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 intersectionof psychiatry and cardiology has primarily focused onthe relationship between negative psychological syn-dromes (e.g., depression) and cardiac outcomes, withless emphasis on positive psychological attributes, suchas optimism, gratitude, and well-being, as they relate tocardiac disease. Methods: Literature is reviewed inthree specific areas regarding positive attributes andcardiac disease: (1) associations between positive attri-butes and cardiac outcomes, (2) potential mechanisms—both behavioral and physiologic—by which positive psy-chological states may impact cardiovascular health, and(3) interventions aimed at cultivating positive psycholog-ical attributes in healthy and medically ill persons.Results: There is significant evidence that positive psy-chological attributes—especially optimism—may be in-dependently associated with superior cardiac outcomes.
Positive attributes appear to be associated with in-
ness.7,8

Psychosomatics 53:4, July-August 2012

creased participation in cardiac health behaviors (e.g.,healthy eating, physical activity) linked to beneficialoutcomes; data linking positive psychological states andbiomarkers of cardiac health (e.g., inflammatory mark-ers) is mixed but suggests a potential association. Posi-tive psychological interventions have consistently beenassociated with improved well-being and reduced de-pressive symptoms, though there have been few suchstudies in the medically ill. Conclusions: These findingsregarding the relationship between positive psychologi-cal attributes and cardiac health are promising and sug-gest that positive psychology interventions may be worthstudy in this population. However, questions remainabout the strength and specificity of these relationships,the most salient positive psychological attributes, andthe impact of positive psychological interventions onhealth outcomes in cardiac patients.

(Psychosomatics 2012; 53:303–318)

Psychological factors play an important role in thedevelopment and progression of cardiac disease.

For example, patients who suffer from depression earlyin life are more likely to develop and die from cardiacdisease than those without depression, independent oftraditional cardiac risk factors.1– 4 Among patients withestablished cardiac disease, depression is independentlyassociated with recurrent cardiac events and mortalityover the next year.5,6 Similarly, anxiety (including anx-iety disorders such as generalized anxiety disorder) isassociated with adverse cardiac outcomes in initiallyhealthy persons and in patients with acute cardiac ill-

Given the link between psychological factors and car-diac health, multiple studies have targeted psychologicalsymptoms in cardiac patients in an attempt to improvemedical outcomes. However, such studies have typically

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 Ma-son University, VA (TBK); Benson Henry Institute for Mind BodyMedicine, Boston, MA (ERP). Send correspondence and reprint requeststo Jeff C. Huffman, M.D., Massachusetts General Hospital 55 FruitStreet/Blake 11, Boston, MA; e-mail: [email protected]

© 2012 The Academy of Psychosomatic Medicine. Published by
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Positive Attributes and Cardiac Outcomes

focused on the minority of cardiac patients who have adiagnosable psychiatric disorder such as major depression.Furthermore, interventions focusing on these disordershave failed to improve medical outcomes in cardiac pa-tients in the vast majority of cases.9–13

Positive psychological states, such as mindfulness andgratitude, and enduring strengths of character, such ascuriosity and self-discipline, have been less well-studied incardiac patients, and there has been limited research oninterventions to cultivate such positive attributes in thiscohort.14 However, there is increasing data that positivepsychological attributes may play a critical role in cardiachealth and recovery from illness. Even after adjusting fordemographic factors, cardiac risk factors, and health be-haviors, optimism and other positive cognitions/emotionshave been associated with superior cardiovascular out-comes in persons with and without known heart dis-ease.15–20 Furthermore, the association between positiveattributes and cardiac outcomes has been independent ofnegative psychological states in many cases, suggestingthat cardiovascular benefits associated with positive attri-butes may be more than the absence of distress and dis-order.18,19,21–25

The field of positive psychology has focused on thecultivation of positive cognitive and emotional states,largely through specific exercises that promote system-atic and deliberate activities.26 –28 Trials of positive psy-chology interventions have shown promising results ina variety of populations totaling more than 4000 per-sons, with improvements in mood, vitality, and well-being.29,30 However, despite their potential impact,there has been limited study of such interventions inpatients with medical illness; this is especially true forheart disease.

In this article, we aim to provide a broad overview ofthe literature studying links between positive psychologi-cal attributes and cardiac disease (for the purposes of thisreview, ‘positive psychological attributes’ will refer bothto positive emotions [e.g., happiness] and cognitions [e.g.,optimism, gratitude]). First, we will review establishedrelationships between positive psychological attributesand cardiovascular outcomes. We will next describe po-tential behavioral and biological mechanisms that mayunderlie these relationships. Finally, we will outline cur-rent data regarding positive psychology and related inter-ventions that could promote psychological health in indi-viduals with—and at risk for—cardiac illness. Where
appropriate, we have inserted major issues sections that
304 www.psychosomaticsjournal.org

discuss the limitations and questions regarding existingempirical research.

