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Published online before print July 16, 2007, 10.1097/PSY.0b013e3180cab76c
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Psychosomatic Medicine 69:501-508 (2007)
© 2007 American Psychosomatic Society

ORIGINAL ARTICLES

Spirituality, Religion, and Clinical Outcomes in Patients Recovering From an Acute Myocardial Infarction

James A. Blumenthal, PhD, Michael A. Babyak, PhD, Gail Ironson, MD, Carl Thoresen, PhD, Lynda Powell, PhD, Susan Czajkowski, PhD, Matthew Burg, PhD, Francis J. Keefe, PhD, Patrick Steffen, PhD, Diane Catellier, PhD for the ENRICHD Investigators

From the Department of Psychiatry and Behavioral Sciences (J.A.B., M.A.B., F.J.K., P.S.), Duke University Medical Center, Durham, North Carolina; Department of Psychiatry (G.I.), University of Miami, Miami, Florida; School of Education (C.T.), Stanford University, Stanford, California; Department of Community Medicine (L.P.), Rush-Presbyterian Hospital, Chicago, Illinois; Department of Psychology (M.B.), Yale-New Haven Veterans Administration Hospital, New Haven, Connecticut; National Heart Lung and Blood Institute (S.C.), Bethesda, Maryland; and Department of Biostatistics (D.C.), University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Address correspondence and reprint requests to James Blumenthal, Box 3119, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC 27710. E-mail: Blume003{at}mc.duke.edu


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 NOTES
 REFERENCES
 
Objective: To assess the prospective relationship between spiritual experiences and health in a sample of patients surviving an acute myocardial infarction (AMI) with depression or low social support.

Methods: A subset of 503 patients participating in the enhancing recovery in coronary heart disease (ENRICHD) trial completed a Daily Spiritual Experiences (DSE) questionnaire within 28 days from the time of their AMI. The questionnaire assessed three spirituality variables—worship service/church attendance, prayer/meditation, and total DSE score. Patients also completed the Beck Depression Inventory to assess depressive symptoms and the ENRICHD Social Support Inventory to determine perceived social support. The sample was subsequently followed prospectively every 6 months for an average of 18 months to assess all-cause mortality and recurrent AMI.

Results: Of the 503 participants who completed the DSE questionnaire at the time of index AMI, 61 (12%) participants either died or sustained a recurrent MI during the follow-up period. After adjustment for gender, education level, ethnicity, and a composite medical prognosis risk score derived specifically for the ENRICHD trial, we observed no relationship between death or nonfatal AMI and total spirituality as measured by the DSE (p = .446), worship service attendance (p = .120), or frequency of prayer/meditation (p = .679).

Conclusion: We found little evidence that self-reported spirituality, frequency of church attendance, or frequency of prayer is associated with cardiac morbidity or all-cause mortality post AMI in patients with depression and/or low perceived support.

Key Words: coronary heart disease • religion • spirituality • depression • social support

Abbreviations: AMI = acute myocardial infarction; BDI = Beck Depression Inventory; CHD = coronary heart disease; DSE = Daily Spiritual Experiences scale; ECG = electrocardiogram; ENRICHD = Enhancing Recovery In Coronary Heart Disease; ESSI = ENRICHD Social Support Inventory; HR = hazard ratio.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 NOTES
 REFERENCES
 
There is growing interest in the health benefits of spiritual and religious beliefs and practices. Many persons believe that prayer can have healing powers and that religious involvement can promote both mental and physical well-being. Koenig (1), for example, noted that >850 articles have been published on religion and mental health and 350 articles have been published on religion and physical health, with the majority of studies reportedly showing that religious involvement is associated with better health outcomes. Similarly, Luskin (2) noted that "almost all studies (on religion and health) show a positive health value," and Ellison and Levin (3) indicated that religious practice is associated with desirable effects "on a wide range of health outcomes." Despite these positive claims, the health benefits of religion and religious practices remain controversial primarily because of uncritical advocacy combined with the lack of scientific rigor in many of these studies (4,5). It is increasingly recognized that many of these studies suffer from serious methodological shortcomings, including failure to adjust for multiple comparisons, imprecise assessments of religious practices, lack of control of potential confounders such as age, education, and health status, and misrepresentation of results because of biased and selective reporting. Whereas Sloan and colleagues (4) concluded that "even in the best studies, the evidence of an association between religion, spirituality, and health is weak and inconsistent," Powell, Shahabi, and Thoresen (6) disagreed, noting that the dismissal of any relationship was "premature and that the intriguing evidence to date warrants continued and careful investigation."

