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Religious and Other Predictors of Psychosocial Adjustment in Cancer Patients

Received November 20, 1997; revised February 11, 1997; accepted July 30, 1999. From Hillside Hospital, North Shore-Long Island Jewish Health System, Glen Oaks, New York; and the Department of Psychiatry, Our Lady of Mercy Medical Center, Bronx, New York. Address reprint requests to Dr. Rifkin, Hillside Hospital, Glen Oaks, NY 11004.

ABSTRACT

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The authors tested the hypothesis that religious variables, such as a person's belief that his/her illness was God's will, would predict psychosocial adjustment in 50 patients who were predominantly Catholic Hispanic women attending a medical oncology clinic (42 women, 8 men). The patients were free of an Axis I mental disorder, cognitive impairment, and severe pain and were not undergoing intensive chemotherapy. By using the Psychosocial Adjustment to Illness Scale as the outcome measure, the authors found few associations with religious variables, but many to clinical variables.

Key Words: Religion • Psychosocial Adjustment • Cancer

INTRODUCTION

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During our work with depressed cancer patients, we found that many nondepressed patients attributed their relative freedom from sad mood and despondency to their convictions that their illnesses were God's will. In this study, conducted in 1983, we tested whether religious and other factors predicted psychosocial adjustment.

METHODS

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The subjects we studied attended the medical oncology clinic at City Hospital Center at Elmhurst, Queens, New York, and met the following criteria.

1. They were over 17 years old.
   
2. They had no disorder that clearly interfered with cognition, such as central nervous system lesions, mental retardation, current substance abuse or dependence, or severe hepatic or renal dysfunction.
   
3. They scored higher than 50% on the Karnofsky Performance Scale,¹ to eliminate subjects whose functioning was so poor that there was little opportunity for a predictor to show validity, for example, a bedridden patient who could not feed or dress him- or herself would have little chance to exercise a variation in psychosocial adjustment.
   
4. They had less than a 75-mm score on a visual analogue scale of pain. A patient in severe pain is not likely to show much variation in psychosocial adjustment because of religiosity.
   
5. They scored less than 18 on the 21-item Hamilton Depression Rating Scale,² since a patient with a higher score is likely to have a psychiatric disorder that might overwhelm the predictive power of religiosity. Patients noticed by the clinic staff to have symptoms of a mental disorder were referred to a consultant psychiatrist for evaluation. We excluded any patient found to have an Axis I psychiatric disorder.
   
6. They were not undergoing intensive chemotherapy for at least 2 weeks, since side effects of such treatment might, transiently, affect adjustment.
   
7. They consider themselves Christians or Jews.
   
8. They gave written, informed consent.
   

We studied 50 eligible subjects selected from the clinic roster without concern for gender, age, type of cancer, prognosis, ethnicity, or socioeconomic status. All patients were Christian. Ours is a sample of convenience. They were not selected randomly. We chose patients who met our criteria as they became available, aiming for a sample size of about 50.

Assessments

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1. Visual Analogue Scale (VAS): "How important is religion to you?," from "not at all important" to "most important."
   
2. VAS: "Do you attribute your fortune and misfortune to God's Will?", from "My sickness has nothing to do with God's will" to "My sickness is God's will."
   Both VASs were 10-cm lines. We defined the endpoints and asked the subjects to check where they fit.
   
3. Religious Imagination Scale (RIS):³ This scale lists six images of God, each with a 7-point scale of contrasting images, that is, i) mother-father, ii) master-spouse, iii) judge-lover, iv) friend-king, v) creator-healer, and vi) redeemer-liberator.
   
4. VAS for pain rated by the patient from "no pain at all" to "most possible pain." We asked the subject to rate the previous 4 weeks.
   
5. VAS scale for pain: as Number 4 above, but rated by the treating physician.
   
6. Karnofsky Performance Scale:¹ This is a 100-point scale that assesses functioning in a patient with a physical disorder.
   
7. The 21-item Hamilton Depression Rating Scale.²
   
8. The Hamilton Anxiety Rating Scale.⁴
   
9. The Severity of Organic Disease Scale: This scale measures pain, functioning, and expectation of future pain and poor functioning. The scale was developed for depressed patients with medical disorders and used in a study of antidepressants.⁵
   

We measured psychosocial adjustment with the Psychosocial Adjustment to Illness Scale (PAIS),⁶ a multidimensional, semistructured interview done by an interviewer unaware of the subject's responses to questions about religion. The PAIS assesses and quantifies psychosocial adjustment in seven areas: healthcare orientation, vocational environment, domestic environment, sexual relationships, extended family relationships, social environment, and psychological distress.

