religiosity and longitudinal change in psychosocial functioning in adult offspring of depressed...

DEPRESSION AND ANXIETY 00:1–9 (2013)

Research ArticleRELIGIOSITY AND LONGITUDINAL CHANGE IN

PSYCHOSOCIAL FUNCTIONING IN ADULT OFFSPRINGOF DEPRESSED PARENTS AT HIGH RISK FOR MAJOR

DEPRESSION

Stephanie Kasen, Ph.D.,1,2∗ Priya Wickramaratne, Ph.D.,1,2,3 and Marc J. Gameroff, Ph.D.1,2

Background: Recent findings suggest that beliefs about religious or spiritual im-portance or attending religious/spiritual services may protect high-risk offspringagainst depression. This research has not extended to examining religiosity inrelation to psychosocial functioning in high-risk offspring. Methods: Offspringselected for having a depressed parent and offspring of nondepressed parents wereevaluated for lifetime major depressive disorder (MDD) in childhood and ado-lescence, and at 10-year (T10) and 20-year (T20) follow-ups. Relations betweenself-reported religiosity at T10 and longitudinal change in psychosocial func-tion from T10 to T20 (assessed by clinical ratings on Global Assessment Scale[GAS]) were examined separately in 109 daughters and 76 sons by risk status.Results: Lifetime MDD was diagnosed in 57.8% of daughters and 40.8% ofsons by T20. Among daughters, only those with lifetime MDD showed improvedpsychosocial functioning in relation to higher level of service attendance at T10,their mean GAS score improving by 3.5 points (P = .018) over the next decade.For daughters with and without lifetime MDD, relations between higher levelsof religiosity and improved psychosocial function were of greater magnitude inthose with a depressed parent. Among sons, only those with lifetime MDD showedimproved psychosocial function in relation to higher level of religious/spiritualimportance, their mean GAS score improving by 4.6 points (P < .0001) over thenext decade; that relation was of greater magnitude in sons with both lifetimeMDD and a depressed parent. Conclusions: Greater improvement in psychoso-cial functioning in relation to religious involvement in more vulnerable offspringsupports religiosity as a resilience factor. Depression and Anxiety 00:1–9, 2013.C© 2013 Wiley Periodicals, Inc.

Key words: religion/spirituality; religious services attendance; functional de-cline; resilience; high risk

1Division of Epidemiology, New York State Psychiatric Insti-tute, New York, New York2College of Physicians and Surgeons, Columbia University,New York, New York3Mailman School of Public Health, Columbia University, NewYork, New York

Contract grant sponsor: John Templeton Foundation; Contract grantsponsor: National Institute of Mental Health; Contract grant number:

2 R01 MH36917; Contract grant sponsor: National Institute of DrugAbuse.

∗Correspondence to: Stephanie Kasen, Division of Epidemiology,Unit 24, New York State Psychiatric Institute, 1051 Riverside Drive,New York, NY 10032. E-mail: [email protected] for publication 18 November 2012; Revised 14 April 2013;Accepted 20 April 2013

DOI 10.1002/da.22131Published online in Wiley Online Library(wileyonlinelibrary.com).

C© 2013 Wiley Periodicals, Inc.

2 Kasen et al.

INTRODUCTIONPreviously we found that offspring of depressed par-ents reporting higher levels of religious or spiritual im-portance or service attendance were at decreased oddsfor subsequent major depression and other disorders.[1]

Moreover, associations were of greater magnitude inthese offspring compared to offspring of nondepressedparents, suggesting that religious involvement may fos-ter resilience in individuals at high risk for depres-sion. The current study extends this research to ex-amine associations between self-reported religiosity andlongitudinal change in psychosocial functioning as as-sessed with the Global Assessment Scale (GAS).[2]

Psychosocial dysfunction is characterized by interper-sonal difficulties, impaired social skills, disturbances inachievement or occupational role performance, negativeaffect, and psychological distress that may portend, ac-company, or follow clinical level pathology, especiallydepression, increasing risk for recurrent depression, andpoor quality of life.[3–7] Accordingly, we address the fol-lowing research questions regarding long-term associ-ations between religiosity and change in psychosocialfunction in offspring at risk for functional decline:

1. Is religious/spiritual importance or attending servicesassociated with improved psychosocial function overthe next decade in offspring at risk for functional de-cline due to a history of major depressive disorder(lifetime MDD), and are such associations limited toor of greater magnitude in offspring with than off-spring without lifetime MDD?

