The intersection of religion and severe mental illness
The relationship between religious experience and psychopathology represents one of the most enduring and clinically significant debates in psychiatry. Religious beliefs and practices are central to the lives of the majority of the global population, shaping identity, meaning-making and social belonging across cultures and throughout the life course. Reference Koenig, King and Carson1 Within clinical psychiatry, the challenge lies in distinguishing the deeply personal and culturally embedded dimensions of religious experience from symptoms of mental disorder, a task that demands not only diagnostic acuity, but also cultural sensitivity and epistemic humility. Reference Bhugra and Bhui2–Reference Runions4
Bipolar affective disorder is a recurrent, severe mood disorder characterised by episodes of mania, hypomania, depression and mixed states, affecting approximately 1–2.4% of the global population, Reference Merikangas, Jin, He, Kessler, Lee and Sampson5 and is associated with significant morbidity, functional impairment, elevated mortality and substantial economic burden. Reference Murray, Vos, Lozano, Naghavi, Flaxman and Michaud6 Religious preoccupation, encompassing heightened religiosity, religious grandiosity, religious delusions and spiritual experiences interpreted within a religious framework, has long been recognised as a prominent feature of manic and mixed episodes, yet its clinical significance and cultural determinants remain incompletely understood. Reference Bhugra7,Reference Drinnan and Lavender8
Religious preoccupation in bipolar affective disorder
The phenomenology of religious preoccupation in bipolar disorder spans a broad spectrum. At one end lies hyper-religiosity, a quantitative intensification of pre-existing religious practice that is ego-syntonic and personally meaningful. Reference Koenig9,Reference Mohr, Brandt, Borras, Gilliéron and Huguelet10 At the other end lie religious delusions, fixed, false and culturally incongruent beliefs with religious content that represent a qualitative departure from the individual’s habitual religious framework. Reference Siddle, Haddock, Tarrier and Faragher11 Between these poles lie religious grandiosity, religious hallucinations and spiritual experiences of special mission or cosmic significance. Reference Cook3,Reference Koenig9 Religious delusions are among the most common delusion types across psychotic and mood disorders, with prevalence estimates in clinical samples ranging from 10 to >40%, depending on sample characteristics and cultural context. Reference Cook3,Reference Siddle, Haddock, Tarrier and Faragher11–Reference Kraepelin13 The relationship between religious preoccupation and mood state is complex: although religious grandiosity and hyper-religiosity are most strongly associated with manic episodes, religious themes may also emerge during depressive phases as guilt, perceived divine punishment and spiritual despair, Reference Drinnan and Lavender8,Reference Abu-Raiya and Pargament14 and in the euthymic state, increased religious engagement is frequently reported as a coping strategy. Reference Mohr, Brandt, Borras, Gilliéron and Huguelet10,Reference Whitley15
Cultural context and clinical significance
Culture exerts a pervasive influence on the expression, attribution and management of psychiatric symptoms. Reference Bhugra and Bhui2,Reference Kirmayer16 Within cultural psychiatry, culture shapes pathoplasticity, the tendency for culturally specific symbols and belief systems to determine the content of psychopathology. Reference Kirmayer16 In bipolar disorder, the religious figures, sacred texts and cosmological frameworks that populate a patient’s religious preoccupation reflect the cultural milieu in which they have been socialised, making cross-cultural comparison inherently complex. Reference Bhugra7,Reference Dein, Cook, Powell and Eagger17 Culture also influences the threshold at which religious experience is interpreted as pathological: in highly religious societies, genuine psychopathology may be under-recognised or attributed to spiritual causes, Reference Campion and Bhugra18,Reference Gureje, Nortje, Makanjuola, Oladeji, Seedat and Jenkins19 whereas in more secular settings, minority religious practices risk being overpathologised. Reference Lukoff, Lu and Turner20 Cultural context further shapes pathways to care, as faith healers and religious leaders frequently represent first-line sources of help, often resulting in delayed biomedical intervention. Reference Gureje, Nortje, Makanjuola, Oladeji, Seedat and Jenkins19,Reference Kirov and Murray21
Rationale for the present review
Despite the clinical importance of religious preoccupation in bipolar disorder and its cross-cultural variation, the existing literature has not been comprehensively mapped from a transcultural perspective. The most directly comparable prior synthesis is that of Jackson et al, which identified only 18 empirical studies, focusing predominantly on Western quantitative research and excluding culturally contextualised qualitative work from non-Western settings. Reference Jackson, McLawhorn, Slutzky, Glatt and Daly22–Reference De Fazio, Gaetano, Caroleo, Cerminara, Giannini and Jaén Moreno24 A scoping review adopting explicit cross-cultural criteria and encompassing diverse study designs is therefore warranted. The present review aims to systematically map the literature on religious preoccupation in bipolar disorder across cultural and religious contexts, synthesise evidence on cultural determinants of clinical interpretation and management, and identify key gaps to guide future research.
Method
Study design
This scoping review followed the methodological framework described by Peters et al for the Joanna Briggs Institute, and is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). Reference Peters, Marnie, Tricco, Pollock, Munn and Alexander25,Reference Tricco, Lillie, Zarin, O’Brien, Colquhoun and Levac26 The protocol was pre-registered on the Open Science Framework (10.17605/OSF.IO/V3WA6).
Eligibility criteria
Eligibility criteria were structured using the population, concept and context framework recommended by the Joanna Briggs Institute. Reference Peters, Marnie, Tricco, Pollock, Munn and Alexander25
Population
Studies involving individuals of any age with a diagnosis of bipolar disorder (any subtype) based on clinical judgement or standardised diagnostic criteria (DSM or ICD, any edition) were included. Two categories of sources were eligible. First, bipolar-specific empirical studies comprised studies with bipolar-only samples, mixed samples reporting bipolar findings separately and case reports in which bipolar disorder was established. Second, contextual sources, including reviews, historical and conceptual works, mixed clinical samples without separately reported bipolar findings, and studies of community beliefs about bipolar disorder, were eligible when they directly informed the cultural interpretation, phenomenology, help-seeking, clinical management or historical understanding of religion and spirituality in relation to bipolar disorder, despite not contributing separately extractable bipolar-specific empirical data. Contextual sources contributed only to the conceptual and thematic synthesis and were excluded from the geographic distribution of bipolar-specific empirical evidence. Studies focused exclusively on other diagnoses that made no such contextual contribution were excluded.
