- Email: [email protected]
The Relationship Between Religiosity and Tobacco, Alcohol Use, and Depression in an Elderly Community Population
The Relationship Between Religiosity and Tobacco, Alcohol Use, and Depression in an Elderly Community Population Sergio Luı´s Blay, M.D., Ph.D., Adriana Daher Batista, Ph.D., Sergio Baxter Andreoli, M.D., Ph.D., Fa´bio Leite Gastal, M.D., Ph.D.
Objective: The objective of this study is to examine the religious characteristics of older subjects and the associations of these characteristics to the use of tobacco, alcohol, and depression. Methods: Data from a multistage random sample were used to examine associations between religiosity and health behaviors (tobacco use, alcohol) and depression among elderly house hold residents aged 60⫹ in Rio Grande do Sul, Brazil. Survey measures included sociodemographic characteristics, four aspects of religiosity, tobacco use, alcohol abuse and dependence, depression, life style, social context, functional status, and health conditions. Results: After controlling for demographic, social connections, health behavior, functional status, and health conditions, evangelical affiliation reduced the odds of being a current tobacco user by 51%. Those reporting affiliation as Afro-Brazilian and not having a religion had, respectively, a 74% and 124% increased risk. All other religious domains protect against tobacco use. Not having a religion affiliation and the experience of a religious change increased the risk of alcohol misuse by 88% and 31%, respectively. In contrast, orienting-motivating force increased the odds of depression by 38%. Participating in social religious activities had reduced the risk of depression by 16%. Conclusion: Several aspects of religiosity reduced the odds of being a tobacco user. Not having a religion and the experience of a religious change increased the risk of alcohol misuse. However, the domain orienting-motivating force increased the odds, and participating in social religious activities had reduced the risk of a depressive state. (Am J Geriatr Psychiatry 2008; 16:934 –943) Key Words: Religion, depression, substance abuse, alcohol use disorder, tobacco use
R
eligion is relatively neglected in empirical studies exploring correlates of mental illness and
substance abuse.1–3 In addition, when they are considered, a major limitation is the use of religious
Received January 16, 2008; revised June 16, 2008; accepted June 20, 2008. From the Department of Psychiatry, Federal University of Sa˜o Paulo, Sa˜o Paulo, SP, Brazil (Escola Paulista de Medicina - UNIFESP) (SLB, SBA); Hermínio Ometto University Center, Araras, SP, Brazil (ADB); and Project Scientific Committee and Brazilian National Accreditation Organization, Brazil (FLG). Send correspondence and reprint requests to Sergio Luı´s Blay, M.D. Ph.D., Department of Psychiatry - UNIFESP, R. Botucatu, 740 CEP 04023–900, Sa˜o Paulo, SP, Brazil. e-mail: [email protected] © 2008 American Association for Geriatric Psychiatry
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Blay et al. affiliation as the only measure of religiosity.4 Researchers in the psychology of religion have found that religion is far from uniform processes.5 Rather, they are complex entities involving cognitive, emotional, behavioral, interpersonal, and psychological dimensions. Several domains are potentially related to health outcomes, so there is a particular need for measures of religion that are theoretically and functionally linked to mental and physical health.6 Despite some recent publications, studies examining different dimensions of religiosity and depression remain scarce. Findings from reviews, clinical investigations, and cross-sectional population studies provide conflicting results, reporting positive, negative, and no relationship between religiosity and depression.7–13 A recent meta-analysis of 147 independent investigations involving 98,975 subjects found that religiosity is modestly but consistently associated with a lower level of depressive symptoms.14 In their first article, Kendler et al.,15 using a large twin sample, examined the relationship between dimensions of religiosity and current psychiatric symptoms. Their major finding was that the dimensions of religiosity were not strongly related to risk for psychiatric symptoms and disorders. More recently, Kendler et al.16 used a multidimensional approach to identify the numerous dimensions of religious and spiritual beliefs and behaviors. They showed that some dimensions of religiosity, specifically social religiosity, unvengefulness, thankfulness, were related to lower risk of depression. Two Brazilian studies used a screening questionnaire for common mental disorders (depression, anxiety, and somatization disorders) in two different religious populations. Lotufo Neto,17 in a sample of 207 ministers of religion, found that intrinsic religiosity was associated with better mental health. In the other investigation, a random sample of 115 spiritist mediums had lower psychiatric symptom scores than samples from the general population.18 Such findings may reflect coping strategies that may present these processes through a number of pathways such as life meaning, inspiration, hope, optimism, increase sense of control, behavior rules, and social support among others. Community surveys and clinical studies have found a clear inverse correlation between religiosity
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and alcohol and tobacco use. Most of the investigations were conducted among adolescents, when drug use usually starts, and younger adult populations.19 –22 The greater the religious involvement, the lower the rates of alcohol/drug use/abuse.1 Some small qualitative and quantitative studies in specific communities in Brazil (studies not specifically focusing on elders and religion) have examined the relationships between religious participation and substance abuse and psychiatric problems. Based on cross-sectional observation of 93 subjects aged 60 years and over, Barros et al.23 found that Protestant religious practices among the people living in Campinas, State of Sa˜o Paulo, may be beneficial in protecting against alcohol abuse. Sanchez et al.,24 in a qualitative study, investigated factors protective against drug use among adolescent residents in very poor and violent areas of Sa˜o Paulo. The most important factor was having a structured family; religiousness was the second most important protective factor. Family structure was, in turn, associated with family religiousness. The study found that 81% of the nonusers practiced a religion; among users, only 13% did so. Although past research has shown that religious affiliation and beliefs can have a positive impact on health, longevity, and recovery from severe medical illness, it is not known if religious participation in its various dimensions is associated with substance abuse and depression within the elderly population in Brazil, a developing country in South America. Elderly in the community may have a different approach to religion than clinic-based samples. In addition, the elderly often struggle with chronic medical problems, marital difficulties, functional limitations, isolation, widowhood, fewer social activities, economic constraints, and have a need for medical or social support systems. Both psychiatric and medical morbidities may be substantial.25 On the basis of the studies reviewed earlier, we will test the following hypotheses, while controlling for demographic, socioeconomic, social ties, and health behavior characteristics. First, older people in Brazil who have a religious focus are less likely to use tobacco than those who do not have such a focus; second, older people in Brazil who have a religious focus are less likely to report problems with use of alcohol; third, older people in Brazil
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Religiosity and Tobacco, Alcohol Use, and Depression who have a religious focus are more likely to be protected against depression.
METHODS Sample This cross-sectional study of noninstitutionalized persons ⱖ60 years of age was based on multistage, random sampling in nine homogeneous areas covering the state of Rio Grande do Sul, Brazil. The region is located in the southern area of the country, with a largely agro-industrial economy, populated primarily by descendents of European immigrants. Data were gathered in 1995 in face-to-face household surveys of 7,920 residents of urban and rural counties. The structured interview included assessment of sociodemographic characteristics, mental and physical health, functional status, health service use, activity (exercise and employment), and living arrangements. Details on methods have been reported previously.25 The study was approved by the Ethics Committee of the Federal University of Sa˜o Paulo. Participants gave oral consent; a family member could be present if they wished. Data Gathering and Quality Control. Data were gathered by interviewers trained in standardized data collection. To increase the quality of data collection, all interviewers and field supervisors underwent formal training. This included a detailed description of the research project and its methodology, role playing techniques, and tests of fieldwork reliability. Tape-recorded interviews were used to discuss the research instrument and to improve interviewing skills and data collection techniques. Field supervisors closely monitored data collection and revisited participants to ensure fieldwork quality control. Careful review of the database identified data entry problems in one region. This region was excluded from analysis. In the remaining eight regions, a total of 7,040 persons were approached in the first round: 880 subjects in each area. No proxy information was collected. Nonresponse was negligible: 79 persons (1.1%) did not take part in the assessment, primarily refusals, yielding an overall response rate of 99% (N ⫽ 6,961).
