Religious Beliefs May Affect Psychological Recovery After Cardiac Surgery

Laurie Barclay, MD

August 10, 2006

August 10, 2006 -- Faith-based, positive religious resources can help patients recover from cardiac surgery, according to findings from a study presented at the 114th annual convention of the American Psychological Association (APA). The study suggests that enhanced hope and perceived social support can protect psychological well-being during stressful procedures and experiences, whereas having negative religious thoughts and struggles may hinder recovery.

"Faith-based positive religious coping styles used in general lives may protect the psychological well-being of patients undergoing open-heart surgery," said Amy L. Ai, PhD, an associate professor of health sciences at the University of Washington in Seattle, and an affiliated researcher in integrative medicine and cardiac surgery at the University of Michigan Health System (UMHS) in Ann Arbor. "This positive effect was manifest through enhanced hope and perceived social support prior to stressful experiences, such as cardiac surgery. Having negative thoughts and faith-based struggles, which are not limited to patients with a religious faith, were related to poor postoperative recovery."

"This study found that religiousness probably led to positive religious coping, which in turn led to less psychological distress," Harold G. Koenig, MD, a professor of psychiatry and behavioral sciences and associate professor of medicine at Duke University Medical Center in Durham, North Carolina, told Medscape. Dr. Koenig was not involved in this study, but he reviewed it for Medscape as an independent expert. "The mechanism by which religious faith had this effect was explained by the fact that cardiac patients who used positive religious coping also had greater social support and hope."

Faith-Health Research

Dr. Ai described numerous objectives for this study. These included advancing the faith-health research area using clinical samples; differentiating positive and negative aspects of faith effects; identifying psychosocial mechanisms underlying faith effects and exploring the precise role of faith factors; and using better measures and sophisticated designs, such as longitudinal follow-up, adequate controls, and causal modeling.

Additional rationales underlying this research included the need to link both secular-based psychological theories and theology-based assumptions to test and to interpret faith effects; the need to offer clinically meaningful information concerning faith effects on health-related well-being for physicians and other healthcare professionals; and the need to pursue a better understanding of human nature, including the mind-body connection and its implications for health and mental health outcomes.

"As Jung once noted, scientists may have nothing to say about God or creation, yet faith-related phenomena (atheist or theist), as important aspects of human experiences, must be better understood through scientific evidence," Dr. Ai told Medscape. "The purpose of the faith-health research area is way beyond a narrow focus on making evident whether religion is a 'good-or-bad guy.' "

Between 1999 and 2002, Dr. Ai and coauthor Crystal Park, PhD, from the University of Connecticut in Farmington, studied patients aged 35 years or older undergoing nonemergent, nontransplant, major cardiac surgery at UMHS within the subsequent 8 weeks. Specific procedures included nonemergent coronary artery bypass graft, aneurysm repairs, and valve repair or replacement.

Patients underwent 3 interviews. The first took place several weeks before surgery and examined patient demographics, general religiousness, general health rating, and distress manifest in depression and anxiety symptoms. The second interview, conducted a few days before surgery, assessed hope, social support, and religious coping styles. The third interview was postoperative and evaluated distress in terms of depression and anxiety symptoms. Of 481 patients who completed the first face-to-face interview at the clinic, 309 patients completed all 3 interviews.

Positive and Negative Religious Coping

In this study, acts of positive religious coping were defined as religious forgiveness, seeking spiritual support, collaborative religious coping or fellowship with others who share the same beliefs, spiritual connection, religious purification, and thoughts of religious benevolence. Negative coping styles included spiritual discontent, thoughts of punishing God, insecurity, demonic thoughts, interpersonal religious discontent, religious doubt, and discontented spiritual relations.

Positive religious coping styles had positive effects on both hope and social support, whereas negative styles were inversely related to social support. Perceived social support and hope contributed to less depression and anxiety for postoperative patients who used positive religious coping styles. Negative, but not positive, religious coping styles were also directly related to postoperative distress. Religiousness contributed only to positive, and not to negative, religious coping styles, but there was no direct effect of religiousness on social support, hope, or postoperative distress.

