Comparison of religiosity and spirituality in patients of depression with and without suicidal attempts.

AIM: This study is aimed to compare the religiosity and spirituality of patients with first-episode depression with suicidal ideation and those with recent suicidal attempts. Additional aim was compare the religiosity and spirituality of patients with first-episode depression with healthy controls.
METHODS: Patients of first episode depression with suicidal ideation and healthy controls were assessed by Centrality of Religiosity Scale (CRS), Duke University Religion Index (DUREL), Brief Religious coping scale (R-COPE), and Spiritual Attitude Inventory (SAI).
RESULTS: Patients with depression were divided into two groups based on the presence (n = 53) or absence (n = 62) of suicidal attempts in the previous 14 days. Both the patients with and without suicide attempts were matched for depression severity. Both the patient groups did not differ in terms of religiosity and spirituality as assessed using CRS and SAI. Both depression groups had lower scores on religiosity as compared to healthy controls as assessed on CRS. The two groups also had a lower score on the "sense of hope" which is a part of SAI, when compared to healthy controls. Compared to patients without suicide attempts (i.e., ideators group) and healthy controls, subjects with suicide attempts more often used negative religious coping. Total numbers of lifetime suicide attempts in the attempt group were associated with the ideology domain of the CRS.
CONCLUSION: Compared with healthy controls, patients with depression have lower levels of religiosity and spirituality. In the presence of comparable severity of depression, higher use of negative religious coping is associated with suicide attempts. Copyright:

INTRODUCTION

Depressive disorders are a major cause of morbidity and mortality worldwide and in India.[1] Major depression is also considered to be a risk factor for suicide and suicidal behavior,[2] which includes suicidal ideation, suicidal plan, and suicidal attempt.[3]

Various risk factors have been implicated for suicidal behavior in patients with depression which can be categorized as demographic, psychological (including the presence of psychiatric disorders), biological, environmental, and socio-cultural factors.[34] In the socio-cultural domain, religious beliefs, and spirituality influence suicidal behavior. Both of these have been known to play an important role across cultures in making suicide acceptable to society or condemning it as a sin.[56789] As a result of this influence, various studies have been done in the general population and patients with depression to measure the role of religiosity and spirituality in suicidal behaviour.[1011121314151617]

Religiosity and spirituality are both believed to have a protective and predisposing role in suicide.[518] In terms of traditional practices, in Eastern cultures like India, suicide has been institutionalized in the custom of “suttee.”[19] Islam has always accorded severe disapprobation to the suicidal act.[7] The attitude of the Greek and Roman world towards suicide was, on the whole, a permissive one.[7] The Christian world has always opposed the act of suicide with great determination, regarding it as a form of murder.[20]

Contemporary research done in the general population shows that suicide rates are lower in religious countries than in secular ones.[11] In terms of different dimensions or components of religiosity and spirituality, data suggest that suicidal gestures/suicidal attempts/suicidal ideations are negatively related to religious commitment,[31421] religious affiliations,[322] and high moral objection.[2123] It is further suggested that religious affiliation/commitment/participation is associated with lower aggression,[1421] impulsivity,[101224] better social ties,[321] reduced alienation,[314] and better social support.[1422] All these factors possibly contribute to lower suicidal behaviors. Studies that have evaluated higher religious attendance suggest that it plays a protective role in terms of the development of suicidal ideations[121325262728293031] and suicide attempt.[13263132333435] A longitudinal study showed that the recurrence of suicide attempts is associated with the “meaning of life.”[36] However, some of the studies have also come up with negative findings, i.e., lack of association of religious attendance with suicidal ideation and suicide attempt.[373839] Occasional studies have also reported a higher rate of history of suicidal attempt among those with a religious affiliation and higher suicidal ideations among depressed patients who regard religion to be more important and those who more frequently attended religious services.[40] Studies have also shown that private religious practices are also associated with lower rates of suicidal ideation.[41] A systematic review that evaluated the association of suicidal behavior with religion, reported that among the various components of religion, religious affiliation does not always protect against suicidal ideations. However, religious affiliation has a protective effect against suicidal attempts.[5] Another component of religion, i.e., religious service attendance also did not appear to be protective against suicidal ideations after adjusting for the social support as a covariate, however, religious service attendance emerged as a protective factor against suicide attempts.[5]

Some of the studies have evaluated the relationship of depression with religiosity and spirituality. Studies have shown the association of religiosity and spirituality, with the severity of depression.[16] In terms of suicidal behavior, religious beliefs, and practices have been reported to be protective factors for suicidal behavior. However, there is some data to suggest the contrary. Studies in patients of depression, which have evaluated religiosity and spirituality with depression have done so in the form of religious affiliations,[4243] religious participation[44] in the form of attending religious places, spiritual practices in the form of beliefs, meditation, and religious coping.[1342]

Available data suggest that suicide and suicidal behavior have a negative association with identifying oneself as spiritual, higher religious attendance and religious worship and having religious affiliation.[510] Studies that have compared suicide attempters and nonattempters suggest that nonattempters have a greater fear of social disapproval and greater moral objections to suicide.[12134445] Data also suggest that the severity of suicidal ideation has a negative correlation with moral objects to suicide/religious beliefs.[46] Studies that have focused on the lethality of the attempt suggest that moral objections were a significant reason for living in patients attempting low lethality suicide. In terms of religious coping data suggest that religious coping and relationship with God prevented the general and clinical population (i.e., those with depression too) from suicide.[47] However, data also suggest that religion can have detrimental effects by inspiring guilt and fear which in turn can reduce life satisfaction.[40]

