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. Author manuscript; available in PMC: 2013 Jan 23.
Published in final edited form as: Psychol Med. 2011 Aug 17;42(3):509–519. doi: 10.1017/S0033291711001516

Religiosity and resilience in persons at high risk for major depression

S Kasen 1,2,*, P Wickramaratne 1,2,3,4, M J Gameroff 1,2,3, M M Weissman 1,2,3
PMCID: PMC3552391  NIHMSID: NIHMS432715  PMID: 21849093

Abstract

Background

Few studies have examined religiosity as a protective factor using a longitudinal design to predict resilience in persons at high risk for major depressive disorder (MDD).

Method

High-risk offspring selected for having a depressed parent and control offspring of non-depressed parents were evaluated for psychiatric disorders in childhood/adolescence and at 10-year and 20-year follow-ups. Religious/spiritual importance, services attendance and negative life events (NLEs) were assessed at the 10-year follow-up. Models tested differences in relationships between religiosity/spirituality and subsequent disorders among offspring based on parent depression status, history of prior MDD and level of NLE exposure. Resilience was defined as lower odds for disorders with greater religiosity/spirituality in higher-risk versus lower-risk offspring.

Results

Increased attendance was associated with significantly reduced odds for mood disorder (by 43%) and any psychiatric disorder (by 53%) in all offspring ; however, odds were significantly lower in offspring of non-depressed parents than in offspring of depressed parents. In analyses confined to offspring of depressed parents, those with high and those with average/low NLE exposure were compared: increased attendance was associated with significantly reduced odds for MDD, mood disorder and any psychiatric disorder (by 76, 69 and 64% respectively) and increased importance was associated with significantly reduced odds for mood disorder (by 74%) only in offspring of depressed parents with high NLE exposure. Moreover, those associations differed significantly between offspring of depressed parents with high NLE exposure and offspring of depressed parents with average/low NLE exposure.

Conclusions

Greater religiosity may contribute to development of resilience in certain high-risk individuals.

Keywords: High-risk, longitudinal, major depression, religiosity, resilience

Introduction

Heightened susceptibility to depression has been attributed to familial risk (both genetic and environmental) (Weissman et al. 1987; Kendler, 1995; Warner et al. 1999) and stressful life circumstances (Monroe & Simons, 1991; Kessler, 1997; Kendler et al. 1999a; Tenant, 2002). Nevertheless, not all individuals exposed to these risks develop depression, indicating that other factors acting to deter pathological features may be operating. Identification of protective factors, especially those that may offset predisposing risk for psychiatric illness, is as important as establishing which factors elevate vulnerability. In this study we investigated whether attendance at religious or spiritual services and personal beliefs regarding the importance of religion or spirituality predict resilience in individuals at increased risk for major depressive disorder (MDD) and other forms of psychopathology.

Resilience has been conceptualized as the capacity to withstand adversity or resist a liability or predisposition that substantially elevates risk for maladjustment, depression or other such negative consequences (Garmezy et al. 1984; Masten et al. 1990; Luthar & Cicchetti, 2000). Assessed qualities or outcomes that connote resilience involve the development of specific competencies under stressful conditions, or the absence of pathological features with severe threat or increased vulnerability (Masten et al. 1990; Rutter, 1999; Luthar et al. 2000; Luthar, 2006); in other words, relatively positive adaptation when the likelihood of dysfunction or disorder is high. Factors that protect against dysfunction or disorder in most persons, including personal resources (e.g. self-esteem or coping ability), positive family/friend relationships and extended support systems at school, work and other community settings, may also reinforce an individual’s capacity to manage adversity, thereby fostering resilience (Werner & Smith, 1992; Aldwin, 1994; Grotberg, 1999; Rutter, 2000).

There is increasing recognition of religious involvement as a protective influence that may prevent or assuage the development of depression (McCullough & Larson, 1998, 1999; Koenig et al. 2001). A meta-analysis of 147 independent studies confirmed a modest but significant inverse association between attendance at religious services and depressive symptoms across general population, convenience and clinical samples (Smith et al. 2003). Our group found a lowered probability for lifetime MDD with greater personal beliefs of religious importance among mothers of current study offspring (Miller et al. 1997), and Kendler and colleagues reported similar associations between dimensions of religiosity and lifetime internalizing and externalizing disorders (Kendler et al. 1997, 1999a, b, 2003; Kendler & Myers, 2009; Vance et al. 2010). Associations between religious/spiritual beliefs and remission of MDD have been reported in clinical samples (Koenig et al. 1998), and some studies support a prospective link between religiosity and depressive symptoms (Krause, 2009) and disorder (Ellison & Flannelly, 2009).

