Religious Service Attendance and Major Depression

A Case of Reverse Causality?

Joanna Maselko; R. David Hayward; Alexandra Hanlon; Stephen Buka; Keith Meador

Disclosures

Am J Epidemiol. 2012;175(6):576-583. 

In This Article

Abstract and Introduction

Abstract

Although previous studies have found a protective association between attendance at religious services and depression, the extent to which this association is driven by depressed persons' dropping out of religious activities is not clear. The authors examined whether early onset of a major depressive episode (MDE) predicted a subsequent decrease in religious service attendance. Data came from 3 follow-up studies of the National Collaborative Perinatal Project birth cohort (mean age = 37 years at last follow-up; n = 2,097; 1959–2001). The generalized estimating equations method was used to calculate the impact of an early MDE diagnosis (before age 18 years) on the likelihood of change in level of religious service attendance from childhood to adulthood. Twenty-seven percent of study participants met the criteria for lifetime MDE (n = 567), of whom 31% had their first onset prior to age 18 years. Women with early MDE onset were 1.42 times more likely (95% confidence interval: 1.19, 1.70) than women with adult-onset MDE or no lifetime MDE to stop attending religious services by the time of the first adult follow-up wave. No significant associations were observed among men. These findings suggest that women are more likely to stop attending religious services after onset of depression. Selection out of religious activities could be a significant contributor to previously observed inverse correlations between religious service attendance and psychopathology during adulthood.

Introduction

While there is considerable interest in the relation between religious activity and common mental disorders, research findings have been inconclusive because of methodological limitations (studies are typically cross-sectional) and the framing of hypotheses. Protective,[1,2] null,[3] or inverse[4] correlations with major depressive episode (MDE) or depressive symptoms have been reported and often depend on the study design, the religiosity variable used,[5] the age of the cohort studied, or the gender of the study participant. Weak study designs are prevalent. While many researchers and clinicians agree that spirituality and religiosity can be important in an individual patient's mental health, the potential biologic, psychological, and social processes linking spirituality/religiosity to mental health might be deleterious or salubrious depending on the circumstances. Even so, given surveys showing that patients want their doctors to consider their religiosity and spirituality,[6] clinicians have been urged to acknowledge the potential importance of spirituality in their patients' lives[7] and at least take a spiritual history.[8] However, more empirical evidence is needed to better understand the complex association between religious activity and psychopathology.

While religious activity may have a causal role in the development of depression, a key issue that plagues much of the research in this area is the question of selection, or reverse causation: People who start to become depressed may stop attending religious services, while others may become even more religiously active when they become depressed (see Figure 1). For example, disengagement from one's usual social activities is one of the common symptoms of MDE, so it is conceivable that the onset of a depressive episode would precipitate a decline in religious service attendance. Indeed, higher levels of depressive symptoms have been correlated with reporting negative social interactions at church,[9] which in turn are associated with church dissatisfaction and decreases in religious engagement.[10] This would induce an inverse correlation between church attendance and depressive symptoms, making church attendance appear protective. On the other hand, the presence of emotional problems may also increase the use of religiosity as a coping strategy,[11] which could translate into an increase in the frequency of religious activities. This would induce a positive correlation between religiosity and distress, a correlation that has been observed in studies of prayer and mental health,[12] as well as studies linking emotional distress to increased likelihood of a future religious conversion.[13] It has been well documented that religiosity often changes over the life course,[14] with especially important changes occurring during the transition to adulthood.[15] The extent to which either of the above-described scenarios plays out in the population could be a major driver of the observed religiosity-depression association.

Figure 1.

Causal and selection models of the relation between engagement in religious activity and first major depressive episode (MDE).

The majority of the studies finding beneficial prospective relations between religiosity and depression have used samples of adults in later middle adulthood or older adulthood.[1,16] Given that the median age of MDE onset is 32 years (with 25% of patients typically experiencing onset before age 19 years),[17] it is uncertain to what extent this reflects a genuine protective effect and to what extent it reflects a tendency for people with recurring episodes of depression to stop attending religious services earlier in life. Indeed, a recent review of psychiatric symptoms among adolescents revealed both protective and deleterious associations with religiosity,[18] suggesting the presence of bidirectional relations in this age group.[19] Even longitudinal studies limited to older adults are likely to be prone to selection effects, since one of the above-mentioned scenarios is likely to have already occurred. Therefore, a life-course perspective with data on religious activity and psychopathology spanning more than 1 stage of the life course is most optimal for understanding the complex association between religiosity and psychopathology.

In the present study, we addressed the issue of selection effects in the relation between religious activity and depression over time by analyzing religious service attendance from childhood to middle adulthood, together with information on the onset of MDE. In previous research with a subset of the current sample, current attendance at religious services was found to be correlated with lower lifetime odds of an MDE diagnosis.[20] In the current analysis, patterns of religious service attendance were examined among persons with early (before age 18 years), later (age 18 years onwards), and no lifetime diagnosis of MDE. Specifically, we hypothesized that persons with early depression onset would be more likely to change their levels of religiosity as they transitioned to adulthood. Given that the majority of persons in this sample attended religious services as children,[4] we expected the religious change to be in the direction of stopping religious service attendance. Furthermore, given known differences in depression and religiosity by gender,[21,22] all analyses were conducted separately for women and men.

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