Positive Psychological Attributes and Cardiac Outcomes: Associations, Mechanisms, and Interventions

Psychosomatics 2012:53:303–318

© 2012 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.

Review Articles Positive Psychological Attributes and Cardiac Outcomes: Associations, Mechanisms, and Interventions Christina M. DuBois, B.A., Scott R. Beach, M.D., Todd B. Kashdan, Ph.D., Maren B. Nyer, Ph.D., Elyse R. Park, Ph.D., M.P.H., Christopher M. Celano, M.D., Jeff C. Huffman, M.D.

Background: Intervention research at the intersection of psychiatry and cardiology has primarily focused on the relationship between negative psychological syndromes (e.g., depression) and cardiac outcomes, with less emphasis on positive psychological attributes, such as optimism, gratitude, and well-being, as they relate to cardiac disease. Methods: Literature is reviewed in three specific areas regarding positive attributes and cardiac disease: (1) associations between positive attributes and cardiac outcomes, (2) potential mechanisms— both behavioral and physiologic— by which positive psychological states may impact cardiovascular health, and (3) interventions aimed at cultivating positive psychological attributes in healthy and medically ill persons. Results: There is significant evidence that positive psychological attributes— especially optimism—may be independently associated with superior cardiac outcomes. Positive attributes appear to be associated with in-

creased participation in cardiac health behaviors (e.g., healthy eating, physical activity) linked to beneficial outcomes; data linking positive psychological states and biomarkers of cardiac health (e.g., inflammatory markers) is mixed but suggests a potential association. Positive psychological interventions have consistently been associated with improved well-being and reduced depressive symptoms, though there have been few such studies in the medically ill. Conclusions: These findings regarding the relationship between positive psychological attributes and cardiac health are promising and suggest that positive psychology interventions may be worth study in this population. However, questions remain about the strength and specificity of these relationships, the most salient positive psychological attributes, and the impact of positive psychological interventions on health outcomes in cardiac patients. (Psychosomatics 2012; 53:303–318)

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Given the link between psychological factors and cardiac health, multiple studies have targeted psychological symptoms in cardiac patients in an attempt to improve medical outcomes. However, such studies have typically

sychological factors play an important role in the development and progression of cardiac disease. For example, patients who suffer from depression early in life are more likely to develop and die from cardiac disease than those without depression, independent of traditional cardiac risk factors.1– 4 Among patients with established cardiac disease, depression is independently associated with recurrent cardiac events and mortality over the next year.5,6 Similarly, anxiety (including anxiety disorders such as generalized anxiety disorder) is associated with adverse cardiac outcomes in initially healthy persons and in patients with acute cardiac illness.7,8 Psychosomatics 53:4, July-August 2012

Received February 2, 2012; revised March 30, 2012; accepted April 2, 2012. From Dept. of Psychiatry, Massachusetts General Hospital, Boston, MA (CMD, SRB, MBN, ERP, CMC, JCH); Harvard Medical School, Boston, MA (SRB, MBN, ERP, CMC, JCH); Dept. of Psychology, George Mason University, VA (TBK); Benson Henry Institute for Mind Body Medicine, Boston, MA (ERP). Send correspondence and reprint requests to Jeff C. Huffman, M.D., Massachusetts General Hospital 55 Fruit Street/Blake 11, Boston, MA; e-mail: [email protected] © 2012 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.

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Positive Attributes and Cardiac Outcomes focused on the minority of cardiac patients who have a diagnosable psychiatric disorder such as major depression. Furthermore, interventions focusing on these disorders have failed to improve medical outcomes in cardiac patients in the vast majority of cases.9 –13 Positive psychological states, such as mindfulness and gratitude, and enduring strengths of character, such as curiosity and self-discipline, have been less well-studied in cardiac patients, and there has been limited research on interventions to cultivate such positive attributes in this cohort.14 However, there is increasing data that positive psychological attributes may play a critical role in cardiac health and recovery from illness. Even after adjusting for demographic factors, cardiac risk factors, and health behaviors, optimism and other positive cognitions/emotions have been associated with superior cardiovascular outcomes in persons with and without known heart disease.15–20 Furthermore, the association between positive attributes and cardiac outcomes has been independent of negative psychological states in many cases, suggesting that cardiovascular benefits associated with positive attributes may be more than the absence of distress and disorder.18,19,21–25 The field of positive psychology has focused on the cultivation of positive cognitive and emotional states, largely through specific exercises that promote systematic and deliberate activities.26 –28 Trials of positive psychology interventions have shown promising results in a variety of populations totaling more than 4000 persons, with improvements in mood, vitality, and wellbeing.29,30 However, despite their potential impact, there has been limited study of such interventions in patients with medical illness; this is especially true for heart disease. In this article, we aim to provide a broad overview of the literature studying links between positive psychological attributes and cardiac disease (for the purposes of this review, ‘positive psychological attributes’ will refer both to positive emotions [e.g., happiness] and cognitions [e.g., optimism, gratitude]). First, we will review established relationships between positive psychological attributes and cardiovascular outcomes. We will next describe potential behavioral and biological mechanisms that may underlie these relationships. Finally, we will outline current data regarding positive psychology and related interventions that could promote psychological health in individuals with—and at risk for— cardiac illness. Where appropriate, we have inserted major issues sections that 304

