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.Research is rapidly expanding in the area of religion, spirituali-ty, and mental health. Two volumes of the Handbook of Religion andHealth document nearly 2500 quantitative, original data basedstudies examining these relationships all over the world (Koeniget al., 2001, 2012a). Although most studies have been conducted inWestern nations involving Christian populations, an increasingnumber are being published from Middle Eastern countries wherethe majority are Muslim. To better understand the research comingout of these two areas of the world, awareness of the similaritiesand differences between these faith traditions is needed, since thecontent of religious beliefs may inuence mental healthoutcomes.

1. Similarities

Many beliefs in Islam are similar to Christianity. In Islam, thereis deep devotion and surrender to one God and a belief that God ismerciful and forgiving. There is great reverence for the Quran asthe word of God and for prophet Mohammed, whose life andteachings Muslims follow (values and morals very similar toChristians). There is also belief in and reverence for Jesus (Isa) theMessiah, who is considered a prophet just like Noah, Abraham,Moses, and David. Muslims believe that Jesus was born of a virgin

(Mary), was a great healer, rose bodily into heaven, and will returnnear the day of judgment to restore justice and defeat the anti-Christ. There is belief in and reverence for the Torah, Pslams(Zabur), and the Gospels (Injil). There is belief in heaven (a place ofeternal happiness) and hell (a place of eternal punishment). Fridayis the day of worship in Islam (like Sunday for Christians), andmany attend the local mosque, where the imam gives a sermonabout practical issues in life and where worship and prayer takeplace.

Another common belief is giving support to the poor andneedy. Muslims are required to give 2.5% per year of all savings(Zakat), similar to the tithe of 10% of yearly income (but notsavings) that Christians are expected to give. In Islam, there isstrong belief that everyone is equal before God regardless of socialstanding, as exemplied by people from all classes dressing insimilar clothes during the pilgrimage (Hajj) to Mecca. Fasting issimilar in Christianity and Islam, although more stronglyemphasized in Islam, where fasting is required during Ramadanand encouraged at other times as well. The majority of Christianspray at least once daily, whereas Muslims are required to pray vetimes daily and in many Muslim countries all business stops for20 min as prayer occurs. Family values are held in great esteem byboth traditions.

There is also a strong belief in turning to God when difcultsituations arise, which helps Muslims to reinterpret these crises togive them purpose and meaning. As with Christians, this helpsMuslims to see adversity as part of Gods plan (and for Muslims,adversity is a sign of Gods love for them).

in relieving the symptoms of depression and anxiety.

2012 Elsevier B.V. All rights reserved.

* Corresponding author at: Box 3400 Duke University Medical Center, Durham,

NC 27705, United States. Tel.: +1 919 681 6633; fax: +1 919 383 6962.

E-mail address: koenig@geri.duke.edu (H.G. Koenig).

1876-2018/$ see front matter 2012 Elsevier B.V. All rights reserved.http://dx.doi.org/10.1016/j.ajp.2012.04.004Religion, spirituality and mental health

Harold G. Koenig a,b,*, Faten Al Zaben c, Doaa Ahmea Center for Spirituality, Theology and Health, Duke University Medical Center, Durham, bKing Abdulaziz University, Jeddah, Saudi ArabiacDepartment of Psychiatry, King Abdulaziz University, Jeddah, Saudi Arabia

A R T I C L E I N F O

Article history:

Received 4 April 2012

Accepted 24 April 2012

Keywords:

Religion

Psychiatry

Islam

Christianity

Research

A B S T R A C T

Research on religion, spirit

countries and now increasin

from these two areas of the

similarities and differences

overlap between these relig

emphasis on family life (alth

practice, it is not surprising

these religious traditions ha

faith traditions have been de

integrating patients religiou

jo u rn al h om epag e: ww w the West and the Middle East

Khalifa c

, United States

lity and mental health has been rapidly accumulating from Western

ly from the Middle East. We review here the latest research on this topic

orld, one largely Christian and the other largely Muslim, after discussing

these faith traditions. Contrary to popular thought, there is considerable

us groups in beliefs, practices of worship, moral beliefs and values, and

ugh also some distinct differences). Because of the similarity in belief and

at research on mental health and devout religious involvement in both

ended to produce similar results. Religious psychotherapies within these

loped and are now being rened and used in clinical trials to determine if

esources into therapy is more or less effective than conventional therapies

f Psychiatry

els evier .c o m/lo cat e/a jp

H.G. Koenig et al. / Asian Journal of Psychiatry 5 (2012) 180182 1812. Differences

There are also differences between the two belief systems, oftenthe focus of attention and source of strife between followers. Someof these beliefs are not reconcilable, and must be accepted andhonored, not argued about. The biggest difference is Muslim andChristian beliefs about Jesus. Muslims believe that Jesus is a holyprophet like Abraham, Noah, Moses, and David, but is not God andshould not be worshiped as God. They also believe that Jesus didnot die and was not crucied, but rose bodily into heaven. Muslimsbelieve that the Bible has errors in it that humans inserted, incontrast to the Quran, which is wholly perfect and without error.Like a book that goes through revisions as new informationbecomes available, the Torah from Moses is seen as the rstedition, the Gospels from Jesus are viewed as the second edition,and the Quran is believed to be the third and nal edition, andprophet Mohammed, the last and nal prophet (yet not Divine).Muslims do not believe in original sin, but rather that everyone isborn pure, that we corrupt ourselves by committing sins, and thatthe balance of good deeds and bad deeds determines whether aperson will go to heaven or to hell. Praying ve times daily wipesthe slate clean of sins committed between prayers.

There is a wide range of beliefs in Christianity, as there is inIslam (e.g., Sunni, Shia, Susm, Ahmadiyya). Christians believethere is only one God. However, most Christians believe that God ismanifested in three forms (like water comes in liquid, solid, andgas forms) God the Father, God the Son, and God the Holy Spirit.Most Christians also believe in original sin, i.e., the desire to liveand control life apart from God. Original sin separates people froma holy God who cannot stand in the presence of sin. To rectify this,God made many attempts to reform mankind by sending prophets,but without much success. Therefore, the belief is that God took ona human form in Jesus, lived a sinless life, and paid the ultimateprice suffered and died a painful and humiliating death to fullycompensate for both the original sin and for all sins that separatedhumans from God. Those who wish to accept this sacrice mustbelieve that Jesus was God and that he died for their sins.Acknowledging this, according to many Christians, will save theperson from eternal separation from God, assure them of salvation,and make the person clean before God (salvation by Gods grace,not by works). Realizing the deep love expressed by God throughthis act, the Christian experiences an overwhelming sense of reliefand then surrenders their life to God, not because of fear of going tohell, but because of a profound sense of gratitude. This arouses alove for God and an internal desire to serve God. The person is thenexpected to turn their life around and bring it into alignment withthe life and teachings of Jesus (sanctication). This is similar tothe process by which Muslims put their lives into alignment withGod by emulating the life and teachings of prophet Mohammed.

Thus, there are many similarities and also distinct differences,mainly in belief (rather than in practice). The primary bond thatunites Christians and Muslims together is (1) the worship of andsurrender to one God, (2) almost identical morals and values andmany similar practices, and (3) a desire to live a life that emulatesthat of their respective prophets (Jesus and Mohammed), whoseteachings while specic to the culture, time, and circumstances inhistory during which they lived, are very similar. It would not besurprising, then, that these two belief systems have similarinuences on mental health.

3. Research from the West

Approximately three-quarters of quantitative research onreligion/spirituality (R/S) and health focus on mental health, andis documented in the Handbook. The vast majority of this researchcomes from Western countries with largely Christian populations.Well-being. At least 326 quantitative studies have examinedrelationships with well-being, with 256 (79%) nding greaterhappiness, satisfaction with life, or well-being in the more R/S. Ofthe 120 most methodologically rigorous studies, 98 (82%) alsofound this. Less than 1% (2 of 326 studies) report lower well-being.

