Religiosity, Guilt, Altruism and Forgiveness in Alcohol Dependence: Results of a Cross-sectional and Prospective Cohort Study

Religiosity, Guilt, Altruism and Forgiveness in Alcohol Dependence: Results of a Cross-sectional... Abstract Aims To compare religious denomination, religiosity, guilt, altruism and forgiveness between alcohol-dependent patients and healthy control subjects and to prospectively investigate their relationship to the disorder’s 24-month course following in-patient withdrawal treatment. Method This study in Franconia (a mainly Christian protestant region of southern Germany) applied six questionnaires to evaluate religiosity, guilt, altruism and forgiveness in 166 alcohol-dependent in-patients during withdrawal and compared findings with that of 240 healthy controls. Results Compared to controls religious denomination was more frequently reported by the patients (OR = 1.72, P = 0.014) and patients showed higher guilt (P < 0.001). The subjective attainability of altruism was lower in patients than in controls (P = 0.015). Higher scores on scale of inter-religious private practice predicted earlier (Rho = −0.184, P = 0.021) and more frequent alcohol-related readmissions during the follow-up (Rho = 0.207, P = 0.009). Higher religious affiliation was related to earlier (Rho = −0.214, P = 0.008) and more frequent alcohol-related readmissions (Rho = 0189, P = 0.020). Lower values of subjective attainability of altruism predicted a worse outcome (earlier [Rho = 0.231, P = 0.003] and more frequent readmissions [Rho = −0.223, P = 0.004]). The sex-specific analyses show that some of the associations are stronger in women and others are stronger in men; however, these gender differences are small and possibly biased by multiple hypothesis testing. Conclusions We identified religious denomination, private religious practice, religious affiliation, guilt and reduced attainability of altruism as risk factors for alcohol dependence and a worse follow-up outcome. Our findings may help to establish future preventive and therapeutic strategies. INTRODUCTION Religiosity has been a subject of research for more than 70 years with respect to the etiology, maintenance and treatment of alcohol dependence (Piderman et al., 2007). Some studies indicate a protective role of religiosity in the etiology and maintenance of alcohol dependence (Rice, 1941; Seliger, 1947; Drerup et al., 2011). However, findings regarding religious affiliation and early religious activity on the development and the course of alcohol dependence are inconclusive (Shalloo, 1941; Walters, 1957). (For research focusing on religiosity in mental and physical health, see Koenig et al. (2012) and in gaming disorder, see Braun et al. (2016).) Recently, the religiosity/spirituality section of the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) has published a position paper ‘Recommendation for Dealing with Religiosity/Spirituality in Psychiatry and Psychotherapy’ (Utsch et al., 2017). This review of the literature finds that the correlation between power of faith and therapeutic effects is modulated by other mechanisms such as psychological or neurobiological. In this study of religiosity and related psychological traits of guilt, altruism and forgiveness, we compare alcohol-dependent patients and healthy controls. Secondly we investigated the parameters' potential in predicting alcohol-related hospital readmission following in-patient withdrawal treatment for alcoholism. METHODS Study cohort This project on religious denomination, religiosity, guilt, altruism and forgiveness was part of the bicentric, cross-sectional, and longitudinal Neurobiology of Alcoholism (NOAH) study. In total, we recruited 200 alcohol-dependent patients who were admitted as in-patients for withdrawal treatment and 240 healthy controls, recruited from the south German region of Franconia via local and online advertisements as well as via flyers. Patients met criteria for alcohol dependence according to the ICD-10 (WHO, 1992) and/or for alcohol use disorder according to the DSM-5 (APA, 2013). Further details on the study design may be drawn from Lenz et al. (2017) and from Weinland et al. (2017). We followed the patients for 24 months after study inclusion. The number of alcohol-related hospital readmissions and the days to first readmission were extracted from the electronic patients’ records. In case of no alcohol-related readmission during the follow-up according to the patients' records, we set the days to first readmission to 730 days. The study was conducted according to the ethical principles of the World Medical Association (sixth revision of the Declaration of Helsinki, Seoul 2008) and the International Conference on Harmonization Guidelines for Good Clinical Practice (1996). It was approved by the Ethics Committee of the Medical Faculty of the Friedrich-Alexander University Erlangen-Nürnberg (NOAH study ID 81_12 B). All participants provided written informed consent prior to inclusion. Employed questionnaires For detecting the religious and psychological dimensions of interest, we applied six well-evaluated questionnaires: Centrality of Religiosity Scale (CRS; Huber and Huber, 2012). The scale was applied to measure the centrality as the importance or salience of religious meanings in personality. It quantifies the general intensities of the following five theoretically defined core dimensions which together can be considered as representative of individual religiosity. Public practice items: How often do you take part in religious services? How important is it to take part in religious services? How important is it for you to be connected to a religious community? Private practice items: How often do you pray? How often do you meditate? How important is personal prayer for you? How important is meditation for you? How often do you pray spontaneously when inspired by daily situations? How often do you try to connect to the divine spontaneously when inspired by daily situations? Religious experience items: How often do you experience situations in which you have the feeling that God or something divine intervenes in your life? How often do you experience situations in which you have the feeling that you are in one with all? How often do you experience situations in which you have the feeling that God or something divine wants to communicate or to reveal something to you? How often do you experience situations in which you have the feeling that you are touched by a divine power? How often do you experience situations in which you have the feeling that God or something divine is present? Ideology items: To what extent do you believe that God or something divine exists? To what extent do you believe in an afterlife, e.g. immortality of the soul, resurrection of the dead or reincarnation? In your opinion, how probable is it that a higher power really exists? Intellect items: How often do you think about religious issues? How interested are you in learning more about religious topics? How often do you keep yourself informed about religious questions through radio, television, Internet, newspapers or books? Brief Instrument (BI). The questionnaire was employed to detect ‘religious affiliation’ and ‘well-being’ (Mehnert and Koch, 2001). It represents a compendium of the Spiritual Experience Index (Genia, 1991), the Spiritual Well-Being Scale (Paloutzian/Ellison, 1982) and the Religious Problem Solving Scale (Pargament et al., 1988). Multidimensional Inventory for Religious/Spiritual Well-Being (MIRSB, Unterrainer et al., 2010; MIRSB-E, Unterrainer et al., 2012). The inventory allows quantification of the following scales. General religiosity items: My faith gives me a feeling of security. It is possible for me to find contentment in intimate conversations with God. I will be able to overcome all problems with God’s help. In certain moments in my life, I feel very close to God. With God’s help, I will be happy once again. I know that God is merciful. I enjoy attending to religious community events. I feel the presence of God in nature. Forgiveness items: There are things which I cannot forgive. There are people whom I hate. There are people whom I will never be able to forgive. There are things which people should not forgive. If somebody hurts me, I usually try to get revenge. The thought of seeing my enemies suffer satisfies me. There are people who deserve to be treated badly. I have forgiven those people who have hurt me. Hope immanent items: I view the future with optimism. I think that things will improve in the future. I think my life is moving in the right direction. I think that I will have more positive than negative experiences in the future. I think that I will live my life in the future just as I envisage it. I have a precise picture of what my future should be like. The future seems to be extremely uncertain. I believe that the future holds exciting challenges for me. Connectedness items: I have experienced the feeling of being absorbed into something greater. I believe that I will be reborn after my death. There are people with whom I feel a supernatural connection. I have had experiences through which I have realized that nothing ever dies. I believe in further existence after death. I have experienced things which I cannot express in words. I have experienced things which radiate a special kind of energy. I believe that I will have experiences in the future to which very few people have access. Hope transcendent items: I often think about the fact that I will have to leave my loved ones behind. I would do anything to prolong the lives of those I love. It is hard for me to think that my loved ones will one day no longer live. I am terrified of being forgotten after my death. I would do anything to prolong my life. I am scared about what will happen to me after my death. All hope ends with death. I fear being made accountable for the things I have done wrong after my death. Experience of sense and meaning items: I have experienced true (authentic) feelings. I have experienced deep affection. I have experienced true friendship. I have often experienced openness and honesty. I have experienced things which I want to experience again and again. I have often had experiences which have deeply affected me. In my experience, it is possible for me to become so involved in something that I forget everything around me. I have had one or more experiences in which the meaning of life became clear to me. Interpersonal Guilt questionnaire (IGQ; O’Connor et al., 1997; German short version; Albani et al., 2002a, b). The questionnaire allows distinguishing the subscales Separation Guilt, Survivor Guilt and Organized Guilt as components of Interpersonal Guilt (=sum score). Altruism (=acting for the welfare of others) as a component of the life goals questionnaire GOALS (Pöhlmann and Brunstein, 1997; Pöhlmann et al., 2010). Importance: How important is it for you to reach this goal in your lifetime? Attainability: How good do you think your chances are to reach this goal in your lifetime? Success: How successful are you currently in attaining this goal? For detecting the level of forgiveness in patients and controls, we used the scale on willingness to forgive (‘Skala der Bereitschaft zu Verzeihen’ [SBV], Allemand et al., 2008), which allows distinguishing the willingness to pardon as a function depending on the degree of regret on the part of the transgressor. Statistical analysis Sum scores of questionnaire items for all sub- and sum-scales were calculated and are presented as median and interquartile range (IQR) in the text and the tables. We used χ2 tests for nominal variables and Mann–Whitney U tests for continuous variables to compare alcohol-dependent patients with healthy control subjects. Correlations were calculated with Spearman’s rank correlation method. Cronbach’s alpha was calculated to estimate the internal consistency reliability. Questionnaire datasets with missing values were excluded. In a first step, we analyzed the total sample. Because of the well-known sex differences in alcohol dependence (Lenz et al., 2012; WHO, 2014) the NOAH study was balanced with regard to gender. That enabled us to subsequently conduct analyses separately for men and women. The P values < 0.05 for two-sided tests were considered to be statistically significant. We used IBM SPSS Statistics Version 21 for Windows (SPSS Inc., Chicago, IL, USA). RESULTS We here investigated 166 alcohol-dependent patients and 240 healthy control subjects (for sociodemographic characteristics, see Table 1) because 34 patients discontinued study participation prematurely and were excluded if they failed to complete at least one of the questionnaires. Table 1. Sociodemographic characteristics   Alcohol-dependent patients (n = 166)  Healthy control subjects (n = 240)  P  Age (years)  48 (42–54)  48 (39–56)  0.893a  Gender (n;♀/♂)  74/92  107/133  0.999b  BMI (kg/m2)  24.7 (22.1–28.5)  26.5 (23.5–29.3)  0.004a  Months of employment (previous year)  4 (0–12)  12 (5–12)  <0.001a  Active smoker (%)  77.4  20.4  <0.001b  Active and ex-smoker (%)  88.0  54.2  <0.001b  AUDIT score  –  3 (2–5)    Previous withdrawal treatments (n)  6 (2–12)  –    Age at onset of alcohol dependence (years)  32 (25–41)  –    Lifetime drinking (kg)  483 (270–1,195)  –    Daily ethanol intake (g/d since onset)  110 (60–240)  –      Alcohol-dependent patients (n = 166)  Healthy control subjects (n = 240)  P  Age (years)  48 (42–54)  48 (39–56)  0.893a  Gender (n;♀/♂)  74/92  107/133  0.999b  BMI (kg/m2)  24.7 (22.1–28.5)  26.5 (23.5–29.3)  0.004a  Months of employment (previous year)  4 (0–12)  12 (5–12)  <0.001a  Active smoker (%)  77.4  20.4  <0.001b  Active and ex-smoker (%)  88.0  54.2  <0.001b  AUDIT score  –  3 (2–5)    Previous withdrawal treatments (n)  6 (2–12)  –    Age at onset of alcohol dependence (years)  32 (25–41)  –    Lifetime drinking (kg)  483 (270–1,195)  –    Daily ethanol intake (g/d since onset)  110 (60–240)  –    Median (interquartile range) and absolute as well as relative frequencies; missing values <10% for body mass index (BMI), months of employment (previous year), smoking status, German version of the Alcohol Use Disorders Identification Test (AUDIT) score, age at onset of alcohol dependence, < 25% for previous withdrawal treatments, lifetime drinking, daily ethanol intake. aMann–Whitney U-test, bχ2 test. P < 0.05 in bold. Table 1. Sociodemographic characteristics   Alcohol-dependent patients (n = 166)  Healthy control subjects (n = 240)  P  Age (years)  48 (42–54)  48 (39–56)  0.893a  Gender (n;♀/♂)  74/92  107/133  0.999b  BMI (kg/m2)  24.7 (22.1–28.5)  26.5 (23.5–29.3)  0.004a  Months of employment (previous year)  4 (0–12)  12 (5–12)  <0.001a  Active smoker (%)  77.4  20.4  <0.001b  Active and ex-smoker (%)  88.0  54.2  <0.001b  AUDIT score  –  3 (2–5)    Previous withdrawal treatments (n)  6 (2–12)  –    Age at onset of alcohol dependence (years)  32 (25–41)  –    Lifetime drinking (kg)  483 (270–1,195)  –    Daily ethanol intake (g/d since onset)  110 (60–240)  –      Alcohol-dependent patients (n = 166)  Healthy control subjects (n = 240)  P  Age (years)  48 (42–54)  48 (39–56)  0.893a  Gender (n;♀/♂)  74/92  107/133  0.999b  BMI (kg/m2)  24.7 (22.1–28.5)  26.5 (23.5–29.3)  0.004a  Months of employment (previous year)  4 (0–12)  12 (5–12)  <0.001a  Active smoker (%)  77.4  20.4  <0.001b  Active and ex-smoker (%)  88.0  54.2  <0.001b  AUDIT score  –  3 (2–5)    Previous withdrawal treatments (n)  6 (2–12)  –    Age at onset of alcohol dependence (years)  32 (25–41)  –    Lifetime drinking (kg)  483 (270–1,195)  –    Daily ethanol intake (g/d since onset)  110 (60–240)  –    Median (interquartile range) and absolute as well as relative frequencies; missing values <10% for body mass index (BMI), months of employment (previous year), smoking status, German version of the Alcohol Use Disorders Identification Test (AUDIT) score, age at onset of alcohol dependence, < 25% for previous withdrawal treatments, lifetime drinking, daily ethanol intake. aMann–Whitney U-test, bχ2 test. P < 0.05 in bold. We tested whether belonging to a religious denomination is related to alcohol dependence and found an increased risk for alcohol dependence in the study subjects with a religious denomination in comparison to participants without a religious denomination; this effect was stronger in males than in females (χ2 = 6.0, df = 1, OR = 1.72, P = 0.014; patients (n): 43 without religious denomination, 58 Protestants, 54 Roman Catholics, 7 with another religious denomination, 4 with missing data; controls (n): 92 without religious denomination, 77 Protestants, 63 Roman Catholics, 8 with another religious denomination; females, χ2 = 1.8, df = 1, OR = 1.60, P = 0.179, males, χ2 = 4.5, df = 1, OR = 1.83, P = 0.035). The risk for an alcohol-related readmission during the 24-month follow-up did not significantly differ between patients with and patients without a religious denomination (χ2 = 0.5, df = 1, OR =1.32, P = 0.464; females, χ2 = 0.6, df = 1, OR =1.54, P = 0.447, males, χ2 = 0.3, df = 1, OR =1.29, P = 0.592). Afterwards, we investigated differences of religiosity, guilt, altruism and willingness to forgive between patients and healthy controls subjects. The patients scored higher on the subscales of religious experiences (basic) (median(patients) 6 [IQR 3–9] vs. median(controls) 5 [IQR 3–8], U = 16,467, P = 0.041), private practice (inter-religious) (6 [4–9] vs. 5 [3–7], U = 16,501, P = 0.046), connectedness (22 [15–30] vs. 19 [12–26], U = 13,233, P < 0.001) and experience of sense and meaning (38 [32–42] vs. 35 [31–39], U = 13,714, P = 0.003), survivor guilt (18 [13–24] vs. 11 [8–15], U = 8,659, P < 0.001), separation guilt (17 [12–22] vs. 14 [11–17], U = 12,773, P < 0.001), organized guilt (27 [23–30] vs. 24 [20–28], U = 12,883, P < 0.001), and the guilt sum score (61 [52–71] vs. 50 [43–58], U = 9,488, P < 0.001). They scored lower on well-being (42 [36–49] vs. 50 [44–56], U = 10,080, P < 0.001), forgiveness (32 [24–40] vs. 37 [31–42], U = 13,055, P < 0.001), hope immanent (33 [27–40] vs. 38 [33–42], U = 12,282, P < 0.001), hope transcendent (31 [26–36] vs. 37 [31–41], U = 10,053, P < 0.001), the MIRSB sum score (175 [155–194] vs. 179 [164–205], U = 14,595, P = 0.031), attainability (15 [12–17] vs. 16 [13–18], U = 16,677, P = 0.015) and on success of altruism (13 [10–16] vs. 14 [12–16], U = 16,344, P = 0.006). There were no significant group differences for the following subscales: intellect (basic) (5 [4–8] vs. 6 [5–8], U = 17,180, P = 0.173), ideology (basic) (8 [5–11] vs. 8 [5–12], U = 18,216, P = 0.673), public practice (basic) (5 [3–7] vs. 5 [3–7], U = 18,333, P = 0.747), private practice (basic) (6 [3–11] vs. 6 [3–9], U = 17,309, P = 0.206), religious experiences (inter-religious) (5 [4–8] vs. 5 [3–7], U = 17,814, P = 0.428), religious affiliation (19 [13–32] vs. 19 [12–32], U = 16,433, P = 0.567), general religiosity (19 [8–32] vs. 18 [9–31], U = 16,457, P = 0.739), importance of altruism (16 [13–19] vs. 16 [14–18], U = 19,158, P = 0.804), and willingness to pardon without regret (8 [6–11] vs. 9 [7–11], U = 17,550, P = 0.143) or with regret (13 [11–16] vs. 