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1ORIGINAL PAPER
2Mental Disorders, Religion and Spirituality 1990 to 2010:
3A Systematic Evidence-Based Review
4Raphael M. Bonelli •Harold G. Koenig
5
6!Springer Science+Business Media New York 2013
7Abstract Religion/spirituality has been increasingly examined in medical research dur-
8ing the past two decades. Despite the increasing number of published studies, a systematic
9evidence-based review of the available data in the field of psychiatry has not been done
10 during the last 20 years. The literature was searched using PubMed (1990–2010). We
11 examined original research on religion, religiosity, spirituality, and related terms published
12 in the top 25 % of psychiatry and neurology journals according to the ISI journals citation
13 index 2010. Most studies focused on religion or religiosity and only 7 % involved inter-
14 ventions. Among the 43 publications that met these criteria, thirty-one (72.1 %) found a
15 relationship between level of religious/spiritual involvement and less mental disorder
16 (positive), eight (18.6 %) found mixed results (positive and negative), and two (4.7 %)
17 reported more mental disorder (negative). All studies on dementia, suicide, and stress-
18 related disorders found a positive association, as well as 79 and 67 % of the papers on
19 depression and substance abuse, respectively. In contrast, findings from the few studies in
20 schizophrenia were mixed, and in bipolar disorder, indicated no association or a negative
21 one. There is good evidence that religious involvement is correlated with better mental
22 health in the areas of depression, substance abuse, and suicide; some evidence in stress-
23 related disorders and dementia; insufficient evidence in bipolar disorder and schizophrenia,
24 and no data in many other mental disorders.
25 Keywords Religiosity !Spirituality !Psychiatry !Depression !Substance abuse !Suicide
26
A1 R. M. Bonelli
A2 Sigmund Freud University, Vienna, Austria
A3 R. M. Bonelli
A4 Institute of Religiosity in Psychiatry and Psychotherapy, Vienna, Austria
A5 H. G. Koenig (&)
A6 Duke University Medical Center, Box 3400, Durham, NC 27710, USA
A7 e-mail: koenig@geri.duke.edu
A8 H. G. Koenig
A9 King Abdulaziz University (KAU), Jeddah, Saudi Arabia
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27 Religious and spiritual dimensions of mental health have not received much study in
28 psychiatry during the last 150 years. In the late nineteenth century, Jean Charcot and
29 Sigmund Freud began to associate religion with hysteria and neurosis. This began a deep
30 divide that would separate religion from mental health care for the next century (Koenig
31 2009). In 1969, after reviewing the research in this area, Victor Sanua stated: ‘‘The con-
32 tention that religion as an institution has been instrumental in fostering general well-being,
33 creativity, honesty, liberalism, and other qualities is not supported by empirical data. […]
34 there are no scientific studies which show that religion is capable of serving mental health’’
35 (p 1,203) (Sanua 1969).
36 (Larson et al. 1986) challenged this view by conducting systematic reviews of quan-
37 titative research on religion in psychiatry. In 1986, they reported that only 2.5 % of
38 psychiatric articles reviewed included a religious variable. Six years later, they assessed all
39 measures of religious commitment reported in research studies published in two prominent
40 research journals in psychiatry in 1978 through 1989, finding 139 religious measures
41 examined in 35 studies. In contrast to Sanua’s conclusion, they found that 72 % of studies
42 reported a positive relationship between religious involvement and better mental health,
43 16 % worse mental health, and 12 % no correlation (Larson et al. 1992). For many years,
44 the work of Larson and colleagues served as the state-of-the-art review of associations
45 between religion and mental health. Since then, however, research on the topic has
46 increased dramatically across health disciplines, but has yet to be analyzed in a systematic
47 way in psychiatry.
48 Due to the large number of reports available, reviews on the topic are often biased by
49 the author’s selection of papers. Our aim was to conduct a systematic evidence-based
50 review of research on mental disorders and religion/spirituality between 1990 and 2010,
51 using simple but rigorous selection criteria, applying a standardized rating for the quality
52 of each study’s design/methods, and providing a systematic summary of the results.
53 Methods
54 The literature was searched using the electronic database of PubMed (1990–December
55 2010). The search terms used were ‘‘religio’’ (i.e., religion, religiosity, and religiousness)
56 or ‘‘spiritu’’ (i.e., spiritual and spirituality), searching only the title of the article. A total of
57 5,200 publications were found among all journals listed in PubMed. To identify the highest
58 quality papers, we selected publications in psychiatric journals ranked in the top 25 % by
59 the ISI citation index 2010, that is, the top 32 journals out of 126 listed. Using this
60 procedure, we identified 108 papers of which 66 were reports of original data-based
61 quantitative research. Interestingly, 13 out of these 32 top journals (41 %) had published
62 no research on this topic during that 20-year period (at least none that listed ‘‘religio’’ or
63 ‘‘spiritu’’ in the title). Fourteen of the 66 papers were excluded because they focused on
64 non-psychiatric diseases (i.e., hypertension, myocardial infarct, and epilepsy). The same
65 procedure was performed in the top neurological journals, defined by their impact factor
66 (as with psychiatry journals). Of the 185 neurological journals listed in the ISI citation
67 index, 41 fell into this category. In those journals, we located 15 additional papers, of
68 which two reported original research on mental disorders, defined by the International
69 Classification of Diseases (ICD-10), Chapter V Mental and Behavioral Disorders, of the
70 World Health Organization (WHO). Both papers were included in our review (Kaufman
71 et al. 2007; Coin et al. 2010). Twenty-nine of the 41 neurology journals (69.0 %) had no
72 research articles on religion/spirituality between 1990 and 2010.
