Systematic review of clinical trials examining the effects of religion on health. (Review Article).ABSTRACT: Using MEDLINE The online medical database of the U.S. National Library of Medicine (NLM) whose parent is the National Institutes of Health, Bethesda, MD. MEDLINE contains millions of articles from thousands of medical journals and publications. The consumer section of the site (http://medlineplus. , (limited to the English language English language, member of the West Germanic group of the Germanic subfamily of the Indo-European family of languages (see Germanic languages). Spoken by about 470 million people throughout the world, English is the official language of about 45 nations. and the reference lists of the randomized controlled trials A randomized controlled trial (RCT) is a scientific procedure most commonly used in testing medicines or medical procedures. RCTs are considered the most reliable form of scientific evidence because it eliminates all forms of spurious causality. (RCTs), we assessed the impact of religion on health outcomes via systematic, critical review of the medical literature. All RCTs published from 1966 to 1999 and all non-RCTs published from 1996 to 1999 that assessed a relationship between religion and measurable health outcome were examined. We excluded studies dealing with nonreligious spirituality, ethical issues, coping, well-being, or life satisfaction. We used the Canadian Medical Association The Canadian Medical Association (CMA), with more than 65,000 members, is the largest association of doctors in Canada and works to represent their interests nationally. It formed in 1867, three months after Confederation. Journal's guidelines for systematic review of the medical literature to evaluate each manuscript. Nine RCTs and 25 non-RCTs met these inclusion/exclusion criteria inclusion/exclusion criteria Clinical research The medical or social reasons why a person may/may not qualify for participation in a clinical trial . Randomized controlled trials showed that intercessory in·ter·ces·sion n. 1. Entreaty in favor of another, especially a prayer or petition to God in behalf of another. 2. Mediation in a dispute. prayer may improve health outcomes in patients admitted to a coronary care unit coronary care unit n. Abbr. CCU A hospital unit that is specially equipped to treat and monitor patients with serious heart conditions, such as coronary thrombosis. but showed no effect on alcohol abuse. Islamic-based psychotherapy speeds recovery from anxiety and depression in Muslims. Non-RCTs indicate that religious activities appear to benefit blood pressure, immune function Immune function The state in which the body recognizes foreign materials and is able to neutralize them before they can do any harm. Mentioned in: Herbalism, Traditional Chinese, Stress Reduction , depression, and mortality. ********** RELIGION is a source of comfort to some and conflict to others. The vast majority of Americans (94%) claim to believe in God. (1) Among older Americans, 98% believe in God, and 95% pray regularly. (2) However, physicians tend to ignore religious issues in the care of their patients, (3) and the majority of scientists reject any belief in God. (4) In published medical literature, there is similar conflict. Sloan et al (5) reviewed the literature and found inconsistent and weak links between religion and health. In contrast, the reviews by Levin and Schiller (6) and by Larson et al (7) identified generally positive effects of religion on physical and mental health, leading some authors to call for a revival in the soul of health care. (8) Given this conflict, we conducted a systematic, critical review of the medical literature. We focused on rigorously designed studies--ie, randomized controlled trials (RCTs). To avoid missing potentially important scientific investigations that used less rigorous designs, we also reviewed recently published cross-sectional or other studies assessing the interaction (positive or negative) between religion and health. METHODS Our goal was to assess the impact (positive or negative) of religion on health outcomes. We used standard definitions of religion. Webster's dictionary Webster's Dictionary - Hypertext interface. defines religion as, "a set of beliefs concerning the cause, nature and purpose of the universe ... usually involving devotional de·vo·tion·al adj. Of, relating to, expressive of, or used in devotion, especially of a religious nature. n. A short religious service. de·vo and ritual observances, and often containing a moral code for the conduct of human affairs. A specific fundamental set of beliefs and practices generally agreed upon Adj. 1. agreed upon - constituted or contracted by stipulation or agreement; "stipulatory obligations" stipulatory noncontroversial, uncontroversial - not likely to arouse controversy by a number of persons or sects." (9) For the purposes of this review, we accepted any reproducible measure of religion in accordance with that definition. Importantly, however, we did not assess spirituality. Spirituality was excluded because it is a set of "personal views and behaviors that express a sense of relatedness to the transcendental dimension or to something greater than the self" (10) Therefore, we reviewed such activities as prayer or church attendance but not seances. Health outcome was defined as any outcome that can be quantitated by reproducible, universally accepted, and established diagnostic criteria that are validated by current medical literature. Death is an easily understood health outcome. Our first step was to search MEDLINE for RCTs of religion or religious activities with any health outcome. The following inclusion criteria
