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Presented in this chapter are selected recent studies that have been chosen to illustrate the type of research now being reported in the literature. These studies are again reported in categories of mental health outcome: coping with stress, depression and anxiety, alcohol and drug use/abuse, psychological well-being, quality of life, personality traits, and studies of Buddhist interventions. The chapter ends with unpublished original research that (1) compares the mental health and well-being of Buddhists with that of those with other religious affiliation (Christian, Muslim, Hindu, etc.) and those with no religious affiliation, and (2) examines associations between religiosity and well-being in Buddhists using data from large national and cross-national surveys conducted primarily in East Asia.
Several quantitative scales measuring Buddhist beliefs/practice have been developed over the past 10 years, greatly facilitating future research in this area. Besides the 11-item Buddhist Beliefs and Practices Scale (Emavardhana & Tori, 1997) discussed in the last chapter, those newer scales include the 66-item Buddhist COPE that assesses 14 types of Buddhist coping behaviours (Phillips et al., 2012); the 30-item Measure of Nonattachment that examines grasping or clinging behaviour among Buddhists (Sahdra et al., 2010); and the 24-item Scale of Attitude toward Buddhism that measures positive and negative beliefs about Buddhism (Thanissaro, 2011). Although not used often, these are tools that researchers may use in the future to quantify Buddhist belief and activity in order to examine relationships with mental health outcomes. Caution, though, is needed when using these scales since, as with other spirituality scales, many of the items on these scales include indicators of positive mental health, resulting in measurement contamination and tautological, un-interpretable relationships with mental health outcomes (Koenig, 2008; Tsuang & Simpson, 2008; MacDonald, 2017). Fortunately, most studies described below did not use these scales, instead choosing specific Buddhist beliefs and practices in order to examine their relationship to mental health.
Coping with Stress
Cook and Hayes (2010) surveyed 154 Asian American and 154 Caucasian American college students at the University of California, Davis, comparing coping styles between the groups: (a) acceptance of emotions and willingness to take action (Hays et al.’s Acceptance and Action Questionnaire), (b) resignation acceptance due to fate (Resignation Acceptance Questionnaire), (c) tendency to suppress unwanted thoughts (Bear Suppression Inventory), and (d) attempts to control unwanted thoughts (Thought Control Questionnaire). Psychological health was measured by the Fear of Sadness Scale and Symptom Check List-90-R. Results indicated that Asian American students scored significantly lower than Caucasian students on psychological acceptance, but significantly higher on resignation acceptance. Negative psychological symptoms (indicated by a score of 65 or higher on the SCL-90-R) were also significantly higher among Asian American students (63%) compared to Caucasian students (34%). Asian Buddhists (n=27) were not more psychologically healthy than Asian Christians (n=72) nor were there any differences in psychological coping styles (Buddhists were not more self-accepting despite Buddhist teachings). Among Asian Buddhists, frequency of religious practice was not correlated with greater psychological acceptance.
Falb and Pargament (2013) surveyed 92 Buddhist end-of-life caregivers in the U.S. identified through contemplative caregiver training programs and a Buddhist chaplaincy listserv. Participants were 89% Caucasian, 78% with post-graduate degrees, and 67% female. Caregiver identities were 29% clergy, 25% medical professional, 20% volunteer, and 19% family or friend. The purpose was to identify positive and negative Buddhist coping behaviours and their relationship to spiritual well-being (SWB) (assessed by the FACIT-Sp), burnout (Maslach Burnout Inventory, MBI), depression (CESD), and posttraumatic growth (PTG Inventory). Phillips et al’s 66-item Buddhist COPE was used to assess Buddhist coping behaviours. Controlled for in analyses were number of months of caregiving, age, self-rated spirituality, months meditating, and participating in a contemplate caregiver training program. Regression analyses identified independent correlations between the 14 Buddhist coping subscales and 7 mental health outcomes (a total of 98 analyses). Results indicated significant associations between BCOPE subscales and mental health outcomes: BCOPE “morality” subscale with lower MBI depersonalisation (B=-0.35) and greater PTG (B=0.37); the BCOPE “mindfulness” subscale and greater SWB (B=0.36); the BCOPE “dharma” subscale and lower PTG (B=-0.40); the BCOPE “impermanence” subscale and both less MBI exhaustion (B=-0.37) and greater PTG (B=0.38); the BCOPE “inner being” subscale and greater MBI exhaustion (B=0.44); the BCOPE “not self subscale and less MBI exhaustion (B=-0.36); and especially the BCOPE “bad Buddhist” subscale and greater MBI exhaustion (B=0.34), lower SWB (B=-0.19), and higher CESD (B=0.33). No other significant relationships (p<0.05) were found between individual BCOPE subscales and mental health outcomes. Overall, then, positive BCOPE subscales were associated with less burnout and greater spiritual well-being, whereas negative BCOPE subscales were correlated with less SWB and greater depression.
