Religion, Congestive Heart Failure, And Chronic Pulmonary Disease
Journal of Religion and Health, Vol. 41, No. 3, Fall 2002 ( 2002)
HAROLD G. KOENIG
ABSTRACT: Objective: To examine the prevalence of religious beliefs and practices in hospi-
talized patients with congestive heart failure (CHF) or chronic pulmonary disease (CPD), and
determine relationships with physical and mental health. Methods: Subjects were a consecutive
sample of 196 patients age 55 or over admitted to Duke University Medical Center with a diag-
nosis of CHF or CPD. Patients underwent a 60–90 minute interview and physical exam to assess
physical health, social support, mental health, religious activities and attitudes (attendance,
prayer and scripture study, intrinsic religiosity). Results: Religious practices were widespread;
98% had a religious affiliation; 48% reported attending religious services weekly or more; 70%
reported praying or reading religious scriptures at least daily; and over 85% consistently indi-
cated intrinsic religious beliefs and attitudes. Religious activities and attitudes were inversely
related to measures of physical illness severity and functional disability, and were less common
among patients with prior psychiatric problems, hospitalizations for depression, drinking prob-
lems, and those currently taking psychotropic drugs. Religious activities (especially religious
attendance) were associated with greater social support, but were only weakly related to less
depression. Conclusions: Religious beliefs and activities are common among patients with CHF
and CPD, are associated with less severe illness and functional disability, fewer prior psychiatric
problems, and less psychotropic drug use. Treatment implications are discussed.
KEY WORDS: religion; spirituality; congestive heart failure; chronic pulmonary disease.
An international health study conducted by the World Health Organization
and the World Bank in conjunction with Harvard medical school, concluded
that the largest health problems of the next quarter-century will be chronic
conditions that affect the elderly.1 By the year 2020, they predict that heart
disease will be the most disabling health condition and chronic lung disease
will be the world’s greatest killer.
In the United States alone there are an estimated 5 million people living
with congestive heart failure (CHF), with up to 700,000 incident cases devel-
oping annually.2,3 Over the next decade, due to the aging of the population and
Dr. Harold Koenig is Associate Professor of Psychiatry and Associate Professor of Medicine at
the Duke University Medical Center and the GRECC, VA Medical Center in Durham, N.C.
263 2002 Blanton-Peale Institute
264 Journal of Religion and Health
improvements in survival of patients with CHF, the prevalence of that dis-
ease will increase by 2–3 fold.3 Heart failure is often considered a terminal
illness that outside of heart transplantation has no hope for cure; 1-year and
5-year mortality rates are 20% and 50%, respectively.4,5 Patients with CHF
are frequently in and out of the hospital, with readmission rates ranging from
40% to 57%.6,7
Chronic pulmonary disease (CPD) is likewise prevalent and disruptive to
life. In 1998, the National Health Interview Survey estimated that 9 million
Americans reported a diagnosis of chronic bronchitis within the past year.8
While death rates from chronic illnesses such as stroke and heart disease are
decreasing, the death rate is increasing for CPD. Between 1979 and 1993, the
age-adjusted death rate for chronic obstructive pulmonary disease increased
by 14% among men and by 122% among women.9
Most patients with heart failure and chronic lung disease fight a difficult
battle with dependency, suffocating physical symptoms, and poor quality of
life. The end result is a high rate of emotional distress due to inability to
cope.10-13 These negative emotions adversely affect cardiac rehabilitation and
contribute to difficulties and delays in returning to normal activity.14 In CHF,
negative emotions can increase the risk of further heart damage, which may
then contribute to the development or worsening of heart failure.15,16 In CPD,
depression is frequently correlated with disability and poor functioning, and
appears to impede pulmonary rehabilitation.12,17
Because of the devastating psychological, physical and social impairments
caused by CHF and CPD, it is important to identify beliefs and behaviors
that enable patients to cope better with these conditions. Religious involve-
ment has been associated with less depression and improved coping in pa-
tients with other chronic health conditions.18-22 No study, however, has yet
examined the religious behaviors and attitudes of patients with CHF and
CPD, nor has any addressed the role they play in adaptation to illness.
This study sought to answer several questions about the relationship be-
tween religion and health in patients with CHF or CPD. First, how wide-
spread are religious beliefs and practices in this population? Second, are cer-
tain religious practices associated with greater severity of illness, whereas
others associated with less severe illness? Third, is religious involvement as-
sociated with greater social support and less depression, as might be ex-
pected based on previous research in medical populations? Fourth, will reli-
gious activities be more common among those with a history of psychiatric
problems, substance abuse, or a family history of psychiatric problems, be-
cause of a connection between religion and psychopathology (e.g., religion ei-
ther causing psychiatric problems or resulting from them)? Finally, will reli-
gious beliefs and practices be more or less common among persons who have
received or are receiving psychiatric treatment (psychotropic drugs or psy-
Harold G. Koenig 265
Procedure. Between February and July 1998, a consecutive series of pa-
tients age 55 or over admitted to the general medicine service at Duke Uni-
versity Medical Center with a diagnosis of either CHF or CPD (chronic ob-
structive lung disease, emphysema, asthma, etc.) were identified for study
participation. Patients were excluded from the study for the following rea-
sons: severe physical illness, delirium, or dementia precluded psychological
testing; inability to communicate because of aphasia, tracheostomy, or severe
hearing loss; gone for a medical or surgical procedure, could not be located,
died, was discharged before seen, or otherwise not interviewable; and if fam-
ily, nurse, housestaff, or attending physician failed to give consent or pre-
vented the interview. After obtaining written informed consent from the pa-
tient, a research nurse conducted a 60–90 minute interview in the patient’s
room, completed a brief physical exam, and reviewed the medical record.
