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Research studies seldom include only Protestants, only Orthodox, or only Catholics. Since most of the research involving Christians comes from the United States and the United Kingdom, where the majority of the population is Protestant (51.5% and 54.5%, respectively) (Pew Research Centre, 2011), the research findings on religiosity and mental health has been summarised below for Christians-majority populations. Given that strategy, the reader should be aware that these studies also include not only Protestant Christians but also a substantial number of Catholics (and some Eastern Orthodox as well).
The research findings presented here are based on a comprehensive and systematic review of the literature up through 2010 (Koenig et al., 2012) that focuses on Christians (Koenig & Al Shohaib, 2014, p 123). Since this literature summary is now rather dated, a few more recent studies are also described that illustrate more recent findings since that earlier review. A more comprehensive review of recent research from which these studies are taken is available elsewhere (CSTH, 2017). The present research review focuses on religious coping, depression, self-esteem, suicide, anxiety, substance use/abuse, psychosis, psychological well-being, locus of control, personality traits, and social health.
Religious Coping
Over 400 quantitative studies were conducted prior to 2010 that document a high prevalence of religious coping among Christians when facing psychological stressors, important losses, traumatic events, or changes in physical health. For example, one study of medically ill hospitalised patients found that 90% said they used religion to help them to cope with health problems, and over 40% indicated (spontaneously without prompting) that their religious belief was the most important factor that kept them going (Koenig, 1998). Likewise, in a national survey of the U.S. population after the September 11th terrorist attacks on the World Trade Centres reported in the New England Journal of Medicine, researchers found that 90% of respondents indicated they turned to religion as a primary way of coping with the anxiety and stress of this period (Schuster et al., 2001).
Christian religious beliefs provide meaning to negative life events, and provide a community of support that helps to counteract stress and prevent the negative emotions that often follow such stressors. Hundreds of additional qualitative studies studies have been published that verify these conclusions from quantitative studies. But is that really true? Is religious involvement related to better mental health and improved coping with stress?
Depression
There were 414 quantitative studies in Christian majority populations published up through 2010. Of those, 254 (61%) reported a significant inverse correlation between religiosity/spirituality (R/S) and depression. In contrast, 26 studies (6%) reported a significant positive relationship between R/S and depression. Inverse relationships between religiosity and depression appear to be particularly strong among those who are experiencing stressful life circumstances, suggesting a stress-buffering effect (Smith et al., 2003).
Among observational studies, particularly those with a cross-sectional designs, it is not possible to identify the direction of causation in the relationships identified, underscoring the need for prospective studies and clinical trials. Lower rates of depression among those who are more religious may simply mean that depression prevents religious involvement (rather than religion preventing depression). A more recent prospective study reported exactly that, i.e., those who were depressed were more likely over time to stop or reduce their attendance at religious services (Maselko et al., 2012). In contrast, a 12-year prospective study of 48,984 women (53% Protestant) participating in the Nurses’ Health Study conducted by the Harvard School of Public Health found that effects were actually bidirectional in nature, i.e., religious attendance prevented depression and depression prevented religious attendance (Li et al., 2016). Results were similar when examined in Protestants and Catholics separately.
Of 28 randomised clinical trials (RCTs), 17 (61%) reported a significant reduction in depressive symptoms among those receiving a religious or spiritual (R/S) intervention greater than in those receiving standard care or a control condition; only two RCTs (7%) reported that R/S interventions were less effective. More recently, in a RCT that compared religious cognitive behavioural therapy (RCBT) to conventional secular CBT (CCBT) in 132 person with major depressive disorder (62% Protestant), both treatments decreased depressive significantly over time and to a similar degree. However, RCBT was particularly effective in highly religious clients, who also tended to be more compliant with RCBT than with CCBT (Koenig et al., 2015).