Anxiety, Depression and Suicide
Philips et al (2012)’s original validation study of the BCOPE examined associations with mental health outcomes in 869 non-Asian Buddhists in the U.S. (39% Mahayana, 34% Varayana, 21% Theravada). Participants were 55% female, average age 46 years, and 87% Caucasian. Associations between BCOPE subscales, anxiety and depression were examined, after controlling for demographic and general spiritual characteristics (i.e., years practicing Buddhism and self-rated spirituality). The BCOPE “bad Buddhist” subscale (wished could stop judging self; forced things instead of accepting them) was associated with greater anxiety and greater depression; the “fatalistic karma” subscale (felt powerless since karma caused event; helpless since situation due to karmic past) with more depression; and the “impermanence” subscale (reminded self that stress would pass; recognised all things change) with less depression (all <0.001).
In the validation study of the Nonattachment Scale (conducted in U.S. college students), Sahdra et al., 2010 also found moderately strong inverse associations between nonattachment scores and both depression (r=-0.27, p<0.01) and anxiety (r=-0.35, p<0.01). As indicated earlier, some of the positive relationships reported in both the Phillips et al and Sahdra et al studies are likely due to inclusion of items assessing positive mental health constructs in these Buddhist scales.
Death anxiety. Hui and Coleman (2012) surveyed 141 older adults Hong Kong Chinese Buddhists to examine the relationship between reincarnation beliefs and death anxiety, hypothesising that belief in reincarnation would protect from death anxiety. Chinese Buddhists age 55 or older who had taken the Three Refuges (Buddha, Buddha Dharma, and Sangha) were eligible to participate. Approximately half of the sample was ages 55-59 years old, 68% were female, 62% were married, and 57% were retired. Reincarnation beliefs were assessed using an 8-item Buddhist Reincarnation Beliefs Scale, which assessed belief in karma as the determinant of the next rebirth, reincarnation as imprisonment, and the possibility of transcending reincarnation. The 15-item Chinese Death Anxiety Scale was used to assess anxiety surrounding death and dying. Results indicated that participants had on average a strong belief in reincarnation and a low level of personal death anxiety. However, no association was found between reincarnation belief and death anxiety either in the overall sample or the sample dichotomised by age group. Researchers hypothesise that the lack of relationship might be because “Buddhists view reincarnation not as a solace but rather as a renewal of sufferings due to unwholesome karma” (p 949).
Wong and colleagues (2015) surveyed 123 Christians and 137 Buddhists (matched on demographic characteristics) living in Hong Kong, comparing the two groups on religiosity and death attitudes. Adults (ages 18 to 80) were invited by their religious congregations to fill out a questionnaire; response rates were 94% for Buddhists and 77% for Christians. Religiosity was assessed with the 14-item Intrinsic/Extrinsic-Revised Scale (I/E-R), and death attitudes by the 32-item Revised Collett-Lester Fear of Death and Dying Scale and by the 32-item Death Attitude Profile-Revised Scale (DAP-R). Also measured were stressful life events within the past two years (death of close friend or relative, serious illness of close friend or relative, or presence of serious life-threatening illness), current physical illnesses, mental health (General Health Questionnaire), and demographics (age, education, etc.). Regardless of religion, higher levels of intrinsic religiosity (religion as an end in its self) were associated with lower levels of fear of death and dying, and higher levels of death acceptance. Likewise, regardless of religion, extrinsic religiosity (religion as a means to achieve other ends) was associated with greater fear of death and dying. Christians scored higher on fear of death and dying then Buddhists, although differences were small (2.96 vs. 2.85, p<0.05). Extrinsic religiosity was unrelated to death acceptance for Christians but significantly predicted death acceptance and death avoidance in Buddhists. Thus, more extrinsically religious Buddhists were more likely to accept death and to avoid death. Researchers concluded that intrinsic religiosity protected both Buddhists and Christians from fear of death and helped them to accept death, although attributed differences in the belief systems of Buddhists and Christians to explain the associations with extrinsic religiosity among Buddhists (note however the difference in these findings and those of Tapanya and colleagues (1997) discussed in the last chapter).