Other studies, albeit fewer in number, have tested a buffering effect hypothesis, comparing associations between religiosity and depression in high- and low-risk groups; for example, in parents who experienced the recent death of a child versus parents whose child died more than 2 years previously (Maton, 1989), in spouse-caretakers of dementia patients versus spouses of healthy adults (Robinson & Kaye, 1994), and in persons currently undergoing stress versus persons without such exposure (Kendler et al. 1999b). Although these studies tend to support moderation of the stress–depression association by religious beliefs or behaviors, other studies have reported mixed or statistically non-significant findings (Thearle et al. 1995; Strawbridge et al. 1998; Tsuang et al. 2002; Maselko et al. 2009).

The current study

In this study, religious service attendance and the importance of religion/spirituality are treated as potential protective factors that predict resilience in high-risk youths. In that context, high risk is defined as having a parent who received treatment for moderate or severe depression, and resilience is defined as significantly lower odds for subsequent MDD in relation to increased service attendance and importance of religion/spirituality in higher-risk compared to lower-risk offspring. Our group (Weissman et al. 1987, 1997; Warner et al. 1999) and others (Beardslee et al. 1985; Orvaschel et al. 1988; Hammen et al. 1990, 1991) have shown parent depression to be a powerful predictor of offspring depression, especially early-onset depression (Wickramaratne & Weissman, 1998), a known risk for recurrent depressive episodes (e.g. Kessler et al. 2001; Hammen et al. 2008). Offspring of depressed parents are also exposed to elevated levels of negative life events (NLEs; Downey & Coyne, 1990), another well-established precipitating risk for depression. Such research suggests that early-onset depression and high NLE exposure may be among the key mechanisms that underlie heightened vulnerability in offspring of depressed parents, and would explain in part why these youths often follow an increasingly depression-prone pathway into adulthood (e.g. Kandel & Davies, 1986; Weissman et al. 1997). Accordingly, in analyses confined to these already high-risk offspring, we examined whether relationships between religiosity/spirituality and disorder were stronger for those with additional risk, defined as having a history of prior MDD or high exposure to NLE, than for those without additional risk.

Parent depression and other risks examined here may also precede other forms of psychiatric illness (Kandel & Davies, 1986; Harrington et al. 1990; Weissman et al. 1997; Kasen et al. 2001). Moreover, religiosity has been examined as a protective factor in relation to externalizing disorders and to other internalizing disorders (e.g. Tsuang et al. 2002; Kendler et al. 2003; Maselko et al. 2009), albeit to a lesser extent than depression. Furthermore, resilience may be better defined as the absence of any psychiatric disorder under adverse circumstances rather than as the absence of a specific disorder. Therefore, resilience was examined at three hierarchical levels : (a) MDD, (b) mood disorder (which includes MDD) and (c) any psychiatric disorder (any mood, anxiety, disruptive or substance disorder).

This study has the potential to strengthen or extend previous findings related to religiosity and depression. First, because the study sample was drawn from offspring of depressed and non-depressed parents, a risk–resilience model in which religious variables might interact with predisposing risks to influence disorder can be tested (Ingram & Luxton, 2005). Using that model, we examined (1) whether service attendance or importance of religion/spirituality was related to disorder in offspring of depressed and non-depressed parents and, among offspring of depressed parents only, in those with additional risk and those without additional risk, and (2) whether relationships between attendance or importance and disorder differed significantly across offspring of depressed and non-depressed parents, or across offspring of depressed parents with and without additional risk. Second, use of a longitudinal design allowed us to estimate the predictive utility of service attendance and religious/spiritual importance. Third, because offspring of depressed parents often follow a problematic trajectory, we investigated in these already high-risk offspring whether greater attendance or importance mitigated associations between additional risks (prior MDD or high NLE exposure) and disorders. Fourth, depression and other forms of psychopathology were assessed at the diagnostic level.

We hypothesized that (1) increased service attendance and the importance of religion or spirituality would protect against subsequent disorder in offspring of depressed and non-depressed parents, and that (2) associations would be stronger in offspring of depressed parents. Because early-onset MDD and high NLE exposure characterize the trajectory followed by offspring of depressed parents, we also hypothesized that (3) odds for subsequent disorders would be lower in relation to greater religiosity among offspring of depressed parents with prior MDD or high NLE exposure than offspring of depressed parents without these additional risks. If our hypotheses were supported, the study findings would meet definition criteria for interpreting religiosity as a protective factor that may build resilience in high-risk individuals.