To generate this review, we performed a search ofmajor psychology and medical databases (e.g., Medline,PsycInfo) using relevant search terms (e.g., optimism, car-diovascular disease), and reviewed cited literature fromidentified articles to discover additional relevant literature.However, this is not a comprehensive, systematic over-view of the literature on these topics; for such reviews, seeBoehm and Kubzansky (positive psychological well-beingand cardiac health)31 and Sin and Lyubomirsky (positivepsychology interventions).30

Links Between Positive Psychological Attributes andCardiovascular Outcomes

Optimism is the positive attribute most consistentlylinked to cardiovascular health.15–17,32–34 Most studies ofoptimism in this context have focused on dispositionaloptimism, a trait construct that quantifies the extent towhich a person consistently has positive, confident expec-tations about his or her own future outcomes; this con-struct is typically measured using the Life OrientationTest-Revised (LOT-R),35 a six-item scale that containsoptimism and pessimism subscales. For example, Scheierand colleagues34 found that dispositional optimism wasindependently associated with reduced readmissions fol-lowing coronary artery bypass graft (CABG) surgery, aftercontrolling for age, education level, and serum cholesterollevel. Data from the longitudinal Zutphen Elderly Studyfound that dispositional optimism was associated with re-duced all-cause and cardiovascular mortality in 773 el-derly men, independent of cardiovascular risk factors andsociodemographic factors.33

Among women, Tindle and colleagues’16 analysis of97,253 participants from the Women’s Health Initiativestudy36 found that dispositional optimism was associatedwith reduced cardiac and all-cause mortality, independentof other covariates such as age, hypertension, hyperlipid-emia, smoking, and diabetes mellitus.16 Overall, a com-prehensive meta-analysis of 83 studies found optimism tobe positively and independently related to physical health,including healthy cardiovascular outcomes, less pain,fewer cancer symptoms, greater immunological function-ing, and reduced mortality.17

Other positive attributes have also been linked to areduced risk of developing cardiac illness. Vitality, inaddition to optimism, was independently associated with
reduced risk of incident heart disease in a cohort of 7942

DuBois et al.

healthy adults, taken from a larger study.32,37 In anotherstudy of a large subsample (over 6000 patients) from theNational Health and Nutrition Examination Surveys Istudy, there was a significant association between greaterpositive affect (feelings of enthusiasm, vitality, and inter-est) and reduced risk of heart disease, even after control-ling for health behaviors and depressive symptoms.22

In addition to reduced risks of cardiac illness, positivepsychological attributes might reduce rates of mortality inthis cohort. In a sample of more than 800 patients under-going cardiac catheterization, Brummett and colleagues38

found that greater positive affect was associated with sur-vival over the course of an average prospective time frameof 11 years; however, this association failed to remainafter adjusting for negative affect. Finally, a recent, com-prehensive meta-analysis of 26 studies (involving morethan 50,000 participants) found that subjective well-beingwas associated with lower rates of mortality in both ini-tially healthy and medically ill populations, independent ofmedical disease state and treatment.39

Possible Mechanisms Connecting Positive PsychologicalAttributes and Cardiac Outcomes

Published models linking positive emotions with car-diac outcomes include both behavioral and physiologiccomponents.15 Individuals with greater optimism andother positive psychological states may have superior car-diac outcomes because they are more likely to engage inhealthy behaviors, such as healthy eating, physical activ-ity, smoking cessation, and medication adherence, each ofwhich is associated with superior cardiac outcomes.22,40

Positive attributes have also been associated with lesserabnormalities of physiologic biomarkers that are linkedto cardiac outcomes, such as measures of inflammationand autonomic nervous system activity. We will firstreview the impact of positive attributes on cardiachealth behaviors.

Health Behaviors

Diet

Optimism has been linked to healthier baseline dietand superior dietary adherence. Kelloniemi and col-leagues41 found that young Finnish adults with greateroptimism consumed a greater quantity of fruits, vegeta-bles, and high-fiber foods, and a smaller quantity of alco-
hol, coffee, and candy. Optimism may also facilitate

healthy dietary change, as suggested by a large study ofpostmenopausal women enrolled in the large Women’sHealth Initiative Dietary Modification Trial. Women withgreater optimism at baseline who were randomized to thelow-fat intervention arm of the trial were more likely tohave beneficial dietary changes change in all three studieddomains (fat, fruit/vegetable, grain) at the one-year fol-low-up.42 Similarly, the Zutphen Elderly Study that fol-lowed elderly men for as many as 15 years found thatdispositional optimism was linked to a greater likelihoodof healthy dietary changes, defined as greater consumptionof fruit, vegetables, and whole grain bread.33

Physical Activity

Several studies suggest that older adults with greateroptimism have higher rates of physical activity, anotherfactor essential to cardiac health.33,40,43 The Zutphen El-derly Study found that dispositional optimism was signif-icantly associated with increased physical activity, inde-pendent of age, education, living arrangement, self-ratedhealth, cardiovascular disease, diabetes mellitus, cancer,and body mass index.33 Steptoe and colleagues40 foundthat dispositional optimism in older adults was associatedwith brisk walking (in both sexes) and vigorous physicalactivity (in women), independent of multiple relevant co-variates, such as age, chronic illnesses, medication count,socioeconomic status, and BMI. In addition, Browningand colleagues43 found that optimism may influence ad-herence to a recommended exercise routine. Older adultswho held healthy attitudes about exercise, including opti-mism and the concept that health behavior is under one’sown control (e.g., “there is a lot that older adults can do tostay healthy,”) were more likely to engage in exercise.