2. Does parent depression modify relations betweenreligious/spiritual qualities and change in psychoso-cial function in either offspring with or without life-time MDD?

Risk for early onset depression and psychosocial dys-function is elevated among offspring of depressed par-ents due to factors related to genetic transmission andthe detrimental impact of parent depression on homeenvironment and childrearing experiences.[6–16] Relativeto nondepressed parents, depressed parents are less in-volved with their children, have fewer positive interac-tions with and more negative feelings about their chil-dren, and discipline their children with greater frequencyand severity.[13, 17–21] Children of depressed parents alsoare at increased risk for additional forms of psychi-atric illness that are associated with psychosocial dys-function, and that may interfere with the maturationalprocess.[15, 16, 19] Consequently, satisfactory resolution ofcritical developmental tasks may be compromised, es-pecially among offspring with a history of depression,placing them at increasingly high risk for continuingproblems.[20, 22–25]

It has been proposed that religious involvement maycounteract the negative effects of stress-inducing orotherwise adverse situations and promote psycholog-ical well-being by strengthening perceptions of per-

sonal mastery and the meaningfulness of life, and byincreasing supportive social networks that share com-mon values and beliefs.[26–29] That notion has been sup-ported empirically by associations between greater reli-giosity and lowered probability of major depression andrelated syndromes in high-risk individuals [1, 30–33] andolder adults.[34–37] Research based on adolescent sam-ples indicates that religiosity has a modest protective ef-fect against depression and externalizing problems, suchas conduct and substance use disorders and borderlinepersonality disorder.[38–41] Nonetheless, relative to thebreadth of research on religiosity and clinical disorder,especially depression, comparable research on psychoso-cial functioning is far less common. Even fewer stud-ies have examined religiosity as a potential resiliencefactor by testing whether protective effects that havebeen observed are limited to or of greater magnitudein higher-risk individuals compared to lower-risk indi-viduals. Some related research has compared the influ-ence of religious involvement on depression in high- andlow-stress groups; however, although such studies tendto support mitigation of the stress-depression associa-tion by religiosity,[27, 42] others have reported mixed ornonsignificant findings.[43–46]

Resilience has been conceptualized as the capacity towithstand hardship or other adverse circumstances or re-sist an inherent liability or predisposition that substan-tially elevates risk for depression, dysfunction, or otherdebilitating outcome.[47–49] Research by our group andothers suggests that early-onset depression is the key un-derlying mechanism explaining heightened vulnerabil-ity in offspring of depressed parents.[6, 8–10, 16] Accord-ingly, factors that elevate offspring risk for poor psy-chosocial function in the current study are defined as(1) lifetime MDD by T20, and (2) having a parent whoreceived treatment for moderate or severe depression.Religious or spiritual importance and attending servicesare regarded as possible protective factors that may fosterresilience in vulnerable youths. Resilience is operational-ized here as greater improvement in psychosocial func-tion in relation to increased religiosity in more vulnera-ble offspring compared to less vulnerable offspring. Weexamine whether such relations are limited to vulnerableoffspring versus less vulnerable offspring, and whetherdifferences in relations based on offspring vulnerabil-ity are significant. Because associations among religios-ity, offspring MDD, parent depression, and psychosocialfunction may vary by gender,[33, 43] daughters and sonsare examined separately. Two hypotheses are tested:

1. Because MDD has been linked to psychosocial dys-function and is the key mechanism by which par-ent depression affects offspring, we hypothesizedthat relations between increased religiosity (reli-gious/spiritual importance and service attendance) atT10 and improved psychosocial function over thenext decade would be limited to and (statistically)stronger in offspring with than offspring without life-time MDD, independent of parent depression status.

