Religiousness and mental health: a review

242 SPECIAL ARTICLE Religiousness and mental health: a review Religiosidade e saúde mental: uma revisão Alexander Moreira-Almeida,1,2,3,4 Francisco Lotufo Neto,1 Harold G Koenig3,4 Abstract Objective: The relationship between religiosity and mental health has been a perennial source of controversy. This paper reviews the scientific evidence available for the relationship between religion and mental health. Method: The authors present the main studies and conclusions of a larger systematic review of 850 studies on the religion-mental health relationship published during the 20th Century identified through several databases. The present paper also includes an update on the papers published since 2000, including researches performed in Brazil and a brief historical and methodological background. Discussion: The majority of well-conducted studies found that higher levels of religious involvement are positively associated with indicators of psychological well-being (life satisfaction, happiness, positive affect, and higher morale) and with less depression, suicidal thoughts and behavior, drug/alcohol use/abuse. Usually the positive impact of religious involvement on mental health is more robust among people under stressful circumstances (the elderly, and those with disability and medical illness). Theoretical pathways of the religiousness-mental health connection and clinical implications of these findings are also discussed. Conclusions: There is evidence that religious involvement is usually associated with better mental health. We need to improve our understanding of the mediating factors of this association and its use in clinical practice. Keywords: Mental health; Religion; Religion and Medicine; Religion and Psychology; Spirituality Resumo Objetivo: A relação entre religiosidade e saúde mental tem sido uma perene fonte de controvérsias. O presente artigo revisa a evidência científica disponível sobre a relação entre religião e saúde mental. Método: Os autores apresentam os principais estudos e as conclusões de uma revisão sistemática abrangente dos estudos sobre a relação religião-saúde mental. Utilizando-se de várias bases de dados, a revisão identificou 850 artigos publicados ao longo do século XX. O presente artigo também inclui uma breve contextualização histórica e metodológica, além de uma atualização com artigos publicados após 2000 e a descrição de pesquisas conduzidas no Brasil. Discussão: A ampla maioria dos estudos de boa qualidade encontrou que maiores níveis de envolvimento religioso estão associados positivamente a indicadores de bem estar psicológico (satisfação com a vida, felicidade, afeto positivo e moral mais elevado) e a menos depressão, pensamentos e comportamentos suicidas, uso/abuso de álcool/drogas. Habitualmente, o impacto positivo do envolvimento religioso na saúde mental é mais intenso entre pessoas sob estresse (idosos, e aqueles com deficiências e doenças clínicas). Mecanismos teóricos da conexão religiosidade-saúde mental e as implicações clínicas destes achados são discutidos. Conclusões: Há evidência suficiente disponível para se afirmar que o envolvimento religioso habitualmente está associado a melhor saúde mental. Atualmente, duas áreas necessitam de maior investimento: compreensão dos fatores mediadores desta associação e a aplicação deste conhecimento na pratica clínica. Descritores: Saúde Mental; Religião; Religião e Medicina; Religião e Psicologia; Espiritualidade 1 2 3 4 Center for the Study of Religious and Spiritual Problems (NEPER), Department of Psychiatry, Universidade de São Paulo (USP), São Paulo (SP), Brazil João Evangelista Hospital, São Paulo (SP), Brazil Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina Geriatric Research, Education, and Clinical Center, VA Medical Center, Durham, North Carolina Center for the Study of Religious and Spiritual Problems (NEPER), Department of Psychiatry, Universidade de São Paulo (USP), São Paulo (SP), Brazil Financing: Post-Doctoral fellowship provided by Hospital João Evangelista (HOJE) Conflicts of Interest: None Submitted: 9 January 2006 Accepted: 15 March 2006 Correspondence Alexander Moreira-Almeida 2748 Campus Walk Ave. Apt.18b 27705 – Durham – NC Phone: (919) 309-1405 E-mail: Rev Bras Psiquiatr. 2006;28(3):242-50 243 Moreira-Almeida A et al. Introduction Although some scholars had predicted that religiosity would tend to disappear or sharply decrease throughout the 20th Century 1-2 that has not been the case, especially in the American Continent. According to a 2005 US poll,3 88% of Americans in the United States describe themselves as religious and/or spiritual, and only 7% said that spirituality is not important at all in their daily life. In the Brazilian 2000 Census,4 only 7% declared themselves as religiousless. Even this 7% probably included many people with some expression of spirituality but not related to an organized religion. However, despite the large importance of religion and spirituality for the population, until recently, religion and spirituality were not included in the training curriculum of the mental health professionals and were set aside in clinical practice. In the last two decades, things begun to change. Literally, thousands of papers have been published on the relationship of religion and health in the medical and psychological academic literature. Indeed, many medical schools have integrated spirituality into the curriculum. In the US, 84 out of 126 accredited medical schools are offering courses on spirituality in medicine. 5 However, if we understand prejudice as a “preconceived opinion” or an “opinion formed without just grounds or before sufficient knowledge”,6 we can see that the field studying the relationship between religion and health is undoubtedly full of prejudice. In that case, the prejudice may be for or against religion. The field has seen extremes between naive acceptances of all claims that “religion is good” to a radical skepticism that rejects even good scientific evidence. In studying the relationship of spirituality with health, it is not necessary to assume any position about the ontological reality of God or the spiritual realm. We can test whether measures of religious beliefs or behaviors are associated with health outcomes, regardless if we believe in the beliefs under investigation. 7-10 The definitions of religiosity and spirituality have been a perennial source of controversy. According to Betson & Ventis, as early as 1912 the psychologist James Leuba detected 48 distinct definitions of religion. 11 We will adopt the definitions given by Koenig et al.:12 1) Religion: is an organized system of beliefs, practices, rituals, and symbols designed to facilitate closeness to the sacred or transcendent (God, higher power, or ultimate truth/reality). 2) Spirituality: is the personal quest for understanding answers to the ultimate questions about life, about meani (...truncated)