Mental health disorders constitute a formidable public health challenge across India, with recent epidemiological surveys indicating that approximately 150 million individuals require active mental healthcare interventions nationwide. The National Mental Health Survey 2015-16 documented prevalence rates exceeding 10% for common mental disorders, highlighting the substantial burden these conditions impose on individuals, families, and healthcare systems. Within this context, suicide represents a particularly devastating outcome, with India accounting for nearly one-third of global suicide deaths among young adults aged 15-29 years. Contemporary psychiatric research increasingly recognizes the importance of protective factors that may buffer against adverse mental health outcomes. Among these, religious involvement and psychological resilience have garnered significant scientific attention due to their potential therapeutic implications. Religious engagement encompasses diverse dimensions including organized worship attendance, private spiritual practices, and intrinsic faith-based beliefs that provide meaning and purpose during adversity. Psychological resilience represents the capacity to adapt positively when confronting significant life challenges, trauma, or ongoing stressors. Emerging evidence suggests that religious involvement may serve protective functions against psychiatric morbidity through multiple pathways. Meta-analytic reviews consistently demonstrate inverse relationships between various religiosity measures and depression, anxiety, and suicidal behaviors across diverse populations (1). Clinical studies indicate that higher resilience levels predict better treatment outcomes, faster recovery, and reduced risk of suicide attempts among psychiatric patients (2). A landmark Brazilian study among depressed inpatients found that intrinsic religiosity significantly predicted resilience levels and fewer suicide attempts, independent of clinical severity (3). India's complex religious landscape offers unique advantages for examining these relationships. The subcontinent hosts diverse faith traditions with religious observance remaining central to most citizens' lives, with over 85% of Indians considering religion very important personally. The Duke University Religion Index (DUREL) and Connor-Davidson Resilience Scale (CD-RISC) have been successfully validated across numerous cultural contexts including Indian populations (4,5). This investigation aimed to examine associations between religious involvement, psychological resilience, and suicide risk among psychiatric outpatients in Chennai, Tamil Nadu, using these validated instruments to identify predictors of resilience for targeted interventions.

This cross-sectional observational study was conducted at the Department of Psychiatry, Tagore Medical College & Hospital, Chennai, Tamil Nadu during January-June 2024. The Institutional Ethics Committee approved the study protocol. Participants comprised adult psychiatric outpatients recruited through consecutive sampling during routine clinic visits. Inclusion criteria specified age 18-65 years, confirmed psychiatric diagnosis per ICD-10 criteria, ability to comprehend Tamil or English, stable mental state permitting assessment, and written informed consent. Exclusion criteria included acute psychotic episodes with severe thought disorder, severe cognitive impairment, active substance intoxication, and refusal to participate. Sample size calculations assuming medium effect correlations between religiosity and resilience determined a minimum requirement of 84 participants. The target sample was increased to 180 to accommodate incomplete responses and enable subgroup analyses. Demographic data were collected through structured questionnaires including age, gender, education, occupation, marital status, income, religious affiliation, illness duration, and psychiatric diagnosis. The Duke University Religion Index (DUREL) measured organizational religious activity, non-organizational religious activity, and intrinsic religiosity through five items with scores ranging 5-15. The Connor-Davidson Resilience Scale (CD-RISC-25) assessed psychological resilience through 25 items with scores ranging 0-100. The Columbia Suicide Severity Rating Scale (C-SSRS) evaluated suicide risk through structured clinical assessment providing categorical risk classifications. Investigators conducted assessments in private clinic rooms ensuring confidentiality. Participants completed questionnaires independently with assistance provided when needed. Statistical analyses using SPSS included descriptive statistics, Pearson correlations, analysis of variance, and multiple linear regression with significance set at p < 0.05.

