Spiritual and Religious Beliefs as Risk Factors for the Onset of Major Depression

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Spiritual and religious beliefs as risk factors for the onset of major depression: an international cohort study

B. Leurent, I. Nazareth, J. BellónSaameño, M.I. Geerlings, H. Maaroos, S. Saldivia, I. Švab, F. TorresGonzález, M. Xavier and M. King

Psychological Medicine / FirstView Article / January 2013, pp 1 12DOI: 10.1017/S0033291712003066, Published online:

Link to this article: http://journals.cambridge.org/abstract_S0033291712003066

How to cite this article:B. Leurent, I. Nazareth, J. BellónSaameño, M.I. Geerlings, H. Maaroos, S. Saldivia, I. Švab, F. TorresGonzález, M. Xavier and M. King Spiritual and religious beliefs as risk factors for the onset of major depression: an international cohort study. Psychological Medicine, Available on CJO doi:10.1017/S0033291712003066

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Spiritual and religious beliefs as risk factors forthe onset of major depression: an internationalcohort study

B. Leurent1,2, I. Nazareth2, J. Bellon-Saameno3, M.-I. Geerlings4, H. Maaroos5, S. Saldivia6, I. Svab7,

F. Torres-Gonzalez8, M. Xavier9 and M. King1*

1 Mental Health Sciences Unit, Faculty of Brain Sciences, University College London Medical School, UK2 Research Department of Primary Care and Population Health, University College London Medical School, UK3 Department of Preventive Medicine, El Palo Health Centre, Malaga, Spain4 University Medical Centre, Utrecht, The Netherlands5 Faculty of Medicine, University of Tartu, Estonia6 Departamento de Psiquiatrıa y Salud Mental, Universidad de Concepcion, Chile7 Department of Family Medicine, University of Ljubljana, Slovenia8 CIBERSAM-Granada University, Granada, Spain9 Department of Mental Health, Faculdade Ciencias Medicas, CEDOC, Lisboa, Portugal

Background. Several studies have reported weak associations between religious or spiritual belief and psychological

health. However, most have been cross-sectional surveys in the USA, limiting inference about generalizability. An

international longitudinal study of incidence of major depression gave us the opportunity to investigate this

relationship further.

Method. Data were collected in a prospective cohort study of adult general practice attendees across seven countries.

Participants were followed at 6 and 12 months. Spiritual and religious beliefs were assessed using a standardized

questionnaire, and DSM-IV diagnosis of major depression was made using the Composite International Diagnostic

Interview (CIDI). Logistic regression was used to estimate incidence rates and odds ratios (ORs), after multiple

imputation of missing data.

Results. The analyses included 8318 attendees. Of participants reporting a spiritual understanding of life at

baseline, 10.5% had an episode of depression in the following year compared to 10.3% of religious participants

and 7.0% of the secular group (p<0.001). However, the findings varied significantly across countries, with

the difference being significant only in the UK, where spiritual participants were nearly three times more likely

to experience an episode of depression than the secular group [OR 2.73, 95% confidence interval (CI) 1.59–4.68].

The strength of belief also had an effect, with participants with strong belief having twice the risk of

participants with weak belief. There was no evidence of religion acting as a buffer to prevent depression after

a serious life event.

Conclusions. These results do not support the notion that religious and spiritual life views enhance psychological

well-being.

Received 13 July 2012 ; Revised 19 November 2012 ; Accepted 6 December 2012

Key words : General practice, longitudinal, major depression, religion, spirituality.

Background

Research findings, most originating from the USA,

have generally reported a positive, albeit weak, re-

lationship between higher levels of religious involve-

ment and better health once other influences, such as

age, sex and social support, have been taken into ac-

count (Koenig et al. 1998, 2001 ; McCullough & Larson,

1999 ; Johnstone et al. 2008). Nevertheless, many other

studies do not find such an association (Payne et al.

1991; Schaefer, 1997 ; Lewis et al. 2000; Gartner et al.

2012). There have been at least two meta-analyses of

relevant studies. The first examined the relationship

between religiosity and psychological adjustment

(Hackney & Sanders, 2003), while excluding studies

measuring a wider concept of spirituality or those

examining the relationship with mental disorders.

* Address for correspondence : Professor M. King, Mental Health

Sciences Unit, University College London, Charles Bell House, 67–73

Riding House Street, London W1W 7EJ, UK.

