Available online at www.sciencedirect.

com

ScienceDirect
Comprehensive Psychiatry 70 (2016) 17 – 24
www.elsevier.com/locate/comppsych

Do spirituality and religiousness differ with regard to personality and

recovery from depression? A follow-up study
Sanea Mihaljevic a,⁎, Branka Aukst-Margetic b , Snjezana Karnicnik a ,
Bjanka Vuksan-Cusa c , Milan Milosevic d
a
Psychiatry department, General Hospital Virovitica, Gajeva 21, 33 000, Virovitica, Croatia
b
Department of Psychiatry, Clinical Hospital Center, Kišpatićeva 12, 10 000, Zagreb, Croatia
c
Medical Faculty Osijek, Cara Hadrijana 10/E, 31000, Osijek, Croatia
d
School of public health Andrija Stampar, Rockfellerova4, 10000, Zagreb, Croatia

Abstract

Background: The studies show that both spirituality and religiousness are protective for mental health. Personality is related with course and
outcome of depression, as well as spirituality and religiousness, and their relations toward to recovery from depression are underresearched.
This study followed influence of spirituality and religiousness on course and outcome of depression in patients with depressive episode,
controlled for personality dimensions.
Methods: The patients were assessed with self-report measures of depression (Beck Depression Inventory), spirituality (WHO-Quality of
Life-Spiritual, Religious, Personal Beliefs), religiousness (Duke University Religion Index) and personality (Temperament and Character
Inventory). Ninety nine patients finished a year long follow up.
Results: Higher spirituality influenced recovery of depression in patients with depressive episode, but religiousness did not show to be
significant predictor of recovery for depression. Dimension harm avoidance was significant predictor of improvement of depression in all
points of measurement.
Limitations: Some limitations of this research are small sample size, usage of the self-report measures of depression in follow-up period, and
the predominantly Catholic affiliation of the participants that can impact the generalizability of our data to other denominations.
Conclusion: Spirituality and dimension harm avoidance are significant predictors of recovery from depression during a year long follow up.
© 2016 Elsevier Inc. All rights reserved.

1. Introduction earlier ones on the links between linked spirituality and

Spirituality, religiousness and personality have proven in
a series of studies to be important factors for the continuation
and course of depression, though their mutual association
and their relations towards recovering from depression have
been insufficiently studied. Research to date on the effects of
spirituality and religiousness on health have primarily been
directed at specific subpopulations, such as the elderly
[1,2,3,4,5,6], adolescents [7], the physically ill [8,9,10],
those suffering from carcinoma [11,12,13,14], and the
terminally ill [15,16]. Studies examining a population of
persons of employable age suffering from depressive
disorders are scarce. Furthermore, most studies, particularly
⁎ Corresponding author. Tel.: +385 98244 805.
E-mail address: saneanadj@gmail.com (S. Mihaljevic).
http://dx.doi.org/10.1016/j.comppsych.2016.06.003
0010-440X/© 2016 Elsevier Inc. All rights reserved.
religiousness with depression have primarily used
one-dimensional questionnaires of religiousness, placing
the emphasis on exclusively examining the concepts of
religiousness and have primarily performed a cross-sectional
examination of these associations. However, a systematic
approach to the study of religiousness has proven to have a
multidimensional construct. One of the dimensions of
religiousness, in that sense, is its spiritual dimension,
which a number of authors claim to be separate from
religious belief [16] as a distinctive construct, and as such
should be investigated independently. In that sense, there are
a number of issues that require further study. Only recently
have there been studies to address the relationship of
spirituality as a construct that differs from religiousness and
depression [12,13,14,16]. The initial results of these studies
have shown that there is a correlation between higher levels
18 S. Mihaljevic et al. / Comprehensive Psychiatry 70 (2016) 17–24
of spirituality and lower levels of depression. Furthermore, it
has been found that spiritual quality supports the total quality
of life, and that it should be considered as a concept that is
neither psychological nor sociological, but is instead its own
separate and important entity [17].
Spirituality can be explained as the universal property that rises
above religious affiliation, as a personal quest for answers to the
ultimate questions about life, about purpose, and about relations
with higher values. Spirituality includes moral values, and can
“lead to” or “arise from” various religious rituals and formations
in the community [18]. Religiousness (Latin re-, ligare = to
reconnect) is defined as an organized system of belief, the practice
of rituals and symbols created to strengthen the closeness with the
sacred and transcendental (God, a higher being, or the ultimate
truth/reality) [18]. While religiousness in the psychometric sense
is a better defined variable, the need arises for the development of
a specific instrument for measuring spirituality [19]. It is believed
that it should not be conceptualized through objective terms, such
as the frequency of attending religious meetings, but can be well
encompassed through a subjective self-assessment using a
multidimensional questionnaire [17].
