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Religiosity among patients with schizophrenia

An exploratory study

Triveni, Davuluri; Grover, Sandeep; Chakrabarti, Subho

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doi: 10.4103/psychiatry.IndianJPsychiatry_17_17
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Religion is understood as an expression involving affiliations, beliefs, practices, and rituals followed by an individual pursuing the same. Various religions usually follow specific beliefs about the life after death and have rules about conduct which guide life within a social group. Religion is often organized and practiced within a community, but it can also be practiced alone and in private.[1] Further, religion/religiosity is understood to have many dimensions, and many authors have tried to describe different dimensions of religion/religiosity. Glock[2] described 5 dimensions as the intellectual, ideological, public, private, and experiential dimension and considered these to be autonomous.

Religion and spirituality are considered part and parcel of lives of many individuals, especially in the Indian context. Suffering from schizophrenia does not take away the belief and faith of a person in God. Studies across the world have provided preliminary evidence for the role of religion and spirituality on the manifest psychopathology, coping with illness, help seeking, quality of life (QOL), and treatment adherence among patients with schizophrenia.[3] Despite this, the relationship of religion and schizophrenia has been understudied, minimized, or ignored in mental health assessment, diagnoses, and treatment.[4] The biopsychosocial model of understanding and managing patients with schizophrenia usually does not take into account the religious beliefs of the patient. However, those who consider the importance of religion in determining the health outcome suggest that religiousness and spirituality influences health outcomes through behavioral (spirituality may be associated with a healthy lifestyle), social (religious groups provide supportive communities for their members), psychological (beliefs about God, ethics, human relationships, life and death), and physiological (religious practices elicit a relaxation response) pathways.[5]

Surprising there are limited data on religiosity of patients with schizophrenia from India. Available data suggest that many patients seek help of faith healers to get rid of symptoms of illness,[6] and it has also been shown that indigenous healing methods are considered complementary to the medical management of mental illness.[7] A study from South India demonstrated that 58% of patients with psychotic illnesses meet a religious healer before psychiatric consultation.[8] In fact, some of the studies suggest that seeking religious help for mental disorders is often a first step in the management of mental disorders as a result of cultural explanations for the illness.[9] In terms of outcome measures, studies suggest that spirituality and religiosity have an important influence on overall QOL of patients with schizophrenia.[10] Further, the data suggest that spirituality and religiosity domains of QOL are closely associated with coping mechanisms used by the patients.[11]

Considering the availability of limited research in this area, there is a need to understand the extent of religiosity, influence of religion on severity of psychopathology, religious coping, and QOL of patients with schizophrenia. Accordingly the present study aimed to: (1) assess the level of religiosity, religious coping, and QOL of patients with schizophrenia; (2) compare the religiosity and religious coping of patients with schizophrenia with a healthy control group; (3) assess the correlation between level of religiosity and religious coping with residual psychopathology, level of functioning, and QOL.


This study was done at the outpatient services of a tertiary care hospital. The study was approved by the Ethics Review Committee of the Institute and 100 patients were recruited after obtaining written informed consent. The healthy control group included 50 subjects. To be included in the study, subjects with schizophrenia were required to be aged between 18 and 60 years, fulfill the diagnosis of schizophrenia, as per DSM-IV, duration of illness of more than 2 years and able to read Hindi and or English. In addition, the patients were required to be clinically “stable” which was defined as “no clear-cut exacerbation of symptoms in the last 3 months on anamnestic recall and scrutiny of medical records” and “on a stable dose of psychotropics in the last 3 months, i.e., not more than 50% hike or reduction of dosages of psychotropics during this period.” Patients with comorbid affective disorders, anxiety disorders, organic brain disorders, substance-use disorders, and mental retardation were excluded. The healthy controls were also required to be aged between 18 and 60 years and free from any psychiatric disorder.

The healthy control group was selected among the staff of the hospital and caregivers of the patients with mental illnesses. Before recruitment, a detailed psychiatric evaluation was done to rule out any psychiatric disorder at the time of assessment or in the past.

Level of religiosity was measured by religiousness measure scale[12] and duke religion index (DUREL)[13] and religious coping in patients was measured by brief religious coping scale (brief RCOPE).[14] In addition, patients were rated on positive and negative symptom scale (PANSS)[15] and global assessment of functioning (GAF)[16] scale. QOL was assessed using the World Health Organization QOL (WHOQOL)-BREF version (Hindi version).[17]

Religiousness measure scale[12] is a 17-item scale, with one item assessing religiousness, 3 items assessing religious involvement, 7 items assessing religious influence on daily life, and 6 items assess religious hope. Another item assesses whether the person will marry person from another religion or not. Most of the items have questions with responses on 7-point Likert scale except item 1 and 7 having Yes/No responses. Each facet score is derived by averaging the score obtained from the responses to the questions comprising that particular facet.

