Spirituality, wellness, and quality of life☆

Definition 

First, what is spirituality? Although spirituality can be distinguished from religion, the two concepts heavily overlap. Spirituality is a more popular (and useful) term than is religion. The reason is because spirituality makes no distinctions or divisions between patients—everyone at some level can consider himself or herself spiritual.

View Large Image Download to PowerPoint

Fig 1.

Most research conducted thus far on relationships to health, however, has examined religious beliefs, practices, and commitments, not spirituality. Because spirituality is so broad and individualized, it is difficult to standardize and measure. For religion, however, this is much easier. Most of what we know about spirituality and health, then, is really about religion and health. Furthermore, there is good reason to think that individualized spirituality divorced from doctrine, ethical standards, or responsibility to others, may not have the same health effects as religion. When talking to patients, however, it is almost always best to talk in terms of spirituality. In clinical practice, distinguishing spirituality and religion from each other is much less of an issue because the majority of patients consider themselves both spiritual and religious. For that reason, I will be using these terms interchangeably.

Comp: Drop 〈CAB〉 from the end of the article here. Follow style. Use red

Mental health and well-being 

Research is rapidly accumulating on the relationship between religion, spirituality, and mental health—especially in patients with health problems. Before the year 2000, there were more than 700 quantitative studies, of which two-thirds (nearly 500) found a statistically significant relationship between religious involvement and better mental health, greater social support, or less substance abuse (1). Between 2000 and 2002, more than 1,100 additional studies, articles, and reviews were published on the link between religion/spirituality and mental health. The amount of attention paid this subject is beginning to nearly approach that paid to social support. This is truly remarkable, given the near complete avoidance of this area by academics before 1990. Here is a summary of the findings (before the year 2000).

Why better mental health? 

There are at least 10 reasons why religious/spiritual beliefs and practices might be related to better mental health. Religion/spirituality provides:

Comp: Drop the second 〈CAB〉 here from the end of the article. Follow style and use red.

On the other hand, religious beliefs do not always foster positive mental health. There are certainly cases, often well known to clinicians, where religious beliefs seem to be contributing to excessive guilt, obsessive preoccupations, worries, or social ostracism. For some psychosocial stressors (especially dealing with turbulent family relationships), stronger religious beliefs and practices have been associated with more depression and greater stress (2). Thus, religiousness (or spirituality) is not always associated with better mental health, greater well-being, and stronger social relationships; in general, however, they are.

Physical health and medical outcomes 

Whatever the explanation, there is increasing evidence that connections between religion, spirituality, and physical health do in fact exist. Based on a systematic review of the literature (1), the following is known:

Immune/endocrine function. 5 of five studies found that religious beliefs and practices are associated with better immune or endocrine functioning. These studies have been conducted in older adults, HIV-positive younger adults, long-term survivors with AIDS, and women with metastatic breast cancer, and have examined immune outcomes such as CD-4 counts, T-lymphocytes, natural killer cells, the cytokine interleukin-6, and cortisol levels.

Cancer mortality. Five of seven studies reported that persons who are more religious are less likely to die of cancer. Some of this effect has to do with health behaviors, although health behaviors do not usually explain the entire effect.

Blood pressure. Twelve of 14 studies found lower systolic or diastolic blood pressure among those who were more religiously active. The only two studies not finding an association did not actually measure the subjects' blood pressure but rather depended on self-report. One study found a 40% reduced likelihood of diastolic hypertension (P <.0001) in a sample of more than 3,600 randomly selected older adults (after controlling for usual predictors of blood pressure) (3).

Heart disease. Eleven of 16 studies reported less coronary artery disease (CAD), lower likelihood of CAD-related death, or better survival after open-heart surgery in those who are more religious. In one study of more than 10,000 middle-aged Israeli men followed for more than 23 years, investigators found a 20% reduction in CAD death rate among those who scored higher on a religious orthodoxy scale, an effect that was independent of biological risk factors (4).

Stroke. One Yale study found that religious attendance was associated with the lower stroke incidence during a 6-year period in a sample of more than 2,800 older adults in Connecticut (5).

Health behaviors. Of 25 studies examining cigarette smoking, 23 found lower rates of smoking among the more religious. Three of five studies found increased likelihood of exercise. Three of three studies found lower cholesterol. Finally, at least one study found better sleep patterns. On the other hand, 0 of 6 studies found that the religious were less likely to be overweight, suggesting that faith-based weight reduction programs have a ways to go.

Sexual behaviors. Studies also find that religious involvement is inversely related to favorable attitudes toward nonmarital sex and to premarital and extramarital sexual activity. Of 38 studies, 37 found that the religious had significantly lower rates or more negative attitudes toward nonmarital sex, compared to those who were less religious. The vast majority of these studies (n = 32) were in adolescents or college students. There is also evidence that sexually transmitted diseases are less frequent among the more religious, who are also less likely to have multiple sexual partners and become involved in high-risk sexual activity (1).

