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Over 100 measures of religiousness and spirituality are used in research investigating the associations between religion and health. These measures are often used to assess "religiousness in general," but this approach lumps together widely divergent worldviews in ways that can distort religion beyond recognition. The authors suggest that the existing measures of religiousness are perhaps better understood as reverse-coded measures of "secularism." This argument suggests that the existing data regarding religiousness and health might be best interpreted as demonstrating a small, robust health liability associated with a deliberately secular worldview. If true, this conclusion might change the direction of future research, and it would imply that meaningful inferences about the health associations of religious practice will depend on developing tools that measure specific religions in their particularity. [ABSTRACT FROM AUTHOR]

Objective: African Americans have less use of antidepressants than whites, suggesting racial differences in the diagnosis and treatment of mood disorders. This study assessed whether this racial disparity is present among patients with a very high risk of severe mood disorders--that is, those with completed suicides.Methods: Completed suicides that occurred between 1986 and 2004 were identified by examining records of Tennessee Medicaid/TennCare enrollees aged 18 to 84 years who had no serious medical illness or chronic psychosis. Use of antidepressants in the 365 days before the suicide was ascertained from filled prescriptions. Unconditional logistic regression was used to adjust for racial differences in demographic characteristics and somatic comorbidity.Results: The study included 127 African Americans and 1,379 whites who completed suicide. African Americans had significantly reduced odds of receiving treatments for mood disorders in the year preceding the suicide: 29% of African Americans had filled an antidepressant prescription, compared with 51% of whites (adjusted odds ratio=.43, 95% confidence interval=.26-.71, p<.001). In contrast, there was no significant difference between the two racial groups in the proportions filling prescriptions for antipsychotic medications (13% of African Americans and 11% of whites). These findings persisted after the analysis controlled for other comorbidities linked with suicide, including alcohol or substance abuse, seizure disorders, borderline personality disorder, and serious neurological conditions.Conclusions: Although there are several other potential explanations, the study findings provide indirect evidence that there is underdiagnosis or undertreatment of African Americans with serious mood disorders. Further research on this question in African-American populations is essential. [ABSTRACT FROM AUTHOR]

Objective: This study compared the religious characteristics of psychiatrists with those of other physicians and explored whether nonpsychiatrist physicians who are religious are less willing than their colleagues to refer patients to psychiatrists and psychologists.Methods: Surveys were mailed to a stratified random sample of 2,000 practicing U.S. physicians, with an oversampling of psychiatrists. Physicians were queried about their religious characteristics. They also read a brief vignette about a patient with ambiguous psychiatric symptoms and were asked whether they would refer the patient to a clergy member or religious counselor, or to a psychiatrist or a psychologist.Results: A total of 1,144 physicians completed the survey, including 100 psychiatrists. Compared with other physicians, psychiatrists were more likely to be Jewish (29% versus 13%) or without a religious affiliation (17% versus 10%), less likely to be Protestant (27% versus 39%) or Catholic (10% versus 22%), less likely to be religious in general, and more likely to consider themselves spiritual but not religious (33% versus 19%). Nonpsychiatrist physicians who were religious were more willing to refer patients to clergy members or religious counselors (multivariate odds ratios from 2.9 to 5.7) and less willing to refer patients to psychiatrists or psychologists (multivariate odds ratios from .4 to .6).Conclusions: Psychiatrists are less religious than other physicians, and religious physicians are less willing than nonreligious physicians to refer patients to psychiatrists. These findings suggest that historic tensions between religion and psychiatry continue to shape the care that patients receive for mental health concerns. [ABSTRACT FROM AUTHOR]

OBJECTIVES: The authors assessed gender differences in hepatitis C infection and associated risk behaviors among persons with severe mental illness. METHOD:S: The sample consisted of 777 patients (251 women and 526 men) from four sites. RESULTS: Across sites, the rate of hepatitis C infection among men was nearly twice that among women. Clear differences were noted in hepatitis C risk behaviors. Men had higher rates of lifetime drug-related risk behaviors: needle use (23.1 percent compared with 12.5 percent), needle sharing (17.6 percent compared with 7.7 percent), and crack cocaine use (45.2 percent compared with 30.8 percent). Women had significantly higher rates of lifetime sexual risk behaviors: unprotected sex in exchange for drugs (17.8 percent compared with 11.2 percent), unprotected sex in exchange for money or gifts (30.6 percent compared with 17 percent), unprotected vaginal sex (94 percent compared with 89.7 percent), and anal sex (33.7 percent compared with 22.6 percent). Gender appeared to modify some sex risks. Unprotected sex in exchange for drugs increased the risk of hepatitis C seropositivity for both men and women. In the multivariate model, gender was not significantly associated with hepatitis C seropositivity after adjustment for other risk factors. CONCLUSION:S: Gender differences in the lifetime rates of drug risks explain the higher rates of hepatitis C infection among men with severe mental illness. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Previous reports have indicated that persons with severe mental illness have an elevated risk of contracting HIV, hepatitis B, and hepatitis C compared with the general population. This study extends earlier findings by examining the factors that are most predictive of serologic status among persons with severe mental illness. METHOD:S: A total of 969 persons with severe mental illness from five sites in four states were approached to take part in an assessment involving testing for blood-borne infections and a one-time standardized interview containing questions about sociodemographic characteristics, substance use, risk behaviors for sexually transmitted diseases, history of sexually transmitted diseases, and health care. RESULTS: The greater the number of risk behaviors, the greater was the likelihood of infection, both for persons in more rural locations (New Hampshire and North Carolina), where the prevalence of infection was lower, and those in urban locations (Hartford, Connecticut; Bridgeport, Connecticut; and Baltimore, Maryland), where the prevalence was higher. Although no evidence was found that certain behaviors increase a person's risk of one blood-borne infection while other behaviors increase the risk of a different infection, it is conceivable that more powerful research designs would reveal some significant differences among the risks. CONCLUSION:S: Clinicians should be attentive to these risk factors so as to encourage appropriate testing, counseling, and treatment. [ABSTRACT FROM AUTHOR]

