Prog Health Sci 2019, Vol 9, No 1 Connecting dots: understanding religiosity, depression, breast cancer

Connecting the dots: understanding the relationship between religiosity, psychological

resilience and depression in breast cancer patients

Fradelos EC.*A-F

Psychiatric Department, AGHCD “Sotiria”, Athens, Greece

___________________________________________________________________________
A- Conception and study design; B - Collection of data; C - Data analysis; D - Writing the paper;
E- Review article; F - Approval of the final version of the article; G - Other (please specify)
__________________________________________________________________________________________

ABSTRACT
__________________________________________________________________________________________

Introduction: Death anxiety, fear of abundance, for the Social Science V25. Descriptive statistics
isolation, stigma of the disease and medication side such means, and frequencies were calculated and
effects are among the most common sources of inferential statistics such correlation test, simple and
anxiety and depression in patients with breast multiple regression analysis were applied.
cancer. Results: Approximately 1 in 3 patients suffered
Purpose: To examine the possible relationship symptoms of depression while they were reporting
between religiosity, psychological resilience and moderate religiosity and resilience values. Based on
depression on breast cancer patients. the four-step mediation analysis religiosity was
Materials and methods: A cross-sectional design strongly associated with psychological resilience but
was employed in this study which 152 breast cancer it was not found to affect directly either depression,
patients participated. Data were collected with the but psychological resilience can be a mediator
following instruments: Patient Health between religiosity and depression.
Questionnaire-2-item scale, Connor-Davidson Conclusion: This study supports the notion that
Resilience Scale 25 and Centrality of Religiosity religiosity and spirituality can have a beneficial
Scale and a special designed sheet reporting social, influence on health outcomes.
demographic and clinical characteristics. Statistical Keywords: Religiosity, breast cancer, depression,
analyses were conducted with the Statistical Package psychological resilience
__________________________________________________________________________________________

DOI:

*Corresponding author:
Evangelos C. Fradelos, RMHN, MSc, PhD,
Psychiatric Department, AGHCD “Sotiria”,
Athens, Greece
e-mail: [email protected]

Received: 13.03.2019
Accepted: 05.04.2019
Progress in Health Sciences
Vol. 9(1) 2019 pp 98-104
© Medical University of Białystok, Poland

