Spirituality and depressive symptoms in primary care outpatients.

Background: Although many studies have examined the relationship between religiosity and depressive symptoms in patient populations, there has been little work to understand and measure the effect of spirituality on depressive symptoms.

Objective: The purpose of this study was to examine the association of spirituality and symptoms of depression in primary care outpatients.

Methods: A cross-sectional analysis was performed of a dataset using 509 primary care outpatients who participated in an instrument validity study in the Kansas City (US) area. Patients were administered the Zung Depression Scale (ZDS) and the Spirituality Index of Well-Being (SIWB) in the waiting area before or after their appointment. Bivariate and multivariate analyses were performed to determine the relationship between the factors of interest and depressive symptoms.

Results: In bivariate analyses, less insurance coverage (P < 0.01) and greater spirituality (P < 0.01) were associated with less reported depressive symptoms. In a model adjusted for covariates, spirituality (P < 0.01) remained independently associated with less symptoms.

Conclusion: Primary care outpatients who report greater spirituality are more likely to report less depressive symptoms.

Key Words: spirituality, depression, primary care

**********

There is ongoing interest in examining the association of religion and spirituality with health-related outcomes. (1) Although religion and spirituality are often omitted as variables in epidemiologic studies of depression, a recent research review concluded that (1) studies on religious affiliation suggest that Jews and individuals unaffiliated with any religious tradition have an increased risk of reporting depressive symptoms; (2) some aspects of religious involvement (eg, high involvement in religious community activities) are associated with less depression, and (3) such involvement may play a role by helping people cope with stressful life circumstances; however, (4) certain measures of religious involvement (eg, private activities and held beliefs) are not strongly associated with depression. (2)

One major limitation of work in this area has been the lack of valid and reliable instruments that conceptualize and measure the religion variable (eg, religious salience, religious motivation), subsequently compromising many studies. (3,1) A second measurement drawback has been the absence of instruments that conceptualize and measure spirituality within healthcare settings. The construct "spirituality" has become part of contemporary American culture, (4) and by extension, part of the patient experience of health and illness. (5) Conceptual distinctions between religion and spirituality, and the operationalization of constructs that measure these domains, are critical in studies that examine health outcomes. (1) Religion or religiosity has been viewed as the various organized, individual, and attitudinal manifestations of different faith traditions, while spirituality often connotes and expresses a sense of meaning, purpose, and/or power either from within or from a transcendent source. (6)

The present study builds on our prior work to develop a research instrument designed to measure a dimension of spirituality that would be useful in health-related quality-of-life studies. (7) Our conceptualization of spirituality and subjective well-being were grounded by a qualitative study using patient focus group interviews and have been described elsewhere. (8) In brief, group participants outlined a congruent, meaningful life scheme and self-efficacy beliefs as primary domains in their depiction of spirituality and its relationship to subjective well-being. (9,10) In addition to providing a conceptual framework, this qualitative work provided stimulus material for the development of the Spirituality Index of Well-Being, a 12-item measure that was found to be a valid and reliable measure in both an outpatient geriatric and primary care population. (7,11)

To further understand and clarify the relationship between spirituality and depressive symptoms, we performed a secondary data analysis from a cross-sectional study of primary care outpatients in a large Midwestern city in the United States. (11) The purpose of the present study was to examine the association of spirituality and symptoms of depression in primary care patients.

Methods

Overview

This was a secondary analysis of data from a larger cross-sectional study designed to test a valid and reliable measure of spirituality that would be useful in patient populations. A systematic sample of adult outpatients from multiple primary care clinic sites in the Kansas City metropolitan area were administered a cross-sectional survey that included demographic information, the Zung Depression Scale (ZDS) and the Spirituality Index of Well-Being (SIWB).