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73 The remaining 54 papers were reviewed by both authors. After examining the studies,
74 the authors agreed to exclude six more papers because they did not focus on a specific
75 psychiatric disorder, but rather on well-being (Tsuang et al. 2002), coping (Winter et al.
76 2009; Rammohan et al. 2002; Hebert et al. 2007), spiritual healing (Bishop et al. 2010), or
77 the serotonin system (Borg et al. 2003). Two papers on schizophrenia did not examine the
78 association between religious/spiritual involvement and schizophrenia, so they were
79 excluded as well (Jones and Watson 1997; Trindade et al. 2010). One more paper was
80 excluded because it turned out to be a case report (Burt and Rudolph 2000), and the studies
81 by Reynolds et al.(Reynolds et al. 2000) and Fallon et al. (1990) were excluded because
82 they did not statistically examine the religion/spirituality–mental health relationship. The
83 remaining 43 studies were then rated for the quality of their design, measures, and sta-
84 tistical methods.
85 Assessing Quality of Methods
86 The quality of each study was rated by both authors using a score between 1 (lowest
87 quality) and 10 (excellent quality) according to the following eight criteria: study design
88 (clinical trial, prospective cohort, cross-sectional, etc.); sampling method (random, sys-
89 tematic, or convenience); number of religion/spirituality measures; quality of measures;
90 quality of mental health outcome measure; contamination between outcome and religion/
91 spirituality measures; inclusion of control variables; and statistical method, based on a
92 scheme adapted from Cooper (Cooper 1984). Although Cooper’s primary focus was on
93 conducting research reviews (identifying studies and integrating them), he also described
94 how to judge the overall quality of a study’s methods. He emphasized the definition of
95 variables; validity and reliability of measures; representativeness of the sample (sample
96 size, sampling method, and response rates); research methods (quality of experimental
97 manipulation and adequacy of control group for clinical trials); how well the execution of
98 the study conformed to the design; appropriateness of statistical tests (power, control
99 variables); and the interpretation of results. Our study ratings followed these guidelines,
100 emphasizing quality of design/execution, variable measurement, and quality of the sta-
101 tistical analyses. The Pearson correlation between the two ratings was 0.76. Disagreements
102 were resolved, and the ratings presented here represent a consensus of the two authors. The
103 mean value of the quality scores between studies reporting positive relationships between
104 religious/spiritual involvement and mental health outcomes versus non-positive findings
105 did not differ significantly (7.06 vs. 7.08). The quality of the methods and statistics pre-
106 sented in Table 1were arrived at by consensus and were rated using five levels: poor, fair,
107 good, very good, and excellent.
108 Over 40 different measures of religion/spirituality were used in the different studies. All
109 assessed degree of involvement, comparing subjects along this dimension. The study
110 findings were placed into six categories: NA: no association with mental health outcome;
111 POS: at least one significant positive association and no significant negative associations;
112 (POS): positive association, but significance level borderline (0.05 \p\0.10); NEG: at
113 least one significant negative association with better mental health and no significant
114 positive ones; (NEG): negative association, but significance borderline (0.05 \p\0.10);
115 and MIX: mixed (both significant positive and significant negative associations with
116 mental health depending on the religious/spiritual characteristic measured).
117 Finally, based on other evidence-based reviews (Bonelli and Wenning 2006), the level
118 of evidence for the correlation between religious/spiritual involvement and mental health
119 in different psychiatric disorders was standardized in four categories: good evidence, some
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Table 1 Quality ratings and findings for the 43 research reports
First author, year of publication Journal of publication Number of
subjects
Study design QDM QStat QS R/S
impact
on MH
F00–F09 organic, including symptomatic, mental disorders
Kaufman et al. (2007) Neurology 70 Prospective study Very good Very good 8 POS
Coin et al. (2010) Curr Alzheimer Res 64 Prospective study Excellent Excellent 9 POS
F10–F19 mental and behavioral disorders due to psychoactive substance abuse
Francis and Mullen (1993) Addiction 4,753 Cross-sectional cohort study Very good Fair 5 POS
Mullen et al. (1996) Addiction 985 Cross-sectional & longitudinal Fair Fair 3 POS
Kendler et al. (1997)AmJPsychiatry 1,902Cross-sectionalandretrospectiveExcellentExcellent9POS
Miller et al. (2000) J Am Acad Child Adolesc Psychiatry 676 Cross-sectional cohort study Excellent Excellent 8 POS
