1. Religion, spirituality and mental
health: results from a national
study of English households
Michael King, Louise Marston, Sally McManus, Terry Brugha,
Howard Meltzer and Paul Bebbington
BJP 2013, 202:68-73
Journal Club Presentation
Dr Yasir Hameed (MRCPsych)
Specialist Registrar Psychiatry
17/12/2013

2. Outline
o Clinical scenario
o Background on study/author
o Interactive use of checklist to appraise
the paper
o Media attention
o MCQs

3. Clinical scenario
A 70 year old lady was admitted to the psychiatric unit with
features suggestive of severe depressive episode without
psychotic symptoms of 3 months duration.
She is a member of Jehovah Witnesses and was very active in
the her congregation.
She initially refused medication but was persuaded by her
husband to take it. She prayed with him and her friends while
on the ward and nurses reported improvement in her
symptoms.

4. Clinical questions
o Did her religious background play a role in her
improvement?
o Would her prognosis change if she was an atheist,
or spiritual (but not religious) person.
o How her faith contributed to her recovery?

5. Spirituality does not make
sense?

6. Background
o This was Cross Sectional Survey
commissioned by the National Centre for
Social Research, an independent research
agency with an interest in social attitudes.
o Part of the third National Psychiatric Morbidity
Study in England 2006-2007.
o Who is Michael King?

7. The study
o Background
Mental health and religion. Most research is American.
?Measures of spirituality.
o Aims
Associations between a spiritual/religious beliefs &
psychiatric symptoms.
o Method
Data analysis of interviewing 7403 people (third National
Psychiatric Morbidity Study in England).

8. Abstract (cont’d)
o Results
35% had a religious understanding of life
19% were spiritual but not religious
46% were neither religious nor spiritual
o Religious people = neither religious nor spiritual
people with regard to the prevalence of mental
disorders, EXCEPT that:
o Religious people less likely to have ever used drugs
(odds ratio (OR) = 0.73, 95% CI 0.60–0.88) or be a
hazardous drinker (OR = 0.81, 95% CI 0.69–0.96).

9. Abstract (cont’d)
Spiritual people more likely to:
o Have ever used (OR = 1.24, 95% CI 1.02–1.49) or be
dependent on drugs (OR = 1.77, 95% CI 1.20–2.61)
o Have abnormal eating attitudes (OR = 1.46, 95% CI
1.10–1.94) Generalised anxiety disorder (OR = 1.50,
95% CI 1.09–2.06), any phobia (OR = 1.72,95% CI
1.07–2.77) or any neurotic disorder (OR = 1.37, 95%
CI 1.12–1.68).
o They were also more likely to be taking psychotropic
medication (OR = 1.40, 95% CI 1.05–1.86).

10. Abstract (cont’d)
Conclusions
People who have a spiritual understanding of
life in the absence of a religious framework are
vulnerable to mental disorder.

11. Get ready for the appraisal…

12. Screening Questions
1. Did the study address a clearly focused
issue?
2. Did the authors use an appropriate
method to answer their question?

13. Detailed questions
o 3.Were the subjects recruited in an
acceptable way? (multi-stage sampling)
o 4.Were the measures accurately measured
to reduce bias?
o 5. Were the data collected in a way that
addressed the research issue?

14. Measures
o Royal Free interview for religious and
spiritual beliefs
o The revised Clinical Interview Schedule
(CIS-R)
o The Psychosis Screening Questionnaire
(PSQ)
o Close Persons Questionnaire
o The Trauma Screening Questionnaire
(TSQ)

15. Measures (cont’d)
o The SCOFF questionnaire ( make yourself Sick,
lost Control, lost more than One stone in a 3
month period?, Fat when others say you are too
thin? Food dominates your life?)
o Problem gambling (DSM IV)

16. Measures (cont’d)
o Questions on use of recreational drugs came
from the Diagnostic Interview Schedule.
o One question explored how happy the
participants felt ranging from very, to fairly and
not too happy.
o Psychotropic medication/psychotherapy or
counselling.

17. Sample size
o 6. Did the study have enough
participants to minimize the play of
chance?

18. Analysis
o 7. How are the results presented and what
is the main result?
o 8. Was the data analysis sufficiently
rigorous?
o 9. Is there a clear statement of findings?

19. Characteristics
Neither
religious or
spiritual Spiritual Religious P
Male, % 55 44 43 <0.001
Age, years: % <0.001
16–24 19 11 10
25–34 19 16 13
35–44 20 21 17
45–54 16 18 16
55–64 13 17 17
65–74 7 10 14
75+ 5 8 14

20. Characteristics Neither
religious or
spiritual
Spiritual Religious P
White British 93 86 74
White non-British 4 6 6
Black 1 3 6
South Asian 1 2 9
Mixed or Other 2 3 4

21. Characteristics Neither religious
or spiritual
Spiritual Religious P
Education, % <0.001
No qualifications 25 21 30
School or foreign
qualifications 51 46 39
Post-school
qualifications 24 32 30

22. Characteristics Neither
religious or
spiritual
Spiritual Religious P
Married 46 53 60
Cohabiting 13 12 6
Single 28 21 17
Widowed 5 6 10
Divorced 6 7 5
Separated 2 2 2

23. Characteristics Neither
religious or
spiritual
Spiritual Religious P
Social support,
mean 20.0 20.2 20.3
Strength of
religious
understanding,
meana 6.2 7.0
Importance of
religious practice,
meana 4.4 6.2 <0.001

