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August 2007 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Koenig, H. G. "Spirituality and depression: a look at the evidence." Southern Medical Journal 100, no. 7 (July 2007): 737-739.


SUMMARY and COMMENT: Harold Koenig offers here a brief state-of-the-evidence review of the relationship between spirituality and depression, including a note about "the most recent and largest study to date"--a study of his own, reported in two articles that have just themselves been published. It is aimed at physicians, as part of the Southern Medical Journal's periodic series on Spirituality and Medicine, but CPE students and researchers alike should find it highly thought-provoking and clinically pertinent.

Koenig begins by making connections both between depression and suicide and between religious beliefs/practices and patients' coping. Studies not only show that patients identify religion as a coping mechanism but "when the religiousness of patients is measured, studies usually indicate that those who are more religious experience less depression (i.e., are coping better)" [p. 737]. However, the relationship between religion and depression is not simple. Some research suggests that "once depression worsens to the point that somatic symptoms are present, then religious involvement may be less effective in resolving symptoms (and may itself be influenced by the depression)" [p. 737].

The findings of key studies are used to illustrate and build a picture of the connections between spirituality/religion and depression, including some little-cited work from Islamic and Buddhist contexts and a handful of investigations by the author. Koenig summarizes his latest research, still in press at the time of writing:

In the most recent and largest study to date, religion and depression were examined in severely ill hospitalized patients with congestive heart failure or chronic pulmonary disease. This study found that religious involvement was widespread among the 411 patients with major depression and 585 patients with minor depression (diagnosed using the Structured Clinical Interview for Depression). However, it was not as common in depressed patients as it was among 428 nondepressed control patients with an assortment of illnesses. After controlling for demographic and physical health factors, depressed patients were more likely to be religiously unaffiliated, to indicate they were "spiritual but not religious," and were less likely to pray, read scripture, or score high on intrinsic religiosity. Furthermore, among depressed patients themselves, frequency of religious attendance, prayer, scripture reading, and intrinsic religiosity were all inversely correlated with depressive symptoms. Finally, among 845 of the depressed patients in this study who were followed after discharge by telephone and by in-person home visits, those who were more involved in religious community activities and those who were the most religious overall (15% of the sample) remitted over 50% faster from depression than did less religious patients. Social factors could explain only a small proportion of these effects. [p. 738]
For the two new articles upon which this summary is based, see the author's "Religion and depression in older medical inpatients" and "Religion and remission of depression in medical inpatients...," in Items of Related Interest (below).

Koenig tells his physician audience:

...if our patients tell us that religion helps them to cope with the stress of medical illness, if religious patients are less depressed than those who are not religious, if religious patients with depression recover more quickly over time than those who are less religious, and if randomized clinical trials show that religious-oriented therapies help patients recover faster from depression, then this strongly suggests that religion can help to either prevent or facilitate recovery from depression. [p. 738]
His advice to clinicians is to be sensitive to the importance of religion in the lives of patients, speak with patients about their religious or spiritual beliefs in appropriate ways, and think of referrals to chaplains. Though, regarding chaplain referrals, he cautions:
...patients may or may not be willing to see a chaplain for help in dealing with [illness-precipitated religious] struggles, since many feel angry at or disappointed with God and anyone who represents God. For this reason, it is important for clinicians to gently inquire about such struggles, since patients may be more likely to share such feelings with them. Given the impact on the patients' quality of life and medical outcomes, it is important for clinicians to gently encourage these patients to see trained pastoral counselors or chaplains who can help them work through these issues. [p. 738]
Koenig furthermore recommends that if depressed patients are "religious and their depressive illness is impairing their religious involvement, then depression should be aggressively treated and the patient's prior religious activity encouraged" [p. 739].