14 [11–16], U = 17,867, P = 0.238). The gender-specific results are shown in Table 2. Table 2. Gender-specific differences of religiosity, guilt, altruism and willingness to pardon between alcohol-dependent patients and healthy control subjects   N (items)#  Cronbach’s alpha  Females  Males    Patients  Controls      Patients  Controls        Median (IQR)  U  Pa  Median (IQR)  U  Pa  Centrality of religiosity scale      n = 68  n = 107      n = 89  n = 131       Intellect (basic)  3  0.883  6  (4–8)  6  (5–9)  3,259  0.242  5  (4–8)  6  (5–8)  5,498  0.471   Ideology (basic)  3  0.903  9  (6–12)  9  (5–12)  3,440  0.542  7  (4–11)  7  (4–10)  5,748  0.859   Public practice (basic)  3  0.904  5  (4–7)  5  (3–8)  3,562  0.812  4  (3–7)  5  (3–6)  5,765  0.885   Private practice (basic)  3  0.946  6  (4–12)  7  (3–11)  3,387  0.438  6  (3–10)  5  (3–8)  5,425  0.366   Religious experiences (basic)  3  0.933  6  (4–9)  6  (3–9)  3,275  0.261  5  (3–9)  4  (3–7)  5,076  0.091   Private practice (inter-religious)  3  0.770  6  (4–8)  5  (3–9)  3,500  0.670  5  (3–9)  4  (3–7)  4,809  0.025   Religious experiences (inter-religious)  3  0.812  5  (4–8)  6  (4–8)  3,557  0.801  5  (3–9)  5  (3–7)  5,260  0.210  Religiousness and well-being      n = 67  n = 95      n = 85  n = 129       Religious affiliation  10  0.930  19  (14–31)  25  (12–35)  3,049  0.649  17  (12–34)  17  (13–28)  5,082  0.365   Well-being  11  0.780  43  (38–51)  53  (47–58)  1,645  <0.001  42  (35–47)  49  (41–54)  3,454  <0.001  Multidimensional inventory for religious/spiritual well-being      n = 67  n = 96      n = 85  n = 125       General religiosity  8  0.945  19  (10–35)  24  (13–37)  2,922  0.320  17  (8–31)  16  (9–26)  5,164  0.728   Forgiveness  8  0.828  35  (26–42)  39  (34–43)  2,524  0.019  31  (24–38)  34  (29–41)  4,140  0.007   Hope immanent  8  0.868  35  (27–40)  39  (33–43)  2,453  0.010  32  (26–39)  37  (33–42)  3,715  <0.001   Connectedness  8  0.827  24  (17–30)  21  (13–29)  2,721  0.095  21  (14–30)  17  (12–24)  4,021  0.003   Hope transcendent  8  0.722  32  (25–37)  37  (30–41)  2,246  0.001  30  (27–35)  37  (33–41)  2,712  <0.001   Experience of sense and meaning  8  0.722  38  (31–43)  36  (32–40)  2,822  0.183  37  (32–42)  34  (29–38)  4,058  0.004   Sum score  48  0.865  182  (164–196)  191  (169–216)  2,611  0.041  173  (151–192)  174  (162–193)  4,713  0.165  Interpersonal guilt questionnaire      n = 68  n = 102      n = 86  n = 129       Survivor guilt  7  0.851  18  (12–23)  12  (8–15)  1,838  <0.001  18  (14–24)  11  (8–16)  2,534  <0.001   Separation guilt  7  0.790  15  (11–21)  13  (10–17)  2,588  0.005  19  (13–22)  15  (12–18)  3,831  <0.001   Organized guilt  7  0.768  28  (23–32)  25  (22–30)  2,644  0.009  27  (23–29)  23  (19–26)  3,744  <0.001   Sum score  21  0.877  60  (51–72)  51  (43–59)  2,069  <0.001  62  (54–71)  49  (43–58)  2,709  <0.001  Altruism      n = 71  n = 107      n = 91  n = 133       Importance  4  0.830  17  (14–19)  16  (14–19)  3,648  0.652  16  (13–18)  16  (14–17)  5,988  0.892   Attainability  4  0.833  16  (14–17)  16  (14–18)  3,529  0.418  14  (12–16)  16  (13–18)  4,875  0.013   Success  4  0.842  13  (10–16)  14  (12–16)  3,041  0.023  12  (9–16)  13  (12–16)  5,291  0.108  Willingness to pardon      n = 70  n = 107      n = 90  n = 133       Without regret  4  0.789  8  (6–10)  8  (6–11)  3,459  0.388  8  (6–11)  9  (7–11)  5,414  0.224   With regret  4  0.852  12  (11–15)  13  (10–16)  3,455  0.382  14  (11–16)  14  (11–16)  5,655  0.483    N (items)#  Cronbach’s alpha  Females  Males    Patients  Controls      Patients  Controls        Median (IQR)  U  Pa  Median (IQR)  U  Pa  Centrality of religiosity scale      n = 68  n = 107      n = 89  n = 131       Intellect (basic)  3  0.883  6  (4–8)  6  (5–9)  3,259  0.242  5  (4–8)  6  (5–8)  5,498  0.471   Ideology (basic)  3  0.903  9  (6–12)  9  (5–12)  3,440  0.542  7  (4–11)  7  (4–10)  5,748  0.859   Public practice (basic)  3  0.904  5  (4–7)  5  (3–8)  3,562  0.812  4  (3–7)  5  (3–6)  5,765  0.885   Private practice (basic)  3  0.946  6  (4–12)  7  (3–11)  3,387  0.438  6  (3–10)  5  (3–8)  5,425  0.366   Religious experiences (basic)  3  0.933  6  (4–9)  6  (3–9)  3,275  0.261  5  (3–9)  4  (3–7)  5,076  0.091   Private practice (inter-religious)  3  0.770  6  (4–8)  5  (3–9)  3,500  0.670  5  (3–9)  4  (3–7)  4,809  0.025   Religious experiences (inter-religious)  3  0.812  5  (4–8)  6  (4–8)  3,557  0.801  5  (3–9)  5  (3–7)  5,260  0.210  Religiousness and well-being      n = 67  n = 95      n = 85  n = 129       Religious affiliation  10  0.930  19  (14–31)  25  (12–35)  3,049  0.649  17  (12–34)  17  (13–28)  5,082  0.365   Well-being  11  0.780  43  (38–51)  53  (47–58)  1,645  <0.001  42  (35–47)  49  (41–54)  3,454  <0.001  Multidimensional inventory for religious/spiritual well-being      n = 67  n = 96      n = 85  n = 125       General religiosity  8  0.945  19  (10–35)  24  (13–37)  2,922  0.320  17  (8–31)  16  (9–26)  5,164  0.728   Forgiveness  8  0.828  35  (26–42)  39  (34–43)  2,524  0.019  31  (24–38)  34  (29–41)  4,140  0.007   Hope immanent  8  0.868  35  (27–40)  39  (33–43)  2,453  0.010  32  (26–39)  37  (33–42)  3,715  <0.001   Connectedness  8  0.827  24  (17–30)  21  (13–29)  2,721  0.095  21  (14–30)  17  (12–24)  4,021  0.003   Hope transcendent  8  0.722  32  (25–37)  37  (30–41)  2,246  0.001  30  (27–35)  37  (33–41)  2,712  <0.001   Experience of sense and meaning  8  0.722  38  (31–43)  36  (32–40)  2,822  0.183  37  (32–42)  34  (29–38)  4,058  0.004   Sum score  48  0.865  182  (164–196)  191  (169–216)  2,611  0.041  173  (151–192)  174  (162–193)  4,713  0.165  Interpersonal guilt questionnaire      n = 68  n = 102      n = 86  n = 129       Survivor guilt  7  0.851  18  (12–23)  12  (8–15)  1,838  <0.001  18  (14–24)  11  (8–16)  2,534  <0.001   Separation guilt  7  0.790  15  (11–21)  13  (10–17)  2,588  0.005  19  (13–22)  15  (12–18)  3,831  <0.001   Organized guilt  7  0.768  28  (23–32)  25  (22–30)  2,644  0.009  27  (23–29)  23  (19–26)  3,744  <0.001   Sum score  21  0.877  60  (51–72)  51  (43–59)  2,069  <0.001  62  (54–71)  49  (43–58)  2,709  <0.001  Altruism      n = 71  n = 107      n = 91  n = 133       Importance  4  0.830  17  (14–19)  16  (14–19)  3,648  0.652  16  (13–18)  16  (14–17)  5,988  0.892   Attainability  4  0.833  16  (14–17)  16  (14–18)  3,529  0.418  14  (12–16)  16  (13–18)  4,875  0.013   Success  4  0.842  13  (10–16)  14  (12–16)  3,041  0.023  12  (9–16)  13  (12–16)  5,291  0.108  Willingness to pardon      n = 70  n = 107      n = 90  n = 133       Without regret  4  0.789  8  (6–10)  8  (6–11)  3,459  0.388  8  (6–11)  9  (7–11)  5,414  0.224   With regret  4  0.852  12  (11–15)  13  (10–16)  3,455  0.382  14  (11–16)  14  (11–16)  5,655  0.483  The table shows median and interquartile range (IQR) of the questionnaire scores (= sum of subitems). #Number of questionnaire items for scale calculation. aMann–Whitney U-test. P < 0.05 in bold. Table 2. Gender-specific differences of religiosity, guilt, altruism and willingness to pardon between alcohol-dependent patients and healthy control subjects   N (items)#  Cronbach’s alpha  Females  Males    Patients  Controls      Patients  Controls        Median (IQR)  U  Pa  Median (IQR)  U  Pa  Centrality of religiosity scale      n = 68  n = 107      n = 89  n = 131       Intellect (basic)  3  0.883  6  (4–8)  6  (5–9)  3,259  0.242  5  (4–8)  6  (5–8)  5,498  0.471   Ideology (basic)  3  0.903  9  (6–12)  9  (5–12)  3,440  0.542  7  (4–11)  7  (4–10)  5,748  0.859   Public practice (basic)  3  0.904  5  (4–7)  5  (3–8)  3,562  0.812  4  (3–7)  5  (3–6)  5,765  0.885   Private practice (basic)  3  0.946  6  (4–12)  7  (3–11)  3,387  0.438  6  (3–10)  5  (3–8)  5,425  0.366   Religious experiences (basic)  3  0.933  6  (4–9)  6  (3–9)  3,275  0.261  5  (3–9)  4  (3–7)  5,076  0.091   Private practice (inter-religious)  3  0.770  6  (4–8)  5  (3–9)  3,500  0.670  5  (3–9)  4  (3–7)  4,809  0.025   Religious experiences (inter-religious)  3  0.812  5  (4–8)  6  (4–8)  3,557  0.801  5  (3–9)  5  (3–7)  5,260  0.210  Religiousness and well-being      n = 67  n = 95      n = 85  n = 129       Religious affiliation  10  0.930  19  (14–31)  25  (12–35)  3,049  0.649  17  (12–34)  17  (13–28)  5,082  0.365   Well-being  11  0.780  43  (38–51)  53  (47–58)  1,645  <0.001  42  (35–47)  49  (41–54)  3,454  <0.001  Multidimensional inventory for religious/spiritual well-being      n = 67  n = 96      n = 85  n = 125       General religiosity  8  0.945  19  (10–35)  24  (13–37)  2,922  0.320  17  (8–31)  16  (9–26)  5,164  0.728   Forgiveness  8  0.828  35  (26–42)  39  (34–43)  2,524  0.019  31  (24–38)  34  (29–41)  4,140  0.007   Hope immanent  8  0.868  35  (27–40)  39  (33–43)  2,453  0.010  32  (26–39)  37  (33–42)  3,715  <0.001   Connectedness  8  0.827  24  (17–30)  21  (13–29)  2,721  0.095  21  (14–30)  17  (12–24)  4,021  0.003   Hope transcendent  8  0.722  32  (25–37)  37  (30–41)  2,246  0.001  30  (27–35)  37  (33–41)  2,712  <0.001   Experience of sense and meaning  8  0.722  38  (31–43)  36  (32–40)  2,822  0.183  37  (32–42)  34  (29–38)  4,058  0.004   Sum score  48  0.865  182  (164–196)  191  (169–216)  2,611  0.041  173  (151–192)  174  (162–193)  4,713  0.165  Interpersonal guilt questionnaire      n = 68  n = 102      n = 86  n = 129       Survivor guilt  7  0.851  18  (12–23)  12  (8–15)  1,838  <0.001  18  (14–24)  11  (8–16)  2,534  <0.001   Separation guilt  7  0.790  15  (11–21)  13  (10–17)  2,588  0.005  19  (13–22)  15  (12–18)  3,831  <0.001   Organized guilt  7  0.768  28  (23–32)  25  (22–30)  2,644  0.009  27  (23–29)  23  (19–26)  3,744  <0.001   Sum score  21  0.877  60  (51–72)  51  (43–59)  2,069  <0.001  62  (54–71)  49  (43–58)  2,709  <0.001  Altruism      n = 71  n = 107      n = 91  n = 133       Importance  4  0.830  17  (14–19)  16  (14–19)  3,648  0.652  16  (13–18)  16  (14–17)  5,988  0.892   Attainability  4  0.833  16  (14–17)  16  (14–18)  3,529  0.418  14  (12–16)  16  (13–18)  4,875  0.013   Success  4  0.842  13  (10–16)  14  (12–16)  3,041  0.023  12  (9–16)  13  (12–16)  5,291  0.108  Willingness to pardon      n = 70  n = 107      n = 90  n = 133       Without regret  4  0.789  8  (6–10)  8  (6–11)  3,459  0.388  8  (6–11)  9  (7–11)  5,414  0.224   With regret  4  0.852  12  (11–15)  13  (10–16)  3,455  0.382  14  (11–16)  14  (11–16)  5,655  0.483    N (items)#  Cronbach’s alpha  Females  Males    Patients  Controls      Patients  Controls        Median (IQR)  U  Pa  Median (IQR)  U  Pa  Centrality of religiosity scale      n = 68  n = 107      n = 89  n = 131       Intellect (basic)  3  0.883  6  (4–8)  6  (5–9)  3,259  0.242  5  (4–8)  6  (5–8)  5,498  0.471   Ideology (basic)  3  0.903  9  (6–12)  9  (5–12)  3,440  0.542  7  (4–11)  7  (4–10)  5,748  0.859   Public practice (basic)  3  0.904  5  (4–7)  5  (3–8)  3,562  0.812  4  (3–7)  5  (3–6)  5,765  0.885   Private practice (basic)  3  0.946  6  (4–12)  7  (3–11)  3,387  0.438  6  (3–10)  5  (3–8)  5,425  0.366   Religious experiences (basic)  3  0.933  6  (4–9)  6  (3–9)  3,275  0.261  5  (3–9)  4  (3–7)  5,076  0.091   Private practice (inter-religious)  3  0.770  6  (4–8)  5  (3–9)  3,500  0.670  5  (3–9)  4  (3–7)  4,809  0.025   Religious experiences (inter-religious)  3  0.812  5  (4–8)  6  (4–8)  3,557  0.801  5  (3–9)  5  (3–7)  5,260  0.210  Religiousness and well-being      n = 67  n = 95      n = 85  n = 129       Religious affiliation  10  0.930  19  (14–31)  25  (12–35)  3,049  0.649  17  (12–34)  17  (13–28)  5,082  0.365   Well-being  11  0.780  43  (38–51)  53  (47–58)  1,645  <0.001  42  (35–47)  49  (41–54)  3,454  <0.001  Multidimensional inventory for religious/spiritual well-being      n = 67  n = 96      n = 85  n = 125       General religiosity  8  0.945  19  (10–35)  24  (13–37)  2,922  0.320  17  (8–31)  16  (9–26)  5,164  0.728   Forgiveness  8  0.828  35  (26–42)  39  (34–43)  2,524  0.019  31  (24–38)  34  (29–41)  4,140  0.007   Hope immanent  8  0.868  35  (27–40)  39  (33–43)  2,453  0.010  32  (26–39)  37  (33–42)  3,715  <0.001   Connectedness  8  0.827  24  (17–30)  21  (13–29)  2,721  0.095  21  (14–30)  17  (12–24)  4,021  0.003   Hope transcendent  8  0.722  32  (25–37)  37  (30–41)  2,246  0.001  30  (27–35)  37  (33–41)  2,712  <0.001   Experience of sense and meaning  8  0.722  38  (31–43)  36  (32–40)  2,822  0.183  37  (32–42)  34  (29–38)  4,058  0.004   Sum score  48  0.865  182  (164–196)  191  (169–216)  2,611  0.041  173  (151–192)  174  (162–193)  4,713  0.165  Interpersonal guilt questionnaire      n = 68  n = 102      n = 86  n = 129       Survivor guilt  7  0.851  18  (12–23)  12  (8–15)  1,838  <0.001  18  (14–24)  11  (8–16)  2,534  <0.001   Separation guilt  7  0.790  15  (11–21)  13  (10–17)  2,588  0.005  19  (13–22)  15  (12–18)  3,831  <0.001   Organized guilt  7  0.768  28  (23–32)  25  (22–30)  2,644  0.009  27  (23–29)  23  (19–26)  3,744  <0.001   Sum score  21  0.877  60  (51–72)  51  (43–59)  2,069  <0.001  62  (54–71)  49  (43–58)  2,709  <0.001  Altruism      n = 71  n = 107      n = 91  n = 133       Importance  4  0.830  17  (14–19)  16  (14–19)  3,648  0.652  16  (13–18)  16  (14–17)  5,988  0.892   Attainability  4  0.833  16  (14–17)  16  (14–18)  3,529  0.418  14  (12–16)  16  (13–18)  4,875  0.013   Success  4  0.842  13  (10–16)  14  (12–16)  3,041  0.023  12  (9–16)  13  (12–16)  5,291  0.108  Willingness to pardon      n = 70  n = 107      n = 90  n = 133       Without regret  4  0.789  8  (6–10)  8  (6–11)  3,459  0.388  8  (6–11)  9  (7–11)  5,414  0.224   With regret  4  0.852  12  (11–15)  13  (10–16)  3,455  0.382  14  (11–16)  14  (11–16)  5,655  0.483  The table shows median and interquartile range (IQR) of the questionnaire scores (= sum of subitems). #Number of questionnaire items for scale calculation. aMann–Whitney U-test. P < 0.05 in bold. We analyzed whether religiosity, guilt, altruism and forgiveness predicted alcohol-related readmission following in-patient alcohol withdrawal treatment (Table 3). Patients with alcohol-related readmission scored higher on the private practice (basic and inter-religious), and the religious experiences (inter-religious) subscales. Higher private practice (inter-religious) also correlated with more alcohol-related readmissions during the follow-up and fewer days to first alcohol-related readmission. The patients with alcohol-related readmission scored higher on the religious affiliation subscale and higher scores predicted more alcohol-related readmissions and fewer days to first readmission. Moreover, we found lower attainability of altruism in patients with alcohol-related readmission and lower scores also predicted more alcohol-related readmissions and fewer days to first readmission. Table 3. Associations of religiosity, guilt, altruism, and willingness to pardon with 24-month alcohol-related readmissions   Total cohort    Alcohol-related readmission  Number of readmissions  Days to first readmission    Yes  No                Median (IQR)  U  Pa  Rho  Pb  Rho  Pb  Centrality of religiosity scale  n = 94  n = 63               Intellect (basic)  6  (4–9)  5  (4–8)  2,548  0.136  0.106  0.186  −0.101  0.206   Ideology (basic)  9  (5–11)  6  (3–11)  2,455  0.068  0.111  0.166  −0.107  0.183   Public practice (basic)  5  (3–7)  4  (3–7)  2,657  0.265  0.070  0.387  −0.054  0.503   Private practice (basic)  7  (3–11)  5  (3–10)  2,396  0.040  0.089  0.266  −0.101  0.209   Religious experiences (basic)  6  (3–9)  5  (3–8)  2,452  0.064  0.107  0.184  −0.089  0.270   Private practice (inter-religious)  7  (4–9)  5  (3–7)  2,237  0.009  0.207  0.009  −0.184  0.021   Religious experiences (inter-religious)  6  (4–9)  4  (3–7)  2,366  0.031  0.123  0.126  −0.125  0.120  Religiousness and well-being  n = 94  n = 58               Religious affiliation  22  (15–36)  15  (11–29)  1,991  0.005  0.189  0.020  −0.214  0.008   Well-being  42  (35–48)  44  (37–50)  2,474  0.339  −0.092  0.262  0.064  0.432  Multidimensional inventory for religious/spiritual well-being  n = 91  n = 61               General religiosity  23  (10–34)  14  (8–32)  2,317  0.082  0.087  0.289  −0.105  0.196   Forgiveness  31  (23–41)  33  (26–40)  2,467  0.246  −0.112  0.168  0.109  0.180   Hope immanent  31  (27–39)  36  (28–42)  2,343  0.104  −0.093  0.255  0.125  0.125   Connectedness  23  (16–30)  21  (13–31)  2,422  0.183  0.109  0.181  −0.131  0.107   Hope transcendent  31  (27–36)  32  (25–39)  2,697  0.766  0.017  0.832  0.008  0.923   Experience of sense and meaning  38  (31–42)  37  (32–43)  2,670  0.690  0.031  0.707  0.012  0.880   Sum score  178  (155–195)  174  (156–194)  2,722  0.839  0.021  0.795  −0.022  0.791  Interpersonal guilt questionnaire  n = 90  n = 64               Survivor guilt  18  (13–24)  17  (13–24)  2,690  0.486  0.043  0.597  −0.061  0.454   Separation guilt  18  (13–23)  16  (12–21)  2,461  0.124  0.042  0.607  −0.075  0.358   Organized guilt  27  (23–30)  27  (23–31)  2,799  0.766  −0.007  0.933  −0.002  0.982   Sum score  61  (54–73)  60  (50–69)  2,560  0.240  0.050  0.537  −0.071  0.379  Altruism  n = 98  n = 64               Importance  16  (13–19)  16  (13–17)  2,867  0.353  0.024  0.764  −0.021  0.787   Attainability  14  (12–16)  16  (14–17)  2,440  0.016  −0.223  0.004  0.231  0.003   Success  12  (10–16)  13  (11–16)  2,763  0.199  −0.111  0.161  0.097  0.219  Willingness to pardon  n = 99  n = 61               Without regret  8  (6–11)  8  (6–11)  2,949  0.802  −0.094  0.239  0.109  0.172   With regret  13  (10–16)  13  (11–16)  2,820  0.482  −0.025  0.754  0.116  0.143    Total cohort    Alcohol-related readmission  Number of readmissions  Days to first readmission    Yes  No                Median (IQR)  U  Pa  Rho  Pb  Rho  Pb  Centrality of religiosity scale  n = 94  n = 63               Intellect (basic)  6  (4–9)  5  (4–8)  2,548  0.136  0.106  0.186  −0.101  0.206   Ideology (basic)  9  (5–11)  6  (3–11)  2,455  0.068  0.111  0.166  −0.107  0.183   Public practice (basic)  5  (3–7)  4  (3–7)  2,657  0.265  0.070  0.387  −0.054  0.503   Private practice (basic)  7  (3–11)  5  (3–10)  2,396  0.040  0.089  0.266  −0.101  0.209   Religious experiences (basic)  6  (3–9)  5  (3–8)  2,452  0.064  0.107  0.184  −0.089  0.270   Private practice (inter-religious)  7  (4–9)  5  (3–7)  2,237  0.009  0.207  0.009  −0.184  0.021   Religious experiences (inter-religious)  6  (4–9)  4  (3–7)  2,366  0.031  0.123  0.126  −0.125  0.120  Religiousness and well-being  n = 94  n = 58               Religious affiliation  22  (15–36)  15  (11–29)  1,991  0.005  0.189  0.020  −0.214  0.008   Well-being  42  (35–48)  44  (37–50)  2,474  0.339  −0.092  0.262  0.064  0.432  Multidimensional inventory for religious/spiritual well-being  n = 91  n = 61               General religiosity  23  (10–34)  14  (8–32)  2,317  0.082  0.087  0.289  −0.105  0.196   Forgiveness  31  (23–41)  33  (26–40)  2,467  0.246  −0.112  0.168  0.109  0.180   Hope immanent  31  (27–39)  36  (28–42)  2,343  0.104  −0.093  0.255  0.125  0.125   Connectedness  23  (16–30)  21  (13–31)  2,422  0.183  0.109  0.181  −0.131  0.107   Hope transcendent  31  (27–36)  