Spirituality, Religion, and Depression: Treatment and Well-Being

Introduction

Over the last thirty years, one of the most interesting paradoxes in the study and treatment of depression has been that increased knowledge about the biomedical and genetic causes of the disease has been coupled with a renewed interest in the effect of religion and spirituality on human mental health and well-being. No matter how religion and spirituality are defined — and many scholars and laypersons see no great distinctions between the two — there are now hundreds of studies that demonstrate the beneficial effects of religion on both mental and physical health. Indeed, the more firmly held and intrinsic a person's religious convictions are, the more salutary the effect. Religious people are more optimistic, hopeful, and trusting, and have more purpose and meaning in life than those with weak or no religious views. All of these qualities are, of course, lacking in depressive patients, which is why strong religious or spiritual beliefs serve as a protective factor against depression.

There are also many studies demonstrating that prayer and meditation have a positive effect on physical, emotional, and psychological well-being. This is not to suggest that the biomedical model should be abandoned or that treatment with antidepressants should be discontinued — only that holistic and spiritual concerns are a very important aspect of any integrated treatment plan for depression.

Defining Spirituality and Religion

A person can be "spiritual" without being religious in the traditional sense: they may believe in God or a supreme being and an afterlife without belonging to any formal religious organization or following its theology, doctrines, and precepts. In recent times, even this religion/spirituality dichotomy may be breaking down, as many people define themselves as religious without participating in any organized religion. They may borrow ideas and traditions from many different religions and spiritual traditions, creating their own personal, individualized faith no longer subject to any outside authority or text, but only to their individual conscience. By 2002, for instance, only 18% of U.S. Catholics had a great deal of confidence in organized religion, while 30% had an unfavorable view of the Catholic Church. These trends affected other religions as well, apart from evangelical and fundamentalist Protestants. There has been a large decrease in participation in organized religion in the U.S. over the past decade, with many believers "looking for alternatives: what many call 'spirituality'" (Honeygosky, 2006, p. 3).

Spirituality is a more ambiguous and nebulous term than religion — more inward-looking and subjective, not based in formal religious organizations or traditions, and indeed spirituality often "dismisses religion" (Honeygosky, p. 5). There are many spiritual and religious activities that now take place outside of formal settings, such as retreats, prayer, meditation, and devotional reading, either alone or in groups. A study of 500 young adult Catholics in 1997 found that only 10% were "core" believers while 90% were "peripheral" and did not "hold their Catholic identity as central" or "find meaning in parish life." They were skeptical of the Pope, organized religion, the clergy, and the doctrines of the church, and many described their real faith as independent of any external church authorities. Even though few of them turned to New Age, Eastern, or non-Christian religions as was common in the 1960s and 1970s, they did not really participate in any formal or informal religious activities at all (Honeygosky, p. 7).

In surveys conducted in the U.S., Japan, and other countries, most respondents do not make distinctions between religion and spirituality that trouble academics, but see them as related. Even so, most scholars insist that such distinctions have validity. Cox et al. (2005) define religion as "the cognitive, behavioral and systematic aspects of a person's belief system," while spirituality is more generalized and concerned with "the transcendent and emotional qualities of life in relation to the ultimate meaning" — or, as the German theologian Paul Tillich called it, the "ultimate concern" (p. 285). In the traditional meaning, religion encompassed "all aspects of the human relationship to the divine or transcendent — that which is greater than us," while for modern psychologists and social scientists it means a way of life, faith communities, and their habits, practices, and beliefs (Nelson, 2009, p. 4). Islam emphasizes the transcendence of God; in Eastern religions God is immanent within and among us; in Christianity God is both. Strong transcendence refers to something totally beyond human control or understanding, unlike weak transcendence, which social scientists study as a normal part of human life and communities. For modern science and philosophy, transcendence is "just another word for human power and ability," with considerable doubt about whether a God who cannot be seen truly exists at all. Glock and Stark defined religion as consisting of certain specific aspects such as ritual, experience, morality, and ethics, while Ninian Smart (1998) also described it as having legal, emotional, doctrinal, and mystical aspects (Nelson, p. 6).