Concept
The central concept encompasses religious preoccupation in the context of bipolar disorder (operationally defined to include hyper-religiosity, religious grandiosity, religious delusions, beliefs in divine mission or prophetic calling, religious hallucinations and mood-contingent changes in religious practice or belief) as well as the broader role of religion and spirituality in the illness experience, including religious coping, spiritual well-being, religious explanatory models, faith-based help-seeking and the influence of religious context on clinical pathways and outcomes. Studies addressing purely theological or philosophical content without a clinical focus were excluded.
Context
All geographic, cultural and religious settings were eligible, including Islamic, Christian, Hindu, Buddhist, Jewish, Indigenous, animist and secular contexts. Studies with cross-cultural or comparative designs were specifically sought.
Study designs
Qualitative, quantitative (cross-sectional, cohort, case–control and randomised controlled trials), mixed-methods studies, case reports and case series were eligible. Reviews, historical and conceptual publications, and other directly relevant non-empirical sources were retained as contextual sources and contributed to the conceptual and thematic synthesis, but not to the quantitative description or geographic distribution of bipolar-specific empirical evidence. Conference abstracts without sufficient methodological detail and editorials, commentaries or letters that provided neither substantive empirical evidence nor a directly relevant conceptual or contextual contribution were excluded.
Information sources and search strategy
A systematic electronic search was conducted across three primary databases: PubMed/Medline, Scopus and Google Scholar (931 results retrieved, of which the first 200 were screened manually, consistent with established scoping review practice). Regional databases were additionally searched to ensure representation from low- and middle-income countries, including SciELO, African Journals Online (AJOL), IndMed and the World Health Organization Institutional Repository for Information Sharing (WHO IRIS); all records retrieved were already identified through the primary database searches. The search strategy combined two concept blocks, using Boolean operators: (a) bipolar disorder terms and (b) religious and spiritual terms. Cultural context was applied as a screening criterion rather than a search filter to avoid over-restriction. No date restrictions were applied; searches spanned from database inception to 14 March 2026, and data were extracted from the included studies on 15 March 2026. Full search strings are provided in Supplementary Appendix A.
No language restrictions were applied at the search stage. Studies published in languages other than English were eligible for inclusion; where non-English titles or abstracts indicated potential relevance, full texts were obtained and assessed with the assistance of native-speaking colleagues or online translation tools. For Google Scholar, the first 200 results ranked by relevance were screened manually. This approach is consistent with established scoping review practice, as the relevance of Google Scholar results declines substantially beyond the first pages of ranked output, and screening additional results yields diminishing returns relative to the time investment required. Reference Haddaway, Collins, Coughlin and Kirk27
Selection of sources of evidence
Retrieved records were compiled in Microsoft Excel version 16 (Microsoft Excel, version 16 (Microsoft Corporation, Redmond, Washington, USA; https://www.microsoft.com/microsoft-365/excel) and deduplicated using exact DOI matching and normalised-title matching, with all flagged matches manually reviewed. Two reviewers independently screened all titles and abstracts, followed by full-text review of potentially eligible records. A liberal inclusion approach was adopted at the title and abstract stage: records were retained if either reviewer considered them potentially relevant. Disagreements were resolved through discussion to consensus. Interrater agreement between the two reviewers was quantified with Cohen’s κ at both the title and abstract stage and the full-text stage. The PRISMA-ScR flow diagram is presented in Fig. 1.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews flow diagram. AJOL, African Journals Online; WHO IRIS, World Health Organization Institutional Repository for Information Sharing.
Fig. 1 Long description
The flowchart details the process of identifying and screening studies related to religious experience and psychopathology. The process begins with the identification of studies via databases and registers. Records are identified from PubMed/medline, Scopus, regional databases, and Google Scholar. Duplicate records are removed before screening. The remaining records are screened, and those excluded are noted. Reports sought for retrieval are assessed for eligibility. Reports excluded for specific reasons are listed. Finally, sources included in the review are noted.
Data charting
A standardised data charting form was developed a priori and piloted on five randomly selected included sources, after which minor modifications were made to the extraction categories. Both reviewers (M.E. and S.A.B.) independently charted data from all included sources, using the final form; discrepancies between the two charted data-sets were identified and resolved through discussion, with a third reviewer (A.A.O.) consulted where consensus could not be reached. Charted data included study identification (author, year, country, journal); study design and setting; population characteristics (sample size, age, gender, diagnostic criteria, illness phase); cultural and religious context; type and description of religious phenomena reported; interpretive frameworks used by patients, families and clinicians; clinical management approaches; outcomes and authors’ theoretical reflections. Non-empirical and contextual sources were charted using the same form, but with population and outcome fields recorded as ‘not applicable’ where relevant; these sources contributed to conceptual and contextual themes rather than to quantitative summaries. Each included source was classified as a bipolar-specific empirical study (a bipolar-only sample, a mixed sample with separately reported bipolar findings or a case report of a patient with bipolar disorder) or as a contextual or non-empirical source; the classification of every source is reported in Supplementary Table 1. Geographic region was classified according to World Health Organization regional groupings, assigned on the basis of the study setting where an empirical setting exists, with reviews and conceptual and historical works recorded as not applicable; the regional distribution in Table 1 is restricted to bipolar-specific empirical studies; religious tradition was assigned on the basis of the religious frameworks explicitly addressed in each study’s text. Studies addressing multiple religious traditions were assigned to all applicable traditions and are therefore counted in more than one religious group. The single study conducted across two World Health Organization regions (Austria and Japan) is reported separately as multi-region rather than counted within each region. Each included source was permitted to contribute to multiple thematic categories where its content was relevant to more than one theme; the counts reported within each theme refer to included sources of both evidence types. Selected study characteristics, including the population charted for each source and its evidence-type classification, are presented in Supplementary Table 1.
Distribution of included sources by design, and of bipolar-specific empirical studies by geographic region
Table 1 Long description
A table with 12 rows and 4 columns summarizing the distribution of included sources by study design and geographic region. The columns are labeled ‘Study design (all included sources, n = 83)’, ‘n’, ‘%’, and ‘Study reference numbers’. The rows detail various study designs such as cross-sectional, qualitative, narrative/literature review, case report/case series, historical/archival analysis, mixed-methods, prospective cohort, and randomised controlled trial. The table also includes a breakdown of bipolar-specific empirical studies by geographic region according to WHO classifications, with regions including Americas, European, Eastern Mediterranean, South-East Asia, Western Pacific, African, and Multi-region. The table lists the number of studies, their percentage, and the corresponding study reference numbers for each category.