Hope and optimism. At least 40 studies have examinedrelationships with hope, 29 (73%) nding greater hope amongthe more R/S. Likewise, 26 of 32 studies (81%) have found greateroptimism as well.

Meaning and purpose. Among 45 studies that examinedrelationships with R/S, 42 (93%) found greater meaning or purposeamong the more R/S.

Self-esteem. Of 69 studies examining relationships with self-esteem, 42 (61%) found signicantly higher levels of self-esteem inthe more R/S; only two studies (3%) reported lower self-esteem. Ofthe 25 methodologically most rigorous studies, 17 (68%) reportedgreater self-esteem.

Internal locus of control. Of 21 studies, 13 (62%) reportedsignicantly higher internal personal control among the more R/S.

Depression. Of 444 studies, 272 (61%) found less depression orfaster remission from depression, or a reduction in depressionseverity in response to a R/S intervention. Only 6% reported greaterdepression. Of the 178 methodologically most rigorous studies,119 (67%) found inverse relationships.

Suicide. Of 141 studies, 106 (75%) reported signicant inverserelationships between R/S and suicide (completed suicide,attempted suicide, attitudes toward suicide); 80% of the best-designed studies reported this nding.

Anxiety. About half (49%) of 299 studies found inverserelationships between R/S and anxiety. Of the 67 most rigorouslydesigned studies, 38 (55%) reported less anxiety. Of 40 experimen-tal studies or clinical trials, 29 (73%) reported a reduction inanxiety.

Alcohol and drug use/abuse. Of 278 studies that examinedrelationships between R/S and alcohol use or abuse, 240 (86%)found less among the more R/S whereas less than 1% reported apositive relationship. For drug use/abuse, 155 of 185 studies (84%)found less drug abuse among those who were more R/S; of 38prospective cohort studies, clinical trials or experimental studies,36 (95%) reported this nding.

4. Research from the Middle East

There have been far fewer studies reported from Middle Easterncountries (including Pakistan, Afghanistan, Malaysia, Egypt,Bangladesh) with largely Muslim populations.

Well-being. There were 18 studies published between 1887 and2010, with 13 (72%) reporting positive associations (ve fromIsrael, ve from Kuwait, two from Malaysia, one from Pakistan).Four reported no association (two from Malaysia, one each fromIsrael and Lebanon [Christians = Muslims]), one reported signi-cant positive and negative associations (Israel).

Hope and optimism. Two studies were published during thisperiod, one reporting a positive association (Malaysia) and onending no association (Kuwait/United Kingdom).

Meaning and purpose. One study was published, which found apositive relationship (Israel).

Self-esteem. Four studies were identied, two reporting positiveassociations (Iraq, Iran/US) and two nding no association(Pakistan, Malaysia).

Internal locus of control. Two studies were identied, onereporting higher locus of control (LOC) among religious women inIran, and one lower LOC in Arabs vs. Jews in Israel.

Depression. Seventeen studies were published, 13 (76%)reporting less depression (two from Malaysia, three from Israel,one each from Palestine, Lebanon, Egypt, Kuwait, Iran, Iran/US,

Afghanistan, Pakistan); one nding a trend in that direction (Iran);one reporting greater depression (Israel); and two reporting noassociation (Iran, Israel).

Suicide. Seven studies were found, ve (71%) reporting lesssuicide (two from Israel, two from Turkey, one from Kuwait/US)and two nding no association (Israel, Turkey).

Anxiety. Of 33 studies, 16 (48%) found less anxiety (three fromMalaysia, four from Kuwait, two from Iran, two from Pakistan, twofrom Israel, one each from Afghanistan, Egypt, Turkey); ve (15%)found more anxiety among the R/S (three from Israel, one eachfrom Malaysia and Turkey/Canada), three found mixed results(Israel, Iran/US), and eight reported no association (three fromIsrael, and one each from Iran, Kuwait, Turkey, Kuwait/UnitedKingdom, Middle East in general).

