Religious Involvement, Spirituality and Medicine : Subject Review and Implications for Clinical Practice

Mr. Keyur Vasantlal Shastri

The words ‘religion’ & ‘spiritualism’ in a layman’s conception means some basic, age-old cultures and customs which acts as a binding force in a community. Religion is derived from the term "religo" which means "good faith," "ritual," and other similar meanings.

Or it may have come The English word "religion" is derived from the Middle English "religioun" which came from the from the Old French "religion." It may have been originally derived from the Latin word Latin "religãre" which means "to tie fast."

Religion organizes the collective   spiritual experiences of a group of people into a system of beliefs and practices’. Religiosity’ refers to the extent and degree of adherence of an individual towards the core value and beliefs of a religion. ’Spirituality’ on the other hand means ‘breathe’. Spiritual is a much deeper aspect of religion. Spiritualism is more scientific and dynamic and its scope is much wider than religion .Spiritualism is concerned with metaphysical issues like the reason and purpose of life, transcendence from the mundane world, divine justice etc. Though on a holistic approach there may exist fundamental difference between religion and spirituality but spirituality is more or less regarded the same as that of religion because though the path of a formal religion may differ from spirituality, their aim coincide with each other. In other words religion is the formalized approach to spiritualism.

Since time immemorial it has been observed that religious involvements do have a pivotal role in the physical as well as mental well being of human beings. Surveys of general population and that of patients have consistently found that more than 90% of people believe in higher being and that 96% of patients believe spiritual well being is a cardinal factor in health .Despite all these, the spiritual needs of the patients are almost always neglected. But the situation has changed since post cold-war era and now there is a greater acceptance of the role of religion and spiritualism in mitigating diseases. Clinician’s interest has increased in patient spirituality because of the growing number of studies that have empirically shown the relation between religious involvement and better health outcomes. This article reviews the published studies, meta-analysis, systematic and subject reviews that have co-related religious involvement and spiritual interventions (e.g. Pastoral care, meditation, sudarshankriya, HRQL etc) with a greater well being of human beings.

Use of Religious and Spiritual Variables in Medical Research:

Religious and spiritual variables are very seldom used in medical research. The medical practitioners rely more on the bio-medical model to explain and diagnose the diseases and hence physical evidence is paramount for them .A review of 2348 studies published in four major psychiatry journals between 1978-1982 revealed that only 59 articles (2.5%) accounted for spiritual variables. Similar reviews have shown that only 11.8% adolescent health studies, 10% of nursing and mental health studies, 3.5% of family practice studies and only 3.6% gerontology studies used religious or spiritual variables. While bio-medical concept can magnificently define disease mechanisms eg. Bacterial infections, it falls fat in explaining psychological, sociological and spiritual factors that influence most of the maladies.

Religious Involvement, Spirituality and Physical Health:

A majority of the nearly 350 studies of physical health that used religious and spiritual variables have found that these two parameters are essentially associated with better health outcomes.

Mortality:

During the past three decades, at least 18 prospective studies have shown that religious people have a better and longer life than their counterpart. The population chosen for the study included not only communities but also specific groups. The religious variables used in these studies included activities like membership in religious congregation, attendance at religious services, residing within a religious community and self reported religiosity.

A holistic approach has been used to infer the relation between religious activities and better health outcome. A 28 year study of 5286 adults (aged 21 – 65 years) found that frequent attendants (once per week at least) of religious services were 23% less likely to die than the non-attendants. Similarly there had been similar studies for different intervals on this issue. A nine years study of 22080 American adults found the risk of death for non-attendants to be 1.87 times higher than the frequent attendants (p< 0.01) after controlling for numerous demographic, baseline health, behavioral, social and economic variables. Hence it can be inferred that a religious person has a higher odds of survival than a less religious person.