Study designs are classified according to primary methodology across all 83 included sources; studies with mixed designs are categorised by their dominant method. The geographic distribution is reported for the 46 bipolar-specific empirical studies only (bipolar-only samples, mixed samples with separately reported bipolar findings and case reports of patients with bipolar disorder), classified according to World Health Organization (WHO) regional groupings on the basis of study setting; one study conducted across two WHO regions (Austria and Japan) is reported as multi-region. The 37 contextual and non-empirical sources (reviews, historical and conceptual works, mixed samples without separately reported bipolar findings, and general-population studies) are identified in Supplementary Table 1 and are not assigned to regions. *Percentages do not sum to 100% due to rounding.
Synthesis
A narrative and thematic synthesis was conducted. Descriptive statistics characterised the included literature by study design and geographic region; these are presented as frequencies and percentages in Table 1. Publication year, religious tradition and type of religious phenomenon are summarised narratively in the Results, with the religious tradition charted for each source reported in Supplementary Table 1. Thematic analysis followed the six-phase framework described by Braun and Clarke: familiarisation with the full charted data-set; generation of initial codes applied independently by two reviewers across all charted data; identification of candidate themes by collating related codes into broader patterns; review of themes against the charted data to assess internal coherence and external distinctiveness; definition and naming of final themes; and write-up with illustrative evidence drawn from across the included studies. Reference Braun and Clarke28 Coding was conducted inductively from the data rather than imposed from a pre-existing framework, although the research questions guided analytical attention towards phenomenology, cultural determinants of interpretation, clinical management, pathways to care and the dual protective and adverse dimensions of religiosity. Cross-cultural comparisons were made within and across themes to identify patterns of similarity and divergence across geographic, religious and clinical settings. All authors reviewed and discussed the final thematic structure before write-up. No quantitative pooling or meta-analysis was conducted, consistent with scoping review methodology.
Results
Study selection
A total of 1870 records were entered into the combined screening pool: 1117 from PubMed/Medline, 553 from Scopus and the first 200 of 931 Google Scholar results ranked by relevance. Four regional databases (SciELO, AJOL, IndMed and WHO IRIS) were additionally searched and yielded no unique records beyond those already identified. Following removal of 102 duplicates, 1768 records were screened at title and abstract stage, of which 1281 were excluded. A total of 487 full-text records were assessed for eligibility; 404 were excluded at full-text review for the following reasons: primary diagnosis not bipolar affective disorder with no eligible contextual contribution (n = 144), no distinct religious or spiritual content in bipolar context (n = 107), insufficient methodological detail to extract data (n = 67) and other prespecified eligibility criteria not met (n = 86). Eighty-three sources met the inclusion criteria and were included in the final synthesis, comprising 46 bipolar-specific empirical studies and 37 contextual or non-empirical sources. Interrater reliability was good to excellent at both screening stages (title/abstract κ = 0.82; full-text κ = 0.87). The PRISMA-ScR flow diagram is presented in Fig. 1.
Characteristics of included sources
The 83 included sources were published between 1966 and 2026, with a marked increase in publication volume from the early 2000s onwards. Of the 83 included sources, 46 were bipolar-specific empirical studies and 37 were contextual or non-empirical sources (Supplementary Table 1). Study designs comprised cross-sectional studies (n = 31, 37.3%); qualitative studies (n = 17, 20.5%); narrative and literature reviews, including scoping and systematic reviews, and one commentary (n = 16, 19.3%); case reports and case series (n = 10, 12.0%); historical and archival analyses (n = 4, 4.8%); mixed-methods studies (n = 2, 2.4%); prospective cohort studies (n = 2, 2.4%) and one randomised controlled trial (n = 1, 1.2%). Selected characteristics of all included sources are reported in Supplementary Table 1.
Geographically, the literature showed a substantial skew towards high-income settings. Among the 46 bipolar-specific empirical studies, classified according to World Health Organization region, studies from the Americas accounted for 32.6% (n = 15) and studies from the European region accounted for 23.9% (n = 11), together comprising over half of the empirical evidence base (Table 1). Studies from the Eastern Mediterranean region constituted 13.0% (n = 6), the South-East Asian and Western Pacific regions each contributed 10.9% (n = 5) and the African region contributed 6.5% (n = 3). One study conducted across two regions (Austria and Japan) completed the empirical corpus (2.2%). Contextual and non-empirical sources (n = 37) were not included in this regional distribution. Studies from Indigenous populations were exceptionally scarce, with no study primarily addressing Indigenous religious frameworks in bipolar disorder. Religious traditions explicitly addressed across the corpus were Christianity (n = 25 sources), Islam (n = 18), traditional African and Indigenous belief systems (n = 5), Hinduism (n = 5), Buddhism and East Asian religious frameworks (n = 1) and Judaism (n = 1); four sources addressed more than one tradition and are counted under each. The remaining 32 sources examined religiosity or spirituality generically, without foregrounding a specific religious tradition.
Thematic findings
Theme 1: Phenomenology of religious preoccupation across cultural settings
Religious preoccupation was documented as a feature of bipolar disorder across all regional settings represented in the corpus, although the specific content, attributed meaning, and culturally recognisable form of these experiences varied substantially.
