Definitions

Religion means to bind together! and a belief in and reverence for a supernatural power regarded as creator and governor of the universe. Spirituality, on the other hand, is defined as a dynamic, personal, and experiential process of belief.

Religion/Spirituality Involvement in Medicine:

APA issued Guidelines Regarding Possible Conflict Between Psychiatry"s Religious Commitment and Psychiatry"s Practice! DSM-IV includes Religion or Spirituality Problem! section instruction in religion-spiritual issues is a curricular requirement of accredited psychiatric residencies APA recommends that doctors inquire about religion and spiritual orientation of patients

Benefits to clinicians of religious/spirituality focus:

communicates to patient that their life experience is of interest and value to them increases understanding of clinical condition"s association with a religious-spiritual problem allows the development of a case formulation of interpersonal responses and psychiatric patterns identifies areas of support and community involvement that may be helpful adjuncts to treatment

Reasons to acknowledge and support a patients spirituality:

people regard spiritual and physical health as equally important enhances coping and quality of life during illness enhances cultural sensitivity enriches the doctor/patient relationship

Illness Prevention: Spirituality and Life Satisfaction

Study sample: reviewing findings from three national surveys totaling more than 5,600 older Americans Study results: Attending religious services was linked with improved physical health or personal well-being. Other studies: 12 other studies published since 1980 found persons in organized religious activity had higher levels of life satisfaction.
Levin JS, Chatters LM. Religion, health, and psychological wellbeing in older adults: findings from three national surveys. J Aging Health 1998;10(4):504-531.

Those who are religious tend to demonstrate:

less cardiovascular disease decrease in blood pressure and hypertension more health promoting behaviors a decrease in depression, anxiety, and suicide less alcohol abuse or use of illicit drugs

Illness Prevention: Substance Abuse

Individuals suffering from these (alcohol or drug abuse) problems are found to have a low level of religious involvement . . . spiritual re(engagement) appears to be correlated with recovery.!
Miller WR. Addiction 1998;93(7):9791998;93(7):979-90.

Religion and Spirituality in Substance Abuse/Dependence Treatment

and spirituality has long been emphasized as an important factor in recovery from addiction.! Alcoholics Anonymous (AA) derived from a Christian Fellowship in 1935 12 Steps

First Three Steps

Admit powerlessness over alcohol Belief in a power greater than ourselves! Turn will over to the care of God as we understood Him!

Steps 4 through 7
Take a moral inventory Admit to God, to ourselves, and to another human being the exact nature of our wrongs Ready to have God remove all these defects of character Ask Him to remove our shortcomings

Steps 8, 9 and 10
Made a list of all persons harmed and became willing to make amends to them all Made direct amends wherever possible Ongoing personal inventory and promptly admitted when we were wrong

Final Two Steps

Through prayer and meditation improve our conscious contact with God, #as we understood Him" Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs!

Research involving Spirituality

Religious/spiritual involvement predicts less use of and fewer problems with alcohol, tobacco and illicit drugs Mechanisms are poorly understood
Principles avoidance Social support for abstinence Involvement in activities that are incompatible with use Prosocial values

Research Involving AA
Modest correlation found between improved drinking behavior and:
having a sponsor engaging in twelfth step work leading a meeting increasing participation compared to a prior involvement

Research Involving AA
Involvement with AA is associated with better outcomes after professional treatment Project Match compared Twelve-Step Facilitation Therapy (TFT) with CBT and MET TFT group did at least as well and did better on measures of complete abstinence

Patient Need: Social Histories of Chronic Drug and Alcohol Abuse

Study Results (cont.):
Religious Histories: Parents and Subjects Frequency Comparison (as ratios) for: Narcotic Abusers (NA) and Alcohol Abusers (AA) to control sample: Religious History Items: Mother"s Religious Involvement Father"s Religious Involvement fourths During Adolescence: Increased Religious Interest During Adolescence: Decreased Religious Interest greater NA/Controls no difference one-half AA/Controls one-fifth higher three-

one-fourth 4 times greater

one-eighth 4$ times

Larson DB & Wilson WP. Religious life of alcoholics. Southern Medical Journal. 1980; 73(6): 723-727. Cancellaro LA, Larson DB, Wilson WP. Religious life of narcotic addicts. Southern Medical Journal. 1982; 75(10): 1166-1168.

