We thank Dein et al ^{Reference Dein, Cook, Powell and Eagger1} for opening up the debate about religion and its impact on mental well-being. This debate does not come a moment too soon.

We feel compelled to refute the suggestions that research unequivocally shows an association between religiosity and well-being. ^{Reference Blazer2} The research findings are wildly contradictory and it would be unreasonable to draw any firm conclusion on the basis of current knowledge. Furthermore, the research in this area is often biased, plagued by poor methodology (definitions of spirituality and religion are controversial, much variation exists between different faith groups, ‘hidden’ supportive measures of any community tend to be responsible for well-being rather than religion per se) and the research is almost invariably carried out by groups of researchers that have a vested interest in showing positive results for religiosity. The last point also applies to Dein and colleagues as they represent the Royal College of Psychiatrists' Spirituality and Psychiatry Special Interest Group. None of these points of contention is raised in the article.

In our personal experience we can come to think of a handful of patients that indeed seemed to have been consoled by religious beliefs, but hundreds of patients who have been tormented by fear of having transgressed some Bronze Age dogma about sexuality, having sinned in other ways or simply having taken their God's name in vain. A common sight on psychiatric wards is frightened patients shivering with fear when they hear what they perceive to be God's, not to mention Satan's, voice in their hallucinations. Some studies report that patients with schizophrenia and religious beliefs do indeed have worse long-term outcomes than patients with non-religious delusions. ^{Reference Doering, Müller, Köpcke, Pietzcher, Gaebel and Linden3} The rigid cognitive belief system that underpins religious ideology plays straight into delusional beliefs that cause endless anguish, for example, ‘If I break my pact with God (e.g. divorcing a violent husband, having sex out of wedlock), He will punish me’. Meeting such patients gives the concept of being ‘God fearing’ a whole new dimension. This commonplace suffering seems to have escaped the authors entirely.

Dein et al complain that there is a gap between patients' and psychiatrists' level of religiosity, the patients being more religious. Initially, this observation begs the question of whether religion could be part of the complex set of aetiological factors that constitutes the pathogenesis of mental illness in the first place and perhaps maintains it. Unquestioned belief in authorities always spells trouble, which recent events in the Catholic Church so amply exemplify. Some perturbed patients may find the certainties of religion tempting, but at what cost? Nevertheless, a good point is made that we must enquire more about the patient's religious beliefs as they can have a profound impact on lives from an early age. Yes, just think of the consistent mistreatment of women and children in some religions, beliefs in utterly unverifiable concepts (walking on water, miracles, angels with wings, devils, etc.) and the survival of your own death through an immortal soul, going to Heaven if you have been good but going to Hell if you have not. No wonder if you have a fragile mind that religious beliefs can push you over the edge.

We remind Dr Dein and his colleagues that instead of promoting private views, however strong and well meant they are, our traditional mandate as doctors is ‘first of all, do no harm’. A more important question than whether the psychiatrist should pray with the patients or not - consider what this would entail if you had a Satanist under your care - seems to us to be how religious groups systematically have targeted vulnerable psychiatric patients in an attempt to boost flagging numbers of their congregations. It is a despicable practice that pretends to offer lonely people a ‘new family’ for the ‘minor cost’ of believing in, and sometimes financially supporting, various belief systems of a more or less outrageous nature. It may be advantageous to a lonely or marginalised individual to find a ready-made group of accepting individuals with whom to associate, but religious groups do not have the monopoly on providing such solace. The issue of compassion is certainly not just the preserve of religious orders. So no, it is not ‘time to move away from the old tendency to see religious and spiritual experiences as pathology’. But it is time to enquire in a respectful and gentle manner about patients' beliefs in general, not only religious ones, and for all, the psychiatrist should always remain the patient's foothold in a reality that often for them appears broken and fragile. Religious beliefs and practices may be helpful for some in terms of companionship and certainty, but clinical evidence indicates that for others they are sources of extreme distress and contribute to ongoing mental health problems.