US Religious Leaders’ Views on the Etiology and Treatment of Depression

Key Points

Question

What do clergy believe about the etiology and appropriate treatment of depression?

Findings

In this cross-sectional study of a nationally representative sample of 890 primary leaders of religious congregations, the leaders overwhelmingly embraced a medical understanding of the causes and treatment of depression. When clergy endorsed religious causes and treatment, those religious views mainly supplemented rather than replaced a medical view, although a nontrivial minority endorsed only religious interpretations.

Meaning

Most of the leaders endorsed views about the etiology and appropriate treatment of depression in line with contemporary medical models, which should encourage further collaboration between medical professionals and religious leaders to address mental health difficulties in communities.

Abstract

Importance

Religious leaders commonly provide assistance to people with mental illness, but little is known about clergy views regarding mental health etiology and appropriate treatment.

Objective

To assess the views of religious leaders regarding the etiology and treatment of depression.

Design, Setting, and Participants

This cross-sectional study used the National Survey of Religious Leaders, which is a nationally representative survey of leaders of religious congregations in the United States, with data collected from February 2019 to June 2020. Data were analyzed in September and October 2022.

Main Outcomes and Measures

Views about causes of depression (chemical imbalance, genetic problem, traumatic experience, demon possession, lack of social support, lack of faith, and stressful circumstances) and appropriate treatments (seeing a mental health professional, taking prescribed medication, and addressing the situation through religious activity).

Results

The analytic sample was limited to congregations’ primary leaders (N = 890), with a 70% cooperation rate. Clergy primarily endorsed situational etiologies of depression, with 93% (95% CI, 90%-96%) endorsing stressful circumstances, 82% (95% CI, 77%-87%) endorsing traumatic experiences, and 66% (95% CI, 59%-73%) endorsing lack of social support. Most clergy also endorsed a medical etiology, with 79% (95% CI, 74%-85%) endorsing chemical imbalance and 59% (95% CI, 52%-65%) endorsing genetics. A minority of clergy endorsed religious causes: lack of faith (29%; 95% CI, 22%-35%) or demon possession (16%; 95% CI, 10%-21%). Almost all of the religious leaders who responded to the survey would encourage someone with depressive symptoms to see a mental health professional (90%; 95% CI, 85%-94%), take prescribed medication (87%; 95% CI, 83%-91%), and address symptoms with religious activity (84%; 95% CI, 78%-89%). A small but nontrivial proportion endorsed a religious cause of depression without also endorsing chemical imbalance (8%; 95% CI, 5%-12%) or genetics (20%; 95% CI, 13%-27%) as a likely cause. A similar proportion would encourage someone exhibiting depressive symptoms to engage in religious treatment without also seeing a mental health professional (10%; 95% CI, 5%-14%) or taking prescribed medication (11%; 95% CI, 8%-15%).

Conclusions and Relevance

In this cross-sectional survey, the vast majority of clergy embrace a medical understanding of depression’s etiology and treatment. When clergy employ a religious understanding, it most commonly supplements rather than replaces a medical view, although a nontrivial minority endorse only religious interpretations. This should encourage greater collaboration between medical professionals and clergy in addressing mental health needs.

This cross-sectional study assesses the views of religious leaders regarding the etiology and treatment of depression.

Introduction

Up to one-fourth of individuals seeking mental health treatment seek help from a clergyperson.¹ This prompts concern about the extent to which clergy accept contemporary medical wisdom about mental health causes and treatment. Previous research on this subject has relied on small, nonrepresentative samples of clergy and has produced mixed results.^2,3,4,5,6,7 To our knowledge, there is no established conclusion about clergy views regarding mental health causes and treatment. We use the National Survey of Religious Leaders (NSRL) to provide, for the first time from a nationally representative sample, information about the extent to which clergypersons hold views about the etiology and treatment of depression that are medical, religious, or a combination of both.

Methods

In our cross-sectional study, we used the NSRL, a national survey of a nationally representative sample of leaders of religious congregations in the United States, conducted from February 2019 to June 2020.⁸ The NSRL gathered data, primarily via an online self-administered questionnaire, from 1600 congregational leaders, including 890 primary leaders and 710 secondary leaders. Eighty-two percent of respondents completed the survey online in a self-administered way, 7% completed the online survey via an interview, and 11% completed and returned a paper questionnaire. Herein, we use only the data from the 890 primary leaders. The cooperation rate was 70% among primary leaders. eAppendix 1 in Supplement 1 provides details about sampling, data collection, and response rates. We use data from the 890 primary leaders in the sample. The eTable in Supplement 1 contains selected demographic characteristics of this sample.

