Religion, Spirituality, Geriatric Mental Health: Research & Clinical Applications

Transcription

1 Religion, Spirituality, Geriatric Mental Health: Research & Clinical Applications Harold G. Koenig, MD Professor of Psychiatry and Associate Professor of Medicine Duke University Medical Center, Durham, North Carolina USA Adjunct Professor, King Abdulaziz University, Jeddah, Saudi Arabia Adjunct Professor, Ningxia Medical University, Yinchuan, People s Republic of China

2 Overview Session I Research Background (9:00-10:30) Definitions Use of religion to cope Review of early research (prior to 2010) Review of latest research at Columbia, Duke, etc ( ) Theoretical model to explain effects Further resources Break (10:30-10:40) Session II Clinical Applications (10:40-11:30) Reasons for addressing spirituality in geriatric mental healthcare How and when to address spirituality Duke - Adventist Health System Project Discussion (11:30-12:00)

3 Definition of Terms Religion Beliefs, practices, and rituals related to the Transcendent, where in Western traditions, the Transcendent is also called God, Allah, HaShem, or a Higher Power, or in Eastern traditions, may be called Vishnu, Krishna, Buddha, or Ultimate Reality. Religions usually have doctrines about life after death and rules to guide behavior. Religion is often organized as a community, but can also exist outside of an institution and may be practiced alone and in private. Secular Humanism Secular humanism views human existence without reference to religion, i.e., God, the transcendent, a higher power, or ultimate truth. The focus is on the rational self, science, & community as the ultimate source of power & meaning. Spirituality According to the traditional definition, spirituality was the core of what it meant to be religious, i.e., describing those who were deeply religious, living a life dedicated and surrendered to the Divine. The modern definition of spirituality, however, has become much broader, including not only those who are deeply religious, but those who are superficially religious & those who are not religious at all (secular humanists).

4 Important points to take away 1. Religion is more specific and easily measured and is a more useful construct when conducting research that seeks to identify specific characteristics of the individual that prevent disease or alter disease course. 2. Spirituality is an ideal term to use in clinical settings when talking to and engaging with patients, where patients should be allowed to define the term for themselves. However, it is not useful for conducting research given its vague, nebulous, and largely self-defined nature.

5 Sigmund Freud Future of an Illusion, 1927 Religion would thus be the universal obsessional neurosis of humanity... If this view is right, it is to be supposed that a turning-away from religion is bound to occur with the fatal inevitability of a process of growth If, on the one hand, religion brings with it obsessional restrictions, exactly as an individual obsessional neurosis does, on the other hand it comprises a system of wishful illusions together with a disavowal of reality, such as we find in an isolated form nowhere else but amentia, in a state of blissful hallucinatory confusion

6 Sigmund Freud Civilization and Its Discontents The whole thing is so patently infantile, so incongruous with reality, that to one whose attitude to humanity is friendly it is painful to think that the great majority of mortals will never be able to rise above this view of life.

7 Religion as a Coping Behavior 1. Many persons turn to religion for comfort when stressed 2. Religion used to cope with common problems in life, especially those experienced by older adults in the setting of physical and psychiatric illness 3. Religion often used to cope with challenges such as: - uncertainty - fear - pain and disability - loss of control - discouragement and loss of hope

8 Religious Coping - definition The use of religious beliefs or practices to cope with and make sense of negative life experiences (and sometimes positive ones, too). For example, in Western religious traditions, behaviors such as praying to derive comfort and hope in emotionally trying times; reading religious writings for inspiration and guidance; attending religious services to be uplifted by singing and worshiping together as a group; seeking support from members of one s congregation, or giving support to others for religious reasons. RC may also involve cognitive processes, including beliefs about a better life after death when pain and suffering will be no more, or beliefs in a loving, caring God who is in control, has a purpose for the world and individuals in it, and has the power to transform difficult circumstances so that good outcomes are possible. Thus, both behaviors and beliefs are involved in RC.