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discuss the limitations and questions regarding existing empirical research. To generate this review, we performed a search of major psychology and medical databases (e.g., Medline, PsycInfo) using relevant search terms (e.g., optimism, cardiovascular disease), and reviewed cited literature from identified articles to discover additional relevant literature. However, this is not a comprehensive, systematic overview of the literature on these topics; for such reviews, see Boehm and Kubzansky (positive psychological well-being and cardiac health)31 and Sin and Lyubomirsky (positive psychology interventions).30 Links Between Positive Psychological Attributes and Cardiovascular Outcomes Optimism is the positive attribute most consistently linked to cardiovascular health.15–17,32–34 Most studies of optimism in this context have focused on dispositional optimism, a trait construct that quantifies the extent to which a person consistently has positive, confident expectations about his or her own future outcomes; this construct is typically measured using the Life Orientation Test-Revised (LOT-R),35 a six-item scale that contains optimism and pessimism subscales. For example, Scheier and colleagues34 found that dispositional optimism was independently associated with reduced readmissions following coronary artery bypass graft (CABG) surgery, after controlling for age, education level, and serum cholesterol level. Data from the longitudinal Zutphen Elderly Study found that dispositional optimism was associated with reduced all-cause and cardiovascular mortality in 773 elderly men, independent of cardiovascular risk factors and sociodemographic factors.33 Among women, Tindle and colleagues’16 analysis of 97,253 participants from the Women’s Health Initiative study36 found that dispositional optimism was associated with reduced cardiac and all-cause mortality, independent of other covariates such as age, hypertension, hyperlipidemia, smoking, and diabetes mellitus.16 Overall, a comprehensive meta-analysis of 83 studies found optimism to be positively and independently related to physical health, including healthy cardiovascular outcomes, less pain, fewer cancer symptoms, greater immunological functioning, and reduced mortality.17 Other positive attributes have also been linked to a reduced risk of developing cardiac illness. Vitality, in addition to optimism, was independently associated with reduced risk of incident heart disease in a cohort of 7942 Psychosomatics 53:4, July-August 2012

DuBois et al. healthy adults, taken from a larger study.32,37 In another study of a large subsample (over 6000 patients) from the National Health and Nutrition Examination Surveys I study, there was a significant association between greater positive affect (feelings of enthusiasm, vitality, and interest) and reduced risk of heart disease, even after controlling for health behaviors and depressive symptoms.22 In addition to reduced risks of cardiac illness, positive psychological attributes might reduce rates of mortality in this cohort. In a sample of more than 800 patients undergoing cardiac catheterization, Brummett and colleagues38 found that greater positive affect was associated with survival over the course of an average prospective time frame of 11 years; however, this association failed to remain after adjusting for negative affect. Finally, a recent, comprehensive meta-analysis of 26 studies (involving more than 50,000 participants) found that subjective well-being was associated with lower rates of mortality in both initially healthy and medically ill populations, independent of medical disease state and treatment.39 Possible Mechanisms Connecting Positive Psychological Attributes and Cardiac Outcomes Published models linking positive emotions with cardiac outcomes include both behavioral and physiologic components.15 Individuals with greater optimism and other positive psychological states may have superior cardiac outcomes because they are more likely to engage in healthy behaviors, such as healthy eating, physical activity, smoking cessation, and medication adherence, each of which is associated with superior cardiac outcomes.22,40 Positive attributes have also been associated with lesser abnormalities of physiologic biomarkers that are linked to cardiac outcomes, such as measures of inflammation and autonomic nervous system activity. We will first review the impact of positive attributes on cardiac health behaviors. Health Behaviors Diet Optimism has been linked to healthier baseline diet and superior dietary adherence. Kelloniemi and colleagues41 found that young Finnish adults with greater optimism consumed a greater quantity of fruits, vegetables, and high-fiber foods, and a smaller quantity of alcohol, coffee, and candy. Optimism may also facilitate Psychosomatics 53:4, July-August 2012

healthy dietary change, as suggested by a large study of postmenopausal women enrolled in the large Women’s Health Initiative Dietary Modification Trial. Women with greater optimism at baseline who were randomized to the low-fat intervention arm of the trial were more likely to have beneficial dietary changes change in all three studied domains (fat, fruit/vegetable, grain) at the one-year follow-up.42 Similarly, the Zutphen Elderly Study that followed elderly men for as many as 15 years found that dispositional optimism was linked to a greater likelihood of healthy dietary changes, defined as greater consumption of fruit, vegetables, and whole grain bread.33 Physical Activity Several studies suggest that older adults with greater optimism have higher rates of physical activity, another factor essential to cardiac health.33,40,43 The Zutphen Elderly Study found that dispositional optimism was significantly associated with increased physical activity, independent of age, education, living arrangement, self-rated health, cardiovascular disease, diabetes mellitus, cancer, and body mass index.33 Steptoe and colleagues40 found that dispositional optimism in older adults was associated with brisk walking (in both sexes) and vigorous physical activity (in women), independent of multiple relevant covariates, such as age, chronic illnesses, medication count, socioeconomic status, and BMI. In addition, Browning and colleagues43 found that optimism may influence adherence to a recommended exercise routine. Older adults who held healthy attitudes about exercise, including optimism and the concept that health behavior is under one’s own control (e.g., “there is a lot that older adults can do to stay healthy,”) were more likely to engage in exercise. Smoking At least four studies have suggested that optimistic individuals are less likely to smoke. The previously noted studies of older adults led by Giltay and Steptoe that found dispositional optimism to be independently linked with physical activity also found optimism to be independently associated with lower rates of smoking.33,40 In a study performed in Finland, the proportion of current smokers was lower among optimistic men and women, and individuals with greater optimism were likely to be categorized as having no lifetime smoking history.41 A final study found that middle school students with greater optimism reported less frequent use of cigarettes.44 Though www.psychosomaticsjournal.org