Method

Descriptions of sampling criteria and procedures summarized below are published in detail elsewhere (Weissman et al. 1987, 1997, 2006).

Sample composition

Subjects were biological offspring of depressed and non-depressed parents followed longitudinally. High-risk offspring were selected in 1982 for the presence of moderate or severe MDD in one or both parents at study entry based on Research Diagnostic Criteria (RDC); parents received treatment at an out-patient clinic at Yale University, New Haven, Connecticut. Non-depressed parents were drawn from a 1975 survey from the same community and had no history of psychiatric illness based on four lifetime diagnostic interviews.

The original sample interviewed at baseline was composed of 220 offspring from 91 families. Forty-three new offspring from the same families were interviewed 2 years later when they became age eligible (≥6 years old), making a total of 263 offspring eligible for reinterview at the 10-year follow-up. Newly age-eligible offspring first interviewed at the 10-year follow-up were not included in the current study and are not described. Of the 263 offspring, 222 (84.4%) were reinterviewed at the 10-year follow-up; among the 41 not interviewed, 20 refused consent, 18 could not be located, two were deceased, and one had Down syndrome. At the 20-year follow-up, 83.3% (185/222) were reinterviewed and comprised the analytic sample for this study. Among the 37 not interviewed, 26 refused consent, seven could not be located or scheduled, and four were deceased. In the current study sample, 68.1% (126/185) were at high risk based on parent depression and, at the 10-year follow-up, 58.9% (109/185) were female and the mean age was 29.0 (range 17–38) years (see Table 2 for background characteristics by parent depression status and in combined samples all 185 offspring). The 37 offspring reinterviewed at the 10-year but not the 20-year follow-up did not differ significantly from the study sample with regard to parent depression status or age, education, religious/spiritual importance or service attendance at the 10-year follow-up. However, the current study sample had a higher proportion of females (59% v. 35%, χ2=7.19, df=1, p=0.007).

Table 2.

Background characteristics at the 10-year follow-up in 185 offspring by parent depression status

Characteristics Offspring of depressed parents (n=126) Offspring of non-depressed parents (n=59) p levela Total sample (n=185)
Age (years), mean (S.D.) 29.5 (6.3) 27.9 (5.6) 0.11 29.0 (6.1)
Female, % 59.5 57.6 0.81 58.9
Education level, %
 Less than high-school graduate 3.9 1.7 0.42 3.2
 High-school graduate 38.6 33.9 0.58 36.8
 Some post-secondary 7.1 5.1 0.60 6.5
 4-year/advanced college degree 43.3 50.8 0.36 45.9
 Other 7.1 8.5 0.75 7.6
Marital statusb, %
 Never married 40.5 39.0 0.83 39.9
 First marriage 42.0 47.5 0.51 43.7
 Separated/divorced 12.0 8.4 0.55 10.9
 Remarried 5.5 5.1 0.87 5.5
Religious denomination, %
 Catholic 60.3 67.8 0.33 62.7
 Protestant 19.0 11.9 0.22 16.8
 Other affiliationc 20.6 20.3 0.96 20.5
Attendance, raw mean score (S.D.) 1.88 (1.34) 2.37 (1.41) 0.02 2.02 (1.38)
Importance, raw mean score (S.D.) 2.72 (0.86) 2.98 (0.88) 0.06 2.81 (0.88)
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S.D., Standard deviation.

a

Probability levels for between-group (offspring of depressed parents versus offspring of non-depressed parents) differences.

b

Marital status is based on 124 offspring of depressed parents and 183 total offspring.

c

In the total sample, other affiliations include personal beliefs (n=10), unknown (n=10), Jewish (n=9), agnostic (n=8), and Buddhist (n=1).

Assessments

Psychiatric diagnoses

Semi-structured diagnostic interviews were conducted across all waves with the Schedule for Affective Disorders and Schizophrenia – Lifetime Version (SADS-L; Mannuzza et al. 1986) or, for those between ages 6 and 17, with the Kiddie-SADS (epidemiological version K-SADS-E; Orvaschel et al. 1982; Kaufman et al. 1997). Diagnostic interviews yielded DSM-III diagnoses at baseline and DSM-III-R diagnoses at the 10-year follow-up. At the 20-year follow-up, the SADS-L interview was modified to meet DSM-IV criteria. Interviews were conducted independently by trained mental health professionals blind to parent clinical status and previous offspring assessments. Final diagnoses are based on the best estimate procedure (Leckman et al. 1982), described in detail elsewhere (Weissman et al. 1997).