In Western Christian settings, the predominant documented phenomena were grandiose beliefs of messianic identity, divine calling or identification with biblical figures, as well as accounts of direct communication from God. Dutch qualitative studies documented considerable heterogeneity in how patients with bipolar disorder interpreted their religious and spiritual experiences, with some experiencing them as simultaneously meaningful and disruptive to functioning. Reference Ouwehand, Wong, Boeije and Braam29–Reference Ouwehand, Zock, Muthert, Boeije and Braam31 Ouwehand et al found, in a cross-sectional study of Dutch out-patients with bipolar disorder, that a substantial proportion reported religious or spiritual experiences and regarded them as relevant to their illness experience. Reference Ouwehand, Braam, Renes, Muthert, Stolp and Garritsen32 Clinical case analyses from the USA described how religious content in manic episodes presented diagnostic and therapeutic challenges in practice, Reference Duckham33,Reference Raab34 whereas forensic research identified associations between glossolalia, mania and religious and sexual delusions among mentally disordered offenders in a maximum-security forensic setting. Reference Hempel, Meloy, Stern, Ozone and Gray35 Historical and archival studies traced the evolution of the ‘religious mania’ construct from the eighteenth century through Pinel and Esquirol to modern psychiatric nosology, illustrating the shifting boundary between religious deviance and psychiatric disorder. Reference Belzen36–Reference Meyers39 One of the earliest contextual clinical sources in this corpus, Sedman and Hopkinson, described the psychopathology of mystical and religious conversion experiences across psychiatric diagnostic categories, including mania. Reference Sedman and Hopkinson40 Gender differences in the presentation of psychotic mania have also been reported: in a 2009 German in-patient study, psychotic women experienced more delusions and hallucinations than men, including more delusions of reference and paranoid delusions, and more mixed states, although the study did not report gender differences in religious delusions specifically. Reference Bräunig, Sarkar, Effenberger, Schoofs and Krüger41,Reference Jerrell and Shugart42
In South Asian, predominantly Hindu settings, religious preoccupation was expressed through beliefs of deity possession, direct communication with deities, manifestation of supernatural powers and spiritual battle narratives. Reference Grover, Hazari, Aneja, Chakrabarti and Avasthi43–Reference Sethi and Khanna45 Grover et al, in a cross-sectional study of 185 patients with bipolar disorder who were in remission in North India, found that 37.8% reported lifetime psychopathology with religious or supernatural content. In Iranian settings, qualitative work documented that patients navigated between Islamic spiritual and psychiatric explanatory frameworks in their help-seeking and illness interpretation. Reference Grover, Hazari, Aneja, Chakrabarti and Avasthi43
In Islamic contexts across Pakistan, Egypt, Turkey, Iran, Morocco, Tunisia and Saudi Arabia, religious preoccupation was characterised by beliefs in divine revelation, personal prophetic status and possession by jinn, spirit entities in Islamic cosmology believed capable of influencing human affairs and, in some illness narratives, of taking possession of a person. Reference Mianji and Kirmayer46–Reference Eddahby, Kadri and Moussaoui53 Ramadan fasting has been examined as a possible period of clinical vulnerability, although the available evidence is limited and inconsistent: a controlled study of 62 lithium-treated patients found no significant change in serum lithium levels or mental state during fasting, and a review of the topic concluded that the 2 principal studies reached opposite conclusions and that the evidence was insufficient to guide advice on fasting. Reference Farooq, Nazar, Akhtar, Irfan, Subhan and Ahmed52,Reference Eddahby, Kadri and Moussaoui53 Qualitative evidence indicated that patients reported significant ambivalence about fasting yet received minimal psychiatric guidance. Reference Mejri, Ouali, Gronholm, Zgueb, Ouertani and Nacef50 A cross-sectional North African study found an inverse association between religiosity and suicidality across depressive and bipolar patients. Reference El Oumary, Lahlou, Salehddine, Ouhamou, Laaraj and Tempier54
In Sub-Saharan African settings, religious preoccupation was documented within frameworks of Pentecostal and Evangelical Christianity and traditional African belief systems. Reference Dei-Asamoa, Blocker, Ercis, Frye, Ozerdem and Fiagbe55–Reference Tsehay, Kelkile, Fekadu, Cohen, Kiros and Hanlon59 Qualitative studies from Ethiopia documented that patients and families attributed illness episodes to divine will or spiritual causes and engaged with religious explanatory models extensively, Reference Demissie, Hanlon, Ng, Fekadu and Mayston56 whereas mixed-methods research from Nigeria revealed complex interactions between illness attribution, religious practice and care-seeking. Reference Jidong, Husain, Ike, Husain, Taru and Nnaemeka57 A cultural analysis from Igboland, Nigeria, further illustrated how spiritual and moral frameworks shape the interpretation of suicide, including where it occurs in the context of psychiatric conditions such as bipolar disorder. Reference Anih, Eme, Nwaogaidu and Ibenekwu60
In East and South-East Asian settings, religious preoccupation was described within Buddhist, Confucian, and Islamic cultural frameworks. Reference Ahmad Ramli, Tilse and Wilson61–Reference Mohamad Shariff, Wright and Crawford65 A Taiwanese qualitative study found that families invoked Buddhist and traditional Chinese cosmological frameworks alongside biomedical explanations, Reference Lan, Zelman and Chao63 whereas Malaysian studies documented positive associations between religious practice and mental health outcomes alongside underaddressed spiritual distress. Reference Mohamad Shariff, Wright and Crawford64,Reference Mohamad Shariff, Wright and Crawford65 A South Korean general-population survey found that beliefs about the causes of bipolar disorder included supernatural and fate-related attributions alongside biological and social explanations. Reference Park, Jang, Furnham, Jeon and Park66
In Latin American, predominantly Brazilian settings, multiple quantitative studies treated religiosity as a formal clinical variable, documenting consistent associations between intrinsic religiosity, positive religious coping, better quality of life, fewer depressive symptoms and lower lifetime suicide attempt rates. Reference Caribé, Studart, Bezerra-Filho, Brietzke, Nunes Noto and Vianna-Sulzbach67–Reference Studart-Bottó, Caribé, Bezerra-Filho, Marques, Cerqueira-Silva and Prates70
Theme 2: Cultural determinants of pathological versus normative interpretation
Across 27 included sources, distinguishing culturally normative religious experience from psychopathological religiosity was identified as a central clinical problem. The most consistently cited indicators of pathological religious experience included departure from the individual’s pre-morbid religious baseline, social rupture evidenced by family or community concern, co-occurrence with other diagnostic features of mania or psychosis, absence of insight combined with escalating risk and rigidity of beliefs inconsistent with the individual’s own tradition. Reference Ouwehand, Wong, Boeije and Braam29,Reference Grover, Hazari, Aneja, Chakrabarti and Avasthi43 Bartholomew and O’Dea argued that the construct of ‘religious mania’ had historically been applied inconsistently, and that clinician unfamiliarity with patients’ religious traditions was a systematic source of misattribution. Reference Bartholomew and O’Dea71 Seminal work in the Amish community demonstrated that cultural factors shaped both the presentation and recognition of bipolar illness, Reference Egeland, Hostetter and Eshleman72 and religious obsessions were identified as a prominent subtype requiring differentiated clinical assessment in Iranian patients with bipolar disorder. Reference Shabani and Alizadeh73
In the Dutch longitudinal qualitative literature, Ouwehand and colleagues documented across multiple studies that patients engaged in sustained interpretive work to distinguish mood-contingent religious experiences from what they regarded as genuine spiritual events, a process that was iterative, influenced by illness course and often unsupported by clinical staff. Reference Ouwehand, Muthert, Zock, Boeije and Braam30–Reference Ouwehand, Braam, Renes, Muthert, Stolp and Garritsen32,Reference Ouwehand74–Reference Ouwehand, Zock and Muthert76 Cross-sectional evidence from the USA produced a more complex pattern: higher private religious activity was associated with mixed states, whereas depression and mania were not significantly associated with religious involvement; a subsequent commentary questioned whether the null finding for depression partly reflected the analytic approach used. Reference Cruz, Pincus, Welsh, Greenwald, Lasky and Kilbourne77,Reference Aubin, Mandhouj and Reynaud78 In a French sample of patients with major depression examined for bipolar spectrum features, high religious involvement combined with mixed features was associated with increased suicidal risk. Reference Azorin, Kaladjian, Fakra, Adida, Belzeaux and Hantouche79 These findings highlight that the relationship between religious involvement and outcomes is not uniformly protective.
