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Spirituality and Religiousness are Associated With Fewer Depressive Symptoms in Individuals With Medical Conditions
& 2016 Published by Elsevier Inc. on behalf of The Academy of Psychosomatic Medicine.
Psychosomatics 2016:]:]]]–]]]
Original Research Reports Spirituality and Religiousness are Associated With Fewer Depressive Symptoms in Individuals With Medical Conditions Aurelie Lucette, M.S., Gail Ironson, M.D., Ph.D., Kenneth I. Pargament, Ph.D., Neal Krause, Ph.D.
Background: The increased prevalence of depressive symptoms among adults diagnosed with chronic health issues has been largely documented. Objectives: Research is needed to clarify the effect of religiousness/ spirituality in relation to chronic health conditions and depression, to establish whether these variables can serve as protective factors. Methods: Self-report data from a nationwide study of spirituality and health were used. Individuals with at least 1 chronic illness (N ¼ 1696) formed the subsample for this study. Religiousness/spirituality variables included frequency of church attendance, prayer, religious meaning, religious hope, general meaning, general hope, peace, and view of God. Other variables included depressive symptoms and demographics (age, gender, ethnicity, and education). Results: A series of hierarchical regression analyses revealed that chronic conditions were consistently associated with more depressive symptoms. Greater religiousness/spirituality was significantly associated
with fewer depressive symptoms, contributing 16% of the variance above demographics and the number of chronic illnesses. The religiousness/spirituality variables conferring the greatest protection against depression were psychospiritual variables (general meaning and general hope, followed by peace). Also significant but making a smaller contribution to less depression were church attendance, religious meaning, religious hope, and positive view of God. Only prayer did not relate significantly to less depression. Conclusion: Maintaining a sense of spirituality or religiousness can benefit well-being of individuals diagnosed with a chronic health condition, especially having meaning, maintaining hope, and having a sense of peace. Patients could potentially benefit from being offered the resources that support their spiritual/religious practices and beliefs as they cope with chronic illness. (Psychosomatics 2016; ]:]]]–]]])
INTRODUCTION Chronic Illness and Depressive Symptoms Beyond the social and economical challenges, depression is an important consequence of physical health problems that adds to the heavy burdens that health problems already create, and, as such, it represents a major public health concern.1 Depressive symptoms are particularly prevalent among adults Psychosomatics ]:], ] 2016
Received October 28, 2015; revised March 11, 2016; accepted March 19, 2016. From Department of Psychology, University of Miami, 5665 Ponce de Leon Blvd, Coral Gables, FL (AL, GI); Department of Psychology, Bowling Green State University, Bowling Green, OH (KIP); School of Public Health, University of Michigan, Ann Arbor, MI (NK). Send correspondence and reprint requests to Gail Ironson, M.D., Ph.D., Department of Psychology, University of Miami, 5665 Ponce de Leon Blvd, Coral Gables, FL 33124-0751; e-mail: [email protected] & 2016 Published by Elsevier Inc. on behalf of The Academy of Psychosomatic Medicine.
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Spirituality, Religiousness, Illness, and Depression living with chronic health conditions.2,3 In turn, the coexistence of chronic illness and depressive symptoms has been linked to detrimental outcomes, such as significant decrements in health and physical quality of life,4 increased health care utilization and costs,5,6 faster disease progression across a range of illnesses,7–9 and even mortality.10,11 Considering that almost half of the American population is diagnosed with at least 1 chronic condition, and that more than 60% of individuals older than 65 years have more than 1 condition,12 it is critical to examine factors that might prevent or alleviate depressive symptoms among those individuals.
Religiousness/Spirituality, Chronic Illness, and Depressive Symptoms In recent years, mounting research has examined the relationship between religiousness/spirituality (R/S) on one hand, and psychologic states on the other hand, highlighting the positive effect of these factors on mental health.13–15 A significant number of individuals use R/S to cope with adversity,16 including when they navigate the challenges of living with a debilitating chronic illness,17 thus offering possible relief from the difficulties associated with the challenges they face. For instance, R/S factors, including religious attendance, private prayer, greater intrinsic religiosity, and religious involvement have been linked with better depression outcomes in both the general population and among medically ill individuals.18–21 Similarly, having a positive view of one’s relationship with God has been associated with lower depressed affect in a sample of primary care patients.22 Through their religious and spiritual beliefs and practices, individuals with a chronic health condition can find hope, meaning, and peace, which in turn help them better adjust to the challenges they face.23,24
Purpose of the Current Study The purpose of the current study was to examine the association of R/S and depressive symptoms among individuals with chronic health conditions and to determine whether these variables, relevant for a significant number of individuals, can serve as protective factors. Spirituality has often been described as a search or a connection for the sacred,15 or 2
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transcendent that goes beyond structured and organized religions.13,20 On the contrary, religion is more often associated with a set of beliefs and practices that are organized and originated in long-established traditions.13,20 Thus, although they overlap, spirituality extends beyond religion, and even individuals who describe themselves as nonreligious can draw upon spirituality to cope with adversity.25 In addition, as meaning and hope are deeply rooted in religious and spiritual traditions,14,26 yet may derive from other sources overlapping psychology, following the suggestion of Pargament,27 we refer to these constructs in a more general context as “psychospiritual.” Thus, we included both classically-related R/S variables (church attendance and prayer) and functionally-related R/S measures (religious hope, religious meaning, and positive and negative views of God) as well as psychospiritual variables (general meaning, general hope, and sense of peace). We hypothesized that chronic illness would be significantly related to depression, and that all aspects of R/S would be associated with fewer depressive symptoms even after controlling for relevant demographics and the number of chronic conditions. We also wanted to determine which aspects of R/S would have the strongest association with less depression. A secondary analysis explored whether moving from a global assessment of meaning (or hope) that subsumes all domain-specific evaluations to a domain-specific measure of meaning (or hope) that focuses solely on religion would provide additional insight into the relationship between chronic illness and depressive symptoms. METHODS The present study was conducted as part of the Landmark Spirituality and Health Survey (LSHS) in 2014 among a sample of 3010 adults representative of the adult US population. The overarching aim of this survey was to examine religious and spiritual factors in relation to health outcomes. Data collection for this nationwide, face-to-face survey was conducted by the National Opinion Research Center (NORC) in participants’ homes. Clustered random household sampling was used for this survey. Additional information can be obtained from the LSHS website (http:// landmarkspirituality.sph.umich.edu/). This article focuses on those who have at least 1 chronic health condition, a total sample of 1696 participants. Psychosomatics ]:], ] 2016
Lucette et al. Measures Depressive Symptoms A total of 4 items from the Center for Epidemiologic Studies-Depression Scale28 reflecting depressed affect were used to assess depressive symptoms. The 4 items reflecting somatic symptoms of depression were omitted in the current analyses to avoid confounding effects from the participants’ chronic illness symptoms. Participants rated the frequency with which they had experienced each of the 4 depressive symptoms (e.g., “I felt I could not shake off the blues, even with the help of my family and friends”) on a 4-point Likert scale ranging from Rarely/None of the time (1) to Most/All of the time (4). Items were summed with a higher score indicating higher depressive symptoms. Items from the Center for Epidemiologic Studies-Depression Scale were designed to assess depressive symptoms in the general population and have previously demonstrated good internal consistency and adequate test-retest reliability.42 Internal consistency in this study was good for the depressed affect subscale (α ¼ 0.85).