9 Self-Rated Religious Coping Moderate to Large Extent Large Extent or More % 22.7% Small to Moderate % None 0 5.0% 40.1% 10 The Most Important Factor

10 Stress-induced Religious Coping America s Coping Response to Sept 11th: 1. Talking with others (98%) 2. Turning to religion (90%) 3. Checked safety of family/friends (75%) 4. Participating in group activities (60%) 5. Avoiding reminders (watching TV) (39%) 6. Making donations (36%) Based on a random-digit dialing survey of the U.S. on Sept New England Journal of Medicine 2001; 345:

11 How Religion Influences Coping 1. Positive world view 2. Meaning and purpose 3. Psychological integration 4. Hope (and motivation) 5. Personal empowerment 6. Sense of control (prayer) 7. Role models for suffering (facilitates acceptance) 8. Guidance for decision-making (reduces stress) 9. Answers to ultimate questions 10. Social support (both human and Divine) Not lost with physical illness or disability

12 Example of Religious Coping (JAMA 2002; 288 (4): ) years old 2. Multiple serious medical problems 3. Chronic, progressive, unrelenting pain 4. Traditional medical treatments ineffective 5. Alternative medical treatments ineffective 6. Limited material resources lives alone 7. But, doing well psychologically 8. Positive, hopeful and optimistic 9. Functioning independently- without assist 10. Concerned with meeting others needs 11. How does she do it? Religion, she says

13 Religion How does it help to cope? "I don t dwell on the pain. Some people are sick and have pain and it gets the best of them. Not me. I pray a lot. I believe in God, and I give my whole heart, body, and soul over to him Sometimes I pray and I'm in deep serious prayer and all of a sudden, my pain gets easy. It slackens up and I drop off to sleep, and wake up and I can do things for myself. So prayer helps me a lot I give God my heart and soul and you don t have to worry about nothing. He leads you and directs you, and he takes care of you. And I believe in that. That is my belief."

14 Religious Coping does it really help?

15 Systematic Review of the Research 1887 to 2010 Handbook of Religion and Health (Oxford University Press, 2001, 2012) with some recent research ( ) highlighted

16 Depression The most common emotional disorder found in medical settings 20% with major depression 20% with minor depressive disorders Religious involvement is related to: Less depression, faster recovery from depression 272 of 444 studies (61%) [67% of best] More depression (6%)

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18 Religion/Spirituality and Cortical Thickness: A functional MRI Study Areas in red indicate reduced cortical thickness Religion NOT very important Religion very important Citation: Miller L et al (2014). Neuroanatomical correlates of religiosity and spirituality in adults at high and low familial risk for depression. JAMA Psychiatry 71(2):128-35

19 Is Emotional Disorder Different in the Religious? Is depression the same in those with deep religious faith? Even if depressed, research suggests that deeply religious people experience more positive emotions: -greater purpose and meaning -greater optimism and hope -more gratitude and thankfulness -more generosity Koenig HG, Berk LS, Daher N, Pearce MJ, Belinger D, Robins CJ, Nelson B, Shaw SF, Cohen HJ, King MB (2014). Religious involvement, depressive symptoms, and positive emotions in the setting of chronic medical illness and major depression. Journal of Psychosomatic Research 77:

20 Positive Emotions Beck Depression Inventory st 2nd 3rd 4th 5th Religiosity Quintiles 10

21 Religious Psychotherapy Study 132 persons with major depressive disorder and chronic medical illness (the majority over age 50) randomized to Religious CBT vs. Conventional Secular CBT 65 from Durham County, North Carolina (Duke University) 67 from Los Angeles County (Glendale Adventist) Ten 50-minute psychotherapy sessions by telephone over 12 weeks

22 5 religious-integrated psychotherapies: Christian Jewish Buddhist Muslim Hindu Manuals and workbooks now up on our Duke website: And soon to have a training video on website as well

