Religion and Health: Clinical Considerations and Applications Harold G Koenig, Duke University Medical Center, Durham, NC, USA; and King Abdulazie Unversity, Jeddah, Saudi Arabla Faten W Al Zaben and Saad Al Shohaib, King Abdulaic University, Jeddah, Saudi Arabia 1 2015 Eel L. Al sights reserved This aril is revision of he prevus edition atl by EL. volume 1, pp, 1308718040, 2001, Elsevier Lia Abstract “This ari provides a brief review of research on religion and health and suggested diical applications. Most ofthe research reviewed was published between 1960 and 2010 and is based on a systematic review, although more sleced recent research has alo been included, The majoiy ofthe esearch summarized hee indicates tha religious involvement is elated to better ‘ental health, sal health health behavior, and physical health overall, We examine here why thie might be the cate, and ‘hen make recommendations on what health professionals should do diferendy based on these eseasch Bindings Religion and health have been of considerable interest to humans ‘throughout reconied history, although until recently the relation. ship between the two had not been carefully examined through scientific esearch, This has changed in the past 25 yeas, as increasing attention has been paid to the connections between religion and health by psychological, soca, behavioral, and medical researchers. Most of the worlds populations religious belief are often central to how the people view lf and in partic: ‘la, how they make sense of trauma los, and phyialillnes Based on an international survey of 51 927 persons from 57 countries, only 13% of te world’s population are atheists, and most of these individuals are concentrated in China (47% atheist) and Japan (319% atheist) (WIN-Callup Intemational, 2012), Furthermore, only 23% of the wotlds population are rot religious (again, most are concentrated in East Ala Hindus are most likely to say they are religious (82%) compared to Chaistans (819%), Muslims (74%), and Jews (48%4). Rligiosty i highest among the poor (66% of those in| the lowest quintile of income) and uneducated (68% of those with les than a secondary education). ‘Te mor religioue ofthe 57 counties surveyed were Ghana, Nigeria, Armenia, Fiji, and Macedonia (all ver 9094) The least religious were Sweden, Turkey, the Czech Republic, Japan, and ‘China (under 30%). In Turkey (a Muslim county), only 239% described themselves as religious. In the Ceech Republic (Christan country, but until recently Communist), only 20% described themselves a¢ religious, Globally, there was 4 996 decline in religiosity fom 2005 to 2012. During this time, the countries showing the greatest decline in religiosity were Viet nam (—28%), Switzerland (~2196), France (219%), South Africa (199), and Iceland (17%). Countries showing an increate in religiosity were Pakistan (696), Macedonia (5%) Moldova (5%), Seebia (5), and Malaysia (496). Interestingly, those under age 30 and over age 65 were most likely to describe themselves a religious (60% and 66%, respectively) What Is Religion? According othe definition provided inthe Handbook of Religion and Heath, “[Religion] Involves beliefs, practices, and rituals related to the transcendent, where the transcendent is God, Allah, HaShem, or a Higher Power in Wester religious traditions orto Brahman, manifestations of Brahman, Buddha, Dao, or ultimate truth/reality in Easter traditions. This often involves the mystical or supematural. Religions usually have specific beliefs about life after death and niles about conduct within 2 social group. Religion is a mult-dimensional construc that includes belief, behaviors, stwals, and ceremo: nies that may be held or practiced in private or public setings, but are in some way derived from established traditions that developed overtime within a community, Religion is also an organized system of belief, practices, and symbols designed (a) wo facilitate closeness to the transcendent, and (b) to foster an understanding of one's relationship and responsibly to ‘others in living together in a community” (Koenig ets, 2012: 1p 45), Religion is distinguished from the teem “spirivaliy,” Which is now understood as a broader concept than religion {although may sufer from measurement contamination when conducting research) (Koenig, 2008), Is Religion Related to Health? We examine the rexeatch findings related to religion) spirituality (BS) and health in four sections: mental health, social heath behavioral health, and physical health. This summary is based ‘on a systematic review of peer-reviewed quantitative, original rescarcheports published largely ftom 1960 through mid-2010, ‘This etearchis described in more detail inthe wo editions ofthe Handbook of Religion and Health (Soenig ea, 2001, 2012). Besides summarizing the reearch ndings, the Handbooks also provide quality ratings or each ofthe approximately 3300 studies. These quality ratings range from 0 (low) to 10 (high) and are based on six citeria: study design, sampling method, number of R/S measures, quality of measures (both religious predictors and health outcomes), inclusion of contol variables, and statistical method, We summarize the research findings below in terms of the total number of studies and ofthe studies swith quality ratings of 7 or higher ‘Mental Health ‘Most of the research on religion and health (80%) focuses on ‘mental health, Of primary importance is that religion is ofen pi dlargn a TOTSBeTE-PORORTOSE- 8140267 et264 _Religion and Health: Clinical