Importantly, most studies reporting significantly lower all-cause mortality for those regularly attending religious services (7,8) have been performed on healthy people rather than on those with a specific medical diagnosis such as coronary heart disease (CHD). To date, few studies have demonstrated that spiritual or religious factors influence the course of medical illness, despite the common belief that religious and spiritual beliefs and practices may often help patients cope with medical illness (9,10). In a comprehensive review of the field, Powell and colleagues (6) noted that there were only four, well-designed prospective studies that examined the relationship of religion and cardiovascular health. Hummer et al. (7) and Oman et al. (8) studied 21,204 and 6545 healthy adults, respectively, and found church attendance to be inversely related to cardiovascular mortality, which was mediated, in whole or in part, by healthy lifestyle behavioral practices. Goldbourt et al. (11) observed an inverse relationship between religious orthodoxy and CHD mortality in 10,059 Israeli civil servants, which they claimed was statistically significant after adjusting for healthy lifestyle, although the independent contributions of synagogue attendance and other religious practices could not be determined. Finally, Colantonio et al. (12) reported that several measures of religiosity and the 7-year incidence of cerebrovascular disease (i.e., stroke) were not significantly related to events when potential confounders and traditional risk factors were included in multivariate models.

Taken together, these findings suggest that, at least in healthy individuals, some aspects of spirituality or religion, especially church attendance, may be associated with improved cardiovascular health. Such effects may be primarily indirect, due to spiritual or religious beliefs or practices influencing physical and social emotional factors such as less smoking, reduced alcohol abuse, or improved social support, which, in turn, alter disease risk (13). Although there have been several interventional studies on cardiac patients involving intercessory prayer, which essentially have yielded negative or inconclusive results (14–17), there are limited prospective, observational studies of religion and spirituality in patients with established coronary disease. Thus, the primary purpose of this study was to examine three key components of religion—spiritual experiences, prayer, and church attendance—on objective health outcomes in a sample of patients with CHD.1


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 NOTES
 REFERENCES
 
Research Participants
Patients in the present study were a subset of participants in the Enhancing Recovery In Coronary Heart Disease (ENRICHD) randomized clinical trial in which 2481 patients with acute myocardial infarction (AMI) at increased risk by virtue of their being depressed or having low social support received either a special psychosocial intervention or usual care. Patients were enrolled from clinical centers across the United States (Durham, North Carolina; Chicago, Illinois; Palo Alto, California; Birmingham, Alabama; Miami, Florida; Seattle, Washington; St. Louis, Missouri; New Haven, Connecticut; and Boston, Massachusetts) from October 1996 to October 1999. Patient recruitment details and trial results are described elsewhere (19). Patients were eligible if they had had an AMI within the prior 28 days and met the criteria for either major or minor depression or dysthmia, or low social support. Approval of the protocol was obtained from all local Institutional Review Boards (IRBs) before initiating recruitment, and written informed consent was obtained from all participants.

After the start of the trial, we initiated an ancillary study in which we collected data from a subset of 503 patients who met the eligibility criteria and completed a psychometric assessment of religious practices and spirituality at the time of their baseline evaluation. These individuals were sequentially approached after obtaining IRB approval for the additional psychometric testing at all participating clinical centers; patients were not preselected on the basis of any additional criteria. The mean (median) time from the index AMI to the completion of the spirituality questionnaire was 8 days (5).

Measures of Spirituality and Religion
Participants completed a survey of religious attitudes, practices, and beliefs developed for the ENRICHD study and adapted from the Daily Spiritual Experience Scale (DSE) (20) The DSE is a 16-item, Likert scale designed to measure those aspects of life that make up day-to-day spiritual experience for many people. Representative items include "I find strength in my religion or spirituality," "I feel thankful for my blessings," and "I ask for God's help in the midst of daily activities." Internal consistency is high (>0.90). For the purposes of this study, we selected three measures a priori: DSE total score, church/worship attendance, and participation in prayer/meditation.

