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Discussion
Levels of Religious Commitment
This group of psychiatric inpatients expressed levels of religious
commitment that were similar to or higher than those in the Canadian
population. While there is no available Canadian data for direct
comparison to the question about “belief in God who rewards
and punishes,” about 78% of the Canadian population reports
a “belief in God” (2). In our study, it is reasonable
to assume that the addition of “rewards and punishes”
would lower the number, because fewer people believe in Hell or
the Devil (2,24).
Similarly, Kroll and Sheehan reported on a survey of 52 psychiatric
inpatients in Minnesota that found high rates of religious belief
and experience and practice which corresponded to the levels in
the American population (18). In the UK, Neeleman and Lewis (19)
also reported that psychiatric patients have higher levels of religious
beliefs and attitudes than do nonpsychiatric comparison groups.
The patients surveyed included 75 psychotic inpatients, deliberate
self-harm inpatients, depression outpatients, and a comparison group
of 25 orthopedic outpatients. The intensity of religious beliefs
was most pronounced among the more severely ill subjects. Our psychiatric
inpatient sample had a high incidence of psychiatric comorbidity
and prior hospitalizations, indicating a high degree of chronicity
and severity. These findings, including our own, contrast with earlier
reports that patients with mental illness profess or practice less
religious commitment (26).
Outcomes and Religious Commitment
Our results reveal the types of religious commitment that significantly
influenced the selected outcome variables (depressive symptoms,
length of hospital stay, satisfaction with life, and alcohol use).
These included frequency of worship attendance, use of religion
as an identified coping resource, and intrinsic religiousness. Those
religious measures that did not significantly impact outcome variables
were prayer frequency and expressed levels of religious beliefs.
Religious Commitment and Depressive Symptoms.
This study demonstrates, after controlling for covariates, that
the levels of depressive symptoms were lower for those patients
with more frequent worship attendance and higher levels of intrinsic
religiousness. In accordance with our results, many studies have
shown worship attendance to associate with lower levels of depressive
symptoms (3,6,7,27). In a stringent review of 29 primarily nonclinical
studies that examine the cross-sectional relation of worship attendance
and depressive symptoms, McCullough (5) found 24 were associated
with lower levels of depressive symptoms. After controlling for
2 or 3 covariates, the association dropped, yielding regression
coefficients in the range of b = –0.10. Controlling for 6 covariates
in our clinical study, however, did not significantly change the
association of worship attendance or intrinsic religiousness with
depressive symptoms, and values remained significant at levels around
b = – 0.20. In the clinical situation, worship service attendance
may have a more important role, given the low marital rates and
poor social supports seen in our study.
Religious Commitment and Length of Stay. A
notable finding in our group of inpatients was that the length of
stay in the psychiatric ward was significantly shorter for those
patients with more frequent worship attendance and for those who
used religious thoughts or activities as the most important strategy
to cope with their illness.
Few studies have included a religious variable as a predictor of
mental health services outcome (for example, length of stay). Religious
affiliation was found to be significantly related to length of stay
in a general hospital psychiatric unit in Brazil (1992) (28), without
control for covariates. In a cost analysis of the impact of religious
faith and practice on patients suffering from depression, church
attendance showed an inverse relation to cost for health care (1995)
(29). Koenig and Larson found that in a group of medically ill elderly,
the more frequent church attenders had fewer days in hospital when
they were admitted and had fewer admissions 1 year after the index
admission (17).
Why worship attendance or religious coping should impact length
of stay or mental-health recovery in general is a complex question,
and studies are virtually nonexistent (30). There are at least 3
possible mechanisms through which worship attendance may work to
promote better mental health and quicker recovery from mental illness
(30,31). First, it may regulate lifestyle and behaviours (for example,
discouraging use of addictive substances). Second, it may enhance
social and coping resources, because fellowship is often an explicit
part of the organizational mandate of many faith groups. In fact,
many of this sample were living alone, and 50% had poor social supports.
Third, religion may provide a sense of coherence and meaning to
life. Understanding one’s meaning or purpose in life and finding
meaning in suffering were found to account for a significant proportion
of the relation between religious involvement and health (30,31).
Religious Commitment and Satisfaction with Life.
Worship-attendance frequency was the only religious predictor of
increased life satisfaction. Our results reveal that religiously
active people report greater life satisfaction or happiness—a
finding that has been generally consistent in previous research.
In a metaanalytic study of papers that are now over 20 years old,
Witter and others (32) found religious activity positively related
to well-being.