DUREL[13] is a 5-item scale, with 2 items rated on 6-point scale and 3 items rated on 5-point scale. It assesses 3 major dimensions of religiosity, i.e., organizational religious activity, nonorganizational religious activity, and intrinsic religiosity. The scale has been shown to have high test–retest reliability, high internal consistency, and high convergent validity with other measures of religiosity.

Brief RCOPE[14] is a 14-item scale assessing religious coping in the form of 2 overarching factors, i.e., positive and religious coping. Positive religious coping (PRC) methods reflect a secure relationship with a transcendent force, a sense of spiritual connectedness with others, and a benevolent world view. Negative religious coping (NRC) methods reflect underlying spiritual tensions and struggles within oneself, with others, and with the divine. The scale has been shown to have high internal consistency, test–retest reliability, construct validity, predictive validity, and incremental validity.

The WHOQOL-BREF version (Hindi version) is the only multilingual QOL instrument.[17] It places emphasis on subjective evaluation of respondent's health and living conditions. Four domains of QOL are measured – physical health, psychological health, social relationship, and environment. In addition, another domain of general health is considered. The scale has 26 items scored from 1–5 with total score range of 26–130. Its psychometric properties have been found to be comparable to those of the full version (WHOQOL-100). The scale has shown good discriminant validity, concurrent validity, internal consistency, and test–retest reliability.

All the patients with clinical diagnosis of schizophrenia were approached, and the purpose of the study was explained and those who provided written informed consent were evaluated further. Initially, the subjects were assessed using the Mini International Neuropsychiatric Interview-PLUS version MINI-PLUS[18] to confirm the diagnosis of schizophrenia and rule out the presence of other psychiatric disorders. Only those subjects who fulfilled the selection criteria were recruited.

After documenting the sociodemographic and clinical details, patients were rated on PANSS for schizophrenia[15] and GAF[16] scale. Then, the patients were evaluated on the religiousness measure scale, DUREL, RCOPE, and WHOQOL-BREF.[17] Healthy controls were evaluated on the religiousness measure scale,[12] DUREL,[13] and RCOPE.[14]

Data were analyzed using Statistical Package for the Social Sciences version 14.0. Mean and standard deviations were calculated for the continuous variables and frequency and percentages were calculated for the categorical variables. The relationship between religiosity measures and different variables was assessed using Pearson product-moment correlations or Spearman's rank correlation analysis as per the requirement. Comparisons were done using Chi-square test and Fisher's exact test.


The demographic and clinical profile of the study sample is shown in Table 1. The mean age of the patients was about 35.6 years and mean years of education was 11.7 years. Males outnumbered the females. There was nearly equal distribution of currently married and current unmarried subjects. About two-third of the patients were not on a paid job, a significant number of them (n = 37) were homemakers. Most of the patients belonged to families of middle socioeconomic class as per the Kuppuswamy's socioeconomic scale.[19] About two-third of the patients were Hindus and from urban localities. Those from nonnuclear families outnumbered those from nuclear families.

Table 1:
Demographic and clinical profile of the study sample (n=100)

As shown in Table 1, about three-fourth of the patients were diagnosed with paranoid schizophrenia. The mean age of onset was about 24.2 years and mean duration of illness was 137.5 months. The mean number of hospitalizations was 0.63 and mean number of relapses in the past was 3.45.

Majority of the patients were receiving an atypical antipsychotic medication, with olanzapine being the most common (N = 40), followed by risperidone (N = 25) and clozapine (N = 12). Few patients were receiving typical antipsychotics and more than one antipsychotic medication (N = 10). About one-third of the patients received trihexyphenidyl (N = 31). One-sixth of the patients received antidepressants (N = 17) and few patients received propranolol (N = 6).

The mean total PANSS score was 45.4 and the mean GAF scale score was 79.5 when functioning of last 1 month was considered [Table 1].

In terms of QOL, the mean score was highest for the environment domain, followed by physical health, psychological health, and social relationships and was least for the domain of general health [Table 1].