Study Population

Subjects were adult outpatients who presented for care at one often family practices in the greater Kansas City area. To achieve a 5% margin of error, a minimum of 384 subjects were required for enrollment in the parent validity study. The preliminary sample size was set to 512, based upon a 75% participation rate and was subsequently rounded up to 550 to standardize the number of subjects (n = 55) per site. Subjects were eligible if they were 18 years of age or older, English speaking, had no discernable cognitive impairment as determined by study personnel, and were willing to participate in the study.

Data Collection

Systematic sampling was used to recruit and enroll subjects into the study. At every practice site, physician schedules were reviewed before consecutive half-day blocks of patient care to identify every fourth patient until a total of 55 subjects were ascertained. After registering, patients were approached in the waiting area to determine eligibility, and, if eligible, were consented and enrolled into the study. Subjects found to be ineligible were excluded and replaced with the next patient on the physician schedule. Surveys at all sites were administered by a single, trained research assistant either before or after the appointment.

Measures

Our understanding and conceptualization of spirituality was grounded from a qualitative study using patient focus groups that explored and described spirituality and its relationship with subjective health and well-being. (8) According to this conceptual framework, perceived threats or actual changes to functioning or health status trigger two patient-initiated tasks: the gathering and processing of health-related information, and the interpretation and incorporation of this data within the context of the patient's life experience. These tasks rely upon both lay illness explanations and professional information to construct or maintain an individual system of meaning. (12) Core beliefs are sources that contribute to these meaning systems and originate from social structures, such as networks of friends or family, faith communities, and secular institutions.

The coping literature refers to the activity of "meaning making" as a cognitive representation of one's life that provides a sense of order and purpose. (13) This representation, or life scheme, is one primary domain of spirituality within the conceptual framework. It is similar to the construct of sense of coherence, which is described as a positive, pervasive way of viewing the world, and one's life in it, lending elements of comprehensibility, manageability, and meaningfulness. (9) Self-efficacy, the second domain, depicts an individual's belief in their capacity to organize and perform activities required for a prescribed goal. (10) Within our framework of spirituality, self-efficacy beliefs are specific to the task of overcoming challenges to global functioning. A belief in surmounting real or apparent threats to individual problems and difficulties, regardless of perceived resources or individual capacities, is a key assumption within this domain.

Spirituality, within the context of good health status and well-being, can be conceptualized as a congruent, meaningful life scheme and highly functional self-efficacy belief that synergistically promotes personal agency. (8) Agency beliefs refer to the individual's self-view as an active participant who constructs their own life course through the choices and actions that they take, given the opportunities and constraints of their circumstances.

The Spirituality Index of Well-Being (SIWB) contains six items that gauge life scheme and six items that assess functional self-efficacy. The SIWB has demonstrated prior reliability and validity in a primary care population. (11) For example, confirmatory factor analysis found the following fit indices: Chi-square (54, n = 508) = 508.35, P < 0.001; Comparative Fit Index = 0.98; Tucker-Lewis Index = 0.97; Root-Mean-Square Approximation = 0.13. The index had the following reliability results: the self-efficacy subscale had an alpha of 0.86 and test-retest r = 0.77; the life scheme subscale had an alpha of 0.89 and test-retest r = 0.86; the total scale had an alpha of 0.91 and test-retest r = 0.79, demonstrating very good reliability. In addition, the SIWB had significant and expected correlations with other quality-of-life instruments that measure well-being or spirituality; Zung Depression Scale (r = -0.42, P < 0.001); General Well-Being Scale (r = 0.64, P < 0.001) and the Spiritual Well-Being Scale (SWB) (r = 0.62, P < 0.001). There was a modest correlation between the Religious Well-Being Subscale of the SWB and the SIWB (r = 0.35, P < 0.001). (11)

The Zung Depression Scale (ZDS) is a widely recognized 20-item measure of self-reported depressive symptoms that has been used in outpatient populations. (14-16) Respondents rate each item regarding how they felt during the preceding week on a 4-point Likert scale. Scale scores are summed and are corrected for 10-items that are reverse scored, and total ZDS scores have been interpreted and utilized in studies in various ways. One study categorized the ZDS at 4 levels: (1) within normal range/no significant psychopathology (ZDS index below 50); (2) minimal to mild depression (ZDS index 50-59); (3) moderate to severe depression (ZDS index 60-69); (4) severe to extreme depression (ZDS index 70 and above). (16) Another study reported persons with ZDS scores of 55 or greater as at risk of major depression with possible subclinical depression. (17)

In addition to responses to the SIWB and ZDS, the following demographic information was also collected: age, gender, race/ethnicity, education level, marital status, health insurance status, and length of time with their current medical provider.

