Phone-Based Interventions With Automated Mindfulness ... - PsycNET

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Phone-Based Interventions With Automated Mindfulness and Mastery Messages Improve the Daily Functioning for Depressed Middle-Aged Community Residents Alex J. Zautra, Mary C. Davis, John W. Reich, John A. Sturgeon, and Anne Arewasikporn Arizona State University Howard Tennen University of Connecticut Health Center, Farmington, CT

The value of two self-help programs that rely on automated instructional materials were tested versus an attention control in a community sample with symptoms of depression. A randomized controlled trial was designed to examine the effects of a brief, daily intervention targeting either personal control/mastery (MC) or mindful awareness/acceptance (MA) compared with an attention-control treatment that consisted of tips for a healthy lifestyle (HT). Seventy-three individuals with mild to moderate symptoms of depression received a brief in-person orientation to the treatment and then received the MC, MA, or HT interventions delivered in prerecorded automated messages via phone each morning. Each evening, participants completed an online daily diary that included the outcome measures. Multilevel analyses of diary data revealed significantly greater improvements in emotional health and self-reported physical health for the treatment conditions across the 31-day trial in comparison to HT controls. For measures of emotional health, the effects of MC and MA were equivalent. Only the MA condition led to better self-reported physical health than the HT control condition. The everyday lives of middle-aged community members initially reporting mild to Alex J. Zautra, Mary C. Davis, John W. Reich, John A. Sturgeon, and Anne Arewasikporn, Department of Psychology, Arizona State University; Howard Tennen, Department of Community Medicine and Health Care, University of Connecticut Health Center, Farmington, CT. This project was supported by NIA Grant RO1–AG-6026006 NIA Supplement Grant RO1–AG-0266006. The authors gratefully acknowledge the support of the Arizona State University Office of Research and Sponsored Projects, Dr. Rick Shangraw, Vice-President. Correspondence concerning this article should be addressed to Alex J. Zautra, P.O. Box 871104, Arizona State University, Tempe, AZ 85287-1104. E-mail: [email protected] 206 Journal of Psychotherapy Integration 2012, Vol. 22, No. 3, 206 –228

© 2012 American Psychological Association 1053-0479/12/$12.00 DOI: 10.1037/a0029573

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moderate depression were improved by interventions that were delivered primarily via automated daily messages designed to enhance personal mastery, mindfulness, and acceptance. Across the 31 days of the study, the MA group demonstrated the most robust effects. The personal mastery condition also yielded benefits compared with attention-controls, though those effects were less pronounced. In sum, the findings encourage further development and testing of innovative and accessible intervention methods to address mental health problems of older adults in the community. Keywords: psychological distress telephone interventions, mindfulness, personal mastery, adult mental health, depression

Among the many challenges to adaptation, depression and related conditions are among the most prevalent chronic conditions faced by adults in midlife, which when unchecked, can hasten decline in health and well-being as people age (Barefoot & Schroll, 1996; Wilhelm, Mitchell, Slade, Brownhill, & Andrews, 2003). The low energy, fatigue, and affective distress that characterize this condition have been identified as risk factors for both specific conditions, such as cardiovascular disease, and all-cause morbidity and mortality (Greenberg et al., 2003; Schmitz, Wang, Malla, & Lesage, 2007; Stern, Dhanda, & Hazuda, 2001). Yet less than 26% of those in the U.S. with mild to moderate psychiatric symptoms, including depression, receive any treatment for their condition (Bijl et al., 2003; Simon et al., 2001; García-Lizana & Munoz-Mayorga, 2010), and access to care is even lower among Latino and other minority groups (Dunlop, Song, Lyons, Mannheim, & Chang, 2003). Interventions that operationalize key components of successful therapies for depression in accessible formats may enhance the well-being and lower the risk profiles of diverse populations with depressive symptoms. In the study of successful adaptation to difficulties in the lives of middle-aged and older adults, several key factors consistently emerge as important predictors, including mastery, cognitive restructuring, emotional regulation, behavioral activation, and social engagement (Folkman & Moskowitz, 2004; Hollon & Ponniah, 2010; Kashdan & Rottenberg, 2010). Given the importance of these ingredients in the preservation of health and wellbeing as people age, interventions that target one or more of these factors should fortify those at risk. Current interventions typically target several of these key dimensions together with other purportedly active ingredients. Unfortunately, intervention packages that include multiple components cannot identify which components are responsible for the benefits that accrue as a result of the treatment, a problem noted by García-Lizana and MunozMayorga (2010) in their review of the efficacy trials in telemedicine for depression (see also Hollon & Ponniah, 2010). Disentangling the components of these programs to identify and test the unique value of specific treatment