Kendler et al. (2003)AmJPsychiatry 2,616Cross-sectionalandretrospectiveVerygoodFair6POS
Blay et al. (2008) Am J Geriatr Psychiatry 6,961 Cross-sectional cohort study Very good Very good 8 MIX
Chi et al. (2009) Addiction 357 Cross-sectional and longitudinal Good Very good 7 MIX
Ghandour et al. (2009) Addiction 1,837 Cross-sectional and retrospective Good Good 6 POS
Harden (2010) J Child Psychol Psychiatr 5,348 Cross-sectional and longitudinal Excellent Excellent 9 NA
F20–F29 schizophrenia, schizotypal, and delusional disorders
Nimgaonkar et al. (2000) Am J Psychiatry 8,542 Retrospective cohort study Very good Very good 8 POS
Mohr et al. (2006) Am J Psychiatry 115 Cross-sectional study Good good 6 POS
Moss et al. (2006) Schizophr Res 195 Cross-sectional and retrospective Good Very good 7 MIX
Borras et al. (2007) Schizophr Bull 103 Cross-sectional study Good Fair 6 MIX
Linden et al. (2010)PsycholMed n.a.RetrospectivecohortstudyVerygoodVerygood8NEG
Mitchell and Romans (2003) J Affect Disord 147 Cross-sectional study Fair Fair 5 MIX
Cruz et al. (2010) Bipolar Disord 334 Cross-sectional study Good Good 6 NEG
F32 depressive episode and F33 recurrent depressive disorder
Pressman et al. (1990) Am J Psychiatry 30 Prospective study Good Fair 6 POS
Koenig et al. (1992) Am J Psychiatry 850 Cross-sectional and longitudinal Excellent Very good 9 POS
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Table 1 continued
First author, year of publication Journal of publication Number of
subjects
Study design QDM QStat QS R/S
impact
on MH
Azhar and Varma (1995a) Psychother Psychosom. 64 Randomized clinical trial Fair Good 5 POS
Miller et al. (1997) J Am Acad Child Adolesc Psychiatry 211 Prospective cohort study Very good Very good 8 POS
Braam et al. (1997) Acta Psychiatr Scand 177 Prospective cohort study Very good Good 7 POS
Koenig et al. (1997) Am J Geriatr Psychiatry 4,000 Cross-sectional cohort study Very good Very good 8 POS
Koenig et al. (1998) Am J Psychiatry 86 Prospective study Very good Very good 9 POS
Braam et al. (1999) J Affect Disord 3,051 Cross-sectional cohort study Very good Very good 7 MIX
Braam et al. (2001) Psychol Med 8,398 Cross-sectional cohort study Very good Very good 8 POS
Braam et al. (2001) Psychol Med 17,739 Cross-sectional cohort study Very good Very good 8 POS
Miller and Gur (2002) J Am Acad Child Adolesc Psychiatry 3,356 Cross-sectional cohort study Very good Good 7 POS
Horowitz and Garber (2003) J Am Acad Child Adolesc Psychiatry 240 Prospective cohort study Very good Good 7 (POS)
Nasser and Overholser (2005) Acta Psychiatr Scand 62 Cross-sect/prospective study Good Very good 6 POS
King et al. (2007) Psychol Med 709 Cross-sectional study Good Very good 7 MIX
King et al. (2007) Psychol Med 402 Prospective study Very good Very good 7 MIX
Koenig (2007) Am J Geriatr Psychiatry 1,424 Case–control study Very good Very good 7 POS
Chatters et al. (2008) Am J Geriatr Psychiatry 837 Cross-sectional cohort study Very good Very good 8 POS
Cruz et al. (2009) Am J Geriatr Psychiatry 130 Cross-sectional study Good Good 5 POS
Maselko et al. (2009)PsycholMed 918Cross-sectionalandretrospectiveVerygoodFair6POS
Braam et al. (2010) J Affect Disord 776 Cross-sectional cohort study Very good Very good 8 MIX
Dew et al. (2010) J Affect Disord 145 Cross-sectional and longitudinal Very good Very good 7 POS
Suicide
Neeleman et al. (1997) Psychol Med 28,085 Cross-sectional cohort study Excellent Very good 10 POS
Dervic et al. (2004) Am J Psychiatry 371 Cross-sectional study Good Good 7 POS
Rasic et al. (2009) J Affect Disord 36,984 Cross-sectional cohort study Excellent Very good 9 POS
F40–F48 neurotic, stress-related, and somatoform disorders
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Table 1 continued
First author, year of publication Journal of publication Number of
subjects
Study design QDM QStat QS R/S
impact
on MH
Azhar et al. (1994) Acta Psychiatr Scand 62 Randomized clinical trial Good Good 5 POS
Azhar and Varma (1995b) Acta Psychiatr Scand 30 Randomized clinical trial Good Good 5 POS
Kaplan et al. (2005) J Clin Psychiatry 314 Cross-sectional cohort study Very good Good 8 POS
Abbreviations QS quality score, MH mental health, POS significant, (POS) trend, NEG significant, (NEG) trend, NA no association, MIX mixed, QDM quality of design and
method, QStat quality of statistics, Ref reference in the text; see text for details
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120 evidence, insufficient evidence, and no evidence. The evidence in favor of a positive
121 correlation between religious/spiritual involvement and mental health was considered
122 ‘‘good’’ when supported by at least 66 % of the studies available (irrespective of quality)
123 and confirmed by at least three high-quality studies (quality score 6 or higher). The
124 evidence was considered ‘‘some’’ when supported by at least 66 % of the studies (irre-
125 spective of quality) and confirmed by one high-quality study. The evidence was considered
126 ‘‘insufficient’’ when there were some positive findings, but they did not reach the 66 %
127 criterion and/or no study had a quality score of 6 or higher.
