Religiosity and Spirituality of patients with severe mental disorders.

BACKGROUND: Religion and spirituality form an integral part of life, yet have been poorly studied in patients with mental illness. AIM: This study evaluated the religious and spiritual practices, a sense of purpose/connection, religious/spiritual belief and sense of hope/control among clinically stable patients diagnosed with schizophrenia, bipolar disorder, and depression and compared the same with healthy controls. It also aimed to evaluate the association of residual psychopathology with various dimensions of religiosity and spirituality.
MATERIALS AND METHODS: Patients diagnosed with schizophrenia, bipolar disorder, and major depressive disorder, in a state of clinical remission were assessed on the Spiritual Attitude Inventory and compared with a healthy control group.
RESULTS: A total of 284 participants were recruited, which included patients with major depressive disorder (n = 72), bipolar disorder (n = 75), schizophrenia (n = 63), and healthy controls (n = 74). The groups were matched for age and gender. As compared to healthy controls, participants with any severe mental disorder had significantly lower participation in organized religious activities. In terms of existential well-being, all patient groups had significantly lower scores than the healthy control group. Patients with severe mental disorders significantly more frequently used negative religious coping than the healthy controls and also had lower scores on the sense of purpose. No significant difference was observed between the three patient groups on various dimensions of religiosity and spirituality as assessed in the present study. In patients with schizophrenia, higher use of negative religious coping was associated with greater residual psychopathology.
CONCLUSION: Considering the association of negative religious coping with residual psychopathology, there is a need to incorporate psychological interventions to address religious and spiritual issues for patients with various severe mental disorders. Copyright:

INTRODUCTION

Religion is defined as “an organized system of beliefs, practices, rituals, and symbols designed to facilitate closeness to the sacred or transcendent.”[1] It is often organized and practiced within a community, but it can also be practiced alone and in private. Religiosity is often used synonymously with such terms as religiousness, orthodoxy, faith, belief, piousness, devotion, and holiness.[2] These synonyms reflect what studies of religiosity would term as dimensions of religiosity, rather than terms that are equivalent to religiosity.[1] In contrast to religion/religiosity, spirituality is understood as a complex multidimensional concept that defies clear cut boundaries.[345] Spirituality can be defined as one's striving for an experience of connection with oneself, connectedness with others, with nature and connectedness with the transcendent. Connectedness is an essential element of spirituality. Connectedness with the transcendent includes connectedness with something or someone beyond the human level, such as the universe, transcendent reality, a higher power, or God.[6] However, religion/religiosity and spirituality are often used interchangeably in the literature. Religiosity and spirituality are not monolithic concepts and are understood as religious affiliations, religious practices (public and private), spiritual beliefs and practices, religious coping, religious quality of life, etc.

Literature concerning the association of various dimensions of religiosity and spirituality with mental disorders is limited. Available evidence suggests that religiosity and spirituality influence the expression of psychopathology, self-harm behavior, substance use pattern, help-seeking, illness models, coping with the symptoms, treatment adherence, and quality of life of patients with severe mental disorders.[78910]

There are limited data in the form of comparison of religious practices of patients with various mental disorders and the general population and available data are inconsistent.[1112] Some of the studies report higher,[11] whereas others report lower involvement of patients of schizophrenia in religious activities when compared to the general population.[12] A previous study from India, which compared the religious and spiritual practices of patients of schizophrenia with healthy controls, reported a lack of difference between the two groups.[13] Studies that have evaluated the religiousness and religious practices among patients with schizophrenia from the developed countries suggest that about one-third of the patients are highly involved in various religious communities, and another one-third reported spirituality to have a significant role in their life.[14] A study reported the practice of private religious and spiritual practices by 91% of the patients, and about two-thirds of the participants with schizophrenia reported attending the public religious services or activities.[15]

Some of the studies have evaluated the association of severity of mental disorders with religiosity and spirituality. Some of the researchers have also evaluated the relationship of severity of depression with religiosity and spirituality, and these studies suggest that even after controlling for variables such as social support and substance abuse, factors such as forgiveness, negative religious support, loss of faith, and negative religious coping have a significant association with the severity of depression.[16] Further, in the follow-up of these patients, it was noted that loss of faith in God predicted a lower level of improvement in depression scores over 6 months, even after controlling for the severity of depression at the baseline.[16] Another study, which evaluated the association of religiosity and spirituality, showed that spirituality (assessed in the domains of awareness, grandiosity, and instability scores) correlated with the severity of depression.[17] Studies involving clinically stable patients of schizophrenia suggest a lower level of religiosity is associated with a higher level of negative symptoms and general psychopathology.[13] Studies that have evaluated the religious coping suggest that compared to healthy controls, patients of schizophrenia more often use negative religious coping.[13] Based on these studies, it can be concluded that there are differences in the religious and spiritual practices of patients with severe mental disorders compared to healthy controls. However, the evidence is still preliminary on various accounts.

