Reply to the association between religion/spirituality and mental health in cancer (2016)

We thank Drs. Garssen and Visser for their constructive comments on our meta-analysis of the relationship between R/S and mental health in cancer.1 We are in agreement with several of their recommendations for strengthening this research and provide detailed responses below. Before doing so, however, it is worth noting that the other meta-analyses they cited were not focused on cancer and were published ≥10 years ago in social science journals. Thus, a meta-analytic summary and synthesis specifically within the context of cancer was warranted and valuable, and presented a more nuanced, comprehensive, and up-to-date view of the data than was previously reported. First, the authors asked why we included what they termed “meaningless studies” (ie, studies of spiritual well-being [SWB] and mental health associations) “in the first place only to reject them later?” Reporting effect sizes both with and without SWB measures enabled us to clearly characterize the problem of confounding SWB predictors with mental health outcomes. Using this approach, the degree to which the overall relation between affective measures of R/S and mental health outcomes is inflated by SWB measures could be more clearly delineated. We also discussed this problem in our commentary.2 Second, in our article,1 space did not permit for subanalyses of associations between specific R/S measures and specific measures of mental health. Excluding both SWB and spiritual distress leaves only 3 studies (all of which were cross-sectional, with 8 effect size estimates) that included an affective R/S measure, which were too little data with which to say anything meaningful. However, Garssen and Visser raised an important concern regarding the relationship between spiritual distress and general distress. Evidence from 2 longitudinal studies conducted with patients with cancer suggested that R/S struggle may be a predictor of emotional distress. Among 94 recipients of stem cell transplantation, Sherman et al3 found that greater pretransplant negative RCOPE (religious coping) predicted greater posttransplant anxiety and depression. A similar pattern was found among 284 women with breast cancer who were followed for 8 to 12 months in the study by Hebert et al.4 In models adjusted for demographic factors, religiosity, and personality, baseline anger with God predicted a poorer mental quality of life and greater depressive symptoms. Further research is obviously needed to determine the nature and direction of the relationship between R/S distress and other types of distress among patients with cancer, but evidence suggests that spiritual distress constitutes more than simply general distress and may contribute to negative well-being. Third, Drs. Garssen and Visser correctly pointed out that we did not perform a subanalysis of studies that only used psychometrically robust scales for R/S. Given space constraints, we could include only a limited number of subanalyses and thus we chose to focus on providing a broad overview of the findings for R/S and mental health relationships as well as a more nuanced summary of these relationships as a function of the type of R/S dimension, type of mental health outcome, and potential moderating variables. We acknowledged the need for greater attention to the selection of psychometrically strong R/S measures in the accompanying commentary.2 Fourth, Drs. Garssen and Visser argued that our investigation should have focused more heavily on the subset of longitudinal studies. For the 7 longitudinal studies that provided data regarding the predictive relationship between R/S and mental health, the average effect size (including 73 unique effect size estimates) was a z of 0.119 (95% confidence interval [95% CI], 0.017-0.221). Four studies included affective measures of R/S, with an average z of 0.229 (95% CI, 0.150-0.307 [43 effect sizes]); 4 studies included behavioral measures of R/S, with an average z of -0.040 (95% CI, -0.203 to 0.122 [13 effect sizes]); 1 study included cognitive measures of R/S (4 effect sizes); and 3 studies included other measures of R/S (13 effect sizes). Excluding measures of SWB reduces the sample to only 5 studies (35 unique effect size estimates), with an average z of 0.037 (95% CI, -0.058 to 0.132). Further longitudinal studies are needed before any strong conclusions are drawn regarding the predictive relationship between R/S and mental health. Research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health under award number K07CA158008. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors made no disclosures. John M. Salsman, PhD Department of Social Sciences and Health Policy Wake Forest School of Medicine Winston Salem, North Carolina; Comprehensive Cancer Center of Wake Forest University Winston Salem, North Carolina James E. Pustejovsky, PhD Department of Educational Psychology University of Texas at Austin Austin, Texas Crystal L. Park, PhD Department of Psychology University of Connecticut Storrs, Connecticut Allen C. Sherman, PhD Behavioral Medicine Winthrop P. Rockefeller Cancer Institute University of Arkansas for Medical Sciences Little Rock, Arkansas Thomas V. Merluzzi, PhD Department of Psychology University of Notre Dame Notre Dame, Indiana Suzanne C. Danhauer, PhD Department of Social Sciences and Health Policy Wake Forest School of Medicine Winston Salem, North Carolina Comprehensive Cancer Center of Wake Forest University Winston Salem, North Carolina Heather S.L. Jim, PhD Health Outcomes and Behavior Department H. Lee Moffitt Cancer Center Tampa, Florida George Fitchett, PhD Department of Religion, Health and Human Values Rush University Medical Center Chicago, Illinois