1. State of the Art in Research on Faith and Health Harold G. Koenig, MD Departments of Psychiatry and Medicine Duke University Medical Center GRECC VA Medical Center

2. 1.Definitions: Religion and Spirituality 2.Research on R/S and mental health 3.Research on R/S and health behaviors 4.Research on R/S, physical health, and longevity 5.Understanding the relationship between R/S and health 6.Further resources Overview 10:15-11:00

3. Definitions

4. Religion Involves beliefs, practices, and rituals related to the ‘transcendent,” where the transcendent is that which relates to the mystical, supernatural, or God in Western religious traditions, or to Divinities, ultimate truth/reality, or enlightenment in Eastern traditions. Religions usually have specific beliefs about life after death and rules about conduct within a social group. Religion is often organized and practiced within a community, but it can also be practiced alone and in private. Central to its definition, however, is that religion is rooted in an established tradition that arises out of a group of people with common beliefs and practices concerning the transcendent. Religion is a unique construct, whose definition is generally agreed upon.

5. Spirituality Spirituality is a concept which today is viewed as broader and more inclusive than religion. It is a term more popular today, more so than religion. Spirituality is considered personal, something individuals define for themselves that may be free of the rules, regulations, and responsibilities associated with religion. Spirituality is more difficult to define than religion, and agreement on what the term means is often lacking – especially since the definition of spirituality has been changing, and expanding.

10. Comments on Measuring Spirituality in Research 1.Currently, “spirituality” is either measured as (1) religion, (2) positive psychological states, or (3) positive character traits 2.Positive psychological states include having purpose and meaning in life, being connected with others, experiencing peace, harmony, and well-being 3.Positive character traits include being forgiving, grateful, altruistic, or having high moral values and standards 4.Problem: Atheists or agnostics may deny any connection with spirituality, but rightly claim their lives have meaning, purpose, are connected to others, practice forgiveness and gratitude, are altruistic, have times of great peacefulness, and hold high moral values (Journal of Nervous and Mental Disease 2008; 196(5):349-355)

11. Measuring Spirituality (cont) 5.Problem: Confusing to use religious language (spirituality or that having to do with the spirit) to describe secular psychological terms 6.Problem: Can no longer examine relationships between spirituality and mental health (since spirituality scales confounded by items assessing mental health) *** 6.Problem: Can no longer examine relationships between spirituality and physical health (since mental health affects physical health through the mind-body relationship) 7.Problem: Can no longer study the negative effects of spirituality on health, since positive effects are predetermined by the definition of spirituality Result: Meaningless tautological associations between spirituality and health

12. To keep things simple and clear, I use the terms religion and spirituality interchangeably, or simply use the word religion When research has been conducted on religion it has been distinctive and not confounded with indicators of positive mental health, as research involving spirituality has.

13. Research on Religion and Mental Health 1.Well-being 2.Depression 3.Suicide 4.Anxiety 5.Substance abuse

18. Religious involvement is related to: Greater well-being and happiness (278 of 359 studies) (77%) Less depression, faster recovery from depression (204 of 324 studies) (63%) * Sources: Handbook of Religion and Health (2001, Oxford University Press) Handbook of Religion and Health (2011, 2 nd ed, OUP) Well-being and Depression (systematic review: 1806-2009)*

19. Religious involvement is related to: Less suicide and more negative attitudes toward suicide (106 of 141 or 74% of studies) Why? A religious world-view gives people a reason for living – it gives life meaning. Suicide (systematic review)

20. Religious involvement is related to: Significantly greater meaning and purpose in life (42 of 45 studies) (93%) Significantly greater hope (29 of 39 studies) (74%) Meaning, Purpose, and Hope (systematic review)

21. Religious involvement is related to: Significantly more forgiveness (34 of 40 studies) (85%) Significantly more altruism / volunteering (33 of 47 studies) (70%) Significantly more gratitude (5 of 5 studies) (100%) Forgiveness, Altruism, and Gratitude (systematic review)

