State of the Art in Research on Faith and Health Harold G. Koenig, MD Departments of Psychiatry and Medicine Duke University Medical Center GRECC VA Medical.

State of the Art in Research onState of the Art in Research on

Faith and HealthFaith and Health

Harold G. Koenig, MDHarold G. Koenig, MD

Departments of Psychiatry and MedicineDepartments of Psychiatry and Medicine

Duke University Medical CenterDuke University Medical Center

GRECC VA Medical CenterGRECC VA Medical Center

1. Definitions: Religion and Spirituality

2. Research on R/S and mental health

3. Research on R/S and health behaviors

4. Research on R/S, physical health, and longevity

5. Understanding the relationship between R/S and health

6. Further resources

Overview 10:15-11:00

Definitions

Religion

Involves beliefs, practices, and rituals related to the ‘transcendent,” where the transcendent is that which relates to the mystical, supernatural, or God in Western religious traditions, or to Divinities, ultimate truth/reality, or enlightenment in Eastern traditions. Religions usually have specific beliefs about life after death and rules about conduct within a social group. Religion is often organized and practiced within a community, but it can also be practiced alone and in private. Central to its definition, however, is that religion is rooted in an established tradition that arises out of a group of people with common beliefs and practices concerning the transcendent. Religion is a unique construct, whose definition is generally agreed upon.

Spirituality

Spirituality is a concept which today is viewed as broader and more inclusive than religion. It is a term more popular today, more so than religion. Spirituality is considered personal, something individuals define for themselves that may be free of the rules, regulations, and responsibilities associated with religion. Spirituality is more difficult to define than religion, and agreement on what the term means is often lacking – especially since the definition of spirituality has been changing, and expanding.

Spirituality

Religion

Traditional-Historical Understanding

Source

Secular

Mental Health Physical Health

Meaning

Purpose

Connectedness

Peace

Hope

Depression

Anxiety

Addiction

Suicide

CardiovascularDisease

Cancer

Mortality

Psy

chon

euro

imm

unol

ogy

vs.Ex. well-being

Spirituality

Religion

Modern Understanding

Source

Secular


Meaning

Purpose

Connectedness

Peace

Hope

Depression

Anxiety

Addiction

Suicide


Cancer

Mortality

Psy

chon

euro

imm

unol

ogy

vs.Ex. well-being

Spirituality

Religion

Modern Understanding - Tautological Version

Source

Secular


Meaning

Purpose

Connectedness

Peace

Hope

Depression

Anxiety

Addiction

Suicide


Cancer

Mortality

Psy

chon

euro

imm

unol

ogy

vs.

Ex. well-being

Spirituality

Religion

Modern Understanding - Clinical Application only

Source

Secular


Meaning

Purpose

Connectedness

Peace

Hope

Depression

Anxiety

Addiction

Suicide


Cancer

Mortality

Psy

chon

euro

imm

unol

ogy

Ex. well-being

Not a Researchable Model

Comments on Measuring Spirituality in Research

1. Currently, “spirituality” is either measured as (1) religion, (2) positive psychological states, or (3) positive character traits

2. Positive psychological states include having purpose and meaning in life, being connected with others, experiencing peace, harmony, and well-being

3. Positive character traits include being forgiving, grateful, altruistic, or having high moral values and standards

4. Problem: Atheists or agnostics may deny any connection with spirituality, but rightly claim their lives have meaning, purpose, are connected to others, practice forgiveness and gratitude, are altruistic, have times of great peacefulness, and hold high moral values

(Journal of Nervous and Mental Disease 2008; 196(5):349-355)

Measuring Spirituality (cont)

5. Problem: Confusing to use religious language (spirituality or that having to do with the spirit) to describe secular psychological terms

6. Problem: Can no longer examine relationships between spirituality and mental health (since spirituality scales confounded by items assessing mental health) ***

6. Problem: Can no longer examine relationships between spirituality and physical health (since mental health affects physical health through the mind-body relationship)

7. Problem: Can no longer study the negative effects of spirituality on health, since positive effects are predetermined by the definition of spirituality

Result:Meaningless tautological associations between spirituality and health

To keep things simple and clear, I use the terms religion and spirituality interchangeably, or simply use the word religion

When research has been conducted on religion it has been distinctive and not confounded with indicators of positive mental health, as research involving spirituality has.