32  (25–39)  2,697  0.766  0.017  0.832  0.008  0.923   Experience of sense and meaning  38  (31–42)  37  (32–43)  2,670  0.690  0.031  0.707  0.012  0.880   Sum score  178  (155–195)  174  (156–194)  2,722  0.839  0.021  0.795  −0.022  0.791  Interpersonal guilt questionnaire  n = 90  n = 64               Survivor guilt  18  (13–24)  17  (13–24)  2,690  0.486  0.043  0.597  −0.061  0.454   Separation guilt  18  (13–23)  16  (12–21)  2,461  0.124  0.042  0.607  −0.075  0.358   Organized guilt  27  (23–30)  27  (23–31)  2,799  0.766  −0.007  0.933  −0.002  0.982   Sum score  61  (54–73)  60  (50–69)  2,560  0.240  0.050  0.537  −0.071  0.379  Altruism  n = 98  n = 64               Importance  16  (13–19)  16  (13–17)  2,867  0.353  0.024  0.764  −0.021  0.787   Attainability  14  (12–16)  16  (14–17)  2,440  0.016  −0.223  0.004  0.231  0.003   Success  12  (10–16)  13  (11–16)  2,763  0.199  −0.111  0.161  0.097  0.219  Willingness to pardon  n = 99  n = 61               Without regret  8  (6–11)  8  (6–11)  2,949  0.802  −0.094  0.239  0.109  0.172   With regret  13  (10–16)  13  (11–16)  2,820  0.482  −0.025  0.754  0.116  0.143  The table shows median and interquartile range (IQR) of the questionnaire scores (=sum of subitems). aMann–Whitney U-test, bSpearman correlation. P < 0.05 in bold. Table 3. Associations of religiosity, guilt, altruism, and willingness to pardon with 24-month alcohol-related readmissions   Total cohort    Alcohol-related readmission  Number of readmissions  Days to first readmission    Yes  No                Median (IQR)  U  Pa  Rho  Pb  Rho  Pb  Centrality of religiosity scale  n = 94  n = 63               Intellect (basic)  6  (4–9)  5  (4–8)  2,548  0.136  0.106  0.186  −0.101  0.206   Ideology (basic)  9  (5–11)  6  (3–11)  2,455  0.068  0.111  0.166  −0.107  0.183   Public practice (basic)  5  (3–7)  4  (3–7)  2,657  0.265  0.070  0.387  −0.054  0.503   Private practice (basic)  7  (3–11)  5  (3–10)  2,396  0.040  0.089  0.266  −0.101  0.209   Religious experiences (basic)  6  (3–9)  5  (3–8)  2,452  0.064  0.107  0.184  −0.089  0.270   Private practice (inter-religious)  7  (4–9)  5  (3–7)  2,237  0.009  0.207  0.009  −0.184  0.021   Religious experiences (inter-religious)  6  (4–9)  4  (3–7)  2,366  0.031  0.123  0.126  −0.125  0.120  Religiousness and well-being  n = 94  n = 58               Religious affiliation  22  (15–36)  15  (11–29)  1,991  0.005  0.189  0.020  −0.214  0.008   Well-being  42  (35–48)  44  (37–50)  2,474  0.339  −0.092  0.262  0.064  0.432  Multidimensional inventory for religious/spiritual well-being  n = 91  n = 61               General religiosity  23  (10–34)  14  (8–32)  2,317  0.082  0.087  0.289  −0.105  0.196   Forgiveness  31  (23–41)  33  (26–40)  2,467  0.246  −0.112  0.168  0.109  0.180   Hope immanent  31  (27–39)  36  (28–42)  2,343  0.104  −0.093  0.255  0.125  0.125   Connectedness  23  (16–30)  21  (13–31)  2,422  0.183  0.109  0.181  −0.131  0.107   Hope transcendent  31  (27–36)  32  (25–39)  2,697  0.766  0.017  0.832  0.008  0.923   Experience of sense and meaning  38  (31–42)  37  (32–43)  2,670  0.690  0.031  0.707  0.012  0.880   Sum score  178  (155–195)  174  (156–194)  2,722  0.839  0.021  0.795  −0.022  0.791  Interpersonal guilt questionnaire  n = 90  n = 64               Survivor guilt  18  (13–24)  17  (13–24)  2,690  0.486  0.043  0.597  −0.061  0.454   Separation guilt  18  (13–23)  16  (12–21)  2,461  0.124  0.042  0.607  −0.075  0.358   Organized guilt  27  (23–30)  27  (23–31)  2,799  0.766  −0.007  0.933  −0.002  0.982   Sum score  61  (54–73)  60  (50–69)  2,560  0.240  0.050  0.537  −0.071  0.379  Altruism  n = 98  n = 64               Importance  16  (13–19)  16  (13–17)  2,867  0.353  0.024  0.764  −0.021  0.787   Attainability  14  (12–16)  16  (14–17)  2,440  0.016  −0.223  0.004  0.231  0.003   Success  12  (10–16)  13  (11–16)  2,763  0.199  −0.111  0.161  0.097  0.219  Willingness to pardon  n = 99  n = 61               Without regret  8  (6–11)  8  (6–11)  2,949  0.802  −0.094  0.239  0.109  0.172   With regret  13  (10–16)  13  (11–16)  2,820  0.482  −0.025  0.754  0.116  0.143    Total cohort    Alcohol-related readmission  Number of readmissions  Days to first readmission    Yes  No                Median (IQR)  U  Pa  Rho  Pb  Rho  Pb  Centrality of religiosity scale  n = 94  n = 63               Intellect (basic)  6  (4–9)  5  (4–8)  2,548  0.136  0.106  0.186  −0.101  0.206   Ideology (basic)  9  (5–11)  6  (3–11)  2,455  0.068  0.111  0.166  −0.107  0.183   Public practice (basic)  5  (3–7)  4  (3–7)  2,657  0.265  0.070  0.387  −0.054  0.503   Private practice (basic)  7  (3–11)  5  (3–10)  2,396  0.040  0.089  0.266  −0.101  0.209   Religious experiences (basic)  6  (3–9)  5  (3–8)  2,452  0.064  0.107  0.184  −0.089  0.270   Private practice (inter-religious)  7  (4–9)  5  (3–7)  2,237  0.009  0.207  0.009  −0.184  0.021   Religious experiences (inter-religious)  6  (4–9)  4  (3–7)  2,366  0.031  0.123  0.126  −0.125  0.120  Religiousness and well-being  n = 94  n = 58               Religious affiliation  22  (15–36)  15  (11–29)  1,991  0.005  0.189  0.020  −0.214  0.008   Well-being  42  (35–48)  44  (37–50)  2,474  0.339  −0.092  0.262  0.064  0.432  Multidimensional inventory for religious/spiritual well-being  n = 91  n = 61               General religiosity  23  (10–34)  14  (8–32)  2,317  0.082  0.087  0.289  −0.105  0.196   Forgiveness  31  (23–41)  33  (26–40)  2,467  0.246  −0.112  0.168  0.109  0.180   Hope immanent  31  (27–39)  36  (28–42)  2,343  0.104  −0.093  0.255  0.125  0.125   Connectedness  23  (16–30)  21  (13–31)  2,422  0.183  0.109  0.181  −0.131  0.107   Hope transcendent  31  (27–36)  32  (25–39)  2,697  0.766  0.017  0.832  0.008  0.923   Experience of sense and meaning  38  (31–42)  37  (32–43)  2,670  0.690  0.031  0.707  0.012  0.880   Sum score  178  (155–195)  174  (156–194)  2,722  0.839  0.021  0.795  −0.022  0.791  Interpersonal guilt questionnaire  n = 90  n = 64               Survivor guilt  18  (13–24)  17  (13–24)  2,690  0.486  0.043  0.597  −0.061  0.454   Separation guilt  18  (13–23)  16  (12–21)  2,461  0.124  0.042  0.607  −0.075  0.358   Organized guilt  27  (23–30)  27  (23–31)  2,799  0.766  −0.007  0.933  −0.002  0.982   Sum score  61  (54–73)  60  (50–69)  2,560  0.240  0.050  0.537  −0.071  0.379  Altruism  n = 98  n = 64               Importance  16  (13–19)  16  (13–17)  2,867  0.353  0.024  0.764  −0.021  0.787   Attainability  14  (12–16)  16  (14–17)  2,440  0.016  −0.223  0.004  0.231  0.003   Success  12  (10–16)  13  (11–16)  2,763  0.199  −0.111  0.161  0.097  0.219  Willingness to pardon  n = 99  n = 61               Without regret  8  (6–11)  8  (6–11)  2,949  0.802  −0.094  0.239  0.109  0.172   With regret  13  (10–16)  13  (11–16)  2,820  0.482  −0.025  0.754  0.116  0.143  The table shows median and interquartile range (IQR) of the questionnaire scores (=sum of subitems). aMann–Whitney U-test, bSpearman correlation. P < 0.05 in bold. The gender-specific subgroup analyses revealed that private practice (inter-religious), hope immanent, attainability and success of altruism, and willingness to pardon with regret were predominantly predictive in female alcohol-dependent patients and religious experiences (inter-religious), religious affiliation, connectedness and attainability of altruism in male patients (Tables 4 and 5). Table 4. Associations of religiosity, guilt, altruism and willingness to pardon with 24-month alcohol-related readmissions in female patients   Female patients    Alcohol-related readmission  Number of readmissions  Days to first readmission    Yes  No                Median (IQR)  U  Pa  Rho  Pb  Rho  Pb  Centrality of religiosity scale  n = 35  n = 33               Intellect (basic)  6  (4–9)  5  (4–8)  462  0.152  0.161  0.188  −0.177  0.148   Ideology (basic)  9  (6–12)  8  (5–12)  487  0.265  0.101  0.412  −0.093  0.452   Public practice (basic)  6  (4–7)  5  (3–7)  543  0.662  0.052  0.675  −0.065  0.597   Private practice (basic)  7  (5–12)  5  (4–11)  447  0.107  0.149  0.226  −0.144  0.242   Religious experiences (basic)  7  (5–9)  5  (4–10)  496  0.310  0.102  0.410  −0.091  0.463   Private practice (inter-religious)  7  (5–9)  5  (3–8)  420  0.051  0.275  0.023  −0.240  0.049   Religious experiences (inter-religious)  6  (4–7)  5  (4–8)  498  0.321  0.120  0.330  −0.124  0.316  Religiousness and well-being  n = 36  n = 31               Religious affiliation  24  (16–35)  16  (11–31)  427  0.097  0.195  0.113  −0.197  0.110   Well-being  43  (37–52)  45  (38–51)  524  0.669  −0.044  0.722  0.014  0.912  Multidimensional inventory for religious/spiritual well-being  n = 34  n = 33               General religiosity  24  (12–36)  18  (8–34)  478  0.293  0.100  0.422  −0.121  0.330   Forgiveness  33  (22–43)  37  (30–42)  493  0.390  −0.092  0.460  0.132  0.286   Hope immanent  31  (27–39)  37  (31–42)  396  0.038  −0.240  0.050  0.217  0.077   Connectedness  24  (17–28)  24  (18–32)  561  0.995  −0.005  0.971  −0.022  0.860   Hope transcendent  31  (26–36)  33  (25–40)  532  0.716  −0.004  0.977  0.053  0.669   Experience of sense and meaning  38  (30–42)  38  (32–44)  525  0.647  −0.012  0.924  0.023  0.853   Sum score  181  (156–195)  185  (169–200)  482  0.322  −0.106  0.395  0.105  0.397  Interpersonal guilt questionnaire  n = 34  n = 34               Survivor guilt  18  (13–25)  18  (11–22)  516  0.446  0.047  0.701  −0.121  0.326   Separation guilt  17  (13–23)  14  (11–20)  478  0.219  0.042  0.735  −0.103  0.405   Organized guilt  28  (22–32)  28  (23–32)  573  0.946  −0.041  0.743  −0.060  0.628   Sum score  60  (51–79)  59  (49–69)  513  0.422  0.030  0.809  −0.114  0.354  Altruism  n = 37  n = 34               Importance  18  (15–19)  16  (14–20)  591  0.658  −0.019  0.875  −0.048  0.690   Attainability  15  (12–17)  16  (15–19)  442  0.030  −0.278  0.019  0.220  0.066   Success  12  (10–16)  15  (12–17)  454  0.043  −0.255  0.032  0.220  0.066  Willingness to pardon  n = 37  n = 33               Without regret  8  (5–11)  7  (6–11)  599  0.887  −0.063  0.606  0.053  0.665   With regret  12  (10–14)  13  (11–16)  481  0.126  −0.188  0.119  0.246  0.040    Female patients    Alcohol-related readmission  Number of readmissions  Days to first readmission    Yes  No                Median (IQR)  U  Pa  Rho  Pb  Rho  Pb  Centrality of religiosity scale  n = 35  n = 33               Intellect (basic)  6  (4–9)  5  (4–8)  462  0.152  0.161  0.188  −0.177  0.148   Ideology (basic)  9  (6–12)  8  (5–12)  487  0.265  0.101  0.412  −0.093  0.452   Public practice (basic)  6  (4–7)  5  (3–7)  543  0.662  0.052  0.675  −0.065  0.597   Private practice (basic)  7  (5–12)  5  (4–11)  447  0.107  0.149  0.226  −0.144  0.242   Religious experiences (basic)  7  (5–9)  5  (4–10)  496  0.310  0.102  0.410  −0.091  0.463   Private practice (inter-religious)  7  (5–9)  5  (3–8)  420  0.051  0.275  0.023  −0.240  0.049   Religious experiences (inter-religious)  6  (4–7)  5  (4–8)  498  0.321  0.120  0.330  −0.124  0.316  Religiousness and well-being  n = 36  n = 31               Religious affiliation  24  (16–35)  16  (11–31)  427  0.097  0.195  0.113  −0.197  0.110   Well-being  43  (37–52)  45  (38–51)  524  0.669  −0.044  0.722  0.014  0.912  Multidimensional inventory for religious/spiritual well-being  n = 34  n = 33               General religiosity  24  (12–36)  18  (8–34)  478  0.293  0.100  0.422  −0.121  0.330   Forgiveness  33  (22–43)  37  (30–42)  493  0.390  −0.092  0.460  0.132  0.286   Hope immanent  31  (27–39)  37  (31–42)  396  0.038  −0.240  0.050  0.217  0.077   Connectedness  24  (17–28)  24  (18–32)  561  0.995  −0.005  0.971  −0.022  0.860   Hope transcendent  31  (26–36)  33  (25–40)  532  0.716  −0.004  0.977  0.053  0.669   Experience of sense and meaning  38  (30–42)  38  (32–44)  525  0.647  −0.012  0.924  0.023  0.853   Sum score  181  (156–195)  185  (169–200)  482  0.322  −0.106  0.395  0.105  0.397  Interpersonal guilt questionnaire  n = 34  n = 34               Survivor guilt  18  (13–25)  18  (11–22)  516  0.446  0.047  0.701  −0.121  0.326   Separation guilt  17  (13–23)  14  (11–20)  478  0.219  0.042  0.735  −0.103  0.405   Organized guilt  28  (22–32)  28  (23–32)  573  0.946  −0.041  0.743  −0.060  0.628   Sum score  60  (51–79)  59  (49–69)  513  0.422  0.030  0.809  −0.114  0.354  Altruism  n = 37  n = 34               Importance  18  (15–19)  16  (14–20)  591  0.658  −0.019  0.875  −0.048  0.690   Attainability  15  (12–17)  16  (15–19)  442  0.030  −0.278  0.019  0.220  0.066   Success  12  (10–16)  15  (12–17)  454  0.043  −0.255  0.032  0.220  0.066  Willingness to pardon  n = 37  n = 33               Without regret  8  (5–11)  7  (6–11)  599  0.887  −0.063  0.606  0.053  0.665   With regret  12  (10–14)  13  (11–16)  481  0.126  −0.188  0.119  0.246  0.040  The table shows median and interquartile range (IQR) of the questionnaire scores (=sum of subitems). aMann–Whitney U-test, bSpearman correlation. P < 0.05 in bold. Table 4. Associations of religiosity, guilt, altruism and willingness to pardon with 24-month alcohol-related readmissions in female patients   Female patients    Alcohol-related readmission  Number of readmissions  Days to first readmission    Yes  No                Median (IQR)  U  Pa  Rho  Pb  Rho  Pb  Centrality of religiosity scale  n = 35  n = 33               Intellect (basic)  6  (4–9)  5  (4–8)  462  0.152  0.161  0.188  −0.177  0.148   Ideology (basic)  9  (6–12)  8  (5–12)  487  0.265  0.101  0.412  −0.093  0.452   Public practice (basic)  6  (4–7)  5  (3–7)  543  0.662  0.052  0.675  −0.065  0.597   Private practice (basic)  7  (5–12)  5  (4–11)  447  0.107  0.149  0.226  −0.144  0.242   Religious experiences (basic)  7  (5–9)  5  (4–10)  496  0.310  0.102  0.410  −0.091  0.463   Private practice (inter-religious)  7  (5–9)  5  (3–8)  420  0.051  0.275  0.023  −0.240  0.049   Religious experiences (inter-religious)  6  (4–7)  5  (4–8)  498  0.321  0.120  0.330  −0.124  0.316  Religiousness and well-being  n = 36  n = 31               Religious affiliation  24  (16–35)  16  (11–31)  427  0.097  0.195  0.113  −0.197  0.110   Well-being  43  (37–52)  45  (38–51)  524  0.669  −0.044  0.722  0.014  0.912  Multidimensional inventory for religious/spiritual well-being  n = 34  n = 33               General religiosity  24  (12–36)  18  (8–34)  478  0.293  0.100  0.422  −0.121  0.330   Forgiveness  33  (22–43)  37  (30–42)  493  0.390  −0.092  0.460  0.132  0.286   Hope immanent  31  (27–39)  37  (31–42)  396  0.038  −0.240  0.050  0.217  0.077   Connectedness  24  (17–28)  24  (18–32)  561  0.995  −0.005  0.971  −0.022  0.860   Hope transcendent  31  (26–36)  33  (25–40)  532  0.716  −0.004  0.977  0.053  0.669   Experience of sense and meaning  38  (30–42)  38  (32–44)  525  0.647  −0.012  0.924  0.023  0.853   Sum score  181  (156–195)  185  (169–200)  482  0.322  −0.106  0.395  0.105  0.397  Interpersonal guilt questionnaire  n = 34  n = 34               Survivor guilt  18  (13–25)  18  (11–22)  516  0.446  0.047  0.701  −0.121  0.326   Separation guilt  17  (13–23)  14  (11–20)  478  0.219  0.042  0.735  −0.103  0.405   Organized guilt  28  (22–32)  28  (23–32)  573  0.946  −0.041  0.743  −0.060  0.628   Sum score  60  (51–79)  59  (49–69)  513  0.422  0.030  0.809  −0.114  0.354  Altruism  n = 37  n = 34               Importance  18  (15–19)  16  (14–20)  591  0.658  −0.019  0.875  −0.048  0.690   Attainability  15  (12–17)  16  (15–19)  442  0.030  −0.278  0.019  0.220  0.066   Success  12  (10–16)  15  (12–17)  454  0.043  −0.255  0.032  0.220  0.066  Willingness to pardon  n = 37  n = 33               Without regret  8  (5–11)  7  (6–11)  599  0.887  −0.063  0.606  0.053  0.665   With regret  12  (10–14)  13  (11–16)  481  0.126  −0.188  0.119  0.246  0.040    Female patients    Alcohol-related readmission  Number of readmissions  Days to first readmission    Yes  No                Median (IQR)  U  Pa  Rho  Pb  Rho  Pb  Centrality of religiosity scale  n = 35  n = 33               Intellect (basic)  6  (4–9)  5  (4–8)  462  0.152  0.161  0.188  −0.177  0.148   Ideology (basic)  9  (6–12)  8  (5–12)  487  0.265  0.101  0.412  −0.093  0.452   Public practice (basic)  6  (4–7)  5  (3–7)  543  0.662  0.052  0.675  −0.065  0.597   Private practice (basic)  7  (5–12)  5  (4–11)  447  0.107  0.149  0.226  −0.144  0.242   Religious experiences (basic)  7  (5–9)  5  (4–10)  496  0.310  0.102  0.410  −0.091  0.463   Private practice (inter-religious)  7  (5–9)  5  (3–8)  420  0.051  0.275  0.023  −0.240  0.049   Religious experiences (inter-religious)  6  (4–7)  5  (4–8)  498  0.321  0.120  0.330  −0.124  0.316  Religiousness and well-being  n = 36  n = 31               Religious affiliation  24  (16–35)  16  (11–31)  427  0.097  0.195  0.113  −0.197  0.110   Well-being  43  (37–52)  45  (38–51)  524  0.669  −0.044  0.722  0.014  0.912  Multidimensional inventory for religious/spiritual well-being  n = 34  n = 33               General religiosity  24  (12–36)  18  (8–34)  478  0.293  0.100  0.422  −0.121  0.330   Forgiveness  33  (22–43)  37  (30–42)  493  0.390  −0.092  0.460  0.132  0.286   Hope immanent  31  (27–39)  37  (31–42)  396  0.038  −0.240  0.050  0.217  0.077   Connectedness  24  (17–28)  24  (18–32)  561  0.995  −0.005  0.971  −0.022  0.860   Hope transcendent  31  (26–36)  33  (25–40)  532  0.716  −0.004  0.977  0.053  0.669   Experience of sense and meaning  38  (30–42)  38  (32–44)  525  0.647  −0.012  0.924  0.023  0.853   Sum score  181  (156–195)  185  (169–200)  482  0.322  −0.106  0.395  0.105  0.397  Interpersonal guilt questionnaire  n = 34  n = 34               Survivor guilt  18  (13–25)  18  (11–22)  516  0.446  0.047  0.701  −0.121  0.326   Separation guilt  17  (13–23)  14  (11–20)  478  0.219  0.042  0.735  −0.103  0.405   Organized guilt  28  (22–32)  28  (23–32)  573  0.946  −0.041  0.743  −0.060  0.628   Sum score  60  (51–79)  59  (49–69)  513  0.422  0.030  0.809  −0.114  0.354  Altruism  n = 37  n = 34               Importance  18  (15–19)  16  (14–20)  591  0.658  −0.019  0.875  −0.048  0.690   Attainability  15  (12–17)  16  (15–19)  442  0.030  −0.278  0.019  0.220  0.066   Success  12  (10–16)  15  (12–17)  454  0.043  −0.255  0.032  0.220  0.066  Willingness to pardon  n = 37  n = 33               Without regret  8  (5–11)  7  (6–11)  599  0.887  −0.063  0.606  0.053  0.665   With regret  12  (10–14)  13  (11–16)  481  0.126  −0.188  0.119  0.246  0.040  The table shows median and interquartile range (IQR) of the questionnaire scores (=sum of subitems). aMann–Whitney U-test, bSpearman correlation. P < 0.05 in bold. Table 5. Associations of religiosity, guilt, altruism and willingness to pardon with 24-month alcohol-related readmissions in male patients   Male patients    Alcohol-related readmission  Number of readmissions  Days to first readmission    Yes  No                Median (IQR)  U  Pa  Rho  Pb  Rho  Pb  Centrality of religiosity scale  n = 59  n = 30               Intellect (basic)  6  (4–9)  5  (4–8)  788  0.392  0.079  0.459  −0.062  0.565   Ideology (basic)  8  (4–11)  5  (3–9)  678  0.070  0.156  0.144  −0.154  0.149   Public practice (basic)  5  (3–7)  4  (3–6)  729  0.162  0.104  0.333  −0.061  0.567   Private practice (basic)  6  (3–11)  4  (3–8)  681  0.067  0.095  0.375  −0.120  0.261   Religious experiences (basic)  6  (3–9)  4  (3–6)  677  0.062  0.135  0.207  −0.116  0.280   Private practice (inter-religious)  6  (4–10)  5  (3–6)  671  0.059  0.170  0.112  −0.144  0.177   Religious experiences (inter-religious)  5  (4–9)  4  (3–6)  622  0.020  0.143  0.182  −0.153  0.153  Religiousness and well-being  n = 58  n = 27               Religious affiliation  21  (14–36)  14  (11–23)  539  0.021  0.180  0.100  −0.235  0.030   Well-being  42  (35–47)  43  (36–49)  734  0.643  −0.091  0.410  0.074  0.503  Multidimensional inventory for religious/spiritual well-being  n = 57  n = 28               General religiosity  22  (9–32)  10  (8–25)  612  0.077  0.103  0.350  −0.128  0.244   Forgiveness  30  (23–37)  32  (24–38)  774  0.822  −0.081  0.461  0.036  0.746   Hope immanent  31  (27–39)  32  (25–40)  797  0.989  0.046  0.673  0.028  0.802   Connectedness  22  (16–31)  16  (12–26)  586  0.047  0.206  0.058  −0.238  0.028   Hope transcendent  30  (28–35)  31  (25–36)  795  0.974  0.048  0.660  −0.035  0.748   Experience of sense and meaning  38  (32–42)  37  (32–43)  790  0.940  0.066  0.549  −0.012  0.915   Sum score  174  (155–194)  163  (146–178)  619  0.093  0.159  0.147  −0.160  0.145  Interpersonal guilt questionnaire  n = 56  n = 30               Survivor guilt  19  (14–23)  17  (14–24)  806  0.758  0.061  0.579  −0.016  0.881   Separation guilt  19  (13–23)  18  (12–21)  759  0.460  0.034  0.758  −0.023  0.832   Organized guilt  27  (23–29)  25  (22–29)  748  0.403  0.075  0.490  0.005  0.967   Sum score  62  (55–72)  61  (51–69)  767  0.505  0.059  0.592  −0.013  0.906  Altruism  n = 61  n = 30               Importance  16  (13–19)  16  (13–17)  772  0.222  0.100  0.344  −0.029  0.787   Attainability  13  (12–16)  15  (12–17)  819  0.414  −0.142  0.178  0.212  0.044   Success  13  (10–16)  12  (9–15)  870  0.703  0.018  0.866  −0.009  0.936  Willingness to pardon  n = 62  n = 28               Without regret  8  (6–11)  9  (7–11)  817  0.652  −0.153  0.150  0.183  0.083   With regret  14  (11–16)  14  (11–16)  851  0.882  0.052  0.628  0.062  0.565    Male patients    Alcohol-related readmission  Number of readmissions  Days to first readmission    Yes  No                Median (IQR)  U  Pa  Rho  Pb  Rho  Pb  Centrality of religiosity scale  n = 59  n = 30               Intellect (basic)  6  (4–9)  5  (4–8)  788  0.392  0.079  0.459  −0.062  0.565   Ideology (basic)  8  (4–11)  5  (3–9)  678  0.070  0.156  0.144  −0.154  0.149   Public practice (basic)  5  (3–7)  4  (3–6)  729  0.162  0.104  0.333  −0.061  0.567   Private practice (basic)  6  (3–11)  4  (3–8)  681  0.067  0.095  0.375  −0.120  0.261   Religious experiences (basic)  6  (3–9)  4  (3–6)  677  0.062  0.135  0.207  −0.116  0.280   Private practice (inter-religious)  6  (4–10)  5  (3–6)  671  0.059  0.170  0.112  −0.144  0.177   Religious experiences (inter-religious)  5  (4–9)  4  (3–6)  622  0.020  0.143  0.182  −0.153  0.153  Religiousness and well-being  n = 58  n = 27               Religious affiliation  21  (14–36)  14  (11–23)  539  0.021  0.180  0.100  −0.235  0.030   Well-being  42  (35–47)  43  (36–49)  734  0.643  −0.091  0.410  0.074  0.503  Multidimensional inventory for religious/spiritual well-being  n = 57  n = 28               General religiosity  22  (9–32)  10  (8–25)  612  0.077  0.103  0.350  −0.128  0.244   Forgiveness  30  (23–37)  32  (24–38)  774  0.822  −0.081  0.461  0.036  0.746   Hope immanent  31  (27–39)  32  (25–40)  797  0.989  0.046  0.673  0.028  0.802   Connectedness  22  (16–31)  16  (12–26)  586  0.047  0.206  0.058  −0.238  0.028   Hope transcendent  30  (28–35)  31  (25–36)  795  0.974  0.048  0.660  −0.035  0.748   Experience of sense and meaning  38  (32–42)  37  (32–43)  790  0.940  0.066  0.549  −0.012  0.915   Sum score  174  (155–194)  163  (146–178)  619  0.093  0.159  0.147  −0.160  0.145  Interpersonal guilt questionnaire  n = 56  n = 30               Survivor guilt  19  (14–23)  17  (14–24)  806  0.758  0.061  0.579  −0.016  0.881   Separation guilt  19  (13–23)  18  (12–21)  759  0.460  0.034  0.758  −0.023  0.832   Organized guilt  27  (23–29)  25  (22–29)  748  0.403  0.075  0.490  0.005  0.967   Sum score  62  (55–72)  61  (51–69)  767  0.505  0.059  0.592  −0.013  0.906  Altruism  n = 61  n = 30               Importance  16  (13–19)  16  (13–17)  772  0.222  0.100  0.344  −0.029  0.787   Attainability  13  (12–16)  15  (12–17)  819  0.414  −0.142  0.178  0.212  0.044   Success  13  (10–16)  12  (9–15)  870  0.703  0.018  0.866  −0.009  0.936  Willingness to pardon  n = 62  n = 28               Without regret  8  (6–11)  9  (7–11)  817  0.652  −0.153  0.150  0.183  0.083   With regret  14  (11–16)  14  (11–16)  851  0.882  0.052  0.628  0.062  0.565  The table shows median and interquartile range (IQR) of the questionnaire scores (=sum of subitems). aMann–Whitney U-test, bSpearman correlation. P < 0.05 in bold. Table 5. Associations of religiosity, guilt, altruism and willingness to pardon with 24-month alcohol-related readmissions in male patients   Male patients    Alcohol-related readmission  Number of readmissions  Days to first readmission    Yes  No                Median (IQR)  U  Pa  Rho  Pb  Rho  Pb  Centrality of religiosity scale  n = 59  n = 30               Intellect (basic)  6  (4–9)  5  (4–8)  788  0.392  0.079  0.459  −0.062  0.565   Ideology (basic)  8  (4–11)  5  (3–9)  678  0.070  0.156  0.144  −0.154  0.149   Public practice (basic)  5  (3–7)  4  (3–6)  729  0.162  0.104  0.333  −0.061  0.567   Private practice (basic)  6  (3–11)  4  (3–8)  681  0.067  0.095  0.375  −0.120  0.261   Religious experiences (basic)  6  (3–9)  4  (3–6)  677  0.062  0.135  0.207  −0.116  0.280   Private practice (inter-religious)  6  (4–10)  5  (3–6)  671  0.059  0.170  0.112  −0.144  0.177   Religious experiences (inter-religious)  5  (4–9)  4  (3–6)  622  0.020  0.143  0.182  −0.153  0.153  Religiousness and well-being  n = 58  n = 27               Religious affiliation  21  (14–36)  14  (11–23)  539  0.021  0.180  0.100  −0.235  0.030   Well-being  42  (35–47)  43  (36–49)  734  0.643  −0.091  0.410  0.074  0.503  Multidimensional inventory for religious/spiritual well-being  n = 57  n = 28               General religiosity  22  (9–32)  10  (8–25)  612  0.077  0.103  0.350  −0.128  0.244   Forgiveness  30  (23–37)  32  (24–38)  774  0.822  −0.081  0.461  0.036  0.746   Hope immanent  31  (27–39)  32  (25–40)  797  0.989  0.046  0.673  0.028  0.802   Connectedness  22  (16–31)  16  (12–26)  586  0.047  0.206  0.058  −0.238  0.028   Hope transcendent  30  (28–35)  31  (25–36)  795  0.974  0.048  0.660  −0.035  0.748   Experience of sense and meaning  38  (32–42)  37  (32–43)  790  0.940  0.066  0.549  −0.012  0.915   Sum score  174  (155–194)  163  (146–178)  619  0.093  0.159  0.147  −0.160  0.145  Interpersonal guilt questionnaire  n = 56  n = 30               Survivor guilt  19  (14–23)  17  (14–24)  806  0.758  0.061  0.579  −0.016  0.881   Separation guilt  19  (13–23)  18  (12–21)  759  0.460  0.034  0.758  −0.023  0.832   Organized guilt  27  (23–29)  25  (22–29)  748  0.403  0.075  0.490  0.005  0.967   Sum score  62  (55–72)  61  (51–69)  767  0.505  0.059  0.592  −0.013  0.906  Altruism  n = 61  n = 30               Importance  16  (13–19)  16  (13–17)  772  0.222  0.100  0.344  −0.029  0.787   Attainability  13  (12–16)  15  (12–17)  819  0.414  −0.142  0.178  0.212  0.044   Success  13  (10–16)  12  (9–15)  870  0.703  0.018  0.866  −0.009  0.936  Willingness to pardon  n = 62  n = 28               Without regret  8  (6–11)  9  (7–11)  817  0.652  −0.153  0.150  0.183  0.083   With regret  14  (11–16)  14  (11–16)  851  0.882  0.052  0.628  0.062  0.565    Male patients    Alcohol-related readmission  Number of readmissions  Days to first readmission    Yes  No                Median (IQR)  U  Pa  Rho  Pb  Rho  Pb  Centrality of religiosity scale  n = 59  n = 30               Intellect (basic)  6  (4–9)  5  (4–8)  788  0.392  0.079  0.459  −0.062  0.565   Ideology (basic)  8  (4–11)  5  (3–9)  678  0.070  0.156  0.144  −0.154  0.149   Public practice (basic)  5  (3–7)  4  (3–6)  729  0.162  0.104  0.333  −0.061  0.567   Private practice (basic)  6  (3–11)  4  (3–8)  681  0.067  0.095  0.375  −0.120  0.261   Religious experiences (basic)  6  (3–9)  4  (3–6)  677  0.062  0.135  0.207  −0.116  0.280   Private practice (inter-religious)  6  (4–10)  5  (3–6)  671  0.059  0.170  0.112  −0.144  0.177   Religious experiences (inter-religious)  5  (4–9)  4  (3–6)  622  0.020  0.143  0.182  −0.153  0.153  Religiousness and well-being  n = 58  n = 27               Religious affiliation  21  (14–36)  14  (11–23)  539  0.021  0.180  0.100  −0.235  0.030   Well-being  42  (35–47)  43  (36–49)  734  0.643  −0.091  0.410  0.074  0.503  Multidimensional inventory for religious/spiritual well-being  n = 57  n = 28               General religiosity  22  (9–32)  10  (8–25)  612  0.077  0.103  0.350  −0.128  0.244   Forgiveness  30  (23–37)  32  (24–38)  774  0.822  −0.081  0.461  0.036  0.746   Hope immanent  31  (27–39)  32  (25–40)  797  0.989  0.046  0.673  0.028  0.802   Connectedness  22  (16–31)  16  (12–26)  586  0.047  0.206  0.058  −0.238  0.028   Hope transcendent  30  (28–35)  31  (25–36)  795  0.974  0.048  0.660  −0.035  0.748   Experience of sense and meaning  38  (32–42)  37  (32–43)  790  0.940  0.066  0.549  −0.012  0.915   Sum score  174  (155–194)  163  (146–178)  619  0.093  0.159  0.147  −0.160  0.145  Interpersonal guilt questionnaire  n = 56  n = 30               Survivor guilt  19  (14–23)  17  (14–24)  806  0.758  0.061  0.579  −0.016  0.881   Separation guilt  19  (13–23)  18  (12–21)  759  0.460  0.034  0.758  −0.023  0.832   Organized guilt  27  (23–29)  25  (22–29)  748  0.403  0.075  0.490  0.005  0.967   Sum score  62  (55–72)  61  (51–69)  767  0.505  0.059  0.592  −0.013  0.906  Altruism  n = 61  n = 30               Importance  16  (13–19)  16  (13–17)  772  0.222  0.100  0.344  −0.029  0.787   Attainability  13  (12–16)  15  (12–17)  819  0.414  −0.142  0.178  0.212  0.044   Success  13  (10–16)  12  (9–15)  870  0.703  0.018  0.866  −0.009  0.936  Willingness to pardon  n = 62  n = 28               Without regret  8  (6–11)  9  (7–11)  817  0.652  −0.153  0.150  0.183  0.083   With regret  14  (11–16)  14  (11–16)  851  0.882  0.052  0.628  0.062  0.565  The table shows median and interquartile range (IQR) of the questionnaire scores (=sum of subitems). aMann–Whitney U-test, bSpearman correlation. P < 0.05 in bold. DISCUSSION To the authors’ knowledge, the study reported here is the first to gender-specifically compare religious denomination, religiosity, guilt, altruism and forgiveness between alcohol-dependent patients and age as well as sex-matched healthy control subjects and to evaluate their predictive potential for alcohol-related readmission following in-patient withdrawal treatment. We found an association between likelihood of being in the patient sample and acknowledging a religious denomination. By contrast, Hodge et al. (2001) reported that spiritual or religious involvement in south west USA was associated with decreased risk of alcohol or drug abuse, problems, and dependence. Similarly, Michalak et al. (2007) found in their examination of the data from the US National Alcohol Survey that religious affiliation was associated with abstinence from alcohol use. However, in the USA religion might relate differently to alcohol behaviors, because denominations which prohibit alcohol (e.g. Mormons, Seventh Day Adventists and Muslims) are more frequent there than in our European Franconian sample. Most of our study subjects were Catholics or Protestants and might thus be more accustomed to ritual incorporation of alcohol in form of wine due to their religious background. As suggested by Haber et al. (2011), personality profiles strongly influence the relationship between alcohol dependence and religion. This may also account for inconsistencies between different studies. Our finding that religious affiliation is positively related to attitude towards alcohol is in accordance with Walters’ findings (1957) of a transgenerational effect. In 50 alcohol-dependent patients of a Midwest Veterans Administration Hospital, he found that parents of alcohol-dependent individuals were more likely to be church members than parents of control subjects. To provide additional supporting evidence for our result of religiosity being relevant to alcohol dependence, we analyzed associations of religiosity with alcohol-related hospital readmission during the 24-month follow-up. Interestingly, higher private practice was not only associated with alcohol dependence per se; we found also that higher private practice and higher religious affiliation predicted a shortened interval to first alcohol-related readmission as well as more frequent readmissions. In summary, religious denomination and religiosity are related to increased risk for alcohol dependence and a worse 24-month outcome in our cohort. Identifying underlying mechanisms was beyond the scope of this study. Nevertheless, we speculate that life burden and chronic illnesses motivate people to ask about the sense of life and other existential items. An answer to these fundamental questions can be found in a religious world outlook. This aspect could contribute to the association between religiosity and alcohol dependence as well as religiosity and worse outcome, as shown in our study. Moreover, Dutton and van der Linden (2017) discuss that intelligence is negatively associated with religiousness. That might stimulate the hypothesis that premorbid intelligence is negatively related to developing alcohol dependence. However, further studies are needed to illuminate the concrete underpinnings. We measured higher scores on religious experiences, connectedness, experience of sense and meaning, and guilt in the patients’ cohort in comparison to the healthy controls. The significantly higher scores in patients’ connectedness might be confounded by repetitive inebriation experiences. This bias has been well-known for millenia: ‘And be not drunk with wine, wherein is excess; but be filled with the Spirit’ (Ephesians 5: 18 in: Witkiewitz et al., 2016). Accordingly, we speculate that the higher scores on the scale of experience of sense and meaning in alcohol-dependent patients are also a consequence of frequent inebriation experiences. The alcohol-dependent patients’ higher scores on the scales for interpersonal guilt are understandable. An individual might decide to engage in alcohol misuse to deal with guilt or shame and vice versa the pathological alcohol consumption might also cause a feeling of guilt (Ianni et al., 2010, Webb et al., 2006). Self-blame as a maladaptive coping strategy has been associated with a worse outcome in alcohol-dependent patients (Tapert et al., 2004). Whether the feeling of guilt is a cause or consequence of alcohol dependence remains to be shown; however, our data suggest that it might be a relevant psychotherapeutic target to prevent and to deal with alcohol dependence. In comparison to healthy control subjects, patients scored lower on well-being (BI), forgiveness, and immanent and transcendent hope (MIRSB) suggesting that these factors might be protective against alcohol dependence. The lowered patients’ levels of forgiveness perhaps reflect a wish for revenge. At this point, one might hypothesize, that patients have less tendency of self-forgiving, which would be in line with the increased feelings of guilt discussed above because forgiveness of self has been evaluated as a strategy for coping with feelings of guilt and shame (Hall and Finchman, 2005). Thus, forgiveness as a specific dimension of religiousness should be tested as an element to enhance recovery. However, its operating mechanisms in general are unknown (Webb et al., 2011). Interestingly, we found no significant difference between alcohol-dependent patients and healthy control subjects with regard to the SBV forgiveness scales. The MIRSB and SBV questionnaires differ in that the MIRSB forgiveness scale is surveyed in a quite general and abstract way, whereas the SBV uses concrete exemplifications to explore the willingness to forgive. Moreover, the SBV differentiates between the willingness to pardon without and with regret. The lack of a group difference on the SBV scales agrees with results showing that forgiveness did not predict alcohol dependence outcomes (Webb et al., 2011; Langman and Chung, 2013). The sex-balanced cohort which enabled analysis of gender-specific effects of religiosity on alcohol dependence is a strength of our study. However, the gender differences shown in the tables should not be over-interpreted and need validation in future studies. The Franconian region, where the study was conducted, is mainly inhabited by Protestants. This reduces the generalizability of the study findings and is a relevant limitation. Moreover, we cannot exclude that some of the findings classified as significant represent false positives. According to the explorative study design, our data have not been corrected for multiple testing and need to be confirmed in future investigations. CONCLUSION As far as we know, this study shows for the first time an increased risk for alcohol dependence and a worse outcome in study subjects with a religious denomination, more private religious practice, religious affiliation, guilt and reduced attainability of altruism. Further research is needed to analyze the role of the personality within the trio of alcohol dependence, religiosity and personality and to develop differentiated strategies to enhance the positive components of religiosity on alcohol dependence. ACKNOWLEDGEMENTS We thank Dr. Andreas Ahnert, Ute Hamers and Dr. Kristina Bayerlein for the opportunity and the support to recruit patients at the Klinik für Psychiatrie, Psychotherapie, Psychosomatik of the Klinikum am Europakanal Erlangen. We gratefully appreciate the support of Juliane Behrens, Sarah Kubis, Katrin Mikolaiczik, Sarah Saigali, Marina Sibach, and Petya Tanovska in recruiting patients and healthy control subjects. We recognize Prof. Dr. Teresa Biermann for inspirational support concerning the topic of religiosity/spirituality. We express our gratitude to Prof. Dr. Jonathan D. Chick for revisional hints. Conflict of Interest Statement The authors declare that they have no conflict of interest. Authors’ contribution Conceived and designed the experiments: B.B., C.W., J.K., B.L. Performed the experiments: B.B., C.W., B.L. Analyzed the data and wrote the article: B.B., B.L. Commented on the article and provided intellectual input: J.K. 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Religiosity, Guilt, Altruism and Forgiveness in Alcohol Dependence: Results of a Cross-sectional and Prospective Cohort Study

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Oxford University Press
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© The Author(s) 2018. Medical Council on Alcohol and Oxford University Press. All rights reserved.
