]>AMGP61071S1064-7481(12)61071-910.1097/00019442-199700510-00006American Association for Geriatric PsychiatryFIGURE 1Simplified model of the interactions between stress and adjustment, with factors that might influence the relationship (adapted, with permission, from Koenig et al.2)TABLE 1Correlation matrix of independent, mediating, and dependent variables (Pearson r)Life SatisfactionPsychological DistressDepressionMasterySocial SupportReligious CommitmentFunctional status0.170.160.020.23**−0.03−0.11Life satisfaction—0 49****0.49****0.51****0.50****0.30***Psychological distress——0.72****0.46****0,41****0.18*Depression———049***0.52****0.40****Mastery————0.40****0.38****0.05 <P < 0.10;**P < 0.05;***P < 0.01;****P < 0.001.TABLE 2Stepwise multiple-regression models for mental health outcomesModelCumulative R2FchangeR' changePLife Satisfaction Mastery0.2670.0001 Mastery0.3696.Π0.1020.0004  + Social Support0.0005 Mastery0.3956.300.0260.0154  + Social Support0.0003  + Functional Status0.0689 Mastery0.4203.090.0250.0433  + Social Support0.0011  + Functional Status0.0310  + Religious Commitment0.0676Psychological Distress Functional Status0.2850.0001 Functional Status0.3877.090.1020.0001  + Social Support0.0004 Functional Status0.4156.640.0280.0001  + Social Support0.0114  + Mastery0.0538Depression Mastery0.285 Mastery0.3827.650.0970.0002  + Social Support0.0006 Mastery0.4354.500.0530.0005  + Social Support0.0029  + Religious Commitment0.0075The authors gratefully acknowledge the cooperation of the Ohio Province of the Sisters of Notre Dame de Namur.Funding was provided in part by the John Templeton Foundation and Radnor, Penn, and Monarch Pharmaceuticals, a division of King Pharmaceuticals, Bristol, TN.Regular ArticlePsychosocial Predictors of Mental Health in a Population of Elderly Women Test of an Explanatory ModelDavidBienenfeldM.D.*Harold G.KoenigM.D., M.H.ScDavid B.LarsonM.D., M.S.P.H.Kimberly ASherrillM.D., M.P.H.Department of Psychiatry, Wright State University School of Medicine*Address correspondence to Dr. Bienenfeld, Department of Psychiatry, Wright State University School of Medicine, Box 927, Dayton OH 45401-0927The understanding of adjustment to aging calls for models that illustrate the interaction of psychosocial and health factors. The authors surveyed a group of retired Catholic sisters, examining the contributions of psychosocial f actors and religiousness to life satisfaction, psychological distress, and depression. Life satisfaction was best explained by a four-factor model that included mastery, social support, physical functioning, and religious commitment. General level of distress was best predicted by physical functioning, social support, and mastery, but not religiousness. Depression, on the other hand, was predicted by mastery, social support, and religious commitment. These data are consistent with a proposed model in which internal, external, and coping resources mediate the psychological impact of impaired functional status.An important task facing geriatric psychiatry is the elucidation of factors that may predispose to the development of mental disorders and the identification of those that may protect against the emergence of psychopathology.1 Such data are most useful when put into meaningful clusters that translate into coherent and clinically applicable explanatory models.Aging presents multiple stressors, including changes in health, loss of loved ones, diminution of functional capacities, and alterations of societal roles. Different individuals, however, experience different degrees of distress and disruption in the face of comparable stressors. Mediating variables may be grouped into internal, external, and coping strategies.2 Internal resources are part of the individual's make-up, like hereditary factors, personality, and life history. External resources are those elements outside the personality that help to buffer against stress, for example, health, adequate finances, or emotional support from others. Coping strategies, on the other hand, are those observable behaviors or thought processes by which the individual attempts to diminish the adverse effects of stressors.3 Strictly defined, “coping” describes only behaviors implemented to modify stressors. However, psychological processes that alter the perception or appraisal of stressors (beliefs, for example) may also serve this coping function.A number of investigators have attempted to model how persons adapt to stress. Folkman and Lazarus4 examined coping strategies as mediators of emotion. Their model includes internal resources, like personality, as well as problem-focused and emotion-focused coping behaviors, but largely excludes external resources, like social support. They report that mastery and interpersonal trust (personality factors), primary appraisal, and coping behavior can explain a significant amount of the variance in psychological symptoms after a given stressor.5 With few exceptions,6 they have worked with primarily nongeriatric samples.Russell and Cutrona7 examined the effects of external resources on adaptation by older adults to stressful life events and daily hassles, finding that social support plays an important role as a buffer against depressive symptoms. Studying a highly stressed group of caregivers of Alzheimer's (AD) patients, Vitaliano and colleagues8 examined a model that sees psychological distress as the result of several factors, including type and level of stress, individual vulnerability, and presence of psychological and social resources. Their research showed that persons with high vulnerability and low resources had higher distress levels and that perception of changeability (or locus of control) influenced the amount of stress that caregivers perceived. Finally, Haley and colleagues' work,9 which also examined adaptation in caregivers to dementia patients, underscored the importance of looking at multidimensional models of stress and coping. Like other investigators, they found that social support and coping behaviors mediated the relationship between stress (caregiver