The document discusses applying spirituality clinically from two perspectives in dialogue. It begins with a declaration of conflict of interest as the author has religious faith. It then discusses how to define and measure spirituality versus religion. Several studies are summarized that examine relationships between religion, spirituality and health outcomes like depression, anxiety, blood pressure and mortality. The author suggests a respectful approach to discussing spirituality with patients and hopes to stimulate interest in further studying this topic to benefit primary care in Brazil.

1. Aplicações Clínicas da
Espiritualidade
duas perspectivas em diálogo

2. Declaração de Conflito de
Interesse
• Tenho fé religiosa.
• Sou cristão.
• Faço parte do Movimento dos Focolares, um
movimento internacional de leigos, de origem
católica, de caráter ecumênico (diversas
igrejas), interreligioso (também budistas,
muçulmanos, judeus, hindus), e de pessoas
com credos humanistas não religiosos, como
ateus ou agnósticos.

3. Por que conflito?
• Não posso estar seguro de que o desejo de
que as evidências dêem suporte à minha fé
religiosa não influenciem minhas análises. No
entanto, não creio em vencer debates, e sim
em buscar a verdade!
• Como lido com este possível conflito?
• Buscando uma análise crítica e confiando que
o Rodrigo e vocês não vão deixar eu me
atrapalhar.

4. O que espero/não espero
• Espero demonstrar que é um campo de
estudo relevante e, quem sabe, estimular
interessados a formar um Grupo (GT) na
SBMFC para buscar tornar o tema mais bem
conhecido e útil para APS.
• Não espero parecer saber muito sobre o
tema. Recém comecei a estudá-lo.
• Não espero demonstrar nada sobre Deus. Ele
não é um objeto/sujeito de estudo científico.

5. Definindo para refletir:
espiritualidade X religião
• Religião envolve crenças, práticas e rituais
concernentes ao “sagrado”, pensado como
Deus ou a Realidade Primeira, vividas no seio
de tradições que congregam e organizam
pessoas.
• Como nesta definição não se incluem
“resultados”, religião pode ser correlacionada
com desfechos em saúde.

6. Definindo para refletir:
espiritualidade X religião
“ Espiritualidade é a busca pessoal
pelo entendimento de respostas a
questões sobre a vida, seu
significado e relações com o
sagrado e transcendente, que
pode ou não estar relacionada a
propostas de uma determinada
religião.”
Dr. Harold KoenigKoenig HG, McCullough M, Larson DBB. Handbook of religion and
health: a century of research reviewed. New York: Oxford University
press; 2001.

7. Nessa perspectiva:

8. Como medir espiritualidade?
• Definir espiritualidade de um modo vago demais
(“valorizar conexões humanizadas”, “ser
otimista”) traz confusão entre preditor e
desfecho nas pesquisas.
• Pessoas que não se identificam com a
espiritualidade, como ateus humanistas, podem
reivindicar as mesma definições vagas para si.
• Em aplicação clínica, espiritualidade pode ser
definida de modo flexível, compartilhado com as
pessoas. Para pesquisa, é difícil definir e medir.

9. Como religião afeta Saúde?
Religion
Mental
Health
Social
Support
Health
Behaviors
Stress
Hormones
Immune
System
Autonomic
Nervous
System
Disease
Detection &
Treatment
Compliance
Smoking
High Risk Behaviors
Alcohol & Drug Use
Infection
Cancer
Heart Disease
Hypertension
Stomach &
Bowel Dis.
Accidents
& STDs*
Geneticsusceptibility,Gender,Age,Race,Education,Income
Liver & Lung
Disease
Stroke
ChildhoodTraining
AdultDecisions
ValuesandCharacter
AdultDecisions
Model of Religion's Effects on Health
Handbook of Religion and Health (Oxford University Press, 2001)

10. Vejamos alguns estudos

11. Psychosocial factors in the etiology and prognosis of coronary
heart disease: systematic review of prospective cohort
studies
BMJ, 1999;318:1460-1467.

12. PROVIDING SOCIAL SUPPORT MAY BE MORE
BENEFICIAL THAN RECEIVING IT:
Results From a Prospective Study of Mortality
PSYCHOLOGICAL SCIENCE
S.L. Brown et al.
Fig. 1. Hierarchical logistic regression model of the effects of receiving instrumental support from others (RISO) and giving instrumental sup-
port to others (GISO). All effects have been adjusted for the effects of age and gender. *p .05. GESS giving emotional support to a spouse;
RESS receiving emotional support from a spouse.

13. Religion and Well-being in Older Adults
Religious categories based on quartiles (i.e., low is 1st quartile, very high is 4th quartile)
Low Moderate High Very High
Church Attendance or Intrinsic Religiosity
Well-being
The Gerontologist 1988; 28:18-28
Religion and Well-being in Older Adults
Religious categories based on quartiles (i.e., low is 1st quartile, very high is 4th quartile)
Low Moderate High Very High
Church Attendance or Intrinsic Religiosity
Well-being The Gerontologist 1988; 28:18-28

14. Religion and Depression in Hospitalized Patients
Geriatric Depression Scale
Information based on results from 991 consecutively admitted patients (differences significant at p<.0001)
35%
23%
22%
17%
Low Moderate High Very High
Degree of Religious Coping
PercentDepressed

15. 0 4 8 12 16 20 24
Weeks of Followup
0
20
40
60
80
100
ProbabilityofNon-Remission %
Other Patients
Highly Religious (14%)
diagnosis
845 medical inpatients > age 50 with major or minor depression
HR=1.53, 95% CI=1.20-1.94, p=0.0005, after control for
demographics, physical health factors, psychosocial
stressors, and psychiatric predictors at baseline

