INTL. J. PSYCHIATRY IN MEDICINE, Vol.

37(2) 213-227, 2007

RELIGIOSITY, ANXIETY, AND DEPRESSION AMONG

A SAMPLE OF IRANIAN MEDICAL STUDENTS*

SASAN VASEGH, MD
MOHAMMAD-REZA MOHAMMADI, MD
Tehran University of Medical Sciences, Iran

ABSTRACT

Objective: There are many studies of religion and mental health in a Christian
context, but studies in Islamic countries are few. Most previous studies used
only a single question for measuring religion, and several of them showed
negative associations between religion and indexes of anxiety or depression
among older people. This study preliminary assesses the associations between
religious variables, anxiety, and depression in a sample of Muslim students.
Method: This cross-sectional study examines a sample of medical students
(N = 285) for association(s) between religiosity, anxiety, and depression. The
subjects completed a Muslim religiosity questionnaire including religious
beliefs, emotions, and behaviors subscales and the Beck anxiety and depression inventories during their psychiatry rotation at Roozbeh psychiatric
hospital, Tehran, Iran. Results: all the three religious subscales were negatively associated with and negatively predicted depression and anxiety; but
only prediction of anxiety by the religious beliefs score was statistically significant. Conclusions: These findings provide further evidence for a protective
role of religion against anxiety and depression but more studies are required.
(Intl. J. Psychiatry in Medicine 2007;37:213-227)

Key Words: medical students, anxiety, depression, religion, Iran

*This study was conducted by Dr. Vasegh as a residency thesis by his personal funding. Data
collection and preparation was done when Dr. Vasegh was at Tehran University of Medical Sciences
(T.U.M.S.). He now works as a psychiatrist at Ilam University of Medical Sciences west of Iran
and is a research collaborator of T.U.M.S.
213
2007, Baywood Publishing Co., Inc.

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INTRODUCTION
Recently, there has been increasing interest in the relationships between various
aspects of religion and mental or physical health. There are many studies associating religious variables with positive health outcomes [1-3]. For example,
studies have shown that religious beliefs and practices relate to decreased suicide,
decreased anxiety, decreased substance abuse, decreased depression and faster
recovery from it, increased hope and optimism, more sense of meaning in life,
and more satisfaction in marital life [4], though some religious beliefs or behaviors
can result in mental strain or negative health consequences [1, 4-6]. Yet, the
percentage of published studies in which a religious variable has been measured
is surprisingly low, and most of these studies have relied on only one variable to
measure religion [7], and has been done in a Christian context [8]. In addition,
many of the studies on religion and mental or physical health have been done in
older or sick people [1, 9], and there are very few published studies about religion
and health in Islamic countries among young persons.
Although not even one similar study could be found in a Muslim context, some
interesting randomized trials have shown faster recovery of religious anxious
or depressed Muslim patients using additional Islamic religious psychotherapy
compared with the usual treatment [10, 11] and some other studies have shown
less suicide rates among Muslims [12, p. 138].
Depression and anxiety are among the most common and debilitating mental
health conditions. Although there are many studies linking religion to depression
[13], anxiety has been largely ignored [14]. University and college students
usually experience many educational, cultural, social, and financial stresses,
which can lead to anxiety and depression [15, 16], and these in turn have
significant correlations with physical illness [17] and academic impairment [18].
Medical students are reported to bear more stress compared with other students,
and depression rates in this group increase more from the first to second year of
medical school, compared to a sample of control students [15]. Rosals findings
suggest that this increase continued through the 4th year of medical school [19].
In the present study we examined the associations between multiple religious
variables with depression and anxiety among a sample of 4th-year medical
students in Tehran, Iran. Effects of several covariates are controlled for, and
results are compared with previous studies conducted in Western cultures.
METHOD
Participants
The participants were medical students who entered Roozbeh Psychiatric
Hospital of Tehran University of Medical Sciences to complete their one month
psychiatry rotation from March to December 2004. Of 286 students meeting these