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Positive Attributes and Cardiac Outcomes optimism is associated with decreased smoking, unrealistic optimism (also referred to as optimistic bias, discussed further below) may impede attempts to quit smoking because patients may underestimate the difficulties inherent in smoking cessation.45 Adherence to Medical Treatment There is extensive work in patients with human immunodeficiency virus (HIV) linking positive psychological attributes and medication adherence,46 – 48 but more limited evidence in cardiac patients. A study of patients undergoing heart transplant for end-stage cardiac disease found that optimism about the upcoming transplant operation was associated with greater adherence to the complex post-transplant medication regimen in the 6 months following the procedure.49 A larger study of over 1000 patients with hypertension found that a ‘sense of coherence’ (a sense of having a meaningful life and a sense that life challenges can be understood and controlled), but not optimism, was associated with adherence to antihypertensive medications.50 In sum, positive psychological attributes have been linked with improved adherence to a number of behaviors that are important to cardiovascular health. Such behaviors have included healthy eating, exercise/activity, smoking cessation, and medication adherence. Additional studies have also found links between positive attributes and other health-related behaviors, such as alcohol use and sleep quality.31 Positive Psychological Attributes and Physiologic Changes Positive attributes have also been linked to biological indicators of superior cardiac outcomes, though the results of studies of this association have been somewhat mixed. Autonomic Function Autonomic dysfunction is associated with adverse cardiac outcomes, including mortality.51,52 Optimism and other positive attributes have been associated with reduced autonomic dysfunction. Positive affect has been linked to individual differences in resting respiratory sinus arrhythmia (an index of autonomic nervous system function),53 and optimism has been linked to lower systolic and diastolic ambulatory blood pressure.54 In addition, positive affect has shown associations with less reactivity of blood pressure and heart rate to stress,55 and faster cardiovascu306

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lar recovery from the induction of negative emotional states including fear and sadness.55,56 Among patients with coronary artery disease, higher levels of positive affect were associated with increased vagal control, demonstrated by increases in the low-frequency power component of heart rate variability; this relationship held after controlling for covariates that included age, medications, and posture of participant.57 Positive affect was also associated with more rapid recovery of heart rate variability following exposure to mental stress in a cohort of college students.58 In contrast, Ryff and Singer59 did not find positive psychological well-being to be associated with resting systolic blood pressure in a study of older women. Inflammation Elevated inflammatory markers are predictors of adverse cardiac events.60 – 62 Studies of the association between positive attributes and inflammation have been mixed. Three carefully controlled studies in large prospective cohorts, and two smaller epidemiologic studies, have found some association between positive affect/optimism and inflammatory markers. In the prospective Multi-Ethnic Study of Atherosclerosis (MESA) study63 of over 6000 men and women, dispositional optimism was measured via LOT-R. Dispositional optimism in this cohort was associated with lower levels of interleukin-6 (IL-6), C-reactive protein (CRP), and fibrinogen. After correcting for sociodemographic factors, negative psychosocial factors, health behaviors, body mass index, hypertension, and diabetes mellitus, only an association between the LOT-R pessimism subscale (not the optimism subscale) and fibrinogen remained. Steptoe and colleagues64 assessed participants’ responses to stress in a laboratory setting and found that persons reporting higher levels of happiness had smaller plasma fibrinogen responses to stress, independent of psychological distress, gender, age, body mass index, smoking status, and socioeconomic status. A study of 2873 healthy adults taken from a larger prospective study37 found positive affect and life satisfaction to be associated with lower IL-6 and CRP in women but not men.65 Similarly, Prather and colleagues66 found that positive affect was associated with lower IL-6, specifically in older women, after controlling for relevant risk factors and depression. A recent analysis of data from 340 older men without existing heart disease (taken from the VA Normative Aging Study) found optimism to be associated with lower IL-6, a result that remained significant after adjusting for multiple covariates including depressive Psychosomatics 53:4, July-August 2012