Chronic Health Conditions Participants were provided a list of 12 chronic illness (i.e., arthritis/rheumatism, cataract/glaucoma/eye disease, asthma/emphysema/other respiratory diseases, hypertension, heart attack/issues, diabetes, ulcers, liver disease, kidney disease, urinary tract disorder, cancer/malignant tumor, and prostate trouble) and were asked to identify whether they had experienced each of them in the past 12 months.29 The total number of chronic health problems experienced within the past year was computed by adding all items endorsed as “yes,” and a higher score indicated that participants had experienced more chronic health issues.
taken from the Fetzer Institute/National Institute on Aging Working Group.30 Private Prayer Frequency of private prayer was assessed using a 1-item question (“How often do you pray by yourself?”). Participants were asked to select the answer that best reflected the frequency at which they pray from 8 options ranging from Never to Several times a day, with higher scores indicating more frequent prayer. This item was also taken from the Fetzer Institute/National Institute on Aging Working Group.30 Religious Meaning Religious meaning in life was assessed using 3 items (e.g., “God put me in this life for a purpose”).31 Participants rated their agreement with each statement on a 4-point Likert scale, ranging from Strongly Agree (1) to Strongly Disagree (4). Items were reverse scored and a total score was computed, with higher scores indicating greater religious meaning. Internal consistency for the 3 items administered in this study was very good (α ¼ 0.91). Religious Hope In total, 3 items adapted from the Scioli’s Hope Scale32 were presented to assess religious hope (e.g., “My religion or spiritual beliefs help me see that things will turn out well in the future”). Participants rated their agreement with each statement on a 4-point Likert scale ranging from Not me (0) to Exactly like me (3), with higher scores indicating greater religious hope. Internal consistency for the 4 items administered in this study was very good (α ¼ 0.93). General Meaning in Life
Religiousness and Spirituality Measures Religious Services Attendance Frequency of services attendance was assessed using 1 item (“How often do you attend religious services?”). Participants were asked to select the answer that best reflected their attendance from 9 options ranging from Never to Several times a week, with higher scores indicating more frequent attendance. This item was Psychosomatics ]:], ] 2016
To assess general meaning in life, 6 items were used.33–35 Participants rated the extent to which they agreed with statements related to meaning in life (e.g., “I feel like I have found a really significant meaning in life”) on a 4-point Likert scale ranging from Strongly Agree (1) to Strongly Disagree (4). Items were reverse scored, and a composite score was computed by summing items, with higher scores indicating a greater sense of meaning in life. Internal consistency in the www.psychosomaticsjournal.org
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Spirituality, Religiousness, Illness, and Depression study was good (α ¼ 0.85). Because of previous issues with confounding of mood with well-being measures, we were careful to choose items that did not measure mood or affect. General Hope/Optimism Participants were presented with 4 items to assess hope and optimism. Of the 4 items, 3 were taken from the life orientation test36 and the fourth one was developed by Krause37 to assess dispositional optimism (“I feel confident that the rest of my life will turn out well”). Participants rated their agreement with the 4 statements on a 4-point Likert scale ranging from Strongly Agree (1) to Strongly Disagree (4). A composite score was computed by summing items, with higher scores indicating greater hope or optimism. Test-retest reliability of the life orientation test was acceptable (r ¼ 0.79).36 Internal consistency for the 4 items assessed in this study was acceptable (α ¼ 0.76). Again, because of previous issues with confounding of mood with well-being measures, we were careful to choose items that did not measure mood or affect. Peace A total of 4 items from the Ironson-Woods Spirituality/Religiousness Index (Sense of Peace subscale)38 were used to assess peace. Participants were asked to rate the extent to which they agreed with statements (e.g., “My beliefs and practices give me a sense of peace”) on a 4-point Likert scale ranging from Strongly Agree (1) to Strongly Disagree (4). Items were reverse scored, and a composite score was computed by summing items, with higher scores indicating a greater sense of peace. The IronsonWoods Spirituality/Religiousness Index total score (α ¼ 0.96) and Sense of Peace (α ¼ 0.94) subscale have previously demonstrated good reliability.38 Internal consistency for the 4 items presented in this study was good (α ¼ 0.88). View of God View of God was assessed using 6 items from the View of God inventory.39 Both positive view (benevolent/forgiving) and negative view of God (harsh/ judgmental/punishing) were assessed. Participants rated their agreement with the 6 statements on a 4
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5-point Likert scale ranging from Strongly Agree (1) to Strongly Disagree (5). A total of 2 composite scores were created to reflect positive and negative views of God (3 items each). A higher score on the positive view of God subscale indicated more positive views. A higher score on the negative view of God subscale indicated more negative views of God. Both subscales have previously demonstrated good internal consistency (Positive view of God α ¼ 0.86 and negative view of God α ¼ 0.78).39 Internal consistency for the 3 items assessed in this study was acceptable (positive view of God α ¼ 0.89 and negative view of God α ¼ 0.71). Demographics Control Variables Age, gender, education, and ethnicity were selfreported. The coding was as follows: gender ¼ 1 male, 2 ¼ female; education is a continuous variable reflecting the number of years of formal education; and ethnicity 1 ¼ White; 2 ¼ Black/African American. Planned Analyses Descriptive statistics (means, standard deviation, and range) of study variables were computed. The analyses were restricted to participants who reported experiencing at least 1 chronic health problem over the past 12 months. A series of hierarchical regression analyses was conducted with depressive symptoms as the dependent variable. Demographics were entered in Block 1, the number of chronic health problems in Block 2, and R/S variables was entered last in Block 3. Analyses were conducted using SPSS version 21.0. Statistical significance was set at p o 0.05. RESULTS Characteristics of the Sample and Variables Participants’ demographic characteristics and descriptive statistics are presented in Table 1. Among the 3010 individuals who participated in the survey, 1076 reported no chronic conditions and were therefore not included in the present analyses. A total sample of 1727 participants reported at least 1 chronic health condition and identified as either White or Black/African American. Among this sub-sample, 31 participants had missing data for age, thus yielding a final sample size of 1696 individuals. The sample Psychosomatics ]:], ] 2016
Lucette et al. TABLE 1.
