Journal of Religion and Health

, Volume 53, Issue 2, pp 562–578 | Cite as

In Search of Serenity: Religious Struggle Among Patients Hospitalized for Suspected Acute Coronary Syndrome

  • Gina Magyar-Russell
  • Iain Tucker Brown
  • Inna R. Edara
  • Michael T. Smith
  • Joseph E. Marine
  • Roy C. Ziegelstein
Original Paper

Abstract

Hospitalization for a sudden cardiac event is a frightening experience, one that is often marked by uncertainty about health status, fear of recurrent cardiac problems, and related existential, religious, and spiritual concerns. Religious struggle, reflecting tension and strain regarding religious and spiritual issues, may arise in response to symptoms of acute coronary syndrome (ACS). The present study examined the prevalence and types of religious struggle using the Brief RCOPE, as well as associations between religious struggle, psychological distress, and self-reported sleep habits among 62 patients hospitalized with suspected ACS. Fifty-eight percent of the sample reported some degree of religious struggle. Questioning the power of God was the most frequently endorsed struggle. Those struggling religiously reported significantly more symptoms of anxiety, depression, and sleep disturbance. Non-White participants endorsed greater use of positive religious coping strategies and religious struggle. Results suggest that patients hospitalized for suspected ACS experiencing even low levels of religious struggle might benefit from referral to a hospital chaplain or appropriately trained mental health professional for more detailed religious and spiritual assessment. Practical means of efficiently screening for religious struggle during the often brief hospitalization period for suspected ACS are discussed.

Keywords

Acute coronary syndrome Cardiac patients Religious struggle Religion Spirituality 

Introduction

Acute coronary syndrome (ACS) is a term used for any condition brought on by sudden, reduced blood flow to the heart (Arbab-Zadeh et al. 2012; Trost and Lange 2011). The term ACS includes unstable angina and myocardial infarction (MI), depending on whether myocardial cell death occurs (MI) or not (unstable angina). In both cases, patients typically experience chest pain, often with shortness of breath, nausea, vomiting, and sudden, heavy sweating (Trost and Lange 2011).

Clearly, the symptoms of an ACS may be frightening and viewed as an imminent threat to health that can raise existential concerns for religious, spiritual, and non-religious individuals alike (Ai et al. 2010a). How religiousness and spirituality are utilized in the midst of life-altering health events continues to be an emerging area of study, with recent emphasis on negative religious coping or religious struggle, because of its reliable association with poor adjustment and heightened symptoms of mental and physical health problems (Exline and Rose 2005; Pargament et al. 2005).

A growing body of empirical research examining the associations between religion and health continues to demonstrate the complex and multiple roles religiousness plays in quality of health and well-being (Ano and Vasconcelles 2005; Hall et al. 2008; Weaver et al. 2006). In terms of using various forms of religion and spirituality to cope with significant life stressors, Pargament (1997) divides strategies into positive and negative religious coping. Positive methods of religious coping generally reflect a secure relationship with God, spiritual connectedness with others, constructive support-seeking behaviors, and stress-related growth. In these ways, religion can play a protective and consoling role, leading to novel and health-promoting religious appraisals that take into account the challenging realities of adverse health conditions (Pargament 1996, 1997). However, some individuals may mobilize religion in a maladaptive capacity, feeling, for example, punished by God and spiritually alienated from others. In this sense, religion is concomitant with struggle, straining, and reaching for help from God or a religious congregation, yet engaging in potentially destructive coping strategies that have been associated with depression, anxiety, poor physical functioning, and spiritual injury (Exline and Rose 2005; Pargament et al. 2005a, b).

Religious struggle refers to a particular manner of coping; it reflects tension and strain about religious and spiritual issues within oneself, with other people, and/or with the divine (Pargament et al. 2005a, b). Specifically, religious and spiritual struggles include “efforts to conserve or transform a spirituality that has been threatened or harmed” (Pargament et al. 2005b, p. 247). Within the world’s major religions, religious struggle is considered normative; the path of human life is neither straightforward nor painless. Instead, it is fraught with challenges, obstacles, wrong turns, and dead-ends. In Jewish and Christian thought, religious struggles are not simply “stressors,” but represent critical “forks in the road” that, depending on how they are managed, can lead to despair and hopelessness or renewal, growth, and transformation (Pargament et al. 2005b, p. 246).

The prevalence, nature, and implications of religious and spiritual struggle have, for the most part, just begun to be studied empirically among medical patient populations in the last decade. One of the earliest studies demonstrating the dramatic impact of struggling religiously was the seminal work of Oxman et al. (1995). In a sample of 232 patients undergoing open heart surgery (coronary artery bypass grafting (CABG), aortic valve replacement, or both), these researchers found that individuals who reported deriving no strength or comfort from religion had three times the risk of postoperative mortality after controlling for previous cardiac surgery, activities of daily living, age, and social participation in groups. In a two-year longitudinal investigation of 596 medically ill, hospitalized patients aged 55 and older, Pargament et al. (2001a) found that, after controlling for demographic variables and indices of physical and mental health, higher religious struggle scores at baseline assessment during hospitalization were predictive of greater risk of mortality 2 years later. Specific forms of religious struggle that predicted a 19–28 % increase in risk of death during the two-year follow-up period included the items: “Wondered whether God had abandoned me,” “Questioned God’s love for me,” and “Decided the devil made this happen.”