23 Research Study for Treatment of Depression in Chronically Ill, Disabled Physiological Changes (Stress Hormones, Immunity, Inflammation) Chronic Physical Illness and Disability Religious Cogn-Behav Therapy Public prac, rit Private prac, rit Human Virtues Optimism, Meaning & Purpose vs. R commitment Gratefulness Altruism Dysfunctional Cognitions & Behaviors Major Depressive Disorder Conventional Cogn-Behav Therapy R experiences R coping Generosity Social Support Genetic Influences Demographic Influences Age, Race, Gender, Education

24 Mean BDI score 28 Results CCBT RCBT Baseline Week4 Week8 Week12 Week24 Time Group by time interaction B=0.50, SE=0.55, t=0.91, p=0.36, Cohen s d=0.10, favors RCBT Koenig et al. Journal of Nervous and Mental Disease 2015; 203(4):

25 Depressive Symptoms (BDI) 30 Conventional CBT Religious CBT Week Treatment response in those with HTR1A genotype C/C (B for group by time interaction=3.33, SE=1.17, df=62, t=2.86, p<0.01, n=28, Cohen s d=0.73, in those with low religiosity) Koenig et al. Austin Journal of Psychiatry & Behavioral Sciences 2015; 2(1): 1036

26 Difference significant between RCBT and SCBT at 12 week f/u (t=-2.10, p=0.038) in per-protocol analysis Koenig et al. Depression & Anxiety 2015, in press

27 Suicide (systematic review) Religious involvement is related to: Less suicide and more negative attitudes toward suicide (106 of 141 or 75% of studies) Why? A religious worldview gives people a reason for living it gives life meaning -- especially those with chronic disabling medical illness, or faced with life-threatening medical diagnoses

28 Alcohol Use/Abuse/Dependence (systematic review) Religious involvement is related to: Less alcohol use / abuse / dependence 240 of 278 studies (86%) [90% of best]

29 Illicit Drug Use (systematic review) Religious involvement is related to: Less drug use / abuse / dependence 155 of 185 studies (84%) [86% of best] [95% of RCT or experimental studies]

30 Loss of Faith and PTSD Symptoms 1,385 veterans from Vietnam (95%), World War II and/or Korea (5%) involved in outpatient or inpatient PTSD programs. VA National Center for PTSD and Yale University School of Medicine. Weakened religious faith was an independent predictor of use of VA mental health services independent of severity of PTSD symptoms and level of social functioning. Investigators concluded that the use of mental health services was driven more by their weakened religious faith than by clinical symptoms or social factors. Fontana, A., & R. Rosenheck. Trauma, change in strength of religious faith, & mental health service use among veterans treated for PTSD. Journal of Nervous & Mental Disease 2004; 192:

31 Treating Moral Injury in PTSD (seeking funding support) Spiritually-oriented Cognitive Processing Therapy (SOCPT) for Moral Injury in older Veterans/Active Duty U.S. Military with PTSD or sub-threshold PTSD Now conducting un-funded pilot studies at Charlie Norwood VAMC, Durham VAMC, San Antonio VAMC, and Houston VAMC Seeking $300,000 to conduct pilot study involving SOCPT vs. Conventional Secular CPT in 75 older Veterans with PTSD symptoms (often revived when sick) Ultimate goal is a multi-center study to establish SOCPT as an evidence-based treatment for moral injury in PTSD (using psychologists), and then develop a version for VA chaplains and train them to administer it

32 Well-being and Happiness (systematic review) Religious involvement is related to: Greater well-being and happiness 256 of 326 studies (79%) [82% of best] Lower well-being or happiness (<1%)

33 Well-being Religion and Well-being in Older Adults Religion and Well-being in Older Adults The Gerontologist 1988; 28:18-28 The Gerontologist 1988; 28:18-28 Low Mode rate High Ve ry High Church Attendance or Intrinsic Religiosity Religious categories based on quartiles (i.e., low is 1st quartile, very high is 4th quartile)