Inclusion criteria are a set of conditions that must be met in order to participate in a clinical trial. and exclusion criteria exclusion criteria AIDS Donor exclusion criteria, see there were used. To be included, a trial must have been published in English during the 33 years between 1966 and 1999. Trials were excluded if they were designed to assess yoga, meditation, or noncontact therapeutic touch, because they did not meet the definitions of religion used in this review. We also excluded trials designed primarily to assess the implications of refusing therapy (eg, Jehovah's Witnesses Jehovah's Witnesses, Christian group originating in the United States at the end of the 19th cent., organized by Charles Taze Russell, whose doctrine centers on the Second Coming of Christ. refusing transfusion-related products). The Medical Subject Headings (MeSH) used to search MEDLINE were defined by initially searching for articles with religion as the major topic of the citation. Additional headings were defined by analyzing "main MeSH" and "additional MeSH" of the retrieved citations. The following headings were thus used to conduct the MEDLINE search: Religion; Religion (AND) Medicine; Religion (OR) Intercessory Prayer; Prayer; Prayer Therapy; Religious Rites; Faith; Medicine, Traditional; Religiosity re·li·gi·os·i·ty n. 1. The quality of being religious. 2. Excessive or affected piety. Noun 1. religiosity - exaggerated or affected piety and religious zeal religiousism, pietism, religionism ; Religion (AND) Psychology; and Religion (AND) Health. The abstracts from each search were printed, and using these inclusion/exclusion criteria, 18 articles were recovered. The 18 articles were read independently by all four of us, then we used consensus to evaluate whether the study assessed religion and a health outcome. Two of the 18 articles were excluded because they were not true RCTs, and 7 were excluded because although the abstract suggested that the article would fit within the inclusion criteria, the full-length article revealed details that excluded the study (ie, patient satisfaction was the only health outcome). Nine RCTs remained. A second MEDLINE search, not limited to RCTs, was conducted using MeSH: "religion" or "prayer" (as the major focus of the citation or as a word in the title). Studies addressing only ethical issues in religion, attitudes toward religion, coping, well-being, or life satisfaction were excluded. This search was limited to 3 years (1996-1999) and produced 1,410 citations, the abstracts of which were printed. All abstracts were systematically analyzed by two of us (M.T. and V.K.) looking for Looking for In the context of general equities, this describing a buy interest in which a dealer is asked to offer stock, often involving a capital commitment. Antithesis of in touch with. the word "prayer" or "religion" in the title, or for an abstract that suggested that the article analyzed an association between religion and any measurable health outcome. If a citation did not have an abstract, the article was retrieved in full for further evaluation of relevance. Using these inclusion/exclusion criteria, 46 abstracts were selected. The 46 articles were then independently reviewed by each of us. By consensus, 23 articles were excluded based on our exclusion criteria. Twenty-three articles were included for this review. In addition, the two studies that were erroneously listed in MEDLINE as RCTs were added to this group, making the number of articles included for review from this (non-RCT) search 25. We next reviewed the list of references from the RCTs for additional citations that were otherwise missed. This final step did not reveal additional citations. After retrieval of all articles, each of us independently read all articles. After independent review, we did a joint critical review of each article. The RCTs were evaluated using published guidelines for the systematic review of RCTs. (11) The 25 non-RCTs were reviewed in accordance with guidelines for the review of articles to elucidate etiology or causation. (12) DATA SYNTHESIS data synthesis Meta-analysis, see there Randomized Controlled Trials We found 5 RCTs assessing the efficacy of prayer. The earliest is a double-blind study double-blind study, n experimental technique in clinical research in which neither the researcher nor the patient knows whether the treatment administered is considered inactive (placebo) or active (medicinal). of the effect of intercessory prayer as an adjunct to the treatment of childhood leukemia leukemia (l  kē`mēə), cancerous disorder of the blood-forming tissues (bone marrow, lymphatics, liver, spleen) characterized by excessive production of immature or mature . (13) In this study, Protestant
prayer appeared to decrease mortality among children with leukemia.
