The relationship between religious involvement and clinical status of patients with bipolar disorder

doi:10.1111/j.1399-5618.2009.00772.x

Bipolar Disord. Author manuscript; available in PMC 2011 February 1.

Published in final edited form as:

Bipolar Disord. 2010 February; 12(1): 68–76.

doi: 10.1111/j.1399-5618.2009.00772.x

PMCID: PMC2853940

NIHMSID: NIHMS164798

The relationship between religious involvement and clinical status of patients with bipolar disorder

Mario Cruz,^a Harold Alan Pincus,^b^c Deborah E Welsh,^d Devra Greenwald,^e Elaine Lasky,^e and Amy M Kilbourne^d^f

^aAdvanced Center for Intervention and Services, Research for Late-life Mood and Anxiety Disorders, Western Psychiatric Institute and Clinic, Pittsburgh, PA

^bDepartment of Psychiatry, Irving Institute for Clinical and Translational Research, Columbia University College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York, NY

^cRAND Corporation, Pittsburgh, PA

^dVA Ann Arbor National Serious Mental Illness Treatment Research and Evaluation Center, Ann Arbor, MI

^eVA Pittsburgh Center for Health Equity Research and Promotion, Pittsburgh, PA

^fDepartment of Psychiatry, University of Michigan, Ann Arbor, MI, USA

Corresponding author: Mario Cruz, M.D. Advanced Center for Intervention and Services Western Psychiatric Institute and Clinic 3811 O’Hara Street Pittsburgh, PA 15213, USA Fax: 412-383-5412 ; Email: cruzm/at/upmc.edu

The publisher's final edited version of this article is available at Bipolar Disord

Abstract

Objective

Religion and spirituality are important coping strategies in depression but have been rarely studied within the context of bipolar disorder. The present study assessed the association between different forms of religious involvement and the clinical status of individuals treated for bipolar disorder.

Methods

A cross-sectional observation study of follow-up data from a large cohort study of patients receiving care for bipolar disorder (n = 334) at an urban Veterans Affairs mental health clinic was conducted. Bivariate and multivariate analyses were performed to assess the association between public (frequency of church attendance), private (frequency of prayer/meditation), as well as subjective forms (influence of beliefs on life) of religious involvement and mixed, manic, depressed, and euthymic states when demographic, anxiety, alcohol abuse, and health indicators were controlled.

Results

Multivariate analyses found significant associations between higher rates of prayer/meditation and participants in a mixed state [odds ratio (OR) = 1.29; 95% confidence interval (CI) = 1.10-1.52, chi square = 9.42, df = 14, p < 0.05], as well as lower rates of prayer/meditation and participants who were euthymic (OR = 0.84; 95% CI = 0.72-0.99, chi square = 4.60, df = 14, p < 0.05). Depression and mania were not associated with religious involvement.

Conclusions

Compared to patients with bipolar disorder in depressed, manic, or euthymic states, patients in mixed states have more active private religious lives. Providers should assess the religious activities of individuals with bipolar disorder in mixed states and how they may complement/deter ongoing treatment. Future longitudinal studies linking bipolar states, religious activities, and treatment-seeking behaviors are needed.

Keywords: bipolar disorder, religion

Bipolar disorder (BD) is a devastating illness impacting individuals’ social (1, 2), occupational (3-7), and physical well-being (8-10). Because BD is a relapsing, remitting, and often chronic disease, it is important to identify attitudinal, behavioral, or social factors that help individuals suffering from BD cope with manic, mixed, and depressive episodes.

In terms of coping, the religious beliefs, attitudes, and behaviors of individuals with BD deserve exploration. Religious beliefs are a principal form of coping with life stresses for many individuals in the United States. More than half of Americans rank the importance of religion very high in their lives, attend religious services regularly, and pray daily (11).

Although studies suggest potential beneficial effects of different forms of religious coping for individuals in the community at large (12-15) or with psychiatric illnesses (16-19), there are few studies assessing the relationship between the frequency of religious activities and the strength of spiritual beliefs and BD (20). The authors found only one study addressing the relationship of religious activities or beliefs with patients treated for BD (21). This study assessed the spiritual beliefs and religious activities of 84 remitted BD patients in New Zealand. The investigators found that most BD patients held strong religious or spiritual beliefs (78%) and attended religious functions or were involved in private religious activities frequently. Most saw a direct link between their beliefs and the management of their illness. Many used religious coping, and often spiritual beliefs put them in conflict with illness models (24%) and advice (19%) from their medical advisors.

