Religious vs. Conventional Cognitive Behavioral Therapy for Major Depression in Persons With Chronic Medical Illness A Pilot Randomized Trial Harold G. Koenig, MD,*†‡§k Michelle J. Pearce, PhD,*§¶ Bruce Nelson, MA,# Sally F. Shaw, PhD,# Clive J. Robins, PhD,** Noha S. Daher, DrPH,††‡‡ Harvey Jay Cohen, MD,†§ Lee S. Berk, DrPH,§‡‡kk Denise L. Bellinger, PhD,kk Kenneth I. Pargament, PhD,¶¶ David H. Rosmarin, PhD,## Sasan Vasegh, MD,*** Jean Kristeller, PhD,††† Nalini Juthani, MD,‡‡‡ Douglas Nies, PhD,# and Michael B. King, MD, PhD§§§ Abstract: We examine the efficacy of conventional cognitive behavioral ther- apy (CCBT) versus religiously integrated CBT (RCBT) in persons with major de- pression and chronic medical illness. Participants were randomized to either CCBT (n = 67) or RCBT (n = 65). The intervention in both groups consisted of ten 50-minute sessions delivered remotely during 12 weeks (94% by tele- phone). Adherence to treatment was similar, except in more religious participants in whom adherence to RCBT was slightly greater (85.7% vs. 65.9%, p = 0.10). The intention-to-treat analysis at 12 weeks indicated no significant difference in outcome between the two groups (B = 0.33; SE, 1.80; p = 0.86). Response rates and remission rates were also similar. Overall religiosity interacted with treatment group (B = -0.10; SE, 0.05; p = 0.048), suggesting that RCBT was slightly more efficacious in the more religious participants. These preliminary findings suggest that CCBT and RCBT are equivalent treatments of major depression in persons with chronic medical illness. Efficacy, as well as adherence, may be affected by client religiosity. Key Words: Religious, spiritual, psychotherapy, CBT, major depression, chronic illness, randomized clinical trial (J Nerv Ment Dis 2015;203: 243–251) D epression is common among those with chronic medical illness, in whom rates of major depression are up to three times more preva- lent than in the general population (Koenig et al., 1997; Rosemann et al., 2007). Religious coping has also been shown to be widely prevalent among those with medical illness and has been associated with less depression and faster recovery from depression (Koenig, 2007; Koenig et al., 1992, 1998). Psychotherapy that integrates the religious beliefs of medically ill clients into therapy may be particularly effective in reliev- ing depression in this setting. Cognitive behavioral therapy (CBT) is a standard treatment of depression (Butler et al., 2006). Not surprisingly, psychological approaches such as CBT have been particularly effective in treating depression in medical patients who need help addressing maladaptive beliefs about their illness that initiate and maintain depression (Bower et al., 2000; Kessler et al., 2009; Serfaty et al., 2009; Ward et al., 2000). Most stud- ies in primary care patients have compared CBTwith control conditions such as “usual care” by the physician, a “talking control” condition, or alternative forms of therapy such as nondirective counseling (Bower et al., 2000; Katon et al., 1996; Kessler et al., 2009; Serfaty et al., 2009; Ward et al., 2000). Head-to-head comparisons of varying forms of CBT are rare. Historically, there has been little common ground between reli- gious and psychological concepts of mental health (Freud, 1927/1962). This has generated negative attitudes toward religion among mental health professionals as well as negative attitudes among religious cli- ents toward psychological treatments, which they may view as unsym- pathetic to their religious beliefs and values (Weaver, 1995). Religious patients may also avoid psychotherapy because they feel that depression is shameful and that seeking therapy means abandoning their faith. Some may feel guilty about being depressed and thus fail to address it with their clergy and avoid seeking support within the faith community. Religious psychotherapy may help to normalize depressed religious pa- tients' need for psychotherapy and thus overcome a major barrier to treatment. Many depressed persons have expressed a desire to have their religious beliefs considered in psychotherapy, especially those with co- morbid medical illness (Rose et al., 2001; Stanley et al., 2011). The efficacy of religiously integrated psychotherapy—therapy that takes into account and uses the religious beliefs of clients—has not been previously evaluated for the treatment of depression in individ- uals with chronic medical illness. Religiously integrated CBT (RCBT) has been shown in small clinical trials to speed time to remission in de- pressed religious clients without medical illness compared with conven- tional CBT (CCBT; Propst, 1980; Propst et al., 1992). Likewise, a number of studies that addressed clients' religious beliefs in therapy have reported results superior to secular treatments or usual care in re- ligious patients (Azhar and Varma, 1995; Razali et al., 1998; Rosmarin et al., 2010; Xiao et al., 1998). This may not be as true, however, in those who are less religious (Razali et al., 2002). Furthermore, a num- ber of preliminary clinical trials have not found religious-integrated therapies to be more effective than secular treatments in religious pa- tients (Hook et al., 2010; Rye and Pargament, 2002). In this pilot randomized clinical trial, we compared CCBT and RCBT (delivered primarily by telephone) for the treatment of major *Department of Psychiatry and Behavioral Sciences, and †Department of Medicine, Duke University Medical Center, Durham, NC; ‡Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia; §Center for Spirituality, Theology and Health, Duke University, Durham, NC; kSchool of Public Health, Ningxia Medical University, Yinchuan, People's Republic of China; ¶School of Medicine, University of Maryland, Baltimore; #Department of Research, Glendale Adventist Medical Center, CA; **Department of Psychology and Neuroscience, Duke Uni- versity Medical Center, Durham, NC; ††Epidemiology, Biostatistics, and Popula- tion Medicine, School of Public Health, and ‡‡Allied Health Studies, School of Allied Health Professions, Loma Linda University, CA; §§Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC; kkDepartment of Pathology and Human Anatomy, School of Medicine, Loma Linda University, CA; ¶¶Department of Psychology, Bowling Green State University, OH; ##Department of Psychiatry, McLean Hospital/Harvard Medical School, Belmont, MA; ***Department of Psychiatry, Shahid Beheshti University of Medical Sciences, Tehran, Iran; †††Department of Psychology, Indiana State Uni- versity, Terre Haute; ‡‡‡Department of Psychiatry, Albert Einstein College of Med- icine, New York, NY; and §§§Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK. Dr Juthani is a retired professor of psychiatry at the Albert Einstein College of Medicine in New York. Send reprint requests to Harold G. Koenig, MD, Box 3400, Duke University Medical Center, Durham, NC 27710. E-mail: Harold.Koenig@duke.edu. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0022-3018/15/20304–0243 DOI: 10.1097/NMD.0000000000000273 ORIGINAL ARTICLE The Journal of Nervous and Mental Disease • Volume 203, Number 4, April 2015 www.jonmd.com 243 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.