The mean age of the participants of the control group was 35.84 (standard deviation [SD] - 12.85; range 20–75) and the mean number of years of education was 11.72 (SD - 4.4; range 0–18). About two-third of the participants were male (N = 32; 64%). Majority of the participants were married (N = 30; 60%), educated beyond matric (N = 31; 62%), were currently employed (N = 42; 84%), belonged to middle socioeconomic status (N = 37; 74%), had income more than 7322 rupees (N = 34; 68%), Hindu by religion (N = 39; 78%), from nuclear families (N = 29; 58%), and urban background (N = 36; 72%). When compared with the study group, participants in the control group were more educated (t-test value −2.507; P = 0.013), significantly higher proportions of the participants in the control group were employed (Chi-square test value 27.043; P < 0.001), and significantly higher proportion of them had income more than rupees 7322 (Chi-square test value 37.88; P < 0.001).

Religiosity and religious coping

Of the 100 patients of schizophrenia, 99% reported that they believed in God. The mean score for the religious involvement domain was 12.55, for religious influence was 30.91 and that for religious hope subscale was 29.33 [Table 2]. Total religiosity score as per religious measure scale was 73.01. When the data of patient group were compared with the healthy control, no significant difference was noted in the various domains of religious measure scale.

Table 2:
Religiosity as assessed by Religiousness Measure Scale and Duke Religion Index

As shown in Tables 2 and 3, on DUREL, the mean score on the religious attendance domain was 4.39 with 60% of patients attending the religious places either once a week or more and only 11% of patients reported not attending the religious place at all. In terms of private religious activities domain, the mean score was 4.25, with 56% of patients reporting indulging in private religious activity at least once a day and only 14% reported not indulging in private religious activity at all. On the intrinsic religiosity domain, the mean score was 11.4 with half of the participants scoring 14 or 15 (i.e., maximum attainable score) and about two-third of the participants scored more than 10.

Table 3:
Assessment of religious practices of patients with schizophrenia as per Duke Religion Index

There was no significant difference between the study group and the healthy control groups on any of the variables.

The mean score of PRC subscale was 14.56 and that for NRC subscale was 8.31. In terms of frequency of use (never used vs. ever used), 98% patients used at least one of the coping mechanisms from the PRC and 70% of them used at least one of the NRC. When the data of patient group were compared with the healthy control, as is evident from Table 4, patients did not differ from the healthy controls in terms of mean scores and in terms of frequency of use (never used vs. ever used) on the various items of PRC. However, compared to healthy controls, the mean scores for the patients were significantly higher for NRC and the frequency (never used vs. ever used) of use was also significantly higher for NRC.

Table 4:
Religious coping strategies utilized by patients as assessed by the Brief Religious Coping scale (n=100)

Association between sociodemographic variables and religiosity and spirituality

When the correlation analysis was carried out for studying the relationship of age of the patients and level of education of patients with religiosity measure scale, DUREL, and religious coping, no significant correlations were seen. When the comparisons were done for categorical variables, on religious measure scale, higher level of religious involvement was seen for those belonging to rural locality (11.67 [SD - 5.26] vs. 14.11 [SD - 5.09]; t-value −2.250 [0.027]*).

Those patients who belonged to nuclear families had higher mean scores for private religious activity (4.81 [1.53] vs. 3.82 [2.05], t-value 2.650**; [0.009]) and intrinsic religiosity (12.46 [3.54] vs. 10.64 [4.63]; t-value 2.138*, [0.035]) as per DUREL. In terms of religious coping, those who belonged to nuclear families (16.11 [5.43] vs. 13.38 [7.17]; t-value 2.083*, [0.040]) and rural locality (16.33 [5.95] vs. 13.5 [6.77], t-value −2.048*, [0.043]) had higher positive RCOPE scores.

When the correlation analysis was carried out for studying the relationship of age of onset and duration of illness with religiosity measure scale, DUREL, and religious coping, no significant correlations were seen. When the relationship was studied with diagnostic subtypes, no significant difference was noted between paranoid and nonparanoid subtypes on religiosity measure scale, DUREL, and religious coping.

In terms of psychopathology, as shown in Table 5, PANSS-negative symptom score, PANSS general psychopathology symptom score, and total PANSS score correlated negatively with various aspects of religiosity except for negative RCOPE score. There were few correlations between PANSS-positive symptom subscale score and various domains of religious measure scale. There was a significant positive correlation between the GAF score and various aspects of religiosity except for negative RCOPE score.

Table 5:
Correlation between Positive and Negative Symptom Scale and religiosity measures, Duke Religion Index, and religious coping

As depicted in Table 5, there were significant positive correlations between QOL and various aspects of religiosity except for negative RCOPE score.