Descriptives of Study Variables Mean (SD) or frequency
Demographics Age (years) Mean age Below 50 Above 50 Gender (female) Education (years) Ethnicity White Black African American
TABLE 2. Score range
Hierarchical General Linear Model Relating Demographics and Chronic Health Issues to Depressive Symptoms Depressive symptoms
59.45 (17.5) 30% 70% 60% 13.5 (3.1)
0–22
84% 16%
– –
Block 1. Demographic characteristics Age Gender Ethnicity Education R2
Chronic health issues
2.5 (1.6)
1–10
Block 2. Chronic health issues ΔR2
Depressive symptoms
6.17 (2.7)
4–16
4.89 (2.9)
1–9
6.23 (2.33) 12.47 (2.9) 8.38 (2.5) 24.24 (3.8) 15.76 (2.6) 16.61 (2.7) 12.75 (2.20) 5.56 (2.78)
1–8 3–15 3–12 6–30 4–20 4–20 3–15 3–15
R/S variables Religious service attendance Private prayer Religious meaning Religious hope General meaning in life General hope/optimism Peace Positive view of God Negative view of God
18–96
Note: N¼1696. SD ¼ standard deviation.
was diverse regarding education, gender, and age. Participants were predominantly White, and they reported an average of 2.5 chronic health conditions.
Chronic Health Conditions, Depressive Symptoms, and R/S Variables The aim of the study was to determine the relationship between depressive symptoms and R/S variables among adults experiencing 1 or more chronic health issue(s). Results from the hierarchical regression analyses revealed that, among control variables, age, gender, and education were significantly correlated with depressive symptoms (Table 2). Women, younger participants, and those with less education reported more depressive symptoms. The number of chronic health conditions was also significantly associated with depressive symptoms, such that experiencing more health problems was linked to greater depressive symptoms. Psychosomatics ]:], ] 2016
β
t
p-value
0.14 0.12 0.04 0.17 0.07
5.92 5.03 1.74 7.16
o0.001 o0.001 0.08 o0.001
0.23 0.11
9.36
o0.001
Note: N ¼ 1696.
Above and beyond demographics and number of chronic health issues, most R/S variables were associated with depressive symptoms (Table 3). The strongest associations with less depression were found for the psychospiritual variables of general meaning, general hope, and to a lesser extent, having a sense of peace. They accounted for 12%, 11%, and 4% of the variance in depression, making them moderate effect sizes. Although other R/S variables were significantly related to less depression (including church attendance, religious meaning, religious hope, and positive view of God), the effects were small, with the variance accounting for less than 2% for any variable. Finally, only private prayer was not significantly associated with depression, whereas negative view of God (reverse scored) showed a trend toward being associated with less depression. Although these analyses were conducted using the depressed affect subscale as the dependent variable to avoid confounding effects of participants’ chronic illnesses, it should be noted that results held significant when the 8-item depression score including the somatic items was used in the analysis. A comparison of the relative contributions of general meaning/hope and religious meaning/hope showed that the religious component of meaning added a small, but significant amount of variance to the prediction of depression above general meaning (ΔR2 ¼ 0.007; t(1543) ¼ 3.65; p o 0.001), whereas in a separate regression, religious hope did not add to general hope (t(1598) ¼ 1.06; p ¼ 0.29). When all 9 R/S variables were entered together into the model, R/S variables explained an additional www.psychosomaticsjournal.org
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Spirituality, Religiousness, Illness, and Depression 16% (ΔR2 ¼ 0.16; F(9, 1436) ¼ 35.99; p o 0.001) of the variability in depressive symptoms, above and beyond demographics and chronic illnesses. As the β for the association with depression went from 0.23–0.14 when the R/S variables were added into the model predicting depression (β ¼ 0.14; t ¼ 5.55; p o 0.001), and as the ΔR2 was significant, there was support for the notion that R/S variables added significant variance to the association with depression, above and beyond demographics and chronic illness.
construed as psychospiritual constructs,27 may provide an important linkage to reduced depression among the medically ill. General meaning, and more specifically finding meaning, as opposed to searching for meaning,40 has previously been linked to mental health among patients with cancer.41 It has also been shown that, in contrast to faith, general meaning and peace contributed unique variance in quality of life in patients with cancer,42 further suggesting that the previously documented effect of religiousness on mental health might be attributed at least in part, to processes of finding meaning and peace. Similar findings have been noted in a sample of African American patients with HIV, among which existential well-being, construed as a composite of meaning and peace, was related to their psychologic well-being, more so than religious well-being.43 Beyond the association with depression, general meaning has also been found to relate to a sense of general hope,44 and recent findings suggest that meaning can successfully be targeted through interventions to reduce depressive symptoms and hopelessness.45 General hope has also been found to relate to more positive mood states and well-being in the medically ill, and it was found more often among those with greater spiritual well-being and intrinsic religiosity.46 Our findings are in line with past studies and suggest that the 2 most important R/S protectors from depression in the face of chronic illness may be finding general meaning and maintaining hope. Consistent with prior results from a small literature,22 the present results provide further evidence that individuals’ view of God may be useful to examine
DISCUSSION As was noted in the introduction, several researchers have hypothesized that individuals can find hope, meaning, and peace through their religious and spiritual beliefs and practices, which in turn help them better adjust to the challenges they face.13,20,23 Although this study provides evidence for the importance of most R/S variables, general meaning and general hope have the strongest relationship to fewer depressive symptoms. Although several of the more traditionally religious variables (church attendance, religious meaning, and religious hope) were also significantly related to lower depression, it appears that the psychospiritual variables have a stronger relationship to lower depression (i.e., explain more variance). In fact, the specific contribution of religious meaning and hope above general meaning and hope was only significant for religious meaning, but it was small. Finally, positive view of God also significantly predicted less depression, although to a lesser extent than other variables. This suggests that general meaning, general hope, and peace, which can be
TABLE 3.
