state of the art in research on faith and health harold g. koenig, md departments of psychiatry and...
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State of the Art in Research onState of the Art in Research on
Faith and HealthFaith and Health
Harold G. Koenig, MDHarold G. Koenig, MD
Departments of Psychiatry and MedicineDepartments of Psychiatry and Medicine
Duke University Medical CenterDuke University Medical Center
GRECC VA Medical CenterGRECC VA Medical Center
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1. Definitions: Religion and Spirituality
2. Research on R/S and mental health
3. Research on R/S and health behaviors
4. Research on R/S, physical health, and longevity
5. Understanding the relationship between R/S and health
6. Further resources
Overview 10:15-11:00
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Definitions
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Religion
Involves beliefs, practices, and rituals related to the ‘transcendent,” where the transcendent is that which relates to the mystical, supernatural, or God in Western religious traditions, or to Divinities, ultimate truth/reality, or enlightenment in Eastern traditions. Religions usually have specific beliefs about life after death and rules about conduct within a social group. Religion is often organized and practiced within a community, but it can also be practiced alone and in private. Central to its definition, however, is that religion is rooted in an established tradition that arises out of a group of people with common beliefs and practices concerning the transcendent. Religion is a unique construct, whose definition is generally agreed upon.
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Spirituality
Spirituality is a concept which today is viewed as broader and more inclusive than religion. It is a term more popular today, more so than religion. Spirituality is considered personal, something individuals define for themselves that may be free of the rules, regulations, and responsibilities associated with religion. Spirituality is more difficult to define than religion, and agreement on what the term means is often lacking – especially since the definition of spirituality has been changing, and expanding.
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Spirituality
Religion
Traditional-Historical Understanding
Source
Secular
Mental Health Physical Health
Meaning
Purpose
Connectedness
Peace
Hope
Depression
Anxiety
Addiction
Suicide
CardiovascularDisease
Cancer
Mortality
Psy
chon
euro
imm
unol
ogy
vs.Ex. well-being
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Spirituality
Religion
Modern Understanding
Source
Secular
Mental Health Physical Health
Meaning
Purpose
Connectedness
Peace
Hope
Depression
Anxiety
Addiction
Suicide
CardiovascularDisease
Cancer
Mortality
Psy
chon
euro
imm
unol
ogy
vs.Ex. well-being
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Spirituality
Religion
Modern Understanding - Tautological Version
Source
Secular
Mental Health Physical Health
Meaning
Purpose
Connectedness
Peace
Hope
Depression
Anxiety
Addiction
Suicide
CardiovascularDisease
Cancer
Mortality
Psy
chon
euro
imm
unol
ogy
vs.
Ex. well-being
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Spirituality
Religion
Modern Understanding - Clinical Application only
Source
Secular
Mental Health Physical Health
Meaning
Purpose
Connectedness
Peace
Hope
Depression
Anxiety
Addiction
Suicide
CardiovascularDisease
Cancer
Mortality
Psy
chon
euro
imm
unol
ogy
Ex. well-being
Not a Researchable Model
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Comments on Measuring Spirituality in Research
1. Currently, “spirituality” is either measured as (1) religion, (2) positive psychological states, or (3) positive character traits
2. Positive psychological states include having purpose and meaning in life, being connected with others, experiencing peace, harmony, and well-being
3. Positive character traits include being forgiving, grateful, altruistic, or having high moral values and standards
4. Problem: Atheists or agnostics may deny any connection with spirituality, but rightly claim their lives have meaning, purpose, are connected to others, practice forgiveness and gratitude, are altruistic, have times of great peacefulness, and hold high moral values
(Journal of Nervous and Mental Disease 2008; 196(5):349-355)
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Measuring Spirituality (cont)
5. Problem: Confusing to use religious language (spirituality or that having to do with the spirit) to describe secular psychological terms
6. Problem: Can no longer examine relationships between spirituality and mental health (since spirituality scales confounded by items assessing mental health) ***
6. Problem: Can no longer examine relationships between spirituality and physical health (since mental health affects physical health through the mind-body relationship)
7. Problem: Can no longer study the negative effects of spirituality on health, since positive effects are predetermined by the definition of spirituality
Result:Meaningless tautological associations between spirituality and health
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To keep things simple and clear, I use the terms religion and spirituality interchangeably, or simply use the word religion
When research has been conducted on religion it has been distinctive and not confounded with indicators of positive mental health, as research involving spirituality has.
