The contribution of spirituality and spiritual copingto anxi.docx

The contribution of spirituality and spiritual coping
to anxiety and depression in women with a recent
diagnosis of gynecological cancer
N. BOSCAGLIA*, D.M. CLARKE*, T.W. JOBLINGy & M.A.
QUINNz
*Department of Psychological Medicine and General Practice,
Monash University,
Melbourne, Australia; yDepartment of Obstetrics and
Gynaecology, Monash Medical Centre,
Melbourne, Australia; and zDepartment of Obstetrics and
Gynaecology, and Oncology Unit,
Melbourne University, Royal Women’s Hospital, Melbourne,
Australia
Abstract. Boscaglia N, Clarke DM, Jobling TW, Quinn MA. The
con-
tribution of spirituality and spiritual coping to anxiety and
depression
in women with a recent diagnosis of gynecological cancer. Int J
Gynecol
Cancer 2005;15:755–761.
The objective of this study was to determine whether, after
accounting
for illness and demographic variables, spiritual involvement and
beliefs
and positive and negative spiritual coping could account for any
of the
variation in anxiety and depression among women within 1
year’s diag-

nosis of gynecological cancer (GC). One hundred patients from
out-
patient GC clinics at two Melbourne-based hospitals completed
a brief
structured interview and self-report measures of anxiety,
depression,
spirituality, and spiritual coping. Using two sequential
regression analy-
ses, we found that younger women with more advanced disease,
who
used more negative spiritual coping, had a greater tendency
towards
depression and that the use of negative spiritual coping was
associated
with greater anxiety scores. Although not statistically
significant, pa-
tients with lower levels of generalized spirituality also tended
to be
more depressed. The site of disease and phase of treatment were
not
predictive of either anxiety or depression. We conclude that
spirituality
and spiritual coping are important to women with GC and that
health
professionals in the area should consider these issues.
KEYWORDS: anxiety, coping, depression, gynecological

cancer, spirituality.
In a recent issue of this journal, Ramondetta and
Sills(1) published a review of the literature concerning
the role of spirituality in gynecological cancer (GC).
The authors concluded that ‘‘concerns for the spiritual
health of patients may prove significant for both a
patient’s comprehensive sense of well-being and for the
relationship that is created between patients and
physicians.’’ In this study, we examined empirically
the relationship between spirituality and mood (ie,
anxiety and depression).
A diagnosis of cancer is a significant life event that
may have considerable psychological, physical, and
financial sequelae. In particular, a diagnosis of GC
Address correspondence and reprint requests to: Nadia
Boscaglia,
Department of Psychological Medicine, Monash University,
Monash Medical Centre, 246 Clayton Rd., Clayton, Victoria
3800,
Australia. Email: [email protected]
# 2005 IGCS
Int J Gynecol Cancer 2005, 15, 755–761
may elicit disturbances to body image; feelings of
helplessness, dependency, shame, guilt, and vulnera-
bility; a sense of loss of femininity and motherhood;
and sexual difficulties(1,2). Not surprisingly, women
with GC have a heightened frequency of depression,
anxiety, and adjustment disorders(3).

Certain factors that increase the risk for mood distur-
bance among women with GC include site of cancer
(ovarian cancer worst)(4,5), treatment with triple-agent
chemotherapy, younger age(6,7), and current treat-
ment(6,8). In general, more advanced cancers are associ-
ated with more frequent psychiatric complications(9).
Psychological health is important when faced with
a diagnosis of cancer. Depressive symptoms in associa-
tion with medical illness have been found to affect qual-
ity of life and social functioning, exert a negative impact
on treatment compliance(10), and lead to increased use
of healthcare services(11). Similarly, anxiety can interfere
with physical and psychosocial functioning; thus, for
those who are physically compromised by illness, high
levels of anxiety are of concern(12).
Recent research indicates that spirituality is one factor
that may contribute to good mental health during the
course of cancer. Spirituality is a set of beliefs and atti-
tudes that give meaning and purpose to life through
a sense of connectedness with the self, others, the natu-
ral environment, a higher power, and/or other super-
natural forces. These beliefs and attitudes empower
and transcend the self and are embodied in feelings,
thoughts, experiences, and behaviors(13–15). Spirituality
is a broader concept than religion or religiosity, which
refers to organized beliefs and practices such as those
found in formal denominations or recognized systems
of theological ideas; as such, religion can be viewed
as a dimension of spirituality(14,16). Among those with
life-threatening illnesses, spirituality has been found
to be positively associated with psychosocial adjust-
ment(17) and quality of life(18); and spiritual well-being
was inversely associated with death distress(19) and

anxiety(20).
Religion and spirituality may be incorporated as
part of one’s coping(21,22), whereby coping is defined
as the process by which individuals respond to stress-
ful stimuli. Within the coping process, there are two
subprocesses, appraisal and coping efforts (or meth-
ods). Appraisal refers to the individual’s evaluation of
the event(23); this evaluation influences one’s coping
efforts. Coping efforts are the actions through which
coping can resolve the stressful event and has effects
on physical and emotional health(24). Research shows
that an individual’s mood and quality of life after
receiving a cancer diagnosis can be, in part, accounted
for by his/her coping efforts(25–27).
People bring with them a general orienting system
to the coping process. A spiritual orientation (eg,
general beliefs, practices, aspirations, and relation-
ships) is but one part of a larger orienting system(22).
In the coping process, both the spiritual (general reli-
gious and spiritual beliefs, involvement, and practi-
ces) and nonspiritual elements of this orienting
system are translated into specific methods of coping.
It is these coping methods that have the most direct
implications for health and well-being(14,28–30). In-
deed, research indicates that specific spiritual coping
efforts are better predictors of event outcomes (eg,
mood, adjustment) than are measures of generalized
spirituality(21,28,31). Put simply, spiritual coping is the
use of religious/spiritual beliefs and practices to
reduce the emotional distress caused by loss or
change(32).
Researchers(30) have identified two patterns of spiri-
tual coping* (broadly termed, positive and negative)

that have important implications for health. Positive
spiritual coping methods reflect an expression of ‘‘a
sense of spirituality, a secure relationship with God,
a belief that there is meaning to be found in life, and
a sense of spiritual connectedness with others’’(30, p712).
In contrast, the negative spiritual coping pattern is an
expression of ‘‘a less secure relationship with God,
a tenuous and ominous view of the world, and a reli-
gious struggle in the search for significance’’(30, p712).
Each of the two patterns is made up of specific types
of spiritual coping methods (Table 1). Research dem-
onstrates that among various samples, the positive
spiritual coping pattern was associated with fewer
symptoms of psychological distress(30,33) and higher
levels of stress-related growth(30); and the negative
spiritual coping pattern was associated with more
depression(30,33) and poor quality of life(30).
There are few studies that have examined the
impact of spirituality on psychological state in women
with GC(1). This is surprising, given that there are sev-
eral factors that make salient the study of spirituality
in this particular group. Life-threatening events such
as cancer, particularly those that pose threats to self-
image or important areas of personal functioning,
often lead to people relying on their spiritual re-
sources(14,18). Further, religious and spiritual coping
appears to be used more often by women than
men(17). In this study, our aim was to determine
*While Pargament et al.(28–30) use the term ‘‘religious
coping,’’ we
prefer the term ‘‘spiritual coping.’’ This difference in
terminology is
reflective of each author’s definition of the terms religion and
spir-

ituality, that is, Pargament et al. view religion in much the same
was as we view spirituality.
756 N. Boscaglia et al.
# 2005 IGCS, International Journal of Gynecological Cancer 15,
755–761
whether spiritual involvement and beliefs and posi-
tive and negative spiritual coping accounted for any
of the variance in psychological distress (anxiety
and depression) among women with GC, over and
above that accounted for by illness and demographic
variables.
Materials and methods
One hundred and twenty-three patients were re-
cruited from outpatient GC clinics at the Royal Wom-
en’s Hospital and the Monash Medical Centre,
Melbourne. Exclusion criteria included age less than
18 or more than 70 years, inability to speak/read
English, diagnosis .12 months before, and the pres-
ence of known intracranial disease or cognitive
impairment. After obtaining written consent, patients
engaged in a 15-min interview about demographic
and illness information. At the end of the interview,
patients were given a questionnaire pack, which they
completed at home and returned by mail. After
excluding those women who did not complete all ele-
ments of the study, the sample was reduced to 100
women.
Patients (N ¼ 100) were aged between 20 and 70

years (mean ¼ 52.52, SD ¼ 12.17), and were within
a year ’s diagnosis of GC at interview (mean weeks
since diagnosis ¼ 22.21, SD ¼ 14.58). The women were
predominantly Australian born (71%), and the major-
ity of patients (70%) were married, with 80% having
had children. In terms of religion, 42% of the sample
was Christian, 33% Roman Catholic, 19% reported
having ‘‘no religion,’’ and 6% ‘‘other.’’ Disease charac-
teristics are presented in Table 2.
Measures
Depression was measured using the Beck Depression
Inventory for Primary Care(34), anxiety was assessed
using the State Anxiety Scale from the Spielberger
State Trait Anxiety Inventory(35), and spirituality was
assessed using the Spiritual Involvement and Beliefs
Scale-Revised(36). The Spiritual Involvement and Be-
liefs Scale-Revised comprises 22 items that examine
Table 1. Positive and negative spiritual coping methods
Positive spiritual
coping methods Explanation
Negative spiritual
coping methods Explanation
Benevolent religious
reappraisal
Redefining the stressor through religion
as benevolent and potentially beneficial
Spiritual discontent Expressions of confusion and

dissatisfaction with God
Collaborative religious
coping
Seeking control through a partnership
with God in problem solving
Interpersonal spiritual
discontent
Expressions of confusion and
dissatisfaction with clergy
or members
Seeking spiritual
support
Searching for comfort and reassurance
through God’s love and care
Punishing God
reappraisal
Redefining the stressor as a
punishment from God for the
individual’s sins
Religious forgiveness Looking to religion for help in letting
go of anger, hurt, and fear associated
with an offense
Demonic reappraisal Redefining the stressor as the
act of the Devil
Spiritual purification Searching for spiritual cleansing through

religious actions
Reappraisal of
God’s powers
Redefining God’s powers to influence
the stressful situation
Spiritual focus Seeking relief from the stressor
through a focus on one’s religion
or spirituality
Spiritual connection Seeking a sense of connectedness with
transcendent forces
Adapted from Pargament et al.(30, p711).
Table 2. Disease characteristics (N ¼ 100)
Characteristic Options for response N
Cancer site Endometrium 38
Ovary 32
Cervix 23
Vulva 5
Vagina 1
Fallopian tube 1
FIGO staging I 60
II 11
III 28
IV 1
Treatment type Surgery 87
Chemotherapy 41
Radiotherapy/brachytherapy 25