Methods: A probability sample of 3,968 community-dwelling adults aged 64-101 years residing in the Piedmont of North Carolina was surveyed in 1986 as part of the Established Populations for the Epidemiologic Studies of the Elderly (EPESE) program of the National Institutes of Health. Attendance at religious services and a wide variety of sociodemographic and health variables were assessed at baseline. Vital status of members was then determined prospectively over the next 6 years (1986 1992). Time (days) to death or censoring in days was analyzed using a Cox proportional hazards regression model.Results: During a median 6.3-year follow-up period, 1,777 subjects (29.7%) died. Of the subjects who attended religious services once a week or more in 1986 (frequent attenders), 22.9% died compared to 37.4% of those attending services less than once a week (infrequent attenders). The relative hazard (RH) of dying for frequent attenders was 46% less than for infrequent attenders (RH: 0.54, 95% CI 0.48-.0.61), an effect that was strongest in women (RH 0.51, CI 0.434).59) but also present in men (RH 0.63, 95% CI 0.52-0.75). When demographics, health conditions, social connections, and health practices were controlled, this effect remained significant for the entire sample (RH 0.72, 95% CI 0.64-.81), and for both women (RH 0.65, 95% CI 0.554-.76, p<.0001) and men (RH 0.83, 95% CI 0.69-1.00, p=.05).Conclusions: Older adults, particularly women, who attend religious services at least once a week appear to have a survival advantage over those attending services less frequently. [ABSTRACT FROM AUTHOR]

Context: Falls are a major health problem in nursing homes, but no interventions have been shown to prevent falls in nursing home residents.Objective: To evaluate an intervention program designed to prevent falls and associated injuries in high-risk nursing home residents.Design: Randomized controlled trial.Setting and Participants: Seven pairs of middle Tennessee nursing homes with 1 facility in each pair randomly assigned to the intervention. Facilities had 482 (261 control, 221 intervention) residents who qualified for the study because they had high risk of falls and a potential safety problem that could be addressed by the intervention.Intervention: Comprehensive structured individual assessment with specific safety recommendations that targeted suboptimal practices for environmental and personal safety, wheelchair use, psychotropic drug use, and transferring and ambulation. Facility staff were encouraged to implement the individual recommendations and to improve overall facility safety.Main Outcome Measures: The mean proportion of recurrent fallers and incidence rate of injurious falls in the facility in the year following the intervention.Results: The mean proportion of recurrent fallers in intervention facilities (43.8%) was 19.1% (95% confidence interval, 2.4%-35.8%) lower than that in control facilities (54.1%, P=.03). Intervention facilities had a nonsignificant trend toward a lower mean rate of injurious falls (13.7 vs 19.9 per 100 person-years, reduction of 31.2%, P=.22). Subgroup analyses suggested greatest benefits for residents for whom the recommended interventions were carried out or who had 3 or more falls in the preceding year.Conclusion: The high rate of falls and related injuries in nursing homes should not be viewed as inevitable, but as outcomes that can be substantially improved through structured safety programs. [ABSTRACT FROM AUTHOR]

Recent evidence indicates that spirituality and religion are associated with both physical and psychological health. Because a belief that rewards are largely determined by external forces tends to be detrimental to mental health, the idea that God can be equated with such an external force seems contradictory to the proven benefits of religion and spirituality. The purpose of this article is to examine changes in perceived control in the context of spiritual turning points as uncovered in the narrative histories of 30 elderly people. We propose that for many people who derive benefits from religion or spirituality, God may act as a mediator, in the sense that trusting in God provides personal control. In addition to creating a model of God-mediated control, the study's findings suggest a relationship between recall for type of control during a spiritual turning point and the interpretation of that turning point in late life. [ABSTRACT FROM AUTHOR]

Because of the high prevalence of post-traumatic stress disorder (PTSD) among veteran men and the limited research on victimization in this group, we recruited 133 male veterans with combat-related PTSD from a psychiatric inpatient unit and assessed them for lifetime physical and sexual trauma. Results indicated that 96% of the sample had experienced some form of victimization over their lifetimes; 60% reported childhood physical abuse, 41% childhood sexual abuse, 93% adulthood physical assault, and 20% adulthood sexual assault. In the preceding year alone, 46% experienced either physical or sexual assault. These findings support the need for routine inquiry into the histories of noncombat victimization in this cohort. Determining the lifetime history of trauma exposure may have implications for vulnerability to subsequent development of PTSD and the risk of future violence. [ABSTRACT FROM AUTHOR]

The Department of Veterans Affairs (VA) has prioritized improving the identification of veterans at risk for suicide and ensuring adequate staffing of personnel to assist veterans in need. It is imperative that suicide prevention efforts make use of the full range of available resources, including diverse professionals with distinctive skillsets. Chaplains are engaged in suicide prevention efforts in VA, but the literature lacks examples of chaplain-involved suicide prevention efforts that clearly describe how chaplains are engaged, the training and/or qualifications chaplains possess in the area of suicide prevention, and the reach and impact of such efforts. The purpose of this report is to describe the development and implementation of a novel, innovative, and ongoing chaplain-led suicide prevention outreach initiative for veterans at high risk for suicide. Results indicated the program was feasible and supported at the systems level, and chaplains were able to collaboratively sustain outreach efforts over the course of a year. Chaplain suicide prevention outreach was found to be acceptable to veterans, who overwhelmingly indicated openness to and appreciation for outreach. Chaplains can address the spiritual crisis underlying suicidality, bolster spiritual protective factors, and are a part of holistic care. Considerations for implementation and future investigation are discussed.

