E d it o r ia l

R e lig io n /S p iritu a lity a n d D e p re ssio n :

W h a t C a n W e L e a rn Fro m E m p iric a l S tu d ie s?

I n this issue, Miller and colleagues present data from a longitudinal study of offspring
from a sample of depressed and nondepressed subjects to determine if religion or spiri-
tuality influenced the onset and course of major depression over the 10 years of follow-
up (1). They found, among individuals who affiliated as either Protestant or Catholic,
that subjects who reported religion or spirituality as highly important were 76% less
likely to experience an episode of major depression during the follow-up. In contrast,
religious attendance and denomination had no impact. The protective effect was ex-
perienced primarily among subjects at high risk because their parents experienced de-
pression.
Though this study is the first long-term outcome study on the impact of religion or
spirituality on the emergence of depression, it confirms a growing literature, including
a previous study by the authors (2–5), that generally supports the benefit of religion or
spirituality (usually religious participation) in decreasing the frequency and recurrence
of depressive disorders. Studies to date have suggested three conclusions, all of which
can be debated: 1) individuals with no religious affiliation are at greater risk for depres-
sive symptoms and disorders, 2) people involved in their faith communities may be at
reduced risk for depression, and 3) private religious activities and beliefs are not strong-
ly related to risk for depression (6). Depression has been the most frequently studied
of the psychiatric disorders in relationship to religion
or spirituality, in large part because of the overlap in
The importance of expression of both. For example, guilt associated with
religion or spirituality depression often is connected with a religious belief
depends in large part on system, and apparent depressive symptoms (such as
the “dark night of the soul”) are associated with reli-
how it is conceived, and gious experiences (7).
those conceptions may Given the strong and passionate views of American
vary significantly across society regarding religion, such studies raise at least
three questions. First, should studies that explore the
generations. association of religion or spirituality with health even
be fielded and reported in the empirical scientific
literature? Investigators have answered by voting with their feet (or, rather, with their
questionnaires and computers). Hundreds of studies investigating the association of re-
ligion or spirituality with health have been published over the past three decades, sum-
marized in two editions of a widely cited book, The Handbook of Religion and Health (6,
8). The question as to whether such studies should be published is still raised, but most
major journals do not turn away research reports strictly on the basis of an evaluation
that the subject matter of religion or spirituality is not appropriate for an empirically
oriented platform that shares methodologically sound investigations.
Second, what are the strengths and weaknesses of the methodologies employed in
such studies? This question is much more interesting and instructive. For example,
studies of religious affiliation in relationship to a marker of depression (suicide) can be
traced back over a century to Emil Durkeim. In Suicide (1897), he explored the differing
suicide rates among Protestants and Catholics in German-speaking Europe and found
that affiliation as Catholic was protective against suicide, a finding that was criticized

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methodologically even then because it was from an ecological study (9). He argued that
stronger social control among Catholics results in lower suicide rates. Miller and col-
leagues did not find a difference between Protestants and Catholics, and perhaps this
reflects an overall weakening of social control by denominations during the 115 years
since Durkeim’s work as well as a different social setting in New York. Religious affili-
ation with mainline religious groups today probably has much less influence on the
individual than at the turn of the 20th century.
In addition, how does one even conceive of measuring such a nebulous topic as reli-
gion or spirituality? Some demarcate religion from spirituality, suggesting that religion
implies a particular faith tradition that includes acceptance of a metaphysical or super-
natural reality whereas spirituality does not and is not bound to any particular religious
tradition. Yet in today’s world, this distinction is perhaps artificial and a combined focus
on religion and spirituality is warranted.
A short list of the dimensions of religion or spirituality include the following: religious
belief (e.g., belief versus nonbelief), religious affiliation, religious participation (e.g., at-
tendance at religious services or financial support of a faith community or larger effort),
nonorganizational religiosity (e.g., engaging in private prayer or meditation), subjective
religiosity (e.g., importance of religion), and spiritual well-being (e.g., feeling connected
to a higher being or finding inner spiritual strength). Numerous scales have been devel-
oped, both brief and extensive. These scales have been used to determine the religious
or spiritual “pulse” of the nation as well as to explore the relationship between religion
or spirituality and health. For example, the Gallup Poll found in 2010 that 54% of those
surveyed felt religion to be “very important” when respondents were asked about the
importance of religion in their lives (10). That very question turned out to be a signifi-
cant predictor of protection against recurrence of depression in the present study. De-
spite the complexity of religion and spirituality, relatively simple questions may exhibit
strong power for predicting health outcome, just as simple questions about subjective
physical well-being are strong predictors of health outcomes (11). With both, however,
some mystery remains as to what we actually are measuring.
We must also recognize that this study focused on a sample with an average age of
29.3 years (SD=5.5). Most studies of depression and religion or spirituality have focused
on older adults (3; 4; 6, pp. 118–135). And these studies have predominantly found that
religious activities, especially attendance at religious services, are more important than
“attitudes,” such as the expressed importance of religion. A relatively recent sociologi-
cal survey by Smith and Snell of religious attitudes among young adults found them less
active in structured religious activities but nevertheless continuing to view their spiritu-
ality as important. The spirituality they described, however, is quite different from that
of their parents (12). Smith and Snell summarized the religion or spirituality of many
adolescents and young adults in the United States today as “moral therapeutic deism,” a
far cry from traditional Protestant and Catholic beliefs. “Moral” suggests an orientation
toward being “good and nice,” “therapeutic” suggests being primarily concerned with
one’s own happiness, and “deism” suggests a view of God as distant and not normally
involved in one’s life. Therefore, the importance of religion or spirituality depends in
large part on how it is conceived, and those conceptions may vary significantly across
generations.
Finally, how is one to interpret these empirical findings given the strong and often
nonempirical rationale for (or against) religious beliefs and their benefits (or their dan-
gers)? Results from studies such as that by Miller and colleagues or studies that find no
connection or a negative relationship between religion or spirituality and depression
are at great risk of being overgeneralized. They may be falsely taken as proof of concept
for interventions. Observational studies are not designed to support an intervention.
The study under review is an empirical study and should be taken for what it is, no more
and no less. Let the data speak for themselves. Nevertheless, the findings do suggest
that clinicians should consider the religion or spirituality of their patients as part of the

