The relationship between religious involvement and clinical status of patients with bipolar disorder

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Cruz M, Pincus HA, Welsh DE, Greenwald D, Lasky E, Kilbourne AM. The relationship between religious involvement and clinical status of patients with bipolar disorder. Bipolar Disord 2010: 12: 68–76. © 2010 The Authors. Journal compilation © 2010 John
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  The relationship between religious involvement and clinicalstatus of patients with bipolar disorder Mario Cruz a , Harold Alan Pincus b,c , Deborah E Welsh d , Devra Greenwald e , Elaine Lasky e ,and Amy M Kilbourne d,f a Advanced Center for Intervention and Services, Research for Late-life Mood and AnxietyDisorders, Western Psychiatric Institute and Clinic, Pittsburgh, PA b Department of Psychiatry, Irving Institute for Clinical and Translational Research, ColumbiaUniversity College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York, NY c RAND Corporation, Pittsburgh, PA d VA Ann Arbor National Serious Mental Illness Treatment Research and Evaluation Center, AnnArbor, MI e VA Pittsburgh Center for Health Equity Research and Promotion, Pittsburgh, PA f Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA Abstract Objective— Religion and spirituality are important coping strategies in depression but have beenrarely studied within the context of bipolar disorder. The present study assessed the associationbetween different forms of religious involvement and the clinical status of individuals treated forbipolar disorder. Methods— A cross-sectional observation study of follow-up data from a large cohort study of patients receiving care for bipolar disorder (n = 334) at an urban Veterans Affairs mental healthclinic was conducted. Bivariate and multivariate analyses were performed to assess the associationbetween public (frequency of church attendance), private (frequency of prayer/meditation), as wellas subjective forms (influence of beliefs on life) of religious involvement and mixed, manic,depressed, and euthymic states when demographic, anxiety, alcohol abuse, and health indicatorswere controlled. Results— Multivariate analyses found significant associations between higher rates of prayer/ meditation and participants in a mixed state [odds ratio (OR) = 1.29; 95% confidence interval (CI)= 1.10-1.52, chi square = 9.42, df = 14, p < 0.05], as well as lower rates of prayer/meditation andparticipants who were euthymic (OR = 0.84; 95% CI = 0.72-0.99, chi square = 4.60, df = 14, p <0.05). Depression and mania were not associated with religious involvement. Conclusions— Compared to patients with bipolar disorder in depressed, manic, or euthymicstates, patients in mixed states have more active private religious lives. Providers should assess thereligious activities of individuals with bipolar disorder in mixed states and how they maycomplement/deter ongoing treatment. Future longitudinal studies linking bipolar states, religiousactivities, and treatment-seeking behaviors are needed. Corresponding author  : Mario Cruz, M.D. Advanced Center for Intervention and Services Western Psychiatric Institute and Clinic3811 O’Hara Street Pittsburgh, PA 15213, USA Fax: 412-383-5412 authors of this paper do not have any commercial associations that might pose a conflict of interest in connection with thismanuscript. NIH Public Access Author Manuscript  Bipolar Disord  . Author manuscript; available in PMC 2011 February 1. Published in final edited form as: Bipolar Disord  . 2010 February ; 12(1): 6876. doi:10.1111/j.1399-5618.2009.00772.x. N I  H -P A A  u t  h  or M an u s  c r i   p t  N I  H -P A A  u t  h  or M an u s  c r i   p t  N I  H -P A A  u t  h  or M an u s  c r i   p t    Keywords bipolar disorder; religionBipolar disorder (BD) is a devastating illness impacting individuals’ social (1,2),occupational (3-7), and physical well-being (8-10). Because BD is a relapsing, remitting,and often chronic disease, it is important to identify attitudinal, behavioral, or social factorsthat help individuals suffering from BD cope with manic, mixed, and depressive episodes.In terms of coping, the religious beliefs, attitudes, and behaviors of individuals with BDdeserve exploration. Religious beliefs are a principal form of coping with life stresses formany individuals in the United States. More than half of Americans rank the importance of religion very high in their lives, attend religious services regularly, and pray daily (11).Although studies suggest potential beneficial effects of different forms of religious copingfor individuals in the community at large (12-15) or with