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Measures Main Independent Variables Religiosity. In the present study, four relevant questions related to issues raised by Hill and Hood5, are available in our data set. One allows us to determine religious affiliation, the specific question asked was: 1. “Which is your religious affiliation?” Interviewees could choose one of following answers: Catholic, Evangelic (with strict attitudes toward smoking, drinking, dancing, dressing, etc.), Spiritism, Jewish, Afro-Brazilian, Other (Buddhism, Daoism, Islamism, Esoteric), None. Responses were grouped as None, Catholic, Evangelic, Spiritism, Afro-Brazilian, Others. The other three questions address each of three religious domains with possible connections to areas of health research: 2. Religious change—transformation: The idea that people can change and grow religiously is central to most religious traditions.26 Religion traditions are not stable conditions, they are dynamic. The possibilities of change, growth, deterioration, or stability are all alternatives across the lifespan. The relevant question was: “As the years pass by, do you believe you. . . . ” Interviewees could choose one of the following answers: became more religious, became less religious, no change concerning religiosity. Responses were dichotomized into “became more religious” versus the rest. 3. Orienting-motivating force: To the devout, religion are not a set of beliefs and practices divorced from everyday life. Instead religion are ways of life to be sought, experienced, and sustained.6,27 This aspect was assessed by the following question: “What do you consider the most important life value?” Responses were dichotomized into “religion” versus all other responses. 4. Social religiosity: In one sense, religion is an institutional (social-material) phenomenon. Many believers of major religions have a fairly structured life, featuring regular attendance at formal religious services and associated activities. The religious are differentiated by specific beliefs and attitudes, requirements of membership, and modes of social organization and life style.13 The
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Blay et al. relevant question was: “Do you participate in any social activity?” Interviewees could choose a religious social activity along with other activities. Responses were dichotomized into “religion association” and “other.” Main Dependent Variables. Current tobacco use was assessed by the following question: “Do you use tobacco regularly now?” Response options were “no” and “yes.” Based on Hasin’s criteria,28 alcohol abuse or dependence was determined by a positive response to any of the following five questions: 1) Has your family, your friends, your physician, or your priest ever commented or suggested that you were drinking too much? 2) Have you ever tried to stop drinking but been unable to do so? 3) Have you ever had trouble at work or school because of alcohol, such as drinking or missing work? 4) Have you ever been involved in fights or arrested for being drunk? 5) Has it ever seemed to you that you were drinking too much? The answer options were coded as yes or no. Assessment of Depression Morbidity. Assessment of depression morbidity was determined by the sixitem Short Short Psychiatric Evaluation Schedule (Short-SPES).29 This is an evaluated modification of the 15-item SPES,30 relevant to the older Brazilian population. Performance on the SPES was not affected by sex, age, marital status, income, education, or minority status. Previous study of this measure in Brazil determined that the Short-SPES could identify psychiatric “caseness” in the older population. The psychiatric disorders identified were overwhelmingly depressive states and anxiety disorders (i.e., psychiatric conditions most prevalent in the elderly). Each question requires a yes/no answer regarding presence in the past 30 days. The total score reflects the number of positive answers, yielding a potential scoring range of 0 – 6. A score of 2 or above identifies “psychiatric cases” with a sensitivity of 82% and specificity of 77%.29 A study of interrater reliability showed complete agreement between examiners. Covariates Demographic Characteristics. Gender, age (60 – 80; ⱖ81 years), ethnicity (white, African Brazilian, Multiracial), education (⬍4 years of schooling versus ⱖ4 years of schooling), income (⬍U.S. $200/month ver-
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sus ⱖU.S. $200/month), and place of birth (rural versus urban). Family, Social Connections, Health Behavior. Marital status (married, previously married, never married), living arrangements (live alone or with someone else), presence of children, whether currently employed (yes, no), and whether physically active (yes, no). These covariates were chosen because of their potential relationships (either direct or indirect) with religious participation and/or health/survival based on previous studies (See Ref. 31). Functional and Health Status. Activities of daily living was assessed by a five-item unidimensional scale, that sought information on whether participants could clean the house; take their medicines; bathe/comb hair/dress; eat; walk/sit/lie down/ get around indoors/walk up stairs. The number of impaired activities was recorded as 0, 1–2, and 3 or more. Participants self-reported on the presence, within the previous 6 months, of each of the 12 medical conditions common to the elderly. The conditions examined in the current analysis were vascular conditions (any mention of heart disease, hypertension, diabetes, stroke, varicose veins), respiratory problems (any mention of bronchitis or pneumonia), excretory problems (any mention of kidney and urinary infection), osteoarticular problems (any mention of osteoporosis, arthritis, backache). Statistical Analysis Categorical variables were presented in absolute and relative frequencies (%). 2 was used to analyze bivariate relationships. Multivariable logistic regression, entering first sociodemographic, then family, social connections, health behavior, and finally functional and health characteristics, were used to identify characteristics associated with 1) tobacco use, 2) alcohol abuse and dependence, and 3) depression. The primary independent variables are religious affiliation and the three aspects of religiosity. Multivariate significance tests in the logistic regression analysis were carried out using Wald 2 tests.32,33 Standard errors and 99% confidence intervals were estimated using STATA, version 9.2 (StataCorp, College Station, TX, 2007), which takes into account complex sampling de-
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Religiosity and Tobacco, Alcohol Use, and Depression signs. Given the multiple tests performed, we report as significant results with two-tailed p ⱕ0.001, noting results with p value of 0.01 and 0.05.
RESULTS Table 1 presents the characteristics of the sample. Table 2 shows the bivariate association of these characteristics with specific religious affiliation, and Table 3 with religiosity beliefs. Significant gender and place of birth differences were seen for all religionrelated items. Religious affiliation is also associated with ethnicity, education, income, and marital status. Religious change is more frequently associated with low income and marital status. Orienting—motivat-
TABLE 1.
Religious Domains and Sociodemographic Characteristics of Respondentsa (N ⴝ 6,961)
Religious affiliation Catholic Evangelic Spiritism Afro-Brazilian None Others Religious change and transformation Yes No Orienting-motivating force Yes No Social religiosity Yes No Gender Female Male Age (years) 60–80 ⱖ81 Ethnicity White African Brazilian Multiracial Education ⬍4 years ⱖ4 years Income ⬍U.S. $200/month ⱖU.S. $200/month Area of birth Rural Urban a
Data missing for some variables.
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N
%
5,245 1,077 1343 112 112 42
75.7 15.5 4.9 1.6 1.6 .6
2,728 4,180
39.5 61.5
323 6,579
4.7 95.3
2,028 4,935
29.1 70.9
4,593 2,368
66.0 34.0
6,234 727
89.5 10.4
5,862 473 625
84.2 6.8 9.0
5,891 1,047
84.6 15.0
4,323 2,414
62.1 34.7
4,529 2,363
65.1 33.9
ing force is associated with being female and absence of children. Social religiosity is associated with younger age and being physically active. These unadjusted findings showed that religious affiliation and the association with religiosity were more likely to be reported by women, younger persons, those born in urban areas, and persons with lower income. In sociodemographic life style, functional, and health status controlled analyses (Table 4); elderly Brazilians who report their religious affiliation as Evangelical had a significantly lower risk of being a current tobacco user by 51%. Although those reporting affiliation as Afro-Brazilian and none had, respectively, a 74% and 124% increased risk of being a tobacco user, those who experienced a religious change, had religion as an orienting-motivating force, or participated in social religious activities had, respectively, a 21%, 34%, and 27% lower risk of being a current tobacco user. None of the religionrelated domains protected against alcohol misuse. Indeed, elderly who report none religious affiliation had a significantly increased risk (88%) of being an alcohol abuser or alcohol dependent. Those who experienced a religious change had a 31% increased risk of being an alcohol misuser. Religious affiliation, as measured here, did not reduce the risk of depression. Indeed, experiencing religion as an orientingmotivating source increased the risk of depression by 38%, whereas participating in social religious activities had reduced the risk of depression by 16%.
DISCUSSION On the basis of a large data set, and controlling for sociodemographic, life style, health behavior, functional status, and health conditions, we found that several aspects of religion were involved in reducing the odds of being a tobacco user; those reporting none religious affiliation or who experienced a religious change increased the odds of being or having been an alcohol abuser and dependent. However, the orienting-motivating force increased the odds of being a depressive subject by 38%, whereas participating in social religious activities had reduced the risk of depression by 16%. Some of these findings are in line with the literature, others are not. We hypothesized that religion would have a
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Blay et al.
TABLE 2.
Religious Affiliation and Sociodemographic Characteristics Religious Affiliation
Gender Female Male Age (years) 60–80 ⱖ81 Ethnicity White African Brazilian Multiracial Education ⬍4 years ⱖ4 years Income ⬍U.S. $200/month ⱖU.S. $200/month Area of birth Rural Urban a
None N (%)
Catholic N (%)
Evangelic N (%)
Spiritism N (%)
Afro-Brazilian N (%)
Others N (%)
Total N (%)
42 (37.5) 70 (62.5)
3446 (65.7) 1798 (34.3)
746 (69.3) 331 (30.7)
231 (67.3) 112 (32.7)
83 (74.1) 29 (25.9)
30 (71.4) 12 (28.6)
4578 (66.1) 2352 (33.9)
.001 (5)
98 (87.5) 14 (12.5)
4706 (89.7) 539 (10.3)
958 (89.0) 119 (11.0)
311 (90.7) 32 (9.3)
104 (92.9) 8 (7.1)
36 (85.7) 6 (14.3)
6213 (89.6) 718 (10.4)
.625 (5)
90 (80.4) 10 (8.9) 12 (10.7)
4485 (85.5) 313 (6.0) 446 (8.5)
870 (80.9) 88 (8.2) 118 (11.0)
280 (81.6) 35 (10.2) 28 (8.2)
74 (66.1) 24 (21.4) 14 (12.5)
34 (81.0) 2 (4.8) 6 (14.3)
5833 (84.2) 472 (6.8) 624 (9.0)
.001 (10)
81 (73.0) 30 (27.0)
3426 (65.5) 1804 (34.5)
795 (74.2) 277 (25.8)
167 (48.7) 176 (51.3)
78 (69.6) 34 (30.4)
24 (57.1) 18 (42.9)
4571 (66.2) 2339 (33.8)
.001 (5)
62 (59.0) 43 (41.0)
3231 (63.6) 1848 (36.4)
757 (71.3) 305 (28.7)
165 (50.3) 163 (49.7)
79 (71.8) 31 (28.2)
23 (56.1) 18 (43.9)
4317 (64.2) 2408 (35.8)
.001 (5)
68 (61.8) 42 (38.2)
3415 (65.7) 1779 (34.3)
803 (75.3) 263 (24.7)
149 (44.0) 190 (56.0)
51 (45.5) 61 (54.5)
24 (57.1) 18 (42.9)
4510 (65.7) 2353 (34.3)
.001 (5)
p Values based on 2 test, df indicates degrees of freedom.
TABLE 3.