98
Prog Health Sci 2019, Vol 9, No 1 Connecting dots: understanding religiosity, depression, breast cancer

INTRODUCTION has been a subject of controversy and led to

contradictory results of many studies. According to
According to World Health Organization a study conducted by Gall, Miguez de Renart and
(WHO), breast cancer is the most frequent cancer Boonstra, an established relationship with god and
among women and it is estimated that over 1.5 religious coping behavior were related to the breast
million women each year are affected from breast cancer patient’s well-being and religiosity was
cancer and the rates are higher among women in strongly correlated with a lack of psychological
developed countries. Moreover, in 2015 nearly distress [13]. Nairn and Merluzzi yielded the exact
570,000 women died from breast cancer, number opposite results as they found that religious support
that consisted 15% of cancer deaths among women did not mediate symptom distress and was not
[1]. directly related to Quality of Life (QoL) among
Being diagnosed with breast cancer and breast cancer patients [14]. Other studies suggested
cancer in general is a major stressor in one’s life, that a mediating variable must interact to link
mostly since the diagnosis makes the individual to religiosity and psychological outcomes. For example
confront his own mortality as he faces the prospect according to the study of Lim and Yi in which 161
of death [2]. In addition a variety of changes are women diagnosed with breast and gynecologic
induced in patients daily life and the variety of cancer were participated, it was found that
therapeutic interventions that are used with spirituality and religiosity may increase social
individuals with breast cancer may contribute to support and social support can have a positive effect
alteration of body image. As a result, patients may on QoL of those patients [15].
feel less attractive and have low self-esteem whch Aim of the present study is to examine the
may lead to depression [3]. The prevalence of possible relationship between religiosity,
depression among breast cancer patients varies from psychological resilience and depression on breast
4.5 up to 42% and has been associated with the Cancer patients. Moreover, we aim to examine the
progress of the disease itself, the amount of the effect of religiosity on psychological resilience and
experienced pain, the functional level and autonomy depression among breast cancer patients.
[4-6]. While it is estimated that prevalence rates for
anxiety are more increased. More specifically MATERIALS AND METHODS
according to recent studies 30-40% of people
diagnosed with breast cancer are experiencing Study design, Participants and Setting
moderate and severe levels of anxiety. Breast cancer A cross-sectional design was employed in
may lead to many associated factors of anxiety such this study which was conducted in outpatient
as the disease itself and various somatic symptoms oncology department of a Greek hospital between
such as agitation, headaches, nausea, vomiting, February and March 2017. Women who were
anorexia and menstruation disturbances. Death attending the facility for follow up after their
anxiety, fear of abundance, isolation, stigma of the mastectomy or lumpectomy, were recruited to
disease and medication side effects are among the participate in the study. Inclusion criteria were to be
most common sources of anxiety in breast cancer [6- 18 years old or older, underwent breast surgery,
8]. While one of the greatest challenges in the ability to communicate in Greek language and to be
detection of depression and anxiety in breast cancer orientated in time and space and not being diagnosed
patients is to distinguish between the symptoms of with a psychiatric disease. From the total of 180
depression/anxiety and those caused by the cancer eligible patients that were recruited only 164 agreed
itself or by its treatment. to participate in this study and completed and
Religion and spirituality are for many submitted the questionnaire. After screening for
people important dimensions of their existence as incomplete data 152 questionnaires remained and
they are a source of support that contributes to the were included to the analysis.
wellbeing and the daily difficulties of their lives [9].
Also, the search for the use of religious support is Ethical considerations
getting more and more frequent for patients dealing Patients who met the entry criteria were
with chronic diseases, such as cancer [10]. informed by the researcher for the purposes of the
According to the study of Choumanova, Wanat, study and participated only after they had given their
Barrett and Koopman the use of religiosity as a written consent. All of the patients participated in the
coping strategy may facilitate the process of study on a voluntary basis and had their anonymity
recovery [11]. While in the context of a study preserved. All participants were informed about their
conducted by Khodaveirdyzadeh et al in 2016, it was rights to refuse or to discontinue their participation,
found that the use of spiritual coping strategies can according to the ethical standards of the Helsinki
have a crucial role in adjustment process in patients Declaration of 1983. The study was approved by the
with breast cancer [12]. The impact that religion and Medical Research Ethics Committee of the hospital.
spirituality may have on the particular patient group