Occasional studies from India have looked at the relationship between suicidal behavior and religiosity in patients of depression. A study from north India reported that patients with high religiosity reported lower suicidal intent and fewer suicide attempts than those with low religiosity.[48]

From this review, it is evident that there are a limited number of studies that have evaluated the association of suicidal behavior with religiosity and spirituality, especially in patients with depression. Further, most of these studies have measured only one or a few dimensions of religion and/or spirituality. There is a lack of studies on the influence of religion and spirituality on suicidal behavior in the Indian population despite their importance in the day-to-day socio-cultural context. This study is aimed to compare the religiosity and spirituality of patients with first-episode depression with suicidal ideation (no lifetime suicide attempt) and those with suicidal ideations along with recent suicidal attempts. Additional aim was to compare the religiosity and spirituality of patients with first-episode depression with healthy controls. An attempt was also made to evaluate the role of religiosity and spirituality in predicting the severity of suicidal ideations, suicidal intent, and lifetime number of suicide attempts.

METHODOLOGY

This cross-sectional study was conducted in a tertiary care multispecialty teaching hospital. The study was approved by the ethics committee of the institute and all the patients were recruited after obtaining written consent.

The study included three groups of patients, i.e., Group I consisted of patients with first-episode depression (as confirmed using the Mini-International Neuropsychiatric Interview [MINI]-PLUS)[49] with suicidal ideation with a recent suicidal attempts (i.e., within the past 14 days), whereas Group II comprised patients with first-episode depression with suicidal ideation alone (without lifetime suicidal attempt). Group-I and II were matched for age, gender, socio-economic status, and severity of depression. Group-III included healthy participants, who were free from any psychiatric morbidity (as confirmed by MINI-Screen),[49] and did not have any suicidal ideations.

The study participants were recruited by purposive sampling. To be included in the study, the participants of Group-I and Group-II were required to be diagnosed with Major depressive episode as diagnosed by MINI–PLUS,[49] aged 16–75 years, able to read Hindi/English, having suicidal ideation (as per item 9 of Beck Depression Inventory)[50] and providing written informed consent. In addition, patients with suicidal attempt were required to have the presence of suicidal intent (moderate level, as assessed by Beck's Suicidal Intent Scale)[51] and must have made a suicide attempt in 2 weeks preceding the assessment for the study, but were currently medically stable and able to participate in a psychiatric interview.

Patients with primary psychotic illness (nonaffective), bipolar affective disorder, organic brain syndrome, intellectual disability, those suffering from a terminal medical illness like cancer, and patients attempting self-harm behavior without suicidal intent were excluded.

Participants meeting the selection (i.e., fulfilling all the inclusion criteria and not meeting any of the exclusion criteria) criteria in all the three groups were assessed on the Centrality of Religiosity Scale (CRS),[52] Brief Religious Coping Scale (Brief R-COPE)[53] and the Spiritual Attitude Inventory for the assessment of religiosity and spirituality.

In addition, both the patients' groups were assessed on Beck Depression Inventory,[50] Beck Hopelessness Scale (BHS),[54] Patient Health Questionnaire (PHQ-15),[55] Young Mania Rating Scale (YMRS)[56] and Irritability, Depression, and Anxiety Scale (IDA)[57] for the assessment of psychopathology. YMRS was used to record any subsyndromal symptoms of mania, considering that according to DSM-5,[58] patients of unipolar depression can also have mixed features. Impulsivity was assessed using the Barratt Impulsiveness Scale (BIS).[59] Columbia Suicide Severity Rating Scale (CSSR-S) was used to assess suicidal behavior. Social support was assessed using the Multi-dimensional Scale of Perceived Social Support.[60]

The Centrality of Religiosity Scale

The CRS is a measure of the centrality, importance, or salience of religious meanings in personality. It measures the general intensities of five theoretical defined core dimensions of religiosity. The dimensions of public practice, private practice, religious experience, ideology, and intellectual dimensions can together be considered as representative for the total of religious life. From a psychological perspective, the five core-dimensions can be seen as channels or modes, in which personal religious constructs are shaped and activated. The activation of religious constructs in personality can be regarded as a valid measure of the degree of religiosity of an individual. In the original description of the CRS scale,[52] authors had provided norms for the Indian population. According to this, the mean item score for each item of CRS 7 items (Cri7) is 3.88. The Hindi version of this scale, which has been validated in India, was used in this study.[61]

Brief Religious Coping Scale (Brief R-COPE)

The Religious Coping scale was designed by Pargament in the year 2000. The original scale consists of 105 items. Later 21 items and 14 items (Brief RCOPE) versions were also developed. The items for the scale were generated through interviews with people experiencing major life stressors. Two overarching forms of religious coping, positive and negative, were articulated through factor analysis of the full R-COPE. Positive religious coping methods reflect a secure relationship with a transcendent force, a sense of spiritual connectedness with others, and a benevolent world view. Negative religious coping methods reflect underlying spiritual tensions and struggles within oneself, with others, and with the divine. Reliability estimates were generally high, indicating good internal consistency. Cronbach's alpha was. 80 or greater for all but two scales (Marking Religious Boundaries and Reappraisal of God's Power). Empirical studies document the internal consistency of the positive and negative subscales of the Brief RCOPE. Moreover, empirical studies provide support for the construct validity, predictive validity, and incremental validity of the subscales.[53] For this study, the Hindi version of Brief RCOPE[61] was used to assess religious coping among patients.