Overall Survival. Of 52 mortality studies examining survival, 39 (75%) reported longer survival for the more religious. This is especially true for those who attended religious services regularly. For example, in a 9-year prospective study of a national sample of more than 20,000 adults, investigators found that those attending religious services at least weekly experienced about a 7-year longer survival (14 years for African Americans), an effect equivalent to that of not smoking cigarettes (6).

Further research is needed to determine whether religious or spiritual involvement actually “causes” better health, improves health outcomes, and extends survival. Randomized clinical trials, the only way to establish causality, are currently lacking in this field. Despite this limitation, however, there is growing circumstantial evidence from epidemiological studies, including a host of large prospective cohort studies, that this may indeed be the case. Furthermore, there is also ample scientific plausibility for such an effect.

Why better physical health? 

If emotional and social factors influence human physiology, as research increasingly suggests they do with regard to immune, endocrine, and cardiovascular function (7), then this could provide a plausible mechanism by which religious or spiritual beliefs influence physical health. We explain these effects in terms of known psychological, social, and behavioral pathways (belief, faith, and practice), not supernatural influences that are beyond the scope of scientific examination. Improved coping with stress, more positive emotions, greater social support, and better health behaviors have all been proven to influence the body's response to disease and illness. Religious or spiritual beliefs and practices, as noted, likely impact these psychosocial and behavioral factors, that in turn influence physical health.

How does this work? By enhancing positive emotions such as well-being, hope, and a sense of purpose and meaning in life, religious beliefs and practices may help to counteract the negative stressors that set off the fight–flight response. The flight–fight response, when allowed to proceed unimpeded, produces changes in immune function, cortisol and epinephrine levels, blood pressure, and cardiac function that interfere with health and healing.

Social support provided by a faith community may have the same buffering effect, but also includes more careful monitoring of the individual. Concerned members of a congregation are likely to be calling and checking up on a sick member, inquiring about their medical care and whether they are taking their medications, whether they need a ride to the doctor's office, or need practical assistance in other ways. This monitoring impacts on early disease detection and medical compliance.

Religious teachings also encourage healthy living, including respect for and maintenance of the physical body, and discourage unhealthy behaviors such as cigarette smoking, excessive alcohol use, drug use, and risky sexual practices. All of these factors impact on health status.

Addressing patients' spiritual needs 

Spiritual factors are relevant to medical care. Not only do religious beliefs and practices tend to be associated with better health and more successful coping, they also appear to influence medical decision-making and may at times conflict with medical care (8). Spiritual struggles may also influence medical outcomes, and not always positively (9). Thus, taking a spiritual history is not only necessary to identify spiritual resources that can be used to maintain health and facilitate well-being, but also to identify beliefs that may directly impact on the medical treatment. There is also evidence that addressing spiritual needs enhances the doctor–patient relationship and helps to build trust, whereas ignoring spiritual issues can lead to miscommunication and rejection of medical recommendations (and even to lawsuits). Despite these considerations, fewer than 10% of physicians regularly inquire about spiritual issues even in religious regions of the United States (10).

A brief spiritual history, then, is recommended for all patients with serious or chronic medical illness (see Table 1) . (11). This includes asking about whether religious beliefs are comforting or stress inducing, whether any beliefs might conflict with medical care, whether there are beliefs that might influence medical decision-making down the road, whether the patient is a member of a faith community that is providing support, and whether there are any spiritual needs that someone ought to address. If spiritual needs are identified, then referral to pastoral care services is indicated. A spiritual history can be included as part of the social history at the time of hospital admission, during a new patient evaluation, or as part of an outpatient visit when acute problems are not being dealt with (12).

Table 1. A brief spiritual history (11).

	1. Do your religious or spiritual beliefs provide comfort and support or do they cause stress?
	2. How would these beliefs influence your medical decisions if you became really sick?
	3. Do you have any beliefs that might interfere or conflict with your medical care?
	4. Are you a member of a religious or spiritual community and is it supportive?
	5. Do you have any spiritual needs that someone should address?

Patients most applicable 

A spiritual history is particularly relevant for patients with chronic medical illness, disability, serious or terminal illness, the elderly, women, and racial minority groups such as African-Americans or Hispanics. Research has shown that these groups are those that are most religious, and therefore religious factors are more likely to influence coping with illness, medical care, and treatment decisions.

Conclusions 

Spiritual and religious factors can have a powerful influence on the health and well-being of patients. The majority of studies demonstrate a consistent and persistent effect on health and well-being, especially in stressed populations–the sick and disabled, members of minority groups, women, and the elderly. Taking a spiritual history is quickly becoming the standard of care in such patient groups. Ignoring these issues is no longer possible in a health care system that focuses on the whole patient.

Comp. See hard copy attached