Religion-based interventions for mental health disorders: A systematic review

Chhaya Shantaram Kurhade; Aarti Jagannathan; Shivarama Varambally; Sushrutha Shivanna

doi:10.4103/ijoyppp.ijoyppp_14_21

REVIEW ARTICLE

Year : 2022 | Volume : 10 | Issue : 1 | Page : 20-33

Religion-based interventions for mental health disorders: A systematic review

Chhaya Shantaram Kurhade¹, Aarti Jagannathan¹, Shivarama Varambally², Sushrutha Shivanna³
¹ Department of Psychiatric Social Work, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
² Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
³ International Centre for Spiritual Studies, Amrita Vishwa Vidyapeetham, Coimbatore, Tamil Nadu, India

Date of Submission	21-Jun-2021
Date of Acceptance	09-Jan-2022
Date of Web Publication	26-Apr-2022

Correspondence Address:
Ms. Chhaya Shantaram Kurhade
Scholar of Psychiatric Social Work, NIMHANS, Bengaluru
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijoyppp.ijoyppp_14_21

Abstract

Religion-based psychotherapy is therapy formulated based on the norms and values of one particular philosophy or ideology of a religion. Many studies have shown that religion and spirituality play an essential role in helping people with mental health issues. This is the first systematic review of five religion-based interventions (including five major religions: Islam, Hinduism, Christianity, Buddhism, and Sikhism) for people with mental health disorders. The five electronic databases included PubMed (MEDLINE), ProQuest, EBSCO-host Google Scholar, and Cochrane Database of Systematic Reviews to retrieve eligible studies (randomized clinical trials (RCTs) and case studies). Published studies between 1st January 2000 to 30th June 2020 examined the efficacy of mental health outcomes based on religion-based psychotherapy. Two researchers independently screened studies, extracted data, and assessed the risks of bias. The total number of articles identified through [MeSH] terms was 87160. After sorting out the duplicates, 13073 articles remained. 12727 articles were excluded for not meeting the inclusion criteria; 12678 were out of topic, and 49 included spiritual interventions. A total of 346 full-text articles were assessed, out of which 318 had methodological issues, and the authors were contacted by email; despite that, 5 failed to respond. 23 articles were found eligible, out of which 17 were case studies and 6 were intervention studies. Surprisingly, we were unable to find any intervention studies based on Hinduism. Results from included studies show that religion-based therapies have led to effective ways in managing anxiety, depression, psychological stress, and alcohol dependence. The findings of this review suggest a lack of experimental studies based on Hinduism, which is an area that needs exploration. Nevertheless, results from included studies show that religion-based psychological interventions are feasible and have the potential to improve anxiety, depression, psychological stress, and alcohol dependence. However, the included religion-based intervention studies have shown poor replicability and a high risk of bias due to a lack of standardization and methodological rigor. Thus, religion-based interventions need to follow standardized methods to enhance the quality of evidence.

Keywords: Mental health disorder, psychotherapy, religion

How to cite this article:
Kurhade CS, Jagannathan A, Varambally S, Shivanna S. Religion-based interventions for mental health disorders: A systematic review. J Appl Conscious Stud 2022;10:20-33

How to cite this URL:
Kurhade CS, Jagannathan A, Varambally S, Shivanna S. Religion-based interventions for mental health disorders: A systematic review. J Appl Conscious Stud [serial online] 2022 [cited 2023 May 28];10:20-33. Available from: http://www.jacsonline.in/text.asp?2022/10/1/20/343848

Introduction

Religion is not meant to be just a belief system or faith but a lifestyle that one needs to follow for the benefit of society. There must be respect for culture and religious belief systems while also allowing for the freedom to offer an equally valid, albeit different, perspective (Koenig, 2009). Religion-based therapies aim to integrate and provide a holistic view of values, principles, and paradigms (Dein et al., 2010). Religion-based interventions have received remarkable attention in the last two decades (Post & Wade, 2009).