Contribution of R/S Variables to Depressive Symptoms After Controlling for Demographics and Number of Chronic Illnesses Depressive symptoms
Religious services attendance Private prayer Religious meaning Religious hope General meaning General hope Peace Positive view of God Negative view of God
β
t
p value
ΔR2
0.05 0.01 0.05 0.13 0.36 0.35 0.20 0.07 0.04
1.93 0.27 2.03 5.5 16.1 15.32 8.41 2.87 1.76
0.05 0.79 0.04 o0.001 o0.001 o0.001 o0.001 0.004 0.08
0.002 o0.001 0.002 0.02 0.12 0.11 0.04 0.004 0.002
Note: Each R/S variable was entered in a separate model after controlling for demographics and number of chronic illnesses.
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Lucette et al. in relation to their mental well-being. Thus, the ability to maintain a positive view of God as loving when dealing with chronic illness represents another R/S variable less well studied that may contribute to wellbeing. Overall, our findings further corroborate and extend findings on traditional R/S variables as well as positive view of God to a large nationwide sample of the chronically ill. Limitations and Future Studies Some limitations should be noted in the current findings. First, the findings are based on crosssectional data and should be examined using a prospective design to further clarify the effect of R/S on depressive symptoms across time and clarify directionality. This is especially true of behaviors that may be influenced by the presence of illness. For example, in this study, private prayer was the only R/S variable not related to depression. Although the reason is not known, a “religious coping mobilization” effect may be operating here, i.e., when people become ill, they may pray more. This is impossible to discern in a crosssectional study and could be further investigated properly in a longitudinal study. It is also possible that prayer by itself is unrelated to depressive symptoms but rather confers a protective advantage when combined with other religious activity, as previously evidenced by Koenig among a sample of patients diagnosed with cardiovascular illness.19 Future studies should thus also examine R/S variables in context. In addition, although we measured many R/S variables, there are other important ones dealing with the relationship component of the definition of spirituality that could be mentioned in future studies, such as connectedness to something greater than oneself.47 Second, it should be noted that there are psychosocial correlates of R/S variables that might be active ingredients in the relationship observed in the present study. Future studies should examine whether R/S variables influence depressive symptoms in the medically ill above and beyond these concomitants, such as social support, coping strategies, and positive psychology constructs potentially at play. Third, all variables were self-reported, which can possibly lead to biases related to social desirability. Future studies should rely on medical chart reviews when possible to identify chronic illness, and diagnostic Psychosomatics ]:], ] 2016
interviews could be conducted to objectively assess clinical depression. Finally, meaning and hope were significantly correlated with depression (r ¼ 0.41 and r ¼ 0.36, respectively), yet the correlations were not so high as to suggest that they were identical constructs. Although this was expected, however, confounding may occur when the predictor measures themselves incorporate items that assess mood or affect. We tried to minimize this possibility. There are also conceptual issues—i.e., are hope and depression opposite sides of the same coin? Some have noted a conceptual distinction. Nunn48 states “Hope is the general tendency to construct and respond to the perceived future positively.” Thus, the focus for hope is on expectations about the future, whereas depression has more of a focus on affect in the present. In addition, Nunn48 notes “[People can be] without hope, but not despairing.” The cardinal symptoms of depression are sadness and loss of interest, which are distinct from, but likely correlated with lack of hope. In addition, even considering some overlap within similar constructs, positive aspects are often not just the opposite of negative aspects, and often have independent variance.49
CONCLUSIONS Despite these limitations, the current findings make a significant contribution to the literature on spirituality and religiousness in the context of co-occuring medical illness, a known risk factor for resistance in the treatment of mood disorders,50 by examining the role of several core R/S variables concurrently in a diverse and nationally representative sample of individuals with a chronic health condition (rather than those with a specific illness). In addition, extending the study of the relationship between R/S variables and depressive symptoms among the medically ill patients is deemed important considering that this population is likely to rely on spirituality to cope.17 In fact, Koenig24 suggested the importance of integrating a spiritual history into patient care as a preliminary step to assess the centrality of such issues in their coping efforts. Yet, addressing R/S with patients remains a sensitive issue, and continued research and discussions across disciplines were needed to define appropriate practices to broach such topics in medical settings across the illness trajectory.51,52 Our study suggests that issues related to meaning www.psychosomaticsjournal.org
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Spirituality, Religiousness, Illness, and Depression in life and the maintenance of hope may be important factors protecting against depression in the medically ill; although much of this may come from a spiritual or religious orientation, psychospiritual aspects should be considered as well.
Acknowledgments: We would like to thank the John Templeton Foundation for funding the Landmark Spirituality and Health Survey (Neal Krause, P.I.). Disclosure: The authors disclosed no proprietary or commercial interest in any product mentioned or concept discussed in this article.