Demographic Characteristics The study included 180 participants attending the psychiatry outpatient department at Tagore Medical College, Chennai. The mean age of participants was 34.2 ± 11.7 years (range: 18-65 years). Gender distribution showed 58.3% (n=105) males and 41.7% (n=75) females. Educational status revealed that 42.2% (n=76) had completed secondary education, 31.1% (n=56) had higher secondary education, 18.9% (n=34) were graduates, and 7.8% (n=14) had primary education only. Regarding marital status, 61.1% (n=110) were married, 32.2% (n=58) were unmarried, and 6.7% (n=12) were divorced or widowed. Employment status demonstrated that 48.9% (n=88) were employed, 29.4% (n=53) were unemployed, 12.8% (n=23) were students, and 8.9% (n=16) were homemakers. Monthly family income distribution showed 36.7% (n=66) earning below ₹20,000, 34.4% (n=62) earning ₹20,000-40,000, 21.1% (n=38) earning ₹40,000-60,000, and 7.8% (n=14) earning above ₹60,000. Table 1: Sociodemographic Characteristics of Study Participants (N=180) Variable Category Frequency (n) Percentage (%) Age Group 18-25 years 48 26.7 26-35 years 62 34.4 36-45 years 41 22.8 46-55 years 21 11.7 56-65 years 8 4.4 Gender Male 105 58.3 Female 75 41.7 Education Primary 14 7.8 Secondary 76 42.2 Higher Secondary 56 31.1 Graduate 34 18.9 Religion Hindu 142 78.9 Muslim 21 11.7 Christian 15 8.3 Others 2 1.1 Employment Employed 88 48.9 Unemployed 53 29.4 Student 23 12.8 Homemaker 16 8.9 Clinical Characteristics Psychiatric diagnoses distribution revealed major depressive disorder in 35.6% (n=64) of participants, anxiety disorders in 28.3% (n=51), bipolar disorder in 16.7% (n=30), schizophrenia in 12.2% (n=22), and other psychiatric conditions in 7.2% (n=13). Duration of mental illness showed that 41.1% (n=74) had illness duration of less than 2 years, 32.8% (n=59) had 2-5 years, 16.7% (n=30) had 5-10 years, and 9.4% (n=17) had illness duration more than 10 years. Religiosity Assessment Using the Duke University Religion Index (DUREL), the mean total religiosity score was 11.8 ± 3.4 (range: 5-15). For individual domains, organizational religious activity (ORA) showed a mean score of 3.2 ± 1.6, non-organizational religious activity (NORA) had a mean score of 3.8 ± 1.4, and intrinsic religiosity (IR) demonstrated a mean score of 4.8 ± 1.2. Based on DUREL total scores, participants were categorized as having low religiosity (scores 5-8) in 18.9% (n=34), moderate religiosity (scores 9-12) in 52.2% (n=94), and high religiosity (scores 13-15) in 28.9% (n=52). Table 2: Detailed Religiosity Assessment using Duke University Religion Index (DUREL) (N=180) DUREL Components Score Distribution Frequency (n) Percentage (%) Mean ± SD Organizational Religious Activity (ORA) 3.2 ± 1.6 Never 1 32 17.8 Once a year or less 2 28 15.6 A few times a year 3 43 23.9 A few times a month 4 35 19.4 Once a week or more 5 42 23.3 Non-organizational Religious Activity (NORA) 3.8 ± 1.4 Rarely or never 1 18 10.0 A few times a month 2 25 13.9 Once a week 3 48 26.7 Two or more times/week 4 46 25.6 Daily 5 43 23.9 Intrinsic Religiosity (IR) - Item 3 4.2 ± 1.0 Definitely not true 1 8 4.4 Tends not to be true 2 12 6.7 Unsure 3 28 15.6 Tends to be true 4 67 37.2 Definitely true 5 65 36.1 Intrinsic Religiosity (IR) - Item 4 4.1 ± 1.1 Definitely not true 1 11 6.1 Tends not to be true 2 15 8.3 Unsure 3 32 17.8 Tends to be true 4 58 32.2 Definitely true 5 64 35.6 Intrinsic Religiosity (IR) - Item 5 4.3 ± 0.9 Definitely not true 1 6 3.3 Tends not to be true 2 9 5.0 Unsure 3 24 13.3 Tends to be true 4 71 39.4 Definitely true 5 70 38.9 Combined Intrinsic Religiosity Score 12.6 ± 2.8 Low (3-9) 23 12.8 Moderate (10-12) 89 49.4 High (13-15) 68 37.8 Total DUREL Score Categories 11.8 ± 3.4 Low Religiosity (5-8) 34 18.9 Moderate Religiosity (9-12) 94 52.2 High Religiosity (13-15) 52 28.9 Religious Practice Patterns by Demographics: Variable High ORA (n=42) High NORA (n=43) High IR (n=68) High Total DUREL (n=52) Gender Male 22 (52.4%) 24 (55.8%) 35 (51.5%) 26 (50.0%) Female 20 (47.6%) 19 (44.2%) 33 (48.5%) 26 (50.0%) Age Groups 18-35 years 28 (66.7%) 30 (69.8%) 48 (70.6%) 38 (73.1%) 36-65 years 14 (33.3%) 13 (30.2%) 20 (29.4%) 14 (26.9%) Education Up to Secondary 26 (61.9%) 28 (65.1%) 42 (61.8%) 34 (65.4%) Higher Secondary+ 16 (38.1%) 15 (34.9%) 26 (38.2%) 18 (34.6%) Resilience Assessment The Connor-Davidson Resilience Scale (CD-RISC-25) revealed a mean total resilience score of 64.3 ± 16.8 (range: 22-100). Individual resilience categories showed that 22.2% (n=40) had low resilience (scores 0-50), 58.9% (n=106) had moderate resilience (scores 51-75), and 18.9% (n=34) had high resilience (scores 76-100). Table 3: Resilience Scores and Distribution (N=180) Resilience Category Score Range Frequency (n) Percentage (%) Mean ± SD Low Resilience 0-50 40 22.2 41.8 ± 7.2 Moderate Resilience 51-75 106 58.9 63.4 ± 8.1 High Resilience 76-100 34 18.9 82.7 ± 6.9 Total Sample 22-100 180 100.0 64.3 ± 16.8 Suicide Risk Assessment Using the Columbia Suicide Severity Rating Scale (C-SSRS), suicide