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0735-0414
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Abstract

Abstract Aims To compare religious denomination, religiosity, guilt, altruism and forgiveness between alcohol-dependent patients and healthy control subjects and to prospectively investigate their relationship to the disorder’s 24-month course following in-patient withdrawal treatment. Method This study in Franconia (a mainly Christian protestant region of southern Germany) applied six questionnaires to evaluate religiosity, guilt, altruism and forgiveness in 166 alcohol-dependent in-patients during withdrawal and compared findings with that of 240 healthy controls. Results Compared to controls religious denomination was more frequently reported by the patients (OR = 1.72, P = 0.014) and patients showed higher guilt (P < 0.001). The subjective attainability of altruism was lower in patients than in controls (P = 0.015). Higher scores on scale of inter-religious private practice predicted earlier (Rho = −0.184, P = 0.021) and more frequent alcohol-related readmissions during the follow-up (Rho = 0.207, P = 0.009). Higher religious affiliation was related to earlier (Rho = −0.214, P = 0.008) and more frequent alcohol-related readmissions (Rho = 0189, P = 0.020). Lower values of subjective attainability of altruism predicted a worse outcome (earlier [Rho = 0.231, P = 0.003] and more frequent readmissions [Rho = −0.223, P = 0.004]). The sex-specific analyses show that some of the associations are stronger in women and others are stronger in men; however, these gender differences are small and possibly biased by multiple hypothesis testing. Conclusions We identified religious denomination, private religious practice, religious affiliation, guilt and reduced attainability of altruism as risk factors for alcohol dependence and a worse follow-up outcome. Our findings may help to establish future preventive and therapeutic strategies. INTRODUCTION Religiosity has been a subject of research for more than 70 years with respect to the etiology, maintenance and treatment of alcohol dependence (Piderman et al., 2007). Some studies indicate a protective role of religiosity in the etiology and maintenance of alcohol dependence (Rice, 1941; Seliger, 1947; Drerup et al., 2011). However, findings regarding religious affiliation and early religious activity on the development and the course of alcohol dependence are inconclusive (Shalloo, 1941; Walters, 1957). (For research focusing on religiosity in mental and physical health, see Koenig et al. (2012) and in gaming disorder, see Braun et al. (2016).) Recently, the religiosity/spirituality section of the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) has published a position paper ‘Recommendation for Dealing with Religiosity/Spirituality in Psychiatry and Psychotherapy’ (Utsch et al., 2017). This review of the literature finds that the correlation between power of faith and therapeutic effects is modulated by other mechanisms such as psychological or neurobiological. In this study of religiosity and related psychological traits of guilt, altruism and forgiveness, we compare alcohol-dependent patients and healthy controls. Secondly we investigated the parameters' potential in predicting alcohol-related hospital readmission following in-patient withdrawal treatment for alcoholism. METHODS Study cohort This project on religious denomination, religiosity, guilt, altruism and forgiveness was part of the bicentric, cross-sectional, and longitudinal Neurobiology of Alcoholism (NOAH) study. In total, we recruited 200 alcohol-dependent patients who were admitted as in-patients for withdrawal treatment and 240 healthy controls, recruited from the south German region of Franconia via local and online advertisements as well as via flyers. Patients met criteria for alcohol dependence according to the ICD-10 (WHO, 1992) and/or for alcohol use disorder according to the DSM-5 (APA, 2013). Further details on the study design may be drawn from Lenz et al. (2017) and from Weinland et al. (2017). We followed the patients for 24 months after study inclusion. The number of alcohol-related hospital readmissions and the days to first readmission were extracted from the electronic patients’ records. In case of no alcohol-related readmission during the follow-up according to the patients' records, we set the days to first readmission to 730 days. The study was conducted according to the ethical principles of the World Medical Association (sixth revision of the Declaration of Helsinki, Seoul 2008) and the International Conference on Harmonization Guidelines for Good Clinical Practice (1996). It was approved by the Ethics Committee of the Medical Faculty of the Friedrich-Alexander University Erlangen-Nürnberg (NOAH study ID 81_12 B). All participants provided written informed consent prior to inclusion. Employed questionnaires For detecting the religious and psychological dimensions of interest, we applied six well-evaluated questionnaires: Centrality of Religiosity Scale (CRS; Huber and Huber, 2012). The scale was applied to measure the centrality as the importance or salience of religious meanings in personality. It quantifies the general intensities of the following five theoretically defined core dimensions which together can be considered as representative of individual religiosity. Public practice items: How often do you take part in religious services? How important is it to take part in religious services? How important is it for you to be connected to a religious community? Private practice items: How often do you pray? How often do you meditate? How important is personal prayer for you? How important is meditation for you? How often do you pray spontaneously when inspired by daily situations? How often do you try to connect to the divine spontaneously when inspired by daily situations? Religious experience items: How often do you experience situations in which you have the feeling that God or something divine intervenes in your life? How often do you experience situations in which you have the feeling that you are in one with all? How often do you experience situations in which you have the feeling that God or something divine wants to communicate or to reveal something to you? How often do you experience situations in which you have the feeling that you are touched by a divine power? How often do you experience situations in which you have the feeling that God or something divine is present? Ideology items: To what extent do you believe that God or something divine exists? To what extent do you believe in an afterlife, e.g. immortality of the soul, resurrection of the dead or reincarnation? In your opinion, how probable is it that a higher power really exists? Intellect items: How often do you think about religious issues? How interested are you in learning more about religious topics? How often do you keep yourself informed about religious questions through radio, television, Internet, newspapers or books? Brief Instrument (BI). The questionnaire was employed to detect ‘religious affiliation’ and ‘well-being’ (Mehnert and Koch, 2001). It represents a compendium of the Spiritual Experience Index (Genia, 1991), the Spiritual Well-Being Scale (Paloutzian/Ellison, 1982) and the Religious Problem Solving Scale (Pargament et al., 1988). Multidimensional Inventory for Religious/Spiritual Well-Being (MIRSB, Unterrainer et al., 2010; MIRSB-E, Unterrainer et al., 2012). The inventory allows quantification of the following scales. General religiosity items: My faith gives me a feeling of security. It is possible for me to find contentment in intimate conversations with God. I will be able to overcome all problems with God’s help. In certain moments in my life, I feel very close to God. With God’s help, I will be happy once again. I know that God is merciful. I enjoy attending to religious community events. I feel the presence of God in nature. Forgiveness items: There are things which I cannot forgive. There are people whom I hate. There are people whom I will never be able to forgive. There are things which people should not forgive. If somebody hurts me, I usually try to get revenge. The thought of seeing my enemies suffer satisfies me. There are people who deserve to be treated badly. I have forgiven those people who have hurt me. Hope immanent items: I view the future with optimism. I think that things will improve in the future. I think my life is moving in the right direction. I think that I will have more positive than negative experiences in the future. I think that I will live my life in the future just as I envisage it. I have a precise picture of what my future should be like. The future seems to be extremely uncertain. I believe that the future holds exciting challenges for me. Connectedness items: I have experienced the feeling of being absorbed into something greater. I believe that I will be reborn after my death. There are people with whom I feel a supernatural connection. I have had experiences through which I have realized that nothing ever dies. I believe in further existence after death. I have experienced things which I cannot express in words. I have experienced things which radiate a special kind of energy. I believe that I will have experiences in the future to which very few people have access. Hope transcendent items: I often think about the fact that I will have to leave my loved ones behind. I would do anything to prolong the lives of those I love. It is hard for me to think that my loved ones will one day no longer live. I am terrified of being forgotten after my death. I would do anything to prolong my life. I am scared about what will happen to me after my death. All hope ends with death. I fear being made accountable for the things I have done wrong after my death. Experience of sense and meaning items: I have experienced true (authentic) feelings. I have experienced deep affection. I have experienced true friendship. I have often experienced openness and honesty. I have experienced things which I want to experience again and again. I have often had experiences which have deeply affected me. In my experience, it is possible for me to become so involved in something that I forget everything around me. I have had one or more experiences in which the meaning of life became clear to me. Interpersonal Guilt questionnaire (IGQ; O’Connor et al., 1997; German short version; Albani et al., 2002a, b). The questionnaire allows distinguishing the subscales Separation Guilt, Survivor Guilt and Organized Guilt as components of Interpersonal Guilt (=sum score). Altruism (=acting for the welfare of others) as a component of the life goals questionnaire GOALS (Pöhlmann and Brunstein, 1997; Pöhlmann et al., 2010). Importance: How important is it for you to reach this goal in your lifetime? Attainability: How good do you think your chances are to reach this goal in your lifetime? Success: How successful are you currently in attaining this goal? For detecting the level of forgiveness in patients and controls, we used the scale on willingness to forgive (‘Skala der Bereitschaft zu Verzeihen’ [SBV], Allemand et al., 2008), which allows distinguishing the willingness to pardon as a function depending on the degree of regret on the part of the transgressor. Statistical analysis Sum scores of questionnaire items for all sub- and sum-scales were calculated and are presented as median and interquartile range (IQR) in the text and the tables. We used χ2 tests for nominal variables and Mann–Whitney U tests for continuous variables to compare alcohol-dependent patients with healthy control subjects. Correlations were calculated with Spearman’s rank correlation method. Cronbach’s alpha was calculated to estimate the internal consistency reliability. Questionnaire datasets with missing values were excluded. In a first step, we analyzed the total sample. Because of the well-known sex differences in alcohol dependence (Lenz et al., 2012; WHO, 2014) the NOAH study was balanced with regard to gender. That enabled us to subsequently conduct analyses separately for men and women. The P values < 0.05 for two-sided tests were considered to be statistically significant. We used IBM SPSS Statistics Version 21 for Windows (SPSS Inc., Chicago, IL, USA). RESULTS We here investigated 166 alcohol-dependent patients and 240 healthy control subjects (for sociodemographic characteristics, see Table 1) because 34 patients discontinued study participation prematurely and were excluded if they failed to complete at least one of the questionnaires. Table 1. Sociodemographic characteristics   Alcohol-dependent patients (n = 166)  Healthy control subjects (n = 240)  P  Age (years)  48 (42–54)  48 (39–56)  0.893a  Gender (n;♀/♂)  74/92  107/133  0.999b  BMI (kg/m2)  24.7 (22.1–28.5)  26.5 (23.5–29.3)  0.004a  Months of employment (previous year)  4 (0–12)  12 (5–12)  <0.001a  Active smoker (%)  77.4  20.4  <0.001b  Active and ex-smoker (%)  88.0  54.2  <0.001b  AUDIT score  –  3 (2–5)    Previous withdrawal treatments (n)  6 (2–12)  –    Age at onset of alcohol dependence (years)  32 (25–41)  –    Lifetime drinking (kg)  483 (270–1,195)  –    Daily ethanol intake (g/d since onset)  110 (60–240)  –      Alcohol-dependent patients (n = 166)  Healthy control subjects (n = 240)  P  Age (years)  48 (42–54)  48 (39–56)  0.893a  Gender (n;♀/♂)  74/92  107/133  0.999b  BMI (kg/m2)  24.7 (22.1–28.5)  26.5 (23.5–29.3)  0.004a  Months of employment (previous year)  4 (0–12)  12 (5–12)  <0.001a  Active smoker (%)  77.4  20.4  <0.001b  Active and ex-smoker (%)  88.0  54.2  <0.001b  AUDIT score  –  3 (2–5)    Previous withdrawal treatments (n)  6 (2–12)  –    Age at onset of alcohol dependence (years)  32 (25–41)  –    Lifetime drinking (kg)  483 (270–1,195)  –    Daily ethanol intake (g/d since onset)  110 (60–240)  –    Median (interquartile range) and absolute as well as relative frequencies; missing values <10% for body mass index (BMI), months of employment (previous year), smoking status, German version of the Alcohol Use Disorders Identification Test (AUDIT) score, age at onset of alcohol dependence, < 25% for previous withdrawal treatments, lifetime drinking, daily ethanol intake. aMann–Whitney U-test, bχ2 test. P < 0.05 in bold. Table 1. Sociodemographic characteristics   Alcohol-dependent patients (n = 166)  Healthy control subjects (n = 240)  P  Age (years)  48 (42–54)  48 (39–56)  0.893a  Gender (n;♀/♂)  74/92  107/133  0.999b  BMI (kg/m2)  24.7 (22.1–28.5)  26.5 (23.5–29.3)  0.004a  Months of employment (previous year)  4 (0–12)  12 (5–12)  <0.001a  Active smoker (%)  77.4  20.4  <0.001b  Active and ex-smoker (%)  88.0  54.2  <0.001b  AUDIT score  –  3 (2–5)    Previous withdrawal treatments (n)  6 (2–12)  –    Age at onset of alcohol dependence (years)  32 (25–41)  –    Lifetime drinking (kg)  483 (270–1,195)  –    Daily ethanol intake (g/d since onset)  110 (60–240)  –      Alcohol-dependent patients (n = 166)  Healthy control subjects (n = 240)  P  Age (years)  48 (42–54)  48 (39–56)  0.893a  Gender (n;♀/♂)  74/92  107/133  0.999b  BMI (kg/m2)  24.7 (22.1–28.5)  26.5 (23.5–29.3)  0.004a  Months of employment (previous year)  4 (0–12)  12 (5–12)  <0.001a  Active smoker (%)  77.4  20.4  <0.001b  Active and ex-smoker (%)  88.0  54.2  <0.001b  AUDIT score  –  3 (2–5)    Previous withdrawal treatments (n)  6 (2–12)  –    Age at onset of alcohol dependence (years)  32 (25–41)  –    Lifetime drinking (kg)  483 (270–1,195)  –    Daily ethanol intake (g/d since onset)  110 (60–240)  –    Median (interquartile range) and absolute as well as relative frequencies; missing values <10% for body mass index (BMI), months of employment (previous year), smoking status, German version of the Alcohol Use Disorders Identification Test (AUDIT) score, age at onset of alcohol dependence, < 25% for previous withdrawal treatments, lifetime drinking, daily ethanol intake. aMann–Whitney U-test, bχ2 test. P < 0.05 in bold. We tested whether belonging to a religious denomination is related to alcohol dependence and found an increased risk for alcohol dependence in the study subjects with a religious denomination in comparison to participants without a religious denomination; this effect was stronger in males than in females (χ2 = 6.0, df = 1, OR = 1.72, P = 0.014; patients (n): 43 without religious denomination, 58 Protestants, 54 Roman Catholics, 7 with another religious denomination, 4 with missing data; controls (n): 92 without religious denomination, 77 Protestants, 63 Roman Catholics, 8 with another religious denomination; females, χ2 = 1.8, df = 1, OR = 1.60, P = 0.179, males, χ2 = 4.5, df = 1, OR = 1.83, P = 0.035). The risk for an alcohol-related readmission during the 24-month follow-up did not significantly differ between patients with and patients without a religious denomination (χ2 = 0.5, df = 1, OR =1.32, P = 0.464; females, χ2 = 0.6, df = 1, OR =1.54, P = 0.447, males, χ2 = 0.3, df = 1, OR =1.29, P = 0.592). Afterwards, we investigated differences of religiosity, guilt, altruism and willingness to forgive between patients and healthy controls subjects. The patients scored higher on the subscales of religious experiences (basic) (median(patients) 6 [IQR 3–9] vs. median(controls) 5 [IQR 3–8], U = 16,467, P = 0.041), private practice (inter-religious) (6 [4–9] vs. 5 [3–7], U = 16,501, P = 0.046), connectedness (22 [15–30] vs. 19 [12–26], U = 13,233, P < 0.001) and experience of sense and meaning (38 [32–42] vs. 35 [31–39], U = 13,714, P = 0.003), survivor guilt (18 [13–24] vs. 11 [8–15], U = 8,659, P < 0.001), separation guilt (17 [12–22] vs. 14 [11–17], U = 12,773, P < 0.001), organized guilt (27 [23–30] vs. 24 [20–28], U = 12,883, P < 0.001), and the guilt sum score (61 [52–71] vs. 50 [43–58], U = 9,488, P < 0.001). They scored lower on well-being (42 [36–49] vs. 50 [44–56], U = 10,080, P < 0.001), forgiveness (32 [24–40] vs. 37 [31–42], U = 13,055, P < 0.001), hope immanent (33 [27–40] vs. 38 [33–42], U = 12,282, P < 0.001), hope transcendent (31 [26–36] vs. 37 [31–41], U = 10,053, P < 0.001), the MIRSB sum score (175 [155–194] vs. 179 [164–205], U = 14,595, P = 0.031), attainability (15 [12–17] vs. 16 [13–18], U = 16,677, P = 0.015) and on success of altruism (13 [10–16] vs. 14 [12–16], U = 16,344, P = 0.006). There were no significant group differences for the following subscales: intellect (basic) (5 [4–8] vs. 6 [5–8], U = 17,180, P = 0.173), ideology (basic) (8 [5–11] vs. 8 [5–12], U = 18,216, P = 0.673), public practice (basic) (5 [3–7] vs. 5 [3–7], U = 18,333, P = 0.747), private practice (basic) (6 [3–11] vs. 6 [3–9], U = 17,309, P = 0.206), religious experiences (inter-religious) (5 [4–8] vs. 5 [3–7], U = 17,814, P = 0.428), religious affiliation (19 [13–32] vs. 19 [12–32], U = 16,433, P = 0.567), general religiosity (19 [8–32] vs. 18 [9–31], U = 16,457, P = 0.739), importance of altruism (16 [13–19] vs. 16 [14–18], U = 19,158, P = 0.804), and willingness to pardon without regret (8 [6–11] vs. 9 [7–11], U = 17,550, P = 0.143) or with regret (13 [11–16] vs. 14 [11–16], U = 