Disorders assessed at the 20-year follow-up cover the 10-year interval since the 10-year follow-up and constitute this study’s primary dependent variables. MDD was considered separately and as a mood disorder along with dysthymia and bipolar I or II disorder. Any psychiatric disorder [a mood disorder, an anxiety disorder (generalized anxiety, obsessive–compulsive, panic, phobic, post-traumatic stress), a disruptive disorder (attention deficit hyperactivity, conduct, oppositional defiant) or a substance disorder (alcohol/illicit drug abuse or dependence)] was also examined. The risk factor ‘prior MDD’ was based on Religiosity and resilience in high-risk persons 511 lifetime MDD assessed at baseline and again at the 10-year follow-up, when offspring were average age 29 years. In the current study sample, 24.3% (45/185), 33.0% (61/185) and 51.9% (96/185) of offspring were diagnosed with MDD, a mood disorder and any psychiatric disorder respectively in the 10-year interval between the 10- and 20-year follow-ups, and 45.4% (84/185) were diagnosed with prior MDD by, on average, age 29.

Religiosity

At the 10-year follow-up, offspring responded to religious items from the demographic section of the SADS-L. Denomination was assessed with the questions: ‘How would you describe your current religious beliefs ? Is there a particular denomination or organization that you are part of ?’ Nearly two-thirds of the current sample (116/185) were Catholic, with other groups much fewer in number (31 Protestant, 10 personal beliefs, 10 unknown, nine Jewish, eight agnostic, and one Buddhist). Service attendance was assessed with the question: ‘How often, if at all, do you attend church, synagogue, or other religious or spiritual services? ’ (response options: 0=never, 1=less than once a year, 2=once or twice a year, 3=about once a month, 4=once a week). The mean score (2.02, S.D.=1.38) indicated that, at the 10-year follow-up, average service attendance in the total sample was once or twice a year. Personal beliefs regarding religious/spiritual importance were assessed with the question: ‘How important to you is religion or spirituality ?’ (response options: 1=not important at all, 2=slightly important, 3=moderately important, 4=highly important). The mean score (2.81, S.D.=0.88) indicated that, at the 10-year follow-up, a nearly moderate level of importance was normative for the total sample. Religion variables are referred to in this study as denomination, attendance and importance.

NLEs

NLEs reported at the 10-year follow-up for the preceding 10 years were examined as a predisposing risk for disorders diagnosed over the next 10-year interval (i.e. between the 10- and the 20-year follow-up); event rates are shown in Table 1. The mean NLE score was 3.1 (S.D.=2.0, range 0–10) out of a possible 17 events. The cut-off score ≥5 (equivalent to 1 S.D. above the mean) specified offspring with high (n=38; 20.5%) or average/low (n=147; 79.5%) NLE exposure.

Table 1.

Rates of negative life events (NLEs) reported by 185 offspring at the 10-year follow-up for the preceding 10 years

NLE n (%)
Death of family member or close other 120 (64.9)
Separation or divorce from partner or spousea 75 (40.5)
Serious illness in family member 69 (37.3)
Lost job 50 (27.0)
Drug or mental health problem in family member 36 (19.5)
Victim of a crime or assault 36 (19.5)
Lost a close friend 32 (17.3)
Serious illness (self) 24 (13.0)
Family member in legal trouble 21 (11.4)
Witness to a crime or assault 19 (10.3)
Suicide attempt by family member 17 (9.2)
Problems on the job 14 (7.6)
In legal trouble (self) 12 (6.5)
Financial problems 11 (5.9)
Socially isolated 11 (5.9)
Offspring placed in care 4 (2.2)
Problems with offspring 3 (1.6)
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a

Includes separated or divorced from partner/spouse ; partner/spouse not living at home; and end of love relationship.

Analyses

To test the study hypotheses while adjusting for non-independence among offspring from the same family, we used the SAS GENMOD procedure (SAS/STAT software, version 9.0; SAS Institute Inc., USA) using a generalized estimating equation (GEE) approach (Liang & Zeger, 1986). All analyses were controlled (a priori) for age, gender and denomination. As there were sufficient numbers of offspring of only Catholic and Protestant denominations to permit meaningful comparisons, dummy coding was used to compare Protestant offspring (n=31) and Catholic offspring (n=116, reference group). Models based on both offspring of depressed parents and offspring of non-depressed parents (n=185) (i.e. testing hypotheses 1 and 2) examined effects of attendance or importance (each separately) with parent depression status, prior MDD, NLE exposure, and all two-way interaction terms formed by their multiplicative combinations. Models based only on offspring of depressed parents (n=126) (i.e. testing hypothesis 3) examined effects of attendance or importance (each separately) with prior MDD, NLE exposure, and all two-way interaction terms formed by their multiplicative combinations.