Although potentially of real importance, this study has several
limitations. Specifically, the sample size was small (n = 18), the
randomization randomization (ranˈ·d ·m technique was not described, and no attempt was made to
control for other variables (eg, type of leukemia) that may have
influenced the outcome. (13) Nevertheless, if Protestant prayer improves
survival in children with leukemia, the implications are substantial.
The next prayer RCT RCT Randomized Controlled Trial RCT Regimental Combat Team (infantry regiment with their own artillery, engineers, medical and tanks) RCT Rollercoaster Tycoon RCT Randomized Clinical Trial RCT Rhondda Cynon Taff was the double-blind study of Byrd (14) on intercessory prayer as an adjunct to usual care for patients admitted to a coronary care unit (CCU CCU abbr. 1. coronary care unit 2. critical care unit CCU critical care unit. CCU Critical care unit, see there ). Approximately 400 consenting patients admitted to a CCU were randomly assigned by a computer-generated list to either a prayer group or control group. The treatment group received daily intercessory prayer by evangelical Christians This is a list of people who are notable due to their influence on the popularity or development of evangelical Christianity or for their professed Evangelicalism. Historical
Diuretics are medicines that help reduce the amount of water in the body. Purpose Diuretics are used to treat the buildup of excess fluid in the body that occurs with some medical conditions such as congestive heart , and ventilator ventilator /ven·ti·la·tor/ (ven´ti-la-tor) 1. an apparatus for qualifying the air breathed through it. 2. a device for giving artificial respiration or aiding in pulmonary ventilation. support in CCU patients. This study was limited, however, because the number of intercessors intercessors, n.pl in spiritual healing, individuals who offer prayer to a higher power on behalf of another person in need of assistance or healing. (ie, the dose of the intervention) was not controlled and the numerical specifics of multivariate analysis multivariate analysis, n a statistical approach used to evaluate multiple variables. multivariate analysis, n a set of techniques used when variation in several variables has to be studied simultaneously. were not reported. Nevertheless, the rigorous study design, the homogeneity of the intervention (though not the dose), and the statistically and clinicall y significant outcomes made this a landmark study. The most recently published RCT was an attempt to replicate Byrd's study. The investigators studied approximately 1,000 patients consecutively admitted to the CCU over 12 months. (15) Patients were randomized ran·dom·ize tr.v. ran·dom·ized, ran·dom·iz·ing, ran·dom·iz·es To make random in arrangement, especially in order to control the variables in an experiment. according to according to prep. 1. As stated or indicated by; on the authority of: according to historians. 2. In keeping with: according to instructions. 3. their medical record number into the prayer or control group. Prayer group subjects received intercessory prayer from a team of five Christians (of various denominations) for 28 days, as an adjunct to usual care. Subjects, health care providers, and intercessors were blinded to the assignment of the intervention. The investigators used a continuous variable that described outcomes from excellent to catastrophic. From this study, one can conclude that Christian prayer results in 10% better outcomes in the intervention group. O'Laoire (16) studied the effect of intercessory prayer on self-esteem, anxiety and depression. In this study, adult volunteers responded to advertisements for a prayer study. Their self-esteem, depression, and anxiety were evaluated using multiple instruments. Volunteers were then randomly assigned to one of three groups (n = 100 in each), though the randomization technique was not stated. One group received directed prayer (ie, God, please decrease Smith's anxiety), one group received nondirected prayer (ie, God, may your will be done in Mr. Smith), and one group received no prayer. Another group volunteered to be the prayer intercessors. Unfortunately, the complexity of the study and the overwhelming quantity of data presented made it was difficult to discern positive or negative effects of prayer on the studied outcomes. In a randomized, double-blind study of prayer as an adjunct to traditional therapy for patients admitted to a university center for the treatment of alcohol abuse, there was no difference in outcomes between the prayer group and the control group. (17) Intervention consisted of intercessory prayer by a mixed group of Protestant, Catholic, and Jewish intercessors praying in whatever way they chose. At 6 months of study, there was no difference in alcohol intake between the prayer and control groups. However, both groups had a near 100% response rate to treatment. Therefore, it seems unlikely that