risk assessment revealed that 41.7% (n=75) of participants had no suicide risk, 32.8% (n=59) had low risk, 18.9% (n=34) had moderate risk, and 6.6% (n=12) had high suicide risk. Suicidal ideation was present in 58.3% (n=105) of participants, with 38.1% (n=40) reporting passive ideation and 61.9% (n=65) reporting active ideation. History of suicide attempts was reported by 16.7% (n=30) of participants. Correlation Analysis Pearson correlation analysis revealed significant associations between study variables. Religiosity showed a strong positive correlation with resilience (r = 0.642, p < 0.001). Both religiosity (r = -0.518, p < 0.001) and resilience (r = -0.589, p < 0.001) demonstrated significant negative correlations with suicide risk scores. The correlation between religiosity and suicide risk remained significant after controlling for age and gender (r = -0.467, p < 0.001). Table 4: Correlation Matrix of Study Variables Variables 1 2 3 4 5 1. Age 1 2. Duration of Illness 0.234* 1 3. Religiosity (DUREL) 0.187* 0.089 1 4. Resilience (CD-RISC) 0.156* -0.142 0.642** 1 5. Suicide Risk (C-SSRS) -0.089 0.298** -0.518** -0.589** 1 *p < 0.05, **p < 0.001 Group Comparisons Analysis of variance (ANOVA) revealed significant differences in religiosity scores across different psychiatric diagnoses (F = 4.23, p = 0.003). Post-hoc analysis showed that participants with anxiety disorders had significantly higher religiosity scores compared to those with schizophrenia (p = 0.002). Resilience scores also differed significantly across diagnostic groups (F = 6.78, p < 0.001), with highest scores in anxiety disorders and lowest in major depressive disorder. Gender comparison using independent t-test showed that females had significantly higher religiosity scores than males (12.6 ± 3.1 vs 11.3 ± 3.5, t = 2.67, p = 0.008). However, no significant gender differences were observed in resilience scores (t = 1.42, p = 0.157) or suicide risk (t = -0.89, p = 0.375). Table 5: Mean Scores by Psychiatric Diagnosis Diagnosis n Religiosity Mean ± SD Resilience Mean ± SD Suicide Risk Mean ± SD Major Depression 64 11.2 ± 3.6 58.7 ± 15.2 4.8 ± 2.1 Anxiety Disorders 51 13.1 ± 2.8 71.4 ± 14.6 3.2 ± 1.8 Bipolar Disorder 30 11.8 ± 3.2 65.3 ± 16.9 4.1 ± 2.3 Schizophrenia 22 9.8 ± 3.9 60.1 ± 18.7 5.2 ± 2.4 Others 13 11.9 ± 3.1 66.8 ± 15.3 3.9 ± 1.9 Regression Analysis Multiple linear regression analysis was conducted to identify predictors of resilience. The model explained 48.3% of variance in resilience scores (R² = 0.483, F = 21.67, p < 0.001). Religiosity emerged as the strongest predictor (β = 0.592, p < 0.001), followed by age (β = 0.183, p = 0.012) and educational status (β = 0.156, p = 0.028). Gender and duration of illness were not significant predictors in the final model. Table 6: Multiple Linear Regression Analysis for Resilience Predictors Predictor B SE β t p-value 95% CI Constant 18.42 4.67 - 3.94 < 0.001 9.21, 27.63 Religiosity (DUREL) 2.89 0.31 0.592 9.32 < 0.001 2.28, 3.50 Age 0.26 0.10 0.183 2.54 0.012 0.06, 0.46 Education 2.14 0.97 0.156 2.21 0.028 0.23, 4.05 Model Summary: R² = 0.483, Adjusted R² = 0.474, F(3,176) = 21.67, p < 0.001

This investigation examined relationships between religious involvement, psychological resilience, and suicide risk among psychiatric outpatients in Chennai, revealing substantial associations with important clinical implications. The mean DUREL score of 11.8 ± 3.4 observed in our population contrasts with findings from other clinical samples. Portuguese cancer patients demonstrated higher religiosity with mean DUREL scores of 13.2 ± 2.8 (6), while Iranian medical students showed comparable levels at 11.5 ± 3.6 (7). The moderate religiosity levels in our Chennai sample align closely with Brazilian psychiatric populations, where inpatients exhibited DUREL scores averaging 12.1 ± 3.2 (3). This consistency across diverse psychiatric populations suggests that mental health challenges may influence religious engagement patterns regardless of cultural context. The CD-RISC resilience scores in our study (64.3 ± 16.8) fall within the moderate range compared to international psychiatric samples. Brazilian depressed inpatients showed notably lower resilience scores of 52.7 ± 15.3 (3), while Indian university students demonstrated higher levels at 71.2 ± 13.4 (5). Swedish community samples reported mean CD-RISC scores of 68.1 ± 14.2 (8), indicating that our psychiatric population maintains resilience levels approaching community norms. Critical care nurses, representing a high-stress professional group, exhibited similar scores of 65.8 ± 17.1 (9), suggesting that psychiatric patients retain substantial adaptive capacity despite their diagnoses. The robust correlation between religiosity and resilience (r = 0.642) represents one of the strongest associations reported in psychiatric literature. Mosqueiro and colleagues documented a more modest correlation of r = 0.43 between intrinsic religiosity and resilience among Brazilian depressed patients (3), while studies in cancer