(Email : [email protected])

Psychological Medicine, Page 1 of 12. f Cambridge University Press 2013doi:10.1017/S0033291712003066

ORIGINAL ARTICLE

A small positive correlation between religiosity and

psychological status was found (r=0.10, p<0.0001)

when combining all effect sizes from 35 cross-sectional

studies. Seventy-eight negative relationships were

found in the data set of 264 effect sizes. Greater effects

were seen with institutional religiosity than personal

devotion, and with psychological distress rather

than of life satisfaction. The authors concluded that

greater ‘ internality ’ of religious belief was associated

with more positive psychological outcomes. A second

meta-analysis of 147 studies (of which 15 were long-

itudinal) examined associations between religiosity

and/or spirituality and depressive symptoms and/or

depressive disorder (Smith et al. 2003). Religious/

spiritual belief seemed to have a small negative

(x0.096) correlation with depressive symptoms but

the protective effect of belief was stronger on risk

of major depression after significant life events.

Unfortunately, the authors did not distinguish evi-

dence from longitudinal versus cross-sectional studies

in their analysis.

Numerous cross-sectional studies have been con-

ducted since 2003, including some outside the USA. In

one very large Canadian community health study,

greater participation in worship was associated with

lower odds of psychiatric disorders but people who

placed greater importance on spiritual values had

higher odds of most psychiatric disorders (Baetz et al.

2006). A further cross-sectional study of more than

6000 people in Korea also reported that strong spiri-

tual values were associated with increased rates of

current depressive disorder (Park et al. 2012).

Most of the studies in the meta-analyses described

above (Hackney & Sanders, 2003 ; Smith et al. 2003)

were cross-sectional in nature and thus we need more

prospective research in a variety of cultures and so-

cieties. Recent prospective studies have been small

scale but generally positive in their findings. Kasen

et al. (2012) andMiller et al. (2012) reported data on 114

adults who were the grown-up children of a cohort of

people at high risk of depression, and matched con-

trols, enrolled in a multi-generational 10-year longi-

tudinal study. Participants for whom religion or

spirituality was highly important seemed to be pro-

tected from major depression, especially relapse in

those with a history of depression (Miller et al. 2012).

Religion was also more protective in participants

exposed to negative life events (Kasen et al. 2012).

However, there were few participants, the sample

was very specific (catholic or protestant Caucasians,

who were offspring of depressed parents for the ex-

posed cohort) and findings were of borderline signifi-

cance.

In earlier cross-sectional work in a large sample of

people from a range of ethnic groups in England and

Wales, we reported that holding a spiritual life view

without religious affiliation was associated with a

higher prevalence of anxiety and depression (King

et al. 2006a). However, the direction of this association

was unclear. Lack of religion may lead to common

mental disorders in vulnerable people who seek

meaning in their lives. Conversely, people developing

a common mental disorder who are not affiliated

to any religious group may become involved in a

search for meaning for relief from symptoms. The

New Age movements and other non-traditional faiths

in Western Europe may reflect a search for meaning in

societies such as the UK, where religious practice has

declined steeply in recent decades. We previously

undertook a prospective study to develop a risk pre-

diction algorithm for the onset of major depression in

general practice attendees in seven countries : six

European and one Latin American (King et al. 2008).

These data provided an opportunity to examine the

impact of spiritual and religious beliefs on the devel-

opment of depression. Our aims were to : (1) examine

the impact of a religious or spiritual life view on

onset of major depression over 12 months ; (2) assess

whether this impact varied for first or recurrent

episodes of depression ; (3) examine how the impact

varied by religious denomination, change in life

view and change in strength of belief over the

12 months ; and (4) determine whether the form of life

view mediated the impact of significant life events on

onset of major depression. Our principal hypothesis

was that people expressing a spiritual life view in the

absence of religious affiliation or practice are more

likely to develop DSM-IV major depression than those

who have a religious life view or are secular in out-

look.

Method

Study setting and design

The study, described in detail elsewhere (King et al.

2006b, 2008), was approved by research ethics com-

mittees in each country. It was a prospective cohort

study conducted in (1) 25 general practices in the

Medical Research Council (MRC) General Practice

Research Framework (GPRF) in the UK; (2) nine large

primary care centres in Andalucıa, Spain ; (3) 74 gen-

eral practices nationwide in Slovenia ; (4) 23 general

practices nationwide in Estonia ; (5) seven large gen-

eral practice centres near Utrecht, The Netherlands ;

(6) two large primary care centres in the Lisbon area of

Portugal ; and (7) 78 general practices in Concepcion

and Talcahuano in the Eighth Region of Chile. General

practices covered urban and rural populations with

considerable socio-economic variation.