128 Results
129 Of the 43 studies identified, 36 focused exclusively on some aspect of religion, two
130 emphasized only spirituality, and five examined both religion and spirituality. The specific
131 term used in the two studies that only examined spirituality assessed ‘‘spiritual beliefs’’
132 (Mitchell and Romans 2003; Nasser and Overholser 2005), whose measurement included
133 religious beliefs in addition to more diffusely defined spiritual, philosophical, and exis-
134 tential beliefs. In the five studies using both terms, most did not make clear distinctions
135 between spirituality and religion, which is not surprising given challenges involved in
136 differentiating these concepts for research purposes and the usual practice of assessing
137 spirituality using religious measures—see Discussion. For these reasons, we present the
138 results in terms of religious involvement (as did the Larson reviews).
139 The findings are summarized in Table 1, presented by the order of ICD-10 chapter
140 V. Among the 43 studies, we found two on organic mental disorders [ICD-10 F0], nine on
141 psychoactive substance abuse [F1], five on schizophrenia [F2], 24 on affective disorders
142 (including suicide) [F3], and three on neurosis [F4]. No studies were found in the five
143 remaining categories Behavioral syndromes associated with physiological disturbances
144 [F5], Disorders of adult personality and behavior [F6], Mental retardation [F7], Disorders
145 of psychological development [F8], and Behavioral emotional disorders with onset in
146 childhood [F9]. Table 2summarizes the results. In total, 72 % reported a positive rela-
147 tionship between religious involvement and better mental health, 2 % a trend toward a
148 positive association, 2 % no association, 19 % found mixed (positive and negative) results,
Table 2 Results summarized according to diagnostic groups
POS (POS) NA MIX (NEG) NEG ALL QS
n%n%n%n%n%n%n%
F0 dementia 2 100 0 0 0 0 0 0 0 0 0 0 2 100 8.50
F1 addiction 6 66.7 0 0 1 11.1 2 22.2 0 0 0 0 9 100 6.78
F2 schizophrenia 2 40 0 0 0 0 2 40 0 0 1 20 5 100 7.00
F3 depression 15 78.9 1 5.3 0 0 3 15.8 0 0 0 0 19 100 5.50
F3 suicide 3 100 0 0 0 0 0 0 0 0 0 0 3 100 7.14
F3 bipolar 0 0 0 0 0 0 1 50 0 0 1 50 2 100 8.67
F4 neurosis 3 100 0 0 0 0 0 0 0 0 0 0 3 100 6.00
All mental disorders 31 72.1 1 2.3 1 2.3 8 18.6 0 0 2 4.7 43 100 7.05
Abbreviations POS significant (POS), trend, NEG significant (NEG), trend, NA no association, MIX mixed,
QS quality score; see text for details
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149 and 5 % found a negative association. In other words, 93 % of the studies found at least
150 one positive association (significant, trend, or mixed), whereas 23 % reported at least one
151 negative relationship. All studies on dementia [F0], suicide [F3], and neurosis [F4] found a
152 positive association between religion and mental health, as well as 79 % of the studies on
153 depression [F3] and 67 % of those on substance abuse [F1]. In contrast, most findings in
154 schizophrenia [F2] were predominantly mixed or positive, whereas those in bipolar dis-
155 order [F3] were mixed or negative. Among the 43 papers, only three (7 %) were inter-
156 vention studies (Azhar and Varma 1995; Azhar et al. 1994; Azhar and Varma 1995).
157 The quality and volume of this research have been increasing during the past 20 years.
158 We found 14 papers published before 2000 and 29 afterward. A weak positive correlation
159 between quality score and year of publication was found (?0.16). Publications before 2000
160 had an average quality score of 6.86, publications from 2000 to 2005 had a score of 7.00,
161 and papers from the years 2006 to 2010 had a score of 7.21. Interestingly, both of the
162 studies with negative results were published during this last period, as well as the only no
163 association study and six of eight studies with mixed findings. Overall, the soundest
164 methodology and design were found for studies on suicide (quality score 8.67) and
165 dementia (8.50), somewhat lower scores were given to studies on depression (7.14),
166 schizophrenia (7.00) and addiction (6.78), and relatively poor quality was assigned to
167 studies on neurosis (6.00) and bipolar disorder (5.50).
168 Specific Studies
169 Organic Mental Disorders
170 Two studies were in the category F00–F09 Organic Mental Disorders (Kaufman et al.
171 2007; Coin et al. 2010) and had many characteristics in common. Both focused on Alz-
172 heimer’s disease [ICD-10 code F00], both used a sound methodology for making the
173 diagnosis, both examined religious involvement as the primary predictor, both were pro-
174 spective, and both were rated high for quality of design and statistical methods, resulting in
175 an high-quality score. Both studies measured cognitive decline over 12 months with the
176 Mini-Mental State Examination. Both study populations had a mean age of about 78 years
177 and had more female than male subjects. Finally, both studies reported that higher levels of
178 religiosity correlated with slower cognitive decline over time.