Measures. Religion. Religious affiliation was categorized into none, agnos-
tic, atheist, Presbyterian, Lutheran, Episcopalian, Methodist, Baptist, Pen-
tecostal, Assembly of God, other fundamentalist, other Protestant, Catholic,
Mormon, other non-traditional Christian, and Jewish.23 A question about
years of affiliation with the denomination was also asked. Public religious
activity was measured using a single item of religious attendance (How often
do you attend church or other religious meetings?), with six response options
ranging from never to more than once a week. Private religious activity was
measured with a single item (How often do you spend time in private reli-
gious activities, such as prayer, meditation, or Bible study?), with six re-
sponse options ranging from rarely or never to more than once a day. Intrinsic
religiosity (assessing depth of religious faith) was assessed using the 10-item
Physical Health. Both subjective and objective measures were used. Physi-
cal functioning was assessed with the Duke Activity Status Index (DASI)26
and the Specific Activity Scale (SAS).27 The DASI is a 12-item self-report
questionnaire that measures functional capacity in patients with CHF or
CPD. It has been validated in subjects undergoing exercise testing and is
correlated with peak oxygen uptake (Spearman correlation 0.80). The items
largely involve activities of daily living such as personal care, ambulation,
household tasks, sexual function and recreational activities. The SAS is a 21-
item self-report questionnaire that asks about activities of daily living that
are used to calculate metabolic equivalent tasks (METs) in patients with
chronic heart disease; this instrument is used widely to determine New York
Heart Association class.
The final subjective measure of physical health was Guyatt’s Chronic Heart
266 Journal of Religion and Health
Failure and Respiratory Disease Questionnaire,28,29 a disease-specific measure
that assesses three domains of functioning (dyspnea, fatigue, and emotional
function). The dyspnea subscale (the only domain assessed in this study) ex-
amines shortness of breath in the past two weeks while performing the five
activities most important to the patient. Each item of the Guyatt Dyspnea
Scale (GDS) is rated by the patient on a 1 to 7 scale from “extremely short of
breath” to “not at all short of breath.”
Objective global measures of physical illness severity were the Charleson
Comorbidity Index (CCI),30 the Cumulative Illness Rating Scale (CIRS),31 the
American Society of Anesthesiologists (ASA) severity of illness scale,32 and
New York Heart Association Classification (NYHC).33 The CCI was used to
assign “weights” to each of 31 possible active medical diagnoses in order to
determine a total comorbidity score for each patient; this comorbidity score
strongly predicts 1-year mortality. The CIRS is a clinician-rated 12-item mea-
sure that assesses severity of impairment of the body’s 12 major organ sys-
tems (cardiac, vascular, respiratory, gastrointestinal, hepatic, renal, etc.), rating
each on a 0 to 4 scale from none to extremely severe. Inter-rater reliability is
high (Kendall’s W 0.83 to 0.91, based on independent ratings of 20 patients by
six physicians), and CIRS scores have been validated at autopsy as an indica-
tor of total physical illness burden.34 The ASA is a single item clinician-rated
scale that assesses overall illness severity on a 1 to 5 scale; like the other
scales, it is a strong predictor of mortality in hospitalized patients.
Finally, the NYHC is a common measure of clinical severity and prognosis
in patients with CHF. Patients were placed into four NYHA functional classes
(I–IV) based on subjective symptoms and into four classes (A–D) based on
objective results from ECGs, stress tests, x-rays, echocardiograms, radiologic
images, etc., as recommended by the NYHA classification guide.
Social and Mental Health. The 11-item version of the Duke Social Support
Index (DSSI) assesses two major components of social support—social net-
work and subjective support.35 This version was developed specifically for use
in chronically ill elders and differs from the full 35-item version primarily by
not containing the social interaction and instrumental support subscales.36
Past psychiatric history was assessed by five questions that asked about
prior mental or nervous disorder requiring treatment, mental health visits,
hospitalizations for the treatment of depression, and history of problems due
to drinking alcohol. In addition, patients were asked about current psycho-
tropic drug use, and more specifically, about antidepressant use. Family psy-
chiatric history was determined by five questions asking about the presence
of any blood relatives (parents, siblings, children, grandchildren) who had a
mental or nervous disorder, were admitted to a mental or psychiatric hospi-
tal, took nerve medication for three months or longer, attempted or commit-
ted suicide, or had problems due to drinking alcohol or drug abuse. Yes to any
of these questions resulted in the patient being categorized as having a posi-
tive family psychiatric history.