None of the previous studies have evaluated the religious and spiritual practices, religious coping, and a sense of purpose/connectedness in the same study sample. Further, none of the previous studies have compared these variables across different psychiatric disorders and healthy controls. In this background, the present study aimed to evaluate the religious and spiritual practices, sense of purpose/connection, religious/spiritual belief and sense of hope/control among clinically stable patients diagnosed with schizophrenia, bipolar disorder, and depression and compare the same with healthy controls. Further, this study also aimed to evaluate the association of residual psychopathology with various dimensions of religiosity and spirituality.

MATERIALS AND METHODS

This study was conducted at the Post Graduate Institute of Medical Education and Research, Chandigarh, which is a tertiary care multispecialty public-funded hospital. The study was approved by the ethics committee of the institute, where it was conducted, and all the participants were recruited after obtaining written informed consent. The inclusion criteria for the study were patients fulfilling the diagnostic criteria of one of following mental disorders, i.e. schizophrenia, bipolar disorder or major depressive disorder (recurrent depression or first episode) as per the Diagnostic and Statistical Manual of Mental Disorders-IV criteria,[18] confirmed by using MINI-PLUS.[19] In addition, the participants were required to be aged between 18 and 60 years, of either gender with the duration of illness of at least 1 year. Patients were also required to be clinically stable and in clinical remission. Clinical stability was defined as “receiving stable doses of psychotropics in the past 3 months, with no more than a 50% increase or decrease of dosages of psychotropics” during this period. Clinical remission for schizophrenia was defined by criteria proposed by Andreasen et al.;[20] a score of ≤7 on the 17-item Hamilton Depression Rating Scale (HDRS)[21] and/or score of ≤7 on the Young Mania Rating Scale (YMRS)[22] were used to define clinical remission in patients with bipolar disorder; a score of ≤7 on the 17-item HDRS was used to define clinical remission in a patient with major depressive disorder (first episode or recurrent depression).

Patients with comorbid psychiatric disorders, chronic physical illness, and organic brain syndromes were excluded from the study.

Control group participants were selected randomly from the caregivers accompanying the patients and hospital staff. To be included in the control group, the participants were required to be free from psychopathology as per the General Health Questionnaire (GHQ) -12 item version).[23] A GHQ-12 item scale score of ≤2 was used to define a lack of psychological morbidity.

All the participants were assessed on the Spiritual Attitude Inventory (SAI). SAI was designed as a tool to assist chaplains, behavioral health professionals, and other clinicians with the assessment of spiritual needs. It is a 28-item scale, developed by combining four validated measures of religion and spirituality to address the areas of religious and spiritual practices, sense of purpose/connection, religious/spiritual belief, and sense of hope/control. The validated scales from which the items are derived include Duke Religion Index (DUREL),[24] Existential Well-Being Scale (EWBS), a subscale of the Spiritual Well Being Scale (SWBS),[25] Religious/spiritual belief as measured by the Negative Religious Coping (NRCOPE) subscale of Brief religious coping scale,[26] sense of hope/control measured by the internal/external subscale of the Multiple Health Locus of Control Scale (MHLC),[27] The internal consistency of DUREL has been estimated at α = 0.85[24] among healthy adults. Internal consistency coefficients of SWBS has been reported to be α = 0.73–0.98.[25] Cronbach's alpha coefficient (internal consistency) for religious coping scale has been reported to range from 0.69 to 0.81.[26] The internal/external subscale of the MHLC has internal consistency coefficients of α = 0.60 in a diverse Canadian sample.[27]

In addition, patients of schizophrenia were rated on the Positive and Negative Syndrome Scale (PANSS).[28] Patients of bipolar disorder were assessed on HDRS and YMRS, and patients of major depressive disorder were assessed on HDRS. Global Assessment of Functioning (GAF) scale was used to assess the level of functioning of all the 3 patient groups.[29]

Data were analyzed using Statistical Package for Social Sciences, Version-14 (SPSS-14, SPSS for Windows, Version 14.0. Chicago, SPSS Inc.). Continuous variables were evaluated in the form of mean and standard deviation (SD). Categorical variables were evaluated in the form of frequency and percentages. Comparisons were made using a t-test, Mann–Whitney U = test, Chi-square test, and ANOVA with post hoc analysis. Association of religiosity and spirituality with other variables was evaluated using Pearson's correlation coefficient or Spearman rank correlation. Comparisons of categorical variables were made using a t-test or Chi-square test.