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Spirituality for Use in Health Research. Kalamazoo, MI: John E. Fetzer Institute; 1999 Krause N: Religious meaning and subjective well-being in late life. J Gerontol B Soc Sci 2003; 58B:S160–S170 Scioli A, Ricci M, Nyugen T, Scioli ER: Hope:its nature and measurement. Psychol Relig Spiritual 2011; 3:78–97 Battista J, Almond R: The development of meaning in life. Psychiatry 1973; 36:409–427 Wong PT: Implicit theories of meaningful life and development of the Personal Meaning Profile (PMP). In: Wong PT, Fry PS, (eds.). The Human Quest for Meaning: A Handbook of Psychological Research and Clinical Applications. Mahwah, NJ: Erlbaum; 1998, pp. 111–140 Krause N: Stressors in highly valued roles, meaning in life, and the physical health status of older adults. J Gerontol Soc Sci 2004; 59B:S287–S297 Scheier MF, Carver CS: Optimism, coping, and health: assessment and implications of generalized outcome expectancies. Health Psychol 1985; 4(3):219–247, http://dx.doi. org/10.1037/0278-6133.4.3.219 Krause N: A comprehensive strategy for developing closedended survey items for use in studies of older adults. J Gerontol Soc Sci 2002; 57B:S263–S274 Ironson G, Solomon GF, Balbin EG, et al: The Ironson-Woods Spirituality/Religiousness Index is associated with long survival, health behaviors, less distress, and low cortisol in people with HIV/AIDS. Ann Behav Med 2002; 24(1):34–48 Ironson G, Stuetzle R, Ironson D, et al: View of God as benevolent and forgiving or punishing and judgmental predicts HIV disease progression. J Behav Med 2011; 34(6):414–425 Park CL, Edmondson D, Fenster JR, Blank TO: Meaning making and psychological adjustment following cancer: the mediating roles of growth, life meaning, and restored justworld beliefs. J Consult Clin Psychol 2008; 76(5):863–875, http://dx.doi.org/10.1037/a0013348 Canada AL, Murphy PE, Fitchett G, Peterman AH, Schover LR: A 3-factor model for the FACIT-Sp. Psychooncology 2008; 17(9):908–916, http://dx.doi.org/10.1002/pon.1307 Whitford HS, Olver IN: The multidimensionality of spiritual wellbeing: peace, meaning, and faith and their
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association with quality of life and coping in oncology. Psychooncology 2012; 21(6):602–610, http://dx.doi.org/ 10.1002/pon.1937 Coleman CL, Holzemer WL: Spirituality, psychological well-being, and HIV symptoms for African Americans living with HIV disease. J Assoc Nurses AIDS Care 1999; 10(1):42–50, http://dx.doi.org/10.1016/S1055-3290 (06)60231-8 Brown AJ, Sun CC, Urbauer D, et al: Targeting those with decreased meaning and peace: a supportive care opportunity. Support Care Cancer 2015; 23(7):2025–2032, http://dx.doi.org/10.1007/s00520-014-2568-6 Breitbart W, Rosenfeld B, Pessin H, et al: Meaningcentered group psychotherapy: an effective intervention for improving psychological well-being in patients with advanced cancer. J Clinic Oncol 2015; 33(7):749–754 Fehring RJ, Miller JF, Shaw C: Spiritual well-being, religiosity, hope, depression, and other mood states in elderly people coping with cancer. Oncol Nurs Forum 1997; 24(4):663–671 Pulchaski C, Ferrell B, Virani R, et al: Improving the quality of spiritual care as a dimension of palliative care: the report of the Consensus Conference. J Palliat Med 2009; 12(10):885–904 Nunn KP: Personal hopefulness: a conceptual review of the relevance of the perceived future for psychiatry. Br J Med Psychol 1996; 69(3):227–245 Goldstein M, Strube MJ: Independence revisited: the relation between positive and negative affect in a naturalistic setting. Pers Soc Psychol B 1994; 20(1):57–64 Iosifescu DV: Treating depression in the medically ill. Psychiatr Clin North Am 2007; 30(1):77–90, http://dx.doi. org/10.1016/j.psc.2006.12.008 Kristeller JL, Rhodes M, Cripe LD, Sheets V: Oncologist Assisted Intervention Study (OASIS): patient acceptability and initial evidence of effects. Int J Psychol Relig 2005; 35:329–347 Sloan RP, Bagiella E, VandeCreek L, et al: Should physicians prescribe religious activities? N Engl J Med 2000; 342(25):1913–1916, http://dx.doi.org/10.1056/nejm200006223422513
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Original Research Reports Spirituality and Religiousness are Associated With Fewer Depressive Symptoms in Individuals With Medical Conditions Aurelie Lucette, M.S., Gail Ironson, M.D., Ph.D., Kenneth I. Pargament, Ph.D., Neal Krause, Ph.D.
Background: The increased prevalence of depressive symptoms among adults diagnosed with chronic health issues has been largely documented. Objectives: Research is needed to clarify the effect of religiousness/ spirituality in relation to chronic health conditions and depression, to establish whether these variables can serve as protective factors. Methods: Self-report data from a nationwide study of spirituality and health were used. Individuals with at least 1 chronic illness (N ¼ 1696) formed the subsample for this study. Religiousness/spirituality variables included frequency of church attendance, prayer, religious meaning, religious hope, general meaning, general hope, peace, and view of God. Other variables included depressive symptoms and demographics (age, gender, ethnicity, and education). Results: A series of hierarchical regression analyses revealed that chronic conditions were consistently associated with more depressive symptoms. Greater religiousness/spirituality was significantly associated
with fewer depressive symptoms, contributing 16% of the variance above demographics and the number of chronic illnesses. The religiousness/spirituality variables conferring the greatest protection against depression were psychospiritual variables (general meaning and general hope, followed by peace). Also significant but making a smaller contribution to less depression were church attendance, religious meaning, religious hope, and positive view of God. Only prayer did not relate significantly to less depression. Conclusion: Maintaining a sense of spirituality or religiousness can benefit well-being of individuals diagnosed with a chronic health condition, especially having meaning, maintaining hope, and having a sense of peace. Patients could potentially benefit from being offered the resources that support their spiritual/religious practices and beliefs as they cope with chronic illness. (Psychosomatics 2016; ]:]]]–]]])
INTRODUCTION Chronic Illness and Depressive Symptoms Beyond the social and economical challenges, depression is an important consequence of physical health problems that adds to the heavy burdens that health problems already create, and, as such, it represents a major public health concern.1 Depressive symptoms are particularly prevalent among adults Psychosomatics ]:], ] 2016
Received October 28, 2015; revised March 11, 2016; accepted March 19, 2016. From Department of Psychology, University of Miami, 5665 Ponce de Leon Blvd, Coral Gables, FL (AL, GI); Department of Psychology, Bowling Green State University, Bowling Green, OH (KIP); School of Public Health, University of Michigan, Ann Arbor, MI (NK). Send correspondence and reprint requests to Gail Ironson, M.D., Ph.D., Department of Psychology, University of Miami, 5665 Ponce de Leon Blvd, Coral Gables, FL 33124-0751; e-mail: [email protected] & 2016 Published by Elsevier Inc. on behalf of The Academy of Psychosomatic Medicine.
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Spirituality, Religiousness, Illness, and Depression living with chronic health conditions.2,3 In turn, the coexistence of chronic illness and depressive symptoms has been linked to detrimental outcomes, such as significant decrements in health and physical quality of life,4 increased health care utilization and costs,5,6 faster disease progression across a range of illnesses,7–9 and even mortality.10,11 Considering that almost half of the American population is diagnosed with at least 1 chronic condition, and that more than 60% of individuals older than 65 years have more than 1 condition,12 it is critical to examine factors that might prevent or alleviate depressive symptoms among those individuals.
