Session on Church's care for depressed patients

Below are papers read at the session "Church's care for depressed patients" of the XXVII International Educational Christmas Readings
January 26, 2019, Moscow (continuation)

Depressive Disorders and Religiosity

E.V. Guedevani

This paper presents a world data review taken from scientific literature devoted to the impact of religiosity on depressive conditions.

Religiosity Impact on Mental Health

To date, there have been numerous studies showing an improvement in the overall psychological well-being associated with a religious worldview, and various coping strategies for the above-mentioned disorders have been described [1, 2, 3, 4, 5, 6, 7]. There is a link between religious commitment and lower rates of depressive disorders, suicide attempts and suicide [8, 9, 10, 11, 12, 13].

Meta-analysis of 143 independent studies presented by T. Smith et al. [14] has shown that religious commitment is moderately but reliably associated with lower levels of depressive symptoms, whilst the protective role of religiosity is more pronounced in persons who have experienced a psychologically traumatic situation. Some researchers believe that trauma gives an impetus to an individual's deeper spiritual development and contributes to inner stability and conscious living of life, recognizing its value [15, 16, 17, 18].

A later analysis by H. G. Koenig et al. [19] of all quantitative studies published in peer-reviewed academic journals in English between 1872 and 2010 revealed that 272 out of 444 studies (61%) recorded a decrease in the severity of depressive symptoms and shortening of the duration of depressive phases due to religiosity. In 106 out of 141 studies (75%), it was noted that religiosity correlates with fewer suicides and a negative attitude towards them. This analysis shows that there are valid and reliable data acquired through a wide range of studies that reveal an inverse correlation between religious activity or personal participation in religious rites and depressive symptoms, depression generating effects of stressful life events or suicide rates.

A multicenter cross-referenced study conducted at the health clinics of five University hospitals in Korea revealed that anxiety and depression symptoms are more pronounced in a subgroup with low religiosity, as opposed to a subgroup with high or zero religiosity (p < 0.01), and the well-being factor reaches higher values in a subgroup with high or low religiosity, as opposed to a non-religious subgroup (р <0.05) [20].

L. Mitchell, S. Romans [21] have studied religious commitment among patients with the bipolar affective disorder in remission. The majority of the patients were highly religious or had strong spiritual beliefs (78%) and often followed certain religious practices (81.5%). Many of them saw a direct link between their own beliefs and coping with their illness. Many used religious coping strategies. The researchers have concluded that religious or spiritual thoughts are important for many patients with bipolar disorder and determine how they perceive their illness.

D. Anyfantakis and his co-authors aimed to study the protective role of religiosity in case of depression. The target group was represented by 220 patients from SPILI III (1988-2012), who attended a primary health care facility in the rural town of Spili in Crete, most of whom (98.5%) were Orthodox Christians. Highly religious group participants from rural Crete manifested a lower probability of depression. In addition, D. Anyfantakis and his colleagues pointed out that their involvement in religious activities enhanced social contacts, optimism and group membership, and directly led to higher social responsibility and lower likelihood of depression [22].

Modern foreign literature on the impact of religiosity on health often refers to such concepts as extrinsic and intrinsic religiosity. These terms were first described by Gordon Allport and his colleagues in the 1960s [23]. According to their data, individuals with intrinsic religiosity consider religion as the foundation of their existence and follow it throughout their lives. Whereas extrinsic religiosity primarily serves other, more finite goals, rather than the central religious beliefs as such. Thus, people characterized by their extrinsic religiosity use their religious commitments to satisfy basic needs, such as social relations or personal comfort.

Clinicians use these concepts in their research and often find correlations between intrinsic religiosity and the sense of general well-being and positive outcome of the illness [24, 25, 26, 27, 28, 29, 30, 31, 32, 33].

So, for example, Michael E. McCullough from the University of Miami [34], having reviewed 80 literary sources, concludes that extrinsic religiosity is associated with an increased risk of depressive disorder and a higher degree of depressive symptomatology. Intrinsic religiosity, on the contrary, is negatively related with depressive symptoms.

Special attention should be given to studies of senior age patients with depression. A prospective study of the effect of religiosity on depressive disorders was carried out using 87 senior age individuals hospitalized with depression. It was discovered that intrinsic religiosity was associated with a faster onset of remission (70%) with an average follow-up duration of 47 weeks. As for patients with somatic disorders whose disability remained at the same level of severity during one year of follow-up (meaning little or no response to treatment), the rate of remission after depression increased by 106% [35].