DuBois et al. symptoms.67 In contrast, Friedman and colleagues68 did not find an association between IL-6 and older women, even after controlling for depression and cardiac risk factors. Additional Physiologic Effects Endothelial dysfunction is independently associated with adverse cardiac outcomes,69 and negative psychological syndromes (e.g., depression) have been linked to endothelial dysfunction.70 The previously noted analysis from the Normative Aging Study found optimism to be positively associated with one marker of endothelial function (soluble intracellular adhesion molecule [sICAM] receptor) in multivariate models, though not with a second, related marker (soluble vascular cell adhesion molecule [sVCAM]).67 Activation of the hypothalamic-pituitary-adrenal axis/hypercortisolemia has also been linked to cardiac health, and positive affect and optimism have both shown inverse relationships with cortisol levels.71 Much of the work on the physiological benefits of positive attributes has focused on optimism or momentary positive emotions. However, a systematic study in women age 65 years and older assessed the association between multiple biological indicators of physical health and eudaimonic well-being (eudaimonic well-being is an aggregate of positive constructs that includes purpose, selfactualization, autonomy, and positive relations with others; this is in contrast to hedonic well-being, a construct associated with happiness, pleasure attainment, and pain avoidance68,72–74). In a preliminary exploration of eudiamonic- and hedonic well-being and medical health, a sense of personal growth and life purpose were linked to higher high-density lipoprotein (HDL) cholesterol and lower salivary cortisol. Higher life purpose scores were also associated with lower levels of IL-6 receptors.72 Furthermore, multiple eudaimonic constructs/factors were also associated with lower glycosylated hemoglobin. Indicators of hedonic well-being were not associated with most biological factors. In other studies examining associations between positive attributes and cardiovascular risk factors, Richman and colleagues75 found that in graduate students and general medicine patients, vitality was associated with lower cholesterol during a 1-year period, taking into account age, gender, smoking, anger, anxiety, exercise, alcohol intake, and marital status. However, a study by Shepperd and colleagues76 found no association of dispositional optimism with HDL, low-density lipoprotein (LDL), or total Psychosomatics 53:4, July-August 2012

cholesterol, after controlling for age, depression, and relevant risk factors.76 Overall, there have been some links between positive attributes and physiologic markers of cardiovascular health. However, these links appear to be less consistent and less powerful than the links between these positive constructs and health behaviors. Additional research, using large cohorts, controlling for multiple relevant covariates, and simultaneously including measures of health behavior and biomarkers, is needed to further clarify these connections. Major Issues Are the Number and Quality of Existing Studies Sufficient to Support a Claim that Positive Attributes Cause Better Cardiac Outcomes? At this stage, it would be premature to claim that positive psychological attributes cause superior cardiac outcomes. The medical literature is filled with examples of initially promising results and associations later contradicted by additional, larger, and better-controlled studies,77 and given the limitations of the extant literature on positive attributes, caution is warranted. There is substantial variability in the positive psychological constructs being studied, and some studies suffer from limitations related to sample size and use of crosssectional (rather than prospective) data. At the same time, there are now a substantial number of prospective studies in this field, and the vast majority of such studies have found a significant association between positive states and medical outcomes. Regarding the heterogeneity of psychological attributes and measures, it is certainly true that multiple positive psychological constructs have been examined using a variety of measures. However, as noted, there is mounting evidence for dispositional optimism as an attribute that is consistently linked to superior outcomes, and this construct has been measured using the LOT-R in nearly all recent studies.15–17,32–34 Although the use of relatively small samples and cross-sectional trials dot this literature, there are several large, prospective studies examining the links between positive attributes and cardiac health. A number of the above studies have been prospective epidemiologic studies that included over 1000 subjects,16,18,23,63,65 though several studies have been cross-sectional and are therefore less informative regarding causality or directionalwww.psychosomaticsjournal.org

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Positive Attributes and Cardiac Outcomes ity, given that following a healthy diet, exercising, and/or having lower levels of inflammation may well lead to subsequent optimism, vitality, and overall well-being. Another alternative is the possibility of bidirectionality, with positive states leading to better behavior/physiology, and such improvements in behaviors and physiology facilitating the further development of positive psychological attributes. More large, prospective studies in a variety of populations will further strengthen the literature. Additional work on the independence of positive psychological constructs from one another is needed. Do the Studies Linking Positive Attributes and Cardiac Health Account Properly for Relevant Sociodemographic and Medical Variables? Do They Control for Depression? The issue of covariate control is a vital one in establishing an independent relationship between positive attributes and medical outcomes. In the meta-analysis examining positive states and mortality by Chida and colleagues,39 the majority of studies that demonstrated a protective relationship between positive states and mortality controlled for sociodemographic factors such as age, sex, race, and socioeconomic status, and those in medically ill populations generally controlled for basal disease state. Furthermore, the majority of studies on positive psychological states and cardiac outcomes consider key cardiac risk factors (i.e., physical activity, hypertension, diabetes mellitus, smoking, and hyperlipidemia). Some studies control for all of these factors,16,22,24,32 and some control for the majority of these factors.18 –20,25,34,78 Of note, however, one study controlled for all five risk factors but did not find a significant result after adding negative affect into the analysis.79 Regarding depression, at least eight studies have additionally controlled for depressive symptoms using validated scales that included the Center for Epidemiologic Studies-Depression scale (CES-D),80 Hospital Anxiety and Depression Scale (HADS),81 Hamilton Rating Scale-Depression (HRS-D),82 and Beck Depression Inventory (BDI).83 Even after controlling for depression, six studies still found relationships between positive states/attributes—in the forms of life orientation, satisfaction with aging, and optimism—with allcause mortality.84 – 89 The remaining two studies, mentioned earlier, found relationships between positive states and lower IL-667 and reduced risk of heart disease22 after controlling for depression. However, some 308

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studies noted above found that links between positive states and medical outcomes did not remain after controlling for ‘negative affect’.38,68,79