Church/Worship Service Attendance was measured by the single item "I go to religious services." Response options ranged from "never or almost never" to "at least once a week."

Prayer and Meditation was measured by the item "I pray or meditate privately." Response options ranged from "never or almost never" to "more than once daily."

Spirituality was measured by the total score derived from the 16 items.

Additional Psychometric Measures
Depression was assessed by the Beck Depression Inventory (BDI) (21). The BDI is a 21-item paper and pencil self-report questionnaire designed to measure the severity of depression in patients with a psychiatric diagnosis of depression.

Social support was assessed by the ENRICHD Social Support Inventory (ESSI) (22). The ESSI is a 7-item measure developed as a screening tool for the ENRICHD study and includes items that have been associated with medical outcomes in prior studies. The ESSI uses a 5-item Likert-type format ranging from "none of the time" to "all of the time." Items are varied and focus on perceived emotional support, instrumental support, appraisal support, and marital status. Representative items include the following: a) "Is there someone available to you whom you can count on to listen to you when you need to talk?" b) "Can you count on anyone to provide you with emotional support (talking over problems or helping you make a difficult decision)?" and c) "Is there someone available to give you good advice about a problem?"

Clinical Outcomes
Follow-up assessments were conducted 6 months after study enrollment and annually thereafter. Assessments included a review of the patient's medical history with a particular focus on any hospitalizations from the time of prior assessment, a physical examination, and a resting electrocardiogram (ECG) to detect silent AMI. The primary end point for the ENRICHD clinical trial and for the present study was recurrent AMI or death from any cause. Medical end points were identified by follow-up visits and phone calls, routine hospital surveillance, or contact with the patients' physicians. The records of every identified hospitalization were obtained for review. Classification of primary end points using standardized criteria from medical records was performed by members of an Endpoint Review Committee, who were masked as to treatment group assignment and DSE scores.

Statistical Analysis
We evaluated the relationship between the three spiritual experiences variables and time to end point (death or recurrent AMI) using Cox proportional hazards models. Separate models were estimated for each of the three hypothesized spiritual experiences predictors. The individual Church Attendance and Prayer items were modeled as ordinal variables; the total DSE score was modeled as a continuous variable.

Before modeling, we observed that there were few events in the 2nd, 3rd, and 4th response categories for the Prayer (several times a year, once or twice a month, once or twice a week) and Attendance items (less than once a year, once or a few times per year, several times a year). Therefore, to improve the power and the stability of our estimates in the time-to-event models, these sparse cells were collapsed (23), resulting in four ordinal categories. We tested the effect of this ordinal variable with respect to event risk by first evaluating the omnibus significance test of no overall difference among the categories. If the overall effect was statistically significant, we proceeded to interpret the individual contrasts against the reference category.

In the time-to-event models, we first estimated all relationships unadjusted for other variables, and then adjusted for four covariables that we selected a priori: gender, education level, ethnicity, and a composite medical risk score developed by the ENRICHD investigators (24). Time to event was calculated as the time elapsed between the index MI and the first end point or for patients not experiencing an event of interest, the date of last follow-up. We evaluated model assumptions using the approach described in Harrell's work (23) and found these to be reasonably met. All analyses were conducted using SAS 9.1 (Cary, NC) and the Hmisc and Design libraries in the R statistical package (available at http://cran.r-project.org). Because ten (<2%) patients, including three patients who experienced a clinical event, had missing data on the educational level covariable, the final time-to-event models were estimated using SAS PROC MI and 50 imputations (19). We compared BDI and ESSI scores for the Attendance and Prayer items using the general linear model, with significance tests generated by the Tukey HSD procedure (25). Pearson correlations were used to evaluate the relationship between the total DSE score and the BDI and ESSI scores.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 NOTES
 REFERENCES
 
Five hundred three participants completed the DSE questionnaire at the time of the index AMI. Table 1 displays the baseline demographic and medical characteristics of the participants. The sample was predominantly non-Hispanic/white with a mean age of about 60 years. One third of patients endorsed being affiliated with the Roman Catholic faith; about one quarter indicated that they were Baptists; and a quarter indicated that they were Protestants.


