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JMIR Ment Health. 2018 Oct-Dec; five(4): e11290.

Online Positive Affect Journaling in the Improvement of Mental Distress and Well-Being in General Medical Patients With Elevated Anxiety Symptoms: A Preliminary Randomized Controlled Trial

Monitoring Editor: John Torous

Joshua Thousand Smyth, PhD, ^{ane, ii} Jillian A Johnson, PhD,^one Brandon J Auer, PhD,² Erik Lehman, MS,³ Giampaolo Talamo, MD,² and Christopher N Sciamanna, MD, MPHⁱⁱ

^one Section of Biobehavioral Wellness, The Pennsylvania Country University, Academy Park, PA, U.s.a.

ⁱⁱ Department of Medicine, Penn State Higher of Medicine, The Pennsylvania Land Academy, Hershey, PA, U.s.

³ Department of Public Health Sciences, Penn State College of Medicine, The Pennsylvania State Academy, Hershey, PA, United States

Joshua Chiliad Smyth, Department of Biobehavioral Health, The Pennsylvania State Academy, 231 Biobehavioral Wellness Building, The Pennsylvania Land University, University Park, PA, 16802, United States, Phone: 1 8148638402, Email: ude.usp@7811smj.

Joshua M Smyth

¹ Department of Biobehavioral Health, The Pennsylvania State University, Academy Park, PA, United States

² Section of Medicine, Penn Land College of Medicine, The Pennsylvania State University, Hershey, PA, U.s.a.

Jillian A Johnson

¹ Department of Biobehavioral Health, The Pennsylvania Land University, Academy Park, PA, United States

Brandon J Auer

² Department of Medicine, Penn State College of Medicine, The Pennsylvania Country University, Hershey, PA, United states

Erik Lehman

ⁱⁱⁱ Department of Public Health Sciences, Penn State Higher of Medicine, The Pennsylvania Country University, Hershey, PA, Usa

Giampaolo Talamo

² Section of Medicine, Penn State College of Medicine, The Pennsylvania State University, Hershey, PA, Us

Christopher N Sciamanna

ⁱⁱ Department of Medicine, Penn Land Higher of Medicine, The Pennsylvania State University, Hershey, PA, U.s.

Received 2018 Jun 13; Revisions requested 2018 Jul 25; Revised 2018 Sep 14; Accepted 2018 Sep 16.

Supplementary Materials

Multimedia Appendix 1.

Result variables over time.

GUID: D4E557AC-EB35-4DCA-B6E6-6E35FB5D4A8A

Multimedia Appendix ii.

CONSORT‐EHEALTH checklist (5 1.6.1).

GUID: 55D4F07D-C889-45B7-803F-87025F9573D8

Abstract

Background

Positive affect journaling (PAJ), an emotion-focused cocky-regulation intervention, has been associated with positive outcomes among medical populations. It may exist adapted for Web-based broadcasting to address a need for scalable, evidence-based psychosocial interventions among distressed patients with medical weather.

Objective

This study aimed to examine the impact of a 12-week Spider web-based PAJ intervention on psychological distress and quality of life in general medical patients.

Methods

A total of 70 adults with various medical weather condition and elevated anxiety symptoms were recruited from local clinics and randomly assigned to a Web-based PAJ intervention (n=35) or usual intendance (north=35). The intervention grouping completed 15-min Web-based PAJ sessions on iii days each week for 12 weeks. At baseline and the end of months 1 through 3, surveys of psychological, interpersonal, and physical well-being were completed.

Results

Patients evidenced moderate sustained adherence to Spider web-based intervention. PAJ was associated with decreased mental distress and increased well-being relative to baseline. PAJ was also associated with less depressive symptoms and anxiety after 1 month and greater resilience later on the beginning and 2d month, relative to usual intendance.

Conclusions

Web-based PAJ may serve as an effective intervention for mitigating mental distress, increasing well-being, and enhancing physical functioning among medical populations. PAJ may be integrated into routine medical intendance to improve quality of life.

Keywords: adult, anxiety, depression, emotions, expressed emotion, internet, stress, psychological/physiopathology, surveys and questionnaires, treatment effect, writing

