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Journal of Behavioral Medicine
ISSN 0160-7715
Volume 34
Number 6
J Behav Med (2011) 34:489-496
DOI 10.1007/s10865-011-9325-9
Does social support mediate the moderating
effect of intrinsic religiosity on the
relationship between physical health and
depressive symptoms among Jews?
Steven Pirutinsky, David H.Rosmarin,
Cheryl L.Holt, Robert H.Feldman,
Lee S.Caplan, Elizabeth Midlarsky &
Kenneth I.Pargament
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Does social support mediate the moderating effect of intrinsic
religiosity on the relationship between physical health
and depressive symptoms among Jews?
Steven Pirutinsky •David H. Rosmarin •Cheryl L. Holt •
Robert H. Feldman •Lee S. Caplan •Elizabeth Midlarsky •
Kenneth I. Pargament
Received: May 24, 2010 / Accepted: January 20, 2011 / Published online: February 10, 2011
ÓSpringer Science+Business Media, LLC 2011
Abstract Previous research in the general population
suggests that intrinsic religiosity moderates (mitigates) the
effect of poor physical health on depression. However, few
studies have focused specifically on the Jewish community.
We therefore examined these variables in a cross-sectional
sample of 89 Orthodox and 123 non-Orthodox Jews. Based
on previous research suggesting that non-Orthodox Juda-
ism values religious mental states (e.g., beliefs) less and a
collectivist social religiosity more, as compared to Ortho-
dox Judaism, we hypothesized that the moderating effect of
intrinsic religiosity would mediated by social support
among non-Orthodox but not Orthodox Jews. As predicted,
results indicated that the relationship between physical
health and depression was moderated by intrinsic religi-
osity in the sample as a whole. Furthermore, this effect was
mediated by social support among non-Orthodox Jews, but
not among the Orthodox. The importance of examining
religious affiliation and potential mediators in research on
spirituality and health is discussed.
Keywords Spirituality Depression Judaism
Social support Illness
A substantial body of research indicates that individuals
with chronic illnesses, pain, or physical disabilities have
higher rates of depressive symptoms (Moussavi et al. 2007;
Keawe’aimoku et al. 2003) and that chronic physical con-
ditions and depression are frequently comorbid (Mathers
2001). Furthermore, a number of longitudinal studies have
demonstrated that chronic disease, poor self-perceived
health, and functional limitations are associated with future
episodes of depression (Vink et al. 2008). As a result, there
has been a long-standing interest in identifying protective
factors that ameliorate the influence of poor physical health
on depressive symptoms. One factor identified by previous
research is religion (e.g., Pargament 1997), which multiple
studies now suggest significantly ties with lower depressive
symptoms among the chronically ill (Koenig et al. 2001a,
b). In fact, although religiosity generally correlates with
lower depressive symptoms, it appears to be particularly
salutary among individuals experiencing high amounts of
life stress such as the physically ill (Smith et al. 2003).
However, the influence of religion on human function-
ing is not monolithic and likely fluctuates dependent on the
attitudes, beliefs, and behaviors espoused by an individ-
ual’s faith (Pirutinsky 2009). Indeed, some suggest that
religion, like geographic origin or ethnic identity, is best
understood as a source of cultural influence with a diverse
and varied impact (Cohen 2009), and it is therefore
important to examine the meaning of religion within par-
ticular groups, since generalizations may be inaccurate.
Moreover, even within broad religious categories (e.g.,
Christians, Jews, Muslims) there may be within group
variations in belief and culture that alter the importance of
S. Pirutinsky (&)E. Midlarsky
Department of Clinical and Counseling Psychology, Teachers
College, Columbia University, Box 303, 525 West 120th St.,
New York, NY 10027, USA
e-mail: sp2813@columbia.edu
D. H. Rosmarin
McLean Hospital/Harvard Medical School, Belmont, MA, USA
C. L. Holt R. H. Feldman
University of Maryland, College Park, MD, USA
L. S. Caplan
Morehouse School of Medicine, Atlanta, GA, USA
K. I. Pargament
Bowling Green University, Toledo, OH, USA
123
J Behav Med (2011) 34:489–496
DOI 10.1007/s10865-011-9325-9
Author's personal copy
religious factors to health. Furthermore, not all forms of
religion appear equally adaptive. One widely studied dis-
tinction is between extrinsic religiosity, which involves
using religion as a means to an end (e.g., church mem-
bership to establish a place within a community) and
intrinsic religiosity, defined as a sincere and intentional
integration of religion into one’s life (Allport and Ross
1967). Meta-analytic findings suggest that measures of
intrinsic religiosity correlate with lower depressive symp-
toms, while measures of extrinsic religiosity correlate with
greater risk (Smith et al. 2003).