Cardiovascular Disease:

Recent studies have found an essential relationship between cardiovascular diseases and religious & spiritual practices. A case control studies found that secular Jewish persons have significantly higher chances of myocardial infarction compared to the orthodox Jews (men: OR 4.2, 95% CI 2.6-6.6; women: OR 7.3, 95% CI 2.3-23.0) adjusted for age, ethnicity and body mass index. Again  a 23 year prospective study of 10,059 male Israeli civil servants and municipal employees found that orthodox  Jewish people had a 20% decreased risk of fatal coronary heart disease (CHD)  than non-religious men adjusted for age, blood pressure, lipids, smoking, diabetes, body mass index and baseline CHD. 12 out of recent 16 studies showed that religious involvement is actually associated with less cardiovascular disorders.

Hypertension:

Studies have found that religious involvement is associated with lower blood pressure and less hypertension. Koenig et al examined the relationship between religious activities and blood pressure among 3963 adults (aged 65 years or older) adjusted for age, ethnicity, education, body mass index and previous blood pressure. They found that frequent attenders of religious activities (e.g. Prayer) were 40% less likely to have diastolic hypertension > 90mm Hg compared with infrequent attenders. Finally 14 out of 16 studies have evidently showed that religious involvement indeed decreases risk of  hypertension and high blood pressure.

Depression and Anxiety:

Depression is a common illness. 6-10% of the world population suffers from depression. Recent longitudinal studies have examined the possible relationship between religious involvement and depression. In a study of the treatment of depressed religious persons, standard cognitive behavourial therapy (CBT) was compared with a combination of standard CBT with religious content. With pastoral care alone there had been a significant reduction in post treatment depression compared to reduction in depression by using only CBT. It has also been found that religious psychotherapy has a greater influence in controlling depression than standard therapy alone. Of 29 studies conducted on this relationship, 24 firmly found that religiously involved people do have fewer depressive symptoms and less depression than their counterparts.

Religious involvement has also shown to be associated with less anxiety. Various studies conducted on this issue has amply proved that religious involvement can reduce anxiety irrespective of age, caste, creed, ethnicity, sex and demographic variables.  A study examined the relationship between spiritual well-being and anxiety in 114 adults with newly diagnosed with cancer. Patients with spiritual well-being had less anxiety than the non-religious patients. In case of anxiety studies too nearly 70 prospective studies found that religious involvement was associated with less anxiety and fear.

Alcoholism, Cigarette Smoking and other forms of substance abuse:

Religious persons are less likely to abuse alcohol, cigarette or other habit forming substances than non-religious persons. One prospective study of 1014 male medical students found out that religiously involved students were much less likely to abuse alcohol than their non-religious colleagues. On the other hand a number of cross-sectional studies have found an inverse relationship between cigarette smoking and religious involvement. A recent 3 year study on this issue has shown the same result among 4569 adults.

A review by Miller concluded that there was strong evidence in favour of the role of religious involvement in reducing abuse of habit forming substances.

Cancer Treatment: Role of Yoga and Prayer:

Medical science has made amazing progress over the years. One of its facets is the rediscovery of the miracle of Yoga. Practiced and advocated over centuries by sages and rishis, Yoga directs and regulates the subtle life force, the very essence of our life. Yogas like sudarshan kriya and pranayama have shown to reduce stress and hence reduce the risk of cancer. Behavourial or psychological factors like chronic stress can aggravate the risk of cancer by the following mechanisms:

• Influence of stress on natural killer (NK) cells.
• Poorer repair of damaged DNA.
• Modulation of apoptosis
• Oxidative stress.

A prospective study of police trainees of age group between 21-27 for 5 months in AOL workshop showed that sudarshan kriya and pranayama lowers the blood lactate level. Increase of lactate in blood aggravates stress and anxiety. Sudarshan kriya and pranayama also significantly increased the blood level of glutathione and anti-oxidant enzymes like super oxide dimutase and catalase. In the same study it was also observed that sudarshan kriya can also increase the number of NK cells and T cells.

Although more clinical studies are needed to document the benefits of programs that combine pranayama (yogic breathing) Asanas (yoga postures), and meditation, there is sufficient evidence to consider Sudarshan Kriya Yoga to be a beneficial, low-risk, low-cost adjunct to the treatment of stress, anxiety, post-traumatic stress disorder (PTSD), depression, stress-related medical illnesses, substance abuse, and rehabilitation of criminal offenders. SKY has been used as a public health intervention to alleviate PTSD in survivors of mass disasters. Yoga techniques enhance well-being, mood, attention, mental focus, and stress tolerance. Proper training by a skilled teacher and a 30-minute practice every day will maximize the benefits. Health care providers play a crucial role in encouraging patients to maintain their yoga practices.