Introduction

Background

At nowadays, 60% of all people living in the United States have at least one chronic health status, and 42% accept multiple chronic conditions [i]. As advances in the treatment of disease continue to prolong life and the overall population continues to age, these numbers are likely to increase. The significant costs associated with managing medical conditions are well known. The majority of diseases agree the potential to worsen the overall wellness of patients past limiting their functional chapters, productivity, and health-related quality of life and are a major correspondent to health care expenditures [2-4]. Patients with medical conditions confront several challenges and often need to modify life aspirations, daily routines, and employment. Although some patients experience periods of grieving and adjustment subsequently a diagnosis, many others experience sustained distress that can further bear on concrete and mental health and quality of life [4]. Given the link between severe or chronic medical weather and psychological distress, it is not surprising that comorbidity between medical and mental health atmospheric condition is the rule rather than the exception [5]. The 2001 to 2003 National Comorbidity Survey Replication, for example, found that more than 68% of adults with a mental health disorder reported having at to the lowest degree ane general medical disease and that 29% of people with a medical status besides had a comorbid mental health problem [6,vii]. Stressful life events often precede anxiety and mood disorders [eight], and the accompanying psychological strain associated with the diagnosis of, and living with, a major medical illness places these patients at risk for comorbidity and worse health outcomes overall. Stress and dysphoric mood by and large may worsen the prognosis and progression of disparate diseases [nine,10] and is a major contributor to many of the leading causes of death in the United States such as cancer, coronary heart illness, respiratory disorders, and suicide, among others [11]. In light of evidence that stress and dysphoria might be a modifiable risk factor for the development and progression of medical illnesses, finding ways to reduce distress in patients with one or more existing medical conditions is a major public health concern.

Psychological interventions (eg, cognitive behavioral therapy, CBT) have been shown to reduce psychological distress in chronic disease populations [12-14]. Although psychological interventions are increasingly desirable amidst patients [15], there are several barriers to accessing contiguous psychological intendance amongst people with chronic health atmospheric condition (eg, toll or insurance coverage, access, and stigma) [15-eighteen]. The internet has emerged as an effective tool for disseminating efficacious mental health interventions [19] and may serve to overcome some of these barriers to accessing mental health services. For instance, a meta-assay of internet-based CBT interventions observed that they are constructive for reducing depression and anxiety [20], and a study by Farrer et al [21] observed a 44% reduction in depressive symptoms over 6 months among those randomized to net-based CBT versus simply 11% among controls. To date, withal, these evidence-based net interventions are either not readily accessible or widely disseminated among the general population and, therefore, do not address the problem of admission to psychological services.

Relative to internet-based therapeutic or counseling interventions, positive bear upon journaling (PAJ), a elementary intervention that is cost-efficient and easily disseminated to patients, is becoming increasingly pop. PAJ is a modified version of the traditional expressive writing paradigm [22,23] wherein the participants write about a traumatic experience for approximately 15- to 20-min intervals, often across a period of three to five days. Reviews of expressive writing suggested that it was modestly effective in improving a number of physical and mental health outcomes [24,25] although large heterogeneities in efficacy accept been documented.

For example, several studies have found clinical benefits tied to expressive writing in patients with autoimmune and inflammatory conditions such every bit arthritic conditions, lupus, and asthma [25-29], fibromyalgia [30,31], irritable bowel syndrome [32], and HIV or AIDS [33,34]. In improver, expressive writing has been constitute to have benign furnishings on blood pressure level [35] and on several health-relevant outcomes post-obit the experience of a eye attack such as reduced numbers of medical appointments and prescription medications, increased cocky-care behaviors, improved cardiac symptoms [36], and improved wellness-related quality of life [37]. Expressive writing has also been associated with small, but consistent, improvements to well-existence among various cancer groups—especially chest, renal, and prostate cancer patients [38]. Finally, a relatively small written report of 40 people diagnosed with major depressive disorder institute that those writing about their deepest thoughts and feelings related to emotional events had meaning reductions in depression immediately later on writing and over 1 month thereafter [39].

A number of efforts accept been fabricated to modify the original expressive writing approach to exist better suited for employ across several contexts and populations. One stream of this process is reflected in the integration of positive psychology, a big and growing area of research that has linked positive psychological and emotional dispositions and states of existence (eg, optimism, happiness, subjective well-beingness, and positive affect) to various beneficial outcomes. Some of the reported benefits of these positive dispositions include fewer physical symptoms [forty], faster wound healing [41], healthier functioning biological processes (eg, neuroendocrine, inflammatory, and cardiovascular action) [42], meliorate interpersonal relationships [43], college quality of life [44], increased longevity [45], and decreased morbidity [46,47]. As such, the expressive writing prototype has been adapted to have participants write almost positive aspects of their lives and themselves (eg, making meaning out of or finding benefit in past experiences [48,49] and focusing on positive aspects of one'southward self [50]) under the notion that this would yield similar benefits to those observed in the positive psychology literature. As a whole, we refer to this array of positive-focused writing approaches as PAJ.

Positive affect interventions among both patients and salubrious individuals have led to improvements in a number of health outcomes. In 2 studies comparing an educational control (ie, educational workbook and behavioral contract) with a positive impact intervention (ie, cocky-affirmation inducement over bimonthly phone sessions with staff and unexpected gifts before calls), positive affect improved medication adherence in hypertensive African American patients [51] and physical activity in patients following a percutaneous coronary procedure [52]. In addition, Stanton et al [53] found that 4 sessions of written expressive disclosure or benefit finding resulted in lower physical symptom reports and medical appointments amid breast cancer patients at iii-month follow-up. In healthy samples, Armitage et al [54] found beneficial effects of completing a self-affirmation questionnaire or cocky-affirming implementation intention on booze intake at 1-month follow-upwardly, whereas Burton and King [55] observed that participants randomized to write simply two min for 2 sequent days in a laboratory about a recent positive upshot showed moderate reductions in physical symptoms (Cohen d=0.65) at iv- to vi-calendar week follow-upward.