any intervention could have been better than the control group outcome. In addition, the intervention was rather heterogeneous (mixed group of intercessors praying as they saw fit). We found three RCTs (by two groups of authors) testing the efficacy of religion-based psychotherapy in the treatment of religious people with anxiety or depression. (18-20) All three studies evaluated the effect of Islam-based psychotherapy on religious (Muslim) Malays suffering from anxiety and depression. Using patients who fulfilled the criteria for either anxiety or depression, the intervention groups were given religious psychotherapy in addition to traditional secular psychotherapy. The religious psychotherapy consisted of advice or encouragement based on the Koran and Hadith hadith (hädēth`), a tradition or the collection of the traditions of Muhammad, the Prophet of Islam, including his sayings and deeds, and his tacit approval of what was said or done in his presence. . Outcome assessments were blinded to whether subjects were in the religious or the nonreligious treatment group. In each study, it appeared that religious (Islamic) psychotherapy speeds recovery from anxiety and depression in Muslims. However, the investigators did not control for the use of antidepressants Antidepressants Medications prescribed to relieve major depression. Classes of antidepressants include selective serotonin reuptake inhibitors (fluoxetine/Prozac, sertraline/Zoloft), tricyclics (amitriptyline/ Elavil), MAOIs (phenelzine/Nardil), and heterocyclics , benzodiazepines Benzodiazepines Definition Benzodiazepines are medicines that help relieve nervousness, tension, and other symptoms by slowing the central nervous system. Purpose Benzodiazepines are a type of antianxiety drugs. , or Bomahs (healers). From these studies, one could conclude that Islam-based psychotherapy may speed recover y from anxiety and depression in Muslims. Propst (21) studied the efficacy of religious cognitive-behavioral therapy Cognitive-Behavioral Therapy Definition Cognitive-behavioral therapy is an action-oriented form of psychosocial therapy that assumes that maladaptive, or faulty, thinking patterns cause maladaptive behavior and "negative" emotions. as treatment for clinical depression in Christian patients. Patients were evaluated before and after receiving one of the following: (1) religion-based cognitive therapy cognitive therapy n. Any of a variety of techniques in psychotherapy that utilize guided self-discovery, imaging, self-instruction, and related forms of elicited cognitions as the principal mode of treatment. with a religious therapist, (2) religion-based therapy with a nonreligious therapist, (3) nonreligious or standard cognitive therapy with a religious therapist, (4) standard cognitive therapy with a nonreligious therapist, (5) pastoral counseling Pastoral counseling is a branch of counseling in which ordained ministers, rabbis, priests and others provide therapy services. Practitioners in the United States are subject to the standards of the American Association of Pastoral Counseling and many are either licensed as a LPC , or (6) no treatment. The primary limitation of this study is its complexity making it difficult to extract useful information. Nevertheless, religious patients who had therapy of any kind appeared to recover as measured by the Hamilton Rating Scale for Depression and the Beck Depression Inventory Beck Depression Inventory A trademark for a standardized questionnaire used to diagnose depression. Beck Depression Inventory . In summary, RCTs support the thesis that Christian intercessory prayer improves health outcomes in patients admitted to a CCU and may improve survival in children with leukemia. In addition, Islamic-based psychotherapy appears to speed recovery from anxiety and depression in Muslims. Randomized controlled trials do not allow conclusions pertaining per·tain intr.v. per·tained, per·tain·ing, per·tains 1. To have reference; relate: evidence that pertains to the accident. 2. to the impact of intercessory prayer on alcohol abuse or mental health. Non-RCT Studies Among the recent non-RCTs that we reviewed, religious activity appeared to be beneficial to immune function, blood pressure, mental health, and survival. Focusing specifically on immune function, there appears to be a positive (but weak) association between attendance at religious services and better immune status in older North Carolina North Carolina, state in the SE United States. It is bordered by the Atlantic Ocean (E), South Carolina and Georgia (S), Tennessee (W), and Virginia (N). Facts and Figures Area, 52,586 sq mi (136,198 sq km). Pop. residents. (22) The correlation between religious activity and immune status concurs with the data showing that in HIV-infected homosexual men, religious behavior is strongly associated with improved immune status (CD4 counts) (23) Although these two studies are the first of their kind, they introduce an issue