Letters to the Editor 83

Figure 1 A) Axial computed tomographic image (soft-tissue algorithm) showing a hypoattenuating lesion involving the genu of
the corpus callosum. B-D) Brain magnetic resonance images: B) sagittal, T2-TSE; C) axial, diffusion-weighted imaging (DWI);
D) axial, T2-FLAIR. Hyperintense lesions involving the entire corpus callosum were seen on T2-TSE and T2-FLAIR
sequences. The same lesions were also hyperintense on DWI, with a low apparent diffusion coefficient reflecting restricted
diffusion.

References life events can have an important influence on alcohol

use. In our study, the population was predominantly
1 World Health Organization (WHO). Global status report on alcohol composed by Catholics (67.3%), followed by Evangelical
and health 2014 [Internet]. 2014 [cited 2014 Dec 11]. [Link]
Protestants (23.3%). These religious affiliations usually
[Link]/substance_abuse/publications/global_alcohol_report/en/
2 Geibprasert S, Gallucci M, Krings T. Alcohol-induced changes in the have stronger opinions regarding public policy than do
brain as assessed by MRI and CT. Eur Radiol. 2010;20:1492-501. other religious traditions, including advocating for more
3 Zuccoli G, Siddiqui N, Cravo I, Bailey A, Gallucci M, Harper CG. restrictive alcohol policies.2 There are distinct differences
Neuroimaging findings in alcohol-related encephalopathies. AJR Am in alcohol use between religious traditions, as we reported
J Roentgenol. 2010;195:1378-84. in a recent article.3 For instance, Afro-Brazilian religions
4 Heinrich A, Runge U, Khaw AV. Clinicoradiologic subtypes of
Marchiafava- Bignami disease. J Neurol. 2004;251:1050-9.
(i.e., Umbanda) utilize alcohol in their rituals, whereas
5 Carrilho PE, Santos MB, Piasecki L, Jorge AC. Marchiafava-Bignami some Brazilian Protestant Evangelicals forbid its use
disease: a rare entity with a poor outcome. Rev Bras Ter Intensiva. entirely, whether for religious or non-religious purposes.
2013;25:68-72. With regard to the concepts of spirituality and religiosity
and their measurement, we agree that these are distinct
constructs, sometimes difficult to distinguish. According
to Koenig et al.,4 spirituality is ‘‘the personal quest for
Spirituality or religiosity: is understanding answers to ultimate questions about life,
about meaning and about relationship to the sacred or
there any difference? transcendent, which may (or may not) lead to or arise
from the development of religious rituals and the
Rev Bras Psiquiatr. 2015;37:83–
–84 formation of community.’’ Several authors have examined
doi:10.1590/1516-4446-2014-3610 relationships between spirituality, religiosity, and mental
health, with varying results. For example, King et al.5
We read with interest the letter published by Dr. Abayomi1 investigated associations between a spiritual or religious
concerning our article entitled ‘‘Religious beliefs and understanding of life and psychiatric symptoms in 7,403
alcohol control policies: a Brazilian nationwide study.’’2 people in England. They found religious people were
We agree that cultural values, personality, and stressful similar to those who were neither religious nor spiritual

Rev Bras Psiquiatr. 2015;37(1)