Numerous studies have observed that religion and spirituality have a significant impact on mental health (Baetz & Toews, 2009; Joshi & Kumari, 2011). Thus, incorporating elements of religion and spirituality in psychotherapy as an adjunct intervention for people with mental health disorders could be well accepted and feasible. There is notable evidence to show that one's religious and spiritual beliefs influence the outcome of one's health (Elkonin et al., 2014; Koenig, 2012). People who are religious by nature have been shown to have a higher sense of happiness and fulfillment in life. Furthermore, they are less depressed, less anxious, and less likely to commit suicide (Hostetler, 2010). This suggests that religion-based modified psychotherapies are as effective as conventional therapies in dealing with mental health outcomes (Azhar et al., 1994; Propst, 1980). More importantly, according to a systematic review, randomized control trials have demonstrated that arbitrator prayers may improve health outcomes in patients with coronary disease and may show recovery in patients with anxiety and depression with Islamic-based interventions. Even the religious activities reported in nonrandomized control trials have a positive effect on blood pressure, depression, and mortality (Townsend et al., 2002). It was observed that involvement in religious and spiritual activities led to several benefits, including enhanced social and interpersonal relationships, affirmation of shared beliefs, improving coping skills, resolving guilt, and diminishing fear of punishment, and was seen to promote mental health and physical health (Paukert et al., 2011; Gonçalves et al., 2017).

This systematic review sought to examine religion-based interventions (including five major religions: Islam, Hinduism, Christianity, Buddhism, and Sikhism) for people suffering from mental health disorders. The authors believe that this review will aid in understanding the feasibility and effectiveness of religion-based psychotherapies as an adjunct intervention in clinical settings for people with mental health disorders.

Methods

The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines and Cochrane collaboration recommendations provide the basis for this review study. The review included studies conducted between January 1, 2000, and June 30, 2020. A comprehensive search was conducted by two independent researchers (C. K and A. J.) on major biomedical and specialist databases and websites. The reference list of relevant review articles was also checked.

Selection criteria

Studies reporting interventions based on principles of Islam, Hinduism, Christianity, Buddhism, and Sikhism for people with mental health disorders were included. We excluded the articles involving spirituality-based interventions as the definition of spirituality in these articles was varied and did not fit the definition of religion-based interventions. Furthermore, the review included only English language publications.

Search strategies

A Boolean expression was created to search the literature to discover the most relevant articles on A Boolean expression was created to search the literature to discover the most relevant articles on (Psychotherapy OR counseling OR faith based psychotherapy OR intervention) AND (Religion OR Islamic OR Islam OR Muslim OR Quran), (Psychotherapy OR counseling OR faith based psychotherapy OR intervention) AND (Religion OR Hinduism OR Hindu OR Ramayana OR Bhagavad Gita) AND (Psychotherapy OR counseling OR faith based psychotherapy OR intervention) AND (Religion OR Sikhism OR Sikh OR Guru Granth Sahib) AND (Psychotherapy OR counseling OR faith based psychotherapy OR intervention) AND (Religion OR Christianity OR Christian OR Church OR Bible based therapy) AND (Psychotherapy OR counseling OR faith based psychotherapy OR intervention) AND (Religion OR Buddhism OR Buddhist). The five databases searched were PubMed (MEDLINE), ProQuest, EBSCOhost, Google Scholar, and Cochrane review.

Data extraction

Phase 1: The titles and abstracts of all papers were reviewed by C. K. Studies were excluded if: (1) they were nonintervention studies, (2) group interventions, (3) interventions provided to clients with nonmental health disorders, and (4) repeated versions of the same article identified across databases
Phase 2: All included articles were fully read to assess (a) the type of religion-based intervention provided, (b) the type of study (randomized clinical trial, case studies, etc.), and (c) the methodological quality of the articles (risk of bias).

Risk of bias in individual studies

The risk of bias across studies was assessed through the Cochrane Back Review Scale (Higgins et al., 2019) and the modified Cochrane Collaboration tool to assess the risk of bias for randomized controlled trials. Bias was assessed as a judgment (high, low, or unclear) for individual elements from five domains (selection, performance, attrition, reporting, and others). The score was chosen to provide a better understanding of the items because it was very similar to the Consolidated Standards of Reporting Trial (CONSORT) guidelines for nonpharmacological clinical trials that do not blind patients or providers of interventions (Schulz et al., 2010). The cutoff was six or more points. Two independent researchers (AJ and CK) classified the item, and the disagreement was resolved by consensus.

Results

[Figure 1] presents the flowchart of the review results; the total number of articles identified through Medical Subject Headings terms was 87,160. After sorting out for duplication, 13,073 articles remained. 12,727 articles were excluded for not meeting the inclusion criteria, out of which 12,678 were out of topic and 49 included spiritual interventions. A total of 346 full-text articles were assessed, out of which 318 had methodological issues, and the authors were contacted by E-mail; despite that, 5 failed to respond. Twenty-three articles were found eligible, out of which 17 were case studies and 6 were intervention studies.

