Research Grants

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1045-1130
Religion, Spirituality and Health Are They
Connected
Harold G. Koenig, MD Departments of Medicine and
Psychiatry Duke University Medical Center GRECC
VA Medical Center
2
Overview

• Defining ambiguous terms
• Coping with illness
• Research on religion and mental health
• Research on religion and physical health
• Further resources
• Respondents

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Defining Ambiguous Terms
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Religion vs. Spirituality vs. Humanism
Religion beliefs, practices, a creed with dos
and donts, community-oriented,
responsibility-oriented, divisive and unpopular,
but easier to define and measure Spirituality
some relationship to the Sacred or transcendent
spirituality is more personal, individual-focused,
and inclusive although a popular term, is
difficult to define and quantify Secular
Humanism areas of human experience and behavior
that lack a connection to the transcendent, to a
higher power, or to ultimate truth focus is on
the human self as the ultimate source of power
and meaning Most of research has been done on
religion. There are problems when trying to
examine the association between spirituality and
health.
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Concerns About Measuring Spirituality

• Spirituality is either measured as religion, or
  as positive psychological or character traits
• Positive psychological states include having
  purpose and meaning in life, being connected with
  others, experiencing peace, harmony, and
  well-being
• Positive character traits include being
  forgiving, grateful, altruistic, or having high
  moral values and standards
• 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

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Concerns About Measuring Spirituality

• Can no longer look at relationships between
  spirituality and mental health (since
  spirituality scales confounded by items assessing
  mental health)
• Can no longer examine relationships between
  spirituality and physical health (since mental
  health affects physical health)
• 7. The result of 5 and 6 is meaningless
  tautological associations between spirituality
  and health
• 8. Can no longer study the negative effects of
  spirituality on health, since positive effects
  are predetermined by the definition of
  spirituality
• 9. Confusing to use religious language
  (spirituality or that having to do with the
  spirit) to describe secular psychological terms
• (see Concerns about measuring
  spirituality in research. Journal of Nervous
  and Mental Disease, 2008, in press

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Spirituality An Expanding Concept
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Spirituality

• The very idea and language of spirituality,
  originally grounded in the self-disciplining
  faith practices of religious believers, including
  ascetics and monks, then becomes detached from
  its moorings in historical religious traditions
  and is redefined in terms of subjective
  self-fulfillment.
• C. Smith and M.L. Denton, Soul Searching The
  Religious and Spiritual Lives of American
  Teenagers, p.175

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In summary

• When talking about research, I will talk in terms
  of RELIGION (as a multi-dimensional concept)
• When conducting research, spirituality should be
  understood in traditional terms the deeply
  religious whose lives and lifestyles reflect
  their faith (ideal models Mother Teresa, Martin
  Luther King, Gandhi, Siddhartha Gautama, etc.)
• 3. When clinical applications are considered,
  the term SPIRITUALITY should be used, where
  spirituality is broadly inclusive and
  self-defined by patients themselves

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Religion and Coping with Illness

• Many persons turn to religion for comfort when
  sick
• Religion is used to cope with problems common
  among those with medical illness
• - uncertainty
• - fear
• - pain and disability
• - loss of control
• - discouragement and loss of hope

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Stress-induced Religious Coping
Americas 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
3451507-1512
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Religion and Mental Health
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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 growthIf, 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
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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.
Part of a presentation given by Rachel Dew, M.D.,
Duke post-doc fellow
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Religion and Neurosis

• May be used to justify hatred, aggression,
  prejudice
• May be used to gain power and control over others
• Can foster rigid thinking, obsessive practices
• Can foster anxiety, fear, and excessive guilt
  (sin)
• May produce psychosocial strains
• May be used defensively to avoid addressing
  issues
• Common in thought content of psychotic persons
• Can interfere with mental health care (stop meds)
• Can foster negative attitudes toward MH
  professionals
• Can delay diagnosis and effective treatment

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Religion and Mental Health Research
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Cartoon with Prayzac
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Spiritual Injury 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
servicesindependent 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
19257984.
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Religion and Mental Health Research Before Year
2000

• Well-being, hope, and optimism (91/114)
• Purpose and meaning in life (15/16)
• Social support (19/20)
• Marital satisfaction and stability (35/38)
• Depression and its recovery (60/93)
• Suicide (57/68)
• Anxiety and fear (35/69)
• Substance abuse (98/120)
• Delinquency (28/36)
• Summary 478/724 quantitative studies
• Handbook of Religion and Health (Oxford
  University Press, 2001)

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Attention Received Since Year 2000 Religion,
Spirituality and Mental Health