Objectives

The goal of this randomized controlled trial was to examine whether a 12-calendar week internet-based PAJ intervention could reduce mental distress (chief outcome) and positively influence psychological, interpersonal, and concrete well-beingness (secondary outcomes), relative to usual care, in a heterogeneous sample of patients with elevated anxiety symptoms. It was hypothesized that participants randomized to the intervention would feel decreases in mental distress (ie, Hospital Anxiety and Depression Calibration score; HADS) and improvements in psychological well-existence (eg, perceived stress and resilience), interpersonal well-being (ie, social back up), and concrete well-being (eg, days during which pain inhibited usual activities) over the 12-week intervention menstruum. It was as well hypothesized that participants randomized to receive the intervention would written report less mental distress and greater levels of psychological, interpersonal, and physical well-being than those in the command condition at each cess catamenia.

Methods

Sample and Recruitment

All report procedures were canonical by the Pennsylvania Country Hershey Medical Center's (PSHMC) institutional review lath, and all participants provided written informed consent before engaging in whatever inquiry-related activeness. This study was registered on ClinicalTrials.gov (reference number {"type":"clinical-trial","attrs":{"text":"NCT01873599","term_id":"NCT01873599"}}NCT01873599), with recruitment and active intervention occurring from June 2013 to Feb 2014.

Potential participants were recruited through flyers placed around the PSHMC campus and advertisements placed in PSHMC media and local community newspapers in central Pennsylvania. In addition, oncology patients at The Pennsylvania State University Hershey Cancer Institute with an Eastern Cooperative Oncology Group (ECOG) Operation Condition score of 0 to iii (not completely disabled) were identified through registry review and sent a letter describing the study. Participants were provided with a toll-costless number to telephone call if they were interested in participating, as well as an opt-out card that could exist mailed back past those who were uninterested. Individuals who did not respond were contacted through phone past a research staff member within 2 weeks to make up one's mind their interest in participating.

Eligibility for inclusion was based on (1) English fluency, (two) between 21 and 80 years of age, (iii) cyberspace admission, (4) self-report of moderate to pregnant stress during the concluding month, (5) non currently pregnant and no plans to go pregnant within the adjacent iii months, (6) no plans to motion within the adjacent 6 months, (7) no hospitalization for a psychiatric status in the last twelvemonth, (8) not a high risk for suicidality equally assessed by selected questions from the Structured Clinical Interview for Diagnostic and Statistical Transmission of Mental Disorders [56]. Although non an explicit requirement, it was causeless that potential participants be familiar with using a computer and accessing websites.

Individuals interested in participation and who met the initial inclusion criteria were invited for a laboratory visit and farther assessed for eligibility. Eligible participants: (1) reported a score of 8 to 15 on the anxiety subscale of the HADS [57] and (2) had an ECOG performance status of 0 (fully agile) through 3 (express cocky-care) [58]. Participants who met all inclusion criteria were invited to participate.

Random Assignment

Randomization (ane:one) was washed through sealed envelopes prepared by someone other than the enquiry staff conducting the written report visits and opened by participants during the baseline visit after completing informed consent. See Figure ane for flow diagram of recruitment procedure.

Procedure

Eligible participants met the inquiry staff during a scheduled baseline visit to discuss study procedures and provide written informed consent. During the baseline visit, all participants completed baseline surveys and were randomized (through computer-generated sequences provided in sealed envelopes) to 1 of the ii conditions. Participants assigned to the intervention condition received an introduction and training session to orient them to the intervention website where they would complete the writing sessions. All participants completed self-report survey assessments on the Spider web at the end of months 1, 2, and 3 using a secure information capture system (REDCap Penn State). Participants received souvenir cards following the completion of each survey (ie, United states $40 bounty for completing all 3 assessments).

Intervention

Participants in the PAJ intervention condition were asked to complete Web-based writing sessions for 15 min on 3 days each week for the duration of the 12-week study. The amount of fourth dimension spent writing at each session is similar to prior expressive writing studies although the duration of the intervention in this study was longer than many other prior studies [23,25,59] to ensure the potential for adequate dose of intervention. This was the first version tested of this intervention; the intervention content was frozen during the trial and not adjusted. During each Spider web-based writing session, participants logged onto the written report website and wrote a journal entry on i of the 7 commonly used positive affect prompts (eg, What are you thankful for? What did someone else do for you?; full details bachelor upon request) [60]; all entries were saved on a secure server. During the study, journal entries of participants in the intervention status were screened by research staff to monitor content. Participants who did not complete a periodical entry inside any given 7-solar day menses were sent an email reminder (this email reminder besides included reminders of how study staff could help them resolve any technical difficulties, in case, any existed). As there is no clinical standard of care treatment for medical patients with mild to moderate anxiety symptoms, participants randomized to the wait-list control grouping received their usual intendance for the duration of the written report. Afterwards they had completed all report procedures, participants in the command condition were given access to the PAJ intervention.