Introduction: Moral injury, predominantly studied in military populations, has garnered increased attention in the healthcare setting, in large part due to the psychological and emotional consequences of the COVID-19 pandemic. The measurement of moral injury with instrumentation adapted from military settings and validated by frontline healthcare personnel is essential to assess prevalence and guide intervention. This study aimed to validate the Moral Injury Outcome Scale (MIOS) in the population of acute care., Methods: A sample of 309 acute care nurses completed surveys regarding moral injury, depression, anxiety, burnout, professional fulfillment, spiritual wellbeing, and post-traumatic stress disorder symptoms. Confirmatory factor analysis was conducted as well as an assessment of reliability and validity., Results: The internal consistency of the 14-item MIOS was 0.89. The scale demonstrated significant convergent and discriminant validity, and the test of construct validity confirmed the two-factor structure of shame and trust violations in this clinical population. Regression analysis indicated age, race, and marital status-related differences in the experience of moral injury., Discussion: The MIOS is valid and reliable in acute care nursing populations and demonstrates sound psychometric properties. Scores among nurses diverge from those of military personnel in areas that may inform distinctions in interventions to address moral injury in these populations., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Tao, Nieuwsma, Meador, Harris and Robinson.)

Objectives: Moral reasoning is an underexamined and potentially useful area of research relative to the care of moral injury in veterans. However, the most widely used measure of moral reasoning, the moral foundations questionnaire (MFQ), has not been validated in this population., Methods: Post-9/11 veterans (N = 311) completed questionnaires which included the MFQ. Veterans' scores were compared to the general US population. Confirmatory factor analysis was used to test existing models of the MFQ in the sample. Exploratory factor analysis (EFA) was also used to examine potentially improved model fits., Results: The two leading, preexisting MFQ models were both poor fits for the data. EFA results produced a four-factor model for the veteran sample using 25 of the original 30 items of the MFQ., Conclusions: Measuring moral reasoning among veterans may be important in understanding the experience of moral injury. However, the most widely used scale (MFQ) performs poorly among a sample of post-9/11 veterans, indicating that veterans may respond differently to the measure than the general US population. Military culture may uniquely influence veterans' moral reasoning, suggesting the need for military specific measures for this construct., (Published 2022. This article is a U.S. Government work and is in the public domain in the USA.)

Background: Ethical issues in trauma surgery are commonplace but scarcely studied. We aim to characterize the ethical dilemmas trauma surgeons encounter in clinical practice and describe perceptions about the ability to manage these dilemmas and strategies they use to address them., Methods: Members of a U.S. trauma society were electronically surveyed on handling ethically challenging scenarios. The survey instrument was developed using published ethics literature and iterative cognitive interviews. Domains included perceived frequency of encountering and self-efficacy of managing ethical situations in trauma surgery. Common situations were defined as those encountered monthly or weekly. Ethical problems were categorized within 7 larger categories: general ethics, autonomy, communication, justice, end-of-life, conflict, and other. Descriptive analyses were performed; group comparisons were analyzed using analysis of variance., Results: Of 1,748 surveyed, 548 responded (30.6%) and 154 (28%) were female. Most were White, under 55 years age, had completed fellowship training, and were practicing at a level I or II trauma center. The most encountered ethical categories were generic ethics and communication (79%). Issues involving conflict were least frequent (21%). Respondents felt most uncomfortable with autonomy topics. Respondents with high self-efficacy in handling ethical situations were older, in practice ≥15 years, served on an ethics committee, and/or frequently experienced ethical challenges., Conclusion: Most trauma surgeons regularly encounter ethical challenges, especially those related to communication. Trauma surgeons encounter ethical issues involving conflict least often, and lowest self-efficacy scores with issues involving autonomy. Experienced trauma surgeons reported higher self-efficacy scores in managing ethical issues. Future work should examine how self-efficacy translates to observed behavior, and how trauma surgeons build and enhance their ethical skillsets in the care of the injured patient., (Published by Elsevier Inc.)

Background: Moral injury has primarily been studied in combat veterans but might also affect healthcare workers (HCWs) due to the COVID-19 pandemic., Objective: To compare patterns of potential moral injury (PMI) between post-9/11 military combat veterans and healthcare workers (HCWs) surveyed during the COVID-19 pandemic., Design: Cross-sectional surveys of veterans (2015-2019) and HCWs (2020-2021) in the USA., Participants: 618 military veterans who were deployed to a combat zone after September 11, 2001, and 2099 HCWs working in healthcare during the COVID-19 pandemic., Main Measures: Other-induced PMI (disturbed by others' immoral acts) and self-induced PMI (disturbed by having violated own morals) were the primary outcomes. Sociodemographic variables, combat/COVID-19 experience, depression, quality of life, and burnout were measured as correlates., Key Results: 46.1% of post-9/11 veterans and 50.7% of HCWs endorsed other-induced PMI, whereas 24.1% of post-9/11 veterans and 18.2% of HCWs endorsed self-induced PMI. Different types of PMI were significantly associated with gender, race, enlisted vs. officer status, and post-battle traumatic experiences among veterans and with age, race, working in a high COVID-19-risk setting, and reported COVID-19 exposure among HCWs. Endorsing either type of PMI was associated with significantly higher depressive symptoms and worse quality of life in both samples and higher burnout among HCWs., Conclusions: The potential for moral injury is relatively high among combat veterans and COVID-19 HCWs, with deleterious consequences for mental health and burnout. Demographic characteristics suggestive of less social empowerment may increase risk for moral injury. Longitudinal research among COVID-19 HCWs is needed. Moral injury prevention and intervention efforts for HCWs may benefit from consulting models used with veterans., (© 2022. This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.)