34 Meaning, Purpose, Hope, Optimism (systematic review) Religious involvement is related to: Greater meaning and purpose 42 of 45 studies (93%) [100% of best] Greater hope 29 of 40 studies (73%) Great optimism 26 of 32 studies (81%) *All of the above have consequences for older adults motivation for self-care and efforts toward recovery*

35 Social Support (systematic review) Religious involvement is related to: Great social support (61 of 74 studies) (82%)

36 The Relationship between Religion and Health: All Studies C NG (NG) M (P) P NA C NG (NG) M (P) P NA Number of studies includes some studies counted more than once (see Appendices of 1 st and 2 nd editions). Prepared by Dr. Wolfgang v. Ungern-Sternberg

37 Models and Mechanisms How might religion influence health in later life? Theoretical model involving causal pathways and constructs along pathways that help explain the religion-health relationship next slide

38 Immune, Endocrine, Cardiovascular Functions Physical Health and Longevity Theoretical Model of Causal Pathways (c) Handbook of Religion & Health, 2nd ed Spirituality Decisions, Lifestyle Choices, Health Behaviors faith community Public prac, rit Positive Emotions SOURCE Belief in, attachment to God Theological Virtues: faith, hope, love Private prac, rit R commitment R experiences Psychological Traits / Virtues Forgiveness Honesty Courage Self-discipline Altruism Humility Gratefulness Patience Dependability Social Connections faith community R coping Negative Emotions Mental Disorders Genetics, Developmental Experiences, Personality *Model for Western monotheistic religions (Christianity, Judaism, and Islam)

39 Research now being done to understand the underlying biological mechanism that may help explain WHY religious involvement is related to better physical health in later life and greater longevity

40 Duke Stressed Caregiver Study 251 family caregivers (ages 40-75) caring for severely disabled family member 151 from Durham, North Carolina (Duke) 100 from Los Angeles County (Glendale Adventist) Outcomes: (1) develop new 10-item comprehensive and sensitive measure of religious commitment (2) examine religiosity and caregiver adaptation (3) examine religiosity and caregiver telomere length

41 Poor Caregiver Adaptation (depressive symptoms, perceived stress, caregiver burden) Caregiver Adaptation (low scores indicate better adaptation) Deciles of Religious Involvement Koenig et al. (2016). Journal of the American Geriatrics Society, in press (January)

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43 Telomere Length (bp) Age, years

44 Religious involvement and Telomere Length Results: Pending

45 Conclusions 1. Religion is easier to measure than spirituality, so most of the research supporting clinical applications in geriatric mental health care has to do with religious involvement 2. Religion is commonly used by older adults to cope with chronic medical illness and psychiatric illness 3. Religious involvement is associated with less emotional disorder, greater well-being, less substance abuse, and greater social support especially in older adults 4. Consequently, religious involvement is also related to better physical health and greater longevity

46 Further Resources

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48 Oxford University Press, 2012

49 June 2014

50 Monthly FREE e-newsletter CROSSROADS Exploring Research on Religion, Spirituality & Health Summarizes latest research Latest news Resources Events (lectures and conferences) Funding opportunities To sign up, go to website:

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52 Summer Research Workshop August 15-19, 2016 Durham, North Carolina 5-day intensive research workshop focus on what we know about the relationship between spirituality and health, applications, how to conduct research and develop an academic career in this area. Leading spirituality-health researchers at Duke, Yale University, Johns Hopkins, and elsewhere to give presentations: -Strengths and weaknesses of previous research -Theological considerations and concerns -Highest priority studies for future research -Strengths and weaknesses of measures of religion/spirituality -Designing different types of research projects - Primer on statistical analysis of religious/spiritual variables -Carrying out and managing a research project -Writing a grant to NIH or private foundations -Where to obtain funding for research in this area -Writing a research paper for publication; getting it published -Presenting research to professional and public audiences; working with the media Partial tuition Scholarships are available If interested, contact Dr. Koenig: Harold.Koenig@duke.edu