While some have studied the mediating pathways
through which intrinsic religiosity exerts these effects (e.g.,
Ardelt and Koenig 2009), the mechanisms are not fully
established and may vary across religious affiliations. One
possibility is that intrinsic religiosity itself acts as a psy-
chological resource, by encouraging protective religious
mental states (e.g., Pargament 1997). However, beyond
these mental processes, research suggest that religious
individuals have more social contact (Putnam 2000) and
that social support is protective against depression (Ane-
shensel and Stone 1982; Stice et al. 2004). Accordingly,
intrinsic religiosity may ameliorate stress and influence
depressive symptoms through increased social support
(Koenig et al. 2001a,b). Although extrinsic religiosity may
also increase social contact, intrinsic religiosity appears to
provide more effective social support (Salsman et al.
2005), perhaps because relationships formed in the context
of a shared religious worldview are particularly accessible
and protective in times of stress (Ai et al. 2009). Conse-
quently, given possible variation in the psychological
effects of religious beliefs across religious groups and the
paucity of research in the Jewish context (Schnall 2006),
we explored the protective effect of intrinsic religiosity and
the possible mediating role of social support in the context
of poor physical health among Jews.
Jewish religious culture
Over the past two centuries, the Jewish community has
divided into various sub-groups defined by religious and
cultural differences. A primary distinction can be made
between Orthodox and non-Orthodox Judaism. Orthodox
Judaism is premised on acceptance of a divinely originated
Torah (Hebrew Bible) and adherence to the 613 biblical
commandants, as interpreted in the Talmud and applied to
all aspects of daily life (Schnall 2006). Orthodox Jewish
doctrine and culture also focuses explicitly on religious
mental states such as belief in an afterlife (Pirutinsky 2009)
and a personal relationship with God founded upon faith
and trust (Rosmarin et al. 2009). Within the health context,
Orthodox Judaism views physical illness as a God-given
message and challenge, which can lead to spiritual and
religious growth (Leyser 1994). Accordingly, limited pre-
vious research suggests that among Orthodox Jews, reli-
gious mental states, such as belief in God’s benevolence
and utilization of religious coping strategies, are strongly
related to better mental health, while among non-Orthodox
Jews these appear unrelated (Rosmarin et al. 2009).
In contrast, non-Orthodox Judaism does not require
strict adherence to specific laws and beliefs, instead
emphasizing interpersonal ethics, social action (‘‘Tikun
Olam’’), and communal participation over mental states.
Thus, some argue that non-Orthodox Judaism represents a
collectivist religion focused on the expression of religiosity
through social interrelation (Cohen and Hill 2007).
Accordingly, limited research suggests that religious
mental states are largely irrelevant to psychological func-
tioning among non-Orthodox Jews (Cohen 2002). Applied
to the current context, given that non-Orthodox Judaism
emphasizes religious social involvement over mental
states, intrinsic religiosity may not directly protect against
the stress of physical illness among non-Orthodox Jews.
Instead, intrinsic religiosity may moderate the effects of
poor physical health among non-Orthodox Jews by pro-
viding accessible and effective social support, which in
turn protects against depression. Restated, social support
may fully mediate the moderating effect of intrinsic reli-
giosity among non-Orthodox Jews. On the other hand,
among Orthodox Jews, who focus on religious mental
states and practices over social connection, intrinsic reli-
giosity is likely directly relevant and social support may
not mediate this effect.
In summary, consistent with previous research in the
general population, we expected that intrinsic religiosity
would moderate, or mitigate, the effects of physical health
on depressive symptoms among both Orthodox and non-
Orthodox Jews, such that among those high in intrinsic
religiosity, poor physical health would be less related to
depressive symptoms (Hypothesis 1). However, consistent
with the existing theoretical and empirical distinctions be-
tween non-Orthodox and Orthodox Judaism, we also
hypothesized that the moderating effect of intrinsic religi-
osity would be mediated by social support among non-Or-
thodox Jews, but not among the Orthodox (Hypothesis 2).