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  		TABLE 1. Baseline Characteristics (n = 503)

 

In addition to the baseline (at the time of study enrollment) assessment, a subset of patients completed the DSE at 6 and 18 months after their MI (and study enrollment). The within-person correlations were high (range 0.75–0.83). Although we did not have access to spirituality data before the index MI, the Pearson correlations between baseline DSE score and subsequent 6-month assessment for patients who had completed the DSE at both time points were as follows: Attendance: r = .79 (n = 361); Prayer item: r = .72 (n = 360; total DSE score: 0.76 (n = 351).

Comparison of Participating Subsample With Entire Sample of Patients Randomized to ENRICHD Clinical Trial
We evaluated the differences on demographic and medical background variables between patients in the present study (n = 503) and those ENRICHD participants who were enrolled in the trial before the beginning of the substudy and did not complete the DSE questionnaire (n = 1978). Patients in the present sample tended to be older on average than the nonparticipating patients (61.1 years versus 59.6 years; p = .013), but did not differ with respect to the proportion of women (44.9% versus 43.4%; p = .544) or minorities (31.9% versus 34.1%; p = .355), or to the proportion not completing high school (25.2% versus 26.4%; p = .228). Patients in the present sample had lower mean BDI scores (16.2 versus 14.2; p <. 001) and higher mean ESSI scores (23.8 versus 22.8; p = .004). The present sample had a higher proportion in Killip classes I (80.7% versus 75.6%) and III (6.6% versus 5.6%) but a lower proportion in classes II (11.0% versus 16.7%) and IV (1.8% versus 2.1%; p = .023). In addition, the participants had a lower proportion of patients with a history of MI before the index MI (22.8% versus 28.4%; p = .013). The samples did not differ statistically on mean serum creatinine levels (1.2 versus 1.2 mg/dl; p = .54), left ventricular ejection function (45.2% versus 45.5%; p = .676), or in the proportion of patients with a history of cardiac heart failure (31.7% versus 35.7%; p = .092), stroke or transient ischemic attack (9.6% versus 9.6%; p = .991), pulmonary disease (20.4% versus 18.1%; p = .230), or diabetes (33.25 versus 33.3%; p = .937).

Spiritual Experiences and Death or Nonfatal MI
The median follow-up time was 561 days, ranging from 2 to 1091days (interquartile range = 534–690 days). Of the 503 participants who completed the DSE questionnaire at the time of index AMI, 61 (12%) participants either died (n = 29) or sustained a second AMI (n = 32) during the follow-up period.


Attendance of Worship Services
Table 2 presents the raw event rates across the six response choices for the Attendance item. The lowest event rate was among the "at least weekly" category (9%); however, the highest event rate was in the category with the next highest attendance frequency, "once or twice a month" (21%). We collapsed across the 2nd, 3rd, and 4th response categories for the time-to-event analysis,2 yielding the following ordinal categories: a)at least once a week; b) once or twice a month; c) several times a year or less (collapsed category); and d) never or almost never. In the unadjusted model, the omnibus test for an overall attendance effect was statistically significant (p = .015). Using the "Never" category as the reference group, the hazard ratios (HRs) for the remaining categories were as follows: a) at least weekly, HR = 0.6, p = .129; b) once or twice a month, HR = 1.5, p = .242; c) several times a year or less, HR = 0.5, p = .083. After adjustment for background covariables, however, the omnibus test for attendance was no longer statistically significant (p = .120). Figure 1 (left panel) displays the HRs for each predictor in the adjusted model; the pattern of HRs across the categories was similar to that observed in the unadjusted results.