Due to the acute nature of physical symptoms, the urgent medical attention required, and the often brief period of hospitalization associated with ACS, research is needed to better understand the prevalence and related consequences of religious struggle among ACS patients. Religious struggle among other cardiac patient populations has demonstrated that roughly half of participants endorse some level of spiritual questioning, doubt, or distress, albeit at relatively low mean levels (Fitchett et al. 2004; Park et al. 2011; Thompson et al. 2009). What is significant, however, is that cardiac patients who report even a small degree of religious struggle demonstrate associated adverse mental, emotional, and physical functioning.

For instance, in a sample of hospitalized patients with congestive heart failure (CHF), diabetes, or cancer, Fitchett et al. (2004) found that religious struggle was associated with higher levels of depressive symptoms and emotional distress in all three groups, but that CHF patients reported significantly higher scores on a measure of religious struggle than the other two patient groups. Park et al. (2011) longitudinally examined the associations between religious struggle and subsequent mental and physical well-being in 101 end-stage CHF patients. In addition to predicting greater depression and lower life satisfaction, religious struggle also predicted greater number of nights subsequently hospitalized. Religious struggle remained a significant predictor of hospitalization and lower physical functioning at the 3-month follow-up assessment. In a sample of 44 MI and CABG patients, Miller et al. (2007) found that religious struggle was associated with lower levels of quality of life and decreased confidence in the ability to perform physical tasks.

In a series of studies, Ai and colleagues (Ai et al. 2009, 2010a, b) have begun to uncover possible biological mechanisms through which religious struggle might exert its toll on the mental and physical health of cardiac patients. In a sample of 235 patients undergoing cardiac surgery, Ai et al. (2009) found that religious struggle was associated with excess preoperative levels of plasma interleukin-6 (IL-6), a stress-related pro-inflammatory cytokine, after controlling for medical correlates. Additionally, in a similar sample of 162 patients undergoing open heart surgery, religious struggle and IL-6 were found to mediate the indirect effects of preoperative anxiety on postoperative depression (Ai et al. 2010a). Finally, in 156 patients undergoing open heart surgery, Ai et al. (2010b) found that preoperative religious struggle mediated the effects of anxiety and anger on IL-6 levels immediately before surgery, and the link between religious struggle and IL-6 further mediated the effects of anxiety and anger on postoperative hostility. These authors suggest that because only those patients who reported religious struggle manifested excess plasma IL-6, perhaps it is not stress alone that changes IL-6 levels, but existential fear and religious uncertainty that may trigger an inflammatory response and influence long-term health outcomes (Ai et al. 2010b).

Taken together, empirical evidence suggests that religious struggle has a complex and compelling relationship with the mind and body that requires continued investigation for a more complete understanding. Moreover, although used with less frequency than positive forms of religiousness (Ai et al. 2007; Ai et al. 2008; Oman and Thoresen 2005; Park et al. 2008; Park et al. 2011), research findings suggest that even a small degree of religious struggle among cardiac patients is a warning sign for adverse mental, emotional, and physical health outcomes.

The Current Study

The present study adds to the empirical research on religiousness among cardiac patients by focusing on the religious coping styles, with particular emphasis on religious struggle, of patients hospitalized for suspected ACS. Examining the religious and spiritual methods by which patients hospitalized for suspected ACS address the critical nature of their condition will help determine how hospital-based mental health professionals and clergy can best assist these patients, especially given the sense of urgency that often surrounds ACS treatment.

The current study aimed to (1) describe the prevalence and types of religious struggles reported by patients hospitalized for suspected ACS and (2) examine associations between religious struggle, self-reported sleep habits, and psychological distress among patients hospitalized for suspected ACS. Based on the previous studies in the empirical literature (reviewed above), it was hypothesized that (a) religious struggle, although endorsed at a low mean level, would be reported by roughly half of the sample, (b) “questioning the power of God” would be the most widely endorsed religious struggle, and (c) religious struggle would be associated with higher levels of psychological distress and sleep disturbance. Although we know of no research to date that has examined the links between religious struggle and sleep disturbance, we hypothesized that religious struggle would be associated with greater sleep disturbance due to the physical, emotional, and existential demands on individuals who use negative religious coping strategies in response to the stressor of suspected ACS. Analyses investigating links between religious struggle, age, gender, race, cardiac condition severity, and mortality were also conducted.