Religious Involvement, Spirituality and Coping:

It’s very natural that distressing events like surviving catastrophes and natural calamities, caring for diseased relatives or friends, death of near and dear ones and other such do have a demoralizing effect on the human beings. Being humans, each and everyone do suffer from such phases of life. Religious involvement in such cases can mitigate the drastic and adverse effect of such experiences. A recent prospective cohort study included 135 relatives and close friends of patients with terminal illness who were followed for up to 14 months after their loved ones death. Those having strong faith in religion and spiritual beliefs were found to come out of their grief and become resolute than those not professing religious beliefs. Religious and spiritual coping is a more common phenomenon among persons with asthma, HIV diseases, chronic pain, end stage renal disease, multiple sclerosis and cancer.

Religious and spiritual coping may have important prognostic implication and conclusions. Cross sectional and longitudinal studies have shown less depression during illness. This was further distinctly proved by various prospective studies. Religious involvement has been shown to buffer the noxious effects of stressful life events.

Negative Effects of Religious Involvement and Spirituality:

Unlike the above observations, few systematic population based studies have also related religious involvement with adverse health outcome. Like other factors, religious and spiritual involvement may cause degradation in health related factors. Religious involvement can adversely affect ones physical health by encouraging practices like avoidance of traditional treatment, failure to seek timely medical care etc. It may also affect the mental well being. For e.g. mentally ill religious persons may avoid psychiatric care. Again some unhealthy beliefs that integrate into the core religion with the passage of time may also have a negative impact on an individual.

Noted psychoanalysts Sigmund Freud and Albert Ellis regarded religious involvement as a suggestive of psychopathology. However meta-analysis of 24 such studies showed that there is no direct relation between religious involvement and psychopathology.

Possible beneficial Mediators of Religious Involvement and Spirituality:

Like other factors e.g. Exercise, religious involvement and spirituality too enhance resistance to disease through interaction of multiple mediators. Members of a religious community may have a shared genetic ancestry that promotes health. Developmental factors may also mediate the effect of religious involvement on health. For e.g. Children belonging to religious families not only learn healthy behaviors but also view them as a source of hope and comfort during hostile periods. Religiously involved persons can tackle the burden of a stressful life in a more efficient manner. Hence they have a better mental stability than the non-religious persons. Good mental health ultimately leads to a better physical health. We have already discussed that religious persons embrace health promoting behaviors like eating proper diet, abstaining from abusive and habit forming substances etc.

Religious practices can engender positive emotions like love, hope, compassion, gratitude etc and can retard harboring of negative thoughts like suicide, hostility etc. Such positive emotions can limit the activation of sympathetic branch of ANS and decreased release of stress hormones like adrenaline & nor-adrenaline. Infact religious involvements do have a say on immune function. Such activities alleviate the immunity of a person. Finally religious involvement also accounts for the placebo effect in an individual.

Clinical Implications of Patient’s Religious Involvement and Spirituality:

1) Practical aspects:

The results of the surveys and the studies reviewed that patient care can be done more efficiently by acknowledging patient’s spiritual belief. William .J. Mayo said that, ‘there is spiritual as well as material quality in the care of sick people and too great efficiency in material detail may hamper progress’. William Osler called faith ‘An unfailing stream of energy’. Today even the US joint commission on the accreditation of Healthcare Organization recommends and requires the routine assessment of patient’s spiritual needs.

Though most clinicians do not initiate any spiritual discussion along with the patient, there is an immense requirement of religious discourse of the practitioner with the patient. The reasons may be cited as follows:

1. Patients regard their spiritual health equally important as that of their physical health.
2. Research suggests that religious involvement is a cardinal factor in improving the health of the patient.
3. Religious notions give rise to positive emotions like hope, love, transcendence etc which can help in mitigating the disease.
4. Patients suffering from religious, spiritual and existential concerns may not inform their clinicians about them.

