FLOATING

CURRENT
OPINION Spirituality in geriatric psychiatry
Alessandra Lucchetti a, Ricardo Barcelos-Ferreira a, Dan G. Blazer b,
and Alexander Moreira-Almeida a

Purpose of review
Academic recognition of the implications of religion/spirituality (R/S) for mental health is increasing, with a
growing number of studies involving older adults. The present review provides an overview of these studies,
highlighting the influence of R/S on older adults’ mental health and the clinical implications of addressing
R/S in the geriatrics and gerontology context.
Recent findings
The available evidence suggests that R/S involvement is usually associated with lower levels of depression,
substance use/abuse, and cognitive declining and better quality of life, well being, and functional status in
older persons. Despite the number of studies showing this relationship, few have yet investigated the effects
of addressing spiritual needs or carrying out R/S interventions in this age group.
Summary
Evidence is mounting that R/S is most important in geriatric psychiatry. In general, studies have shown a
positive relationship between R/S and mental health in the older population. Health professionals should
be attentive to these spiritual needs. Nevertheless, more studies are needed to investigate the mechanisms
of the R/S–mental health association and how to integrate R/S in clinical practice.
Keywords
aged, geriatrics, mental health, religion and medicine, spirituality

INTRODUCTION spirituality to geriatric psychiatry. The review also

Spirituality is the search and connection with the
sacred and the transcendent (God, higher power, or
ultimate truth/reality). It often, but not necessarily,
takes place in the context of religions (’organized
systems of beliefs, practices, rituals, and symbols
designed to facilitate closeness to the sacred or
transcendent’) [1,2 ].
&
There has been a growing academic recognition
of the implications of religion/spirituality (R/S) for
health, with an increasing number of studies doc-
umenting this relationship. A recent systematic
review identified more than 3 300 original quanti-
tative studies, most of them in mental health. A
substantial part (around 1/3) investigated older peo-
ple [3]. However, despite the extant literature, this
subject is not recognized by many mental health
practitioners. The present review aims to provide an
overview of the influence of R/S on older adults’
mental health.
In order to identify papers relevant to this
review, we performed a PubMed search with the
keywords: ‘(religio OR spiritu) AND (old OR
elder OR aged) AND (mental OR psych)’. We
selected the more recent and representative papers
on the topic of the importance and implications of
includes some classic seminal and landmark papers
on the field.
IMPACT OF RELIGION AND SPIRITUALITY
IN MENTAL HEALTH
Available evidence provides robust and consistent
though not universal evidence that R/S involvement
is related to better health, specially lower frequency
of depression, suicidal behavior, overall mortality,
alcohol and other substance use/abuse, and higher
frequencies of well being, meaning, and quality of
life. However, negative views and applications of
religion (such as dysfunctional religious coping, for
a
Research Center in Spirituality and Health (NUPES), School of Medi-
cine, Universidade Federal de Juiz de Fora (UFJF), Juiz de Fora – MG,
Brazil and bDepartment of Psychiatry and Behavioral Science, Duke
University Medical Center, Durham, North Carolina, USA
Correspondence to Alexander Moreira-Almeida, Universidade Federal de
Juiz de Fora - School of Medicine, Av. Eugênio Nascimento s/n, 36036-
380, Juiz de Fora - MG, Brazil. Tel: +55 32 2102 3848;
fax: +55 32 2102 3848; e-mail: alex.ma@medicina.ufjf.br
Curr Opin Psychiatry 2018, 31:373–377
DOI:10.1097/YCO.0000000000000424

0951-7367 Copyright ß 2018 Wolters Kluwer Health, Inc. All rights reserved. www.co-psychiatry.com

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

Geriatric psychiatry
KEY POINTS
 R/S are common in older persons and usually
associated with lower levels of depression, substance
use/abuse, and cognitive declining and better quality
of life, well being, and functional status.
 Taking a brief spiritual history is a practical and simple
way of assessing patients’ R/S.