53 Discussion (till 10:30) Break 10:30-10:40

54 10:40-11:30 Time is NOW to Start Addressing Spiritual Issues in Geriatric Mental Health Care

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56 Reasons for Doing So 1. Many older adults have spiritual needs and religious beliefs related to psychiatric illness that influence satisfaction with care, healthcare costs, and compliance with psychiatric treatment 2. Religion influences coping with illness and affects the older adult s emotional state and motivation to recover 3. Emotional state likely influences physical health outcomes, which in term may affect depression, anxiety or other emotional problems 4. Religious beliefs influence older adults decisions about mental health care, especially compliance with treatments (and can negatively influence it unless religious beliefs are addressed) 5. Standards of care (JCAHO) require respect for patients cultural and spiritual beliefs, especially in substance abuse treatment and behavioral health

57 Applications in Geriatric Mental Health Care Mental Health Professionals (MHPs) should take a spiritual history -- explore these issues with their older patients Respect, value, support beliefs and practices of the patient Identify (A) spiritual issues involved in the mental health disturbance, (B) spiritual resources, and (C) spiritual needs Ensure that someone meets patient s spiritual needs (as part of mental health care provided or by referral to pastoral counselor) Pray with older patients if patient requests (be sensible, though) From: Spirituality in Patient Care (Templeton Foundation Press, 2013)

58 Contents of the Spiritual History 1. Do your spiritual or religious beliefs provide comfort? If no, did they ever? If yes, how? 2. Are your spiritual or religious beliefs a source of stress, or in some way related to what you are going through now? 3. Do you have religious beliefs that might influence your decisions about taking medication or receiving psychotherapy? 4. Are you a member of a faith community, such as a church, synagogue, or mosque? If yes, is it supportive? If not, was this ever a source of support (and if so, why are you not involved now)? 5. Do you have any other spiritual concerns that you d like to talk about? (either with me or with a pastoral counselor) 1 Adapted from Koenig HG (2002). JAMA 288 (4):

59 Challenges to Addressing Spirituality Issues In Geriatric Mental Health Care 1. Increased volume of psychiatric knowledge (that MHP is responsible for) 2. Increased need to document and deal with Electronic Medical Record 4. Increasingly complex medical problems that go with chronic illness in an aging population 5. Must also address needs of the caregiver / family 6. Increased time spent dealing with insurance companies, and their growing reluctance to pay for medications 7. Greater and greater struggle to get reimbursed from Medicare 8. More and more patients to see in less and less time (patients more and more dissatisfied, increased pressure of lawsuits)

60 The Result: 1. MHPs feeling harried and time-pressured 2. Medical errors, unnecessary tests, reduced patient compliance 3. MHP has problems at home because of demands of work 4. Work becomes just a job for pay 5. Lost sense of calling or why went into mental health profession 6. Not caring anymore 7. Coping by turning to alcohol or drugs 8. Burnout no time, no desire, and no capacity to provide whole person geriatric mental health care

61 Inquiring about and addressing the spiritual aspects of mental health care depends not only on psychiatrists and other mental health professionals The Health Care System must make it possible to inquire about and address Spiritual Issues as part of Geriatric Mental Health Care

62 Hospital System Changes that might facilitate MHPs inquiring about and addressing spiritual issues 1) Give MHP the time to address the mental, social, and spiritual needs of older adults (i.e., fewer patients) 2) Hire adequate staff that can help with doing the busywork (documentation, checks, assistance with EMR, writing prescriptions, etc.) so that this does not use up precious MHP time 3) Focus on scheduling, decrease no shows, improving patient flow, structure clinic setting in a way that minimizes MHP downtime, simplify EMR 4) Hire adequate numbers of social workers and pastoral counselors who are trained to address the spiritual/religious needs of elders 5) And provide training on why, how, and when to address spiritual issues in the mental health care of older adults