Limited clinical assessment of patients’ religious beliefs, despite their perceived relevance to illness management, was reported across several geographically diverse settings. This assessment gap was documented in New Zealand, Reference Mitchell and Romans80 India Reference Grover, Hazari, Aneja, Chakrabarti and Avasthi43 and Iran. Reference Mianji and Kirmayer46 Cultural formulation approaches, including the DSM-5 Outline for Cultural Formulation, were recommended in studies from multiple settings, Reference Bhugra and Bhui2,Reference Mianji and Kirmayer46,Reference Cruz, Pincus, Welsh, Greenwald, Lasky and Kilbourne77 but their systematic application in routine clinical practice remained inconsistent.
Theme 3a: Diagnosis and risk assessment
Diagnostic difficulties associated with religious preoccupation in bipolar disorder were described across 18 sources. Differentiating bipolar disorder with psychotic features from schizophrenia and schizoaffective disorder on the basis of religious symptom content alone was identified as problematic in cross-sectional and case-based studies from multiple settings. Turgut and Yenilmez found differences in delusion content between acutely manic patients with psychotic features and patients with schizophrenia in a Turkish cross-sectional study, but noted that cross-sectional assessment was insufficient for confident diagnostic differentiation. Reference Turgut and Yenilmez81 Substance-related and organic presentations added further diagnostic considerations: manic episodes with religious and spiritual content were described following ibogaine use in individuals with no prior bipolar diagnosis, Reference Marta, Ryan, Kopelowicz and Koek82 and acute psychosis with mystical delusions was reported following corticosteroid discontinuation in a patient without established bipolar disorder. Reference Bartolomei, Lorenzini, Martelli, Gambaro, Zeppegno and Gramaglia83 A case report from India additionally described Geschwind-syndrome features, including hyper-religiosity and hypergraphia, in remitted bipolar disorder without evidence of epilepsy. Reference Balasubramanian, Sarkar, Ravi and Kattimani84
Risk assessment in the context of religious preoccupation was specifically addressed in 14 included sources. Case-based and forensic literature described elevated behavioural risk where manic religious grandiosity included beliefs of divine protection, exceptional status or supernatural invulnerability, Reference Hempel, Meloy, Stern, Ozone and Gray35 whereas across several settings, religious guilt, spiritual punishment beliefs and perceived divine condemnation were associated with suicidal ideation during depressive phases. Multiple studies found that moral or religious objections to suicide and higher religiosity were associated with reduced suicidal behaviour, Reference El Oumary, Lahlou, Salehddine, Ouhamou, Laaraj and Tempier54,Reference Caribé, Studart, Bezerra-Filho, Brietzke, Nunes Noto and Vianna-Sulzbach67,Reference Dervic, Carballo, Baca-Garcia, Galfalvy, Mann and Brent85,Reference Olmos, Pigott, Soares and Sanches86 whereas religious obsessions were associated with elevated suicidal ideation. Reference Abdel Hamid, Nasreldin, Gohar, Saleh and Tarek87 Lamis et al found that existential, but not religious, well-being moderated the relationship between childhood sexual abuse and suicidal ideation in bipolar disorder. Reference Lamis, Kapoor and Evans88
Theme 3b: Treatment adherence and clinical management
Treatment adherence in the context of religious preoccupation was examined in 22 included sources. Medication refusal or delay attributed to religious beliefs or spiritual explanatory models was documented across Christian, Islamic, Hindu and African traditional settings. The identified mechanisms included attribution of symptoms to spiritual rather than biological causes, belief that pharmacotherapy would interfere with a divinely ordained experience, concurrent engagement with religious or traditional healers who advised against biomedical treatment, and internalised stigma associated with religious frameworks. Reference Grover, Hazari, Aneja, Chakrabarti and Avasthi43,Reference Mianji and Kirmayer46,Reference Mohsin, Aravala, Rahman, Ali, Taher and Mitra89
Three studies from Islamic settings drew attention to Ramadan fasting as an underaddressed but incompletely understood clinical consideration for patients with bipolar disorder. Farooq et al reported no statistically significant change in serum lithium levels or mental state among 62 lithium-treated patients during Ramadan fasting, Eddahby et al reviewed the topic and concluded that the available evidence was contradictory, and Mejri et al found that the majority of Tunisian patients with bipolar disorder who fasted during Ramadan had received no psychiatric guidance on the subject. Reference Mejri, Ouali, Gronholm, Zgueb, Ouertani and Nacef50,Reference Farooq, Nazar, Akhtar, Irfan, Subhan and Ahmed52,Reference Eddahby, Kadri and Moussaoui53 Additionally, higher religious coping was unexpectedly associated with greater internalised stigma in a Turkish cross-sectional study, complicating the straightforwardly protective narrative around religious coping. Reference Erdoğan Kaya and Erdogan Akturk48 Complementary and alternative medicine use, including faith healing, was found to be prevalent among patients with bipolar disorder in a US study, and was associated with sociodemographic and clinical factors. Reference Kilbourne, Copeland, Zeber, Bauer, Lasky and Good90
Theme 4: The role of religious and traditional healers in pathways to care
Involvement of religious leaders, faith healers and traditional practitioners in pathways to care was documented in 24 included sources across Sub-Saharan Africa, South Asia, the Middle East and North Africa, and East and South-East Asia.