 There is a great need of developing and testing
spiritually integrated interventions in geriatric
psychiatry.
example seeing God as punitive or passive deferral to
God) has adverse impacts on health status and
mortality rates. A challenging area is the under-
standing of the mediators, the mechanisms by
which R/S may impact health. The study of mecha-
nisms remains in its early stages. With further devel-
opment it will be very useful in determining the
‘active ingredients’ of R/S, which have a great poten-
tial for application in prevention and treatment
[1,4]. We will present and briefly discuss the main
recent studies that illustrate R/S and mental health
associations in a variety of older populations includ-
ing nonclinical community samples, medical inpa-
tients, and rehabilitation setting.
Several studies have demonstrated associations
of religious services attendance with better func-
tional status and some of private religious practices
with worse functionality. However, there have been
doubts about the causal direction (e.g. whether
religious attendance prevents functional decline
or vice versa) and if certain private religious practices
are coping strategies for those more impaired who
can no longer attend religious services [4]. In order
to investigate these correlations, one study followed
2924 older adults (mean age 73 years) over 10 years.
The investigators explore the impact of several reli-
gious dimensions [attendance, private practices
(prayer, meditation or Bible study) and use of reli-
gious media] over three domains of functional status
(limitations in basic activities of daily living, instru-
mental activities of daily living, and mobility). Data
were collected during four interviews throughout
the study, controlling for potential confounders
such as demographics, social support, depressive
symptoms, cognitive, and health status. Religious
attendance was a strong independent protector
against the three dimensions of functional decline.
In contrast, private religiosity had no association
with functionality. Use of religious media predicted
higher functional impairment in the unadjusted
analyses, but not in the adjusted model, suggesting
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that such use may reflect an indirect or spurious
association mediated by the confounders such as
health and prior functional status. In summary,
religious attendance protected against functional
decline in the three domains and this effect was
stable during the years of follow-up yet not
explained by indirect effects of social support,
depression, and health status [5].
Another study investigated older Brazilian
adults with functional impairment who were out-
patients in a rehabilitation clinic. Self-reported
importance of religion, controlling for several con-
founding variables, correlated with less pain and
depressive symptoms, and with better quality of life
and cognitive functioning. Religious service atten-
dance was not associated with any of the outcomes.
Anxiety was not related to R/S [6].
One of the most consistent findings in studies of
the relationship of R/S and mental health is the
inverse correlation between religious involvement
and depression. Most extant studies are cross-
sectional, vulnerable to issues of causal direction.
However, these findings have been replicated in
longitudinal studies, several involving the elderly.
Intrinsic religiousness predicted 70% faster depres-
sion remission among medically ill older inpatients
[7] and a steady decline of depressive symptoms over
4 years in a community sample of United States’
older adults (average age 75 years) even after con-
trolling for demographic, health and social variables
[8]. In another study of elderly medical inpatients,
839 patients with heart failure and/or chronic pul-
monary disease and depression, isolated religious
variables were not associated with depression remis-
sion, but a combination of religious involvement
variables (such as attendance, prayer and religious
readings) predicted a 53% faster remission of depres-
sion after controlling for confounding variables [9].
Different R/S dimensions may have distinctive
impacts on depression’s phases as showed in a
nationally representative United States sample
of 1992 depressed and 5740 nondepressed older
adults (average age ¼ 68.1 years) followed for 2 years.
Among the nondepressed, those who frequently
attended religious services at baseline were 35% less
likely to be depressed after two years. However,
among the depressed, frequent prayer predicted less
chance of remaining depressed at follow-up. These
results persisted after controlling for several demo-
graphic, health, and social covariables [10].
Older adults are exposed to many traumatic
events, specially related to life-threatening illness
to themselves or loved ones and to bereavement.
Investigators in a 7-year longitudinal survey of an
United States nationally representative sample
found that religious doubt predicted a marked
Volume 31  Number 4  July 2018

increase in depressive symptoms over time after the
death of a spouse or children. However, the absence
of religious doubt predicted an almost stable depres-
sive score. However, religious doubts had no impact
on nonbereavement trauma [11].