Though Mitchell and Romans’ study (21) identified important relationships between religious beliefs and activities in BD, all participants were in remission at the time of the interview. Their findings cannot give us an appreciation of variation in the frequency of religious activities or strength of religious beliefs when BD patients are in manic, depressed, mixed, or euthymic states.

Assessing variation in religious involvement by BD state could help in determining whether individuals with BD turn to religious involvement as a means of coping with dysfunctional BD states, a relationship hypothesized by Ellison and Levin (22). Ellison and Levin theorized that religious involvement may provide a sense of meaning and coherence that counteracts stress, assists with coping, provides a network of like-minded persons who can serve as social resources, and promotes the development of psychological resources, including self-esteem and a sense of personal worth.

To expand the psychiatric literature regarding the relationship between different forms of religious involvement and spirituality with individuals suffering from BD, we asked the following questions: Do the different states of BD influence individuals’ responses to questions about the frequency of church attendance, prayer/meditation, and the degree to which religious beliefs influence their life? And is there a significant response difference between individuals with BD who are in euthymic, depressed, manic, or mixed states to questions about their religious activities and beliefs when functional disability, psychological distress, and destructive behaviors are controlled for in the analyses?

Methods

Patient characteristics

Data for the present analyses was obtained from baseline and exit self-reports of participants from the Continuous Improvement for Veterans in Care–Mood Disorders (CIVIC-MD), a longitudinal, observational study of BD patients from a large, urban outpatient mental health clinic.

The purpose of CIVIC-MD was to identify patient factors associated with quality and outcomes of care for BD. Details regarding CIVIC-MD are described elsewhere (22). In brief, the CIVIC-MD self-report surveys included information on participants’ degree of religious involvement, demographic characteristics, and clinical as well as health/disability status. After complete description of the study to the subjects, written informed consent was obtained.

Survey data were captured at baseline and study exit. The CIVIC-MD study was approved by the Institutional Review Board and Research Development Committee of the Veterans Affairs (VA) Pittsburgh Health Care System. Study enrollment occurred from July 11, 2004 to July 11, 2006, while baseline and one-year follow-up surveys were conducted between July 2005 and July 2007.

Participant data were included for this study if they had completed both baseline and one-year follow-up surveys. Demographic data was captured at study entry. Religious involvement, clinical, and health/disability data were captured from the follow-up survey.

Measures

Religious involvement data were captured using the Duke Religious Index (DRI) (23). The DRI is a 5-item scale that captures information on respondent’s involvement in the three accepted major dimensions of religiousness: the public, private, and subjective dimensions of religious involvement. The first item is a measure of the public dimension and asks, “How often do you attend church, synagogue, or other religious meetings?” Responses are rated as follows: 1 = never, 2 = once a year or less, 3 = a few times a year, 4 = a few times a month, 5 = once a week, and 6 = more than once a week. The second item is a measure of the private dimension and asks “How often do you spend time in private religious activities, such as prayer, meditation, or Bible study?” Responses range from 1 (rarely or never) to 6 (more than once a day). Items 3-5 are statements that measure subjective or intrinsic religiosity: “In my life, I experience the presence of the Divine,” “My religious beliefs are what really lie behind my whole approach to life,” and “I try hard to carry my religion over into all other dealings in life.” These statements are rated on a scale from 1 to 5 (1 = definitely not true; 5 = definitely true). Items are reverse-scored for analyses, with low scores indicating high involvement in attending religious activities, praying/meditating, or influence of beliefs on life (http://www.growingasoul.com/DUREL+English+version.pdf).

Mood state was captured using the Internal State Scale (ISS) (24). The ISS is a 17-item self-report form developed to concurrently assess both manic and depressive symptoms over time in individuals suffering from BD (25). Each item constitutes a 10-point Likert-type scale that ranges from 0 to 100. Each item scale has an anchor of 0 = not at all, rarely, and 100 = very much so, much of the time, with the exception of the last item, which scores 0 = depressed and down and 100 = manic and high. The subject is instructed to score these items on the basis of the way he or she has felt during the previous 24 hours. The authors have defined four subscales: Activation (A) correlates highly and specifically with clinician ratings of mania (r = 0.60 versus Young Mania Rating Scale); Depression Index (DI) correlates highly and specifically with clinician ratings of depression (r = 0.84 versus Hamilton Depression Rating Scale); Perceived Conflict (PC) correlates most highly with the Brief Psychiatric Rating Scale (r = 0.56); and Well-Being (WB) (26). For the present analyses, two subscales were used to differentiate participant mood state: the WB and A subscales. WB and A provide a discriminate function that separates individuals in depressed, manic/hypomanic, euthymic (24), and mixed states (25). Participants are considered to have depression when they score < 125 on WB and < 155 on A. For mania, participants must score ≥ 125 on WB and ≥ 155 on A. For mixed states, participants must score < 125 on WB and ≥ 155 on A. For euthymia, participants must score ≥ 125 on WB and < 155 on A (25).