The spiritual attitude inventory

It 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 currently validated measures of religion and spirituality to address the following areas:

Religious spiritual practice as measured by the Duke Religion Index (DUREL).[62] Internal consistency of this scale has been estimated at α = 0.85 among healthy adults

Sense of purpose/connection as measured by the Existential Well-Being Scale (EWBS), a subscale of the Spiritual Well-Being Scale.[63] Based on data from over 900 participants in seven different studies, internal consistency coefficients of α = 0.73 to 0.98 were reported

Religious/spiritual belief as measured by the Negative Religious Coping (NRCOPE)[53] scale. Cronbach's coefficient alpha (internal consistency) was estimated in three different samples and it ranged from 0.69 to 0.81

Sense of hope/control measured by the internal/external subscale of the Multiple Health Locus of Control Scale (MHLC).[64] This subscale has internal consistency coefficients of α = 0.60 in a diverse Canadian sample.

The Hindi version of this scale, which has been validated in India, was used in this study.[6165]

Data were analyzed using Statistical Package of Social Science-16th Version (SPSS-16) (SPSS Inc. Released 2007. SPSS for Windows, Version 16.0. Chicago, SPSS Inc.). Continuous variables were analyzed in the form of mean and standard deviations and the categorical variables were analyzed in the form of frequency and percentages. Comparisons were made using unpaired t-test, Mann Whitney U test, and the Chi-square test. Correlations of religiosity and spirituality with suicidal behavior (i.e., the severity of suicidal ideations, number of lifetime attempts), demographic variables, and clinical variables were studied using Pearson's correlation coefficient and Spearman's rank correlation coefficient. Regression analysis was used to study the contribution of religiosity and spirituality, demographic variables and clinical variables to suicidal ideation, attempt, and intent.

RESULTS

Group-I (i.e., those with a suicidal attempt in the previous 2 weeks) included 53 patients and the Group-II (i.e., those with suicidal ideations, but no suicidal attempt in the lifetime) included 62 patients. The healthy control group (Group-III) comprised 102 subjects. As per the study design, all three groups were matched for age, gender, and socio-economic status. As shown in Table 1, both the patient groups (Group-I and II) did not differ significantly from each other on any of the sociodemographic variables. Both groups did not differ significantly from the healthy control on various demographic variables except for marital status, education, and occupation [Table 1].

Table 1

Sociodemographic profile of the study groups

Sociodemographic variables	Mean (SD) [range]/frequency (%)			Comparison of suicidal attempt and suicidal ideation group, t-test/Chi-square test (P)	Comparison of suicidal attempt and healthy control group, t-test/Chi-square test	Comparison of suicidal ideation and healthy control group, t-tests/Chi-square test
	MDD with Suicidal attempt Group-I (n=53)	MDD with Suicidal ideation Group-II (n=62)	Healthy controls Group-III (n=102)
Age	30.56 (9.20) [18-60]	34.66 (13.41) [16-71]	32.98 (8.49) [20-57]	1.93 (0.06)	1.63 (0.10)	0.98 (0.32)
Gender
Male	25 (47.2)	32 (51.6)	52 (51.0)	0.22 (0.63)	0.20 (0.65)	0.006 (0.93)
Female	28 (52.8)	30 (48.4)	50 (49.0)
Current marital status
Currently married	28 (52.8)	37 (59.7)	39 (38.2)	0.54 (0.46)	3.02 (0.08)	7.13 (0.007)**
Currently unmarried	25 (47.2)	25 (40.3)	63 (61.8)
Education - number of years	11.90 (3.34) [5-19]	11.64 (3.70) [0-17]	15.08 (2.72) [10-20]	−0.39 (0.69)	6.37 (<0.00.1)***	6.83 (<0.00.1)***
Education
Matric and below	21 (39.6)	27 (43.5)	6 (5.9)	0.18 (0.67)	27.60 (<0.00.1)***	34.03 (<0.00.1)***
Above matric	32 (60.4)	35 (56.5)	96 (94.1)
Current employment status
Currently employed currently	27 (50.9)	30 (48.4)	88 (86.3)	0.07 (0.78)	22.73 (<0.00.1)***	27.42 (<0.00.1)***
Unemployed	26 (49.1)	32 (51.6)	14 (13.7)
Income
Patient	8,143 (13,138) [0-55,000] (median 0)	8,766 (12,248) [0-45,000] (median 0)	26,949 (21,321) [0-100,000] (median 25,000)	1.610 (0.84)#
Family	25,773 (28,8790) [0-125,000] (median 14,000)	25,943 (21,245) [0-90,000] (median 20,000)	59,215 (52,053) [15,000-300,000] (median 40,000)	1448 (0.27)#
Religion
Hindu	26 (49.1)	35 (56.5)	57 (55.9)	0.62 (0.42)	0.65 (0.41)	0.005 (0.94)
Non-Hindu¢	27 (50.9)	27 (43.5)	45 (44.1)
Family type
Nuclear	25 (47.2)	33 (53.2)	58 (56.9)	0.41 (0.51)	1.31 (0.25)	0.20 (0.64)
Nonnuclear	28 (52.8)	29 (46.8)	44 (43.1)
Locality
Urban	32 (60.4)	29 (46.8)	94 (92.2)	2.12 (0.14)	23.16 (<0.001)	33.82 (<0.001)
Rural	21 (39.6)	33 (53.2)	8 (7.8)

¢Non-Hindu: Suicidal attempt group: Sikh (n=25), Muslim (n=2); Suicidal ideation group: Sikh (n=23), Muslim (n=4); #Mann-Whitney U value. SD – Standard deviation; MDD: Major Depressive Disorder. *P,0.05; **P<0.01;***P<0.001