RESULTS

The study included 210 patients with severe mental disorders and 74 healthy controls. Among the patients with a severe mental disorder, 72 were diagnosed with major depressive disorder, 75 were diagnosed with bipolar disorder, and 63 were diagnosed with schizophrenia. The mean age of the study groups varied from 36 to 41 years, with no significant difference across different groups. In all the groups, there was a slight preponderance of male participants with no significant difference across different groups. Compared to other groups, a significantly higher proportion of patients with schizophrenia were single. Compared to other groups, a significantly higher proportion of healthy participants were from the urban background [Table 1]. The mean age of onset of illness was highest for patients with major depressive disorder and least for those with schizophrenia, with a significant difference between patients with schizophrenia and depression and also for patients with bipolar disorder and schizophrenia. The GAF score for the whole study sample was 71.5, with no significant difference between the three diagnostic groups. Both the affective disorder group patients had a low level of residual symptoms, and the PANSS total score for patients with schizophrenia was 41.46 (SD: 3.93) [Table 1].

Table 1

Demographic and clinical profile of study participants

Variable	Whole sample (n=284)	Group-I Depression (n=72)	Group-II Bipolar disorder (n=75)	Group-III Schizophrenia (n=63)	Group-IV Controls (n=74)	ANOVA/Chi-square test	Post-hoc
Age	38.64 (10.73)	40.03 (11.72)	40.8 (11.86)	37.51 (10.54)	36.08 (7.82)	3.12 (0.06)	II>I>III>IV
Sex (males)	146 (51.4)	37 (51.4)	39 (52.0)	33 (52.4)	37 (50.0)	0.09 (0.99)
Marital status
Married	216 (76.1)	57 (79.2)	62 (82.7)	38 (60.3)	59 (79.7)	11.30 (0.01)*
Currently unmarried	68 (23.9)	15 (20.8)	13 (17.3)	25 (39.7)	15 (20.3)
Education	11.99 (3.85)	10.82 (3.34)	10.99 (3.94)	11.08 (3.85)	14.92 (2.54)	24.15 (<0.001)***	III>II>I
							IV>I***
							IV>II***
							IV>III***
Locality
Urban	196 (69.0)	48 (66.7)	39 (52.0)	40 (63.5)	69 (93.2)	31.55 (<0.001)***
Rural	88 (31.0)	24 (33.3)	36 (48.0)	23 (36.5)	5 (6.8)
Age of onset	33.32 (11.07)	35.50 (13.26)	34.09 (10.42)	29.93 (8.03)		4.67 (0.01)*	I>III*
Duration of illness	79.71 (76.51)	66.25 (60.14)	80.80 (72.52)	93.82 (94.33)		2.20 (0.11)	No differences between groups
GAF	71.51 (10.80)	69.30 (8.27)	72.45 (12.72)	72.93 (10.62)		2.36 (0.09)	No differences between groups
HDRS score		1.93 (2.43)	2.22 (2.50)			2488.5 (0.38)@
YMRS score			1.1 (1.97)
PANSS total score				41.46 (3.93)
Positive subscale				9.58 (0.85)
Negative subscale				9.19 (1.01)
General psychopathology subscale				22.68 (2.99)

@Mann-Whitney U-test; *P<0.05;**P<0.01; ***P<0.001. GAF – Global Assessment of Functioning; HDRS – Hamilton Depression Rating Scale; YMRS – Young Mania Rating Scale; PANSS – Positive and Negative Syndrome Scale

The Cronbach's alpha for the study sample for various subscales was: DUREL (0.769), SWBS (0.865), NRCOPE (0.961), and MHLC items was 0.90. These values indicated that these subscales had good internal consistency for the study sample.

In terms of religiosity as assessed by DUREL, compared to healthy controls, participants of all the severe mental disorders had significantly lower participation in organized religious activities. However, there was no significant difference between the diseased groups and the healthy controls for the nonorganized religious activities and intrinsic religiosity. However, on one of the items of intrinsic religiosity (my religious beliefs are what lie behind my whole approach to life), patients in all the groups scored significantly less than the controls [Table 2]. On all the items of existential well-being, patients of all the groups scored significantly less than the healthy controls, with no significant difference between the various patient groups. In terms of negative religious coping and locus of control, compared to the healthy controls, patients in all mental disorder groups significantly more frequently used negative religious coping and had significantly lower scores on MHLC with no significant difference between the various psychiatric disorders [Table 2].

