Religion, Spirituality, Geriatric Mental Health: Research ... · PDF fileReligion, Spirituality, Geriatric Mental Health: Research & Clinical Applications Harold G. Koenig, MD Professor

Religion, Spirituality, Geriatric Mental Health:

Research & Clinical Applications

Harold G. Koenig, MD

Professor of Psychiatry and Associate Professor of Medicine

Duke University Medical Center, Durham, North Carolina USA

Adjunct Professor, King Abdulaziz University, Jeddah, Saudi Arabia

Adjunct Professor, Ningxia Medical University, Yinchuan, People’s Republic of China

Session I Research Background (9:00-10:30) • Definitions • Use of religion to cope • Review of early research (prior to 2010) • Review of latest research at Columbia, Duke, etc (2010-2015) • Theoretical model to explain effects • Further resources Break (10:30-10:40) Session II Clinical Applications (10:40-11:30) Reasons for addressing spirituality in geriatric mental healthcare How and when to address spirituality Duke - Adventist Health System Project Discussion (11:30-12:00)

Overview

Definition of Terms Religion

Beliefs, practices, and rituals related to the Transcendent, where in Western

traditions, the Transcendent is also called God, Allah, HaShem, or a Higher Power,

or in Eastern traditions, may be called Vishnu, Krishna, Buddha, or Ultimate

Reality. Religions usually have doctrines about life after death and rules to guide

behavior. Religion is often organized as a community, but can also exist outside of

an institution and may be practiced alone and in private.

Secular Humanism

Secular humanism views human existence without reference to religion, i.e., God,

the transcendent, a higher power, or ultimate truth. The focus is on the rational

self, science, & community as the ultimate source of power & meaning.

Spirituality

According to the traditional definition, spirituality was the core of what it meant to be

religious, i.e., describing those who were deeply religious, living a life dedicated and

surrendered to the Divine. The modern definition of spirituality, however, has become

much broader, including not only those who are deeply religious, but those who are

superficially religious & those who are not religious at all (secular humanists).

Important points to take away 1. Religion is more specific and easily measured – and is a

more useful construct when conducting research that seeks to identify specific characteristics of the individual that prevent disease or alter disease course.

2. Spirituality is an ideal term to use in clinical settings when talking to and engaging with patients, where patients should be allowed to define the term for themselves. However, it is not useful for conducting research given its vague, nebulous, and largely self-defined nature.

Sigmund Freud Future of an Illusion, 1927

“Religion would thus be the universal obsessional

neurosis of humanity... If this view is right, it is to be

supposed that a turning-away from religion is bound to

occur with the fatal inevitability of a process of

growth…If, on the one hand, religion brings with it

obsessional restrictions, exactly as an individual

obsessional neurosis does, on the other hand it comprises

a system of wishful illusions together with a disavowal of

reality, such as we find in an isolated form nowhere else

but amentia, in a state of blissful hallucinatory

confusion…”

Sigmund Freud Civilization and Its Discontents

“The whole thing is so patently infantile, so

incongruous with reality, that to one whose

attitude to humanity is friendly it is painful to

think that the great majority of mortals will

never be able to rise above this view of life.”

Religion as a Coping Behavior

1. Many persons turn to religion for comfort when

stressed

2. Religion used to cope with common problems in life,

especially those experienced by older adults in the

setting of physical and psychiatric illness

3. Religion often used to cope with challenges such as:

- uncertainty

- fear

- pain and disability

- loss of control

- discouragement and loss of hope

Religious Coping - definition

The use of religious beliefs or practices to cope with and make sense of negative life experiences (and sometimes positive ones, too). For example, in Western religious traditions, behaviors such as praying to derive comfort and hope in emotionally trying times; reading religious writings for inspiration and guidance; attending religious services to be uplifted by singing and worshiping together as a group; seeking support from members of one’s congregation, or giving support to others for religious reasons. RC may also involve cognitive processes, including beliefs about a better life after death when pain and suffering will be no more, or beliefs in a loving, caring God who is in control, has a purpose for the world and individuals in it, and has the power to transform difficult circumstances so that good outcomes are possible. Thus, both behaviors and beliefs are involved in RC.