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Research on Religion and Mental Health
1. Well-being2. Depression3. Suicide4. Anxiety5. Substance abuse
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Religion and Well-being in Older Adults
Religious categories based on quartiles (i.e., low is 1st quartile, very high is 4th quartile)
Low Moderate High Very High
Church Attendance or Intrinsic Religiosity
Wel
l-b
ein
g
The Gerontologist 1988; 28:18-28
Religion and Well-being in Older Adults
Religious categories based on quartiles (i.e., low is 1st quartile, very high is 4th quartile)
Low Moderate High Very High
Church Attendance or Intrinsic Religiosity
Wel
l-b
ein
gThe Gerontologist 1988; 28:18-28
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Religion and Depression in Hospitalized Patients
Geriatric Depression ScaleInformation based on results from 991 consecutively admitted patients (differences significant at p<.0001)
35%
23% 22%
17%
Low Moderate High Very High
Degree of Religious Coping
Per
cen
t D
epre
ssed
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Time to Remission by Intrinsic Religiosity
0 10 20 30 40 50
Weeks of Followup
0
20
40
60
80
100
Pro
babi
lity
of
Non
-Rem
issi
on
%
Low Religiosity
Medium Religiosity
High Religiosity
(N=87 patients with major or minor depression by Diagnostic Interview Schedule)
American Journal of Psychiatry 1998; 155:536-542
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0 4 8 12 16 20 24
Weeks of Followup
0
20
40
60
80
100P
roba
bili
ty o
f N
on-R
emis
sion
%
Other Patients
Highly Religious (14%)
diagnosis
845 medical inpatients > age 50 with major or minor depression
HR=1.53, 95% CI=1.20-1.94, p=0.0005, after control for demographics, physical health factors, psychosocial stressors, and psychiatric predictors at baseline
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Religious involvement is related to: • Greater well-being and happiness
(278 of 359 studies) (77%)
• Less depression, faster recovery from depression(204 of 324 studies) (63%)
* Sources:Handbook of Religion and Health (2001, Oxford University Press)Handbook of Religion and Health (2011, 2nd ed, OUP)
Well-being and Depression(systematic review: 1806-2009)*
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Religious involvement is related to:
Less suicide and more negative attitudes toward suicide
(106 of 141 or 74% of studies)
Why?
A religious world-view gives people a reason for living – it gives life meaning.
Suicide(systematic review)
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Religious involvement is related to:
• Significantly greater meaning and purpose in life(42 of 45 studies) (93%)
• Significantly greater hope(29 of 39 studies) (74%)
Meaning, Purpose, and Hope(systematic review)
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Religious involvement is related to:
• Significantly more forgiveness(34 of 40 studies) (85%)
• Significantly more altruism / volunteering(33 of 47 studies) (70%)
• Significantly more gratitude(5 of 5 studies) (100%)
Forgiveness, Altruism, and Gratitude(systematic review)
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Religious involvement is related to:
• Great social support(61 of 74 studies) (82%)
Social Support(systematic review)
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Religion and Health Behaviors
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Religion is related to:
• More exercise/physical activity(25 of 37 studies) (68%)
• Less cigarette smoking, especially among the young(120 of 134 studies) (90%)
• Less alcohol/drug use, especially among the young(276 of 324 studies) (85%)
Health Behaviors
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The Mind-Body Relationship
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Religion
MentalHealth
SocialSupport
HealthBehaviors
StressHormones
ImmuneSystem
Autonomic Nervous System
DiseaseDetection &TreatmentCompliance
Smoking High Risk Behaviors Alcohol & Drug Use
Infection
Cancer
Heart Disease
Hypertension
Stomach &Bowel Dis.
Accidents& STDs*
Gen
etic
su
scep
tib
ility
, Gen
der
, Age
, Rac
e, E
du
cati
on, I
nco
me
Liver & Lung Disease
Stroke
Chi
ldho
od T
rain
ing
Adu
lt D
ecis
ions
Val
ues
and
Cha
ract
er
Adu
lt D
ecis
ions
* Sexually Transmitted Diseases
Model of Religion's Effects on HealthHandbook of Religion and Health (Oxford University Press, 2001)
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Religion and Physical Health
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Religion & Physiological Functions
Immune
Endocrine
Cardiovascular
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Religious involvement is related to:
Better immune functions(19 of 31 studies) (61%)
Better endocrine functions(21 of 32 studies) (66%) (majority involving meditation)
Immune and Endocrine Functions(systematic review)
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Serum IL-6 and Attendance at Religious Services
Never/Almost Never 1-2/yr to 1-2/mo Once/wk or more
Frequency of Attendance at Religious Services
6
8
10
12
14
16
18
Per
cent
wit
h IL
-6 L
evel
s >
5 (1675 persons age 65 or over living in North Carolina, USA)
* bivariate analyses** analyses controlled for age, sex, race, education, and physical functioning (ADLs)
Citation: International Journal of Psychiatry in Medicine 1997; 27:233-250
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Religious involvement is related to:
Lower blood pressure(36 of 62 studies) (58%)