Personality is defined as the characteristics of a person
responsible for consistency in feelings and thoughts and is
determined genetically and by environmental factors which is
also believed, to a certain extent, for the concepts of spirituality
and religiousness [20]. Personality characteristics have also been
associated with depression in community samples as well in
other populations [21,22,23]. The personality model especially
relevant for the research of associations between personality
and spirituality/religiousness is psychobiological model by
Cloninger and his collegues. This model is based on four
temperament and three character dimensions: harm avoidance
(HA), which is defined as pessimistic worrying in anticipation of
problems; novelty seeking (NS), which describes the initiation
of the appetitive approach in response to novelty; reward
dependence (RD) which describes the maintenance of the
behavior in response to cues of social reward and persistence
(P), which is defined as perseverance despite frustration and
fatigue. The character dimension self-directedness (SD) is
defined as having will-power and determination, cooperative-
ness (C) describes individual differences with regard to
tolerance and empathy and self-transcendence (ST) character-
izes individual differences in spirituality. The characterological
aspects of personality involve individual differences in
self-concepts about goals and values, in contrast to the
temperament dimensions that are biologically based and involve
differences in automatic emotional reactions and habits [21].
This model has shown the associations between its particular
dimensions with depression, but although this is the first model
that includes spirituality construct in one of its dimension
(self-transcendence), the associations with spirituality and
religiosity and depression have not yet been assessed.
Research that has examined the associations between
personality and spirituality or religiousness has so far been
based on the five-factor model of personality [24,25,26].
Johnstone et al. found that the personality traits in the
five-factor model were primarily associated with spirituality
(extroversion positive, neuroticism negative), but not with
religiousness and the support offered by the religious
community [27]. This also confirms the hypothesis that
spirituality and religiousness encompass related, though
different aspects of a relationship with the transcendental.
Cross-sectional studies do not show a cause and effect
relationship, and as such suffer criticism due to possible
tautology (e.g. spirituality as positive measure and depres-
sion) [28]. For that reason, longitudinal studies are those
which could provide an answer to the question of whether
baseline measurements of the existence of spiritual values
could be predictor of recovery from depression.
To the extent of our knowledge, a mutual association
between the dimensions of personality with spirituality and
religiousness with regard to recovery from depression has not
previously been studied. Therefore, the objective of this study
was to examine the influence of the specific roles of both
spirituality and religiousness on the recovery from depression,
with regard to the dimensions of the psycho-biological model
of personality.
2. Methods
The study evaluated patients at their first contact with
psychiatry service for depressive episode and evaluated at
month one, three, six and twelve. The diagnosis of depressive
episodes was made by the research psychiatrist according to the
criteria of the International Classification of Diseases (10th
edition). At the baseline patients filled out sociodemographic
questionnaires and self-assessment questionnaires: Beck
Depresssion Inventory (BDI), WHO-Quality of Life-Spiritual,
Religious, Personal Beliefs (WHOQOL-SRPB) and Duke
University Religion Index (DUREL). At the follow up visits
patients were evaluated with BDI. In order to avoid the effect of
depressive symptoms on the measures of personality, subjects
were assessed with Temperament and Character Inventory
(TCI) 6 months after the inclusion. Data were collected from
May 2011 to August 2013 at the Psychiatric Department and in
the Psychiatric Outpatient Clinic of Virovitica General Hospital,
and the study was approved by the hospital Ethics Committee.
After the purpose and procedures of the study had been
thoroughly explained, the subjects signed the informed consent.
The self-assessment questionnaire (BDI) that is filled out
in specific time intervals in the monitoring was given to
subjects during outpatient control sessions, during inpatient
treatment, via the telephone (for 2 subjects) or by post
(questionnaire sent with return envelope – 20 subjects).
2.1. Subjects
Participants in the study were patients treated both as in
and outpatients who came in for the treatment of depressive
episode that they experienced for the first time, or at the start
of a new depressive episode as part of a recurrent depressive
disorder. Exclusion criteria for patients were: previous manic
 S. Mihaljevic et al. / Comprehensive Psychiatry 70 (2016) 17–24
episodes, alcoholism or addiction to psychoactive com-
pounds, grave personality disorders, grave symptoms of
anxiety, psychotic symptoms, cognitive disorders, and grave
somatic illness. All included participants were treated with
SSRI and benzodiazepines.
A total of 120 subjects were included, though 17 subjects
were later excluded due to the incomplete filling out of the
questionnaires. Only those subjects who completed all five
measurements were included. One subject was excluded due
to the record of hypomanic episode over the year of
monitoring, two other subjects were excluded due to the
appearance of borderline personality disorder, and one
subject was excluded due to the appearance of alcoholism.
