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Religion, spirituality and mental health: results from a national study of English households

  • Michael King (a1), Louise Marston (a2), Sally McManus (a3), Terry Brugha (a4), Howard Meltzer (a4) and Paul Bebbington (a5)...
Abstract
Background

Religious participation or belief may predict better mental health but most research is American and measures of spirituality are often conflated with well-being.

Aims

To examine associations between a spiritual or religious understanding of life and psychiatric symptoms and diagnoses.

Method

We analysed data collected from interviews with 7403 people who participated in the third National Psychiatric Morbidity Study in England.

Results

Of the participants 35% had a religious understanding of life, 19% were spiritual but not religious and 46% were neither religious nor spiritual. Religious people were similar to those who were neither religious nor spiritual with regard to the prevalence of mental disorders, except that the former wereless likely to have ever used drugs (odds ratio (OR)=0.73, 95% CI 0.60-0.88) or be a hazardous drinker (OR=0.81, 95% CI 0.69-0.96). Spiritual people were more likely than those who were neither religious nor spiritual to have ever used (OR = 1.24, 95% CI 1.02-1.49) or be dependent on drugs (OR = 1.77, 95% CI 1.20-2.61), and to have abnormal eating attitudes (OR = 1.46, 95% Cl 1.10-1.94), generalised anxiety disorder (OR =1.50, 95% Cl 1.09-2.06), any phobia (OR = 1.72, 95% CI 1.07-2.77) or any neurotic disorder (OR = 1.37, 95% CI 1.12-1.68). They were also more likely to be taking psychotropic medication (OR = 1.40, 95% CI 1.05-1.86).

Conclusions

People who have a spiritual understanding of life in the absence of a religious framework are vulnerable to mental disorder.

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Corresponding author
Michael King, Unit of Mental Health Sciences, Faculty of Brain Sciences, University College London Medical School, Charles Bell House, 67-73 Riding House Street, London W1W 7EH, UK. Email: michael.king@ucl.ac.uk
Footnotes
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Declaration of interest

None.

Footnotes
References
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3 Johnstone, B, Franklin, KL, Yoon, DP, Burris, J, Shigaki, C. Relationships among religiousness, spirituality, and health for individuals with stroke. J Clin Psychol Med Settings 2008; 15: 308–13.
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7 King, M, Speck, P, Thomas, A. Spiritual and religious beliefs in acute illness is this a feasible area for study? Soc Sci Med 1994; 38: 631–6.
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Religion, spirituality and mental health: results from a national study of English households

  • Michael King (a1), Louise Marston (a2), Sally McManus (a3), Terry Brugha (a4), Howard Meltzer (a4) and Paul Bebbington (a5)...
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eLetters

The spiritual or religious understanding and mental health - Is not SEM a better alternative to traditional statistical analysis ?

Dr. Partha Sarathi Biswas, Psychiatrist
06 March 2013

Religious attitudes are generally acknowledged to be important elements in the social-psychological make-up of the individual. [1] Religion and to be religious play an important role in social life, valuesand mental health of human being. Study has shown that the religion is important in majority of individuals' life and considered to be valued as part of their normal decision making process. [2] King et al [3] knocked avery simple design of study in this area of modern psychiatry with a very healthy sample size which could have been more conclusive if conceptualized in the line of structural equation model (SEM).

Many psychological and social reasons could explain the mental disorder such as adverse experiences during childhood, mental illness in family, discord, violence, stressful family life, peer pressure and brain insults etc. [4] The relationship of personality characteristics to different forms of psychiatric disorders has drawn widespread attention. One approach to examining underlying etiological sources of mental illnessmay be found in the large literature on relationships among spirituality-religiosity-personality- psychosocial issues-psychopathology. [5] A model is a statistical statement about the relations among variables. InSEM, there is a set of structural equations. Path analysis is a flexible and powerful statistical methodology used to examine the relationships between measured variables. Structural equation modeling is a statistical technique for estimating so-called causal relationships using a combination of qualitative causal assumptions. [6] Traditional statisticalapproaches to data analysis specify default models, assume measurement occurs without error, and are somewhat inflexible. However, structural equation modeling requires specification of a model based on theory and research, is a multivariate technique incorporating measured variables andlatent constructs, and explicitly specifies measurement error. A model (diagram) allows for specification of relationships between variables. SEMgives us the power not available with "traditional" statistical procedures. You are challenged to design and plan research where SEM is anappropriate analysis tool.