Smoking

At least four studies have suggested that optimisticindividuals are less likely to smoke. The previously notedstudies of older adults led by Giltay and Steptoe that founddispositional optimism to be independently linked withphysical activity also found optimism to be independentlyassociated with lower rates of smoking.33,40 In a studyperformed in Finland, the proportion of current smokerswas lower among optimistic men and women, and indi-viduals with greater optimism were likely to be catego-rized as having no lifetime smoking history.41 A finalstudy found that middle school students with greater op-
timism reported less frequent use of cigarettes.44 Though


optimism is associated with decreased smoking, unrealis-tic optimism (also referred to as optimistic bias, discussedfurther below) may impede attempts to quit smoking be-cause patients may underestimate the difficulties inherentin smoking cessation.45

Adherence to Medical Treatment

There is extensive work in patients with human im-munodeficiency virus (HIV) linking positive psychologi-cal attributes and medication adherence,46–48 but morelimited evidence in cardiac patients. A study of patientsundergoing heart transplant for end-stage cardiac diseasefound that optimism about the upcoming transplant oper-ation was associated with greater adherence to the com-plex post-transplant medication regimen in the 6 monthsfollowing the procedure.49 A larger study of over 1000patients with hypertension found that a ‘sense of coher-ence’ (a sense of having a meaningful life and a sense thatlife challenges can be understood and controlled), but notoptimism, was associated with adherence to antihyperten-sive medications.50

In sum, positive psychological attributes have beenlinked with improved adherence to a number of behaviorsthat are important to cardiovascular health. Such behaviorshave included healthy eating, exercise/activity, smokingcessation, and medication adherence. Additional studieshave also found links between positive attributes and otherhealth-related behaviors, such as alcohol use and sleepquality.31

Positive Psychological Attributes and PhysiologicChanges

Positive attributes have also been linked to biologicalindicators of superior cardiac outcomes, though the resultsof studies of this association have been somewhat mixed.

Autonomic Function

Autonomic dysfunction is associated with adversecardiac outcomes, including mortality.51,52 Optimism andother positive attributes have been associated with reducedautonomic dysfunction. Positive affect has been linked toindividual differences in resting respiratory sinus arrhyth-mia (an index of autonomic nervous system function),53

and optimism has been linked to lower systolic and dia-stolic ambulatory blood pressure.54 In addition, positiveaffect has shown associations with less reactivity of blood
pressure and heart rate to stress,55 and faster cardiovascu-

lar recovery from the induction of negative emotionalstates including fear and sadness.55,56 Among patientswith coronary artery disease, higher levels of positiveaffect were associated with increased vagal control, dem-onstrated by increases in the low-frequency power com-ponent of heart rate variability; this relationship held aftercontrolling for covariates that included age, medications,and posture of participant.57 Positive affect was also as-sociated with more rapid recovery of heart rate variabilityfollowing exposure to mental stress in a cohort of collegestudents.58 In contrast, Ryff and Singer59 did not findpositive psychological well-being to be associated withresting systolic blood pressure in a study of older women.

Inflammation

Elevated inflammatory markers are predictors of ad-verse cardiac events.60–62 Studies of the association be-tween positive attributes and inflammation have beenmixed. Three carefully controlled studies in large prospec-tive cohorts, and two smaller epidemiologic studies, havefound some association between positive affect/optimismand inflammatory markers. In the prospective Multi-Eth-nic Study of Atherosclerosis (MESA) study63 of over 6000men and women, dispositional optimism was measured viaLOT-R. Dispositional optimism in this cohort was associ-ated with lower levels of interleukin-6 (IL-6), C-reactiveprotein (CRP), and fibrinogen. After correcting for so-ciodemographic factors, negative psychosocial factors,health behaviors, body mass index, hypertension, and di-abetes mellitus, only an association between the LOT-Rpessimism subscale (not the optimism subscale) and fi-brinogen remained. Steptoe and colleagues64 assessed par-ticipants’ responses to stress in a laboratory setting andfound that persons reporting higher levels of happinesshad smaller plasma fibrinogen responses to stress, inde-pendent of psychological distress, gender, age, body massindex, smoking status, and socioeconomic status.

A study of 2873 healthy adults taken from a largerprospective study37 found positive affect and life satisfac-tion to be associated with lower IL-6 and CRP in womenbut not men.65 Similarly, Prather and colleagues66 foundthat positive affect was associated with lower IL-6, spe-cifically in older women, after controlling for relevant riskfactors and depression. A recent analysis of data from 340older men without existing heart disease (taken from theVA Normative Aging Study) found optimism to be asso-ciated with lower IL-6, a result that remained significant
after adjusting for multiple covariates including depressive

DuBois et al.

symptoms.67 In contrast, Friedman and colleagues68 didnot find an association between IL-6 and older women,even after controlling for depression and cardiac risk fac-tors.