In Sub-Saharan African settings, faith healers and prayer camps were identified as primary initial care providers. The sole randomised controlled trial in this corpus, Ofori-Atta et al, evaluated the addition of psychiatric pharmacotherapy to usual care in a Ghanaian prayer camp (intervention n = 71, control n = 68). Reference Ofori-Atta, Attafuah, Jack, Baning and Rosenheck58 In that particular trial, participants receiving the combined intervention showed significantly greater short-term improvement on the Brief Psychiatric Rating Scale at 6 weeks. Pervasive supernatural illness attribution and its consequences for care pathways were documented across West African settings, Reference Dei-Asamoa, Blocker, Ercis, Frye, Ozerdem and Fiagbe55 and in Jamaica, supernatural explanatory models were found to be prevalent among both patients and clinicians. Reference James, Carpenter, Peltzer and Weaver91 Ethiopian studies revealed iterative help-seeking across religious, traditional and biomedical services, with faith-based explanatory models dominating early illness attribution. Reference Demissie, Hanlon, Ng, Fekadu and Mayston56,Reference Tsehay, Kelkile, Fekadu, Cohen, Kiros and Hanlon59,Reference Hailegabriel and Berhanu92
In South Asian settings, 44.3% of Indian patients with bipolar disorder in remission reported that their first treatment contact had been with a religious or supernatural practitioner. Reference Grover, Hazari, Aneja, Chakrabarti and Avasthi43 Religious healing pathways remained prominent even among South Asian diaspora populations with access to formal psychiatric services, Reference Mohsin, Aravala, Rahman, Ali, Taher and Mitra89 and qualitative evidence from Pakistan documented that severe mental illness frequently prompted recourse to religious practitioners before psychiatric services, with consequent implications for marital and family stability. Reference Siddiq Shekhani, Mashhood, Hashmi, Dossani-Lallany, Asad and Khan93 In Ethiopian settings, Hailegabriel and Berhanu found that family caregivers navigated substantial uncertainty about illness causation, mobilising religious community support while also engaging with biomedical services. Reference Hailegabriel and Berhanu92 Tsehay et al documented that faith and traditional healers occupied important roles in care pathways and had complex, sometimes adversarial relationships with formal psychiatric services. Reference Tsehay, Kelkile, Fekadu, Cohen, Kiros and Hanlon59 In South-East Asian settings, religious frameworks shaped both illness interpretation and resource mobilisation among family caregivers. Reference Ahmad Ramli, Tilse and Wilson61 Across these diverse settings, the relationship between religious and biomedical services was characterised by both complementarity and tension. Reference Jidong, Husain, Ike, Husain, Taru and Nnaemeka57,Reference Tsehay, Kelkile, Fekadu, Cohen, Kiros and Hanlon59
Theme 5: Religion as a resource
Twenty-three included sources examined religion and spirituality as resources for coping, meaning-making or recovery in bipolar disorder. The most systematic quantitative evidence came from Brazilian studies: intrinsic religiosity and positive religious coping were consistently associated with better quality of life and lower depression scores, Reference Stroppa and Moreira-Almeida69 and a 2-year prospective study found that higher religiosity longitudinally predicted reduced depressive symptoms and improved quality of life, providing longitudinal evidence for this association. Reference Stroppa, Colugnati, Koenig and Moreira-Almeida94 An international cross-sectional study of patients with schizophrenia and bipolar disorder found no significant association between religiosity and psychological resilience; within the bipolar disorder type 1 subgroup, greater importance of religion and spirituality was modestly associated with residual manic symptoms. Reference Mizuno, Hofer, Frajo-Apor, Wartelsteiner, Kemmler and Pardeller95
Religiosity or specific dimensions of religious engagement were associated with lower suicidality in several clinical studies, although the populations and findings were heterogeneous. Reference El Oumary, Lahlou, Salehddine, Ouhamou, Laaraj and Tempier54,Reference Caribé, Studart, Bezerra-Filho, Brietzke, Nunes Noto and Vianna-Sulzbach67,Reference Olmos, Pigott, Soares and Sanches86 Contextual general-population evidence also identified associations between religiosity and psychiatric or psychotic phenomena, but did not provide direct bipolar-specific outcome estimates. Reference Brito, Amad, Rolland, Geoffroy, Peyre and Roelandt96 Religious coping was among the most commonly endorsed adaptive resources in both US Reference Pollack, Harvin and Cramer97 and Israeli populations, Reference Granek, Danan, Bersudsky and Osher98 and spiritual engagement was associated with recovery beyond clinical remission. Reference Katz, Gulati and Fuller-Thomson99–Reference Hatchard and Missiuna101
Qualitative studies provided rich contextual detail, documenting that patients used prayer and religious community as central coping mechanisms during and between episodes, Reference Demissie, Hanlon, Ng, Fekadu and Mayston56,Reference Mohamad Shariff, Wright and Crawford64,Reference Mohamad Shariff, Wright and Crawford65 that family caregivers mobilised religious community networks as primary support resources Reference Hailegabriel and Berhanu92,Reference Ganguly, Chadda and Singh102 and that Buddhist and traditional Chinese spiritual frameworks were integrated into recovery narratives alongside biomedical care. Reference Ouwehand, Wong, Boeije and Braam29,Reference Kwok103 Ganguly et al, in a qualitative study of caregiver burden in schizophrenia and bipolar disorder in India, reported that religious coping was frequently invoked by family members as a means of sustaining caregiving capacity over time. Reference Ganguly, Chadda and Singh102
Conversely, negative religious coping, including spiritual struggle, perceived divine punishment and interpersonal conflict with religious communities, was associated with adverse outcomes across multiple studies.
Religious obsessions were associated with suicidal ideation. Reference Abdel Hamid, Nasreldin, Gohar, Saleh and Tarek87 In a French sample of patients with major depression who were examined for bipolar spectrum features, high religious involvement combined with mixed features was associated with increased suicidal risk. Reference Azorin, Kaladjian, Fakra, Adida, Belzeaux and Hantouche79 In a pooled schizophrenia and bipolar disorder sample, lower spiritual well-being was associated with more dysfunctional thoughts. Reference Yanık and Ayhan104 These findings suggest that the quality and content of religious coping, rather than its mere presence, may be associated with the direction of clinical outcomes.
Gaps in the literature
Several important gaps were identified through the synthesis. First, evidence from Islamic and particularly Middle Eastern and North African clinical settings was disproportionately sparse relative to the global Muslim population, with most available studies relying on case reports or small cross-sectional samples rather than systematic epidemiological or qualitative research. Second, evidence from East Asian settings remained very limited, particularly research directly examining Buddhist and Confucian frameworks, despite the large populations involved and the distinct cosmological perspectives these traditions may bring to the interpretation of mental illness. Third, research involving Indigenous populations globally was extremely limited and frequently lacked sufficient detail about the specific cultural frameworks employed. Methodologically, the predominance of cross-sectional designs and small case series restricted causal inference regarding illness course, treatment response or the direction of the religiosity-outcome relationship. Validated, culturally adapted instruments for assessing religious preoccupation specifically in bipolar disorder were absent for most non-Western settings; existing measures were predominantly developed in Christian Western contexts. The three studies addressing Ramadan and bipolar disorder represent a promising but underdeveloped literature on religious practice-specific clinical risk. Reference Mejri, Ouali, Gronholm, Zgueb, Ouertani and Nacef50,Reference Farooq, Nazar, Akhtar, Irfan, Subhan and Ahmed52,Reference Eddahby, Kadri and Moussaoui53 Finally, no longitudinal study tracked the trajectory of religious preoccupation across multiple mood episodes to examine whether religious content is mood-contingent, stable or progressive across the illness course.