• Growing interest entire journal issues on topic
• (J Personality, J Family Psychotherapy,
  American Behavioral Scientist, Public Policy and
  Aging
• Report, Psychiatric Annals, American J of
  Psychotherapy partial, Psycho-Oncology,
• International Review of Psychiatry, Death
  Studies, Twin Studies, J of Managerial
  Psychology,
• J of Adult Development, J of Family Psychology,
  Advanced Development, Counseling Values,
• J of Marital Family Therapy, J of Individual
  Psychology, American Psychologist,
• Mind/Body Medicine, Journal of Social Issues, J
  of Health Psychology, Health Education
• Behavior, J Contemporary Criminal Justice,
  Journal of Family Practice partial, Southern
  Med J )
• Growing amount of research-related articles on
  topic
• PsycInfo 2001-2005 5187 articles (2757
  spirituality, 3170 religion) 11198
  psychotherapy 46
• PsycInfo 1996-2000 3512 articles (1711
  spirituality, 2204 religion) 10438
  psychotherapy 34
• PsycInfo 1991-1995 2236 articles ( 807
  spirituality, 1564 religion) 9284 psychotherapy
  24
• PsycInfo 1981-1985 936 articles ( 71
  spirituality, 880 religion) 5233
  psychotherapy 18
• PsycInfo 1971-1975 776 articles ( 9
  spirituality, 770 religion) 3197
  psychotherapy 24

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Religion and Physical Health

• The mind-body relationship
• Model of religions effects on physical health
• Research on religion and physical health
• Research resources

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The Mind-Body Relationship
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Effects of Negative Emotions on Health

• Rosenkranz et al. Proc Nat Acad Sci 2003
  100(19)11148-11152
• experimental evidence that negative affect
  influences immune function
•   Kiecolt-Glaser et al. Proc Nat Acad Sci 2003
  100(15) 9090-9095
• stress of caregiving affects IL-6 levels for
  as long as 2-3 yrs after death of patient
•   Blumenthal et al. Lancet 2003 362604-609
• 817 undergoing CABG followed-up up for 12
  years controlling grafts, diabetes,
• smoking, LVEF, previous MI, depressed pts
  had double the mortality
• Brown KW et al. Psychosomatic Medicine 2003
  65636643
• depressive symptoms predicted cancer
  survival over 10 years
• Epel et al. Proc Nat Acad Sci 2004 101
  17312-17315
• psychological stress associated with
  shorter telomere length, a determinant of cell
• senescence/ longevity women with highest
  stress level experienced telomere
• shortening suggesting they were aging at
  least 10 yrs faster than low stress women
• Kubzansky et al. Arch Gen Psychiatry 2007
  641393-1401

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Religion and Physical Health
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Religion and Physical Health Research

• Immune function (IL-6, lymphocytes, CD-4, NK
  cells)
• Death rates from cancer by religious group
• Predicting cancer mortality (Alameda County
  Study)
• Diastolic blood pressure (Duke EPESE Study)
• Predicting stroke (Yale Health Aging Study)
• Coronary artery disease mortality (Israel)
• Survival after open heart surgery (Dartmouth
  study)
• Overall survival (Alameda County Study)
• Summary of the research

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Replication
Lutgendorf SK, et al. Religious participation,
interleukin-6, and mortality in older adults.
Health Psychology 2004 23(5)465-475 Prospective
study examines relationship between religious
attendance, IL-6 levels, and mortality rates in a
community-based sample of 557 older adults.
Attending religious services more than once
weekly was a significant predictor of lower
subsequent 12-year mortality and elevated IL-6
levels (gt 3.19 pg/mL), with a mortality ratio
of.32 (95 CI 0.15,0.72 p lt.01) and an odds
ratio for elevated IL-6 of 0.34 (95 CI 0.16,
0.73, p lt.01), compared with never attending
religious services. Structural equation modeling
indicated religious attendance was significantly
related to lower mortality rates and IL-6 levels,
and IL-6 levels mediated the prospective
relationship between religious attendance and
mortality. Results were independent of covariates
including age, sex, health behaviors, chronic
illness, social support, and depression.
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Predicting Cancer Mortality
Mortality data from Alameda County, California,
1974-1987 3 Lifestyle practices smoking
exercise 7-8 hours of sleep n2290 all
white All Attend Attend Church
Weekly Weekly3 Practices no
smoking SMR for all cancer
mortality 89 52 13 SMR Standardized
Mortality Ratio (compared to 100 in US
population) Enstrom (1989). Journal of the
National Cancer Institute, 811807-1814.
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Religious Attendance and Survival in the Alameda
County Study
28-year follow-up of 5,286 persons living in
Alameda County, CA initially seen in 1965
comparing frequent church attendees to infrequent
attendees I. Frequent attendees had lower
mortality rates (RH0.65) (35 lower) II.
During follow-up frequent attendees
were a. more likely to stop smoking b. more
likely to increase exercising c. more likely to
increase social contacts d. more likely to stay
married III. Adjusting for the 4 health
practices did not significantly change
frequent attendees mortality rates Strawbridge
et al. (1997). American Journal of Public Health,
87957-961.
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Summary Physical Health

• Better immune/endocrine function (7 of 7)
• Lower mortality from cancer (5 of 7)
• Lower blood pressure (14 of 23)
• Less heart disease (7 of 11)
• Less stroke (1 of 1)
• Lower cholesterol (3 of 3)
• Less cigarette smoking (23 of 25)
• More likely to exercise (3 of 5)
• Lower mortality (11 of 14) (1995-2000)
• Clergy mortality (12 of 13)
• Less likely to be overweight (0 of 6)
• Many new studies since 2000

