Religion and Spirituality in Psychiatry

Consultation-Liaison Psychiatry 193driving depression. Incomplete or only partialtreatment response, which is so common in medicalpatients, may be due to lingering existentialconcerns that were not adequately addressed aspart of the overall treatment plan.Given the massive losses and life change thatphysical illness causes, it is not surprising thatdepressive disorders are so common in hospitalsettings. Eventually, patients’ efforts to meet thesemultiple challenges become exhausted. Our studiesshow that rates of major or minor depressionin older patients acutely hospitalized with medicalillness approximate 50 percent, (4) and, ratesare even higher among younger hospitalizedpatients where medical illness and disability arenot “on time” as they are in older adults.(5) Themajority of these depressive disorders are undiagnosedand untreated.(6) Even if depression isidentified as a problem, primary care physiciansoften lack the training to manage such disordersappropriately.(7) Despite their lack of expertisein treating depression, medical physicians referonly about 10 percent of these patients to psychiatrists,even when the patient has a major depressivedisorder.(7) Some physicians may rationalizethat patients with chronic illness and multiplelosses have a good reason to be depressed, andso there is no need for treatment of this “normal”reaction to illness. Such therapeutic nihilism canonly be addressed by education and by the experienceof positive results when these patients aretreated or referred for psychiatric care.Because emotional disorders in medicalpatients are often a direct result of inability tocope with massive life change and loss, mentalhealth specialists should seek out resources thatcan help patients adjust successfully to illness.Identifying and supporting such coping resourcescan complement existing biological, psychological,and social therapies.3. ROLE OF RELIGION/SPIRITUALITYConsultation-liaison (CL) psychiatrists and othermental health professionals should be aware ofthe roles, both positive and negative, that religiousbeliefs and practices can play in the adjustment ofpatients to medical illness. On the one hand, religiousbeliefs may be a symptom or cause of psychiatricdisorder. On the other hand, religion maybe a powerful coping resource for some patients,prevent the development of emotional disorder, orreduce the time it takes for these disorders to remit.Let us consider each of these possibilities below.3.1. Religious Belief as a SymptomReligious beliefs may be a symptom of depressionor other emotional illness. For example, the medicalpatient may attribute the extreme guilt andsadness from their depressive disorder to havingcommitted the “unpardonable” sin that doomshim or her to eternal damnation and suffering.The patient may feel great remorse and sense offailure and explain these feelings as punishmentfor trespasses of some sort, either real or imagined.Religion may also be used to normalizeweight loss or improper attention to nutrition.The religious patient may try to cover up anorexiaor weight loss by claiming that he or she is fastingfor religious reasons. In all these instances, thereligious belief is used to justify symptoms whoseunderlying cause is depression, not religion. Inthis case, then, the depressive symptom doesnot result from religion, but from the underlyingdepressive disorder and is simply explainedby the patient in religious terms because of his orher religious worldview.3.2. Religious Belief as a CauseIn some instances, religious beliefs may actuallylead to the development or worsening ofemotional disorder in vulnerable individuals.Religious beliefs and teachings may promote feelingsof excessive guilt or remorse. Here, religiousbelief is contributing to the worsening of symptoms.High religious standards and values may bedifficult to live up to. Honesty, generosity, selflessness,kindness, and gratefulness are difficult tolive out even by the most saintly among us. Howoften such guilt or shame occurs – and proof thatit is the religion that is the origin of the negativeemotional symptoms – is uncertain, given the