Existential thinking and religious/spiritual struggles in patients with major depressive disorder receiving cognitive-behavioral therapy

Existential and spiritual issues may influence the symptoms and outcome of major depressive disorder (MDD). This study examined the interplay between existential thinking (fundamentals of meaning, purpose, and mortality), religious/spiritual (R/S) struggles (distress related to loss or questioning of faith, conversion to a new faith, or questioning of spiritual values), and mood/anxiety symptoms in individuals with MDD undergoing a 16-week course of cognitive-behavioral therapy (CBT). Participants were MDD patients with and without R/S struggles, as well as healthy controls. Before and after CBT, we assessed depressive and anxiety symptoms, existential thinking, and R/S struggles by using standard scales and interviews. Results revealed that MDD patients with R/S struggles exhibited significantly higher levels of existential thinking than non-clinical control participants and MDD patients without R/S struggles both before and after CBT. While existential thinking did not change during CBT, depressive and anxiety symptoms decreased in all MDD patients. Critically, patients with DSM-5 R/S problems showed substantial reductions in R/S struggle scores during CBT. However, these values remained elevated compared to non-clinical controls and MDD patients without R/S struggles, even when the therapy was completed. Correlation analyses indicated positive associations between existential thinking, R/S struggles, and depression in MDD. These findings highlight that existential and spiritual dimensions are integral to a subtype of MDD and may require a tailored clinical approach in addition to conventional symptom-focused treatments.