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  		TABLE 2. Frequency of Worship Attendance and Rates of Death or Recurrent MI

 

Figure 14
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  		Figure 1. Risk of death or recurrent myocardial infarction (MI) among 503 post MI patients associated with frequency of worship service attendance (left panel) and frequency of prayer (right panel) along with adjustment covariates (i.e., Medical Risk score, Gender, Ethnicity, and Education). There were 61 events (29 deaths, 32 MIs). Values represent point estimate of hazard ratio (HR) and 95% Confidence limits from multivariable Cox proportional hazards model. HRs for Attendance and Prayer represent comparison to "Never" category of variable. Medical Risk is modeled as a continuous variable, scaled such that the HR compares a typical patient with a score of 3.1 (75th percentile value of Medical Risk in the present sample) with a patient with a score of 2.1 (25th percentile value of Medical Risk in the present sample). The omnibus test for the overall effect of Attendance was not statistically significant (p = .107). The omnibus test for the overall effect of Prayer also was not statistically significant (p = .679).

 

Frequency of Prayer
Table 3 displays the raw event rates for the categories of prayer frequency. Event rates were highest among patients who reported praying many times daily (20%) and lowest among patients who never prayed (6.6%). However, the time-to-event analysis demonstrated that the unadjusted relationship between prayer frequency and event was not statistically significant (omnibus test, p = .102). Using the "Never" category as the reference group, the HRs for the remaining frequency categories were as follows: a) more than once daily, HR = 3.3, p = .034; b) daily or almost daily, HR = 1.9, p = .238; c) once or twice a week or less (the collapsed category), HR = 1.7, p = .354. After adjustment for covariates, the p value for the omnibus test of the group of categories was no longer significant (p = .679). Examining the individual response categories, the HR for "more than once daily" becomes attenuated, but the pattern of HRs remained essentially similar as that seen in the unadjusted analyses (Figure 1, right panel).


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  		TABLE 3. Frequency of Prayer and Rates of Death or Recurrent MI

 

Total DSE Score
The relationship of spirituality and the probability of death or recurrent MI is displayed in Figure 2. The unadjusted relationship between the total DSE score and time to event was marginally significant (p = .086), with the greater risk associated with higher total DSE scores. Scaling the total continuous DSE score so that the HR compared a typical patient at the 75th percentile on the scale with one at the 25th percentile, the HR was 1.4 (95% Confidence Interval (CI): 0.95, 2.2). After the adjustment for covariates, however, the relationship was positive but was not significant and was smaller in effect size (HR = 1.2; 95% CI: 0.8–1.8; p = .446).


Figure 24
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  		Figure 2. Predicted probability of death or recurrent myocardial infarction as a function of the total Daily Spiritual Experiences scale (DSE) score, for a non-Hispanic white male patient with an average medical risk composite score using a restricted cubic spline to model nonlinearity. Dotted lines represent 95% Confidence bands. The relationship between the total Spiritual Experiences score and time to event was not statistically significant before adjustment for background variables (p = .086) or after adjustment (p = .446).

 

Relationship Between Spirituality and Depression and Low Social Support
We also examined the relationship between the spirituality variables and measures of depressive symptoms and social support obtained at baseline; we determined whether adjustment for these variables changed the association between the spirituality variables and survival. Table 4 shows the mean BDI and ESSI scores for each of the six original response categories of the Attendance and Prayer items. For Attendance, patients who were in the church attendance "at least once a week" category had significantly lower BDI scores than those in the "never" category (p = .045), but did not differ from any of the other frequency categories. Similarly, patients in the "at least once a week" category also had higher social support scores than those in the "never" category (p = .002) but again did not differ from any other group. Patients in the "never" category also had significantly lower social support scores than those in the "several times a year" category (p = .035). There were no statistically significant differences among the Prayer response categories on either the BDI or ESSI scores. There was a modest, inverse relationship between BDI scores and the total DSE score (r = –.12; p = .006), but we observed no relationship between ESSI and total DSE scores (r = .06; p = .195).