0

0.1-4.9

5.0-7.4

7.5-9.9

10

5.0%

5.0%

22.7%

27.3%

40.1%

Self-Rated Religious Coping

The Most Important Factor

Large Extent or More

Moderate to Large Extent

None

Responses by 337 consecutively admitted patients to Duke Hospital (Koenig 1998)

Small to Moderate

Stress-induced Religious Coping

America’s Coping Response to Sept 11th:

1. Talking with others (98%)

2. Turning to religion (90%)

3. Checked safety of family/friends (75%)

4. Participating in group activities (60%)

5. Avoiding reminders (watching TV) (39%)

6. Making donations (36%)

Based on a random-digit dialing survey of the U.S. on Sept 14-16

New England Journal of Medicine 2001; 345:1507-1512

How Religion Influences Coping

1. Positive world view 2. Meaning and purpose 3. Psychological integration 4. Hope (and motivation) 5. Personal empowerment 6. Sense of control (prayer) 7. Role models for suffering (facilitates acceptance) 8. Guidance for decision-making (reduces stress) 9. Answers to ultimate questions 10. Social support (both human and Divine) Not lost with physical illness or disability

Example of Religious Coping (JAMA 2002; 288 (4): 487-493)

1. 83 years old

2. Multiple serious medical problems

3. Chronic, progressive, unrelenting pain

4. Traditional medical treatments ineffective

5. Alternative medical treatments ineffective

6. Limited material resources – lives alone

7. But, doing well psychologically

8. Positive, hopeful and optimistic

9. Functioning independently- without assist

10. Concerned with meeting others’ needs

11. How does she do it? Religion, she says

Religion – How does it help to cope?

"I don’t dwell on the pain. Some people are sick

and have pain and it gets the best of them.

Not me. I pray a lot…. I believe in God,

and I give my whole heart, body, and soul over to him…

Sometimes I pray and I'm in deep serious prayer and

all of a sudden, my pain gets easy. It slackens up and

I drop off to sleep, and wake up and I can do things

for myself. So prayer helps me a lot – I give God my

heart and soul – and you don’t have to worry about

nothing. He leads you and directs you,

and he takes care of you. And I believe in that.

That is my belief."

Religious Coping – does it really help?

Systematic Review of the Research

1887 to 2010

Handbook of Religion and Health

(Oxford University Press, 2001, 2012)

with some recent research (2014-2015)

highlighted

Religious involvement is related to: Less depression, faster recovery from depression 272 of 444 studies (61%) [67% of best] More depression (6%)

Depression The most common emotional disorder found in medical settings

20% with major depression

20% with minor depressive disorders

Citation: Miller L et al (2014). Neuroanatomical correlates of religiosity and spirituality in adults at high

and low familial risk for depression. JAMA Psychiatry 71(2):128-35

Religion/Spirituality and Cortical Thickness:

A functional MRI Study

Areas in red indicate reduced cortical thickness

Religion NOT very important Religion very important

Is Emotional Disorder Different in the

Religious?

Is depression the same in those with deep religious faith?

Even if depressed, research suggests that deeply religious

people experience more positive emotions:

-greater purpose and meaning

-greater optimism and hope

-more gratitude and thankfulness

-more generosity

Koenig HG, Berk LS, Daher N, Pearce MJ, Belinger D, Robins CJ, Nelson B, Shaw SF, Cohen

HJ, King MB (2014). Religious involvement, depressive symptoms, and positive emotions in

the setting of chronic medical illness and major depression. Journal of Psychosomatic

Research 77:135–143

1st 2nd 3rd 4th 5th

130

140

150

160

170

180

190

200

Religiosity Quintiles

Po

sitiv

e E

mo

tio

ns

10

15

20

25

30

35

40

45

50

Be

ck D

ep

ressio

n In

ven

tory

Religious Psychotherapy Study

132 persons with major depressive disorder and chronic

medical illness (the majority over age 50) randomized to

Religious CBT vs. Conventional Secular CBT

65 from Durham County, North Carolina (Duke University)

67 from Los Angeles County (Glendale Adventist)

Ten 50-minute psychotherapy sessions by telephone over 12

weeks

5 religious-integrated psychotherapies:

Christian

Jewish

Buddhist

Muslim

Hindu

Manuals and workbooks now up on our Duke website: http://www.spiritualityandhealth.duke.edu/index.php/religious-cbt-study/therapy-manuals