17,867, P = 0.238). The gender-specific results are shown in Table 2. Table 2. Gender-specific differences of religiosity, guilt, altruism and willingness to pardon between alcohol-dependent patients and healthy control subjects   N (items)#  Cronbach’s alpha  Females  Males    Patients  Controls      Patients  Controls        Median (IQR)  U  Pa  Median (IQR)  U  Pa  Centrality of religiosity scale      n = 68  n = 107      n = 89  n = 131       Intellect (basic)  3  0.883  6  (4–8)  6  (5–9)  3,259  0.242  5  (4–8)  6  (5–8)  5,498  0.471   Ideology (basic)  3  0.903  9  (6–12)  9  (5–12)  3,440  0.542  7  (4–11)  7  (4–10)  5,748  0.859   Public practice (basic)  3  0.904  5  (4–7)  5  (3–8)  3,562  0.812  4  (3–7)  5  (3–6)  5,765  0.885   Private practice (basic)  3  0.946  6  (4–12)  7  (3–11)  3,387  0.438  6  (3–10)  5  (3–8)  5,425  0.366   Religious experiences (basic)  3  0.933  6  (4–9)  6  (3–9)  3,275  0.261  5  (3–9)  4  (3–7)  5,076  0.091   Private practice (inter-religious)  3  0.770  6  (4–8)  5  (3–9)  3,500  0.670  5  (3–9)  4  (3–7)  4,809  0.025   Religious experiences (inter-religious)  3  0.812  5  (4–8)  6  (4–8)  3,557  0.801  5  (3–9)  5  (3–7)  5,260  0.210  Religiousness and well-being      n = 67  n = 95      n = 85  n = 129       Religious affiliation  10  0.930  19  (14–31)  25  (12–35)  3,049  0.649  17  (12–34)  17  (13–28)  5,082  0.365   Well-being  11  0.780  43  (38–51)  53  (47–58)  1,645  <0.001  42  (35–47)  49  (41–54)  3,454  <0.001  Multidimensional inventory for religious/spiritual well-being      n = 67  n = 96      n = 85  n = 125       General religiosity  8  0.945  19  (10–35)  24  (13–37)  2,922  0.320  17  (8–31)  16  (9–26)  5,164  0.728   Forgiveness  8  0.828  35  (26–42)  39  (34–43)  2,524  0.019  31  (24–38)  34  (29–41)  4,140  0.007   Hope immanent  8  0.868  35  (27–40)  39  (33–43)  2,453  0.010  32  (26–39)  37  (33–42)  3,715  <0.001   Connectedness  8  0.827  24  (17–30)  21  (13–29)  2,721  0.095  21  (14–30)  17  (12–24)  4,021  0.003   Hope transcendent  8  0.722  32  (25–37)  37  (30–41)  2,246  0.001  30  (27–35)  37  (33–41)  2,712  <0.001   Experience of sense and meaning  8  0.722  38  (31–43)  36  (32–40)  2,822  0.183  37  (32–42)  34  (29–38)  4,058  0.004   Sum score  48  0.865  182  (164–196)  191  (169–216)  2,611  0.041  173  (151–192)  174  (162–193)  4,713  0.165  Interpersonal guilt questionnaire      n = 68  n = 102      n = 86  n = 129       Survivor guilt  7  0.851  18  (12–23)  12  (8–15)  1,838  <0.001  18  (14–24)  11  (8–16)  2,534  <0.001   Separation guilt  7  0.790  15  (11–21)  13  (10–17)  2,588  0.005  19  (13–22)  15  (12–18)  3,831  <0.001   Organized guilt  7  0.768  28  (23–32)  25  (22–30)  2,644  0.009  27  (23–29)  23  (19–26)  3,744  <0.001   Sum score  21  0.877  60  (51–72)  51  (43–59)  2,069  <0.001  62  (54–71)  49  (43–58)  2,709  <0.001  Altruism      n = 71  n = 107      n = 91  n = 133       Importance  4  0.830  17  (14–19)  16  (14–19)  3,648  0.652  16  (13–18)  16  (14–17)  5,988  0.892   Attainability  4  0.833  16  (14–17)  16  (14–18)  3,529  0.418  14  (12–16)  16  (13–18)  4,875  0.013   Success  4  0.842  13  (10–16)  14  (12–16)  3,041  0.023  12  (9–16)  13  (12–16)  5,291  0.108  Willingness to pardon      n = 70  n = 107      n = 90  n = 133       Without regret  4  0.789  8  (6–10)  8  (6–11)  3,459  0.388  8  (6–11)  9  (7–11)  5,414  0.224   With regret  4  0.852  12  (11–15)  13  (10–16)  3,455  0.382  14  (11–16)  14  (11–16)  5,655  0.483    N (items)#  Cronbach’s alpha  Females  Males    Patients  Controls      Patients  Controls        Median (IQR)  U  Pa  Median (IQR)  U  Pa  Centrality of religiosity scale      n = 68  n = 107      n = 89  n = 131       Intellect (basic)  3  0.883  6  (4–8)  6  (5–9)  3,259  0.242  5  (4–8)  6  (5–8)  5,498  0.471   Ideology (basic)  3  0.903  9  (6–12)  9  (5–12)  3,440  0.542  7  (4–11)  7  (4–10)  5,748  0.859   Public practice (basic)  3  0.904  5  (4–7)  5  (3–8)  3,562  0.812  4  (3–7)  5  (3–6)  5,765  0.885   Private practice (basic)  3  0.946  6  (4–12)  7  (3–11)  3,387  0.438  6  (3–10)  5  (3–8)  5,425  0.366   Religious experiences (basic)  3  0.933  6  (4–9)  6  (3–9)  3,275  0.261  5  (3–9)  4  (3–7)  5,076  0.091   Private practice (inter-religious)  3  0.770  6  (4–8)  5  (3–9)  3,500  0.670  5  (3–9)  4  (3–7)  4,809  0.025   Religious experiences (inter-religious)  3  0.812  5  (4–8)  6  (4–8)  3,557  0.801  5  (3–9)  5  (3–7)  5,260  0.210  Religiousness and well-being      n = 67  n = 95      n = 85  n = 129       Religious affiliation  10  0.930  19  (14–31)  25  (12–35)  3,049  0.649  17  (12–34)  17  (13–28)  5,082  0.365   Well-being  11  0.780  43  (38–51)  53  (47–58)  1,645  <0.001  42  (35–47)  49  (41–54)  3,454  <0.001  Multidimensional inventory for religious/spiritual well-being      n = 67  n = 96      n = 85  n = 125       General religiosity  8  0.945  19  (10–35)  24  (13–37)  2,922  0.320  17  (8–31)  16  (9–26)  5,164  0.728   Forgiveness  8  0.828  35  (26–42)  39  (34–43)  2,524  0.019  31  (24–38)  34  (29–41)  4,140  0.007   Hope immanent  8  0.868  35  (27–40)  39  (33–43)  2,453  0.010  32  (26–39)  37  (33–42)  3,715  <0.001   Connectedness  8  0.827  24  (17–30)  21  (13–29)  2,721  0.095  21  (14–30)  17  (12–24)  4,021  0.003   Hope transcendent  8  0.722  32  (25–37)  37  (30–41)  2,246  0.001  30  (27–35)  37  (33–41)  2,712  <0.001   Experience of sense and meaning  8  0.722  38  (31–43)  36  (32–40)  2,822  0.183  37  (32–42)  34  (29–38)  4,058  0.004   Sum score  48  0.865  182  (164–196)  191  (169–216)  2,611  0.041  173  (151–192)  174  (162–193)  4,713  0.165  Interpersonal guilt questionnaire      n = 68  n = 102      n = 86  n = 129       Survivor guilt  7  0.851  18  (12–23)  12  (8–15)  1,838  <0.001  18  (14–24)  11  (8–16)  2,534  <0.001   Separation guilt  7  0.790  15  (11–21)  13  (10–17)  2,588  0.005  19  (13–22)  15  (12–18)  3,831  <0.001   Organized guilt  7  0.768  28  (23–32)  25  (22–30)  2,644  0.009  27  (23–29)  23  (19–26)  3,744  <0.001   Sum score  21  0.877  60  (51–72)  51  (43–59)  2,069  <0.001  62  (54–71)  49  (43–58)  2,709  <0.001  Altruism      n = 71  n = 107      n = 91  n = 133       Importance  4  0.830  17  (14–19)  16  (14–19)  3,648  0.652  16  (13–18)  16  (14–17)  5,988  0.892   Attainability  4  0.833  16  (14–17)  16  (14–18)  3,529  0.418  14  (12–16)  16  (13–18)  4,875  0.013   Success  4  0.842  13  (10–16)  14  (12–16)  3,041  0.023  12  (9–16)  13  (12–16)  5,291  0.108  Willingness to pardon      n = 70  n = 107      n = 90  n = 133       Without regret  4  0.789  8  (6–10)  8  (6–11)  3,459  0.388  8  (6–11)  9  (7–11)  5,414  0.224   With regret  4  0.852  12  (11–15)  13  (10–16)  3,455  0.382  14  (11–16)  14  (11–16)  5,655  0.483  The table shows median and interquartile range (IQR) of the questionnaire scores (= sum of subitems). #Number of questionnaire items for scale calculation. aMann–Whitney U-test. P < 0.05 in bold. Table 2. Gender-specific differences of religiosity, guilt, altruism and willingness to pardon between alcohol-dependent patients and healthy control subjects   N (items)#  Cronbach’s alpha  Females  Males    Patients  Controls      Patients  Controls        Median (IQR)  U  Pa  Median (IQR)  U  Pa  Centrality of religiosity scale      n = 68  n = 107      n = 89  n = 131       Intellect (basic)  3  0.883  6  (4–8)  6  (5–9)  3,259  0.242  5  (4–8)  6  (5–8)  5,498  0.471   Ideology (basic)  3  0.903  9  (6–12)  9  (5–12)  3,440  0.542  7  (4–11)  7  (4–10)  5,748  0.859   Public practice (basic)  3  0.904  5  (4–7)  5  (3–8)  3,562  0.812  4  (3–7)  5  (3–6)  5,765  0.885   Private practice (basic)  3  0.946  6  (4–12)  7  (3–11)  3,387  0.438  6  (3–10)  5  (3–8)  5,425  0.366   Religious experiences (basic)  3  0.933  6  (4–9)  6  (3–9)  3,275  0.261  5  (3–9)  4  (3–7)  5,076  0.091   Private practice (inter-religious)  3  0.770  6  (4–8)  5  (3–9)  3,500  0.670  5  (3–9)  4  (3–7)  4,809  0.025   Religious experiences (inter-religious)  3  0.812  5  (4–8)  6  (4–8)  3,557  0.801  5  (3–9)  5  (3–7)  5,260  0.210  Religiousness and well-being      n = 67  n = 95      n = 85  n = 129       Religious affiliation  10  0.930  19  (14–31)  25  (12–35)  3,049  0.649  17  (12–34)  17  (13–28)  5,082  0.365   Well-being  11  0.780  43  (38–51)  53  (47–58)  1,645  <0.001  42  (35–47)  49  (41–54)  3,454  <0.001  Multidimensional inventory for religious/spiritual well-being      n = 67  n = 96      n = 85  n = 125       General religiosity  8  0.945  19  (10–35)  24  (13–37)  2,922  0.320  17  (8–31)  16  (9–26)  5,164  0.728   Forgiveness  8  0.828  35  (26–42)  39  (34–43)  2,524  0.019  31  (24–38)  34  (29–41)  4,140  0.007   Hope immanent  8  0.868  35  (27–40)  39  (33–43)  2,453  0.010  32  (26–39)  37  (33–42)  3,715  <0.001   Connectedness  8  0.827  24  (17–30)  21  (13–29)  2,721  0.095  21  (14–30)  17  (12–24)  4,021  0.003   Hope transcendent  8  0.722  32  (25–37)  37  (30–41)  2,246  0.001  30  (27–35)  37  (33–41)  2,712  <0.001   Experience of sense and meaning  8  0.722  38  (31–43)  36  (32–40)  2,822  0.183  37  (32–42)  34  (29–38)  4,058  0.004   Sum score  48  0.865  182  (164–196)  191  (169–216)  2,611  0.041  173  (151–192)  174  (162–193)  4,713  0.165  Interpersonal guilt questionnaire      n = 68  n = 102      n = 86  n = 129       Survivor guilt  7  0.851  18  (12–23)  12  (8–15)  1,838  <0.001  18  (14–24)  11  (8–16)  2,534  <0.001   Separation guilt  7  0.790  15  (11–21)  13  (10–17)  2,588  0.005  19  (13–22)  15  (12–18)  3,831  <0.001   Organized guilt  7  0.768  28  (23–32)  25  (22–30)  2,644  0.009  27  (23–29)  23  (19–26)  3,744  <0.001   Sum score  21  0.877  60  (51–72)  51  (43–59)  2,069  <0.001  62  (54–71)  49  (43–58)  2,709  <0.001  Altruism      n = 71  n = 107      n = 91  n = 133       Importance  4  0.830  17  (14–19)  16  (14–19)  3,648  0.652  16  (13–18)  16  (14–17)  5,988  0.892   Attainability  4  0.833  16  (14–17)  16  (14–18)  3,529  0.418  14  (12–16)  16  (13–18)  4,875  0.013   Success  4  0.842  13  (10–16)  14  (12–16)  3,041  0.023  12  (9–16)  13  (12–16)  5,291  0.108  Willingness to pardon      n = 70  n = 107      n = 90  n = 133       Without regret  4  0.789  8  (6–10)  8  (6–11)  3,459  0.388  8  (6–11)  9  (7–11)  5,414  0.224   With regret  4  0.852  12  (11–15)  13  (10–16)  3,455  0.382  14  (11–16)  14  (11–16)  5,655  0.483    N (items)#  Cronbach’s alpha  Females  Males    Patients  Controls      Patients  Controls        Median (IQR)  U  Pa  Median (IQR)  U  Pa  Centrality of religiosity scale      n = 68  n = 107      n = 89  n = 131       Intellect (basic)  3  0.883  6  (4–8)  6  (5–9)  3,259  0.242  5  (4–8)  6  (5–8)  5,498  0.471   Ideology (basic)  3  0.903  9  (6–12)  9  (5–12)  3,440  0.542  7  (4–11)  7  (4–10)  5,748  0.859   Public practice (basic)  3  0.904  5  (4–7)  5  (3–8)  3,562  0.812  4  (3–7)  5  (3–6)  5,765  0.885   Private practice (basic)  3  0.946  6  (4–12)  7  (3–11)  3,387  0.438  6  (3–10)  5  (3–8)  5,425  0.366   Religious experiences (basic)  3  0.933  6  (4–9)  6  (3–9)  3,275  0.261  5  (3–9)  4  (3–7)  5,076  0.091   Private practice (inter-religious)  3  0.770  6  (4–8)  5  (3–9)  3,500  0.670  5  (3–9)  4  (3–7)  4,809  0.025   Religious experiences (inter-religious)  3  0.812  5  (4–8)  6  (4–8)  3,557  0.801  5  (3–9)  5  (3–7)  5,260  0.210  Religiousness and well-being      n = 67  n = 95      n = 85  n = 129       Religious affiliation  10  0.930  19  (14–31)  25  (12–35)  3,049  0.649  17  (12–34)  17  (13–28)  5,082  0.365   Well-being  11  0.780  43  (38–51)  53  (47–58)  1,645  <0.001  42  (35–47)  49  (41–54)  3,454  <0.001  Multidimensional inventory for religious/spiritual well-being      n = 67  n = 96      n = 85  n = 125       General religiosity  8  0.945  19  (10–35)  24  (13–37)  2,922  0.320  17  (8–31)  16  (9–26)  5,164  0.728   Forgiveness  8  0.828  35  (26–42)  39  (34–43)  2,524  0.019  31  (24–38)  34  (29–41)  4,140  0.007   Hope immanent  8  0.868  35  (27–40)  39  (33–43)  2,453  0.010  32  (26–39)  37  (33–42)  3,715  <0.001   Connectedness  8  0.827  24  (17–30)  21  (13–29)  2,721  0.095  21  (14–30)  17  (12–24)  4,021  0.003   Hope transcendent  8  0.722  32  (25–37)  37  (30–41)  2,246  0.001  30  (27–35)  37  (33–41)  2,712  <0.001   Experience of sense and meaning  8  0.722  38  (31–43)  36  (32–40)  2,822  0.183  37  (32–42)  34  (29–38)  4,058  0.004   Sum score  48  0.865  182  (164–196)  191  (169–216)  2,611  0.041  173  (151–192)  174  (162–193)  4,713  0.165  Interpersonal guilt questionnaire      n = 68  n = 102      n = 86  n = 129       Survivor guilt  7  0.851  18  (12–23)  12  (8–15)  1,838  <0.001  18  (14–24)  11  (8–16)  2,534  <0.001   Separation guilt  7  0.790  15  (11–21)  13  (10–17)  2,588  0.005  19  (13–22)  15  (12–18)  3,831  <0.001   Organized guilt  7  0.768  28  (23–32)  25  (22–30)  2,644  0.009  27  (23–29)  23  (19–26)  3,744  <0.001   Sum score  21  0.877  60  (51–72)  51  (43–59)  2,069  <0.001  62  (54–71)  49  (43–58)  2,709  <0.001  Altruism      n = 71  n = 107      n = 91  n = 133       Importance  4  0.830  17  (14–19)  16  (14–19)  3,648  0.652  16  (13–18)  16  (14–17)  5,988  0.892   Attainability  4  0.833  16  (14–17)  16  (14–18)  3,529  0.418  14  (12–16)  16  (13–18)  4,875  0.013   Success  4  0.842  13  (10–16)  14  (12–16)  3,041  0.023  12  (9–16)  13  (12–16)  5,291  0.108  Willingness to pardon      n = 70  n = 107      n = 90  n = 133       Without regret  4  0.789  8  (6–10)  8  (6–11)  3,459  0.388  8  (6–11)  9  (7–11)  5,414  0.224   With regret  4  0.852  12  (11–15)  13  (10–16)  3,455  0.382  14  (11–16)  14  (11–16)  5,655  0.483  The table shows median and interquartile range (IQR) of the questionnaire scores (= sum of subitems). #Number of questionnaire items for scale calculation. aMann–Whitney U-test. P < 0.05 in bold. We analyzed whether religiosity, guilt, altruism and forgiveness predicted alcohol-related readmission following in-patient alcohol withdrawal treatment (Table 3). Patients with alcohol-related readmission scored higher on the private practice (basic and inter-religious), and the religious experiences (inter-religious) subscales. Higher private practice (inter-religious) also correlated with more alcohol-related readmissions during the follow-up and fewer days to first alcohol-related readmission. The patients with alcohol-related readmission scored higher on the religious affiliation subscale and higher scores predicted more alcohol-related readmissions and fewer days to first readmission. Moreover, we found lower attainability of altruism in patients with alcohol-related readmission and lower scores also predicted more alcohol-related readmissions and fewer days to first readmission. Table 3. Associations of religiosity, guilt, altruism, and willingness to pardon with 24-month alcohol-related readmissions   Total cohort    Alcohol-related readmission  Number of readmissions  Days to first readmission    Yes  No                Median (IQR)  U  Pa  Rho  Pb  Rho  Pb  Centrality of religiosity scale  n = 94  n = 63               Intellect (basic)  6  (4–9)  5  (4–8)  2,548  0.136  0.106  0.186  −0.101  0.206   Ideology (basic)  9  (5–11)  6  (3–11)  2,455  0.068  0.111  0.166  −0.107  0.183   Public practice (basic)  5  (3–7)  4  (3–7)  2,657  0.265  0.070  0.387  −0.054  0.503   Private practice (basic)  7  (3–11)  5  (3–10)  2,396  0.040  0.089  0.266  −0.101  0.209   Religious experiences (basic)  6  (3–9)  5  (3–8)  2,452  0.064  0.107  0.184  −0.089  0.270   Private practice (inter-religious)  7  (4–9)  5  (3–7)  2,237  0.009  0.207  0.009  −0.184  0.021   Religious experiences (inter-religious)  6  (4–9)  4  (3–7)  2,366  0.031  0.123  0.126  −0.125  0.120  Religiousness and well-being  n = 94  n = 58               Religious affiliation  22  (15–36)  15  (11–29)  1,991  0.005  0.189  0.020  −0.214  0.008   Well-being  42  (35–48)  44  (37–50)  2,474  0.339  −0.092  0.262  0.064  0.432  Multidimensional inventory for religious/spiritual well-being  n = 91  n = 61               General religiosity  23  (10–34)  14  (8–32)  2,317  0.082  0.087  0.289  −0.105  0.196   Forgiveness  31  (23–41)  33  (26–40)  2,467  0.246  −0.112  0.168  0.109  0.180   Hope immanent  31  (27–39)  36  (28–42)  2,343  0.104  −0.093  0.255  0.125  0.125   Connectedness  23  (16–30)  21  (13–31)  2,422  0.183  0.109  0.181  −0.131  0.107   Hope transcendent  31  (27–36)  32  (25–39)  2,697  0.766  0.017  0.832  0.008  0.923   Experience of sense and meaning  38  (31–42)  37  (32–43)  2,670  0.690  0.031  0.707  0.012  0.880   Sum score  178  (155–195)  174  (156–194)  2,722  0.839  0.021  0.795  −0.022  0.791  Interpersonal guilt questionnaire  n = 90  n = 64               Survivor guilt  18  (13–24)  17  (13–24)  2,690  0.486  0.043  0.597  −0.061  0.454   Separation guilt  18  (13–23)  16  (12–21)  2,461  0.124  0.042  0.607  −0.075  0.358   Organized guilt  27  (23–30)  27  (23–31)  2,799  0.766  −0.007  0.933  −0.002  0.982   Sum score  61  (54–73)  60  (50–69)  2,560  0.240  0.050  0.537  −0.071  0.379  Altruism  n = 98  n = 64               Importance  16  (13–19)  16  (13–17)  2,867  0.353  0.024  0.764  −0.021  0.787   Attainability  14  (12–16)  16  (14–17)  2,440  0.016  −0.223  0.004  0.231  0.003   Success  12  (10–16)  13  (11–16)  2,763  0.199  −0.111  0.161  0.097  0.219  Willingness to pardon  n = 99  n = 61               Without regret  8  (6–11)  8  (6–11)  2,949  0.802  −0.094  0.239  0.109  0.172   With regret  13  (10–16)  13  (11–16)  2,820  0.482  −0.025  0.754  0.116  0.143    Total cohort    Alcohol-related readmission  Number of readmissions  Days to first readmission    Yes  No                Median (IQR)  U  Pa  Rho  Pb  Rho  Pb  Centrality of religiosity scale  n = 94  n = 63               Intellect (basic)  6  (4–9)  5  (4–8)  2,548  0.136  0.106  0.186  −0.101  0.206   Ideology (basic)  9  (5–11)  6  (3–11)  2,455  0.068  0.111  0.166  −0.107  0.183   Public practice (basic)  5  (3–7)  4  (3–7)  2,657  0.265  0.070  0.387  −0.054  0.503   Private practice (basic)  7  (3–11)  5  (3–10)  2,396  0.040  0.089  0.266  −0.101  0.209   Religious experiences (basic)  6  (3–9)  5  (3–8)  2,452  0.064  0.107  0.184  −0.089  0.270   Private practice (inter-religious)  7  (4–9)  5  (3–7)  2,237  0.009  0.207  0.009  −0.184  0.021   Religious experiences (inter-religious)  6  (4–9)  4  (3–7)  2,366  0.031  0.123  0.126  −0.125  0.120  Religiousness and well-being  n = 94  n = 58               Religious affiliation  22  (15–36)  15  (11–29)  1,991  0.005  0.189  0.020  −0.214  0.008   Well-being  42  (35–48)  44  (37–50)  2,474  0.339  −0.092  0.262  0.064  0.432  Multidimensional inventory for religious/spiritual well-being  n = 91  n = 61               General religiosity  23  (10–34)  14  (8–32)  2,317  0.082  0.087  0.289  −0.105  0.196   Forgiveness  31  (23–41)  33  (26–40)  2,467  0.246  −0.112  0.168  0.109  0.180   Hope immanent  31  (27–39)  36  (28–42)  2,343  0.104  −0.093  0.255  0.125  0.125   Connectedness  23  (16–30)  21  (13–31)  2,422  