The purpose of the model is to account for variation and covariation of the measured variables (MVs). Path analysis (e.g., regression) tests models and relationships among MVs. Confirmatory factor analysis tests models of relationships between latent variables (LVs or common factors) and MVs which are indicators of common factors. How large a sample size did they need? Rule of thumb is between 5 to 20 times of number of free parameters. [7] Lower sample sizes are needed for models with no latent variables, models where all loadings are fixed (usually to one), models with strong correlations and simpler models. Best way to determine if you have a large enough sample is to conduct a power analysis. In the index study sample size was 7403 which would have accounted for minimum 370 freevariables for a SEM.

Taking consideration of all, I think the authors of the study (King et al., 2013) could thought of a SEM analysis taking additional variables into the study which would give better understanding of the origin and perpetuation of mental illness.

Reference

1 Putney S, Middleton R. Dimensions and Correlates of Religious Ideologies. Social Forces 1961; 39: 285-290.

2 Hoge D R. Religion in America: The demographics of belief and affiliation. Religion and the clinical practice of psychology. American Psychological Association, 1996.

3 King M, Marston L, McManus S, Brugha T, Meltzer H, Bebbington P. Religion, spirituality and mental health: results from a national study ofEnglish households. The British Journal of Psychiatry 2013; 202: 68-73.

4 Khan W, Salman S. Personality profile of drug addicts and normal. Journal of Personality and Clinical Studies 2003; 19: 23-24.

5 Krueger RF, McGue M, Iacono WG. The higher-order structure of common DSM mental disorders : internalization, externalization, and their connections to personality. Personality and Individual Differences 2001;30: 1245-1259.

6 Hayduk L, Cummings GG, Boadu K, Pazderka-Robinson H, Boulianne S. Testing! Testing! One, two three - Testing the theory in structural equation models! Personality and Individual Differences 2007; 42: 841-50.

7 Tanaka JS. "How big is big enough?": Sample size and goodness of fit in structural equation models with latent variables. Child Development1987; 58: 134-146.

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Conflict of interest: None declared

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Religion, spirituality and mental health: results from a national study of English households

Christopher C. Cook, Professor
25 February 2013

We note with interest the conclusion of this study, which states that'people who have a spiritual understanding of life in the absence of a religious framework are vulnerable to mental disorder'. A second equally important finding is that 'religious people were similar to those who wereneither religious nor spiritual with regard to the prevalence of mental disorders, except that the former were less likely to have ever used drugsor be a hazardous drinker'. This lack of difference, as with the key conclusion concerning those who are spiritual but not religious, runs counter to the substantial body of evidence collated by Koenig et al (H. G. Koenig et al., 2001, H.G. Koenig et al., 2012, Harold G. Koenig, 2012) who conclude that religion/spirituality are generally associated with better mental health.

The authors point out that 'the cross-sectional nature of the data means that we cannot attribute cause and effect to any relationship between spiritual beliefs and mental health', and they draw attention to important differences between the UK and North America (where the bulk of previous research has been conducted). The headline conclusion of the study may nonetheless leave professionals and others with the impression that 'spirituality' is bad for one's health, an impression that we believewould be mistaken.

Our post-modern culture is geared increasingly to a way of life that does not question deeply such things as the meaning of birth and death, why we are here and what it is all for. Instead, social norms often emphasise aspiration to goals of material ambition and success. For many, it seems that this can result in estrangement from the most fundamental spiritual needs and values of humankind (a theme that comes up at meetingsof the Spirituality and Psychiatry Special Interest Group of the College).

With the decline in religious observance, the numbers of 'spiritual but not religious' (19% in this study) are rising, and perhaps more so in the UK than in the US. Wrestling with the deepest questions about life is in the nature of the human condition. However, without a religious faith that can also provide a person with both community and support, the road is long and hard and the journey often a lonely one. Previous research (Pargament, 2011, pp.111-128) suggests that spiritual struggles have the potential for either good or bad mental health outcomes, and we wonder whether the kind of society in which we are now living is less than supportive of the good outcome.

We know that spiritually informed therapies are effective in the field of substance misuse (Cook, 2009), and mindfulness-based approaches derived from spiritual practice are now recommended by NIHCE for relapse prevention of depression (National Institute for Health and Clinical Excellence, 2009). Further, we believe that spirituality has an important secular dimension which is finding expression in the recovery movement in psychiatry.