None 1
Currently in active treatment Yes 20
No 80
Contribution of spirituality to mood in women with
gynecological cancer 757
755–761
rituals and belief in a higher power, internalized beliefs
and spiritual growth, meditation and existential beliefs,
and humility and daily application of spiritual princi-
ples(36). The Brief RCOPE of Pargament et al.(30) was
used to assess positive and negative spiritual coping.
The Brief RCOPE comprises 14 items that divide into
two subscales, positive and negative religious coping.
The creators of the scale advise that the Brief RCOPE
is applicable to ‘‘a wide range of Judeo-Christian
groups . [and] may be applicable to members of other
ethnocentric religions as well, such as Islam’’(30, p722). To
make the scale more acceptable to nonbelievers of the
main monotheistic religions, certain aspects of the scale
were altered; in particular, in addition to the word God,
the phrase, a power greater than myself was added.
Statistical analyses
Data were analyzed using SPSS 10.0.7. Two sequential
regression analyses were employed to determine
whether spirituality (step 2) and then positive and
negative spiritual coping (step 3) accounted for any of
the variance in anxiety and depression, over and

above the variance accounted for by illness and demo-
graphic variables (step 1). The illness and demo-
graphic variables (ie, age, presence of ovarian cancer
relative to other forms of GC, active treatment vs no
active treatment, stage of disease—I or II vs III or IV,
and having had chemotherapy) were selected a priori,
according to the findings of past research. After data
screening, one multivariate outlier was removed
(reducing the data set to N ¼ 99), and skewed varia-
bles were transformed to meet assumptions.
Results
Use of the published cutoff scores of the Beck Depres-
sion Inventory for Primary Care(34) revealed that 24%
of the sample exhibited at least mild symptoms of
depression (13% of the sample had mild symptoms,
6% moderate symptoms, and 5% severe symptoms).
The mean anxiety score was 38.56 (where a higher
score indicates a greater level of anxiety), compared
with a mean anxiety score for women in the general
population (aged between 40 and 69) of 34.35(35). The
correlation coefficients among illness variables were in
the expected direction (eg, presence of ovarian cancer
correlated with having had chemotherapy) and
ranged from .50 to .70.
In the first regression (Table 3), depression scores
served as the criterion variable. R was not significantly
different from zero at the end of steps 1 or 2 but was
significantly different from zero after step 3. Step 1:
R ¼ .31, F(5,93) ¼ 1.92, P ¼ .098; step 2: R ¼ .31,
F(6,92) ¼ 1.61, P ¼ .153; and step 3: R ¼ .53, F(8,98) ¼
4.37, P , .01. In the final model, the predictors ac-
counted for 28% of the variance in depression scores,

change statistics: R2 ¼ .28, F(2,90) ¼ 11.54, P , .01.
Specifically, younger age, later stage of disease, and
greater use of negative religious coping predicted
significantly a higher level of depression. Although
not statistically significant, spirituality made a strong
contribution to the variance in depression scores
(b ¼ 2.378, P ¼ .053), whereby a lower level of spiritu-
ality was associated with a higher level of depression.
In the second regression (Table 4), anxiety served as
the dependent variable. Predictors were entered as for
the first regression. After each of the three steps, R
was not significantly different from zero (P . .10).
Nonetheless, we examined the change statistics and
unique contributions from each of the predictors. We
found that the addition of positive and negative spiri-
tual coping to the equation resulted in a significant
improvement in the model, change statistics: R2 ¼ .12,
F(2,90) ¼ 4.33, P , .05. Negative spiritual coping
was the only significant predictor of anxiety scores
Table 3. Summary of final model from the sequential regression
analysis for variables predicting transformed depression scoresa
Variable B Standard error of B b t P
Age 2.017 .008 2.185 22.015 .047*
Ovarian cancer .201 .294 .086 0.684 .496
Phase of treatment .086 .337 .032 0.255 .800
Chemotherapy .188 .291 .084 0.644 .521
Stage of disease .632 .276 .264 2.293 .024*
Spirituality 2.015 .008 2.378 21.959 .053
Positive spiritual copingb 29.020 4.891 2.365 21.844 .068
Negative spiritual copingb 214.766 4.128 2.352 23.577 .001**
aSquare root transformation applied.

bInverse transformation applied.
*P , .05.
**P , .01.
755–761
(b ¼ 2.25, P , .05), whereby more negative spiritual
coping was associated with higher levels of anxiety.
Discussion
This study was conducted to examine the contribution
of spirituality and positive and negative spiritual cop-
ing to mood in women within a year ’s diagnosis of
GC. Our results indicate that almost one quarter of the
sample experienced at least mild depressive symp-
toms and that levels of anxiety were higher than that
of women in the general population. Our findings also
show that among women diagnosed with GC within
the past year, those who were younger, had more
advanced disease, and who used more negative spiri-
tual coping had a greater tendency towards depressed
mood, and, although not statistically significant,
patients with lower levels of spirituality also tended to
be more depressed. The use of negative spiritual cop-
ing was associated with greater anxiety scores.
Turning first to the predictive role of age in mood
outcomes in GC, our results are not surprising. Youn-
ger women treated for GC may face the added stress
of potential infertility or be concerned about the future

of their families/children, thus, placing younger
women at increased risk for psychological distress(7).
Indeed, research has demonstrated that among
women with ovarian cancer, younger patients (,50
years) were more likely to be depressed than older
patients(6).
Later stage of disease was another significant pre-
dictor of depression in our sample; this is in agreement
with research findings that indicate that among
women with GC (and cancer patients in general) more
advanced disease is associated with higher levels of
depression(4,9). On the other hand, we found that
phase of treatment (active treatment vs no current
treatment) and site of GC (ovarian vs nonovarian
GC) were not predictive of depression or anxiety.
These findings contrast with the findings of other
studies(4–6,8) and may be reflective of the high degree
of support provided to women in the active phase of
treatment. Indeed, many studies have found that social
support is protective against mood disturbance(37).
In this study, the use of negative spiritual coping
significantly predicted depression and anxiety, and
there was a near significant (P ¼ .053) trend for lower
levels of spirituality to be predictive of higher levels
of depression. This is consistent with extant research
in which an association between higher levels of
spirituality and good psychological adjustment to
cancer(17–20) has been demonstrated. Findings such as
these are typically explained by the hypothesized
‘‘stress buffering’’ and ‘‘meaning-making’’ role of spiri-
tuality. Kim and Seidlitz(38) suggest that spirituality
can buffer the effects of stress through its influence on
thinking, emotions, and behavior. They argue that

spiritual beliefs may help a person to find meaning in
life, thus limiting the mental health consequences of
adverse experiences. God and related religious and
philosophical systems may offer a type of schemata
for explaining and predicting the vacillating course of
cancer(39), thus helping to give the illness meaning and
perspective and to provide answers to existential
questions that arise(40). Spiritual practices can also fos-
ter the development of supportive social networks
and thus promote health behaviors and reduce nega-
tive emotions(38). In addition, spiritual beliefs, in the
sense of beliefs related to a connection to something
bigger than the self, can help cancer patients tolerate
the difficulties of their illness(41). It appears then that
for women who are spiritually inclined, spirituality
may function as an important resource during the
course of GC.
What, then, of the finding that negative spiritual
coping significantly predicted both depression and
anxiety in our sample? As stated, the use of negative
spiritual coping expresses a less secure relationship
Table 4. Summary of final model from the sequential regression
analysis for variables predicting transformed anxiety scoresa
Variable B SE B b t P
Age 2.009 .009 2.094 20.930 .355
Ovarian cancer .061 .332 .025 0.183 .855
Phase of treatment .074 .381 .027 0.194 .847
Chemotherapy .287 .329 .127 0.873 .385
Stage of disease .192 .312 .078 0.616 .540
Spirituality 2.011 .009 2.264 21.234 .221
Positive spiritual copingb 25.776 5.529 2.229 21.045 .299
Negative spiritual copingb 210.505 4.667 2.245 22.251 .027*

aSquare root transformation applied.
bInverse transformation applied.
*P , .05.
755–761
with a higher power and a tenuous and ominous view
of the world. Perhaps then, those who use negative
spiritual coping methods are mobilizing their spiritual
resources ineffectively, translating their spiritual be-
liefs into unhelpful strategies that promote (rather
than protect from) depression and anxiety. However,
given that the study was cross-sectional, the possibil-
ity that the participants’ psychological distress pre-
ceded the use of negative religious coping methods
cannot be excluded.
In addition to its cross-sectional design, another lim-
itation to the present study is the lack of consideration
of other variables that may predict mood. In particu-
lar, we have not examined the role of non-spiritual
coping methods, disposition, or social support in
mood outcomes. A larger study that examines the con-
tribution of such variables to emotional outcomes and
well-being in women with GC is required. Alternately,
a qualitative approach, in which women are asked to
elaborate on their own methods of spiritual coping,
may help elucidate the most important aspects of spir-
ituality (if any) for women with GC.