that deserves future study. Religion also has an apparent beneficial effect on blood pressure. Among female alumnae from two colleges and immigrants to America, religious activity is associated with the absence of high blood pressure. (24,25) Intrinsic religiosity (eg, private prayer, devotional reading) may protect against the development of hypertension (systolic Systolic The phase of blood circulation in which the heart's pumping chambers (ventricles) are actively pumping blood. The ventricles are squeezing (contracting) forcefully, and the pressure against the walls of the arteries is at its highest. and diastolic Diastolic The phase of blood circulation in which the heart's pumping chambers (ventricles) are being filled with blood. During this phase, the ventricles are at their most relaxed, and the pressure against the walls of the arteries is at its lowest. ). Although this association is strong only among immigrants, it is consistent between studies. The health outcome that has received the most study is mental health. In prospective cohort studies, religious activity is associated with (1) remission of depression in Protestant and Catholic Netherlanders, (26) (2) remission of depression in ill older adults, (27) (3) protection against depression in Protestant and Catholic offspring who share the same religion as their mother, (28) and (4) a protective effect from symptoms of depression in female twins. (29) The beneficial effect of religion is strong for all these outcomes, with the exception of the twin study. In contrast, Kennedy et al (30) reported that in older adults living in the New York New York, state, United States New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of , being Jewish was weakly associated with depression. However, this association has not been confirmed in other studies. Cross-sectional studies have also suggested a beneficial effect of religious activity on mental health. Religiosity is strongly associated with less depression in Spanish spousal caregivers, (31) and church attendance is associated with absence of depression in community-dwelling older adults. (32) In several additional cross-sectional studies, the association between religious involvement and depression remains consistent from study to study but does not reach statistical significance. These studies suggest that (1) private prayer may be associated with decreased depression after coronary artery bypass surgery Coronary artery bypass surgery, also coronary artery bypass graft surgery, and colloquially heart bypass or bypass surgery is a surgical procedure performed to relieve angina and reduce the risk of death from coronary artery disease. among married men, (33) (2) church attendance may be associated with decreased medical illness burden and depressive symptoms in older Judeo-Christian adults, (34) (3) religious activity may be associated with decreased depression among African Americans with cancer, (35) (4) religious involvement may be associated with fewer depressive symptoms among older Dutch men, (36) (5) religiosity may limit stressors in depressed patients, (37) and (6) religious commitment may protect against depression among retired Catholic Sisters. (38) Religion may also have a protective effect against suicide. Although limited by nation-specific reporting biases, cross-sectional data Cross-sectional data in statistics and econometrics is a type of one-dimensional data set. Cross-sectional data refers to data collected by observing many subjects (such as individuals, firms or countries/regions) at the same point of time, or without regard to differences in time. from 26 countries show a strong association between religiosity and lower suicide rates in Judeo-Christian older adults. (39) In a prospective cohort of older adults residing in New Haven New Haven, city (1990 pop. 130,474), New Haven co., S Conn., a port of entry where the Quinnipiac and other small rivers enter Long Island Sound; inc. 1784. Firearms and ammunition, clocks and watches, tools, rubber and paper products, and textiles are among the many , Connecticut, church attendance was associated with better physical functional status over 12 years. (40) However, this study contained few indicators of religious involvement other than church attendance, and was the only study of its kind in our review. We found a single study evaluating the impact of religion on psychosocial adjustment in cancer patients. However, no statistically significant results were presented, perhaps because the convenience sample of subjects was small or because religion had no effect. (41) Survival (as opposed to death) may be the most important health outcome. In two large prospective cohorts in California, church attendance (at least weekly) was associated with decreased mortality. (42,43) This association was strong in both studies, and is consistent with the extant literature Extant literature refers to texts that have survived from the past to the present time. Extant literature can be divided into extant original manuscripts, copies of original manuscripts, quotations and paraphrases of passages of non-extant texts contained in other works, . In addition, two recent cross-sectional studies showed that religious activity in older adults is associated with lower mortality in both men and women. (44,45) Finally, a historical cohort also shows a consistent association of the protective effect of religion on mortality. (46) In this study of kibbutzim