Illness Prevention: Spirituality and Marijuana Use

Survey undertaken by Harvard School of Public Health and University of Michigan"s Survey Research Center.
Study Sample: 17,592 college students sampled from 140 U.S. colleges with survey sample nationally representative of U.S. college population. Study Results: Increased Risk-Marijuana Use - Lower Grades % Grade B! and below - More time hanging! with friends - Four-Fold Increased Risk: Parties Important or Very Important - Five-Fold Increased Risk: Cigarette Smoking - Six-Fold Increased Risk: Binge Drinking
Bell R., et al, The correlates of college student marijuana use: results of a US National Survey.! Addiction. 1997; 92(5);57192(5);571-581.

Illness Prevention: Spirituality and Marijuana Use

Study Results (cont.): Lowered Risk-Marijuana Use
- One-Half Risk: students who viewed Community Service as important! to them - One-Fourth Risk: Students who viewed Religion as !very important! to them - Religion as important % strongest predictor of marijuana use, even stronger in size than identification as party animal! - After controlling for other predictor variables - Religion as important % still at ONE-THIRD the risk This study supports the notion that college drug use is social in nature (which) makes it resistant to changehowever the findings do suggest approaches to prevention!
Bell R., et al, The correlates of college student marijuana use: results of a US National Survey.! Addiction. 1997; 92(5);57192(5);571-581.

Illness Prevention: Spirituality and Smoking

Study sample: Duke Central Carolina sample of nearly 400 adults over age 65 Study results: Older adults who both attended religious services and prayed (or read the Bible) were nine times less likely to smoke. Frequently attending services -- strongest predictor of not smoking (much stronger than prayer/Bible reading).
Koenig HG, et al. The relationship between religious activities and cigarette smoking in older adults. J Gerontol: Medical Sciences 1998;53A(6):M1-M9.

Illness Prevention
Suicide and Religious Affiliation
Studies have found that those with no Religious Affiliation versus those with a Religious Affiliation: 1) 2) 3) 4) find suicide more acceptable are more likely to have suicidal ideation are more likely to have attempted suicide if providers, they have more favorable attitudes towards physician-assisted suicide

Illness Prevention: Mothers Religion and Depression in their Children

Study sample: 60 mothers and their 151 children who were followed up 10 years later Study results: If mothers viewed religion as highly important: daughters (not sons) 60% less likely to have had major depressive disorder mothers themselves 80% less likely to have had major depressive episode during 10 year follow-up
Miller, L., et al. Religiosity and depression: ten-year follow-up of depressed mothers and offspring. J Am Acad Child Adolesc Psychiatry 1997;36(10):1416-25.

Questions That Can Be Used to Facilitate Clinical Discussions About Patient Spirituality
From SPIRITual History:! 1. What does your spirituality/religion mean to you? 2. What aspects of your religion/spirituality would you like me to keep in mind as I care for you? 3. Would you like to discuss the religious or spiritual implications of your health care? 4. As we plan for your care near the end of life, how does your faith impact on your decisions?
Maugans TA. The SPIRITual history. Arch Fam Med 1996; 5:11-6.

Taking a spiritual history. . .

S Spiritual Belief System P Personal Spirituality I Integration in a Spiritual Community R Ritualized Practices and Restrictions I Implications for Health Care T Terminal Events Planning (advance directives, DNR wishes, DPOA etc..)

Research tells us:

patients want clinicians to consider spiritual issues religious commitments are associated with health enhancing behaviors and attitudes influence preventative practices in all aspects of medicine incorporating spiritual concepts in some areas of treatment enhances their relevance for patients using religion-oriented treatments for religious patients may be effective for treating some psychiatric disorders recovery from episodes of major mental illness may be associated with religious involvement

Prevention, Could it be done in psychiatry? Why is this? The effectiveness of preventive interventions is so weak No time to do more than assess and treat the most impaired. Managers are only interested in the number of patients seen and treated,

Preventive outcomes are difficult to quantify. The training of psychiatrists contains little of relevance to prevention. Effective prevention requires changes in the structure of society and in organisations over which psychiatrists have little control.

In 1156 BC, when Egyptian pharaoh Ramses V died of smallpox. The idea that smallpox might some day be driven from the earth was the stuff of fantasy. Throughout the centuries, smallpox killed millions of people.

It was not until 1776, however, that an English surgeon, Dr. Edward Jenner, discovered that giving a person a small dose of the relatively benign cowpox virus could provide protection against the dreaded smallpox virus ( Jenner,! 2000).

In 1977, smallpox was declared eradicated from the earth ( smallpox,! Encyclopaedia Britannica Online, 2000).