psychiatric illnesses (16-19), thereare few studies assessing the relationship between the frequency of religious activities andthe strength of spiritual beliefs and BD (20). The authors found only one study addressingthe relationship of religious activities or beliefs with patients treated for BD (21). This studyassessed the spiritual beliefs and religious activities of 84 remitted BD patients in NewZealand. The investigators found that most BD patients held strong religious or spiritualbeliefs (78%) and attended religious functions or were involved in private religious activitiesfrequently. Most saw a direct link between their beliefs and the management of their illness.Many used religious coping, and often spiritual beliefs put them in conflict with illnessmodels (24%) and advice (19%) from their medical advisors.Though Mitchell and Romans’ study (21) identified important relationships betweenreligious beliefs and activities in BD, all participants were in remission at the time of theinterview. Their findings cannot give us an appreciation of variation in the frequency of religious activities or strength of religious beliefs when BD patients are in manic, depressed,mixed, or euthymic states.Assessing variation in religious involvement by BD state could help in determining whetherindividuals with BD turn to religious involvement as a means of coping with dysfunctionalBD states, a relationship hypothesized by Ellison and Levin (22). Ellison and Levintheorized that religious involvement may provide a sense of meaning and coherence thatcounteracts stress, assists with coping, provides a network of like-minded persons who canserve as social resources, and promotes the development of psychological resources,including self-esteem and a sense of personal worth.To expand the psychiatric literature regarding the relationship between different forms of religious involvement and spirituality with individuals suffering from BD, we asked thefollowing questions: Do the different states of BD influence individuals’ responses toquestions about the frequency of church attendance, prayer/meditation, and the degree towhich religious beliefs influence their life? And is there a significant response differencebetween individuals with BD who are in euthymic, depressed, manic, or mixed states toquestions about their religious activities and beliefs when functional disability,psychological distress, and destructive behaviors are controlled for in the analyses? Cruz et al.Page 2  Bipolar Disord  . Author manuscript; available in PMC 2011 February 1. N I  H -P A A  u t  h  or M an u s  c r i   p t  N I  H -P A A  u t  h  or M an u s  c r i   p t  N I  H -P A A  u t  h  or M an u s  c r i   p t    Methods Patient characteristics Data for the present analyses was obtained from baseline and exit self-reports of participantsfrom the Continuous Improvement for Veterans in Care–Mood Disorders (CIVIC-MD), alongitudinal, observational study of BD patients from a large, urban outpatient mental healthclinic.The purpose of CIVIC-MD was to identify patient factors associated with quality andoutcomes of care for BD. Details regarding CIVIC-MD are described elsewhere (22). Inbrief, the CIVIC-MD self-report surveys included information on participants’ degree of religious involvement, demographic characteristics, and clinical as well as health/disabilitystatus. After complete description of the study to the subjects, written informed consent wasobtained.Survey data were captured at baseline and study exit. The CIVIC-MD study was approvedby the Institutional Review Board and Research Development Committee of the VeteransAffairs (VA) Pittsburgh Health Care System. Study enrollment occurred from July 11, 2004to July 11, 2006, while baseline and one-year follow-up surveys were conducted betweenJuly 2005 and July 2007.Participant data were included for this study if they had completed both baseline and one-year follow-up surveys. Demographic data was captured at study entry. Religiousinvolvement, clinical, and health/disability data were captured from the follow-up survey. Measures Religious involvement data were captured using the Duke Religious Index (DRI) (23). TheDRI is a 5-item scale that captures information on respondent’s involvement in the threeaccepted major dimensions of religiousness: the public, private, and subjective dimensionsof religious involvement. The first item is a measure of the public dimension and asks,“How often do you attend church, synagogue, or other religious meetings?” Responses arerated as follows: 1 = never, 2 = once a year or less, 3 = a few times a year, 4 = a few times amonth, 5 = once a week, and 6 = more than