Data Analysis

Descriptive analyses were used to describe the study sample. To increase our sensitivity of detecting depressive symptoms, we dichotomized summed responses from the ZDS into patients with symptoms (for those scoring 50 or higher) and patients without symptoms (for those scoring 49 and lower). Age and the summed scores from the total and subscales of the SIWB, and total and subscales from the SWB scale were treated as continuous variables. Total and subscale SIWB scores were reverse scored so that higher scores indicated greater reported spirituality. Level of education, gender, and race (white versus nonwhite) were treated as categorical variables. Marital status was dichotomized between uncoupled (single, divorced, widowed, separated) and coupled (married, life partner), while self-reported insurance status was divided between greater coverage (private, private + Medicare, Medicare) and lower levels of coverage (Medicaid, Medicare + Medicaid, no insurance).

Bivariate analyses were performed to determine the relationship between each factor and symptoms. A multivariate logistic model that included all factors, and ZDS responses as the dependent variable, was fit to determine independent predictors of depressive symptoms. All analyses were performed using STATA statistical software (Intercooled Version 7, College Station, TX).

Results

A total of 550 subjects were approached and 509 patients participated in the study (92.6% participation rate) and Table 1 contains the demographic distribution of participants and nonparticipants. The mean age of participants was 46.78 years (SD 17.12), while nonparticipants had a mean age of 50.02 years (SD 18.24). Both participants and nonparticipants were predominantly white and female. Approximately half of the study population was married and most completed at least a high school education. A majority of participants had an established relationship with their physician for 7 years or less, in addition to reporting private health insurance.

A total of 15 patients (3%) of the sample population reported depressive symptoms based on summed Zung Depression Scale scores of 50 or greater. Summed scores from the Spirituality Index of Well-Being (SIWB) ranged from 0 to 60, with higher scores indicating greater spirituality. In this sample, the mean for the SIWB total scale was 49.14 (SD 8.63) and mean for the ZDS was 23.57 (SD 11.42).

Table 2 lists the unadjusted and adjusted variables associated with depression. Less insurance coverage (P < 0.01) and greater spirituality (P < 0.01) were associated with less reported depressive symptoms in bivariate analyses, and spirituality (P < 0.01) remained independently associated with symptoms in multivariate analysis.

Discussion

The purpose of this study was to examine the association between depressive symptoms and spirituality in a primary care outpatient population. In our sample, greater spirituality was found to be independently and inversely associated with depressive symptoms. There are several potential mechanisms by which spirituality affects both physical and mental health. (2) In our conceptual framework, a perceived or real threat to a patient's health or functional status promotes two tasks: the gathering and processing of diagnostic, prognostic, and treatment information, and the interpretation and meaning-making of these data within the context of the patient's life course. (8) Depressive symptoms may be alleviated by coping strategies and the coping literature describes the activity of meaning-making as a cognitive representation of one's life which provides a sense of order and purpose. (13) Conceptually, spirituality is the product of this meaning-making work and is the composite of a congruent, meaningful life scheme and a high degree of positive intentionality or self-efficacy. (8)

Meaning-making and the promotion of personal agency, based upon Viktor Frankl's existential logotherapy, are well recognized in the psychotherapeutic disciplines. (18,19) Within the fields of palliative and end-of-life care, meaning-making has been part of an impetus to understand and develop person-centered approaches to care by focusing on spiritual issues that are grounded in existential meaning. (20) For example, a study of terminal cancer patients found that level of spirituality, also operationalized by meaning, was the strongest independent predictor of suicidal ideation, hopelessness, and desire for a hastened death, even after adjusting for the effect of depressive symptoms and other relevant variables. (21) Our study results are consistent with these findings and suggest that the process of making and finding meaning in life may be one plausible mechanism that links spirituality and depressive symptoms.