Additional Physiologic Effects

Endothelial dysfunction is independently associatedwith adverse cardiac outcomes,69 and negative psycholog-ical syndromes (e.g., depression) have been linked to en-dothelial dysfunction.70 The previously noted analysisfrom the Normative Aging Study found optimism to bepositively associated with one marker of endothelial func-tion (soluble intracellular adhesion molecule [sICAM] re-ceptor) in multivariate models, though not with a second,related marker (soluble vascular cell adhesion molecule[sVCAM]).67 Activation of the hypothalamic-pituitary-ad-renal axis/hypercortisolemia has also been linked to car-diac health, and positive affect and optimism have bothshown inverse relationships with cortisol levels.71

Much of the work on the physiological benefits ofpositive attributes has focused on optimism or momentarypositive emotions. However, a systematic study in womenage 65 years and older assessed the association betweenmultiple biological indicators of physical health and eu-daimonic well-being (eudaimonic well-being is an aggre-gate of positive constructs that includes purpose, self-actualization, autonomy, and positive relations withothers; this is in contrast to hedonic well-being, a constructassociated with happiness, pleasure attainment, and painavoidance68,72–74). In a preliminary exploration of eudia-monic- and hedonic well-being and medical health, a senseof personal growth and life purpose were linked to higherhigh-density lipoprotein (HDL) cholesterol and lower sal-ivary cortisol. Higher life purpose scores were also asso-ciated with lower levels of IL-6 receptors.72 Furthermore,multiple eudaimonic constructs/factors were also associ-ated with lower glycosylated hemoglobin. Indicators ofhedonic well-being were not associated with most biolog-ical factors.

In other studies examining associations between pos-itive attributes and cardiovascular risk factors, Richmanand colleagues75 found that in graduate students and gen-eral medicine patients, vitality was associated with lowercholesterol during a 1-year period, taking into account age,gender, smoking, anger, anxiety, exercise, alcohol intake,and marital status. However, a study by Shepperd andcolleagues76 found no association of dispositional opti-
mism with HDL, low-density lipoprotein (LDL), or total

cholesterol, after controlling for age, depression, and rel-evant risk factors.76

Overall, there have been some links between positiveattributes and physiologic markers of cardiovascularhealth. However, these links appear to be less consistentand less powerful than the links between these positiveconstructs and health behaviors. Additional research, us-ing large cohorts, controlling for multiple relevant cova-riates, and simultaneously including measures of healthbehavior and biomarkers, is needed to further clarify theseconnections.

Major Issues

Are the Number and Quality of Existing Studies Sufficientto Support a Claim that Positive Attributes Cause BetterCardiac Outcomes?

At this stage, it would be premature to claim thatpositive psychological attributes cause superior cardiacoutcomes. The medical literature is filled with examplesof initially promising results and associations later con-tradicted by additional, larger, and better-controlledstudies,77 and given the limitations of the extant litera-ture on positive attributes, caution is warranted. Thereis substantial variability in the positive psychologicalconstructs being studied, and some studies suffer fromlimitations related to sample size and use of cross-sectional (rather than prospective) data. At the sametime, there are now a substantial number of prospectivestudies in this field, and the vast majority of such stud-ies have found a significant association between posi-tive states and medical outcomes.

Regarding the heterogeneity of psychological attri-butes and measures, it is certainly true that multiple pos-itive psychological constructs have been examined using avariety of measures. However, as noted, there is mountingevidence for dispositional optimism as an attribute that isconsistently linked to superior outcomes, and this con-struct has been measured using the LOT-R in nearly allrecent studies.15–17,32–34

Although the use of relatively small samples andcross-sectional trials dot this literature, there are severallarge, prospective studies examining the links betweenpositive attributes and cardiac health. A number of theabove studies have been prospective epidemiologicstudies 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 directional-


ity, given that following a healthy diet, exercising, and/orhaving lower levels of inflammation may well lead to sub-sequent optimism, vitality, and overall well-being. Anotheralternative is the possibility of bidirectionality, with positivestates leading to better behavior/physiology, and such im-provements in behaviors and physiology facilitating the fur-ther development of positive psychological attributes. Morelarge, prospective studies in a variety of populations willfurther strengthen the literature. Additional work on the in-dependence of positive psychological constructs from oneanother is needed.

Do the Studies Linking Positive Attributes and CardiacHealth Account Properly for Relevant Sociodemographicand Medical Variables? Do They Controlfor Depression?

The issue of covariate control is a vital one in estab-lishing an independent relationship between positive attri-butes and medical outcomes. In the meta-analysis exam-ining positive states and mortality by Chida andcolleagues,39 the majority of studies that demonstrated aprotective relationship between positive states and mortal-ity controlled for sociodemographic factors such as age,sex, race, and socioeconomic status, and those in medi-cally ill populations generally controlled for basal diseasestate. Furthermore, the majority of studies on positivepsychological states and cardiac outcomes consider keycardiac risk factors (i.e., physical activity, hypertension,diabetes mellitus, smoking, and hyperlipidemia). Somestudies control for all of these factors,16,22,24,32 and somecontrol for the majority of these factors.18–20,25,34,78 Ofnote, however, one study controlled for all five risk factorsbut did not find a significant result after adding negativeaffect into the analysis.79

Regarding depression, at least eight studies haveadditionally controlled for depressive symptoms usingvalidated scales that included the Center for Epidemi-ologic Studies-Depression scale (CES-D),80 HospitalAnxiety and Depression Scale (HADS),81 HamiltonRating Scale-Depression (HRS-D),82 and Beck Depres-sion Inventory (BDI).83 Even after controlling for de-pression, six studies still found relationships betweenpositive states/attributes—in the forms of life orienta-tion, satisfaction with aging, and optimism—with all-cause mortality.84 – 89 The remaining two studies, men-tioned earlier, found relationships between positivestates and lower IL-667 and reduced risk of heart dis-
ease22 after controlling for depression. However, some

studies noted above found that links between positivestates and medical outcomes did not remain after con-trolling for ‘negative affect’.38,68,79

What About Controlling for Negative Psychological StatesOther than Depression?