Harold G. Koenig 267
Depression was measured in terms of both symptoms and diagnosis. The
research nurse (trained in psychiatric diagnosis) administer a structured in-
terview based on the Diagnostic Interview Schedule (DIS)37 that identified the
presence or absence of nine symptoms of major depression and whether or not
there was associated impairment of social or occupational functioning. Based
on this interview, diagnoses of major or minor depression based on DSM-IV
criteria were made.38 In addition, the research nurse completed the observer-
rated 17-item Hamilton Depression Rating Scale (HDRS)39 to determine symp-
Statistical Analyses. Relationships between religious activities and health
measures were examined using linear regression when dependent variables
were continuous and logistic regression when dependent variables were di-
chotomous. All analyses were controlled for age, gender, ethnicity, and educa-
tion. Standardized betas and odds ratios were calculated. Frequency of public
and private religious activities was dichotomized to once/week or more vs.
less than once/week (attendance) and once/day or more vs. less than once/day
(prayer and Bible study) for analyses involving the calculation of odds ratios.
A total of 276 patients met inclusion criteria during the study period and
were asked to participate. Of those, 196 completed the interview and 83 re-
fused to participate (71% adjusted response rate). Comparison of these two
groups revealed that those who refused tended to be older (71.8 vs. 68.3
years, p .02), African-American (74.2% vs. 26.0%, p .0001), and diag-
nosed with CPD (65.1% vs. 45.3%, p .001). There were no significant differ-
ences between those who refused and those who participated in terms of gen-
der, severity of illness, or length of hospital stay prior to being approached for
The average age of the final sample was 69.3 years (SD 8.3); average educa-
tion was 11.1 years (SD 4.0); and 55.6% were women and 69.9% Caucasian.
Physical health, social and mental health characteristics of the sample are
described in Table 1. Approximately half of the patients had a primary diag-
nosis of CHF and the other half had CPD, with 10% having both diagnoses
present. Most patients had moderate to severe illness (ASA score 3.6), and
of those with CHF, two-thirds (66.4%) were categorized as NYHC III or IV.
With regard to mental health, about one-fourth of patients had a prior history
of mental or nervous disorder requiring treatment and 45% had a history a
psychotropic drug use. Major depression was present in 28% of the sample,
and minor depression in about 11%.
How widespread are religious beliefs and practices in this population? As
described in Table 2, nearly 98% of the sample indicated an affiliation was
some religious group. Approximately half of the sample was Baptist, which is
268 Journal of Religion and Health
Physical and Mental Health Characteristics of the Sample
(SD) / % (N)
Duke Activity Status Index, range 12–36 17.2 (SD 5.1)
Specific Activity Scale, range 21–42 24.2 (SD 4.4)
Guyatt Dyspnea Scale, range 5–35 14.9 (SD 6.0)
Diagnosis, % with CHF 54.7% (107)
Cumulative Illness Rating Scale, range 0–48 11.1 (SD 5.2)
ASA Severely of Illness Scale, range 1–5 3.6 (SD 0.7)
New York Heart Association class (functional capacity), 66.4% (79 of 119)
III and IV
New York Heart Association class (objective assessment), 79.2% (95 or 120)
C and D
Social Support, range 11–33 26.8 (SD 4.3)
History of mental or nervous disorder requiring treat- 27.5% (52)
Past hospitalization for depression treatment, yes 5.3% (10)
History of drinking problems, yes 10.6% (20)
History of psychotherapy/counseling, yes 28.7% (54)
History of psychotropic use, yes 44.6% (83)
Current psychotropic drug use (any), yes 52.9% (55 of 104)
Current antidepressant use, yes 27.2% (25 of 92)
Family psychiatric history, yes 66.7% (124)
Major Depression, yes 27.6% (54)
Hamilton Depression Rating Scale, range 0–52 12.0 (SD 8.4)
N’s vary by 10% or less, except where noted.
similar to the older adult population of central North Carolina. The majority
of participants had been affiliated with a religious group for most of their
adult lives (average 49 years). Despite relatively severe medical illness and
functional disability, nearly half (48%) reported attending religious services
at least once a week or more. Likewise, private religious activities were com-
mon with over 70% indicating such practices daily or more frequently. Intrin-
sic religious attitudes were also widespread, with over 85% of the sample
consistently indicating “tends to be true” or “definitely true” to intrinsic state-
ments. For example, 87% indicated that religious faith “involves all of my
Harold G. Koenig 269
Religious Characteristics on the Sample (n 196)1
% (N) or
None, Agnostic, Atheist 2.1% (4)
Other Protestant 7.4% (14)
Presbyterian, Lutheran, Episcopalian 8.9% (17)
Methodist 13.7% (26)
Baptist 47.4% (90)
Pentecostal, Assembly of God, other fundamentalist 13.2% (25)
Catholic 4.7% (9)
Mormons & non-traditional Christian 1.6% (3)
Jewish 1.1% (2)
Years associated with denomination 49.3 (SD 22.2)
Attendance at Religious Services (once/week or more) 48.1% (92)
Participation in Prayer or Bible study (once/day or more) 70.2% (134)
Intrinsic Religiosity (% indicating definitely true or tends
to be true)
Faith involves all of my life 86.8% (164)
I experience presence of God in my life 89.9% (169)
I refuse to let religious considerations influence my life 34.4% (65)
There is nothing as important as serving God 91.0% (172)
My faith sometimes restricts my actions 69.8% (132)
Religious beliefs lie behind whole approach to life 87.8% (165)
Try hard to carry religion into other activities in life 86.2% (163)
Should seek God’s guidance in every decision 93.1% (176)
There are more important things in life than religion 32.8% (62)
Beliefs don’t matter; only living a moral life matters 49.2% (93)
N’s vary by less than 5%.