THE NEED FOR SERVICES TO PROMOTE MENTAL HEALTH AND PREVENT MENTAL AND BEHAVIORAL DISORDERS

After reviewing the evidence critically, the view of the following psychiatric authorities is that worthwhile, effective evidence-based preventive interventions do exist.
The World Health Organization (Jenkins & #stsun,1998), The US Institute of Medicine (Mrazek & Haggerty, 1994) The Royal College of Psychiatrists (CR104 February 2002) The European Community (Lahtinen et al, 1999) The Department of Health (1999a )

Mental Illnesses Worldwide: The Global Burden of Disease

Five of the "top ten" causes of disability have been identified as mental disorders, and unipolar depression is expected to be the second leading cause of disability worldwide in 2020.

Psychiatric and neurological conditions could increase their share of the total global burden by almost half, from 10.5 percent of the total burden to almost 15 percent in 2020. This is a bigger proportionate increase than that for cardiovascular diseases (Murray & Lopez, 1996, p. 37).

Mental Illness in USA

22 23% of the U.S. adult population (=44 million people) have diagnosable mental disorders during a 1-year period,.

The rate increases to 28 to 30 % When addictive disorders are added.

Mental Illness in USA

*60% of visits to physicians for medical symptoms are due to psychosocial problems, *11- 36% only of mental disorder&s is being diagnosed in general medical practice.

MENTAL DISORDERS MOST LIKELY TO BE TARGETED FOR PREVENTION INTERVENTIONS AT THIS TIME 1. Conduct Disorder 2. Oppositional Defiant Disorders 3. Dysthymia 4. Major Depressive Disorders. 5. Prodromal phase of manic-depressive illness and schizophrenia,

Predisposing (e.g. loss of mother in childhood and

genetic predisposition) Precipitating (e.g. stressful life events). **There is a shift in focus from high-risk populations to high-risk situations, because: *Easier to identify *Greater immediate prevention pay-off

Those in high-risk populations: prevention return takes longer.

Geoffrey Rose&s 'prevention paradox&(1993) prevention targeted at high-risk individuals produces the best pay-off for those particular individuals, but the best payoff for the population as a whole is provided by universal measures.

Different stressful events may lead, in different people, to different illness outcomes e.g., stress causes myocardial infarction, bronchial asthma and skin diseases .

Mechanisms by which social support may affect mental health: ( by a direct effect on well-being regardless of whether the individual is under stress ( indirectly by reducing exposure to social adversity (e.g. individuals with deficient social networks may be more likely to experience stressful events, and to use less effective coping strategies) ( interactively by buffering the individual from the maladaptive effects of stress.

Strategies based on life event and social support theory

Identifying the target population for preventive activities Delivering individual social support (by families and friends , counsellors, primary care teams and specialists).

Improving coping capacities

This may be done by classes, psychological therapies or modelling on peers. Altering environmental settings

Strategies
Environmental settings can be selected, changed or created in prevention

Developing natural support systems

These strategies may be categorised as follows: ( supporting existing systems ( creating a new but natural support system ( educating carers ( development of alliances ( mental health education.

Material and social disadvantage ( work ( housing, ( urban areas have higher rates of illness than rural areas ( poverty ( inadequate education

Resilience refers to a dynamic process encompassing positive adaptation within the context of significant adversity.

1.Prenatal and infancy 2.Childhood, puberty and early adolescence (2%14 years) 3. Late adolescence and young adulthood (15%25 years) 4.Adulthood 5.Older people 6.Approaching death

1. Neighbourhood and the community 2. Early years provision, school and higher education 3. The workplace 4. Residential care settings 5. Criminal justice system and prisons 6. Primary care 7. The general hospital 8. Specialist psychiatric care

Prenatal and infancy Targets for prevention

Reduction in rates of: ( depressive and anxiety disorders in pregnant women ( postnatal maternal depression ( babies born with single gene and chromosomal disorders associated with severe learning disability syndromes ( alcohol and drug use in pregnant women

( preventable disabilities after birth ( attachment disorder ( child abuse and neglect ( behaviour problems in children in their early years ( children with delayed language development ( delay in the identification of congenital sensory deficits ( young children with generally delayed development.

Preventive interventions Care in pregnancy Postnatal care

Psychiatrists can encourage and support routine screening by health visitors followed by regular supportive visiting with a problem-solving approach. Child and adolescent psychiatrists can encourage and support selective home visiting by health visitors during the pregnancy and first year of life for babies at risk of abuse or neglect, and general or specific cognitive, especially language, delay. Child and adolescent psychiatrists can support health visitors giving advice to mothers of young children showing unusual levels of disobedience and/or overactivity.

Risk Factors Non-specific

( low income ( poor housing ( unemployment ( lack of parental education ( lack of a supportive partner ( marital discord ( domestic violence ( mental or physical health problems in either parent ( maternal alcohol or illegal drug abuse ( low birthweight ( weak early parent)child attachment.