In terms of clinical variables, the mean age of onset was significantly lower for the participants of the suicidal attempt group, when compared to the suicidal ideation group [Table 2]. However, both the groups did not differ in terms of duration of illness, comorbid physical and psychiatric disorders, comorbid substance use disorders, presence of psychotic symptoms in the current episode, family history of mental illness, and family history of attempted suicide. Compared to the suicide attempt group, a higher proportion of the patients in the suicide ideation group had a family history of completed suicide [Table 2]. In terms of psychopathology, both the study groups did not differ in terms of total BDI score, scores on various domains of IDA, PHQ-15 score, and impulsivity as assessed by BIS total score. However, compared to patients with suicidal ideation only, patients with suicidal attempts had significantly higher scores on BHS and the suicidal ideation item of BDI and a significantly lower score on the multi-dimensional social support scale [Table 2].

Table 2

Clinical profile of the study participants

Variables	Mean (SD) [range]/frequency (%)		Chi square/t-test (P)
	Suicidal attempt Group (n=53)	Suicidal ideation Group (n=62)
Age of onset (years)	30.02 (9.22) [17-57]	34.2 (13.4) [16-71]	1.97 (0.05)*
Duration of illness (months)	6.52 (7.36) [1-36] (median=4)	8.21 (8.9) [1-48] (median=5)	1366 (0.12)#
Comorbid physical diagnosisΨ	10 (18.9)	13 (21.0)	0.08 (0.77)
Comorbid psychiatric illness$	10 (18.9)	14 (22.6)	0.24 (0.62)
Substance use	2 (3.8)	6 (8.1)	0.32 (0.57)@
Presence of psychotic symptoms	5 (9.4)	7 (11.3)	0.10 (0.74)
Family history of mental illness	15 (28.3)	22 (35.5)	0.67 (0.41)
Family history of attempted suicide	5 (9.4)	10 (16.1)	1.12 (0.29)
Family history of completed suicide	3 (5.7)	5 (8.1)	0.02 (0.89)@
Psychopathology
BDI total score	37.50 (8.07) [24-52]	34.67 (8.26) [20-53]	−1.85 (0.06)
BDI suicidal ideation item score	2.11 (0.70) [1-3]	1.84 (0.63) [1-3]	−2.21 (0.02)*
YMRS total score	4.55 (2.32) [1-10]	3.47 (1.60) [1-7]	−2.85 (0.005)**
IDA-depression	9.28 (2.64) [2-13]	9.02 (2.97) [4-14]	−0.50 (0.61)
IDA-anxiety	8.45 (3.16) [2-13]	8.81 (2.80) [3-14]	0.63 (0.52)
IDA-irritability outward	7.21 (2.94) [1-11]	6.21 (2.90) [0-11]	−1.82 (0.07)
IDA-irritability inward	8.40 (2.24) [2-12]	8.36 (2.44) [3-12]	−0.09 (0.92)
BHS total	16.38 (2.92) [11-20]	14.77 (3.8) [4-20]	−2.70 (0.008)**
PHQ-15 total score	14.01 (6.18) [4-25]	13.47 (5.78) [1-27]	−0.47 (0.63)
BIS total score	71.74 (8.96) [48-85]	70.10 (9.02) [50-89]	−0.97 (0.33)
Perceived social support scale total score	37.59 (9.46) [21-65]	43.84 (11.29) [21-67]	3.23 (0.002)**

@Yate’s correction; #Mann–Whitney U value; *P<0.05; **P<0.01; ΨPhysical illnesses include: Suicidal attempt group: Hypertension (n=3), diabetes mellitus (n=2), migraine (n=2), epilepsy (n=1) and gall stones (n=2), Suicidal ideation group: Hypertension (n=2), diabetes mellitus (n=4), thyroid abnormalities (n=2), migraine (n=1), renal stone disease (n=2), benign prostatic hypertrophy (n=1), and cardiac disease (n=1); $Psychiatric illnesses include: Suicidal attempt group: Obsessive compulsive disorder (n=2), dissociative disorders (n=3), posttraumatic stress disorder (n=1), borderline personality disorder (n=2), homosexuality (n=1) and generalized anxiety disorder (n=1), suicidal ideation group: obsessive compulsive disorder (n=3), dissociative disorders (n=1), agoraphobia (n=2), social phobia (n=2), somatization (n=2), borderline personality disorder (n=2), erectile dysfunction (n=2); γFamily history includes: suicidal attempt group: Affective disorders (n=13), substance use disorders (n=2), Suicidal ideation group: Affective disorders (n=13), psychotic disorders (n=2) and substance use disorders (n=7). SD – Standard deviation; BDI – Beck Depression Inventory; YMRS – Young Mania Rating Scale; IDA – Irritability, Depression and Anxiety; BHS – Beck Hopelessness Scale; PHQ – Patient Health Questionnaire; BIS – Barratt Impulsiveness Scale

In terms of the severity of current suicidal ideations, both the groups did not differ significantly on various items of CSSR-S. However total suicide ideation score as per CSSR-S was significantly higher for the suicide attempt group [Table 3]. As per the study design, patients in the suicidal ideation group had no lifetime history of attempted suicide. However, compared to patients in the suicidal attempt group, significantly fewer patients in the suicidal ideation group had a history of nonsuicidal behavior, interrupted attempts, aborted attempts, and preparatory behavior. In the current episode too, suicidal behavior was less frequent in the suicidal ideation group [Table 3].