E Extrinsic statements (in contrast to Intrinsic statements).
life,” 88% that religious beliefs are “what really lie behind my whole approach
to life,” 91% that “nothing is as important to me as serving God as best I
know how,” and 93% that “one should seek God’s guidance when making
every important decision.”
Religious variables were correlated with one another. Religious attendance
was only modestly associated with private religious activities (Pearson
270 Journal of Religion and Health
r 0.26) and more strongly with intrinsic religiosity (r 0.38). The stron-
gest correlation was between private religious activities and intrinsic reli-
giosity (r 0.47).
Are certain religious practices associated with greater severity of illness,
whereas others associated with less severe illness? Table 3 provides the results
of regression analyses that examined the associations between the three ma-
jor religious variables (public, private, and intrinsic religiosity) and physical,
social, and mental health measures. All analyses were controlled for age, gen-
der, ethnicity and education.
Religious attendance was inversely related to overall severity of illness
(ASA) (beta 0.19) and both measures of NYHA class (beta 0.22 for
functional capacity and beta 0.20 for objective assessment); there was
also a weak inverse relationship with shortness of breath (Guyatt Dyspnea
Subscale). Private religious activities were also inversely related to physical
functioning as measured by the DASI (beta 0.15) and by NYHA func-
tional class (beta 0.19). Intrinsic religiosity was inversely related to
shortness of breath measured by the Guyatt scale (beta 0.15). Thus, in
general, religious activities and intrinsic religious attitudes were inversely
related to severity of the medical illness, level of physical functioning, and
perceived shortness of breath.
Analyses were performed in order to test whether religious practices mod-
erated the relationship between objective physical illness severity and self-
reported disability. In other words, did any given level of objective medical
illness cause as much functional disability (measured subjectively) in highly
religious patients as it did in less religious patients? Regression analyses
were done with self-reported disability (measured by the DASI and SAS) as
the dependent variable and objective illness severity (measured by the CIRS
and CCI) as the independent variables, controlling for demographics. Public,
private, and intrinsic religiosity were then entered into successive models to
see whether these variables could explain some of the variance in the rela-
tionship between objective severity and perceptions of disability. Results (not
shown) indicated that religious variables did not moderate the relationship
between physical illness severity and level of self-reported disability to any
Is religious involvement associated with greater social support and less de-
pression? Religious attendance was positively related to social support (beta
0.21, p .01), and trends were in a similar direction for private religious
activities and intrinsic religiosity. While relationships between religious vari-
ables and both depressive symptoms and diagnoses of major depression were
in the expected direction, they were weak and did not reach statistical signifi-
cance. Was this relationship confounded by severity of the patients’ medical
illnesses? Controlling for physical illness severity (CIRS and CCI) and self-
reported disability (DASI and SAS) (analyses not shown) did not substan-
tially strengthen the weak inverse relationships between religious variables
Harold G. Koenig 271
Relationship Between Religious Activities and Health Measures
Religious Private Religious Intrinsic
Health Measure Attendance Activities Religiosity
Physical Health Beta1 Beta Beta
Duke Activity Status Index
(ADLs) 0.10 0.15* 0.02
Specific Activity Scale (ADLs) 0.11 0.09 0.04
Guyatt Dyspnea Scale (SOB) 0.14 0.04 0.15*
Cumulative Illness Rating
Scale 0.08 0.08 0.05
ASA Severely of Illness Scale 0.19* 0.04 0.06
NYHA class (functional
capacity) 0.22* 0.19* 0.09
NYHA class (objective assess) 0.20* 0.02 0.02
Mental Health Odds1 Odds Odds
Past psychiatric history 0.77 0.37** 0.97
Past hospitalization for
depression 0.11* 0.27 0.91*
History of drinking problems 0.60 0.36 0.90**
History of psychotherapy 1.36 0.77 0.98
History of psychotropic use 0.83 0.99 1.00
Current antidepressant use2 0.58 0.52 1.00
Current psychotropic drug
(any)3 0.48 0.89 0.99
Family psychiatric history 0.86 1.90 0.98
Major Depression 0.78 0.67 0.97
Beta Beta Beta
Hamilton Depression Rating
Scale 0.14 0.05 0.09
Social Support 0.21** 0.16 0.13
Standardized beta (Beta) from linear regression model; Odds Ratio (OR) from logistic regression
model (religious variables dichotomized for these analyses); ADL Activities of Daily Living;
SOB Shortness of Breath.