2 B. Leurent et al.

Study participants

Consecutive attendees aged 18–75 years were re-

cruited in Europe between April 2003 and September

2004 and in Chile between October 2003 and February

2005. Exclusion criteria were inability to understand

the country’s main language, psychosis, dementia and

incapacitating physical illness. Recruitment varied

slightly because of local service differences. In the UK

and The Netherlands, researchers spoke to patients

while they waited in the practices. In the remaining

European countries, general practitioners (GPs) in-

troduced the study before contact with researchers. In

Chile, attendees were stratified on age and gender on

the basis of local figures and participants were selected

randomly within each stratum. Participants gave in-

formed consent and undertook a research evaluation

within 2 weeks. Only attenders without a DSM-IV di-

agnosis of major depressive disorder at baseline were

part of this analysis.

Assessments at baseline

Each instrument or question not available in the rel-

evant languages was translated from English and

back-translated by professional translators (King et al.

2006b).

Demography

We collected standard information on participants’

sex, age, education, marital status, employment and

ethnicity.

Religious and spiritual beliefs

The self-report version of the Royal Free Interview

for Spiritual and Religious Beliefs (King et al. 2001)

examines religious affiliation and practice, and spiri-

tual beliefs whether or not in the context of religion. In

this study only the first three items of the question-

naire were used. Before the questions are posed the

respondent reads an introductory statement : ‘ In using

the word religion, we mean the actual practice of a

faith, e.g. going to a temple, mosque, church or syna-

gogue. Some people do not follow a religion but do

have spiritual beliefs or experiences. For example, they

believe that there is some power or force other than

themselves, which might influence their life. Some

people think of this as God or gods, others do not.

Some people make sense of their lives without any

religious or spiritual belief ’. On the basis of this state-

ment, respondents were asked to indicate whether

their understanding of life was primarily religious,

spiritual, or neither religious nor spiritual (this latter

category will be referred to as ‘secular ’). If religious or

spiritual they were then asked to indicate whether

they regarded themselves as having a specific religion.

People with a spiritual life view may identify them-

selves with a religion, even if they do not practice it.

Finally, religious and spiritual participants were asked

to indicate on scale from 1 to 6 how strongly they held

their life view.

Diagnosis of depression

A DSM-IV diagnosis of major depression in the pre-

ceding 6 months was made using the Depression

Section of the Composite International Diagnostic

Interview (CIDI ; Robins et al. 1988; WHO, 1997).

Screen for lifetime history of depression

Lifetime depression was considered possible if the re-

spondent answered affirmatively to both of the first

two questions of the CIDI Depression Section (WHO,

1997).

Life events

The List of Threatening Experiences questionnaire

(Brugha et al. 1985) enquired about major life events in

the preceding 6 months.

Social support

Adequacy of support from family and friends was

measured using brief standardized questions (Blaxter,

1990).

Follow-up assessments at 6 and 12 months

All participants were re-evaluated for DSM-IV major

depression after 6 and 12 months. At 6 months they

also completed the Royal Free Interview for Spiritual

and Religious Beliefs and the questions on life events.

Statistical analysis

To manage missing data we undertook multiple im-

putation by chained equation, using the ice procedure

in Stata (Royston, 2005). We generated two imputed

databases each containing 30 imputed versions using

all relevant variables predicting depression or miss-

ingness ; one database was used for the analysis of the

understanding of life and the other for the analysis of

religious denomination and strength of belief in re-

ligious or spiritual participants. Regression results

were combined using Rubin’s rule (mim command

in Stata). We explored the pattern of missing data

and performed sensitivity analyses on complete cases.

t tests and x2 tests were used to compare groups at

baseline. Incidence rates of major depression were

Spiritual and religious beliefs and psychological well-being 3

obtained on imputed data by univariable logistic re-

gression and presented graphically. Odds ratios (ORs)

unadjusted and adjusted for age, sex, education, em-

ployment, social support, past history of depression

and country were computed using logistic regression.

Interactions between the predictor and each covariate

were tested and the model was stratified if an inter-

action was found. In view of multiple testing, we

considered an interaction significant at the level of

p<0.01. All other p values reported are two-sided, and

considered significant at the level of p<0.05. Incidence

rates and ORs are reported along with their 95% con-

fidence intervals (CIs). Standard errors are based on

robust sandwich estimates to account for the cluster-

ing effect of each general practice (Huber, 1967).

For the analyses on imputed data, the exact number

of participants in each category of the exposure

variables cannot be reported as it varied slightly

with each imputation. In the presence of missing

data, CIs are a more reliable guide to the precision

around estimates than estimated frequencies. Statis-

tical analyses were performed using Stata Release 11

(Stata Corp, 2009).

Results

Response rates and prevalence of DSM-IV major

depression at recruitment

Response to recruitment was high in Portugal (76%),

Estonia (80%), Slovenia (80%) and Chile (97%) but

lower in the UK (44%) and The Netherlands (45%).