Method
Participants and procedures
Participants were recruited to participate in a study of
‘‘Religion, Spirituality and Health in the Jewish Commu-
nity’’ through e-mails sent to distribution lists of Orthodox
& non-Orthodox Jewish organizations (e.g., Aish HaTorah,
490 J Behav Med (2011) 34:489–496
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Hebrew Union College), and internet-based advertising on
Jewish Internet outlets (e.g., synagogue announcement
groups, event listings, discussion forums). Participants
were volunteers who were not paid for their participation.
Analyses were completed with data supplied by those who
reported known Orthodox affiliations (Hassidic =5, Yes-
hiva Orthodox =45, Modern Orthodox =69, Sephardic-
Religious =2; Chabad/Lubavitch =2) or non-Orthodox
affiliations (Conservative =32, Reform =30, Recon-
structionist =5, Humanistic =3, Sephardic-Traditional =
3, Other Jewish =14). A total of 212 participants (123
Orthodox and 89 non-Orthodox) completed an internet-
based survey containing all measures. The majority of the
sample was female (n =157; 74.05%) and participants
ranged in age from 19 to 79 years (M=41.74,
SD =15.10). Most of the sample resided in the U.S.
(82.5%), with smaller proportions from Canada (6.6%),
Israel (5.7%), and other countries (2.2%). The resulting
non-Orthodox and Orthodox groups did not differ in terms
of age (t(120) =.11, P=.74), country (v
2
(10) =12.00,
P=.28) or gender (v
2
(1) =2.61, P=.11).
Measures
Intrinsic religiosity
Intrinsic religiosity was measured using the three item
intrinsic religiosity subscale from the Duke Religion Index
(Koenig et al. 1997). These items read ‘‘My religious be-
liefs are what really lie behind my whole approach to life’’,
‘‘In my life, I experience the presence of the Divine (i.e.,
God)’’, and ‘‘I try hard to carry my religion over into all
other dealings in life’’. These were rated on a five point
scale ranging from ‘‘Definitely not true’’ to ‘‘Definitely
true’’. This scale has demonstrated adequate internal con-
sistency (a=.78), test–retest reliability (ICC =.91), and
correlation with similar measures (Storch et al. 2004).
Furthermore, unlike many measures of intrinsic religiosity,
such as Allport and Ross’s (1967) Religious Orientation
Scale, this index does not include items specifically refer-
ring to individual, emotional, or social-based motivations
for religion, which may be inappropriate in the Jewish
context (Cohen et al. 2005). Internal reliability in the
sample was high (a=.87).
Physical health
Physical health was measured using the Physical Compo-
nent Summary score of the Short Form Health Survey (SF-
12; Gandek et al. 1998; Ware et al. 1996). This 12 item
self-report scale, derived from the 36-item Short Form
Health Survey (SF-36), measures physical functioning and
bodily pain. It has demonstrated excellent test–retest reli-
ability and construct validity, and correlates highly with
SF-36 scores (Gandek et al. 1998; Ware et al. 1996). Scores
range from 0 to 100, with lower scores indicating poorer
health and functioning.
Depressive symptoms
Depressive symptoms were assessed using a short form of
the Center for Epidemiologic Studies Depression Scale
(CES-D; Radloff 1977). This scale contains 10 items and
has been validated extensively as a measure of depressive
symptoms (e.g., Andresen et al. 1994). Scores range from 0
to 30, and scores of 10 or above indicate clinically sig-
nificant levels of depression. Internal consistency in the
current sample was high (a=.89).
Social support
Perceived social support was examined using a single item
measure previously used in numerous studies analyzing the
national Behavioral Risk Factor Surveillance System sur-
vey data (Nelson et al. 2001), which asked participants:
‘‘How often do you get the social and emotional support you
need? Please include support from any source’’. This item
was scored on a five point scale consisting of ‘‘Never’’,
‘‘Rarely’’, ‘‘Sometimes’’, ‘‘Usually’’, and ‘‘Always’’.