Religious adults may deal in different ways with
stressful situations. A U.S. national survey of 1005
older Mexican Americans (average age 73.9 years)
revealed that open and positive R/S in the face of
suffering (e.g. pain and suffering make us more
aware of how much we need God or deepen our
faith and make it stronger) was associated with
optimism and perceived close relationship with
God, but not with self-rated health. However, reli-
giously suffering in silence (e.g. God will reward
those who suffer in silence) correlated with poorer
self-rated health. Church attendance was related to
seeking something positive in the face of suffering,
but not with suffering in silence, suggesting that an
open and positive coping strategy could be fostered
by religious service attendance [12].
The impact on health may differ also by sex and
type of R/S involvement among older adults. A
longitudinal study of a United States nationally
representative sample found that attendance to
religious services predicted less depressive symp-
toms in men but not women. However, nonorga-
nizational R/S (reading the bible, watch religious
programs or prayer) was related to less death
anxiety in women but not in men [13]. This study
demonstrates the R/S and mental health relation-
ship is complex, depending on the R/S dimension
measured and on the population studied. There
is consistent evidence that the protective effect
size of R/S is higher in subgroups under more
stressful situations such as poverty, disability, and
trauma [1].
In sample of 1534 older adults living in a low-
income region in São Paulo, Brazil, those attending
religious services were related to a 50% lower preva-
lence of common mental disorders (depression, anx-
iety, and somatoform disorders) compared with
those who did not attend. Religious elderly reported
higher social support (both offered and received),
but this failed to be a significant mediator of the
association found in the study [14]. This study high-
lights the challenges in determining the mecha-
nisms/mediators by which R/S may impact mental
health.
A recent study illustrates the several and com-
plex interfaces between R/S and mental health in the
elderly. In this14-year prospective study of a U.S.
national sample of 89 708 women (initial average
age around 62 years old), suicide deaths among
women who attended religious services at least once
a week were one seventh of those women who
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Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Spirituality in geriatric psychiatry Lucchetti et al.
attended less often even after controlling for several
health and demographic variables (e.g. age, income,
health, and employment status). In addition, fre-
quent religious service attendance was correlated
with lower alcohol, tobacco, and antidepressant
use, and higher social integration and more likely
to be married. Because these are also factors related
to suicide risk, the authors further controlled for this
variables, but controlled analysis did not change the
effect sizes of religious attendance on suicide risk. In
summary, this large longitudinal study demon-
strated that frequent religious attendance is a strong
predictor of lower suicide deaths. Less substance use,
depression, and better social integration, although
correlated, were not the mechanisms by which reli-
gious frequency impacts suicide rates. Some possible
mediators were religious coping strategies, moral
values and beliefs, meaning, and purpose in life
&&
[15 ]. Another analysis using the same sample
found that frequent religious attendance predicted
a 33% decrease in all-cause mortality over the 14-
year follow-up, even after controlling for many
demographic, social, and health covariates. Rele-
vant mediators that partially explained the associa-
tion were depressive symptoms, smoking, social
support, and optimism [16].
There has been a growing tendency to value
broader and more comprehensive outcomes, often
relayed to positive psychiatry/psychology such as
&
well being [17], wisdom [18], and flourishing [19 ],
which often involve spirituality among its subcom-
ponents. For example, a recent systematic review
evaluated 11 articles and noted that R/S was related
to slower cognitive decline and to better coping
strategies and improved quality of life in patients
with dementia [20].
Health-related quality of life is an important
factor in elderly well being. A cross-sectional study
of 911 Brazilian older adults (mean age 72 years)
living in São Paulo confirmed that different types of
religious involvement have different associations
depending on gender. Women tended to have
higher R/S than men. Among women, attending
religious services was related to better physical
and mental health-related quality of life. For men,
intrinsic religiosity (e.g. importance of religion in
life, to what extent religion helps understand hard-
ships, and religion gives meaning to life) was related
to higher levels of the mental component of well
being [21].