The sample in this study finally consisted of 99 subjects, of
which 56 (56.6%) were female. The average age of subjects was
48.37 years (SD = 8.38, min 30, max 65). Eighty one percent of
the sample were married and living with a spouse at the time of
inclusion in the study. Slightly less than a half of the subjects
(46.5%) were employed while the rest of the subjects were either
unemployed (29.3%) or retired. Most participants (91.9%)
declared themselves as Catholics.
2.2. Instruments
Duke University Religion Index, (DUREL) [29] is a
self-assessment questionnaire of religiousness and consists
of five items with responses given on the Likert five-point
scale. The first item of the questionnaire measures extrinsic
religiousness through the measurement of organizational
religious activity (OR) and second non-organizational
religious activity (NOR). The score of last three items
measures intrinsic religiousness (IR). The total score ranges
from 5 to 27, though the authors do not recommend
summation into a total score, but instead use of the three
separate subscales (OR, NOR, IR). In our study, the
Cronbach alpha for the DUREL questionnaire was 0.908
in our sample for the entire questionnaire, and 0.923 for the
subscale of intrinsic religiousness.
Beck Depression Inventory (BDI) – the self-report
21-items scale for the assessment of mood with a score
range 0 to 63 [30]. The internal consistency of the inventory
in our sample was 0.93.
WHO-Quality of Life-Spiritual, Religious, Personal
Beliefs (WHOQOL-SRPB) [31] is a subscale of the
WHOQOL-100 which is a subjective, cross-cultural
quality-of-life questionnaire and one of few such instruments
that includes a spiritual component. The SRPB is a
self-administered questionnaire that covers eight dimen-
sions: spiritual connectedness, meaning and purpose in life,
experience of awe and wonder, wholeness and integration,
spiritual strength, inner peace, hope and optimism, and faith.
The SRPB includes 32 questions (four questions per
dimension), answered on 5-point Likert-type scales that
range from “not at all” to “an extreme amount”. It showed
the internal consistency coefficient of 0.96 in our sample.
SRPB was developed to evaluate how spirituality, religiosity
19
and personal beliefs are related to the quality of life in health
and health care. The scale was previously validated in the
Croatian population [32].
Temperament and Character Inventory [20]. Personality
was assessed using the Croatian adaptation of the Temper-
ament and Character Inventory (TCI). The TCI is a
self-report questionnaire based on 240 items requiring a
true/false answer. The instrument was previously validated
on a sample of 360 persons [33]. It showed good reliability
with Cronbach's alpha coefficients of the dimensions
novelty seeking (0.66), harm avoidance (0.79), reward
dependence (0.52), persistence (0.47), self-directedness
(0.85), cooperativeness (0.7) and self-transcendence (0.81).
As the study followed the patients over a period of 1 year,
the TCI measurement was performed after six months of the
inclusion to minimize the impact of depressive symptoms on
the scores of personality dimensions.
Sociodemographic data were collected with the multi-
choice questionnaire.
2.3. Statistics
Descriptive statistics were performed with the appropriate
measures of central tendency (arithmetic mean and standard
deviation, median and interquartile ranges) for the contin-
uous variables, while the categorical and nominal variables
were displayed as frequencies and their corresponding
shares. In the analysis of differences between individual
measurements (at months 1, 3, 6 and 12) pertaining to
spirituality (WHOQOLSRPB categories – low, medium and
high) and for intrinsic religiousness (score of final three
DUREL items), the MANOVA was used for repeated
measures. The categorization of individual groups was
performed in relation to the central tendency of total scores
(WHOQOLSRPB & DUREL). Pearson correlations were
computed to examine the zero-order relationship among the
variables. The differences between the qualitative and
categorical variables were assessed using the chi square test.
In the prediction of level of depression in relation to spirituality
and religiousness, the linear regression model was used. All P
values less than 0.05 were considered significant. Analyses were
performed using the software package IBM SPSS Statistics
version 19.0.0.1 (www.spss.com).
3. Results
Among subjects, 35 (35.4%) were included in the study
during their first depressive episode, and 64 (64.6%) during a
repeated depressive episode. Depression was monitored
using the scores on the BDI. The mean BDI for the group at
the baseline was 29.03 (SD = 7.41; min 20, max 49),
indicating a moderate to high depressive population
(moderate depression 21–30, high depression 31–40). The
changes to depression over time were statistically significant
(p b 0.001) (Fig. 1).
20 S. Mihaljevic et al. / Comprehensive Psychiatry 70 (2016) 17–24

questionnaire WHOQOL-SRPB was divided into three

Fig. 1. The changes to depression over time (p b 0.001).
The Pearson's correlation tests showed the statistically
significant inverse relationship between depression and spiritu-
ality at the baseline and at the all monitoring points (Table 1).