Theologians and religious philosophers make less of a distinction between religion and spirituality than other scholars, given that religious people are also spiritual and vice versa. Spirituality can mean "our search for the transcendent" or for personal knowledge and experience of the divine. It can simply refer to values, meaning, and inner awareness beyond the self or ego, or a "search for higher values, inner freedom, and things that give life meaning." Christians are spiritual in that they claim to have personal experiences with God, Jesus Christ, and the Holy Spirit, and theologians prefer a "thick" definition of spirituality that places it firmly within the context of a specific religious tradition (Nelson, p. 9). Both religion and spirituality seek answers to ultimate questions about why we are here and the meaning and purpose of life, or why suffering and evil exist in the world. Jews, Christians, and Muslims worship a transcendent God who is also personal, while in Buddhism the transcendent being is impersonal. Christianity in particular is full of paradoxes about why an omnipotent God allows evil and suffering in the world, and why human free will permits the choice of evil, at least within certain environmental limitations.

For the purposes of psychology, the main interest in religion or spirituality is functional rather than substantive — studying their effects on individuals and communities rather than the truth or falsehood of particular doctrines and teachings. Intrinsic religious faith that has a deeper, more internalized and personal meaning is more likely to benefit those who pray during periods of stress and illness than an extrinsic faith that offers only "social and other personal benefits" (Cox et al., p. 290). For John Swinton, spirituality "relates to such things as love, hope, meaning, purpose" — all of which are dimmed or extinguished in depressives (Swinton, 2001, p. 93). In a 2002 study, Pargament concluded that psychological well-being correlated with an "internalized, intrinsically motivated faith based on a secure relationship with God," and that while fundamentalism was linked to increased prejudice it also "increased well-being." In addition, religion was "most helpful to socially marginalized groups" (Cox et al., p. 296). A 1998 study revealed a stronger relationship to well-being with organized, public religion than with private spirituality, although a 2000 study also concluded that those with spiritual meaning in their lives generally had higher levels of well-being (Cox et al., p. 297). People who use religion "for their own self-interest or personal gain tend to have a higher likelihood of depression," and a 1998 study of Korean-Americans showed higher levels of depression in those who were only extrinsically religious (Cox et al., p. 300).

Beck and Alford list the following as symptoms of depression: dejected mood, loss of emotional attachments, negative feelings toward self, indecisiveness, distortion of body image, self-blame and self-criticism, paralysis of the will, avoidance, escapist and withdrawal wishes, loss of appetite, sleep disturbance, loss of sexual desire, worthlessness, and nihilistic and somatic delusions (Beck and Alford, 2009, p. 84). St. John of the Cross called depression "the Dark Night of the Soul," while F. Scott Fitzgerald described it as a condition in which it feels perpetually like four o'clock in the morning (Auer and Ang, 2007, p. x). According to Biebel and Koenig (2010), depression is "a state of existence marked by a sense of being pressed down, weighed down, or burdened, which affects a person physically, mentally, spiritually and relationally." In the United States, 5–10% of the population is clinically depressed at any given time, yet only 1–3% of these receive treatment. Other studies indicate that about 6.7% of the adult population suffers from major depression in any given year, with episodes lasting 4–8 months, and that it is the second leading cause of disability (Hutchinson et al., 2007, p. 268).

Understanding Depression

Women are three times more likely to be depressed than men, with 5–12% suffering from major or severe depression compared to 2–3% of men. Males are also more likely to deny or mask depressive symptoms, less likely to express emotions or seek treatment, and more likely to self-medicate with drugs and alcohol (Hutchinson et al., p. 269). Susan Simonds identified gender roles, stress, poverty, and victimization as factors in the higher rates of depression in women (Simonds, 2001, p. 5). More women fall below the poverty line than men, and this is a well-known pathway to depression. Race, culture, social class, and sexual orientation all "interact with gender to create a complex picture of identity issues" (Simonds, p. 6). During the life stages of women's development, there were several "key crossroads" at which the danger of depression was greatest: puberty, in which "girls' sexual and social development thrust them into a struggle to please others as well as remain true to themselves"; the transition to young adulthood, when women often compromise "their dreams for the sake of sustaining relationships with significant others and family"; pre-menopause and menopause in their 40s, due to changes in hormonal balance as well as social and cultural factors; and finally after age 60, "as women begin to face the loss of their own vitality and health as well as the loss of significant relationships" (Simonds, p. 7).