The psychospiritual nature of moral injury invites consideration regarding how chaplains understand the construct and provide care. To identify how chaplains in the VA Healthcare System conceptualize moral injury, we conducted an anonymous online survey ( N  = 361; 45% response rate). Chaplains responded to a battery of items and provided free-text definitions of moral injury that generally aligned with key elements in the existing literature, though with different emphases. Over 90% of chaplain respondents indicated that they encounter moral injury in their chaplaincy care, and a similar proportion agreed that chaplains and mental health professionals should collaborate in providing care for moral injury. Over one-third of chaplain respondents reported offering or planning to offer a moral injury group. Separately, nearly one-quarter indicated present or planned collaboration with mental health to provide groups that in some manner address moral injury. Previous training in evidence-based and collaborative care approaches appears to contribute to the likelihood of providing integrated psychosocial-spiritual care. Results and future directions are discussed, including a description of moral injury that may be helpful to understand present areas of emphasis in VA chaplains' care for moral injury.

Jeff Levin's Religion and Medicine (2020) offers a substantial review of the multicultural intersections of these significant threads of the human story. While Levin's framing of the conceptual significance and intellectual implications of these intersections in the last few decades falls short, the arc of his historical overview and his inclusive commitments give readers a broad sense of this story through the lens of religion and public health. This essay considers the conceptual, sociopolitical, and intellectual dynamics and implications within his historical recounting, with particular attention to the distortions of both religion and medicine that arise from commodified presumptions of the merit-based cultural notion that "we get what we deserve." In order to best interpret how the significant human dimension of religion and spirituality should be understood in considering the health and care of pluralistic diverse communities, it is crucial to examine the implications of the intersections of religion and medicine in clinical practice and in the health of communities.

Moral injury merits further study to clarify its identification, prevalence, assessment and intersection with psychosocial and psychiatric problems. The present study investigated the screening potential of the Brief Moral Injury Screen (BMIS) in a sample of post-9/11 veterans (N = 315) and comparatively evaluated how this tool, the Moral Injury Events Scale (MIES), and the Moral Injury Questionnaire-Military Version (MIQ-M) relate to psychiatric diagnoses and mental illness symptom severity. Those who endorsed failing to prevent or doing something morally wrong had the highest symptomatology scores on measures of posttraumatic stress disorder, depression, suicidality, alcohol abuse and drug abuse, followed by those who reported solely witnessing a moral injury event. Posttraumatic stress disorder and depressive symptoms correlated most strongly with scores on the MIQ-M; suicidality, alcohol abuse and drug abuse scores correlated most strongly with scores on the BMIS and MIQ-M. Moral injury, as measured by three scales, was robustly correlated with worse outcomes on various symptom measures. The three scales appear to differentially predict mental illness symptomatology and diagnoses, with the BMIS predicting suicidality and alcohol and drug abuse as well as better than other measures., (Published 2020. This article is a U.S. Government work and is in the public domain in the USA.)

Background: United States military veterans experience disproportionate rates of suicide relative to the general population. Evidence suggests religion and spirituality may impact suicide risk, but less is known about which religious/spiritual factors are most salient. The present study sought to identify the religious/spiritual factors most associated with the likelihood of having experienced suicidal ideation and attempting suicide in a sample of recent veterans., Methods: Data were collected from 1002 Iraq/Afghanistan-era veterans (M age  = 37.68; 79.6% male; 54.1% non-Hispanic White) enrolled in the ongoing Veterans Affairs Mid-Atlantic Mental Illness Research, Education and Clinical Center multi-site Study of Post-Deployment Mental Health., Results: In multiple regression models with stepwise deletion (p < .05), after controlling for depression and posttraumatic stress disorder (PTSD) diagnoses, independent variables that demonstrated a significant effect on suicidal ideation were perceived lack of control and problems with self-forgiveness. After controlling for age, PTSD diagnosis, and substance use problems, independent variables that demonstrated a significant effect on suicide attempt history were perceived as punishment by God and lack of meaning/purpose., Conclusions: Clinical screening for spiritual difficulties may improve detection of suicidality risk factors and refine treatment planning. Collaboration with spiritual care providers, such as chaplains, may enhance suicide prevention efforts., (© 2020 Wiley Periodicals, Inc.)

The clinical clerkships in medical school are the first formal opportunity for trainees to apply bioethics concepts to clinical encounters. These clerkships are also typically trainees' first sustained exposure to the "reality" of working in clinical teams and the full force of the challenges and ethical tensions of clinical care. We have developed a specialized, embedded ethics curriculum for Vanderbilt University medical students during their second (clerkship) year to address the unique experience of trainees' first exposure to clinical care. Our embedded curriculum is centered around core "ethics competencies" specific to the clerkship: for Medicine, advanced planning and end-of-life discussions; for Surgery, informed consent; for Pediatrics, the patient-family-provider triad; for Obstetrics and Gynecology, women's autonomy, unborn child's interests, and partner's rights; and for Neurology/Psychiatry, decision-making capacity. In this paper, we present the rationale for these competencies, how we integrated them into the clerkships, and how we assessed these competencies. We also review the additional ethical issues that have been identified by rotating students in each clerkship and discuss our strategies for continued evolution of our ethics curriculum.

Faith-based communities (FBCs) are recognized by most states as key players within systematic suicide prevention efforts. The aim of the present study was to conduct a thematic analysis of documents that detail the suicide prevention efforts of individual states with respect to the role(s) delegated to FBCs. Thematic analysis is recognized as a useful methodology for identifying implications for policy and practice. Documents were procured from all states, with the exception of New Mexico ( n  = 49). The findings suggest six areas relevant to collaboration with FBCs: suicide prevention training for the FBC, suicide prevention training for individual faith leaders, community engagement, faith leaders as gatekeepers, culturally sensitive suicide prevention, and postvention support. These state guideline documents consistently affirm the importance of engaging FBCs in suicide prevention efforts and cover a range of recommendations, though generally lack specifics with respect to how FBCs can optimally engage.