Statistical method
To assess whether intrinsic religiosity moderated the effect
of poor physical health on depression in the sample as a
whole (Hypothesis 1), we utilized multiple regression using
mean-subtracted (centered) variables (Aiken and West
1991). This regression included the main effects of both
poor physical health and intrinsic religiosity (Step 1) and a
multiplicative interaction term examining if the effect of
poor physical health was moderated by the level of intrinsic
religiosity (Step 2). We conducted an additional regression
analysis examining if the strength of this moderation effect
differed between Orthodox and non-Orthodox participants.
To determine whether higher social support may ex-
plain, or mediate, the moderating effect of intrinsic reli-
giosity, and whether this relationship differed across
Orthodox and non-Orthodox Jews (Hypothesis 2), we uti-
lized the causal steps approach of Baron and Kenny (1986),
as adapted to the mediated moderation context by Muller
et al. (2005).
1
Thus, we tested regression models examin-
1
In the present paper, moderation describes how the level of intrinsic
religiosity alters the effect of poor physical health on depression,
while mediation describes the pathway through which intrinsic reli-
giosity impacts depressive symptoms by relating with greater social
support. This pattern is referred to as mediated moderation and was
J Behav Med (2011) 34:489–496 491
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ing whether: (1) the moderating effect of intrinsic religi-
osity was related to higher social support (Path a) (2)
higher social support was related to lower depressive
symptoms (Path b) and (3) if the moderating effect of
intrinsic religiosity was attenuated once social support was
controlled for (Path c‘) within each group.
Results
Descriptive statistics for all study variables are presented in
Table 1. Orthodox and non-Orthodox participants reported
equivalent levels of physical health, depression and social
support; however, Orthodox Jews reported higher levels of
intrinsic religiosity.
In regards to Hypothesis 1, results revealed that lower
intrinsic religiosity and lower physical health did inde-
pendently predict higher depressive symptoms (Table 2).
Furthermore, these factors interacted such that intrinsic
religiosity moderated (mitigated) the relationship of
physical health difficulties on depression. This moderation
effect did not differ significantly between Orthodox and
non-Orthodox participants (DR
2
=.01, F(4, 201) =.43,
P=.79). To examine the nature of this interaction, we
plotted model predictions for depressive symptoms at
various levels of intrinsic religiosity and physical health for
both Orthodox and non-Orthodox participants (Fig. 1).
Examination of the plot and post-hoc tests revealed that
among those low in intrinsic religiosity (1 SD below the
mean) lower physical health significantly related to higher
depressive symptoms (B=-.42, t(208) =5.53,
P\.001), while among those with high intrinsic religi-
osity (1 SD above the mean) physical health was not sig-
nificantly related to depressive symptoms (B=-.08,
t(208) =1.06, P=.29). Consistent with previous findings
in the general population, these results suggest that intrinsic
religiosity may protect against (moderate) the effects of
poor physical health on depression among both Orthodox
and non-Orthodox Jews. Moreover, model predictions for
those with low intrinsic religiosity and poor physical health
fell in the clinically depressed range (CESD [10). In
contrast, predictions for those with high intrinsic religiosity
were below the clinical threshold (CESD \8), suggesting
that intrinsic religiosity may moderate even clinically sig-
nificant levels of symptoms. Given the large number of
females in the sample, we ran an additional regression
examining gender effects and found no interaction
(DR
2
=.008, F(4, 201) =.5, P=.74).
In regards to Hypothesis 2 (Fig. 2), among non-Ortho-
dox Jews, the moderating effect of intrinsic religiosity re-
lated to higher social support (b=.21, t(85) =2.03,
P\.05; Path a), and this higher social support was related
to lower depressive symptoms (b=-.34, t(85) =3.24,
Table 1 Descriptive statistics
Orthodox non-Orthodox td
MSD MSD
Intrinsic religiosity 13.25 2.14 10.99 3.32 6.03* .81
Physical health 31.08 7.27 33.12 9.22 1.80 .25
Depressive symptoms 18.18 6.50 18.71 6.56 .58 .08
Social support 3.61 .96 3.60 .88 .10 .01
*P\.001; df =210 for ttests
Table 2 The moderating effect of intrinsic religiosity on depression in the context of physical health
Variable Step 1 Step 2
BSE BbBSE Bb
Intrinsic religiosity -.57*** .14 -.24 -.59*** .14 -.27
Physical health -.24*** .05 -.30 -.25*** .05 -.31
Religiosity 9health .06** .02 .20
DR
2
.15 .04
Ffor DR
2
18.43*** 9.56**
** P\.01; *** P\.001
Footnote 1 continued
analyzed in a manner identical to the causal steps method for simple
meditation, except that the interaction (religiosity by health) was
entered as the predictor variable and the main effects (religiosity and
heath) were treated as covariates (see Kenny 2009 for a discussion).