CLINICAL IMPLICATION
As demonstrated by the studies above, the impact of
R/S on older persons’ mental health is significant,
which leads to important clinical implications.
www.co-psychiatry.com 375
Geriatric psychiatry
Therefore, health professionals should be attentive
to the spiritual needs of their patients in order to
provide more integrative care. Although there are
several ways to address spiritual and religious needs,
a brief spiritual history [22] is usually the best strat-
egy to investigate patients’ beliefs, to understand
how patients deal with his illnesses, to determine
how they receive support from religious communi-
ties, and how these beliefs can influence medical
decisions. If the health professional identifies spiri-
tual needs, he or she can discuss that need with the
patient and, if needed, refer him/her to a chaplain or
to a religious leader.
Recently, many organizations have recom-
mended addressing R/S beliefs routinely in psychi-
atric consultation. In 2016, the World Psychiatric
Association released a Position Statement on R/S in
&
Psychiatry [2 ] recommending that:
(1) A tactful consideration of patients’ religious
beliefs and practices and their spirituality
should routinely be considered and will some-
times be an essential component of psychiatric
history taking.
(2) There is a need for more research on both reli-
gion and spirituality in psychiatry, especially on
their clinical applications.
(3) The approach to religion and spirituality should
be person-centered. Psychiatrists should not
use their professional position for proselytizing
for spiritual or secular worldviews. Psychiatrists
should be expected always to respect and be
sensitive to the spiritual/religious beliefs and
practices of their patients, families and care-
givers of their patients.
These recommendations demonstrate how tak-
ing a spiritual history has become an important
method for engaging a patient in a conversation
about his/her R/S. In this context, there are many
instruments that can be used to address spiritual
needs. Although there are no instruments specifically
designed for older persons, most S/R tools can be
extended to different age groups. According to a
recent systematic review [22], 25 different spiritual
history tools were identified in the scientific litera-
ture: FICA, SPIRITual, FAITH, HOPE, and the Royal
College of Psychiatrists Assessment were the instru-
ments which best assesses R/S. Professionals must
keep in mind that these instruments are one tool
for addressing R/S and may or may not be used based
on professionals’ training and experience with the
theme [23].
Despite the growing recommendations concern-
ing how clinicians address R/S in clinical practice, few
studies have investigated the effects of taking a
376 www.co-psychiatry.com
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
spiritual history and spiritual interventions, particu-
larly in the older population. A Brazilian study
revealed that 87.3% [6] of older adults in rehabilita-
tion wanted their doctors or health professional to
ask about their spiritual and religious beliefs. Simi-
larly, an American study found that older adults (55
years old or more) would like to have R/S incorpo-
rated into their treatment for depression and anxiety
[24]. Nevertheless, few professionals address these
issues in clinical practice [25].
Concerning the use of clinical trials related to R/
S, a recent systematic review [26] evaluated how R/S
interventions influenced mental health outcomes.
Of the 23 studies included in the analysis, most R/S
interventions were able to decrease stress, depressive
and anxiety symptoms, and alcohol use. However,
when meta-analyses were performed, these inter-
ventions, compared to control interventions, were
associated with a decrease in anxiety but not depres-
sive symptoms. Although this review provides
promising verification of the efficacy of this type
of intervention, no study addressing the elderly
population was included.
R/S clinical trials are scarce in the field of psy-
chogeriatrics, and in most areas of research. Older
adults tend to be excluded from trials [27]. In
our search, we identified two trials. The first one
included those aged 65 years or more diagnosed
with dementia in Taiwan [28]. This randomized
controlled trial found that a 6-week spiritual remi-
niscence intervention (which emphasizes the recon-
nection and enhancement of the meaning of one’s
own experience) showed higher improvement in
hope, life satisfaction, and spiritual well being com-
pared to a control group.