Relationship Between Religion and Sociodemographic Characteristicsa Religious Change/Transformation
Characteristic
Present
Absent
N
%
N
%
p
42.5 33.6
2625 1554
57.5 66.4
40.0 35.2
3720 460
39.1 40.6 42.4
Demographic characteristics Gender Female 1942 Male 786 Age (years) 60–80 2478 ⱖ81 250 Ethnicity White 2273 African Brazilian 191 Multiracial 263 Education ⬍4 years 1842 ⱖ4 years 876 Income ⬍U.S. $200/ month 1783 ⱖU.S. $200/ month 885 Area of birth Rural 1865 Urban 840 a
p (df)a
Orienting-Motivating Forces Present
Absent
df
N
%
N
%
p
0.001
1
243 80
5.3 3.4
4318 2260
94.7 96.6
0.001
60.0 64.8
0.01
1
283 40
4.6 5.6
5911 668
95.4 94.4
0.232
3542 280 357
60.9 59.4 57.6
0.244
2
265 25 32
4.6 5.3 5.1
5545 443 590
95.4 94.7 94.9
0.633
40.4 37.6
2714 1456
59.6 62.4
0.023
1
222 99
4.9 4.3
4333 2229
95.1 95.7
41.5
2515
58.5
0.001
1
215
5.0
4084
95.0
36.8
1523
63.2
100
4.2
2303
95.8
41.5 35.8
2626 1508
58.5 64.2
230 86
5.1 3.7
4556 2263
94.9 96.3
0.001
1
Social Religiosity Present
Absent
df
N
%
N
%
p
dfa
1
1494 533
32.5 22.5
3099 1835
67.5 77.5
0.001
1
1868 166
29.9 22.8
4372 561
70.1 77.2
0.001
1
2
1683 140 204
28.7 29.6 32.6
4179 333 421
71.3 70.4 67.4
0.122
2
0.273
1
1330 696
29.0 29.2
3264 1648
71.0 70.3
0.539
1
0.134
1
1327
30.7
2996
69.3
0.005
1
663
27.5
1757
72.5
1447 556
31.9 24.0
3082 1797
68.1 76.0
0.001
1
0.006
1
p Values based on 2 test, df indicates degrees of freedom.
positive influence, reducing the likelihood of adverse behaviors and protecting mental health. We
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found that religious involvement as measured by Evangelical religious affiliation and three other di-
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Religiosity and Tobacco, Alcohol Use, and Depression
TABLE 4.
Association Between Religiosity Domains and Current Tobacco Use, Alcohol Abuse or Dependence, and Depression in Elderly General Community Population With Sociodemographic Characteristics, Lifestyle and Social Context, Health Behavior, Functional Status, Health Conditions Controlleda Alcohol Abuse and Dependency
Tobacco 99.9% CI Sig. Sociodemographic characteristicsb Religious affiliation Catholic Evangelic Spiritism Afro-Brazilian Others None Religious change and transformation (yes) Orienting,. motivating forces (yes) Social religiosity (yes)
OR
Lower Upper
Depression
99.9% CI Sig.
OR
Lower Upper
99.9% CI Sig.
OR
Lower Upper
0.000g 0.470 0.002g 0.894 0.001g
Reference 0.53 0.36 1.12 0.73 1.84 1.03 0.996 0.24 2.36 1.29
0.70 1.67 3.92 3.063 4.32
0.534 0.631 0.338 0.787 0.036e
Reference 0.89 0.58 1.15 0.57 1.47 0.47 1.16 0.16 1.94 0.84
1.36 2.31 4.58 8.32 4.46
0.233 0.567 0.654 0.125 0.464
Reference 1.09 0.90 0.93 0.67 1.08 0.62 1.67 0.76 0.84 0.45
1.32 1.30 1.88 3.64 1.58
0.001g 0.01f 0.001g
0.77 0.56 0.70
0.64 0.31 0.57
0.92 1.02 0.85
0.02e 0.271 0.005f
1.29 0.68 0.76
1.62 0.30 0.54
1.97 1.56 1.06
0.014f 0.02e 0.08
1.10 1.34 0.88
0.93 0.96 0.73
1.30 1.84 1.07
Reference 0.50 0.36 1.10 0.73 1.70 0.94 0.92 0.30 2.22 1.20
0.69 1.65 3.05 2.85 4.18
0.562 0.612 0.346 0.943 0.075
Reference 0.88 0.57 1.12 0.56 1.39 0.45 1.00 0.13 1.77 0.70
1.34 2.24 4.31 7.80 4.13
0.543 0.584 0.354 0.894 0.075
Reference 1.78 0.88 .905 0.64 1.03 0.59 1.65 0.76 .816 0.43
1.31 1.26 1.80 3.61 1.54
0.64 0.31 0.57
0.92 10.02 0.85
0.01f 0.240 0.09
1.30 0.66 0.79
0.98 0.26 00.54
2.72 1.67 1.14
0.123 0.02e 0.224
1.10 1.34 0.91
0.93 0.96 0.76
1.31 1.86 1.11
Reference 0.49 0.36 1.09 0.72 1.68 0.92 1.03 0.34 2.27 1.23
0.69 1.66 3.05 3.12 4.17
0.458 0.624 0.376 0.802 0.052e
Reference 0.85 0.55 1.11 0.55 1.40 0.48 1.02 0.13 1.87 0.80
1.32 2.25 4.41 8.25 4.39
0.264 0.917 0.289 0.265 0.523
Reference 1.08 0.85 1.03 0.71 1.20 0.65 1.43 0.62 1.11 0.56
1.31 1.48 2.12 3.32 2.17
0.75 0.57 0.69
0.91 1.03 0.85
0.02e 0.315 0.08f
1.28 0.69 0.77
1.68 1.81 1.13
0.91 0.02e 0.01f
.1.01 1.34 0.83
1.21 1.91 0.99
Family, social connections, health behaviorc Religious affiliation Catholic Evangelic 0.000g Spiritism 0.425 Afro-Brazilian 0.01f Others 0.955 None 0.001g Religious change and transformation (yes) 0.001g Orienting, motivating forces (yes) 0.01e Social religiosity (yes) 0.001g Functional status and health conditionsd Religious affiliation Catholic Evangelic 0.001g Spiritism 0.476 Afro-Brazilian 0.013f Others 0.776 None 0.001g Religious change and transformation (yes) 0.001g Orienting, motivating forces (yes) 0.01f Social religiosity (yes) 0.001g
0.77 0.56 0.70
0.62 0.31 0.56
0.98 0.27 0.53
0.84 0.95 0.70
Notes: OR: odds ratio; CI: confidence interval. a Multivariate logistic regression; Wald 2 tests with df ⫽ 1. b Model 1: Adjusted for gender, age, ethnicity, education, income, and area of birth. c Model 2: Adjusted for Model 1 ⫹ family, social connections, and health behavior. d Model 3: Adjusted for Model 2 ⫹ functional status, vascular, respiratory, excretory, and osteoarticular problems. e p ⬍0.05. f p ⬍0.01. g p ⬍0.001.
mensions of religiosity were associated with a reduced frequency of using tobacco. Koenig et al.20 and Ahmed et al.19 report a similar finding for their U.S. samples. There has been criticism that the sole use of religious affiliation is too narrow a concept to study this issue.34 However, in the
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present study, even when other aspects of religiosity are controlled, with the exception of AfroBrazilian and none affiliation, being Evangelical seem to protect against tobacco use. We are aware that Evangelic regulations usually prohibit the use of tobacco, but it seems that other factors within
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Blay et al. other religions may contribute to increase the use of tobacco such as the Afro-Brazilian affiliation. Our results did not confirm that religious affiliation reduces the odds of alcohol abuse or dependence.15,16 Further analysis found a positive association between alcohol abuse or dependence and other dimensions of religiosity such as those reporting not having religious affiliation and those who experienced a religious change. We are aware of behavior control, including avoidance of alcohol, in Evangelic belief, but this norm of conduct does not hold true in this study as well as for other religions which includes the use of wine in celebrations and does not prohibit appropriate use. Although further investigations is needed to study this problem, this unexpected finding suggests that the probable protective effect by religion with respect to alcohol abuse or dependence may be more prominent in younger age groups such as adolescents and adults.35 Religiosity has a more powerful relationship with current tobacco use than with alcohol abuse and dependence. Although there is some protection for Evangelicals, we have to consider other possibilities. Religious affiliation could be a response to tobacco use and used as a coping strategy to abstain from tobacco. The present study allowed to identify that alcohol abuse-dependence is associated with various factors. We observed that not having a religion or those who experienced a religious change are associated with contexts that facilitate unhealthy patterns of alcohol consumption. As indicated by other investigations, religiousness seems to be a factor of protection toward abusive consumption of alcohol and other drugs.15,16,23 This does not hold true in the present study. Within our settings, religion has an organized church-based network that is independent of other social networks. The religiously observant have a fairly structured life, featured mainly by attending regular religious services, planned activities and are under the antialcohol norms usually preached by Evangelicals and their social group. Elderly subjects with alcohol abuse and dependence may also, and in consequence, have impaired physical and social functioning. They may not be able to participate in the public aspects of religiosity because of increased need for transportation, personal support, and other issues, explaining, in part, the absence of potential benefits of religious domains. Research in Sa˜o Paulo,
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Brazil to determine how the adult population views alcohol dependence and their emotional reactions to individuals with this disorder, showed that Evangelicals were among those most likely to report negative reactions toward such persons.36 This negative reaction may be an important motivation to handle these problems and may be effective in keeping people away from alcohol. However, this does not hold true within elderly Brazilians. We expected that older people with stronger religious association would be more likely to be protected against depression. In controlled analysis, we found that those who consider religion the most important life value (an indicator of the ‘orienting and motivating’ religious domain) were about 38% more likely to have depression whereas participating in social religious activities had reduced the risk of depression by 16%.Several previous reviews have shown a wide range of associations between religion and depression. Bergin7 reported that 23% of studies found a negative relationship, 47% a positive relationship, and 30% no relationship. Larson and Larson37 found 16% negative, 72% positive, and 12% no relationship. However, McCullough and Larson31 reported that “intrinsic religious motivation” may be the aspect of religiosity most protective for depressive disorders, and Smith et al.14 reported a positive relationship between religiosity and mental wellness. Research has shown that religion is an important source of support for older adults and that older subjects tend do be more religious.38 There is evidence that the subjective importance of religion generally increases among those who are dealing with serious illness. Religiosity has been found to be an important aspect in patients’ ability to cope with serious and chronic illness.39 According to our data, participating in social religious activities is important to protect against depression. Explanations for this type of association between religion and depression are potentially explained by the social interaction, social networks, possibility to change experiences, express feelings, plan activities, structure life rules, among others. One may consider that the relationship of depression and religion is not direct but rather mediated by many variables such as attention, cognition, lack of insight, acceptance of illness, sadness, culpability, anhedonia, nihilism, self-cure, personality traits, religiousness as a
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Religiosity and Tobacco, Alcohol Use, and Depression psychopathologic symptom, among others. We observed that those who consider religion as the most important life value increased the risk of being depressed. It is reasonable to suppose that depressive patients are angry with themselves, with others, and with God, for their suffering and functional impairment. Religion may have a negative effect on coping, which may be shown through an increase in feelings of culpability, guilt, and neurosis.40 In addition, depression and its relation with religion may also be mediated by the severity of the depressive state. Limitations This study has certain limitations. First, philosophical. We have tried to assess the immaterial, or to understand religiosity, or the ineffable, by means of the scientific methods. Methods of science may offer inept or inappropriate ways to understand religiosity. Second, the study is limited by the constraints of a cross-sectional design such as the exam of causaleffect associations. The religious information, as well as all other measures, was assessed at the same point in time and at only one point in time. Some information reflects current conditions, some reflects conditions that occurred earlier resulting in possible recall and social desirability bias. Religious beliefs and health conditions may change over time and under certain circumstances. Third, although our data establish association of religion with tobacco use, misuse of alcohol and depression, no causal relationship can be considered. Just as religion may modify the risk of getting an illness and change its course, the experience of illness may change the religious belief and behavior, or some other variable may affect both religiosity and disease. Fourth, even though the sample was large, the number of subjects for some religious affiliations, for religion as an orienting-motivating force, and for alcohol abuse and dependence was relatively small, reducing power to detect statis-
tical differences. Fifth, we sampled only community residents, deliberately excluding persons in hospitals or nursing homes, where prevalence of substance use and depression morbidity is likely to be different and probably higher. Sixth, the findings cannot be generalized beyond the study area. The widely differing cultural and socioeconomic backgrounds present in Brazil may not have been fully represented. Seventh, religious assessment and psychiatric assessment was based on a screening questionnaire and not on a comprehensive religious and psychiatric assessment interview. Eighth, depression in community subjects may have a fluctuating course. The cross-sectional nature of this investigation cannot capture this fluctuating state, and this may have affected the observed results. Ninth, severity of depression was not assessed. It is possible that affiliation and religion characteristics may have more effect on milder cases that may be associated with environmental strains than on conditions with a greater physical basis. However, in community studies, mild to moderate cases are expected to be more frequent. Nevertheless, present data indicate that after controlling for demographic, family, social connections, health behavior, functional and health characteristics factors, religious affiliation, and religiosity domains are independently involved in substance abuse and depression and may provide guidelines and facilitate healthful behaviors, although there may be limitations in the extent to which mental health can be modified. We thank Dr. Sergio Antoˆnio Carlos—President of the State Council of the Elderly (Conselho Estadual do Idoso) for allowing us to use the dataset of the “Elderly of RS—a multidimensional study of their living conditions” study. The authors thank Gerda G. Fillenbaum, Ph.D., for help with the manuscript. This work was supported by grants from Conselho Estadual do Idoso, Secretaria do Trabalho, Cidadania e Assisteˆncia Social; and by Governo do Estado do Rio Grande do Sul.