Ethical constraints did not allow collection of data on

non-responders at baseline. Across all countries the

response to follow-up at 6 months was at 89.5%. A

total of 10045 people took part : 219 were excluded on

grounds of age, 143 had a missing CIDI diagnosis

and five a missing practice identification at baseline.

Of the remaining 9678, 8318 without DSM-IV major

depression (86%) at baseline were analysed. The me-

dian age was 49 years, two-thirds were women,

and 75% of participants held a religious or spiritual

understanding of life. Women were more likely

than men to have a religious or spiritual understand-

ing of life, and a past history of depression was least

common in people with a spiritual understanding

(Table 1). The characteristics of participants by coun-

try are reported in Supplementary Table S1 (available

online). Eleven per cent of participants did not com-

plete the 6-month follow-up and 16% did not com-

plete the 12-month follow-up. Non-completers tended

to be younger and less educated and had experienced

more serious life events in the 6 months before base-

line.

Understanding of life and onset of DSM-IV major

depression over 12 months

Of participants reporting a religious understanding of

life, 10.3% experienced an episode of major depression

over the subsequent 12 months, compared to 10.5% of

participants with a spiritual life view and 7.0% of the

secular group (p<0.001). This finding was examined

more closely in a logistic regression with secular

participants as the reference group. The results are

reported unadjusted and adjusted for age, sex, edu-

cation, employment, social support, past history of

depression and country. Participants with a spiritual

understanding of life had a greater risk of major de-

pression at 6 or 12 months than participants with

neither a spiritual nor a religious life view (Table 2).

Participants holding a religious understanding of life

were also more at risk than secular participants, but

this finding lost statistical significance after adjust-

ment. When stratified by country, however, our find-

ing that a spiritual life view predisposed people to

major depression was significant only in the UK,

where spiritual participants were nearly three times

more likely to experience an episode of depression

than the secular group (OR 2.73, 95% CI 1.59–4.68)

(Table 2). In a post-hoc analysis, using international

surveys (European Values Study, 2012 ; World Values

Survey, 2012) we ranked the countries on the pro-

portion of people considering themselves religious

(from least to most : the UK, Estonia, The Netherlands,

Spain, Chile, Slovenia, Portugal). The variation in re-

sults between countries was not explained by the im-

portance of religion in each country (results available

from the authors on request).

Understanding of life and onset of first episode or

recurrence of major depression over 12 months

To investigate the effect of religion on first episode

versus recurrence of depression, we stratified the

analysis by lifetime history of depression. The effect of

a religious versus a secular understanding of life

was similar in predicting new onset (OR 1.60, 95% CI

1.05–2.42) and recurrence (OR 1.44, 95% CI 1.07–1.93).

A spiritual view of life did not predict onset of de-

pression in participants with no history of depression

(OR 1.04, 95% CI 0.63–1.73) but was related to new

occurrence for participants with a past history of de-

pression (OR 1.61, 95% CI 1.19–2.17). However, this

interaction was not significant (p=0.15).

Religious denomination and onset of major

depression

In the 6094 participants with a spiritual or religious

understanding of life, the incidence of major

4 B. Leurent et al.

Table 1. Demographic characteristics and understanding of life

Understanding of life

Totala

(n=8318) p valuebReligious

(n=4348, 52%)

Spiritual

(n=1746, 21%)

Neither

(n=2087, 25%)

Country, n (%)

UK 462 (10.6) 300 (17.2) 354 (17.0) 1131 (13.6) <0.001

Spain 714 (16.4) 136 (7.8) 153 (7.3) 1006 (12.1)

Slovenia 322 (7.4) 328 (18.8) 387 (18.5) 1048 (12.6)

Estonia 189 (4.3) 227 (13.0) 506 (24.2) 923 (11.1)

The Netherlands 358 (8.2) 143 (8.2) 469 (22.5) 1077 (12.9)

Portugal 833 (19.2) 75 (4.3) 97 (4.6) 1005 (12.1)

Chile 1470 (33.8) 537 (30.8) 121 (5.8) 2128 (25.6)

Gender, n (%)

Female 3045 (70.0) 1235 (70.7) 1235 (59.2) 5599 (67.3) <0.001

Male 1303 (30.0) 511 (29.3) 852 (40.8) 2719 (32.7)

Age (years), n (%)

18–29 498 (11.5) 332 (19.0) 406 (19.5) 1244 (15.0) <0.001

30–39 585 (13.5) 356 (20.4) 429 (20.6) 1380 (16.6)

40–49 764 (17.6) 356 (20.4) 398 (19.1) 1540 (18.5)

50–59 946 (21.8) 333 (19.1) 435 (20.8) 1745 (21.0)