Depression. Roemer (2010a) analysed data from a random sample of 600 Japanese adults living in the Kyoto Prefecture, examining the relationship between religious beliefs and depressive symptoms in this largely Shinto-Buddhist population (over the years, Shintoism and Mahayana Buddhism in Japan have become closely interwoven). Religious involvement was assessed by a 6-item Religious Coping Index (RCI) (i.e., religion provides comfort and peace, praying purifies me, kami-hotoke helps me, kami-hotoke gives aid, kami-hotoke protects me, kami-hotoke curses people). Also assessed were ownership of a household ancestor alter (Butsudan) or Shinto shrine (kamidana), frequency of rituals conducted there, frequency of visits to ancestral grave-sites, belief in the existence of kami or hotoke, importance of respecting ancestors, and religiousness (belief that “faith [shinko] and religiousness [shukyoteki na koto] are important for mental and physical health”). Depressive symptoms were assessed with the 10-item Japanese CESD. After controlling for socio-demographic variables and health characteristics, RCI score (religious coping) was positively related to depressive symptoms (B=0.12, p<0.01). Ownership of a Shinto altar was also positively associated with depression (B=0.07, p<0.05), as was belief in the existence of kami (gods, deities, spirits) and hotoke (ancestors, buddhas) (B=0.13, p<0.01) and belief that ancestors should be respected (B=0.15, p<0.001). The only religious characteristics inversely related to depression were ownership of an ancestor altar and frequency of making ancestor grave site visits (both B=-0.16, p<0.01). Religiousness was not associated with depression. Roemer concluded that: “Overall, there is strong evidence that certain dimensions of religiousness are associated with well-being in Japan, and as the results of this study revealed, these connections are mainly harmful” (p 579). This statement, however, goes considerably beyond what can be said from these cross sectional data.
Xue and colleagues (2016) at the Ragama Rheumatology and Rehabilitation Hospital in Sri Lanka surveyed 61 inpatients (85% Buddhist) with traumatic spinal cord injury (SCI). Measures included the SCI Independence Scale, the 6-item Benefit through Spirituality/Religiosity Scale, Sheehan Disability Inventory, and Beck Depression Inventory (BDI). Linear regression was used to examine predictors of depressive symptoms, controlling for sociodemographic variables. Over 40% of participants scored in the significant depression range of the BDI. The only predictors of depressive symptoms were degree of impairment in physical functioning (B=0.54, p<0.001) and benefit through S/R activities (B–0.31, p<0.05). Researchers concluded that “The findings emphasise the need for rehabilitative programming to support patients’ S/R activities and mental well-being, promoting reintegration into their community roles” (p. 1158).
Suicide. I was able to locate eight reports published since 2010 on religion and suicide in Buddhist majority countries (or where Buddhism was the majority religion among those affiliated with a religion). Three reports involved cross-national studies, and of the other five studies, all five were conducted in China. In the first cross-national study, Stack and Kposowa (2011) analysed data from a random sample of over 50,000 people participating in the World Values Survey, Wave 4, finding that suicide acceptability was significantly lower in Buddhists than in those with no religious affiliation (B=-0.181, p<0.01), a finding that persisted after controlling for religiosity and numerous demographic controls. However, in a later analysis of WVS Wave 4 data (using a smaller sample of 42,299), no association was found with suicide acceptability either (a) at the individual level between Buddhist affiliation and no affiliation or (b) at the country level (percentage Buddhist) (Boyd & Chung, 2012).
The other cross-national study by Peltzer and colleagues (2017) surveyed 4,675 undergraduate students in Cambodia, Indonesia, Malaysia, Myanmar, Thailand and Vietnam, examining likelihood of ever having suicidal ideation or make a suicide attempt. Three-quarters of the sample were from Buddhist-majority countries. Overall, those with higher organisational religiosity (attending religious services) were significantly less likely to have experienced suicidal ideation, although no difference was found for any measure of religious involvement and suicide attempt.
In the first of the five studies conducted in mainland China, Li and Phillips (2010) surveyed 629 college students along with other community groups in Eastern China. In the college student sample, researchers assessed presence of religious belief (yes vs. no), and if yes, asked about religious affiliation (35 out of 48 students with a religious affiliation were Buddhist). Acceptability of suicide was measured using a 25-item scale assessing the acceptability of suicide in a variety of situations. Presence of religious belief (any) was associated with increased acceptability of suicide.
Wang and colleagues (2015) examined suicidal ideation and behaviour in a population-based sample of 2,769 community-dwelling adults in Western China, finding no association between religious affiliation and suicidal thoughts or behaviours. Likewise, Zou and colleagues (2016) surveyed a representative sample of 983 urban and rural adults from northeastern China, finding that religious belief was again unrelated to attitudes toward suicide. Hong and colleagues (2016) surveyed 15,957 adults age 60 years or older from across China; religiosity was assessed by asking respondents if they were religious and then if yes, what their religious affiliation was. Results indicated that Christians (17% of the sample) were more likely than those with no religious affiliation to attempt suicide in last 12 months. However, there were no differences in suicidal thoughts or attempts between Buddhists (34.3% of the sample, i.e., the most common religious group) and those with no religious affiliation.
Sun and Zhang (2017) compared 791 medically serious suicide attempters with 791 controls aged 15-54 years in rural areas of North and South China, finding that religious belief was somewhat more common among male suicide attempters; however, once other risk factors were taken into account, the difference in religious belief decreased to non-significance. Specific religious affiliation was not given.