The most common correlations (at four time points) were found
for the domains wholeness and integration, inner peace, hope
and optimism. It is evident that depression was not significantly
correlated with organizational religious activity (OR) and
non-organizational religious activity (NOR) at the baseline or
at any of the measurement time points, while there was a
statistically significant inverse correlation with intrinsic reli-
giousness (IR) at the start of the study and after 12 months of
monitoring (Table 1). Depression was found to correlate with
the personality dimensions in line with the literature, i.e. a
statistically significant correlation was found with the dimension
harm avoidance at all measurement points, while an inverse
correlation was found with the dimensions self-directedness and
cooperativeness (Table 1).
3.1. Multivariate analysis
To obtain a clearer overview of the course of the effects of
spirituality on depression, the score of the spirituality
groups, based on the standard deviation. Values higher
than 115 (94 + 21) indicate strong spirituality, from 73 to
114 moderate spirituality, and less than 72 a weak level of
spirituality (Fig. 2). Examining the total differences in BDI
among the WHOQOL-SPRB groups (without taking into
account individual time points), they were significant
(p b 0.001). Examining only the dynamics of BDI among
individual time points, this was also significant (p b 0.001).
However, examining the effects of time points and
WHOQOL-SPRB on BDI, the result was no longer
significant (p = 0.866). Examining the relationship between
two selected groups (e.g. high spirituality vs. low spiritual-
ity), it is clear that though there are no significant differences
on the dynamics among all three groups simultaneously,
there are significant differences in the levels of depression
between those with low and high levels of spirituality
(p b 0.001) and between those with low and moderate
spirituality (p = 0.001). The difference between those with
moderate and high spirituality was not significant (p =
0.168). Overall, it can be concluded that subjects with
moderate to high spirituality showed a significantly lower
level of depression, with respect to all five observed
measurements, that those with low spirituality (Fig. 2).
With regard to religiousness, considering that the
questionnaire for intrinsic religiousness DUREL (the final
three questions) had a small number of sections, we divided
it into three levels taking the percentage distribution into
account. Values above 12 (above the 75th percentile) were
considered as high, those from 7 to 12 as moderate, and those
less than 7 as low level of religiousness. Only the dynamics
in the total score of the BDI (independent of groups
according to DUREL) proved to be significant in this

Table 1
Pearson's correlations between depression (measured with BDI) and spirituality (measured with WHOQOL-SRPB) and religiousness (OR – organized
religiousness, NOR – not organized religiousness; IR – intrinsic religiousness) and personality dimensions (TCI) at all monitoring points.
After 1 month After 3 months After 6 months After 12 months
WHOQOL-SRPB: total − 0.317** − 0.319** − 0.261** − 0.348**
WHOQOL-SRPB: spiritual connectedness − 0.130 − 0.142 − 0.251* − 0.310**
WHOQOL-SRPB: meaning in life − 0.283** − 0.303** − 0.197 − 0.279**
WHOQOL-SRPB: awe − 0.251* − 0.276** − 0.129 − 0.198
WHOQOL-SRPB: wholeness and integration − 0.267** − 0.258* − 0.238* − 0.275**
WHOQOL-SRPB: spiritual strength − 0.306** − 0.268 − 0.212* − 0.297**
WHOQOL-SRPB: inner peace − 0.265* − 0.308** − 0.194* − 0.229*
WHOQOL-SRPB: hope and optimism − 0.395** − 0.349** − 0.236* − 0.322**
WHOQOL-SRPB: faith − 0.188* − 0.185 − 0.196 − 0.286**
OR 0.028 − 0.063 − 0.043 − 0.140
NOR 0.078 0.048 0.075 − 0.052
IR − 0.090 − 0.131 − 0.126 − 0.269**
Novelty seeking − 0.143 − 0.126 − 0.042 − 0.120
Harm avoidance 0.516** 0.491** 0.344** 0.206**
Reward dependence − 0.176 − 0.185 − 0.129 − 0.175
Persistence − 0.085 − 0.038 0.047 0.017
Self-directedness − 0.489** − 0.428** − 0.320** − 0.280**
Cooperativeness − 0.276** − 0.306** − 0.271** − 0.156*
Self-transcendence − 0.033 0.047 0.149 0.031
*p b 0.05, * * p b 0.01.
 S. Mihaljevic et al. / Comprehensive Psychiatry 70 (2016) 17–24 21

Fig. 2. Graphic demonstration of BDI rate in relationship with spirituality divided in three categories (WHOQOL-SRPB weak, moderate, strong) in time.

breakdown, while the relationships to individual groups
according to DUREL showed no significant differences in
the dynamics of BDI (in the ANOVA and in post hoc
testing) (Fig. 3).