Respondents read a vignette, adapted from the 2006 General Social Survey, describing a hypothetical congregant meeting the DSM-IV criteria for major depressive disorder (eAppendix 2 in Supplement 1).⁹ Respondents were asked how likely it is that this situation might be caused by chemical imbalance, genetic or inherited problem, traumatic experience, demon possession, lack of community or social support, lack of faith, and stressful circumstances in the congregant’s life. They also were asked how likely they are to encourage this person to seek help from a mental health professional, take prescribed medication, and address the situation through prayer, scripture study, or other religious activity. Respondents addressed each possible cause and treatment separately, with response options of not at all likely, a little bit likely, moderately likely, and very likely.

We categorized each respondent’s congregation into 1 of 5 religious traditions based on its denominational affiliation: predominantly Black Protestant (21.6% of the sample, weighted), predominantly White conservative or evangelical Protestant (43.2%), predominantly White mainline Protestant (20.6%), Roman Catholic (6.1%), or other (8.5%). The “other” category includes Jewish, Muslim, Hindu, and Buddhist leaders. There are not enough such leaders in the sample to separate for meaningful analysis. eAppendix 3 in Supplement 1 provides more detail about this categorization.

Duke University’s institutional review board approved the NSRL. Participants provided informed consent when completing the NSRL questionnaire. This cross-sectional study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

We incorporated considerations of sampling error by calculating 95% CIs around each percentage we report. Data were analyzed using SPSS Statistics, version 28.0 (IBM Corp) and R, version 4.1.3 (R Foundation for Statistical Computing). Data were analyzed in September and October 2022.

Results

Figure 1 shows the percentages of religious leaders who said that each of the offered causes of the depressive symptoms described in the vignette was at least moderately likely. Situational etiologies were the most commonly endorsed, with 93% (95% CI, 90%-96%) saying stressful circumstances, 82% (95% CI, 77%-87%) saying a traumatic experience, and 66% (95% CI, 59%-73%) saying lack of social support. Biological explanations—chemical imbalance and genetics—were endorsed by 79% (95% CI, 74%-85%) and 59% (95% CI, 52%-65%) of clergy, respectively. The 2 religious causes were endorsed by a minority of clergy, with 29% (95% CI, 22%-35%) saying lack of faith and 16% (95% CI, 10%-21%) saying demon possession.

Figure 1. Religious Leaders' Beliefs About Causes and Treatments for Depression.

The number of religious leaders for each belief about causes and treatments indicates the total unweighted number of valid responses for each measure.

Figure 1 also shows the percentages of religious leaders who said they were at least moderately likely to encourage each of the offered treatments. Most endorsed a medical approach, with 90% (95% CI, 85%-94%) saying they would encourage seeking help from a mental health professional and 87% (95% CI, 83%-91%) saying they would encourage taking prescribed medicine. Most leaders also encouraged religious treatment, with 84% (95% CI, 78%-89%) saying they would encourage addressing the situation through prayer, scripture study, or other religious activity.

Figure 2 places clergy in 1 of 3 categories: those holding only a medical view, holding only a religious view, or combining both views. We examined the religious vs medical comparison separately for each nonreligious cause. Figure 2 shows this breakdown using the 2 biological causes offered to respondents. About one-half of clergy—56% (95% CI, 48%-63%) for chemical imbalance and 49% (95% CI, 41%-57%) for genetics—endorsed only the medical cause. About one-third—36% (95% CI, 28%-43%) for chemical imbalance and 31% (95% CI, 23%-39%) for genetics—endorsed both medical and religious causes. Eight percent (95% CI, 5%-12%) endorsed a religious cause without also endorsing chemical imbalance as a likely cause, and 20% (95% CI, 13%-27%) endorsed a religious cause without also endorsing genetics as a likely cause.

Figure 2. Religious Leaders' Beliefs about Medical, Religious, or Combined Cause and Treatment for Depression.