Patients in the second trial with a mean age of
52 years found no significant difference in the
impact on the life purpose [29] and optimism [30]
between religious cognitive behavioral therapy
(RCBT) and conventional cognitive behavioral ther-
apy (CCBT) among patients with major depression
and chronic medical illness. However, RCBT pro-
duced an improvement over the therapeutic alliance
initially compared to CCBT [31] and RCBT was more
effective than CCBT in increasing life expectancy in
clients who were highly religious [29]. These results
show at least comparative efficacy of RCBT com-
pared to CCBT.
Although widely recommended by scientific
organizations and institutions [23] and included
in many medical curricula [32], there remains a
shortage of studies that have assessed how spiritual-
ity and religiosity can influence clinical practice,
particularly in older persons. These results can serve
as an incentive for new studies to be conducted in
this population.
Volume 31  Number 4  July 2018

CONCLUSION
The relationship between R/S and mental health in
the elderly has been well investigated, providing
robust evidence that R/S is important for most of
this population. Higher levels of R/S are common in
older persons and usually associated with lower
levels of depression, substance use/abuse, and cog-
nitive decline and better quality of life, well being,
and functional status. There is still a shortage of
translational studies to clinical practice in this age
group, but the importance of at least taking a brief
spiritual history has been well established.
There is good evidence that R/S can have a
promising role in geriatric psychiatry. However,
more translational research is urgent in order to
apply the epidemiological evidence to clinical prac-
tice. In this sense, it is crucial the investigation of the
mechanisms of the R/S–mental health association
and the development of clinical strategies that inte-
grate R/S in preventive and treatment interventions.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED
READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
& of special interest
&& of outstanding interest
1. Moreira-Almeida A, Neto FL, Koenig HG. Religiousness and mental health: a
review. Rev Bras Psiquiatr 2006; 28:242–250.
2. Moreira-Almeida A, Sharma A, van Rensburg BJ, et al. WPA Position State-
& ment on Spirituality and Religion in Psychiatry. World Psychiatry 2016;
15:87–88.
WPA guidelines on the essential aspects of how to integrate R/S in psychiatric
practice.
3. George LK, Kinghorn WA, Koenig HG, et al. Why gerontologists should care
about empirical research on religion and health: transdisciplinary perspec-
tives. Gerontologist 2013; 53:898–906.
4. King D, Carson V. Handbook of religion and health. New York: Oxford; 2012;
2:1991-5.
5. Hybels CF, Blazer DG, George LK, Koenig HG. The complex association
between religious activities and functional limitations in older adults.
Gerontologist 2012; 52:676–685.
6. Lucchetti G, Lucchetti AGL, Badan-Neto AM, et al. Religiousness affects
mental health, pain and quality of life in older people in an outpatient
rehabilitation setting. J Rehab Med 2011; 43:316–322.
0951-7367 Copyright ß 2018 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Spirituality in geriatric psychiatry Lucchetti et al.
7. Koenig HG, George LK, Peterson BL. Religiosity and remission of depression
in medically ill older patients. Am J Psychiatry 1998; 155:536–542.
8. Sun F, Park NS, Roff LL, et al. Predicting the trajectories of depressive
symptoms among southern community-dwelling older adults: the role of
religiosity. Aging Ment Health 2012; 16:189–198.
9. Koenig HG. Religion and remission of depression in medical inpatients with
heart failure/pulmonary disease. J Nerv Ment Dis 2007; 195:389–395.
10. Ronneberg CR, Miller EA, Dugan E, Porell F. The protective effects of
religiosity on depression: a 2-year prospective study. Gerontologist 2014;
56:421–431.
11. Hayward RD, Krause N. How religious doubt moderates depression symp-
toms following older adult bereavement. Death Stud 2014; 38:217–223.
12. Krause N, Bastida E. Religion, suffering, and self-rated health among older
Mexican Americans. J Gerontol B Psychol Sci Soc Sci 2011; 66:207–216.
13. McFarland MJ. Religion and mental health among older adults: do the effects
of religious involvement vary by gender? J Gerontol B Psychol Sci Soc Sci
2010; 65:621–630.