Specific for postnatal depression ( family history of depression ( previous episode of depression ( traumatic pregnancy or delivery.

Specific for child abuse and neglect:

( young age of parents ( parental history of unhappy or disrupted childhood ( history of persistent aggressive behaviour in one or both parents ( domestic violence ( child born with a congenital or developmental disorder ( persistently crying baby.

Specific for early development of behaviour problems:

( maternal depression ( adverse temperamental characteristics in the baby, such as negative mood and irregularity ( developmental delay or disorder ( large family size.

Specific for delayed language development:

( smoking in pregnancy ( more than occasional consumption of alcohol in pregnancy ( inadequate cognitive stimulation ( behaviour problems in the child ( large family size. Specific for single gene or chromosomal disorder: ( advanced maternal age ( previous birth of a child with a congenital anomaly ( family history of a genetically determined anomaly.

Protective factors
( a supportive relationship with a partner ( efficient, responsive antenatal services ( positive infant temperamental characteristics ( good living conditions.

Settings relevant for preventive activity

( obstetric units ( primary care ( prison units for mothers and babies ( mother and baby psychiatric units ( primary and secondary schools ( day nurseries

Stakeholders ( parents ( obstetricians ( midwives ( health visitors ( GPs ( staff of voluntary organisations.

Childhood, puberty and early adolescence (2 14 years)

Significance for prevention of psychiatric disorders

Risk, vulnerability and protective factors for this age group

Non-specific risk factors for conduct, depressive and anxiety disorders, and later misuse of illegal drugs and alcohol, include adverse temperamental characteristics in the child, parental mental illness, parental substance misuse, parental marital disharmony, parental personality disorder, chronic or acute stress at school, at home or in the neighbourhood, as well as early use of tobacco, alcohol and illegal drugs. Specific risk factors for conduct disorder include inadequate parental supervision, use of physical methods of punishment, violence in the home, a family history of criminal behaviour, a history of ADHD in the child, a delinquent peer group, academic underachievement and attendance at a 'failing& school.

Targets for prevention

Reduce the: ( numbers of children with conduct, depressive and anxiety disorders ( level of bullying in schools ( number of school exclusions ( numbers of children smoking cigarettes ( deaths from solvent inhalation ( misuse of alcohol, cannabis and other illegal drugs ( rates of sexual abuse ( rates of unsafe and regretted sexual activity ( rates of deliberate self-harm (DSH). Improve the identification and treatment of ADHD.

Preventive interventions
Parent education and parent management training The use of authoritarian methods of child rearing, involving high levels of punitiveness, inconsistency in discipline, lack of concern for, or interest in, the child&s point of view and lack of warmth are related to the development of these types of behavioural problems.

Anti-bullying programmes in schools

Bullying is a potent cause of depressive reactions in school children. The modelling of bullying behaviour by older pupils can have an effect on the behaviour of younger children, increasing their risk of developing conduct disorder.

Drug and alcohol education in schools

Linking education to multi-level programmes targeting communities, schools and individuals to reduce rates of smoking and misuse of alcohol and illegal substances has been shown to be moderately effective in expensive programmes delivered in the USA. Such programmes need to begin in primary school if they are to catch children before they become start consuming such substances.

Identification of students with depressive symptoms in schools

Although suicide prevention programmes in schools have not been shown to be effective and may indeed even have harmful effects, the identification by teachers of children showing sudden or gradual onset of withdrawn and depressive behaviour, followed by the offer of counselling, may have more positive effects in the prevention of depressive disorders in this age group

Risk factors:
( adverse temperamental characteristics ( parental marital disharmony ( parental mental illness ( parental physical illness ( family history of affective disorder ( lack of parental supervision ( habitual exposure to violent images on video film or computer games ( violent physical methods of discipline ( early experience of abuse ( peer involvement in delinquency or illegal drug consumption ( parents with learning difficulties.

Protective factors:
( an optimistic temperament in the child ( authoritative parenting ( a positive relationship with an adult outside the family ( a special talent . a regular exercise.

Settings relevant for preventive activity:

( nursery schools ( early learning centres ( primary schools ( secondary schools ( special educational units attached to ordinary schools ( special schools ( primary health care clinics ( youth offender teams ( drug action teams ( youth offender institutions.

Stakeholders:
( health visitors ( teachers in ordinary and special schools ( family practitioners ( clinical child psychologists ( educational psychologists ( child psychotherapists ( child and adolescent psychiatrists ( youth officers ( probation officers ( health education officers ( community paediatricians ( school nurses ( community child psychiatric nurses ( social workers ( families.