Depression and Anxiety

Research Article: Psychosocial Functioning in Adult Offspring 3

2. Because depressed parents may provide a less support-ive nurturing environment than nondepressed par-ents, offspring religiosity may serve as a substitutefor that deficit. We hypothesized that relations be-tween religiosity and improved psychosocial functionwould be stronger in offspring of depressed parentsthan offspring of nondepressed parents irrespectiveof lifetime MDD.

If those hypotheses were supported, findings from thecurrent study would meet specified criteria for recogni-tion of religiosity as a protective factor that builds re-silience in vulnerable individuals.

METHODSA full description of sampling and study procedures summarized in

this section may be found elsewhere.[15,50,51]

SAMPLESubjects are biological offspring of depressed and nondepressed par-

ents followed longitudinally. High-risk offspring were selected in 1982for presence of moderate or severe depression in one or both parentsreceiving treatment at an outpatient clinic at Yale University, NewHaven, CT. Nondepressed parents and their offspring were drawnfrom a 1975 longitudinal survey conducted in the same community;these parents had no history of depression or other psychiatric illnessas assessed by four lifetime diagnostic interviews. Initial interviews(at Time 1 [T1]) were conducted with 220 offspring from 91 fami-lies. All families were contacted for reinterview 2 years later (T2); 85families (93%) consented to participate. At T2, 174 (79%) offspringinterviewed at T1 were reinterviewed and 43 offspring from the samefamilies were interviewed for the first time, for a sample of 217 off-spring. Of the 263 offspring interviewed at T1 or T2 (or both), 222(84.4%) were reinterviewed at 10-year follow-up (T10); of the 41 notreinterviewed, 20 refused consent, 18 were not located, two were de-ceased, and one had Down’s syndrome. At 20-year follow-up (T20),83.3% (185/222) of the T10 sample were reinterviewed and comprisethe analytic sample in this study; of the 37 offspring not reinterviewedat T20, 26 refused consent, seven could not be located or scheduled,and four were deceased.

At T10, mean age of the current study sample (N = 185) was 29.0(range 17–38) years, 58.9% were female, and 68.1% were offspringof depressed parents (126/185). The 37 offspring reinterviewed atT10 but not T20 did not differ significantly from the current studysample with regard to parent depression, age, education, or T10 reli-gious/spiritual importance, service attendance, or GAS rating; how-ever, proportion of females was lower (35% vs. 59%, χ2 = 7.19,df = 1, P = .007).

The New York State Psychiatric Institute/Columbia University In-stitutional Review Board approved study procedures and protocols atall waves. Informed written consent was obtained from all study par-ticipants at each assessment.

MEASURESPsychosocial Functioning. Psychosocial functioning in the past

week was assessed with the GAS,[2] a 100-point continuous scale, 1representing the most dysfunctional symptomatic individual and 100representing the healthiest. To facilitate ratings, scoring criteria aredefined at 10-point intervals (1–10, 11–20, 21–30, etc.). A score of 81or above indicates above-average functioning and a score between 71and 80 indicates average functioning; scores below 71 indicate increas-

ingly poorer functioning. Trained clinicians blind to prior offspringassessments based their ratings on self-reported interview data cov-ering symptoms, deviant behavior, relationship quality, interpersonalskills, and role performance in educational and occupational domains.Mean (SD) GAS were 79.3 (12.1) at T10 and 80.4 (9.7) at T20 amongdaughters (N = 109), and 80.5 (12.3) at T10 and 81.8 (9.1) at T20among sons (N = 76).

GAS ratings were shown to distinguish between functioning priorto and during depressive episodes[52] and between responders and non-responders to depression treatment,[53] and to predict increased riskfor suicide attempt[54] and recurrent depression.[55] Unidimensionalmeasures of functioning are reported to correlate with measures ofpersonality and social qualities as well as with symptom severity andtreatment outcomes,[52,56] affording a person-centered (vs. disease-centered) approach to evaluating well-being. These measures also aremore sensitive to change over time than diagnostic measures[2,57,58]

and provide a useful tool for longitudinal research.Lifetime MDD. Offspring MDD was assessed at each wave by

semistructured diagnostic interview with the Schedule for AffectiveDisorders and Schizophrenia—Lifetime Version (SADS-L)[59] or, forthose under age 17 at T1 and T2, with the Kiddie-SADS (epidemi-ological version K-SADS-E).[60,61] Diagnostic interviews, conductedindependently by trained clinicians blind to parent clinical status andprevious offspring assessments yielded DSM-III diagnoses prior to T10and DSM-III-R diagnoses at T10.