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215

criteria, only one student refused to give informed consent and participate in the
study, and a total of 285 students completed the study questionnaires.
Procedures
On the first days of each month, a group of medical students enter Roozbeh
Psychiatric Hospital to complete their one-month psychiatry rotation and most
of them attend an introductory session by entrance. At the end of this session, one
of the authors (S. Vasegh) introduced the current study and those who gave
informed consent received the study questionnaires including Beck Anxiety and
Depression Inventories, questions about demographic variables and other covariates, and a religious questionnaire. All of the questionnaires were anonymous
but the students were asked to write a private personal 5-character code on the first
page so that they could recognize their own Beck scores later. After about one
week, results of the Beck Depression and Anxiety Inventories were provided
to the students, and counseling was provided if needed.
Measurements
Depression was measured using a Persian version of the Beck Depression
Inventory-II, a 21-item self-report questionnaire which has good reliability and
validity in college student populations [20-22], even Persian and Arabic versions
of it in Arabic and Iranian students [23-25]. Each item was scored on a 0-3 scale
(total range: 0-63) with higher scores indicating more severe depression in the
past week, including today.
Anxiety was measured using a Persian translation of the Beck Anxiety
Inventory, a 21-item self-report questionnaire used to measure state anxiety in
undergraduate students, which has good internal consistency and significant
correlations with several other related anxiety measures [26]. The items are
rated for the past week, including today on a 4-point scale from 0 (not at all)
to 3 (severe and barely tolerable) with the total score (range: 0-63) reflecting
severity of anxiety.
Religiosity was measured using a Persian questionnaire consisting of three
parts: religious beliefs (5 questions), religious emotions (5 questions), and
religious behaviors (5 questions). An English translation of this questionnaire
is presented in Figure 1.
No similar study was found in a Muslim context, so most questions of this
questionnaire were found originally by a discussion group consisting of the
authors and some interested psychologists consulting with some Islamic clergies.
First, a pool of about 40 questions was prepared and most reliable questions were
separated through a pilot study. Then, after some literary and cultural revision, the
final questionnaire was prepared. Only a few items such as religious salience
(question A) and believing in God (question B) were used before in several
previous studies in various forms [12, pp. 128, 129].

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Figure 1. An English translation of the religious questionnaire

used in this study.

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217

Because asking about religion was believed to be culturally sensitive, most

questions of religious beliefs or emotions was first started by a religious (or
anti-religious) statement; then the participant was asked to mark his or her
agreement with that belief or emotional state from completely agreed to completely opposed. If the question stated a religious belief or emotional state,
completely agreed scored 5 and completely opposed scored 0. If the question
stated an anti-religious belief or emotional state, completely agreed scored 0
and completely opposed scored 5. So each question ranged from 0 to 5 with
higher scores indicating more agreement with that religious belief or emotion.
Each religious behavior question asked about the frequency of doing a particular
religious behavior, with responses ranging from 0 to 4.
Religious Beliefs Score (range 0-25) was computed by summing up the scores
of five questions. Four of these questions (questions B, C, M, and N) were about
what most Iranian Muslim people call the three fundamentals of the religion.
These include tawheed (Arabic, monotheistic belief in God; question B), maaad
(Arabic, belief in the afterlife; questions C and N), and nobowwat (Arabic, belief
in the prophet; question M). The fifth question (H) was intended to measure
religious commitment, i.e., how much the participant believed religious commands should be completely or absolutely obeyed. One of Islamic instructions
taught in Iran is that Muslim men should not use golden ornaments and Muslim
women should completely cover their hair against strange men; but probably only
very religious people believe in these instructions absolutely. So the question H
believed in these statements are used as evidence of religious commitment.
Religious Emotions Score (range 0-25) was computed summing up five
questions (the questions A, F, G, L, and O). Except question A that asks about
feeling of importance of religion as a whole, other questions were about positive
or negative emotions toward specific religious concepts or behaviors, including
religious holy leaders (L), God (O), reading religious scriptures (F), and doing
Islamic daily prayers (G).
Religious Behaviors Score (range 0-21) was computed summing up five
questions (the questions D, E, I, G, and K). According to Islamic teachings, doing
five daily prayers is a duty for every adult Moslem and these prayers are
sometimes referred to as the pillar of the religion. Each of the five daily prayers
must be done in a specific time (for example, the Morning Prayer must be done
between the dawn and sunrise and the Noon Prayer must be done between the
noon and sunset), and it is strongly recommended to do these prayers early in
their time. So two of the questions were about doing daily prayers (the question I)
and the time pattern of doing daily prayers (the question J). Also, there are many
optional religious scriptures and prayers that Iranian religious people read and
say according to their interest. Four of these prayers included in the question E
are among the most famous of these prayers and are often read socially and weekly
in the mosques while people weep and ask many wishes from God. The students
reading these prayers collectively four times or more per month scored 4. Those