99
Prog Health Sci 2019, Vol 9, No 1 Connecting dots: understanding religiosity, depression, breast cancer

Instruments
A four part self-administrated Questionnaire RESULTS
was used for data collection in this study consisting
by: A total of 152 breast cancer patients were
1. A sheet containing sociodemographic and included in this study. The mean age of the patients
clinical characteristics such as: age, living was 53.25 years (SD=12.10) and most of them were
arrangement, number of children, married 55.3%, urban residents 58,6% with a high
educational level, type of surgery and stage school degree 41.4%. Regarding sample’s clinical
of cancer. characteristics, 69.7% of the patients underwent
2. Patient Health Questionnaire Two-Item mastectomy and were diagnosed in stage three breast
(PHQ-2) questionnaire was used to assess cancer 43.4%. Sample’s demographic, social, and
depression. These is ultra-brief instrument clinical characteristics are provided in Table 1.
that IS used for the detection of depression, The mean score of religiosity was 3.4±1, for
suitable for use in epidemiological studies. depression was 2.08±1.7, and for psychological
It is a four point Likert scale ranging from resilience was 65.55±19.0. Of the subjects, 38.2% of
“0 = not at all” to “3 = nearly every day” the cases were classified as cases of depressed.
and they offers results from 0 to 6 for each Correlations of the variables are shown in
questionnaire. According to receiver- Table 2. Religiosity was found to be strongly related
operating characteristic curve analysis, the only to psychological resilience (r=0.246*p<0.001),
optimal cutpoint is ≥ 3 [16-19]. while psychological resilience was found to be
3. Psychological resilience was assessed using strongly related with depression and anxiety as well.
the Connor-Davidson Resilience Scale 25 For exploring the relationship between
(CD-RISC25). The CD-RISC25 is a religiosity, psychological resilience, depression and
unidimensional measure that reflects the the possible mediating effect of psychological
ability of an individual to cope and recover resilience the four step madiating analysis was
from challenges such as illness, emotional perfomed. According to the recommendations three
pressure or painful feelings. Test is simple linear regression and one multiple regression
consisted of 25 questions that are answered analysis were perfomed (Tables 3-6) [24].
in a a 5-point scale (0 = “not true at all” to Depression seemed to be affected from religiosity
4 = “true nearly all the time”) providing a and psychological resilience. More specific as is it
total sum score ranging from 0–100, with shown in Table 1, first we calculated the effect of
higher scores reflecting greater resilience. religiosity in depression using simple linear
[20,21]. regression, which demostrated a statistical
4. Religiosity was assessed using the significant effect (β = -0.316 (0.139), t=-2.274
Centrality of Religiosity Scale (CRS) p=0.024).
which consists of 15 items (CRS-15) The second step included the calculation of
answered on a 5-point Likert scale ranging the effect of religiosity in psychological resilience
from “not at all” to “very much”[22]. The which also proved significant (β=5.80 (1.39),
Greek version of the instrument was used in t=4.151, p=0.000).
this study [23]. In the third step the effect of psychological
resilience in depression was examined and it was
Statistical Analysis found to be significant (β = -0.037 (0.007), t= -
Descriptive statistics such as means and 4.807, p=0.000).
standard deviations for continuous data and In the final fourth step multiple regression
frequencies were used to present sample social, analysis was perfomed with depression as dependent
demographic and clinical characteristics. Normality variable and religiosity and psychological resilience
was first tested for each variable. Pearson as predictors.
correlation coefficient was used to identify the The purpose of this test was to see if the
relationship between the examined variables. Simple effect of religiosity is reduced in the presence of
linear regression analysis with enter method was psychological resilience, as it was and thus the
applied to identify the effect of religiosity on madiating effect of psychological resilience was
resilience and mental health of breast cancer patients proved; results indicated that it is not affected (β = -
and to identify the effect of resilience on mental 0.124 (0.139), p=0.374).
health of breast cancer patients. Statistical analyses In addition, the Sobel statistic value testing
were conducted with SPSS, version 25.0. the mediating effect was statistically significant (p
Significance for all statistical tests was set at 0.05 or < 0.001) (see Figure 1)
less (2-tailed).

100
Prog Health Sci 2019, Vol 9, No 1 Connecting dots: understanding religiosity, depression, breast cancer

Table 1. Sample characteristics

N (%)
Marital Status Single 24(15.8)
Married 84(55.3)
Divorced 26(17.1)
Widowed 18(11.8)
Area of Residence Rural 26 (17.1)
Semi-urban 37 (24.3)
Urban 89 (58.6)
Educational Level Mandatory Education 21 (20.3)
High School 63(41.4)
University 58(38.2)
Occupation Unemployed 15(9.9)
Household 22(14.5)
Private Sector 21(13.8)
Public Sector 30(19.7)
Pension 29(19.1)
Other 35(23)
Religion Affiliation Christian Orthodox 135 (88.8)
Christian Catholic 9 (5.9)
Muslim 2 (1.3)
Other 6 (3.9)
Stage Of Cancer I 25 (16.4)
II 44 (28.9)
III 66 (43.4)
IV 17 (11.2)
Type of Surgery Mastectomy 106 (69.7)
Ongectomy 46 (30.3)