And soon to have a training video on website as well

Religious

Cogn-Behav

Therapy

Public prac, rit

Private prac, rit

R commitment

R coping

Optimism,Meaning & Purpose

Social Support

DysfunctionalCognitions &Behaviors

Ph

ysio

log

ica

l C

ha

nge

s(S

tre

ss H

orm

one

s,

Imm

unity,

Inflam

ma

tion

)

Genetic Influences

Chronic Physical Illness and Disability

R experiences

HumanVirtues

Gratefulness

Altruism

Generosity

Majo

r D

epre

ssiv

e D

isord

er

DemographicInfluencesAge, Race, Gender,Education

vs.

Research Study for Treatment of Depression in Chronically Ill, Disabled

Conventional

Cogn-Behav

Therapy

Results

Baseline Week4 Week8 Week12 Week24

0

4

8

12

16

20

24

28M

ean

BD

I sco

re

Time

CCBT

RCBT

Group by time interaction B=0.50, SE=0.55, t=0.91, p=0.36, Cohen’s d=0.10, favors RCBT

Koenig et al. Journal of Nervous and Mental Disease 2015; 203(4):243-251

Treatment response in those with HTR1A genotype C/C (B for group by time interaction=3.33,

SE=1.17, df=62, t=2.86, p<0.01, n=28, Cohen’s d=0.73, in those with low religiosity)

Koenig et al. Austin Journal of Psychiatry & Behavioral Sciences 2015; 2(1): 1036

0 4 8 12

10

15

20

25

30

De

pre

ssiv

e S

ym

pto

ms (

BD

I)

Week

Conventional CBT

Religious CBT

Difference significant between RCBT and SCBT at 12 week f/u (t=-2.10, p=0.038) in per-protocol analysis

Koenig et al. Depression & Anxiety 2015, in press

Religious involvement is related to: Less suicide and more negative attitudes toward suicide (106 of 141 or 75% of studies) Why? A religious worldview gives people a reason for living – it gives

life meaning -- especially those with chronic disabling medical illness, or faced with life-threatening medical diagnoses

Suicide (systematic review)

Religious involvement is related to: Less alcohol use / abuse / dependence 240 of 278 studies (86%) [90% of best]

Alcohol Use/Abuse/Dependence (systematic review)

Illicit Drug Use (systematic review)

Religious involvement is related to: Less drug use / abuse / dependence 155 of 185 studies (84%) [86% of best] [95% of RCT or experimental studies]

Loss of Faith and PTSD Symptoms

1,385 veterans from Vietnam (95%), World War II and/or Korea

(5%) involved in outpatient or inpatient PTSD programs. VA

National Center for PTSD and Yale University School of Medicine.

Weakened religious faith was an independent predictor of use of VA

mental health services—independent of severity of PTSD

symptoms and level of social functioning. Investigators concluded

that the use of mental health services was driven more by their

weakened religious faith than by clinical symptoms or social

factors.

Fontana, A., & R. Rosenheck. Trauma, change in strength of

religious faith, & mental health service use among veterans treated

for PTSD. Journal of Nervous & Mental Disease 2004; 192:579–

84.

Treating Moral Injury in PTSD (seeking funding support)

Spiritually-oriented Cognitive Processing Therapy (SOCPT) for

Moral Injury in older Veterans/Active Duty U.S. Military with

PTSD or sub-threshold PTSD

Now conducting un-funded pilot studies at Charlie Norwood

VAMC, Durham VAMC, San Antonio VAMC, and Houston VAMC

Seeking $300,000 to conduct pilot study involving SOCPT vs.

Conventional Secular CPT in 75 older Veterans with PTSD

symptoms (often revived when sick)

Ultimate goal is a multi-center study to establish SOCPT as an

evidence-based treatment for moral injury in PTSD (using

psychologists), and then develop a version for VA chaplains and

train them to administer it

Religious involvement is related to: Greater well-being and happiness 256 of 326 studies (79%) [82% of best] Lower well-being or happiness (<1%)

Well-being and Happiness (systematic review)

Religion and Well-being in Older Adults

Religious categories based on quartiles (i.e., low is 1st quartile, very high is 4th quartile)