63 Duke Adventist Health System Project

64 The Spiritual Care Team: Health professionals integrating spirituality into whole person health care together

65 Spiritual Care Team 1. The psychiatrist/psychologist may have very little time or training to address older adults spiritual issues. Therefore, other team members need to take up the slack by providing practical assistance and support. 2. The Spiritual Care Team includes mental health staff such as the nurse, clinic manager, receptionist, social worker, and chaplain (or pastoral counselor); will vary depending on setting 3. Each member of the spiritual care team has a specific role to play --- to enable the provision of whole-person geriatric mental health care to patients and caregivers

66 What does providing whole person geriatric mental health care look like? 1. The psychiatrist or lead mental health clinician conducts a spiritual history in order to identify and document spiritual issues likely to influence care 2. Spiritual needs are addressed by someone, and follow-up occurs to ensure that spiritual issues are addressed 3. An atmosphere is created that is open to discussing this subject with older patients and doing so in a supportive manner, recognizing the benefits to health and well-being

67 Spiritual Care Team Members and Roles 1. Psychiatrist/Psychologist identifies and documents spiritual issues, resources and needs takes spiritual history 2. Spiritual care coordinator coordinates the addressing of spiritual needs (if psychiatrist/psychologist not trained) 3. Nurse/s assists (or is) the spiritual care coordinator 4. Chaplain or pastoral counselor - addresses the spiritual issues and/or needs of the patient [depending if available] 5. Social worker - works with other team members to develop long-term plan and arrange for long-term follow-up 6. Receptionist/other clinic staff ensures religious affiliation in EMR

68 Lead Mental Health Professional 1. Conducts a spiritual history 2. Documents responses (in EMR, if privacy can be assured) 3. Ensures someone addresses spiritual issues identified 4. Is willing to discuss spiritual concerns related to psychiatric care with patient and/or family 5. Follows up to ensure that spiritual issues are addressed

69 Spiritual Care Coordinator (often a nurse or clinic manager) 1. Duties - obtains information from spiritual history - coordinates the addressing of spiritual needs - prepares patient for pastoral care referral, if needed - provides spiritual support to other team members 2. Training - reads Spirituality in Patient Care (Templeton Press, 2013) - watches all 5 CME videos and is familiar with content 3. Person best suited for this role - has a strong, active spiritual life - is a strong leader, but gentle and sensible - has good relationship with other mental health professionals - has good relationship with other team members & patients

70 Role of the Chaplain / Pastoral Counselor 1. The only person on the spiritual care team trained to address the spiritual needs of patients 2. After receiving a referral, the chaplain will do a comprehensive spiritual assessment (different from MHP s) 3. The chaplain will clarify spiritual needs and then come up with a spiritual care plan to address those needs 4. The chaplain will work with the social worker to implement the spiritual care plan after hospital discharge or following clinic visit, and follow up to ensure needs are met 5. The chaplain will work with Spiritual Care Coordinator to meet the spiritual needs of members of the team

71 Working Together to Achieve Common Goals 1. Each member of the spiritual care team has a specific responsibility 2. Assuming each member of the spiritual care team does his or her job, the following goals will be achieved: Patients spiritual needs related to psychiatric care will be identified Those needs will be addressed effectively Whole person geriatric mental health care will be delivered An atmosphere will be created where the patient/family feels free to discuss spiritual issues related to psychiatric care MHP time is minimized Each member of the team will feel emotionally and spiritually supported by one another

72 Conclusions There are many scientific, financial, and common sense reasons for assessing & addressing spiritual issues in geriatric mental health care But, there are many challenges to doing so, often related to lack of time and MHP s discomfort with subject Lack of training is the most important barrier The Health Care System has a role to play in enabling MHPs to address older adults spiritual issues in mental health care Collaboration as a team is essential for success

73 Discussion (till 12:00)