Measures

Sociodemographics and Health Behaviors

Participants' age, gender, race, ethnicity, marital status, and educational level were obtained at baseline. During this fourth dimension, participants self-reported basic information related to their specific disease and health behaviors (ie, smoking, physical activity, and alcohol use) using standard self-report items from the Behavioral Risk Factor Surveillance System [61].

Main Outcome

The HADS [57] consists of 2 scales, anxiety and low, with each consisting of vii items rated on a scale from 0 through 3. Items are aggregated for each subscale (range=0-21), with higher scores indicating greater feet or depressive symptom severity, and for a total HADS score (range=0-42), with college scores indicating greater mental distress. Diverse cut-off scores are available for the HADS. A score of eight or greater on the anxiety subscale (HADS-A) has a specificity of 0.78 and sensitivity of 0.9 for clinically significant anxiety, whereas scores below viii indicate noncases [62]; the inclusion criterion of a HADS-A score of 8 to 15 was intended to include participants with mild to moderate symptoms, whereas those with nonsignificant or severe symptoms (HADS-A scores of fifteen-21) were excluded as the PAJ intervention was expected to have limited benefit for those individuals. In this report, Cronbach blastoff at baseline was .65 for anxiety, .86 for depression, and .85 for HADS total score.

Secondary Outcomes

The Brief Resilience Scale (BRS) [63] is a 6-item measure out of perceived resilience, including items such every bit "Information technology does not have me long to recover from a stressful event." Each item is rated on a scale from 1 (strongly disagree) to 5 (strongly agree). All items are aggregated for a total score (range=6-30); college scores bespeak greater resilience. The BRS has loftier levels of internal consistency, with Cronbach alpha ranging from .80 to .91 [63]. In this study, Cronbach alpha was .90 at baseline.

The Good for you Days Measure [61] assesses self-reported concrete health and functioning. Respondents answered 4 items to indicate (1) general health (ie, "Would you say that in general your health is 'poor' – 'excellent'"), (ii) days during which pain inhibited their usual activities (ie, "During the by 30 days, for nearly how many days did hurting go far difficult for you to practise your usual activities...?"), (3) sleep quality (ie, "During the past thirty days, for virtually how many days have you felt y'all did non become plenty rest or sleep?"), and (4) number of days they felt good for you and full of energy (ie, "During the past xxx days, for about how many days have you lot felt very salubrious and total of energy?").

The Perceived Stress Scale [64] consists of 10 items that assess perceived stress rated on a calibration from 0 (never) to 4 (very oft). A sample item includes "In the final month, how oftentimes have you felt nervous and stressed?" Items are combined for a total score, with higher scores indicating greater stress. The measure demonstrates strong internal consistency. In this study, Cronbach alpha was .91 at baseline.

The Positive and Negative Affect Schedule (PANAS) [65] consists of two subscales, each including 10 items. Respondents signal the extent to which they felt specific positive emotions (eg, excited and proud) and negative emotions (eg, upset and agape) over the last month on a calibration from 1 (not at all) to five (extremely). Subscales are scored separately (range=10-l); higher scores indicate greater positive affect and greater negative bear on. Internal consistencies are high (Cronbach alpha=.85-.88) [65]. In this study, Cronbach blastoff for the positive touch subscale was .90 and negative affect subscale was .90 at baseline.

The Satisfaction with Life Scale (SWLS) [66] is a 5-item scale that assesses overall life satisfaction with items such equally "In most ways my life is close to my platonic" and "I am satisfied with my life." Each item is rated on a scale from one (strongly disagree) to 7 (strongly agree), and a total score is calculated using all items (range=v-35); higher scores indicate greater satisfaction with one's life. The SWLS has a test-retest reliability of 0.82 [66]. In this report, Cronbach alpha was .93 at baseline.

The Social Provisions Scale [67] assesses diverse dimensions of social support. The calibration consists of 24 items that brand up half dozen components, each consisting of 4 items pertaining to zipper, social integration, reassurance of worth, reliable alliance, guidance, and opportunity for nurturance. The respondent rates the extent to which each statement describes their current social network on a calibration from ane (strongly disagree) to four (strongly concur). Items are aggregated separately for each component (range=iv-16) and for a total perceived support score (range=24-96); higher scores indicate a greater degree of perceived back up provisions. In this study, Cronbach alpha for zipper was .76, .88 for social integration, .72 for reassurance of worth, .84 for reliable brotherhood, .83 for guidance, .79 for opportunity for nurturance, and .93 for total perceived support at baseline.