Thus, the overall trend is no association between religious belief and suicidal ideation in Buddhist-majority samples (5 of 8 studies), although one study found increased acceptability of suicide and two other studies found decreased suicidal ideation or suicide acceptability (both cross-national studies). In conclusion, more recent studies generally find little relationship between religiosity and suicidal ideation, attempts, or acceptability in Buddhists (despite theoretical considerations that might anticipate higher suicide rates or acceptability in Buddhists).
Alcohol and Drug Use/Abuse
Chamratrithirong and colleagues (2010) surveyed a random sample of 420 pairs of parents and teens from the Bangkok (Thailand) metropolitan area to examine the effects of family spiritual beliefs/practices on substance use and sexual behaviours of adolescents ages 13-14 year. Data were utilised from the 2007 Thai family Matters Project. Buddhist spiritual beliefs in adolescents and parents were assessed by “perception of the importance of religion to self” (44% of adolescents indicating “a lot”), “belief in the help of religious prayer or meditation (31%), and “belief in reincarnation and in the law of karma” (25% for belief in reincarnation and 47% for belief in karma). Buddhist spiritual practices were assessed by “regular religious prayer or meditation” (34%), “religious prayer or meditation when life is stressful” (14%), “practices of merit making including Tamboon (donation) and Saihart (offering food to monks)” (7%), and “observation of the Five Precepts including abstinence from killing, stealing, sexual misconduct, lying, and substance use” (10%). Results indicated that spiritual beliefs and practices (SBP) of teens were not related to alcohol use once parental monitoring and age were controlled for. However, parent (but not teen) spiritual beliefs (B=-0.057, p<0.05) and practices (B=-0.063, p<0.05) were related indirectly to lower cigarette smoking. Neither parent nor teen SBP were related to sexual intention; however, concerning pre-sexual behaviours, parents’ spiritual beliefs (B=-0.044, p<0.001), parents’ spiritual practices (B=-0.041, p<0.01), and teens’ spiritual beliefs (B=-0.079, p<0.01) were indirectly or inversely related, and teen spiritual practices were directly and inversely related (B=-0.14, p<0.01).
Wongtongkam et al (2014) examined a sample of 1,778 Thai adolescents (97% male) attending public technical colleges in Bangkok (capital city of Thailand) and Nakhon Ratchasima (rural province). Religiosity was assessed as one of 12 peer/individual domains possibly influencing alcohol or drug use. Again, higher religious involvement was associated with a 38% decreased risk of using alcoholic beverages, after adjusting for age, gender, grade completed, enrolment department, daily income, and family income (OR=0.62, 95% CI 0.41-0.95). Religiosity was not associated with other illicit drug use (sniffing glue, cocaine, marijuana, methamphetamine, heroin, ecstasy), although the prevalence rate was low (2%).
In perhaps the methodologically most rigorous study of predictors of problematic alcohol use in a Buddhist country, Assanangkornchai and colleagues (2010) analysed data from the Thai National Household Survey for Substance and Alcohol Use that surveyed a random national sample of 26,633 persons aged 12-65 years from across Thailand. A standard measure for assessing alcohol use (the AUDIT) was administered to participants, 91% of whom were Buddhist. Results indicated that 63% were lifetime abstainers (i.e., never drank more than one or two alcoholic drinks in their lifetime), and 29% were current drinkers. Based on AUDIT scores, 7% were classified as moderate level problem or harmful drinkers, and 0.6% as very severe-level problem drinkers or probable alcohol dependence. Although level of religious involvement was not assessed, Buddhist religious affiliation was associated with a greater likelihood of experiencing hazardous-harmful drinking, independent of gender, age, education, marital status, occupation, household area, and region of the country (members of other religious affiliations were at significantly lower risk compared to Buddhists; adjusted OR=0.70, 95% CI 0.55-0.92).
Psychological Well-Being
Roemer (2010b) analysed data from 14,322 participants surveyed during the 2000-2005 Japanese General Social Surveys (combined samples from these years). These are random national samples of Japanese adults. Participants were asked “Do you have a religion you believe in?” Three possible response were “yes,” “I don’t really believe [in one], but I have a family religion,” and “no.” If yes, participants were asked their religion: Buddhism (4.5%, n=547), New Religion (3.3%, n=402), Christianity (0.9%, n=114), and other (0.9%, n=105). Somewhat surprisingly, 90.4% (n=10,957 of 12,121) indicated they had no religion in which they personally believed. All participants (n=14,186) were asked to rate their level of devotion to their religion on a scale ranging from 0 (none) to 3 (devoted). Subjective well-being was assessed by life satisfaction (0 dissatisfied to 4 satisfied) in the domains of leisure activities, family life, friendships, household income, and area of residence. Summing responses each domain resulted in a life satisfaction index ranging from 0 to 20. Happiness was measured by a single item with responses ranging from 1 (unhappy) to 5 (happy). After controlling for sociodemographic variables, health, status, hobbies, social class, marital and employment status, results indicated that level of religious devotion was positively related to life satisfaction (B=0.28, p<0.001) Likewise, compared to those with no religion, Buddhists (B=0.50, p<0.01), New Religionists (B=0.37, p<0.05), and Christians (B=1.01, p<0.01) were all more likely to e satisfied with life. The same finings were noted for happiness, causing the researcher to conclude that “… this study reveals that religious devotion and affiliation with certain religions are positively and significantly correlated with life satisfaction and happiness in Japan” (p 411). These results (and conclusion) are quite different from the Roemer (2010a) report on religion and depression in Japan summarised earlier.