burden) and adaptation (life satisfaction, depression).None of the studies, however, examined stressors, internal resources, external resources, coping behaviors, and mental health outcomes in elderly subjects all within a single model. In particular, no study has examined religious commitment as a potential factor in the coping process. Given the widespread use of religion by older adults in coping with distress, our proposed model provides a unique contribution to the literature because it integrates religious commitment with other internal and external resources that mediate the effects of stressors on emotional health.Religious commitment has increasingly kindled the interests of mainstream researchers in aging. A number of studies have been published demonstrating the importance of religious factors for the mental well-being of older adults.2,10–16 Religious coping behaviors (prayer, depending on God, etc.) and degree of religious commitment have been related to greater subjective well-being, independent of the effects of health, social support, and financial status.15,17 Nevertheless, only a few studies have empirically examined the effects of religious commitment as a coping behavior in adaptation to poor health or physical disability. Sherrill et al.18 found that studies examining the effects of a religious variable on health represented less than 4% of quantitative articles in the major journals of geriatrics and gerontology from 1985 through 1991.Here, we describe a model where the relationship between biopsychosocial stressors and psychological adjustment is mediated by internal resources (hereditary factors, personality factors, life experiences), external resources (health, wealth, social support), and coping strategies (religion; Figure 1). We test this model by choosing single indicators for each of the domains above. We see the relationship between physical disability (biopsychosocial stressor) and life satisfaction, level of psychological distress, and depressive symptoms (indicators of adjustment) as being mediated by mastery (internal resource), social support (external resource), and religious commitment (coping strategy).Testing a conceptual model such as ours would require a very large sample to control for the potentially large number of variables that could confound these relationships. However, a design that samples a narrow subgroup of subjects with similar demographic characteristics would make such an investigation feasible. Our study has adopted such an approach by studying a group of retired Catholic sisters. This sample naturally controls for a number of important demographic variables: 1) gender (women only); 2) marital status (single); 3) economic status (uniform by definition); 4) educational and occupational histories (virtually all teachers or administrators); and 5) retirement status. With life experiences and financial status now controlled, we are free to estimate the relationships between other variables in our model.We hypothesize that subjects who experience poorer physical health (i.e., greater functional disability) will have lower life satisfaction, greater psychological distress, and more depression. Conversely, those with greater mastery, social support, and religious commitment will experience greater life satisfaction, less depression, and less general psychological distress.METHODSSample and ProcedureWe identified a group of retired Catholic sisters, or “women religious” (“Women religious” refers to both nuns and sisters, titles that are not interchangeable, contrary to common usage; nuns are cloistered—sisters need not be. “Religious” in this context is often used as a noun, for example, “Catholic religious.”); subjects were living in two retirement/nursing homes in Cincinnati and Columbus, Ohio, and invited all 128 women to complete a 144-item self-administered questionnaire. Of those, 24 lived in a nursing home setting and 104 in two retirement homes. Eighty-nine (70%) agreed to participate and completed a questionnaire mat was divided in half and administered over 2 consecutive days. Most of the women completed the questionnaire without assistance, although eight were assisted by staff members because of visual or physical limitations.VariablesBiopsychosocial StressorLevel of physical disability was the stressor chosen for this analysis. Questions were taken from the Philadelphia Geriatrics Center Multidimensional Assessment Instrument (PGC-MAI), a measure widely used in the assessment of functional status.19,20 We used two subscales of the PGC-MAI: the instrumental activities of daily living scale (IADL) and physical self-maintenance scale (PSMS). For the IADL scale, a few items were modified to take into account the institutional environment. Three inapplicable items were dropped (grocery shopping, handling own finances, and doing own handyman work) because of their lack of relevance. One item in the PSMS, frequency of soiling or wetting, was dropped at the request of the Catholic order because it was felt to be too sensitive for this group.Indicators of AdjustmentLife satisfaction was measured by use of the 20-item Life Satisfaction Index A (LSIA) of Neugarten et al.,21 a commonly used life satisfaction scale in gerontological research. Psychological distress was assessed by the 28-item version of the General Health Questionnaire (GHQ).22,23 The GHQ inquires about symptoms of anxiety, depression, and somatization. In order to maintain consistency with the life satisfaction variable, scoring was performed so that higher distress yielded a lower score. The 14-item depression subscale from the GHQ was scored separately to assess depression as an independent variable.24 Scoring was loaded in the same way as for psychological distress, so that higher scores indicated better adjustment, that is, less depression.Resources and Coping VariablesThe concept of mastery (an internal resource), as conceptualized by Pearlin and colleagues,25 represents the degree of control or influence a person perceives over his or her environment or future. A number of studies