Adherence

Adherence generally describes the extent to which individuals are exposed to the content of the intervention. For this report, participants were asked to consummate Spider web-based PAJ sessions an average of iii xv-min sessions per week, over 12 weeks, for a total of 36 journaling sessions throughout the course of the study. Overall PAJ adherence rate was calculated using 2 methods: (one) weekly journaling counts for each participant—derived from Web-based user log-in counts—were recoded into a binary variable (ie, yes or no) based on journaling >one time per week. The journaling counts for all weeks were then summed, divided by 12, and multiplied by 100 to calculate the overall 12-calendar week adherence rate and (2) total journaling counts for all participants were summed for all weeks of the written report, divided by 36, and multiplied by 100. Although it would be desirable to count actual time (minutes per session) spent engaged in the PAJ intervention, the website was non capable of accurately tracking this information (eg, if a person left the estimator to consummate another chore).

Sample Size

The sample size was calculated based on an predictable baseline mean of 11.0 (SD three) on the HADS-A. This anticipated value was derived from a study of 273 medical patients participating in a Web-based educational program. Using G*Power, nosotros assumed treatment condition SDs similar to those reported by Yun et al [68] and a v% type-I error rate for a two-sided hypothesis test, terminal that 31 subjects per grouping would provide 80% power to notice a difference in the HADS-A at 3 months (10.0 vs 8.0). This effect size is based on a clinical trial of CBT for distressed medical patients wherein the CBT arm decreased their HADS-A score by three.one points more than controls [seven], and a Web-based CBT intervention past Farrer et al [21] observed a 44% reduction in low scores over half-dozen months. This study estimated a reduction of 2.0 in the HADS-A measure (xviii% reduction). Anticipating a dropout rate of <x%, we planned to recruit lxx subjects at baseline.

Analytic Programme

All analyses were conducted using SAS Software version 9.iv (SAS Institute, Cary, NC). First, descriptive statistics were calculated for all variables at baseline and at each of the 3 follow-upward assessments, and response rates were calculated using the Web-based user log-in tracking logs. Categorical variables were summarized with frequencies and percentages, and continuous variables were summarized with means, SDs, medians, and quartiles. The distribution of continuous variables was checked using box plots, histograms, and normal probability plots. For demographic variables and other characteristics measured at baseline, comparison tests were conducted between the intervention and control groups using a two-sample t test or Wilcoxon rank-sum test with means for continuous variables and using a chi-square test with percentages for categorical variables. A Fisher exact test was used equally needed when cell counts were too small for the chi-foursquare test to be valid.

Second, in making comparisons of the differences from baseline to each of the iii months within and between groups, nosotros used 2 approaches depending on the blazon of issue variable. For continuous outcome variables, we first establish the change from baseline at each subsequent month. A linear mixed-effects model was then employed, which included factors for grouping (intervention vs command), month, the interaction betwixt the intervention group and calendar month, and the baseline measurement for aligning, and the differences between groups were quantified with means. For binary upshot variables, a generalized estimating equations model was used that included factors for group, month, and the interaction between the group and calendar month, and differences betwixt groups were quantified with percentages and odds ratios. All comparisons were adjusted for age, sexual practice, income, and preexisting journaling—reflecting self-reported frequency (ie, "Never," "Less than once per month," "1-3 times per calendar month," and "At least once per calendar week") of writing in a diary or periodical in the year leading up to the study—past including these factors equally additional covariates in the models. Missing data were not a significant trouble for the primary effect variable (at less than 5%) or for the secondary upshot variables (at less than x% at almost) and were not an issue for any independent variables.

Results

Participants

A total of 99 people were assessed for eligibility, of which 88 patients were interested in participating. Subsequently further screening, 70 people were eligible, consented, and randomized to the intervention (north=35) or usual care (n=35) condition (Figure ane). A total of 3 participants were lost to follow-upwards during the 12-week assessment period and all participants were included in analyses. No unanticipated harms were reported, and at that place were no privacy breaches or major technical problems during the trial. Participants in this report had a wide range of chronic wellness weather, including arthritic conditions (eg, rheumatoid arthritis, gout, lupus, and fibromyalgia; 19/69, 27%), diabetes (type 1 or type 2; 12/70, 17%), asthma (12/lxx, 17%), cancer (13/seventy, xi%-19%, all cancer types combined), prediabetes (4/70, 6%), kidney disease (not including kidney stones, bladder infection, or incontinence; 3/69, four%), chronic obstructive pulmonary disease (1/69, 1%), heart disease (1/70, 1%), and stroke (ane/69, 1%). Demographic and other baseline characteristics are shown in Table i. There were no significant differences betwixt the intervention and control groups on whatsoever baseline characteristics (demographics, principal, or secondary outcomes).

Table 1

Participant and baseline characteristics.