Table 3

Suicidal behavior in study participants

Variables	Mean (SD) [range]/frequency (%)		Chi-square/t-test (P)
	Suicidal attempt group (n=53)	Suicidal ideation Group (n=62)
Wish to be dead	53 (100.0)	62 (100.0)	-
Nonspecific active suicidal thoughts	53 (100.0)	62 (100.0)	-
Active suicidal ideation without intent	53 (100.0)	62 (100.0)	-
Active suicidal ideation with some intent but no plan	53 (100.0)	62 (100.0)	-
Active suicidal ideation with plan and intent	53 (100.0)	58 (93.5)	3.54 (0.12)
Reasons for ideation
Completely to get attention, revenge or reaction from others	0	0	4.38 (0.11)
Equally to get attention, revenge, or reaction from others and stop feeling pain	2 (3.8)	1 (1.6)
Mostly to end or stop pain or the way they were	12 (22.6)	6 (9.7)
Completely to end or stop pain or the way they were feeling	39 (73.6)	55 (88.7)
Current total CSSR-S suicide ideation score	19.91 (3.02) [11-24]	16.5 (3.02) [9-24]	−6.02 (<0.001)***
Lifetime suicidal behavior as per the CSSR-S
Suicide attempt	53 (100.0)
Total no of actual attempts	1.79 (1.21) [1-5]	0
Nonsuicidal behavior	18 (34.0)	3 (4.8)	16.24 (<0.001)***
Interrupted attempt	22 (41.5)	4 (6.5)	20.07 (<0.001)***
Aborted attempt	6 (11.3)	3 (4.8)	0.887 (0.35)
Preparatory behavior	8 (15.1)	0	7.86 (0.005)@,**
Suicidal behavior during the assessment period	53 (100.0)	7 (11.2)	89.72 (<0.001)@,***

@Yate’s correction; **P<0.01; ***P<0.001. Actual attempt: A potentially self-injurious act committed with at least some wish to die, as a result of the act. Nonsuicidal behavior: Self-injurious behavior without suicidal intent. Interrupted attempt: When the person is interrupted (by an outside circumstance) from starting the potentially self-injurious act (if not for that, an actual attempt would have occurred). Aborted attempt: When a person begins to take steps toward making a suicide attempt but stops themselves before they actually have engaged in any self-destructive behavior. Preparatory acts or behavior: Acts or preparation towards imminently making a suicide attempt. Suicidal behavior: Actual attempt, interrupted attempt, aborted attempt, and preparatory behavior. SD – Standard deviation; CSSR-S – Columbia Suicide Severity Rating Scale

In the group with suicide attempts, the most commonly employed method for the suicidal attempt was an overdose of prescription medications (26.4%), followed by hanging/strangulation (20.8%), consumption of poison (18.9%), drowning (13.2%), wrist slitting (9.4%), burning self (5.7%), jumping from height (3.8%), and other methods (1.9%).

Religiosity and spirituality

On DUREL, both the depression groups did not differ significantly in terms of organized, nonorganized religious activities and intrinsic religiosity. Both the groups also did not differ significantly on various dimensions of religiosity and level of religiosity as assessed by CRS, the total score of Sense of Purpose items from EWBS, and total score of Sense of Hope items from MHLC scale. Compared to patients in the suicidal ideation group, patients in the suicidal attempt group had a significantly higher mean negative RCOPE subscale score. However, both groups did not differ in terms of the positive RCOPE subscale [Table 4].