What are the implications of this work for primary care physicians who manage the majority of patients with depression? (22) First, spirituality should be viewed as conceptually distinct from religion and may be framed in a perspective of meaning and meaning-making as the patient experiences health and illness. Second, interventions that seek to enhance or promote spirituality in clinical settings should be meaning-centered and take into account the larger context of the patient's life course. Preliminary clinical interventions in end-of-life care have used a blend of basic psychotherapeutic principles and techniques, such as life narrative and life review, to provide palliative and supportive care to patients. (20) As physicians of context and continuity, these skills can be incorporated by primary care physicians into routine patient care, particularly among patients facing serious chronic illness, disability, or the end of life.

Although not statistically significant, the study trends were consistent with existing literature regarding the direction of association of demographic factors (eg, race, gender) with depression and depressive symptoms; women and whites report higher rates of symptoms. (23,24) The prevalence of symptoms in our sample, determined by the Zung Depression Scale, was 3% and is lower than national estimates. For example, a report from the U.S. Surgeon General lists one-year prevalence rates of major depressive episodes at 6.5% and unipolar major depression at 5.3% based on Epidemiologic Catchment Area and National Comorbidity Study estimates. (24) The US National Institute of Mental Health also reports a 9.5% prevalence rate of depressive disorders, comprised of major depressive disorder, dysthymic disorder, and bipolar disorder. (23) Finally, the prevalence of depressive symptoms, determined by the ZDS, was found to be 21% in a national sample of patients from primary care practices. (17) The variation in these prevalence rates speaks to the challenge of case definition and case finding in depressive symptoms.

We were surprised by the finding of an unadjusted association of less depressive symptoms in patients who had Medicaid or no health insurance in bivariate analysis. Major depression is associated with high medical utilization and medical costs (25) and the indirect costs of depression, such as decreased productivity and work absenteeism, are twice as high as the direct medical costs. (26) However, our sample predominantly reported having health insurance (75%), which may have impacted our analytical power.

There were several limitations to our study. The cross-sectional design of the study also did not allow us to draw any definitive conclusions about the causal relationships of the variables, and we did not examine site response rates or clustering by individual practice site. The study population was largely white, which limits the power to analyze by ethnicity, but our demographic proportion of white to nonwhite was comparable to the racial and ethnic distribution in the region. (27)

In summary, we found that spirituality, as conceptualized by a congruent, meaningful life scheme and a high degree of positive intentionality or self-efficacy, was independently associated with less depressive symptoms in a sample of primary care outpatients. Although patients report that spirituality is important within selected healthcare settings in the United States, (28) particularly in the lives of minority elderly (29,30) patients and in the context of serious illness and end-of-life care, (31) uncovering a plausible mechanism that explains how spirituality impacts physical and mental health has been elusive. Further exploration of the existential aspects of meaning, and the processes involved in meaning-making, may promote a fuller understanding of this linkage.

Acknowledgments

We are grateful to Lynn Maxwell and to the practices in the greater Kansas City area that participated in this study.

References

1. George LK, Larson DB, Koenig HG, et al. Spirituality and health: what we know, what we need to know. Journal of Social and Clinical Psychology 2000;19:102-116.

2. Koenig HG, McCullough ME, Larson DB. Handbook of Religion and Health. New York, Oxford University Press, 2001.

3. Sloan RP, Bagiella E, Powell T. Religion, spirituality, and medicine. Lancet 1999;353:664-667.

4. Wuthnow R. After Heaven: Spirituality in America since 1950. Berkeley, University of California Press, 1998.

5. Hebert RS, Jenckes MW, Ford DE, et al. Patient perspectives on spirituality and the patient-physician relationship. J Gen Intern Med 2001;16:685-692.

