We note with interest the conclusion of King et al's study, ^{Reference King, Marston, McManus, Brugha, Meltzer and Bebbington1} which states that ‘people who have a spiritual understanding of life in the absence of a religious framework are vulnerable to mental disorder’. A second, equally important finding is that ‘religious people were similar to those who were neither religious nor spiritual with regard to the prevalence of mental disorders, except that the former were less likely to have ever used drugs […] or be a hazardous drinker’. This lack of difference, as with the key conclusion concerning those who are spiritual but not religious, runs counter to the substantial body of evidence collated by Koenig et al, ^{Reference Koenig, Mccullough and Larson2-Reference Koenig4} who conclude that religion/spirituality are generally associated with better mental health.

King et al point out that ‘the cross-sectional nature of the data means that we cannot attribute cause and effect to any relationship between spiritual beliefs and mental health’, and they draw attention to important differences between the UK and North America (where the bulk of previous research has been conducted). The headline conclusion of the study may nonetheless leave professionals and others with the impression that ‘spirituality’ is bad for one's health, an impression that we believe would be mistaken.

Our post-modern culture is geared increasingly to a way of life that does not question deeply such things as the meaning of birth and death, why we are here and what it is all for. Instead, social norms often emphasise aspiration to goals of material ambition and success. For many, it seems that this can result in estrangement from the most fundamental spiritual needs and values of humankind (a theme that comes up at meetings of the Royal College of Psychiatrists' Spirituality and Psychiatry Special Interest Group).

With the decline in religious observance, the numbers of ‘spiritual but not religious’ (19% in this study) are rising, and perhaps more so in the UK than in the USA. Wrestling with the deepest questions about life is in the nature of the human condition. However, without a religious faith that can also provide a person with both community and support, the road is long and hard and the journey often a lonely one. Previous research (Pargament, ^{Reference Pargament5} pp. 111-128) suggests that spiritual struggles have the potential for either good or bad mental health outcomes, and we wonder whether the kind of society in which we are now living is less than supportive of the good outcome.

We know that spiritually informed therapies are effective in the field of substance misuse, ^{Reference Cook, C, Powell and Sims6} and mindfulness-based approaches derived from spiritual practice are now recommended by the National Institute for Health and Clinical Excellence for relapse prevention of depression. ⁷ Further, we believe that spirituality has an important secular dimension which is finding expression in the recovery movement in psychiatry.

We must therefore guard against any misreading of this study by King et al that would suggest spirituality is bad for mental health. We do, however, support strongly research that is able both to delineate causal pathways and provide comparison between the cultures and contexts of the USA and the UK.