At T20, the SADS-L interview was modified to meet DSM-IV cri-teria. Final diagnoses are based on the best estimate procedure,[62]

described elsewhere.[50] Rate of offspring lifetime MDD by T20 is57.8% in daughters (63 of 109) and 40.8% in sons (31 of 76).

T10 Religiosity. Offspring reported being predominantlyCatholic (116 of 185; 63.0%) or Protestant (31 of 185; 16.8%), orbelonging to one of several other affiliations (38 of 185). The ques-tion: “How important to you is religion or spirituality?” (1 = notimportant at all, 2 = slightly important, 3 = moderately important,4 = highly important) assessed personal religious/spiritual importance.Mean (SD) scores 2.85 (0.84) in daughters and 2.74 (0.93) in sons atT10 reflect nearly moderate importance. Attendance was assessed withthe question: “How often, if at all, do you attend church, synagogue,or other religious or spiritual services?’ (0 = never, 1 = less than oncea year, 2 = once or twice a year, 3 = about once a month, 4 = oncea week). Mean (SD) scores of 2.07 (1.37) in daughters and 1.95 (1.40)in sons are equivalent to attending once or twice a year. The predic-tive validity of these measures for MDD and other disorders has beenestablished.[1,32]

Social class. Social class, based on maternal report at study en-try, is classified by Hollingshead’s[63] five-point (1 = lower class to5 = upper class) two-factor index that combines parents’ educationand occupation levels into a single score. Mean (SD) scores of 2.72(1.0) for daughters and 2.68 (1.2) for sons reflect the predominantlyworking/middle class composition of the sample.

ANALYSESTo test study hypotheses while adjusting for nonin-

dependence among offspring from the same family, weemployed SAS GENMOD[64] with a generalized esti-mating equations approach.[65] All analyses were con-trolled (a priori) for age, social class, and denomination.As there were sufficient numbers of only Catholic andProtestant denominations to permit meaningful com-parisons, dummy coding was used, with Protestant off-spring compared to Catholic offspring (reference group).


4 Kasen et al.

Relations between importance and attendance (exam-ined simultaneously) and longitudinal change in psy-chosocial function were examined in daughters and sonsby risk factors: First, daughters (sons) with and with-out lifetime MDD were compared (independent of par-ent depression); second, among daughters (sons) withlifetime MDD, those with and those without depressedparents were compared; third, among daughters (sons)without lifetime MDD, those with and those with-out depressed parents were compared. To determinewhether relations between religious qualities and psy-chosocial function were modified by lifetime MDD (hy-potheses 1) or parent depression (hypothesis 2), inter-actions between these risk factors and religious qual-ities were tested by combining daughter (son) riskpairs.

The difference between T10 and T20 GAS scores(GAS20 − GAS10) is the dependent variable. Contraryto beliefs that change scores are unstable and introducebias due to regression to the mean, these scores provideunbiased estimates in many research designs, especiallywhen, as in the current study, baseline ratings of the de-pendent variable (T10 GAS scores) differ significantlybetween groups (daughters/sons with and without life-time MDD, see Table 1) and subjects are not randomlyselected into each group.[66–70] Religious/spiritual im-portance and service attendance are treated as contin-uous predictors and standardized, thus, magnitude ofthese effects are comparable. Lifetime MDD is codedas absent (0) or present (1). Given their widespread use,raw GAS scores are used to facilitate interpretation. Es-timates of change in GAS from T10 to T20 correspondto a 1 SD difference in level of religious/spiritual im-portance or service attendance. Accordingly, being 1SD higher than the standardized mean (0) is equiva-lent to the difference between nearly moderate impor-tance and nearly high importance, and between attend-ing once or twice a year to attending at least once amonth.