References 1. Koenig HG, McCullough M, Larson DB: Handbook of Religion and Health: A Century of Research Reviewed. New York, Oxford University Press, 2001 2. Koening HG, Hays JC, Larson DB, et al: Does religious attendance prolong survival? A six-year follow-up study of 3968 older adults. J Gerontol Med Sci 1999; 54A:M370 –M376 3. Sloan RP, Bagiella E, Powell T: Religion, spirituality, and medicine. Lancet 1999; 353:664 – 667
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4. Larson DB, Swyers JP, McCullough MI: Scientific Research on Spirituality and Health: A Consensus Report. Rockville, Md, National Institute for Healthcare Research, 1998 5. Hill PC, Hood RW Jr: Measures of Religiosity. Birmingham, AL, Religious Education Press, 1999 6. Hill PC, Pargament KI: Advances in the conceptualization and measurement of religion and spirituality. Implications for physical and mental health research. Am Psychol 2003; 58: 64 –74
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Blay et al. 7. Bergin AF: Religiosity and mental health: a critical reevaluation a meta analysis. Prof Psychol 1983; 14:170 –184 8. Ferraro KF, Kelley-Moore JA: Religious consolation among men and women: do health problems spur seeking? J Sci Study Relig 2000; 39:220 –234 9. Husaini BA, Blasi AJ, Miller O: Does public and private religiosity have a moderating effect on depression? A bi-racial study of elders in the American South. Int J Aging Hum Dev 1999; 48:63–72 10. Braam AW, Deeg DJ, Poppelaars JL, et al: Prayer and depressive symptoms in a period of secularization: patterns among older adults in the Netherlands. Am J Geriatr Psychiatry 2007; 15:273–281 11. Van Ness PH, Larson DB: Religion, senescence, and mental health: the end of life is not the end of hope. Am J Geriatr Psychiatry 2002; 10:386 –397 12. Koenig HG: Religion and depression in older medical inpatients. Am J Geriatr Psychiatry 2007; 15:282–291 13. Yohannes AM, Koenig HG, Baldwin RC, et al: Health behaviour, depression and religiosity in older patients admitted to intermediate care. Int J Geriatr Psychiatry 2008; 23:735–740 14. Smith TB, McCullough ME, Poll J: Religiousness and depression: evidence for a main effect and the moderating influence of stressful life events. Psychol Bull 2003; 129:614 – 636 15. Kendler KS, Gardner CO, Prescott CA: Religion, psychopathology, and substance use and abuse; a multimeasure, genetic-epidemiologic study. Am J Psychiatry 1997; 154:322–329 16. Kendler KS, Liu XQ, Gardner CO, et al: Dimensions of religiosity and their relationship to lifetime psychiatric and substance use disorders. Am J Psychiatry 2003; 160:496 –503 17. Lotufo Neto F: Psiquiatria e religia˜o: a prevaleˆncia de transtornos mentais entre ministros religiosos [Psychiatry and religion: the prevalence of mental disorders among clergy]. [Thesis]. Sa˜o Paulo: Faculdade de Medicina, Universidade de Sa˜o Paulo, 1997. Available at: http://www.teses.usp.br/. Accessed September 25, 2007 18. Almeida AM: Fenomenologia das experieˆncias mediu ´ nicas, perfil e psicopatologia de me´diuns espı´ritas. [Phenomelogy of Mediumistic Experiences, Profile and Psychopathology of Spiritist Mediums]. [Thesis]. Sa˜o Paulo: Faculdade de Medicina, Universidade de Sa˜o Paulo, 2004. Available at: http://www.teses.usp.br/. Accessed September 25, 2007 19. Ahmed F, Brown DR, Gary LE, et al: Religious predictors of cigarette smoking: findings for African American women of childbearing age. Behav Med 1994; 20:34 – 43 20. Koenig HG, George LK, Cohen HJ, et al: The relationship between religious activities and cigarette smoking in older adults. J Gerontol A Biol Sci Med Sci 1998; 53:M426 –M434 21. Dalgalarrondo P, Soldera MA, Correa Filho HR, et al: Religion and drug use by adolescents. Rev Bras Psiquiatr 2004; 26:82–90 22. Tavares BF, Beria JU, Lima MS: Factors associated with drug use among adolescent students in southern Brazil. Rev Sau ´ de Pu ´ blica 2004; 38:787–796
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23. Barros MB, Botega NJ, Dalgalarrondo P, et al: Prevalence of alcohol abuse and associated factors in a population-based study. Rev Saude Publica 2007; 41:502–509 24. Sanchez ZV, Oliveira LG, Nappo SA: Fatores protetores de adolescentes contra o uso de drogas com eˆnfase na religiosidade [Protective factors from adolescents against drug use emphasizing the role of religiosity]. Cienc Saude Coletiva 2004; 9:43–55 25. Blay SL, Andreoli SB, Fillenbaum GG, et al: Depression morbidity in later life: prevalence and correlates in a developing country. Am J Geriatr Psychiatry 2007; 15:790 –799 26. Ulman C: The Transformed Self: The Psychology of Religious Conversion. New York, Plenum, 1989 27. Gorsuch RL, Venable GD: Development of an “ age universal” I-E scale. J Sci Study Relig 1983; 22:181–187 28. Hasin DS, Grant B, Endicott J: The natural history of alcohol abuse: implications for definitions of alcohol use disorders. Am J Psychiatry 1990; 147:1537–1541 29. Blay SL, Ramos LR, Mari JJ: Validity of a Brazilian version of the Older Americans Resources and Services (OARS) mental health screening questionnaire. J Am Geriatr Soc 1988; 36:687– 692 30. Pfeiffer E: A short psychiatric evaluation schedule. A new 15-item monotonic scale indicative of functional psychiatric disorder, in Brain Function in Old Age. Bayer Symposium 1979, vol. 22, pp 228 –236 31. McCullough ME, Larson DB: Religion and depression: a review of the literature. Twin Res 2001; 2:126 –136 32. Hosmer DW, Lemeshow S: Applied Logistic Regression. New York, Wiley, 1989 33. Fleiss JL, Williams JPW, Dubro AF: Logistic regression of psychiatric data. J. Psychiatr Res 1986; 20:145–209 34. Miller WR, Thorensen CE: Spirituality, religion, and health. An emerging research field. Am Psychol 2003; 58:24 –35 35. Rachal JV, Maisto SA, Guess LL, et al: Alcohol use among youth, in Alcohol Consumption and Related Problems. Edited by The National Institute on Alcohol Abuse and Alcoholism. Washington, DC, US Government Printing Office, 1982, pp 55–95 36. Peluso Ede TP, Blay SL: Public perception of alcohol dependence. Rev Bras Psiquiatr 2007; 30:19 –24 37. Larson DB, Larson SS: The Forgotten Factor in Physical and Mental Health: What Does the Research Show? An Independent Study Seminar. Rockville, Md, National Institute for Healthcare Research, 1994 38. Koenig HG, Larson DB, Mathews DA: Religion and psychotherapy with older adults. J Geriatr Psychiatr 1996; 29:155–184 39. Pargament KJ: The Psychology of Religion and Coping: Theory, Research, Practice. New York, Guilford, 1997 40. Freud S: O futuro de uma ilusa˜o (Future of an illusion). Edic¸˜ao Standard Brasileira das Obras Psicolo ´gicas Completas de Sigmund Freud.Vol XXI. Imago Editora. Rio de Janeiro, 1927, pp 15– 63
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Objective: The objective of this study is to examine the religious characteristics of older subjects and the associations of these characteristics to the use of tobacco, alcohol, and depression. Methods: Data from a multistage random sample were used to examine associations between religiosity and health behaviors (tobacco use, alcohol) and depression among elderly house hold residents aged 60⫹ in Rio Grande do Sul, Brazil. Survey measures included sociodemographic characteristics, four aspects of religiosity, tobacco use, alcohol abuse and dependence, depression, life style, social context, functional status, and health conditions. Results: After controlling for demographic, social connections, health behavior, functional status, and health conditions, evangelical affiliation reduced the odds of being a current tobacco user by 51%. Those reporting affiliation as Afro-Brazilian and not having a religion had, respectively, a 74% and 124% increased risk. All other religious domains protect against tobacco use. Not having a religion affiliation and the experience of a religious change increased the risk of alcohol misuse by 88% and 31%, respectively. In contrast, orienting-motivating force increased the odds of depression by 38%. Participating in social religious activities had reduced the risk of depression by 16%. Conclusion: Several aspects of religiosity reduced the odds of being a tobacco user. Not having a religion and the experience of a religious change increased the risk of alcohol misuse. However, the domain orienting-motivating force increased the odds, and participating in social religious activities had reduced the risk of a depressive state. (Am J Geriatr Psychiatry 2008; 16:934 –943) Key Words: Religion, depression, substance abuse, alcohol use disorder, tobacco use