This is an important issue, given that anxiety andanger have been associated with adverse cardiac out-comes, and that anger/hostility in particular has beenlinked with cardiac outcomes in randomized controlledtrials. For example, Friedman and colleagues90 foundthat in patients with a prior myocardial infarction andType A personalities (a group of personality traits char-acterized by hostility, ease of arousal, and time-ur-gency), a 4.5-year behavioral counseling program totarget their personalities led to reductions in cardiacmorbidity and mortality, compared with a control groupwho received only cardiac counseling. During a 1-yearfollow-up, the counseling group continued to have sig-nificantly lower rates of mortality compared with thecontrol condition.91 An ongoing limitation of positivepsychology literature is the lack of control in somestudies for negative psychological states other than de-pression. However, in addition to the previously notedstudies that controlled for depression, there are a sub-stantial number of studies that controlled for negativestates (such as anxiety, anger, hostility, or aggression).

With respect to anxiety, a pair of studies examiningthe links between vitality and outcomes did control forboth depression and anxiety, and these studies foundindependent associations between all-cause mortality21

and non-cardiac mortality,22 respectively. Overall, atleast six studies in this field have controlled for anxiety,with all demonstrating an association between positiveemotional states and improved outcomes, independentof anxiety.18 –20,23,75,78

At least five studies in this field have controlled forhostility, and all such studies found an independentassociation between positive emotional states and im-proved outcomes.18,19,23–25 A study by Richman andcolleagues75 controlled for both anger and anxiety, andfound that mental vitality was associated with reducedprevalence of heart disease, independent of traditionalrisk factors that included age, gender, smoking, maritalstatus, exercise, and alcohol intake. For additional in-formation regarding these important issues, see Boehm
and Kubzansky.31

DuBois et al.

When Measuring Positive Attributes, Aren’t We SimplyMeasuring an Absence of Depression and Other NegativeConstructs?

First, as noted, many of the studies cited have foundthat positive attributes (e.g., optimism) are linked withsuperior outcomes even after controlling for depression,suggesting that these attributes have independent effectson outcome. Furthermore, though there is clear overlapbetween positive attributes and negative states such asdepression, these constructs only have some associationwith one another in clinical samples. For example, opti-mism and depression appear to demonstrate a moderatecorrelation with one another (r � �0.28 to 0.60 [medianr � �0.43]) in ten identified studies examining such cor-relations (see Table 1).35,92–100 Even in cardiac patientswith known depression, a recent analysis of a large trial ofcardiac surgery patients found that optimism was notstrongly correlated with depressive symptoms (r ��0.27), and optimism was associated with decreased riskof rehospitalization independent of depressive symp-toms.100 Similar correlations are seen with other positive

TABLE 1. Correlations between Positive Attributes and Negativ

Study Population

Achat et al. (2000)93 Healthy middle- to older-aged menBandiera et al. (2002)100 Healthy college studentsde Moor et al. (2006)92 Ovarian cancerHerzberg et al. (2006)35 Healthy and medically ill

(diabetes, CHD, hypertension,hyperlipidemia)

Hirsch and Britton (2010)99 Opiate dependenceMorgenstern et al. (2011)94 StrokeRajandram et al. (2011)97 Cancer survivorsScheier et al. (1994)95 Healthy college studentsScioli et al. (1997)96 Healthy college studentsTindle et al. (2012)98 Coronary artery bypass graftChipperfield et al. (2000)134 Elderly community-dwelling adults

McCullough et al. (2002)136 Healthy college studentsMcCullough et al. (2002)136 Healthy college students

Puskar et al. (2008)140 Healthy rural adolescents

BDI � Beck Depression Inventory; BSI � Brief Symptom InventDispositional Envy Scale; GQ-6 � Gratitude Questionnaire-6; HADScale-Depression; LOT � Life Orientation Test; LOT-R � Life Orien
Screening Questionnaire; PHQ-9 � Patient Health Questionnaire-9; STAXI �

attributes and depression, and with other negative statessuch as anxiety and anger, though these relationships areless well-studied (Table 1).