Linear regression analysis (ENTER method) was used to
determine the predictions of depression by measuring the
scores on the BDI scale at the baseline and at every
monitoring time point. The test has proven to be significant
at all time points. Considering that the authors of the
religiousness questionnaire (DUREL) [29] do not recom-
mend the use of all dimensions of religiousness (OR, NOR
and IR) in the same regression analysis for the purpose of
avoiding multiple colinearities, the regression analysis was
performed independently for each type of religiousness.
Table 2 shows that a higher scores on the dimension harm
avoidance and a lower score on the spirituality (overall
WHOQOL-SRPB scale) were predictors on the BDI score
after 12 months.

Fig. 3. Graphic demonstration of BDI rate in relationship with religiosity divided in three categories (DUREL weak, moderate, strong) in time.
22 S. Mihaljevic et al. / Comprehensive Psychiatry 70 (2016) 17–24
Table 2
Linear regression analyses for depression after 12 months (BDI 5) as
dependent variable, and personality dimensions, spirituality and intrinsic
religiousness as predictors (F = 4.094; p = 0.000; R = 0.474, R 2 = 0.225,
corr. R 2 = 0.164).
Beta T P
TCI: novelty seeking − 0.087 − 0.877
TCI: harm avoidance 0.302 2.657
TCI: reward dependence − 0.230 − 1.536
TCI: persistence 0.206 1.548
TCI: self-directendness 0.077 0.571
TCI: cooperativeness − 0.124 − 0.989
TCI: self-transcendence 0.201 1.872
WHOQOL-SRPB: total − 0.304 − 2.341
IR − 0.055 − 0.518
When analyzing the association between depression and
individual domains of spirituality (without the overall
WHOQOL-SRPB), we found that no domain was indepen-
dently responsible for the association with recovery at any
measurement point. When examining the association
between depression and intrinsic religiousness, without the
effect of spirituality, we found that intrinsic religiousness
was not a significant predictor of recovery from depression at
any time point.
4. Discussion
To the extent of our knowledge, this is the first study to
monitor the effects of spirituality and religiousness on the
rate of recovery from depression in persons of working age,
i.e. from 30 to 65 years. Furthermore, this is the first study to
investigate the correlation of the psycho-biological person-
ality model with the effects of spirituality and religiousness
on recovery from depression.
The first question this study aimed to answer whether
spirituality and religiousness affected those suffering from
depression in the rate of recovery from depression, and
whether the effect of spirituality was greater than the effect
of religiousness. The Pearson's correlations showed that a
higher level of spirituality was more strongly associated with
a lower level of depressiveness than was religiousness after
one year of monitoring. Both the correlation and regression
analysis showed the spirituality is a construct that is strongly
inversely correlated with depression. Considering that we
applied a multi-dimensional questionnaire, the correlation
method of analysis showed that the domains of wholeness
and integration, inner peace and hope and optimism gave
the strongest contribution to the association between
spirituality and depressiveness. This was slightly contrary
to the findings of Nelson et al. in which the components of
spirituality, such as sense of meaning and peace gave the
highest contributions to the association of spirituality with
depression [14]. The WHOQOL-SPRB measures universal
concepts and it is considered that if a person with depression has
maintained these concepts, they could more easily recover from
depression. A person with depression can lose faith in God, i.e.
intrinsic religiousness can be diminished and not act protective-
ly, though the spiritual concepts are those that are tied to
resistance in general and when preserved, they can represent the
driving strength for recovery.
Some studies have found differences in the association
0.383
between spiritual and religiousness with depression [14,34].
0.009
0.128 Though these studies have a cross-sectional character, it was
0.125 a significant find that spirituality showed a higher correlation
0.569 with depression that with intrinsic religiousness. It is necessary
0.326 to stress that in the majority of studies to date, spirituality is
0.065
primarily observed through one or two questions (such as: How
0.021
0.605 important is spirituality in your life?). In the present study we
included the domains of the spirituality questionnaire in the
regression analysis, which indicated that individual domains of
spirituality have no predictive value in the recovery from
depression, unlike the total sum of all domains contained in the
WHOQOL-SRPB questionnaire.
Intrinsic religiousness in our study also proved to have an
effect on recovery from depression, though in the regression,
this effect was lost where religiousness was a predictor. This was
contrary to the earlier findings in a geriatric population [3,6] who
did not examine an association with personality dimensions.
Also, the values of the arithmetic means of religiousness in that
geriatric sample were significantly higher than in ours, which
was expected considering that religiousness tends to become
stronger with increasing age [18].