179 The first study by Kaufman et al. (2007) examined the effects of two religious variables
180 on annual cognitive decline, a self-rating of spirituality, and frequency of private religious
181 activities (prayer, Bible study, meditation, etc.). These predictors accounted for 16.5 % of
182 the variance in annual cognitive score in a multiple regression model. In contrast, neither
183 measure of quality of life predicted rate of cognitive decline. The second study by Coin
184 et al. (2010) had a slightly more cognitively impaired sample (baseline MMSE 20.7)
185 compared to the Kaufman study (23.6). Not only did these researchers measure cognitive
186 decline, but also included functional and behavioral measures. Two groups were formed
187 based on a measure of religiosity that included religious attendance, praying, reading
188 religious literature, and watching/listening to religious programs on TV or radio; 35
189 subjects had moderate or high religiosity and 29 no or low religiosity. Cognitive, func-
190 tional, and behavioral scores did not differ significantly between the two groups at base-
191 line. However, a year later, the high religiosity group showed no significant decline in
192 cognitive and behavioral scores, while the low religiosity group scored significantly worse
193 on both. All patients, however, experienced a progressive decline in functional abilities.
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194 Researchers also examined caregiver burden, finding a significant reduction over time in
195 caregivers of religious patients.
196 Substance Abuse
197 Nine studies were in the category F10-F19 Psychoactive Substance Abuse (Kendler et al.
198 1997; Miller et al. 2000; Kendler et al. 2003; Harden 2010; Chi et al. 2009; Francis and
199 Mullen 1993; Ghandour et al. 2009; Mullen et al. 1996; Blay et al. 2008), with an average
200 quality score of 6.67. Out of the nine substances listed in F10–F19, six of them were
201 covered by the studies found. All nine papers focused on alcohol abuse [F10], two of them
202 exclusively (Harden 2010; Ghandour et al. 2009), three on nicotine dependency [F17]
203 (Kendler et al. 1997; Mullen et al. 1996; Blay et al. 2008), and four on other forms of
204 substance abuse (Miller et al. 2000; Kendler et al. 2003; Chi et al. 2009; Francis and
205 Mullen 1993) including use of heroin [F11] (Francis and Mullen 1993), marijuana [F12]
206 (Miller et al. 2000; Francis and Mullen 1993), cocaine [F14] (Miller et al. 2000), nicotine
207 [F17] (Kendler et al. 2003; Francis and Mullen 1993), butane gas [F18] (Francis and
208 Mullen 1993), glue [F18] (Francis and Mullen 1993), ‘‘drug abuse’’ in general (Kendler
209 et al. 2003; Chi et al. 2009), and ‘‘any contraband drug’’ (Miller et al. 2000). Three of the
210 nine subcategories were not covered: there were no studies on the use of sedatives or
211 hypnotics [F13], other stimulants, including caffeine [F15], and hallucinogens [F16]. Four
212 papers focused on adolescents (Miller et al. 2000; Harden 2010; Chi et al. 2009; Francis
213 and Mullen 1993), another four on adults (Kendler et al. 1997,2003; Ghandour et al. 2009;
214 Mullen et al. 1996), and one on a geriatric population (Blay et al. 2008). Two papers were
215 based on the population-based Virginia Twin Registry (Kendler et al. 1997,2003), both of
216 them including several other lifetime psychiatric disorders besides substance abuse in their
217 analyses. One study had only female participants (Kendler et al. 1997). Six out of nine
218 studies found an inverse relationship between religiosity and substance abuse, and one
219 study found an inverse relationship with drug dependency but not with alcohol misuse (Chi
220 et al. 2009). The findings in the five substances studied [F11, F12, F14, F17, and F18]
221 besides alcohol all reported inverse relationships between religious involvement and
222 substance abuse.
223 The only study in this group that found no association between substance abuse and
224 religiosity was the most recent and highest quality publication with the largest sample,
225 Harden (2010), on the age at first onset of drinking, using twins and siblings (aged
226 11–21 years) who were concordant or discordant for religiosity. In this dataset, the mean
227 age at drinking initiation for the ‘‘Both Religious’’ group (14.4 years) was slightly but
228 significantly later than for the ‘‘Both Non-Religious’’ group (13.9 years). In the case of
229 religious discordance between the siblings, however, the mean age at first drink for the
230 ‘‘Self Religious Only’’ group (14.2) was equal to the mean age at first drink for the
231 ‘‘Sibling Religious Only’’ group (14.2), indicating that siblings who differed in their
232 religiosity both drink earlier in a non-religious family and later in a religious family. They
233 could not, however, exclude family religiosity as the key factor.
234 Psychotic Disorders
235 Five studies were in the F20–F29 Schizophrenia, Schizotypal, and Delusional Disorders
236 category (Nimgaonkar et al. 2000; Mohr et al. 2006; Linden et al. 2010; Borras et al. 2007;
237 Moss et al. 2006), with an average quality score of 7.00. Most examined patient with
238 disorders within the overall group [F20–F29], although one study focused on Acute and
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239 Transient Psychotic Disorders [F23] (Linden et al. 2010). The latter work from Linden and
240 colleagues reported that intensive religious experiences increased the likelihood of tran-
241 sient psychotic disorders, whereas the four remaining publications reported that religious
242 involvement was related to greater compliance or higher well-being in patients with
243 schizophrenia. Moss et al. (2006) also found a longer duration of untreated psychosis in
244 Protestants compared to those with no affiliation, and Borras et al. (2007) found more
245 noncompliance in the ‘‘spiritual but not collectively practicing’’ than in the ‘‘not religious’’
246 and the ‘‘spiritual and collectively practicing’’ group.