0.183  0.109  0.181  −0.131  0.107   Hope transcendent  31  (27–36)  32  (25–39)  2,697  0.766  0.017  0.832  0.008  0.923   Experience of sense and meaning  38  (31–42)  37  (32–43)  2,670  0.690  0.031  0.707  0.012  0.880   Sum score  178  (155–195)  174  (156–194)  2,722  0.839  0.021  0.795  −0.022  0.791  Interpersonal guilt questionnaire  n = 90  n = 64               Survivor guilt  18  (13–24)  17  (13–24)  2,690  0.486  0.043  0.597  −0.061  0.454   Separation guilt  18  (13–23)  16  (12–21)  2,461  0.124  0.042  0.607  −0.075  0.358   Organized guilt  27  (23–30)  27  (23–31)  2,799  0.766  −0.007  0.933  −0.002  0.982   Sum score  61  (54–73)  60  (50–69)  2,560  0.240  0.050  0.537  −0.071  0.379  Altruism  n = 98  n = 64               Importance  16  (13–19)  16  (13–17)  2,867  0.353  0.024  0.764  −0.021  0.787   Attainability  14  (12–16)  16  (14–17)  2,440  0.016  −0.223  0.004  0.231  0.003   Success  12  (10–16)  13  (11–16)  2,763  0.199  −0.111  0.161  0.097  0.219  Willingness to pardon  n = 99  n = 61               Without regret  8  (6–11)  8  (6–11)  2,949  0.802  −0.094  0.239  0.109  0.172   With regret  13  (10–16)  13  (11–16)  2,820  0.482  −0.025  0.754  0.116  0.143  The table shows median and interquartile range (IQR) of the questionnaire scores (=sum of subitems). aMann–Whitney U-test, bSpearman correlation. P < 0.05 in bold. Table 3. Associations of religiosity, guilt, altruism, and willingness to pardon with 24-month alcohol-related readmissions   Total cohort    Alcohol-related readmission  Number of readmissions  Days to first readmission    Yes  No                Median (IQR)  U  Pa  Rho  Pb  Rho  Pb  Centrality of religiosity scale  n = 94  n = 63               Intellect (basic)  6  (4–9)  5  (4–8)  2,548  0.136  0.106  0.186  −0.101  0.206   Ideology (basic)  9  (5–11)  6  (3–11)  2,455  0.068  0.111  0.166  −0.107  0.183   Public practice (basic)  5  (3–7)  4  (3–7)  2,657  0.265  0.070  0.387  −0.054  0.503   Private practice (basic)  7  (3–11)  5  (3–10)  2,396  0.040  0.089  0.266  −0.101  0.209   Religious experiences (basic)  6  (3–9)  5  (3–8)  2,452  0.064  0.107  0.184  −0.089  0.270   Private practice (inter-religious)  7  (4–9)  5  (3–7)  2,237  0.009  0.207  0.009  −0.184  0.021   Religious experiences (inter-religious)  6  (4–9)  4  (3–7)  2,366  0.031  0.123  0.126  −0.125  0.120  Religiousness and well-being  n = 94  n = 58               Religious affiliation  22  (15–36)  15  (11–29)  1,991  0.005  0.189  0.020  −0.214  0.008   Well-being  42  (35–48)  44  (37–50)  2,474  0.339  −0.092  0.262  0.064  0.432  Multidimensional inventory for religious/spiritual well-being  n = 91  n = 61               General religiosity  23  (10–34)  14  (8–32)  2,317  0.082  0.087  0.289  −0.105  0.196   Forgiveness  31  (23–41)  33  (26–40)  2,467  0.246  −0.112  0.168  0.109  0.180   Hope immanent  31  (27–39)  36  (28–42)  2,343  0.104  −0.093  0.255  0.125  0.125   Connectedness  23  (16–30)  21  (13–31)  2,422  0.183  0.109  0.181  −0.131  0.107   Hope transcendent  31  (27–36)  32  (25–39)  2,697  0.766  0.017  0.832  0.008  0.923   Experience of sense and meaning  38  (31–42)  37  (32–43)  2,670  0.690  0.031  0.707  0.012  0.880   Sum score  178  (155–195)  174  (156–194)  2,722  0.839  0.021  0.795  −0.022  0.791  Interpersonal guilt questionnaire  n = 90  n = 64               Survivor guilt  18  (13–24)  17  (13–24)  2,690  0.486  0.043  0.597  −0.061  0.454   Separation guilt  18  (13–23)  16  (12–21)  2,461  0.124  0.042  0.607  −0.075  0.358   Organized guilt  27  (23–30)  27  (23–31)  2,799  0.766  −0.007  0.933  −0.002  0.982   Sum score  61  (54–73)  60  (50–69)  2,560  0.240  0.050  0.537  −0.071  0.379  Altruism  n = 98  n = 64               Importance  16  (13–19)  16  (13–17)  2,867  0.353  0.024  0.764  −0.021  0.787   Attainability  14  (12–16)  16  (14–17)  2,440  0.016  −0.223  0.004  0.231  0.003   Success  12  (10–16)  13  (11–16)  2,763  0.199  −0.111  0.161  0.097  0.219  Willingness to pardon  n = 99  n = 61               Without regret  8  (6–11)  8  (6–11)  2,949  0.802  −0.094  0.239  0.109  0.172   With regret  13  (10–16)  13  (11–16)  2,820  0.482  −0.025  0.754  0.116  0.143    Total cohort    Alcohol-related readmission  Number of readmissions  Days to first readmission    Yes  No                Median (IQR)  U  Pa  Rho  Pb  Rho  Pb  Centrality of religiosity scale  n = 94  n = 63               Intellect (basic)  6  (4–9)  5  (4–8)  2,548  0.136  0.106  0.186  −0.101  0.206   Ideology (basic)  9  (5–11)  6  (3–11)  2,455  0.068  0.111  0.166  −0.107  0.183   Public practice (basic)  5  (3–7)  4  (3–7)  2,657  0.265  0.070  0.387  −0.054  0.503   Private practice (basic)  7  (3–11)  5  (3–10)  2,396  0.040  0.089  0.266  −0.101  0.209   Religious experiences (basic)  6  (3–9)  5  (3–8)  2,452  0.064  0.107  0.184  −0.089  0.270   Private practice (inter-religious)  7  (4–9)  5  (3–7)  2,237  0.009  0.207  0.009  −0.184  0.021   Religious experiences (inter-religious)  6  (4–9)  4  (3–7)  2,366  0.031  0.123  0.126  −0.125  0.120  Religiousness and well-being  n = 94  n = 58               Religious affiliation  22  (15–36)  15  (11–29)  1,991  0.005  0.189  0.020  −0.214  0.008   Well-being  42  (35–48)  44  (37–50)  2,474  0.339  −0.092  0.262  0.064  0.432  Multidimensional inventory for religious/spiritual well-being  n = 91  n = 61               General religiosity  23  (10–34)  14  (8–32)  2,317  0.082  0.087  0.289  −0.105  0.196   Forgiveness  31  (23–41)  33  (26–40)  2,467  0.246  −0.112  0.168  0.109  0.180   Hope immanent  31  (27–39)  36  (28–42)  2,343  0.104  −0.093  0.255  0.125  0.125   Connectedness  23  (16–30)  21  (13–31)  2,422  0.183  0.109  0.181  −0.131  0.107   Hope transcendent  31  (27–36)  32  (25–39)  2,697  0.766  0.017  0.832  0.008  0.923   Experience of sense and meaning  38  (31–42)  37  (32–43)  2,670  0.690  0.031  0.707  0.012  0.880   Sum score  178  (155–195)  174  (156–194)  2,722  0.839  0.021  0.795  −0.022  0.791  Interpersonal guilt questionnaire  n = 90  n = 64               Survivor guilt  18  (13–24)  17  (13–24)  2,690  0.486  0.043  0.597  −0.061  0.454   Separation guilt  18  (13–23)  16  (12–21)  2,461  0.124  0.042  0.607  −0.075  0.358   Organized guilt  27  (23–30)  27  (23–31)  2,799  0.766  −0.007  0.933  −0.002  0.982   Sum score  61  (54–73)  60  (50–69)  2,560  0.240  0.050  0.537  −0.071  0.379  Altruism  n = 98  n = 64               Importance  16  (13–19)  16  (13–17)  2,867  0.353  0.024  0.764  −0.021  0.787   Attainability  14  (12–16)  16  (14–17)  2,440  0.016  −0.223  0.004  0.231  0.003   Success  12  (10–16)  13  (11–16)  2,763  0.199  −0.111  0.161  0.097  0.219  Willingness to pardon  n = 99  n = 61               Without regret  8  (6–11)  8  (6–11)  2,949  0.802  −0.094  0.239  0.109  0.172   With regret  13  (10–16)  13  (11–16)  2,820  0.482  −0.025  0.754  0.116  0.143  The table shows median and interquartile range (IQR) of the questionnaire scores (=sum of subitems). aMann–Whitney U-test, bSpearman correlation. P < 0.05 in bold. The gender-specific subgroup analyses revealed that private practice (inter-religious), hope immanent, attainability and success of altruism, and willingness to pardon with regret were predominantly predictive in female alcohol-dependent patients and religious experiences (inter-religious), religious affiliation, connectedness and attainability of altruism in male patients (Tables 4 and 5). Table 4. Associations of religiosity, guilt, altruism and willingness to pardon with 24-month alcohol-related readmissions in female patients   Female patients    Alcohol-related readmission  Number of readmissions  Days to first readmission    Yes  No                Median (IQR)  U  Pa  Rho  Pb  Rho  Pb  Centrality of religiosity scale  n = 35  n = 33               Intellect (basic)  6  (4–9)  5  (4–8)  462  0.152  0.161  0.188  −0.177  0.148   Ideology (basic)  9  (6–12)  8  (5–12)  487  0.265  0.101  0.412  −0.093  0.452   Public practice (basic)  6  (4–7)  5  (3–7)  543  0.662  0.052  0.675  −0.065  0.597   Private practice (basic)  7  (5–12)  5  (4–11)  447  0.107  0.149  0.226  −0.144  0.242   Religious experiences (basic)  7  (5–9)  5  (4–10)  496  0.310  0.102  0.410  −0.091  0.463   Private practice (inter-religious)  7  (5–9)  5  (3–8)  420  0.051  0.275  0.023  −0.240  0.049   Religious experiences (inter-religious)  6  (4–7)  5  (4–8)  498  0.321  0.120  0.330  −0.124  0.316  Religiousness and well-being  n = 36  n = 31               Religious affiliation  24  (16–35)  16  (11–31)  427  0.097  0.195  0.113  −0.197  0.110   Well-being  43  (37–52)  45  (38–51)  524  0.669  −0.044  0.722  0.014  0.912  Multidimensional inventory for religious/spiritual well-being  n = 34  n = 33               General religiosity  24  (12–36)  18  (8–34)  478  0.293  0.100  0.422  −0.121  0.330   Forgiveness  33  (22–43)  37  (30–42)  493  0.390  −0.092  0.460  0.132  0.286   Hope immanent  31  (27–39)  37  (31–42)  396  0.038  −0.240  0.050  0.217  0.077   Connectedness  24  (17–28)  24  (18–32)  561  0.995  −0.005  0.971  −0.022  0.860   Hope transcendent  31  (26–36)  33  (25–40)  532  0.716  −0.004  0.977  0.053  0.669   Experience of sense and meaning  38  (30–42)  38  (32–44)  525  0.647  −0.012  0.924  0.023  0.853   Sum score  181  (156–195)  185  (169–200)  482  0.322  −0.106  0.395  0.105  0.397  Interpersonal guilt questionnaire  n = 34  n = 34               Survivor guilt  18  (13–25)  18  (11–22)  516  0.446  0.047  0.701  −0.121  0.326   Separation guilt  17  (13–23)  14  (11–20)  478  0.219  0.042  0.735  −0.103  0.405   Organized guilt  28  (22–32)  28  (23–32)  573  0.946  −0.041  0.743  −0.060  0.628   Sum score  60  (51–79)  59  (49–69)  513  0.422  0.030  0.809  −0.114  0.354  Altruism  n = 37  n = 34               Importance  18  (15–19)  16  (14–20)  591  0.658  −0.019  0.875  −0.048  0.690   Attainability  15  (12–17)  16  (15–19)  442  0.030  −0.278  0.019  0.220  0.066   Success  12  (10–16)  15  (12–17)  454  0.043  −0.255  0.032  0.220  0.066  Willingness to pardon  n = 37  n = 33               Without regret  8  (5–11)  7  (6–11)  599  0.887  −0.063  0.606  0.053  0.665   With regret  12  (10–14)  13  (11–16)  481  0.126  −0.188  0.119  0.246  0.040    Female patients    Alcohol-related readmission  Number of readmissions  Days to first readmission    Yes  No                Median (IQR)  U  Pa  Rho  Pb  Rho  Pb  Centrality of religiosity scale  n = 35  n = 33               Intellect (basic)  6  (4–9)  5  (4–8)  462  0.152  0.161  0.188  −0.177  0.148   Ideology (basic)  9  (6–12)  8  (5–12)  487  0.265  0.101  0.412  −0.093  0.452   Public practice (basic)  6  (4–7)  5  (3–7)  543  0.662  0.052  0.675  −0.065  0.597   Private practice (basic)  7  (5–12)  5  (4–11)  447  0.107  0.149  0.226  −0.144  0.242   Religious experiences (basic)  7  (5–9)  5  (4–10)  496  0.310  0.102  0.410  −0.091  0.463   Private practice (inter-religious)  7  (5–9)  5  (3–8)  420  0.051  0.275  0.023  −0.240  0.049   Religious experiences (inter-religious)  6  (4–7)  5  (4–8)  498  0.321  0.120  0.330  −0.124  0.316  Religiousness and well-being  n = 36  n = 31               Religious affiliation  24  (16–35)  16  (11–31)  427  0.097  0.195  0.113  −0.197  0.110   Well-being  43  (37–52)  45  (38–51)  524  0.669  −0.044  0.722  0.014  0.912  Multidimensional inventory for religious/spiritual well-being  n = 34  n = 33               General religiosity  24  (12–36)  18  (8–34)  478  0.293  0.100  0.422  −0.121  0.330   Forgiveness  33  (22–43)  37  (30–42)  493  0.390  −0.092  0.460  0.132  0.286   Hope immanent  31  (27–39)  37  (31–42)  396  0.038  −0.240  0.050  0.217  0.077   Connectedness  24  (17–28)  24  (18–32)  561  0.995  −0.005  0.971  −0.022  0.860   Hope transcendent  31  (26–36)  33  (25–40)  532  0.716  −0.004  0.977  0.053  0.669   Experience of sense and meaning  38  (30–42)  38  (32–44)  525  0.647  −0.012  0.924  0.023  0.853   Sum score  181  (156–195)  185  (169–200)  482  0.322  −0.106  0.395  0.105  0.397  Interpersonal guilt questionnaire  n = 34  n = 34               Survivor guilt  18  (13–25)  18  (11–22)  516  0.446  0.047  0.701  −0.121  0.326   Separation guilt  17  (13–23)  14  (11–20)  478  0.219  0.042  0.735  −0.103  0.405   Organized guilt  28  (22–32)  28  (23–32)  573  0.946  −0.041  0.743  −0.060  0.628   Sum score  60  (51–79)  59  (49–69)  513  0.422  0.030  0.809  −0.114  0.354  Altruism  n = 37  n = 34               Importance  18  (15–19)  16  (14–20)  591  0.658  −0.019  0.875  −0.048  0.690   Attainability  15  (12–17)  16  (15–19)  442  0.030  −0.278  0.019  0.220  0.066   Success  12  (10–16)  15  (12–17)  454  0.043  −0.255  0.032  0.220  0.066  Willingness to pardon  n = 37  n = 33               Without regret  8  (5–11)  7  (6–11)  599  0.887  −0.063  0.606  0.053  0.665   With regret  12  (10–14)  13  (11–16)  481  0.126  −0.188  0.119  0.246  0.040  The table shows median and interquartile range (IQR) of the questionnaire scores (=sum of subitems). aMann–Whitney U-test, bSpearman correlation. P < 0.05 in bold. Table 4. Associations of religiosity, guilt, altruism and willingness to pardon with 24-month alcohol-related readmissions in female patients   Female patients    Alcohol-related readmission  Number of readmissions  Days to first readmission    Yes  No                Median (IQR)  U  Pa  Rho  Pb  Rho  Pb  Centrality of religiosity scale  n = 35  n = 33               Intellect (basic)  6  (4–9)  5  (4–8)  462  0.152  0.161  0.188  −0.177  0.148   Ideology (basic)  9  (6–12)  8  (5–12)  487  0.265  0.101  0.412  −0.093  0.452   Public practice (basic)  6  (4–7)  5  (3–7)  543  0.662  0.052  0.675  −0.065  0.597   Private practice (basic)  7  (5–12)  5  (4–11)  447  0.107  0.149  0.226  −0.144  0.242   Religious experiences (basic)  7  (5–9)  5  (4–10)  496  0.310  0.102  0.410  −0.091  0.463   Private practice (inter-religious)  7  (5–9)  5  (3–8)  420  0.051  0.275  0.023  −0.240  0.049   Religious experiences (inter-religious)  6  (4–7)  5  (4–8)  498  0.321  0.120  0.330  −0.124  0.316  Religiousness and well-being  n = 36  n = 31               Religious affiliation  24  (16–35)  16  (11–31)  427  0.097  0.195  0.113  −0.197  0.110   Well-being  43  (37–52)  45  (38–51)  524  0.669  −0.044  0.722  0.014  0.912  Multidimensional inventory for religious/spiritual well-being  n = 34  n = 33               General religiosity  24  (12–36)  18  (8–34)  478  0.293  0.100  0.422  −0.121  0.330   Forgiveness  33  (22–43)  37  (30–42)  493  0.390  −0.092  0.460  0.132  0.286   Hope immanent  31  (27–39)  37  (31–42)  396  0.038  −0.240  0.050  0.217  0.077   Connectedness  24  (17–28)  24  (18–32)  561  0.995  −0.005  0.971  −0.022  0.860   Hope transcendent  31  (26–36)  33  (25–40)  532  0.716  −0.004  0.977  0.053  0.669   Experience of sense and meaning  38  (30–42)  38  (32–44)  525  0.647  −0.012  0.924  0.023  0.853   Sum score  181  (156–195)  185  (169–200)  482  0.322  −0.106  0.395  0.105  0.397  Interpersonal guilt questionnaire  n = 34  n = 34               Survivor guilt  18  (13–25)  18  (11–22)  516  0.446  0.047  0.701  −0.121  0.326   Separation guilt  17  (13–23)  14  (11–20)  478  0.219  0.042  0.735  −0.103  0.405   Organized guilt  28  (22–32)  28  (23–32)  573  0.946  −0.041  0.743  −0.060  0.628   Sum score  60  (51–79)  59  (49–69)  513  0.422  0.030  0.809  −0.114  0.354  Altruism  n = 37  n = 34               Importance  18  (15–19)  16  (14–20)  591  0.658  −0.019  0.875  −0.048  0.690   Attainability  15  (12–17)  16  (15–19)  442  0.030  −0.278  0.019  0.220  0.066   Success  12  (10–16)  15  (12–17)  454  0.043  −0.255  0.032  0.220  0.066  Willingness to pardon  n = 37  n = 33               Without regret  8  (5–11)  7  (6–11)  599  0.887  −0.063  0.606  0.053  0.665   With regret  12  (10–14)  13  (11–16)  481  0.126  −0.188  0.119  0.246  0.040    Female patients    Alcohol-related readmission  Number of readmissions  Days to first readmission    Yes  No                Median (IQR)  U  Pa  Rho  Pb  Rho  Pb  Centrality of religiosity scale  n = 35  n = 33               Intellect (basic)  6  (4–9)  5  (4–8)  462  0.152  0.161  0.188  −0.177  0.148   Ideology (basic)  9  (6–12)  8  (5–12)  487  0.265  0.101  0.412  −0.093  0.452   Public practice (basic)  6  (4–7)  5  (3–7)  543  0.662  0.052  0.675  −0.065  0.597   Private practice (basic)  7  (5–12)  5  (4–11)  447  0.107  0.149  0.226  −0.144  0.242   Religious experiences (basic)  7  (5–9)  5  (4–10)  496  0.310  0.102  0.410  −0.091  0.463   Private practice (inter-religious)  7  (5–9)  5  (3–8)  420  0.051  0.275  0.023  −0.240  0.049   Religious experiences (inter-religious)  6  (4–7)  5  (4–8)  498  0.321  0.120  0.330  −0.124  0.316  Religiousness and well-being  n = 36  n = 31               Religious affiliation  24  (16–35)  16  (11–31)  427  0.097  0.195  0.113  −0.197  0.110   Well-being  43  (37–52)  45  (38–51)  524  0.669  −0.044  0.722  0.014  0.912  Multidimensional inventory for religious/spiritual well-being  n = 34  n = 33               General religiosity  24  (12–36)  18  (8–34)  478  0.293  0.100  0.422  −0.121  0.330   Forgiveness  33  (22–43)  37  (30–42)  493  0.390  −0.092  0.460  0.132  0.286   Hope immanent  31  (27–39)  37  (31–42)  396  0.038  −0.240  0.050  0.217  0.077   Connectedness  24  (17–28)  24  (18–32)  561  0.995  −0.005  0.971  −0.022  0.860   Hope transcendent  31  (26–36)  33  (25–40)  532  0.716  −0.004  0.977  0.053  0.669   Experience of sense and meaning  38  (30–42)  38  (32–44)  525  0.647  −0.012  0.924  0.023  0.853   Sum score  181  (156–195)  185  (169–200)  482  0.322  −0.106  0.395  0.105  0.397  Interpersonal guilt questionnaire  n = 34  n = 34               Survivor guilt  18  (13–25)  18  (11–22)  516  0.446  0.047  0.701  −0.121  0.326   Separation guilt  17  (13–23)  14  (11–20)  478  0.219  0.042  0.735  −0.103  0.405   Organized guilt  28  (22–32)  28  (23–32)  573  0.946  −0.041  0.743  −0.060  0.628   Sum score  60  (51–79)  59  (49–69)  513  0.422  0.030  0.809  −0.114  0.354  Altruism  n = 37  n = 34               Importance  18  (15–19)  16  (14–20)  591  0.658  −0.019  0.875  −0.048  0.690   Attainability  15  (12–17)  16  (15–19)  442  0.030  −0.278  0.019  0.220  0.066   Success  12  (10–16)  15  (12–17)  454  0.043  −0.255  0.032  0.220  0.066  Willingness to pardon  n = 37  n = 33               Without regret  8  (5–11)  7  (6–11)  599  0.887  −0.063  0.606  0.053  0.665   With regret  12  (10–14)  13  (11–16)  481  0.126  −0.188  0.119  0.246  0.040  The table shows median and interquartile range (IQR) of the questionnaire scores (=sum of subitems). aMann–Whitney U-test, bSpearman correlation. P < 0.05 in bold. Table 5. Associations of religiosity, guilt, altruism and willingness to pardon with 24-month alcohol-related readmissions in male patients   Male patients    Alcohol-related readmission  Number of readmissions  Days to first readmission    Yes  No                Median (IQR)  U  Pa  Rho  Pb  Rho  Pb  Centrality of religiosity scale  n = 59  n = 30               Intellect (basic)  6  (4–9)  5  (4–8)  788  0.392  