Organizational religious activity (e.g. attending services)
and non-organizational religious activity (e.g. prayer and
meditation) did not prove to have a predictive effect on the
outcome of depression in our study. This finding was not in
accordance with previous longitudinal studies [1,3,10]. The
lack of an association in this study could be explained by the
fact that persons in a state of depression are more inclined to
social isolation and passiveness, and as such leave the home
and attend services less often due to the environment that
they perceive as mentally and socially demanding. Further,
in more highly secularized countries, the religious communities
are smaller, and their members are more closely bound to one
another. In a country such as Croatia, where religious gatherings
(such as Sunday mass) are still attended by a large number of
people, the ties between community members are lost, and
often, they do not know one another. Accordingly, the protective
effect of social support as a function of organized religiousness
is lost, as discussed by Durkheim [35].
On the basis of the stronger inverse association obtained of
depression with spirituality than with religiousness, it can be
concluded that relying on the fundamental life values such as the
meaning of life, meaning, hope and faith as such (not necessary
religious) (facets of the WHOQOL-SRPB questionnaire)
strengthen the contribution to recovery from depression more
than religiousness (both intrinsic and extrinsic).
Though we separated the constructs of spirituality and
religiousness by using different measures, there was of course a
certain amount of overlap. Many people are simultaneously both
spiritual and religious, while others are not. Namely, among
 S. Mihaljevic et al. / Comprehensive Psychiatry 70 (2016) 17–24
persons in which those two constructs are separate, i.e.
spirituality has a positive effect as opposed to religiousness,
this can reflect persons locus of control [16,36]. Spiritual
persons often find strength within them, and as a result feel
self-control and experience better spiritual satisfaction. On the
other hand, persons who primarily experience religiousness, and
not spirituality, can seek guidance through religion, placing the
source of control outside themselves. This external locus of
control can occasionally give rise to feelings of helplessness
and depressiveness.
In the present study, the same relationships found in the
correlations were confirmed in the multivariate analysis that
included the personality dimension according to the
psycho-biological model in addition to spirituality and
religiousness. The regression analysis intended to confirm
the predictors of depression at each individual measurement
point and showed that the significant predictors of
depression in the 12 months follow up were harm-avoid-
ance and spirituality. The high harm avoidance may be the
predisposing TCI trait for major depressive disorder in
general and was increased even when patients were in
euthymic phase [37]. Also, individuals with higher scores on
harm avoidance showed poorer treatment response [38]
which is in line with our findings. Another dimension which
is found in the literature to be associated with depression
outcomes is self-directedness that was correlated with BDI
scores in all points of measurement (along with harm
avoidance and cooperativeness) but is not significant
predictor in final linear regression in our study.
Another significant predictor of depression in the final
linear regression was spirituality measured at baseline.
Changes in spiritual and existential perspectives have been
associated with depression at onset as well associated with
depression outcome [39], that our study actually showed.
According to our knowledge, to date there have been no
published studies that have examined the association of
spirituality and religiousness with the Cloninger personality
model in those suffering from depression, though there are
studies that have examined these associations using the
five-factor model. Johnstone et al. found that certain
personality traits (measured with NEO-FFI) differed in
their association with spirituality and religiousness, and that
there are certain differences in personality traits with regard
to religious denomination [27]. In that study, spirituality
positively correlated with positive personality traits, such as
extroversion, while it correlated negatively with the negative
personality traits (i.e. neuroticism). Personality traits corre-
lated with religiousness in a much weaker extent, in that
neuroticism correlated positively with organized religious-
ness, i.e. social support of the religious community.
Neuroticism and harm-avoidance were highly correlated
dimensions and therefore this conclusion can support our
results [40]. Piedmont also found that spirituality is a
stronger predictor of depressiveness than personality traits
[41]. However, some authors believe that spirituality and
religiousness should be considered as character adaptations
23
based on the fundamental personality traits (e.g. tempera-
ment). Accordingly, it can be expected that each positive
effect of spirituality/religiousness is, at the very least, the
result of the basic personality traits [24,27].
In our work, self-transcendence did not show any
predictive value on depression as spirituality did, what is
in concordance with fact that concept of self-transcendence
is similar but not identical with spirituality. It is quite logic
that self-transcendence will be predictive or correlated with
spirituality because of their similarities. We measured
personality as whole integration of dimensions of tempera-
ment and character not (only) as particular subscale. It is
interesting that self-transcendence did not show any
significant correlation with BDI during follow up period
(Table 1) and in regression analyses did not show any
predictive value on BDI score after 12 months of monitoring
(Table 2). This finding is a proof for differentiation of
self-transcendence (as one personality dimension) and
spirituality (multidimensional concept).
5. Limitations
Our study also has some limitations. Some authors
believe that the spiritual scales contain spirituality that is
defined by positive human traits [28,42] and that this is
tautology, particularly when used in studies addressing
mental illness. In their opinion, questions about spirituality
are also indicators of mental health, and should not be
included in the definition of spirituality as such. There could
be tautology at several levels, such as whether a low level of
spirituality is a part of depression, and whether har-
m-avoidance is also depression. Depression can concern
parts of life, behavior and functioning that are not associated
with either spirituality or religiousness. So, to exclude these
limitations we performed longitudinal study.