The present study attempted to study the level of religiosity and religious coping among patients with schizophrenia. It is hoped that understanding the importance of religion for the patients and its influence on outcome variables such as residual psychopathology and QOL can help the clinicians in better organization of services as per the needs of the patients, improve outcome of patients and in developing a holistic approach to treatment.

For this study, 100 patients of schizophrenia who were clinically stable were assessed for religiosity on 2 standardized scales, i.e., religiosity measure scale and DUREL. Religious coping was assessed using brief RCOPE.

The typical sociodemographic profile of the study population was that of a subject of either gender, unemployed, educated up to 10th standard, from middle socioeconomic status, belonging to a Hindu religion, and from urban background. This sociodemographic profile mimics the profile of patients attending this center and other centers from India which has focused on clinically stable patients of schizophrenia.[202122] However, when compared to some of the previous studies from this center,[23242526] the proportion of married subjects in the present study were slightly higher. Paranoid schizophrenia was the most common subtype of schizophrenia, which is commensurate with the global literature[27] and previous studies from India, including those from our center.[2324252628] Mean age of onset of illness was found to be around 24 years, which is in the range of typical age of onset of schizophrenia as reported in the vast amount of literature available. Mean duration of illness was found to be about 11.5 years, which is also similar to that reported in previous studies from this center.[2324252628] The mean number of hospitalizations in the past was 0.63, and the mean number of visits to the hospital in the past 3 months was 2.3. This profile is typical of patients attending this center.[2324252628] All these findings suggest that patients included in the present study were representative of those attending the psychiatry outpatient services of a tertiary care hospital.

Nearly nine-tenths of the patients received a single antipsychotic, with nearly two-third of them being on either olanzapine or risperidone. This is keeping in line with the previous studies from this center and data from a study of prescription patterns in India.[2930] Psychopathology was assessed by means of PANSS, and the total PANSS score was found to be 45.4. This is similar to that reported by one of the recent studies from this center, which also evaluated clinically stable patients.[313233] The mean GAF score was found to be 79.4 suggesting that the study participants had relatively higher level of functioning and possibly lower level of dysfunction/disability. Overall, the clinical profile of patients resembled the population with chronic, but relatively stable severe mental illnesses attending this particular facility, as observed among a number of prior studies from the same center.[2021222324313233]

On the religious measure scale, one item which assessed religiousness (do you believe in God) of the patient showed that 99 out of the 100 patients answered in affirmation. This suggests that almost all patients with schizophrenia believed in God. On DUREL, 60% of patients reported attending the religious places at least once a week and 75% of patients reported indulging in private religious or spiritual activities such as prayer, meditation, or the study of religious texts at least few times a month. In terms of intrinsic religiosity, about two-third of them scores toward the higher range.

When the data of patient group were compared with the healthy control data, no significant difference was noted in the various domains of religious measure scale, religious attendance, private religious activities, and intrinsic religiosity as assessed by DUREL. These findings possibly suggest that patient group do not differ from the healthy controls on religious practices and involvement. In terms of religious coping, there was no significant difference between the patients and healthy controls in terms of mean scores of various items of PRC and frequency of use (never used vs. ever used). In terms of NRC, patients had higher mean scores for various items of NRC and higher proportion of them used (never used vs. ever used NRC). These findings suggest that compared to healthy controls patients more often use NRC mechanisms. It can be hypothesized that with chronic illness, faith of the patients in God gets eroded, and hence, they more often use NRC. Accordingly, clinicians should evaluate this aspect, instill hope in patients, and encourage the patients to avoid using NRC.

There is a lack of consensus with regard to religious belief and practices among patients of schizophrenia when compared to general population. A study from the West compared religious practices in patients with schizophrenia and general population suggest that religious involvement is higher among patients.[34] When the findings of the present study are compared with the WIN-Gallup International Global Index of Religiosity and Atheism, 2012,[35] similar conclusions can be drawn. However, when one compared the findings of the present study with healthy controls, there was no difference. Accordingly, findings of the present study do not support this assertion. However, occasional studies from the west also suggest that religious attendance is less among patients of schizophrenia compared to the age-matched healthy peers.[36] Accordingly, it can be said that in the absence of data about religious beliefs and practices of subjects in general population from the same catchment area, it would be premature to reach to any conclusion with regard to the religious beliefs/faith and practices among patients with schizophrenia. Further, it is important to note that the present study was limited to patients of schizophrenia visiting a tertiary care center and it is possible that many patients who did not believe in God may not be seeking treatment.