Method

Participant Selection

Participants were consecutive patients 18 years of age and older who were admitted to the cardiology inpatient service of a large urban medical center in the mid-Atlantic region of the United States for a suspected ACS from June 2009 to June 2010. Of 239 potentially eligible patients, 72 were excluded from study participation due to: (a) inability to read or comprehend questionnaires in English (n = 6); (b) excessive difficulty hearing the research assistant (n = 6); (c) positive toxicology screen on admission for cocaine (n = 5); (d) intubation and/or sedation more than three days after hospital admission (n = 18); (e) dementia or cognitive impairment (as assessed by the Mini-Mental State Exam, MMSE; n = 24); (f) the ACS occurred more than 24 h prior to hospital presentation (n = 7); (g) severe psychiatric disorder (n = 2); and hostility to staff/room secured by police (n = 4). Seventy-eight patients declined to participate (felt too ill or overwhelmed, n = 29; “not interested” in participating in research, answering questions, or providing informed consent for medical record review, n = 49), 24 were unavailable for approach prior to discharge (e.g., away from room for a procedure, sleeping, in physical therapy), and 3 did not provide complete data. Thus, 62 participants were included in the present study.

Diagnosis of ACS was retrospectively confirmed by the two cardiologists on the study protocol (JEM and RCZ). Patients who were subsequently determined not to have ACS via the adjudication process were included in the present analyses because subjects were medically treated under a presumptive diagnosis of ACS. Additionally, all participants shared the psychological experience of hospitalization for a sudden health event. The study research coordinator approached eligible patients on the cardiac units to discuss the study, obtain informed consent, and administer study questionnaires in the patients’ hospital room. Data collection was completed an average of 2.5 (SD = 2.5) days after inpatient admission for suspected ACS.

Measures

Mental State

The Mini-Mental State Exam (MMSE; Folstein et al. 1975) is an 11-item test that has been shown to discriminate between patients with and without cognitive disturbances and has demonstrated good test–retest reliability over a 24-hour period, as well as over a period of 28 days (α = .89 and .98, respectively). Patients were required to score 24 or higher in order to participate in the present study to maximize the likelihood that they comprehended questionnaire items.

Depression and Anxiety

The Hospital Anxiety and Depression Scale (HADS; Zigmond and Snaith 1983) was used to assess symptoms of anxiety and depression. The HADS has been widely used to measure anxiety and depression in a wide variety of settings. It is a 14-item self-report measure that includes seven anxiety items and seven depression items from which separate anxiety and depression subscale scores are calculated. Moorey et al. (1991) reported strong internal consistency: Cronbach’s alpha was .93 for the anxiety scale and .90 for the depression scale.

Insomnia

The Insomnia Severity Index (ISI; Bastien et al. 2000) is a 5-item questionnaire that asks respondents to rate the severity of their insomnia problems during the last 2 weeks (i.e., the 2 weeks prior to the acute coronary event). The ISI asks the patient to rate difficulty falling asleep, difficulty staying asleep, problems waking up too early, satisfaction with current sleep pattern, extent to which a sleep problem interferes with daily functioning, the degree to which the patient believes others notice a sleep problem, and how worried or distressed the patient is about a current sleep problem. The ISI demonstrates adequate psychometric properties with a cutoff score of 15 shown to identify cases of clinical insomnia and a Chronbach’s alpha of .74 (Bastien et al. 2000).

Daytime Sleepiness

The Epworth Sleepiness Scale (ESS; Johns 1994) is an 8-item instrument widely used to assess excessive daytime sleepiness. This measure asks how likely the respondent is to fall asleep or doze during specific commonly encountered daily life situations or activities, such as when sitting and reading or when a passenger in a car. A score of 10 or higher is considered to be clinically significant daytime sleepiness (Johns 1994). In a sample of sleep-disordered patients, the internal consistency of the scale was satisfactory (α = .86; Violani et al. 2003).

Religious Coping and Religious Struggle

Positive and negative religious coping methods were measured using the Brief RCOPE (Pargament et al. 1998). The Brief RCOPE is comprised of fourteen items (7 positive and 7 negative) drawn from the full RCOPE (Pargament et al. 1998; 2000). Responses are summed to create positive and negative subscale scores. Religious struggle was assessed with the negative religious coping subscale of the Brief RCOPE, consistent with prior studies in the empirical literature (Ai et al. 2009; Fitchett et al. 2004). Respondents were asked to indicate how much or how frequently they engage in religious methods of coping with their recent health event. Items are rated on a four-point scale from 0, “not at all,” to 3, “a great deal,” with higher scores indicating more frequent use of each coping strategy. Cronbach’s alpha coefficients for the positive subscale range from .87 to .90 and from .69 to .81 for the negative subscale (Pargament et al. 1998).

Health History

Health history and demographic information were collected via electronic medical records as well as by a self-report questionnaire (developed in one of the author’s [MTS] behavioral sleep medicine clinic) to solicit general medical and psychiatric history and demographic information, such as age, gender, and race. Participants also answered four items that assess global religiousness. These four questions pertain to frequency of attendance at religious services, frequency of private prayer, and self-rated religiousness and spirituality (National Opinion Research Center 1998). Global religiousness items were included along with other demographic questions in the health history questionnaire and were scored by standardizing the four items into z scores and then summing these values to obtain a total global religiousness score (Pargament et al. 2005a).