Table 2. Correlations between Religiosity. Psychological resilience. Depression and Anxiety

Religiosity Psychological Resilience Depression

Religiosity 1 0.246** -0.138

Psychological 0.246** 1 -0.392**

Resilience

Table 3. The effect of religiosity in depression

R2 F p β SD t p

41% 2.279 0.050 -0.316 0.139 -2.274 0.024

Table 4. The effect of religiosity in resilience

R2 F p β SD t p

14% 6.060 0.000 5.806 1.39 4.151 0.000

Table 5. The effect of resilience in depression

R2 F p β SD t p

41% 6.015 0.000 -0.037 0.007 -4.807 0.000

101
Prog Health Sci 2019, Vol 9, No 1 Connecting dots: understanding religiosity, depression, breast cancer

Table 6. The effect of religiosity and resilience in depression

R2 F p β SD t p

Resilience -0.033 0.008 -4.254 0.000

41% 5.138 0.000
Religiosity -0.124 0.139 -0.891 0.374

Figure 1. A pathway leading to understand how religiosity imrove Depression in Breast Cancer patients

DISCUSSION cancer can cause various changes in one’s life related

to ages and social roles [25]. In addition the
The purpose of this study was to examine importance of evaluating and integrating religiosity
the possible relationship between religiosity, and religious preference of breast cancer patients is
psychological resilience and depression on breast highlighted in many contemporary researches. It is
Cancer patients and to understand the way that argued that religion and spirituality can contribute to
religiosity can affect psychological resilience and coping with their condition and should be recognized
depression among breast cancer patients. Although by health care professionals [26].
religiosity was strongly associated with According to our results 38.2% were
psychological resilience no association was found classified as depressed, percentage that can be
between religiosity with depression. To the considered as very high. Similar high percentages
contrary, according to our results, a strong were reported in a recent study conducted in Nepal
relationship between resilience and depression was and which involved evaluation of 149 patients.
found. The statistical tests and their results lead us to Nonetheless, such results disagree with other studies
the conclusion that although depression does not that self-reported measures of the prevalence of
seem to be affected by religiosity, it positively depression among cancer patients varying from 7-
affects resilience, which, in its turn, positively 17% and those percentages are decreasing in studies
affects anxiety and depression, suggesting that which psychiatrists or clinical psychologists are
resilience can be a mediating factor between these conducting diagnostic interviews [28,29]. In
variables. addition, it is worth mention that our results for high
First, according to Huber’s categorization prevalence of depression could be interpreted in the
Greek breast cancer patients can be characterized as light of the general social and economic situation in
having a moderate level of religious commitment. Greece and the increase in mental distress in the
The mean value of religiosity in our sample is similar general population [30].
to many other European countries such as Spain and One of the key findings in our study is that,
Italy [22]. There is a general assumption that a religiosity was strongly associated with
cancer diagnosis can be associated with changes in a psychological resilience, but it was found not to
person’s religiosity, although some other factors can directly affect either depression or anxiety. When in
influence these changes. Being diagnosed with this equation psychological resilience is added, we