Low Moderate High Very High

Church Attendance or Intrinsic Religiosity

Wel

l-b

ein

g

The Gerontologist 1988; 28:18-28

Religion and Well-being in Older Adults

Religious categories based on quartiles (i.e., low is 1st quartile, very high is 4th quartile)

Low Moderate High Very High

Church Attendance or Intrinsic Religiosity

Wel

l-b

ein

gThe Gerontologist 1988; 28:18-28

Religious involvement is related to: Greater meaning and purpose 42 of 45 studies (93%) [100% of best] Greater hope

29 of 40 studies (73%) Great optimism

26 of 32 studies (81%) *All of the above have consequences for older adults’ motivation for self-care and efforts toward recovery*

Meaning, Purpose, Hope, Optimism (systematic review)

Religious involvement is related to: • Great social support (61 of 74 studies) (82%)

Social Support (systematic review)

0

500

1000

1500

2000

2500

C NG (NG) M (P) P NA

C

NG

(NG)

M

(P)

P

NA

Number of studies includes some studies counted more than once (see Appendices

of 1st and 2nd editions). Prepared by Dr. Wolfgang v. Ungern-Sternberg

The Relationship between Religion and Health: All Studies

Models and Mechanisms How might religion influence health in later life? Theoretical model involving causal pathways and constructs along pathways that help explain the religion-health relationship – next slide

Belief in,

attachment to

God

Public prac, rit

Private prac, rit

R commitment

R coping

Positive Emotions

Negative EmotionsMental Disorders

Social Connections

Ph

ysical H

ea

lth a

nd

Lo

ng

evity

Imm

une, E

ndocrine, C

ard

iovascula

r F

unctions

Theoretical Model of Causal Pathways

Genetics, Developmental Experiences, Personality

Decisions, Lifestyle Choices, Health Behaviors

SOURCE

R experiences

Spirituality

faith

community

PsychologicalTraits / Virtues

ForgivenessHonestyCourageSelf-disciplineAltruismHumilityGratefulnessPatienceDependability

Theolo

gic

al V

irtues:

faith

, hope, lo

ve

faith

community

*Model for Western monotheistic religions (Christianity, Judaism, and Islam)

(c) Handbook of Religion & Health, 2nd ed

Research now being done to

understand the underlying

biological mechanism that may

help explain WHY religious

involvement is related to better

physical health in later life and

greater longevity

Duke Stressed Caregiver Study

251 family caregivers (ages 40-75) caring for severely disabled

family member

151 from Durham, North Carolina (Duke)

100 from Los Angeles County (Glendale Adventist)

Outcomes: (1) develop new 10-item comprehensive and

sensitive measure of religious commitment

(2) examine religiosity and caregiver adaptation

(3) examine religiosity and caregiver telomere length

Poor Caregiver Adaptation (depressive symptoms,

perceived stress, caregiver burden)

0 1 2 3 4 5 6 7 8 9 10

60

65

70

75

80

85

90

95

100C

are

giv

er

Ad

ap

tati

on

(lo

w s

core

s indic

ate

bett

er

adapta

tion)

Deciles of Religious Involvement

Koenig et al. (2016). Journal of the American Geriatrics Society, in press (January)

40-44 45-49 50-54 55-59 60-64 65-69 70-75

5300

5400

5500

5600

5700

5800

5900T

elo

me

re L

en

gth

(b

p)

Age, years

Religious involvement and

Telomere Length

Results: Pending

Conclusions

1. Religion is easier to measure than spirituality, so most of the research supporting clinical applications in geriatric mental health care has to do with religious involvement

2. Religion is commonly used by older adults to cope with chronic medical illness and psychiatric illness

3. Religious involvement is associated with less emotional disorder, greater well-being, less substance abuse, and greater social support – especially in older adults

4. Consequently, religious involvement is also related to better physical health and greater longevity

Further Resources

Oxford University Press, 2012

June 2014

CROSSROADS…

Exploring Research on Religion, Spirituality & Health

• Summarizes latest research

• Latest news

• Resources

• Events (lectures and conferences)

• Funding opportunities

To sign up, go to website: http://www.spiritualityandhealth.duke.edu/

Monthly FREE e-Newsletter

Summer Research Workshop August 15-19, 2016

Durham, North Carolina

5-day intensive research workshop focus on what we know about the relationship

between spirituality and health, applications, how to conduct research and develop an

academic career in this area. Leading spirituality-health researchers at Duke, Yale