Positive Psychology Interventions

Positive psychological attributes appear to be im-portant to health, but can they be cultivated or taught?Careful study of the factors contributing to positivepsychological well-being have estimated that after ac-counting for other factors (genetic, demographic, andcultural factors, and external life events), intentionalchoices and behaviors account for approximately 40%of the variance in well-being.101,102 Positive psychologyinterventions—which promote intentional behaviors toimprove well-being— have targeted activities in severaldomains, including altruism, optimism, gratitude, andusing one’s strengths of character (Table 2). Such ex-ercises are typically brief, easy to administer, and havelow provider and participant burden.103 Most of theseexercises involve brief instruction about the details andrationale for the task, followed by independent comple-

ological Constructs

ositive Attribute Negative ConstructCorrelation

Coefficient (r)

mism (LOT)131 Depression (CES-D)80 �0.44mism (LOT-R)35 Depression (BDI)83 �0.42mism (LOT-R)35 Depression (CES-D)80 �0.39mism (LOT-R)35 Depression (DSQ)132 �0.47

mism (LOT-R)35 Depression (CES-D)80 �0.60mism (LOT-R)35 Depression (PHQ-9)133 �0.31mism (LOT-R)35 Depression (HADS)81 �0.55mism (LOT)131 Depression (BDI)83 �0.42mism (LOT)131 Depression (CES-D)80 �0.28mism (LOT-R)35 Depression (HRS-D)82 �0.34satisfaction (LSIA)135 Sadness �0.29

Anger (Self-reportedfrequency in prior 2days)

�0.21

itude (GQ-6)137 Anxiety (BSI)138 �0.20itude (GQ-6)137 Envy (before

controllingcovariates) (DES)139

�0.39

mism (LOT-R)35 Anger (state) �0.29Anger (trait)

(STAXI)141–0.21

S-D � Center for Epidemiologic Studies-Depression scale; DES �ospital Anxiety and Depression Scale; HRS-D � Hamilton RatingTest-Revised; LSIA � Life Satisfaction Index A; DSQ � Depression

e Psych

P

OptiOptiOptiOpti

OptiOptiOptiOptiOptiOptiLife

GratGrat

Opti

ory; CE� H

tation
State-Trait Anger Expression Inventory.


TABLE 2. Sample Positive Psychology Exercises

Exercise (Domain) Summary/Instructions to Participants Selected Impact

Best possible self (Optimism) 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 topersistent improvements in well-being long after the intervention.143

Best future social relationships(Optimism)

Imagine your best possible interpersonal relationships (with family, friends, and colleagues) over the nextseveral 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 apilot study of cardiac patients, with good effect.104

Counting blessings (Gratitude) 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

Gratitude letter (Gratitude) Recall another person’s kindness and write a letter that describes the feelings of gratitude associated withthis event.

Completing a gratitude letter led to sustained improvement of well-being for up to 6 months in onestudy.143

Benefit finding (Gratitude) Write about your genuine feelings toward medical illness and any benefits that may have resulted from thissituation.

Women with breast cancer who completed this exercise had reduced physical symptoms, fewer medicalappointments, and better heart rate habituation to stress than control subjects.145

Three acts of kindness(Altruism)

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 toperform all of their kind acts on the same day given evidence that such clustering may be mosteffective.101

Pleasurable and meaningfulacts (Purpose, Happiness)

Complete three acts in a single day: a pleasurable act done alone (e.g., gardening), a pleasurable act donewith others (e.g., walking with friends), and a meaningful or important act (e.g., creating a blood sugarlog).

This exercise aims to help participants foster engagement, pleasure, and meaning in their lives, as all threedomains have been linked to life satisfaction.147

Using strengths (Strengths) 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 6-months post-treatment.29

Forgiveness letter(Forgiveness)

Write a letter of forgiveness to a person who did or said something that made you upset. If you cannotforgive 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 ifthe participant experiences the forgiveness as genuine.148

Forgiveness exercises(Forgiveness)

At least two years after a hurtful event, engage in exercises related to defining forgiveness, examiningemotions, 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 andidentification with “survivor status,” compared with attentional controls.149

Loving-kindness meditation(Life satisfaction)

Utilize a focused form of meditation aimed at cultivating mindfulness and loving feelings toward self andothers.

This intervention has been linked to reduced depressive symptoms and increased life satisfaction, primarilythrough increases in positive emotions.150

Cultivating sacred moments(Spirituality)

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 ofmeaning and purpose in life.151

Positive writing (Happiness/joy)

Write about the most positive, happy, ecstatic moments of your life. Include all of the emotions youexperienced. Think also about how you can use this experience now to tap into inspiring, positivefeelings.

152
Subjects who completed this exercise reported higher levels of life satisfaction compared with controls.
310 www.psychosomaticsjournal.org Psychosomatics 53:4, July-August 2012

DuBois et al.

tion of the exercise by the participant. In some cases,the ‘instructor’ and participant reconvene to discuss theprocess and outcome of the exercise.

Positive psychology interventions have consistentlybeen linked to increased positive emotions and cogni-tions,30 especially if the exercises are systematically per-formed, episodic, varied, and meaningful to the partici-pant. Completing activities in an intensive but intermittentmanner appears to be important. For example, participantsin one study asked to perform one act of kindness on fiveseparate days each week experienced no gains in well-being, but experienced significant gains when asked toperform the five separate acts of kindness in a singleday.101

Below, we review the literature on positive psychol-ogy interventions. To date, most of these exercises havebeen studied in healthy research subjects or depressedindividuals. There has been substantially less study ofthese exercises in medically ill populations.