84 Letters to the Editor

with regard to the prevalence of mental disorders, except References

that those who were religious were less likely to have
ever used drugs or to be a hazardous drinker. On the 1 Abayomi O. Still on religiosity and alcohol use. Rev Bras Psiquiatr.
2014;36:360-1.
other hand, spiritual people were more likely than those 2 Lucchetti G, Koenig HG, Pinsky I, Laranjeira R, Vallada H. Religious
who were neither religious nor spiritual to have ever used beliefs and alcohol control policies: a Brazilian nationwide study. Rev
or to be dependent on drugs and to have abnormal eating Bras Psiquiatr. 2014;36:4-10.
attitudes, generalized anxiety disorder, any phobia, or 3 Lucchetti G, Peres MF, Lucchetti AL, Koenig HG. Religiosity and
any neurotic disorder. Furthermore, Laurent et al.6 found tobacco and alcohol use in a Brazilian shantytown. Subst Use
Misuse. 2012;47:837-46.
that those who indicated that they were spiritual but not 4 Koenig HG, McCullough ME, Larson DB. Handbook of religion and
religious in the UK were nearly three times more likely to health. New York: Oxford University Press; 2001.
develop an episode of major depressive disorder during a 5 King M, Marston L, McManus S, Brugha T, Meltzer H, Bebbington P.
12-month follow-up period compared to those who were Religion, spirituality and mental health: results from a national study
of English households. Br J Psychiatry. 2013;202:68-73.
neither religious nor spiritual (OR 2.73, 95%CI 1.59-4.68).
6 Leurent B, Nazareth I, Bellon-Saameno J, Geerlings MI, Maaroos H,
In contrast, in a much smaller study, Farias et al.7 Saldivia S, et al. Spiritual and religious beliefs as risk factors for the
compared modern spiritual individuals (n=114) with onset of major depression: an international cohort study. Psychol
traditional religious believers (n=86) in England. The Med. 2013;43:2109-20.
authors found anxiety, depression, and insecure attach- 7 Farias M, Underwood R, Claridge G. Unusual but sound minds: mental
health indicators in spiritual individuals. Br J Psychol. 2013;104:364-81.
ment were not significant predictors of spirituality. The
results of this study also revealed that spiritual believers
reported high satisfaction with social support, with this
variable predicting involvement in modern spirituality. Edgar Allan Poe’s psychic
Furthermore, spiritual practices correlated negatively with
death anxiety scores. These conflicting results are not daguerreotype
easy to reconcile. First, since all these studies were
conducted in the United Kingdom, cultural context would Rev Bras Psiquiatr. 2015;37:84–
–85
not seem to play a significant role. Second, as only one doi:10.1590/1516-4446-2014-1520
study6 actually followed participants over time, the other
Recently made freely accessible by the J. Paul Getty Trust
two cross-sectional studies provide no information about
and Museum in Los Angeles, the famous ‘‘Annie’’ daguerreo-
the time sequence. Third, important psychiatric outcomes
type of Edgar Allan Poe (Figure 1) invites introspection
such as depression and anxiety were addressed in both
about the author’s personality and mental illnesses.
studies. Some major differences between these three
Poe was an author, poet, editor, and literary critic, part of
studies also warrant mention. The instruments used to
the American Romantic movement. Known for his tales of
assess religiosity/spirituality and mental health were
mystery and the macabre, he is considered the inventor of
different, which could help to explain the varying results;
detective fiction.1,2 However, he is also known for his troubled
the enrollment of patients was diverse (two nationwide mind, beset by alcoholism and bipolar affective disorder.1,2
studies vs. one convenience sample); and the same
A pioneering author who tried to earn a living through
psychiatric outcomes were not assessed in all three studies. writing alone, Poe led a life of hardship and some
In view of these findings, more research needs to be professional unpleasantnesses.1,2 This suffering always
done comparing those who are religious and spiritual with influenced his work and is present throughout his
those who are spiritual but not religious in a variety of masterpieces, as he wrote in The Fall of the House of
locations and cultural settings to elucidate the role that Usher: ‘‘It was, he said, a constitutional and a family evil,
spiritual and religious beliefs play in mental health and and one for which he despaired to find a remedy.’’
substance use. Bipolar affective disorder is characterized by high rates
of morbidity and disability and may be misdiagnosed as
Giancarlo Lucchetti,1,2,3 Harold G. Koenig,4,5 major depressive disorder in some settings.3,4 Alcoholism
Ilana Pinsky,6 Ronaldo Laranjeira,6 Homero Vallada7 is a chronic remitting and relapsing condition and remains
1
Department of Medicine, Universidade Federal de Juiz de Fora a serious cause of morbidity and mortality, despite
(UFJF), Juiz de Fora, MG, Brazil. 2Hospital João Evangelista
(HOJE), São Paulo, SP, Brazil. 3Associação Médico-Espı́rita
progress in identifying new pharmacological strategies
Internacional, São Paulo, SP, Brazil. 4Duke University Medical for its treatment through neurobiological research.5,6
Center, Durham, North Carolina, USA. 5King Abdulaziz University, The ‘‘Annie’’ daguerreotype was taken by Mrs. Anne
Jeddah, Saudi Arabia. 6Department of Psychiatry, Universidade Richmond, a friend of Poe, and shows him in plain, pedestrian
Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil. attire, unkempt, with a vacant look, mixing surprise and
7
Department of Psychiatry, Universidade de São Paulo (USP), São
Paulo, SP, Brazil untidiness, disclosing a depressive mood and suffering.

Submitted May 07 2014, accepted May 09 2014. João R. de Oliveira,1 Matheus F. Oliveira2
1
Neuropsychiatric Department, Universidade Federal de
Pernambuco (UFPE), Recife, PE, Brazil. 2Neurosurgery Residency
Program, Hospital do Servidor Público Estadual de São Paulo, São
Disclosure Paulo, SP, Brazil

The authors report no conflicts of interest. Submitted Jul 26 2014, accepted Aug 04 2014.

Rev Bras Psiquiatr. 2015;37(1)