Suggestions for the Use of the Article for Discussion in CPE: 

This would be an excellent article for CPE groups that have yet to delve into issues of research methodology and are interested primarily in broad presentations of results --groups in the first month or so in a program. Methodological questions could then be pursued subsequently by reading any of the key studies cited. Discussion would naturally seem to revolve around the topic of depression, and this could serve as means of introduction to the subject of working with psychiatric patients. Inviting a physician--perhaps a psychiatrist-to the discussion could be helpful. Koenig asks, in light of his summary of findings, "What should be done with this information?" [p.738], and while he is addressing physicians, the same could be put to chaplains: what might be the clinical implications of this research for pastoral care? Students may also want to talk about the mention of physician-patient interaction around spirituality and chaplain referrals (p. 738) and so move into those whole other topics (in which case, the Articles-of-the-Month for May 2004, September 2004, and perhaps October 2005 should be of further interest).


Related Items of Interest:

I. The two articles referenced in this month's featured piece, which were still in press at the time of Koenig's writing:

Koenig, H. G. "Religion and depression in older medical inpatients." American Journal of Geriatric Psychiatry 15, no. 4 (April 2007): 282-291. [(Abstract:) OBJECTIVE: The objective of this study is to examine the religious characteristics of older medical inpatients with major and minor depression, compare them with religious characteristics of nondepressed patients, and examine their relationship to severity and type of depression. METHODS: Medical inpatients over age 50 at Duke University Medical Center (DUMC) and three community hospitals were identified with depressive disorder using a structured psychiatric interview. Detailed information was obtained on their psychiatric, medical, and religious characteristics. Religious characteristics of these patients were then compared with those of nondepressed patients in a concurrent study at DUMC controlling for demographic, health, and social factors. Among depressed patients, relationships to severity and type of depression were also examined. RESULTS: Religious involvement among 411 patients with major and 585 with minor depression was widespread, although not as frequent as in 428 nondepressed patients. After controlling for demographic and physical health factors, depressed patients were more likely to indicate no religious affiliation, less likely to affiliate with neofundamentalist denominations, more likely to indicate "spiritual but not religious," less likely to pray or read scripture, and scored lower on intrinsic religiosity. Among depressed patients, there was no relationship between religion and depression type, but depression severity was associated with a lower religious attendance, prayer, scripture reading, and lower intrinsic religiosity. Social factors only partially explained these relationships. CONCLUSION: Older medically ill hospitalized patients with depression are less religiously involved than nondepressed patients or those with less severe depression. Implications for clinicians are discussed.]

Koenig, H. G. "Religion and remission of depression in medical inpatients with heart failure/pulmonary disease." Journal of Nervous & Mental Disease 195, no. 5 (May 2007): 389-395. [(Abstract:) The impact of religious involvement on time to remission of depression was examined in older medical inpatients with heart failure and/or chronic pulmonary disease (CHF/CPD). Inpatients older than 50 years with CHF/CPD were systematically diagnosed with depressive disorder using a structured psychiatric interview. Cox proportional hazards regression was used to examine the effects of religious involvement on time to remission, controlling for covariates. Of 1000 depressed patients identified at baseline, follow-up data on depression course were obtained on 87%. Patients involved in group-related religious activities experienced a shorter time to remission. Although numerous religious measures were unrelated by themselves to depression outcome, the combination of frequent religious attendance, prayer, Bible study, and high intrinsic religiosity, predicted a 53% increase in speed of remission (HR 1.53, 95% CI 1.20-1.94, p = 0.0005, n = 839) after controls. Patients highly religious by multiple indicators, particularly those involved in community religious activities, remit faster from depression.]

II. In addition to the studies cited by Koenig in his relatively short but rich bibliography, the following recent articles may be of interest:

Dein, S. [Centre for Behavioural and Social Sciences in Medicine, London]. "Religion, spirituality and depression: implications for research and treatment." Primary Care and Community Psychiatry 11, no. 2 (2006): 67-72. [(Abstract:) Background: There has been a recent interest in religion and spirituality in psychiatric research and practice. Scope: After outlining the problems involved in examining religious/spiritual variables in psychiatric research, this review examines the relationship between depression and various measures of being religious. A search of databases containing published literature on religion and depression was carried out using the databases PubMed, Psycinfo and Medline from 1996 to 2006. Findings: The literature suggests that those who are religious have a lower incidence of depressive symptoms/depression and that being religious may increase the speed of recovery from depressive disorder. This protective effect is less clear cut for psychotic depression. Conclusions: This review ends by discussing the clinical implications and potential areas for future research.]

