Religion, Congestive Heart Failure, And Chronic Pulmonary Disease

Journal of Religion and Health, Vol. 41, No. 3, Fall 2002 ( 2002) Religion, Congestive Heart Failure, and Chronic Pulmonary Disease HAROLD G. KOENIG ABSTRACT: Objective: To examine the prevalence of religious beliefs and practices in hospitalized 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 diagnosis 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 indicated 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 problems, 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 disease 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 involvement has been associated with less depression and improved coping in patients 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 between religion and health in patients with CHF or CPD. First, how widespread are religious beliefs and practices in this population? Second, are certain religious practices associated with greater severity of illness, whereas others associated with less severe illness? Third, is religious involvement associated with greater social support and less depression, as might be expected based on previous research in medical populations? Fourth, will religious activities be more common among those with a history of psychiatric problems, substance abuse, or a family history of psychiatric problems, because of a connection between religion and psychopathology (e.g., religion either causing psychiatric problems or resulting from them)? Finally, will religious beliefs and practices be more or less common among persons who have received or are receiving psychiatric treatment (psychotropic drugs or psychotherapy)?

Harold G. Koenig 265 Methods Procedure. Between February and July 1998, a consecutive series of patients 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 obstructive 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 family, nurse, housestaff, or attending physician failed to give consent or prevented the interview. After obtaining written informed consent from the patient, 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, agnostic, 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 religious activities, such as prayer, meditation, or Bible study?), with six response 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 Hoge scale.24,25 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 measure 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 psychotropic drug use, and more specifically, about antidepressant use. Family psychiatric 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 hospital, 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 interview 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- tom severity. 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 education. 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. Results 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 refused 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 gender, severity of illness, or length of hospital stay prior to being approached for the study. The average age of the final sample was 69.3 years (SD 8.3); average education 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 diagnosis 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 TABLE 1 Physical and Mental Health Characteristics of the Sample (n 196)1 Mean (SD) / % (N) Physical Health 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 Mental Health Social Support, range 11–33 26.8 (SD 4.3) History of mental or nervous disorder requiring treat- 27.5% (52) ment, yes 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) 1 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 common 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 statements. For example, 87% indicated that religious faith “involves all of my

Harold G. Koenig 269 TABLE 2 Religious Characteristics on the Sample (n 196)1 % (N) or Mean (SD) Denomination 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) (E) 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) (E) Beliefs don’t matter; only living a moral life matters 49.2% (93) (E) 1 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 religiosity (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 major religious variables (public, private, and intrinsic religiosity) and physical, social, and mental health measures. All analyses were controlled for age, gender, 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 functional 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 relationship 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 substantial degree. Is religious involvement associated with greater social support and less depression? 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 variables and both depressive symptoms and diagnoses of major depression were in the expected direction, they were weak and did not reach statistical significance. 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 substantially strengthen the weak inverse relationships between religious variables

Harold G. Koenig 271 TABLE 3 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 1 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. 2 25 current users compared to 66 past users. 3 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 depressive 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 activities. 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 hospitalization 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, although 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 religious). Discussion 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 shortness 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 patients with CHF or CPD to relax and function better. This would be consistent 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, compared to those who prayed more often.44 In the present study, however, private 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 attendance) 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 relationship 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 substantially strengthen the inverse relationship between religious activities and depression. 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) increased from 0.05 to 0.11; likewise, compared to those praying less frequently, 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 problems, especially prior hospitalizations for depression and problems with alcohol. 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 attitudes and activities. Unfortunately, the present study provides no informa- tion on whether religious involvement preceded or followed psychiatric problems. 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 frequently 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 association between religious coping and family psychiatric history.19 One explanation might be that private religious activities are used to cope with the difficulties 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, however, 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 psychiatric therapies. Summary and treatment implications. CHF and CPD have an enormous impact on quality of life for both the patient and family. Nearly 30% of patients 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 coping. Clinicians should be aware of just how common religious belief and practices 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 consecutive 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, spirituality) 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 religion is less prevalent. Religious beliefs and practices, however, are widespread 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 religiousness 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 clinicians take a brief spiritual history to identify spiritual needs of patients with illnesses like these that seriously impair quality of life. Acknowledgment Funded by NIMH grants MH01138 and MH57662, and by the John Tem- pleton Foundation, Radnor, Pennsylvania, grant 517. References 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 congestive 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; 33:595–601. 7. Vinson JM, Rich MW, Spery JC, Shah AS, McNamara T. Early readmission of elderly patients 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 (1):59–71. 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 congestive heart failure: Social and emotional factors. Ann Intern Med 1971; 75:1–7.

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278 Journal of Religion and Health derking, W.R., & Santorelli, S.F. Effectiveness of a meditation-based stress reduction program 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 1999; 159:1803–1806. 51. Sloan RP, Bagiella E, VandeCreek L, Hover M. Should physicians prescribe religious activities? NEJM 2000; 342:1913–1916. 52. Lo B, Quill T, Tulsky J. Discussing palliative care with patients. Ann Intern Med 1999; 130:744–749. 53. Princeton Religion Research Center. Religion in America. Princeton, NJ: the Gallup poll, 1996. 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.

Religion, Congestive Heart Failure, And Chronic Pulmonary Disease

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