R
eligion is relatively neglected in empirical studies exploring correlates of mental illness and
substance abuse.1–3 In addition, when they are considered, a major limitation is the use of religious
Received January 16, 2008; revised June 16, 2008; accepted June 20, 2008. From the Department of Psychiatry, Federal University of Sa˜o Paulo, Sa˜o Paulo, SP, Brazil (Escola Paulista de Medicina - UNIFESP) (SLB, SBA); Hermínio Ometto University Center, Araras, SP, Brazil (ADB); and Project Scientific Committee and Brazilian National Accreditation Organization, Brazil (FLG). Send correspondence and reprint requests to Sergio Luı´s Blay, M.D. Ph.D., Department of Psychiatry - UNIFESP, R. Botucatu, 740 CEP 04023–900, Sa˜o Paulo, SP, Brazil. e-mail: [email protected] © 2008 American Association for Geriatric Psychiatry
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Blay et al. affiliation as the only measure of religiosity.4 Researchers in the psychology of religion have found that religion is far from uniform processes.5 Rather, they are complex entities involving cognitive, emotional, behavioral, interpersonal, and psychological dimensions. Several domains are potentially related to health outcomes, so there is a particular need for measures of religion that are theoretically and functionally linked to mental and physical health.6 Despite some recent publications, studies examining different dimensions of religiosity and depression remain scarce. Findings from reviews, clinical investigations, and cross-sectional population studies provide conflicting results, reporting positive, negative, and no relationship between religiosity and depression.7–13 A recent meta-analysis of 147 independent investigations involving 98,975 subjects found that religiosity is modestly but consistently associated with a lower level of depressive symptoms.14 In their first article, Kendler et al.,15 using a large twin sample, examined the relationship between dimensions of religiosity and current psychiatric symptoms. Their major finding was that the dimensions of religiosity were not strongly related to risk for psychiatric symptoms and disorders. More recently, Kendler et al.16 used a multidimensional approach to identify the numerous dimensions of religious and spiritual beliefs and behaviors. They showed that some dimensions of religiosity, specifically social religiosity, unvengefulness, thankfulness, were related to lower risk of depression. Two Brazilian studies used a screening questionnaire for common mental disorders (depression, anxiety, and somatization disorders) in two different religious populations. Lotufo Neto,17 in a sample of 207 ministers of religion, found that intrinsic religiosity was associated with better mental health. In the other investigation, a random sample of 115 spiritist mediums had lower psychiatric symptom scores than samples from the general population.18 Such findings may reflect coping strategies that may present these processes through a number of pathways such as life meaning, inspiration, hope, optimism, increase sense of control, behavior rules, and social support among others. Community surveys and clinical studies have found a clear inverse correlation between religiosity
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and alcohol and tobacco use. Most of the investigations were conducted among adolescents, when drug use usually starts, and younger adult populations.19 –22 The greater the religious involvement, the lower the rates of alcohol/drug use/abuse.1 Some small qualitative and quantitative studies in specific communities in Brazil (studies not specifically focusing on elders and religion) have examined the relationships between religious participation and substance abuse and psychiatric problems. Based on cross-sectional observation of 93 subjects aged 60 years and over, Barros et al.23 found that Protestant religious practices among the people living in Campinas, State of Sa˜o Paulo, may be beneficial in protecting against alcohol abuse. Sanchez et al.,24 in a qualitative study, investigated factors protective against drug use among adolescent residents in very poor and violent areas of Sa˜o Paulo. The most important factor was having a structured family; religiousness was the second most important protective factor. Family structure was, in turn, associated with family religiousness. The study found that 81% of the nonusers practiced a religion; among users, only 13% did so. Although past research has shown that religious affiliation and beliefs can have a positive impact on health, longevity, and recovery from severe medical illness, it is not known if religious participation in its various dimensions is associated with substance abuse and depression within the elderly population in Brazil, a developing country in South America. Elderly in the community may have a different approach to religion than clinic-based samples. In addition, the elderly often struggle with chronic medical problems, marital difficulties, functional limitations, isolation, widowhood, fewer social activities, economic constraints, and have a need for medical or social support systems. Both psychiatric and medical morbidities may be substantial.25 On the basis of the studies reviewed earlier, we will test the following hypotheses, while controlling for demographic, socioeconomic, social ties, and health behavior characteristics. First, older people in Brazil who have a religious focus are less likely to use tobacco than those who do not have such a focus; second, older people in Brazil who have a religious focus are less likely to report problems with use of alcohol; third, older people in Brazil
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Religiosity and Tobacco, Alcohol Use, and Depression who have a religious focus are more likely to be protected against depression.
METHODS Sample This cross-sectional study of noninstitutionalized persons ⱖ60 years of age was based on multistage, random sampling in nine homogeneous areas covering the state of Rio Grande do Sul, Brazil. The region is located in the southern area of the country, with a largely agro-industrial economy, populated primarily by descendents of European immigrants. Data were gathered in 1995 in face-to-face household surveys of 7,920 residents of urban and rural counties. The structured interview included assessment of sociodemographic characteristics, mental and physical health, functional status, health service use, activity (exercise and employment), and living arrangements. Details on methods have been reported previously.25 The study was approved by the Ethics Committee of the Federal University of Sa˜o Paulo. Participants gave oral consent; a family member could be present if they wished. Data Gathering and Quality Control. Data were gathered by interviewers trained in standardized data collection. To increase the quality of data collection, all interviewers and field supervisors underwent formal training. This included a detailed description of the research project and its methodology, role playing techniques, and tests of fieldwork reliability. Tape-recorded interviews were used to discuss the research instrument and to improve interviewing skills and data collection techniques. Field supervisors closely monitored data collection and revisited participants to ensure fieldwork quality control. Careful review of the database identified data entry problems in one region. This region was excluded from analysis. In the remaining eight regions, a total of 7,040 persons were approached in the first round: 880 subjects in each area. No proxy information was collected. Nonresponse was negligible: 79 persons (1.1%) did not take part in the assessment, primarily refusals, yielding an overall response rate of 99% (N ⫽ 6,961).