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who read these prayers collectively 0, 1, 2, or 3 times per month scored 0, 1,

2, or 3, respectively. The question K was about fasting during the Ramadhan
lunar month during which every adult Muslim must fast (i.e., not drink, not eat,
not have sexual activity, etc., from dawn to sundown) throughout the month.
Total Religious Score (range 0-71) was computed by adding up the religious
beliefs, emotions, and behaviors scores.
The religious questions were ordered in a mixed manner believing this would
lead to more precise answers and greater validity. All three subscales and the total
questionnaire showed good two-week test-retest reliability (N = 15). Cronbachs
alpha was 0.926 for the total religious questionnaire, 0.800 for religious beliefs
score, 0.852 for religious emotions score, and 0.824 for religious behaviors
score in this study.
There were also questions asking about other variables including age, sex,
marital status, regular substance use, history of depression in the family, presence
of any important socioeconomic problems during the last month, the presence of
important physical or psychiatric illnesses (other than depression), and existence
of physical or psychiatric illness (other than depression) in the subjects family.
Statistical Analysis
Because the distribution of the data in this study were found to differ
significantly from normal distribution, Spearmans rho was used to obtain
correlations between religious variables, depression, and anxiety.
Multiple linear regression analysis was conducted to examine the effect of
religious variables on anxiety and depression, and to examine and control for the
effects of other sociodemographic variables.
RESULTS
Of the subjects, 151 (53%) were male and 134 (47%) were female; 214 (75.1%)
were unmarried; and age ranged from 20 to 31 years (mean = 23.8, SD = 1.6).
concerning religion, 279 (97%) indicated their religion as Islam, 1 (.4%) as
Christian, and 5 (1.8%) as other religions. Of the Muslim subjects, 276 (98.9%)
identified their religious affiliation as Shia and 3 (1%) as Sunni.
Results of the Beck Depression and Anxiety Inventories and the religious
questionnaire scores are presented in Table 1.
Correlations, Comparing Groups, and Regression Analyses
The One-Sample Kolmogorov-Smirnov Test revealed that none of these
variables had normal distribution, so Spearmans rho was used to obtain
correlations between religious variables, depression, and anxiety (Table 2.).
All of the religious variables were found to have negative correlations
with anxiety and depression scores, but the correlations were small (r < 0.20).

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219

Table 1. Results of the Beck Depression and Anxiety Inventories and

the Religious Questionnaire Scores
Minimum

Maximum

Mean

SD

Beck Depression Inventory

.00

36.00

8.45

6.75

Beck Anxiety Inventory

.00

38.00

7.90

6.55

Religious Beliefs Score

.00

25.00

19.36

5.41

Religious Emotions Score

.00

25.00

18.65

5.16

Religious Behaviors Score

.00

21.00

10.93

5.33

Total Religious Score

.00

68.00

49.14

14.43

Table 2. Correlations between Religious Variables with

Depression and Anxietya

BDI
BAI
RBelS
REmS
RBehS
TRS

BDI

BAI

.633**

RBelS

REmS

RBehS

TRS

.113

.063

.071

.104

.170**

.106

.107

.148*

.716**

.701**

.883**

.719**

.888**

.911**

aBDI,

Beck Depression Inventory; BAI, Beck Anxiety Inventory; RBelS, Religious Beliefs
Score; REmS, Religious Emotions Score; RBehS, Religious Behaviors Score; TRS, Total
Religious Score.
*p < .05. **p < .01.