Table 2

Religiosity and Spirituality as assessed on the subscale of the Spiritual Attitude Inventory

Variable	Whole sample (n=284)	Group-I depression (n=72)	Group-IIBipolar disorder (n=75)	Group-III Schizophrenia (n=63)	Group-IV Controls (n=74)	Comparison	Post-hoc
DUREL
Organized religious activities
How often do you attend church or other religious meetings?	3.54 (1.11)	3.39 (0.96)	3.35 (1.08)	3.36 (0.91)	4.03 (2.54)	6.834 (<0.001)***	I>II>III; IV>I*** IV>II***; IV>III***
Nonorganized religious activities
How often do you spend time in private religious activities, such as prayer, meditation or Bible study?	3.09 (1.06)	3.18 (1.03)	3.06 (1.08)	3.08 (0.93)	3.04 (1.22)	0.24 (0.86)	I>III>II>IV
In my life, I experience the presence of the Divine (i.e., God)	3.44 (0.89)	3.35 (0.65)	3.36 (0.72)	3.53 (0.79)	3.49 (1.23)	0.75 (0.51)	III>IV>II>I
My religious beliefs are what really lie behind my whole approach to life	3.65 (1.01)	3.81 (0.99)	3.79 (1.00)	3.77 (0.94)	3.25 (1.01)	5.38 (0.001)***	I>III>II; IV>I*** IV>II***; IV>III***
I try hard to carry my religion over into all other dealings in life	3.09 (0.75)	3.09 (0.51)	3.08 (0.55)	3.11 (0.51)	3.08 (1.19)	0.022 (0.99)	III>I > IV>II
Intrinsic religiosity	10.17 (2.08)	10.25 (1.76)	10.23 (1.92)	10.41 (1.77)	9.82 (2.71)	1.07 (0.36)	II>I > III>IV
Existential well-being scale/sense of purpose
I don’t know who I am, where I came from or where I’m going	3.37 (1.17)	3.06 (0.98)	3.05 (1.07)	3.16 (0.96)	4.18 (1.27)	18.75 (<0.001)***	II>I > III; IV>I*** IV>II***;IV>III***
I feel that life is a positive experience	3.65 (1.11)	3.32 (0.77)	3.51 (0.91)	3.33 (0.72)	4.43 (1.44)	20.34 (<0.001)***	III>II>I; IV>I*** IV>II***; IV>III***
I feel unsettled about my future.	3.75 (1.13)	3.56 (0.98)	3.73 (1.18)	3.64 (0.98)	4.07 (1.33)	2.93 (0.034)*	II>III>I
I feel very fulfilled and satisfied with life	3.83 (1.07)	3.56 (0.82)	3.52 (0.86)	3.59 (0.84)	4.59 (1.28)	20.75 (<0.001)***	III>II>I; IV>I*** IV>II***; IV>III***
I feel a sense of well-being about the direction my life is headed in	3.93 (0.97)	3.65 (0.63)	3.69 (0.68)	3.81 (0.67)	4.51 (1.38)	14.16 (<0.001)***	II>I > III; IV>I*** IV>II***; IV>III***
I don’t enjoy much about life	3.72 (1.05)	3.49 (0.92)	3.62 (0.96)	3.55 (0.74)	4.21 (1.33)	8.12 (<0.001)***	II>III>I; IV>I*** IV>II***; IV>III***
I feel good about my future	3.65 (1.08)	3.31 (0.71)	3.52 (0.67)	3.33 (0.78)	4.41 (1.49)	20.89 (<0.001)***	III>II>I; IV>I*** IV>II***; IV>III***
I feel that life is full of conflict and unhappiness	3.35 (1.14)	3.38 (0.97)	3.59 (1.06)	3.40 (0.82)	3.06 (1.54)	2.50 (0.059)	III>II>I > IV
Life doesn’t have much meaning	3.66 (0.95)	3.35 (0.48)	3.43 (0.49)	3.45 (0.50)	4.37 (1.44)	23.96 (<0.001)***	II>III>I ; IV>I*** IV>II***; IV>III***
I believe there is some real purpose for my life	3.64 (1.15)	3.38 (0.97)	3.57 (1.04)	3.55 (0.88)	4.02 (1.49)	4.35 (0.005)**	III>II>I; IV>I***
EWBS/sense of purpose total	36.55 (7.28)	34.04 (6.04)	35.23 (7.04)	34.81 (5.46)	41.89 (7.61)	22.32 (<0.001)***	II>I > III; IV>I*** IV>II***; IV>III***
Negative religious coping
Wondered whether God had abandoned me	3.09 (0.95)	3.49 (0.50)	3.57 (0.49)	3.53 (0.50)	1.83 (0.81)	146.02 (<0.001)***	III>II>I; IV<I*** IV<II***;IV<III***