25 current users compared to 66 past users.
55 current users compared to 48 past users.
.05 p .10, *p .05, **p .01 (controlled for age, gender, ethnicity, education).
272 Journal of Religion and Health
and depression, although there was a trend for private religious activities in
that direction. The standardized beta relating prayer and Bible study to de-
pressive symptoms (HDRS) increased from 0.05 to 0.11 (.05 p .10)
when physical health variables were controlled. Likewise, the likelihood of
major depression in patients who prayed or read religious scriptures at least
daily compared to those who prayed less often dropped from 33% less likely
(OR 0.67) to 49% less likely (OR 0.51, p .10).
Will religious activities be more common among those with prior psychiatric
problems, substance abuse, or a family psychiatric history? A history of prior
treatment for mental or nervous disorder tended to be less common among
those were more religiously involved, particularly for private religious activ-
ities. Subjects who prayed or studied the Bible daily or more were 63% less
likely to report prior psychiatric problems than did those less frequently en-
gaged in private religious activities (OR 0.37, p .01). A history of hospi-
talization for depression was also less common among the more religious.
Such hospitalization was 89% less likely among those who attended religious
services weekly or more, compared to those who attended less often (OR
0.11); was 73% less likely in those who prayed or studied the Bible daily or
more (OR 0.27), compared to those who prayed less often; and was 9% less
likely for every point higher on the 50-point intrinsic religiosity measure
(OR 0.91). Similarly, a history of drinking problems was less frequent
among those who prayed or studied the Bible frequently or who scored higher
on intrinsic religiosity. A history of family psychiatric problems tended to be
more common among those who prayed or studied the Bible frequently, al-
though this did not reach statistical significance.
Will religious beliefs and practices be more or less common among persons
who have received or are receiving psychiatric treatment? There was also a
weak relationship between religious attendance and current psychotropic
drug use, with those attending religious services frequently being less likely
to take such drugs, but again this did not reach statistical significance. There
was no indication that psychotropic drug use or psychotherapy in the past
was less common among those who were more religious (despite the fact that
a history of psychiatric problems tended to be less common among the reli-
This is the first study to examine the prevalence of religious activities and
attitudes in persons hospitalized with CHF or CPD, and then relate these
religious behaviors to physical and mental health. Religious practices were
widespread in this population. Almost all patients (98%) were affiliated with
some religious group, nearly one-half reported attending religious services
weekly or more often despite health problems, and over 70% indicated they
Harold G. Koenig 273
prayed or studied the Bible daily or more often. It is not a great leap from
here to conclude that many of these religious activities were directed at help-
ing patients cope with the stress of their medical conditions. An earlier study
at this same hospital directly asked 331 patients whether or not religion was
used to cope with illness; nearly 90% indicated it was (and over 40% indicated
religious beliefs and activities were the most important and effective coping
behaviors they used).22
Religious involvement in the present study was inversely related to severe
physical illness, dyspnea, and physical disability. This was especially true for
religious attendance. The most obvious explanation is that those who were
sicker were physically unable to attend religious services. In other words,
their illnesses prevented them from going. Alternatively, religious attendance
may have helped to prevent the progression of disease and onset of disability,
as Idler and Kasl found in a community sample of nearly 3000 older adults.40
While physical disability in the short-term prevented religious attendance,
the effect of religious attendance on preventing disability overtime was con-
siderably stronger in that study.
Private religious activities and intrinsic religious attitudes in the present
study also tended to be associated with less functional disability and short-
ness of breath. The latter finding is somewhat unexpected, given previous
reports linking more severe illness with increased turning to religion for so-
lace.25,41 Private religious activities such as prayer, meditation, and scripture
study, however may provide a sense of comfort and peace that enabled pa-
tients with CHF or CPD to relax and function better. This would be consis-
tent with a considerable body of literature showing a relationship between
prayer or meditation and lower anxiety.42,43 In a study of 4000 community-
dwelling older adults in the North Carolina area, Haley and colleagues also
found that persons who did not pray had the highest level of disability, com-
pared to those who prayed more often.44 In the present study, however, pri-
vate religious activities did not appear to reduce the disability associated
with severe physical illness, as Idler found.45,41
With regard to mental health, religious activities (especially religious at-
tendance) were associated with greater social support. While social support
was related to less depression (analyses not shown), there was only a weak
and statistically non-significant relationship between religious variables and
fewer depressive symptoms or lower rates of depressive disorder. This finding
contrasts with reports from other studies indicating a significant inverse rela-
tionship between religious activities and depression, both in community-
dwelling older populations46,47 and in clinical samples.18,19 One explanation for
our failure to replicate that find might have been that severe medical illness
confounded the relationship between religion and depression. Controlling for
physical illness severity and functional disability, however, did not substan-
tially strengthen the inverse relationship between religious activities and de-
pression. The only exception was for private religious activities, although the
274 Journal of Religion and Health
effect was small. When physical illness was controlled, the inverse correlation
between private religious activities and depressive symptoms (HDRS) in-
creased from 0.05 to 0.11; likewise, compared to those praying less fre-
quently, the odds of major depression among those praying at least daily
dropped from 0.67 (33% less likely) to 0.51 (49% less likely).