0.079  0.459  −0.062  0.565   Ideology (basic)  8  (4–11)  5  (3–9)  678  0.070  0.156  0.144  −0.154  0.149   Public practice (basic)  5  (3–7)  4  (3–6)  729  0.162  0.104  0.333  −0.061  0.567   Private practice (basic)  6  (3–11)  4  (3–8)  681  0.067  0.095  0.375  −0.120  0.261   Religious experiences (basic)  6  (3–9)  4  (3–6)  677  0.062  0.135  0.207  −0.116  0.280   Private practice (inter-religious)  6  (4–10)  5  (3–6)  671  0.059  0.170  0.112  −0.144  0.177   Religious experiences (inter-religious)  5  (4–9)  4  (3–6)  622  0.020  0.143  0.182  −0.153  0.153  Religiousness and well-being  n = 58  n = 27               Religious affiliation  21  (14–36)  14  (11–23)  539  0.021  0.180  0.100  −0.235  0.030   Well-being  42  (35–47)  43  (36–49)  734  0.643  −0.091  0.410  0.074  0.503  Multidimensional inventory for religious/spiritual well-being  n = 57  n = 28               General religiosity  22  (9–32)  10  (8–25)  612  0.077  0.103  0.350  −0.128  0.244   Forgiveness  30  (23–37)  32  (24–38)  774  0.822  −0.081  0.461  0.036  0.746   Hope immanent  31  (27–39)  32  (25–40)  797  0.989  0.046  0.673  0.028  0.802   Connectedness  22  (16–31)  16  (12–26)  586  0.047  0.206  0.058  −0.238  0.028   Hope transcendent  30  (28–35)  31  (25–36)  795  0.974  0.048  0.660  −0.035  0.748   Experience of sense and meaning  38  (32–42)  37  (32–43)  790  0.940  0.066  0.549  −0.012  0.915   Sum score  174  (155–194)  163  (146–178)  619  0.093  0.159  0.147  −0.160  0.145  Interpersonal guilt questionnaire  n = 56  n = 30               Survivor guilt  19  (14–23)  17  (14–24)  806  0.758  0.061  0.579  −0.016  0.881   Separation guilt  19  (13–23)  18  (12–21)  759  0.460  0.034  0.758  −0.023  0.832   Organized guilt  27  (23–29)  25  (22–29)  748  0.403  0.075  0.490  0.005  0.967   Sum score  62  (55–72)  61  (51–69)  767  0.505  0.059  0.592  −0.013  0.906  Altruism  n = 61  n = 30               Importance  16  (13–19)  16  (13–17)  772  0.222  0.100  0.344  −0.029  0.787   Attainability  13  (12–16)  15  (12–17)  819  0.414  −0.142  0.178  0.212  0.044   Success  13  (10–16)  12  (9–15)  870  0.703  0.018  0.866  −0.009  0.936  Willingness to pardon  n = 62  n = 28               Without regret  8  (6–11)  9  (7–11)  817  0.652  −0.153  0.150  0.183  0.083   With regret  14  (11–16)  14  (11–16)  851  0.882  0.052  0.628  0.062  0.565    Male patients    Alcohol-related readmission  Number of readmissions  Days to first readmission    Yes  No                Median (IQR)  U  Pa  Rho  Pb  Rho  Pb  Centrality of religiosity scale  n = 59  n = 30               Intellect (basic)  6  (4–9)  5  (4–8)  788  0.392  0.079  0.459  −0.062  0.565   Ideology (basic)  8  (4–11)  5  (3–9)  678  0.070  0.156  0.144  −0.154  0.149   Public practice (basic)  5  (3–7)  4  (3–6)  729  0.162  0.104  0.333  −0.061  0.567   Private practice (basic)  6  (3–11)  4  (3–8)  681  0.067  0.095  0.375  −0.120  0.261   Religious experiences (basic)  6  (3–9)  4  (3–6)  677  0.062  0.135  0.207  −0.116  0.280   Private practice (inter-religious)  6  (4–10)  5  (3–6)  671  0.059  0.170  0.112  −0.144  0.177   Religious experiences (inter-religious)  5  (4–9)  4  (3–6)  622  0.020  0.143  0.182  −0.153  0.153  Religiousness and well-being  n = 58  n = 27               Religious affiliation  21  (14–36)  14  (11–23)  539  0.021  0.180  0.100  −0.235  0.030   Well-being  42  (35–47)  43  (36–49)  734  0.643  −0.091  0.410  0.074  0.503  Multidimensional inventory for religious/spiritual well-being  n = 57  n = 28               General religiosity  22  (9–32)  10  (8–25)  612  0.077  0.103  0.350  −0.128  0.244   Forgiveness  30  (23–37)  32  (24–38)  774  0.822  −0.081  0.461  0.036  0.746   Hope immanent  31  (27–39)  32  (25–40)  797  0.989  0.046  0.673  0.028  0.802   Connectedness  22  (16–31)  16  (12–26)  586  0.047  0.206  0.058  −0.238  0.028   Hope transcendent  30  (28–35)  31  (25–36)  795  0.974  0.048  0.660  −0.035  0.748   Experience of sense and meaning  38  (32–42)  37  (32–43)  790  0.940  0.066  0.549  −0.012  0.915   Sum score  174  (155–194)  163  (146–178)  619  0.093  0.159  0.147  −0.160  0.145  Interpersonal guilt questionnaire  n = 56  n = 30               Survivor guilt  19  (14–23)  17  (14–24)  806  0.758  0.061  0.579  −0.016  0.881   Separation guilt  19  (13–23)  18  (12–21)  759  0.460  0.034  0.758  −0.023  0.832   Organized guilt  27  (23–29)  25  (22–29)  748  0.403  0.075  0.490  0.005  0.967   Sum score  62  (55–72)  61  (51–69)  767  0.505  0.059  0.592  −0.013  0.906  Altruism  n = 61  n = 30               Importance  16  (13–19)  16  (13–17)  772  0.222  0.100  0.344  −0.029  0.787   Attainability  13  (12–16)  15  (12–17)  819  0.414  −0.142  0.178  0.212  0.044   Success  13  (10–16)  12  (9–15)  870  0.703  0.018  0.866  −0.009  0.936  Willingness to pardon  n = 62  n = 28               Without regret  8  (6–11)  9  (7–11)  817  0.652  −0.153  0.150  0.183  0.083   With regret  14  (11–16)  14  (11–16)  851  0.882  0.052  0.628  0.062  0.565  The table shows median and interquartile range (IQR) of the questionnaire scores (=sum of subitems). aMann–Whitney U-test, bSpearman correlation. P < 0.05 in bold. Table 5. Associations of religiosity, guilt, altruism and willingness to pardon with 24-month alcohol-related readmissions in male patients   Male patients    Alcohol-related readmission  Number of readmissions  Days to first readmission    Yes  No                Median (IQR)  U  Pa  Rho  Pb  Rho  Pb  Centrality of religiosity scale  n = 59  n = 30               Intellect (basic)  6  (4–9)  5  (4–8)  788  0.392  0.079  0.459  −0.062  0.565   Ideology (basic)  8  (4–11)  5  (3–9)  678  0.070  0.156  0.144  −0.154  0.149   Public practice (basic)  5  (3–7)  4  (3–6)  729  0.162  0.104  0.333  −0.061  0.567   Private practice (basic)  6  (3–11)  4  (3–8)  681  0.067  0.095  0.375  −0.120  0.261   Religious experiences (basic)  6  (3–9)  4  (3–6)  677  0.062  0.135  0.207  −0.116  0.280   Private practice (inter-religious)  6  (4–10)  5  (3–6)  671  0.059  0.170  0.112  −0.144  0.177   Religious experiences (inter-religious)  5  (4–9)  4  (3–6)  622  0.020  0.143  0.182  −0.153  0.153  Religiousness and well-being  n = 58  n = 27               Religious affiliation  21  (14–36)  14  (11–23)  539  0.021  0.180  0.100  −0.235  0.030   Well-being  42  (35–47)  43  (36–49)  734  0.643  −0.091  0.410  0.074  0.503  Multidimensional inventory for religious/spiritual well-being  n = 57  n = 28               General religiosity  22  (9–32)  10  (8–25)  612  0.077  0.103  0.350  −0.128  0.244   Forgiveness  30  (23–37)  32  (24–38)  774  0.822  −0.081  0.461  0.036  0.746   Hope immanent  31  (27–39)  32  (25–40)  797  0.989  0.046  0.673  0.028  0.802   Connectedness  22  (16–31)  16  (12–26)  586  0.047  0.206  0.058  −0.238  0.028   Hope transcendent  30  (28–35)  31  (25–36)  795  0.974  0.048  0.660  −0.035  0.748   Experience of sense and meaning  38  (32–42)  37  (32–43)  790  0.940  0.066  0.549  −0.012  0.915   Sum score  174  (155–194)  163  (146–178)  619  0.093  0.159  0.147  −0.160  0.145  Interpersonal guilt questionnaire  n = 56  n = 30               Survivor guilt  19  (14–23)  17  (14–24)  806  0.758  0.061  0.579  −0.016  0.881   Separation guilt  19  (13–23)  18  (12–21)  759  0.460  0.034  0.758  −0.023  0.832   Organized guilt  27  (23–29)  25  (22–29)  748  0.403  0.075  0.490  0.005  0.967   Sum score  62  (55–72)  61  (51–69)  767  0.505  0.059  0.592  −0.013  0.906  Altruism  n = 61  n = 30               Importance  16  (13–19)  16  (13–17)  772  0.222  0.100  0.344  −0.029  0.787   Attainability  13  (12–16)  15  (12–17)  819  0.414  −0.142  0.178  0.212  0.044   Success  13  (10–16)  12  (9–15)  870  0.703  0.018  0.866  −0.009  0.936  Willingness to pardon  n = 62  n = 28               Without regret  8  (6–11)  9  (7–11)  817  0.652  −0.153  0.150  0.183  0.083   With regret  14  (11–16)  14  (11–16)  851  0.882  0.052  0.628  0.062  0.565    Male patients    Alcohol-related readmission  Number of readmissions  Days to first readmission    Yes  No                Median (IQR)  U  Pa  Rho  Pb  Rho  Pb  Centrality of religiosity scale  n = 59  n = 30               Intellect (basic)  6  (4–9)  5  (4–8)  788  0.392  0.079  0.459  −0.062  0.565   Ideology (basic)  8  (4–11)  5  (3–9)  678  0.070  0.156  0.144  −0.154  0.149   Public practice (basic)  5  (3–7)  4  (3–6)  729  0.162  0.104  0.333  −0.061  0.567   Private practice (basic)  6  (3–11)  4  (3–8)  681  0.067  0.095  0.375  −0.120  0.261   Religious experiences (basic)  6  (3–9)  4  (3–6)  677  0.062  0.135  0.207  −0.116  0.280   Private practice (inter-religious)  6  (4–10)  5  (3–6)  671  0.059  0.170  0.112  −0.144  0.177   Religious experiences (inter-religious)  5  (4–9)  4  (3–6)  622  0.020  0.143  0.182  −0.153  0.153  Religiousness and well-being  n = 58  n = 27               Religious affiliation  21  (14–36)  14  (11–23)  539  0.021  0.180  0.100  −0.235  0.030   Well-being  42  (35–47)  43  (36–49)  734  0.643  −0.091  0.410  0.074  0.503  Multidimensional inventory for religious/spiritual well-being  n = 57  n = 28               General religiosity  22  (9–32)  10  (8–25)  612  0.077  0.103  0.350  −0.128  0.244   Forgiveness  30  (23–37)  32  (24–38)  774  0.822  −0.081  0.461  0.036  0.746   Hope immanent  31  (27–39)  32  (25–40)  797  0.989  0.046  0.673  0.028  0.802   Connectedness  22  (16–31)  16  (12–26)  586  0.047  0.206  0.058  −0.238  0.028   Hope transcendent  30  (28–35)  31  (25–36)  795  0.974  0.048  0.660  −0.035  0.748   Experience of sense and meaning  38  (32–42)  37  (32–43)  790  0.940  0.066  0.549  −0.012  0.915   Sum score  174  (155–194)  163  (146–178)  619  0.093  0.159  0.147  −0.160  0.145  Interpersonal guilt questionnaire  n = 56  n = 30               Survivor guilt  19  (14–23)  17  (14–24)  806  0.758  0.061  0.579  −0.016  0.881   Separation guilt  19  (13–23)  18  (12–21)  759  0.460  0.034  0.758  −0.023  0.832   Organized guilt  27  (23–29)  25  (22–29)  748  0.403  0.075  0.490  0.005  0.967   Sum score  62  (55–72)  61  (51–69)  767  0.505  0.059  0.592  −0.013  0.906  Altruism  n = 61  n = 30               Importance  16  (13–19)  16  (13–17)  772  0.222  0.100  0.344  −0.029  0.787   Attainability  13  (12–16)  15  (12–17)  819  0.414  −0.142  0.178  0.212  0.044   Success  13  (10–16)  12  (9–15)  870  0.703  0.018  0.866  −0.009  0.936  Willingness to pardon  n = 62  n = 28               Without regret  8  (6–11)  9  (7–11)  817  0.652  −0.153  0.150  0.183  0.083   With regret  14  (11–16)  14  (11–16)  851  0.882  0.052  0.628  0.062  0.565  The table shows median and interquartile range (IQR) of the questionnaire scores (=sum of subitems). aMann–Whitney U-test, bSpearman correlation. P < 0.05 in bold. DISCUSSION To the authors’ knowledge, the study reported here is the first to gender-specifically compare religious denomination, religiosity, guilt, altruism and forgiveness between alcohol-dependent patients and age as well as sex-matched healthy control subjects and to evaluate their predictive potential for alcohol-related readmission following in-patient withdrawal treatment. We found an association between likelihood of being in the patient sample and acknowledging a religious denomination. By contrast, Hodge et al. (2001) reported that spiritual or religious involvement in south west USA was associated with decreased risk of alcohol or drug abuse, problems, and dependence. Similarly, Michalak et al. (2007) found in their examination of the data from the US National Alcohol Survey that religious affiliation was associated with abstinence from alcohol use. However, in the USA religion might relate differently to alcohol behaviors, because denominations which prohibit alcohol (e.g. Mormons, Seventh Day Adventists and Muslims) are more frequent there than in our European Franconian sample. Most of our study subjects were Catholics or Protestants and might thus be more accustomed to ritual incorporation of alcohol in form of wine due to their religious background. As suggested by Haber et al. (2011), personality profiles strongly influence the relationship between alcohol dependence and religion. This may also account for inconsistencies between different studies. Our finding that religious affiliation is positively related to attitude towards alcohol is in accordance with Walters’ findings (1957) of a transgenerational effect. In 50 alcohol-dependent patients of a Midwest Veterans Administration Hospital, he found that parents of alcohol-dependent individuals were more likely to be church members than parents of control subjects. To provide additional supporting evidence for our result of religiosity being relevant to alcohol dependence, we analyzed associations of religiosity with alcohol-related hospital readmission during the 24-month follow-up. Interestingly, higher private practice was not only associated with alcohol dependence per se; we found also that higher private practice and higher religious affiliation predicted a shortened interval to first alcohol-related readmission as well as more frequent readmissions. In summary, religious denomination and religiosity are related to increased risk for alcohol dependence and a worse 24-month outcome in our cohort. Identifying underlying mechanisms was beyond the scope of this study. Nevertheless, we speculate that life burden and chronic illnesses motivate people to ask about the sense of life and other existential items. An answer to these fundamental questions can be found in a religious world outlook. This aspect could contribute to the association between religiosity and alcohol dependence as well as religiosity and worse outcome, as shown in our study. Moreover, Dutton and van der Linden (2017) discuss that intelligence is negatively associated with religiousness. That might stimulate the hypothesis that premorbid intelligence is negatively related to developing alcohol dependence. However, further studies are needed to illuminate the concrete underpinnings. We measured higher scores on religious experiences, connectedness, experience of sense and meaning, and guilt in the patients’ cohort in comparison to the healthy controls. The significantly higher scores in patients’ connectedness might be confounded by repetitive inebriation experiences. This bias has been well-known for millenia: ‘And be not drunk with wine, wherein is excess; but be filled with the Spirit’ (Ephesians 5: 18 in: Witkiewitz et al., 2016). Accordingly, we speculate that the higher scores on the scale of experience of sense and meaning in alcohol-dependent patients are also a consequence of frequent inebriation experiences. The alcohol-dependent patients’ higher scores on the scales for interpersonal guilt are understandable. An individual might decide to engage in alcohol misuse to deal with guilt or shame and vice versa the pathological alcohol consumption might also cause a feeling of guilt (Ianni et al., 2010, Webb et al., 2006). Self-blame as a maladaptive coping strategy has been associated with a worse outcome in alcohol-dependent patients (Tapert et al., 2004). Whether the feeling of guilt is a cause or consequence of alcohol dependence remains to be shown; however, our data suggest that it might be a relevant psychotherapeutic target to prevent and to deal with alcohol dependence. In comparison to healthy control subjects, patients scored lower on well-being (BI), forgiveness, and immanent and transcendent hope (MIRSB) suggesting that these factors might be protective against alcohol dependence. The lowered patients’ levels of forgiveness perhaps reflect a wish for revenge. At this point, one might hypothesize, that patients have less tendency of self-forgiving, which would be in line with the increased feelings of guilt discussed above because forgiveness of self has been evaluated as a strategy for coping with feelings of guilt and shame (Hall and Finchman, 2005). Thus, forgiveness as a specific dimension of religiousness should be tested as an element to enhance recovery. However, its operating mechanisms in general are unknown (Webb et al., 2011). Interestingly, we found no significant difference between alcohol-dependent patients and healthy control subjects with regard to the SBV forgiveness scales. The MIRSB and SBV questionnaires differ in that the MIRSB forgiveness scale is surveyed in a quite general and abstract way, whereas the SBV uses concrete exemplifications to explore the willingness to forgive. Moreover, the SBV differentiates between the willingness to pardon without and with regret. The lack of a group difference on the SBV scales agrees with results showing that forgiveness did not predict alcohol dependence outcomes (Webb et al., 2011; Langman and Chung, 2013). The sex-balanced cohort which enabled analysis of gender-specific effects of religiosity on alcohol dependence is a strength of our study. However, the gender differences shown in the tables should not be over-interpreted and need validation in future studies. The Franconian region, where the study was conducted, is mainly inhabited by Protestants. This reduces the generalizability of the study findings and is a relevant limitation. Moreover, we cannot exclude that some of the findings classified as significant represent false positives. According to the explorative study design, our data have not been corrected for multiple testing and need to be confirmed in future investigations. CONCLUSION As far as we know, this study shows for the first time an increased risk for alcohol dependence and a worse outcome in study subjects with a religious denomination, more private religious practice, religious affiliation, guilt and reduced attainability of altruism. Further research is needed to analyze the role of the personality within the trio of alcohol dependence, religiosity and personality and to develop differentiated strategies to enhance the positive components of religiosity on alcohol dependence. ACKNOWLEDGEMENTS We thank Dr. Andreas Ahnert, Ute Hamers and Dr. Kristina Bayerlein for the opportunity and the support to recruit patients at the Klinik für Psychiatrie, Psychotherapie, Psychosomatik of the Klinikum am Europakanal Erlangen. We gratefully appreciate the support of Juliane Behrens, Sarah Kubis, Katrin Mikolaiczik, Sarah Saigali, Marina Sibach, and Petya Tanovska in recruiting patients and healthy control subjects. We recognize Prof. Dr. Teresa Biermann for inspirational support concerning the topic of religiosity/spirituality. We express our gratitude to Prof. Dr. Jonathan D. Chick for revisional hints. Conflict of Interest Statement The authors declare that they have no conflict of interest. Authors’ contribution Conceived and designed the experiments: B.B., C.W., J.K., B.L. Performed the experiments: B.B., C.W., B.L. Analyzed the data and wrote the article: B.B., B.L. Commented on the article and provided intellectual input: J.K. 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Alcohol and AlcoholismOxford University Press

Published: Apr 18, 2018

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