Positive Psychology Interventions in Healthy Individuals

Over 20 different positive psychology exerciseshave been used in intervention studies in healthy sub-jects (see Table 2 for sample exercises). These exerciseshave been administered in person or remotely over theinternet, have been performed in a variety of cohorts(e.g., college students, elderly persons), and have con-sistently led to short-term gains. A meta-analysis by Sinand Lyubomirsky30 of more than 50 trials involvingmore than 4000 participants found that positive psy-chology interventions have consistently led to increasesin self-reported life satisfaction, other well-being indi-cators (e.g., positive affect, optimism), and reductionsin depressive symptoms; this includes positive changesin ‘trait-like’ dispositions such as dispositional opti-mism.104,105 The authors found that the overall effectsize of positive psychology interventions on depressivesymptoms (r � 0.31; medium effect size) was essen-tially identical to that seen in reviews of standard (andtypically much more intensive and costly) psychother-apies (r � 0.32).106 These effects were also greater thanthe calculated effect size for antidepressants on moodsymptoms in depressed patients (d � 0.32; small effectsize) in recent reviews.36,107

There has been much less study of the sustainabilityof gains in positive attributes in this population. However,Cohn and Fredrickson108 conducted a follow-up of a lov-
ing-kindness meditation intervention for healthy partici-

pants. They found that participants who were randomizedto the intervention maintained the gains they made duringthe initial intervention, including greater mindfulness, in-creased social support, reduced illness, and greater lifesatisfaction over a 15-month follow-up.

Positive Psychology Interventions in DepressedIndividuals

Positive psychology interventions have also beenstudied in patients with depression. Using a random-ized, placebo-controlled design in patients with mild tomoderate depression, Seligman and co-workers29 foundthat a subset of positive psychology exercises led toimmediate reductions in depressive symptoms. Partici-pants were randomized to completion of one of sixpositive psychology exercises or to a control condition,and three of the six exercises (documenting daily threereasons to feel grateful, completing a gratitude visit,and using strengths in new ways) were associated withsignificantly greater ratings of happiness compared withthe control group. Though patients in the experimentalcondition only completed these exercises for 1 week,two of the exercises (three reasons to feel grateful anduse of strengths) were associated with persistent andsignificant reductions in depressive symptoms at the6-month follow-up, compared with patients in the con-trol condition.

In another pair of studies, this same research groupfirst evaluated a six-exercise group positive psychother-apy intervention over 1 year in young adults with mildto moderate depression. Compared with individuals inthe no-treatment group, participants receiving the inter-vention had a significant decrease in depressive symp-toms. Next, the authors found that individual positivepsychotherapy delivered to outpatients with major de-pression over the course of 1 year led to greater remis-sion rates than did treatment as usual and treatment asusual plus medication.103

Additionally, Freedman and co-workers109 examinedthe effect of a forgiveness intervention on female survi-vors of incest who also suffered from depression. The12-week once-weekly intervention focused on confrontingnegative emotions, reframing the situation, using empathyand compassion, and recognizing negative feelings asso-ciated with the situation. After the intervention, the exper-imental group experienced significantly reduced rates ofanxiety and depression and increased hope and enthusi-
asm, relative to the control group.


Positive Psychology Interventions in Those with Noncar-diac Medical Illness

Although some ‘resiliency programs’ in medical pa-tients have included small components of positive psy-chology interventions,110,111 specific trials of positive psy-chology interventions in the medically ill have beenrare.112 Regarding noncardiac populations, there havebeen several small studies of positive psychology inter-ventions in cancer patients, and there is some suggestionthat these interventions improve social support and qualityof life, reduce pain and anxiety, and promote adher-ence.113–115 However, such interventions have not beenlinked to substantial improvements in ‘harder’ outcomes,such as survival times or biomarkers. We are not aware ofpositive psychological interventions in patients with otherchronic non-cardiac diseases, such as renal disease, dia-betes, or HIV.

Positive Psychology Interventions in Cardiac Populations

While there has been minimal study of positivepsychology interventions in patients with cardiac dis-ease, related interventions have been used in this pop-ulation. Mindfulness-based stress reduction (MBSR)provides systematic training in mindfulness meditationas a self-regulation approach to stress reduction andemotion management.116,117 At least three small studiesof cardiac patients found MBSR to be associated withreduced psychological symptoms and distress, and insome studies, improved quality of life and decreasedphysical symptoms.118 –120

Similarly, the relaxation response (RR) uses medi-tation in the form of guided relaxation,121 and has beenfound to lower blood pressure in healthy adults122 andto reduce tension, anger, and rates of supraventriculartachycardia in cardiac surgery patients (without effectson other physiologic variables/outcomes).123 In a ran-domized trial, RR decreased systolic blood pressure(approximately 9 mmHg) in elderly patients with stageI systolic hypertension, allowing significantly more par-ticipants in the RR group to eliminate an antihyperten-sive medication, compared with a lifestyle modificationgroup.124

However, it appears that there have been only twosystematic positive psychological intervention trials forcardiac patients. Charlson and colleagues112 have re-ported methods, but not results, from a randomized
controlled trial that aimed to help three populations

(persons with hypertension, asthma, and coronary arterydisease) increase positive affect and feelings of self-affirmation over the course of 12 months. Huffman andcolleagues104 completed a three-arm, randomized feasi-bility study among patients recently hospitalized for anacute coronary syndrome or heart failure. This trialcompared positive psychology exercises related to op-timism, altruism, and gratitude to two control condi-tions (RR and an attentional control). The authors foundthe positive psychology intervention to be feasible andto have greater effects than the two control conditionson mood, anxiety, happiness, and mental health-relatedquality of life. However, this small exploratory trial(n � 26 completers) had insufficient power to detectsignificant between-group differences and these find-ings must be replicated.