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components can have considerable value in advancing intervention research. To that end, in the current study we aimed to test the relative value of two components of cognitive– behavioral interventions: one designed to enhance personal mastery through behavioral activation, the other to advance cognitive-emotion regulation through mindful awareness exercises. These treatments were contrasted with a health education attention control condition. Personal mastery has long been recognized as an important predictor of mental and physical health. Perceiving a contingent relationship between one’s choices and outcomes is related to greater emotional and physical health, (Pearlin & Schooler, 1978; Affleck, Tennen, Pfeiffer, & Fifield, 1987; Lewinsohn & Gotlib, 1995) and better capacity to adapt to a variety of stressors (Thompson, 1981; Perlmuter & Langer, 1983; Reich & Zautra, 1981, 1990), including economic stress (Pudrovska, Schieman, Pearlin, & Nguyen, 2005), job loss (Price, Choi, & Vinokur, 2002), and caregiver burden (Roepke et al., 2009). A number of investigations have established links between a sense of control and personal mastery and depression. Benassi, Sweeney, and Dufour (1988); Marshall and Lang (1990); Lewinsohn and Gotlib (1995); Newsom, Knapp, and Schulz (1996) and Lachman and Agrigoroaei (2010) all presented summaries of studies showing that higher levels of mastery or control are related to reduced depressive symptomatology. Additionally, personal control is related to lowered depression in chronically ill adults (Penninx et al., 1998), enhances the effectiveness of social support in reducing anxiety related to poorer health (Gadalla, 2009), and predicts preservation of functional health as people age (Lachman & Agrigoroaei, 2010). A body of research also has developed investigating whether a sense of control can be enhanced by interventions. Early studies by Langer and Rodin (1976); Rodin and Langer (1977); and Schulz (1976) demonstrated that perceived control could be enhanced by psychoeducational interventions. Reich and Zautra (1989, 1990) implemented a four-session, 10-week personal control intervention for at-risk older adults. Postintervention results showed reduced psychological distress. Vinokur and Schul (1997) showed that an intervention to enhance adjustment to unemployment had it effects on reducing depression mediated by increases in personal mastery. More recent studies expanded on these findings and showed positive benefits such as improved mental health and enhanced immunocompetence (Bandura, 1989; Blazer, 2002; Ong, 2010). Hollon and Ponniah (2010) suggest that behavioral activation methods, which are fundamental to mastery/control interventions, may prove more cost-effective than cognitive therapies in the treatment of affective disorders because they are less demanding conceptually. In addition to mastery, cognitive strategies that promote greater awareness and acceptance of the full range of emotions have been linked to decreased distress and enhanced well-being (e.g., Brown, Ryan, &

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Creswell, 2007; Hayes & Feldman, 2004). According to Segal, Williams, and Teasdale (2002), heightened awareness coupled with acceptance and nonjudgment of current experience acts to interrupt the maladaptive automatic responding that commonly occurs during negative emotional states. Moreover, greater attention to the whole range of experiences also facilitates awareness of positive affective states, even when coping with stress. Greater access to positive affect, in turn, facilitates more adaptive, flexible responses to current circumstances, with the potential to enhance well-being and functional health and reduce helplessness in the management of everyday life problems (Zautra, Johnson, & Davis, 2005). Mindfulness-based treatment attempts to enhance individuals’ capacity to process the full range of emotional experiences with greater awareness and nonjudgment (Segal et al., 2002). Thus, a mindfulness-based approach can address the biases toward negative and away from positive emotional cues that characterize depression (Roberts-Wolfe, Sacchet, Hastings, Roth, & Britton, 2012). Over the past decade, interventions that target emotion regulation problems through enhanced awareness and acceptance have figured more prominently in cognitive– behavioral treatment for a variety of mental and physical conditions and garnered empirical support ( Allen, Chambers, Knight, & Melbourne Academic Mindfulness Interest Group, 2003). Rather than encouraging control of thoughts and feelings, acceptance intervention strategies promote the development of greater awareness of and change in the meaning given to these internal experiences (Hayes, 1994). Mindfulness meditation is one emerging treatment approach that offers useful methods to enhance the ability to regulate emotion through awareness and acceptance (Baer, 2003; Kabat-Zinn, 1990; Segal et al., 2002). Training in mindfulness awareness/acceptance (MA) includes regular practice of exercises to increase self-regulation of attention from moment to moment, which helps to promote more intentional, considered choices of responses to everyday events. Available evidence points to the utility of MA in relapse prevention among individuals with a history of depression (Ma & Teasdale, 2004) and in promotion of well-being among individuals with stress-related disorders (Baer, 2003). Recent work by Zautra et al. (2008) also suggests that a mindfulness intervention fosters emotional resilience in chronic pain patients, especially patients with a history of depression. Patients receiving MA showed greater improvements in vitality, and for patients with recurrent depression, MA also led to greater gains in health in comparison to other two intervention conditions. For these concepts to be applicable to public health, the interventions need to be accessible to the community at large, powerful enough to be effective in doses that can be delivered directly at relatively low cost, and