Feature		Full (Due north=lxx)	Control (n=35)	Intervention (n=35)	P valuea
Historic period in years, mean (SD)		46.9 (12.8)	47.2 (12.3)	46.v (xiii.5)	.82
Female, north (%)		60 (87)	30 (85)	30 (88)	.99
White, northward (%)		65 (95)	33 (94)	32 (97)	.99
Hispanic, northward (%)		1 (1)	1 (3)	0 (0)	.99
Married, n (%)		44 (64)	25 (71)	xix (56)	.18
Education (college iv+ years), n (%)		41 (59)	18 (51)	23 (68)	.17
Employed for wages, n (%)		53 (77)	26 (74)	27 (79)	.61
Income (<U.s. $50,000), due north (%)		21 (33)	9 (30)	12 (35)	.65
Current smoker, north (%)		iii (four)	ane (3)	ii (6)	.99
General health (excellent or very proficient), n (%)		34 (49)	14 (41)	20 (57)	.nineteen
Hospital anxiety and depression scale, mean (SD)
	Total	xiv.three (half-dozen.6)	xiv.3 (7.1)	xiv.three (6.i)	.74
	Anxiety	9.eight (iii.4)	9.five (iii.4)	x.one (three.4)	.44
	Depression	4.half-dozen (four.0)	4.ix (4.2)	4.3 (iii.7)	.68
Perceived stress scale, mean (SD)		nineteen.ix (7.2)	20.4 (six.7)	19.4 (7.seven)	.55
Brief resilience scale, mean (SD)		xx.1 (5.3)	20.eight (4.3)	xix.v (vi.ane)	.37
Satisfaction with life calibration, mean (SD)		nineteen.0 (8.0)	19.7 (7.3)	18.3 (8.6)	.48
Social provisions scale, mean (SD)
	Full	79.0 (12.0)	78.6 (10.9)	79.3 (xiii.ane)	.55
	Zipper	12.5 (2.half-dozen)	12.6 (2.iv)	12.5 (2.8)	.94
	Social integration	13.ii (ii.7)	13.3 (ii.four)	13.1 (2.9)	.94
	Reassurance of worth	12.nine (2.2)	12.8 (i.9)	12.9 (2.4)	.41
	Reliable alliance	13.six (2.6)	thirteen.4 (2.6)	xiii.8 (2.6)	.47
	Guidance	13.3 (ii.7)	thirteen.i (2.6)	13.v (2.ix)	.35
	Opportunity for nurturance	13.6 (2.5)	13.7 (2.2)	thirteen.five (2.7)	.96
Positive and negative affect scale, hateful (SD)
	Positive affect	31.ix (eight.two)	33.iv (vii.8)	30.4 (8.4)	.fifteen
	Negative outcome	16.0 (6.half-dozen)	sixteen.seven (six.ix)	15.three (6.two)	.20
Days pain inhibited usual activities, mean (SD)		3.5 (6.9)	3.7 (six.1)	3.4 (7.6)	.08
Days non getting enough slumber, mean (SD)		12.three (9.7)	13.1 (10.3)	11.5 (9.ii)	.68
Days felt healthy and full of energy, mean (SD)		fourteen.0 (10.0)	12.8 (nine.iv)	15.3 (10.5)	.30
Improve mental wellness than 1 calendar month agone, n (%)		17 (25)	six (xviii)	11 (31)	.xviii

Within-Group Differences

Our initial analyses examined changes over fourth dimension within each grouping. All results for the within-grouping differences beyond the three-month report period are shown in Multimedia Appendix 1. Results indicated that the PAJ intervention reduced mental distress and improved well-being. Specifically, the intervention grouping reported lower HADS-A at all 3 assessments (at the end of months ane through three), more resilience at the end of month 2, less perceived stress at all 3 assessment points, and a greater percentage (ie, 56.3% vs 31.3%) of participants reported improve mental health at the end of the first month, relative to baseline. No other within-group differences were observed in the intervention grouping. Compared with the baseline, the control grouping reported less social integration at the end of month three, more days in hurting inhibiting usual activities at the end of calendar month 2, and a greater percentage (ie, 41.4% vs xx%) of participants reported better mental wellness at the terminate of calendar month three, relative to the previous month. No other within-grouping differences were observed in the control group.

Between-Grouping Differences

We next examined differences between the groups over time. Results for the between-group differences across the 3-month study menses are also indicated in Multimedia Appendix 1. Compared with the control grouping, the intervention grouping exhibited lower anxiety at the end of month 1, lower mental distress at the end of months 1 and 2, greater resilience and lower perceived stress at the end of calendar month i, greater cocky-reported social integration at the end of month two, and at the end of month 2, they reported fewer days in which hurting prohibited usual activities.

Adherence

We also examined patient adherence to suggested journaling frequency (or dose). Overall adherence to the intervention, operationalized by dividing the mean corporeality of completed sessions by the maximum corporeality of sessions, was moderate in the sample from this study (mean 47.viii% with a range of 2.viii%-172.ii%; 1 participant journaled 62 times with the remainder having rates at or below the expected 100%). When operationalizing adherence as completing at to the lowest degree one journaling session per week, a level consistent with the broader expressive writing literature [23], the adherence charge per unit was 66.iv% (range of 41.7%-100%). Subsequently the offset week of journaling, participants journaled an average of 0.94 times with a peak of 2.iii times per week in week two. Overall, the number of journaling sessions generally decreased equally time progressed (see Figure 2). Adherence to PAJ sessions was largely unrelated to outcomes (data not shown; results available upon request).