60–69 1022 (23.5) 266 (15.2) 293 (14.0) 1619 (19.5)

70–76 533 (12.3) 103 (5.9) 126 (6.0) 790 (9.5)

Married/living with partner, n (%)

No 1333 (30.7) 615 (35.3) 634 (30.5) 2614 (31.5) 0.001

Yes 3005 (69.3) 1129 (64.7) 1445 (69.5) 5681 (68.5)

Missing 10 2 8 23

Education, n (%)

Above school 656 (15.1) 533 (30.5) 749 (36.0) 1965 (23.7) <0.001

Secondary 1324 (30.5) 627 (35.9) 820 (39.4) 2844 (34.3)

Primary/no education 2011 (46.3) 388 (22.2) 343 (16.5) 2769 (33.4)

Trade/other 349 (8.0) 197 (11.3) 167 (8.0) 718 (8.7)

Missing 8 1 8 22

Employment, n (%)

Employed/student 1663 (38.4) 975 (56.1) 1313 (63.5) 4003 (48.4) <0.001

Retired 1017 (23.5) 276 (15.9) 336 (16.2) 1662 (20.1)

Unemployed/other 1654 (38.2) 487 (28.0) 420 (20.3) 2610 (31.5)

Missing 14 8 18 43

European ethnicity, n (%)

No 1535 (35.4) 563 (32.3) 162 (7.8) 2265 (27.3) <0.001

Yes 2806 (64.6) 1180 (67.7) 1921 (92.2) 6039 (72.7)

Missing 7 3 4 14

Past history of depression, n (%)

No 2021 (46.5) 728 (41.8) 1039 (49.9) 3863 (46.5) <0.001

Yes 2322 (53.5) 1015 (58.2) 1046 (50.2) 4445 (53.5)

Missing 5 3 2 10

Family and friends support

Mean (S.D.) 12.7 (2.4) 12.3 (2.7) 12 (2.7) 12.4 (2.5) <0.001

Missing 34 10 19 77

Religious denomination, n (%)

Catholic 2680 (62.2) 563 (33.0) 3243 (53.9) <0.001

Protestant 1248 (29.0) 317 (18.6) 1565 (26.0)

Other religion 243 (5.6) 118 (6.9) N.A. 361 (6.0)

No specific religion 137 (3.2) 708 (41.5) 845 (14.1)

Missing 40 40 80

Strength of belief

Mean (S.D.) 4.3 (1.5) 3.7 (1.6) N.A. 4.1(1.6) <0.001

Missing 90 30 120

S.D., Standard deviation ; N.A., not applicable.a Including 137 missing understanding of life.b p value for difference between understanding of life, from t tests or x2 tests, as appropriate.


depression over the subsequent 12 months was similar

across the different religious denominations (Catholic

9.8%, Protestant 10.9%, other religion 11.5%, no spe-

cific religion 10.8%, p=0.65). In a post-hoc analysis

in the 1746 participants who reported a spiritual

understanding of life, a similar incidence of major de-

pression over the subsequent 12 months was found

between those who were able to nominate a religious

affiliation and those who were not (10.7% v. 11.1%,

p=0.41).

Strength of belief at baseline and onset of major

depression

Higher strength of belief in the 6094 participants

who reported a spiritual or religious life view was as-

sociated with a greater likelihood of DSM-IV major

depression over the subsequent 12 months after ad-

justment for age, sex, education, employment, social

support, past history of depression, and country

(unadjusted OR per unit increase on the scale of

strength of belief 1.14, 95% CI 1.07–1.21 ; adjusted OR

1.08, 95% CI 1.00–1.15) (Fig. 1). There was no interac-

tion between country and strength of belief (p=0.16).

Those with a strongly held belief were twice as likely

to experience major depression in the subsequent

12 months as those with a weakly held belief.

Change in strength of belief and subsequent onset

of major depression

The incidence rate of depression between 6 and

12 months was 5.5%. We examined whether change

over the first 6-month follow-up in the strength of

spiritual or religious belief (strength score at 6 months

minus score at baseline) was associated with onset

of major depression between 6 and 12 months, after

adjustment for strength of belief at baseline and other

Table 2. Odds ratios (ORs) for onset of major depression over 12 months by understanding

of life, compared to neither religious nor spiritual

Unadjusted OR (95% CI) Adjusted ORa (95% CI)

Overall

Religious 1.52 (1.19–1.93)** 1.14 (0.87–1.50)

Spiritual 1.56 (1.21–2.02)** 1.32 (1.02–1.70)*

UK

Religious 1.35 (0.68–2.68) 1.86 (0.88–3.92)