What About Controlling for Negative Psychological States Other than Depression? This is an important issue, given that anxiety and anger have been associated with adverse cardiac outcomes, and that anger/hostility in particular has been linked with cardiac outcomes in randomized controlled trials. For example, Friedman and colleagues90 found that in patients with a prior myocardial infarction and Type A personalities (a group of personality traits characterized by hostility, ease of arousal, and time-urgency), a 4.5-year behavioral counseling program to target their personalities led to reductions in cardiac morbidity and mortality, compared with a control group who received only cardiac counseling. During a 1-year follow-up, the counseling group continued to have significantly lower rates of mortality compared with the control condition.91 An ongoing limitation of positive psychology literature is the lack of control in some studies for negative psychological states other than depression. However, in addition to the previously noted studies that controlled for depression, there are a substantial number of studies that controlled for negative states (such as anxiety, anger, hostility, or aggression). With respect to anxiety, a pair of studies examining the links between vitality and outcomes did control for both depression and anxiety, and these studies found independent associations between all-cause mortality21 and non-cardiac mortality,22 respectively. Overall, at least six studies in this field have controlled for anxiety, with all demonstrating an association between positive emotional states and improved outcomes, independent of anxiety.18 –20,23,75,78 At least five studies in this field have controlled for hostility, and all such studies found an independent association between positive emotional states and improved outcomes.18,19,23–25 A study by Richman and colleagues75 controlled for both anger and anxiety, and found that mental vitality was associated with reduced prevalence of heart disease, independent of traditional risk factors that included age, gender, smoking, marital status, exercise, and alcohol intake. For additional information regarding these important issues, see Boehm and Kubzansky.31 Psychosomatics 53:4, July-August 2012

DuBois et al. When Measuring Positive Attributes, Aren’t We Simply Measuring an Absence of Depression and Other Negative Constructs?

attributes and depression, and with other negative states such as anxiety and anger, though these relationships are less well-studied (Table 1).

First, as noted, many of the studies cited have found that positive attributes (e.g., optimism) are linked with superior outcomes even after controlling for depression, suggesting that these attributes have independent effects on outcome. Furthermore, though there is clear overlap between positive attributes and negative states such as depression, these constructs only have some association with one another in clinical samples. For example, optimism and depression appear to demonstrate a moderate correlation with one another (r ⫽ ⫺0.28 to 0.60 [median r ⫽ ⫺0.43]) in ten identified studies examining such correlations (see Table 1).35,92–100 Even in cardiac patients with known depression, a recent analysis of a large trial of cardiac surgery patients found that optimism was not strongly correlated with depressive symptoms (r ⫽ ⫺0.27), and optimism was associated with decreased risk of rehospitalization independent of depressive symptoms.100 Similar correlations are seen with other positive

Positive Psychology Interventions

TABLE 1.

Positive psychological attributes appear to be important to health, but can they be cultivated or taught? Careful study of the factors contributing to positive psychological well-being have estimated that after accounting for other factors (genetic, demographic, and cultural factors, and external life events), intentional choices and behaviors account for approximately 40% of the variance in well-being.101,102 Positive psychology interventions—which promote intentional behaviors to improve well-being— have targeted activities in several domains, including altruism, optimism, gratitude, and using one’s strengths of character (Table 2). Such exercises are typically brief, easy to administer, and have low provider and participant burden.103 Most of these exercises involve brief instruction about the details and rationale for the task, followed by independent comple-

Correlations between Positive Attributes and Negative Psychological Constructs

Study Achat et al. (2000)93 Bandiera et al. (2002)100 de Moor et al. (2006)92 Herzberg et al. (2006)35

Population

Positive Attribute (LOT)131 (LOT-R)35 (LOT-R)35 (LOT-R)35

Optimism Optimism Optimism Optimism

Hirsch and Britton (2010)99 Morgenstern et al. (2011)94 Rajandram et al. (2011)97 Scheier et al. (1994)95 Scioli et al. (1997)96 Tindle et al. (2012)98 Chipperfield et al. (2000)134

Healthy middle- to older-aged men Healthy college students Ovarian cancer Healthy and medically ill (diabetes, CHD, hypertension, hyperlipidemia) Opiate dependence Stroke Cancer survivors Healthy college students Healthy college students Coronary artery bypass graft Elderly community-dwelling adults

McCullough et al. (2002)136 McCullough et al. (2002)136

Healthy college students Healthy college students

Gratitude (GQ-6)137 Gratitude (GQ-6)137

Puskar et al. (2008)140

Healthy rural adolescents

Optimism (LOT-R)35

Optimism (LOT-R)35 Optimism (LOT-R)35 Optimism (LOT-R)35 Optimism (LOT)131 Optimism (LOT)131 Optimism (LOT-R)35 Life satisfaction (LSIA)135

Negative Construct Depression Depression Depression Depression

(CES-D)80 (BDI)83 (CES-D)80 (DSQ)132

Depression (CES-D)80 Depression (PHQ-9)133 Depression (HADS)81 Depression (BDI)83 Depression (CES-D)80 Depression (HRS-D)82 Sadness Anger (Self-reported frequency in prior 2 days) Anxiety (BSI)138 Envy (before controlling covariates) (DES)139 Anger (state) Anger (trait) (STAXI)141

Correlation Coefficient (r) ⫺0.44 ⫺0.42 ⫺0.39 ⫺0.47 ⫺0.60 ⫺0.31 ⫺0.55 ⫺0.42 ⫺0.28 ⫺0.34 ⫺0.29 ⫺0.21 ⫺0.20 ⫺0.39 ⫺0.29 – 0.21

BDI ⫽ Beck Depression Inventory; BSI ⫽ Brief Symptom Inventory; CES-D ⫽ Center for Epidemiologic Studies-Depression scale; DES ⫽ Dispositional Envy Scale; GQ-6 ⫽ Gratitude Questionnaire-6; HAD ⫽ Hospital Anxiety and Depression Scale; HRS-D ⫽ Hamilton Rating Scale-Depression; LOT ⫽ Life Orientation Test; LOT-R ⫽ Life Orientation Test-Revised; LSIA ⫽ Life Satisfaction Index A; DSQ ⫽ Depression Screening Questionnaire; PHQ-9 ⫽ Patient Health Questionnaire-9; STAXI ⫽ State-Trait Anger Expression Inventory.