Figure 1: PRISMA diagram

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Results of case studies

Islam case studies

The number of case studies that provided interventions based on tenets of Islam was 7. These interventions were observed to be provided to the age group of 20–58 years with diagnosis of “Religious, Obsessive-Compulsive Disorder, Depression, Panic attack (Agoraphobia), Generalized Anxiety Disorder, Grief, and Substance Use Disorder.”
The intervention was developed from the tenets of Islam for treating mental health disorders. The components of the interventions included religion-based teaching, principles, values, beliefs, remembering and prayers, and reading scriptures (Quran). However, they were termed differently, such as “Religious-psychotherapy,” “Islamic psychotherapy,” “Metaphor therapy,” “Islamic integration of exposure response therapy,” and “Religiously integrated therapy.” The interventions were reported to reduce the symptoms and help establish a connection with the divine and facilitate well-being and coping [Table 1].

Table 1: Islam Case studies

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Christianity case studies

The number of case studies identified which provided the intervention based on the tenet of Christianity was 4. These interventions were observed to be provided to the age group of 20–83 years diagnosed with mild-to-moderate depression, anxiety disorder, substance use disorder (cocaine abusers and smoking), emotional disturbance, and geriatric anxiety
The intervention was developed from the tenets of Christianity for treating mental health disorders. Intervention components included religion-based teaching, theoretical principles and practices, values and beliefs (forgiveness, gratitude, generosity, and altruism), attending church, and reading scriptures, reciting Biblical verses referred to as “Christian Cognitive Behavioral Therapy (CBT),” “Religiously Oriented Mindfulness-Based,” “Religious Doubts through Religious Modalities,” “Religion into Cognitive-Behavioral Therapy,” and “Religiously Rational Emotive Behavior Therapy.” Religion-based interventions reportedly could ameliorate symptoms, improve positive coping, facilitate insight, relieve distress, and establish a connection with God [Table 2].

Table 2: Christianity Case-studies

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Buddhism case studies

Four case studies were available in Buddhism, with samples of the age groups participating in the interventions being 21–50 years with diagnosis of depression, nicotine dependence, psychological distress, and grief and obsessive-compulsive disorder
The intervention was developed from the tenets of Buddhism for treating mental health disorders. The components of interventions included religion-based philosophy, teaching, values, principles, and practice. However, they were termed differently, such as “Four Noble Truths Based Problem Solving,” “Buddhist Mindfulness,” and “Mindfulness Meditation Based Cognitive Therapy.” The outcome emphasized reducing compulsive behaviors and a decrease in symptoms of depression under the guidance of meditation, positive coping, and well-being [Table 3].

Table 3: Buddhism Case studies

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Sikhism case study

The number of case studies available in Sikhism was 2, and the studies targeted clients diagnosed with depression, psychological issues, and anxiety
The intervention was developed from the tenets of Sikhism for treating mental health disorders. The components of the interventions included religion-based teaching, principles, values, beliefs, remembering, reciting prayers, and reading scriptures (Guru Granth Sahib). However, they were termed differently, such as the “Sikh Spiritual Model” and “Sikh Life-Stress Model.” These studies, along with interventions based on religious models, showed that they helped reduce life stress (psychological, physical, and spiritual), improved coping and well-being, and mental health issues [Table 4].

Table 4: Sikh Case studies

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Intervention studies

Study characteristics

[Table 1] indicates the total number of studies included as interventional (n = 6) with an age group ranging from 18 to 60 years with a mental health diagnosis. The sample size ranged from 50 to 300 in studies in both the intervention and control groups. The religion-based intervention group underwent different therapies which were variously termed as “Religious–Cultural Psychotherapy,” “Mindfulness-Based Cognitive Therapy,” “Buddhist Mindfulness Meditation,” “Al-Quran recitation,” “Religious CBT,” and “Religious Therapy.” Simultaneously, the control group underwent standard treatment care with supportive psychotherapy techniques such as guidance and reassurance. The follow-up period of these studies ranged from 3 to 12 months. The studies reported outcomes based on clinical scales for mild to major depression, anxiety, and substance dependence.