Major Issues

Why Not Focus on the Effects of Antidepressant Treatmenton Cardiac Outcomes?

Depression in cardiac patients is an important pub-lic health problem and must be addressed. However,only a minority of cardiac patients have clinical depres-sion that requires treatment, and there is no evidencethat antidepressant treatment has utility in patients withsubsyndromal depressive symptoms.125 Furthermore,the impact of antidepressants alone on depressive symp-toms has been relatively modest (and in some cases notbetter than placebo)107 and prospective studies have notyet found that antidepressants are linked to reducedcardiac events or mortality,10,12,126 though there is somesuggestive data from epidemiologic studies.127,128 Incontrast, many patients may benefit from a boost inoptimism or other positive states in the context of med-ical illness, and such an intervention might impacthealth behaviors or physiology. Whether positive psy-chological interventions are effective in this populationis, as yet, entirely unclear.

Might an Intervention that Cultivates Positive StatesCause “Optimistic Bias”?

Optimistic bias is an inaccurate, unrealistic beliefthat positive outcomes will be easily accomplished(such as attaining remission from cancer or terminatingsmoking). Such bias may be associated with less con-
sistent or planful efforts in these conditions, lowering

DuBois et al.

rates of success,45,129 for example, in smoking cessationwhen patients overestimate the ease with which theycan quit.119,120 However, positive psychological inter-ventions generated for medically ill cohorts should ad-dress (and could actually decrease) the risk of optimisticbias. A well-designed positive psychology interventionshould not ignore the obstacles to wellness or the en-dorsement of unrealistic thinking, but instead wouldfocus on cultivating and maintaining positive attributesand using these attributes to reasonably navigate chal-lenging life circumstances.

Why Are There so Few Intervention Studiesin This Area?

Though there is a growing literature on the connec-tions between positive attributes (especially optimism)and cardiovascular outcomes, there is still much to belearned regarding the design and delivery of interven-tions targeting these attributes. The field needs clarifi-cation on the attributes and strengths of character (e.g.,positive affect, optimism, mindfulness, meaning andpurpose in life, gratitude) with the strongest, most con-sistent associations with cardiac health so these may bespecifically targeted. In particular, eudaimonic well-being indices (e.g., meaning and purpose in life) mightrepresent deeper, more valuable targets than indices ofhedonic well-being (e.g., life satisfaction, positive emo-tions, optimism).

Furthermore, though positive psychology interven-tions exist, the majority has been in nonclinical cohorts,and much work will need to be done to adapt interven-tions to be acceptable, relevant, and effective in patientswith significant medical illness. There are additionalconsiderations worthy of contemplation in the refine-ment of positive psychology interventions. For exam-ple, should the interventions in this cohort be combinedwith other established interventions (e.g., behavioralactivation or motivational interviewing) for maximumeffect? Are there situations in which optimism or otherstates should not be cultivated, such as situations whenunrealistic optimism impedes adherence or providesfalse hope? Given that this field is in its relative infancyand that both the intervention target and the methodol-ogy of interventions need further refinement, it is notsurprising that intervention studies have yet to be prev-alent, and certainly there is insufficient evidence for
routine use in clinical practice.

Future Directions

In summary, positive attributes are associated withimproved cardiac outcomes, and this connection is likelymediated by both behavioral and physiologic factors. Pos-itive psychology and related interventions may represent ameans by which positive states and strengths of charactercan be cultivated in patients with—or at risk for—cardiacdisease, though these interventions have not been well-studied in cardiac patients in clinical care settings. Thoughthis line of work has great potential, the field must be cautiousabout these interventions and their effects. Some studies link-ing positive attributes to medical or behavioral outcomeshave been cross-sectional, preventing assessment of causal-ity. Associations between positive attributes and health out-comes may be explained by variables or factors that were notaccounted for in statistical analyses. For example, given theclear links between anxiety and depressive disorders withpoor outcomes, it is important to conduct tests of constructspecificity to ensure that links between positive attributes andsuperior outcomes exist independently of negative psycho-logical syndromes. Even if positive attributes are prospec-tively linked to major cardiac outcomes, there remains apaucity of data regarding whether psychological interven-tions that target these states actually impact objective medicaloutcomes; indeed, this is a lesson hard-learned from the de-pression treatment literature.10–12,130 Furthermore, there ismuch still to be learned regarding the best psychologicaltarget for these interventions and the methods (e.g., content,frequency, duration, mode of delivery) of potential positivepsychology interventions in this population.

Future studies that address these issues have the po-tential to open up a new line of clinically-relevant work inpsychosomatic medicine that could lead to improved well-being and health for the large number of patients who havecardiovascular illness.

This work was supported in part by grant R01-DP00336 from the United States Disease Control andPrevention (CDC) to Herbert Benson. Todd Kashdan wasfunded by the Center for Consciousness and Transforma-tion at George Mason University.

The authors thank Dr. Julia Boehm for providinglinks to published literature and additional informationon positive psychological well-being and cardiachealth.

Disclosure: The authors disclosed no proprietary orcommercial interest in any product mentioned or concept
discussed in this article.


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