suggest that individuals who endorse a greater sense of mastery over the events in their lives are less likely to experience depression and anxiety.25–27 As noted earlier, Folkman and colleagues empirically confirmed the principal role that mastery plays in coping responses that facilitate successful adaption to stressful situations.5 In the current study, we assessed degree of perceived mastery over the environment by use of Pearlin and Schooler's Mastery Scale.25Social support (an external resource) has been shown in a wide range of studies28–30 to buffer against stressful life events. Social support, however, has proven on further analysis to be more than unidimensional. In reviewing the literature, George31 has identified at least three types of support: 1) social network—the resources available to provide instrumental services and emotional support; 2) tangible support—the specific assistance actually provided; and 3) perceptions of social support—the subjective evaluation of the availability and value of such support. Most studies identify perceived support, not objectively tangible support, as the dimension most strongly related to the mental health status of elderly persons.32,33 For this reason, we examine perceived social support here, using Cohen's Interpersonal Support Evaluation List,34 which measures the perceived availability of emotional and instrumental support.Religious commitment (coping strategy) was assessed by a seven-item instrument adapted from the work of Kauffman.35 This scale was modified to reflect the expected high degree of religious commitment in this group. Questions were left unchanged, but response options were broadened. In asking about private prayer, for example, the original Kauffman scale offered three choices, from “seldom/never” to “frequently.” Our survey offered six choices, from “less than once a week” to “more than twice a day.” Questions covered both the behavioral and experiential dimensions of religious commitment,13 including frequency of private prayer and perceived closeness to God.Data AnalysisMeans and standard deviations (SD) were calculated for each variable, and Pearson bivariate correlations were examined (Table 1). Because of the lack of a control group for comparison, we located previous studies for external comparison of mean scores on two key outcome variables, the LSIA and GHQ. We used comparison data from the originators of these two scales.21–24 To determine the independent relationships between variables in our model, we analyzed the data by use of stepwise multiple regression. A separate regression analysis was conducted for each of the three dependent variables (life satisfaction, depression, and distress).RESULTSOur sample ranged in age from 65 to 92 years old. They scored significantly higher (t = 3.8; P < 0.001) on Neugarten's measure of life satisfaction (14.7 ± 3.7), compared with the community-based sample in the metropolitan Kansas City area in her original work (12.4 ± 4.4).21 Also, the likelihood of being distressed, as evidenced by score on the GHQ, was lower in our sample, compared with the results of work by the scale's originators, Goldberg and Hillier.24 Only 21.6% of our sample, compared with 41% of a group of 553 medical outpatients, scored ≥ 5 on the GHQ, a difference that was statistically significant (χ2 = 8.63; P < 0.005).24 Thus, based on these external comparison groups, our sample was significantly more satisfied with their lives, and less likely to experience psychological distress.Univariate analyses demonstrated a strong correlation between mastery and social support, as well as between social support and religious commitment (Table 1). Religious commitment was also positively and significantly related to life satisfaction and mastery, and inversely related to depression, that is, positively related to adjustment (r = 0.40; P < 0.0001). When outcome variables (indicators of adjustment) were examined by means of stepwise multiple regression, the following results were obtained (Table 2). Life satisfaction was best explained by a model consisting of mastery, social support, physical status, and religious commitment (in that order); mastery and social support alone accounted for about one-third of the variance. Thus, following the model in Figure 1, we found evidence that internal resources (mastery) and external resources (perceived social support) buffered against the adverse effects of physical disability on life satisfaction. Religious commitment also helped to mediate the relationship between physical disability and life satisfaction, but to only a minor degree.Although our stressor, physical disability, was only weakly negatively related to life satisfaction in the first regression analysis, it was strongly related to psychological distress in the second regression analysis. In fact, physical disability by itself explained over 28% of the variance in psychological distress. Social support, on the other hand, accounted for a significant portion of the variance in psychological distress (> 10% P < 0.0005), again providing evidence for our model that sees social support as buffering the ill effects of physical disability on distress level. Mastery contributes further to the variance in psychological distress, but at a marginally significant level (2.8% P = 0.05). Taken together, physical disability, social support, and mastery accounted for 42% of the variance in psychological distress.Our third outcome variable, depression, was surprisingly unrelated to physical disability. Nevertheless, it was strongly related to mastery, which accounted for over 28% of the variance in depression. Also, social support and religious commitment added 10% and 5%, respectively, to the variance in depressive symptoms, suggesting that these variables along with a sense of mastery, may help buffer the adverse effects of stressors on mood state. Again, these three variables together accounted for almost 44% of the variance in depression.DISCUSSIONThese data lend empirical support to our proposed model, providing evidence for the importance