Self Esteem
Research has also examined associations between religiosity and self-esteem, which tends to be low among those with depression. Of 65 studies in Christian majority samples published prior to 2010, 40 (62%) reported significantly great self-esteem in those who were ore R/S and only two (3%) found lower self-esteem. These findings are consistent with those for depression.
Suicide
Prior to 2010, 126 studies had examined the relationship between religiosity and attitudes toward suicide, suicidal thoughts, or suicidal behaviours in Christian-majority populations. Of those studies, 99 (79%) found inverse or negative relationships and two (2%) reported positive relationship. In the one of the largest and most rigorous studies on suicide incidence to date, VanderWeele and colleagues (2016) from the Harvard School of Public Health analysed data from a 14-year prospective study of 89,708 women (52% Protestant) participating in the Nurse’s Health Study. They found that women attending religious services at least weekly were 84% less likely to commit suicide than women who never attended (hazard ratio=0.16, 95% CI=0.06-0.46), with more than a five-fold reduction in suicide incidence rate from 7 per 100,000 person-years to only 1 per 100,000 person-years. Results were similar when excluding women who were depressed or had chronic illness at baseline. When analyses were stratified by denomination, the risk among Catholics attending once per week or more was 95% lower compared to those attending less often (HR=0.05, 95% CI, 0.006-0.48). The risk, however, was approximately seven times lower in Catholics than in Protestants (HR 0.34, 95% CI=0.10-1.10). The greater effect in Catholics was explained by the strong prohibitions against suicide (with threat of eternal damnation, which many Catholics still associate with suicide), compared to more lenient attitudes toward suicide among Protestants.
Anxiety
Of 245 studies that explored relationships between R/S and anxiety in Christians, 120 (49%) reported inverse relationships between R/S and anxiety, whereas 24 (10%) found positive relationships. Almost all of these studies were cross-sectional, again limiting speculations on whether religious involvement was the primary factor explaining the relationship or whether anxiety was the primary factor. While religious beliefs can promote anxiety by instilling guilt and fear of eternal damnation, anxiety is also a powerful motivator for religious practice (“there are no atheists in foxholes”). There is another old adage that says “religion comforts the afflicted and afflicts the comforted,” suggested a bidirectional effect may be present as with depression. Of 26 RCTs in Christian populations that included various forms of meditation or other religious interventions, 16 (62%) reported a reduction in anxiety, one reported an increase in anxiety (4%), eight reported no effect (31%), and one reported both positive and negative effects.
Substance Use/Abuse
Of 260 studies that examined R/S and alcohol use/abuse in Christians, 233 (87%) reported significant inverse relationships. Only 4 studies (1.5%) reported positive relationships between R/S and greater alcohol use/abuse. Of 182 studies that focused on R/S and illicit drug use/abuse, 154 (85%) found significant inverse relationships and only two (1%) found positive relationships. More recently, Good and Willoughby (2011) analysed data on 3,993 adolescents surveyed three to four times between 2003 and 2008. Religious affiliations of the geographical region where the study took place were 37% Catholic and 42% Protestant. Religious service attendance and non-religious activity (attendance at clubs at school and outside of school) were assessed. Substance use included frequency of alcohol use, amount of alcohol used per drinking episode, cigarette smoking, and marijuana use. Uncontrolled correlations indicated that religious attendance in every school year (9th through 12th) was significantly and negatively related to substance use. Using cross-lagged path analysis and adjusting for control variables, researchers found that religious attendance was uniquely related to lower rates of substance use, whereas involvement in non-religious club activity was not. Thus, the evidence is clear that religious involvement is related to less substance use/abuse in Christian-majority populations.
Psychosis
The relationship between religiosity and psychotic illness is complex, since severe mental illness gives rise to psychotic symptoms that are often manifested by religious delusions or hallucinations. In this case, it is the mental illness that is driving the pathological expression of religiosity, not religiosity driving the mental illness. This makes cross-sectional correlations difficult to interpret. Our systematic review uncovered 39 studies that examined religiosity and psychotic symptoms in Christian-majority samples. Of those, 10 (26%) found fewer psychotic symptoms in those who were more religious, 9 (23%) reported more psychotic symptoms among the more religious, and the remaining studies found either no association (29%) or both positive and negative associations (21%) depending on the particular religious characteristic measured.