Religious involvement was also associated with fewer past psychiatric prob-
lems, especially prior hospitalizations for depression and problems with alco-
hol. It is possible that religious activities and attitudes helped to prevent the
development of these psychiatric problems. It is equally possible, however,
that psychiatric problems interfered with the development of religious atti-
tudes and activities. Unfortunately, the present study provides no informa-
tion on whether religious involvement preceded or followed psychiatric prob-
lems. As noted earlier, however, psychological stress in general tends to
increase religious activities, not decrease them, as people turn to religion to
help them to cope. Studies have also shown that intrinsic religious attitudes
help to speed the resolution of episodes of depression and improve adaptation
to stress over time.46,48,49
With regard to family psychiatric history, there was little connection with
religious attendance or intrinsic religious attitudes, although a weak trend
did emerge for private religious activities such as prayer. Those who fre-
quently prayed or studied religious scriptures were 90% more likely to have a
family history of psychiatric problems. This finding is consistent with other
research in hospitalized medical patients that has found a significant associa-
tion between religious coping and family psychiatric history.19 One explana-
tion might be that private religious activities are used to cope with the diffi-
culties of growing up in a chaotic home, and then turned to as a coping
behavior when they become seriously ill later in life.
Finally, there was some suggestion that frequent religious attendance was
associated with less current psychotropic drug use, which goes along with a
lower likelihood of being hospitalized for depression in the past. Again, how-
ever, this was a weak non-significant trend, and there was no evidence that
past psychotropic drug use or psychotherapy was less common among those
who were more religious. Thus, in general, religious involvement does not
substantially deter medical patients with CHF or CPD from seeking psychi-
Summary and treatment implications. CHF and CPD have an enormous
impact on quality of life for both the patient and family. Nearly 30% of pa-
tients in this study experienced major depressive disorder, similar to esti-
mates from other studies.10,11 Over 70% of patients prayed or read religious
scriptures daily or more often, and studies of similar populations report such
activities are used to cope with stress caused by medical problems. Although
not demonstrated as clearly in this study as in others, religious behaviors
Harold G. Koenig 275
have generally been associated with less anxiety, less depression, and better
Clinicians should be aware of just how common religious belief and prac-
tices are in patients with chronic heart and lung problems, not just because of
their utility in coping with illness, but because such beliefs may have a major
impact on medical decision-making. Ehman and colleagues surveyed 177 con-
secutive adult outpatients visiting the pulmonary clinic at the Hospital of the
University of Pennsylvania, asking how patients felt about physicians ad-
dressing spiritual or religious issues.50 Nearly half of patients (45%) indicated
that religious beliefs would influence their medical decisions if they became
gravely ill. Of those patients, 94% agreed that physicians should ask patients
about their religious beliefs in that setting (even 45% of respondents who
denied such beliefs thought the physician should ask patients about them).
Only 15% of subjects, however, recalled having been asked about spiritual or
religious beliefs that might impact their medical decisions.
Thus, taking a brief spiritual history on patients hospitalized with serious
cardiac or pulmonary disease is probably a good idea. While there is not uni-
form agreement that clinicians should inquire about religious or spiritual
needs in medical settings,51 there is a growing consensus that these issues
ought to be addressed. A consensus panel of the American College of Physi-
cians52 recently suggested the following questions: “Is faith (religion, spiritu-
ality) important to you in this illness?”; “Has faith been important to you at
other times in your life?”; “Do you have someone to talk to about religious
matters?”; and “Would you like to explore religious matters with someone?”
Such questions are best asked as part of the social history.
Limitations. The present study has a number of limitations. First, the
study took place in central North Carolina that is part of the Bible Belt.
These findings may not generalize to other areas of the country where reli-
gion is less prevalent. Religious beliefs and practices, however, are wide-
spread across the United States according to Gallup polls conducted since
1939, and prevalence of religious activities reported in this study are not
greatly different from national figures for older adults reported by the Gallup
organization (96% belief in God, 43% weekly religious attendance, 80% mem-
ber of a church or synagogue).53 Second, it is possible that religious patients
were more likely to agree to participate in the study, thus increasing the
religiousness of the sample. There is evidence that religious patients may be
more cooperative in general than nonreligious patients.54 An examination of
subjects who refused to participate in the present study, however, revealed
that they were more likely to be older and African-American—characteristics
usually associated with greater religious involvement (thus lowering the reli-
giousness of our sample). These potential biases, then, may have canceled
each other out. Third, the correlations with physical and mental health re-
276 Journal of Religion and Health
ported here were relatively weak, and multiple comparisons were made. The
direction of results, however, was relatively consistent across measures.
In conclusion, religious beliefs and practices are common among patients
with CHF and CPD. Religion is often used by patients with serious illness to
help them cope with their diseases and may have a significant impact on
medical decisions made while in the hospital. It is recommended that clini-
cians take a brief spiritual history to identify spiritual needs of patients with
illnesses like these that seriously impair quality of life.