Results

Sample Characteristics

Table 1 displays the frequencies and relative percentages for demographic variables, as well as diagnostic and historical health information obtained from medical records and responses to yes/no self-report items assessing mental health history and treatment. Of the 62 participants whose data were analyzed, the majority were male (64.5 %), self-identified as Caucasian (75.8 %), and had a history of MI (88.7 %). Mean left ventricular ejection fraction (LVEF), a measure of cardiac disease severity, was 49.0 % (SD = 12.17; see Table 2). Retrospective assessment of ACS diagnosis after discharge from the hospital revealed that 9 (14.5 %) of the 62 participants did not have a final diagnosis of ACS. Type of ACS for participants who received a final diagnosis of ACS is listed in Table 1. In terms of religious affiliation, the majority of those sampled identified as Protestant (49.1 %), Roman Catholic (29.1 %), or other (12.8 %). Of the 62 participants, 37.1 % reported diagnosis and/or treatment for depression, 32.3 % reported diagnosis and/or treatment for anxiety, and 19 % were currently prescribed psychotropic medications.
Table 1

Demographic variables and status or history (Hx) of diagnosis (Dx) or treatment (Tx)

Demographic variable

Frequency

%

Diagnostic/treatment variable

Frequency

%

Gender

  

Type of ACS

  

Male

40

64.5

STEMI

22

35.5

Female

22

35.5

NSTEMI

21

33.9

Race/ethnicity

  

Unstable Angina

10

16.1

African American

10

16.1

Alternate Dxa

9

14.5

Caucasian

47

75.8

Hx of congestive heart failure

  

Asian

3

4.8

No

56

90.3

Latino

1

1.6

Yes

6

9.7

American Indian

1

1.6

Hx of myocardial infarction

  

Marital status b

  

No

7

11.3

Married

22

36.1

Yes

55

88.7

Single

13

21.3

Dx/Tx for insomnia

  

Separated

3

4.9

No

58

93.5

Divorced

11

18.0

Yes

4

6.5

Living with partner

2

3.3

Dx/Tx for depression

  

Widow/widower

10

16.4

No

39

62.9

Education b

  

Yes

23

37.1

Less than High School

4

6.6

Dx/Tx for anxiety

  

Some High School

8

13.1

No

42

67.7

High School Grad/GED

20

32.8

Yes

20

32.3

Technical School

5

8.2

Current Tx for mental health b

  

Some college

15

24.6

No

45

77.6

College graduate

5

8.2

Yes

13

22.4

Master’s degree

2

3.2

Hx of Tx for mental health b

  

Doctorate

2

3.2

No

35

68.5

Employment status b

  

Yes

16

31.4

Full time

20

32.8

Psychotropic medications b

  

Part-time

2

3.3

No

47

81.0

Homemaker

2

3.3

Yes

11

19.0

Retired

13

21.3

Hx problem drugs/alcohol b

  

Unemployed

12

19.7

No

51

83.6

Disabled

12

19.7

Yes

10

16.4

Religious preference b

  

Hx of Tx for drugs/alcohol b

  

Protestant

27

49.1

No

47

87.0

Roman Catholic

16

29.1

Yes

7

13.0

Muslim

2

3.6

Hx of smoking b

  

Hindu

1

1.8

No

12

19.7

Buddhist

1

1.8

Yes

49

80.3

Greek/Russian Orthodox

1

1.8

Current smoker b

  

Other

7

12.8

No

34

66.7

   

Yes

17

33.3

   

Marijuana use b

  
   

No

51

83.6

   

Yes

10

16.4

ACS acute coronary syndrome, NSTEMI non-ST segment elevation myocardial infarction, STEMI ST segment elevation myocardial infarction

aAlternate diagnoses included: atypical chest pain (n = 1), non-cardiac chest pain (n = 2), vasodepressor syncope (n = 1), hypertensive emergency (n = 1), musculoskeletal pain (n = 1), supraventricular tachycardia (n = 1), sinus tachycardia (n = 1), and stress cardiomyopathy (n = 1)

b n less than 62 due to missing data

Table 2

Means, standard deviations, alpha coefficients, and correlations between study variables

Variables (α)

Mean

SD

Age

EF

zRel

PRC

NRC

ISI

HADS-A

HADS-D

ESS

MMSE

Age

56.24

10.68

.03

        

EF

48.96

12.17

 

        

zRel (.83)

−.03

3.27

.05

−.07

.77**

.22

−.09

.08

−.08

−.15

−.06

Religiosity1

1.74

.99

          

Spirituality2

1.73

1.07

          

Private Prayer3

4.92

2.59

          

Attendance4

3.56

3.00

          

PRC (.87)

9.94

7.15

.12

−.01

 

.45**

−.04

.10

−.03

−.05

−.17

NRC (.73)

2.44

3.09

−.02

−.07

  

.15

−.05

.11

−.01

−.21

ISI (.86)

12.24

7.22

−.21

.23

   

.48**

.63**

.22

−.17

HADS-A (.76)