Spiritual 2.73 (1.59–4.68)*** 2.68 (1.52–4.71)**

Spain

Religious 1.41 (0.78–2.54) 1.34 (0.73–2.46)

Spiritual 1.53 (0.73–3.20) 1.50 (0.73–3.07)

Slovenia

Religious 0.62 (0.26–1.46) 0.69 (0.27–1.73)

Spiritual 1.06 (0.52–2.16) 1.10 (0.52–2.34)

Estonia

Religious 1.16 (0.63–2.13) 1.06 (0.51–2.22)

Spiritual 1.08 (0.59–1.98) 1.14 (0.62–2.12)

The Netherlands

Religious 0.63 (0.31–1.28) 0.69 (0.35–1.37)

Spiritual 1.15 (0.62–2.13) 1.07 (0.57–2.02)

Portugal

Religious 2.40 (0.55–10.43) 1.78 (0.39–8.08)

Spiritual 1.96 (0.38–10.05) 1.52 (0.27–8.48)

Chile

Religious 1.12 (0.58–2.17) 1.08 (0.54–2.14)

Spiritual 1.03 (0.53–2.00) 1.04 (0.56–1.96)

CI, Confidence interval.

Values based on imputed data.a Adjusted for age, sex, education, employment, social support, past history of

depression, and country.

* p <0.05, ** p<0.01, *** p<0.001.

6 B. Leurent et al.

covariates. Those whose belief decreased seemed

to be at greater risk of depression whereas those

whose belief increased had slightly less risk (Fig. 2).

However, CIs were wide, especially for the larger

degrees of change.

Change in the nature of life view and subsequent

onset of major depression

Although an understanding of life (religious, spiritual

or secular) is relatively stable in most people

(King et al. 1999), 27.1% of participants in this

study changed their life view between baseline and

the 6-month interview. Thus, we examined whether

change in the nature of the life view between

baseline and 6 months had any association with onset

major depression between 6 and 12 months. Point

estimates were in the direction of higher risk of de-

pression for change in a religious direction and

lower risk for change in a secular direction, but the

CIs were wide and no significant difference was found

(Table 3).

7.4

6.2

10.19.2

11.712.5

0

2

4

6

8

10

12

14

16In

cide

nce

of d

epre

ssio

n ov

er 1

2 m

onth

s (%

)

Weakly 2 3 4 5 Strongly

How strongly do you hold your religious or spiritual view of life?

Incidence 95% CI

n*= 520 443 1075 1255 947 1734

Fig. 1. Incidence of major depression versus strength of spiritual or religious belief. Based on imputed data. * Frequencies based

on observed data, not numbers included in analysis. CI, Confidence interval.

2.21

0.94

1.471.25

1.00 0.93 0.920.77 0.79

0.25

0.5

1

2

4

OR

and

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CI fo

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pres

sion

at 1

2 m

onth

s

–5/–4 –3 –2 –1 0 (Ref.) +1 +2 +3 +4/+5

Difference in strength of belief between baseline and 6 months

n*= 51 140 328 844 2193 806 405 171 113

Fig. 2. Adjusted odds ratio (OR) for onset of major depression between 6 and 12 months after a change in strength of belief

between baseline and 6 months. OR adjusted for strength of belief at baseline, age, sex, education, employment, social support,

past history of depression, and country. Values based on imputed data. * Frequencies based on observed data, not numbers

included in analysis. CI, Confidence interval.


Impact of belief on the relationship between serious

life events and onset of major depression

Finally, we examined whether a religious or spiritual

understanding of life modified the risk of major de-

pression following a serious life event. As expected,

the incidence of major depression between baseline

and 12 months was higher for patients who experi-

enced serious life events (Fig. 3). Understanding of

life was not a significant modifying factor of the

effect of life events on depression (unadjusted p=0.57,

adjusted p=0.48).

Sensitivity of the analysis to imputation of missing

data

When imputed data were compared to the observed

data we found a similar distribution between under-

standing of life categories, but the incidence of major

depression at 6 or 12 months was higher in the im-

puted data (8.7% v. 9.5%), reflecting the higher likeli-

hood of dropping out for patients at risk of depression

at baseline. No major discrepancy was found between

imputed data and complete-case analyses. For ex-

ample, the OR of developing major depression by 6 or

Table 3. Odds ratios (ORs) for onset of major depression between 6 and 12 months, after a

change in understanding of life between baseline and 6 months

Understanding of life

FrequencyaUnadjusted OR

(95% CI)

Adjusted ORb

(95% CI)At baseline At 6 months

Religious Religious 3004 1.00 (Reference) 1.00 (Reference)

Spiritual 658 0.98 (0.62–1.53) 0.97 (0.61–1.55)

Neither 175 0.64 (0.26–1.56) 0.87 (0.35–2.16)

Spiritual Religious 436 1.40 (0.84–2.32) 1.51 (0.87–2.61)

Spiritual 887 1.00 (Reference) 1.00 (Reference)

Neither 253 1.05 (0.54–2.03) 1.09 (0.56–2.14)

Neither Religious 196 1.53 (0.70–3.36) 1.31 (0.53–3.19)

Spiritual 265 1.46 (0.72–2.96) 1.35 (0.66–2.78)

Neither 1413 1.00 (Ref) 1.00 (Ref)

CI, Confidence interval.