We must therefore guard against any misreading of this study by King et al. that would suggest spirituality is bad for mental health. We do, however, support strongly research that is able both to delineate causal pathways and also provide comparison between the cultures and contexts of the US and the UK.

Dr Andrew Powell Professor Christopher CH Cook

AP and CCHC are both members of the Executive Committee of the Spirituality and Psychiatry Special Interest Group of the College. However, the views expressed in this letter are their own and not necessarily those held by the Group as a whole.

References

Cook, C. C. H. (2009) Substance Misuse. In Cook, C., Powell, A. &Sims, A. (Eds.) Spirituality and Psychiatry. London, Royal College of Psychiatrists Press. 139-168.Koenig, H. G. (2012) Religion, Spirituality and Health: The Research and Clinical Implications. ISRN Psychiatry. doi:10.5402/2012/278730Koenig, H. G., King, D. E. & Carson, V. B. (2012) Handbook of Religionand Health, New York, Oxford University Press.Koenig, H. G., Mccullough, M. E. & Larson, D. B. (2001) Handbook of Religion and Health, New York, Oxford.National Institute for Health and Clinical Excellence (2009) Depression: The Treatment and Management of Depression in Adults, London, National Institute for Health and Clinical Excellence.Pargament, K. I. (2011) Spiritually Integrated Psychotherapy, New York, Guilford.

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Conflict of interest: AP and CCHC are both members of the Executive Committee of the Spirituality and Psychiatry Special Interest Group of the College. However, the views expressed in this letter are their own and not necessarily those held by the Group as a whole. CCHC is an Anglican Priest and Director of the Project for Spirituality, Theology & Health at Durham University

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Religion, sprituality and mental health

John Foskett, Canon, Chaplain Emeritus
19 February 2013

Dear Sir

I enjoyed reading Michael King's (et al) paper 'Religion, spirituality and mental health: results from a national study of English households.' ( BJP 2013, 202:68-73). Their research confirmed much of what we discovered in Somerset in 2000 ( Nicholls 2002, Foskett (et al) 2004a, MacMin & Foskett 2004, Foskett (et al) 2004b). Then service users/patients, religious and spiritual leaders and mental health professionals all recognised the important relationship there is between mental health, religion and spirituality, but were unclear as to why this relationship was sometimes for better and at other times for the worst. The fact that the professionals had little understanding of or training ineach others' disciplines and that they had little interaction with one another was a problem our research identified. Patients recognised this lack amongst the professionals by their uneasiness to engage with the mental health and spiritual concerns of their patients. Though I think this is changing with the growth of the RCP's special interest group in spirituality..

The professionals were more confident when the patient was confident in introducing spirituality and/or religion into their consultations. Of course their illnesses often undermined that confidence and so engagement was more difficult for everyone. The research in Somerset also identified the fact that those patients, who had support for their beliefs, however strange and irrational they were, had better mental health than those who did not receive the same support from their psychiatric and religious professionals. They appear similar to the group of patients in King's (et al) research (p.72), whose spiritual life had an existential component 'that was driven by their emotional distress' and had not the benefit of aspiritual person or group who believed and supported them.

We conclude that there is increasing evidence that people who professspiritual beliefs in the absence of of a religious framework are more vulnerable to mental disorder. (King p. 72)

They may also be inspired and gifted people as William James recognised as long ago as 1902. in 'The varieties of religious experience'

'It is evident that from the point of view of their psychological mechanism, the classical mysticisms and these lower mysticisms (mental illnesses) spring from the same level...of which so little is known. That region contains every kind of matter: seraph and snake abide their side byside (James 1902 p 426).

Other research (Jackson & Fulford 1997) confirms how important itis for patients, who are isolated with their beliefs, to be acknowledged and believed rather than ignored, pathologised or demonized. Those interviewed in Somerset, who were searching spiritually and existentially,despite the pain and trauma it involved, valued what it revealed to them.

A human being can have an organic crisis with all sorts of disorders and disruptions to their life which is actually a very valuable experienceand not to be knocked out of them (by medication). (Nicholls p.24)

Theirs' was a spirituality akin to mysticism in which emotional and spiritual trauma are to be expected according to the saints of mystical experience. (Matthew 1995)

References:

Foskett, J. Marriott, J. & Wilson-Rudd, F. (2004a) 'Mental healthreligion and spirituality' Mental health, religion & culture Vol.7 No.1. pp.5-22.

