, it is important for clinicians to gently encourage these patients to see trained pastoral counselors or chaplains who can help them work through these issues.

Finally, if a depressed patient is religious and their depressive illness is impairing their religious involvement, then depression should be aggressively treated and the patient's prior religious activity encouraged. Once depression has been treated, religious activity and support may be the key to maintaining that patient in remission. Although physicians have traditionally believed that inquiry into the religious or spiritual lives of patients lies outside their realm of expertise, it is becoming more and more evident that failure to do so can cause clinicians to miss important information that may influence both patients' mental and physical health.

References

1. Fawcett J, Scheftner W, Clark D, et al. Clinical predictors of suicide in patients with major affective disorders: a controlled prospective study. Am J Psychiatry 1987;144:35-40.

2. Koenig HG, George LK, Peterson BL, et al. Depression in medically ill hospitalized older adults: prevalence, characteristics, and course of symptoms according to six diagnostic schemes. Am J Psychiatry 1997;154:1376-1383.

3. Koenig HG. An 83-year-old woman with chronic illness and strong religious beliefs. JAMA 2002;288:487-493.

4. Ai AL, Peterson C, Tice TN, et al. Faith-based and secular pathways to hope and optimism subconstructs in middle-aged and older cardiac patients. J Health Psychology 2004;9:435-450.

5. 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.

6. Koenig HG. Religious attitudes and practices of hospitalized medically ill older adults. Int'l J Geriatr Psychiatry 1998;13:213-224.

7. Cronan TA, Kaplan RM, Posner L, et al. Prevalence of the use of unconventional remedies for arthritis in a metropolitan community. Arthritis and Rheumatism 1989;32:1604-1607.

8. Saudia TL, Kinney MR, Brown KC, et al. Health locus of control and helpfulness of prayer. Heart Lung 1991;20:60-65.

9. Pressman P, Lyons JS, Larson DB, et al. Religious belief, depression, and ambulation status in elderly women with broken hips. Am J Psychiatry 1990;147:758-760.

10. 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.

11. Koenig HG, Cohen HJ, Blazer DG, et al. Religious coping and cognitive symptoms of depression in elderly medical patients. Psychosomatics 1995;36:369-375.

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

13. Koenig HG. Religion and depression in older medical inpatients. Am J Geriatr Psychiatry, in submission

14. Koenig HG. Religion and remission of depression in medical inpatients with heart failure/pulmonary disease. Am J Psychiatry, in submission.

15. Propst LR, Ostrom R. Watkins P, et al. Comparative efficacy of religious and nonreligious cognitive-behavioral therapy for the treatment of clinical depression in religious individuals. J Consult Clin Psychol 1992;60:94-103.

16. Azhar MZ, Varma SL. Religious psychotherapy in depressive patients. Psychother Psychosom 1995;63:165-173.

17. Azhar MZ, Varma SL. Religious psychotherapy as management of bereavement. Acta Psychiatr Scand 1995;91:233-235.

18. Razali SM, Hasanah CI, Aminah K, ct al. Religious-sociocultural psychotherapy in patients with anxiety and depression. Aust N Z J Psychiatry 1998;32:867-872.

19. Xiao S, Young D, Zhang H. Taoistic cognitive psychotherapy for neurotic patients: a preliminary clinical trial. Psychiatry Clin Neurosci 1998;52(Suppl):S238-241.

20. Kristeller JL, Rhodes M, Cripe LD, et al. Oncologist Assisted Spiritual Intervention Study (OASIS): patient acceptability and initial evidence of effects. Int J Psychiatry Med 2005;35:329-347.

21. Sloan RP, Bagiella E. VandeCreek L, et al. Should physicians prescribe religious activities? N Engl J Med 2000;342:1913-1916.

22. Pargament KI, Koenig HG, Tarakeshwar N, et al. Religious struggle as a predictor of mortality among medically ill elderly patients: a 2-year longitudinal study. Arch Intern Med 2001;161:1881-1885.

Harold G. Koenig, MD

From the Departments of Psychiatry and Behavioral Sciences and Medicine, Duke University Medical Center, GRECC VA Medical Center, Durham, NC.

Reprint requests to Harold G. Koenig, MD, Box 3400, Duke University Medical Center, Durham, NC 27710. Email: [e-mail].