Values based on imputed data.a Frequencies based on observed data, not numbers included in analysis.b Adjusted for age, sex, education, employment, social support, past history of

depression, and country.

5

10

15

20

Inci

denc

e of

dep

ress

ion

over

12

mon

ths

(%)

0 1 >1

Life events between baseline and 6 months

Religious Spiritual

Neither

n* = 3474 2235 1749

Fig. 3. Modifying effect of life understanding on major depression after serious life events. Values based on imputed data.

* Frequencies based on observed data, not numbers included in analysis.

8 B. Leurent et al.

12 months was 1.64 (95% CI 1.26–2.15) for people with

a religious understanding and 1.74 (95% CI 1.34–2.26)

for people with a spiritual understanding of life,

compared to 1.52 and 1.56 respectively on imputed

data (Table 2).

Discussion

Main findings

We found that people who held a religious or spiritual

understanding of life had a higher incidence of de-

pression than those with a secular life view. However,

this finding varied by country ; in particular, people in

the UK who had a spiritual understanding of life were

the most vulnerable to the onset of major depression.

Regardless of country, the stronger the spiritual or re-

ligious belief at baseline, the higher the risk of onset of

depression. Although our main finding of an associ-

ation between religious life understanding and onset

of depression varied by country, we found no

evidence that spirituality may protect people, and

only weak evidence that a religious life view was

possibly protective in two countries (Slovenia and The

Netherlands). Finally, there was no moderating effect

of religious and spiritual understanding of life on the

impact of life events on onset of major depression.

Strengths and limitations

The main strengths of our study are its prospective

cohort design, the involvement of several countries,

the large sample size and the use of standardized as-

sessments of religious/spiritual belief, other risk vari-

ables and major depression. However, combining

people from different cultures creates heterogeneity

and runs the risk of missing real differences within

countries. Despite a large sample size, we lacked

power for some of the analyses, particularly the as-

sessment of statistical interactions. However, to our

knowledge there are very few data sets available con-

taining variables on spiritual and religious beliefs that

are large enough to undertake interaction analyses.

Thus we consider it is important to show the results to

avoid a reporting bias that favours statistically sig-

nificant results (Dwan et al. 2008). Another strength

of this study is the use of multiple imputation to take

account of participants who dropped out. Assuming

predictors of missingness have been examined at

baseline, this should give unbiased findings, as op-

posed to restricting the analysis to participants who

completed both follow-ups only, which may represent

a sample at lesser risk of depression than the original

one. However, participations rates were low in some

countries, and we cannot assume that findings in

general practice attendees can be generalized to the

whole population. Our study sample is likely to have

a more complex medical history ; for example, 53%

reported a lifetime history of depression although

other evidence would suggest this figure is usually in

the range 30–40% (Kruijshaar et al. 2005). However,

our population may be more representative of life

views than those who might participate in a study of

religion. The original aim of this study was to develop

a risk prediction algorithm for depression (PredictD;

King et al. 2008), and thus our analysis is limited to the

religiosity data available. Religion did not appear as a

variable in the final prediction algorithm PredictD,

which included only the most parsimonious combi-

nation of risk factors of depression, but this does

not imply the absence of a relationship between re-

ligiosity and depression. Although our questions were

limited to people’s overall view of religion and spiri-

tuality, rather than the detail of any specific belief,

they applied to all people and not just those with a

Christian background, which is often the case in North

American research. Another limitation is the difficulty

distinguishing religion and spirituality and the trouble

respondents may have in placing themselves in one of

the two categories. This may account for a proportion

of the 27% of participants who changed their life view

between baseline and 6 months. However, the ques-

tions have high repeatability (King et al. 2001) and

clear definitions were given in a short note preceding

the question, ensuring a universal understanding of

the term across the different countries and cultures.

Furthermore, they avoided the common pitfall in re-

ligion studies of conflating questions on religion and

spiritual belief with those on psychological well-being

(Koenig, 2008). Finally, the relationship between

religion, spirituality and mental symptoms should

not necessarily be interpreted as causal in nature.