In the past, severe or major forms of depression were described as "psychotic depression," although the term is no longer used. In its most profound form, the depressive spectrum can lead to delusions and hallucinations resembling psychosis or schizophrenia, as well as the more familiar symptoms of depressed mood, hopelessness, and suicidal ideation (Beck and Alford, p. 85). This most severe form is now known as major depression with psychotic features. In earlier times, bipolar disorders were referred to as "manic-depressive insanity," with cycles and mood swings of euphoria and despair "characterized by remissions and recurrences" but not associated with schizophrenia or other psychotic disorders (Beck and Alford, p. 90). Bipolar I disorder is defined as the "experience of at least one manic episode and no past major depressive episode," while Bipolar II involves one or more mild "hypomanic episodes" and at least one major depressive episode (Beck and Alford, p. 92). A large percentage of patients with unipolar depression will "show a mild hypomanic tendency after recovery from depression," while "manic-like signs and symptoms are present to some extent in all mood disorders" (Beck and Alford, p. 94). In the manic phase, symptoms include elation, increased gratification, increased social attachment, denial of problems, positive self-image, delusions, hyperactivity, insomnia, increased sexual desire, and impulsive and aggressive behavior. Many patients in the manic phase are aware that they are experiencing false euphoria "and a false sense of well-being, and may even feel uncomfortable with such an exaltation of spirit" (Beck and Alford, p. 95).

Freudian theories about the causes of depression have been largely abandoned over the last thirty years and replaced with biochemical models (Auer and Ang, p. 76). Most people with depression have "biochemical depletion to one degree or another" in the brain from physical, environmental, or genetic causes (Biebel and Koenig, 2010). From a physiological and biochemical standpoint, depression is associated with reduced levels of serotonin and norepinephrine and excess dopamine activity in the brain (Hutchinson et al., p. 273). Twin studies have shown that hereditary factors account for 42% of depression in women and 29% in men. Hormonal factors are also more correlated with depression in women because their hormonal levels fluctuate to a greater extent. Traumatic events such as wars, natural disasters, and physical, sexual, and emotional abuse in childhood, as well as the loss of a parent or spouse, all increase the likelihood of depression. For example, 64% of children who were sexually abused will experience depression by age 17 (Hutchinson et al., p. 280). Some studies find that Jews, Catholics, and Pentecostals in the United States all have higher rates of depression than other religious groups, although the evidence is ambiguous (Blazer, 2010, p. 13).

Typically the first episode of depression occurs in the 24–44 age range, although 3–6% of teenagers are also severely or clinically depressed. Every year, 500,000 teenagers attempt suicide in the U.S. and 5,000 succeed (Hutchinson et al., p. 285). About 15–20% of people over 65 have major depression, but only 10% of these receive treatment, and about 25–50% of elderly persons with dementia are also depressed. Major depression occurs in 25% of patients with cancer, heart disease, stroke, arthritis, AIDS, and Parkinson's disease (Hutchinson et al., pp. 268–69). Blacks and Hispanics suffer from the same rates of depression as whites, although they are "often misdiagnosed with schizophrenia." Vietnamese immigrants to the U.S. had higher rates of depression associated with "being a veteran, being older, having less English, and less attachment," while lower income and socioeconomic status in general are also associated with higher rates of depression across gender, race, and ethnic lines (Hutchinson et al., p. 271).