University, Johns Hopkins, and elsewhere to give presentations:

-Strengths and weaknesses of previous research

-Theological considerations and concerns

-Highest priority studies for future research

-Strengths and weaknesses of measures of religion/spirituality

-Designing different types of research projects

- Primer on statistical analysis of religious/spiritual variables

-Carrying out and managing a research project

-Writing a grant to NIH or private foundations

-Where to obtain funding for research in this area

-Writing a research paper for publication; getting it published

-Presenting research to professional and public audiences; working with the media

Partial tuition Scholarships are available

If interested, contact Dr. Koenig: [email protected]

Discussion (till 10:30)

Break 10:30-10:40

Time is NOW to Start Addressing Spiritual Issues in Geriatric Mental Health Care

10:40-11:30

Reasons for Doing So

1. Many older adults have spiritual needs and religious beliefs related to psychiatric illness that influence satisfaction with care, healthcare costs, and compliance with psychiatric treatment

2. Religion influences coping with illness and affects the older adult’s emotional state and motivation to recover

3. Emotional state likely influences physical health outcomes, which in term may affect depression, anxiety or other emotional problems

4. Religious beliefs influence older adults’ decisions about mental health care, especially compliance with treatments (and can negatively influence it unless religious beliefs are addressed)

5. Standards of care (JCAHO) require respect for patients’ cultural and spiritual beliefs, especially in substance abuse treatment and behavioral health

Applications in Geriatric Mental Health

Care

• Mental Health Professionals (MHPs) should take a spiritual history

-- explore these issues with their older patients

• Respect, value, support beliefs and practices of the patient

• Identify (A) spiritual issues involved in the mental health

disturbance, (B) spiritual resources, and (C) spiritual needs

• Ensure that someone meets patient’s spiritual needs (as part of

mental health care provided or by referral to pastoral counselor)

• Pray with older patients if patient requests (be sensible, though)

From: Spirituality in Patient Care (Templeton Foundation Press, 2013)

Contents of the Spiritual History

1. Do your spiritual or religious beliefs provide comfort? If no, did

they ever? If yes, how?

2. Are your spiritual or religious beliefs a source of stress, or in some

way related to what you are going through now?

3. Do you have religious beliefs that might influence your decisions

about taking medication or receiving psychotherapy?

4. Are you a member of a faith community, such as a church,

synagogue, or mosque? If yes, is it supportive? If not, was this ever a

source of support (and if so, why are you not involved now)?

5. Do you have any other spiritual concerns that you’d like to talk

about? (either with me or with a pastoral counselor)

1Adapted from Koenig HG (2002). JAMA 288 (4): 487-493

1. Increased volume of psychiatric knowledge (that MHP is responsible for)

2. Increased need to document and deal with Electronic Medical Record 4. Increasingly complex medical problems that go with chronic illness in an

aging population

5. Must also address needs of the caregiver / family

6. Increased time spent dealing with insurance companies, and their growing reluctance to pay for medications

7. Greater and greater struggle to get reimbursed from Medicare

8. More and more patients to see in less and less time (patients more and more dissatisfied, increased pressure of lawsuits)

Challenges to Addressing Spirituality Issues

In Geriatric Mental Health Care

The Result: 1. MHPs feeling harried and time-pressured

2. Medical errors, unnecessary tests, reduced patient compliance

3. MHP has problems at home because of demands of work

4. Work becomes just a job for pay

5. Lost sense of “calling” or why went into mental health profession

6. Not caring anymore

7. Coping by turning to alcohol or drugs

8. Burnout – no time, no desire, and no capacity to provide whole person geriatric mental health care

Inquiring about and addressing the spiritual aspects of mental health care depends not only on psychiatrists and other mental health professionals

The Health Care System must make it possible to inquire about and address Spiritual Issues as part of Geriatric Mental Health Care

Hospital System Changes that might facilitate MHPs inquiring about and addressing spiritual issues

1) Give MHP the time to address the mental, social, and spiritual needs of older adults (i.e., fewer patients)

2) Hire adequate staff that can help with doing the “busywork” (documentation, checks, assistance with EMR, writing prescriptions, etc.) so that this does not use up precious MHP time