Another possible limitation is the predominantly Catholic
affiliation of the participants what can impair ability of
generalization of results. Patients older than 65 and younger
of 30 were not included as those age groups may differ in
attitude to existential issues and in spirituality [43]. That may
impact the generalizability of our data to other groups of
depressive patients also. Although our patients were not
treated with antidepressants at the time of first assessment,
all were put on medication that could influence the
expression of some TCI dimensions that were assessed
during the follow up part of the study [44]. Other limitations
of this research are small sample size and usage of the self-
report measures of depression in follow-up period.
6. Conclusions
The emphasis to date in psychiatry has primarily been based
on sickness and risk factors, and not on resistance factors [44].
The present study was directed at determining which factors are
24 S. Mihaljevic et al. / Comprehensive Psychiatry 70 (2016) 17–24
important for recovery, i.e. directed at the healthy strength of a
person and the capability to have hope, faith and a purpose to
life. If these components are present, and if depression arises,
on the basis of that strong core, the person can more easily
recover.
References
[1] Braam AW, Beekman AT, Deeg DJ, Smit JH, van Tilburg W.
Religiosity as a protective or prognostic factor of depression in later
life; results from a community survey in the Netherlands. Acta
Psychiatr Scand 1997;96(3):199-205.
[2] Bosworth HB, Park KS, McQuoid DR, Hays JC, Steffens DC. The
impact of religious practice and religious coping on geriatric
depression. Geriatr Psychiatry 2003;18(10):905-14.
[3] Koenig HG, George LK, Peterson BL. Religiosity and remission of
depression in medically ill older patients. Psychiatry 1998;155:536-42.
[4] Koenig HG, George LK, Titus P. Religion, spirituality, and health in
medically ill hospitalized older patients. Geriatr Soc 2004;52(4):554-62.
[5] Koenig HG. Religion and depression in older medical inpatients.
Geriatr Psychiatry 2007;15(4):282-91.
[6] Payman V, Ryburn B. Religiousness and recovery from inpatient
geriatric depression: Findings from the PEJAMA study. Psychiatry
2010;44(6):560-7.
[7] Dew RE, Daniel SS, Goldston DB, McCall WV, Kuchibhatla M,
Schleifer C, et al. A prospective study of religion/spirituality and
depressive symptoms among adolescent psychiatric patients. J Affect
Disord 2010;120(1–3):149-57.
[8] Bekelman DB, Dy SM, Becker DM, Wittstein IS, Hendricks DE,
Yamashita TE, et al. Spiritual well-being and depression in patients
with heart failure. J Gen Intern Med 2007;22(4):470-7.
[9] Cotton S, Puchalski CM, Sherman SN, Mrus JM, Peterman AH,
Feinberg J, et al. Spirituality and religion in patients with HIV/AIDS. J
Gen Intern Med 2006;21(5):S5-13.
[10] Harrison MO, Edwards CL, Koenig HG, Bosworth HB, Decastro L,
Wood M. Religiosity/spirituality and pain in patients with sickle cell
disease. J Nerv Ment Dis 2005;193(4):250-7.
[11] Aukst-Margetić B, Jakovljević M, Ivanec D, Margetić B, Ljubicić D,
Samija M. Religiosity and quality of life in breast cancer patients. Coll
Antropol 2009;33(4):1265-71.
[12] McClain CS, Rosenfeld B, Breitbart W. Effect of spiritual well-being
on end-of-life despair in terminally-ill cancer patients. Lancet
2003;361(9369):1603-7.
[13] McCoubrie RC, Davies AN. Is there a correlation between spirituality
and anxiety and depression in patients with advanced cancer? Support
Care Cancer 2006;14:379-85.
[14] Nelson C, Jacobson CM, Weinberger MI, Bhaskaran V, Rosenfeld B,
Breitbart W, et al. The role of spirituality in the relationship between
religiosity and depression in prostate cancer patients. Ann Behav Med
2009;38(2):105-14.
[15] McGrath P. Religiosity and the challenge of terminal illness. Death
Stud 2003;27(10):881-99.
[16] Nelson CJ, Rosenfeld B, Breitbart W, Galietta M. Spirituality, religion,
and depression in the terminally ill. Psychosomatics 2002;43:213-20.
[17] O'Connell KA, Skevington SM. Spiritual, religious, and personal beliefs
are important and distinctive to assessing quality of life in health: A
comparison of theoretical models. Health Psychol 2010;15(4):729-48.
[18] Koenig HG, McCullough ME, Larson DB. Handbook of Religion and
Health. 1st ed. New York: Oxford University Press; 2001.