Liu and colleagues (2012) examined the association between religious involvement and happiness in a random sample of 1,881 adults living in Taiwan who participated in the Taiwan Social Change Survey. Average age of participants was 43 years, 40% were female, 62% were married, and religious affiliations were Buddhist (24%), Taoist (16%), popular religion (30%), Christian (4%), other religion (6%), and no religion (20%). Religious involvement was assessed by frequency of religious attendance (responses 1-8, average 3.2), making an offering during a pilgrimage (16% yes), worshiping God(s) and ancestral spirits (85% yes), practicing Qigong (1% yes), sitting in meditation (5%), giving thanks, repenting or praying every day (yes=4%), belief in a supreme God (responses 1-4, average 3.1). Happiness was measured by a single item that range from 1 (very unhappy) to 4 (very happy). After controlling for health-related stress (the strongest correlate of happiness) and demographics, the religious practice of “giving thanks, repenting, or praying every day” was associated with greater happiness (B=0.18, p<0.05), whereas belief in “a supreme God in the universe” was associated with less happiness (B=-0.05, p<0.05). No other religious characteristics were associated with happiness. However, there was an interaction between belief in a supreme God and health-related stress, such that among those with health problems, stronger belief in a supreme God was associated with greater happiness (B=0.10, p<0.01). Given that Buddhists made up only 24% of the sample, it is not known whether this finding was also present in the Buddhist subgroup.
Quality of Life
Khumsaen and colleagues (2012) examine predictors of quality of life (QOL) in a study of 120 people living with HIV in Thailand. Included among predictors was spiritual well-being (SWB). Participants included 62% females, and most were ages 31 to 50 years. SWB was measured using the JAREL SWB scale (Hungel-mann et al). QOL was assessed by the World Health Organisation QOL-BREF scale. Regression analyses controlled for age, gender, marital status, employment, education, living status, monthly income time since HIV diagnosis, and social support. SWB predicted higher levels of QOL independent of other predictors (B=0.26, p=0.004). Unfortunately, the JAREL scale (a non-Buddhist spirituality measure) is heavily contaminated with items measuring meaning and purpose in life, satisfaction with life, well-being, and acceptance of life situation, making it difficult to interpret the finding.
Moon and colleagues (2013) examined the association between religiosity/spirituality (R/S) and QOL in 274 adults age 65 or older living alone in Chuncheon city, South Korea. The average age of participants was 77 years and 82% were women. Religious affiliations were 33% Protestant, 18% Buddhist, and 16% Catholic. The Duke Religion Index (DUREL) was used to assess religious involvement (religious attendance, private religious activity, and intrinsic religiosity). The 15-item Geriatric Depression Scale and the Geriatric Quality of Life-Dementia scale were used to assess QOL. While religiosity (particularly intrinsic religiosity) was associated with less depression and greater QOL in Protestants and Catholics, no association was found in Buddhists (although there were only 48 Buddhists in the sample, reducing the power to detect an effect).
In one of the few longitudinal studies, Jang et al (2013) surveyed 284 Korean women with breast cancer undergoing surgery, assessing religiosity, QOL, anxiety, and depression at baseline and 12 month follow-up. The average age of participants was 50 years. Religious affiliation was 51% Christian (35% Protestants, 16% Catholics), 22% Buddhists, and 26% no religion. Religiosity was also assessed with the 5-item Duke Religion Index (combining organisational and private religious activity into a religious activity scale and combining the three intrinsic religiosity items into an IR subscale). QOL was assessed using the European Organisation for the Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core 30; depression was identified by the MINI Neuropsychiatric Inventory (combining major and minor depression for analyses) and observer-rated depressive symptoms by the Montgomery-Asbury Depression Rating Scale. Anxiety and depression were also self-assessed by the Hospital Anxiety Depression Scale (HADS). Results indicated a significant reduction in the prevalence of depressive disorder (major and minor) from baseline to follow-up among Protestants (30.1% to 15.7%, p=0.03), but no change in Buddhists (13.7% to 17.6%, p=0.77), Catholics, or non-affiliates. At baseline, there was a trend for anxiety symptoms on the HADS to be lower among Buddhists (3.0) compared to Protestants (4.0), Catholics (5.5), and those with no religion (4.0) (p<0.10, adjusted for age and education). One year after surgery, anxiety symptoms on the HADS remained somewhat lower (2.0) among Buddhists compared to other Christian groups (4.0-5.0) and those with no religion (4.0) (p=0.18). No significant differences between Buddhists, Christians, and non-affiliates at either baseline or follow-up were found on quality of life or depressive symptoms. In the overall sample, after controlling for age and education, higher intrinsic religiosity (but not religious activities) predicted greater global QOL at 12-month follow-up. Among Buddhists (n=63 at baseline, n=49 at follow-up), religious activities (but not intrinsic religiosity) was associated with fewer baseline depressive symptoms (partial r=-0.42, p<0.01), fewer follow-up anxiety symptoms at 12 months (partial r=-0.30, p<0.05), and greater follow-up global QOL (r=0.29, p<0.05) at 12 months. Researchers concluded that while religiosity influences the quality of life and emotional state of breast cancer patients in Korea, it may differ depending on type of religious affiliation.