populations found correlations ranging from r = 0.35 to r = 0.52 (10). The magnitude of association in our sample suggests that religious involvement may serve as a particularly potent source of psychological strength among Indian psychiatric patients, possibly reflecting the deeply embedded role of spirituality in South Asian coping traditions. Gender differences in religiosity scores (females 12.6 ± 3.1 vs males 11.3 ± 3.5) mirror patterns observed globally. Studies across multiple countries consistently demonstrate female advantage in religious involvement, with effect sizes typically ranging from 0.3 to 0.5 standard deviations (11). However, the absence of gender differences in resilience challenges assumptions about differential coping capacities. This pattern suggests that while women may engage more actively with religious practices, both genders develop comparable psychological resilience when facing mental health challenges. The diagnostic variations in religiosity merit careful consideration. Anxiety disorder patients showed the highest DUREL scores (13.1 ± 2.8), significantly exceeding those with schizophrenia (9.8 ± 3.9, p = 0.002). This difference surpasses the minimal clinically important difference established for DUREL (12). The preserved religious functioning in anxiety disorders contrasts sharply with the impaired religiosity observed in psychotic conditions, likely reflecting the differential impact of these conditions on cognitive capacity and social functioning. The negative correlations between both religiosity (r = -0.518) and resilience (r = -0.589) with suicide risk align with extensive meta-analytic evidence. Recent systematic reviews found comparable effect sizes for religiosity-suicide associations (13). The magnitude of our findings suggests that both constructs represent clinically significant protective factors. The stronger correlation with resilience indicates that adaptive psychological characteristics may provide more immediate protection against suicidal thoughts than religious beliefs alone. Multiple regression analysis revealed religiosity as the dominant predictor of resilience (β = 0.592), explaining substantial variance independently. This predictive strength exceeds that reported in Western populations, where religiosity typically accounts for smaller proportions of resilience variance (14). The combined model explaining nearly half of resilience variance indicates substantial clinical utility for identifying individuals with enhanced adaptive potential. Cross-cultural considerations illuminate the Chennai findings. Religious involvement in Indian society extends beyond personal belief to encompass family traditions, community identity, and social support networks. The higher effect sizes observed in our sample may reflect this multifaceted role of religion in Indian culture. Unlike Western contexts where religiosity often represents individual choice, religious engagement in India frequently involves collective practices that provide robust social support during health crises. Clinical implications emerge from these findings. The strong religiosity-resilience association suggests that spiritual assessment should constitute routine psychiatric evaluation. Patients demonstrating high religious involvement may possess enhanced capacity for psychological adaptation, while those with minimal religious engagement might benefit from alternative resilience-building interventions. The protective associations with suicide risk support incorporating spiritual resources into safety planning and crisis intervention protocols. Several limitations warrant acknowledgment. The cross-sectional design prevents causal inference about directionality between religiosity, resilience, and mental health outcomes. Self-report measures may introduce social desirability bias, particularly for religiosity assessments in culturally religious contexts. The single-center design limits generalizability beyond urban Tamil populations. Additionally, the study did not assess negative religious coping or spiritual struggles, which may moderate the protective effects observed. Future research directions include longitudinal studies examining temporal relationships between spiritual factors and psychiatric recovery. Intervention studies investigating religiously integrated treatments or resilience enhancement programs would provide crucial evidence for clinical application. Qualitative investigations exploring patient perspectives on religious coping mechanisms could inform culturally adapted therapeutic approaches. The Chennai findings contribute to growing evidence supporting the mental health benefits of religious involvement and psychological resilience. The particularly strong associations observed in this Indian sample highlight the importance of cultural context in understanding these relationships. These results advocate for culturally informed psychiatric practice that recognizes and potentially leverages spiritual resources as components of comprehensive care.