To identify the impact of health/psychological/behavioral impediments on individuals practicing their faith, we assessed the presence of functional disability, anxiety, and alcohol abuse. We captured information on functional disability, for it has been posited as an explanation for low rates of prayer/meditation in depressed individuals with medical illnesses (27). Functioning was assessed using the World Health Organization Disability Assessment Schedule (WHODAS-II) (28). The WHODAS-II is a 12-item (4-point Likert) scale assessing the degree of functional impairment experienced within the past month regarding self-care (e.g., bathing, dressing), mobility (e.g., standing, walking), cognition (e.g., remembering), social functioning (e.g., conversing), and role functioning. A total score representing the degree of impairment (higher score = more impairment) was generated by summing the scores for each item.

We posited psychological/behavioral states, such as the presence of anxiety or history of binge drinking, that lead to socially avoidant behaviors or adverse coping strategies that would impede an individual’s ability to practice their faith. The presence of anxiety was assessed using the three anxiety items from the PRIME-MD Patient Questionnaire (29).

Alcohol abuse, defined as whether the patient reported having > 5 drinks on one occasion at any time within the past year, was assessed using three items from the Alcohol Use Disorders Identification Test (AUDIT) (30). This assessment was strongly correlated with the full-length AUDIT (sensitivity = 0.95; specificity = 0.69) (29).

Statistical analyses

Because the DRI has never been validated for use in studies with individuals suffering from BD, we ran Spearman correlation analyses to assess associations among the DRI subscale scores of church attendance, prayer/meditation, and the influence of beliefs on life.

We then performed ANOVAs between the different bipolar states (i.e., euthymia, mania, mixed, depressed) and the DRI subscale scores of church attendance, frequency of prayer/meditation, and influence of beliefs on life to assess the strength of the association between the different bipolar states and participants’ responses to questions related to their religious activities and spiritual beliefs.

We then tested logistic regression models assessing the relationship between the DRI subscales and BD state when health/psychological/behavioral impediment covariates are controlled. Each DRI subscale was tested separately in logistic regression models to avoid multicollinearity. In the first model (Model A), we tested the relationship between the abovementioned covariates and the dependent variables. Models B, C, and D tested the relationship between the individual DRI subscales and the dependent variables, first controlling for covariates.

Results

Patient characteristics

Overall, 720 patients were approached for CIVIC-MD enrollment. A total of 104 patients were determined to be ineligible due to the presence of acute psychiatric symptoms (e.g., mania, psychosis) as determined by their provider. Of the remaining sample (n = 616), 148 patients refused, primarily because of the lack of time to complete the survey due to a pending outpatient appointment, leaving a total of 468 (76%) enrolled participants. Of the 468 enrolled participants, 435 (92%) completed the baseline survey. A total of 335 participants completed and returned baseline and follow-up surveys. Table 1 displays the demographic characteristics of the 335 participants included in the analyses. Study participants were similar in gender and race/ethnic distribution compared to all patients diagnosed with bipolar disorder at this VA facility (n = 769; 12% women, 13% African American).

Table 1

Demographics, clinical, and disability status, as well as Duke Religious Index scores for participants (total n = 335)

Analyses

Spearman correlation analyses revealed significant associations between DRI subscale reverse scores of church attendance and prayer/meditation (r = 0.72, df = 1, p < 0.0001) as well as influence of beliefs on life (r = 0.68, df = 1, p < 0.0001). Also, significant associations were found between DRI subscale reverse scores of prayer/meditation and the influence of beliefs on life (r = 0.78, df = 1, p < 0.0001).

ANOVAs revealed that the frequency of church attendance was significantly associated with euthymic [F = 11.07, df = (1, 331), p = 0.001] and mixed [F = 9.35, df = (1, 331), p = 0.002] states, the frequency of prayer/meditation was associated with euthymic [F = 10.34, df = (1, 331), p = 0.001)] and mixed [F = 10.62, df = (1, 331), p = 0.001)] states, and the influence of beliefs on life was associated with euthymic [F = 7.29, df = (1, 330), p = 0.007] and mixed [F = 12.73, df = (1, 330), p = 0.0004] states.

