Spiritual beliefs in bipolar affective disorder: their relevance for illness management

Abstract

Background: There has been growing interest in investigating religion as a relevant element in illness outcome. Having religious beliefs has been shown repeatedly to be associated with lessened rates of depression. Most of the limited published research has been restricted to elderly samples. Religious coping is thought to play a key role in religion’s effects. Strangely, psychiatric research has neglected this area. Methods: A questionnaire covering religious, spiritual and philosophical beliefs and religious practice was given to a sample of patients with bipolar affective disorder in remission. Results: Most patients often held strong religious or spiritual beliefs (78%) and practised their religion frequently (81.5%). Most saw a direct link between their beliefs and the management of their illness. Many used religious coping, and often religio-spiritual beliefs and practice put them in conflict with illness models (24%) and advice (19%) used by their medical advisors. Limitations: This was a cross-sectional design without a control group and thus it is not possible to determine causal associations from the data set. Conclusions: Religio-spiritual ideas are of great salience to many patients with bipolar disorder and shape the ways in which they think about their illness. Many reported experiencing significant paradigm conflict in understanding and managing their illness between medical and their spiritual advisors. These data suggest that the whole area of religion and spirituality is directly relevant to people living with a chronic psychiatric illness and should be firmly on the discussion agenda of clinicians working with patients with bipolar disorder.

Introduction

The words ‘religion’ and ‘spirituality’ are often used interchangeably. For most commentators on religion/spirituality and health, religion has a narrower sense, encompassing the outward practice of a spiritual understanding and has been the focus of most research to date. The field was broadened by the work of King et al. (1995), among others, who also investigated the link between spirituality and health. Spirituality can be seen as a metaphysical concept representing the belief in a power outside of a person’s existence. The last 40 years have seen the publication in the English literature of articles dealing with religion and physical illness, religion and mental illness, religion and coping, and latterly some authors have responded to the challenge of developing models to explain these relationships. However, given the importance of religion in all cultures and the greater or lesser spirituality orientation of humans, the published body of research in medical literature is meagre. One possible reason is the difficulty of doing good research in this field. There are not generally agreed definitions and for most researchers the variable of religion is too broad, outside the strict confines of medical science.

In a recent exhaustive review, Levin systematically examined the evidence for a relationship between religion and health (Levin, 1994). He found that there was definitely an association which according to Bradford Hill’s criteria may reflect a causal relationship (Hill, 1965). The frequency of religious attendance was positively associated with health in many studies (Levin and Vanderpool, 1987). King et al. explored the course of a person’s spirituality following illness, and found that strength of belief was a better predictor of outcome than a measure of psychiatric morbidity, the General Health Questionnaire (King et al., 1994).

Some researchers have tried to elucidate how spirituality benefits health. Hannay (1980) suggested that the behavioural component of religious allegiance was related to health, rather than the allegiance itself, a view echoed for psychological health by Ness (1980). There is a consensus amongst authors that attendance at religious events is a poor measure of innate religiousness and spirituality. Levin and Markides (1986) reported that greater religious attendance in some elderly was determined in the main by their degree of physical mobility.

Spirituality and mental health both deal with fundamental existential matters. The psychiatric literature shows surprisingly little attention has been paid to religious variables. Of 2348 articles reviewed by Larson et al. (1986) in four leading psychiatric journals, only 59 (2.5%) contained a religious variable with only three having religion as a major emphasis of the study. Surprising as this may be, factors such as the greater secularity among psychiatrists than the general population may explain such results (King and Dein, 1998)—nearly all (95%) of the American public believe in a God, yet only 43% of members of the American Psychiatrists Association do (Larson et al., 1986). Crossley (1995) suggested that some psychiatrists may misconstrue religious belief to be psychopathological.

Notwithstanding these difficulties, some interesting findings have been reported. Church members have been reported as having a distinctly lower rate of psychiatric impairment than non-church members (Lea, 1982, Stark, 1971). It must be remembered that social skills are needed to go to church; those with psychiatric impairment may not attend church, but rather practice their faith in private (Lea, 1982, Lindenthal et al., 1970).

Most empirical papers dealing with religio-spirituality and depression study older adults. These consistently show an inverse relationship between religiosity and depression (Koenig, 1998, Koenig et al., 1998a, Koenig et al., 1998b, Braam et al., 1997, Braam et al., 1999a, Braam et al., 1999b, Pressman et al., 1990). Koenig et al. found intrinsic religiosity was significantly related to the duration of depression (different from church-going, ‘intrinsic’ religiosity seeks to describe the hope and motivation that religion may bring) (Koenig, 1998).

Among the general adult population, psychiatric inpatients have been reported as being as religious as control subjects, although they did not practice their faith as frequently (Kroll and Sheehan, 1989). The only paper we located on the religious lives of patients with bipolar disorder showed no differences from those of controls, although the patients reported more conversion experiences. One-fifth of patients said that their illness had no effect on their religious life (Gallemore et al., 1969).

The beneficial effects of religiousness on mental health and health in general may be explained by religious coping. Two authors stand out in researching this field; Koenig and Pargament. Koenig et al. (including Pargament) defined the concept as “the use of religious beliefs or behaviours to facilitate problem-solving to prevent or alleviate the negative emotional consequences of stressful life circumstances” (Koenig et al., 1998b). The National Institute on Aging has stated that religious coping has been associated with a wide range of health outcomes and needs further study (Koenig et al., 1998b). Two-fifths of hospitalised older adults, without prompting, volunteered religion as their main coping strategy when asked an open-ended question (Koenig, 1998). Certain demographic groups are more likely to use religious coping; these include older adults, females, blacks, those less educated, economically deprived and those affiliated with conservative religious denominations (Koenig et al., 1992). Religious affiliation was found to be the most important determinant of whether someone uses religious coping or not (Koenig et al., 1992).

Some researchers have sought to identify actual mechanisms through which religious coping exerts its effects. Using a range of non-patient samples, Pargament et al. found it to be multi-dimensional, with both positive (i.e. Collaborative methods) and negative coping methods (i.e. Punishing God Reappraisals) used (Hathaway and Pargament, 1990, Pargament et al., 1990, Pargament et al., 1998). A measure of religious coping with proven validity has also been developed for research purposes (the RCOPE) (Pargament et al., 2000). Interestingly they found that positive methods were more commonly used and were related to better religious and psychological outcome after stressful events, with negative methods often related to poorer outcome (Pargament et al., 1998).

These papers on religio-spirituality and mental health represent an emerging area of research, broadly based and falling outside the traditional confines of medical science. This area offers the potential to answer some of the key questions dealing with how religio-spirituality may mediate between coping, social relationships, the use of professional health services and the course of chronic illnesses.

Bearing the findings of previous research in mind, we have sought, through the means of a modest cross-sectional survey, to elucidate the religio-spiritual characteristics of a population of people with bipolar depression. In particular we desired to investigate the possible religious coping mechanisms and behaviours of this population, in a broad, more clinically-focussed sense. We hypothesised that given the importance of religious coping in physical illness, it would also be an important factor in how those with psychiatric illness coped, and that this in turn may have an effect on their management and clinician-patient relationships. Thus, we are focusing on clinical facets and implications of religious coping, rather than focusing on the psychometric perspective of religious coping, as is common in the psychological literature (Pargament et al., 2000).