Personality Traits
O’Connor and colleagues (2012) compared empathy-based guilt, empathic distress, having an overly active moral system, and depressive symptoms in 98 Tibetan Buddhist meditation practitioners and 438 non-Buddhist non-meditating community adults living in the United States. Tibetan Buddhist meditators (identified from a Tibetan Buddhist listserv) were 32% Mahayana, 19% Vajrayana, 8% Pure Land, and 41% other (combination of traditions). Since all Tibetan Buddhist meditators were from the U.S., most were European-American (68%) and were highly educated (16% doctorate, 30% master’s degree, and 26% with college or graduate school). Only 8% were Asian. Of the 438 non-Buddhists recruited via advertisements on Craigslist, 51% were European-American, 15% Asian, and the remainder other ethnicities or mixed; only 17% had doctorates or master’s degrees, and so were considerately less educated than Tibetan Buddhist meditators. Religious affiliation of non-Buddhists was not specified. Personality traits were examined with the 44-item Big Five Inventory (BFI) (neuroticism, extraversion, agreeableness, conscientiousness, and openness to experience). Guilt was measured with the 67-item Interpersonal Guilt Questionnaire (made up of survivor, separation, and omnipotent subscales); empathy was assessed by the 28-item Interpersonal Reactivity Index (made up of perspective-taking, empathic concern, and empathic distress subscales); and altruism was measured by the 45-item Compassionate Altruism Scale (made up of family, friends, and strangers subscales). Results indicated that Buddhist Tibetan meditators scored significantly lower than non-Buddhists on the omnipotent guilt subscale (45.2 vs. 47.6, p<0.01), the empathic distress subscale (15.2 vs. 17.2, p<0.001), and especially on depressive symptoms (CESD=13.2 vs. 21.7, p<0.001) and neuroticism (20.7 vs. 25.4, p<0.001). Buddhists scored higher on the altruism to strangers subscale, as well as on the agreeableness, conscientiousness, and openness subscales of the BFI. In the Tibetan Buddhist meditator subgroup, those whose primary goal of meditation was “other focused” (vs. self-focused) scored significantly lower on depression, empathic distress, and anxiety, and significantly higher on cognitive empathy.
Psychotic Disorder
Huang and colleagues (2011) conducted one of the first studies to examine the interaction between religion, religiosity, religious delusions, and preference for treatment in Asian patients with schizophrenia. They recruited 55 patients with schizophrenia from a university daycare clinic in Taiwan to examine these relationships. Participants were on average 37 years old, 60% were female, 13% married, and 16% had religious delusions/hallucinations. Most (82%) indicated a religious affiliation (44% Buddhism, 24% Christianity, 9% Taoism or folk religion) and 18% no religion. The questionnaire included an 8-item Religiosity Measure that assessed ritual, consequential, ideological, experiential dimensions of religious involvement (the dimensions originally conceptualised by American sociologist Charles Glock in the 1950s). Participants rated their satisfaction with psychiatric therapy and preference for psychiatric treatment, and were assessed by clinicians using the Positive and Negative Syndrome Scale (PANSS) and the Global Assessment of Functioning (GAF) Scale. Participants were divided into three groups: non-positive symptom type (NP) (n=23), positive symptom type with religious delusions/hallucinations (PR) (n=7), and positive symptom type without religious content (PN) (n-=25). There was no difference in religious affiliation (present vs. absent) between the three groups. While total religiosity score (and most of the religiosity subscale scores) was significantly higher among participants with religious delusions (PR), no significant association was found between religiosity scores and psychotic symptom severity score on the PANSS. While there was no significant association between religiosity scores and satisfaction with psychiatric therapy, higher religiosity scores did correlate with a lower preference for psychiatric treatment (r=-0.54, p<0.05).