Considerations and Applications used co cope with difficult life circumstances out ofthe ind vidual’s control. We identified 434 such studies that explored the ole that 8S played in helping people cope with conditions asdiverse as general medical lines, chtonie pain, renal dseate dlabetes, lung disease, malignancy, disorders of the blood, hheatt and other cardiovascular diseases, vision and dental problems, neurological syndromes, acquited immunodet ciency syndrome, systemic lupus enthematosus, inflammatory Dowel disease, musculoskeletal disease, caregiver burden, conic psychiatric illness, loss of loved ones, conditions atthe cend-of life natural disasters, war, acte of terrorism, and a wide range of other challenging traumatic events and difficult circumstances. In most of thete tudies, people reported that R/S was helpful in coping, In some studies of medically ill adults, 90% said religion enabled them to cope at least to a moderate degree and over 40% said it was the most ‘important factor that kept them going ‘Mental Disorders ‘By improving coping, R/S beliefs and practices could influence the development and course of common mental ditorder, including depression, suicide, anxiety, psychosis, and substance suse disorders Depression AC Teast 434 studies had examined the relationship between, R/S and depression prior to mid-2010. Among those, 272 (618%) reported significant inverse relationships besween R/S esson (including nine studies a a statistical tend level) and 28 (5%) reported greater depression in those with more belief in R/S (2 studies a a statistieal tend level), OF the 178 studies rated at 7 or higher on quality, 119 (679%) reported inverse relationships and 13 (7%) positive relationships (Le, greater depression among those who were more religious). At least 30 clinical tals examined the effects of an R/S intervention on depression compared with either standard teatment of a conttal group. OF those, 19 (6384) reported a significant decline in depressive symptoms in response to R/S interventions compared to controls, whereas 2 studies (796) found standard treatments superior 10 R/S interventions Mote recently, prychiatic epidemiologists at Columbia LUniversy have published a series of reports on a cohort of children at low or high risk for depression because of parente with depressive disorder, These studies have found that reli gious involvement may prevent the development of depres son in highstisk persons (Willer et al, 2012, 20185 Kasen etal, 2012) Sulelde The research above is consistent with three-quarters of published research on R/S and suicide attempts, completed suicide, or atdiudes toward suicide, which find lower risk among those who are more R/S. OF 141 studies, 105 (75%) hnave found inverse relationships with R/S, whereas 4 (39) have reported positive relationships, As the methodological rigor of the studies improves, the likelihood of finding inverse relationships inereases from 75% (0 80% (ie, 39 of 449 studies) ‘Anxiety ‘Our review identified 299 studies that had examined rela tionships between R/S and anxiety, of which 147 (499%) found inverse associations with RYS (three at a trend leve!) and 33 (1156) found greater anxiety. Most of the latter (0496), however, were crose-sectional studies, making i impossible to determine whether R/S was the cause of the greater anxiety or whether great anxiety was the cause for RIS involvement. Quality of the stidy did not seem to induence the findings. Fifty-five percent (38 of 67 studies with quality ratings of 7 or higher) reported. inverse relationships, while 10% (7 of 10) reported greater anxiety among the more R/S. Included here were 32 randomized dinical tials, of which 22 (699%) found that R/S interventions were more effective in reducing anxiety than standard treatment of control conditions (only one study reporting wore outcomes in the R/S intervention group and that was among individuals suffering from severe alcohol dependence} Peychosis Relationships with paychoss are less clea. Only about one third (14 of 43) of studies have found inverse relationships between R/S and psychotic symptoms, whereas one-quarter (10 of 43) of studies have reporeed positive relationships, Two studies that reported inverse selationships between R/S and psychosis were prospective in nature, where those who Inad more belie in R/S had better outcomes. The reader is referred elsewhere for a more comprehensive discussion of R/S and paychotic disorders (and ways that clinicians can dlistingush the two) (Koenig, 201) ‘Alcohol and Drug Use/Abuse ‘While the relationship besveen R/S and peychotte symptoms may be somewhat unclear, there i# no doubt about associa tions with alcohol and drug use. Of the 278 studies that ‘examined relationships between alcohol use/abuse and RS, 240 (86%) have found inverse relationships, whereas only 4 studies reported a positive relationship. Studies with the best methodology report the same findings (ie, 90% of 145 studies with quality ratings of 7 or higher report inverse rela tionships with R/S). Relationships between R/S and drug use) abuse aze similar OF 185 studies, 849% have found inverse relationships, whereas only 2 studies reported postive rela Uionships. Again, the findings were not influenced by the ‘quality of the study, Note that most of these studies were conducted on high school and college students, which are particularly vulnerable group and this ithe time when youth ae beginning to establish substance use patterns that will influence the rest of their