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Measures Main Independent Variables Religiosity. In the present study, four relevant questions related to issues raised by Hill and Hood5, are available in our data set. One allows us to determine religious affiliation, the specific question asked was: 1. “Which is your religious affiliation?” Interviewees could choose one of following answers: Catholic, Evangelic (with strict attitudes toward smoking, drinking, dancing, dressing, etc.), Spiritism, Jewish, Afro-Brazilian, Other (Buddhism, Daoism, Islamism, Esoteric), None. Responses were grouped as None, Catholic, Evangelic, Spiritism, Afro-Brazilian, Others. The other three questions address each of three religious domains with possible connections to areas of health research: 2. Religious change—transformation: The idea that people can change and grow religiously is central to most religious traditions.26 Religion traditions are not stable conditions, they are dynamic. The possibilities of change, growth, deterioration, or stability are all alternatives across the lifespan. The relevant question was: “As the years pass by, do you believe you. . . . ” Interviewees could choose one of the following answers: became more religious, became less religious, no change concerning religiosity. Responses were dichotomized into “became more religious” versus the rest. 3. Orienting-motivating force: To the devout, religion are not a set of beliefs and practices divorced from everyday life. Instead religion are ways of life to be sought, experienced, and sustained.6,27 This aspect was assessed by the following question: “What do you consider the most important life value?” Responses were dichotomized into “religion” versus all other responses. 4. Social religiosity: In one sense, religion is an institutional (social-material) phenomenon. Many believers of major religions have a fairly structured life, featuring regular attendance at formal religious services and associated activities. The religious are differentiated by specific beliefs and attitudes, requirements of membership, and modes of social organization and life style.13 The
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Blay et al. relevant question was: “Do you participate in any social activity?” Interviewees could choose a religious social activity along with other activities. Responses were dichotomized into “religion association” and “other.” Main Dependent Variables. Current tobacco use was assessed by the following question: “Do you use tobacco regularly now?” Response options were “no” and “yes.” Based on Hasin’s criteria,28 alcohol abuse or dependence was determined by a positive response to any of the following five questions: 1) Has your family, your friends, your physician, or your priest ever commented or suggested that you were drinking too much? 2) Have you ever tried to stop drinking but been unable to do so? 3) Have you ever had trouble at work or school because of alcohol, such as drinking or missing work? 4) Have you ever been involved in fights or arrested for being drunk? 5) Has it ever seemed to you that you were drinking too much? The answer options were coded as yes or no. Assessment of Depression Morbidity. Assessment of depression morbidity was determined by the sixitem Short Short Psychiatric Evaluation Schedule (Short-SPES).29 This is an evaluated modification of the 15-item SPES,30 relevant to the older Brazilian population. Performance on the SPES was not affected by sex, age, marital status, income, education, or minority status. Previous study of this measure in Brazil determined that the Short-SPES could identify psychiatric “caseness” in the older population. The psychiatric disorders identified were overwhelmingly depressive states and anxiety disorders (i.e., psychiatric conditions most prevalent in the elderly). Each question requires a yes/no answer regarding presence in the past 30 days. The total score reflects the number of positive answers, yielding a potential scoring range of 0 – 6. A score of 2 or above identifies “psychiatric cases” with a sensitivity of 82% and specificity of 77%.29 A study of interrater reliability showed complete agreement between examiners. Covariates Demographic Characteristics. Gender, age (60 – 80; ⱖ81 years), ethnicity (white, African Brazilian, Multiracial), education (⬍4 years of schooling versus ⱖ4 years of schooling), income (⬍U.S. $200/month ver-
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sus ⱖU.S. $200/month), and place of birth (rural versus urban). Family, Social Connections, Health Behavior. Marital status (married, previously married, never married), living arrangements (live alone or with someone else), presence of children, whether currently employed (yes, no), and whether physically active (yes, no). These covariates were chosen because of their potential relationships (either direct or indirect) with religious participation and/or health/survival based on previous studies (See Ref. 31). Functional and Health Status. Activities of daily living was assessed by a five-item unidimensional scale, that sought information on whether participants could clean the house; take their medicines; bathe/comb hair/dress; eat; walk/sit/lie down/ get around indoors/walk up stairs. The number of impaired activities was recorded as 0, 1–2, and 3 or more. Participants self-reported on the presence, within the previous 6 months, of each of the 12 medical conditions common to the elderly. The conditions examined in the current analysis were vascular conditions (any mention of heart disease, hypertension, diabetes, stroke, varicose veins), respiratory problems (any mention of bronchitis or pneumonia), excretory problems (any mention of kidney and urinary infection), osteoarticular problems (any mention of osteoporosis, arthritis, backache). Statistical Analysis Categorical variables were presented in absolute and relative frequencies (%). 2 was used to analyze bivariate relationships. Multivariable logistic regression, entering first sociodemographic, then family, social connections, health behavior, and finally functional and health characteristics, were used to identify characteristics associated with 1) tobacco use, 2) alcohol abuse and dependence, and 3) depression. The primary independent variables are religious affiliation and the three aspects of religiosity. Multivariate significance tests in the logistic regression analysis were carried out using Wald 2 tests.32,33 Standard errors and 99% confidence intervals were estimated using STATA, version 9.2 (StataCorp, College Station, TX, 2007), which takes into account complex sampling de-
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Religiosity and Tobacco, Alcohol Use, and Depression signs. Given the multiple tests performed, we report as significant results with two-tailed p ⱕ0.001, noting results with p value of 0.01 and 0.05.
RESULTS Table 1 presents the characteristics of the sample. Table 2 shows the bivariate association of these characteristics with specific religious affiliation, and Table 3 with religiosity beliefs. Significant gender and place of birth differences were seen for all religionrelated items. Religious affiliation is also associated with ethnicity, education, income, and marital status. Religious change is more frequently associated with low income and marital status. Orienting—motivat-
TABLE 1.
Religious Domains and Sociodemographic Characteristics of Respondentsa (N ⴝ 6,961)
Religious affiliation Catholic Evangelic Spiritism Afro-Brazilian None Others Religious change and transformation Yes No Orienting-motivating force Yes No Social religiosity Yes No Gender Female Male Age (years) 60–80 ⱖ81 Ethnicity White African Brazilian Multiracial Education ⬍4 years ⱖ4 years Income ⬍U.S. $200/month ⱖU.S. $200/month Area of birth Rural Urban a
Data missing for some variables.
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N
%
5,245 1,077 1343 112 112 42
75.7 15.5 4.9 1.6 1.6 .6
2,728 4,180
39.5 61.5
323 6,579
4.7 95.3
2,028 4,935
29.1 70.9
4,593 2,368
66.0 34.0
6,234 727
89.5 10.4
5,862 473 625
84.2 6.8 9.0
5,891 1,047
84.6 15.0
4,323 2,414
62.1 34.7
4,529 2,363
65.1 33.9
ing force is associated with being female and absence of children. Social religiosity is associated with younger age and being physically active. These unadjusted findings showed that religious affiliation and the association with religiosity were more likely to be reported by women, younger persons, those born in urban areas, and persons with lower income. In sociodemographic life style, functional, and health status controlled analyses (Table 4); elderly Brazilians who report their religious affiliation as Evangelical had a significantly lower risk of being a current tobacco user by 51%. Although those reporting affiliation as Afro-Brazilian and none had, respectively, a 74% and 124% increased risk of being a tobacco user, those who experienced a religious change, had religion as an orienting-motivating force, or participated in social religious activities had, respectively, a 21%, 34%, and 27% lower risk of being a current tobacco user. None of the religionrelated domains protected against alcohol misuse. Indeed, elderly who report none religious affiliation had a significantly increased risk (88%) of being an alcohol abuser or alcohol dependent. Those who experienced a religious change had a 31% increased risk of being an alcohol misuser. Religious affiliation, as measured here, did not reduce the risk of depression. Indeed, experiencing religion as an orientingmotivating source increased the risk of depression by 38%, whereas participating in social religious activities had reduced the risk of depression by 16%.
DISCUSSION On the basis of a large data set, and controlling for sociodemographic, life style, health behavior, functional status, and health conditions, we found that several aspects of religion were involved in reducing the odds of being a tobacco user; those reporting none religious affiliation or who experienced a religious change increased the odds of being or having been an alcohol abuser and dependent. However, the orienting-motivating force increased the odds of being a depressive subject by 38%, whereas participating in social religious activities had reduced the risk of depression by 16%. Some of these findings are in line with the literature, others are not. We hypothesized that religion would have a
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Blay et al.
TABLE 2.
Religious Affiliation and Sociodemographic Characteristics Religious Affiliation
Gender Female Male Age (years) 60–80 ⱖ81 Ethnicity White African Brazilian Multiracial Education ⬍4 years ⱖ4 years Income ⬍U.S. $200/month ⱖU.S. $200/month Area of birth Rural Urban a
None N (%)
Catholic N (%)
Evangelic N (%)
Spiritism N (%)
Afro-Brazilian N (%)
Others N (%)
Total N (%)
42 (37.5) 70 (62.5)
3446 (65.7) 1798 (34.3)
746 (69.3) 331 (30.7)
231 (67.3) 112 (32.7)
83 (74.1) 29 (25.9)
30 (71.4) 12 (28.6)
4578 (66.1) 2352 (33.9)
.001 (5)
98 (87.5) 14 (12.5)
4706 (89.7) 539 (10.3)
958 (89.0) 119 (11.0)
311 (90.7) 32 (9.3)
104 (92.9) 8 (7.1)
36 (85.7) 6 (14.3)
6213 (89.6) 718 (10.4)
.625 (5)
90 (80.4) 10 (8.9) 12 (10.7)
4485 (85.5) 313 (6.0) 446 (8.5)
870 (80.9) 88 (8.2) 118 (11.0)
280 (81.6) 35 (10.2) 28 (8.2)
74 (66.1) 24 (21.4) 14 (12.5)
34 (81.0) 2 (4.8) 6 (14.3)
5833 (84.2) 472 (6.8) 624 (9.0)
.001 (10)
81 (73.0) 30 (27.0)
3426 (65.5) 1804 (34.5)
795 (74.2) 277 (25.8)
167 (48.7) 176 (51.3)
78 (69.6) 34 (30.4)
24 (57.1) 18 (42.9)
4571 (66.2) 2339 (33.8)
.001 (5)
62 (59.0) 43 (41.0)
3231 (63.6) 1848 (36.4)
757 (71.3) 305 (28.7)
165 (50.3) 163 (49.7)
79 (71.8) 31 (28.2)
23 (56.1) 18 (43.9)
4317 (64.2) 2408 (35.8)
.001 (5)
68 (61.8) 42 (38.2)
3415 (65.7) 1779 (34.3)
803 (75.3) 263 (24.7)
149 (44.0) 190 (56.0)
51 (45.5) 61 (54.5)
24 (57.1) 18 (42.9)
4510 (65.7) 2353 (34.3)
.001 (5)
p Values based on 2 test, df indicates degrees of freedom.
TABLE 3.
Relationship Between Religion and Sociodemographic Characteristicsa Religious Change/Transformation
Characteristic
Present
Absent
N
%
N
%
p
42.5 33.6
2625 1554
57.5 66.4
40.0 35.2
3720 460
39.1 40.6 42.4
Demographic characteristics Gender Female 1942 Male 786 Age (years) 60–80 2478 ⱖ81 250 Ethnicity White 2273 African Brazilian 191 Multiracial 263 Education ⬍4 years 1842 ⱖ4 years 876 Income ⬍U.S. $200/ month 1783 ⱖU.S. $200/ month 885 Area of birth Rural 1865 Urban 840 a
p (df)a
Orienting-Motivating Forces Present
Absent
df
N
%
N
%
p
0.001
1
243 80
5.3 3.4
4318 2260
94.7 96.6
0.001
60.0 64.8
0.01
1
283 40
4.6 5.6
5911 668
95.4 94.4
0.232
3542 280 357
60.9 59.4 57.6
0.244
2
265 25 32
4.6 5.3 5.1
5545 443 590
95.4 94.7 94.9
0.633
40.4 37.6
2714 1456
59.6 62.4
0.023
1
222 99
4.9 4.3
4333 2229
95.1 95.7
41.5
2515
58.5
0.001
1
215
5.0
4084
95.0
36.8
1523
63.2
100
4.2
2303
95.8
41.5 35.8
2626 1508
58.5 64.2
230 86
5.1 3.7
4556 2263
94.9 96.3
0.001
1
Social Religiosity Present
Absent
df
N
%
N
%
p
dfa
1
1494 533
32.5 22.5
3099 1835
67.5 77.5
0.001
1
1868 166
29.9 22.8
4372 561
70.1 77.2
0.001
1
2
1683 140 204
28.7 29.6 32.6
4179 333 421
71.3 70.4 67.4
0.122
2
0.273
1
1330 696
29.0 29.2
3264 1648
71.0 70.3
0.539
1
0.134
1
1327
30.7
2996
69.3
0.005
1
663
27.5
1757
72.5
1447 556
31.9 24.0
3082 1797
68.1 76.0
0.001
1
0.006
1
p Values based on 2 test, df indicates degrees of freedom.
positive influence, reducing the likelihood of adverse behaviors and protecting mental health. We
Am J Geriatr Psychiatry 16:11, November 2008
found that religious involvement as measured by Evangelical religious affiliation and three other di-
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Religiosity and Tobacco, Alcohol Use, and Depression
TABLE 4.