Table 4

Religiosity as assessed on DUREL, CRS, RCOPE

Variable	Group-I MDD with suicidal attempt (n=53), mean (SD) [range]	Group-II MDD without suicidal ideation (n=62), mean (SD) [range]	Group-III healthy control group (n=102), mean (SD) [range]	Comparison of suicidal attempt and suicidal ideation group t-test (P)	Comparison of suicidal attempt and healthy control group t-test	Comparison of suicidal ideation and healthy control group t-tests
DUREL
Organized religious activities
How often do you attend church or other religious meetings?	3.76 (1.60) [1-6]	3.86 (1.34) [1-6]	3.89 (1.42)	0.36 (0.71)	0.51 (0.60)	0.13 (0.89)
Nonorganized religious activities
How often do you spend time in private religious activities, such as prayer, meditation or Bible study?	2.32 (1.55) [1-6]	2.69 (1.85) [1-6]	3.11 (1.29)	1.15 (0.24)	3.37 (<0.001)***	1.71 (0.08)
Intrinsic religiosity
In my life, I experience the presence of the divine (i.e., God)	3.26 (1.30) [1-5]	3.48 (1.16) [1-5]	3.40 (1.20)	0.95 (0.34)	0.66 (0.50)	0.41 (0.67)
My religious beliefs are what really lie behind my whole approach to life	3.28 (1.13) [1-5]	3.40 (1.11) [1-5]	3.26 (1.02)	0.57 (0.56)	0.11 (0.91)	0.82 (0.41)
I try hard to carry my religion over into all other dealings in life	3.42 (1.35) [1-5]	3.55 (1.21) [1-5]	2.99 (1.24)	0.55 (0.57)	1.98 (0.04)*	2.83 (0.005)**
Intrinsic religiosity total	9.96 (2.83) [3-15]	10.44 (2.68) [3-15]	9.66 (2.77)	0.92 (P=0.36)	0.63 (0.52)	1.77 (0.07)
Centrality of religiosity of scale
Intellect	8.32 (3.08) [3-15]	8.90 (2.79) [3-15]	9.39 (2.94) [3-15]	1.064 (0.28)	2.11 (0.03)*	1.05 (0.29)
Ideology	9.30 (3.40) [4-15]	10.03 (2.94) [4-15]	8.83 (3.30) [3-15]	1.235 (0.21)	00.83 (0.40)	2.35 (0.01)*
Public practice	8.64 (3.33) [3-15]	9.76 (2.97) [3-16]	10.14 (3.28) [4-15]	1.931 (0.05)	2.68 (0.008)**	0.74 (0.45)
Private practice	9.88 (3.08) [3-14]	10.64 (2.78) [4-15]	11.85 (3.02) [3-15]	1.38 (0.16)	3.8 2 (<0.001)***	2.56 (0.01)**
Experience	7.54 (3.40) [3-13]	8.48 (2.76) [3-14]	8.13 (3.30) [3-14]	1.63 (0.10)	1.04 (0.29)	0.69 (0.48)
Total CRS score	44.35 (14.04) [18-72]	48.66 (11.12) [21-72]	48.36 (14.22) [17-71]	1.79 (0.07)	1.67 (0.09)	0.14 (0.88)
Mean CRS score	2.95 (0.93) [1.20-4.80]	3.24 (0.74) [1.40-4.80]	3.22 (0.94) [1.13-4.73]	1.79 (P=0.07)	1.70 (0.09)	0.14 (0.88)
EWBS/sense of purpose total	34.52 (7.07) [16-52]	34.34 (6.53) [15-53]	33.13 (7.16) [13-47]	−0.14 (0.882)	1.51 (0.25)	1.08 (0.27)
MHLC/sense of hope total	23.17 (6.33) [7-32]	23.21 (5.67) [12-36]	26.54 (5.99) [8-36]	0.03 (0.972)	3.25 (0.001)**	3.52 (<0.001)***
RCOPE- positive total score	9.42 (4.13) [0-17]	10.61 (3.99) [0-18]	10.19 (4.54) [1-20]	1.57 (0.11)	1.03 (0.3)	0.60 (0.54)
RCOPE-negative total score	9.17 (4.7) [0-20]	7.34 (4.8) [0-18]	6.61 (5.65) [0-19]	−2.03 (0.04)*	2.82 (0.005)**	0.84 (0.39)

*P<0.05; **P<0.01; ***P<0.001. CRS – Centrality of Religiosity Scale; EWBS – Existential Well-Being Scale; MHLC – Multiple health locus of control scale; SD – Standard deviation; RCOPE – Religious coping; DUREL – Duke University Religion Index; SD – Standard deviation; MDD – Major Depressive Disorder

Compared to the healthy control group, patients in the suicidal attempt group had significantly lower religiosity in the domains of nonorganized religious activities and one of the items of intrinsic religiosity, as assessed by DUREL. When compared with healthy controls, both the suicidal ideation group and the suicidal attempt group had significantly lower religiosity in some of the domains of CRS. In addition, compared with healthy controls, both the suicidal ideation group and the suicidal attempt group had a significantly lower “sense of hope” on the MHLC scale [Table 4]. In terms of religious coping, compared to healthy controls, patients with suicidal attempt, more frequently used religious coping.

Relationship of suicidal behavior and severity of depression with religiosity and spirituality

In the suicide attempt group, higher severity of suicidal ideation as assessed by CSSR-S was associated with higher religiosity in the ideology domain as per CRS. Higher suicidal intent was associated with lower religiosity as per CRS total score, the intellect domain of religiosity, and private religious practices as per the CRS. Higher suicidal intent was also associated with a higher sense of hope score (on MHLC). A higher number of lifetime suicidal attempts were associated with higher religious ideology as per CRS [Table 5]. In the suicide ideation group, the severity of suicidal ideation as assessed by CSSR-S was associated with lower nonorganized religious activities and sense of purpose [Table 5].

Table 5

Correlation with religiosity and spirituality with suicidal behavior and severity of depression

Variable	Suicide attempt group			Suicide ideation group
	C-SSRS	Number of lifetime suicidal attempts	BDI total score	C-SSRS	BDI total score
CRS
Total CRS score	0.18 (P=0.17)	−0.03 (P=0.80)	0.15 (0.26)	−0.13 (P=0.30)	0.03 (0.79)
Intellect domain	0.22 (P=0.11)	−0.09 (P=0.52)	0.003 (0.98)	0.01 (P=0.96)	0.10 (0.43)
Ideology domain	0.27 (P=0.04)*	0.32 (P=0.01)*	0.33 (0.01)*	−0.06 (P=0.62)	−0.004 (0.97)
Public practice	0.13 (P=0.32)	−0.12 (P=0.38)	0.17 (0.20)	−0.21 (P=0.10)	−0.19 (0.12)
Private practice	0.16 (P=0.23)	−0.09 (P=0.52)	−0.03 (0.80)	−0.13 (P=0.28)	−0.01 (0.92)
Experience	0.07 (P=0.57)	−0.09 (P=0.47)	0.18 (0.19)	−0.09 (P=0.48)	0.18 (0.14)
Brief RCOPE
Positive total	0.38 (P=0.40)	−0.05 (P=0.67)	0.25 (0.06)	−0.13 (P=0.31)	0.07 (0.54)
Negative total	0.22 (P=0.11)	0.03 (P=0.79)	0.37 (0.006)**	0.04 (P=0.73)	0.30 (0.01)*
DUREL
Organized religious activities	−0.05 (P=0.68)	−0.23 (P=0.09)	−0.001 (0.99)	−0.12 (P=0.34)	0.01 (0.90)
Nonorganized religious activities	−0.12 (P=0.35)	−0.07 (P=0.58)	−0.01 (0.89)	−0.26 (P=0.03)*	0.009 (0.94)
Intrinsic religiosity	−0.03 (P=0.82)	−0.09 (P=0.51)	−0.018 (0.90)	−0.16 (P=0.19)	0.02 (0.87)
SAI
Sense of purpose	0.11 (P=0.42)	0.10 (P=0.44)	−0.19 (0.16)	−0.30 (P=0.01)*	−0.36 (0.004)**
Sense of hope	0.01 (P=0.91)	0.14 (P=0.30)	−0.25 (0.71)	−0.11 (P=0.38)	−0.28 (0.02)*