Handbook of Religion and Health (Oxford
University Press, 2001)
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Recent Studies - Physical Health Outcomes

• Religious attendance associated with lower
  mortality in Mexican-Americans. Hill et al.
  Journal of Gerontology 2005 60(2)S102-109
• Religious attendance associated with slower
  progression of cognitive impairment with aging in
  older Mexican-Americans
• Hill et al. Journal of Gerontology 2006
  61BP3-P9 Reyes-Ortiz et al. Journal of
  Gerontology 2007 (in press)
• Religious behaviors associated with slower
  progression of Alzheimers dis.
• Kaufman et al. Neurology 2007 6815091514
• Fewer surgical complications following cardiac
  surgery
• Contrada et al. Health Psychology 200423227-38
• Greater longevity if live in a religiously
  affiliated neighborhood
• Jaffe et al. Annals of Epidemiology
  200515(10)804-810
• Religious attendance associated with gt90
  reduction in meningococcal disease in teenagers,
  equal to or greater than meningococcal
  vaccination
• Tully et al. British Medical Journal 2006
  332(7539)445-450

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Recent Studies - Physical Health Outcomes

• Higher church attendance predicts lower fear of
  falling in older Mexican-Americans
• Reyes-Ortiz et al. Aging Mental Health 2006
  1013-18
• HIV patients who show increases in
  spirituality/religion after diagnosis experience
  higher CD4 counts/ lower viral load and slower
  disease progression during 4-year follow-up
• Ironson et al. Journal of General Internal
  Medicine 2006 21S62-68
• Religion and survival in a secular region. A
  twenty year follow-up of 734 Danish adults born
  in 1914.
• la Cour P, et al. Social Science Medicine 2006
  62 157-164
• Nearly 2,000 Jews over age 70 living in Israel
  followed for 7 years. Those who attended
  synagogue regularly were more likely than
  non-attendees to be alive 7 years later (61 more
  likely to be alive vs. 41 more likely to be
  alive for infrequent attendees. Gradient of
  effect.
• European Journal of Ageing 471-82
• Over 70 recent studies with positive findings
  since 2004
• http\\www.dukespiritualityandhealth.org

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Downsides of Religious Involvement Body-Mass
Index by Religious Group
(based on work of Ken Ferraro)
Southern Baptist 26.25 Protestant--Fundamental
25.72 ProtestantPietistic (Methodists,
etc.) 25.70 Protestant--Non-denominational 25.3
9 Catholics 25.33 Non-Traditionalist
25.19 None 24.84 Protestant-
-Reformation Era (Presb, Luth, Epis)
24.79 Jewish 24.72 Non-Christian 24.3
3
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Religious Struggle444 hospitalized medical
patients followed for 2 years
Each of 7 items below rated on a 0 to 3 scale,
based on agreement. For every 1 point increase
on religious struggle scale (range 0-21), there
was a 6 increase in mortality, independent of
physical and mental health (Arch Intern Med,
2001 161 1881-1885)

• Wondered whether God had abandoned me
• Felt punished by God for my lack of devotion
• Wondered what I did for God to punish me
• Questioned the Gods love for me
• Wondered whether my church had abandoned me
• Decided the Devil made this happen
• Questioned the power of God

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Summary
(1130)

• The mind and emotions are directly connected to
  the bodys natural healing mechanisms (immune,
  endocrine, and cardiovascular systems)
• There are scientifically plausible reasons why
  religion ought to be related to better physical
  health
• Religious involvement is related to better
  physical health
• The effect is only moderate in size, but has huge
  public health impact
• Religion can also have negative effects on
  physical health, although more research is needed
• Further research resources (next slide)

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Further Resources

• Spirituality in Patient Care (Templeton Press,
  2007)
• Handbook of Religion and Health (Oxford
  University Press, 2001)
• Healing Power of Faith (Simon Schuster, 2001)
• Faith and Mental Health (Templeton Press, 2005)
• The Link Between Religion Health
  Psychoneuroimmunology the Faith Factor (Oxford
  University Press, 2002)
• Handbook of Religion and Mental Health (Academic
  Press, 1998)
• In the Wake of Disaster Religious Responses to
  Terrorism and Catastrophe (Templeton Press, 2006)
• Faith in the Future Religion, Aging Healthcare
  in 21st Century (Templeton Press, 2004)
• The Healing Connection (Templeton Press, 2004)
• Duke website http//www.dukespiritualityandhealth
  .org

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Summer Research Workshop July and August
2008 Durham, North Carolina
1-day clinical workshops and 5-day intensive
research workshops focus on what we know about
the relationship between religion and health,
applications, how to conduct research and develop
an academic career in this area (July 21-25, Aug
11-15, Aug 30) Leading religion-health
researchers at Duke, UNC, USC, and elsewhere will
give presentations -Previous research on
religion, 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 religion/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 koenig_at_geri.duke.edu