RESULTSSTUDY VARIABLE DIFFERENCES BY OFFSPRINGLIFETIME MDD

Table 1 summarizes demographic and clinical char-acteristics of daughters (N = 109) and sons (N = 76) asclassified by lifetime MDD status.

Daughters with lifetime MDD (N = 63) did not dif-fer significantly from daughters without lifetime MDD(N = 46) by social class, denomination, or T10 religiousqualities: however, they were older (31.07 years vs. 28.49years, P = .021), had lower GAS scores at T10 (74.60vs. 85.74, P < .001) and T20 (77.68 vs. 84.13, P < .001),and a higher rate of depressed parents (81.0% vs. 52.2%,x = 10.60, df = 1.62, P = .001).

Sons with lifetime MDD (N = 31) did not differ fromsons without lifetime MDD (N = 45) by age, social class,denomination, or T10 religious qualities; however, theyhad lower GAS scores at T10 (76.35 vs. 83.29, P =.014) and T20 (79.45 vs. 83.38, P = .064, marginal), anda higher rate of depressed parents (87.1% vs. 53.3%,P = .001).

T10 Religiosity and Change in PsychosocialFunctioning in Daughters. Estimates of change inpsychosocial function associated with importance andattendance are shown for daughters by lifetime MDDstatus (Table 2) and by both lifetime MDD and par-ent depression statuses (Table 3). Interaction coefficientsindicating significant (P < .05) differences in relationsbetween religious/spiritual variables and psychosocialfunction based on offspring lifetime MDD or parent de-pression are noted in the text (not tabled).

A higher level of service attendance at T10 was relatedto improved psychosocial function in daughters with life-time MDD, their mean GAS score increasing by 3.5points per 1 SD increase in attendance level (β = 3.488,SE = 1.477, P = .018); that association was not significantin daughters without lifetime MDD (β = −1.123, SE =1.824, P = .538). Neither religious/spiritual importance

TABLE 1. Study variable differences in daughters and sons by lifetime major depressive disorder (MDD) status

Daughters (n = 109) Sons (n = 76)Lifetime MDD No lifetime MDD Lifetime MDD No lifetime MDD

(n = 63) (n = 46) (n = 31) (n = 45)

T10 age, mean (SD) 31.07 (5.2) 28.49 (6.2)* 28.11(5.0) 27.10(5.6)Social class, mean (SD) 2.67 (0.97) 2.80 (1.07) 2.39 (1.09) 2.89 (1.30)Percentage of (N) Catholic (at T10) 57.2% (36) 65.2% (30) 61.3% (19) 68.9% (31)Percentage of (N) Protestant (at T10) 22.2% (14) 17.4% (8) 9.7% (3) 13.3% (6)Percentage of (N) other affiliations (at T10) 20.6% (13) 17.4% (8) 29.0% (9) 17.8% (8)Percentage of (N) depressed parent 81.0% (51) 52.2% (24)*** 87.1% (27) 53.3% (24)***T10 religious/spiritual importance 2.89 (0.76) 2.80 (0.93) 2.77 (0.96) 2.71 (0.92)T10 attendance at services 2.03 (1.3) 2.13 (1.4) 1.74 (1.21) 2.09 (1.52)T10 GAS (psychosocial function), mean (SD) 74.60 (12.4) 85.74 (7.8)*** 76.35 (11.41) 83.29 (12.12)*T20 GAS (psychosocial function), mean (SD) 77.68 (10.2) 84.13 (7.7)*** 79.45 (9.64) 83.38 (8.45)

Note: All means (SDs) are in raw score units.GAS, Global Assessment Scale.***P < .001; *P < .05 (significant difference between daughters [sons] with and daughters [sons] without lifetime MDD).