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  		TABLE 4. BDI and ESSI Scores by Response Category of Prayer and Attendance Items

 

The relationship between the Attendance item and survival changed very little after simultaneous adjustment for BDI and ESSI scores, using the "Never" category as the reference: a) at least weekly, HR = 0.5, p = .10; b) once or twice a month, HR = 1.2, p = .56; c) several times a year or less, HR = 0.7, p = .29. The pattern also remained unchanged for the Prayer item after adjustment for BDI and ESSI scores, using the "Never" category as the reference: a) more than once daily, HR = 2.0, p = .22; b) daily or almost daily, HR = 1.7, p = .33; c) less than once or twice a week, HR = 1.8, p = .28. Finally, the relationship between the total DSE score and time to death or recurrent MI remained essentially unchanged after the adjustment for BDI and ESSI scores: HR = 1.2, 95% CI: 0.8, 1.9, p = .44.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
NOTES
 REFERENCES
 
Although religion and religious practices provide psychological comfort, support, and reassurance to patients afflicted with serious medical conditions, the physical health benefits of spirituality, religion, and prayer remains controversial due to a paucity of data from well-controlled, methodologically sound investigations. The present report examined the prospective relationship between three key interrelated variables—church/worship service attendance, prayer, and spiritual experiences—and cardiac morbidity and all-cause mortality in a sample of depressed or psychosocially isolated patients who suffered an AMI and participated in the ENRICHD trial. Because sociodemographic factors could contribute to the relationship between spirituality/religiosity and health (26), we adjusted for age, gender, ethnicity, and education as well as an index of disease severity in our analyses. Results showed little evidence to support the notion that religion and spirituality can improve physical health outcomes in this population. Patients who attended church regularly tended to have lower depression and more social support compared with patients who never went to church, and higher spirituality scores were associated with less depression; however, neither spirituality, as assessed by the DSE, nor self-reported frequency of prayer was associated with adverse events over an average follow-up period of 18 months post AMI. Patients with high spirituality scores or who engaged in regular prayer had the same likelihood of dying or suffering a recurrent nonfatal AMI as patients who indicated that they were not high in spirituality or who seldom or never prayed.

Although we observed a significant association between church/worship service attendance and clinical outcomes in the unadjusted analysis, the results were complex: patients who reported that they never attended church tended to have higher event rates than those patients who attended church weekly, but actually had lower event rates compared with patients who attended church several times per month. Patients who attended church several times a month (but not weekly) had >20% event rate, which was the highest event rate among all attendance frequency categories. These results are difficult to interpret and do not seem to be a result of differences in disease severity, perceptions of social support, marital status, or depression. Furthermore, these data seem to conflict with data on church attendance from healthy cohorts. For example, Hummer et al. (7) found that weekly church/worship service attendance compared with less or no attendance protected against the onset of cardiovascular disease in a sample of 21,204 adults followed for 8 years. Interestingly, frequent worship attendance proved more predictive of mortality than light-to-moderate (but not heavy) smoking—a finding also reported by Oman, Thoresen, and McMahon (27) in a sample of almost 2000 older persons. In another study, Oman et al. (8) found that weekly attendance protected against cardiovascular mortality in a sample of 6545 adults followed for 31 years. Goldbourt et al. (11) followed 10,232 adults for 23 years and reported a 10.0% crude CHD mortality rate for the "most orthodox" Jewish study participants compared with 14.5% in the "nonbelievers." Colantonio et al. (12) found that weekly church/worship service attendance predicted a lower risk of stroke in a sample of elderly persons followed for 7 years.

There also have been other studies of religion and cardiovascular health, although these studies have usually involved cardiac risk factors such as blood pressure (28–32). An exception was a study by Friedlander, Kark, and Stein (33) who reported that the risk of MI was greater among secular compared with orthodox Jews living in Israel. In a meta-analysis of 42 independent samples examining the relationship of some form of religious involvement and mortality, McCullough et al. (34) reported that such involvement was associated with lower mortality (odds ratio = 1.29; 95% CI = 1.20–1.39; p = .001); however, when sociodemographic, health, and health behavior control variables were included in the model along with social support, social activities, and marital status, the odds ratio of 1.23 was no longer significant (p = .306). The studies that were included in this meta-analysis were highly diverse and included patients with severe kidney disease (35), cancer (36–39), and chronic medical illnesses (40), but primarily consisted of healthy community dwelling adults. Most studies did not control for baseline health status, and measures of disease severity and other prognostic factors were usually not examined. Moreover, only one study included patients with coronary disease, reporting equivocal results. In this study of 232 coronary bypass patients (41), only a single item—"strength or comfort from religion"—selected from a 5-item scale of religiosity was associated with mortality independent of such potential confounds as age, functional status, and a measure of social participation. However, neither the other four items in the scale nor the total score itself was related to mortality.