Average number of journaling sessions completed by participants over the 12-week study period.

Give-and-take

Main Findings

The principal aim of this report was to examine whether a 12-week Web-based PAJ intervention could reduce mental distress and improve psychological, interpersonal, and physical well-being in a heterogeneous sample of medical patients with pregnant anxiety symptoms. Compared with the patients receiving standard intendance, patients randomized to the PAJ intervention exhibited reduced mental distress, feet, and perceived stress; greater perceived personal resilience and social integration; and fewer days on which pain inhibited usual activities. The PAJ intervention was non associated with improvements in depressive symptoms, satisfaction with life, other indices of social support (ie, attachment, reassurance of worth, reliable brotherhood, guidance, opportunity for nurturance, and overall perceived support), or positive and negative touch on. Overall, the findings from this study propose that PAJ has potential utility every bit an intervention for managing mental distress, peculiarly elevated feet symptoms, and other aspects of well-being among general medical patients. This is consistent with, and extends, prior inquiry on positive writing interventions as a mode to improve aspects of health and well-being [55,69,lxx,71].

Effects on Well-Being

This study demonstrates that PAJ can ameliorate several factors associated with psychological well-being amid patients with mild to moderate anxiety, each of which may have implications for long-term health outcomes. Some of the near notable findings from this report were that the PAJ intervention was associated with amend mental health, including lower feet, mental distress, and perceived stress after only ane month of the intervention and was associated with reduced mental distress beyond time (eg, connected reduction in anxiety and perceived stress beyond the 12-week intervention menstruation). Equally such, PAJ may be an effective way to improve mental well-being and potentially increase longevity through improvements in these outcomes in a diverseness of patient populations. In addition, PAJ was associated with college perceived resilience. Although PAJ may be a useful intervention for improving this outcome, more than piece of work is needed to understand why the beneficial effects of PAJ on resiliency appear to taper off over time and whether the initial increase in resiliency may serve as a mechanistic pathway between PAJ and disease outcomes beyond a variety of medical atmospheric condition.

Another aspect of psychological well-existence with potential implications for health outcomes are perceptions of ane's social environment such as perceived social integration. For instance, perceived social isolation, which is conceptually the opposite of perceived social integration, is known to contribute to increased hazard for early on bloodshed [72]. This written report indicates that PAJ may be beneficial to this end as the results demonstrate greater cocky-reported social integration in the intervention group relative to controls at the end of the 2nd month. Moreover, more than work is needed to sympathize why the effects of PAJ on perceived social integration do not appear to hold over time and whether these benefits can be prolonged.

Surprisingly, 1 indicator of improved well-being (ie, percent of patients who self-reported "somewhat" or "much better" mental health compared with the previous month) was observed in the control grouping. This indicates that patients receiving usual care will fluctuate in their perceived well-being (ie, have occasional upswings in self-reported mental wellness). In improver, PAJ was not observed to improve all indices of well-being (ie, we did not see benign effects on low, satisfaction with life, indices of social support other than perceived integration, or positive and negative impact). This indicates that this intervention may exist constructive for improving some but certainly not all aspects of well-being. To explore the robustness of PAJ for enhancing additional indices of well-being, future studies would benefit from exploring means to modify the expressive writing methods used in this written report to increase their effectiveness (eg, across more well-being outcomes, for longer durations of fourth dimension, or both). For instance, the writing schedule in this study was fairly dense (iii writing sessions per week for 12 weeks). Maybe, patients would benefit from a less dumbo writing schedule or greater variability in the topics offered. Information technology may as well be possible to optimize benefit by tailoring PAJ instructions (overall or adaptively over fourth dimension) to individual patient needs. Furthermore, the writing task used in this study was a modified version of that developed by Pennebaker et al [23], particularly in terms of the number of overall sessions; it is possible that writing in a manner more consistent with earlier expressive writing studies would be preferable.

Timing Furnishings

Regarding the timing effects equally a whole, the showtime calendar month of the PAJ intervention provides a considerable number of improvements in quality of life that are nevertheless observed 2 and 3 months afterwards, albeit to a lesser degree. For instance, PAJ was associated with decreased mental distress and improved well-existence in the beginning month, but the number of benefits and between-grouping differences diminished over fourth dimension. Peradventure, the benefits of PAJ are largely observed inside only at the showtime of the intervention and exercise not provide sustained improvements in mental distress and well-existence over time. However, other studies have demonstrated that longer-lasting positive psychology interventions are constructive at improving subjective and psychological well-being amongst cancer patients [73], and the short-term improvements in cancer patients' mental well-existence observed in this study may interpret into longer-term health benefits. As such, future studies are needed to decide whether PAJ beyond 3 months would provide additional upswings in well-being. Conducting longer investigations of expressive writing in clinical populations may be particularly important as previous work has establish the benefits to misemploy afterward several months of discontinuation [28]. It is worth noting that the sample size of our report was modest, and even afterwards merely three months, improvements were observed that favor the PAJ group. Although a portion of the effect sizes for these significant improvements were small (ie, Cohen d or h: 0.five-0.49), in that location were also several effect sizes of moderate size (ie, Cohen d or h: 0.51-0.64; come across Multimedia Appendix 1). Given the potential for cost-efficiency and reach of this Spider web-based intervention, we view these preliminary results as promising and supportive of a larger follow-up study examining the clinical utility of PAJ interventions.