8.24

4.34

−.32*

.21

    

.60**

.20

−.04

HADS-D (.77)

5.63

4.01

−.23

.02

     

.28*

−.12

ESS (.64)

8.79

4.53

.04

.22

      

−.06

MMSE

27.16

2.07

−.08

−.19

       

n = 62 except for Spirituality and Global Religiousness n = 60; EF ejection fraction; α Chronbach’s alpha; z Rel z score for Global Religiousness; 1 the mean 1.74 indicates the average response was “Moderately religious”; 2 the mean 1.73 indicates the average response was “Moderately spiritual”; 3 the mean of 4.92 indicates the average response was “A few times a week of private prayer”; 4 the mean 3.56 indicates the mean response for this item was “Attendance roughly once a month” at religious or spiritual services; PRC positive religious coping, NRC negative religious coping, ISI Insomnia Severity Index, HADS-A Hospital Anxiety and Depression Scale-Anxiety Subscale, HADS-D Hospital Anxiety and Depression Scale-Depression Subscale, ESS Epworth Sleepiness Scale, MMSE Mini-Mental State Exam

p < .05, ** p < .01, two-tailed

Religiousness and Mental Health Variables

Table 2 presents the descriptive statistics for the religiousness and mental health variables as well as the obtained alpha coefficients for the scales used in the study. On the whole, the sample was both moderately religious and spiritual and engaged in both private and formal public worship with moderate frequency. With a mean HADS-D score of 5.63, respondents in the sample fell within the “normal” range for depression. A mean anxiety score of 8.24 on the HADS-A indicated a “mild” level of anxiety, and scores of 12.24 on the ISI and 8.79 on the ESS suggest the sample does not suffer from clinical levels of insomnia and clinically significant daytime sleepiness, respectively. Further, participants engaged in normative levels of both positive (M = 9.94, SD = 7.15) and negative (M = 2.44, SD = 3.09) religious coping in response to their recent health event (Fitchett et al. 2004; Pargament et al. 1998).

Table 2 also displays the bivariate correlations between religious and mental health variables. Expectedly, the depression and anxiety scales showed a strong positive, statistically significant correlation (r = .60; p < .01), and positive and negative religious coping were positively correlated with one another (r = .45; p < .01). Relatedly, the total global religiosity score evidenced a significant positive correlation with positive religious coping (r = .77; p < .01) and a nonsignificant positive correlation with negative religious coping (r = .22; NS). Insomnia severity (ISI) was highly correlated with the depression and anxiety scales (ISI and HADS-D: r = .63; p < .01, ISI and HADS-A: r = .48; p < .01), suggesting that symptoms of insomnia and mental illness demonstrate a strong positive association in this sample.

Prevalence of Religious Struggles

Table 3 displays the frequency and type of religious struggles endorsed by study participants as measured by the negative religious coping subscale of the Brief RCOPE. As predicted, a high proportion of patients admitted with suspected ACS (58.0–90.3 %) responded “not at all” to the seven negative religious coping items, and the mean total negative religious coping score was 2.44 (SD = 3.09; see Table 2). Also in line with hypotheses and as indicated in Table 3, “Questioned the power of God” was most frequently endorsed (42.0 %), while “Wondered whether God had abandoned me” was least frequently endorsed (9.7 %). When responses to all seven items were examined, more than half of the sample (n = 36, 58 %) reported at least some degree of religious struggle.
Table 3

Percent distribution of negative religious coping item responses (n = 62)

 

Not at all

Somewhat

Quite a bit

A great deal

Questioned the power of God

58.0

19.4

3.2

19.4

Decided the devil made this happen

72.6

16.1

4.8

6.5

Wondered whether my church had abandoned me

88.8

4.8

4.8

1.6

Questioned God’s love for me

77.4

9.7

4.8

8.1

Wondered what I did for God to punish me

88.7

3.2

6.5

1.6

Wondered whether God had abandoned me

90.3

6.5

3.2

0.0

Felt punished by God for my lack of devotion

85.5

11.3

3.2

0.0

Religious Struggle and Positive Religious Coping

Given the premise that an affirmative endorsement of any negative religious coping item signifies at least some degree of religious or spiritual struggle and the precedent for this analytic approach in the literature (Fitchett et al. 2004; Pargament et al. 2005a), the sample was dichotomized into two groups: religious “strugglers” and “non-strugglers.” Participants who scored 0 on the negative religious coping scale were classified as non-strugglers, and participants who scored at least 1 were classified as strugglers. The dichotomized groups were then analyzed for mean level differences across religious and mental health variables. Table 4 shows the results from mean level comparisons. Results indicate that religious strugglers—those participants who identified as engaging in negative religious coping in response to their recent cardiac event—evidenced greater levels of insomnia, depression, and anxiety, as well as lower gross cognitive functioning. Importantly, strugglers also demonstrated higher levels of positive religious coping.
Table 4

Mean differences on main variables between strugglers and non-strugglers

 

Strugglers (N = 36)

M (SD)

Non-strugglers (N = 26)