This study adds empirical evidence to the sugges-
tion of Ramondetta and Sills(1) that spirituality is an
important consideration in the care of women with
GC, and also, raises questions for those working with
GC patients: What do I do if my patient is depressed
or spiritually distressed? To whom do I refer such a
patient? Considering the implications of depression
and anxiety, and the contribution of spirituality and
spiritual coping to mood outcomes, healthcare pro-
viders may need to consider such questions.
Acknowledgments
We are indebted to Ms Helen Sells for her help with
recruitment of participants.
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Accepted for publication October 14, 2004
755–761
Relationship of Religious Beliefs with Anxiety and Depression
Aljohara
University

Running head: RELIGION AND MENTAL HEALTH
1
Relationship of Religious Beliefs with Anxiety and Depression
BOSCAGLIA, N., CLARKE, D. M., JOBLING, T. W., &
QUINN, M. A. (2005). The contribution of
spirituality and spiritual coping to anxiety and depression in
women with a recent diagnosis of gynecological
cancer. International Journal of Gynecological Cancer, 15(5),
755-761.
The objective of this study was to work out whether or not, once
accounting for religious involvement and beliefs, and positive
and negative religious header may account for any of the
variations in anxiety and depression among ladies among one
year's diagnosing of medical specialty cancer. The author
concludes that spirituality and spiritual coping are important to
women with cancer and that health professionals in the area
should consider these issues.
Koenig, H. G. (2009). Research on Religion, Spirituality, and
Mental Health: A Review. The Canadian Journal of
Psychiatry, 54(5), 283–291.
This article talk about the religious and religious factors are
more and more being examined in medical specialty analysis.
Non secular beliefs and practices have long been joined to
hysteria, neurosis, and psychotic delusions. However, recent
studies have known another facet of faith that will function a
psychological and social resource for dealing with stress. When
process the terms faith and spirituality, this paper reviews
analysis on the relation between faith and (or) spirituality, and

psychological state, that specialize in depression, suicide,
anxiety, psychosis, and misuse. The results of Associate in
nursing earlier systematic review are mentioned, and newer
studies within us, Canada, Europe, and alternative countries are
delineated. Whereas non secular beliefs and practices will
represent powerful sources of comfort, hope, and which means,
they're typically elaborately entangled with neurotic and
psychotic disorders, typically creating it tough to work out
whether or not they are a resource or a liability.
Moreira-Almeida, A., Lotufo Neto, F., & Koenig, H. G. (2006).
Religiousness and mental health: a review. Revista brasileira de
psiquiatria, 28(3), 242-250.
This paper reviews the scientific proof offered for the
connection between faith and mental state. Conjointly the
authors gift the most studies and conclusions of a bigger
systematic review of 850 studies on the religion-mental health
relationship printed throughout the twentieth Century known
through many databases. This paper conjointly includes
associate update on the papers printed since 2000, together with
researches performed in Brazil and a short historical and
method background. And Theoretical pathways of the
religiousness-mental health association and clinical implications
of those findings are mentioned.
Ross, C. E. (1990). Religion and psychological distress. Journal
for the Scientific Study of Religion, 236-245.
The author did this paper by employing a sample of Illinois
residents (and dominant for sociodemographics and disposition
to specific feelings). And he found that the stronger an
individual's faith, the lower the extent of psychological distress.
This supports the concept that faith reduces demoralization and
provides hope and that means. However, the author found that
persons with no faith likewise had low levels of distress. Thus,
there was a curving impact of nonsecular belief on distress.
Additionally, the author found that Protestants had very cheap
distress levels, followed by Catholics, Jews, and others.
Variations in belief systems, however, particularly a belief

within the Yankee Protestant ethic, didn't make a case for
variations in distress among nonsecular teams. The strength of
nonsecular beliefs seems to be a lot of vital than content in
explaining the impact of faith on psychological distress.
Williams, D. R., Larson, D. B., Buckler, R. E., Heckmann, R.
C., & Pyle, C. M. (1991). Religion and psychological distress in
a community sample. Social Science & Medicine, 32(11), 1257-
1262.
This paper examines the result of nonsecular group action and
affiliation on psychological distress in a very longitudinal
community study of 720 adults. nonsecular affiliation is
unrelated to mental state standing. In distinction, though
nonsecular group action doesn't directly scale back
psychological distress, it buffers the hurtful effects of stress on
mental state. That is, within the face of nerve-racking events
and physical health issues, nonsecular group action reduces the
adverse consequences of those stressors on psychological well-
being.
Running head:sentencing programs and aggressive tendencies 1
Running head:sentencing programs and aggressive tendencies
2The effect of sentences programs on aggressive
tendencies amongst adolescent offenders
Student Name
Effat University
Abstract
Purpose: The purpose of this research proposal is to plan and
carry out a study that will evaluate the relationship between
family attachment and social interaction. Social interaction is of
special importance due to how current students spend their time,
either between real life social interactions or social

media.Methods: A cross-sectional design will be employed to
measure students’ beliefs, behaviors, and personality at one
point in time. Various measures will be given to measure social
interaction, family attachments, and personality. Implications:
The implications of this study, if it is carried out, is a better
understanding of social isolation during a student’s move to a
university dormitory. Moreover, if family attachment is found
to be associated with better adjustment, then perhaps better
inventions can be made to prevent or reduce adjustment
problems.
Keywords: SocialInteraction, Family Relationships,
Adjustment, Moving
The effect of sentences programs on aggressive tendencies
amongst adolescent offenders
Start writing something really profound and incredible here. If
you do so, perhaps, just perhaps, we might give you an A and
you’ll graduate and become the most incredible psychologist to
have existed on planet Earth.Start writing something really
profound and incredible here. If you do so, perhaps, just
perhaps, we might give you an A and you’ll graduate and
become the most incredible psychologist to have existed on
planet Earth.
Variable 1 (Dependent Variable)
planet Earth.
Variable 2 (Independent Variable)

planet Earth.
Conceptual Framework
planet Earth.
Gaps in Existing Knowledge Base
planet Earth.
Purpose of Research
planet Earth.

Research Questions
planet Earth.Conceptual Definitions
planet Earth.
Hypotheses
planet Earth.
Proposed MethodsSample
Because the best time to establish a habit is considered to be
with individual in early adulthood, our target population will be
young adults in college.
Measures
Executive Functioning.Measured by the NIH ToolBox.
Measures of working memory, flexible switching, processing

speed, inhibition, and initiation will be measured to determine
the overall level of executive functioning for each subject.
Final Numerical Grade. measured by each subject’s cumulative
assignments and tests.Design & Procedure
A correlational cross-sectional design will be used in order to
gather the data and analyze it.
Analytic Plan
A standard independent samples t-test will be performed to
determine statistical significant mean differences on the
dependent variables.
Anticipated Results
We hypothesize that students who receive the intervention of
HIT will have higher post-test EF as well as higher final
numerical grades.
Implications of Results
The results from this study will have both practical and
theoretical implications. From a practical standpoint, the results
will demonstrate that a more practical type of exercise can both
be beneficial physiologically as well as academically.
Therefore, this approach can accommodate to younger adults
who tend to be busy with school and work. From a theoretical
perspective, the data can provide very important empirical
support for psychological and academic benefits of HIT.
References
Last Name, F. M. (Year). Article Title. Journal Title, Pages
From - To.
Last Name, F. M. (Year). Book Title. City Name: Publisher
Name.

Sot Scr Med Vol 3.2, No 11, pp 1257-1262, 1991
Pnnted m Great Bntam All nghts reserved
0277-9536/91 $3 00 + 0 00
Copyright 0 1991 Pergamon Press plc
RELIGION AND PSYCHOLOGICAL DISTRESS IN A
COMMUNITY SAMPLE
DAVID R WILLIAMS,’ DAVID B LARSON,* ROBERT E
BUCKLER,.’ RICHARD C HECKMANN~
and CAROLINE M PYLE’
I Departments of Sociology and Epldemlology and Pubhc
Health, Yale Umverslty, P 0 Box 1965, Yale
Statlon, New Haven, CTO6520, US A, *NatIonal Institute of
Mental Health, 5600 Fishers Lane,
Rockvdle, MD 20857, U S A, ‘Department of Psychology,
Western Seminary, 5511 E Hawthorne,
Portland, OR 97215, U S A 4Department of Psycluatry,
Umverslty of Colorado School of MedIcme, 4200
E 9th Ave. Denver, CO 80262, U S A and SDepartment of
Epldemlology and Pubhc Health, Yale School
of Medlcme, 60 College Street, New Haven, CT 06520, U S A
Abstract-This paper exammes the effect of [email protected]
attendance and affibatlon on psychologlcal distress
m a lonptudmal commumty study of 720 adults Rebglous
atlibatlon IS unrelated to mental health status
In contrast, although rehgous attendance does not directly
reduce psychologlcal distress, It buffers the
deletenous effects of stress on mental health That IS, m the face
of stressful events and physlcal health
problems, rebgous attendance reduces the adverse consequences
of these stressors on psychologlcal