In a nut-shell, supporting a patient’s spiritual beliefs recognizes the person as a whole and should be viewed in the same light as accounting for other factors that may influence the health of an individual.

Nevertheless, a number of hindrances prevent proper spiritual discourse between the patient and the practitioner. First of all, the clinicians practice in the bio-medical model where religious variables are almost irrelevant. Next a very few physicians describe themselves as spiritual. Third, effect on religion in mitigating disease is seldom taught in medical science. Finally, time constraint and lack of concluding evidences also pose as a barrier.

2) Ethical Issues:

Ethical issues are raised when one includes patient spirituality in clinical service. The principle of non-malfeasance (do no harm) suggests that the clinicians should avoid proselytizing to patients. Many people attain hope and resolution from their religious beliefs and in such cases the physicians should never proselytize them.

The beneficent clinician acknowledges and supports a patient’s spirituality. Previously several sensitive factors like patient’s spiritual belief, sexuality, substance abuse etc were not openly discussed. Now days, these matters are openly discussed by clinicians because of their potentiality to cause health damage. The clinician’s duty is not to judge the individual lifestyle and beliefs but to derive their clinical importance. Hence not enquiring about such issues like religious beliefs may constitute a part of negligence on behalf of the clinicians.

Conclusion:

Most patients lead a spiritual life and regard their spiritual as well as physical well being equivalent. Furthermore, people can have greater spiritual needs during illness and adverse situations. But the surveys show a different dismal picture. It shows that though vital, the spiritual needs of the patients are almost often neglected.

A large number of empirical studies in the last few decades have given enough evidence about the role of religious involvement in mitigating both physical ailments as well as mental morbidity. Religious involvement has shown positive outcome in case of disorders as discussed before viz. hypertension, depression and anxiety, cardiovascular diseases and cancer. Apart from them prospective studies have also shown that religious and spiritual involvement also helps in reducing diabetes, suicide tendency, AIDS and other sexually transmitted diseases like syphilis etc.

Although there have been ample evidences of religious involvement and better health outcome, yet it couldn’t account for causality.  While religiously involved persons embrace health promoting behaviors, refrain from wrong acts and have strong support network, yet all these factors do not count for all the benefits of religious involvement and spirituality. Rather these benefits are conveyed through various complex psychosocial and biological mechanisms which aren’t deciphered wholly till date.

Acknowledging and supporting the spiritual needs of a patient can be done by following a straight, broad and holistic approach. Spiritual history and open-ended question sessions by clinicians can increase the patient-practitioner rapport which may help in the cause of curing the patient. The patient must be allowed to freely discuss his biological, psychological and spiritual concerns with the physician. Special spiritual care-takers like chaplains who are committed to pastoral care must be integrated in the medical system in a judicious manner. On the other hand the clinicians should also understand that no bird can fly on only one of its wings. They should both heartily acknowledge the bio-medical model as well as the religious involvement in the attainment of a sound physical, mental and social well being of a person. Such a coherent system will certainly boost the standard of the present medical scenario by leaps and bounds.

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About Authors:

Mr. Keyur Vasantlal Shastri
M.Pharm, P.D.C.R, Lecturer, Abhinav Education Society’s College of Pharmacy (B.Pharm), S. No. 23/2/3, A/P. Narhe, Tal Haveli, Narhe Dist Pune- 411 041 India; E-mail: keyurshastri@gmail.com.

Dr. Vishal Vijay Pande
Ph D, M Pharm, F.N.E.A. , Asstt Prof.- Dept. Of Pharmaceutical Analysis JSPM’S, Jayawantrao Sawant College of Pharmacy & Research,
Hadapsar, Pune -411 028. India; E mail: vishalpande_1376@rediffmail.com.

Prof. Avinash R. Tekade
M Pharm, Asstt. Prof - Dept. of Pharmaceutics & Quality Assurance SES’R.C. Patel College of Pharmacy, Karvand Naka,
Shirpur- 425 405 Dist. Dhule

Mrs. A S Gadekar
M.Pharm, Lecturer in Pharmaceutical Analysis, JSPN College of Pharmacy & Research, Hadapsar, Pune- 411 028
E-mail: agadekar@gmail.com