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Positive Attributes and Cardiac Outcomes

TABLE 2.

Sample Positive Psychology Exercises

Exercise (Domain) Best possible self (Optimism)

Best future social relationships (Optimism)

Counting blessings (Gratitude)

Gratitude letter (Gratitude)

Benefit finding (Gratitude)

Three acts of kindness (Altruism)

Pleasurable and meaningful acts (Purpose, Happiness)

Using strengths (Strengths)

Forgiveness letter (Forgiveness)

Forgiveness exercises (Forgiveness)

Loving-kindness meditation (Life satisfaction)

Cultivating sacred moments (Spirituality)

Positive writing (Happiness/ joy)

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Summary/Instructions to Participants Selected Impact Imagine your best overall possible future (over the next 5 years) and consider how to actualize this future. This exercise has been associated with feeling happier, experiencing less emotional distress, and being sick less often, compared with a control condition.142,143 Furthermore, this exercise has been linked to persistent improvements in well-being long after the intervention.143 Imagine your best possible interpersonal relationships (with family, friends, and colleagues) over the next several years and consider how to take steps toward these optimal relationships. Given the importance of perceived social support in heart disease outcomes, this exercise was tested in a pilot study of cardiac patients, with good effect.104 Recall and record in detail three events in the past week for which you are grateful. This exercise has been linked to beneficial effects on mental health (i.e., depression, optimism, well-being, and social engagement) and physical health/health behaviors (physical complaints, frequency of exercise, amount and quality of sleep).144 Recall another person’s kindness and write a letter that describes the feelings of gratitude associated with this event. Completing a gratitude letter led to sustained improvement of well-being for up to 6 months in one study.143 Write about your genuine feelings toward medical illness and any benefits that may have resulted from this situation. Women with breast cancer who completed this exercise had reduced physical symptoms, fewer medical appointments, and better heart rate habituation to stress than control subjects.145 Perform three kind acts for others within a single day. Prior work has found that performing and recording acts of kindness is associated with improved mood and that such an intervention may provide sustained mood benefit.101,146 Participants are typically asked to perform all of their kind acts on the same day given evidence that such clustering may be most effective.101 Complete three acts in a single day: a pleasurable act done alone (e.g., gardening), a pleasurable act done with others (e.g., walking with friends), and a meaningful or important act (e.g., creating a blood sugar log). This exercise aims to help participants foster engagement, pleasure, and meaning in their lives, as all three domains have been linked to life satisfaction.147 Complete a brief survey of personal strengths, and then select a strength (e.g., perseverance, self-control) to be used deliberately in the next week. Write about how you used the strength and the outcome. A prior controlled trial found that this activity decreased depression and increased happiness at 1- and 6months post-treatment.29 Write a letter of forgiveness to a person who did or said something that made you upset. If you cannot forgive the person for everything they did or said, try to forgive them for one part of their actions. This intervention has been used clinically, and sending the letter is not required and is only encouraged if the participant experiences the forgiveness as genuine.148 At least two years after a hurtful event, engage in exercises related to defining forgiveness, examining emotions, committing to forgiveness, grieving your pain, reframing the situation, exploring empathy, practicing goodwill, and finding meaning and purpose in the situation. Emotionally abused women who completed forgiveness exercises had reduced anxiety, greater self-esteem, were better able to find meaning in suffering, and showed increased environmental mastery and identification with “survivor status,” compared with attentional controls.149 Utilize a focused form of meditation aimed at cultivating mindfulness and loving feelings toward self and others. This intervention has been linked to reduced depressive symptoms and increased life satisfaction, primarily through increases in positive emotions.150 Create a ‘sacred moment in time’ with the use of mindfulness. Focus on an object (jewelry, mantra, nature) that you have deemed sacred, and develop a spiritual connection with qualities of preciousness, blessedness, or holiness. This exercise has been liked to increased positive affect, lesser negative affect, and greater feelings of meaning and purpose in life.151 Write about the most positive, happy, ecstatic moments of your life. Include all of the emotions you experienced. Think also about how you can use this experience now to tap into inspiring, positive feelings. Subjects who completed this exercise reported higher levels of life satisfaction compared with controls.152