RESULTS

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We interviewed 50 subjects, mainly Hispanic Catholic women (Table 1). A stepwise regression analysis of religious variables (RIS: six sets of images of God and VASs: VASs for the importance of religion and attribution of sickness to God) showed only a few statistically significant relationships (Table 2). Only two of the subscales of the PAIS had a significant predictor from the RIS, which did not appear in the total score. The VASs showed no predictive value.

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TABLE 1. Sample demographics

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TABLE 2. Stepwise regression analysis of all predictors

By using all the predictors (Table 3), one at a time, in a stepwise regression analysis, no religious predictors appeared. Pain and/or symptoms of depression and anxiety predicted worse adjustment on all subscales and the total score.

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TABLE 3. Stepwise regression analysis of religious variables

DISCUSSION

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The strength of our study consists of our systematic assessment of religious variables, pain, and mental symptoms taken together as predictors of psychosocial adjustment to cancer. We found that alone, or with other variables, religious factors did not predict adjustment. The subject's perception of pain (but not the treating physician's perception), along with symptoms of anxiety and depression, were strong predictors of adjustment. None of these subjects had sufficient mental symptoms for an Axis I diagnosis.

Drug studies of medically ill depressed subjects have demonstrated the efficacy of antidepressants for some disorders,⁷ but no one has systematically studied patients with cancer and depression. The findings that antidepressants alleviate symptoms of dysthymia⁸ suggest that patients with mild forms of depression associated with medical illness might respond to such treatment. Our results show the probable importance of controlling pain.

Religiosity predicts lower alcohol and drug use,⁹ and less depression from stressful life events.^9,10 In several studies, 50% to 90% of cancer patients described religion as important,^11–13 and a source of comfort and support,^14–16with a third reporting they had unmet spiritual or existential needs.^17–19 Four studies found strong religious belief was associated with decreased levels of pain, anxiety, hostility, and social isolation, and with higher levels of life satisfaction.^20–23 Two studies found that religious belief correlated with a poorer adjustment.^24,25 Filipp et al.,¹⁵ in a large study (N=332) of German cancer patients, assessed them at four points over a year, using "subjective well-being" as the outcome measure, which was a composite score of a 28-item instrument.²⁶ One predictor measured "search for meaning in religion." Over the year, this item remained stable but had a very low correlation at each point: 0.05 to -0.08. We should consider that "search for meaning in religion" may not reflect common religious belief or practice.

Measuring pain and correlating it with outcome in cancer patients has been done, yielding mixed results, largely due, probably, to methodological problems in measuring pain.²⁷ In a study using a subscale of the McGill Pain Questionnaire (MPQ), the Pain Rating Index (PRI),²⁸ in 30 subjects with cancer referred to a pain clinic, the PRI correlated very little with two measures of outcome: the Global Adjustment to Illness scale that measures psychosocial adjustment²⁹ and the Karnofsky Performance Rating³⁰ that assesses ability to engage in work, normal activities, and self-care.

In a study of recipients of bone marrow transplantation, most of whom had cancer, Jenkins et al.³¹ used the PAIS as an outcome measure and assessed mental symptoms in the hospital before transplantation with the Hospital Anxiety and Depression Scale (HADS)³² and with the Composite International Diagnostic Interview³³ to determine psychiatric disorders. Thirty-six subjects completed the PAIS before transplantation, as did 17 of 29 subjects who survived 1 month and 12 of 23 who remained alive after 6 months. The authors report results only for the subscales of the PAIS, not a total score. The total HADS, at all points, correlated with worse scores on PAIS subscales for vocational and psychological adjustment, and at 6 months, with worse scores on the domestic and sexual adjustment subscales. The authors do not provide the data for these statements or tell us if the correlations were statistically significant.

By using psychiatric diagnoses, they found that the diagnosis of an anxiety disorder significantly correlated at both outcome points with only one of seven subscales, domestic adjustment. A diagnosis of a depressive disorder had no significant correlation with any PAIS subscale.

Several studies have assessed religiosity and adjustment to cancer. Hinton³⁵ examined the relationship of religiosity to anxiety about dying and found a curvilinear relationship. The subjects with strong religious faith or strong convictions of atheism had less anxiety than the middle group, which suggests that strong convictions, rather than religiosity per se, prevents anxiety. This sample, unlike ours, consisted of dying patients. Not all had cancer.

Brandt,³⁶ in 31 cancer patients, found religious belief improved coping, but she did not assess quality of life systematically.

