Religion, Spirituality, and Mental Health

Until the early 19th century, psychiatry and religion were closely connected. Religious institutions were responsible for the care of the mentally ill. A major change occurred when Charcot¹ and his pupil Freud² associated religion with hysteria and neurosis. This created a divide between religion and mental health care, which has continued until recently. Psychiatry has a long tradition of dismissing and attacking religious experience. Religion has often been seen by mental health professionals in Western societies as irrational, outdated, and dependency forming and has been viewed to result in emotional instability.³

In 1980, Albert Ellis,⁴ the founder of rational emotive therapy, wrote in the Journal of Consulting and Clinical Psychology that there was an irrefutable causal relationship between religion and emotional and mental illness. According to Canadian psychiatrist Wendall Watters, “Christian doctrine and liturgy have been shown to discourage the development of adult coping behaviors and the human to human relationship skills that enable people to cope in an adaptive way with the anxiety caused by stress.”^5(p148) At its most extreme, all religious experience has been labeled as psychosis.⁶

Psychiatrists are generally less religious than their patients and, therefore, they have not valued the role of religious factors in helping patients cope with their illnesses.⁷ It is only in the past few years that attitudes toward religion have changed among mental health professionals. In 1994, “religious or spiritual problems” was introduced in DSM-IV as a new diagnostic category that invited professionals to respect the patient’s beliefs and rituals. Recently, there has been a burgeoning of systematic research into religion, spirituality, and mental health. A literature search before 2000 identified 724 quantitative studies, and since that time, research in this area has increased dramatically.⁸ The evidence suggests that, on balance, religious involvement is generally conducive to better mental health. In addition, patients with psychiatric disorders frequently use religion to cope with their distress.^9,10

In recent studies, at least 50% of psychiatrists interviewed endorse the view that it is appropriate to inquire about their patients’ religious lives.^11-13 That patients’ religious concerns have been taken seriously is evidenced by the fact that the American Psychiatric Association has issued practice guidelines regarding conflicts between psychiatrists’ personal religious beliefs and psychiatric practice. The Accreditation Council for Graduate Medical Education includes in its psychiatric training requirement, didactic and clinical instruction on religion and spirituality in psychiatric care.

Religion and depression

Studies among adults reveal fairly consistent relationships between levels of religiosity and depressive disorders that are significant and inverse.^8,14 Religious factors become more potent as life stress increases.¹⁵ Koenig and colleagues8 highlight the fact that before 2000, more than 100 quantitative studies examined the relationships between religion and depression. Of 93 observational studies, two-thirds found lower rates of depressive disorder with fewer depressive symptoms in persons who were more religious. In 34 studies that did not find a similar relationship, only 4 found that being religious was associated with more depression. Of 22 longitudinal studies, 15 found that greater religiousness predicted mild symptoms and faster remission at follow-up.

Smith and colleagues¹⁴ conducted a meta-analysis of 147 studies that involved nearly 100,000 subjects. The average inverse correlation between religious involvement and depression was 20.1, which increased to 0.15 in stressed populations. Religion has been found to enhance remission in patients with medical and psychiatric disease who have established depression.^16,17 The vast majority of these studies have focused on Christianity; there is a lack of research on other religious groups. Some research indicates an increased prevalence of depression among Jews.¹⁸

Depression is important to treat not just because of the emotional distress but also because of the increased risk of suicide. In a systematic review that examined 68 studies, researchers looked for a relationship between religion and suicide.⁸ Among these, 57 studies reported fewer suicides or more negative attitudes toward suicide among the more religious. In a recent Canadian cross-sectional study, religious attendance was associated with decreased suicide attempts in the general population and in those with a mental illness, independent of the effects of social supports.¹⁹ Religious teachings may prevent suicide, but social support, comfort, and meaning derived from religious belief also are important.

More recent studies indicate that the relationship between religion and depression may be more complex than previously shown. All religious beliefs and variables are not necessarily related to better mental health. Factors such as denomination, race, sex, and types of religious coping may affect the relationship between religion or spirituality and depression.^20,21 Negative religious coping (being angry with God, feeling let down), endorsing negative support from the religious community, and loss of faith correlate with higher depression scores.²² As Pargament and colleagues^23(p521) state, “It is not enough to know that the individual prays, attends church, or watches religious television. Measures of religious coping should specify how the individual is making use of religion to understand and deal with stressors.”

Very few studies have specifically addressed the relationship between spirituality and depression. In some instances, spirituality (as opposed to religion) might be associated with higher rates of depression.²⁴ On the other hand, there is a substantial negative association between spirituality and the prevalence of depressive illness, particularly in patients with cancer.^25,26