Another situation was observed, for example, in Australia, where the level of religious commitment is much lower than in the U.S., which can be explained by still a widely spread Aboriginal culture [36]. Australian scientist V. Payman and his co-authors [37] conducted a study on the influence of religious copying on depression progress in elderly people. Only 25% of all respondents regularly attended church, and 57% did not attend at all or rarely attended. Analysis of the data with many variables showed a significant correlation between an individual prayer and high levels of physical disability. Intrinsic religiosity was more common in patients with an increasing level of physical disability and high levels of social support. The results were compared against similar studies conducted by American colleagues [35, 38]. The scientists have identified a positive impact of religious coping strategies on the course of a treatment process, and concluded that it is necessary to introduce methods of social support for senior citizens, in particular religious coping strategies, into the clinical practice.

The study by Mosqueiro B. P. et al. [39], who sampled 143 depressed patients, identified that intrinsic religiosity was associated with psychological stability, quality of life, and fewer previous suicide attempts. E.S. Fradelos et al. indicate that a higher importance of an individual's religious beliefs has a positive impact on psychological resilience, which in its turn has a positive impact on mental health, reducing depressive symptoms significantly. Patients with end-stage cancer and those with mastectomy showed higher levels of religiosity and more often expressed spiritual and religious needs, according to the study [40].

Another study of 100 outpatients with the depressive disorder was carried out by C. Ozawa et al. [41]. Their findings show that psychological resilience can serve as a marker of depressive state severity, and is determined by individual characteristics rather than by family environment. In addition, scientists have identified spirituality and/or religiosity as a significant factor reinforcing psychological resilience.

Besides intrinsic religiosity, general psychological well-being is an important component of the positive impact of religion on mental and physical health. Donahue and Benson, in their study of 34 129 adolescents, concluded that overall psychological well-being manifests itself in the three most relevant areas for adolescents: 1) social values and actions (helping others, volunteership); 2) mental health (suicidal thoughts and attempts, self-esteem); 3) risk factors (alcohol, tobacco, substance use; violent or other delinquent behaviors; early sexual life) [42].

Similar conclusions were made by other authors who had studied the protective role of a religion [43, 44, 45, 46]. They pointed out the negative attitude of the main traditional religions towards tobacco use and alcohol consumption, which are serious risk factors for most known diseases. In addition, most religions follow the traditional culture of nutrition and consumption of quality and healthy food. The authors believe that the impact of religious environment and spirituality on stress and the believer's psycho-emotional state is an important preventive mechanism.

Some authors point to significant gender and personality differences in certain aspects of religiousness and spirituality, which also correlate with some psychosocial indicators. At the same time feelings of spiritual affinity and attachment to God invariably correlate with such indicators as general psychological well-being and other positive psychological markers, even with the account the described characteristics [47]. The data presented by Van Cappellen et al. [48] from Duke University also prove that religion or spirituality is connected with the person's general psychological well-being which it ensured by the feelings of reverence, gratitude, love and peace, rather than by positive emotions triggered by entertainment or pride.

Brazilian scientists conducted a cross-referenced study to assess the role of meaning, peacefulness, faith and religiosity in mental health. These indicators were linked to the quality of life and overall psychological well-being of 782 adults. The results presented a close link between meaning and peacefulness, on the one hand, and positive health and well-being, on the other [49].

Religion and the Suicide Level

The problem of suicide is one of the most important global problems of psychiatry today. Approximately 1.53 million people all over the world will be exposed to the suicide risk by 2020, according to WHO epidemiologists [50]. The global statistics proves that the suicide rate is determined by both gender and age, as well as by cultural factors, including religious commitment [51]. The year 1995 reported 900,000 completed suicides, with 3.2:1 ratio of men to women, excluding China, where the suicide rate is higher among women [52]. There is also an age factor: more suicides occur after the age of 45, and the peak of suicidal activity falls on the age over 75 [53].

To date, there has been numerous suicide studies, but the majority of medical and psychological studies do not properly consider religious factors, according to A. Moreira-Almeida and some other authors [54, 55].

The U.S. study [56] of the age 50+ death record (584 suicides and 4,279 natural death outcomes) analyzed gender, race, marital status, age, and frequency of social contact, and found that the suicide rate among those who did not attend religious events was 4 times higher than among those with a high level of religious commitment.