Correlations of anxiety with Religious Beliefs Score (p < 0.01) and Total
Religious Score (p < 0.05) were significant, and correlations of depression
with Religious Beliefs Score (p = 0.058) and Total Religious Score (p = 0.086)
approached significance.
Multiple linear regression analysis from the SPSS statistical package, version
13.0, was used to predict anxiety and depression by individual religious dimensions and total religious score. As is shown in Table 3, all three religious
dimensions and total religious score negatively predicted depression and anxiety,
but only prediction of anxiety by the Religious Beliefs Score was significant.

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Table 3. Multiple Regression Analysis: Prediction of Depression

and Anxiety by Religious Variablesa
Dependent
variable

Independent
variables

BDI

BAI

Std. error

p Value

RBelS

0.144

0.074

0.062

REmS

0.048

0.075

0.518

RBehS

0.110

0.072

0.124

TRS

0.040

0.027

0.143

RBelS

0.164*

0.072

0.024

REmS

0.085

0.073

0.244

RBehS

0.084

0.069

0.226

TRS

0.043

0.026

0.103

aBDI,

Beck Depression Inventory; BAI, Beck Anxiety Inventory; RBelS, Religious Beliefs
Score; RemS, Religious Emotions Score; RBehS, Religious Behaviors Score; TRS, Total
Religious Score.
*p < .05

Because only one or few variables were used as indicators of religiousness in

many previous studies of religion and mental health, we also examined each of
the religious questions individually as predictors of Beck anxiety and depression
scores. The results are shown in Table 4.
To determine which covariates to control for, the covariates including age, sex,
marital status, regular substance use, history of depression in the family, existence
of important socioeconomic problems during the last month, physical or psychiatric illnesses (other than depression) in the subject, and physical or psychiatric
illness (other than depression) in the subjects family, were first examined for
correlations with anxiety and depression. Family disease (existence of any important physical or psychiatric diseases other than depression in the students family),
history of depression in students family, and regular substance use were significantly correlated with the Beck anxiety score; and history of family depression,
last month socioeconomic stress, students important physical disease, and regular
substance use were significantly correlated with the Beck depression score.
After controlling for family disease, history of family depression, and substance
use, religious beliefs score prediction of anxiety became non significant; but
regarding individual questions, asking God daily (question D) and religious
commitment (question H) still significantly predicted anxiety after controlling
for the above three covariates.

0.009
0.566
0.179
0.524
0.634**
0.156
0.237
0.449

0.483
0.567
0.176
0.477
0.364
0.188
0.367
0.238

Belief in God (question B)

Belief in prophets (question M)

Belief in afterlife (question C)

Belief in afterlife judgment (question N)

Religious commitment (question H)

Religious salience (question A)

Feeling affection for God (question O)

feeling affection for prophets (question L)

0.229
0.226
0.580
0.314
0.608
0.598*
0.366*

0.019
0.207
0.779*
0.541*
0.385
0.174
0.181

Doing five daily prayers (question I)

Time of doing five daily prayers (question J)

Fasting during Ramadhan month (question K)

Figure 1 for individual questions.

*p < 0.05. **p < 0.01.

aSee

Monthly reading special prayers (question E)

Daily asking from God (question D)

Feeling interested in religious reading (question F)

Feeling interested in daily prayers (question G)

The religious questions

Prediction of the Beck

Anxiety Inventory Score
(B in linear regression)

Prediction of the Beck

Depression Inventory Score
(B in linear regression)