Foskett, J. Roberts, A. Matthews, R. MacMin, L.Cracknell, P. & Nicholls, V. 'From research to practice'. Mental health religion and culture. Vol.7 No.1 pp.41-58.

Jackson,, M. & Fulford, W. (1997) Spiritual experience and psychopathology, Vol. 1.pp 41-89. Baltimore MD: John Hopkins University Press.

James, W. (1902)) Varieties of religious experience, London: Longmans.

MacMin, L. & Foskett, J. ( 2004) 'Don't be afraid to tell', Mental health religion & culture, Vol.7. No.1 pp. 23-40.

Matthews, I. (1995) The impact of God: Soundings from St John of the Cross. London: Hodder & Stoughton.

Nicholls, V. (Ed) Taken seriously: the Somerset spirituality project.London Mental Health Foundation.

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Conflict of interest: None declared

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Religion, spirituality and mental health in older adults

Elizabeta B. Mukaetova-Ladinska, Senior Lecturer/Honorary Consutant in Old Age Psychiatry
01 February 2013

We read King's et al (2013)1 paper with much interest. While the findings are interesting, they include a minor portion of participants above the age of 65 years (28% people with religious and 18% with spiritual beliefs) and may not necessarily be applicable to older adults who could have different notions of spirituality. Thus, there may be a greater association between notion of religion and spirituality for an older person, but defining oneself as spiritual in the case of a younger person could be a statement contrasting against any association with a church.Spirituality and religious beliefs have increasingly become more relevant in the field of old age psychiatry. Majority of the recent studies highlight the positive impact of both spiritual and religious beliefs on overall mental health functioning, for both people with and without mentalhealth problems as well as their carers2, 3. Positive aspects of spirituality and religious beliefs on care giving, both by family members and nursing staff looking after people with dementia, are also apparent2. These, along with various tangible aspects of traditional culture (e.g. singing, clothes and food), constitute important aspects of culture-appropriate care for dementia sufferers. Furthermore, spirituality and self-efficacy appear to have an additive effect on caregivers' well-being,with a high sense of spiritual meaning and a high self-efficacy, in combination, being associated with lower levels of depression in dementia caregivers4.Aspects of lifestyle, including physical activity, diet, sleep, alcohol, smoking and spiritual or religious beliefs are a key component to successful ageing and reducing the risk of developing a cognitive impairment. In our recent study on lifestyle3, we found nearly 60% of theNewcastle participants to hold spiritual and religious beliefs, in contrast to 95% of the Chennai population (p<0.0001), a figure that is slightly higher than that reported by King et al1. The correlative analysis between distinct components of lifestyle (e.g. diet, spiritualityand exercise) and self-reported physical and mental health problems highlighted a number of similar relationships between our two analysed populations. Thus, holding spiritual and/or religious beliefs was associated with better physical and mental health, less subjective memory problems and worries regarding memory, and even less self-reported depression in both cohorts, and had fewer concerns with blood pressure, diabetes or high cholesterol levels3. These findings suggest that spirituality and having religious beliefs have significant impact on modifying well established risk factors for dementia, such as the metabolic syndrome. Regular social engagement prevents cognitive decline, and regular attendance of religious services as a social activity may act as protective factors. It is likely religious attendance promotes mental stimulation that may reduce cognitive decline5. Given that relaxation (e.g. practising yoga) and attendance of religious services is associated with decrease in depression, anxiety and hostility and lower inflammatory markers e.g. Interleukin 6, C-reactive protein and extracellular superoxide dismutase (reviewed in 3), spirituality and religious beliefs may have a calming effect, and thus a positive influence upon the overall psychological wellbeing of, especially, older adults. Declaration of Interest: NoneReferences:1.King M, Marston L, McManus S, Brugha T, Meltzer H, Bebbington P. Religion, spirituality and mental health: results from a national study ofEnglish households. Br J Psychiatry 2013; 202: 68-73.2.Weitzel T, Robinson S, Barnes MR, Berry TA, Holmes JM, Mercer S, et al.The special needs of the hospitalized patient with dementia. Medsurg Nurs 2011; 20: 13-8.3.Mukaetova-Ladinska EB, Purshouse K, Andrade J, Krishnan M, Jagger C, Kalaria RN. Can healthy lifestyle modify risk factors for dementia? Findings from a pilot community-based survey in Chennai (India) and Newcastle (UK). Neuroepidemiology 2012; 39: 163-70.4.Lopez J, Romero-Moreno R, Marquez-Gonz?lez M, Losada A. Spirituality and self-efficacy in dementia family caregiving: trust in God and in yourself. Int Psychogeriatr 2012; 24: 1943-52. 5.Corsentino, E., N. Collins, Sachs-Ericsson N, Blazer DG. Religious attendance reduces cognitive decline among older women with high levels ofdepressive symptoms. J Gerontol A Biol Sci Med Sci 2009; 64: 1283-9.