We then tested the logistic regression models (See Tables Tables2A2A and andB).B). We found that higher rates of prayer/meditation were associated with being in a mixed state [odds ratio (OR) = 1.29; 95% confidence interval (CI) = 1.10-1.52, chi square = 9.42, df = 14, p < 0.05], while lower rates of prayer/meditation was associated with being euthymic (OR = 0.84, 95% CI = 0.72-0.99, chi square = 4.60, df = 14, p < 0.05).

Table 2A

Multivariate analyses of the relationship between religious involvement items and dichotomous Internal State Scale scores

Table 2B

Multivariate analyses of the relationship between religious involvement items and dichotomous Internal State Scale scores

No significant associations were found between DRI church attendance and influence of beliefs subscale scores and participants’ bipolar state, nor between DRI subscale scores and depressed or manic states.

Discussion

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.

Acknowledgements

Preparation of this paper was supported in part by the following grants: National Institute of Mental Health grants K23 MH071520 (MC) and P30 MH071944 (MC); VA HSRD Merit review #02-283 (AMK); The Irving Institute for Clinical and Translational Research at Columbia University grant UL1 RR024153 (HAP); and University of Pittsburgh grant UL1 RR024153 (HAP), both from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH), and the Mental Health Therapeutics CERT at Rutgers, the State University of New Jersey, funded by the Agency for Healthcare Research and Quality (AHRQ) grant 5 U18 HS016097.

Footnotes

The authors of this paper do not have any commercial associations that might pose a conflict of interest in connection with this manuscript.

References

1. Zhang H, Wisniewski S, Bauer M, Sachs G, Thase M., STEP-BD Investigators Comparisons of perceived quality of life across clinical states in bipolar disorder: date from the first 2000 Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) participants. Compr Psychiatry. 2006;47:161–168. [PubMed]

2. Vojta C, Kinosian B, Glick H, Altshuler L, Bauer M. Self-reported quality of life across mood states in bipolar disorder. Compr Psychiatry. 2001;42:190–195. [PubMed]

3. Simon G, Ludman E, Unützer J, Operskalski B, Bauer M. Severity of mood symptoms and work productivity in people treated for bipolar disorder. Bipolar Disord. 2008;10:718–725. [PubMed]

4. Elinson L, Houck P, Pincus HA. Working, receiving disability benefits, and access to mental health care in individual with bipolar disorder. Bipolar Disord. 2007;9:158–165. [PubMed]

5. Fagiolini A, Kupfer DJ, Masalehdan A, Scott JA, Houck PR, Frank E. Functional impairment in the remission phase of bipolar disorder. Bipolar Disord. 2005;7:281–285. [PubMed]

6. Calabrese J, Hirshfeld R, Frye M, Reed M. Impact of depressive symptoms compared with manic symptoms in bipolar disorder: results of a US community-based sample. J Clin Psychiatry. 2004;65:1499–1504. [PubMed]

7. Bauer M, Kirk G, Gavin C, Williford W. Determinants of functional outcome and healthcare costs in bipolar disorder: a high-intensity follow-up study. J Affect Disord. 2001;65:231–241. [PubMed]

8. Kilbourne A, Rofey DL, McCarthy JF, Post EP, Welsh D, Blow FC. Nutrition and exercise behavior among patients with bipolar disorder. Bipolar Disord. 2007;9:443–452. [PubMed]

9. Kilbourne AM, Cornelius JR, Han X, et al. Burden of general medical conditions among individuals with bipolar disorder. Bipolar Disord. 2004;6:368–373. [PubMed]

10. Bauer M, Unützer J, Pincus H, Lawson W. NIMH Affective Disorders Workgroup. Bipolar disorder. Ment Health Serv Res. 2002;4:225–229. [PubMed]

11. The Pew Forum on Religion & Public Life U.S. Religious Landscape Survey Religious Affiliation: Diverse and Dynamic. Pew Research Center; Washington, DC: 2008.