247 Mood Disorders
248 Twenty-four of the 43 papers were in the F30–F39 Mood (affective) Disorders category.
249 Out of these, two studies were in the F31 Bipolar Affective Disorder (Cruz et al. 2010;
250 Mitchell and Romans 2003) group and 19 in the F32 Depressive Episode or F33 Recurrent
251 Depressive Disorder categories (Pressman et al. 1990; Koenig et al. 1992,1998; Braam
252 et al. 2001; King et al. 2007; Braam et al. 1997,1999; Cruz et al. 2009; Koenig 2007;
253 Koenig et al. 1997; Chatters et al. 2008; Miller et al. 1997; Miller and Gur 2002; Horowitz
254 and Garber 2003; Dew et al. 2010; Azhar and Varma 1995; Maselko et al. 2009; Nasser
255 and Overholser 2005; Braam et al. 2010). No studies, however, were found in the F30.0
256 Hypomania, F34 Persistent Mood Disorders (i.e., Cyclothymia and Dysthymia), or F38
257 Other Mood Disorders groups. We also included three studies on suicide (Neeleman et al.
258 1997; Dervic et al. 2004; Rasic et al. 2009) in this section.
259 The papers on bipolar affective disorder [F31] had the lowest average quality score of
260 all groups. The study by Mitchell and Romans (Mitchell and Romans 2003) found that
261 most patients saw a direct link between their beliefs and the management of their illness,
262 and many used religion to cope with their symptoms. However, a significant minority also
263 indicated that their religious beliefs put them in conflict with illness models (24 %) and
264 with the advice (19 %) provided by their medical advisors. Moreover, Cruz et al. (2010)
265 found increased rates of prayer/meditation in bipolar patients who were in a mixed state
266 and lower rates of prayer/meditation in those who were euthymic. Depression and mania
267 by themselves were not associated with religious involvement in that study.
268 While the role that religion plays in bipolar disorder is unclear or negative, the results
269 reported by the three studies on religious involvement and suicide were consistently in the
270 positive direction (i.e., an inverse relationship with suicidal thoughts, attitudes, and
271 behaviors). Moreover, they had the highest quality score of all diagnostic groups. Neel-
272 eman et al. (1997) examined ecological associations between religion, suicide tolerance,
273 and suicide rates. Overall, there was a negative association between religiousness and
274 suicide tolerance (stronger in women than men), and higher levels of suicide tolerance
275 were associated with higher suicide rates. Higher levels of religiousness, church atten-
276 dance, and religious upbringing were associated with lower suicide rates in women, but not
277 in men. Rasic et al. (2009) found that 0.47 % of religious and 0.83 % of non-religious
278 persons made at least one suicide attempt in the past 12 months. ‘‘Identifying oneself as
279 spiritual’’ and ‘‘religious attendance’’ were both significantly associated with a decreased
280 likelihood of attempted suicide. Finally, Dervic et al. (2004) found that religiously unaf-
281 filiated subjects had significantly more lifetime suicide attempts and more first-degree
282 relatives who committed suicide than subjects with a religious affiliation. Furthermore,
283 subjects with no religious affiliation perceived fewer reasons for living, particularly fewer
284 moral objections to suicide. In addition, religiously unaffiliated subjects had more lifetime
285 impulsivity, aggression, and were more likely to have a past history of substance abuse.
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286 Research on the relationship between religious involvement and depression is the most
287 developed, and as a group, it showed a relatively high-quality score. Eleven of the 19
288 studies examined a geriatric sample (Pressman et al. 1990; Koenig et al. 1992,1998;
289 Braam et al. 2001; King et al. 2007; Braam et al. 1997,1999; Cruz et al. 2009; Koenig
290 2007,1997; Chatters et al. 2008), four studies focused on adolescents (Miller et al. 1997;
291 Miller and Gur 2002; Horowitz and Garber 2003; Dew et al. 2010), and four studies
292 examined adults (Azhar and Varma 1995; Maselko et al. 2009; Nasser and Overholser
293 2005; Braam et al. 2010). Four focused on depression in the medically ill (Pressman et al.
294 1990; Koenig et al. 1992,1998,2007), two on religious coping (Koenig et al. 1992; Braam
295 et al. 2010), two had only female participants (Pressman et al. 1990; Miller and Gur 2002),
296 and two examined mother–offspring relationships (Miller et al. 1997; Horowitz and Garber
297 2003). Five of the 19 studies focused on psychiatric patients (Koenig et al. 1998; Cruz et al.
298 2009; Dew et al. 2010; Azhar and Varma 1995; Nasser and Overholser 2005), two of which
299 were in psychiatric inpatients (Cruz et al. 2009; Nasser and Overholser 2005). The vast
300 majority examined representative population-based samples and examined the prevalence
301 of depression. With regard to the relationship between religiosity and depression, three
302 studies reported mixed results (King et al. 2007; Braam et al. 1999,2010), whereas the
303 other 16 papers found a positive relationship between religious involvement and depression
304 (i.e., less depression in the more religious). All 19 studies reported at least one positive
305 finding, and none found no association or only a negative association.
306 Two of the three studies with mixed results found a U-shaped association, such that
307 those with very high religiosity and very low religiosity were prone to more depression.