Elizabeta B. Mukaetova-Ladinska, MD, PhD, MRCPsych, Institute for Ageing and Vitality, Newcastle University, Newcastle upon Tyne NE4 5PL;Raj N. Kalaria, PhD, FRCPath, Institute for Ageing and Vitality, NewcastleUniversity, Newcastle upon Tyne NE4 5PL

Correspondence: Elizabeta B. Mukaetova-Ladinska, MD, PhD, MRCPsych, Institute for Ageing and Vitality, Newcastle University, Newcastle upon Tyne NE4 5PL, UKe-mail: Elizabeta.Mukaetova-Ladinska@ncl.ac.uk

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Conflict of interest: None declared

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Re: Religion, spirituality and mental health

Suneetha V V D Siddabattuni, Speciality Doctor
01 February 2013

"O God, thou created us in thy image and our hearts will be restless until they find their rest in Thee." - St Augustine

We read with great interest the article by Prof King et al.,1 examining the associations between spiritual or religious understanding oflife and psychiatric symptoms and diagnoses. Although the study was well conducted and well written, spirituality a dimensional construct 2 - a quality that strives for awe and inspiration that enables and motivates human beings to search for meaning and purposes in life - has been reducedto an unitary construct ignoring its ubiquitous nature. Encountered in various ways in all human beings, spirituality is a common human phenomenon. However, the spiritual dimension is the most complex. Culliford 2 in his review on spiritual care and psychiatric treatments rightly identifies the spiritual dimension as complex, however, also points to the simplistic nature given its unity and indivisibility.

The influence of the biomedical model, with its assumptions of cause and effect, specific aetiology, diagnosis and appropriate treatment, leadsto an understanding of mental health/mental disorder as simply the absence/presence of mental illness or CSI-R caseness/non-caseness. The transition from illness experience to disorder is determined by social decision points rather than biomedically determined levels of disorder. Hitherto, viewing this as a dichotomous variable presence/absence of mental disorder/mental health especially when researching a complex topic as spirituality would be an oversimplified application of an epidemiological perspective in psychiatric practice.

According to Trent 3 the assumption is that if people are not ill, they must by default be healthy. Spirituality is an important aspect of being healthy both physically and mentally. Andreasen 4 , in an editorial,has pointed out that our civilization's "loss of soul" may cause psychiatric symptoms such as depression, obsessions, addictions, and violence. She has suggested that it is the responsibility of psychiatriststo remind the medical fraternity the necessity of putting back the soul inmedical ethics and the fact that spirituality is of vital importance for the mental health of people.

Though high quality evidence based research like Prof King et al.,1 is required to make the clinical applications more objective and effective, the reductionistic nature of psychiatric classifications, the inherent diversity within diagnostic categories, the ubiquitous nature of the dimensions of spirituality, western and non-Western definitions and understanding of the term spirituality demand a more nuanced approach as Harold Koening 5, points out in his paper Religion and Mental health: whatshould psychiatrists do? There is some evidence in terms of randomised controlled trial to support dimensions of spirituality (Spiritually Augmented Cognitive Behaviour Therapy - SACB) is effective in dealing withdepression and adolescent problems! 6

References1.King M, Marston L, McManus S, Brugha T, Meltzer H, Bebbington P. Religion, spirituality and mental health: results from a national study ofEnglish households. British Journal of Psychiatry 2013; 202: 68-73.2.Culliford L. Spiritual care and psychiatric treatment: an introduction.Advances in Psychiatric Treatment 2002; 8: 249-258.3.Trent D. A concept of mental health. In Positive Mental Health and its Promotion (eds M. Money & L. Buckley). Liverpool: John Moores University, 1999.4.Andreasen NC. Body and soul. Am J Psychiatry, 1996; 153: 589-90.5.Koenig HG. Handbook of Religion and Mental Health. Academic Press, 1998.6.D'Souza RF. Spiritually augmented cognitive behaviour therapy[SACB] Australas Psychiatry 2004; 12: 148-52.

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