once a week. The second item is a measure of the private dimension and asks “How often do you spend time in private religious activities,such as prayer, meditation, or Bible study?” Responses range from 1 (rarely or never) to 6(more than once a day). Items 3-5 are statements that measure subjective or intrinsicreligiosity: “In my life, I experience the presence of the Divine,” “My religious beliefs arewhat really lie behind my whole approach to life,” and “I try hard to carry my religion overinto all other dealings in life.” These statements are rated on a scale from 1 to 5 (1 =definitely not true; 5 = definitely true). Items are reverse-scored for analyses, with lowscores indicating high involvement in attending religious activities, praying/meditating, orinfluence of beliefs on life ( ).Mood state was captured using the Internal State Scale (ISS) (24). The ISS is a 17-item self-report form developed to concurrently assess both manic and depressive symptoms overtime in individuals suffering from BD (25). Each item constitutes a 10-point Likert-typescale that ranges from 0 to 100. Each item scale has an anchor of 0 = not at all, rarely, and100 = very much so, much of the time, with the exception of the last item, which scores 0 =depressed and down and 100 = manic and high. The subject is instructed to score these itemson the basis of the way he or she has felt during the previous 24 hours. The authors havedefined four subscales: Activation (A) correlates highly and specifically with clinicianratings of mania ( r   = 0.60 versus Young Mania Rating Scale); Depression Index (DI)correlates highly and specifically with clinician ratings of depression ( r   = 0.84 versus Cruz et al.Page 3  Bipolar Disord  . Author manuscript; available in PMC 2011 February 1. N I  H -P A A  u t  h  or M an u s  c r i   p t  N I  H -P A A  u t  h  or M an u s  c r i   p t  N I  H -P A A  u t  h  or M an u s  c r i   p t    Hamilton Depression Rating Scale); Perceived Conflict (PC) correlates most highly with theBrief Psychiatric Rating Scale ( r   = 0.56); and Well-Being (WB) (26). For the presentanalyses, two subscales were used to differentiate participant mood state: the WB and Asubscales. WB and A provide a discriminate function that separates individuals in depressed,manic/hypomanic, euthymic (24), and mixed states (25). Participants are considered to havedepression when they score < 125 on WB and < 155 on A. For mania, participants mustscore ≥  125 on WB and ≥  155 on A. For mixed states, participants must score < 125 on WBand ≥  155 on A. For euthymia, participants must score ≥  125 on WB and < 155 on A (25).To identify the impact of health/psychological/behavioral impediments on individualspracticing their faith, we assessed the presence of functional disability, anxiety, and alcoholabuse. We captured information on functional disability, for it has been posited as anexplanation for low rates of prayer/meditation in depressed individuals with medicalillnesses (27). Functioning was assessed using the World Health Organization DisabilityAssessment Schedule (WHODAS-II) (28). The WHODAS-II is a 12-item (4-point Likert)scale assessing the degree of functional impairment experienced within the past monthregarding self-care (e.g., bathing, dressing), mobility (e.g., standing, walking), cognition(e.g., remembering), social functioning (e.g., conversing), and role functioning. A total scorerepresenting the degree of impairment (higher score = more impairment) was generated bysumming the scores for each item.We posited psychological/behavioral states, such as the presence of anxiety or history of binge drinking, that lead to socially avoidant behaviors or adverse coping strategies thatwould impede an individual’s ability to practice their faith. The presence of anxiety wasassessed using the three anxiety items from the PRIME-MD Patient Questionnaire (29).Alcohol abuse, defined as whether the patient reported having > 5 drinks on one occasion atany time within the past year, was assessed using three items from the Alcohol UseDisorders Identification Test (AUDIT) (30). This assessment was strongly correlated withthe full-length AUDIT (sensitivity = 0.95; specificity = 0.69) (29). Statistical analyses Because the DRI has never been validated for use in studies with individuals suffering fromBD, we ran Spearman correlation analyses to assess associations among the DRI subscalescores of church attendance, prayer/meditation, and the influence of beliefs on life.We then performed ANOVAs between the different bipolar states (i.e., euthymia, mania,mixed, depressed) and the DRI subscale scores of church attendance, frequency of prayer/ meditation, and