308 First, Braam et al. (1999) found more depressive symptoms among older Dutch citizens in
309 a hyperconservative religious climate (examined on the municipality level) using per-
310 centages of votes for hyperconservative political parties. Second, King et al. (2007) found
311 in their cross-sectional and longitudinal analyses of 709 primary care elders more
312 depressive symptoms in those with very high compared to those with moderate levels of
313 private religiosity. This U-shaped relationship between religious involvement and
314 depression should be addressed in future studies, since this possibility was not examined in
315 any other papers. The third study with mixed results reported by Braam et al. (2010) found
316 that while religious attendance was associated with fewer depressive symptoms, religious
317 coping methods considered ‘‘positive’’ were associated with a greater risk of subthreshold
318 depression.
319 Neuroses
320 For neurotic, stress-related, and somatoform disorders (F40–F48), we found only three
321 studies during the last 20 years and the quality score for those was low average. One study
322 was in the category F41 Other Anxiety Disorders (F41.1 Generalized anxiety disorder
323 (Azhar et al. 1994)) and remaining two studies were in the category F43 Reaction to Severe
324 Stress and Adjustment Disorders (both on F43.1 Post-traumatic stress disorder (Kaplan
325 et al. 2005; Azhar and Varma 1995)). No studies were identified in the F40 Phobic Anxiety
326 Disorders, F42 Obsessive–Compulsive Disorder, F44 Dissociative Disorders, or F45 So-
327 matoform Disorders groups.
328 Azhar et al. (1994) conducted a randomized clinical trial in religious Muslim patients
329 with generalized anxiety disorder. Those in the intervention group received religious
330 psychotherapy in addition to supportive psychotherapy and anxiolytic drugs, and were
331 compared with those in the control group that received only supportive psychotherapy and
332 anxiolytic drugs. Those receiving religious psychotherapy showed significantly more rapid
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333 improvement in anxiety symptoms. The same group (Azhar and Varma 1995) 1 year later
334 completed a second randomized clinical trial in bereaved Muslim patients, comparing
335 those who received psychotherapy from a religious perspective with those receiving tra-
336 ditional secular psychotherapy. The patients in the religious psychotherapy group
337 improved significantly more compared to those in the control group by the end of
338 6 months.
339 One of the most interesting studies, however, comes from a Jewish sample (Kaplan
340 et al. 2005) in Israel. Investigators found that highly religious inhabitants from the Gaza
341 Strip, in spite of firsthand daily exposure to violent attacks, reported the fewest and least
342 severe symptoms of stress-related complaints, the least sense of personal threat, and the
343 highest level of functioning among the groups compared. The most severely symptomatic
344 and functionally compromised group involved the predominantly secular inhabitants of a
345 Tel-Aviv suburb, who were the least frequently and least directly affected by exposure to
346 violent attacks.
347 Discussion
348 The present review systematically identified 43 research studies that examined the rela-
349 tionships between religious/spiritual involvement and mental disorders between 1990 and
350 2010, reporting on the quality of the methods and summarizing the results. This article
351 serves as a follow-up to the (Larson et al. 1986,1992) reviews that examined the studies
352 published in the previous 13 years from 1978 through 1989. Their work, particularly the
353 1992 report, focused on religious involvement in terms of ceremony (religious attendance,
354 sacraments, or rituals); religious meaning (personal purpose, values, beliefs, and ethics);
355 religious social support; prayer (personal devotional practices); relationship with God; and
356 ‘‘indeterminate’’ (i.e., use of the term ‘‘religion’’ or ‘‘religiosity’’ without further specifi-
357 cation). The 1992 report searched for studies in only two psychiatry journals. This
358 approach differs from the present one in that we used the search terms ‘‘religio’’ or
359 ‘‘spiritu’’ in the article title of the top 32 psychiatry and 41 neurology journals, allowing for
360 a more representative selection of papers. In addition, we divided our results into ICD-10
361 diagnostic groups, rated each study by quality of design/execution, and categorized studies
362 in terms of level of evidence. Despite these differences in methodology, our findings
363 during the past 20 years were similar to those reported by Larson and colleagues during the
364 13-year period prior to 1990. We, along with Larson’s group, both found that 72 % of
365 studies reported significant positive associations between religious involvement and better
366 mental health.
367 There is good evidence today that religious involvement is correlated with mental health
368 in three major domains of psychiatry: depression, substance abuse, and suicide (Table 3).
369 There is some evidence, largely positive, for two other domains: stress-related disorders
370 and organic mental disorder. Insufficient evidence was found in bipolar and schizophrenia,
371 due to the relatively low quality of the studies and their conflicting results. Finally, there is
372 no evidence of an association between religiosity and other psychiatric disorders such as
373 eating disorders, sexual disorders, phobic anxiety disorders, obsessive–compulsive disor-
374 ders, dissociative disorders, somatoform disorders, personality disorders, mental retarda-
375 tion, or psychiatric disorders in children, at least in the top tier journals of psychiatry and
376 neurology. However, the fact that there is no evidence of an association between religious
377 involvement and a psychiatric disorder does not mean there is no relationship, but rather
378 that these relationships have not yet been studied.