Discussion
Principal findings
This scoping review identified 83 sources, including 46 bipolar-specific empirical studies, across 6 decades and multiple geographic, cultural, and religious contexts, providing a comprehensive cross-cultural synthesis of religious preoccupation in bipolar disorder. The review substantially extends the prior synthesis by Jackson et al, which identified only 18 empirical studies by using narrower inclusion criteria focused on Western Anglophone settings. Reference Jackson, McLawhorn, Slutzky, Glatt and Daly22 By adopting explicit cross-cultural criteria and encompassing qualitative studies, case reports, historical analyses and regional databases, the present review captures evidence from a broad range of non-Western cultural and religious settings that were largely absent from that earlier corpus. The positive associations between intrinsic religiosity, positive religious coping and better bipolar disorder outcomes Reference Caribé, Studart, Bezerra-Filho, Brietzke, Nunes Noto and Vianna-Sulzbach67,Reference Stroppa and Moreira-Almeida69,Reference Stroppa, Colugnati, Koenig and Moreira-Almeida94,Reference Mizuno, Hofer, Frajo-Apor, Wartelsteiner, Kemmler and Pardeller95 are broadly consistent with the wider religion and mental health literature, but the present synthesis adds dimensions not previously examined: the cross-cultural heterogeneity of religious phenomenology, the specific clinical risks associated with negative religious coping and faith healer-mediated treatment delay, preliminary evidence on Ramadan fasting as a religious practice of potential clinical relevance for lithium-maintained patients, and the historical evolution of the ‘religious mania’ construct. Reference Belzen36–Reference van Belzen38
Limited clinical assessment of spirituality among patients with bipolar disorder, despite its perceived relevance to illness management, was reported across several geographically diverse settings, including New Zealand, Reference Mitchell and Romans80 India Reference Grover, Hazari, Aneja, Chakrabarti and Avasthi43 and Iran. Reference Mianji and Kirmayer46 Although the available evidence is insufficient to establish a globally consistent pattern, its occurrence across these settings suggests that the issue is not confined to a single cultural context.
Clinical observations
Drawing on the thematic findings of this review, Table 2 presents a clinical assessment framework for evaluating religious phenomena in bipolar disorder across cultural settings.
Clinical assessment framework for religious phenomena in bipolar affective disorder across cultural settings
Table 2 Long description
The table presents a clinical assessment framework for evaluating religious phenomena in bipolar disorder across cultural settings. It has six rows and four columns. The columns are labeled ‘Assessment domain’, ‘Clinical focus’, and ‘Key considerations’. The rows are labeled ‘Change from premorbid religious baseline’, ‘Congruence with community and religious tradition’, ‘Associated manic or psychotic features’, ‘Risk indicators’, ‘Family and faith leader engagement’, ‘Religious practice and pharmacotherapy interactions’, and ‘Protective religious resources’. Each row provides detailed information under each column header. For example, the ‘Change from premorbid religious baseline’ row discusses whether the current religious preoccupation represents a quantitative intensification or qualitative departure from the individual’s habitual engagement before the current episode, and considers collateral history from family members and community contacts. The ‘Congruence with community and religious tradition’ row examines whether the religious experience is recognized and affirmed within the patient’s own community or regarded as unusual or concerning, and considers community concern or social rupture within the patient’s own tradition. The ‘Associated manic or psychotic features’ row explores whether the religious content co-occurs with other diagnostic features of mania or psychosis, and notes that religious content alone is insufficient for diagnosis. The ‘Risk indicators’ row identifies specific risk factors associated with religious preoccupation in bipolar disorder, such as beliefs in divine invulnerability or supernatural protection, and religious guilt or perceived divine punishment. The ‘Family and faith leader engagement’ row involves structured inquiry with family contacts and, where appropriate, religious or community leaders, and considers whether the family attributes symptoms to spiritual or medical causes, and whether faith leaders are willing to support treatment engagement. The ‘Religious practice and pharmacotherapy interactions’ row assesses the impact of specific religious practices on pharmacological management, such as whether Ramadan fasting affects lithium levels or mood stability. The ‘Protective religious resources’ row highlights the positive dimensions of the patient’s religious engagement, noting that intrinsic religiosity and positive religious coping have been associated with better quality of life, fewer depressive symptoms, and lower suicidality.
This framework is derived from the thematic synthesis of 83 included sources and is intended as a clinical aid rather than a validated screening instrument. Application requires adaptation to the specific cultural, religious and clinical context of each patient.
Several clinical observations emerge from this synthesis
First, the suicidality data from multiple cultural settings identify both a protective dimension of religiosity, through moral prohibitions against suicide and social connectedness, Reference El Oumary, Lahlou, Salehddine, Ouhamou, Laaraj and Tempier54,Reference Caribé, Studart, Bezerra-Filho, Brietzke, Nunes Noto and Vianna-Sulzbach67,Reference Dervic, Carballo, Baca-Garcia, Galfalvy, Mann and Brent85,Reference Olmos, Pigott, Soares and Sanches86 and an adverse dimension through religious guilt, divine punishment beliefs and negative religious coping. Reference Abdel Hamid, Nasreldin, Gohar, Saleh and Tarek87 This bimodal pattern means that the mere presence of religious belief should not be interpreted as a protective factor in suicide risk assessment; the specific content and quality of religious engagement require assessment.
Second, reports that clinicians do not routinely ask about patients’ religious beliefs across several settings point to a potentially important clinical assessment gap. Reference Grover, Hazari, Aneja, Chakrabarti and Avasthi43,Reference Mitchell and Romans80 The DSM-5 Outline for Cultural Formulation and the associated Cultural Formulation Interview provide validated structures for this inquiry, Reference Bhugra and Bhui2,Reference Kirmayer16 and given that religious explanatory models directly influence pathway to care, medication adherence and risk assessment, their assessment should be regarded as a standard component of the clinical evaluation of bipolar disorder.