Religiousness/Spirituality, Chronic Illness, and Depressive Symptoms In recent years, mounting research has examined the relationship between religiousness/spirituality (R/S) on one hand, and psychologic states on the other hand, highlighting the positive effect of these factors on mental health.13–15 A significant number of individuals use R/S to cope with adversity,16 including when they navigate the challenges of living with a debilitating chronic illness,17 thus offering possible relief from the difficulties associated with the challenges they face. For instance, R/S factors, including religious attendance, private prayer, greater intrinsic religiosity, and religious involvement have been linked with better depression outcomes in both the general population and among medically ill individuals.18–21 Similarly, having a positive view of one’s relationship with God has been associated with lower depressed affect in a sample of primary care patients.22 Through their religious and spiritual beliefs and practices, individuals with a chronic health condition can find hope, meaning, and peace, which in turn help them better adjust to the challenges they face.23,24
Purpose of the Current Study The purpose of the current study was to examine the association of R/S and depressive symptoms among individuals with chronic health conditions and to determine whether these variables, relevant for a significant number of individuals, can serve as protective factors. Spirituality has often been described as a search or a connection for the sacred,15 or 2
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transcendent that goes beyond structured and organized religions.13,20 On the contrary, religion is more often associated with a set of beliefs and practices that are organized and originated in long-established traditions.13,20 Thus, although they overlap, spirituality extends beyond religion, and even individuals who describe themselves as nonreligious can draw upon spirituality to cope with adversity.25 In addition, as meaning and hope are deeply rooted in religious and spiritual traditions,14,26 yet may derive from other sources overlapping psychology, following the suggestion of Pargament,27 we refer to these constructs in a more general context as “psychospiritual.” Thus, we included both classically-related R/S variables (church attendance and prayer) and functionally-related R/S measures (religious hope, religious meaning, and positive and negative views of God) as well as psychospiritual variables (general meaning, general hope, and sense of peace). We hypothesized that chronic illness would be significantly related to depression, and that all aspects of R/S would be associated with fewer depressive symptoms even after controlling for relevant demographics and the number of chronic conditions. We also wanted to determine which aspects of R/S would have the strongest association with less depression. A secondary analysis explored whether moving from a global assessment of meaning (or hope) that subsumes all domain-specific evaluations to a domain-specific measure of meaning (or hope) that focuses solely on religion would provide additional insight into the relationship between chronic illness and depressive symptoms. METHODS The present study was conducted as part of the Landmark Spirituality and Health Survey (LSHS) in 2014 among a sample of 3010 adults representative of the adult US population. The overarching aim of this survey was to examine religious and spiritual factors in relation to health outcomes. Data collection for this nationwide, face-to-face survey was conducted by the National Opinion Research Center (NORC) in participants’ homes. Clustered random household sampling was used for this survey. Additional information can be obtained from the LSHS website (http:// landmarkspirituality.sph.umich.edu/). This article focuses on those who have at least 1 chronic health condition, a total sample of 1696 participants. Psychosomatics ]:], ] 2016
Lucette et al. Measures Depressive Symptoms A total of 4 items from the Center for Epidemiologic Studies-Depression Scale28 reflecting depressed affect were used to assess depressive symptoms. The 4 items reflecting somatic symptoms of depression were omitted in the current analyses to avoid confounding effects from the participants’ chronic illness symptoms. Participants rated the frequency with which they had experienced each of the 4 depressive symptoms (e.g., “I felt I could not shake off the blues, even with the help of my family and friends”) on a 4-point Likert scale ranging from Rarely/None of the time (1) to Most/All of the time (4). Items were summed with a higher score indicating higher depressive symptoms. Items from the Center for Epidemiologic Studies-Depression Scale were designed to assess depressive symptoms in the general population and have previously demonstrated good internal consistency and adequate test-retest reliability.42 Internal consistency in this study was good for the depressed affect subscale (α ¼ 0.85).
Chronic Health Conditions Participants were provided a list of 12 chronic illness (i.e., arthritis/rheumatism, cataract/glaucoma/eye disease, asthma/emphysema/other respiratory diseases, hypertension, heart attack/issues, diabetes, ulcers, liver disease, kidney disease, urinary tract disorder, cancer/malignant tumor, and prostate trouble) and were asked to identify whether they had experienced each of them in the past 12 months.29 The total number of chronic health problems experienced within the past year was computed by adding all items endorsed as “yes,” and a higher score indicated that participants had experienced more chronic health issues.
taken from the Fetzer Institute/National Institute on Aging Working Group.30 Private Prayer Frequency of private prayer was assessed using a 1-item question (“How often do you pray by yourself?”). Participants were asked to select the answer that best reflected the frequency at which they pray from 8 options ranging from Never to Several times a day, with higher scores indicating more frequent prayer. This item was also taken from the Fetzer Institute/National Institute on Aging Working Group.30 Religious Meaning Religious meaning in life was assessed using 3 items (e.g., “God put me in this life for a purpose”).31 Participants rated their agreement with each statement on a 4-point Likert scale, ranging from Strongly Agree (1) to Strongly Disagree (4). Items were reverse scored and a total score was computed, with higher scores indicating greater religious meaning. Internal consistency for the 3 items administered in this study was very good (α ¼ 0.91). Religious Hope In total, 3 items adapted from the Scioli’s Hope Scale32 were presented to assess religious hope (e.g., “My religion or spiritual beliefs help me see that things will turn out well in the future”). Participants rated their agreement with each statement on a 4-point Likert scale ranging from Not me (0) to Exactly like me (3), with higher scores indicating greater religious hope. Internal consistency for the 4 items administered in this study was very good (α ¼ 0.93). General Meaning in Life
Religiousness and Spirituality Measures Religious Services Attendance Frequency of services attendance was assessed using 1 item (“How often do you attend religious services?”). Participants were asked to select the answer that best reflected their attendance from 9 options ranging from Never to Several times a week, with higher scores indicating more frequent attendance. This item was Psychosomatics ]:], ] 2016
To assess general meaning in life, 6 items were used.33–35 Participants rated the extent to which they agreed with statements related to meaning in life (e.g., “I feel like I have found a really significant meaning in life”) on a 4-point Likert scale ranging from Strongly Agree (1) to Strongly Disagree (4). Items were reverse scored, and a composite score was computed by summing items, with higher scores indicating a greater sense of meaning in life. Internal consistency in the www.psychosomaticsjournal.org