Association Between Religiosity Domains and Current Tobacco Use, Alcohol Abuse or Dependence, and Depression in Elderly General Community Population With Sociodemographic Characteristics, Lifestyle and Social Context, Health Behavior, Functional Status, Health Conditions Controlleda Alcohol Abuse and Dependency
Tobacco 99.9% CI Sig. Sociodemographic characteristicsb Religious affiliation Catholic Evangelic Spiritism Afro-Brazilian Others None Religious change and transformation (yes) Orienting,. motivating forces (yes) Social religiosity (yes)
OR
Lower Upper
Depression
99.9% CI Sig.
OR
Lower Upper
99.9% CI Sig.
OR
Lower Upper
0.000g 0.470 0.002g 0.894 0.001g
Reference 0.53 0.36 1.12 0.73 1.84 1.03 0.996 0.24 2.36 1.29
0.70 1.67 3.92 3.063 4.32
0.534 0.631 0.338 0.787 0.036e
Reference 0.89 0.58 1.15 0.57 1.47 0.47 1.16 0.16 1.94 0.84
1.36 2.31 4.58 8.32 4.46
0.233 0.567 0.654 0.125 0.464
Reference 1.09 0.90 0.93 0.67 1.08 0.62 1.67 0.76 0.84 0.45
1.32 1.30 1.88 3.64 1.58
0.001g 0.01f 0.001g
0.77 0.56 0.70
0.64 0.31 0.57
0.92 1.02 0.85
0.02e 0.271 0.005f
1.29 0.68 0.76
1.62 0.30 0.54
1.97 1.56 1.06
0.014f 0.02e 0.08
1.10 1.34 0.88
0.93 0.96 0.73
1.30 1.84 1.07
Reference 0.50 0.36 1.10 0.73 1.70 0.94 0.92 0.30 2.22 1.20
0.69 1.65 3.05 2.85 4.18
0.562 0.612 0.346 0.943 0.075
Reference 0.88 0.57 1.12 0.56 1.39 0.45 1.00 0.13 1.77 0.70
1.34 2.24 4.31 7.80 4.13
0.543 0.584 0.354 0.894 0.075
Reference 1.78 0.88 .905 0.64 1.03 0.59 1.65 0.76 .816 0.43
1.31 1.26 1.80 3.61 1.54
0.64 0.31 0.57
0.92 10.02 0.85
0.01f 0.240 0.09
1.30 0.66 0.79
0.98 0.26 00.54
2.72 1.67 1.14
0.123 0.02e 0.224
1.10 1.34 0.91
0.93 0.96 0.76
1.31 1.86 1.11
Reference 0.49 0.36 1.09 0.72 1.68 0.92 1.03 0.34 2.27 1.23
0.69 1.66 3.05 3.12 4.17
0.458 0.624 0.376 0.802 0.052e
Reference 0.85 0.55 1.11 0.55 1.40 0.48 1.02 0.13 1.87 0.80
1.32 2.25 4.41 8.25 4.39
0.264 0.917 0.289 0.265 0.523
Reference 1.08 0.85 1.03 0.71 1.20 0.65 1.43 0.62 1.11 0.56
1.31 1.48 2.12 3.32 2.17
0.75 0.57 0.69
0.91 1.03 0.85
0.02e 0.315 0.08f
1.28 0.69 0.77
1.68 1.81 1.13
0.91 0.02e 0.01f
.1.01 1.34 0.83
1.21 1.91 0.99
Family, social connections, health behaviorc Religious affiliation Catholic Evangelic 0.000g Spiritism 0.425 Afro-Brazilian 0.01f Others 0.955 None 0.001g Religious change and transformation (yes) 0.001g Orienting, motivating forces (yes) 0.01e Social religiosity (yes) 0.001g Functional status and health conditionsd Religious affiliation Catholic Evangelic 0.001g Spiritism 0.476 Afro-Brazilian 0.013f Others 0.776 None 0.001g Religious change and transformation (yes) 0.001g Orienting, motivating forces (yes) 0.01f Social religiosity (yes) 0.001g
0.77 0.56 0.70
0.62 0.31 0.56
0.98 0.27 0.53
0.84 0.95 0.70
Notes: OR: odds ratio; CI: confidence interval. a Multivariate logistic regression; Wald 2 tests with df ⫽ 1. b Model 1: Adjusted for gender, age, ethnicity, education, income, and area of birth. c Model 2: Adjusted for Model 1 ⫹ family, social connections, and health behavior. d Model 3: Adjusted for Model 2 ⫹ functional status, vascular, respiratory, excretory, and osteoarticular problems. e p ⬍0.05. f p ⬍0.01. g p ⬍0.001.
mensions of religiosity were associated with a reduced frequency of using tobacco. Koenig et al.20 and Ahmed et al.19 report a similar finding for their U.S. samples. There has been criticism that the sole use of religious affiliation is too narrow a concept to study this issue.34 However, in the
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present study, even when other aspects of religiosity are controlled, with the exception of AfroBrazilian and none affiliation, being Evangelical seem to protect against tobacco use. We are aware that Evangelic regulations usually prohibit the use of tobacco, but it seems that other factors within
Am J Geriatr Psychiatry 16:11, November 2008
Blay et al. other religions may contribute to increase the use of tobacco such as the Afro-Brazilian affiliation. Our results did not confirm that religious affiliation reduces the odds of alcohol abuse or dependence.15,16 Further analysis found a positive association between alcohol abuse or dependence and other dimensions of religiosity such as those reporting not having religious affiliation and those who experienced a religious change. We are aware of behavior control, including avoidance of alcohol, in Evangelic belief, but this norm of conduct does not hold true in this study as well as for other religions which includes the use of wine in celebrations and does not prohibit appropriate use. Although further investigations is needed to study this problem, this unexpected finding suggests that the probable protective effect by religion with respect to alcohol abuse or dependence may be more prominent in younger age groups such as adolescents and adults.35 Religiosity has a more powerful relationship with current tobacco use than with alcohol abuse and dependence. Although there is some protection for Evangelicals, we have to consider other possibilities. Religious affiliation could be a response to tobacco use and used as a coping strategy to abstain from tobacco. The present study allowed to identify that alcohol abuse-dependence is associated with various factors. We observed that not having a religion or those who experienced a religious change are associated with contexts that facilitate unhealthy patterns of alcohol consumption. As indicated by other investigations, religiousness seems to be a factor of protection toward abusive consumption of alcohol and other drugs.15,16,23 This does not hold true in the present study. Within our settings, religion has an organized church-based network that is independent of other social networks. The religiously observant have a fairly structured life, featured mainly by attending regular religious services, planned activities and are under the antialcohol norms usually preached by Evangelicals and their social group. Elderly subjects with alcohol abuse and dependence may also, and in consequence, have impaired physical and social functioning. They may not be able to participate in the public aspects of religiosity because of increased need for transportation, personal support, and other issues, explaining, in part, the absence of potential benefits of religious domains. Research in Sa˜o Paulo,
Am J Geriatr Psychiatry 16:11, November 2008
Brazil to determine how the adult population views alcohol dependence and their emotional reactions to individuals with this disorder, showed that Evangelicals were among those most likely to report negative reactions toward such persons.36 This negative reaction may be an important motivation to handle these problems and may be effective in keeping people away from alcohol. However, this does not hold true within elderly Brazilians. We expected that older people with stronger religious association would be more likely to be protected against depression. In controlled analysis, we found that those who consider religion the most important life value (an indicator of the ‘orienting and motivating’ religious domain) were about 38% more likely to have depression whereas participating in social religious activities had reduced the risk of depression by 16%.Several previous reviews have shown a wide range of associations between religion and depression. Bergin7 reported that 23% of studies found a negative relationship, 47% a positive relationship, and 30% no relationship. Larson and Larson37 found 16% negative, 72% positive, and 12% no relationship. However, McCullough and Larson31 reported that “intrinsic religious motivation” may be the aspect of religiosity most protective for depressive disorders, and Smith et al.14 reported a positive relationship between religiosity and mental wellness. Research has shown that religion is an important source of support for older adults and that older subjects tend do be more religious.38 There is evidence that the subjective importance of religion generally increases among those who are dealing with serious illness. Religiosity has been found to be an important aspect in patients’ ability to cope with serious and chronic illness.39 According to our data, participating in social religious activities is important to protect against depression. Explanations for this type of association between religion and depression are potentially explained by the social interaction, social networks, possibility to change experiences, express feelings, plan activities, structure life rules, among others. One may consider that the relationship of depression and religion is not direct but rather mediated by many variables such as attention, cognition, lack of insight, acceptance of illness, sadness, culpability, anhedonia, nihilism, self-cure, personality traits, religiousness as a
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Religiosity and Tobacco, Alcohol Use, and Depression psychopathologic symptom, among others. We observed that those who consider religion as the most important life value increased the risk of being depressed. It is reasonable to suppose that depressive patients are angry with themselves, with others, and with God, for their suffering and functional impairment. Religion may have a negative effect on coping, which may be shown through an increase in feelings of culpability, guilt, and neurosis.40 In addition, depression and its relation with religion may also be mediated by the severity of the depressive state. Limitations This study has certain limitations. First, philosophical. We have tried to assess the immaterial, or to understand religiosity, or the ineffable, by means of the scientific methods. Methods of science may offer inept or inappropriate ways to understand religiosity. Second, the study is limited by the constraints of a cross-sectional design such as the exam of causaleffect associations. The religious information, as well as all other measures, was assessed at the same point in time and at only one point in time. Some information reflects current conditions, some reflects conditions that occurred earlier resulting in possible recall and social desirability bias. Religious beliefs and health conditions may change over time and under certain circumstances. Third, although our data establish association of religion with tobacco use, misuse of alcohol and depression, no causal relationship can be considered. Just as religion may modify the risk of getting an illness and change its course, the experience of illness may change the religious belief and behavior, or some other variable may affect both religiosity and disease. Fourth, even though the sample was large, the number of subjects for some religious affiliations, for religion as an orienting-motivating force, and for alcohol abuse and dependence was relatively small, reducing power to detect statis-
tical differences. Fifth, we sampled only community residents, deliberately excluding persons in hospitals or nursing homes, where prevalence of substance use and depression morbidity is likely to be different and probably higher. Sixth, the findings cannot be generalized beyond the study area. The widely differing cultural and socioeconomic backgrounds present in Brazil may not have been fully represented. Seventh, religious assessment and psychiatric assessment was based on a screening questionnaire and not on a comprehensive religious and psychiatric assessment interview. Eighth, depression in community subjects may have a fluctuating course. The cross-sectional nature of this investigation cannot capture this fluctuating state, and this may have affected the observed results. Ninth, severity of depression was not assessed. It is possible that affiliation and religion characteristics may have more effect on milder cases that may be associated with environmental strains than on conditions with a greater physical basis. However, in community studies, mild to moderate cases are expected to be more frequent. Nevertheless, present data indicate that after controlling for demographic, family, social connections, health behavior, functional and health characteristics factors, religious affiliation, and religiosity domains are independently involved in substance abuse and depression and may provide guidelines and facilitate healthful behaviors, although there may be limitations in the extent to which mental health can be modified. We thank Dr. Sergio Antoˆnio Carlos—President of the State Council of the Elderly (Conselho Estadual do Idoso) for allowing us to use the dataset of the “Elderly of RS—a multidimensional study of their living conditions” study. The authors thank Gerda G. Fillenbaum, Ph.D., for help with the manuscript. This work was supported by grants from Conselho Estadual do Idoso, Secretaria do Trabalho, Cidadania e Assisteˆncia Social; and by Governo do Estado do Rio Grande do Sul.