kibbutz Israeli communal settlement in which all wealth is held in common and profits are reinvested in the settlement. The first kibbutz was founded in Palestine in 1909; most have since been agricultural. was associated with decreased mortality over 16 years in comparison to a secular kibbutz. In summary, several studies in multiple cultures suggest that religious activity is positively associated with survival. CONCLUSIONS Involvement in religion or religious activities may promote mental and physical health. (47) Proposed explanations range from promoting positive social and interpersonal functions, affirmation of shared beliefs, improving coping skills, resolution of guilt, diminished fear of punishment, the threat of embarrassment and possibility of social sanctions, and the desire to emulate the lives of a reference person or group. (48,49) Regardless of the mechanism by which religion impacts health, religion is important to patients. More than 70% of Americans say their approach to life is based on their religion, (50) 75% of patients think their physician should address religious issues, and 50% of patients want their physician to pray with them. (3,5) Considering that patients think religion is important, that religion likely benefits health outcomes, and that religion is without financial cost, health care providers should include religion in the care of their patients. In summary, Christian intercessory prayer appears to improve health outcomes in patients admitted to a CCU and may improve survival in children with leukemia. Islamic-based psychotherapy appears to speed recovery from anxiety and depression in Muslims. Religion may also have a positive impact on immune function, blood pressure, depression, suicide rate, and mortality in older adults. Despite the limitations of the various studies, the preponderance of evidence A standard of proof that must be met by a plaintiff if he or she is to win a civil action. In a civil case, the plaintiff has the burden of proving the facts and claims asserted in the complaint. supports the beneficial effect of religion on health outcomes. The need for ongoing research in this arena is evident. While some physicians may be uncomfortable addressing religion in the practice of medicine, this critical review of the literature is no doubt encouraging to those who do address it. References (1.) Gallup G: Religion in America
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These include prayer, congregational support, pastoral care, and religious faith. and mortality. Psychol Aging 1998; 13:242-255 (45.) Koenig HG, Hays JC, Larson DB, et al: Does religious attendance prolong survival? a six-year follow-up study of 3,968 older adults. J Gerontol 1999; 54:M370-M376 (46.) Kark JD, Shemi G, Friedlander Y, et al: Does religious observance promote health? mortality in secular vs religious kibbutzim in Israel. Am J Public Health 1996; 86:341-346 (47.) Ellison C, Levin J: The religion-health connection: evidence, theory, and future directions. Health Educ Behav 1998; 25:700-720 (48.) Levin S, Chatters L, Taylor R: Religious effects on health status and life satisfaction among black Americans. J Gerontol 1995; 50B:S154-S163 (49.) Ellis L: Religiosity and criminality: evidence and explanations of complex relationships. Sociol Perspect 1985; 28:501-520 (50.) Dent S: Spirituality: don't make patients check it at the door. FP Report July 1999; 5:1 KEY POINTS * The vast majority of Americans consider religion as an important part of their life and want health care providers to address religious issues. * Randomized controlled trials indicate that intercessory prayer may improve health outcomes in patients admitted to the coronary care unit but has no apparent effect on alcohol abuse. * Islamic-based psychotherapy speeds recovery from anxiety and depression in Muslims. * Nonrandomized controlled trials indicate that religious beliefs and activities appear to benefit blood pressure, immune function, depression, and mortality. From the Department of Medicine, Virginia Commonwealth University Formed by a merger between the Richmond Professional Institute and the Medical College of Virginia in 1968, VCU has a medical school that is home to the nation's oldest organ transplant program. , and Hunter Holmes McGuire VA Medical Center, Richmond. Reprint requests to Hana Ayele, MD, 1201 Broad Rock Blvd (181), Richmond, VA 23249. |
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