Less heart disease (CAD, CVR, HRV, CRP, cardiac surg, etc.)(35 of 54 studies overall) (65%)
(10 of 14 studies on CAD) (71%)
Cardiovascular Functions(systematic review)
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Low Attendance High Attendance Low Attendance High Attendance77
78
79
80
81
Ave
rage
Dia
stol
ic B
lood
Pre
ssu
re
* Analyses weighted & controlled for age, sex, race, smoking, education, physical functioning, and body mass index
Low Prayer/Bible Low Prayer/Bible High Prayer/Bible High Prayer/Bible
p<.0001*
Religious Activity and Diastolic Blood Pressure(n=3,632 persons aged 65 or over)
High = weekly or more for attendance; daily or more for prayerLow= less than weekly for attendance; less than once/day for prayer
Citation: International Journal of Psychiatry in Medicine 1998; 28:189-213
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Mortality From Heart Disease and Religious Orthodoxy(based on 10,059 civil servants and municipal employees)
Kaplan-Meier life table curves (adapted from Goldbourt et a l 1993. Cardiology 82:100-121)
Follow-up time, years
Su
rviv
al p
rob
abil
ity
Differences remain significant aftercontrolling for blood pressure, diabetes, cholesterol, smoking,weight, and baseline heart disease
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Six-Month Mortality After Open Heart Surgery
Citation: Psychosomatic Medicine 1995; 57:5-15
0
5
10
15
20
25
% D
ead
(2 of 72)
(7 of 86) (2 of 25)
(10 of 49)
(232 patients at Dartmouth Medical Center, Lebanon, New Hampshire)
Hi ReligionHi Soc Support
Hi ReligionLo Soc Support
Lo ReligionHi Soc Support
Lo ReligionLo Soc Support
Hi ReligionHi Soc Support
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Mortality (all-cause)(systematic review)
Religious involvement related to:
• Greater longevity in 55 of 84 studies (65%)
• Shorter longevity in 2 of 84 studies (2%)
• Mixed findings in 12 of 84 studies (14%)
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Standard Mortality Ratios (ages 25-99)
Males Females
California Mormons (n=9815)* 0.54 (0.51-0.57) 0.61 (0.57-0.65)
Attend church wkly (99% M / 99% F)
+ never smoke+married+12 yr ed** 0.45 (0.42-0.48) 0.55 (0.51-0.59)
+ moderate BMI (57% M / 65% F) 0.43 (0.39-0.47) 0.52 (0.47-0.57)** Life Expectancy age 25 84 years 86 years
US Whites (n=15,832)* 0.90 (0.85-0.96) 0.83 (0.79-0.88)
Attend church wkly (28% M / 39% F) 0.78 (0.68-0.88) 0.70 (0.62-0.79)
+ never smoke 0.60 (0.48-0.74) 0.63 (0.55-0.74)
+ married 0.51 (0.40-0.66) 0.52 (0.42-0.66)
+ 12 yr education ** 0.47 (0.33-0.64) 0.38 (0.28-0.52)
+ moderate BMI (7% M / 10% F) 0.43 (0.30-0.61) 0.35 (0.24-0.50)Life Expectancy age 25 (US Whites – all) 74 years 81 years**Life Expectancy age 25 (extrapolated) 84 years 86 years+
*Based on a systematic sample of active Calif. Mormons followed 1980-2004, and random sample of white US adults followed 1988-1997. Preventive Medicine 2008; 46:133-136
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Godbelief, relation,
attachment
Public prac, rit
Private prac, rit
R commit
R coping
Positive Emotions*
Negative Emotions*
*Positive emotions: peace, harmony, existential well-being, happiness, hope/optimism, meaning, purpose*Negative emotions: depression, anxiety, emotional distress, loneliness, low self-esteem
Social sup &connections
Physical H
ealth and Longevity
Imm
une,
End
ocrin
e, C
ardi
ovas
cula
r F
unct
ions
Theoretical Model of Causal Pathways
Genetics, Developmental Experiences, Personality
Decisions, Lifestyle Choices, Health Behaviors
SOURCE
R exp
Spirituality
Handbook of Religion & Health, 2nd Ed, 2011
faithcommunity
Human VirtuesForgivenessHonestyCourageSelf-disciplineAltruismHumilityGratefulnessPatienceDependability
Theologicalvirtues: faith, hope, love
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Spirituality in Patient Care (2007, Templeton Press)
Medicine, Religion and Health (2008, Templeton Press)
Faith and Mental Health (2005, Templeton Press)
Handbook of Religion and Health (2001, Oxford University Press)
Handbook of Religion and Health (2011 Oxford University Press)
The Link Between Religion and Health (2002, Oxford University Press)
Further InformationWebsite: Duke Center for Spirituality, Theology and Healthhttp://www.spiritualityandhealth.duke.edu/
Further Reading
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Summer Research WorkshopsJuly and August 2010
Durham, North Carolina
5-day intensive research workshops focus on what we know about the relationship between spirituality and health, applications, how to conduct research and develop an academic career in this area (see website: http://www.spiritualityhealthworkshops.org/). Leading spirituality-health researchers at Duke and elsewhere will give presentations: -Previous research on spirituality and health-Strengths and weaknesses of previous research-Applying findings to clinical practice-Theological considerations and concerns -Highest priority studies for future research-Strengths and weaknesses of spirituality measures-Designing different types of research projects-Carrying out and managing a research project-Writing a grant to NIH or private foundations-Where to obtain funding for research in this area-Writing a research paper for publication; getting it published-Presenting research to professional and public audiences; working with the media
If interested, contact Harold G. Koenig: [email protected]
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Discussion and Questions
11:00 end