Harold G. Koenig, M.D.

Professor of Psychiatry & Behavioral Sciences. Associate Professor of Medicine, Duke University Medical Center. Geriatric Research, Education and Clinic Center Durham VA Medical Center.

Funding provided by NIMH grant R01-MH57662 (Dr. Koenig). Correspondence to Dr. Koenig, Box 3400,
Duke University Medical Center, Durham, NC 27710;
e-mail: koenig@geri.duke.edu

The publication of this special issue of Revista de Psiquiatria Clinica represents a landmark in the field of religion, spirituality and mental health in Brazil and other Portuguese speaking countries. To my knowledge, this will be the first psychiatric journal to devote an entire issue to the subject. The articles contained here are written by the most important Brazilian researchers in the field, and include several papers from researchers outside of Brazil as well. In this foreword/editorial, I provide a brief summary of how the field of religion, spirituality and mental health has developed, provide my vision for the future of the field, and stress the importance of collaboration between Brazilian clinicians and scientists in ensuring that the psychological, social, and spiritual needs of patients are adequately addressed.

Many of the first hospitals to care for persons with mental illness were operated by monks and priests, and “moral” treatment (that valued the role of religion and the contributions of clergy in care) became the dominant type of psychiatric care in the United States and Europe in the early 1800’s. However, this all changed in the early 1900’s with the writings of Sigmund Freud in psychiatry and G. Stanley Hall in psychology (Koenig, 1995). These writers believed that religion promoted neurosis and that psychological theory would ultimately replace religion as a world-view and source of treatment. Such negative attitudes toward religion were not based on scientific research or systematic study, but rather on the personal opinions and beliefs of these early leaders. For most of the 20th century, as a result, the field of mental health care would undervalue and often devalue the religious beliefs and practices of patients, as evidenced by writings as late as 1980s and 1990s that strongly spoke against religion (Ellis 1988; Watters, 1992).

However, some stirrings of change began within the mental health field in the 1990s and the turn of the 21st century. Systematic research began to demonstrate that religious persons were not always neurotic or unstable, and those with deep religious faith actually seemed to cope better with life stress, recover more quickly from depression, and experience less anxiety and other negative emotions than those who were less religious (Larson et al, 1992; Koenig et al., 1992, 1993; Koenig et al., 1998; Koenig, 2006). Furthermore, researchers in the United States were not the only groups reporting such findings, but also scientists in Canada (Baetz et al., 2002; Gee & Veevers, 1990; Harvey et al., 1987; O’Connor & Vallerand, 1989), Great Britain (Shams & Jackson, 1993; Cook et al., 1997), Ireland (Maltby, 1997), Spain (Luna et al., 1992), Switzerland (Pfeifer & Waelty, 1995), Germany (Schwab & Petersen, 1990; Siegrist, 1996; Becker et al., 2006), the Netherlands and other areas of Europe (Braam et al., 1997; Braam et al., 2004), Malaysia (Razali et al., 1998; Azhar et al., 1994), Thailand (Tapanya et al., 1997), Australia (Francis & Kaldor, 2002; Wollin et al., 2003), Nigeria (Ndom, 1996), Egypt (Thorson, 1998), the Middle-East (Anson et al., 1990; Abdel-Kalek, 2006),and India (Verghese et al., 1989).

In fact, a PsycINFO online search (a database containing 2.3 million research studies and academic articles from 49 countries in 27 languages) using the terms “religion,” “religiosity,’ “religious beliefs,” and “spirituality” reveals some interesting trends. When I restricted the search years to 1971 to 1975, I uncovered 1113 articles. When I repeated the search and restricted the articles to those published between 2001 and 2005, this yielded 6,437 articles, an increase of over 600% in 30 years. Thus, there appears to be a rapid increase in research and academic discussions related to the relationship between religion, spirituality and mental health.

Given that religion is important to the vast majority of Brazilians and others living in South America, it is not surprising that there might be interest in the link between religious involvement and mental health. Of the 6,437 religion-spirituality articles published between 2001 and 2005, 20 involved papers on religion, spirituality and health in Brazilians. Six of the 20 articles reported quantitative results from research studies, and four of these focused on mental health. I briefly review the latter reports here.

The first studied 110 Spiritualists attending a well-known Kardecist Center in Sao Paulo. Socialization, happiness, religiosity, mediumship, personality, and general dissociative experiences were measured using standard scales (Negro et al., 2002). Mediumship activity was associated with increased dissociative experiences, but good scores on socialization and adaptation. A second study involved 989 consecutive patients admitted in a psychiatric unit in a Brazilian hospital (Dalgalarrondo et al., 2004a). Catholics and Protestants (the majority being Pentecostals) were compared on symptoms, diagnoses, length of stay, and clinical outcomes. Protestant patients were younger, more likely to be female, had less education and were less likely to be married. Compared with Catholics, Protestants were more likely to have schizophrenia and were less likely to have substance abuse disorders. There was no difference in length of stay or clinical status at the time of discharge. Investigator explained that the results may be due to patterns of help seeking by the largely Pentecostal Protestant group from lower socioeconomic backgrounds.

A third study examined 2,287 students attending four public and three private schools (Dalgalarrondo et al., 2004b). Use of alcohol, tobacco, medicines, and illicit drugs was examined within the past month. Students with no religious affiliation or without a religious education were significantly more likely to use illicit drugs (ecstasy or cocaine). The final study examined the effects of religious affiliation (Pentecostal, Spiritualists, and Catholics) on substance use and mental health (the latter measured by GHQ-12, with higher scores indicating more psychological morbidity) in 1,796 students (Dalgalarrondo et al., 2005). Pentecostals used less tobacco, alcohol and drugs and had lower GHQ-12 scores; Spiritualists used more psychoactive substances and had higher GHQ-12 scores; and Catholics scored halfway in between the other two groups. These four studies give the reader some sense of the kind of research in this area now being done in Brazil.

Why all the interest in this area? Why study the relationship between religion, spirituality and mental health? There are several reasons. The results of such research have important implications regarding the clinical care of patients. Knowing the impact that religious beliefs may have on the etiology, diagnosis, and outcome of psychiatric disorders will help psychiatrists better understand their patients, appreciate when religious or spiritual beliefs are used to cope with mental illness, and when they may be exacerbating that illness. The vast majority of research thus far in healthy populations suggests that religious beliefs and practices are associated with greater well-being, better mental health, and more successful coping, especially during situations of high stress. This is also true to some extent for psychiatric patients, who often face tremendous environmental and psychosocial stress from their disorders and are in need of effective coping strategies for dealing with this. On the other hand, a few studies also indicate an association between religious involvement and greater psychopathology (see article on religion and psychotic disorders in this issue).

Because of the role that religious and spiritual beliefs may have in psychiatric illness, it is important that psychiatrists conduct a spiritual history during which they explore the beliefs of the patient that may be influencing the mental illness and how the patient is coping with the illness. Furthermore, much more research is needed to better understand how the many different religious belief systems in Brazil and other countries of South America interact with and influence mental disorders.

Thus, the area of religion, spirituality and mental health is a research and clinical area with great potential. It is my hope that this trail blazing issue of the Journal may excite further research and discussion that will ultimately lead to recognition by clinicians of the importance of religious and spiritual beliefs in the mental health and mental illnesses of the patients we serve, thereby ushering in a new era of whole person culturally sensitive psychiatric care.