Ringdal³⁷ studied 253 hospitalized Norwegian cancer patients by using a questionnaire containing 7 psychosocial scales as the dependent variables and a predictor variable of religiosity consisting of the sum of 2 scaled items: "I believe in God" and "Have your religious beliefs been of support to you after you became ill with cancer?" He found two dependent variables significantly correlated with religiosity: 1) positive correlation with general satisfaction with life and 2) negative correlation to a measure of hopelessness (the more religious the less hopelessness). Five other scales showed no significant correlation to religiosity: 1) quality of life, 2) cognitive functioning, 3) and 4) anxiety and depression (2 scales), and 5) social functioning.

These findings come from an analysis controlling for age, gender, educational level, and prognosis. In comparing this study to ours, Ringdal found, if we remove the two scales measuring anxiety and depression, which we used as independent variables, significant correlations of religiosity to measure of adjustment in two of five scales, a somewhat stronger association than we found. They assessed inpatients, we, outpatients, and, of course, there are enormous cultural differences in our samples. Nevertheless, we both show a modest effect of religiosity on adjustment.

Our study differed from the prior studies of the effects of pain, religious belief, and psychiatric symptoms on adjustment in patients with cancer. We selected outpatients who were not in the midst of chemotherapy that might cause significant side effects; measured pain and religious beliefs by VAS; used the RIS; and excluded patients with marked disability, pain, and psychiatric symptoms. We found that pain and symptoms of depression and anxiety correlated with adjustment, whereas religious factors did not.

Our results are limited by how we assessed our independent variables. The direction of causality may be in the other direction, that is, poor adjustment maycause increased sensitivity to pain and to mental symptoms.

Assessing such global and complicated variables as pain and religious belief remains a methodological problem. One approach is to break down these variables into components to allow the emergence of significant predictors. This is the approach of the MPQ, perhaps the most frequently used standardized pain assessment instrument,³⁴ that uses 20 clusters of 2 to 6 adjectives and an estimate of overall pain intensity and related pain ratings. McGowan and Zevon²⁷ examined the relationships of three subscales of the MPQ to psychological and functional states in patients with cancer. The researchers found that the three subscales—affective, sensory, and evaluative—were intercorrelated and did not independently predict function, whereas individual adjective clusters did. This finding shows the difficulty in assessing pain. The researchers found that a global measure of present pain also had no predictive power: -0.1 with the global measure of psychosocial functioning and 0.03 with the Karnofsky Performance scale.

This result differs from ours. The sample used by McGowan and Zevon were outpatients referred to a pain service. Perhaps their sample, selected for the presence of pain, had less variation of pain than our sample of outpatients with cancer selected for not having severe pain.

Limitations

1. The low ratio of subjects to variables reduces our chance of finding significant associations.
   
2. The religious variables, focusing on single questions, probably have less reliabilities than the Hamilton Rating Scales for Depression and Anxiety (HRSD and HRSA), especially the total scores; and reliability improves the likelihood of finding significant correlations. But, we did not find that the total scores of the HRSD and HRSA significant predictors.
   
3. Our subjects were outpatients, not terminally ill, not in the midst of chemotherapy, not in severe pain, and had no Axis I disorder. Sicker patients might show a different pattern of the correlation of religious variables to adjustment. We chose this sample because previous research focused on sicker patients, whereas most patients with cancer would fit the criteria for our study. It seems important to study this group as well as sicker patients.
   
4. We assessed religiosity with cognitive measures. Our results might vary had we used behavioral measures, such as religious attendance, prayer, scripture reading, etc. Our study measured cross-sectional data. We cannot determine if some subjects turned to religion in response to the stressor of cancer. If they had, and if they endorsed more cognitive than behavioral aspects of religion, that factor would disguise the effect of religion on adjustment.
   
5. Given our small sample size, these data might contain a Type II error, in claiming a lack of association when one truly existed. Further research should test this theory.
   

We conclude that for outpatients with cancer the best predictors of adjustment are pain, depression, and anxiety (not to the extent sufficient for an Axis I diagnosis). This finding suggests that treatment should focus on these areas. None of our sample received psychotropic medication. Although we did not find that religious variables predicted adjustment, this is not a definitive conclusion. We should consider that correlations do not prove causality; that poor adjustment may cause our "predictors," since we measured all variables at one cross-sectional point. We recommend further research of this complex and very important field.

REFERENCES

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Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Email this article to a Colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Articles & Searches Download to citation manager Citing Articles via Google Scholar Articles by Rifkin, A. Articles by Pollack, S. Search for Related Content PubMed Citation Articles by Rifkin, A. Articles by Pollack, S. Syndromes Secondary to General Medical Disorders

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