lives Positive Emotions Although of less interest to clinicians, the experience of posi tive emotions is of considerable importance to individuals in the general popslation, who may be quite concerned abot the relationship between R/S involvement and emotional sates such as wellbeing, happiness, optimism, hope, meaning and purpose, and selfesteem, which often make life worth living (or not).Religion and Health: Clinical Considerations and Applications __265 Well-being [Among the 326 studies that examined relationships between 2S and well-being, happiness, or life satisfaction up through mid-2010, neatly 80% (256 studies) reported significant posiuive relationships (eight at a statistical trend), compared to <19% that found inverse relationships, Again, quality of the stady had litle effect on the findings, such that 829% of the 98 best studies reported positive relationships and only ‘one study reported a negative relationship, Hope “The majority of sudies found that R/S individuals are more hopeful. Among the 40 studies we identified in our systematic review, 29 (73%) reported significant positive relationships and no studies found inverse relationships. Optimism (Of the 32 studies examining relationships between R/S and ‘optimism, 26 (819) reported significant positive relation ships and no studies reported invert relationships ‘Meaning and Purpose Sigmund Freud said that “..only religion can answer the question of the purpose of life. One can hardly be wrong in concluding thatthe idea of life having a purpose stands and falls withthe religious system" (Freud, 1930). On this point Freud was probably right, Of the 45 studies that have exam: ined relationships with R(S, 42 (93%) reported significant positive relationships, and of the 10 studies with quality ratings of 7 of higher, all (100%) reported significant positive Self-esteem Although psychiatrists have argued that R/S may adversely affect self-esteem because i fosters humility and discourages pride (Watters, 1992), the research published to date does not support this claim. OF the 69 studies that have examined relationships with self-esteem, 42 (61%) have reporced reste slf-esteem among the more R/S and only two studies Ihave found lower selfesteem, At the quality of the study increases, the results remain favorable toward RS, where 17 of 25 (68%) reported greater self-esteem. These findings are consistent with those feported between R/S and depression (oF suicide, which often result from a loss of self-esteem. Social health involves social support marital stability, absence fof crime and delinquent activities, altruistic activities, and social capital. R/S i telated (0 every one of these, and the direction of those relationships is consistent. Social Support ‘We identified 74 studies examining associations between R/S and social suppor, including a number of social contacts, frequency of interaction with family and friends, and subjective sense of satisfuction with that suppor. Of those sudier 61 (82%) found that R/S war associated with significantly higher socal support and none found lower social support, Nearly all ofthe highest quality studies (27 of 29) found greater socal suppor among the more religious ‘This is especially true for older adults in whom members of| the faith community ate often the most important source of support outside of family members (Culler, 1976; Koenig eval, 1988). Marital Stability (Of the 79 studies we identified up through mid-2010, 68 (36%) reported significant relationships beween R/S and lower rates of divorce, higher rates of two-parent homes, greater marital satisfaction, and lower sates of spousal abuse, Among studies with the best methodology (ratings of 7 oF higher}, 35 of 38 studies reported this finding. These results are consistent with meta-analytic reviews of the Ierature by others (Mahoney et al, 2001) and by more recent research published in this field (Spilman et al, 2013; David and Staffor, 2013) Detinqueney/Crime ‘Of the 104 studies that examined relationships with R/S, again the vast majority (79% or 82 or 104) found inverse relation ships with delinquency during youth and crime during adulthood, Only three studies have reported the opposite, OF the 60 methodologically most rigorous studies, the same proportion (82% or 19 of 60 studies) found less delinquency and crime among the more religious. Altruistic Activities ‘Oursystematicreview of YS and aluuism/volunteerism found that 70% (33 of 47 studies) reported significant positive relationships, and if organ donation studies are excluded {ince some religions prohibit thie practice), the percentage of positive studies increases to 79%, Social Capital Social capital is aterm used to deseribe the overall health of a community, and it ofien attessed by measuring level of ‘community participation, tus, reciprocity between comme nity members, rates of volunteerism, and proportion of the community that participates in cvi, political, or social justice organizations. Again, the vast majority of these studies (79% for 11 of 14 studies) reported that R/S of members ‘8 community relates to significantly greater levels of social capital Behavioral Health Religious beliefs and docirines may influence lifestyle choices related to physical health by emphasizing responsibility ‘0 care for and nourish the body (while avoiding gluttony). Behaviors that harm the body are discouraged, since good health enables the religious petson to serve God and others, We review here studies that have examined relationships