Buddhist Interventions
Rungreangkulkij and colleagues (2011) examined the effects of a Buddhist group therapy intervention on depressive symptom in 62 patients with type II diabetes seen at the Nakae Hospital diabetes clinic in Thailand. Participants were randomised to either the experimental group (n=32) or a control group (n=32). In the experimental therapy, participants were divided into four groups with eight members in each, and met for two hours weekly for six weeks (supplemented by home medication practices). The sessions were conducted in four phases: first, rapport was established between group leaders and members; second, members were educated emphasising the Universal Natural Laws (i.e., that “suffering comes from the members’ cravings for things that are impermanent, and the members’ inability to accept things that have happened”): third, emphasis was placed on practising mindfulness consistently at home; and fourth, members perceptions, beliefs and understanding were assessed to identify causes for their symptoms and they were encouraged to practice mindfulness. The control group received “treatment as usual” by attending follow-up appointments at the diabetes clinic every month or two (i.e., this was not an active control group). The two groups were similar at baseline except that controls were more likely to be receiving current treatment with anti-depressant/anti-anxiety drugs (84.4% vs. 56.2%). Depressive symptoms were assessed at baseline and follow-up by a nurse blind to treatment group using the Q9 (similar to the PHQ-9), which ranges in score from 0 to 24 (0-6=normal, 7-12=mild, 13-18=moderate, 19-27=severe). Treatment response was defined as a Q9 score of 0-6. Results indicated that 30 of 32 (94%) responded to treatment in the intervention group, compared to 21 of 32 (66%) in the control group (p=0.02). The effect size was 1.74 (where 0.80 or over is considered large). Given that this study involved a non-active control group, it is not possible to determine whether the reduction in anxiety was simply due to the content of the intervention or the additional social interaction and attention paid to participants in the intervention group.
Chen and colleagues (2013) conducted an intervention study in 60 Chinese nursing students (average age 20 years) at a medical University in Guangzhou, China. Participants were randomised to either mindfulness meditation training (n=30) or to a control group without meditation training (n=30). The intervention consisted of seven consecutive days of training by a senior psychological counsellor proficient in mindfulness meditation. Mindfulness meditation was taught with no spiritual or religious emphasis, although incorporated traditional Chinese Buddhist cultural concepts. Those in the intervention group practiced mindfulness meditation guided by 30 minutes of standardised instruction daily throughout the seven day period. Participants self-rated themselves at baseline and immediately after the seven-day intervention using the Chinese version of the Zung Self-Rating Anxiety Scale and Zung Self-Rating Depression Scale. Results indicated a significant group by time interaction such that those receiving the active intervention decreased in anxiety compared to the control group (p<0.001), although there was no significant difference between groups on depressive symptoms. Again, since this study used non-active controls, the reduction in anxiety may have simply been due to the additional social attention paid to participants in the intervention group (rather than effects of mindfulness meditation).
In summary, more recent studies based on this non-systematic review show the following. In observational studies comparing the mental health of Buddhists with members of other faith traditions, the findings remain mixed (two reported better mental health in Buddhists, one reported no difference, and one found better mental health in non-Buddhists). In observational studies examining the association between religiosity and mental health in Buddhists, the majority of studies (12 of 24) found a significant positive relationship, one found a negative relationship, and the remainder reported either no relationship or mixed findings. Finally, the two clinical trials found that Buddhist interventions significantly improved mental health, but neither compared those interventions with an active/attention control group, leaving open the possibility that the benefits were due to social attention alone.
National and Cross-National Studies
Although the studies above were focused on Asian Buddhists, observational research involving large random national or international samples is rare. With only a few exceptions, most earlier and more recent studies summarised here involved non-Asian Buddhists residing in the West or non-random relatively small convenience samples of Asian Buddhists outside the West, making it difficult to generalise results to those who make up most of the world’s Buddhist population. For that reason, I sought out large national datasets that included primarily Asian Buddhists to compare Buddhists with other religious groups and examine relationships between religious beliefs/practices and mental health in Buddhists. I was particularly interested in studies that included measures of religious activity that were not contaminated with indicators of mental health. Presented here, then, is information obtained from three random national and cross-national surveys comparing the mental health of Buddhists to that of members of other religious groups and to those with no religious affiliation, as well as examining relationships between religiosity and mental health in Buddhist subgroups (Koenig 2016, unpublished report) (Table 1).
The Spiritual Life Study of Chinese Residents (SLSCR, 2007) surveyed a random sample of 7,021 adults in mainland China (the country that contains almost half of all Buddhists in the world). Analyses indicated that Buddhists were equally as likely to say that they were “very happy” compared to those with no religious affiliation (33.2% vs. 33.2%), but were significantly less likely than members of other religious faiths to indicate they were very happy (33.2% vs. 42.3%, p<0.05). Other religious affiliations in this sample were primarily of Christians (73%), Muslims (12%), and Taoists (10%). Given that many Chinese Buddhists are not active in their religious faith, the analyse was repeated among those who were at least “somewhat religious.” The findings were similar (33.0% of Buddhists indicated they were very happy vs. 42.5% of those affiliated with other religious groups). When asked to list the top three reasons for why they felt happy, Buddhists were less likely than members of other religious groups to list “my religious life” among those reasons. Importance of religious belief in life, however, was not related to happiness in either Buddhists (r=0.02, p=0.43, n-1111) or those affiliated with other religious groups (r=-0.03, p=0.63, n=239). This finding no cross-sectional relationship between religiosity and mental health is common in countries such as China were religion is in disfavour (64.7% of this sample had no religious affiliation). Importance of religion is often an “indicator” of mental stress in such countries, where the threshold for turning to religion is much higher and only those who are suffering significant distress do so (Hvidt et al., 2017).