In general, all studies showed significant improvement in postreligion-based interventions as compared to control groups on primary outcomes such as anxiety, mild to major depression, and reduction in smoking. Islam-based studies reported that religion-based interventions contributed in the enhancement of the psychological well-being and reduction in the number of cigarettes smoked (Razali et al., 2002; Maziha et al., 2018; Bano et al., 2019). Buddhism-based intervention studies documented reduction in relapse and recurrences of depression (Teasdale et al., 2000). Intervention studies using tenets of Christianity reported equivalent effectiveness of religious cognitive behavioral therapy compared to cognitive behavior therapy for symptom reduction in depression [Table 5].

Table 5: Intervention studies

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Risk of bias in individual studies

We found intraclass correlation coefficient reliability between examiners in interpreting the scales (0.889, 95% confidence interval: 0.752–0.893), which shows the positive reliability of the assessment of bias risk. [Table 6] presents the items assessed on the Cochrane review scale. Of the final six intervention studies, none reached the maximum score of 7. The researcher found allocation concealment bias in four out of six studies (Hamdan, 2008; de Zoysa, 2011; Singh, 2008; Turakitwanakan et al., 2017; Tulbure et al., 2018; Shamasundar, 1993).

Table 6: RISK OF BIAS FOR INTERVENTION STUDIES

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Reporting bias was unclear in the four studies (Razali et al., 2002; Turakitwanakan et al., 2017; Maziha et al., 2018; Bano et al., 2019). The source of bias was reported to be high in three studies (Razali et al., 2002; Teasdale et al., 2000; Maziha et al., 2018). We observed that none of the studies used “single-blinding (rater-blinding).” This prevented the articles from reaching the maximum scoring. Only two reported attrition bias out of six studies [Table 6].

Discussion

To respond to the need to develop religion-based interventions and their clinical applications in mental health disorders (Shamasundar, 1993, 2008a; Varma & Ghosh, 1976; Manickam, 2010), a systematic review of five major religion- based interventions was done. The results suggest that the different religion-based interventions are as effective as outcomes as conventional therapies (Post & Wade, 2009; Hook et al., 2010; Nyer et al., 2013). Especially, evidence suggests that providing religion-based interventions helps in the effective management of mental health disorders (Gonçalves et al., 2017). In addition, randomized control trials conducted on religion-based interventions reported effective results in anxiety and depression, stress management, and alcohol dependence and helped in preventing relapses and improving well-being (Azhar et al., 1994; Azhar & Varma, 1995; Stoltzfus, 2007; Fallot, 2001).

To the best of our knowledge, this is the first systematic review of five major religion-based interventions in mental health, despite the existence of other systematic reviews and meta-analyses of religion and spiritual-based interventions. This study exclusively focuses on different types of religion-based interventions and their outcomes in mental health disorders. Thus, we have included various case studies and intervention studies from different religions. It has been observed that despite the heterogeneity in a clinical population, distinct facilitators, and differences in religion-based interventions and models, the target group tends to benefit from their outcome.

The types of studies included in this review seem to have three primary aims: (a) creating religious and spiritual interventions for mental health, (b) evaluating the effectiveness of religious and spiritual interventions, and (c) comparing religious and spiritual intervention with conventional treatment. Several studies were also observed to have combined two of the abovementioned goals. These religion-based interventions focused on preventive and rehabilitative approaches in managing mental health disorders. The preventive-based approach referred to interventions aimed at modifying risk exposure and strengthening the coping mechanisms of the individual. The rehabilitation-based approach helps in accepting illness, adjustment processes, and recovery (Fallot, 2001; Michael et al., 2008). Furthermore, religion-based activities have been shown to promote physical, physiological, behavioral, or social growth (Johnstone et al., 2007; Waldron-Perrine et al., 2011). Thus, effectiveness was measured through clients' emotional stability and well-being (cognitive, behavioral, emotional, and ontological components). In addition, individual skills such as prayer, recital, and engagement in pleasurable religious activities lead to good mood and behavioral changes and many positive psychological effects (Gladding & Crockett, 2019).