of internal resources (mastery), external resources (social support), and coping (religious commitment) in buffering the negative effects of physical disability on psychological adjustment in later life. The results are also consistent with a substantial body of research that shows a relationship between physical disability and emotional distress,36–38 and they demonstrate important roles for social support,7–9 mastery,5,39 and coping behavior3,4,9 in mediating the relationship between psychosocial stress and adjustment.In this analysis, the stressor and buffering factors contributed measurably, and differentially, to mental outcomes. Life satisfaction, a broad measure, was only weakly associated with physical disability, but was strongly related to mastery and social support. Religious commitment was also a weak contributor to life satisfaction. Psychological distress, on the other hand, is a more specific mental health outcome than life satisfaction. As measured in this study, it includes anxiety and somatization. It had the strongest relationship with physical disability, our biopsychosocial stressor; both social support and mastery, on the other hand, were inversely related to psychological distress, as predicted by our model.The explanatory model for depression, the most specific mental health construct, was different from either life satisfaction or psychological distress. Like life satisfaction, depression was weakly correlated with physical disability, but strongly and inversely correlated with mastery and, to a lesser degree, social support and religious commitment. Clinically, depression is marked by a sense of helplessness, the opposite of mastery. Social supports are known to be perceived as unavailable or unreliable to depressed persons, although it is unclear whether the absence of social support makes one vulnerable to depression, or whether depression causes one to perceive existing social supports as unavailable, unreliable, or undeserved.7,27,31,33The inverse relationship between religious commitment and depression, independent of social support or mastery, is noteworthy. The early (and even more recent) psychiatric literature has portrayed religious commitment as a symptom of neurosis40 or evidence of psychological disturbance.41 This study adds weight to recent findings of an inverse relationship between religiousness and depression.16,42 Of course, given the cross-sectional nature of our data, as with social support, we cannot say whether greater religious commitment causes less depression or whether depression causes less religiousness. There are both longitudinal data16 and interventional data,43 however, that support the former idea.We recognize that assigning religious commitment as primarily a coping variable is somewhat arbitrary, because it may to some extent serve as an internal and external resource. These constructs, then, may not be entirely independent of each other. First, religious commitment may act as an internal resource by enhancing mastery and making persons less psychologically vulnerable to stressors. Strong religious commitment provides a belief system that may increase mastery by giving the individual a sense that he or she has more control over their situation; that is, if he or she believes in an all-powerful God who cares about him or her and will respond to prayers, then the person will feel that he or she is not powerless, but instead can take control over a situation by influencing God to act on his or her behalf. Second, religious commitment may enhance social support (external resource) by encouraging involvement in the religious community, which may broaden one's social support network (particularly among elderly persons, whose major voluntary social participation outside family is the church); furthermore, by encouraging people to support and care for others, religious beliefs (the “social gospel”) may help form a more supportive community, which helps to reduce the adverse effects of stress.Nevertheless, in our model, we see religious commitment as primarily a coping strategy because it influences how persons perceive and respond to stressors (i.e., cope), independent of internal and external resources. Indeed, our results would suggest that although religious commitment is positively correlated with both mastery (internal resource) and social support (external resource), there is still an independent effect for religion on life satisfaction and depression. Religious belief may facilitate coping directly by altering the perception of the stressor so that consequences are not seen as disastrous. For example, poor physical health may indicate to the older person that he or she is getting closer to death; if the elder believes that there is an afterlife where he or she will be reunited with family and life will improve, then the prospect of dying is not as terror-filled. Finally, religious commitment may facilitate adaptation by providing both cognitive (trusting God, turning problems over to God) and behavioral (praying to God, singing, participating in communal worship) tools for coping with distress.There are many factors accounting for the unexplained variance in our dependent variables (life satisfaction, general distress, depression). One is measurement error. For example, psychosocial variables, like religious commitment, social support, mastery, and the like, cannot be measured with the same degree of accuracy as physiological variables, like blood pressure or heart rate. Consequently, in mental health or social science research, the explained variance in outcome is seldom greater than 50%. Second, we did not measure other important internal resources (hereditary effects or genetic vulnerability) and external resources (health problems not affecting functional status) that could have contributed substantially to our mental health outcomes. Third, there may be factors that we are not yet aware of that affect mental health (for example, until recently religion was not thought to contribute to mental health in any meaningful way).Our study group