TABLE 2. Religiosity and change in psychosocial function over the next decade in daughters with and daughterswithout lifetime major depressive disorder (MDD)

Daughters with lifetime Daughters without lifetimeMDD (n = 63) MDD (n = 46)

Covariates β SE β SE

Age at T10 0.295 0.363 0.044 0.041Social class − 0.218 2.318 − 2.857* 1.213Protestant − 2.104 4.504 2.533 3.770Other affiliation 4.864 4.727 6.854 4.410Depressed parent − 3.637 4.796 − 1.684 2.412Religious/spiritual importance − 1.891 2.055 2.035 1.855Attendance at services 3.488a 1.477 − 1.123 1.824

Notes: Social class, religious/spiritual importance and attendance at services are standardized. Reference group for Protestant and Other affiliationsis Catholic. GAS ratings (of psychosocial function) are in raw score units.aP < .05.

at T10 nor parent depression was related to significantchange in psychosocial function in daughters with orwithout lifetime MDD; however, associations betweenreligiosity and psychosocial function were modified byparent depression: In daughters with lifetime MDD, par-ent depression interacted with both T10 attendance (β =8.093, SE = 3.988, P = .042) and importance (β = 9.327,SE = 4.424, P = .035); in relation to a higher level ofattendance, improvement in psychosocial function wasof greater magnitude and significant only in daughterswith both lifetime MDD and a depressed parent (β =4.572, SE = 1.776, P = .010) compared to daughterswith lifetime MDD but no depressed parent (β = 4.856,SE = 3.505, P = .166). In relation to higher level of im-portance, decline in psychosocial function was of greatermagnitude and significant only in daughters with lifetime

MDD without a depressed parent (β = −10.808, SE =3.286, P = .001) compared to daughters with both life-time MDD and a depressed parent (β = −1.214, SE =2.117, P = .566) (Table 3). In daughters without lifetimeMDD, parent depression interacted with T10 impor-tance (β = 4.856, SE = 2.456, P = .050): In relation tohigher level of importance, improvement in psychoso-cial function was of greater magnitude and significantonly in daughters of depressed parents (β = 4.993, SE =1.861, P = .007) compared to daughters of nondepressedparents (β = −2.440, SE = 2.273, P = .283).

T10 Religiosity and Change in PsychosocialFunctioning in Sons. Results for sons are shown inTable 4. A higher level of religious/spiritual impor-tance at T10 was related to improved psychosocial func-tion in sons with lifetime MDD, their mean GAS score

TABLE 3. Religiosity and change in psychosocial function over the next decade in daughters: lifetime major depressivedisorder (MDD) by parent depression status

Daughters with lifetime MDD Daughters with lifetime MDDwith depressed parents (n = 51) without depressed parents (n = 12)


Age at T10 0.484 2.782 0.554 0.366Social class − 0.609 2.663 3.953 4.096Protestant − 4.538 3.035 12.724 10.037Other affiliation 3.276 6.019 2.708 7.814Religious/spiritual importance − 1.214 2.117 − 10.808*** 3.286Attendance at services 4.572** 1.776 4.856 3.505

Daughters without lifetime MDD Daughters without lifetime MDDwith depressed parents (n = 24) without depressed parents (n = 22)


Age at T10 − 0.025 0.322 − 0.245 0.360Social class − 3.733**** 0.605 3.418 4.052Protestant 7.353 3.925 − 10.080 9.568Other affiliation 10.551** 4.120 1.403 7.8170Religious/spiritual importance 4.993** 1.861 − 2.440 2.273Attendance at services − 3.439 2.679 1.248 2.263

Notes: Social class, religious/spiritual importance, and attendance at services are standardized. Reference group for Protestant and other affiliationsis Catholic. GAS ratings (of psychosocial function) are in raw score units.****P < .0001; ***P <.001; **P < .01.