Amidst the return of military personnel from post-9/11 conflicts, a construct describing the readjustment challenges of some has received increasing attention: moral injury. This term has been variably defined with mental health professionals more recently conceiving of it as a transgression of moral beliefs and expectations that are witnessed, perpetrated, or allowed by the individual. To the extent that morality is a system of conceptualizing right and wrong, individuals' moral systems are in large measure developmentally and socially derived and interpreted. Thus, in seeking to provide care and aid in reintegration for combat veterans, it is necessary to consider communities that have contributed to an individual's formation and that might have participated in the interpretation of his/her suffering. This can take many forms, but given that morality is often complexly intertwined with issues of religion, faith, and spirituality for many individuals, and recognizing that much of the current focus on moral injury is emanating out of healthcare contexts, we devote particular attention to how chaplains might be more intentionally engaged in healthcare systems such as the Veterans Health Administration to provide non-judgmental, person-centered, culturally-relevant care rooted in communities of practice to veterans with moral injury.

This column describes the development, implementation, and outcomes of a quality improvement learning collaborative that aimed to better integrate chaplaincy with mental health care services at 14 participating health care facilities evenly distributed across the U.S. Department of Veterans Affairs and Department of Defense. Teams of health care chaplains and mental health professionals from participating sites sought to improve cross-disciplinary service integration in six key domains: screening, referrals, assessment, communication and documentation, cross-disciplinary training, and role clarification. Chaplains and mental health providers across all facilities at participating sites were significantly more likely post-collaboration to report having a clear understanding of how to collaborate and to report using a routine process for screening patients who could benefit from seeing a professional from the other discipline. Foundational efforts to enhance cross-disciplinary awareness and screening practices between chaplains and mental health professionals appear particularly promising.

Chaplains play an important role in supporting the mental health of current and former military personnel; in this study, the engagement of Department of Veterans Affairs (VA), Army, Navy, and Air Force chaplains with suicidality among their service users were examined. An online survey was used to collect data from 440 VA and 1,723 Department of Defense (DoD) chaplains as part of the VA/DoD Integrated Mental Health Strategy. Differences were noted for demographics, work setting characteristics, encountering suicidality, and self-perceived preparation for dealing with suicidality. Compared to DoD chaplains, VA chaplains encounter more at-risk service users, yet feel less prepared for dealing with suicidality., (Published 2015. This article is a U.S. Government work and is in the public domain in the USA.)

Background: Recognizing that clergy and spiritual care providers are a key part of mental health care systems, the Department of Veterans Affairs (VA) and Department of Defense (DoD) jointly examined chaplains' current and potential roles in caring for veterans and service members with mental health needs., Objective: Our aim was to evaluate the intersection of chaplain and mental health care practices in VA and DoD in order to determine if improvement is needed, and if so, to develop actionable recommendations as indicated by evaluation findings., Design: A 38-member multidisciplinary task group partnered with researchers in designing, implementing, and interpreting a mixed methods study that included: 1) a quantitative survey of VA and DoD chaplains; and 2) qualitative interviews with mental health providers and chaplains., Participants: Quantitative: the survey included all full-time VA chaplains and all active duty military chaplains (n = 2,163 completed of 3,464 invited; 62 % response rate). Qualitative: a total of 291 interviews were conducted with mental health providers and chaplains during site visits to 33 VA and DoD facilities., Main Measures: Quantitative: the online survey assessed intersections between chaplaincy and mental health care and took an average of 37 min to complete. Qualitative: the interviews assessed current integration of mental health and chaplain services and took an average of 1 h to complete., Key Results: When included on interdisciplinary mental health care teams, chaplains feel understood and valued (82.8-100 % of chaplains indicated this, depending on the team). However, findings from the survey and site visits suggest that integration of services is often lacking and can be improved., Conclusions: Closely coordinating with a multidisciplinary task group in conducting a mixed method evaluation of chaplain-mental health integration in VA and DoD helped to ensure that researchers assessed relevant domains and that findings could be rapidly translated into actionable recommendations.

As a result of their military experience, veterans with mental health problems may have unique motivations for seeking help from clergy. Patterns and correlates of seeking pastoral care were examined using a nationwide representative survey that was conducted among veterans of post-9/11 conflicts (adjusted N = 1,068; 56% response rate). Separate multivariate logistic regression models were used to examine veteran characteristics associated with seeking pastoral care and seeking mental health services. Among post-9/11 veterans with a probable mental disorder (n = 461)-defined as a positive screen for posttraumatic stress disorder, major depressive disorder, or alcohol misuse-20.2% reported talking to a "pastoral counselor" in the preceding year, 44.7% reported talking to a mental health professional, and 46.6% reported talking to neither. In a multivariate analysis for veterans with a probable mental disorder, seeing a pastoral counselor was associated with an increased likelihood of seeing a mental health professional in the past year (OR: 2.16; 95% CI: [1.28, 3.65]). In a separate bivariate analysis, pastoral counselors were more likely to be seen by veterans who indicated concerns about stigma or distrust of mental health care. These results suggest that pastoral and mental health care services may complement one another and underscore the importance of enhancing understanding and collaboration between these disciplines so as to meet the needs of the veterans they serve.

Leaders in health care chaplaincy and practice guidelines, such as the Association of Professional Chaplains' Standards of Practice, call for chaplains to develop an evidence-based approach to their work. The extent to which practicing chaplains accept this new paradigm is unclear. The aim of this study was to gather information regarding chaplains' attitudes and practices with respect to evidence-based chaplaincy care. Data for the study came from surveys of healthcare chaplains working in the Department of Veterans Affairs (VA, n = 440), the Department of Defense (DoD, n = 164), and civilian settings (n = 169). Chaplains from all three contexts strongly endorsed an evidence-based approach to chaplaincy. Approximately three-fourths of the healthcare chaplains from VA and DoD and 42% of those from civilian settings considered their current chaplaincy practices to be evidenced based, with over half in VA and DoD samples and 94% in the civilian sample indicating that they would like their chaplaincy care to be more evidence-based. Approximately half of the VA and DoD chaplains and 35% of the civilian chaplains reported currently using measurement tools in their chaplaincy care. These results suggest that there is generally strong support among practicing chaplains for an evidence-based approach to chaplaincy care.