Feasibility of Intervention

An of import aspect of this study is the demonstrated feasibility of the Web-based writing job intervention. First, participants more often than not enjoyed the intervention (ie, 39.4% reported that the journaling activity fabricated them feel "somewhat ameliorate" and 18.ii% reported that it made them feel "much better"). A total of 67 out of 70 consented and randomized participants competed the report for an overall splendid completion rate of 95%; this compares favorably with other randomized expressive writing interventions in chronic illness samples (eg, 73% [74] and 81% [53]). Overall adherence to the intervention was moderate in the sample of this study (mean 47.8%). Still, when operationalizing adherence every bit completing at least 1 journaling session per week, the adherence rate rose to 66.4% (range of 41.seven%-100%). Once-weekly sessions are common in therapeutic do and are oft used in randomized trials of CBT [75]. Although these adherence rates are adequate, it remains unclear why adherence was not even higher, given the relative ease through which Web-based PAJ modules could exist accessed.

By and large, the number of completed journaling sessions decreased over the course of the intervention. The reasons for this subtract are uncertain but several plausible explanations exist. Ane possibility, although unassessed in this study, is that participants began the journaling process with enthusiasm in the early weeks but experienced reduced interest or increased fatigue with the intervention over time. Another possible explanation is that participants believed there were diminishing returns on therapeutic do good every bit journaling sessions increased; a single weekly journaling session could have been deemed therapeutically equivalent to multiple sessions, for example, Web-based interventions are condign more than prevalent [76] every bit they can be administered at lower costs and disseminated to more people. Future piece of work should investigate factors that drive adherence to Web-based PAJ interventions and explore opportunities to amend the interventions themselves, given the benefits observed in this written report.

Limitations

Given the preliminary nature of investigating this novel Web-based intervention, nosotros included several outcomes and conducted a large number of statistical tests, and the small sample size reduced our power to discover some effects (specially when contrasting between groups); together, these decisions may take contributed to spurious and/or missed associations. Every bit such, intendance should be taken in interpreting whatsoever specific effect, and replication of these effects is warranted before strong conclusions can be made about potential efficacy. In addition, the length of the written report was relatively brusque, and it remains unclear whether longer-term interventions would exist sustainable or bear witness similar improvements in various indices of well-being. Evidence from some clinical populations (eg, patients with asthma [29]) suggests that expressive writing may offer the about benefit for those with moderate level of disease—patients who are relatively healthy do not take much room for comeback, and those with very severe illness may require a more powerful treatment culling. A large percentage (44.iii%) of patients in this study reported excellent or very good health at baseline, possibly limiting the therapeutic benefit that could be observed from journaling; less healthy patients may have greater gains to make in well-being from baseline relative to their healthier counterparts, and time to come studies may consider testing this intervention in a sample of patients with greater disease severity. Finally, the homogenous nature of our small written report sample (95.5% white and 87.0% female), combined with the relatively brief written report time frame, limits the generalizability of our findings to more various patient samples.

Conclusions

The results of this randomized controlled trial provide preliminary testify that PAJ is a feasible and well-accepted intervention that can be implemented on the Web for finer reducing some aspects of mental distress and improving aspects of well-being among medical patients with mild to moderate anxiety symptoms. Moreover, PAJ is likely to exist a more than pleasant and uplifting treatment for patients compared with the traditional expressive writing interventions that focus on writing about securely pitiful and traumatic experiences from the by; this may promote acceptability and treatment appointment relative to other treatments. Thus, this relatively simple and price-effective intervention may represent a low-risk way to improve a variety of well-being domains, particularly among underserved patients.

Acknowledgments

Funding for this written report was provided by the Penn State Social Science Research Plant. The funders have no role in the study design, data drove and analysis, decision to publish, or newspaper preparation. Study data were collected and managed using Research Electronic Data Capture tools hosted at the Penn State Milton S Hershey Medical Middle and Higher of Medicine. The authors would like to thank Vanessa Juth for feedback on an earlier version of this study.

Abbreviations

BRS	Brief Resilience Calibration
CBT	cognitive behavioral therapy
ECOG	Eastern Cooperative Oncology Group
HADS	Hospital Anxiety and Depression Scale
PAJ	positive affect journaling
PANAS	Positive and Negative Touch on Schedule
PSHMC	Pennsylvania State Hershey Medical Center
SWLS	Satisfaction with Life Scale

Multimedia Appendix 1

Issue variables over fourth dimension.

Multimedia Appendix 2

Espoused‐EHEALTH checklist (V 1.6.1).

Footnotes

Conflicts of Interest: None alleged.

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