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Spirituality, Religiousness, Illness, and Depression study was good (α ¼ 0.85). Because of previous issues with confounding of mood with well-being measures, we were careful to choose items that did not measure mood or affect. General Hope/Optimism Participants were presented with 4 items to assess hope and optimism. Of the 4 items, 3 were taken from the life orientation test36 and the fourth one was developed by Krause37 to assess dispositional optimism (“I feel confident that the rest of my life will turn out well”). Participants rated their agreement with the 4 statements on a 4-point Likert scale ranging from Strongly Agree (1) to Strongly Disagree (4). A composite score was computed by summing items, with higher scores indicating greater hope or optimism. Test-retest reliability of the life orientation test was acceptable (r ¼ 0.79).36 Internal consistency for the 4 items assessed in this study was acceptable (α ¼ 0.76). Again, because of previous issues with confounding of mood with well-being measures, we were careful to choose items that did not measure mood or affect. Peace A total of 4 items from the Ironson-Woods Spirituality/Religiousness Index (Sense of Peace subscale)38 were used to assess peace. Participants were asked to rate the extent to which they agreed with statements (e.g., “My beliefs and practices give me a sense of peace”) on a 4-point Likert scale ranging from Strongly Agree (1) to Strongly Disagree (4). Items were reverse scored, and a composite score was computed by summing items, with higher scores indicating a greater sense of peace. The IronsonWoods Spirituality/Religiousness Index total score (α ¼ 0.96) and Sense of Peace (α ¼ 0.94) subscale have previously demonstrated good reliability.38 Internal consistency for the 4 items presented in this study was good (α ¼ 0.88). View of God View of God was assessed using 6 items from the View of God inventory.39 Both positive view (benevolent/forgiving) and negative view of God (harsh/ judgmental/punishing) were assessed. Participants rated their agreement with the 6 statements on a 4
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5-point Likert scale ranging from Strongly Agree (1) to Strongly Disagree (5). A total of 2 composite scores were created to reflect positive and negative views of God (3 items each). A higher score on the positive view of God subscale indicated more positive views. A higher score on the negative view of God subscale indicated more negative views of God. Both subscales have previously demonstrated good internal consistency (Positive view of God α ¼ 0.86 and negative view of God α ¼ 0.78).39 Internal consistency for the 3 items assessed in this study was acceptable (positive view of God α ¼ 0.89 and negative view of God α ¼ 0.71). Demographics Control Variables Age, gender, education, and ethnicity were selfreported. The coding was as follows: gender ¼ 1 male, 2 ¼ female; education is a continuous variable reflecting the number of years of formal education; and ethnicity 1 ¼ White; 2 ¼ Black/African American. Planned Analyses Descriptive statistics (means, standard deviation, and range) of study variables were computed. The analyses were restricted to participants who reported experiencing at least 1 chronic health problem over the past 12 months. A series of hierarchical regression analyses was conducted with depressive symptoms as the dependent variable. Demographics were entered in Block 1, the number of chronic health problems in Block 2, and R/S variables was entered last in Block 3. Analyses were conducted using SPSS version 21.0. Statistical significance was set at p o 0.05. RESULTS Characteristics of the Sample and Variables Participants’ demographic characteristics and descriptive statistics are presented in Table 1. Among the 3010 individuals who participated in the survey, 1076 reported no chronic conditions and were therefore not included in the present analyses. A total sample of 1727 participants reported at least 1 chronic health condition and identified as either White or Black/African American. Among this sub-sample, 31 participants had missing data for age, thus yielding a final sample size of 1696 individuals. The sample Psychosomatics ]:], ] 2016
Lucette et al. TABLE 1.
Descriptives of Study Variables Mean (SD) or frequency
Demographics Age (years) Mean age Below 50 Above 50 Gender (female) Education (years) Ethnicity White Black African American
TABLE 2. Score range
Hierarchical General Linear Model Relating Demographics and Chronic Health Issues to Depressive Symptoms Depressive symptoms
59.45 (17.5) 30% 70% 60% 13.5 (3.1)
0–22
84% 16%
– –
Block 1. Demographic characteristics Age Gender Ethnicity Education R2
Chronic health issues
2.5 (1.6)
1–10
Block 2. Chronic health issues ΔR2
Depressive symptoms
6.17 (2.7)
4–16
4.89 (2.9)
1–9
6.23 (2.33) 12.47 (2.9) 8.38 (2.5) 24.24 (3.8) 15.76 (2.6) 16.61 (2.7) 12.75 (2.20) 5.56 (2.78)
1–8 3–15 3–12 6–30 4–20 4–20 3–15 3–15
R/S variables Religious service attendance Private prayer Religious meaning Religious hope General meaning in life General hope/optimism Peace Positive view of God Negative view of God
18–96
Note: N¼1696. SD ¼ standard deviation.
was diverse regarding education, gender, and age. Participants were predominantly White, and they reported an average of 2.5 chronic health conditions.
Chronic Health Conditions, Depressive Symptoms, and R/S Variables The aim of the study was to determine the relationship between depressive symptoms and R/S variables among adults experiencing 1 or more chronic health issue(s). Results from the hierarchical regression analyses revealed that, among control variables, age, gender, and education were significantly correlated with depressive symptoms (Table 2). Women, younger participants, and those with less education reported more depressive symptoms. The number of chronic health conditions was also significantly associated with depressive symptoms, such that experiencing more health problems was linked to greater depressive symptoms. Psychosomatics ]:], ] 2016
β
t
p-value
0.14 0.12 0.04 0.17 0.07
5.92 5.03 1.74 7.16
o0.001 o0.001 0.08 o0.001
0.23 0.11
9.36
o0.001
Note: N ¼ 1696.
Above and beyond demographics and number of chronic health issues, most R/S variables were associated with depressive symptoms (Table 3). The strongest associations with less depression were found for the psychospiritual variables of general meaning, general hope, and to a lesser extent, having a sense of peace. They accounted for 12%, 11%, and 4% of the variance in depression, making them moderate effect sizes. Although other R/S variables were significantly related to less depression (including church attendance, religious meaning, religious hope, and positive view of God), the effects were small, with the variance accounting for less than 2% for any variable. Finally, only private prayer was not significantly associated with depression, whereas negative view of God (reverse scored) showed a trend toward being associated with less depression. Although these analyses were conducted using the depressed affect subscale as the dependent variable to avoid confounding effects of participants’ chronic illnesses, it should be noted that results held significant when the 8-item depression score including the somatic items was used in the analysis. A comparison of the relative contributions of general meaning/hope and religious meaning/hope showed that the religious component of meaning added a small, but significant amount of variance to the prediction of depression above general meaning (ΔR2 ¼ 0.007; t(1543) ¼ 3.65; p o 0.001), whereas in a separate regression, religious hope did not add to general hope (t(1598) ¼ 1.06; p ¼ 0.29). When all 9 R/S variables were entered together into the model, R/S variables explained an additional www.psychosomaticsjournal.org
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Spirituality, Religiousness, Illness, and Depression 16% (ΔR2 ¼ 0.16; F(9, 1436) ¼ 35.99; p o 0.001) of the variability in depressive symptoms, above and beyond demographics and chronic illnesses. As the β for the association with depression went from 0.23–0.14 when the R/S variables were added into the model predicting depression (β ¼ 0.14; t ¼ 5.55; p o 0.001), and as the ΔR2 was significant, there was support for the notion that R/S variables added significant variance to the association with depression, above and beyond demographics and chronic illness.