6. Wulff DM. Psychology of Religion, Classic and Contemporary, 2nd ed. New York,: John Wiley & Sons, 1997.

7. Daaleman TP, Frey BB, Wallace D, et al. The Spirituality Index of Well-Being: development and testing of a new measure. J Fam Pract 2002;51:952.

8. Daaleman TP, Cobb AK, Frey BB. Spirituality and well-being: an exploratory study of the patient perspective. Social Science and Medicine 2001;53:1503-1511.

9. Antonovsky A. Unraveling the Mystery of Health: How People Manage Stress and Stay Well. San Francisco, Jossey-Bass, 1987.

10. Bandura A. Self-efficacy, the Exercise of Control. New York: WH Freeman Press, 1997.

11. Daaleman TP, Frey BB. The Spirituality Index of Well-Being: a new instrument for health-related quality-of-life research. Ann Fam Med 2004;2:499-503.

12. Kleinman A. The Illness Narratives. New York, Basic Books, 1988.

13. Thompson SC, Janigian AS. Life schemes: a framework for understanding the search for meaning. Journal of Social and Clinical Psychology 1988;7:260-280.

14. Zung WW. A self-rating depression scale. Arch Gen Psychiatry 1965;12:63-70.

15. Passik SD, Kirsh KL, Donaghy KB, et al. An attempt to employ the Zung Self-Rating Depression Scale as a "lab test" to trigger follow-up in ambulatory oncology clinics: criterion validity and detection. J Pain Symptom Manage 2001;21:273-281.

16. Passick SD, Kirsh KL, Donaghy K, et al. Patient-related barriers to fatigue communication: initial validation of the fatigue management barriers questionnaire. J Pain Symptom Manage 2002;24:481-493.

17. Zung WW, Broadhead WE, Roth ME. Prevalence of depressive symptoms in primary care. J Fam Pract 1993;37:337-344.

18. Frankl VF. Man's Search for Meaning. Boston, Beacon House, 1959.

19. Frankl VF. The Will to Meaning. Foundations and Applications of Logo-therapy, expanded edition. New York, Penguin, 1969.

20. Breitbart W. Spirituality and meaning in supportive care: spirituality and meaning-centered group psychotherapy interventions in advanced cancer. Support Care Cancer 2002;10:272-280.

21. 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.

22. Schurman RA, Kramer PD, Mitchell JB. The hidden mental health network. Treatment of mental illness by nonpsychiatrist physicians. Arch Gen Psychiatry 1985;12:89-94.

23. National Institute of Mental Health. NIMH, the Numbers Count. National Institute of Health. Available at: http://nimh.nih.gov/publicat/numbers.cfm. Accessed February 19, 2004.

24. Office of the Surgeon General US Public Health Service. Mental Health: A Report of the Surgeon General. Available at: http://surgeongeneral.gov/Library/MentalHealth/chapter2/sec2_1.html. Accessed February 19, 2004.

25. Eisenberg L. Treating depression and anxiety in primary care. Closing the gap between knowledge and practice. N Engl J Med 1992;326:1080-1084.

26. Greenberg PE, Stiglin LE, Finkelstein SN, et al. The economic burden of depression in 1990. J Clin Psychiatry 1993;54:405-418.

27. US Bureau of the Census. Estimates of the Population of Counties by Age, Sex, and Race/Hispanic Origin, 1991-1997, Internet release date September 4, 1998. Available at: http://census.gov/popest/counties/asrh/.

28. MacLean CD, Susi B, Phifer N, et al. Patient preference for physician discussion and practice of spirituality. J Gen Intern Med 2003;18:38-43.

29. Williams DR, Wilson CM. Race, ethnicity, and aging. In: Binstock RH, George LK, eds. Handbook of Aging and the Social Sciences, 5th ed. San Diego, Academic Press, 2001:160-178.