Religious involvement emerges as a significant protective factor strongly associated with enhanced psychological resilience and reduced suicide risk among urban Indian psychiatric patients. These findings support incorporating spiritual assessment into routine psychiatric evaluation and developing culturally informed interventions that leverage religious resources for mental health promotion. The particularly strong associations observed in this sample highlight the importance of cultural context in understanding religion-mental health relationships. Healthcare providers should consider routine spiritual assessment and explore collaborative relationships with religious communities to optimize patient outcomes. ACKNOWLEDGEMENTS The authors express sincere gratitude to all study participants who voluntarily shared their experiences. We acknowledge the dedicated clinical staff of the Department of Psychiatry, Tagore Medical College & Hospital, for their cooperation during data collection.

1. Du LJ. The associations between religiosity and resilience when individuals are challenged by risk factors of suicide and mental illness. Front Public Health. 2024;12:1442248. 2. Connor KM, Davidson JRT. Development of a new resilience scale: The Connor-Davidson Resilience Scale (CD-RISC). Depress Anxiety. 2003;18:76-82. 3. Mosqueiro BP, da Rocha NS, de Almeida Fleck MP. Intrinsic religiosity, resilience, quality of life, and suicide risk in depressed inpatients. J Affect Disord. 2015;179:128-133. 4. Grover S, Dua D. Translation and adaptation into Hindi of central religiosity scale, brief religious coping scale (Brief RCOPE), and Duke University Religion Index (DUREL). Indian J Psychol Med. 2019;41:556-561. 5. Singh K, Yu X. Psychometric evaluation of the Connor-Davidson Resilience Scale (CD-RISC) in a sample of Indian students. J Psychol. 2010;1:23-30. 6. Martins H, Caldeira S, Domingues TD, Vieira M, Koenig HG. Validation of the Duke University Religion Index (DUREL) in Portuguese Cancer Patients. J Relig Health. 2021;60:3562-3575. 7. Hafizi S, Tabatabaei SM, Koenig HG, Jahani M, Shojaei F, Rashidi N. The Duke University Religion Index (DUREL): Validation and reliability of the Farsi version. Int J Health Care Assur. 2013;26:647-654. 8. Velickovic K, Rahm Hallberg I, Axelsson U, et al. Psychometric properties of the Connor-Davidson Resilience Scale in Sweden. Health Qual Life Outcomes. 2020;18:132. 9. Gillespie BM, Chaboyer W, Wallis M. The influence of personal characteristics on the resilience of operating room nurses. J Adv Nurs. 2007;59:427-438. 10. Macía P, Barranco M, Gorbeña S, Álvarez-Fuentes E, Iraurgi I. Resilience and coping strategies in cancer patients. PLoS One. 2021;16:e0252075. 11. Robinson SL, Maltby J, Gomez R, et al. Religiousness worldwide: translation of DUREL into 20 languages. Meas Instrum Soc Sci. 2022;4:13. 12. Koenig HG, Büssing A. The Duke University Religion Index: A five-item measure for epidemiological studies. Religions. 2010;1:78-85. 13. Mooney CA, Kapustin JF, Fowler J, et al. Systematic Review: Role of Spirituality and Religiosity in Suicidal Risk Assessment. Brain Sci. 2025;15:146. 14. Campbell-Sills L, Stein MB. Psychometric analysis of the Connor-Davidson Resilience Scale. J Trauma Stress.