There are many problems in life that cause anxiety and depression that should not simply be defined as mental illness, but that involve broader issues of spirituality — among these, despair, a loss of meaning and purpose, feelings of failure and inadequacy, and a sense of hopelessness and helplessness. Very often, people suffering from these conditions self-medicate with narcotics or alcohol, and while medications prescribed by physicians and psychiatrists may mask or dampen the symptoms, they do not address the root causes in the "emotional or spiritual dimensions" of life (Kliewer and Saultz, p. 63). In elderly patients, especially those with dementia, depression often goes undiagnosed and untreated, even though "90% of people who die by suicide also have a depressive disorder" (MacKinlay, 2002, p. xviii). Dementia patients in nursing homes commonly suffer from feelings of loneliness, isolation, despair, and loss of humanity that may benefit from spiritual and pastoral care (MacKinlay, p. xvii). Erik Erikson was interested in "spirituality and depression from a developmental perspective" and noted that despair occurred in old age due to fear of death or looking back on a life that appeared futile or wasted. He thought religion played a vital role in a lifelong quest for a sense of integrity, and that many elderly persons were depressed because they believed they had never achieved it (Blazer, p. 9).

Depression and the emotions associated with it always occur within given social, cultural, and historical contexts. Women in Ghana, for example, might view depression during and after menopause as being caused by evil spirits. Hutterites become depressed out of fear "that they might not live up to group expectations" in their very traditional and conservative religious communities (Blazer, p. 6). Sometimes depression in religious and spiritual communities can lead to spiritual and moral growth, even though it can also be a terrible burden.

In modern society, depression is often linked to a loss of faith, meaning, and purpose in a world that devalues traditional religion and where "beliefs are not so much attacked as restricted and trivialized" (Blazer, p. 8). People who lose their religious faith might suffer from "shattered faith syndrome" with symptoms like "chronic guilt, anxiety, and depression; low self-esteem; loneliness and isolation" (Blazer, p. 11). Charles Darwin thought that depression was an adaptive survival mechanism that benefitted the human species by assisting the organism in "withdrawal from unexpected stressors," and modern studies find that mild depression might still have a similar function in dissuading people from pursuing impossible or unrealistic goals (Blazer, p. 12). Evolutionary psychologist John Price also claimed that depression was part of an adaptive survival mechanism to "enable us to let go of worldly attachments" (Smith, 1999, p. 218).

Most studies of depression are objective and based on positivist reasoning, treating depressed patients as objects rather than subjects and neglecting their "inner experiences" of mental illness (Swinton, p. 93). A naturalistic, constructivist approach, on the other hand, holds that "all truth is formulated through an interpretive process within which the researcher is inevitably enmeshed," including the social and cultural context in which both researcher and patient exist (Swinton, p. 98). As Hans-Georg Gadamer put it, no observer is perfectly neutral, objective, and detached — lacking prejudices, biases, and preconceptions — and these factors must be accounted for in any study of depression. Using in-depth interviews with depressive patients who were all committed Christians, Swinton sought to "incorporate something of the essence of the experience of depression and the role of spirituality in living with it," while minimizing researcher bias and prejudice as much as possible (Swinton, p. 105). After analyzing these interviews and discussing them with patients, the study determined that depression was an illness with social, emotional, physical, spiritual, and intellectual dimensions, epitomized by memory loss, confusion, anxiety, guilt, isolation, alienation, withdrawal, loss or gain of weight, headaches, loss of sexual desire, loss of meaning, hopelessness, desolation, and helplessness (Swinton, p. 107).

Conclusion

The evidence demonstrates that individuals with strongly held religious and spiritual convictions are less likely to become depressed, and more likely to recover from it more quickly, with less likelihood of recurrence. This is due to the fact that their faith gives them strength in adversity and crisis, more hope and optimism, and a powerful sense of meaning, purpose, and value in their lives that depressives often lack. These conclusions apply most of all to people who are part of formal, organized religious communities with a firm set of doctrines and beliefs, and to those whose faith is internalized and intrinsic rather than merely situational or opportunistic.

An important facet of any treatment plan for depression, beyond medication and behavioral therapy, must be this spiritual dimension of the disease — addressing the loss of hope, joy, and purpose that accompanies it. Even if treatment does not involve restoring ties to a formal religious community, it should attempt to help the patient seek some creative and transcendent connection with a higher reality or purpose beyond the self and its illness. At the very least, faith and spirituality can give meaning to life in the midst of suffering and chronic illness, and perhaps even lead to new spiritual growth through the pain of the Dark Night of the Soul.