Results

Background characteristics

Offspring of depressed parents did not differ significantly from offspring of non-depressed parents with regard to gender, age, denomination, education level, and marital status at the 10-year follow-up (see Table 2). However, group differences in attendance and importance (raw score means: 1.88 v. 2.37, p= 0.018 and 2.72 v. 2.98, p=0.059 respectively) indicated greater religiosity/spirituality among offspring of non-depressed parents.

Parent depression status and offspring risk

Offspring of depressed parents were at significantly increased odds for prior MDD by the 10-year follow-up [odds ratio (OR) 3.82, p=0.0003], high NLE exposure in the 10 years preceding the 10-year follow-up (OR 2.76, p=0.037), and mood (OR 2.08, p=0.045) and any psychiatric disorder (OR 2.23, p=0.015) between the 10- and 20-year follow-ups (Table 3), confirming the continuing negative trajectory of these high-risk youths. Prior MDD significantly increased the odds for subsequent MDD [OR 3.09, 95% confidence interval (CI) 1.48–6.49, p=0.003), mood disorder (OR 3.31, 95% CI 1.66–6.58, p=0.001) and any psychiatric disorder (OR 2.76, 95% CI 1.46–5.22, p=0.002) between the 10- and 20-year follow-ups, whereas high NLE exposure significantly increased the odds for subsequent MDD (OR 2.03, 95% CI 1.01–4.44, p=0.049) and any psychiatric disorder (OR 2.82, 95% CI 1.28–6.24, p=0.010) but not mood disorder (OR 1.46, 95% CI 0.68–3.13, p=0.329) during that period (not tabulated). After adjusting for prior MDD and NLE exposure, parent depression status was no longer associated significantly with either mood or any psychiatric disorder between the 10- and 20-year follow-ups. No significant interaction effects were observed between parent depression status and age, gender or denomination.

Table 3.

Parent depression status and odds for prior major depressive disorder (MDD) by 10-year follow-up, high exposure to negative life events (NLEs) in the 10 years preceding the 10-year follow-up, and MDD, mood disorder and any psychiatric disorder between the 10-year and 20-year follow-ups, in 185 offspring

OR (95% CI)a OR (95% CI)a,b
Prior MDD 3.82*** (1.86–7.88) –
High exposure to NLEs 2.76* (1.06–7.17) –
MDD 1.57 (0.72–3.42) 1.07 (0.46–2.47)
A mood disorder 2.08* (1.02–4.26) 1.53 (0.72–3.28)
Any psychiatric disorder 2.23* (1.17–4.25) 1.66 (0.84–3.28)
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OR, Odds ratio; CI, confidence interval.

Parent depression status coded 0=non-depressed parents, 1=depressed parent(s).

a

ORs adjusted for age, sex and denomination.

b

ORs adjusted for effects of prior MDD and high exposure to NLEs.

*

p<0.05,

**

p<0.01,

***

p<0.001.

Religiosity and risk for disorder

We report odds for disorder between the 10- and 20-year follow-ups in relation to attendance and importance at the 10-year follow-up separately for offspring of depressed parents (n=126) and offspring of non-depressed parents (n=59) (Table 4), and for offspring of depressed parents with (n=70) and without (n=56) prior MDD and with high (n=32) versus average/low (n=94) NLE exposure (Table 5). Although not tabulated, significant main effects of attendance or importance in the combined samples (i.e. offspring of depressed parents and offspring of non-depressed parents) are noted; significant interactive effects between attendance or importance and parent depression status in the combined samples, and between attendance or importance and additional risk in offspring of depressed parents, are also noted. Attendance and importance were treated as continuous predictors and standardized; thus, noted change in odds for disorder corresponds to a 1 S.D. change in religiosity/spirituality. For example, a 1 S.D. increase in attendance from the standardized mean (0) would be roughly equivalent to an increase in attendance from once or twice a year to at least once a month; a corresponding increase in importance would be roughly equivalent to increasing from nearly moderate importance to nearly highly important.

Table 4.