Although the longitudinal design removes the possi-

bility of reverse causation, unmeasured confounders

in the complex relationship between religiosity and

depression are likely to remain, even after adjustment

for main risk factors of depression.

Relationship to other findings

Our work adds to a growing body of evidence that

spiritual beliefs in the absence of a clear religious

affiliation or practice increase vulnerability to de-

pression (Baetz et al. 2006; Braam et al. 2007; Park et al.

2012) ; it also contrasts with many studies where re-

ligious and spiritual beliefs and practice have been

found to be associated with better mental health.

An explanation for this disparity could be the complex

relationship between the concepts of religiosity

and well-being, and that findings in any specific


population may not generalize to another. Research in

this field has been dominated by North American

studies, whereas in the more secular cultures of

Europe, religious people may feel less supported in

their faith. Alternatively, it may relate to the ways in

which such beliefs are measured in research. In their

meta-analysis, Hackney & Sanders (2003) criticized

many studies for measuring religion and spirituality

with insufficient depth and suggested that a multi-

faceted concept such as religious belief and practice

may have complex associations with mental health.

In their meta-analysis of 147 studies on religious

belief and depression, Smith et al. (2003) found that

extrinsic religious orientation and so-called negative

religious coping were associated with higher levels of

depressive symptoms. However, they also reported

that the negative correlation between religiousness

and depressive symptoms was at its greatest in the

presence of life stress and suggested that religion may

have a buffering effect on the impact of life events. We

did not find evidence of such buffering. They specu-

lated that social desirability of response (exaggerating

religiousness and downrating depressive symptoms),

or the possibility that religious people might be better

at expressing emotion and thus coping with stress,

might explain some of the correlation in their studies

that were mainly cross-sectional in nature.

Recent longitudinal research suggests that attaching

a high importance to religion was associated with

lower risk of recurrence of depression in the subsequent

10 years (Miller et al. 2012) and had a protective effect

after negative life events (Kasen et al. 2012). We have

not been able to replicate either of these findings in

this cohort. Our study was, however, consistent with

their finding of no clear relationship between religious

denomination and depression.

The disparity in the findings suggests that, if there

is an association between religion/spirituality and

psychological well-being, it is likely to be weak. If re-

ligious belief has a powerful positive effect on mental

health, we would expect to detect it in most studies.

Implications

Why a religious or spiritual life view might place

people at risk of depression remains unclear. One ex-

planation is that people predisposed to depression at

baseline may seek meaning in spiritual or religious

sources. The possibility that people predisposed to

depression increase their search for existential mean-

ing in religion and spirituality is supported by our

finding that change in belief over time towards greater

religiosity did seem to be related to greater risk of de-

pression.

In conclusion, we found that holding a religious or

spiritual life view, in contrast to a secular outlook,

predisposed people to the onset of major depression

and that such beliefs and practice did not act as a

buffer to adverse life events. Our findings highlight

the complexity of the relationship between religion,

spirituality and mental health and offer a challenge to

an increasing tendency to regard religion and spiritu-

ality as being good for mental well-being (Schumann

& Meador, 2003).

Supplementary material

For supplementary material accompanying this paper

visit http://dx.doi.org/10.1017/S0033291713003066.

Acknowledgements

The study in Europe was funded by a European

Commission Vth Framework grant (PREDICT-QL4-

CT2002-00683). Funding in Chile was provided by

project FONDEF DO2I-1140. We are grateful for part

support in Europe from: the Estonian Scientific

Foundation (grant 5696) ; the Slovenian Ministry for

Research (grant 4369-1027) ; the Spanish Ministry of

Health (FIS references : PI041980, PI041771, PI042450)

and the Spanish Network of Primary Care Research,

redIAPP (ISCIII-RETIC RD06/0018) and SAMSERAP

group; and the UK NHS Research and Development

office for service support costs in the UK. The funders

had no direct role in the design or conduct of the

study, interpretation of the data or review of the

manuscript.

M. King had full access to the data and takes re-

sponsibility for their integrity and the accuracy of

the data analysis. We thank all patients and general

practice staff who took part ; the European Office at

University College London for their administrative

assistance at the coordinating centre ; K. McCarthy,

the project’s scientific officer in the European

Commission, Brussels, for his helpful support and

guidance ; the UKMRCGPRF; L. Letley from the MRC

GPRF; the GPs of the Utrecht General Practitioners’

Network ; and the Camden and Islington Mental

Health and Social Care Trust. We also acknowledge

the Maristan network, through which the collabor-

ation in Spain, Portugal, the UK and Chile first devel-

oped.

Declaration of Interest

None.

10 B. Leurent et al.

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Spiritual and Religious Beliefs as Risk Factors for the Onset of Major Depression