*P<0.05, **P<0.01. BDI – Beck Depression Inventory; CRS – Centrality of Religiosity Scale; SAI – Spiritual Attitude Inventory; DUREL – Duke University Religiosity Scale; RCOPE – Religious coping; C-SSRS – Columbia Suicide Severity Rating Scale. *P<0.05; **P<0.01

Predictors of suicidal behavior: Regression analysis

Suicidal attempt group

Influence of demographic variables, clinical variables, and religiosity and spirituality, on the severity of suicidal ideation, suicidal intent, and the number of lifetime suicidal attempts were evaluated using linear regression analysis. For this, all the variables, which had a significant association with suicidal ideation, suicidal intent, and the number of lifetime suicidal attempts in the association analysis were entered into the regression analysis as independent variables.

When the variance of the severity of suicidal ideations as per the CSSR-S in the suicidal attempt group was evaluated, 40.8% of the variance was explained YMRS total score, BDI total score, CRS ideology domain score, depression score of IDA scale, socioeconomic class, BIS total score, duration of treatment, and BHS score. When the stepwise method was used, the YMRS total score alone explained 15.2% of the variance. The addition of the depression score of the IDA scale increased the variance to 28.5% and further addition of the CRS ideology domain score increased the variance to 34% [Table 6].

Table 6

Predictors of suicidal ideation score as per Columbia Suicidal Severity Rating Scale in the suicide attempt group

Model	R	R2	Adjusted R2	SE of the estimate
Severity of suicide ideation as per C-SSRS
Enter method
YMRS total + BDI total + CRS ideology + IDA depression + BIS total + duration of treatment + BHS total score	0.699	0.488	0.408	2.326
Stepwise method
YMRS total	0.410	0.168	0.152	2.782
YMRS total + IDA depression	0.559	0.312	0.285	2.554
YMRS total + IDA depression + CRS ideology	0.615	0.378	0.340	2.453
Number of lifetime suicide attempts
Enter method
Marital status + BDI total + BHS true score + duration of illness + IDA inward irritability + education + CRS ideology	0.812	0.659	0.588	0.779
Stepwise method
Duration of treatment	0.376	0.142	0.125	1.136
Duration of treatment + IDA irritability inward	0.536	0.287	0.258	1.045
Duration of treatment + IDA irritability inward + education	0.600	0.361	0.321	1.000
Duration of treatment + IDA irritability inward + education + marital status	0.737	0.544	0.506	0.853

BDI – Beck Depression Inventory; IDA – Irritability, Depression and Anxiety; CRS – Centrality of Religiosity Scale; BHS – Beck Hopelessness Scale; YMRS – Young Mania Rating Scale; BIS – Barratt impulsiveness scale; SE – Standard error; C-SSRS – Columbia Suicide Severity Rating Scale

When all the variables, which had a significant association with the number of suicide attempts were entered into the regression analysis by, enter method, these variables explained 58.8% of the variance. However, in stepwise analysis duration of treatment (12.5%), inward irritability on the IDA scale (13.3%), education (6.3%), and marital status (18.5%) together explained 50.6% of the variance of the number of lifetime suicidal attempts [Table 6].

Suicidal ideation group

When the variance of the severity of suicidal ideations as per the CSSR-S in the suicidal ideation group was evaluated, all the variables which had significant association together explained 31.5% of the variance. When the stepwise method was used, the BHS score alone explained 23.2% of the variance. Nonorganized religious activities domain of CRS explained an additional 5% of the variance and the EWBS score explained 3.9% of the variance [Table 7].

Table 7

Predictors of suicidal ideation score as per Columbia Suicidal Severity Rating Scale in the suicide ideation group

Model	R	R2	Adjusted R2	SE of the estimate
Enter method
BHS total + nonorganized religious activities + EWBS total + YMRS total + IDA depression + BDI total + income of patient	0.627	0.393	0.315	2.502
Stepwise method
BHS total score	0.495	0.245	0.232	2.648
BHS total + nonorganized religious activities	0.553	0.306	0.282	2.561
BHS total + nonorganized religious activities + EWBS total	0.595	0.355	0.321	2.490

BHS – Beck Hopelessness Scale; YMRS – Young Mania Rating Scale; IDA – Irritability, Depression and Anxiety; BDI – Beck Depression Inventory; EWBS – Existential Well-Being Scale; SE – Standard error

DISCUSSION

Among the various psychiatric disorders, depressive disorders are a major cause of health burden across the world. Major depression is one of the mental disorders which is associated with high rates of suicide and suicidal behavior,[2] which includes suicidal ideation, suicidal plan, and suicidal attempt.[3] The only way to prevent completed suicides is to identify people at high risk of suicide. It is suggested that many persons who complete suicide have a history of previous suicidal attempts and nonsuicidal self-harm behaviors.[366] Further, it is suggested that there is some overlap in the risk factors for completed suicide and suicidal attempt.[6667] Hence, studying patients with suicide attempt provides an opportunity to identify the risk factors for completed suicide.[6768]