Attendance and importance at the 10-year follow-up and odds for major depressive disorder (MDD), mood disorder and any psychiatric disorder over the next 10 years in 126 offspring of depressed parents and 59 offspring of non-depressed parents

MDD Mood disorder Any psychiatric disorder
Attendance
 Offspring of depressed parents 0.82 (0.47–1.43) 0.94 (0.58–1.53)a 0.94 (0.61–1.45)b
 Offspring of non-depressed parents 1.84 (0.89–3.80) 0.72 (0.40–1.29) 0.58* (0.34–0.98)
Importance
 Offspring of depressed parents 0.86 (0.58–1.28) 0.99 (0.65–1.52) 0.92 (0.60–1.42)
 Offspring of non-depressed parents 1.16 (0.47–2.90) 1.42 (0.57–3.51) 1.24 (0.63–2.43)
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Values given as odds ratio (95% confidence interval). All odds ratios (ORs) are adjusted for age, sex, denomination, prior MDD and high exposure to negative life events (NLEs) in the preceding 10 years.

a

Significant (p<0.05) interaction effect between attendance and parent depression status.

b

Trend (p<0.10) interaction effect between attendance and parent depression status.

*

p<0.05.

Table 5.

Attendance and importance and odds for major depressive disorder (MDD), mood disorder and any psychiatric disorder over the next 10 years in 126 (high-risk) offspring of depressed parents with and without additional risks : prior MDD and exposure to negative life events (NLEs)

n MDD Mood disorder Any psychiatric disorder
Attendance
 High-risk offspring with prior MDD 70 0.80 (0.37–1.73) 1.16 (0.57–2.32)a 1.14 (0.61–2.15)a
 High-risk offspring with no prior MDD 56 0.87 (0.41–1.85) 0.85 (0.42–1.71) 0.58 (0.30–1.13)*
 High-risk offspring with high NLE exposure 32 0.24** (0.06–0.94)a 0.31** (0.09–1.00)a 0.36* (0.11–1.17)a
 High-risk offspring with average/low NLE exposure 94 1.32 (0.71–2.47) 1.33 (0.77–2.39) 1.02 (0.61–1.71)
Importance
 High-risk offspring with prior MDD 70 0.90 (0.51–1.58) 0.94 (0.51–1.76) 1.24 (0.64–2.44)b
 High-risk offspring with no prior MDD 56 0.88 (0.42–1.84) 1.08 (0.56–2.08) 0.65 (0.35–1.21)
 High-risk offspring with high NLE exposure 32 0.42 (0.12–1.52) 0.26** (0.07–0.94)b 0.50 (0.12–2.00)
 High-risk offspring with average/low NLE exposure 94 1.08 (0.70–1.67) 1.36 (0.84–2.22) 0.94 (0.59–1.51)
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Values given as odds ratio (95% confidence interval). All odds ratios (ORs) are adjusted for age, sex, denomination, and additional risk (prior MDD or high exposure to NLEs).

a

Significant (p<0.05) interaction effect between attendance and additional risk.

b

Significant (p<0.05) interaction effect between importance and additional risk.

*

p<0.10,

**

p<0.05.

Offspring of depressed and non-depressed parents

Increased attendance was associated with reduced odds for mood (OR 0.51, 95% CI 0.30–0.87, p=0.013) and any psychiatric (OR 0.47, 95% CI 0.29–0.79, p=0.004) disorder in the combined samples, but not with MDD (OR 1.05, 95% CI 0.59–1.87, p=0.871). Attendance also moderated relationships between parent depression status and mood (interaction OR 2.13, 95% CI 1.14–3.97, p=0.017) and any psychiatric (interaction OR 1.81, 95% CI 0.96–3.41, p=0.069, trend) disorder: in both interactions, offspring of non-depressed parents were at significantly lower odds for disorder in relation to attendance than offspring of depressed parents. When examined separately by parent depression status, attendance was related to significantly reduced odds for any psychiatric disorder (by 42%, p=0.042) only in offspring of non-depressed parents; however, note that odds for all disorders in relation to attendance were below 1 among offspring of depressed parents (Table 4). Importance was not related significantly to disorder whether offspring of depressed and non-depressed parents were combined or treated separately, nor did it interact with parent depression status in relation to disorder.

Offspring of depressed parents with and without additional risk

Neither attendance nor importance was associated significantly with disorder in offspring of depressed parents (Table 4) ; however, each interacted with additional risk to influence disorder.

Attendance moderated associations between prior MDD and mood (interaction OR 2.82, 95% CI 1.13– 7.05, p=0.027) and any psychiatric (interaction OR 3.03, 95% CI 1.45–6.36, p=0.023) disorder, and importance moderated associations between prior MDD and any psychiatric disorder (interaction OR 2.62, 95% CI 1.17–5.84, p=0.019). In all interactions, those without prior MDD had significantly lower odds for disorders in relation to attendance or importance than those with prior MDD. When examined separately by prior MDD status, no significant religiosity–disorder associations were observed in offspring of depressed parents either with or without prior MDD (Table 5).