For concision, full descriptions of the mediated moderation models
are not included but are available by contacting the first author.
492 J Behav Med (2011) 34:489–496
123
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P=.002; Path b). Moreover, once we controlled for social
support, intrinsic religiosity no longer significantly mod-
erated the relationship between poor physical health and
depressive symptoms (b=-.13, t(85) =1.27, P=.21;
Path c‘), suggesting that the moderating effect of intrinsic
religiosity was fully mediated by higher social support. A
bias-corrected bootstrapping analysis of the mediation
model (Preacher and Hayes 2008; 1,000 sub-samples, 95%
CI) confirmed these findings as the indirect effect of social
support (Path a via b) significantly differed from 0 (-.06
through -.004).
In contrast, among Orthodox Jews, the moderating ef-
fect of intrinsic religiosity was not significantly associated
with social support (b=-.11, t(119) =1.15, P=.25;
Path a). Furthermore, while higher social support was re-
lated to lower depressive symptoms (b=-.36, t(119) =
4.62, P\.001; Path b), intrinsic religiosity remained a
significant moderator of the effects of poor physical health
on depressive symptoms even after controlling for social
support (b=-.19, t(119) =2.35, P=.02; Path c‘).
These findings too were confirmed using a bias-corrected
bootstrapping analysis of the mediation model (Preacher
and Hayes 2008; 1,000 sub-samples, 95% CI: -.01 through
.04). These results suggest that although social support
independently related to depressive symptoms among Or-
thodox Jewish participants, it did not mediate the moder-
ating effect of intrinsic religiosity on depression.
Discussion
It is widely acknowledged that chronic illnesses, poor
health, and functional limitations are risk factors for
depression, and a considerable body of research demon-
strates that for some individuals, religion provides a key
protective resource against these effects (Koenig et al.
2001a,b; Smith et al. 2003). However, religious constructs
have varying salience and meaning across groups (Spilka
et al. 2003). Consequently, the current research examined
the role of intrinsic religiosity as a moderator of the rela-
tionship between poor physical health and depression
among non-Orthodox and Orthodox Jews. Results indi-
5
7
9
11
13
15
High (+1 SD)Med (Mean)Low (-1 SD)
Physical Health
Depressive Symptoms
Orthodox Jews
Low IR (-1 SD)
Med IR (Mean)
High IR (+1 SD)
Non-Orthodox Jews
Low IR (-1 SD)
Med IR (Mean)
High IR (+1 SD)
10
Clinical Cutoff
Fig. 1 Moderating effect of
intrinsic religiosity (IR)
Fig. 2 Social support as a
mediator of the moderating
effect of intrinsic religiosity.
Note:Bold values represent
standardized regression
coefficients among the non-
Orthodox. Underlined values
represent standardized
coefficients among the
Orthodox.*P\.05, **P\.02,
***P\.001
J Behav Med (2011) 34:489–496 493
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cated that among both Orthodox and non-Orthodox Jewish
participants, intrinsic religiosity moderated (weakened) the
effect of poor physical health on depression. However, the
mediating pathway of this effect differed such that it was
fully mediated by social support among non-Orthodox
participants, but unrelated among the Orthodox.