In the socio-cultural domain, religious beliefs and spirituality are thought to influence suicidal behavior. Both of these are known to play an important role across cultures in making suicide acceptable to society or condemning it as a sin.[67102069] Overall, there are limited data on understanding the contribution of religiosity and spirituality to suicidal behavior in patients with mental disorders, especially depression. Only occasional studies[1213] have compared the religiosity and spirituality of suicide attempters and nonattempters. However, none of these studies have looked at the suicidal ideations in the nonattempter groups. Hence, it is not clear as to whether religiosity and spirituality help in the prevention of suicidal attempts in the presence of suicidal ideations. Accordingly, studying the religiosity and spirituality of those with suicidal ideations, but not attempting suicide and comparing them with those who attempt suicide can help in understanding the role of these factors in actual suicide attempts.

In India, religion and spirituality play an important role in the life of most people. However, this has not received much attention in relation to suicidal behavior. The present study, thus, aimed to study the contribution of religiosity and spirituality to suicidal attempts in patients with depression.

In the present study, when the data of patients of both the groups were compared with a healthy control group, patients of both the groups, had significantly lower scores for religiosity as assessed by DUREL and CRS, sense of purpose and sense of hope as assessed by EWBS and MHLC scale, respectively, and positive religious coping as per the RCOPE. However, the patient groups had significantly higher negative religious coping scores, when compared to the healthy control group. Accordingly, it can be said that lower religiosity may be a risk factor for depression. Previous studies, which have compared patients with depression with healthy controls, have also reported similar findings.[7071] The lower religiosity in the patients with depression is a reflection of the depressive state per se or whether this is present premorbidly is difficult to ascertain from our cross-sectional study. Accordingly, there is a need to evaluate this association further, by using longitudinal study design.

In the present study, there was no significant difference between those with suicidal ideations and suicidal attempts in terms of various components of religiosity and spirituality as assessed in the present study, except for the negative religious coping. Compared to patients with suicidal ideations, patients with suicidal attempts used more negative religious coping. The findings of lack of difference between the two groups on various components of religiosity and spirituality suggest that these factors possibly do not contribute to the conversion of a patient with suicidal ideation to a suicidal attempt. Association of negative religious coping with suicide attempts suggests that it may be a risk factor for suicide attempts among patients with suicidal ideations. Accordingly, it can be said that clinicians must evaluate the religious coping mechanisms used by their patients and must encourage their patients not to indulge in negative religious coping.

When the association of religiosity and spirituality was evaluated with suicidal behavior, correlation analysis suggested that lower religiosity as assessed by using CRS was associated with the higher number of the suicide attempt. These findings suggest that lower religiosity is associated with the higher number of suicidal attempts and supports the findings of previous studies which have reported that religiosity has a negative impact on suicidal behavior.[5] In the suicidal ideation group too, the severity of suicidal ideation as assessed by CSSR-S was associated with lower nonorganized religious activities and sense of purpose as assessed by the EWBS scale. These findings also suggest that association of suicidal ideation with lower religiosity.

In the regression analysis, when the predictors of suicidal ideations were evaluated in both the groups, overall, religiosity and spirituality explained up to about 10% variance of the severity of suicidal ideations. These findings provide credence to the findings of general population studies,[1044] which suggest an association of suicidality with religiosity and spirituality.

Available data from bipolar and unipolar disorder suggest the association of suicidal behavior with hopelessness, impulsivity, and subsyndromal manic symptoms.[1572] Further, considering the importance of subsyndromal manic symptoms, DSM-5 has now expanded the concept of mixed features to unipolar depression too.[5873] Keeping these in mind, we had evaluated these variables in the present study, and the regression analysis suggests that subsyndromal manic symptoms as assessed in the form of the YMRS score emerged as a significant predictor of suicidal ideations in the suicide attempt group. In the suicide ideation group, although YMRS emerged as a significant predictor of suicide attempt in the enter method analysis, in the stepwise analysis it did not emerge as one of the most important variables. However, in the suicide attempt group, hopelessness emerged as the most important predictor of the severity of suicidal ideations, which is similar to the existing literature.[1574]

The present study has certain limitations, such as small sample size, purposive sampling, cross-sectional assessment, and inclusion of patients of depression with suicidal ideations and attempts. All the patients were assessed only once while they were symptomatic. It is quite possible that being symptomatic could have influenced their perception of their religiosity and spirituality. Other risk factors like personality which can contribute to suicidal behavior were not assessed. The influence of treatment on suicidal behavior was not assessed. It is quite possible that in some patients treatment of depression could have deterred the patients with suicidal ideations to make a suicidal attempt. Future studies must attempt to overcome these limitations.

CONCLUSIONS

To conclude, the present study suggests that there is no significant difference in the religiosity of patients of depression with suicidal ideation and suicidal attempt, except for higher use of negative religious coping by those who make suicide attempts. However, religiosity and spirituality in patients of depression with suicidal behavior (either suicidal ideation or suicidal attempt) are lower than healthy controls. In terms of religious coping, patients of depression more often use negative religious coping compared to healthy controls and less often use positive religious coping. However, when all the factors are taken together, to evaluate the risk factors for suicidal behavior, the present study further suggests that religiosity and spirituality play no role or a small role in actual suicidal attempts among patients with suicidal ideations.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.