This study demonstrates the reliability and validity of the Clergy Occupational Distress Index (CODI). The five-item index allows researchers to measure the frequency that clergy, who traditionally have not been the subject of occupational health studies, experience occupational distress. We assess the reliability and validity of the index using two samples of clergy: a nationally representative sample of clergy and a sample of clergy from nine Protestant denominations. Exploratory factor analysis and Cronbach's scores are generated. Construct validity is measured by examining the association between CODI scores and depressive symptoms while controlling for demographic, ministerial, and health variables. In both samples, the five items of the CODI load onto a single factor and the Cronbach's alpha scores are robust. The regression model indicates that a high score on the CODI (i.e., more frequent occupational distress) is positively associated with having depressive symptoms within the last 4 weeks. The CODI can be used to identify clergy who frequently experience occupational distress and to understand how occupational distress affects clergy's health, ministerial career, and the functioning of their congregation.

This study examined psychotropic medication claims in a sample of Protestant clergy. It estimated the proportion of clergy in the sample who had a claim for psychotropic medication (i.e., anti-depressants and anxiolytics) in 2005 and examined associations between sociodemographic characteristics, occupational distress and having a claim. Protestant clergy (n = 749) from nine denominations completed a mail survey and provided access to their pharmaceutical records. Logistic regression models assessed the effect of sociodemographic characteristics and occupational distress on having a claim. The descriptive analysis revealed that 16 % (95 % Confidence interval [CI] 13.3 %-18.5 %) of the clergy in the sample had a claim for psychotropic medication in 2005 and that, among clergy who experienced frequent occupational distress, 28 % (95 % CI 17.5 %-37.5 %) had a claim. The regression analysis found that older clergy, female clergy, and those who experienced frequent occupational distress were more likely to have a claim. Due to recent demographic changes in the clergy population, including the increasing mean age of new clergy and the growing number of female clergy, the proportion of clergy having claims for psychotropic medication may increase in the coming years. To the best of our knowledge, this is the first study to examine the use of psychotropic medication among clergy.

Background: Patients commonly present to their physicians with medically unexplained symptoms (MUS), and there is no consensus about how physicians should interpret or treat such symptoms., Objective: To examine how variations in physicians' interpretations of MUS are associated with physicians' religious characteristics and with physician specialty (primary care vs. psychiatry)., Design and Participants: A national survey of a stratified random sample of 1,504 primary care physicians and 512 psychiatrists in 2009-2010., Main Measures: The extent to which physicians believe MUS reflect a root problem that is spiritual in nature or result from conditions that scientific research will eventually explain, and whether such patients would benefit from attention to their relationships, attention to their spiritual life, taking medications, and/or treatment by physicians., Key Results: Response rate was 63 % (1,208/1,909). More religious/spiritual physicians were more likely to believe that MUS reflect a spiritual problem (55 % for high vs. 24 % for low spirituality; OR = 2.8, 1.7-4.5) and that these patients would benefit from paying attention to their spiritual life (79 % for high vs. 55 % for low spirituality; OR = 3.1, 1.8-5.3). Psychiatrists were more likely to believe that scientific research will one day explain MUS (66 % vs. 52 %; OR = 1.9, 1.4-2.5) and that these symptoms will improve with treatment by a physician (54 % vs. 35 %; OR = 2.4, 1.8-3.3). They were less likely to believe that MUS reflect a spiritual problem (23 % vs. 38 %; OR = 0.5, 0.4-0.8)., Conclusions: Physicians' interpretations of MUS vary widely, depending in part on physicians' religious characteristics and specialty. One in three physicians believes that patients with MUS have root problems that are spiritual in nature. Physicians who are more religious or spiritual are more likely to think of MUS as stemming from spiritual concerns. Psychiatrists are more optimistic that these patients will get better with treatment by physicians.

Chaplains play important roles in caring for Veterans and Service members with mental health problems. As part of the Department of Veterans Affairs (VA) and Department of Defense (DoD) Integrated Mental Health Strategy, we used a sequential approach to examining intersections between chaplaincy and mental health by gathering and building upon: 1) input from key subject matter experts; 2) quantitative data from the VA / DoD Chaplain Survey (N = 2,163; response rate of 75% in VA and 60% in DoD); and 3) qualitative data from site visits to 33 VA and DoD facilities. Findings indicate that chaplains are extensively involved in caring for individuals with mental health problems, yet integration between mental health and chaplaincy is frequently limited due to difficulties between the disciplines in establishing familiarity and trust. We present recommendations for improving integration of services, and we suggest key domains for future research.

Objective: To measure how primary care physicians (PCPs) and psychiatrists treat mild depression., Method: We surveyed a national sample of US PCPs and psychiatrists using a vignette of a 52-year-old man with depressive symptoms not meeting Major Depressive Episode criteria. Physicians were asked how likely they were to recommend an antidepressant counseling, combined medication, and counseling or to make a psychiatric referral., Results: Response rate was 896/1427 PCPs and 312/487 for psychiatrists. Compared with PCPs, psychiatrists were more likely to recommend an antidepressant (70% vs. 56%), counseling (86% vs. 54%), or the combination of medication and counseling (61% vs. 30%). More psychiatrists (44%) than PCPs (15%) were 'very likely' to promote psychiatric referral. PCPs who frequently attended religious services were less likely (than infrequent attenders) to refer the patient to a psychiatrist (12% vs. 18%); and more likely to recommend increased involvement in meaningful relationships/activities (50% vs. 41%) and religious community (33% vs. 17%)., Conclusion: Psychiatrists treat mild depression more aggressively than PCPs. Both are inclined to use antidepressants for patients with mild depression., (© 2012 John Wiley & Sons A/S.)