well-bemg
Key words-rehglon, psychologlcal &stress, stress
The relationshIp between rehglon and health status
has been recelvmg mcreasmg sclentlfic attention in
recent years One mdlcator of this interest 1s the
growing number of reviews focused on rehglous
vanables that have appeared m the medical and social
science hterature [l-7] In terms of mental health
outcomes, the literature indicates that more often
than not, religion measures are inversely associated
with indicators of psychological distress Bergm [S]
revlewed 26 studies that assessed the assoclatlon be-
tween rehglon and mental health status He reported
that almost half of the studies found an inverse
assoclatlon between rehglon and psychological symp-
toms with the remainder about equally divided be-
tween those that found a positive relationship and
those that reported no assoclatlon However, given
that 80% of the studres reviewed by Bergm [S] utlhzed
student samples, it IS difficult to draw conclustons
about the generahzablhty of these findings
Studies employmg more representative samples
present a slmllar mixed pattern of findings Two
studies based on national probability samples have
reported an inverse assoclatlon between rehglous
attendance and psychological distress [8,9] Slml-
larly, several community studies have reported m-
verse assoclatlons between measures of religion and
scores on screening scales of global distress [IO-131
At the same time, other community studies report no
assoclatlon between rehglon and mental health status
[14-161

The hterature assessing the mental health conse-
quences of rehglon IS plagued with conceptual and
methodological hmltatlons which require that great
caution should be exercised m mterpretmg the find-
mgs For example, with few exceptions [16, 171
most of the existing studies have used cross-sectional
designs m which rehglous mvolvement and mental
health status are measured simultaneously A given
level of psychological functlonmg can be either
a cause or a consequence of rehglous behefs and
behavior In cross-sectional analyses it 1s lmposslble
to detect causal dlrectlonahty m the relatlonshlps
observed Researchers have also given inadequate
attention to the measurement of the rehglous vanabie
and to the underlying processes by which rehglon
may affect health status [2, IO, 17-201
One way m which rehglous mvolvement may affect
health status 1s by modlfymg the relatlonshlp between
stress and illness Stress has been shown to have
pervasive negative effects on physical and mental
health [21], but psychosocial resources can compen-
sate for or moderate the impact of stress on health
[22] Recently, Krause and Van Tran [23] docu-
mented that rehglous mvolvement 1s a cntlcal psycho-
social factor that counteracts the adverse effects
of stress on feelings of self-esteem and mastery The
literature on stress recognizes that a given psychoso-
cial resource, such as rehglon, may affect psychologl-
cal distress by directly enhancing mental health
status, lrrespectlve of the level of stress, and/or by
buffenng the effects of stress on health [22] The
buffenng hypothesis postulates that m the face of
stress, religion can protect the mdlvldual from the
potentially negative consequences of stress To our

knowledge, there have been no attempts to empln-
tally assess the dynamics of the assoclatlon between
religion, stress and psychological distress
This paper seeks to enhance our understandmg
of the relatlonshlp between rehglous behavior and
mental health by exammmg how two measures of
rehglous mvolvement, rehglous attendance and reh-
glous affiliation, combme with stress to affect psycho-
logical distress In 1967, a random sample of rest-
dents of metropolitan New Haven were mtervlewed
Lmdenthal et al [13] have reported on the cross-
sectional assoclatlons between rehglon and mental
health status They found that both rehglous affiha-
tlon and rehglous attendance were inversely assocl-
1257
1258 DAVID R WILLIAMS et ~1
ated with psychological distress Two years later, a
second wave of data was collected from these New
Haven residents To date, no analyses have related
the 1967 religion measures to distress m 1969 In
addition, although controls were utilized for SOCIO-
demographic vanables m the ongmal study, no
attempts were made to assess the extent to which
the assoclatlon between religion and psychological
distress vanes for structural charactenstlcs such as
race or socloeconomlc status A growing body of
evidence indicates that stress, the resources to cope
with stress, and the efficacy of these resources vary
for groups occupying different structural positions m
society [22]

This paper focuses on the ongmal respondents who
were reinterviewed m 1969 We assess the extent to
which the pattern of findings m the cross-sectional
analyses remam robust m the more ngorous prospec-
tive analyses Specifically, we address the followmg
research questions
1 How do religious attendance and affiliation
relate to psychological distress?
2 Do the consequences of religious mvolvement
vary by major soclodemographlc charactenstlcs
such as age, race, education and gender7
3 To what extent can measures of rehglous
mvolvement buffer or moderate the effects of
stress on health?
METHODS
The analyses reported here use data from the
Myers et al [24,25] lonBtudma1 study of mental
health m New Haven, Connecticut The sample con-
sists of 720 adults who were reinterviewed m 1969
from an ongmal random sample of 938 respondents
who were first interviewed m 1967 Table 1 lists the
means, standard deviations and mtercorrelatlons
among the vanables utilized Our sample IS 44%
male, 11% black, 26% unmarned, and has a median
education level of 12 years and a mean age of 44 8
years
Psychological distress 1s measured by the Gurm
ef al [8] symptom checklist scale This scale consists
of 20 statements of psychophysiological symptoms

that indicate the presence of moods of depression
and anxiety. The symptoms of the Gurm scale
were selected from among those most frequently
mentioned by patients m treatment and they allow
for respondents to be ordered on a contmuum
of reported distress Respondents reported the fre-
quency with which each symptom was expenenced
Scores on the Gunn scale thus range from 20 (all
symptoms expenenced ‘often’) to 80 (all symp-
toms occurrmg ‘never’) In contrast to our use of the
Gunn scale as a contmuous measure, the scale 1s
sometimes used qualitatively to dlstmgmsh between
the mentally impaired (score = 66 or lower), and
the non-impaired We believe that our contmuous
measure of psycholoDca1 distress 1s more theoreti-
cally appropnate for the study of the assoclatlon
between religion and mental health than a more
qualitative dlstmctlon between psychlatnc cases and
normals If rehglon has positive effects on mental
health, they are hkely to be evident throughout the
continuum of mental health status and not only at
the extreme of the dlstnbutlon
Two measures of rehglous commitment at
wave one (1967) are utilized Religious attendance
measures the usual frequency of attending rehglous
services (values range from 1 = never to 6 = more
than once a week) To facilitate interpretation of
product terms m the regression analyses, the religious
attendance measure was converted to a standard
score based on the mean and standard devlatlon
of the total sample, and a constant was added to
this standardized vanable so that the lowest actual
value 1s zero The religious affiliation measure IS
based on the response to the questlon “Are you

affiliated with any church or religious group?”
(1 = yes, 0 otherwise)
Two summary measures of stressful life expen-
ences, occurnng dunng the two years between the
mtervlews, are utlhzed Both measures of stress are
listed m the Appendix The first 1s an index of
undesirable life events The second stress measure 1s
a sum of the number of physical health problems
experienced To avoid confounding between the
measure of psychological distress and the health
problems index, followmg Kessler and Cleary [26], we
excluded those health complamts that mtultlvely
appeared to have a strong psychosomatic compo-
nent From a list of 44 symptoms, we selected those
16 health complamts for which a psychosomatic
component would be muumal
Ordinary least squares (OLS) regression analyses
utlhzmg the regression program m SAS [27] are
used for estimating the magmtude and statistIca
slgmficance of the relatlonshlps among religious
Table I Means, standard dewatmn and mtercorrelatmns (dwmals
onutted) among vdrldbles
I 2 3 4 5 6 7 8 9 IO II I2
Standard
Mean dewauon
I Age -
2 Education’ -39 -
3 Marital staus (married) -08 06 -
4 Gender (male) IS 05 I4
5 Race (black) -15 -15 -20

6 Attendance 1961 -01 09 03
7 Attendance 1969 03 02 02
8 Health problems 20 -15 -07
9 Life events -II -04 -01
10 Gunn 1967 06 I5 I2
II Gunn 1969 00 I5 06
I2 Affihauon 1967 02 I2 08
-
-09
-10
-13
02
-01
I4
IO
-04
44 81 I6 61
3 37 I 50
074 044
044 0 50
- 0 II 0 32
-01 - I68 100
-01 54 - 219 100
08 -06 -08 - 0 73 0 97
07 -04 -06 14 - 0 82 I I4
-12 17 I4 -27 -15 - 72 05 8 I9
-03 IO I2 -37 -32 53 - 72 85 7 74