For the medical-religious cause comparisons, the “religious-only” clergy are those who responded that either demon possession or lack of faith is at least moderately likely and that the specified medical cause (chemical imbalance or genetics) is less than moderately likely. The “medical-only” clergy responded that the specified medical cause is at least moderately likely and neither demon possession nor lack of faith is at least moderately likely. The “medical and religious” clergy responded that the specified medical cause is at least moderately likely and either demon possession or lack of faith also are at least moderately likely. Religious leaders who responded that neither the biological cause nor one of the religious causes is at least moderately likely were excluded. For the treatment comparisons, “religious-only” clergy are those at least moderately likely to encourage addressing the situation through prayer, scripture study, or other religious activity and less than moderately likely to encourage the specified medical treatment (see a mental health professional or take prescribed medication). The “medical-only” clergy responded that they are at least moderately likely to encourage the specified medical treatment and less than moderately likely to encourage religious activity. The “medical and religious” clergy are at least moderately likely to encourage the medical treatment and at least moderately likely to also encourage religious activity. Religious leaders who responded that they were not at least moderately likely to encourage either the medical treatment or the religious treatment were excluded. The number of religious leaders for each belief about causes and treatments indicates the total unweighted number of valid responses for each measure.

Figure 2 also presents the results of a similar analysis for treatments that the clergyperson would encourage. About 15% would encourage only medical treatments of this condition (95% CI, 11%-21% for seeing a mental health professional; 95% CI, 10%-21% for taking prescribed medication). Three-quarters are at least moderately likely to encourage this person to pursue medical and religious treatment (95% CI, 68%-81% for seeing a mental health professional; 95% CI, 67%-80% for taking prescribed medication). About 10% would encourage the person to address their situation through religious means only (95% CI, 5%-14% for religious treatment without seeking help from a mental health professional; 95% CI, 8%-15% for religious treatment without taking prescribed medicine).

Figure 3 presents differences across religious groups in the extent to which clergy would encourage a religious treatment without also encouraging the person to seek help from a medical professional. Leaders of predominantly Black Protestant churches (15%; 95% CI, 2%-28%) and predominantly White conservative or evangelical Protestant churches (13%; 95% CI, 6%-21%) were more likely to encourage only a religious response to these symptoms than either Catholic priests (1%; 95% CI, −0.4% to 2%) or pastors of predominantly White mainline Protestant churches (3%; 95% CI, 1%-5%). The difference between the Black Protestant and predominantly White conservative and evangelical leaders (combined) and the predominantly White mainline Protestant and Catholic leaders (combined) is statistically significant (13.7% vs 2.2%; t = 3.37; 2 tailed P < .001). The pattern is similar for encouraging religious treatment without also encouraging the person to take prescribed medication (eFigure in Supplement 1).

Figure 3. Percentage of Religious Leaders Endorsing Religious Treatment for Depression Without Also Encouraging Seeking Help From a Medical Professional, by Religious Tradition.

The number of religious leaders for each religious tradition indicates the total unweighted number of valid responses within that tradition.

Discussion

Religious causes of depression were, by a large margin, the least endorsed by clergy. Even when clergy maintained that depression has a religious cause, they mainly combined that religious interpretation with a medical one. Religious leaders were much more likely to encourage a religious treatment for the depressive symptoms than they were to endorse a religious cause, but relatively few would encourage only a religious treatment. For the vast majority of religious leaders, the sacred is added onto the profane; it does not replace it.

Still, a nontrivial minority of religious leaders endorsed only religious causes of depression and would encourage only a religious response to it. That proportion was larger among leaders of predominantly Black Protestant churches and predominantly White conservative or evangelical Protestant churches, but, even within those groups, those encouraging only a religious response were in the minority.

Limitations

These results are limited to clergy views about depression. It is possible that clergy views about other mental illnesses would be different. Also, these results provide a snapshot at 1 point in time. It is possible that clergy views have changed since 2019-2020. Another limitation is that the sample size is not large enough to examine differences across religious groups defined in a more fine-grained way.

Conclusions

In this cross-sectional study, most religious leaders adopted either a wholly medical or a combined medical and religious view of depression. A nontrivial minority endorsed only religious causes and would encourage only a religious response to it, but religious views of depression mainly supplement rather than replace medical views. These results suggest that medical professionals should view the vast majority of religious leaders as allies in identifying and properly treating depression.

Supplement 1.

eAppendix 1. NSRL Sample, Data Collection, and Weighting

eAppendix 2. Vignette Presenting a Hypothetical Congregant with Depression Symptoms

eAppendix 3. Religious Group Categorization

eTable. Selected Demographic Characteristics of NSRL Primary Leader Sample

eFigure. Percentage of Primary Leaders of Religious Congregations Endorsing Religious Treatment for Depression Without Also Encouraging the Person to Take Prescribed Medication, by Religious Tradition

eReferences

Supplement 2.

Data Sharing Statement