30. Gallup G, Lindsay DM. Surveying the Religious Landscape, Trends in US Beliefs. Harrisburg,: Morehouse Publishing, 1999.

31. Daaleman TP, VandeCreek L. Placing religion and spirituality in end-of-life care. JAMA 2000;284:2514-2517.

Timothy P. Daaleman, DO, MPH, and Jay S. Kaufman, PhD

From the Department of Family Medicine, Program on Aging, Disability, and Long-Term Care, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill. Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC.

Reprint requests to Timothy P. Daaleman, DO, MPH, Department of Family Medicine, University of North Carolina at Chapel Hill, Campus Box 7595, Manning Drive, Chapel Hill, NC 27599-7595. Email: [e-mail]

Financial Support was provided by the Robert Wood Johnson Foundation Generalist Physician Faculty Scholars Program, the National Institute on Aging [1K23 AG01033], and the Fetzer Institute.

Accepted April 5, 2006.

RELATED ARTICLE: Key Points

* Spirituality, conceptualized as a congruent, meaningful life scheme, and a high degree of positive intentionality, or self-efficacy beliefs, is independently associated with fewer depressive symptoms in primary care outpatients.

* Spirituality can be viewed as conceptually distinct from religion and may be framed in a perspective of meaning and meaning-making as the patient experiences health and illness.

Table 1. Demographic and health service characteristics of study sample
(N = 550)

                                Participants  Nonparticipants
                                (%)           (%)

Gender
  Female                        344 (67.6)    25 (62.5)
  Male                          165 (32.4)    15 (37.5)
Race/ethnicity
  White                         401 (78.8)    30 (75.0)
  African American               94 (18.5)     6 (15.0)
  Hispanic/Latino                 9 (1.8)      2 (5.0)
  Asian American                  4 (0.8)      1 (2.5)
  Other                           1 (0.2)     --
Marital status
  Married                       257 (50.8)
  Single/never married          114 (22.5)
  Divorced                       63 (12.5)
  Widowed                        49 (9.7)
  Separated                      13 (2.6)
  Life partner                   10 (2.0)
Education level
  Less than high school          63 (12.4)
  High school graduate          136 (26.8)
  Vocational/trade school        50 (9.9)
  Some college                  158 (31.2)
  College graduate               68 (13.4)
  Graduate/professional school   32 (6.3)
Length of time with
  current physician
  Less than 1 year              131 (25.8)
  1-3 years                     139 (27.4)
  4-7 years                     112 (22.0)
  7-10 years                     71 (14.0)
  10-15 years                    44 (8.7)
  16 or more years               11 (2.2)
Health insurance
  Private health insurance      319 (62.9)
  Private and Medicare           64 (12.6)
  Medicaid                       42 (8.3)
  Medicare and Medicaid          35 (6.9)
  Medicare                       26 (5.1)
  No insurance                   19 (3.7)
  Other                           2 (0.8)

Table 2. Predictors of depressive symptoms in primary care outpatients
(N = 509)

                       Unadjusted             Adjusted
Factor (a)             OR (95%CI)             OR (95%CI)

Male gender            0.71 (0.25, 2.02)      0.67 (0.20, 2.35)
Nonwhite race          0.56 (0.12, 2.51)      0.38 (0.06, 2.31)
Age                    0.98 (0.94, 1.01)      0.97 (0.93, 1.01)
Married/partnered      0.44 (0.15, 1.31)      1.11 (0.27, 4.67)
Level of education     0.64 (0.42, 0.95)      0.74 (0.44, 1.24)
No insurance/Medicaid  0.19 (0.07, 0.54) (b)  0.71 (0.17, 2.92)
Spirituality           0.84 (0.79, 0.89) (b)  0.85 (0.80, 0.91) (b)

(a) Referent factors: female gender, white race, Age (one year younger),
less social support (single, divorced, widowed, separated), level of
education (one level lower), higher socioeconomic status (private,
private + Medicare, Medicare insurance), SIWB (score of one less).
(b) P< 0.01.