For the past decade, researchers have said that religion is good for your health. Now they are saying religion is not enough. A person also must have a particularly strong faith.

A study published Monday in the Archives of Internal Medicine suggests sick, elderly patients who struggle with their faith are at an increased risk of death in comparison with those who feel more certain in their beliefs.

The study included 596 people ages 55 or older who were hospitalized at Duke University Medical Center or Durham VA Medical Center five or six years ago. Those who felt punished or abandoned by God, or who felt the devil was causing their illness, were more likely to die than those who rejected that type of statement.

"This study focused on the dark side of religious belief," said Kenneth Pargament, a professor of psychology at Bowling Green State University in Ohio and the co-author of the study. "Although religious figures from Moses to Buddha to Jesus went through their own dark nights of the soul, they came out transformed. The key may be whether people can resolve their struggles."

As part of the study, subjects were asked to answer a questionnaire that determined how they coped with their faith--whether they sought spiritual support and community with their congregation, or whether they felt spiritually alienated and questioned God's love. About 95 percent of the study's subjects were conservative or mainline Christians, so the study's conclusions cannot be generalized.

Two years later, patients who experienced religious struggles were associated with a 19 percent to 28 percent increase in risk of dying. Those who coped more positively with their faith reported a better mood, a more independent functioning status and better cognitive functioning. In all, 176 of the patients in the study died; 268 survived. Another 152 were unwilling to respond to follow-up interviews.

Among those who died, said Harold G. Koenig, a professor of psychiatry at Duke University Medical Center and the co-author of the study, some had unresolved issues.

"Many of these patients were asking, 'Why me?'" Koenig said. "They were angry about it. They couldn't really embrace their faith. They were stuck at being angry. That created religious turmoil and generated stress that impacted the immune system."

Koenig suggested the study should encourage doctors to ask their patients about their spiritual history and to refer struggling patients to chaplains, ministers, rabbis, and religious communities capable of helping them resolve their conflicts. So far only about 10 percent of doctors nationwide feel comfortable asking their patients about their religious beliefs, Koenig said.

But others say a person's overall attitude toward life may be as important as faith.

"I know some people who had a very peaceful death and did not have strong religious beliefs," said Ursula Capewell, a nurse who works with terminally ill patients at Duke University Medical Center. "It depends on the individual and whether they feel they have led a productive life."

Furthermore, although faith may be crucial to conservative and mainline Christians, the study does not take into account other faiths in which it is considered normal to wrestle with God, such as Judaism.

Many Christians say they, too, struggled with the onset of their illness or that of their spouse. But they were able to overcome their doubts and remain strong in their faith. P.J. Burns, 82, said he asked God "Why me?" when his wife was diagnosed with Alzheimer's disease more than a decade ago.

"My son straightened me out," said Burns, who lives at The Forest at Duke, a continuing care retirement community in Durham. "He prayed for me. Laid his hand on my shoulder and said, 'Life is tough. Life is hard. But the Lord knows what you're going through.' "

Burns, who attends First Baptist Church in Durham, said the congregation was especially helpful to him, particularly after his wife died two years ago.

"I ran into wonderfully supportive people, people who took me under their wing," he said. "I love many of them, and they love me. That means a lot."

Staff writer Yonat Shimron can be reached via email.