00 41 27 -04 -01 09 02 - 0 75 049
‘The education vanable IS coded as follows 1 = less than 7
years, 2 = 7-9 years, 3 = 10-11 years, 4 = 12 years, 5 = 13-15
years, 6 = college graduate and 7 = graduate on professional
tranung
Rehgon and psychologrcal dtstress m a commumty sample 1259
mvolvement, stress and psychological distress OLS
regression is fully appropnate for our continuous
dependent vanable The correlation matnx from
whtch the regression models were estimated is pre-
sented m Table 1 Pauwtse present correlations were
used m all regression analyses The analyses pro-
ceeded m a senes of steps m which we estimated
the effects of rehgrous mvolvement on psychological
distress This relationship was then adlusted for
potentially confounding sociodemograpmc factors
The soctodemographrc vanables utrhzed are age (m
years), education (nommally scaled vanable coded
from 1 = less than 7 years of education to 7 =
graduate or professtonal training), gender (1 = male),
manta1 status (1 = marned, 0 otherwtse), and race
(1 = black, 0 otherwtse) Subsequent regression
models assessed the association between stress
and psychological distress and the extent to which
rehgtous mvolvement may buffer the effects of stress
on health
A final step m all analyses mvolved entenng the
Time 1 Gunn score as a predictor of Time 2 Gunn
The use of the Ttme 1 distress measure effectively

converts the Time 2 outcome mto change scores, Thts
1s appropnate m these analyses because tt allows
us to determine the extent to whtch any improved
mental health functiontng found among those high
on rehgtous mvolvement ts stgmficantly greater than
any improvement found among those having lower
scores on the rehgion measures
RESULTS
Relrglon and psychologrcaI dzstress
Table 2 presents the results of three regression
analyses that assess the assoctation between psycho-
logical distress and religion In the first model, Ttme
2 (1969) Gunn scores are regressed on the Time 1
(1967) religious attendance and affihatton In the
second regression model, controls are introduced for
soctodemographtc factors (age, education, manta1
status, gender and race) that were measured at Time
1 The final model adds the Time 1 (1967) Gunn score
as a predictor of the Time 2 Gunn score
The first model m Table 2 indicates that although
rehgtous affiliation IS unrelated to psychological drs-
tress, rehgrous attendance IS positively associated
with the Time 2 (1969) Gunn score Persons who
attend rehgtous services regularly report lower levels
of psychologtcal distress than infrequent attenders
and non-attenders This relattonshtp remains robust
when adlusted for the soctodemographtc variables
but tt IS reduced to non-stgmficance when controlled
for Time 1 (1967) psychologtcal distress Religious
attendance at Time 1 is not associated with increases
m psychologtcal well-being, as measured by the Gurm
scales. Thus, m the face of ngorous statistical con-

trols for the possible confounding of public rehgtous
partictpatton with scores on the Gurm scale, we find
that attendance IS unrelated to psychological d:stress
Our prospecttve analyses have failed to replicate the
inverse assoctattons between religious commitment
and psychologtcal distress that were reported for the
cross-secttonal analyses at Time 1 [ 131
We tested for nonhneanty m the assoctatton be-
tween rehgtous attendance and mental health status
Table 2 Analyses of the assoclatlon between Tune 2
(1969) Gunn scores and the rehgton measures at
Tlmc 1 (1967)
i
II III
Independent
vanables (SE) (A) (&
Attendance 0 83’. 0 84.’ 0 16
(0 32) (0 32) (0 28)
Affihatlon -046 -0 88 -0 88
(0 75) (0 74) (0 64)
Age 003
(0 02) (%5
Education 0 94.1 0 48’.
(0 22) (0 19)
Mamed 0 87 0 II
(0 69) (0 60)

Sex (men= 1) I 60** 0 54
(0 60) (0 52)
Race (black = 1) 0 63 I 30
(0 97) (0 84)
Gunn 1967 0 49”
(0 03)
Constant 71 80 66 14 35 81
R2 0010 0 050 0290
** = P < 0 01, 2-taded tests
b = unstandardized regrewon coefficients
Shaver et al [28] reported a curvihnear relatton-
ship between religion measures and psychologtcal
symptoms The very rehgtous and the non-rehgtous
enloyed the best reported health Accordingly, to a
regression equation that included the demographic
vanables and Ttme 1 (1967) rehgious attendance,
we added the squared coefficient for religious attend-
ance (quadratic term) A srgmficant quadratic term
would indicate that the associatton between rehgtous
attendance and distress ts curvtltnear The quadrattc
term was not stgmficant (analysts not shown), mdicat-
mg the absence of curvihneanty m the assoctatton
between religion and psychological distress
We also explored the extent to which vanattons
exist by race, gender and educattonal level m the
assoctatton between the rehgton measures and
psychological distress Specifically, for each of these
soctodemographtc vanables, we regressed Time 2
(1969) Gunn scores on the two religion vanables, all

of the soclodemographlc vanables, and the relevant
muthphcatlve term for the interaction between each
rehgion measure and the soclodemographlc correlate
under consideration In these analyses (not shown),
none of the interaction tests were slgmficant
In cross-sectional studies researchers frequently
assume that the reported level of rehglous mvolve-
ment IS a stable characteristic of the respondent In
contrast, religious behavior may be a fairly transient
phenomenon Lmdenthal et al [ 131, for example,
noted that when faced with stress, respondents
reported a decline m rehgtous attendance The fact
that we are workmg with panel data allows us to
explore the nature of changes m rehgtous attendance
between 1967 and 1969 and the consequences that
these changes could have for mental health status
Ftrst, we noted that attendance levels were relattvely
stable over the course of 2 years Table 1 reveals
that the correlation between rehgtous attendance at
Time 1 (1967) and Time 2 (1969) was 0 54
Second, we divided our sample mto subgroups
based on the combmatlon of the level of rehglous
attendance reported at Ttme 1 (1967) and Time 2
1260 DAVID R WILLIAMS et al
(1969) At each tzme point, all respondents were
classified into one of three categories. high attenders
(persons who attended rehgzous services once a
week or more), moderate attenders (zndzvzduals who
attended once a month to two or three times a month)
and low attenders (those who never attended as

well as those who attended a few times a year
or less) Respondents were then assigned to one of
five categones based on their 1967 and 1969 attend-
ance. The stub/y hzgh group (n = 216) consists of
persons who were hzgh attenders at both time points
The newly hzgh (n = 70) are hzgh attenders m 1969
who were either moderate or low attenders m 1967
The declznzng attendance group (n = 99) 1s com-
pnsed of hzgh attenders at Tzme I who were moderate
or low attenders at Time 2 The moderate group
(n = 152) consists of persons who were moderate
attenders at both time pomts, as well as those who
fluctuated from the moderate to low level or vice
versa between the two data collectzon points Finally,
the stably low (n = 149) were low attenders at both
time points
Table 3 presents the results of analyses that exam-
med the relatzonshzp between attendance patterns
and psychologzcal distress. We anticipated that those
who reported conszstently high levels of attendance
and those who increased then attendance would have
lower levels of [email protected] distress than persons
with consistently low attendance levels The first
model m Table 3 indicates that the stably high, the
newly hzgh and the declzmng attendance group all
had szgmficantly higher scores on the Gurm scale
(that zs, less psychologzcal distress) than the stably
low attendance group Thus, a high level of rehgzous
attendance m 1967 or m 1969, irrespective of their
attendance level at the other tzme point, zs predictive
of psychologzcal well-being However, szmzlar to the
findings m Table 2, these assoczatzons do not remam
szgnzficant when adJusted for Tzme 1 (1967) distress
scores

Relzgzon, stress and mental health
We have noted that rehgzon does not directly
enhance the psychologzcal well-being of zts adherents
Table 3 Analyses of the assOclauon between Time
2 (1969) Gunn scores and attendance at Time I
(1967) combmed wth Time 2 (1969)’
I II
Independent
vanables (Si (A)
Rehgmus attendance
a Stably high 1 63. 0 23
(0 73) (0 67)
b Newly high 2 06’ 0 58
(0 99) (0 90)
c Dechnmg I 90. 041
(0 88) (0 ‘30)
d Moderate 0 68 001
(0 79) (0 71)
e Stably low (omnted)
Time I Gunn 0 40”
(0 03)
Constant
RZ
l P < 0 05. l *P < 0 01, 2-taded tests

‘Both models mclude controls for age, education,
manta1 status, gender and race
b = Unstandardized regressIon coefficients
We now turn to examme the buffenng hypothesis
Can rehgzon protect mdzvzduals from at least some of
the negative consequences of stress’ Table 4 presents
four models that explored the assoczatzons among
rehgzon, stress and psychologzcal distress The use of
the Time 1 measures of religion m these analyses
excludes the posszbzhty that any modifying effects
that we observe are due to changes m rehgzous
mvolvement resulting from stress The first model
shows the assoczatzon of the two stress measures and
the two rehgzon measures to the Time 2 (1969) Gunn
scale, controlhng for the soczodemographzc vanables
The second model adds adJustment for the Time 1
(1967) Gunn score, and models three and four tests
for mteractzons between relzgzous attendance and
hfe events, and attendance and health problems,
respectively
Table 4 shows that both hfe events and health
problems are szgnzficantly inversely associated with
scores on the Gunn scale As expected, stress IS
posrtzvely related to psychologzcal distress Model II
indicates that the coefficients for stress are reduced
Table 4 Analyses of the assoclatlon between Time 2 (1969)
Gunn scores. Time I (I 967)
measures of rehgon and mdlcators of stress’
Independent
vanables

I
b
(SE)
II
(Sk
111
b
(SE)
Attendance
Afiihatlon
Life events (LE)
Health problems (HP)
Gurm 1967
0 62’
(0 28)
-084
(0 66)
- I 77’
(0 23)
-2 69’.
(0 28)
Attendance x LE

0 II
(0 26)
-083
(0 59)
-1 53”
(0 21)
-I 85..
(0 26)
0 39’9
(0 03)
-023
(0 30)
-087
(0 59)
-2 26”
(0 40)
-1 88.
(0 26)
0 39’.
(0 03)
0 43’
-0 32
(0 32)
-065