Funded by NIMH grants MH01138 and MH57662, and by the John Tem-
pleton Foundation, Radnor, Pennsylvania, grant 517.
1. Murray C. Global Burden of Disease. Cambridge, MA: Harvard University Press, 1996.
2. American Heart Association. 2001 Heart and Stroke Statistical Update. Dallas, Texas: Amer-
ican Heart Association, 2000.
3. HFSA guidelines for management of patients with HF caused by LV systolic dysfunction:
Pharmacological approaches. J Cardiac Failure 1998; 5:357–382.
4. Cohn JN, Rector TS. Prognosis of congestive heart failure and predictors of mortality. Am J
Cardiol 1988; 62:25A-30A.
5. Schocken DD, Arrieta MI, Leaverton PE, Ross EA. Prevalence and mortality rate of conges-
tive heart failure in the United States. J Am College Cardiol 1992; 20:301–306.
6. Gooding J, Jette AM. Hospital readmissions among the elderly. J Am Geriatr Soc 1985;
7. Vinson JM, Rich MW, Spery JC, Shah AS, McNamara T. Early readmission of elderly pa-
tients with congestive heart failure. J Am Geriatr Soc 1990; 38:1290–1295.
8. National Center for Health Statistics. Raw Data from the National Health Interview Survey,
U.S., 1998 (Analysis by the American Lung Association Best Practices Division, Using SPSS
an SUDAAN software).
9. Center for Disease Control and Prevention, National Center for Health Statistics, Health,
United States, 1995. DHHS Pub. No. (PHS) 96-1232. Hyattsville, MD, May 1996
10. Koenig HG. Depression in elderly patients with congestive heart failure. Gen Hosp Psychia-
try 1998; 20:29–43.
11. Freedland KE, Carney RM, Rich MW, Caracciolo A, Krotenberg JA, Smith LJ, Sperry J.
Depression in elderly patients with congestive heart failure. J Geriatr Psychiatry 1991; 24
12. Agle DP, Baum GL, Chester EH, Wendt M. Multidiscipline treatment of chronic pulmonary
insufficiency: psychologic aspects of rehabilitation. Psychosom Med 1973; 35:41–49.
13. McSweeney AJ, Grant I, Heaton RK, Adams KM, Timms RM. Life quality of patients with
chronic obstructive pulmonary disease. Arch Intern Med 1982; 142:473–478.
14. Finnegan DL, Suler JR. Psychological factors associated with maintenance of improved
health behaviors in postcoronary patients. J Psychol 1985; 119:87–94.
15. Hackett TP, Rosenbaum JF, Tesa GE. Emotional, psychiatric disorders, and the heart. In
Braunwald E (ed): Heart Disease: A Textbook of Cardiovascular Medicine. Philadelphia, WB
Saunders, 1988; 1883–1900.
16. Perlman LV, Ferguson S, Bergum K, Isenberg EL, Hammarsten JF. Precipitation of conges-
tive heart failure: Social and emotional factors. Ann Intern Med 1971; 75:1–7.
Harold G. Koenig 277
17. Shenkman B. Factors contributing to attrition rates in a pulmonary rehabilitation program.
Heart & Lung 14:53–58.
18. Pressman, P., Lyons, J.S., Larson, D.B., & Strain, J.J. Religious belief, depression, and am-
bulation status in elderly women with broken hips. Am J Psychiatry 1990; 147:758–759.
19. Koenig, H.G., Cohen, H.J., Blazer, D.G., Pieper, C., & Meador, K.G., Shelp, F., Goli, V., &
DiPasquale, R. Religious coping and depression in elderly hospitalized medically ill men. Am
J Psychiatry 1992; 149:1693–1700.
20. Harris, R.C., Dew, M.A., Lee, A., Amaya, M., Buches, L., Reetz, D., & Coleman, G. The role of
religion in heart transplant recipients’ health and well-being. J Religion & Health 1995;
21. Saudia, T.L., Kinney, M.R., Brown, K.C., & Young-Ward, L. Health locus of control and help-
fulness of prayer. Heart & Lung 1991; 20:60–65.
22. Koenig HG. Religious beliefs and practices of hospitalized medically ill older adults. Int’l J
Geriatr Psychiatry 1998; 13:213–224.
23. Koenig HG, McCullough M, Larson D. Handbook of Religion and Health. New York, NY:
Oxford University Press, 2001.
24. Hoge DR. A validated intrinsic religious motivation scale. J for Sci Study of Religion 1972;
25. Koenig HG, Smiley M, Gonzales J. Religion, Health, and Aging. Westport, CT: Greenwood
26. Hlatky MA, Boineau RE, Higginbotham MB, Lee KL, Mark DB, Califf RM, Cobb FR, Pryor
DB. A brief self-administered questionnaire to determine functional capacity (The Duke Ac-
tivity Status Index). Am J Cardiology 1989; 64:651–654.