M (SD)

t value

df

p

ISI

13.89 (6.85)

9.96 (7.22)

−2.18

60

.03

HADS-A

9.17 (4.68)

6.96 (3.53)

−2.02

60

.05

HADS-D

6.50 (4.00)

4.42 (3.79)

−2.06

60

.04

PRC

12.25 (6.42)

6.73 (6.96)

−3.22

60

.00

NRC

4.19 (3.00)

0.00 (0.00)

−7.11

60

.00

ESS

9.11 (4.80)

8.35 (4.16)

−.65

60

.52

MMSE

26.70 (2.35)

27.81 (1.41)

2.15

60

.04

zRel

.46 (3.26)

−.71 (3.24)

−1.38

58

.17

ISI Insomnia Severity Index, HADS-A Hospital Anxiety and Depression Scale-Anxiety Subscale, HADS-D Hospital Anxiety and Depression Scale-Depression Subscale, PRC positive religious coping, NRC negative religious coping, ESS Epworth Sleepiness Scale, MMSE Mini-Mental State Exam, z Rel z score for Global Religiousness

Additional analyses revealed statistically significant positive correlations between religious struggle and: (a) a history of mental health treatment (r = .31, p < .03, n = 51), (b) a history of self-identified problems with drugs and/or alcohol (r = .39, p < .00, n = 61), and (c) treatment for drugs and/or alcohol (r = .29, p < .04, n = 54). Gender (t(60) = −.64, p = .53) and age (r = −.02, p = .88) were not linked to religious struggle in the present sample of patients hospitalized for a suspected ACS. Race, however, was significantly associated with both religious struggle (non-White: M = 4.40, SD = 3.52; White: M = 1.81, SD = 2.68) and positive religious coping (non-White: M = 13.20, SD = 6.53; White: M = 8.89, SD = 7.08), such that non-White patients reported greater use of both negative [t(60) = 3.01, p = .004] and positive [t(60) = 2.09, p = .041] religious coping. LVEF was not significantly linked to any study variables (see Table 2). Lastly, the Social Security Death Index (SSDI) was checked for all study participants on June 9, 2011. At that time, 7 of the 62 (11.3 %) participants had died since their participation in this study in 2009–2010. The Mann–Whitney nonparametric test, utilized due to unequal sample sizes, indicated that those who died (M = 68.7, SD = 8.3) were significantly older than those still living (M = 54.9, SD = 9.9; U = 54.5, p = .002). No other significant differences were found between living and deceased participants.

Discussion

Major life events, such as experiencing ACS, have a profound impact, not only physically, but psychologically, socially, and also spiritually (Pargament et al. 2005a, b; Pargament 1997). Physical health crises in particular often evoke existential issues and call upon a person’s religious and spiritual worldview to adapt and respond to the unanticipated stressor (McConnell et al. 2006; Pargament et al. 2005a, b; Pargament 1997). Although religion and spirituality, in many forms, have generally been found to be helpful in dealing with both sudden health events and prolonged physical illness (see Koenig et al. 2012, for an extensive review), there has been a recent focus in the scientific literature on religious struggle as a risk factor for a host of mental and physical health concerns (Ano and Vasconcelles 2005; Raiya et al. 2008). This study contributes to this line of research by examining the prevalence and types of religious struggles, as well as the relationship between religious struggle and measures of psychological distress and sleep disturbance, among patients hospitalized for a suspected ACS.

Religious struggle was a relatively common experience for patients hospitalized for a suspected ACS (58 %), similar in level and type to previous cardiac patient samples (Fitchett et al. 2004). Individuals experiencing any level of religious struggle were significantly more likely to report sleep disturbance and symptoms of anxiety and depression, as well as to have lower gross cognitive functioning during hospitalization for a suspected ACS.

These findings highlight the importance of assessing religiosity and spirituality during hospitalization for sudden cardiac events. In medical settings, assessment of religiosity and spirituality is often limited to general markers of religion, such as religious affiliation and frequency of religious service attendance. These indices, however, may not adequately identify cardiac patients at risk of religious struggle and their associated psychological distress. More proximal assessment, in the form of religious coping with the recent cardiac event, better serves the clinician and patient by providing a more specific gauge for understanding where and how to approach or intervene regarding religious and spiritual matters. The opportunity for detailed religious and spiritual assessment, however, is limited due to demand and time constraints by hospital-based chaplains and mental health care providers (Fitchett and Risk 2009). Thus, while functional measures like the Brief RCOPE and Brief Multidimensional Measure of Religiousness/Spirituality (BMMRS) are extremely useful research tools, screening instruments for individuals at risk of religious struggle are needed in a hospital setting where length of stay, and therefore opportunity for intervention, is typically limited to a few daytimes.

To this end, Fitchett and Risk (2009) developed the Rush Protocol (RP) which is a 3-item screening protocol (6 items total; a decision tree is followed for each patient with a maximum of 3 questions possible per patient) that can be administered by any health professional with brief training to identify individuals who may benefit from a more in-depth religious assessment by a chaplain or an appropriately trained mental health professional (Fitchett and Risk 2009). Utilizing the RP, or a similar religious struggle screening protocol, could increase the efficiency and productivity of chaplains and mental health care providers by focusing their therapeutic efforts on individuals at greatest risk of religious struggle and its associated patterns of distress.