(0 60)
-I 55”
(0 21)
- 2 70”
(0 44)
0 40.’
(0 03)
(021)
Attendance x HP 0 52.
(0 23)
Constant 70 11 44 53 45 4 453
R’ 0 251 0 399 0 403 0404
l P < 0 05, l *P < 0 01, 2-taded tests
‘All models m&de controls for age, education, manta1 status,
gender and race
b = unstandardued regresston coefficients
Rehgon and psychologxal distress m a commumty sample 1261
but remam slgnrficant when controlled for Time 1
(1967) psychologtcal distress Model II also reveals
that the relationship between attendance and distress
IS reduced to non-sigmficance when controlled for
Tl distress Models three and four reveal that both of
the multtphcative terms for interactions between
stress and rehgious attendance are significant The
interaction terms capture operant religious effects
that would go unnoted otherwise Moreover, the

sign is positive for both mteraction coefficients This
pattern of results reflects classic buffenng effects
That is, at low levels of religious attendance, stress
IS associated with increased levels of psychological
distress However, as the level of religious attendance
increases, the adverse consequences of stress are
reduced Surular analyses for the associatton between
religious affiliation and the stress measures were not
significant
In sum, consistent with other research [7], we find
that our measure of rehgious behavior (religious
attendance) is more consequential for health status
than our mdicator of rehgious affiliation The affiha-
tion measure is unrelated to psychological distress
In contrast, although rehgious attendance does not
directly reduce psychological distress, it does buffer
the impact of stressful life events and physical health
complamts on psychological well-being
DISCUSSION
The findings reported here underscore the import-
ance of giving more systematic research attention to
the consequences of rehgious beliefs and behavior for
health and well-being. National surveys reveal the
contmumg importance of public and pnvate rehgtous
mvolement m contemporary Amencan hfe [29] Our
results indicate that rehgion may be a potent coping
strategy that facihtates adjustment to the stress of hfe
Further exploration of this issue merits serious and
sustained research attention
One compellmg reason to replicate the analyses
reported here is the possibihty that they may reflect
period or cohort effects The data utilized m this

study are over 20 years old It is possible that the
findings documented here are true only for that
earlier time period and would not apply today In a
comprehensive review of the literature on rehgious
involvement and sublective well-bemg, Wetter et al.
[30] found a stronger relationship between religion
and SubJective well-being m earlier studies than m
more recent ones
Our use of longitudmal survey data is clearly an
improvement over merely studying cross-sectional
associations but analyses of two wave panel data
are not without serious hnntanons [31] For example,
the inclusion of Time 1 health status adjusts for
baseline differences among respondents m the levels
of health However, if health status at Time 2
IS also affected by other unmeasured causes, the
Time 1 health status indicator IS an inadequate proxy
for the mynad factors that are not mcluded m the
prediction equation The presence of measurement
error is another serious hmitation Errors of measure-
ment can create spurious covanance among the
variables in the regression models Theoretically-
grounded research that utilizes multiple indicators
of religion and that employs structural equation
modeling procedures [32] can begm to address these
lirmtations
This paper also illustrates some of the cnucal
shortcommgs m current research on religion and
mental health Rehgious attendance and religious
affiliation are the only measures of religious commit-
ment that we utihzed These are two of the most
commonly used measures m research on religion [l]
In contrast, religious mvolvement is a complex multi-

dimensional phenomenon [33-351 Kmg and Hunt
[33], for example, have tdentified more than a dozen
different ways of being rehgious, and have developed
and tested scales to measure each component &ml-
larly, Levm and associates [2.6,20,36] have pro-
posed numerous theoretically mformed mechamsms
by which religion can affect health status that clearly
constttute the most fruitful extant starting ground for
empirical mvestigations of the effects of religion on
health. The advancement of our understandmg of the
nature of the association between religion and health,
is contingent on efforts to comprehensively assess
religion, and identify the cnttcal dimensions of reh-
gious commitment that are linked to health status
Research efforts of thts kmd are necessary
to understand even the results presented here We
reported that religious attendance buffers or moder-
ates the relationship between stress and health How-
ever, we are unable to tell if this effect 1s hnked
to anything mtnnsmally rehgtous Although we
employ controls for formal education m all of the
analyses, it IS still possible that the attendance
measure is a proxy for some aspect of social status
Sociologists have long noted that religious partici-
pation IS frequently a badge of socioeconomic status,
secular m character, and of no greater rehgious
sigmficance than participation m other community
orgamzations [37] And there is abundant evidence
that participation m formal and informal social
groups, rehgious and non-rehgious, can promote
health, reduce stress and buffer the effects of stress on
health [22] Moreover, besides social class, rehgious
attendance may be confounded with functtonal
health [36]

It follows that a simple measure of the frequency
of religious attendance does not adequately cap-
ture public religious participation A comprehensive
assessment of public rehgious mvolvement must
include attendance at rehgious meetings other than
the main weekly worship service, financial support
of religious organizations, and holdmg leadership
and volunteer positions m rehgious groups [35].
Researchers must then seek to identify how these
public aspects of rehgious mvolvement relate to pn-
vate dimensions of religious beliefs and behavior and
how they combme to affect levels of health and
well-being.
Acknowledgements-An earlier version of this paper was
presented at the Ntnety-Seventh Annual Meettngs of the
Amertcan Psychologtcal Assoctatton, New Orleans, August,
1989 We wish to thank Jerome K Myers for permIssIon to
use the data and the anonymous renewers for very helpful
comments on an earlier version of this paper. The research
was supported, m part, by grant Rl l-8812285, from the
National Science Foundation
1262 DAVID R WILLIAMS er al
1
2
3
4
5

6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
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Bergm A E Rehgloslty and mental health a crmcal
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Levm J S and Schlller P L Is there a rehgous factor
m health? J Rehg Hlth 26, 9-36, 1987
Gartner J , Larson D B , Allen G D and Gartner
A F Religious commitment and psychopathology a
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Mental Health Basic Books, New York, 1960
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Idler E L [email protected] mvolvement and the health of the
elderly some hypotheses and an mlhal test Sot Forces
66, 226-238, 1987
Petersen L R and Roy A Rehglowty, anxiety
and meaning and purpose rehgon’s consequences for
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683-685. 1980
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M S Mental statuss and rehglous behavior J Scl
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of urban black adults J Hum Stress 13, 165-174
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ticlpatlon and psychlatnc symptomology Znt J Sot
Psychtat 27, 133-142
Clearly P D and Houts P S The psychological impact
of the three mile island mcldent J Hum Stress 10,
28-34, 1984
Markides K S , Levm J S and Ray L A Rehglon,
agmg, and life satlsfactlon an eight-year, three-wave
lonmtudmal studv The Geront 27. 660-665. 1987
Kaplan B and Blazer D G Rehg&n m the’stress and
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(EdIted bv Miller W R and Martm J E ). DD 57-l 10
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health a theoretlcal overview J Rehg Agrng 4,
133-146, 1987
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port, control and copmg a social epldemlologlcal
view In An Introduction to Health Promotron Research
(EdIted by KIckbusch I and Badura B ) World Health
Organization In press

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Oitrander D R Life events and men&l status a long-
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Myers J K, Lmdenthal J J and Pepper M ‘P Life
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logcal distress Am Sot Rev 45, 463478, 1980
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M J Rehglon and SubJective well-being m adulthood
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J Sot 72, 102-111, 1966

APPENDIX
Life events
Measures of Stress
The 28 undesirable events are (1) failed school or trammg
program, (2) problems m school, (3) moved to a worse
nelghborhood, (4) wldowed, (5) divorced, (6) separated, (7)
trouble with m-laws, (8) serious physical illness, (9) serious
injury or accident, (10) death of a loved one, (11) stdlblrth,
(12) frequent minor illness, (13) mental illness, (14) death
of a pet, (15) demoted or changed to a less responsible Job,
(16) laid off temporarily, (17) busmess faded, (18) trouble
with boss, (19) out of work for over a month, (20) fired,
(21) financial status a lot worse than usual, (22) foreclosure
of mortgage or loan, (23) appearance m court, (24) deten-
tion m Jail, (25) arrested, (26) law suit or legal action,
(27) loss of dnver’s license, and (28) change m relations
with neighbor, friend and relative such as serious or maJor
disagreement
Health problems
The 16 health problems are (I) eye trouble, (2) ear
trouble, (3) sinus trouble, (4) throat trouble, (5) bronchitis,
(6) pneumoma, (7) tuberculosis, (8) bolls and abscesses,
(9) diabetes, (10) kidney trouble, (11) bodily injury,
(12-14) operations, (15) cancer or tumors, and (16) tooth
trouble, excluding routme prophylaxis
In Review

Research on Religion, Spirituality, and Mental Health:
A Review
Harold G Koenig, MD
1
Key Words: religion, spirituality, depression, anxiety,
psychosis, substance abuse
Despite spectacular advances in technology and science,90% of
the world’s population is involved today in some
form of religious or spiritual practice.1 Nonreligious people
make up less than 0.1% of the populations in many Middle-
Eastern and African countries. Only 8 of 238 countries have
populations where more than 25% say they are not religious,
and those are countries where the state has placed limitations
on religious freedom. Atheism is actually rare around the
world. More than 30 countries report no atheists (0%) and in
only 12 of 238 countries do atheists make up 5% or more of
the population. In Canada, 12.5% of the population are non-
religious and 1.9% atheist.
Evidence for religion playing a role in human life dates back
500 000 years ago when ritual treatment of skulls took place
during China’s paleolithic period.2 Why has religion endured
over this vast span of human history? What purpose has it
served and does it continue to serve? I will argue that religion
is a powerful coping behaviour that enables people to make
sense of suffering, provides control over the overwhelming
forces of nature (both internal and external), and promotes
social rules that facilitate communal living, cooperation, and
mutual support.
Until recent times, religion and mental health care were
closely aligned.3 Many of the first mental hospitals were

The Canadian Journal of Psychiatry, Vol 54, No 5, May 2009 �
283
Religious and spiritual factors are increasingly being examined
in psychiatric research.
Religious beliefs and practices have long been linked to
hysteria, neurosis, and psychotic
delusions. However, recent studies have identified another side
of religion that may serve
as a psychological and social resource for coping with stress.
After defining the terms
religion and spirituality, this paper reviews research on the
relation between religion and
(or) spirituality, and mental health, focusing on depression,
suicide, anxiety, psychosis, and
substance abuse. The results of an earlier systematic review are
discussed, and more recent
studies in the United States, Canada, Europe, and other
countries are described. While
religious beliefs and practices can represent powerful sources of
comfort, hope, and
meaning, they are often intricately entangled with neurotic and
psychotic disorders,
sometimes making it difficult to determine whether they are a
resource or a liability.
Can J Psychiatry. 2009;54(5):283–291.
Clinical Implications
� Religious beliefs and practices may be important resources
for coping with illness.
� Religious beliefs may contribute to mental pathology in some
cases.