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DuBois et al. tion of the exercise by the participant. In some cases, the ‘instructor’ and participant reconvene to discuss the process and outcome of the exercise. Positive psychology interventions have consistently been linked to increased positive emotions and cognitions,30 especially if the exercises are systematically performed, episodic, varied, and meaningful to the participant. Completing activities in an intensive but intermittent manner appears to be important. For example, participants in one study asked to perform one act of kindness on five separate days each week experienced no gains in wellbeing, but experienced significant gains when asked to perform the five separate acts of kindness in a single day.101 Below, we review the literature on positive psychology interventions. To date, most of these exercises have been studied in healthy research subjects or depressed individuals. There has been substantially less study of these exercises in medically ill populations. Positive Psychology Interventions in Healthy Individuals Over 20 different positive psychology exercises have been used in intervention studies in healthy subjects (see Table 2 for sample exercises). These exercises have been administered in person or remotely over the internet, have been performed in a variety of cohorts (e.g., college students, elderly persons), and have consistently led to short-term gains. A meta-analysis by Sin and Lyubomirsky30 of more than 50 trials involving more than 4000 participants found that positive psychology interventions have consistently led to increases in self-reported life satisfaction, other well-being indicators (e.g., positive affect, optimism), and reductions in depressive symptoms; this includes positive changes in ‘trait-like’ dispositions such as dispositional optimism.104,105 The authors found that the overall effect size of positive psychology interventions on depressive symptoms (r ⫽ 0.31; medium effect size) was essentially identical to that seen in reviews of standard (and typically much more intensive and costly) psychotherapies (r ⫽ 0.32).106 These effects were also greater than the calculated effect size for antidepressants on mood symptoms in depressed patients (d ⫽ 0.32; small effect size) in recent reviews.36,107 There has been much less study of the sustainability of gains in positive attributes in this population. However, Cohn and Fredrickson108 conducted a follow-up of a loving-kindness meditation intervention for healthy particiPsychosomatics 53:4, July-August 2012

pants. They found that participants who were randomized to the intervention maintained the gains they made during the initial intervention, including greater mindfulness, increased social support, reduced illness, and greater life satisfaction over a 15-month follow-up. Positive Psychology Interventions in Depressed Individuals Positive psychology interventions have also been studied in patients with depression. Using a randomized, placebo-controlled design in patients with mild to moderate depression, Seligman and co-workers29 found that a subset of positive psychology exercises led to immediate reductions in depressive symptoms. Participants were randomized to completion of one of six positive psychology exercises or to a control condition, and three of the six exercises (documenting daily three reasons to feel grateful, completing a gratitude visit, and using strengths in new ways) were associated with significantly greater ratings of happiness compared with the control group. Though patients in the experimental condition only completed these exercises for 1 week, two of the exercises (three reasons to feel grateful and use of strengths) were associated with persistent and significant reductions in depressive symptoms at the 6-month follow-up, compared with patients in the control condition. In another pair of studies, this same research group first evaluated a six-exercise group positive psychotherapy intervention over 1 year in young adults with mild to moderate depression. Compared with individuals in the no-treatment group, participants receiving the intervention had a significant decrease in depressive symptoms. Next, the authors found that individual positive psychotherapy delivered to outpatients with major depression over the course of 1 year led to greater remission rates than did treatment as usual and treatment as usual plus medication.103 Additionally, Freedman and co-workers109 examined the effect of a forgiveness intervention on female survivors of incest who also suffered from depression. The 12-week once-weekly intervention focused on confronting negative emotions, reframing the situation, using empathy and compassion, and recognizing negative feelings associated with the situation. After the intervention, the experimental group experienced significantly reduced rates of anxiety and depression and increased hope and enthusiasm, relative to the control group. www.psychosomaticsjournal.org

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Positive Attributes and Cardiac Outcomes Positive Psychology Interventions in Those with Noncardiac Medical Illness Although some ‘resiliency programs’ in medical patients have included small components of positive psychology interventions,110,111 specific trials of positive psychology interventions in the medically ill have been rare.112 Regarding noncardiac populations, there have been several small studies of positive psychology interventions in cancer patients, and there is some suggestion that these interventions improve social support and quality of life, reduce pain and anxiety, and promote adherence.113–115 However, such interventions have not been linked to substantial improvements in ‘harder’ outcomes, such as survival times or biomarkers. We are not aware of positive psychological interventions in patients with other chronic non-cardiac diseases, such as renal disease, diabetes, or HIV.

(persons with hypertension, asthma, and coronary artery disease) increase positive affect and feelings of selfaffirmation over the course of 12 months. Huffman and colleagues104 completed a three-arm, randomized feasibility study among patients recently hospitalized for an acute coronary syndrome or heart failure. This trial compared positive psychology exercises related to optimism, altruism, and gratitude to two control conditions (RR and an attentional control). The authors found the positive psychology intervention to be feasible and to have greater effects than the two control conditions on mood, anxiety, happiness, and mental health-related quality of life. However, this small exploratory trial (n ⫽ 26 completers) had insufficient power to detect significant between-group differences and these findings must be replicated. Major Issues

Positive Psychology Interventions in Cardiac Populations While there has been minimal study of positive psychology interventions in patients with cardiac disease, related interventions have been used in this population. Mindfulness-based stress reduction (MBSR) provides systematic training in mindfulness meditation as a self-regulation approach to stress reduction and emotion management.116,117 At least three small studies of cardiac patients found MBSR to be associated with reduced psychological symptoms and distress, and in some studies, improved quality of life and decreased physical symptoms.118 –120 Similarly, the relaxation response (RR) uses meditation in the form of guided relaxation,121 and has been found to lower blood pressure in healthy adults122 and to reduce tension, anger, and rates of supraventricular tachycardia in cardiac surgery patients (without effects on other physiologic variables/outcomes).123 In a randomized trial, RR decreased systolic blood pressure (approximately 9 mmHg) in elderly patients with stage I systolic hypertension, allowing significantly more participants in the RR group to eliminate an antihypertensive medication, compared with a lifestyle modification group.124 However, it appears that there have been only two systematic positive psychological intervention trials for cardiac patients. Charlson and colleagues112 have reported methods, but not results, from a randomized controlled trial that aimed to help three populations 312