Thus, consistent with our expectation (Hypothesis 1),
intrinsic religiosity had a robust moderating effect on
depression in the context of physical health, as our model
accounted for over 19% of the variance in depressive
symptoms. In fact, among those high in intrinsic religiosity,
poor physical health was unrelated to depression, while
among those low in intrinsic religiosity, an equivalent de-
gree of poor physical health related to clinically significant
symptoms. This suggests that among both Orthodox and
non-Orthodox Jews with high levels of intrinsic religiosity,
poor physical health is not a risk factor for developing
depressive symptoms, and that intrinsic religiosity may
ameliorate even clinical levels of depression. However,
although intrinsic religiosity appeared equally effective for
Orthodox and non-Orthodox participants, consistent with
previous research (e.g., Rosmarin et al. 2009), Orthodox
participants reported significantly higher levels of intrinsic
religiosity. These results parallel previous findings within
the general population (e.g., Smith et al. 2003), such as
those of Wink et al. (2005), who found that poor physical
health predicted higher of levels depression only among
individuals low in religiousness, while among those high in
religiousness, physical health status was unrelated to
depressive symptoms. Jewish religious culture also appears
to influence other aspects of health, such as stigmatization
of medical conditions (Pirutinsky et al. 2010), treatment
seeking (Pirutinsky et al. 2009), and medical decision-
making (Coleman-Brueckheimer et al. 2009). Thus, further
research into the relevance of religious and spiritual vari-
ables to behavioral health in the Jewish context is war-
ranted.
In addition, previous research suggests that the effect of
intrinsic religiosity may be mediated by greater social
support (Koenig et al. 2001a,b). For example, Salsman
et al. (2005) found that intrinsic, and not extrinsic, reli-
giousness was associated with greater life satisfaction and
less psychological distress, and that this effect was partially
mediated by social support. However, our results indicated
that the mediating role of social support differed between
Orthodox and non-Orthodox Jews (Hypothesis 2). Among
non-Orthodox Jews, higher intrinsic religiosity was related
to higher social support, which in turn appeared to be
protective against depression. In contrast, for Orthodox
Jews, while social support was a significant predictor of
depression, it was unrelated to intrinsic religiosity. These
findings suggest that even apparently equivalent effects
within a single category (Jewish) can involve divergent
processes that are consistent with religious-culture differ-
ences. As discussed above, non-Orthodox Judaism focuses
on religious social interaction more than beliefs (Cohen
and Hill 2007) and consistently the effects of religiosity
were fully mediated by greater social support. In contrast,
Orthodox Judaism emphasizes religious beliefs and prac-
tices over social connection, and accordingly the moder-
ating effect of religiosity was not mediated by social
support. Rather, intrinsic religiosity directly moderated the
impact of poor physical health, perhaps by encouraging
religious reappraisals of adversity (Leyser 1994; Rosmarin
et al. 2009), promoting hopeful outcome expectancies
(Sethi and Seligman 1993), and supporting a comforting
relationship with God (Pargament 1997).
Beyond implications for health among Jews, these find-
ings suggest that religiosity cannot be understood as a
unitary construct exerting equal effects across groups. It is
therefore unsurprising that although considerable research
supports the relevance of religion and spirituality to health
and psychological functioning, there are many contradic-
tory findings (e.g., Gall et al. 2009; McCullough et al. 1999;
Nelson et al. 2002). Given religion’s diversity, unraveling
these complex mechanisms requires a contextual approach
that carefully explores the particular religious processes
relevant to the area under study. It is unlikely that research
using cursory measures (e.g., frequency of religious service
attendance) and heterogeneous samples will enhance our
understanding of religion and health.
This study was limited by its reliance on an internet-
based survey, which may limit the participation of the more
traditional subsets within Orthodox Judaism who do not
generally utilize the internet (Barzilai-Nahon and Barzilai
2005). In addition, women were overrepresented in our
sample, although the effects of gender were not significant,
and the sample did not differ significantly from the
American Jewish population in terms of age, education,
marital status, and income (United Jewish Communities
2003). Also, the present study examined only a single
possible mechanism of the moderating effect of religiosity
(social support) using self-report measures and a cross-
sectional design. Future studies could evaluate the extent to
which other religious and non-religious processes mediate
these relationships, using more comprehensive measures
and longitudinal or experimental designs allowing causal
conclusions. Moreover, this study addressed only the
Jewish context, and there is a need to examine the influence
of religious culture on spirituality and health connections
within other communities. Nevertheless, the present re-
search highlights the need to carefully consider the effects
of religiosity and its moderators and mediators within a
particular religious-culture context.
494 J Behav Med (2011) 34:489–496
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