6 Kasen et al.

TABLE 4. Religiosity and change in psychosocial function over the next decade in sons with and sons without lifetimemajor depressive disorder (MDD)

Sons with lifetime Sons without lifetimeMDD (n = 31) MDD (n = 45)


Age at T10 − 0.149 0.412 0.204 0.356Social class 0.981 2.038 1.717 2.185Protestant − 1.358 3.687 3.039 6.623Other affiliation − 5.559 3.954 − 0.994 3.894Depressed parent 3.022 3.369 6.636 4.189Religious/spiritual importance 4.597a 1.126 3.138 2.348Attendance at services − 2.953 2.946 − 1.262 2.539

Notes: Social class, religious/spiritual importance, and attendance at services are standardized. Reference group for Protestant and other affiliationsis Catholic. GAS ratings (of psychosocial function) are in raw score units.aP < .0001.

increasing by 4.6 points per 1 SD increase in importancelevel (β = 4.597, SE = 1.126, P < .0001); that associationwas not significant among sons without lifetime MDD(β = 3.138, SE = 2.348, P = .181). Neither T10 ser-vice attendance nor parent depression was related to sig-nificant change in psychosocial function in sons withor without lifetime MDD; however, associations be-tween T10 importance and psychosocial function weremodified by parent depression: An interaction betweenparent depression and importance (β = 7.152, SE =1.926, P = .0002) indicated that in sons with lifetimeMDD, the relation between higher level of importanceand improved psychosocial function was of greater mag-nitude in those with depressed parents. Separate anal-ysis of sons with both lifetime MDD and a depressedparent indicated a 6.3 mean GAS score increase per 1SD increase in importance level (β = 6.314, SE = 1.302,P < .0001) (not tabled). There were too few sons withlifetime MDD without a depressed parent (N = 4) topermit a separate analysis.

DISCUSSIONLifetime MDD was related to significantly poorer psy-

chosocial functioning at T10 and T20 among daughters,and to significantly poorer psychosocial functioning atT10 and marginally poorer psychosocial functioning atT20 among sons. Among both daughters and sons, thosewith lifetime MDD were more likely to have a depressedparent. These results corroborate others’ findings of psy-chosocial deficits and impaired functioning for individu-als with a history of depression,[4, 18] and of elevated riskfor MDD in offspring of depressed parents;[15, 16] theyalso attest to the vulnerability of study offspring withthese risk factors.

Among daughters, improved psychosocial function-ing in relation to higher level of service attendancewas significant only in those with lifetime MDD, al-though the difference between daughters with and with-out lifetime MDD was not significant (and both groupsshowed improved functioning). That finding is com-patible with a recent meta-analysis indicating less dis-

tress in persons attending religious services,[71] andwith studies reporting fewer depressive symptoms[72]

and lower disorder rates[73, 74] among churchgoers. At-tending services has been conceptualized as a pub-lic feature of religiosity[75, 76] that increases socialnetworks, a source of both instrumental and emo-tional support.[77] Expanded social resources may rein-force attendance and better psychosocial functioning invulnerable persons.[6, 51] Social supports gained from at-tending services also could serve to compensate offspringwhose parents are unable to provide such support, whichmay explain why the relation between attendance andimproved psychosocial function was of greater magni-tude in daughters with both lifetime MDD and a de-pressed parent than daughters with lifetime MDD with-out a depressed parent.

Among daughters without lifetime MDD, improve-ment in psychosocial function was greater in relation tohigher level of religious/spiritual importance in thosewith depressed parents than in those with nondepressedparents. Such personal beliefs may be part of an over-arching religion/spiritual-based coping strategy[78] usedby individuals to compensate for insecure attachmentto parents, a putative risk among offspring of depressedparents.[9, 18] Attachment styles are formed in childhoodand based on quality of relationships with parents, withearly insecure attachments creating a negative prototypefor later social/interpersonal relationships[79] and lead-ing to higher levels of adult religiosity.[80] In fact, clergyare often consulted by individuals experiencing mentaldistress,[51, 81] and may be perceived as in loco parentisfigures among young adults whose parents are unable toprovide them with the instrumental or emotional sup-port they need.