16. Church Attendance and Anxiety Disorder
(anxiety disorder within past 6 months in 2,964 adults ages 18-89)
Koenig et al (1993). Journal of Anxiety Disorders7:321-342
Young (18-39) Middle-Aged (40-59) Elderly (60-97)
AnxietyDisorder

17. Low Attendance High Attendance Low Attendance High Attendance
77
78
79
80
81
AverageDiastolicBloodPressure
* Analyses weighted & controlled for age, sex, race, smoking,
education, physical functioning, and body mass index
Low Prayer/Bible Low Prayer/Bible High Prayer/Bible High Prayer/Bible
p<.0001*
Religious Activity and Diastolic Blood Pressure
(n=3,632 persons aged 65 or over)
High = weekly or more for attendance; daily or more for prayer
Low= less than weekly for attendance; less than once/day for prayer
Citation: International Journal of Psychiatry in Medicine 1998; 28:189-213

18. Rezando o terço e recitando mantras

19. Effect of rosary prayer and yoga mantras on
autonomic
cardiovascular rhythms: comparative study
BMJ 2001;323:1446–9

20. A Randomized, Wait-List Controlled Clinical
Trial: The Effect of a Mindfulness Meditation-
Based Stress Reduction Program on Mood and
Symptoms of Stress in Cancer Outpatients
Psychosomatic Medicine 62:613–622 (2000)

21. Frequency of Attendance at Religious Services,
Hypertension, and Blood Pressure: The Third National
Health and Nutrition Examination Survey

22. Frequency of Attendance at Religious Services,
Hypertension, and Blood Pressure: The Third National
Health and Nutrition Examination Survey
causalidade
reversa?

23. Mortality From Heart Disease and Religious Orthodoxy
(based on 10,059 civil servants and municipal employees)
Kaplan-Meier life table curves (adapted from Goldbourt et a l 1993. Cardiology 82:100-121)
Follow-up time, years
Survivalprobability
Most Orthodox
Non-Believers
Differences remain significant after
controlling for blood pressure,
diabetes, cholesterol, smoking,
weight, and baseline heart disease

24. Six-Month Mortality After Open Heart Surgery
0
5
10
15
20
25
%Dead
(2 of 72)
(7 of 86) (2 of 25)
(10 of 49)
(232 patients at Dartmouth Medical Center, Lebanon, New Hampshire)
Hi Religion
Hi Soc Support
Hi Religion
Lo Soc Support
Lo Religion
Hi Soc Support
Lo Religion
Lo Soc Support
Hi Religion
Hi Soc Support

25. Frequent Attendance at Religious
Services and Mortality over 28 Years

26. Does Religious Observance Promote
Health? Mortality in Secular vs Religious
Kibbutzim in Israel

28. Religious Involvement and Mortality: A
Meta-Analytic Review
• A meta-analysis of data from 42 independent samples
(125,826 participants) examining the association of a measure
of religious involvement and all-case mortality is reported.
• Religious involvement was significantly associated with lower
mortality (odds ratio = 1.29; 95% confidence interval: 1.20-
1.39), indicating that people high in religious involvement
were more likely to be alive at follow-up than people lower in
religious involvement.
• The strength of the association varied as a function of several
moderator variables, but was robust and on the order of
magnitude that has come to be expected for psychosocial
factors. Conclusions did not appear to be due to publication
bias.

29. Religious Attendance: More Cost-
Effective Than Lipitor?
J Am Board Fam Med 2006;19:103–9.
Results: Weekly attendance at religious services accounts for an additional 2 to 3
life-years com- pared with 3 to 5 life-years for physical exercise and 2.5 to 3.5 life-
years for statin-type agents. The approximate cost per life-year gained was between
$2,000 and $6,000 for regular exercise, $3,000 and $10,000 for regular religious
attendance, and between $4,000 and $14,000 for statin-type agents.

31. Estudos sobre o “como”
• What Do Family Physicians Think About Spirituality In
Clinical Practice? www.jfponline.com/Pages.asp?AID=1139
• Spirituality in general practice: a qualitative evidence
synthesis. British Journal of General Practice, november
2011.
• Patient Preference for Physician Discussion and Practice of
Spirituality. J GEN INTERN MED 2003;18:38-43.
• Spirituality, Religion, and Clinical Care. CHEST / 135 / 6 /
JUNE, 2009.
• Aferindo espiritualidade e religiosidade na pesquisa clínica:
uma revisão sistemática dos instrumentos disponíveis para
a língua portuguesa. Sao Paulo Med J. 2013; 131(2):112-22.

32. Sugestão de Abordagem
• Na entrevista inicial de cada novo paciente, ou
em momentos oportunos de pacientes em
seguimento:
• “Existe algo a respeito de crenças espirituais
ou fé a respeito que tu gostarias que eu
estivesse ciente ou levasse em conta no
cuidado de tua saúde?”

33. Resumindo
• Espiritualidade/religião afetam a saúde,
aparentemente de modo positivo.
• As pessoas parecem desejar que seu médico
de família conheça suas necessidades
espirituais.
• Os médicos de família tem estudado,
pesquisado e publicado a respeito.
• No Brasil, desejamos conhecer isso melhor?
• Lista passando…

34. 2 apoios na Partida

35. Muito obrigado!
• enofilho@uol.com.br
• Coordenação Depto Educação Permanente –
Diretoria Científica da SBMFC