Felt punished by God for my lack of devotion	3.00 (1.11)	3.36 (0.89)	3.54 (0.78)	3.44 (0.79)	1.75 (0.87)	74.44 (<0.001)***	III>II>I; IV<I*** IV<II***;IV<III***
Wondered what I did for God to punish me	3.06 (0.97)	3.33 (0.71)	3.46 (0.67)	3.52 (0.63)	1.98 (0.88)	72.89 (<0.001)***	II>III>I; IV<I*** IV<II***;IV<III***
Questioned God’s love for me	3.02 (1.01)	3.32 (0.78)	3.57 (0.62)	3.39 (0.68)	1.91 (0.96)	69.5 (<0.001)***	III>II>I ;IV<I*** IV<II***; IV<III***
Wondered whether my church had abandoned me	3.05 (1.06)	3.43 (0.69)	3.57 (0.59)	3.57 (0.52)	1.68 (0.91)	127.72 (<0.001)***	II>III>I ; IV<I*** IV<II***; IV<III***
Decided the devil made this happen	2.95 (1.11)	3.29 (0.88)	3.42 (0.84)	3.29 (0.92)	1.85 (0.96)	49.70 (<0.001)***	III>II>I; IV<I*** IV<II***; IV<III***
Questioned the power of God	2.99 (1.16)	3.31 (1.00)	3.50 (0.74)	3.44 (0.93)	1.79 (0.91)	55.86 (<0.001)***	III>II>I; IV<I*** IV<II***;IV<III***
Negative RCOPE total	21.16 (6.67)	23.52 (4.54)	24.65 (3.90)	24.18 (3.92)	12.83 (5.30)	116.23 (<0.001)***	III>II>I ; IV<I*** IV<II***; IV<III***
Multidimensional health locus of control/sense of hope
If I get sick, it is my own behavior that determines how soon I get well again	3.55 (1.02)	3.20 (0.79)	3.49 (0.74)	3.24 (0.85)	4.27 (1.23)	20.91 (<0.001)***	III>II>I; IV>I*** IV>II***; IV>III***
I am in control of my health	3.93 (0.99)	3.75 (0.75)	3.98 (0.77)	3.72 (0.71)	4.27 (1.41)	5.16 (0.002)**	III>I > II; IV>I*** IV>II***; IV>III***
When I get sick, I am to blame	3.53 (0.96)	3.49 (0.73)	3.57 (0.71)	3.44 (0.78)	3.63 (1.41)	0.598 (0.617)	IV>III>II>II
The main thing that affects my health is what I myself do	3.93 (1.12)	3.58 (0.80)	3.87 (0.87)	3.49 (0.88)	4.75 (1.34)	24.50 (<0.001)***	III>I > II; IV>I*** IV>II***; IV>III***
If I take care of myself, I can avoid illness	3.76 (1.26)	3.15 (0.99)	3.56 (0.93)	3.31 (0.97)	4.97 (1.19)	48.266 (<0.001)***	III>II>I; IV>I*** IV>II***; IV>III***
If I take the right actions, I can stay healthy	3.98 (0.97)	3.59 (0.59	3.73 (0.57	3.49 (0.53)	4.74 (1.30)	35.96 (<0.000)***	III>I > II; IV>I*** IV>II***; IV>III***
MHLC/sense of hope total	22.60 (5.19)	20.77 (3.93)	22.20 (3.99)	20.69 (4.03)	26.64 (5.99)	27.366 (<0.001)***	III>I > II; IV>I*** IV>II***; IV>III***
SAI total	97.13 (12.40)	95.16 (13.09)	98.77 (14.01)	96.54 (12.01)	98.27 (10.42)	1.22 (0.3)	III>IV>II>I

*P<0.05;**P<0.01; ***P<0.001. SAI – Spiritual attitude inventory; MHLC – Multiple Health Locus of Control Scale ; EWBS – Existential Well-Being Scale, DUREL – Duke Religion Index

When negative religious coping was assessed as a categorical variable (i.e., ever used or never used), it was seen that patients suffering from depression, bipolar disorder, and schizophrenia used negative religious coping more frequently as compared to healthy controls. There was no significant difference between the patients of depression and bipolar disorder in terms of frequency of use of negative religious coping. However, compared to patients of depression and bipolar disorder, a patient of schizophrenia less frequently used all the negative religious coping mechanisms, except for the one [Table 3].