influence of beliefs on life to assess the strength of the association betweenthe different bipolar states and participants’ responses to questions related to their religiousactivities and spiritual beliefs.We then tested logistic regression models assessing the relationship between the DRIsubscales and BD state when health/psychological/behavioral impediment covariates arecontrolled. Each DRI subscale was tested separately in logistic regression models to avoidmulticollinearity. In the first model (Model A), we tested the relationship between theabovementioned covariates and the dependent variables. Models B, C, and D tested therelationship between the individual DRI subscales and the dependent variables, firstcontrolling for covariates. Cruz et al.Page 4  Bipolar Disord  . Author manuscript; available in PMC 2011 February 1. N I  H -P A A  u t  h  or M an u s  c r i   p t  N I  H -P A A  u t  h  or M an u s  c r i   p t  N I  H -P A A  u t  h  or M an u s  c r i   p t    Results Patient characteristics Overall, 720 patients were approached for CIVIC-MD enrollment. A total of 104 patientswere determined to be ineligible due to the presence of acute psychiatric symptoms (e.g.,mania, psychosis) as determined by their provider. Of the remaining sample (n = 616), 148patients refused, primarily because of the lack of time to complete the survey due to apending outpatient appointment, leaving a total of 468 (76%) enrolled participants. Of the468 enrolled participants, 435 (92%) completed the baseline survey. A total of 335participants completed and returned baseline and follow-up surveys. Table 1 displays thedemographic characteristics of the 335 participants included in the analyses. Studyparticipants were similar in gender and race/ethnic distribution compared to all patientsdiagnosed with bipolar disorder at this VA facility (n = 769; 12% women, 13% AfricanAmerican). Analyses Spearman correlation analyses revealed significant associations between DRI subscalereverse scores of church attendance and prayer/meditation ( r   = 0.72, df = 1, p < 0.0001) aswell as influence of beliefs on life ( r   = 0.68, df = 1, p < 0.0001). Also, significantassociations were found between DRI subscale reverse scores of prayer/meditation and theinfluence of beliefs on life ( r   = 0.78, df = 1, p < 0.0001).ANOVAs revealed that the frequency of church attendance was significantly associated witheuthymic [ F   = 11.07, df = (1, 331), p = 0.001] and mixed [ F   = 9.35, df = (1, 331), p = 0.002]states, the frequency of prayer/meditation was associated with euthymic [ F   = 10.34, df = (1,331), p = 0.001)] and mixed [ F   = 10.62, df = (1, 331), p = 0.001)] states, and the influenceof beliefs on life was associated with euthymic [ F   = 7.29, df = (1, 330), p = 0.007] andmixed [ F   = 12.73, df = (1, 330), p = 0.0004] states.We then tested the logistic regression models (See Tables 2A and B). We found that higherrates of prayer/meditation were associated with being in a mixed state [odds ratio (OR) =1.29; 95% confidence interval (CI) = 1.10-1.52, chi square = 9.42, df = 14, p < 0.05], whilelower rates of prayer/meditation was associated with being euthymic (OR = 0.84, 95% CI =0.72-0.99, chi square = 4.60, df = 14, p < 0.05).No significant associations were found between DRI church attendance and influence of beliefs subscale scores and participants’ bipolar state, nor between DRI subscale scores anddepressed or manic states. Discussion We found that individuals’ responses to questions addressing their frequency of churchattendance, frequency of prayer/meditation, and the influence of their religious beliefs ontheir life were significantly associated with participants in euthymic and mixed states. Whenfunctional disability and the presence/absence of anxiety and binge drinking werecontrolled, we found that lower self-reported rates of prayer/meditation were significantlyassociated with participants in euthymic states, and higher self-reported rates of prayer/ meditation were significantly associated with participants in mixed states. This last findingsuggests that individuals with BD who are in the throes of a mixed state seek support fromprivate religious activities.Our findings support the conceptual framework posited by Ellison and Levin (31). Theirframework provides one potential explanation for our findings. That is, being both depressed Cruz et al.Page 5  Bipolar Disord  . Author manuscript; available in PMC 2011 February 1. N I  H -P A A  u t  h  or M an u s  c r i   p t  N I  H -P A A  u t  h  or M an u s  c r i   p t  N I  H -P A A  u t  h  or M an u s  c r i   p t  
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