102
Prog Health Sci 2019, Vol 9, No 1 Connecting dots: understanding religiosity, depression, breast cancer

see that it can be a mediator between religiosity and self-esteem among breast cancer survivors. Ann
depression. Our results reinforce previous findings Oncol. 2016;27(suppl_6).
in which religiosity or spirituality can affect mental 4. Zainal N, Nik-Jaafar N, Baharudin A, Sabki Z,
health outcomes as mediators through aspects as Ng C. Prevalence of Depression in Breast Cancer
social support [15], sense of coherence [31] and Survivors: a Systematic Review of Observational
physical/emotional functioning among others [32]. Studies. Asian Pac J Cancer Prev 2013;14(4):
In general, religiosity is referring to faith in higher 2649-56.
power and that everything is a part in a greater plan. 5. Jafari A, Goudarzian AH, Nesami MB.
In this light breast cancer patients may find a relief Depression in Women with Breast Cancer: A
and draw strength to continue and to deal with their Systematic Review of Cross-Sectional Studies in
disease. Taking this under consideration, the finding Iran. Asian Pac J Cancer Prev 2018 Jan27;
that psychological resilience mediates the 19(1):1-7.
relationship between religiosity and depression may 6. Fradelos EC, Papathanasiou IV, Veneti A,
be understandable. Daglas A, Christodoulou E, Zyga S, Kourakos
There are some limitations in this study that M. Psychological Distress and Resilience in
should be taken under consideration. First, the use of Women Diagnosed with Breast Cancer in
self-reported measures that totally relies on the Greece. Asian Pac J Cancer Prev. 2017 Sep 27;
honesty of the individual which is reporting. Another 18(9):2545-2550.
limitation is related to the sample of our study that 7. Ching L, Devi M, Kim Emily DNurs A. Anxiety
could be characterized as small, as the convenience in patients with breast cancer undergoing
sampling that was applied leads to a potential treatment: a systematic review. JBI Database
selection bias. System Rev Implement Rep. 2010;8(25):1016-
57.
CONCLUSION 8. Baqutayan SMS. The Effect of Anxiety on Breast
Cancer Patients. Indian J Psychol Med. 2012
This study adds up to the existing evidence Apr;34(2):119-23.
of the international literature regarding the positive 9. Fradelos E, Tzavella F, Koukia E, Papathanasiou
effects of religion and spirituality in health I, Alikari V, Stathoulis J et al. Integrating
outcomes. Chronic Kidney Disease Patient's Spirituality in
Religiosity and Psychological resilience their Care: Health Benefits and Research
may contribute to coping with breast cancer and in Perspectives. Mater Sociomed. 2015;27(5):354.
promoting and maintaining mental health. 10. Borges M, Caldeira S, Loyola-Caetano E,
In conclusion it is valued to integrating Magalhães P, Areco F, Panobianco M.
religiosity and taking under account religious belief Spiritual/Religious Coping of Women with
and preference when providing adequate and Breast Cancer. Religions 2017;8(11):254.
satisfactory care. 11. Choumanova I, Wanat S, Barrett R, Koopman C.
Religion and Spirituality in Coping with Breast
Cancer: Perspectives of Chilean Women. Breast
Funding J 2006 Jul-Aug;12(4):349-52.
None. 12. Khodaveirdyzadeh R, Rahimi R, Rahmani A,
Ghahramanian A, Kodayari N, Eivazi J.
Conflicts of interest Spiritual/Religious Coping Strategies and their
The authors declare that they have no conflicts of Relationship with Illness Adjustment among
interest. Iranian Breast Cancer Patients. Asian Pac J
Cancer Prev. 2016;17(8):4095-9.
REFERENCE 13. Gall TL, Miguez de Renart RM, Boonstra B.
Religious resources in long-term adjustment to
1. Breast cancer. World Health Organi-zation breast cancer. J Psychosoc Oncol 2000;18(2): 21-
[Internet] 2018 [cited 2018 Sept 1]. Available 37
from: http://www.who.int/-cancer/prevention/ 14. Nairn RC, Merluzzi TV. The role of religious
diagnosis-screening/breast-cancer/en/ coping in adjustment to cancer. Psychooncology
2. Burgess C, Cornelius V, Love S, Graham J, 2003 Jul-Aug;12(5):428-41
Richards M, Ramirez A. Depression and an-xiety 15. Lim JW, Yi J. The effects of religiosity,
in women with early breast cancer: five year spirituality, and social support on quality of life:
observational cohort study. BMJ. 2005 Mar a comparison between Korean American and
26;330(7493):702. Korean breast and gynecologic cancer survivors.
3. Karamouzis M, Patsou E, Alexias G, Oncol Nurs Forum. 2009 Nov;36(6):699-708.
Anagnostopoulos F. Association between 16. Kroenke K, Spitzer RL, Williams JB, Löwe B.
physical activity, psychological mood profile and The patient health questionnaire somatic,
anxiety, and depressive symptom scales: a