Few studies from the West have evaluated the religious practices of patients with schizophrenia using different assessment measures and suggest that religious practices are common among patients with schizophrenia and findings from different countries vary. A German study reported that 61% of patients with schizophrenia and affective disorders rated themselves as religious, and 14% rated themselves as highly religious and only 25% rated themselves as not religious.[37] When the findings of the present study are compared with this study, it can be said that more patients of Indian origin are religious compared to that from west. However, when one looks at the religiousness of persons from India and Germany as found in WIN-Gallup international global index of religiosity and atheism, 2012 survey,[35] it can be said that higher percentage of people in India are religious (82% vs. 51% in Germany). Accordingly, it can be said that proportion of patients with schizophrenia being “religious or not” is influenced by the religiousness of the community to which they belong. A study from the United States of America found that 91% of patients reported participation in private religious or spiritual activities and 68% reported participation in public religious services or activities.[36] Findings of the present study are comparable to this study.

In the present study, religious coping used by patients was assessed by using Brief RCOPE, which categorizes the religious coping into positive and NRC. The PRC subscale of the Brief RCOPE taps sense of connectedness with a transcendent force, a secure relationship with a caring God, and a belief that life has a greater benevolent meaning. The NRC subscale of the Brief RCOPE is characterized by signs of spiritual tension, conflict and struggle with God and others, as manifested by negative reappraisals of God's powers (e.g., feeling abandoned or punished by God), demonic reappraisals (i.e., feeling the devil is involved in the stressor), spiritual questioning and doubting, and interpersonal religious discontent.[14] In terms of use of religious coping, 98% of patients in the present study used both PRC and NRC. However, the mean PRC subscale was significantly higher that NRC subscale score, suggesting that patient use positive religious coping more often than the NRC. Findings of the present study are supported by the existing literature which suggests that 80% of patient's use religious coping as a means of dealing with their illness.[38]

A study from the Germany reported that diagnosis, education, gender, duration of illness, and self-evaluation of current mental health status had no significant statistical impact on the importance of religion. Age correlated positively with importance of religion. Patients perceived hospital-based pastoral services to be very helpful.[37] Findings of the present study also suggest that sociodemographic variables such as gender, education, and duration of illness have no relationship with various aspects of religion. However, in contrast to the study from Germany, in the present study, no relationship was noted between various aspects of religion and age of the patient.

With regard to the influence of various aspects of religiosity on severity of symptoms, data suggest that religious activities and beliefs are more in persons who experience more severe symptoms, especially psychotic and general symptoms,[39] whereas others suggest that increased religious activity is associated with reduced level of symptoms.[38] Findings of the present study suggest that higher religious involvement and practices are associated with lower level of negative symptoms, general psychopathology, and total PANSS score. With regard to the positive symptoms, the relationship was not consistent and as strong as seen for other symptoms. Overall religious involvement and practices were associated with better level of functioning in the present study. Findings of the present study suggest that religious involvement, religious practices, and use of religious coping are associated with better QOL. This finding is in concordance with previous studies which suggest that religion is associated with better QOL[364041] and regard to relationship of religion and psychosocial adaptation[42] and better recovery.[204344] Accordingly, it can be said that encouraging the patients to participate in public and private religious activities can reduce the level of residual psychopathology and improve the QOL of patients.

The present study has certain limitations. The study was limited to the patients attending a general hospital psychiatry unit of a tertiary care unit. Hence, the results cannot be generalized to other patient populations. The study was limited to the clinically stable patients. Hence, the findings cannot be generalized to those with a higher level of symptoms. The study involved a cross-sectional evaluation and did not include patients with comorbidities. Hence, there is a need for replication of the study in larger samples drawn from different treatment settings.

To conclude, findings of the present study suggest that majority of the patients with schizophrenia believe in God and quite frequently indulge in public and private religious practices. The level of religiosity and use of PRC among patients with schizophrenia do not differ from healthy controls. However, patients more often use NRC. The present study also suggests that higher level of belief in God, more frequent religious practices, and use of PRC are associated with lower level of psychopathology, better functioning, and better QOL.

Keeping these things in mind, it can be said that there is a need for the clinicians to change their approach with regard to religiosity among patients. In the holistic care of the patients, clinicians should enquire about the religiosity and spirituality, religious and spiritual practices, and religious and spiritual needs of the patients. They should encourage the patients to use PRC strategies and guide the patients to decrease the use of NRC.

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Conflicts of interest

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Religion; religiosity; religious coping; schizophrenia; quality of life

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