Objective: The study examined physicians' beliefs about faith-based alcohol treatments vis-à-vis Alcoholics Anonymous, pharmacologic treatment, and residential treatment., Methods: A survey was mailed to a national sample of U.S. primary care physicians and psychiatrists. It included a brief vignette of a nominally religious 47-year-old man hospitalized for acute alcohol poisoning who requested addiction treatment. Physicians rated the likely effectiveness of three treatment methods: Alcoholics Anonymous, pharmacological therapy by an addiction specialist, and a residential program. Physicians were asked whether they would refer the patient to a faith-based program (beyond Alcoholics Anonymous) and whether an emphasis on spirituality is critical to 12-step program success., Results: The response rate was 896 of 1,427 (63%) for primary care physicians and 312 of 487 (64%) for psychiatrists. Psychiatrists were more likely to rate Alcoholics Anonymous as very effective (64% versus 57% of primary care physicians), more likely to rate residential treatment as very effective (47% versus 38% of primary care physicians), and more likely to rate pharmacologic therapy as very effective (31% versus 22% of primary care physicians). Psychiatrists and primary care physicians were equally likely to consider referring the patient to a faith-based program (71% and 79%) and equally likely to believe that “an emphasis on spirituality is critical to the success of 12-step programs” (81% and 85%)., Conclusions: Psychiatrists were more optimistic than primary care physicians about all three treatments. Physicians in both specialties would refer even nominally religious patients to explicitly faith-based programs (beyond Alcoholics Anonymous). Physicians' enthusiasm for faith-based treatments highlights the need for scientific study of these treatments to determine which elements are most helpful for patients seeking recovery.

People have a strong motivation to maintain a self-concept that is coherent and consistent over time. Religion is an central source of social identity for many people, but its importance is prone to dramatic change across the life course. To maintain a consistent perception of self, recollections of one's own past religiousness may shift to better fit with the present. This study examined changes between early and middle adulthood in retrospective perceptions of religious behavior and identity in childhood. Data from a population-based birth cohort sample were matched with data from individuals who participated in at least two of three adult follow-up studies, at intervals of approximately 10 years. Logistic regression was used to analyze the association of final recollections of childhood behavior and identity with previous recollections and current religious characteristics. Consistent with the predictions of temporal self-appraisal theory, participants' perception of their religious identity as children tended to change over time to match their adult religious identity. Recollections of childhood religious behavior were more stable than recollections of religious identity, and change was unrelated to adult behavior. These results have implications for studying religious characteristics using retrospective measures, regarding their accuracy and their independence from contemporary measures.

Women (n = 15) who were pregnant after a traumatic late pregnancy loss (termination because of fetal death or serious anomalies) completed psychometric screening tests and scales, including the Perinatal Grief Scale (PGS), the Impact of Event Scale (IES), the Duke Depression Inventory (DDI), the Generalized Anxiety Disorder-7 (GAD), and the Hoge Scale for Intrinsic Religiosity (IR). Despite a mean elapsed time since the prior loss of 27 (range, 7-47) months, half (7/15, 47%) of the combined groups had high levels of grief on the PGS. Multiple positive scores on psychometric tests were frequent: Sixty percent (9/15) had high scores on the PGS Active Grief subscale or on the IES. Forty percent (6/15) had a high score on the DDI, and 17% (3/15) on the GAD. IR scores significantly and negatively correlated with scores on the Despair subscale of the PGS. The results from this pilot study suggest that high levels of grief and PTS symptoms are significant problems for pregnant women who have suffered late loss of a wanted pregnancy. Religiosity may play an important part in maternal coping during these stressful pregnancies.

The recent proliferation of research on the connection between religion and health has raised concerns among some scholars about how these studies affect people's understanding of that connection. However, such concerns assume that religion and health research reaches religious audiences and informs their understanding of the connection between religion and health. We explore the veracity of these assumptions, asking two questions: (1) Is religion and health research disseminating into the American public? (2) Do religious persons incorporate religion and health research into their understanding of the connection between religion and health? We conduct two studies to answer these questions. First, we search three newspapers (The New York Times, The Los Angeles Times, and The Atlanta Journal-Constitution) and three news magazines (Newsweek, Time, and U. S. News and World Report) for articles that mention religion and health research. In the second study, we analyze interview transcripts for respondents' mentions of religion and health research when discussing the relationship between religion and health. Our results indicate substantial growth over time in media reporting on religion and health research but reveal that only a limited portion of religious persons cite such research in explaining their conceptualizations of the connection between religion and health.

Background: Contemporary educational approaches to professionalism do not take into account the dominant influence that the culture of academic medicine has on the nascent professional attitudes, beliefs, and behaviors of medical learners. This article examines formation as an organizing principle for professionalism in medical education. Virtue, the foundation to understanding professionalism, is the habits and dispositions that are fostered in individuals but that are embedded in learning environments. Formation, the ongoing integration of an individual, growing in self-awareness and in recognition of a life of service, with others who share in the common mission of a larger group, depicts this process. One model of formation considers a continuum from novice to more advance stages that is predicated on rules that must be applied in greater contextually shaped situations. Within medical education, formation is the process by which lives of service are created and sustained by learning communities that promote human capacities for intuition, empathy, and compassion. An imagined curriculum in formation would link the lived experiences of mentors and learners with an interdisciplinary set of didactic materials in an intentionally progressive fashion.

The spiritual needs of couples (9 mothers and 5 fathers) who were planning to terminate wanted second trimester pregnancies because of serious fetal anomalies were surveyed. Their greatest needs were for a "guidance from a higher power" and for "someone to pray for them." Unlike other reported groups of patients, they did not want or expect their healthcare team to discuss their faith, or to pray with them. Most would prefer support from their own pastors, but their religious community was involved to only a small extent. They would welcome support from hospital chaplains, who could play a substantive and unique pastoral role in this clinical context.

Precise measurement of religiousness remains a vexing problem. In addition to relying almost exclusively on self-report, existing measures of religiousness pay little attention to the specific context of religious belief, and this may override distinctive norms of particular faith traditions and potentially confound the conclusions drawn from such research. To address these limitations, the authors describe a modified form of narrative content analysis that could eventually sort respondents into distinct theological traditions. A pilot test among Episcopalians demonstrates encouraging reliability (kappa 0.74, 95% LCI 0.47, P < 0.0002), and tests for convergent and discriminate validity suggest that the context of religious belief is both relevant and insufficiently assessed by the existing paradigm of religious measurements. If validated in a religiously diverse sample, this approach could be combined with existing, context-free measures of religiousness to generate more meaningful findings.