Besides being related to poor postoperative recovery, the negative effect of religious doubts was also manifest through hopelessness and lower levels of perceived social support before stressful experiences such as cardiac surgery, according to Dr. Ai. She cited a previous 2-year longitudinal study (Pargament et al, Arch Intern Med. 2001;161:1881-1885) in which having religious struggles, linked to poor mental health, predicted mortality.

"If an early attention to these impacts can lead to appropriate intervention, long-term harm may be prevented," she said. "By clarifying the psychosocial mechanisms of potential protective and harmful faith influences, health and mental health professionals can work collaboratively on these key elements in order to enhance disease management and health promotion."

Dr. Ai noted that persistent mental health symptoms and some demographic influences were taken into account in her study, further confirming the observed effects of religious beliefs. General religiosity measures, such as frequencies of religious behaviors including church attendance, are often used in population studies, but these may not be sensitive in clinical cases in which patients are coping with severe crisis.

"Critics on research linking religion and health suggest that it is unethical for medical doctors to promote religion even if positive effects of religiosity are demonstrated," Dr. Ai said. "Indeed, by their education and secular training, often health professionals are in no position to recommend an increase of church attendance or prayer daily to their patients or clients in order to cope with their illness or distress, even based on positive evidence in large population studies. Yet, by distinguishing possible positive aspects of faith-based coping from negative ones in clinical studies, clinicians can well become alarmed about these differentiated impacts and thus pay greater attention to essential components in the client's coping system, both internal and external, under specific conditions."

Study Limitations

Study limitations include cross-sectional simultaneous evaluation of perceived social support,hope, and religious coping styles; reliance on self-report measures; potential confounding factors; lack of cardiac data; and possible lack of generalizability to other populations or to other stressful medical procedures.

"Hope and social support are concepts acceptable to professionals and patients with various belief systems," Dr. Ai said, noting that these factors are not only potential indicators of patient outcomes, but that they are deeply rooted in faith. "Faith distinguishes humans from animals and may contribute profound meaning to a patient's life. Through addressing these concerns, professionals may establish a more effective relationship with patients and can help motivate them in coping with disease-related distress."

The authors conclude that addressing patients' faith can touch a deeper level of their concerns, in contrast to simple manipulation of behavior patterns and regulation of negative emotions and expectations. Findings of this study suggest that integrating faith into mainstream psychology and health research may lead the way to better clinical evaluation and to develop more effective mind-body interventions in the future.

"There are many sensible reasons why professionals want to avoid faith issues: lack of clinical time, lack of training and knowledge to deal with them, avoidance of possible conflict, concern about potential ethical issues, scientific rejection of creationism or 'intelligent design,' etc," Dr. Ai explained. "One of the major problems lies in the lack of understanding why many more patients pursue faith for help than do professionals.... Spirituality is an important motivator for patients' efforts to cope and to strive despite the threat of diseases and mortality."

Directions for Future Research

Directions for future research recommended by Dr. Ai include more longitudinal studies of faith effects on objective health indicators in populations with chronic conditions; long-term studies of the effects of faith factors in cardiac patients; experimental trials of the efficacy of faith-related interventions, designed with the highest ethical and methodological standards; and basic science studies to explore potential biophysical mechanisms underlying faith effects.

"The aim of these studies will not be to verify any religious practices but to achieve better understanding of human nature and to promote health and well-being," Dr. Ai concluded.

"Studies that identify the mechanisms by which religion influences mental health outcomes, especially in high impact conditions such as postcardiac surgery, are crucially needed," Dr. Koenig said. "By using sophisticated statistical methods, Dr. Ai and her colleagues have helped to illuminate what may be an important aspect of the religion-mental health effect."

Dr. Ai reports no financial conflict of interest. Her research is supported by the National Institutes of Health/National Institute on Aging, National Center of Complementary and Alternative Medicine; the John Templeton Foundation; and the John Hartford Foundation.

APA 2006 Annual Convention: Session 1262 - Paper Session: Coping and Religion. Presented August 10, 2006.

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