Fenix, J. B., Cherlin, E. J., Prigerson, H. G., Johnson-Hurzeler, R., Kasl, S. V. and Bradley, E/ H. [Department of Epidemiology and Public Health, Yale School of Medicine, New Haven, CT]. "Religiousness and major depression among bereaved family caregivers: a 13-month follow-up study." Journal of Palliative Care 22, no. 4 (2006): 286-292. [(Abstract:) OBJECTIVE: To examine the association between a multi-item measure of religiousness and major depressive disorder (MDD) in bereaved family caregivers of patients with cancer. DESIGN: A prospective longitudinal study of primary caregivers of consecutive patients (n = 175) with cancer enrolled in the largest hospice in Connecticut. RESULTS: Caregivers with a high religiousness summary score were significantly less likely to have MDD at the 13-month follow-up interview (OR = 0.79, 95% CI: 0.68-0.91). This finding remained significant (OR = 0.74, 95% CI: 0.59-0.91) after adjustment for caregiver MDD at baseline, caregiver age, caregiver burden, and number of activities restricted due to caregiving roles. CONCLUSIONS: Family caregivers who reported greater religiousness at baseline had lower rates of depression in the 13-month follow up after their loss. Collaboration with religious support groups or community groups during bereavement could offer an effective mechanism for speeding the process of recovery for some caregivers.]

Maddi, S. R., Brow, M., Khoshaba, D. M. and Vaitkus, M. [Department of Psychology and Social Behavior, University of California, Irvine, and Department of Sociology, United States Army War College]. "Relationship of hardiness and religiousness to depression and anger." Consulting Psychology Journal: Practice and Research 58, no. 3 (Summer 2006):148-161. [(Abstract:) Both hardiness and religiousness share spirituality, in the sense of searching for meaning in one's life, and have been shown to have a buffering effect on stresses that maintains and enhances performance, morale, and health. This study investigates how hardiness and religiousness compare in their relationship to depression, anger, and the coping and social support mechanisms whereby they may have these relationships. Participants were military and governmental personnel who completed accepted measures of hardiness, religiousness, and other variables on a volunteer basis. Correlational and multiple regression analyses showed that, by comparison with religiousness, hardiness has the larger and more comprehensive negative relationship with depression and anger, and positive relationship with coping and social support. The conceptual and empirical implications of these findings are discussed.]

McCoubrie, R. C. and Davies, A. N. [Department of Palliative Medicine, Elgar House, Southmead Hospital, Westbury-on-Trym, Bristol, UK]. "Is there a correlation between spirituality and anxiety and depression in patients with advanced cancer?." Supportive Care in Cancer 14, no. 4 (April 2006): 379-385. [(Abstract:) AIMS AND OBJECTIVES: To establish whether there is a correlation between spirituality and anxiety and depression in patients with advanced cancer. PATIENTS AND METHODS: Patients with a diagnosis of cancer at St. Peter's day hospice in Bristol were asked to complete three questionnaires to assess anxiety, depression and spirituality. Informed consent was obtained. Anxiety and depression are indicated by the Hospital Anxiety and Depression Scale score, and spirituality is indicated by scores on the Spiritual Well-Being Scale (SWBS) and the Royal Free Interview for Spiritual and Religious Beliefs. As will be explained, religion and spirituality are generally recognized as having different meanings--religion entailing a relationship with a higher being, while spirituality can be thought of in terms of meaning and purpose in life. RESULTS: Eighty-five complete data sets were obtained. A significant negative correlation was found between both anxiety and depression scores and overall spiritual well-being scores (p < 0.0001). When the SWBS subscale scores were analyzed individually, a significant negative correlation was found between the existential well-being scores and the anxiety and depression scores (p < 0.001). However, no correlation was found between the religious well-being scores and anxiety or depression. CONCLUSIONS: This study found a significant negative correlation between spirituality (in particular, the existential aspect) and anxiety and depression in patients with advanced cancer. Religious well-being and strength of belief had no impact on psychological well-being in this study.]