Religion as both protective and risk factor
A key finding of this synthesis is that religion may function both as a coping resource and as a source of clinical risk in bipolar disorder, with different qualities and forms of religious engagement associated with differing clinical outcomes. Several quantitative studies associate intrinsic religiosity and positive religious coping with better quality of life, fewer depressive symptoms and lower suicidality. Reference El Oumary, Lahlou, Salehddine, Ouhamou, Laaraj and Tempier54,Reference Caribé, Studart, Bezerra-Filho, Brietzke, Nunes Noto and Vianna-Sulzbach67,Reference Dervic, Carballo, Baca-Garcia, Galfalvy, Mann and Brent85,Reference Stroppa, Colugnati, Koenig and Moreira-Almeida94,Reference Galvez, Thommi and Ghaemi105 Conversely, negative religious coping, religious obsessions and spiritual struggle have been associated with adverse outcomes, including elevated suicidal ideation and increased internalised stigma. Reference Erdoğan Kaya and Erdogan Akturk48,Reference Azorin, Kaladjian, Fakra, Adida, Belzeaux and Hantouche79,Reference Abdel Hamid, Nasreldin, Gohar, Saleh and Tarek87 The emerging clinical approach supported by this corpus is patient-centred spiritual history-taking that identifies the specific points at which religious belief supports or undermines treatment engagement. Reference Koenig9 Spiritually augmented psychoeducation, in which pharmacological and psychological treatment are contextualised within the patient’s own religious framework, was described across several studies as a mechanism for improving medication adherence and therapeutic alliance, Reference Whitley15,Reference Raab34,Reference Welton106 consistent with the broader evidence for spiritually integrated therapy. Reference Koenig9,Reference Abu-Raiya and Pargament14,Reference Bonelli107
Limitations
This review has several limitations that require explicit acknowledgement. First, despite the inclusion of 83 sources across 6 decades, only 46 are bipolar-specific empirical studies, and this empirical base is markedly skewed towards Western and high-income settings, with only 3 bipolar-specific empirical studies from the African region, and this skew is likely to understate the volume and quality of relevant research conducted in Arabic, Hindi, Portuguese and other non-English languages. Second, the heterogeneity of included study designs, ranging from single case reports to multi-site cross-sectional surveys and one randomised trial, limits the confidence with which causal conclusions can be drawn. Third, no formal critical appraisal of included sources was undertaken, consistent with the review’s primary aim of mapping the breadth and characteristics of the literature rather than estimating pooled effects; conclusions therefore draw on a corpus of widely varying methodological rigour. Fourth, reporting biases in case reports and published qualitative studies may lead to overrepresentation of unusual or dramatic presentations relative to their actual clinical prevalence. Fifth, no psychiatry- or psychology-specific database such as PsycINFO was searched; although PubMed/Medline, Scopus, Google Scholar and four regional databases were used, literature indexed only in PsycINFO, particularly from psychology and pastoral counselling, may have been missed.
Implications for future research
Several research priorities emerge directly from this synthesis. Systematic epidemiological studies examining the prevalence, clinical correlates, and phenomenological characteristics of religious preoccupation across bipolar disorder subtypes and illness phases are needed, with explicit stratification by cultural and religious context. The development and cross-cultural validation of standardised instruments for assessing religious preoccupation specifically in bipolar disorder, calibrated against local norms of religious practice, would substantially advance both research and clinical capacity.
The three studies addressing Ramadan and bipolar disorder represent a nascent and, at present, inconsistent literature; Reference Mejri, Ouali, Gronholm, Zgueb, Ouertani and Nacef50,Reference Farooq, Nazar, Akhtar, Irfan, Subhan and Ahmed52,Reference Eddahby, Kadri and Moussaoui53 systematic prospective studies examining the pharmacokinetic consequences of Ramadan fasting in patients with bipolar disorder, and the effectiveness of proactive clinical management protocols, are urgently needed in Muslim-majority healthcare systems. Longitudinal studies are required to examine the trajectory of religious preoccupation across multiple mood episodes, determine whether religious content is mood-contingent or stable across the illness course, and establish whether the protective effects of religiosity identified in cross-sectional studies replicate in prospective designs.
Controlled evaluations of collaborative care models that integrate religious leaders and traditional practitioners with biomedical psychiatric services are urgently needed in low- and middle-income settings. The randomised controlled trial by Ofori-Atta et al provides an important proof-of-concept in a mixed severe mental illness population, although bipolar-specific outcomes were not reported separately; replication and extension studies across diverse cultural contexts, with diagnosis-specific outcomes, longer follow-up periods and human rights monitoring, are warranted. Reference Ofori-Atta, Attafuah, Jack, Baning and Rosenheck58 Finally, research involving substantially underrepresented populations, including Muslims in East and West Africa, Buddhist and Confucian populations in East and South-East Asia, Indigenous communities globally and secular minorities within highly religious societies, should be prioritised in future research agendas.
In conclusion, religious preoccupation is a clinically significant, cross-culturally documented and phenomenologically diverse feature of bipolar affective disorder that warrants far greater systematic attention than it has hitherto received. This scoping review documents substantial variation in the content, interpretation and clinical management of religious preoccupation across Islamic, Christian, Hindu, traditional African and Western secular settings, and indicates that cultural context may influence multiple dimensions of the clinical encounter, from the patient’s explanatory model and help-seeking behaviour to the clinician’s diagnostic judgement and treatment planning. Religiosity functions as both a coping resource and a source of clinical risk in bipolar disorder, with the quality of religious engagement, rather than its mere presence or absence, associated with differing clinical outcomes. The findings support incorporating cultural formulation approaches into the assessment of religious phenomena in bipolar disorder, the development of culturally adapted assessment tools and the exploration of collaborative care models that engage faith communities as partners in mental healthcare. Addressing the substantial research gaps identified in this review, particularly in Islamic, East Asian, Indigenous and other underrepresented settings, will be essential to developing a genuinely global and culturally sensitive approach to this challenging clinical domain.
Supplementary material
The supplementary material is available online at https://doi.org/10.1192/bjo.2026.12115
Data availability
No new primary data were generated for this study. The full list of included sources with selected charted characteristics is provided in Supplementary Table 1.
Acknowledgements
The authors confirm that no artificial intelligence (AI) tools were used to assist in the writing of this manuscript.
Author contributions
A.A.O. and M.E. conceived the study design and conducted the initial database searches. M.E. and S.A.B. independently performed title/abstract and full-text screening; disagreements were resolved through discussion. A.A.O., M.E. and S.A.B. conducted data charting and thematic synthesis. M.A.M., A.H.O., S.F.J. and M.A.A. provided senior supervision and critical revision of all manuscript drafts. All authors approved the final version of the manuscript for submission.
Funding
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Declaration of interest
None.
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