Table 3

Use of negative religious coping

Ever used	Group-I Depression (n=72)	Group-II Bipolar disorder (n=75)	Group-III Schizophrenia (n=63)	Group-IV Controls (n=74)	Comparison of depression and healthy controls (I vs. IV)	Comparison of bipolar and healthy controls (II vs. IV)	Comparison schizophrenia and healthy controls (III vs. IV)	Comparison depression and schizophrenia (I vs. III)	Comparison of depression and bipolar (I vs. II)	Comparison Bipolar and schizophrenia (II vs. III)
Wondered whether God had abandoned me	72 (100)	75 (100)	63 (100)	43 (58.1)	35.29 (<0.001)***,$	NA	31.11 (<0.001)***,$	NA	NA	NA
Felt punished by God for my lack of devotion	72 (100)	75 (100)	63 (100)	35 (47.3)	49.12 (<0.001)***,$	NA	43.86 (<0.001)***,$	NA	NA	NA
Wondered what I did for God to punish me	72 (100)	75 (100)	63 (100)	48 (64.9)	28.42 (<0.001)***,$	NA	25.08 (<0.001)***,$	NA	NA	NA
Questioned God’s love for me	72 (100)	75 (100)	63 (100)	42 (56.8)	39.87 (<0.001)***,$	NA	33.17 (<0.001)***,$	NA	NA	NA
Wondered whether my church had abandoned me	72 (100)	75 (100)	63 (100)	32 (43.2)	54.63 (<0.001)***,$	NA	48.93 (<0.001)***,$	NA	NA	NA
Decided the devil made this happen	72 (100)	75 (100)	63 (100)	37 (50.0)	45.61 (<0.001)***,$	NA	40.65 (<0.001)***,$	NA	NA	NA
Questioned the power of God	60 (95.2)	69 (92.0)	66 (91.7)	37 (50.0)	30.49 (<0.001)***	0.17 (0.67)$	31.53 (<0.001)***,$	0.23 (0.62)$	0.005 (0.94)	0.17 (0.67)$

$Yates’ correction; *P<0.05;**P<0.01; ***P<0.001. NA – Not available

Relationship of religiosity and spirituality with other variables

None of the continuous demographic and clinical variables had any significant correlation with the various domains of DUREL, EWBS, Negative RCOPE, MHLC, and total SAI score for patients with depression. In patients with bipolar disorder group too, all the continuous variables demographic and clinical did not have any association with DUREL, EWBS, NRCOPE, MHLC, and total SAI score, except for significant association between duration of illness and nonorganized religious activities (How often do you spend time in private religious activities, such as prayer, meditation or Bible study) (Spearman Rank Correlation coefficient - 0.24; P = 0.038*). Among patients with schizophrenia, higher use of negative religious coping was associated with higher residual positive (Pearson correlation coefficient −0.36; P = 0.003**) and negative (Pearson correlation coefficient −0.38; P = 0.002**) symptoms. In addition, higher age of the patients was associated with a lower MHLC score (Pearson correlation coefficient −0.25; P = 0.045*). Among the healthy controls, higher age was associated with lower EWBS score (Pearson correlation coefficient −0.31; P = 0.006**), and more frequent use of negative religious coping (Pearson correlation coefficient −0.37; P = 0.001***). Further, a higher level of education was associated with lower intrinsic religiosity (Pearson correlation coefficient −0.32; P = 0.004**) as assessed on DUREL and higher EWBS score (Pearson correlation coefficient −0.35; P = 0.002**).

Relationship of religiosity (as assessed by duke religion index), existential well Being, negative religious coping and health locus of control

In all the patient groups, all the three domains of DUREL had a significant positive correlation with each other. However, in healthy controls, nonorganized religious activities did not correlate significantly with intrinsic religiosity. In all the patient groups, higher religiosity as per DUREL was associated with higher negative religious coping and higher scores on the existential well-being. However, in the control group, there was no significant relationship between intrinsic religiosity and negative religious coping. Further, in the control group, there was no significant relationship between any of the domains of religiosity and existential well-being. However, higher scores on existential wellbeing were associated with the higher use of negative religious coping. In terms of health locus of control in affective disorder patient groups' higher scores on MHLC, health locus of control was associated with higher use of negative religious coping. However, no such association was seen in patients with schizophrenia. In the healthy controls, higher scores on MHLC, health locus of control were associated with higher use of negative religious coping and also higher existential well-being scores [Table 4].