Attendance also moderated associations between NLE exposure and MDD (interaction OR 0.27, 95% CI 0.09–0.84, p=0.024), mood (interaction OR 0.22, 95% CI 0.08–0.60, p=0.003) and any psychiatric (interaction OR 0.26, 95% CI 0.11–0.63, p=0.003) disorder, and importance moderated associations between NLE exposure and mood disorder (interaction OR 0.18, 95% CI 0.05–0.61, p=0.006). In all interactions, those with high NLE exposure were at significantly lower odds for disorder in relation to attendance or importance compared to those with average/low NLE exposure. Although not significant, interaction effects between importance and NLE exposure were in the same direction for MDD (interaction OR 0.41, 95% CI 0.13–1.37, p=0.150) and any psychiatric disorder (interaction OR 0.54, 95% CI 0.13–2.30, p=0.402). When examined separately by level of NLE exposure, attendance was associated with significantly reduced odds for MDD (by 76%, p=0.041), mood (by 69%, p=0.05) and any psychiatric (by 64%, p=0.091, trend) disorder, and importance was associated with significantly reduced odds for mood disorder (by 74%, p=0.040), only among offspring of depressed parents with high NLE exposure (Table 5).

Discussion

Consistent with the findings of other studies noted earlier, attendance was a protective factor against mood and any psychiatric disorder in the combined samples (i.e. offspring of depressed and non-depressed parents). Nevertheless, effects were stronger in offspring of non-depressed parents and, when examined separately by parent depression status, significant in offspring of non-depressed parents only. Those findings may be explained in part by common familial factors (genetic and environmental), which may underlie both religiosity and vulnerability to depression (D’Onofrio et al. 1999) and were not accounted for in this study. Additional findings that religiosity and history of prior MDD differed significantly by parent depression status, with increased odds for religiosity (Table 2) and decreased odds for prior MDD (Table 3) in offspring of non-depressed parents, bolster that conclusion.

Among offspring of depressed parents, attendance and, albeit to a lesser extent, importance were related to significantly lower odds for MDD, mood and psychiatric disorder in those with high NLE exposure, suggesting that increased religiosity may interrupt the disorder-prone trajectory characteristic of offspring of depressed parents. Moreover, odds for all disorders were significantly lower in relation to increased religiosity in offspring of depressed parents with high NLE exposure than in offspring of depressed parents with average/low NLE exposure, which is consistent with criteria for defining attendance and importance as resilience factors. That finding also confirms other reports that religiosity protects against depression under adverse conditions (Kendler et al. 1999b), and extends them by testing the differential effects of religiosity on psychopathology at the diagnostic level in high- and low-risk persons over a 10-year interval.

Findings regarding service attendance and the importance of religion/spirituality as potential resilience factors were limited to high NLE exposure. Those aspects of religiosity may provide a pragmatic means by which to deal with adversity that does not apply to either past parent depression or prior MDD. Religiously involved people often use religion-related cognitions to minimize threatening experiences (Pargament, 1997). A benign rather than a grim appraisal of NLEs (e.g. believing such events happen for a valid reason and provide opportunities for religious or personal growth) may protect against harmful mental health sequelae (George et al. 2000). In a high-risk sample of unaccompanied minors living outside their country of origin under stressful conditions, religious involvement was reported to be an essential component of all coping strategies applied (Ní Raghallaigh & Gilligan, 2010). Social support, a key factor implicated in resilience (Daud et al. 2008), is another mechanism that may be operating, as religiously involved people, especially those who attend services on a regular basis, have increased access to church-related resources and activities (George et al. 2000; Koenig et al. 2001).

Despite evidence to the contrary (e.g. McCullough & Larson, 1999, 2001; Koenig et al. 2001; Smith et al. 2003), service attendance and religious/spiritual importance did not have a protective effect against MDD. Most previous research is typically based on depressive symptoms, which may be more susceptible to change from external forces than MDD, especially in offspring of depressed parents, where the potential for genetic transmission of MDD is high. In our sample, about 45% of all offspring and 56% of offspring of depressed parents had a prior episode of MDD; thus, roughly half the sample was assessed with a recurrent episode. Effects of religiosity may differ between first-onset MDD and recurrent MDD, which cannot be examined in this sample because of the insufficient sample size. Additionally, previous research has been based primarily on older adults, for whom depression decreases as personal religious beliefs become more firmly ingrained (Koenig, 1992); thus, it also is plausible that religiosity was not yet fully developed in many of our offspring by ages 17–38, when they were assessed for religiosity.