Psychological Well-being
While the majority of studies find less emotional and mental disorder among those who are more religious, the relationship between religiosity and positive emotions is even stronger. Of 301 studies in Christians that examined R/S and well-being, happiness, or life satisfaction, 237 (79%) reported positive relationships. Only three (1%) reported negative relationships. With regard to hope, of 39 studies 29 (74%) found positive relationships and none reported negative relationships. For optimism, 25 of 30 studies (83%) in Christian-majority populations reported positive relationships and no studies reported negative relationships. Finally, 41 of 44 (93%) reported significant positive relationships between R/S and meaning or purpose in life. More recently, in a meta-analysis of results from 75 independent studies examining 66,273 adolescents and young adults examining the relationship between religiosity/spirituality and a wide variety of mental health outcomes, including psychological well-being, Yonker and colleagues (2012) reported the average effect sizes across studies was +0.16 for well-being/happiness (p<0.001). We also found in a cross-sectional study of 132 persons with major depressive disorder (62% Protestant) that while religious involvement was unrelated to depressive symptoms, there was a strong relationship between religiosity and positive emotions (p<0.0001) (Koenig et al., 2014). Thus, religious involvement in Christians is associated with positive emotions in the vast majority of studies.
Locus of Control
An internal locus of control is the extent to which a person believes they have control over their own destiny by the personal decisions they make. In contrast, those with the an external locus believe they are helpless to direct their lives and that powerful other people or institutions are in control of their future. It has long been known that those who have an internal locus of control experience better mental health.
The belief that “God is in control” is not usually included as an example of an external locus of control, although some may interpret it this way. Instead, belief that God is in control is actually an indicator internal locus of control, since the person believes that God is in control of their futures (not powerful humans or institutions). There is also a specific measure called the God Health Locus of Control Scale that tries to determine the extent to which one believes that God is in control of one’s health (or more specifically, that God empowers the individual to take control of their health). Most of the research, however, has not used measures that distinguished an “external local of control” from a “God locus of control,” which has made some of the findings difficult to interpret.
At least 20 studies have examined the relationship between religiosity and locus of control in Christian-majority populations. Of those, 12 (60%) reported a greater sense of personal or internal control among those who were more religious or spiritual. Only 3 studies (15%) found significantly lower control among the more R/S.
Personality Traits
Researchers have also examined the relationship between religiosity and personality traits, which are lifelong patterns of how people relate to themselves and others. Personality traits tend to have a biological component that is rooted in genetic predispositions, so such traits may or may not be easily influenced by religious involvement. Personality traits are often assessed using the “Five-Factor Model” that examines five aspects of personality: extraversion, neuroticism, conscientiousness, agreeableness, openness to experience. I now summarise the research on religiosity and these five personality traits, limiting that research to Christian-majority populations.
Extraversion. Extraversion is a positive psychological trait associated with being more outgoing, talkative, and energetic in social situations when relating to others. Introverted persons are those at the other end of the spectrum who tend to be more inner focused, reflective, and less socially outgoing. Of 46 studies in Christian-majority populations, we found that 18 (39%) reported that those who were more religious were more extroverted (compared to 3 studies or 7% that reported less extraversion).
Neuroticism. Neuroticism reflects an enduring tendency toward anxiety, worry, brooding rumination, fluctuation in mood, and feeling uptight. These individuals are often self-conscious and do not cope well with stressful situations. Of 51 studies in Christian-majority samples, most (61%) found no relationship between neuroticism and religiosity or spirituality , 12 (24%) reported lower neuroticism among those who are more religious, and 5 studies (10%) found more neuroticism in those who were more religious. These findings contrast with those reported by Sigmund Freud who described highly religious persons as suffering from an obsessional neurosis (Freud, 1927).