[ADDED 8/14/07]: Mofidi, M., DeVellis, R. F., DeVellis, B. M., Blazer, D. G., Panter, A T., and Jordan, J. M. [US Department of Health and Human Services, Health Resources and Services Administration, Rockville, MD; University of North Carolina, Chapel Hill; and Duke University, Durham, North Carolina.]. "The relationship between spirituality and depressive symptoms: testing psychosocial mechanisms." Journal of Nervous and Mental Disease 195, no. 8 (August 2007): 681-688. [(Abstract:) Although many studies suggest lower rates of depressive symptoms in those who report greater spirituality, few have investigated the mechanisms by which spirituality might relate to depressive symptoms. The current study aimed to elucidate potential psychosocial mechanisms that link these 2 variables. Data were drawn from a community-dwelling stratified sample of 630 racially diverse adults in rural North Carolina. Spirituality was assessed by 6 items of the Daily Spiritual Experiences Scale. Depressive symptoms were measured using 4 subscales from the Center for Epidemiological Studies-Depression. Hypothesized mediators were optimism, volunteering, and perceived social support. Structural equation modeling was used to test whether proposed mediators explain a link between spirituality and depressive symptoms. The model demonstrated a satisfactory fit. Spirituality was indirectly related to depressive symptoms. More specifically, spirituality was significantly associated with optimism and volunteering but not with social support, and optimism, volunteering and perceived social support were significantly associated with depressive symptoms. The link between spirituality and depressive symptoms is indirect. The relationship is mediated by optimism, volunteering, and social support. Findings present research and practice implications.]

Norton, M. C., Skoog, I., Franklin, L. M., Corcoran, C., Tschanz, J. T., Zandi, P. P., Breitner, J. C., Welsh-Bohmer, K. A., Steffens, D. C. , and the Cache County Investigators [Department of Family, Consumer and Human Development, Utah State University, Logan, UT]. "Gender differences in the association between religious involvement and depression: the Cache County (Utah) study." Journals of Gerontology Series B-Psychological Sciences and Social Sciences 61, no. 3 (May 2006): P129-136. [(Abstract:) We examined the relation between religious involvement, membership in the Church of Jesus Christ of Latter-Day Saints, and major depression in a population-based study of aging and dementia in Cache County, Utah. Participants included 4,468 nondemented individuals between the ages of 65 and 100 years who were interviewed in person. In logistic regression models adjusting for demographic and health variables, frequent church attendance was associated with a reduced prevalence of depression in women but increased prevalence in men. Social role loss and the potential impact of organizational power differential by sex are discussed. Though causality cannot be determined here, these findings suggest that the association between religious involvement and depression may differ substantially between men and women.]

III. Recent case studies of spirituality/religion and depression:

Blazer, D. G. "Spirituality and depression: a case study." Southern Medical Journal 100, no. 7 (July 2007): 759-760.

Vaccaro, B. "Spirituality in the treatment of a man with anxiety and depression." Southern Medical Journal 100, no. 6 (June 2006): 626-627.

IV. Other articles focusing on spirituality and depression in the same issue of the of the Southern Medical Journal, in the special section in which our featured article was published:

Blazer, D. "Spirituality, depression and suicide: a cross-cultural perspective." Southern Medical Journal 100, no. 7 (July 2007): 735-736.

Bostwick, J. M. and Rummans, T. A. "Spirituality, depression and suicide in middle age." Southern Medical Journal 100, no. 7 (July 2007): 746-747.

Cloninger, C. R. "Spirituality and the science of feeling good." Southern Medical Journal 100, no. 7 (July 2007): 740-743.

Josephson, A. M. "Depression and suicide in children and adolescents: a spiritual perspective." Southern Medical Journal 100, no. 7 (July 2007): 744-745.

Steffens, D. C. "Spiritual considerations in suicide and depression among the elderly." Southern Medical Journal 100, no. 7 (July 2007): 748-749.

NOTE: Yet more articles appear in the special section of the July 2007 issue of the Southern Medical Journal (--part of the journal's ongoing Spirituality and Medicine series), but they focus especially on suicide..

V. Previously featured Articles-of-the-Month that touch on the subject of spirituality and depression are those from March 2006 and January 2006.


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