We found that individuals’ responses to questions addressing their frequency of church attendance, frequency of prayer/meditation, and the influence of their religious beliefs on their life were significantly associated with participants in euthymic and mixed states. When functional disability and the presence/absence of anxiety and binge drinking were controlled, we found that lower self-reported rates of prayer/meditation were significantly associated with participants in euthymic states, and higher self-reported rates of prayer/meditation were significantly associated with participants in mixed states. This last finding suggests that individuals with BD who are in the throes of a mixed state seek support from private religious activities.
Our findings support the conceptual framework posited by Ellison and Levin (31
). Their framework provides one potential explanation for our findings. That is, being both depressed and manic poses a greater level of distress than being depressed or manic alone. Higher levels of distress, as posited by Ellison and Levin, would prompt individuals in mixed states to increase the frequency of their religious behaviors. Higher levels of distress in mixed as opposed to manic states are suggested from studies showing that individuals in mixed states have longer illness durations than manic or depressed BD patients (32
), higher rates of relapse (33
), and poorer response to both acute and prophylactic treatment (34
); and that suicidality is more common in mixed as opposed to manic patients (35
). These unfortunate consequences for individuals suffering from mixed BD states may predispose them to seek relief from religion at a higher rate than individuals with BD in manic or depressed states.
Also, our multivariate analyses did not support the bivariate analysis finding of church attendance significantly associated with mixed states. The lack of support for this bivariate finding may be explained by the higher rates of physical disabilities in our mixed group. Because of the functional limitations associated with physical disabilities impeding a person’s ability to attend church, we would expect mixed participants in our sample to resort to more private activities such as prayer/meditation.
Unfortunately, our study could not determine whether the higher rates of prayer/meditation for participants with BD who were in a mixed state indicate that prayer/meditation is a helpful means of coping or the behavioral consequence of underlying psychopathology such as religious delusions. We do not believe that our findings were a consequence of religious delusions or hallucinations in our sample since the parent study excluded individuals who were acutely manic and/or psychotic, and we found that higher ratings of the influence of religious beliefs on life were not significantly associated with BD participants who were in mixed states.
This study’s findings are important for several reasons. Foremost, this is the first study exploring relationships of religious behaviors and spiritual beliefs with differing states of BD. Additionally, this study largely assessed the effect of religious behaviors and spirituality in males with BD, an often overlooked group in studies of BD. Lastly, the findings of this study suggest that praying/meditating is an important coping behavior for individuals with BD who are in mixed states.
This study is not without limitations. First, the CIVIC-MD study was not specifically developed to assess the relationship between religious involvement and BD clinical status. Second, the cross-sectional nature of the study did not allow us to evaluate causal associations between religious involvement and variations in clinical status over time. Third, potential CIVIC-MD participants were excluded if they were acutely manic and/or exhibited psychotic symptoms. Having information on the religious behaviors and beliefs of these individuals with BD who are manic and/or psychotic would have helped to characterize the relationship between religious behaviors and beliefs and mania and/or psychosis. Fourth, we did not have data available to assess associations between religious involvement and perceptions of care and/or positive coping behaviors such as treatment-seeking behaviors and medication adherence. This information would have been helpful in clarifying whether the relationship we found between private religious behaviors and mixed states BD patients promoted positive or negative coping behaviors. Fifth, we were not able to assess whether the severity of depression and mania in mixed states was influenced by religious behaviors or beliefs. Studies of this nature would help to determine if there is a positive or negative impact of religious behaviors or beliefs on BD mixed states. Sixth, the present cross-sectional study assumes the BD population is homogeneous, such that BD participants in a manic state would have similar trajectories as those participants in depressed or mixed state. Future longitudinal studies should address this important issue. Finally, our sample consisted largely of male veterans. Thus, the study’s findings may not accurately reflect the relationship between religious attitudes and behaviors in female veterans or the general public afflicted with BD.
In conclusion, in our sample of patients with bipolar disorder examined cross-sectionally, only patients in mixed states exhibited a more active private religious life. We recommend to mental health providers that if an individual suffering from BD is religious, his/her religious activities should be explored to assess the presence of a mixed state and to determine how his/her religious activities influence treatment-seeking behaviors. Future longitudinal studies linking bipolar states, religious activities, and treatment-seeking behaviors are needed.