is unique in several ways. Not only does the sample represent a narrowly defined group demographically and vocationally, but also, as the data suggest, there are other distinctions. Compared with several other studies using general, community-based populations,22–24 our sample of women appears more satisfied with life and less likely to report psychological distress. This observation is all the more striking given the higher prevalence of certain mental disorders, especially depression, in women.44,45 Although only a handful of other studies have looked at mental health outcomes in Catholic religious groups, virtually all have reported similar differences between lay and Catholic religious.46–48Moore46 and Kelly47 both concluded that mental illness was less common among women religious than in the general population. Kvale and colleagues48 studied morale among retired elderly nuns, and found that on nearly all measures, the sisters had higher morale than their lay counterparts. Our study confirms these findings. Despite the lack of spouses and children, and despite being retired from active employment, these women experienced better emotional well-being than women in the general population. However the mechanism explaining the better mental health functioning of this group remains unclear. The healthier outcome could be related to some shared characteristic, such as the overall high degree of religious commitment, the predictable and reliable financial situation, or the more ready access to health care and monitoring.Perhaps women religious are not as distinctive a group as one might assume, at least in terms of the impact of stress on mental well-being. Magee,49 studying 150 retired women religious, reported that the conditions contributing to the life satisfaction of older adults in general also pertained to his study population. Furthermore, many stressors encountered by Catholic religious professionals are similar to the stressors facing many other older Americans. These stressors include the potential for alienation from society and the personal problems they must handle to deal with the changing world. For example, Kennedy and colleagues50 reported that church reforms introduced role confusion, change in occupational focus, and ideological questioning among a group of Catholic priests they studied. Stressors such as these may contribute further to poorer mental health outcomes through the same mechanisms we described previously: loss of mastery and diminished social support.Despite the homogeneity of this sample, it did generate scores on religious commitment that were normally distributed, although still clustered at the high end of the scale (mean score, 27.3 ± 5.0 out of a possible 35; range: 10–35). Perhaps development of a more complex model of religious coping would be a useful approach in future research.17This is, of course, a unique sample of unmarried, celibate, elderly women who have devoted their lives to their religious vocation. Thus, in these and perhaps other unmeasurable ways, this sample is different from the general population of older adults in America. How these differences may have biased results is difficult to predict. Many women in their later years, however, do find themselves unmarried and celibate, living near or with each other, and often congregating in church. Furthermore, the fact that we found similar relationships in this sample to those of other researchers working with nongeriatric and elderly populations helps to dispel some of these concerns. Another potential bias is the lack of information about nonresponders. If nonresponders were selectively impaired in some way that made them refuse the study, such as having poor cognition, mental illness, or physical debility, our study sample may have been a self-selected healthier group. The relatively high response rate, however, adds confidence to the study findings.SUMMARY AND CONCLUSIONSWe have developed and tested a multidimensional stress and coping model in a selected and homogenous population of elderly Catholic women religious. Conceptualizing physical disability as a biopsychosocial stressor and life satisfaction, psychological distress, and depression as mental health outcomes, we found that internal (mastery), external (social support), and coping resources (religious commitment) predicted better mental health in this population. Our internal resource (sense of mastery) was the strongest single predictor of variance in two separate mental health outcomes, life satisfaction and depression, accounting for 27% for life satisfaction and 29% for depression. Higher level of perceived social support (external resource) was also significantly related to all three mental health outcomes. Finally, religious commitment, often unexamined in models of coping and adaptation, emerged as a positive predictor of life satisfaction and lower levels of depression. These findings further support the validity of a multidimensional coping model for adaptation to biopsychosocial stressors in late life.What implications do these findings have for clinicians caring for elderly patients? First, as in other studies, we found a link between disability and emotional distress. This finding should support close attention to the emotional adjustment of older persons experiencing severe disability from health problems. Optimizing physical functioning and the capacity for independent living must be among the first goals of the treating physician. Second, in counseling disabled elders with emotional disorder or those at risk for it, clinicians should pay particular attention to the patient's sense of helplessness or powerlessness about his or her situation. Discussing with patients the different aspects of their life that they can and cannot control may help to resolve some of these feelings. Third, it is important to encourage involvement in social activities that broaden the patient's support network, particularly activities with age-matched peers who may form a support group for them. 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