103
Prog Health Sci 2019, Vol 9, No 1 Connecting dots: understanding religiosity, depression, breast cancer

systematic review. Gen Hosp Psychiatry 2010 30. Economou M, Angelopoulos E, Peppou L,
Jul-Aug;32(4):345–59. Souliotis K, Stefanis C. Major depression amid
17. Kroenke K, Spitzer RL, Williams JB, Monahan financial crisis in Greece: Will unemployment
PO, Löwe B. Anxiety disorders in primary care: narrow existing gender differences in the
prevalence, impairment, comorbidity, and prevalence of the disorder in Greece? Psychiatry
detection. Ann Intern Med. 2007 Mar Res. 2016;242:260-61.
6;146(5):317–25. 31. Rohani C, Abedi H-A, Sundberg K, Langius-
18. Kroenke K, Spitzer RL, Williams JB. The Patient Eklöf A. Sense of coherence as a mediator of
Health Questionnaire-2:validity of a two-item health-related quality of life dimensions in
depression screener. Med Care. 2003 patients with breast cancer: a longitudinal study
Nov;41(11):1284–92. with prospective design. Health Qual Life
19. Löwe B, Wahl I, Rose M, Spitzer C, Glaesmer H, Outcomes. 2015 Dec;13:195.
Wingenfeld K, Schneider A, Brähler E. A 4-item 32. Holt CL, Wang MQ, Caplan L, Schulz E, Blake
measure of depression and anxiety: validation V, Southward VL. Role of religious involvement
and standardization of the Patient Health and spirituality in functioning among African
Questionnaire-4 (PHQ-4) in the general Americans with cancer: testing a mediational
population. J Affect Disord. 2010 Apr;122(1- model. J Behav Med 2011 Dec;34(6):437-48.
2):86-95.
20. Connor KM, Davidson JR. Development of a
new resilience scale: the Connor-Davidson
Resilience Scale (CD-RISC). Depress Anxiety.
2003;18(2):76–82.
21. Windle G, Bennett KM, Noyes J. A
methodological review of resilience measu-
rement scales. Health Qual Life Outcomes. 2011
Feb;9(1):8.
22. Huber S. The Centrality of Religiosity Scale
(CRS). Religions 2012; 3: 710–724.
23. Fradelos EC, Kourakos M, Zyga S, Tzavella F,
Tsaras K, Christodoulou E, Daglas A,
Papathanasiou IV. Measuring Religiosity in
Nursing: Reliability, Validity and Psycho-metric
Properties of the Greek Translation of the
Centrality of Religiosity Scale-15. Am J Nurs.
2018;7(3-1):25-32.
24. Baron RM, Kenny D. The moderator-mediator
variable distinction in social psychological
research: Conceptual, strategic and statistical
considerations. J Pers Soc Psychol 1986;
51(6):1173–82.
25. McFarland MJ, Pudrovska T, Schieman S,
Ellison CG, Bierman A. Does a cancer diagnosis
influence religiosity? Integrating a life course
perspective. Soc Sci Res. 2013; 42(2):311-20.
26. Feher S, Maly R. Coping with breast cancer in
later life: the role of religious faith.
Psychooncology. 1999;8(5):408-16.
27. Shrestha JS Social support, quality of life and
mental health status in breast cancer patients.
Cancer Rep Rev.2017;1
28. Walker J, Holm Hansen C, Martin P, Sawhney
A, Thekkumpurath P, Beale C, Symeonides S,
Wall L, Murray G, Sharpe M. Prevalence of
depression in adults with cancer: a systematic
review. Ann Oncol. 2013;24(4):895-900.
29. Krebber AMH, Buffart LM, Kleijn G, et al.
Prevalence of depression in cancer patients: a
meta-analysis of diagnostic interviews and self-
report instruments. Psychooncol. 2014;23(2):
121-30.

104