Objective: No systematic information exists on what U.S. medical schools are teaching on spirituality and health or on the attitudes of faculty toward inclusion of this subject in the medical curriculum. We systematically surveyed U.S. medical school deans and assessed both attitudes about and the extent to which spirituality is addressed in medical school curricula., Methods: The responses to a questionnaire were solicited from deans representing 122 U.S. medical schools accredited by the Liaison Committee for Medical Education. Completed surveys were received from 85% (n = 104), with 94% (n = 115) responding to the primary question. Outcomes were proportion of medical schools with curricular content on spirituality and attitudes of deans toward such material., Results: Ninety percent (range 84%-90%) of medical schools have courses or content on spirituality and health (S&H), 73% with content in required courses addressing other topics and 7% with a required course dedicated to S&H. Although over 90% indicate that patients emphasize spirituality in their coping and health care, only 39% say that including S&H is important. When asked if their institution needs more S&H curricular content, 43% indicated they did; however, even if funding and training support were available, only 25% would open additional curricular time. National policy statements, established competencies, or methods to evaluate student competencies in S&H were generally considered unimportant., Conclusions: Most U.S. medical schools have curricular content on S&H, although this varies greatly in scope. Despite acknowledging its importance to patients, the majority of deans are uncertain about including spirituality and do not think more content is needed.

Although existing measures of religiousness are sophisticated, no single approach has yet emerged as a standard. We review the measures of religiousness most commonly used in the religion and health literature with particular attention to their limitations, suggesting that vigilance is required to avoid over-generalization. After placing the development of these scales in historical context, we discuss measures of religious attendance, private religious practice, and intrinsic/extrinsic religious motivation. We also discuss measures of religious coping, wellbeing, belief, affiliation, maturity, history, and experience. We also address the current trend in favor of multi-dimensional and functional measures of religiousness. We conclude with a critique of the standard, "context-free" approach aimed at measuring "religiousness-in-general", suggesting that future work might more fruitfully focus on developing ways to measure religiousness in specific, theologically relevant contexts.

Objective: This study compared the ways in which psychiatrists and nonpsychiatrists interpret the relationship between religion/spirituality and health and address religion/spirituality issues in the clinical encounter., Method: The authors mailed a survey to a stratified random sample of 2,000 practicing U.S. physicians, with an oversampling of psychiatrists. The authors asked the physicians about their beliefs and observations regarding the relationship between religion/spirituality and patient health and about the ways in which they address religion/spirituality in the clinical setting., Results: A total of 1,144 physicians completed the survey. Psychiatrists generally endorse positive influences of religion/spirituality on health, but they are more likely than other physicians to note that religion/spirituality sometimes causes negative emotions that lead to increased patient suffering (82% versus 44%). Compared to other physicians, psychiatrists are more likely to encounter religion/spirituality issues in clinical settings (92% versus 74% report their patients sometimes or often mention religion/spirituality issues), and they are more open to addressing religion/spirituality issues with patients (93% versus 53% say that it is usually or always appropriate to inquire about religion/spirituality)., Conclusions: This study suggests that the vast majority of psychiatrists appreciate the importance of religion and/or spirituality at least at a functional level. Compared to other physicians, psychiatrists also appear to be more comfortable, and have more experience, addressing religion/spirituality concerns in the clinical setting.

Objectives: Since the 1980s, there has been a growing, but little studied, movement that organizes church-based health services under the direction of a coordinator, usually a registered nurse. These Congregational Health Ministries (CHMs) emphasize health promotion and disease prevention. We compared the perceptions of pastors with and without organized CHMs and the characteristics of their congregations' health ministries., Design: We used a quantitative, cross-sectional survey design., Sample: We surveyed a national multidenominational sample of 349 pastors representing over 80 Christian denominations., Results: With limited resources, CHMs provide significant health promotion, disease prevention, and support services. Pastors with CHMs were significantly more involved in health promotion and disease prevention activities. Pastors without CHMs perceived a need for congregations to be involved in health-related services and were willing to become involved if they have adequate resources., Conclusions: Because of long-term trusting relationships that exist between congregants and those who minister to them, religious congregations may be ideally suited to provide cost-effective, community-based health promotion and disease prevention services as well as health-supporting services to community-dwelling elderly and persons with chronic illnesses.

Because of the high prevalence of post-traumatic stress disorder (PTSD) among veteran men and the limited research on victimization in this group, we recruited 133 male veterans with combat-related PTSD from a psychiatric inpatient unit and assessed them for lifetime physical and sexual trauma. Results indicated that 96% of the sample had experienced some form of victimization over their lifetimes; 60% reported childhood physical abuse, 41% childhood sexual abuse, 93% adulthood physical assault, and 20% adulthood sexual assault. In the preceding year alone, 46% experienced either physical or sexual assault. These findings support the need for routine inquiry into the histories of noncombat victimization in this cohort. Determining the lifetime history of trauma exposure may have implications for vulnerability to subsequent development of PTSD and the risk of future violence.

The traditional interpretation of "intrinsic" religiousness has fostered an unchallenged assumption that normative and substantive religious motivation is inherently individual and personal. Social motives for religiousness and structured practices have been characterized as "extrinsic" and as lacking in formative significance. We argue that this view is most applicable in American Protestant religions, and hence existing religious motivation scales reflect a distinctly American Protestant view. We then show that social motives and structured ritual practices are, in fact, as normative as individual motivations in several religious traditions. In particular, we describe the social practices and motives normative for Judaism and certain streams of Christianity. We then discuss the potential relevance of this analysis to emotion, collective identity, and moral judgment.