In the International Social Survey Program (ISSP, 2008), a cross-national survey involving a random sample of over 59,000 adults from 40 countries, Buddhists (most of who were from Taiwan, Japan, and South Korea) were again significantly less likely than those with other religious affiliations to indicate they were very happy (19.2% vs. 26.7, p<0.0001). In that study, other religious faiths were again primarily Christian (86%) and Muslim (5%). As in the SLSCR study, the difference was similar among those who indicated they were at least somewhat religious. However, Buddhists were similar to members of other faith traditions in saying that religion helps people “find inner peace and happiness” (32.1% vs. 35.4%), although among those who were at least somewhat religious. Buddhists were less likely to say so (39.3% vs. 44.7%, p<0.05). Buddhists were also significantly less likely to say that religion helps people “gain comfort in times of trouble or sorrow” compared with non-Buddhists (27.1% vs. 39.4%, p<0.0001), with similar results among those who indicated they were at least somewhat religious. Among Buddhists overall self-rated religiosity was weakly but positively related to happiness (r=0.07, p=0.02, n=1194).
In the World Values Survey (WVS, 2005-2006), a random cross-national survey of over 83,000 adults from 80 countries, however, the results were different. In that study, Buddhists (primarily from Thailand, China, Japan, South Korea, Taiwan, and Hong Kong) were significantly more likely to report that they were “very happy” compared to members of other religious groups (31.5% vs. 28.2%, p<0.0001), with similar (if not stronger) results among those indicating religion was important in their lives. Members of other religious groups were again primarily Christian (61.4%) and Muslim (23.1%). This finding was primarily present among Buddhist from Thailand (a highly religious and largely Buddhist country). When Thai Buddhists were removed from the sample, the findings completely reversed (23.7% of non-Thai Buddhists indicated they were very happy, compared to 28.2% of members of other religious faiths, p<0.0001). When asked how satisfied they were with their lives as a whole (on a scale from 1=completely dissatisfied to 10=completely satisfied), Buddhists in the overall sample rated themselves significantly higher on satisfaction than members of other religious groups (7.11 vs. 6.49, p<0.0001). This finding, though, was also present when Thai Buddhists were removed from the sample (6.80 vs. 6.64, p<0.005).
As noted in the last chapter, Buddhists overall in the WVS were less likely than members of other religious groups to say that religion was “very important” to them (38.0% vs. 58.0%, p<0.0001) (see Table 3 in chapter 4). However, self-rated importance of religion among Buddhists in the WVS was positively related to both greater happiness in life (r=0.21, p<0.0001, n=3193) and to greater life satisfaction (r=0.14, p<0.0001, n=3194).
Table 1. All Buddhists and “religious” Buddhists compared with other religious groups and the non-affiliated on happiness and satisfaction with life.
(Editor: Detailed contents of this table has been omitted. Please contact the Editor if you require the details.)
Conclusions
The studies above compare the mental health of Buddhists and non-Buddhists, examine the relationship between religiosity and mental health in Buddhists, and review Buddhist interventions for improving mental health. With regard to Buddhists vs. non-Buddhists, our systematic review of five studies published prior to 2010 found that three favoured Buddhists over non-Buddhists, one found no difference, and one reported worse mental health; among studies since 2010, two found better mental health in Buddhists, one found no difference, and one reported worse mental health. In three large random national and cross-national studies, one found better mental health in Buddhists (but only Buddhists in Thailand) and the other two reported worse mental health in Buddhists compared to non-Buddhists. Thus, the findings are mixed, making conclusions difficult to make. While there is every reason because of core Buddhist beliefs (see chapter 5) to expect Buddhists to have better mental health than non-Buddhists, then, this is not always so. With regard to the relationship between religiosity and mental health in Buddhists, nearly half of the research (46% or 18 of 39 studies) reported that greater religiosity among Buddhists is associated with better mental health in (4 of 12 earlier studies; 12 of 24 recent studies; 2 of 3 large cross-national random samples); 4 studies (10%) reported no association or mixed findings. Finally, all six intervention studies (100%) show that treatments based on Buddhist beliefs/practices improve mental health (although adequacy of control groups was an issue). In conclusion, these findings suggest that when Buddhists commit to and follow the core Buddhist principles outlined in the Eightfold Path that they usually experience good mental health.