In India, religion influences the pathways of care in treatment modalities of mental health. Pathways of care in religion offer unique, powerful means and vantage points to influence cognitions, emotions, and behaviors (Lahariya et al., 2010; Khemani et al., 2020). Despite the notable increase in professional attention to integrating religion and spirituality into clinical practice (Koenig, 2012), there is still a lacuna in not having sufficient intervention studies based on Hinduism. Some researchers argue that the availability of traditional concepts and practices that promote mental health and well-being may also provide culturally acceptable interventions (Shamasundar, 1993, 2008b; Wig, 2004). Indian mythology or Indian scriptures contain psychotherapeutic themes that provide insight, and facilitate positive coping and well-being within the sociocultural milieu (Shamasundar, 2008b; Bhatia et al., 2013; Jacob & Krishna, 2003). Some researchers have opined for the development of ad hoc theories within the cultural purview (Neki, 1975). Other studies have suggested an integrative model incorporating traditional and culturally determined concepts for the Indian population (Shamasundar, 1993, 2008b). The article discusses how psychiatrists practicing psychotherapy should cater to the needs of patients with mental illnesses relevant to the culture of their state. However, the lack of systematic intervention studies suggests a dire need to conduct intervention studies based on Hinduism (Varma & Ghosh, 1976).

The researchers observed that there was no uniformity found in the criteria followed in reporting case studies based on the case report guidelines (CARE) checklist (Lahariya et al., 2010). Some case studies measured the outcome on a clinical scale, and others had the narrative or client's perspective about improvements in the study. Although in medical research appraisal, the case study stands in the fourth position in the hierarchy of the clinical setting, such studies are important to establish the early effectiveness of interventions (Lancaster, 2000).

The review found that none of the intervention studies achieved the maximum score on the CONSORT guidelines (Schulz et al., 2010). In addition, most of the studies had a high risk of bias due to the inadequate explanation of evaluated items based on allocation concealment, outcome assessment, performance bias, detection bias, and attrition bias despite significant improvement in outcome measurement in the mental health population. In standard clinical trials, reports focus on the importance of allocation concealment for the randomization procedure; otherwise, the inadequacy may affect the results (Liberati et al., 2009). Therefore, an adequate description of methodological procedures is essential in clinical research and for enhancing the quality of the study. Emphasis on minimizing biases in clinical research is critical for future research in this area (Viswanathan et al., 2008).

Some suggestions may be offered for improvement in the methodology of intervention studies in this area. As mentioned in PRISMA, there is a need to investigate and scrutinize research items through scales (Liberati et al., 2009). Further, single-blinding (patients and therapists being blinded to intervention) may not be possible in such interventional studies. To minimize the difficulty faced with double-blinding, the use of “third-party blind” assessment or rater blinding may be useful. This would help in minimizing biases so that evaluation can be carried out without bias. Only 17.9% of studies used “third-party blinding,” showing that this strategy still needs to be considered and explored in future research (Smith et al., 2007). It is suggested to follow CONSORT guidelines focusing on nonpharmacological research and highlight the relevance of some methodological items that would make a difference in the quality of these studies (Boutron et al., 2008).

Qualitative studies report that it might be helpful to include anecdotes from mythological and scriptures in psychotherapy to cater to the cultural differences of people with mental health disorders (Shamasundar, 1993; Manickam, 2010; Bhatia et al., 2013; Manickam, 2013). However, the available studies are few, and most have methodological limitations. Of course, religion-based interventions are in the initial phases of establishing treatment and are not proven to be a standardized alternative treatment like conventional therapies. Thus, it is observed that most research studies are conducted on common mental health disorders rather than severe mental health disorders like schizophrenia or bipolar disorder. Most studies included are case studies, and in this context, we recommend that case studies need to have uniformity in criteria while reporting the findings to have better clarity and measurable outcomes in the future. Intervention studies should ideally follow the standardized protocol based on CONSORT guidelines to avoid bias and enhance the quality of the study.

Conclusion

Preliminary evidence shows that religion-based interventions can be effective for people with mental health problems. Given the significant potential of such interventions based on cultural contexts, there is a further need to conduct methodologically sound and large sample studies to establish its efficacy as a standalone, alternative, or complementary intervention.

Limitation of the study

This research has some limitations regarding the systematic review: (a) In our study, the operation definition of religion-based interventions might have been limited to access some clinical trials as we have excluded spiritual-based intervention or Indian traditional healing system from the study, as there are only thin-line differences between these concepts. (b) Only five databases search engine were used throughout the study, therefore it is possible that some studies indexed in other databases have not been included.

Financial support and sponsorship

This is a nonfunded study approved by NIMHANS Institute Ethical Committee.

Conflicts of interest

There are no conflicts of interest.

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