References 1. Koenig HG, McCullough M, Larson DB: Handbook of Religion and Health: A Century of Research Reviewed. New York, Oxford University Press, 2001 2. Koening HG, Hays JC, Larson DB, et al: Does religious attendance prolong survival? A six-year follow-up study of 3968 older adults. J Gerontol Med Sci 1999; 54A:M370 –M376 3. Sloan RP, Bagiella E, Powell T: Religion, spirituality, and medicine. Lancet 1999; 353:664 – 667
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4. Larson DB, Swyers JP, McCullough MI: Scientific Research on Spirituality and Health: A Consensus Report. Rockville, Md, National Institute for Healthcare Research, 1998 5. Hill PC, Hood RW Jr: Measures of Religiosity. Birmingham, AL, Religious Education Press, 1999 6. Hill PC, Pargament KI: Advances in the conceptualization and measurement of religion and spirituality. Implications for physical and mental health research. Am Psychol 2003; 58: 64 –74
Am J Geriatr Psychiatry 16:11, November 2008
Blay et al. 7. Bergin AF: Religiosity and mental health: a critical reevaluation a meta analysis. Prof Psychol 1983; 14:170 –184 8. Ferraro KF, Kelley-Moore JA: Religious consolation among men and women: do health problems spur seeking? J Sci Study Relig 2000; 39:220 –234 9. Husaini BA, Blasi AJ, Miller O: Does public and private religiosity have a moderating effect on depression? A bi-racial study of elders in the American South. Int J Aging Hum Dev 1999; 48:63–72 10. Braam AW, Deeg DJ, Poppelaars JL, et al: Prayer and depressive symptoms in a period of secularization: patterns among older adults in the Netherlands. Am J Geriatr Psychiatry 2007; 15:273–281 11. Van Ness PH, Larson DB: Religion, senescence, and mental health: the end of life is not the end of hope. Am J Geriatr Psychiatry 2002; 10:386 –397 12. Koenig HG: Religion and depression in older medical inpatients. Am J Geriatr Psychiatry 2007; 15:282–291 13. Yohannes AM, Koenig HG, Baldwin RC, et al: Health behaviour, depression and religiosity in older patients admitted to intermediate care. Int J Geriatr Psychiatry 2008; 23:735–740 14. Smith TB, McCullough ME, Poll J: Religiousness and depression: evidence for a main effect and the moderating influence of stressful life events. Psychol Bull 2003; 129:614 – 636 15. Kendler KS, Gardner CO, Prescott CA: Religion, psychopathology, and substance use and abuse; a multimeasure, genetic-epidemiologic study. Am J Psychiatry 1997; 154:322–329 16. Kendler KS, Liu XQ, Gardner CO, et al: Dimensions of religiosity and their relationship to lifetime psychiatric and substance use disorders. Am J Psychiatry 2003; 160:496 –503 17. Lotufo Neto F: Psiquiatria e religia˜o: a prevaleˆncia de transtornos mentais entre ministros religiosos [Psychiatry and religion: the prevalence of mental disorders among clergy]. [Thesis]. Sa˜o Paulo: Faculdade de Medicina, Universidade de Sa˜o Paulo, 1997. Available at: http://www.teses.usp.br/. Accessed September 25, 2007 18. Almeida AM: Fenomenologia das experieˆncias mediu ´ nicas, perfil e psicopatologia de me´diuns espı´ritas. [Phenomelogy of Mediumistic Experiences, Profile and Psychopathology of Spiritist Mediums]. [Thesis]. Sa˜o Paulo: Faculdade de Medicina, Universidade de Sa˜o Paulo, 2004. Available at: http://www.teses.usp.br/. Accessed September 25, 2007 19. Ahmed F, Brown DR, Gary LE, et al: Religious predictors of cigarette smoking: findings for African American women of childbearing age. Behav Med 1994; 20:34 – 43 20. Koenig HG, George LK, Cohen HJ, et al: The relationship between religious activities and cigarette smoking in older adults. J Gerontol A Biol Sci Med Sci 1998; 53:M426 –M434 21. Dalgalarrondo P, Soldera MA, Correa Filho HR, et al: Religion and drug use by adolescents. Rev Bras Psiquiatr 2004; 26:82–90 22. Tavares BF, Beria JU, Lima MS: Factors associated with drug use among adolescent students in southern Brazil. Rev Sau ´ de Pu ´ blica 2004; 38:787–796
Am J Geriatr Psychiatry 16:11, November 2008
23. Barros MB, Botega NJ, Dalgalarrondo P, et al: Prevalence of alcohol abuse and associated factors in a population-based study. Rev Saude Publica 2007; 41:502–509 24. Sanchez ZV, Oliveira LG, Nappo SA: Fatores protetores de adolescentes contra o uso de drogas com eˆnfase na religiosidade [Protective factors from adolescents against drug use emphasizing the role of religiosity]. Cienc Saude Coletiva 2004; 9:43–55 25. Blay SL, Andreoli SB, Fillenbaum GG, et al: Depression morbidity in later life: prevalence and correlates in a developing country. Am J Geriatr Psychiatry 2007; 15:790 –799 26. Ulman C: The Transformed Self: The Psychology of Religious Conversion. New York, Plenum, 1989 27. Gorsuch RL, Venable GD: Development of an “ age universal” I-E scale. J Sci Study Relig 1983; 22:181–187 28. Hasin DS, Grant B, Endicott J: The natural history of alcohol abuse: implications for definitions of alcohol use disorders. Am J Psychiatry 1990; 147:1537–1541 29. Blay SL, Ramos LR, Mari JJ: Validity of a Brazilian version of the Older Americans Resources and Services (OARS) mental health screening questionnaire. J Am Geriatr Soc 1988; 36:687– 692 30. Pfeiffer E: A short psychiatric evaluation schedule. A new 15-item monotonic scale indicative of functional psychiatric disorder, in Brain Function in Old Age. Bayer Symposium 1979, vol. 22, pp 228 –236 31. McCullough ME, Larson DB: Religion and depression: a review of the literature. Twin Res 2001; 2:126 –136 32. Hosmer DW, Lemeshow S: Applied Logistic Regression. New York, Wiley, 1989 33. Fleiss JL, Williams JPW, Dubro AF: Logistic regression of psychiatric data. J. Psychiatr Res 1986; 20:145–209 34. Miller WR, Thorensen CE: Spirituality, religion, and health. An emerging research field. Am Psychol 2003; 58:24 –35 35. Rachal JV, Maisto SA, Guess LL, et al: Alcohol use among youth, in Alcohol Consumption and Related Problems. Edited by The National Institute on Alcohol Abuse and Alcoholism. Washington, DC, US Government Printing Office, 1982, pp 55–95 36. Peluso Ede TP, Blay SL: Public perception of alcohol dependence. Rev Bras Psiquiatr 2007; 30:19 –24 37. Larson DB, Larson SS: The Forgotten Factor in Physical and Mental Health: What Does the Research Show? An Independent Study Seminar. Rockville, Md, National Institute for Healthcare Research, 1994 38. Koenig HG, Larson DB, Mathews DA: Religion and psychotherapy with older adults. J Geriatr Psychiatr 1996; 29:155–184 39. Pargament KJ: The Psychology of Religion and Coping: Theory, Research, Practice. New York, Guilford, 1997 40. Freud S: O futuro de uma ilusa˜o (Future of an illusion). Edic¸˜ao Standard Brasileira das Obras Psicolo ´gicas Completas de Sigmund Freud.Vol XXI. Imago Editora. Rio de Janeiro, 1927, pp 15– 63
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