Alcohol and drug use/abuse. Of nine studies, eight (89%) foundinverse relationships between R/S (four from Israel, three fromLebanon, one from Turkey) and alcohol use/abuse, and one foundno association (Malaysia). Concerning drug use/abuse, only twostudies were found, one reporting that non-Muslims were morelikely than Muslims to abuse drugs (Bangladesh), and one ndingno association (Israel).

5. Religious psychotherapies

At least 51 clinical trials or experimental studies have now beenpublished, 35 (69%) documenting signicant benets of religiouspsychotherapies (Koenig et al., 2012b). A rigorous clinical trial ofChristian cognitive-behavioral therapy (CBT) found that it wassuperior to conventional CBT (Propst et al., 1992), and there is asimilar trial now in progress examining CBT in ve faith traditions(Christianity, Buddhist, Hinduism, Islam, Judaism) (Koenig, in

ment (Azhar and Varma, 1995b), and generalized anxiety disorder(Azhar et al., 1994; Razali et al., 1998, 2002), all reportingsignicantly better results when prayer and/or reading the Quranis added to therapy.

In conclusion, many similarities exist between Christian andMuslim beliefs and behaviors, and while clearly more research isneeded, both belief systems would be expected to have similarbenets. Both observational studies and randomized clinical trialssuggest that greater religious involvement in these faith traditionsis associated with better mental health.

References

Azhar, M.Z., Varma, S.L., 1995a. Religious psychotherapy in depressive patients.Psychotherapy & Psychosomatics 63, 165173.

Azhar, M.Z., Varma, S.L., 1995b. Religious psychotherapy as management of be-reavement. Acta Psychiatrica Scandinavica 91, 233235.

Azhar, M.Z., Varma, S.L., Dharap, A.S., 1994. Religious psychotherapy in anxietydisorder patients. Acta Psychiatrica Scandinavica 90, 13.

Koenig, H.G., McCullough, M.E., Larson, D.B., 2001. Handbook of Religion and Health,rst edition. Oxford University Press, New York, NY.

Koenig, H.G., King, D.E., Carson, V.B., 2012a. Handbook of Religion and Health,second edition. Oxford University Press, New York, NY.

Koenig, H.G., King, D.E., Carson, V.B., 2012b. Depression (Ch 7) and Anxiety (Ch 9),Handbook of Religion and Health, second edition. Oxford University Press, NewYork, NY.

Koenig, H.G. Religious vs. conventional psychotherapy for major depression inpatients with chronic medical illness: rationale, methods, and preliminaryresults. Depression Research and Treatment 2012, Article ID 460419, http://dx.doi.org/10.1155/2012/460419, in press.

Propst, L.R., Ostrom, R., Watkins, P., Dean, T., Mashburn, D., 1992. Comparativeefcacy of religious and nonreligious cognitive-behavior therapy for the treat-ment of clinical depression in religious individuals. Journal of Consulting andClinical Psychology 60, 94103.

Razali, S.M., Hasanah, C.I., Aminah, K., Subramaniam, M., 1998. Religioussociocul-tural psychotherapy in patients with anxiety and depression. Australian & NewZealand Journal of Psychiatry 32, 867872.

Razali, S.M., Aminah, K., Khan, U.A., 2002. Religiouscultural psychotherapy in the

H.G. Koenig et al. / Asian Journal of Psychiatry 5 (2012) 180182182press). Several clinical trials have also examined Muslim-basedpsychotherapy for depression (Azhar and Varma, 1995a), bereave- management of anxiety patients. Transcultural Psychiatry 39 (1), 130136.

Religion, spirituality and mental health in the West and the Middle EastSimilaritiesDifferencesResearch from the WestResearch from the Middle EastReligious psychotherapiesReferences