Conscientiousness. Persons who are conscientious tend to be well organised, efficient, self-disciplined, productive and successful. This contrasts with the less conscientious person who tends to be laid back and less goal-oriented, and may be at higher risk for antisocial or criminal behaviour as they attempt to “cut corners” and avoid work. Of 28 studies, 19 (68%) found that religiosity in Christians was associated with significantly greater conscientiousness, while only 1 study (4%) reported lower conscientiousness and this finding was only among males in the sample.
Agreeableness. Those who are more agreeable tend to be cooperative, considerate, and attentive to the needs of others. They are characterised by being more trustworthy, honest, and nice when described by others. Of 28 studies in Christians, 24 (86%) reported a significant positive relationship between agreeableness and religiosity, and no studies found a significant negative relationship.
Openness to Experience. This personality dimension involves a preference for variety and new experiences. These individuals tend to reject traditional or conventional ways and prefer doing things “outside the box,” driven by their intellectual curiosity and tendency to question norms. Of 24 studies in Christian-majority populations, 10 (42%) found that religiosity or spirituality (more often spirituality) was associated with significantly greater openness to experience, whereas 2 studies (8%) reported significant negative relationships. Both of these last two studies measured traditional or conservative religious beliefs as their religiosity indicator.
Social Health
By social health, I mean number and quality of social interactions, availability of support from friends and relatives, degree of marital satisfaction and stability, and the absence of antisocial, delinquent, or criminal behaviour.
Social Support. Of 70 studies identified in our systematic review conducted in Christian-majority samples, 58 (83%) reported that those who were more religious experienced greater social support. No studies found lower social support among those who were more religious.
Marital Satisfaction and Stability. The measure of social health assesses the stability of marital ties (absence of divorce or separation), degree of marital satisfaction, and degree to which a person treats their spouse with respect and care (vs. emotional or physical abuse). Of 75 studies, 64 (85%) reported greater marital satisfaction, less divorce or separation, and less spousal abuse among those who were more religious. Again, no studies reported less marital satisfaction or lower stability in those who were more religious.
Antisocial Behaviours. Finally, 99 studies examined delinquency or criminal behaviour and religiosity in Christian populations, with 74 (75%) finding significantly less antisocial behaviour in those who were more religious or spiritual, 5 reporting a nonsignificant trend in this direction, and only 2 studies (2%) indicating more crime or delinquency in the more religious.
Summary of the Research
The majority of quantitative studies in this systematic review found that religious involvement among Protestant-majority Christian populations is related to less depression, greater self-esteem, less suicide, less anxiety, less alcohol and drug use/abuse, greater psychological well-being, greater conscientiousness, more agreeableness, and better social health. Not all these studies are high quality, the vast majority is cross-sectional, and confounding factors are not always controlled. There has been accusation of bias in the reporting of results, with researchers making claims that go beyond the data (see Sloan et al., 1999, for methodological critique, and Koenig et al., 1999, and Benson et al., 1999, for rebuttals). Given the difficulty in obtaining funding support to conduct large well-designed studies on religion and mental health (since the National Institutes of Health and other secular funding bodies are reluctant to support such research), most studies have been carried out with only minimal resources and often with none at all. However, well-designed observational research (including those that have prospectively followed large samples for many years) and randomised clinical trials, while much fewer in number, tend to confirm the findings reported by the many more cross-sectional studies. This research supports causal associations between religiosity and mental health, although relationships are likely to be bi-directional such that religiosity not only affects mental health, but mental health may also affect religiosity. Recent research, often with better methodology than earlier studies, has in general reported similar findings.
In summary, this research does not indicate that religious involvement by Protestant Christians is always associated with good mental health, and there are certainly many individual cases where the exact opposite is true. However, there is a lot of evidence indicating that Protestant beliefs do not in general have negative effects on mental health, and a moderate amount of evidence suggesting these effects are in the positive direction.