Consistent with previous studies among medical patient samples (Lavery and O’Hea 2010; Trevino et al. 2012; Zwingmann et al. 2006), positive and negative religious coping were significantly associated with one another among patients hospitalized with a suspected ACS in this sample. Moreover, religious strugglers reported using significantly greater levels of both positive and negative religious coping strategies in comparison with non-strugglers. These findings support the theory that religiousness and spirituality play a consoling role and are therefore mobilized in all their forms (i.e., positive, negative, and neutral) to cope in the face of a significant life stressor, in this case a sudden cardiac event (Fitchett et al. 1999; Pargament et al. 1998). These findings also lend themselves to the notion that religious and spiritual struggle holds the potential to facilitate growth following a traumatic or difficult life experience (Exline and Rose 2005; Pargament et al. 2005a, b). For instance, for many of the patients hospitalized with a suspected ACS who are engaged in negative forms of religious coping, perhaps their combined efforts with positive religious coping will ultimately result in healthy adjustment to their cardiac status. It might be only those patients with a suspected ACS who “get stuck” in their religious or spiritual struggle who suffer deleterious outcomes (Pargament et al. 2001a, b, 2003, 2004).

Conceptually, it is also important to note that 88.7 % of the current sample had a history of prior MI (see Table 1), indicating that for the vast majority of individuals chest pain and related symptoms of suspected ACS were not novel health experiences. Recurrence of ACS symptoms might create a condition of more chronic existential questioning and religious struggle in comparison with the unanticipated, acute stressor of an initial ACS event. Ideally, longitudinal studies of ACS patients would include similar numbers of individuals both with and without a history of an ACS in order to sort out differences between these groups, as well as to determine the long-term implications of religious struggle during hospitalization for a sudden cardiac event.

Although we found similar mean levels of negative religious coping strategies as in the previous studies of cardiac patients (Ai et al. 2010a, b; Fitchett et al. 2004), we did not find the expected associations between negative religious coping and anxiety, depression, and insomnia. When we dichotomized the sample into religious strugglers and non-strugglers, however, statistically significant differences between groups emerged on all study variables with the exception of daytime sleepiness and global religiousness. It is interesting to note that strugglers and non-strugglers did not differ on mean level of traditional indices of religion and spirituality (i.e., private prayer, religious service attendance, self-rated religiousness, and spirituality), adding further support to the notion that context-specific indices of religion and spirituality are often more informative than global measures for understanding the role religion and spirituality play in the lives of individuals. Similarly, Ai et al. (2010a, b) found that the subgroup of open heart surgery patients who reported religious struggle included both religious and non-religious patients; the common link among these patients was that they perceived the greatest preoperative distress, regardless of their level of religiousness.

Not only did religious strugglers report greater symptoms of depression, anxiety, and insomnia, but they also scored significantly lower on the MMSE, an interviewer-administered measure of gross cognitive function. While this result corroborates findings found among other participant samples, specifically that MMSE scores are greater among older adults who use positive religious coping strategies (Koenig et al. 2004) and lower among medically ill elderly patients with religious struggles (Pargament et al. 2001a, b), to our knowledge, this is the first study to report this association among patients hospitalized for a suspected ACS. Because MMSE scores were not related to age or to any mental health variables in this study, this finding may indicate that religious strugglers are having difficulty processing information on a number of different levels—religiously, emotionally, and cognitively. It is also possible that given the acute nature of the cardiac event and its close proximity to the time of assessment for this study (roughly 2.5 days), those individuals who are still recovering medically and cognitively (including from various drug treatments) are also more likely to be continuing to recover from the event religiously and spiritually. Again, longitudinal data, beginning with initial assessment during hospitalization, would help establish the causal relationship between physical, emotional, cognitive, and religious and spiritual recovery from ACS.

Correlational analyses indicated that religious struggle among patients hospitalized for a suspected ACS was linked to a history of mental health treatment, a history of self-identified problems with drugs and/or alcohol, and self-reported treatment for drugs and/or alcohol. These findings are consistent with the literature in these areas (Hampton et al. 2010; Mason et al. 2009), echoing the call for research that explores the complex associations between specific forms of psychopathology and the various forms of religion and spirituality used to understand, and to cope with, mental health problems (McConnell et al. 2006). Indeed, substance abuse treatment has long been associated with religion and spirituality. Alcoholics Anonymous embraces a 12-step model in which a primary tenet is acknowledgment of “a Power greater than ourselves” as a necessary first step in restoring mental health (Alcoholics Anonymous World Services 2001). It seems that turning to religion in times of mental or physical health challenges may benefit many people in their effort to discern what is within their power to change and what is beyond their control.

