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Spiritual needs in health care

BMJ 2004; 329 doi: (Published 15 July 2004) Cite this as: BMJ 2004;329:123

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Are both religious believers and atheists less depressed than the 'existentially uncertain'?

It is commonly argued that religious belief is a cause of greater
happiness [1]. But in two separate studies we have found that both theism
and atheism are correlated with fewer reported depressive symptoms than
the in-between state of 'existential uncertainty'.

Our first study of the effect of religious conviction on the Beck
Depression Inventory (BDI) surprisingly discovered an ‘inverted-U’
relationship, where the most- and least-religious groups had fewest
depressive symptoms. An 11 item existential conviction scale (ECS) was
devised as a measure of the degree of certainty with which an individual
understands the basis of human life (see below). Fifty-two subjects (24
male: 28 female, age: 18-76) completed the ECS and BDI. All 10 subjects
rated as depressed (‘mild’ depression, BDI score 10+) were roughly
halfway between atheist and theist. There was a significant negative
relationship between ECS and the BDI (Spearman rank correlation -0.44, p
< 0.2).

Strong beliefs may protect against depression, or low mood may
diminish strong beliefs. Alternatively, depressive symptoms and
existential uncertainty may both be a consequence of systemic illnesses,
because immune activation tends to cause malaise symptoms such as fatigue
(leading to depressed mood) and impaired concentration (leading to greater
uncertainty of beliefs) [2,3]. This hypothesis is currently being tested.


1. French S, Joseph S. Religiosity and an association with happiness,
purpose in life and self-actualization. Mental Health, Religion and
Culture. 1999; 2: 118-120.

2. Hart, B. l. (1988). Biological basis of the behaviour of sick
animals. Neuroscience & Biobehavioural Reviews, 12: 123-137.

3. Charlton BG. The malaise theory of depression: Major depressive
is sickness behavior and antidepressants are analgesic. Medical
Hypotheses. 2000; 54: 126-130


Existential Conviction Scale (ECS) Questionnaire

Instructions to subjects

Please mark the line to indicate how strongly you agree with the

Place your mark over to the left if you agree very strongly, over to
the right if you do not agree at all, or anywhere in between to indicate
how strongly you agree with the statement.

If you are unhappy using the word ‘God’, please describe an
alternative you would prefer to use (this applies to all questions that
mention God).


1) My life has a spiritual dimension

2) I am a religious person

3) My life is guided purely by science and logic

4) Religion is an important part of my life

5) I believe in God

6) I am a rationalist

7) I believe that God loves me

8) I believe that whatever happens is part of a divine plan

9) I believe in an afterlife/ life after death

10) I believe that there is nothing more to life than the here and

11) God gives meaning to my life


Notes for Investigators

The above statements should be printed above a line with a bar
marking the halfway point. The Left extreme is marked with Strongly Agree
and the Right extreme is marked with Strongly Disagree. (ie. this
questionnaire is a type of ‘Likert Scale’).

Measurements are done with a ruler and rounded to one decimal point.

Marking scheme

The ECS yields two measures.

1. A measure of religiosity from zero-highest (zero = atheist,
highest = theist)

2. A measure of existential conviction zero-highest (zero =
existentially uncertain, highest = existentially certain).

1. Religiosity

The scale is measured from left to right – extreme left is zero and
extreme right is highest. Religiosity (zero-highest) is measured by the
mean average of scores with a score of 0 for a convinced atheist and
highest score for an extreme theist.

Subjects who – on average - strongly agree with statements 1, 2, 4,
5, 7, 9, 11 and who strongly disagree with statements 3,6,10 would be
classified as religious or ‘theistic’ (and those who strongly disagree
with statements 1, 2, 4, 5, 7, 9, 11 and who strongly agree with
statements 3,6,10 would be classified as atheists). The intermediate
subjects are classified as ‘existentially uncertain’.

2. Existential conviction

Existential conviction (zero-highest) is derived from measuring the
distance from the centre of the scale to the mark made by the subject.
Strong views (whether theistic or atheistic in nature) have greater
divergence and higher scores; while existential uncertainty is defined by
lower distance from the centre and scores nearer to zero.


The ECS scale may freely be used without any need for further
permission. Please cite the scale as follows: Riley J, Best S, Charlton
BG. (2005). The Existential Conviction Scale (ECS). Then give the web
address and date accessed.

Competing interests:
None declared

Competing interests: No competing interests

26 August 2005
Bruce G Charlton
Reader in Evolutionary Psychology
Jennifer Riley, Sophia Best
School of Biology and Psychology, University of Newcastle upon Tyne, NE1 7RU, UK