construed as psychospiritual constructs,27 may provide an important linkage to reduced depression among the medically ill. General meaning, and more specifically finding meaning, as opposed to searching for meaning,40 has previously been linked to mental health among patients with cancer.41 It has also been shown that, in contrast to faith, general meaning and peace contributed unique variance in quality of life in patients with cancer,42 further suggesting that the previously documented effect of religiousness on mental health might be attributed at least in part, to processes of finding meaning and peace. Similar findings have been noted in a sample of African American patients with HIV, among which existential well-being, construed as a composite of meaning and peace, was related to their psychologic well-being, more so than religious well-being.43 Beyond the association with depression, general meaning has also been found to relate to a sense of general hope,44 and recent findings suggest that meaning can successfully be targeted through interventions to reduce depressive symptoms and hopelessness.45 General hope has also been found to relate to more positive mood states and well-being in the medically ill, and it was found more often among those with greater spiritual well-being and intrinsic religiosity.46 Our findings are in line with past studies and suggest that the 2 most important R/S protectors from depression in the face of chronic illness may be finding general meaning and maintaining hope. Consistent with prior results from a small literature,22 the present results provide further evidence that individuals’ view of God may be useful to examine
DISCUSSION As was noted in the introduction, several researchers have hypothesized that individuals can find hope, meaning, and peace through their religious and spiritual beliefs and practices, which in turn help them better adjust to the challenges they face.13,20,23 Although this study provides evidence for the importance of most R/S variables, general meaning and general hope have the strongest relationship to fewer depressive symptoms. Although several of the more traditionally religious variables (church attendance, religious meaning, and religious hope) were also significantly related to lower depression, it appears that the psychospiritual variables have a stronger relationship to lower depression (i.e., explain more variance). In fact, the specific contribution of religious meaning and hope above general meaning and hope was only significant for religious meaning, but it was small. Finally, positive view of God also significantly predicted less depression, although to a lesser extent than other variables. This suggests that general meaning, general hope, and peace, which can be
TABLE 3.
Contribution of R/S Variables to Depressive Symptoms After Controlling for Demographics and Number of Chronic Illnesses Depressive symptoms
Religious services attendance Private prayer Religious meaning Religious hope General meaning General hope Peace Positive view of God Negative view of God
β
t
p value
ΔR2
0.05 0.01 0.05 0.13 0.36 0.35 0.20 0.07 0.04
1.93 0.27 2.03 5.5 16.1 15.32 8.41 2.87 1.76
0.05 0.79 0.04 o0.001 o0.001 o0.001 o0.001 0.004 0.08
0.002 o0.001 0.002 0.02 0.12 0.11 0.04 0.004 0.002
Note: Each R/S variable was entered in a separate model after controlling for demographics and number of chronic illnesses.
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Psychosomatics ]:], ] 2016
Lucette et al. in relation to their mental well-being. Thus, the ability to maintain a positive view of God as loving when dealing with chronic illness represents another R/S variable less well studied that may contribute to wellbeing. Overall, our findings further corroborate and extend findings on traditional R/S variables as well as positive view of God to a large nationwide sample of the chronically ill. Limitations and Future Studies Some limitations should be noted in the current findings. First, the findings are based on crosssectional data and should be examined using a prospective design to further clarify the effect of R/S on depressive symptoms across time and clarify directionality. This is especially true of behaviors that may be influenced by the presence of illness. For example, in this study, private prayer was the only R/S variable not related to depression. Although the reason is not known, a “religious coping mobilization” effect may be operating here, i.e., when people become ill, they may pray more. This is impossible to discern in a crosssectional study and could be further investigated properly in a longitudinal study. It is also possible that prayer by itself is unrelated to depressive symptoms but rather confers a protective advantage when combined with other religious activity, as previously evidenced by Koenig among a sample of patients diagnosed with cardiovascular illness.19 Future studies should thus also examine R/S variables in context. In addition, although we measured many R/S variables, there are other important ones dealing with the relationship component of the definition of spirituality that could be mentioned in future studies, such as connectedness to something greater than oneself.47 Second, it should be noted that there are psychosocial correlates of R/S variables that might be active ingredients in the relationship observed in the present study. Future studies should examine whether R/S variables influence depressive symptoms in the medically ill above and beyond these concomitants, such as social support, coping strategies, and positive psychology constructs potentially at play. Third, all variables were self-reported, which can possibly lead to biases related to social desirability. Future studies should rely on medical chart reviews when possible to identify chronic illness, and diagnostic Psychosomatics ]:], ] 2016
interviews could be conducted to objectively assess clinical depression. Finally, meaning and hope were significantly correlated with depression (r ¼ 0.41 and r ¼ 0.36, respectively), yet the correlations were not so high as to suggest that they were identical constructs. Although this was expected, however, confounding may occur when the predictor measures themselves incorporate items that assess mood or affect. We tried to minimize this possibility. There are also conceptual issues—i.e., are hope and depression opposite sides of the same coin? Some have noted a conceptual distinction. Nunn48 states “Hope is the general tendency to construct and respond to the perceived future positively.” Thus, the focus for hope is on expectations about the future, whereas depression has more of a focus on affect in the present. In addition, Nunn48 notes “[People can be] without hope, but not despairing.” The cardinal symptoms of depression are sadness and loss of interest, which are distinct from, but likely correlated with lack of hope. In addition, even considering some overlap within similar constructs, positive aspects are often not just the opposite of negative aspects, and often have independent variance.49
CONCLUSIONS Despite these limitations, the current findings make a significant contribution to the literature on spirituality and religiousness in the context of co-occuring medical illness, a known risk factor for resistance in the treatment of mood disorders,50 by examining the role of several core R/S variables concurrently in a diverse and nationally representative sample of individuals with a chronic health condition (rather than those with a specific illness). In addition, extending the study of the relationship between R/S variables and depressive symptoms among the medically ill patients is deemed important considering that this population is likely to rely on spirituality to cope.17 In fact, Koenig24 suggested the importance of integrating a spiritual history into patient care as a preliminary step to assess the centrality of such issues in their coping efforts. Yet, addressing R/S with patients remains a sensitive issue, and continued research and discussions across disciplines were needed to define appropriate practices to broach such topics in medical settings across the illness trajectory.51,52 Our study suggests that issues related to meaning www.psychosomaticsjournal.org
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Spirituality, Religiousness, Illness, and Depression in life and the maintenance of hope may be important factors protecting against depression in the medically ill; although much of this may come from a spiritual or religious orientation, psychospiritual aspects should be considered as well.
Acknowledgments: We would like to thank the John Templeton Foundation for funding the Landmark Spirituality and Health Survey (Neal Krause, P.I.). Disclosure: The authors disclosed no proprietary or commercial interest in any product mentioned or concept discussed in this article.
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