24. Neither
religious or
spiritual
Spiritual Religious P
Drug use
Ever used drugs 32 30 16 <0.001
Used any drug
in the past year 12 11 5 <0.001
Drug dependent 4 5 2 <0.001
Dependent on
cannabis 3 4 1 <0.001

25. Neither
religious or
spiritual
Spiritual Religious P
Dependent
on another drug
(+/– cannabis) 1 1 1
Hazardous
drinker 30 23 17 <0.001
Problem
gambling 0.8 0.6 0.7 0.880
Post-traumatic
stress disorder 3 3 3 0.527

26. Neither
religious or
spiritual
Spiritual Religious P
Eating attitudes
SCOFF ≥2 7 9 5 0.001
SCOFF score ≥2
and food interferes
with lifea 2 2 1 0.646
Psychosis Screening
Questionnaire
Definitely
psychotic 0.1 0.4 0.4 0.106
Probably
psychotic 0.3 0.6 0.5 0.118

27. Neither
religious or
spiritual
Spiritual Religious P
Panic disorder 1 1 1 0.618
Generalised
anxiety disorder 4 5 4 0.079
Mixed
anxiety/depressiv
e disorder 8 10 8 0.154
Obsessive–
compulsive
disorder 1 1 0.8 0.127
Any phobia 2 3 2 0.055
Depression 3 3 2 0.057
Any neurotic
disorder 16 19 15 0.011

28. Neither
religious or
spiritual
Spiritual Religious P
Receiving
pharmacologica
l treatment 5 7 6 0.026
Receiving
counselling/
therapy 3 3 2 0.360

29. Findings
o 10. Can the results be applied to the local
population?

30. Conclusion
o People who profess spiritual beliefs in the absence of a
religious framework are more vulnerable to mental
disorder.
o Those who were religious were broadly similar, in terms of
prevalence of mental disorder and use of mental health
treatments, to those who were neither religious nor
spiritual after adjustment for potential confounders, except
they were significantly less likely to use, or be dependent
on, drugs or alcohol.

31. Strengths
o Random selection of a nationally
representative sample
o The sample size
o In-depth assessment of mental health
o Use of standardised questions on religion
and spirituality

32. Limitations
o Cross-sectional surveys, cannot prove cause and
effect.
o Other factors may be at play (e.g., lack of peer
support).
o Religious belief was not examined in details.

33. 11. How valuable is the research?
Why this subject is important?
o There has been a significant increase in research
on spirituality, religion and mental health in recent
years.
o Understanding spirituality/religious background is
essential to provide holistic care.
o Religion & spirituality provide meaning and
purpose that allow for rational interpretations of
life problems

34. Psychiatrists and Spirituality
o More likely to encounter religion/spirituality
issues in clinical settings
o (92% versus 74%)
o More open to addressing religious/spiritual
issues with patients
o (93% versus 53%)
o Psychiatrists are more comfortable, and
have more experience, addressing
religious/spiritual concerns in the clinical
setting
Curlin et al, Am J Psychiatry, 2007

36. Media attention to this study

41. Gordian article

43. MCQs
1. Religious delusions may occur in:
a. schizophrenia
b. depression
c. anxiety states
d. anorexia nervosa
e. organic states.

44. MCQs
1. Religious delusions may occur in:
a. schizophrenia
b. depression
c. anxiety states
d. anorexia nervosa
e. organic states.

45. 2. In terms of religious beliefs and practices:
a. Psychiatrists are generally more religious than their
patients
b. Religious teaching plays little part in psychiatric training
c. There is some evidence that religious patients prefer
religious therapists
d. A significantly greater number of mental health
professionals undergo religious conversion compared with
the general population
e. Hospital chaplains in the UK have no training in mental
health problems.

46. 2. In terms of religious beliefs and practices:
a. Psychiatrists are generally more religious than their
patients
b. Religious teaching plays little part in psychiatric training
c. There is some evidence that religious patients prefer
religious therapists
d. A significantly greater number of mental health
professionals undergo religious conversion compared with
the general population
e. Hospital chaplains in the UK have no training in mental
health problems.

47. 3. In terms of psychotherapy:
a. Freud held a negative view of religion
b. Jung held a positive view of religion
c. Perceptions of God derive from early childhood
relationships
d. Perceptions of God never change during
psychotherapy
e. The addition of religious components to cognitive
therapy may enhance efficacy for religious patients.

48. 3. In terms of psychotherapy:
a. Freud held a negative view of religion
b. Jung held a positive view of religion
c. Perceptions of God derive from early childhood
relationships
d. Perceptions of God never change during
psychotherapy
e. The addition of religious components to cognitive
therapy may enhance efficacy for religious patients.

49. 5. Religious patients’ reluctance to engage in
psychiatric treatment may be overcome by:
a. Using a culture broker
b. Using religious symbols
c. Antipsychotic administration
d. Brief cognitive therapy
e. Using the Mental Health Act

50. 5. Religious patients’ reluctance to engage in
psychiatric treatment may be overcome by:
a. Using a culture broker
b. Using religious symbols
c. Antipsychotic administration
d. Brief cognitive therapy
e. Using the Mental Health Act

51. MCQs taken from:
Dein S. Working with patients with
religious beliefs. Advances in
Psychiatric Treatment (2004). 10:
287-294

52. Thank you