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Why Not Focus on the Effects of Antidepressant Treatment on Cardiac Outcomes? Depression in cardiac patients is an important public health problem and must be addressed. However, only a minority of cardiac patients have clinical depression that requires treatment, and there is no evidence that antidepressant treatment has utility in patients with subsyndromal depressive symptoms.125 Furthermore, the impact of antidepressants alone on depressive symptoms has been relatively modest (and in some cases not better than placebo)107 and prospective studies have not yet found that antidepressants are linked to reduced cardiac events or mortality,10,12,126 though there is some suggestive data from epidemiologic studies.127,128 In contrast, many patients may benefit from a boost in optimism or other positive states in the context of medical illness, and such an intervention might impact health behaviors or physiology. Whether positive psychological interventions are effective in this population is, as yet, entirely unclear. Might an Intervention that Cultivates Positive States Cause “Optimistic Bias”? Optimistic bias is an inaccurate, unrealistic belief that positive outcomes will be easily accomplished (such as attaining remission from cancer or terminating smoking). Such bias may be associated with less consistent or planful efforts in these conditions, lowering Psychosomatics 53:4, July-August 2012

DuBois et al. rates of success,45,129 for example, in smoking cessation when patients overestimate the ease with which they can quit.119,120 However, positive psychological interventions generated for medically ill cohorts should address (and could actually decrease) the risk of optimistic bias. A well-designed positive psychology intervention should not ignore the obstacles to wellness or the endorsement of unrealistic thinking, but instead would focus on cultivating and maintaining positive attributes and using these attributes to reasonably navigate challenging life circumstances. Why Are There so Few Intervention Studies in This Area? Though there is a growing literature on the connections between positive attributes (especially optimism) and cardiovascular outcomes, there is still much to be learned regarding the design and delivery of interventions targeting these attributes. The field needs clarification on the attributes and strengths of character (e.g., positive affect, optimism, mindfulness, meaning and purpose in life, gratitude) with the strongest, most consistent associations with cardiac health so these may be specifically targeted. In particular, eudaimonic wellbeing indices (e.g., meaning and purpose in life) might represent deeper, more valuable targets than indices of hedonic well-being (e.g., life satisfaction, positive emotions, optimism). Furthermore, though positive psychology interventions exist, the majority has been in nonclinical cohorts, and much work will need to be done to adapt interventions to be acceptable, relevant, and effective in patients with significant medical illness. There are additional considerations worthy of contemplation in the refinement of positive psychology interventions. For example, should the interventions in this cohort be combined with other established interventions (e.g., behavioral activation or motivational interviewing) for maximum effect? Are there situations in which optimism or other states should not be cultivated, such as situations when unrealistic optimism impedes adherence or provides false hope? Given that this field is in its relative infancy and that both the intervention target and the methodology of interventions need further refinement, it is not surprising that intervention studies have yet to be prevalent, and certainly there is insufficient evidence for routine use in clinical practice. Psychosomatics 53:4, July-August 2012

Future Directions In summary, positive attributes are associated with improved cardiac outcomes, and this connection is likely mediated by both behavioral and physiologic factors. Positive psychology and related interventions may represent a means by which positive states and strengths of character can be cultivated in patients with— or at risk for— cardiac disease, though these interventions have not been wellstudied in cardiac patients in clinical care settings. Though this line of work has great potential, the field must be cautious about these interventions and their effects. Some studies linking positive attributes to medical or behavioral outcomes have been cross-sectional, preventing assessment of causality. Associations between positive attributes and health outcomes may be explained by variables or factors that were not accounted for in statistical analyses. For example, given the clear links between anxiety and depressive disorders with poor outcomes, it is important to conduct tests of construct specificity to ensure that links between positive attributes and superior outcomes exist independently of negative psychological syndromes. Even if positive attributes are prospectively linked to major cardiac outcomes, there remains a paucity of data regarding whether psychological interventions that target these states actually impact objective medical outcomes; indeed, this is a lesson hard-learned from the depression treatment literature.10 –12,130 Furthermore, there is much still to be learned regarding the best psychological target for these interventions and the methods (e.g., content, frequency, duration, mode of delivery) of potential positive psychology interventions in this population. Future studies that address these issues have the potential to open up a new line of clinically-relevant work in psychosomatic medicine that could lead to improved wellbeing and health for the large number of patients who have cardiovascular illness. This work was supported in part by grant R01DP00336 from the United States Disease Control and Prevention (CDC) to Herbert Benson. Todd Kashdan was funded by the Center for Consciousness and Transformation at George Mason University. The authors thank Dr. Julia Boehm for providing links to published literature and additional information on positive psychological well-being and cardiac health. Disclosure: The authors disclosed no proprietary or commercial interest in any product mentioned or concept discussed in this article. www.psychosomaticsjournal.org

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