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More recently, national polls in both the US (1995) (33) and Canada
(1996) (34) found highly religious people nearly twice as likely
as those lowest in religious commitment to declare themselves very
happy. Further, regardless of experiencing major negative life events,
those who reported a closer relationship with God indicated more
happiness and life satisfaction (26).
Religious Commitment and Alcohol Abuse. This
study adds to a wealth of literature that has consistently revealed
an inverse relation between religiousness and alcohol use in both
population surveys and clinical studies (11,27,35,36). Current alcohol
abuse was significantly and negatively related to worship attendance
and intrinsic religiousness. Moreover, worship attendance was negatively
associated with lifetime alcohol abuse. It is possible that worship
attendance—especially if a lifelong activity—may be important
when deciding to start using substances such as alcohol. Experiencing
higher levels of intrinsic religiousness may be more important than
attendance alone in achieving the ability to quit drinking or to
maintain low levels of use (11).
Religious Beliefs and Prayer Frequency. The
results of this study reveal that intrinsic religiousness can significantly
impact the rates of depression and current alcohol use. We can only
speculate, however, upon why religious beliefs are not correlated
with outcome but religious practices are. Measuring beliefs using
a simple questionnaire may be vague and thus not be meaningful as
an outcome measure (for example, 88% of the US population believes
in God). In a study of nearly 2000 twins, Kendler (11) also found
that religious beliefs had no correlation with outcome but that
religious practices did predict lower levels of depressive symptoms,
current and lifetime risk for alcoholism, and buffering of depressogenic
effects of stressful life events.
We found that prayer frequency did not significantly influence
depression rates. Corresponding to our findings, McCullough (5)
noted that, in the study of depression, private religious activity
has a tenuous relation and any associations are small. It had been
suggested that prayer can be used in various ways, including a passive
manner, which leaves the responsibility for resolving a crisis entirely
up to divine intervention without mobilizing personal resources
(3).
Limitations
Location at 1 site and the small sample size limit the study; however,
it does have equal sex distribution. Although all patients had depression
symptoms, there was a range of comorbid diagnoses, which may conceal
patterns associated with a more homogeneous group, but certainly
confirms the severity of this study sample. It is limited to an
inpatient population, and we do not know if these are generalizable
to psychiatric patients in general. There were 28 patients who refused;
therefore, it is possible that there was a selection influence and
that those with religious interests were more likely to agree to
participate.
The results presented also rely on the assessment of religious
commitment at a single time point and may not reflect past levels
of activity (11). This is pertinent when examining religious commitment
in relation to past length of stay and past levels of alcohol abuse.
These latter 2 measures are also affected by reliance, in part,
on patient report, despite our attempt to corroborate findings objectively
in as many cases as possible. As we noted in the introduction, while
the cross-sectional nature does not allow for determination of causality,
it is consistent with the many studies that have shown a positive
mental health benefit (13), including more recent longitudinal studies
(14,15).
The social-support measurement was based on a subjective evaluation
by patients and their psychiatrists. Given the importance and frequent
low level of this variable, an assessment of patient–psychiatrist
concordance might have been valuable. Finally, worship-attendance
frequency had a consistently positive impact on outcome, but not
knowing which function accounts for the salutory mechanism may underestimate
the total influence of the religious variable (31).
Conclusions
Religious interests of patients are not usually considered in psychiatric
care. This study is the first known Canadian study to examine levels
of spirituality and religiousness among psychiatric inpatients.
We have demonstrated a level of religious commitment in psychiatric
inpatients that is at least similar to or higher than that found
in the general population. Our results show that religious commitment
has a significant impact on depressive symptoms, satisfaction with
life, hospital use, and alcohol use. These findings add to the literature
on positive mental health benefits with religious activity and expand
it to a clinical psychiatric population, albeit on a small level.
Further studies, longitudinal in nature, based on larger numbers
of patients, and more homogeneous patient groups, while accounting
for covariates, will help to further improve our understanding of
the impact of religious beliefs and spirituality on mental health.
These findings reveal the need to begin addressing patient spirituality,
whether helpful, neutral, or harmful—and, particularly when
harmful or complex, to involve chaplains or clergy (37–39).
Given the US findings of the lack of relation between psychiatry
and spiritual advisors (37), we hope Canada will not follow a similar
trajectory, but will instead work toward improving collaboration
between these important groups.
Acknowledgements
Support for the writing of this paper was provided by the John
Templeton Foundation, Radnor, Pennsylvania and Monarch Pharmaceuticals,
a wholly-owned subsidiary of King Pharmaceuticals, Inc, Bristol,
Tennessee. Thanks to Kerri Schellenberg Med IV for her assistance
in interviewing and data collection.
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