In the present study, our 16-item measure of religious practices and spirituality was unrelated to cardiac events and all-cause mortality. Furthermore, an examination of two items—church/worship service attendance and prayer—selected a priori were also unrelated to clinical outcomes. Although this study measured three distinct aspects of religion, including daily spiritual experiences, church/ worship service attendance, and prayer/meditation, there are other variables related to spiritual experiences that may be relevant to health and illness. For example, there is an emerging literature purporting to demonstrate the benefits of forgiveness (42). Multidimensional scales that tap related specific spiritual factors such as meditation, forgiveness, or sense of peace are now available (43,44) and can provide additional insights into the possible health effects of spirituality and religion.

Another spirituality variable of interest is that of religious coping (45,46), which may mediate the relationship between religious practices and quality of life. Studies measuring other aspects of spirituality for which there is some evidence of predictive health outcomes are an increase in spirituality/religiousness after a life-threatening diagnosis (47), which predicted slower disease progression in people with human immunodeficiency virus over 4 years, and religious struggle, which predicted mortality in medically ill patients over 2 years (48). In the latter study, Pargament et al. (48) found that two spiritual discontent items ("Wondered whether God had abandoned me" and "Questioned God's love for me") and one demonic reappraisal item ("Decided the devil made this happen") were associated with an increased risk for mortality in 596 older medical inpatients.

This study of post-AMI patients used a restricted sample of patients who were depressed and/or perceived themselves as having low social support. This unique population of cardiac patients with psychosocial risk factors may limit the generalizability of our findings to the general population of post-MI patients. In addition, the present study, as is the case with many studies of spiritual and religious factors, relied solely on brief self-report measures using only a single item. Although some studies previously have found such single-item measures to be predictive of health outcomes, this construct covers a variety of dimensions and levels (e.g., religious social support, communal prayer, religious denomination, meditative reading, health habits), which may obscure the relationship of church attendance and health outcomes. How best to clarify the so-called "active ingredients" of religious attendance as related to health, along with other spiritual and religious factors, remains a challenge for future research in this area.


   NOTES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 NOTES
REFERENCES
 
1 We use the term "spirituality" here as a key feature of religion. However, a growing number of Americans of all ages, roughly 30% to 35%, identify themselves as "spiritual but not religious." For a discussion of the differences between the constructs of spirituality and religion, see Miller and Thoresen (18). Back

2 We also estimated the time-to-event models using all six of the original categories in the Attendance and Prayer models; it made no material difference in the conclusions drawn. The p value for the adjusted overall effect of the Attendance item was .267, with the following individual hazard ratios (HRs) using "never" as the reference: a) less than once a year, HR = 1.1; b) once or a few times a year, HR = 0.7; c) several times a year, HR = 0.6; d) once or twice a month, HR = 1.3; e) at least once a week, HR = 0.6. For the Prayer item, the p value for the adjusted overall effect was .924. The individual HRs using "never" as the reference were as follows: a) several times a year, HR = 1.8; b) once or twice a month, HR = 1.7; c) once or twice a week, HR = 1.8; d) daily or almost daily, HR = 1.6; e) more than once a day, HR = 2.0. Back

Supported by contracts NO1-HC-55140, NO1-HC-55141, NO1-HC-55142, NO1-HC-55143, NO1-HC-55143, NO1-HC-55144, NO1-HC-55145, NO1-HC-55146, NO1-HC-55147, NO1-HC-55148, from the National Heart, Lung, and Blood Institute (J.A.B., L.P., M.B., D.C.); grant MH 49679 (J.A.B.) from the National Institutes of Health, Bethesda, Maryland; and a grant from the Fetzer Foundation (C.T.).

Received for publication January 21, 2007; revision received March 27, 2007.

DOI:10.1097/PSY.0b013e3180cab76c


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 NOTES
 REFERENCES
 

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