22. Religious involvement is related to: Great social support (61 of 74 studies) (82%) Social Support (systematic review)

23. Religion and Health Behaviors

24. Religion is related to: More exercise/physical activity (25 of 37 studies) (68%) Less cigarette smoking, especially among the young (120 of 134 studies) (90%) Less alcohol/drug use, especially among the young (276 of 324 studies) (85%) Health Behaviors

25. The Mind-Body Relationship

27. Religion and Physical Health

28. Religion & Physiological Functions Immune Endocrine Cardiovascular

29. Religious involvement is related to: Better immune functions (19 of 31 studies) (61%) Better endocrine functions (21 of 32 studies) (66%) (majority involving meditation) Immune and Endocrine Functions (systematic review)

31. Religious involvement is related to: Lower blood pressure (36 of 62 studies) (58%) Less heart disease (CAD, CVR, HRV, CRP, cardiac surg, etc.) (35 of 54 studies overall) (65%) (10 of 14 studies on CAD) (71%) Cardiovascular Functions (systematic review)

35. Mortality (all-cause) (systematic review) Religious involvement related to: Greater longevity in 55 of 84 studies (65%) Shorter longevity in 2 of 84 studies (2%) Mixed findings in 12 of 84 studies (14%)

36. Standard Mortality Ratios (ages 25-99) MalesFemales California Mormons (n=9815)* 0.54 (0.51-0.57)0.61 (0.57-0.65) Attend church wkly (99% M / 99% F) + never smoke+married+12 yr ed ** 0.45 (0.42-0.48)0.55 (0.51-0.59) + moderate BMI (57% M / 65% F)0.43 (0.39-0.47)0.52 (0.47-0.57) ** Life Expectancy age 2584 years86 years US Whites (n=15,832)*0.90 (0.85-0.96)0.83 (0.79-0.88) Attend church wkly (28% M / 39% F)0.78 (0.68-0.88)0.70 (0.62-0.79) + never smoke 0.60 (0.48-0.74)0.63 (0.55-0.74) + married 0.51 (0.40-0.66)0.52 (0.42-0.66) + 12 yr education ** 0.47 (0.33-0.64)0.38 (0.28-0.52) + moderate BMI (7% M / 10% F)0.43 (0.30-0.61)0.35 (0.24-0.50) Life Expectancy age 25 (US Whites – all)74 years81 years **Life Expectancy age 25 (extrapolated)84 years86 years+ *Based on a systematic sample of active Calif. Mormons followed 1980-2004, and random sample of white US adults followed 1988-1997. Preventive Medicine 2008; 46:133-136

39. Spirituality in Patient Care (2007, Templeton Press) Medicine, Religion and Health (2008, Templeton Press) Faith and Mental Health (2005, Templeton Press) Handbook of Religion and Health (2001, Oxford University Press) Handbook of Religion and Health (2011 Oxford University Press) The Link Between Religion and Health (2002, Oxford University Press) Further Information Website: Duke Center for Spirituality, Theology and Health http://www.spiritualityandhealth.duke.edu/ Further Reading

40. Summer Research Workshops July and August 2010 Durham, North Carolina 5-day intensive research workshops focus on what we know about the relationship between spirituality and health, applications, how to conduct research and develop an academic career in this area (see website: http://www.spiritualityhealthworkshops.org/). Leading spirituality-health researchers at Duke and elsewhere will give presentations:http://www.spiritualityhealthworkshops.org/ -Previous research on spirituality and health -Strengths and weaknesses of previous research -Applying findings to clinical practice -Theological considerations and concerns -Highest priority studies for future research -Strengths and weaknesses of spirituality measures -Designing different types of research projects -Carrying out and managing a research project -Writing a grant to NIH or private foundations -Where to obtain funding for research in this area -Writing a research paper for publication; getting it published -Presenting research to professional and public audiences; working with the media If interested, contact Harold G. Koenig: koenig@geri.duke.edu

41. Discussion and Questions 11:00 end