� Psychiatrists should be aware of patients’ religious and
spiritual beliefs and seek to understand
what function they serve.
Limitations
� My review of recent studies is selective, not systematic.
� Studies without statistically significant findings are not
discussed.
� Clinical applications are not addressed.
located in monasteries and run by priests. With some excep-
tions, these religious institutions often treated patients with far
more compassion than state-run facilities prior to 19th-
century mental health reforms (reforms often led by religious
people such as Dorothea Dix and William Tuke). In fact, the
first form of psychiatric care in the United States was moral
treatment, which involved the compassionate and humane
treatment of people with mental illness—a revolutionary
notion at a time when patients were often put on display and
(or) housed in despicable conditions in the back wards of hos-
pitals or prisons.4 Religion was believed to have a positive,
civilizing influence on these patients, who might be rewarded
for good conduct by allowing them to attend chapel services.
However, in the late 19th century, the famous neurologist
Jean Charcot and his star pupil, Sigmund Freud, began to
associate religion with hysteria and neurosis. This created a
deep divide that would separate religion from mental health
care for the next century, as demonstrated by the writings of 3
generations of mental health professionals from Europe, the

United States, and Canada.5–8
Today, attitudes toward religion in psychiatry have begun to
change. The American College of Graduate Medical Educa-
tion now states in its Special Requirements for Residency
Training for Psychiatry9 that all programs must provide train-
ing on religious or spiritual factors that influence psychologi-
cal development. Part of this change has been driven by
scientific research during the past 2 decades that suggests reli-
gious influences need not always be pathological, but can
actually represent resources for health and well-being.
Definitions
Before reviewing the research, religion and spirituality must
be defined, because these terms have ambiguous meanings
that may affect the interpretation of research findings. The
definition of religion is generally agreed on and involves
beliefs, practices, and rituals related to the sacred. I define the
sacred as that which relates to the numinous (mystical, super-
natural) or God, and in Eastern religious traditions, to Ulti-
mate Truth or Reality. Religion may also involve beliefs about
spirits, angels, or demons. Religions usually have specific
beliefs about life after death and rules about conduct that
guide life within a social group. Religion is often organized
and practiced within a community, but it can also be practiced
alone and in private. However, central to its definition is that
religion is rooted in an established tradition that arises out of a
group of people with common beliefs and practices concern-
ing the sacred.
In contrast with religion, spirituality is more difficult to
define. It is a more popular expression today than religion, as
many view the latter as divisive and associated with war, con-
flict, and fanaticism. Spirituality is considered more per-
sonal, something people define for themselves that is largely

free of the rules, regulations, and responsibilities associated
with religion. In fact, there is a growing group of people cate-
gorized as spiritual-but-not-religious, who deny any connec-
tion at all with religion and understand spirituality entirely in
individualistic, secular terms. However, this contemporary
use of spirituality is different from its original meaning.
According to Philip Sheldrake,10 professor of applied theol-
ogy at the University of Durham, England, the origin of the
word spiritual lies in the Latin term spiritualis, which is
derived from the Greek word pneumatikos, as it appears in
Paul’s letters to the Romans and Corinthians. A spiritual per-
son was considered someone with whom the Spirit of God
dwelt, often referring to the clergy.10, p 3 In the Second
Vatican Council, spirituality replaced terms such as ascetical
theology and mystical theology. Although the Greeks used
the word spiritual to distinguish humanity from nonrational
creation, spiritual and (or) spirituality has been distinctly reli-
gious throughout most of Western history. It was not until
much later that Eastern religions adopted the term. Then,
spiritual people were a subset of religious people whose lives
and lifestyles reflected the teachings of their faith tradition.
Spiritual people were those such as Teresa of Ávila, John of
the Cross, Siddhartha Gautama, Mother Teresa, or Mahatma
Gandhi.
The term spirituality in health care has now expanded far
beyond its original meaning. This expansion has resulted
from attempts to be more inclusive in pluralistic health care
settings, to address the needs both of religious and of non-
religious people. This degree of inclusiveness, while admira-
ble in the clinic, makes it impossible to conduct research on
spirituality and relate it to mental health, as there is no unique,
distinct, agreed-on definition. Thus researchers have strug-
gled to come up with measures to assess spirituality.

When measured in research, spirituality is often assessed
either in terms of religion or by positive psychological,
social, or character states. For example, standard measures of
spirituality today contain questions asking about meaning
and purpose in life, connections with others, peacefulness,
� La Revue canadienne de psychiatrie, vol 54, no 5, mai
2009284
In Review
Abbreviations used in this article
5-HT 5-hydroxytryptamine (serotonin)
5-HT1A 5-beta hydroxytryptamine receptor 1
CASA National Center on Addiction and Substance Abuse
MADRS Montgomery-Asberg Depression Rating Scale
MDD major depressive disorder
RCT randomized controlled trial
RS religion and (or) spirituality
existential well-being, and comfort and joy. This is
problematic, as it assures that spirituality in such studies will
be correlated with good mental health. In other words,
spirituality—defined as good mental health and positive
psychological or social traits—is found to correlate with good
mental health. Such research is meaningless and tautological.
To avoid this methodological problem and to maintain the

purity and distinctiveness of the construct, I have proposed
that spirituality be defined in terms of religion,11 where reli-
gion is a multidimensional construct not limited to institu-
tional forms of religion. Thus I will either refer to religion or
use the terms religion and spirituality synonymously (for
example, as RS).
Religion as a Coping Behaviour
Systematic research in many countries around the world finds
that religious coping is widespread. For the general popula-
tion, research published in The New England Journal of Medi-
cine found that 90% of Americans coped with the stress of
September 11th (2001) by “turning to religion.”12, p 1507
During
the week following the attacks, 60% of Americans attended a
religious or memorial service and Bible sales rose 27%.13
Even prior to the year 2000, more than 60 studies had docu-
mented high rates of religious coping in patients with an
assortment of medical disorders ranging from arthritis to dia-
betes to cancer.14 One systematic survey of hospitalized medi-
cal patients (n = 330) found that 90% reported they used
religion to cope, at least to a moderate extent, and more than
40% indicated that religion was the most important factor that
kept them going.15
Psychiatric patients also frequently use religion to cope. A
survey of patients (n = 406) with persistent mental illness at a
Los Angeles County mental health facility found that more
than 80% used religion to cope.16 In fact, most patients spent
as much as one-half of their total coping time in religious prac-
tices such as prayer. Researchers concluded that religion
serves as a “pervasive and potentially effective method of
coping for persons with mental illness, thus warranting its
integration into psychiatric and psychological practice.”16, p

660
In another study, conducted by the Center for Psychiatric
Rehabilitation at Boston University, adults with severe mental
illness were asked about the types of alternative health care
practices they used.17 A total of 157 people with schizophre-
nia, bipolar disorder, or MDD responded to the survey. People
with schizophrenia and MDD reported that the most common
beneficial alternative health practice was an RS activity (more
than one-half reported this); for those with bipolar disorder,
only meditation surpassed RS activity (54%, compared with
41%).
Religious coping is likewise prevalent outside the United
States. A study of psychiatric patients (n = 79) at Broken Hill
Base Hospital in New South Wales found that 79% rated spir-
ituality as very important, 82% thought their therapist should
be aware of their spiritual beliefs and needs, and 67% indi-
cated that spirituality helped them to cope with psychological
pain.18 A survey of patients (n = 52) with lung cancer in
Ontario asked about sources of emotional support. The most
commonly reported support systems were family (79%) and
religion (44%).19 Finally, a study of outpatients (n = 292)
with cancer seen at the Northwestern Ontario Regional Can-
cer Centre, Thunder Bay, found that, among all coping strate-
gies inquired about, prayer was used by the highest number
(64%).20
Why is religious coping so common among patients with
medical and psychiatric illness? Religious beliefs provide a
sense of meaning and purpose during difficult life circum-
stances that assist with psychological integration; they usu-
ally promote a positive world view that is optimistic and
hopeful; they provide role models in sacred writings that
facilitate acceptance of suffering; they give people a sense of

indirect control over circumstances, reducing the need for
personal control; and they offer a community of support, both
human and divine, to help reduce isolation and loneliness.
Unlike many other coping resources, religion is available to
anyone at any time, regardless of financial, social, physical,
or mental circumstances.
I will review studies examining the relation between religion
and mental health in 5 areas: depression, suicide, anxiety,
psychotic disorders, and substance abuse. While some stud-
ies report no association between religious involvement and
mental health, and a handful of studies have reported nega-
tives associations, the majority (476 of 724 quantitative stud-
ies prior to the year 2000, based on a systematic review)
reported statistically significant positive associations.21
Because space is limited, I will briefly mention the results of
that systematic review and then examine, in more detail, stud-
ies that exemplify research published more recently.
Depression
Prior to 2000, more than 100 quantitative studies had exam-
ined the relation between religion and depression.22 Among
93 observational studies, two-thirds found significantly
lower rates of depressive disorder or fewer depressive symp-
toms among the more religious. Among 34 studies that did
not, only 4 found being religious was associated with signifi-
cantly more depression. Among 22 longitudinal studies, 15
found that greater religiousness at baseline predicted fewer
depression symptoms or faster remission of symptoms at
follow-up. Among 8 RCTs, 5 found that religious-based psy-
chological interventions resulted in faster symptom improve-
ment, compared with secular-based therapy or with control
subjects. Supporting these findings was a more recent