Table 4. Individual Religious Questions as Predictors of Anxiety and Depressiona

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DISCUSSION
Concerning depression, most of the previous research on religion has revealed
negative correlations between various measures of religion and depression
or depressive symptoms [13, 27]. The correlation between religiousness and
depressive symptoms across 147 independent investigations (N = 98,975)
meta-analyzed by Smith et al. (2003) was .096 [27], which means greater
religiousness was mildly associated with fewer symptoms. The results of our study
are consistent with previous findings and support the hypothesis that religion plays
a protective role against depression. Most studies of religion and mental health
have been done in a Christian context and many included only elderly sick people
[9], so similar results among our Muslim healthy young sample are interesting.
None of the direct correlations between religious scores and depression were
significant in our study, but the negative correlation between religious beliefs
score and depression approached significance (p = .058). Because of the diversity
of measures of religiousness and depression in previous studies, direct comparison
of the results is not possible, but questions similar to our study (particularly our
religious beliefs subscale) has yielded similar results [28].
No previous studies were found concerning the five daily Islamic prayers and
depression, so this is probably the first published study showing negative and
significant correlations between depression and the five prayers or time of
doing them. These significant negative correlations (r = 0.141 for doing the
five prayers and r = 0.154 for their time) were stronger than the negative
correlation of our total religiousness score (r = 0.104) or religious beliefs score
(r = 0.113), both statistically non-significant.
Although our results agree with some studies showing negative correlations
between religion and lifetime anxiety disorders particularly in younger adults
[29], it should be noted that the results of previous studies concerning religion
and anxiety look mixed and confusing. Some studies showed increased anxiety
in religious people, others showed decreased anxiety, yet others resulted in
nonsignificant relationships [14]. In their 2004 review, Shreve-Neiger and
Edelstein stated 10 studies showing decreased anxiety in religious people, six
studies showing increased anxiety, and four studies showing non-significant
relationships between various measures of anxiety and religion [14]. Four of the
six studies linking religion to increased anxiety were the same as the studies
linking religion to decreased anxiety. In three of these four studies, intrinsic
religiousness correlated with decreased anxiety, and extrinsic religiousness correlated with increased anxiety. In the fourth study, Catholic religious affiliation
was correlated with increased anxiety and frequent church attendance correlated
with decreased anxiety. In the fifth study linking religion to increased anxiety,
sudden religious conversion, which authors defined as changing from one
religion to another or from a nonreligious state to a religious one, was associated with increased anxiety; and in the sixth study, religion was measured by a

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223

self-report questionnaire that included common dimensions of religious

participation and beliefs, but the authors didnt mention the questions specifically.
Intrinsic-extrinsic religiosity concept was first developed by the Harvard
psychologist Gordon Alport in the 1950s [12, pp. 21, 22, 500, 501]. According to
Alport, intrinsically religious people have deep belief in religion and think of
religion as their master motive in their life, but extrinsically religious persons are
interested in religion only in order to achieve a different, nonreligious goal. An
example of the items measuring intrinsic religiosity in the Alports scale is, I
try hard to carry my religion over into all my other dealings in life; and an
example of the items measuring extrinsic religiosity is, A primary reason for my
interest in religion is that my church is a congenial social activity. Although we
have not used any intrinsic-extrinsic religiosity scale, it seems that our religious
beliefs questions primarily measure intrinsic religiosity. Therefore, results of our
study agree with almost all of the previous studies, showing decreased anxiety
in intrinsically religious people.
There are two main approaches concerning direct and indirect effects of religion
on health, the value added approach and the web of causality approach [1].
According to the value added approach, indirect effects of religion on health,
such as reducing adolescent tobacco use [30], are of little interest because only
religious variables adding variance explained to models that include
well-established predictors of morbidity or mortality are important. According to
the web of causality approach, indirect effects of religion on health can have
important intellectual and practical implications. They help us to better understand
and theorize relationships between various variables in webs of causalities and
can, for example, influence public health interventions [1]. Although beneficial
effects of religion on depression or anxiety cannot be concluded empirically
from our cross-sectional study, considering many previous studies in the field
including well designed prospective studies [e.g., 31], there is good evidence for
probable direct and indirect positive impact of some aspects of religiosity on
mental health. In our study, the cross-sectional correlations between religious
variables and anxiety or depression (r < 0.20) were relatively small but compared
with some other well known risk factors such as age, sex, and marital status,
religious variables were more significantly correlated with depression and anxiety.
This is in agreement with previous findings [9].
Theoretically, religion can have many complex interactions with the factors
influencing anxiety and depression. For example, when a religious person
anticipates a significant stress and feels anxiety, some religious activities such as
asking from God can increase (shown in our study), and this may later decrease
him or her anxiety; or when a religious person tolerates significant chronic stresses
and feels depression, some religious activities may decrease [32], and this can
in turn lead to increased depression.
Of the covariates having significant correlations with anxiety and depression in
our study, only regular substance use also had a statistically significant correlation