3) Focus on scheduling, decrease “no shows”, improving patient flow, structure clinic setting in a way that minimizes MHP downtime, simplify EMR

4) Hire adequate numbers of social workers and pastoral counselors who are trained to address the spiritual/religious needs of elders

5) And provide training on why, how, and when to address spiritual issues in the mental health care of older adults

Duke – Adventist Health System Project

The Spiritual Care Team: Health professionals integrating spirituality into whole person health care together

Spiritual Care Team

1. The psychiatrist/psychologist may have very little time or

training to address older adults’ spiritual issues. Therefore, other team members need to take up the slack by providing practical assistance and support.

2. The “Spiritual Care Team” includes mental health staff such as the nurse, clinic manager, receptionist, social worker, and chaplain (or pastoral counselor); will vary depending on setting

3. Each member of the spiritual care team has a specific role to play --- to enable the provision of whole-person geriatric mental health care to patients and caregivers

What does “providing whole person geriatric mental health care” look like? 1. The psychiatrist or lead mental health clinician conducts a

spiritual history in order to identify and document spiritual issues likely to influence care

2. Spiritual needs are addressed by someone, and follow-up occurs to ensure that spiritual issues are addressed

3. An atmosphere is created that is open to discussing this subject with older patients and doing so in a supportive manner, recognizing the benefits to health and well-being

Spiritual Care Team Members and Roles

1. Psychiatrist/Psychologist – identifies and documents spiritual issues, resources and needs – takes spiritual history 2. Spiritual care coordinator – coordinates the addressing of

spiritual needs (if psychiatrist/psychologist not trained) 3. Nurse/s – assists (or is) the spiritual care coordinator

4. Chaplain or pastoral counselor - addresses the spiritual

issues and/or needs of the patient [depending if available] 5. Social worker - works with other team members to develop

long-term plan and arrange for long-term follow-up 6. Receptionist/other clinic staff – ensures religious affiliation

in EMR

Lead Mental Health Professional

1. Conducts a spiritual history

2. Documents responses (in EMR, if privacy can be assured)

3. Ensures someone addresses spiritual issues identified

4. Is willing to discuss spiritual concerns related to psychiatric

care with patient and/or family

5. Follows up to ensure that spiritual issues are addressed

Spiritual Care Coordinator (often a nurse or clinic manager)

1. Duties - obtains information from spiritual history - coordinates the addressing of spiritual needs - prepares patient for pastoral care referral, if needed - provides spiritual support to other team members

2. Training - reads “Spirituality in Patient Care” (Templeton Press, 2013) - watches all 5 CME videos and is familiar with content

3. Person best suited for this role - has a strong, active spiritual life - is a strong leader, but gentle and sensible - has good relationship with other mental health professionals - has good relationship with other team members & patients

Role of the Chaplain / Pastoral Counselor 1. The only person on the spiritual care team trained to address

the spiritual needs of patients

2. After receiving a referral, the chaplain will do a comprehensive spiritual assessment (different from MHP’s)

3. The chaplain will clarify spiritual needs and then come up with a “spiritual care plan” to address those needs

4. The chaplain will work with the social worker to implement the spiritual care plan after hospital discharge or following clinic visit, and follow up to ensure needs are met 5. The chaplain will work with Spiritual Care Coordinator to meet the spiritual needs of members of the team

Working Together to Achieve Common Goals 1. Each member of the spiritual care team has a specific responsibility 2. Assuming each member of the spiritual care team does his or her

job, the following goals will be achieved: • Patients’ spiritual needs related to psychiatric care will be identified • Those needs will be addressed effectively • “Whole person” geriatric mental health care will be delivered • An atmosphere will be created where the patient/family feels free to discuss spiritual issues related to psychiatric care • MHP time is minimized • Each member of the team will feel emotionally and spiritually supported by one another

Conclusions • There are many scientific, financial, and common sense

reasons for assessing & addressing spiritual issues in geriatric

mental health care

• But, there are many challenges to doing so, often related to

lack of time and MHP’s discomfort with subject

• Lack of training is the most important barrier

• The Health Care System has a role to play in enabling MHPs

to address older adults’ spiritual issues in mental health care

• Collaboration as a team is essential for success

Discussion (till 12:00)