Religious Service Attendance and Despair Among Health Professionals—A Catalyst for New Avenues of Inquiry

Religion is one of the oldest social and cultural systems known to mankind and has profoundly shaped social institutions in the US.^1–4 Social scientists during the early 20th century intimated that religion can have implications for health. In addition, social gerontology was the first field of inquiry to systematically examine associations between these rich concepts.² Numerous studies over the past half-century have attempted to examine how religious beliefs, practices, or organizations influence health out-comes, well-being, and longevity. Religious service attendance has emerged from this line of research as a key factor associated with health among individuals, especially in later life.³ Recent studies including individuals followed from midlife and late life (older than 40 years) who attended religious services every week were considerably less likely to die than peers who did not attend religious services.^1,5 These findings have been featured in print, television, and web-based media outlets across the globe, reinforcing the high level of interest in the associations between religion and health; however, the specific mechanisms linking frequent religious services attendance to health have yet to be clearly elucidated. Furthermore, it has been suggested that religious services are positive social environments that foster attitudes, motivations, goals, and social interactions that mitigate the deleterious effects of social and psychological stressors on physiologic dysregulation and risks for mortality.¹

Motivated by an increase in mortality rates among middle-aged non-Hispanic white individuals from 1999 through 2016, Chen and colleagues⁶ present in this issue of JAMA Psychiatry a clever analysis of data from the Nurses’ Health Study II (2001–2017), an ongoing study of registered female nurses, and the Health Professionals Follow-Up Study (1988–2014), an ongoing study of male physicians, to assess whether frequent religious service attendance is associated with a lower risk for so-called deaths of despair: mortality from causes including suicide, unintentional poisoning by alcohol or drug overdose, and chronic liver diseases and cirrhosis. Case and Deaton⁷ had reported deaths during the period of 1999 through 2016 were pronounced among middle-aged white men and women without a college degree and the primary causes of excess death among this population were suicide, opioid abuse, and alcohol-associated conditions, including cirrhosis. Chen and colleagues⁶ adopted the premise introduced by Case and Deaton⁷ that the rise in premature mortality among working-class white individuals can be attributed to a context of hopelessness and indifference brought about by the economic insecurity associated with the reduction of well-paying industrial job prospects and perceived closure of paths for upward mobility. Chen and colleagues⁶ posited that religion can be a source of hope and perhaps resilience, because participation in organized religious services can facilitate social integration, encourage healthy behaviors, and provide a sense of meaning and purpose. The study emerging from this idea represents an important contribution to the literature because it assesses the degree to which regular religious service attendance has implications for deaths from specific causes.

Methodological rigor is a primary strength of Chen et al.⁶ The authors draw analytic samples from 2 large cohorts of female and male health professionals in the US and supplement them with data from death reports from the next of kin, the National Death Index, US state statistical records, and the US postal system. This creative data integration allows for the estimation of Cox proportional hazard regression models of despair-associated deaths by religious service attendance at baseline, adjusting for socioeconomic factors, demographic characteristics, health behaviors, psychological distress, medical history, and other aspects of social integration. Nurses and physicians in the study who attended religious services at least weekly were less likely to die of despair-associated causes than their respective peers who never attended religious services. This finding has been thoroughly assessed and verified with multiple and meticulous sensitivity analyses. The most significant finding of note was that religious service attendance was inversely associated with deaths from suicide for nurses and physicians in the study.⁶ The suicide rate for health professionals is more than double the corresponding rate in the general population, and results from this study⁶ suggest that religious service attendance may be an antidote for or provide substantial relief from overwhelming social, economic, or occupational environments, although such a potential causal link can only be viewed as speculative in an association study. One important caveat is the 2 cohorts analyzed by Chen and colleagues⁶ had advanced levels of educational attainment (albeit high stress and suicide risk), in contrast to the low level of educational attainment associated with deaths of despair reported by Case and Deaton.⁷

The findings from Chen and colleagues⁶ are compelling and contribute to the body of evidence asserting the health benefits of religious practices, such as attending religious services, with a careful, creative, and comprehensive analysis of data from 2 cohorts of health professionals. The authors are also to be commended for extending the religion and health literature with their attempt to consider factors such as despair. Religious organizations are often considered to be compassionate settings where coping resources and strategies and hope are provided to individuals facing stressful social environments or circumstances.^3,8,9 Yet, studies examining the religion and its implications for death rarely focus on important yet complex concepts, such as despair or stress and distress. Despair is presumed to be a primary factor driving behaviors associated with deaths from suicide, drug abuse, and alcohol abuse among health professionals; yet, no measures of despair are present in any of the models in Chen et al.⁶ As a result, no direct evidence is provided about the degree to which despair contributes to premature mortality among health professionals.

The contribution of Chen et al⁶ is also muted by a crude measurement of religiosity. Religious service attendance is a common measure that has not been sufficiently appraised and updated, given societal changes. The type and form of religious services can vary considerably across religions and within religious traditions or denominations. Furthermore, technology has given many congregants multiple ways to participate in religious services without being physically present. The study by Chen et al,⁶ like many of its predecessors, demonstrates the potential of attending religious services; however, the utility of these data is limited to provocation and hypothesis generation, because the science examining how religious participation and other forms of religiosity or spirituality can get under the skin, so to speak, to have implications for health and longevity is underdeveloped.^2,3

In summary, the study presented by Chen and colleagues⁶ in this issue of JAMA Psychiatry raises both important answers and questions; thus, it would be a mistake to dismiss it. Close reading of this article provides some exciting potential avenues of inquiry at the interface of religiosity, spirituality, and health. The robust results from an analysis of individuals with social privilege and high-stress occupations during middle and late life reported in Chen et al⁶ pave the way for the next generation of health disparities research with nuanced considerations of key factors, such as status in society, despair, stress, religious participation, and religious coping and hope. In words thought to be an Arabian proverb or a quote attributable to Thomas Carlyle: he or she who has health has hope, and he or she who has hope has everything.