224 / VASEGH AND MOHAMMADI

with religious variables (r = 0.377 for total religious score, p < 0.001). This
negative correlation, too, has been shown in previous studies [28, 30, 33]. So
it is probable that some of the association between religion and anxiety was
mediated by substance use.
How can we justify using a total religiosity score while some elements of
religion (like private prayer) can differ from other elements (such as church
attendance) regarding interactions with depression and anxiety? Actually among
Muslims, non-organizational religious activities such as prayer are very important
parts of life and are not just turned to during times of stress, and attendance at
Temple worship services are not as obligatory as in Christianity. We wanted
to measure a persons whole religiosity and overall integration of faith into the
life of Muslim students, so we thought that total religiosity is a better reflection
of this. Besides, although some previous studies have shown non-significant or
positive cross-sectional relationships between some non-organizational religious
activities and depression or anxiety, there are several other studies showing
significant negative correlations between them, and it seems that these activities
too can buffer effects of stresses on religious persons [12, pp. 86, 87].
Cognitive Modeling and Future Directions
Religion is multidimensional in nature [1, 28], so perhaps each dimension of it
can differently affect different individuals. According to cognitive theory, the four
basic emotions of sadness, anxiety, anger, and happiness are, respectively, evoked
by thoughts of loss, danger, wrongdoing by others, and gain [34]. Therefore, the
depressed patient has intense feelings of loss, deprivation, and unfulfillment
referring to his or her self, experiences and future, and the anxious patient infers
danger from one or more of his or her experiences. So each religious belief or
practice can decrease depression or anxiety possibly by leading to thoughts of
personal gain or security, and can increase depression or anxiety by leading to
thoughts of deprivation or insecurity. Therefore, the power of a religious belief
to increase or decrease depression or anxiety in a given person, among other
variables, would depend first on the manner of use of this belief by the individuals
cognitive system, whether resulting in thoughts of loss and danger or thoughts
of gain and security; and second, rate of behaviors that directly or indirectly lead
to change of frequency of these thoughts in the individual, such as reading
religious scriptures, attending religious services, saying prayers, meeting and
identifying with religious friends, etc.
This theory explains why some religious beliefs such as having committed
an unforgivable sin or feelings of alienation from God have been associated
with increased depression [5]. This theory also predicts that in a religious
depressed individual, if cognitive techniques can transform religious loss
thoughts to gain thoughts, there would be faster or better recovery from
depression. In the authors psychotherapy experience, drawing attention of some

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225

religious depressed patients to religious gain thoughts such as kindness and

forgiveness of the God could help them to better overcome their guilt feelings.
This is consistent with randomized controlled trials that have shown faster
recovery in religious anxious or depressed patients undergoing similar religiously
oriented psychotherapies [10, 11, 35].
According to this practical view, future directions would include focusing
more on loss-gain or security-insecurity thoughts in religious questionnaires,
conducting more studies on different sociocultural and ethnic groups to better
understand how religious concepts are used in their cognitive system, more use
of qualitative studies for theorizing the role of religious beliefs in these groups,
more precise formulizing of discussion about religious beliefs in psychotherapy,
doing more controlled prospective trials to test the efficacy and side effects of
these approaches, and better studying various religious behaviors, their frequencies, and their cognitive consequences, especially the kinds of thoughts they
evoke in various groups and individuals. According to results of our study, doing
five daily Islamic prayers is an especially good candidate for future studies.
Our study had limitations so the findings should be considered preliminary.
For example, we used a convenience sample of young students, so caution should
be exerted in generalizing the findings. Many previous studies linked church
attendance to positive health outcomes, but no equivalent (e.g., mosque
attendance) was used in our study. Our study was cross-sectional; therefore,
clearly, causality cannot be determined.
On the other hand, our study is perhaps the first study with multiple religious
questions in a Muslim sample, and probably can provide valuable information for
future studies both in Muslim and Christian populations.

ACKNOWLEDGMENTS
The authors would like to thank professor Harold G. Koenig for his valuable
comments and suggestions and also thank all the medical students who participated in our study.

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