27. Goldman L, Hashimoto B, Cook F, Loscalzo. Comparative reproducibility and validity of sys-
tems for assessing cardiovascular functional class: Advantages of a new specific activity
scale. Circulation 1981; 64:1227–1234.
28. Guyatt GH, Nogradi S. Halcrow S, Singer J, Sullivan MJJ, Fallen EL. Development and
testing of a new measure of health status for clinical trials in heart failure. J Gen Intern Med
29. Guyatt GH, Berman LB, Townsend M, Pugsley SO, Chambers LW. A measure of quality of
life for clinical trials in chronic lung disease. Thorax 1987; 42:773–778.
30. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic
comorbidity in longitudinal studies: Development and validation. J Chronic Dis 1987;
31. Linn B, Linn M, Gurel L. Cumulative Illness Rating Scale. J Am Geriatr Soc 1968;16:622–
32. American Society of Anesthesiologists: New classification of physical status. Anesthesiology
33. Criteria Committee of the New York Heart Association. Nomenclature and Criteria for Diag-
nosis of Diseases of the Heart and Great Vessels. 9th ed. Boston, Mass: Litttle, Brown & Co,
34. Conwell Y, Forbes NT, Cox C, Caine ED. Validation of a measure of physical illness burden at
autopsy: The Cumulative Illness Rating Scale. J Am Geriatr Soc 1993; 41:38–41.
35. Koenig HG, Westlund RE, George LK, Hughes DC, Hybels C. Abbreviating the Duke Social
Support Index for use in chronically ill older adults. Psychosomatics 1993; 34:61–69.
36. Landerman R, George L, Campbell R, Blazer D. Alternative models of the stress buffering
hypothesis. Am J Comm Psychol 1989; 17:625–642.
37. Robbins, L, Helzer, J., Croughan, J. National Institute of Mental Health Diagnostic Inter-
view Schedule: History, characteristics, validity. Arch Gen Psychiatry 1981; 38:381–389.
38. DSM-IV. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washing-
ton, DC: American Psychiatric Association, 1994, pp. 327, 720–721.
39. Hamilton M. Development of a rating scale for primary depressive illness. Br J Soc & Clin
Psychol 1967; 6:278–296.
40. Idler, E.L., & Kasl, S.V. Religion among disabled and nondisabled elderly persons, II: Atten-
dance at religious services as a predictor of the course of disability. J Gerontology 1997;
41. Idler, E.L. Religion, health, and nonphysical senses of self. Social Forces 1995; 74:683–704.
42. Kabat-Zinn, J., Massion, A.O., Kristeller, J., Peterson, L.G., Fletcher, K.E., Pbert, L., Len-
278 Journal of Religion and Health
derking, W.R., & Santorelli, S.F. Effectiveness of a meditation-based stress reduction pro-
gram in the treatment of anxiety disorders. Am J Psychiatry 1992; 149, 936–943.
43. Koenig, H.G., Ford, S., George, L.K., Blazer, D.G., & Meador, K.G. Religion and anxiety
disorder: An examination and comparison of associations in young, middle-aged, and elderly
adults. J Anxiety Disorders 1993; 7:321–342.
44. Haley, K.C., Koenig, H.G., Burchett, BM. Relationship between private religious activity and
physical functioning in older adults. J Religion & Health 2001 (in press).
45. Idler, E.L. Religious involvement and the health of the elderly: some hypotheses and an
initial test. Social Forces 1987; 66:226–238.
46. Braam, A.W., Beekman, A.T.F., Deeg, D.J.H., Smith, J.H., & van Tilburg, W. Religiosity as a
protective or prognostic factor of depression in later life; results from the community survey
in the Netherlands. Acta Psychiatrica Scandinavia 1997; 96:199–205.
47. Koenig, H.G., Hays, J.C., George, L.K., & Blazer, D.G., Larson, DB, & Landerman, L.R.
(1997). Modeling the cross-sectional relationships between religion, physical health, social
support, and depressive symptoms. Am J Geriatr Psychiatry 1997; 5:131–143.
48. Koenig, H.G., George, L.K., & Peterson, B.L. Religiosity and remission from depression in
medically ill older patients. Am J Psychiatry 1998; 155:536–542.
49. Rabins, P.V., Fitting, M.D., Eastham, J., & Zabora, J. Emotional adaptation over time in
care-givers for chronically ill elderly people. Age and Ageing 1990; 19:185–190.
50. Ehman, J, Ott B, Short, T, Ciampa R, Hansen-Flaschen, J. Do patients want physicians to
inquire about their spiritual or religious beliefs if they become gravely ill? Arch Intern Med
51. Sloan RP, Bagiella E, VandeCreek L, Hover M. Should physicians prescribe religious activ-
ities? NEJM 2000; 342:1913–1916.
52. Lo B, Quill T, Tulsky J. Discussing palliative care with patients. Ann Intern Med 1999;
53. Princeton Religion Research Center. Religion in America. Princeton, NJ: the Gallup poll,
54. Koenig HG, Pargament KI, Nielsen J. Religious coping and health outcomes in medically ill
hospitalized older adults. J Nerv & Ment Dis 1998; 186:513–521.