Nevertheless, there is a growing body of evidence to suggest that while turning to religion may be helpful for some, individuals suffering from physical illness may be especially vulnerable to getting caught in their religious struggle and its associated adverse correlates (McConnell et al. 2006; Pargament et al. 2001a, b, 2004). On account of the very real life-and-death issues at stake among those with physical illness, religious struggle can shake and threaten previously held religious and spiritual worldviews when physical, cognitive, and emotional resources are low (Pargament 1997). The experience of suspected ACS in particular is a life-altering and life-threatening health event that may be associated with fear of death for many individuals (Soenke et al. 2013). Such fear of death, as well as the unfamiliar and often unsettling hospital environment, may contribute to the psychological burden and religious questioning among suspected ACS patients, again emphasizing the need for effective screening for religious struggle during hospitalization for health events.

Religious strugglers and non-strugglers in this sample did not differ by age or gender, suggesting that both men and women and young and old patients hospitalized with a suspected ACS experience similar levels of religious concerns. Nevertheless, given the small sample size of women in this study and the generally lower number of women admitted to the hospital for a suspected ACS, gender in particular should be investigated further for its association with religious struggle following sudden cardiac events. The finding that non-White patients with suspected ACS reported using significantly more positive and negative forms of religious coping with their recent cardiac event is consistent with the previous research among other patient samples (Trevino et al. 2012). Non-White individuals, in particular African Americans, tend to endorse higher levels of personal religiousness (Levin et al. 1995; Pargament 1997), implying that religion may be well integrated into their worldview and therefore more likely to be a resource that is used in times of distress. Importantly, religious struggle has been identified as a risk factor for poorer mental and physical health, especially among individuals with greater levels of personal religiousness (Pargament et al. 2001b; Rosmarin et al. 2009). Thus, this finding highlights the significance of religious screening among non-White patients hospitalized for suspected ACS. Finally, the lack of significant findings between deceased and living participants on indices of religious coping and struggle may be due to the small number of deceased individuals in this sample. Studies with a larger percentage of deceased participants have found significant links between religious struggle and mortality after controlling for relevant covariates (Oxman et al. 1995; Pargament et al. 2001a, b).

Limitations and Future Directions

The limitations of this study include limited generalizability due to the relatively small sample size of patients hospitalized for suspected ACS and the predominantly Christian, Caucasian, and male composition of the sample. Additionally, the study design was cross-sectional and correlational in nature, therefore precluding causal connections between study variables. Along these lines, longitudinal investigations would help to determine whether religious struggle during and immediately following a cardiac event might be normative and ultimately helpful to come to terms with existential issues. Finally, limitations of measures used in this study highlight an important area for future research. Specifically, the Judeo-Christian language and the type of religious struggle assessed in the seven items of the Brief RCOPE most likely do not capture the full range of religious and spiritual struggles experienced by this patient population. For instance, the negative religious coping subscale of the Brief RCOPE predominantly assesses struggles with the Divine (i.e., God), rather than an equal number of items that assess intrapersonal, interpersonal, and Divine religious struggles (Pargament et al. 2005a, b). Moreover, given the growing rates of religious and spiritual diversity (Chaves 2011; Ferrer 2009), religious and spiritual measures may need to include a “premeasure evaluation” of religious and spiritual language that most accurately captures the participant’s belief system and worldview.

Notwithstanding these limitations, a strong point of this study is that religious struggle was measured with the most commonly used research instrument in the field, the negative religious coping subscale of the Brief RCOPE, which allows for straightforward and useful comparison with religious struggle among other samples. Another major strength is the proximity of assessment of religious struggle to the experience of ACS symptoms and admission to the hospital. The roughly 2 days between admission and participation in this study coincides with the brief length of time in which mental health professionals and chaplains have access to these patients for assessment and intervention of religious and spiritual issues. Data from this investigation provide a realistic representation of both the religious struggles and the associated psychological and cognitive problems that recently admitted patients with a suspected ACS experience. Thus, the findings from the present study provide a benchmark for the types, and levels, of religious and spiritual concerns mental health professionals and spiritual care providers must come to the bedside prepared to address.

Notes

Acknowledgments

This research was supported through the Johns Hopkins University Center for Mind Body Research with funding from the National Institute of Health’s National Center for Complementary and Alternative Medicine (R24AT004641). The authors thank Kellie Hirt for her assistance in participant recruitment and data management.

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Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Gina Magyar-Russell
    • 1
    • 2
  • Iain Tucker Brown
    • 1
    • 4
  • Inna R. Edara
    • 1
  • Michael T. Smith
    • 2
  • Joseph E. Marine
    • 3
  • Roy C. Ziegelstein
    • 3
  1. 1.Department of Pastoral CounselingLoyola University MarylandColumbiaUSA
  2. 2.Department of Psychiatry and Behavioral SciencesJohns Hopkins University School of MedicineBaltimoreUSA
  3. 3.Division of Cardiology, Department of MedicineThe Johns Hopkins University School of MedicineBaltimoreUSA
  4. 4.Department of Humanities, Social Sciences, and Language & LettersNorthern New Mexico CollegeEspañolaUSA

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