[19] Meezenbroek EJ, Garssen D, van den Berg M, van Dierendonck D, Visser
A, Schaufeli WB. Measuring spirituality as a universal human experience:
A review of spirituality questionnaires. J Relig Health 2012;51:336-54.
[20] Cloninger RC, Svrakic DM, Przybeck TR. A psychobiological model
of temperament and character. Arch Gen Psychiatry 1993;50:975-90.
[21] Cloninger CR, Svrakic DM, Przybeck TR. Can personality assessment
predict future depression? A twelve-month follow-up of 631 subjects. J
Affect Disord 2006;92:35-44.
[22] Corruble E, Duret C, Pelissolo A, Falissard B, Guelfi JD. Early and
delayed personality changes associated with depression recovery? A
one-year follow-up study. Psych Res 2002;109:17-25.
[23] Grucza RA, Przybeck TR, Spitznagel EL, Cloninger CR. Personality
and depressive symptoms: A multi-dimensional analysis. J Affect
Disord 2003;74:123-30.
[24] Löckenhoff CE, Ironson GH, O'Cleirigh C, Costa PT. Five-factor
model personality traits, spirituality/religiousness, and mental health
among people living with HIV. J Pers 2009;77(5):1411-36.
[25] Saroglou V. Religion and the five factors of personality: A meta-
analytic review. Pers Individ Diff 2002;32:15-25.
[26] Saroglou V, Muñoz-García A. Individual differences in religion and
spirituality: An issue of personality traits and/or values. J Sci Relig
2008;47:83-101.
[27] Johnstone B, Yoon DP, Cohen D, Schopp LH, McCormack G,
Campbell J, et al. Relationships among spirituality, religious practices,
personality factors, and health for five different faith-traditions. J Relig
Health 2012;51(4):1017-41.
[28] Koenig H. Concerns about measuring “spirituality” in research. J Nerv
Ment Dis 2008;196:349-55.
[29] Koenig HG, Büssing A. The Duke University Religion Index
(DUREL): A five-item measure for use in epidemological studies.
Religions 2010;1:78-85.
[30] Beck AT, Rush AJ, Shaw BF, Emery G. Cognitive Therapy of
Depression. New York: Guilford Press; 1979.
[31] WHOQOL SRPB Group. A cross-cultural study of spirituality,
religion, and personal beliefs as components of quality of life. Soc
Sci Med 2006;62(6):1486-97.
[32] Pibernik-Okanović M. Psychometric properties of the World Health
Organisation quality of life questionnaire (WHOQOL-100) in diabetic
patients in Croatia. Diabetes Res Clin Pract 2001;51(2):133-43.
[33] Aukst-Margetić B, Jakovljević M, Ivanec D, Tošić G, Margetić B.
Novelty seeking and medication adherence in patients with schizo-
phrenia. Psych Res 2011;186(1):141-3 [56].
[34] Tsuang MT, Williams WM, Simpson JC, Lyons MJ. Pilot study of
spirituality and mental health in twins. Psychiatry 2002;159:486-8.
[35] Durkheim E. Suicide: A Study in Sociology. London: Routlege
Classics; 2002.
[36] Saucier G, Skrzypinska K. Spiritual but not religious? Evidence for
two independent dispositions. J Pers 2006;74:1257-92.
[37] de Winter RF, Wolterbeek R, Spinhoven P, Zitman FG, Goekoop JG.
Character and temperament in major depressive disorder and a highly
anxious-retarded subtype derived from melancholia. Compr Psychiatry
2007;48(5):426-35.
[38] Kampman O, Poutanen O. Can onset and recovery in depression be
predicted by temperament? A systematic review and meta-analysis. J
Affect Disord 2011;135(1–3):20-7.
[39] Kim NY, Huh HJ, Chae JH. Effects of religiosity and spirituality on the
treatment response in patients with depressive disorders. Compr
Psychiatry 2015;60:26-34.
[40] Masthoff ED, Trompenaars FJ, Van Heck GL, Hodiamont PP, De Vries J.
The relationship between dimensional personality models and quality of life
in psychiatric outpatients. Psychiatry Res 2007;149(1–3):81-8.
[41] Piedmont RL. Does spirituality represent the sixth factor of
personality? Spiritual transcendence and the five-factor model. J Pers
1999;67:985-1013.
[42] Miller L, Wickramaratne P, Gameroff MJ, Sage M, Tenke CE,
Weissman MM. Religiosity and major depression in adults at high risk:
A ten-year prospective study. Psychiatry 2012;169:89-94.
[43] Koenig HG. Religion, spirituality and aging. Aging Ment Health
2006;10(1):1-3.
[44] Cloninger CR, Zohar AH. Personality and the perception of health and
happiness. J Affect Disord 2011;128(1–2):24-32.