Religion and Spirituality in Psychiatry

194 Harold G. Koeniglack of research in this area. Conventional wisdomand clinical experience, however, suggestthat this does happen. Prospective studies areneeded to help to sort out cause versus effect (thatis, whether religion causes depressive symptoms,or whether depressed patients are more likely togravitate toward religion because it offers comfortor healing).3.3. Religious Belief as a Coping BehaviorRather than being a cause for depression or asymptom of it, religious beliefs and practicesmay be used by patients to cope with the painand suffering that depression causes. This may beparticularly common in medical patients (versuspsychiatric patients) where emotional disorder ismore often the result of difficult circumstances(situational depression). Religious beliefs mayhelp medical patients to reframe their losses in amore positive light, give a sense of purpose andmeaning, and provide hope that something goodcan result from the situation.4. RELIGION AND DEPRESSIONBecause depression is so common and resistantto treatment in patients with medical illness anddisability, CL psychiatrists will be frequently calledon to manage these patients. Although antidepressantmedication and psychotherapy have animportant place in the treatment of medically illpatients with depression, they are often not sufficient.Treatment-resistant depression or partiallytreated depression is extremely common, evenafter all traditional psychiatric therapies have beentried. Thus, helping patients identify resources thatcan help them adapt to the disturbing symptomsof medical illness or to the psychological distressof chronic disability or dependency is an importanttask.A number of cross-sectional and prospectivestudies in medical inpatients suggest that religiouscoping is common in such settings and isassociated with more rapid adaptation to medicalillness and disability. This is especially true forpatients with the most severe illness and greatestdisability and those whose physical conditionsare not responding to medical treatments.In the early 1990s, we studied a consecutivesample of men admitted to the medical and neurologicalservices of the Veterans AdministrationMedical Center in Durham, North Carolina.(8)Eight hundred and fifty men aged 65 or olderwere examined for depressive symptoms usingthe self-rated thirty-item Geriatric DepressionScale (GDS) and Brief Carroll Depression Scale(BCDS); patients over age 70 years were alsoassessed with the observer-rated seventeen-itemHamilton Depression Rating Scale (HDRS).Religious coping was measured using the threeitemReligious Coping Index (RCI) whose scoresrange from 0 to 30. In that study, 21 percent ofpatients indicated that religion was the “mostimportant factor” that enabled them to cope, and56 percent indicated that they depended at least alarge extent on religion to cope.In the cross-sectional analysis that used a multivariatemodel to control for nine other patientcharacteristics relevant to depression, RCI scoreswere significantly and inversely related to bothself-rated (GDS) and observer-rated (HDRS)scales. Particularly important, this associationwas strongest for men with the most severe disability.In the longitudinal phase of the study, allsubjects readmitted within the sixteen-monthstudy period and subsequent five months (averagefollow-up six months) (n = 202) were reassessedfor depressive symptoms (combination ofGDS and BCDS). The baseline RCI score was theonly characteristic that predicted fewer depressivesymptoms on follow-up, after controlling forbaseline depression and other covariates.Although religious beliefs and practices appearto protect against the development of depression,religious people do get depressed. Even when thathappens, however, depressive disorder appears toremit more quickly in these patients (that is, adaptationoccurs more quickly). At least two studiesin medical inpatients are relevant in this regard.In the first study, eighty-seven hospitalized medicallyill patients on general medicine, cardiology,and neurology services of Duke Hospital werediagnosed with depressive disorder using the