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psychiatric evaluation, one more piece of the puzzle that makes up the person, whom
we try to understand as well as possible so we can provide help to the best of our ability.

R e fe re n c e s
1. M iller L, W ickram aratne P, Gam eroff M J, Sage M , Tenke CE, Weissm an M M : Religiosity and m ajor depression
in adults at high risk: a ten-year prospective study. Am J Psychiatry 2012; 169:89–94
2. M iller L, W arner V, W ickram aratne P, Weissm an M : Religiosity and depression: ten-year follow -up of de-
pressed m others and offspring. J Am Acad Child Adolesc Psychiatry 1997; 36:1416–1425
3. Koenig HG , Cohen HJ, Blazer D G , Pieper C , M eador KG , Shelp F, Goli V, D iPasquale B: Religious coping and
depression am ong elderly, hospitalized m edically ill m en. Am J Psychiatry 1992; 149:1693–1700
4. Koenig HG , George LK, Peterson BL: Religiosity and rem ission from depression in m edically ill older patients.
Am J Psychiatry 1998; 155:536–542
5. Sm ith TB, M cCullough M E, Poll J: Religiousness and depression: evidence for a m ain effect and the m oderat-
ing influence of stressful life events. Psychol Bull 2003; 129:614–636
6. Koenig HG , M cCullough M E, Larson D B: Handbook of Religion and Health. New York, O xford University
Press, 2001
7. Blazer D G: Spirituality and depression: a background for the developm ent of D SM -V, in Religious and Spiri-
tual Issues in Psychiatric D iagnoses: A Research Agenda for D SM -V. Edited by Peteet JR, Lu FG , Narrow W E.
Arlington, Va, Am erican Psychiatric Association, 2011, pp 1–22
8. Koenig HG , King D E, Carson VB: Handbook of Religion and Health, 2nd ed. New York, O xford University
Press (in press)
9. D urkeim E: Suicide: A Study in Sociology (1897). Translated by Spaulding JA, Sim pson G . New York, Free
Press, 1951
10. Gallup AM , New port F: The Gallup Poll: Public O pinion 2010. Lanham , M d, Row m an and Littlefield, 2011,
p 458
11. Blazer D G: How do you feel about….? Self perceptions of health/w ell-being and health outcom es in late life.
Gerontologist 2008; 48:415–422
12. Sm ith C , Snell P: Souls in Transition: The Religious Lives of Young Adults in Am erica. New York, O xford Uni-
versity Press, 2009
D A N B L A Z E R , M .D., P h .D.

From the Departm ent of Psychiatry and Behavioral Sciences, Duke University M edical Center, Durham , N.C .
Address correspondence to Dr. Blazer (blaze001@m c.duke.edu). Editorial accepted for publication Septem ber
2011 (doi: 10.1176/appi.ajp.2011.11091407).

Dr. Blazer reports no financial relationships w ith com m ercial interests.

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