In contrast, among daughters with lifetime MDD,those without depressed parents declined in psychosocialfunction with higher level of religious/spiritual impor-tance, differing from those with depressed parents, forwhom there was no significant relation. This seeminglyconflicting (and unexpected) finding raises the question,why would religious/spiritual importance be associatedwith a decline in psychosocial function in daughters with



lifetime MDD but without depressed parents, but im-proved psychosocial function in daughters without life-time MDD but with depressed parents? This inconsis-tency may be explained in part by potential differencesbetween these daughter subgroups that were not mea-sured in the current study. Daughters of depressed par-ents who by T20 did not develop MDD can be charac-terized as both vulnerable (due to parental depression)and resilient (as they demonstrated resistance to develop-ing depression despite high risk). It is plausible that theseyoung women may possess personal or external resourceswhich allowed them to utilize their religious/spiritual be-liefs as a positive force to resolve or adapt to life’s chal-lenges rather than to depend on a higher power to makethings right, a known negative coping mechanism thathas been linked to psychological distress.[28, 78]

Psychosocial functioning was not significantly relatedto attending services in sons, with or without lifetimeMDD. Women are more likely than men to seek out andtake part in religious activities that increase opportuni-ties for social benefits.[82] On the other hand, the findingthat improved psychosocial function in relation to higherlevel of religious/spiritual importance was of greatermagnitude in sons with than sons without lifetime MDD,and, among sons with lifetime MDD, in those with thanthose without depressed parents, corroborates reportsof increased benefits of religious beliefs in at-risk in-dividuals. For example, self-rated religious importancewas shown to predict decline in symptom severity over1 year in a patient sample,[83] whereas findings basedon a sample of high-risk offspring overlapping with thecurrent study sample indicated that religious/spiritualimportance reduced odds for future depression.[32] Vul-nerability in individuals may drive beliefs about reli-gious/spiritual importance; however, those beliefs mayin turn improve subsequent functioning.

Findings should be interpreted keeping study limita-tions in mind. Offspring were 100% Caucasian and pre-dominantly Catholic; therefore, caution should be exer-cised if generalizing findings to samples with other racialcompositions or religious affiliations. Religious/spiritualimportance and service attendance were assessed withone-item scales, whereas others have shown more com-prehensive and varied religious/spiritual dimensions tobe related to psychopathology.[84] MDD diagnoses insuccessive assessments were based on updated ver-sions of the DSM, which may have introduced methodbias,[85]although such bias is more salient to prevalenceestimates that are the basis for estimating service needs.The limited size of the sample and analyses by risk fac-tor status resulted in small cell sizes; accordingly, ex-treme caution should be exercised when interpretingstudy findings.

CONCLUSIONSFindings from the current study suggest that per-

sonal importance of religion or spirituality and attendingservices may serve as qualities that foster resilience in

vulnerable offspring, providing support for study hy-potheses. Daughters and sons with lifetime MDD or adepressed parent (or both) benefited significantly morefrom greater religiosity than their less vulnerable coun-terparts with regard to improved psychosocial function.These findings also extend research on religiosity as aprotective factor in high-risk individuals: First, we testeda risk-resilience model by comparing offspring on thepresence of two established risk factors assessed multi-ple times by clinical diagnostic interviews: preadult on-set MDD and having a depressed parent. Second, dueto the longitudinal design we were able to test the pre-dictive utility of religious qualities on change in psy-chosocial functioning over one decade. Third, groupdifferences in relations between religious qualities andpsychosocial function based on vulnerability status weretested in interaction analyses for significance. The find-ing that, among daughters without lifetime MDD, thosewith depressed parents showed greater improvementin psychosocial function with a higher level of reli-gious/spiritual importance than those without depressedparents is compatible with our hypothesis that vulner-able offspring would benefit more from religious in-volvement than less vulnerable offspring. Nonetheless,as these young women were resilient against developingMDD despite their high-risk status (i.e., as daughters ofdepressed parents), they also may have had the where-withal to use positive religious coping strategies whenproblems occurred, a potential outcome that warrantsfurther attention. Finally, these findings suggest that ex-amining religiosity in vulnerable individuals may provideclinicians with an effective tool for fostering better psy-chosocial functioning.

Acknowledgments. These analyses were funded bythe John Templeton Foundation. Data collection wasfunded by the National Institute of Mental Health (2 R01MH36917) including a supplement from the NationalInstitute of Drug Abuse.

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