Original Paper

The Journal of Primary Prevention

, Volume 34, Issue 6, pp 439-453

First online:

Using Effort-Reward Imbalance Theory to Understand High Rates of Depression and Anxiety Among Clergy

  • Rae Jean Proeschold-BellAffiliated withDuke Global Health Institute, Center for Health Policy and Inequalities Research, Duke University Email author 
  • , Andrew MilesAffiliated withDepartment of Sociology, Duke University
  • , Matthew TothAffiliated withGillings School of Global Public Health, University of North Carolina Chapel Hill
  • , Christopher AdamsAffiliated withDivision of Student Life, Office of the Campus Pastors, Graduate Department of Psychology, Azusa Pacific University
  • , Bruce W. SmithAffiliated withDepartment of Psychology, University of New Mexico
  • , David TooleAffiliated withDuke Divinity School, Duke University

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The clergy occupation is unique in its combination of role strains and higher calling, putting clergy mental health at risk. We surveyed all United Methodist clergy in North Carolina, and 95 % (n = 1,726) responded, with 38% responding via phone interview. We compared clergy phone interview depression rates, assessed using the Patient Health Questionnaire (PHQ-9), to those of in-person interviews in a representative United States sample that also used the PHQ-9. The clergy depression prevalence was 8.7 %, significantly higher than the 5.5 % rate of the national sample. We used logistic regression to explain depression, and also anxiety, assessed using the Hospital Anxiety and Depression Scale. As hypothesized by effort-reward imbalance theory, several extrinsic demands (job stress, life unpredictability) and intrinsic demands (guilt about not doing enough work, doubting one’s call to ministry) significantly predicted depression and anxiety, as did rewards such as ministry satisfaction and lack of financial stress. The high rate of clergy depression signals the need for preventive policies and programs for clergy. The extrinsic and intrinsic demands and rewards suggest specific actions to improve clergy mental health.


Depression Anxiety Clergy Effort-reward imbalance theory Mental health