Research on Religion and Mental Health

1. Well-being2. Depression3. Suicide4. Anxiety5. Substance abuse

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)


Church Attendance or Intrinsic Religiosity

Wel

l-b

ein

gThe Gerontologist 1988; 28:18-28

Religion and Depression in Hospitalized Patients

Geriatric Depression ScaleInformation based on results from 991 consecutively admitted patients (differences significant at p<.0001)

35%

23% 22%

17%


Degree of Religious Coping

Per

cen

t D

epre

ssed

Time to Remission by Intrinsic Religiosity

0 10 20 30 40 50

Weeks of Followup

0

20

40

60

80

100

Pro

babi

lity

of

Non

-Rem

issi

on

%

Low Religiosity

Medium Religiosity

High Religiosity

(N=87 patients with major or minor depression by Diagnostic Interview Schedule)

American Journal of Psychiatry 1998; 155:536-542

0 4 8 12 16 20 24

Weeks of Followup

0

20

40

60

80

100P

roba

bili

ty o

f N

on-R

emis

sion

%

Other Patients

Highly Religious (14%)

diagnosis

845 medical inpatients > age 50 with major or minor depression

HR=1.53, 95% CI=1.20-1.94, p=0.0005, after control for demographics, physical health factors, psychosocial stressors, and psychiatric predictors at baseline

Religious involvement is related to: • Greater well-being and happiness

(278 of 359 studies) (77%)

• Less depression, faster recovery from depression(204 of 324 studies) (63%)

* Sources:Handbook of Religion and Health (2001, Oxford University Press)Handbook of Religion and Health (2011, 2nd ed, OUP)

Well-being and Depression(systematic review: 1806-2009)*

Religious involvement is related to:

Less suicide and more negative attitudes toward suicide

(106 of 141 or 74% of studies)

Why?

A religious world-view gives people a reason for living – it gives life meaning.

Suicide(systematic review)


• Significantly greater meaning and purpose in life(42 of 45 studies) (93%)

• Significantly greater hope(29 of 39 studies) (74%)

Meaning, Purpose, and Hope(systematic review)


• Significantly more forgiveness(34 of 40 studies) (85%)

• Significantly more altruism / volunteering(33 of 47 studies) (70%)

• Significantly more gratitude(5 of 5 studies) (100%)

Forgiveness, Altruism, and Gratitude(systematic review)


• Great social support(61 of 74 studies) (82%)

Social Support(systematic review)

Religion and Health Behaviors

Religion is related to:

• More exercise/physical activity(25 of 37 studies) (68%)

• Less cigarette smoking, especially among the young(120 of 134 studies) (90%)

• Less alcohol/drug use, especially among the young(276 of 324 studies) (85%)

Health Behaviors

The Mind-Body Relationship

Religion

MentalHealth

SocialSupport

HealthBehaviors

StressHormones

ImmuneSystem

Autonomic Nervous System

DiseaseDetection &TreatmentCompliance

Smoking High Risk Behaviors Alcohol & Drug Use

Infection

Cancer

Heart Disease

Hypertension

Stomach &Bowel Dis.

Accidents& STDs*

Gen

etic

su

scep

tib

ility

, Gen

der

, Age

, Rac

e, E

du

cati

on, I

nco

me

Liver & Lung Disease

Stroke

Chi

ldho

od T

rain

ing

Adu

lt D

ecis

ions

Val

ues

and

Cha

ract

er

Adu

lt D

ecis

ions

* Sexually Transmitted Diseases

Model of Religion's Effects on HealthHandbook of Religion and Health (Oxford University Press, 2001)

Religion and Physical Health

Religion & Physiological Functions

Immune

Endocrine

Cardiovascular


Better immune functions(19 of 31 studies) (61%)

Better endocrine functions(21 of 32 studies) (66%) (majority involving meditation)

Immune and Endocrine Functions(systematic review)

Serum IL-6 and Attendance at Religious Services

Never/Almost Never 1-2/yr to 1-2/mo Once/wk or more

Frequency of Attendance at Religious Services

6

8

10

12

14

16

18

Per

cent

wit

h IL

-6 L

evel

s >

5 (1675 persons age 65 or over living in North Carolina, USA)

* bivariate analyses** analyses controlled for age, sex, race, education, and physical functioning (ADLs)

Citation: International Journal of Psychiatry in Medicine 1997; 27:233-250


Lower blood pressure(36 of 62 studies) (58%)

Less heart disease (CAD, CVR, HRV, CRP, cardiac surg, etc.)(35 of 54 studies overall) (65%)

(10 of 14 studies on CAD) (71%)

Cardiovascular Functions(systematic review)

Low Attendance High Attendance Low Attendance High Attendance77

78

79

80

81

Ave

rage

Dia

stol

ic B

lood

Pre

ssu

re

* Analyses weighted & controlled for age, sex, race, smoking, education, physical functioning, and body mass index

Low Prayer/Bible Low Prayer/Bible High Prayer/Bible High Prayer/Bible

p<.0001*

Religious Activity and Diastolic Blood Pressure(n=3,632 persons aged 65 or over)

High = weekly or more for attendance; daily or more for prayerLow= less than weekly for attendance; less than once/day for prayer