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379 The findings in the present report are notable given the general neglect of this topic in
380 many high-quality journals: 41 % of psychiatry and 69 % of neurology journals published
381 no research focused on religion or spirituality during the period we investigated. This is
382 remarkable given that research on religion/spirituality and health has increased dramati-
383 cally during the past 20 years, with close to 2,500 original data-based quantitative reports
384 published during this period, three-quarters addressing religion/spirituality and mental
385 health (Koenig et al. 2012). In 1986, Larson et al. (1986) reviewed 2,348 quantitative
386 studies in four major psychiatric journals between 1978 and 1982, of which only 59
387 included a quantifiable religious variable, 37 of those assessing denomination only. Those
388 findings and the present review underscore the point that religious involvement may still be
389 the ‘‘forgotten factor’’ in the study of many mental disorders, as Larson’s group concluded
390 over 25 years ago (Larson et al. 1986).
391 Among the most important findings in the last 20 years has been a fairly consistent
392 relationship between religious involvement and less depression (and suicide). This is
393 surprising from the classical perspective that the moral restrictions of religion contribute to
394 guilt and, hence, predispose to depression. Moreover, the role of religion in moderating
395 impulsivity, aggression, and substance abuse (with delayed substance abuse in religious
396 families) is also noteworthy and again go against the latter concept. Of interest, however, is
397 that several studies reporting mixed findings found that those with extremely high religi-
398 osity were prone to more depression (as were those with low religiosity). This suggests that
399 the religious life to be truly healthy (like love) needs a certain amount of inner freedom and
400 flexibility.
Table 3 Conclusions from the analysis of the top 25 % Journals 1990–2010
Good evidence Some evidence Poor evidence No
evidence
F0 dementia Positive
correlation
F1 addiction Positive
correlation
F2 schizophrenia Mixed data
F3 bipolar Mixed/negative
data
F3 depression Positive
correlation
F3 suicide Positive
correlation
F4 obsessive–compulsive
disorders
No data
F4 phobic anxiety disorders No data
F4 stress-related disorders Positive
correlation
F5 eating disorders No data
F5 sexual disorders No data
F5 sleeping disorders No data
F6 personality disorders No data
F8 development No data
F9 childhood No data
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401 There are plenty of issues that this review does not address. Since we focused on
402 psychiatric disorder, other aspects of religion, spirituality, and mental health were excluded
403 (well-being, etc.). Another question is whether religious involvement helps to prevent
404 mental illness, affects treatment response, or is simply a marker for good outcomes, such as
405 gender or personality. Addressing this issue will determine whether religion is an unex-
406 ploited clinical opportunity, useful in terms of prevention, or simply a coincidental
407 demographic factor that should be recognized but not addressed clinically. Only 7 % of
408 studies reviewed involved interventions, and all others were observational. While the three
409 religious intervention studies each reported a benefit, they were performed by the same
410 research group in a sample of religious patients and involved the addition of religious
411 psychotherapy to standard treatments (i.e., more time with therapist). These results need to
412 be replicated using better methods, perhaps a direct head-to-head comparison of religious
413 versus conventional psychotherapy with the only difference being the integration of
414 patients’ religious resources into therapy.
415 Another limitation of this review is the challenge of distinguishing terms such as
416 religion, spirituality, and mental health. The 43 studies presented here used many different
417 measures. Not only were different measures of religion and spirituality used, but mental
418 health outcomes were also assessed in many different ways (although usually by structured
419 psychiatric interviews or standard symptom scales). This weakens our conclusions. Of
420 particular concern was the measurement of religion and spirituality. Unlike religion, the
421 term ‘‘spirituality’’ has only recently been used in psychiatric research (since mid-1990s).
422 The fact that the findings from seven studies using spirituality as a predictor (6 out of 7
423 positive) were similar to the findings from the general analysis of all 43 studies suggests
424 that the differences in the operationalization of these terms may not have been that great.
425 Nevertheless, this general lack of measurement precision underscores how important it is
426 for future research on religion, spirituality, and mental health to clearly define how these
427 terms are used and in what ways they are distinct from one another, particularly since
428 definitional overlap that results in tautological relationships can be a serious problem—see
429 Koenig (2008) and Tsuang et al. (2008).
430 In conclusion, hundreds of studies have been published over the last 20 years that have
431 reported connections between religion/spirituality and mental health, and nearly four dozen
432 of those have been published in high-quality journals in psychiatry and neurology, the
433 majority finding positive associations between religious involvement and better mental
434 health. Although many of these studies involve relatively large samples that are followed
435 prospectively, most are cross-sectional in design and intervention studies are few. Fur-
436 thermore, several studies in the past 5 years have reported negative or mixed results,
437 underscoring the need for more research in this area. The greatest need appears to be in the
438 area of religion and chronic mental disorders—schizophrenia, bipolar disorder, long-
439 standing treatment-resistant depression, and severe personality disorders—about which we
440 know very little. The same applies to psychiatric disorders in children; anxiety disorders
441 (OCD, PTSD, phobias); and disorders involving sex, eating, and sleep. No studies
442 reviewed here examined interactions between religion and biological interventions for
443 mental disorder that could determine whether religious involvement enhances or interferes
444 with these treatments. Clearly, the potential for future research appears almost limitless
445 Koenig (2011). The importance of religion to our patients and its potential impact on the
446 horrific disorders they must live with, however, makes this a factor that cannot be
447 forgotten.
448 Conflict of interest There are no conflict of interests present for either author.
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449
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Journal : Small 10943 Dispatch : 14-2-2013 Pages : 17
Article No. : 9691 hLE hTYPESET
MS Code : JORH-D-12-00192 hCP hDISK
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