14. Correa AA, Moreira-Almeida A, Menezes PR, et al. Investigating the role
played by social support in the association between religiosity and mental
health in low income older adults: results from the Sao Paulo Ageing & Health
Study (SPAH). Rev Bras Psiquiatr 2011; 33:157–164.
15. VanderWeele TJ, Li S, Tsai AC, Kawachi I. Association between religious
&& service attendance and lower suicide rates among US women. JAMA
Psychiatry 2016; 73:845–851.
The largest longitudinal study to date on the large impact of R/S on suicide deaths
and the possible mediators.
16. Li S, Stampfer MJ, Williams DR, VanderWeele TJ. Association of religious
service attendance with mortality among women. JAMA Intern Med 2016;
176:777–785.
17. Jeste DV, Palmer BW, Rettew DC, Boardman S. Positive psychiatry: its time
has come. J Clin Psychiatry 2015; 76:675–683.
18. Bangen KJ, Meeks TW, Jeste DV. Defining and assessing wisdom: a review of
the literature. Am J Geriatr Psychiatry 2013; 21:1254–1266.
19. VanderWeele TJ. On the promotion of human flourishing. Proc Natl Acad Sci
& USA 2017; 114:8148–8156.
An important review on positive aspects of mental health, including R/S.
20. Agli O, Bailly N, Ferrand C. Spirituality and religion in older adults with
dementia: a systematic review. Int Psychogeriatr 2015; 27:715–725.
21. Abdala GA, Kimura M, Duarte YA, et al. [Religiousness and health-related
quality of life of older adults]. Rev Saude Publica 2015; 49:55.
22. Lucchetti G, Bassi RM, Lucchetti AL. Taking spiritual history in clinical
practice: a systematic review of instruments. Explore (New York, NY)
2013; 9:159–170.
23. Moreira-Almeida A, Koenig HG, Lucchetti G. Clinical implications of spiri-
tuality to mental health: review of evidence and practical guidelines. Rev Bras
Psiquiatr 2014; 36:176–182.
24. Stanley MA, Bush AL, Camp ME, et al. Older adults’ preferences for religion/
spirituality in treatment for anxiety and depression. Aging Ment Health 2011;
15:334–343.
25. Best M, Butow P, Olver I. Doctors discussing religion and spirituality: a
systematic literature review. Palliat Med 2016; 30:327–337.
26. Goncalves JP, Lucchetti G, Menezes PR, Vallada H. Religious and
spiritual interventions in mental healthcare: a systematic review and meta-
analysis of randomized controlled clinical trials. Psychol Med 2015; 45:
2937–2949.
27. Shenoy P, Harugeri A. Elderly patients’ participation in clinical trials. Perspect
Clin Res 2015; 6:184–189.
28. Wu LF, Koo M. Randomized controlled trial of a six-week spiritual reminis-
cence intervention on hope, life satisfaction, and spiritual well being in elderly
with mild and moderate dementia. Int J Geriatr Psychiatry 2016; 31:
120–127.
29. Daher N, Koenig HG, Pearce MJ, et al. Effects of religious vs. conventional
cognitive-behavioral therapy on purpose in life in clients with major depression
and chronic medical illness: a randomized clinical trial. Int J Exist Psychol
Psychother 2016; 6:16.
30. Koenig HG, Pearce MJ, Nelson B, Daher N. Effects of religious versus
standard cognitive-behavioral therapy on optimism in persons with major
depression and chronic medical illness. Depress Anxiety 2015; 32:835–842.
31. Koenig HG, Pearce M, Nelson B, et al. Effects of religious vs. standard
cognitive behavioral therapy on therapeutic alliance: a randomized clinical
trial. Psychother Res 2016; 26:365–376.
32. Lucchetti G, Lucchetti AL, Puchalski CM. Spirituality in medical education:
global reality? J Relig Health 2012; 51:3–19.
www.co-psychiatry.com 377