12. Olphen J, Schulz A, Israel B, et al. Religious involvement, social support, and health among African-American women on the East Side of Detroit. J Gen Intern Med. 2003;18:549–557. [PMC free article] [PubMed]

13. Mofidi M, DeVellis R, Blazer D, DeVellis B, Panter A, Jordan J. Spirituality and depressive symptoms in a racially diverse US sample of community-dwelling adults. J Nerv Ment Dis. 2006;194:975–977. [PubMed]

14. Braam A, Deeg D, Poppelaars J, Beekman A, Tilburg W. Prayer and depressive symptoms in a period of secularization: Patterns among older adults in the Netherlands. Am J Geriatr Psychiatry. 2007;15:273–281. [PubMed]

15. Allen RS, Phillips LL, Roff LL, Cavanaugh R, Day L. Religiousness/spirituality and mental health among older male inmates. The Gerontologist. 2008;48:692–697. [PubMed]

16. Koenig H, George L, Peterson B. Religiosity and remission of depression in medically ill older patients. Am J Psychiatry. 1998;155:536–542. [PubMed]

17. Phillips R, III, Stein C. God’s will, God’s punishment, or God’s limitations? Religious coping strategies reported by young adults living with serious mental illness. J Clin Psychol. 2007;63:529–540. [PubMed]

18. Cruz M, Schulz R, Pincus HH, P R, Bensasi S, Reynolds C., III The association of public and private religious involvement with severity of depression and hopelessness in older adults treated for major depression. Am J Geriatr Psychiatry. 2009;17:503–507. [PMC free article] [PubMed]

19. Pieper J. Religious coping in highly religious psychiatric inpatients. Mental Health, Religion, and Culture. 2004;7:349–363.

20. Goodwin F, Jamison K. Manic-Depressive Illness Bipolar Disorders and Recurrent Depression. 2nd ed Oxford University Press; New York: 2007. Suicide; p. 262.

21. Mitchell L, Romans S. Spiritual beliefs in bipolar affective disorder: their relevance for illness management. J Affect Disord. 2003;75:247–257. [PubMed]

22. Kilbourne A, Lasky E, Pincus H, et al. The continuous improvement for veterans in care: Mood disorders (CIVIC-MD) study, a VA-academic partnership. Psychiatr Serv. 2008;59:483–485. [PubMed]

23. Koenig H, Meador K, Parkerson G. Religion index for psychiatric research: a 5-term measure for use in health outcomes studies. Am J Psychiatry. 1997;154:885–886. [PubMed]

24. Bauer M, Crits-Christoph P, Ball W, et al. Independent assessment of manic and depressive symptoms by self-rating scale. Characteristics and implications for the study of mania. Arch Gen Psychiatry. 1991;48:807–812. [PubMed]

25. Glick HA, McBride L, Bauer MS. A manic-depressive symptom self-report in optical scanable format. Bipolar Disord. 2003;5:366–369. [PubMed]

26. Bauer MS, Vojta C, Kinosian B, Altshuler L, Glick H. The Internal State Scale: replication of its discriminating abilities in a multisite, public sector sample. Bipolar Disord. 2000;2:340–346. [PubMed]

27. Koenig H. Religion and depression in older medical inpatients. Am J Geriatr Psychiatry. 2007;15:282–291. [PubMed]

28. Rehm J, Ustun T, Saxena S, et al. On the development and psychometric testing of the WHO screening instrument to assess disablement in the general population. Int J Methods in Psychiatr Res. 1999;8:110–122.

29. Spitzer R, Williams J, Kroenke K, et al. Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study. JAMA. 1994;272:1749–1756. [PubMed]

30. Gordon A, Maisto S, McNeil M, et al. Three questions can detect hazardous drinkers. J Fam Pract. 2001;50:313–320. [PubMed]

31. Ellison C, Levin J. The religion-health connection: evidence, theory, and future directions. Health Educ Behav. 1998;25:700–720. [PubMed]

32. Keller M, Lavori P, Coryell W, et al. Differential outcome of pure manic, mixed/cycling, and pure depressive episodes in patients with bipolar illness. JAMA. 1986;255:3138–3142. [PubMed]

33. Tohen M, Waternaux C, Tsuang M. Outcome in mania. A 4-year prospective follow-up of 75 patients utilizing survival analysis. Arch Gen Psychiatry. 1990;47:1106–1111. [PubMed]

34. McElroy S, Keck P, Jr, Pope H, Jr, Hudson J, Faedda G, Swarin A. Clinical and research implications of the diagnosis of dysphoric or mixed mania or hypomania. Am J Psychiatry. 1992;12:1633–1644. [PubMed]

35. Strakowski S, McElroy S, Keck P, Jr, West S. Suicidality among patients with mixed and manic bipolar disorder. Am J Psychiatry. 1996;153:674–676. [PubMed]