Citation: International Journal of Psychiatry in Medicine 1998; 28:189-213

Mortality From Heart Disease and Religious Orthodoxy(based on 10,059 civil servants and municipal employees)

Kaplan-Meier life table curves (adapted from Goldbourt et a l 1993. Cardiology 82:100-121)

Follow-up time, years

Su

rviv

al p

rob

abil

ity

Differences remain significant aftercontrolling for blood pressure, diabetes, cholesterol, smoking,weight, and baseline heart disease

Six-Month Mortality After Open Heart Surgery

Citation: Psychosomatic Medicine 1995; 57:5-15

0

5

10

15

20

25

% D

ead

(2 of 72)

(7 of 86) (2 of 25)

(10 of 49)

(232 patients at Dartmouth Medical Center, Lebanon, New Hampshire)

Hi ReligionHi Soc Support

Hi ReligionLo Soc Support

Lo ReligionHi Soc Support

Lo ReligionLo Soc Support

Hi ReligionHi Soc Support

Mortality (all-cause)(systematic review)

Religious involvement related to:

• Greater longevity in 55 of 84 studies (65%)

• Shorter longevity in 2 of 84 studies (2%)

• Mixed findings in 12 of 84 studies (14%)

Standard Mortality Ratios (ages 25-99)

Males Females

California Mormons (n=9815)* 0.54 (0.51-0.57) 0.61 (0.57-0.65)

Attend church wkly (99% M / 99% F)

+ never smoke+married+12 yr ed** 0.45 (0.42-0.48) 0.55 (0.51-0.59)

+ moderate BMI (57% M / 65% F) 0.43 (0.39-0.47) 0.52 (0.47-0.57)** Life Expectancy age 25 84 years 86 years

US Whites (n=15,832)* 0.90 (0.85-0.96) 0.83 (0.79-0.88)

Attend church wkly (28% M / 39% F) 0.78 (0.68-0.88) 0.70 (0.62-0.79)

+ never smoke 0.60 (0.48-0.74) 0.63 (0.55-0.74)

+ married 0.51 (0.40-0.66) 0.52 (0.42-0.66)

+ 12 yr education ** 0.47 (0.33-0.64) 0.38 (0.28-0.52)

+ moderate BMI (7% M / 10% F) 0.43 (0.30-0.61) 0.35 (0.24-0.50)Life Expectancy age 25 (US Whites – all) 74 years 81 years**Life Expectancy age 25 (extrapolated) 84 years 86 years+

*Based on a systematic sample of active Calif. Mormons followed 1980-2004, and random sample of white US adults followed 1988-1997. Preventive Medicine 2008; 46:133-136

Godbelief, relation,

attachment

Public prac, rit

Private prac, rit

R commit

R coping

Positive Emotions*

Negative Emotions*

*Positive emotions: peace, harmony, existential well-being, happiness, hope/optimism, meaning, purpose*Negative emotions: depression, anxiety, emotional distress, loneliness, low self-esteem

Social sup &connections

Physical H

ealth and Longevity

Imm

une,

End

ocrin

e, C

ardi

ovas

cula

r F

unct

ions

Theoretical Model of Causal Pathways

Genetics, Developmental Experiences, Personality

Decisions, Lifestyle Choices, Health Behaviors

SOURCE

R exp

Spirituality

Handbook of Religion & Health, 2nd Ed, 2011

faithcommunity

Human VirtuesForgivenessHonestyCourageSelf-disciplineAltruismHumilityGratefulnessPatienceDependability

Theologicalvirtues: faith, hope, love

Spirituality in Patient Care (2007, Templeton Press)

Medicine, Religion and Health (2008, Templeton Press)

Faith and Mental Health (2005, Templeton Press)

Handbook of Religion and Health (2001, Oxford University Press)

Handbook of Religion and Health (2011 Oxford University Press)

The Link Between Religion and Health (2002, Oxford University Press)

Further InformationWebsite: Duke Center for Spirituality, Theology and Healthhttp://www.spiritualityandhealth.duke.edu/

Further Reading

Summer Research WorkshopsJuly and August 2010

Durham, North Carolina

5-day intensive research workshops 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 (see website: http://www.spiritualityhealthworkshops.org/). Leading spirituality-health researchers at Duke and elsewhere will give presentations: -Previous research on spirituality and health-Strengths and weaknesses of previous research-Applying findings to clinical practice-Theological considerations and concerns -Highest priority studies for future research-Strengths and weaknesses of spirituality measures-Designing different types of research projects-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

If interested, contact Harold G. Koenig: [email protected]

Discussion and Questions

11:00 end

State of the Art in Research on Faith and Health Harold G. Koenig, MD Departments of Psychiatry and Medicine Duke University Medical Center GRECC VA Medical.

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