Table 4

Correlation between measures of spiritual attitude inventory in the study groups

Variable	Nonorganized religious-activity	Intrinsic religiosity	Negative religious coping	Existential well-being	Internal locus of control
Depression
Organized religious activity	0.63 (<0.001)***	0.59 (<0.001)***	0.27 (0.01)*	0.55 (<0.001)***	−0.16 (0.18)
Nonorganized religious activity		0.68 (<0.001)***	0.09 (0.44)	0.60 (<0.001)***	0.05 (0.64)
Intrinsic religiosity			0.52 (<0.001)***	0.67 (<0.001)***	−0.05 (0.64)
Negative religious coping				0.62 (<0.001)***	0.23 (<0.001)***
Existential well-being					0.15 (0.21)
Bipolar disorder
Organized religious activity	0.67 (<0.001)***	0.70 (<0.001)***	0.48 (<0.001)***	0.82 (<0.001)***	−0.08 (0.47)
Nonorganized religious activity		0.62 (<0.001)***	0.24 (0.03)*	0.75 (<0.001)***	0.003 (0.97)
Intrinsic religiosity			0.51 (<0.001)***	0.62 (<0.001)***	−0.14 (0.23)
Negative religious coping				0.48 (<0.001)***	0.25 (0.02)*
Existential well-being					0.13 (0.26)
Schizophrenia
Organized religious activity	0.73 (<0.001)***	0.59 (<0.001)***	0.40 (0.001)**	0.77 (<0.001)***	−0.07 (0.57)
Nonorganized religious activity		0.72 (<0.001)***	0.34 (0.006)**	0.755 (<0.001)***	0.10 (0.39)
Intrinsic religiosity			0.43 (<0.001)***	0.62 (<0.001)***	−0.13 (0.27)
Negative religious coping				0.66 (<0.001)***	0.11 (0.36)
Existential well-being					0.19 (0.11)
Whole sample
Organized religious activity	0.67 (<0.001)***	0.62 (<0.001)***	0.37 (<0.001)***	0.71 (<0.001)***	−0.10 (0.12)
Nonorganized religious activity		0.67 (<0.001)***	0.20 (0.002)**	0.69 (<0.001)***	0.05 (0.47)
Intrinsic religiosity			0.49 (<0.001)***	0.63 (<0.001)***	−0.11 (0.09)
Negative religious coping				0.59 (<0.001)***	0.21 (0.002)**
Existential well-being					0.16 (0.01)*
Control group
Organized religious activity	0.49 (<0.001)***	0.21 (0.06)	−0.32 (0.004)**	0.21 (0.07)	−0.06 (0.60)
Nonorganized religious activity		0.25 (0.02)*	0.27 (0.01)*	0.18 (0.11)	−0.15 (0.20)
Intrinsic religiosity			−0.22 (0.52)	0.04 (0.68)	0.32 (0.005)**
Negative religious coping				0.52 (<0.001)***	0.42 (<0.001)***
Existential well-being					0.41 (<0.001)***

*P<0.05;**P<0.01; ***P<0.001

DISCUSSION

The present study attempted to compare the level of spirituality and religiosity of patients with various severe mental disorders in clinical remission and healthy controls. Patients were recruited during the phase of remission to minimize the effect of psychopathology. The demographic profile of patients with various psychiatric disorders similar to previous studies.[112628] In terms of religiosity as assessed on the DUREL, patients in all three groups scored similar to controls, except for Organized Religious Activities, in which controls had higher scores than all three groups and one of the items of intrinsic religiosity (my religious beliefs are what really lie behind my whole approach to life), on which patients scored higher than the control group. No significant difference was seen between the three groups. A previous study from this center evaluated the religiosity of patients with schizophrenia by using DUREL and reported a lack of significant difference between patients with schizophrenia and healthy controls.[13] Accordingly, it can be said that the findings of the present study partially support the previous study. Previous studies that have compared the religious practices of patients with various mental disorders and the general population by using other scales have been inconclusive, with some reporting higher,[11] whereas others report lower involvement of patients of schizophrenia in religious activities when compared to the general population.[12] Our findings suggest lower participation in organized religious activities, but a higher influence of religious beliefs on the overall approach to life. As there are inconsistencies in the available literature, our findings must be considered preliminary and must be replicated in future studies.