Research on Religion, Spirituality, and Mental Health: A
Review
The Canadian Journal of Psychiatry, Vol 54, No 5, May 2009 �
285
independently published meta-analysis of 147 studies that
involved nearly 100 000 subjects.23 The average inverse cor-
relation between religious involvement and depression was
–0.10, which increased to –0.15 for studies in stressed popula-
tions. While this correlation appears small and weak, it is of
the same magnitude as seen for sex (a widely recognized fac-
tor influencing the prevalence of depression).
Moreover, individual studies in stressed populations, particu-
larly people with serious medical illness, find a more substan-
tial impact for religion on the prevalence and course of
depression. For example, depressed medical inpatients (n =
1000) aged 50 years or older with either congestive heart fail-
ure or chronic pulmonary disease were identified with depres-
sive disorder using the Structured Clinical Interview for
Depression.24 The religious characteristics of these patients
were compared with those of nondepressed patients (n = 428).
Depressed patients were significantly more likely to indicate
no religious affiliation, more likely to indicate spiritual but not
religious, less likely to pray or read scripture, and scored
lower on intrinsic religiosity. These relations remained robust
after controlling for demographic, social, and physical health
factors. Among the depressed patients, severity of depressive
symptoms was also inversely related to religious indicators.
Among these 1000 depressed patients, investigators followed
865 for 12 to 24 weeks, examining factors influencing speed
of remission from depression.25 The most religious patients

(those who attended religious services at least weekly, prayed
at least daily, read the Bible or other religious scriptures at
least 3 times weekly, and scored high on intrinsic religiosity)
remitted from depression more than 50% faster than other
patients (hazard ratio = 1.53, 95% CI 1.20 to 1.94), controlling
for multiple demographic, psychosocial, psychiatric, and
physical health predictors of remission. Several other studies
have similarly shown a positive impact for religion on course
of depression.26–28
However, for psychiatric patients there have been few studies
on the course of depression. Bosworth et al29 interviewed
elderly psychiatric inpatients (n = 104), assessing public and
private religious practices and religious coping. Depressive
symptoms were assessed at baseline and 6 months later by a
psychiatrist using the MADRS. Baseline positive religious
coping predicted significantly less depression on the MADRS
at the 6-month evaluation, an effect independent of social sup-
port measures, demographics, use of electroconvulsive ther-
apy, and number of depressive episodes.
At least 2 studies (both cross-sectional) have examined rela-
tions between religious involvement and depression in
Canada, one reporting an inverse relation and the other find-
ing a positive relation. O’Connor and Vallerand30 examined
associations between religious motivation and personal
adjustment in a sample of elderly French-Canadians (n =
176) drawn from nursing homes in the greater Montreal area.
Intrinsic religiosity was inversely related to depression and
positively related to life satisfaction, self-esteem, and mean-
ing in life. In the second study, Sorenson et al31 followed
teenaged mothers (n = 261) (87% unmarried) before delivery
and 4 weeks after delivery in southwestern Ontario. They
examined the relation between religion and depressive symp-
toms during the first few weeks after babies were born. Cath-

olics and teenagers affiliated with more conservative
religious groups scored significantly higher on depression,
and those who attended religious services more frequently
also had higher depression scores. However, the highest
depression scores were among girls who cohabitated with
someone while continuing to attend religious services.
Baetz and colleagues32,33 have shown in large cross-sectional
community surveys of the Canadian population that religious
attendance is associated with less depression and fewer psy-
chiatric disorders. However, participants indicating that spir-
itual values were important or perceived themselves as
spiritual or religious had higher levels of psychiatric symp-
toms. The researchers speculated that these people could
have turned to RS to reframe difficult life circumstances
associated with psychiatric illness. Bear in mind that the stud-
ies were conducted in largely healthy community-dwelling
adults with relatively low stress levels.
Two additional unpublished dissertations34,35 report studies
of RS and depression in Canadian men with prostate cancer
and in bereaved caregivers of Canadians dying from AIDS.
Both demonstrated positive effects for RS involvement on
posttraumatic growth and coping with illness. Supporting the
findings of the Canadian caregiver study, Fenix et al36 at Yale
University recently followed caregivers (n = 175) of recently
deceased cancer patients for 13 months, examining associa-
tions between religiousness and the development of MDD.36
Religious caregivers were significantly less likely to have
developed MDD by the 13-month follow-up, a finding that
persisted after adjusting for other risk factors. The same
results have been reported for caregivers of patients with
Alzheimer disease.37,38
Thus studies in medical patients, older adults with serious

and disabling medical conditions, and their caregivers sug-
gest that religious involvement is an important factor that
enables such people to cope with stressful health problems
and life circumstances. However, this may not be true in all
populations, as studies of pregnant unmarried teenagers and
nonstressed community populations above suggest.
Critics say that most studies reporting positive results are
observational and that some unmeasured characteristic may
be related both to religion and to depression, confounding the
� La Revue canadienne de psychiatrie, vol 54, no 5, mai
2009286
In Review
relation. In particular, genetic factors have been implicated. In
a fascinating study that examined the relation of spirituality to
brain 5-HT1A binding using positive emission tomography,
investigators found that 5-HT1A binding was lower in people
who were more spiritually accepting. Note that lower 5-HT1A
binding—the same pattern seen with spirituality—has been
found in patients with anxiety and depressive disorders.39–41
Thus, rather than being genetically less prone to depression,
RS-oriented people may be at increased risk for mood
disorders based on their 5-HT receptor binding profile.
Suicide
In Koenig et al’s42 systematic review of research conducted
before 2000, 68 studies were identified that examined the
religion–suicide relation. Among those studies, 57 found
fewer suicides or more negative attitudes toward suicide

among the more religious, 9 showed no relation, and 2
reported mixed results. Seven of the studies were conducted in
Canada, and of those, 5 found fewer suicides or more negative
attitudes toward suicide among the more religious, 1 found no
association, and 1 reported mixed results.
While recent research suggests that religion prevents suicide
primarily through religious doctrines that prohibit suicide,43
there is also evidence that the comfort and meaning derived
from religious beliefs may be relevant44 and may be especially
important in people with advanced medical illness.45 Reli-
gious involvement may also help to prevent suicide by sur-
rounding the person at risk with a caring, supportive
community.46
Anxiety
While religious teachings have the potential to exacerbate
guilt and fear that reduce quality of life or otherwise interfere
with functioning, the anxiety aroused by religious beliefs can
prevent behaviours harmful to others and motivate pro-social
behaviours. Religious beliefs and practices can also comfort
people who are fearful or anxious, increase sense of control,
enhance feelings of security, and boost self-confidence (or
confidence in Divine beings).
Prior to 2000, at least 76 studies had examined the relation
between religious involvement and anxiety.47 Sixty-nine
studies were observational and 7 were RCTs. Among the
observational studies, 35 found significantly less anxiety or
fear among the more religious, 24 found no association, and
10 reported greater anxiety. However, all 10 of the latter stud-
ies were cross-sectional, and anxiety and (or) fear is a strong
motivator of religious activity. People pray more when they
are scared or nervous and feel out of control (“There are no

atheists in foxholes”). Then, cross-sectional studies are less
useful than longitudinal studies or RCTs. Among the 7 RCTs
examining the effects of a religious intervention on subjects
with anxiety (usually generalized anxiety disorder), 6 found
that religious interventions in religious patients reduced anx-
iety levels more quickly than secular interventions or control
subjects. Studies of Eastern spiritual techniques, such as
mindfulness meditation (from the Buddhist tradition), report
similar effects,48,49 although their efficacy in anxiety disor-
ders has recently been questioned.50
More recent longitudinal studies add to this literature, and
provide information on mechanisms. Wink and Scott51 fol-
lowed subjects (n = 155) for nearly 30 years, from middle age
into later life, studying the impact of religious beliefs and
involvement on death anxiety. Analyses revealed no linear
relations between religiousness, fear of death, and fear of
dying. Subjects with the lowest anxiety levels were those
who were either high or low on religiousness. Anxiety was
highest among subjects who were only moderately religious,
and in particular, those who affirmed belief in an afterlife but
were not involved in any religious practices. Researchers
concluded that it was the degree of religious involvement that
was important in lessening death anxiety not simply belief in
an afterlife.
Religious involvement may also interact with certain forms
of psychotherapy to enhance response to therapy. Investiga-
tors at the University of Saskatchewan explored coping and
motivation factors related to treatment response in patients
(n = 56) with panic disorder participating in a clinical trial.52
Subjects were treated with group cognitive-behavioural ther-
apy, and then were followed up at 6 and 12 months after base-
line evaluation. Self-rated importance of religion was a

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