Religious commitment is not only associated with a lower suicide rate, but it also presents a negative attitude towards suicide and fewer suicide attempts, even among patients with clinical depression. The study of 371 inpatients with depression showed that patients without any religious commitment, despite the same level of depression, had made more suicide attempts over the course of their lives (66.2% vs. 48.3%). Those patients believed that they had less reason to continue their lives and showed little or no moral rejection of suicide, unlike patients with religious believes [57].

The study of an all-United States representative sampling of 16,306 adolescents has revealed that personal religiosity is associated with a low level of suicidal ideas or suicide attempts [58]. Similar results have been presented in the study of 420 adolescents in Turkey. Adolescents with religious education showed less suicidal ideas and a lower acceptance of the idea of suicide in the survey. At the same time, they were ready to provide assistance and expressed sympathy to their close friends with suicidal thoughts who had no religious education [59].

In P. Huguelet's study [60], the issue of religious commitment of 115 outpatients with schizophrenia or schizoaffective disorders and 30 inpatients without psychotic symptoms was examined with the help of semi-structured interviews. In addition to the standard semi-structured interview, their subjective assessment of the role of religion (protective or encouraging) in the decision to commit suicide was taken into account. It was discovered, that 43% of patients with psychosis had previously tried to commit suicide; 25% of all respondents recognized the protective role of religion, which was associated with both moral judgement of suicide and personal use of religious coping strategies. Only one out of ten patients reported on the encouraging role of religion, which they explained by things that generate negative associations and the hope for a better life after death. The paper has shown that religiosity can play a significant role in the rejection of a suicide decision by psychotic patients', although they are known to be at a high risk of serious suicide attempts.

A number of authors, in different years, carried out systematic reviews, that clearly indicate a positive impact of religion on depressive symptoms and a protective role of religion, reducing suicide activity. In his review of 130 sources of sociological literature on suicidal activity over a 15-year period, S. Stack examines various theories of suicidal activity in a population. He clearly refers to a positive impact of the religious factor, which implies the use of many copying techniques and a negative attitude to suicide [61].

The spiritual life of society creates an important existential context for an individuum. Some researchers see the roots of suicide among young people in the lack of significant spiritual experience associated with the "spiritual vacuum" which characterizes the modern world and leads to the loss of meaning and, consequently, the possibility of suicide [62, 63].

Thus, programs involving religious communities in public projects can become one of the most appropriate ways to prevent suicide. The Scottish Choose Life Strategy (The Scottish Executive, 2002) is an example of such a program with the aim to significantly reduce the suicide rate and to work jointly to develop suicide response skills in members of religious communities and religious leaders in case of a death or suicidal behaviors in the community [64]. H. Mowat et al. [65], also in Scotland, have developed a movement of church parish nurses (on the basis of an earlier American Westberg model [66]), where a professional nurse is hired to work in its own parish. This work has been limited to Christian groups so far, and no research has been done on other religious communities.

The meaning-making role of religion deserves special attention, as it is pointed out by G. Kirov et al. [67] in the study of patients who have experienced psychotic states. The authors point out that the psychotic disorder, usually accompanied by fear affect, chaos and helplessness, disrupts the internal order of a person. Faith in God can restore balance and integrity of the person, split by the illness, which the person experiences as revival, happiness, peace and confidence. Thus, faith in terms of psychology is a special form of a defense mechanism, and contributes to the implementation of adaptive coping strategies. Many patients consciously use prayer in times of great suffering and despair, others view their illness as a trial (positive reassessment), or rely on their activity in the church (increased socialization).

The meaning-making aspect is deemed important, because religiosity is closely associated with the process of self-identification [68]. This is confirmed by the data collected from 3,032 respondents from 25 to 74 years old and processed with the help of a multifactor regression model. The findings of the study show that regular participation in the life of religious institutions is associated with a higher religious social identity, and therefore with a higher level of general well-being [69].

Some authors say that religious ethical disapproval is the most obvious protective factor hindering the implementation of a suicidal idea [70]. Despite some differences in attitude to suicide in the basic religions and moral teachings, all of them recognize the unconditional value of human life. This idea is essential and is reflected in the general attitude to life and self-esteem.

Thus, the protective effect of religiosity in case of depressive states and suicidal tendencies can be explained by intrinsic religiosity, which determines the meaning of a believer's life. Specific ways of coping with the illness and suicidal thoughts are of importance; they contribute to the individual's adaptation and development of a sense of general well-being. Religious and ethical disapproval of suicide plays a certain protective role. It is also important to that the individual participates personally in religious rites, as such practices help to reduce depressive effects of stressful life situations [71, 72, 73].

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