Differences between patients with severe mental disorders and healthy controls for organized religious activities could be due to the diagnosis of mental illness per se. Due to the mental illness, patients possibly avoid socialization due to stigma associated with various mental disorders. Accordingly, it would be interesting to evaluate this association these variables in future to understand the impact of mental illnesses on the religiosity of the sufferers.

In terms of the EWBS, evaluating a sense of purpose, all the patients scored significantly less than the healthy controls. Existential well-being “pertains to spirituality as expressed through a sense of meaning and purpose for existence, and a perception of self as being competent and able to cope with the difficulties of life and limitations of human existence.”[3031] Others have tried to define the existential dimension as our ability to relate to self, our experiences, and our situations.[32]

Previous studies that have evaluated existential well-being among patients with mental disorders have mainly evaluated the same as part of the quality of life,[3334] and due to the same, it is difficult to compare the findings of the present study with the existing literature. Lower existential well-being among patients with various mental disorders, compared to healthy controls, suggests that patients believe that they are less competent to deal with difficulties of life and limitations of human existence. A lower level of existential well-being in patients with various mental disorders calls for designing interventions to address the existential crisis in patients with various mental disorders.

In terms of the use of negative religious coping, the present study suggests that compared to healthy controls, patients with severe mental disorders more frequently used negative religious coping. Further, in terms of ever/never use, patients with affective disorder, more frequently use negative religious coping compared to patients with schizophrenia. A previous study that involved patients with schizophrenia also reported a similar profile for the use of ever/never use of negative religious coping[13] Another study, which evaluated the use of negative religious coping of patients presenting with self-harm to the emergency, also reported a higher frequency of negative religious coping among patients with self-harm, irrespective of the presence or absence of axis-I psychiatric disorder.[10] Accordingly, it can be said that the findings of the present study are supported by the existing literature. In the schizophrenia group, higher use of negative religious coping was associated with higher residual positive and negative symptoms, suggesting that higher use of negative religious coping can have an adverse effect on the residual psychopathology. Previous studies have shown that higher use of negative religious coping in patients with depression is associated with higher severity of suicidal ideation.[10] Based on the findings of the present study, it can be recommended that clinicians managing patients with various psychiatric disorders should always evaluate the religious coping of the patients and should encourage them to use more adaptive coping.

In terms of health locus of control, the present study shows that patients with various mental disorders had lower scores on internal locus of control, compared to the healthy controls. This means that they had a lower internal locus of control. Available data in patients of schizophrenia[35] suggest that the internality of locus of control is associated with better recovery, and in healthy persons suggests a lower chance of the development of mental disorders.[36] As our patients were in clinical remission, and no association was noted between psychopathology and locus of control, similar conclusions cannot be drawn from the present study.

The association higher religiosity as per DUREL with higher negative religious coping and higher scores on the existential well-being suggests that there is a correlation of religiosity and spirituality in patients with mental disorders. Further, this study suggests that higher religiosity is associated with higher use of negative coping. Previous studies have also reported similar associations.[37] In terms of health locus of control in affective disorder patient groups' higher scores on MHLC, health locus of control was associated with higher use of negative religious coping. This association was difficult to understand and requires further evaluation.

The present study has certain limitations in the form of small sample size, purposive sampling, and cross-sectional assessment. It is quite possible that the assessment of religious and spiritual practices of the patients may not be a reflection of their premorbid practices, and rather these could have been colored by the whole experience of illness. The present study did not evaluate the association of religious and spiritual practices with quality of life, longitudinal course of illness, other forms of coping and psychological distress. It is important to understand that this was an exploratory study, and hence, the results must be considered preliminary, needing further validation. Future studies must attempt to overcome these limitations.

CONCLUSION

To conclude, the present study suggests that compared to healthy controls, patients with severe mental disorders have lower participation in organized religious activities, more often use negative religious coping, have lower existential well-being, and have higher internal health locus of control. These religious and spiritual practices are usually not associated with demographic and clinical variables, except in patients of schizophrenia, in whom higher use of negative religious coping is associated with higher residual psychopathology. Association of negative religious coping with residual psychopathology, lower existential well-being, and have higher internal health locus of control suggest that there is a need to incorporate the psychological interventions to address these issues for patients with various severe mental disorders.

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Conflicts of interest

There are no conflicts of interest.