Our findings also suggest that attendance has a greater protective influence than importance. We note that others have found inverse relationships between religiosity and depressive symptoms to be stronger when more public aspects of religious involvement, such as service attendance, are examined in contrast to more private aspects, such as strength of beliefs (McCullough & Larson, 1999). Others have reported similar findings for MDD (Maselko et al. 2009). Increased opportunities for social support in religious settings, especially during late adolescence/young adulthood, the period when religiosity was assessed in the current study, may protect against future negative consequences in high-risk persons. An alternative explanation may be that reinforcement of religiosity is more likely to occur in a setting of like-minded persons, increasing the magnitude of attendance effects. In a subset of the current study sample limited to Catholic and Protestant offspring stable for denomination between the 10-year and 20-year follow-ups, increased importance of religion/spirituality protected against MDD in offspring of depressed parents (Miller et al., in press), suggesting that multiple aspects of religiosity may work in tandem to influence risk for disorder.

The significant effect of parent depression status on mood and any psychiatric disorder was not independent of prior MDD or NLEs, corroborating others’ findings that more proximal circumstances may mediate earlier adversity (Hazel et al. 2008). Additionally, although parent depression increased the odds by nearly fourfold for prior MDD by the 10-year follow-up (see Table 3), offspring of depressed parents were not at any significantly greater odds for MDD over the next 10 years (between the 10-year and 20-year follow-ups). In our sample, MDD assessed between the 10- and 20-year follow-ups was predominantly a recurrent episode, which may no longer be contingent upon predisposing risks that underlie earlier onset MDD, as, for example, has been demonstrated by a diminishing relationship between negative events and recurring depressive episodes (Kendler et al. 2000).

Our findings should be interpreted keeping study limitations in mind. The design of high-risk offspring and low-risk controls was ideal for examining religiosity as a resilience factor. However, the offspring were all Caucasian and predominantly Catholic ; thus, caution should be exercised if generalizing findings to samples with differing racial compositions or affiliations. Although denomination was included as an a priori control, only Catholic and Protestant denominations had sufficient numbers for meaningful comparisons. We considered known factors that influence psychopathology or religiosity or both, but did not address other confounders such as disadvantaged socio-economic background or early trauma (e.g. sexual/physical abuse). Insufficient statistical power due to small cell sizes precluded testing three-way interactions to determine whether moderating effects of religion/spirituality on relationships between NLEs and disorders differed by parent depression status ; for the same reason, potential gender differences were not tested. We assessed attendance and importance with one-item scales, whereas others have shown that psychopathology is related to more extensive and varied dimensions of religiosity (e.g. Vance et al. 2010); moreover, items referred to both religiosity and spirituality, which may have differential effects on disorder (Tsuang et al. 2002; Maselko et al. 2009). Religiosity was assessed at the 10-year follow-up and may have changed over the next 10 years when diagnostic outcomes were assessed, thus relationships should be considered associative, not causal. Diagnoses in successive assessments were based on updated versions of the DSM, which may have introduced method bias (Regier et al. 1998), although such bias is more salient to prevalence estimates that provide the basis for determining mental health service needs. Additionally, prior MDD was the strongest predictor of MDD between 10-year and 20-year follow-ups, and the method of ascertainment (diagnostic interviews by trained professionals and best-estimate procedures for final diagnoses) remained stable across assessments. NLE and disorder outcomes were assessed over two consecutive 10-year intervals (between baseline and the 10-year follow-up and between the 10- and 20-year follow-ups respectively), a period of sufficient duration for negative fallout from NLEs to diminish. NLE exposure may have long-term psychological consequences (Tennant et al. 2002), however, sometimes over several decades (Kasen et al. 2010). Our measure of NLEs also did not take into account event severity or duration, which may have lasting effects on those exposed (Brown, 1989). Nonetheless, the mitigating effects of increased attendance on relationships between NLEs and disorder applied to all disorders, providing additional support for this aspect of religiosity as a protective factor that may foster resilience in certain high-risk individuals.

Acknowledgments

These analyses were funded by the John Templeton Foundation. Data collection was funded by the National Institute of Mental Health (2 R01 MH36197) including a supplement from the National Institute of Drug Abuse.

Footnotes

Declaration of Interest

In the past two years Dr S. Kasen received funding from the American Foundation for Suicide Prevention, and Dr M. M. Weissman received funding from the National Institute of Mental Health (NIMH), the National Institute on Drug Abuse (NIDA), the National Alliance for Research on Schizophrenia and Depression (NARSAD), the Sackler Foundation, the Templeton Foundation, and the Interstitial Cystitis Association; he also receives royalties from Oxford University Press, Perseus Press, American Psychiatric Association Press, and MultiHealth Systems.

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