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have widespread appeal. Guided self-help programs with multiple treatment components may meet this need, but current evidence of their effectiveness is mixed (Coull & Morris, 2011; Fledderus, Bohlmeijer, Pieterse, & Schreurs, 2012), suggesting more attention to how specific components of such programs influence well-being is warranted. These objectives shaped the methods chosen for this project. Both the mastery and the mindfulness interventions were expected to benefit daily functioning in comparison to the attention control condition. The authors examined but did not make a priori hypotheses regarding the relative effectiveness of the mastery and mindfulness interventions.

METHOD Study Overview

A randomized controlled trial was designed to examine the effects of 4 weeks of a brief, daily intervention targeting either personal control/ mastery (MC) or mindful awareness/acceptance (MA) to promote positive and decrease negative affects among individuals with mild to moderate symptoms of depression. The two active interventions were contrasted with an attention control treatment that provided information regarding health-promoting behaviors (Health Tips: HT). Seventy-three adults recruited to participate in the trial, and randomly assigned to MC, MA, or HT conditions provided sufficient data for testing the relative merits of these interventions. Participants’ initiation into treatment began with a brief in-person scripted orientation to the treatment condition conducted by a trained research team member. Thereafter, automated telephone message delivery technology methods were used to deliver the interventions. Using an automated telephone message delivery system, the MC, MA, and HT interventions were delivered in prerecorded messages via telephone to participants each morning. Both interventions were compared to the HT condition, which controls for nonspecific elements of the intervention, such as attention, and expectation for improvement. Since only components of a cognitive– behavioral intervention were delivered in this study, the examination of efficacy was limited to changes in functioning reported in daily diaries collected before, during, and at the conclusion of the study. Each evening shortly before bedtime, participants completed an online daily diary containing the outcome measures.

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Participants

The sample comprised 73 middle-aged adults recruited from the community, all of whom reported at least mild levels of depressive symptoms during screening. The inclusionary criteria for this project included: 1) being between the ages of 40 and 65; 2) being English- or Spanish-speaking; 3), reporting at least a mild level of depressive symptoms, reflected in a score of 16 or above on the Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977), a scale used frequently to screen for depression in community populations (e.g., Fledderus et al., 2012) and, 4) no current or recent suicidal ideation reported on screening. There was no maximum score on the CES-D; all participants with scores above 15 were enrolled. In addition to those failing to meet inclusionary criteria, 43 people who initially expressed interest in participating declined either directly at screening (n ⫽ 34), or indirectly by not filling out a minimum of three daily diaries needed to assess preintervention levels of functioning and at least one diary after the intervention began (n ⫽ 9: six with no diaries, two with 1 diary, and one participant with two diaries). Figure 1 provides the consort diagram for this study, and also outlines the steps through the program. The sample was 82% female, with an average age of 54.05 years (SD ⫽ 6.50). Twenty-six percent of the sample for the current study described their ethnicity as Hispanic, and 19.2% was Spanish-speaking.

Procedure

Individuals were recruited for the current project from a larger epidemiological study of resilience among middle-aged residents of Maricopa County, Arizona. Forty census tracts that were representative of 10 distinct community types, based on homogeneous clusters in socioeconomic status, ethnicity, and age within Maricopa County, Arizona were identified, and residents from those tracts were recruited by phone and door-to-door (when telephone contact was not feasible). Residents who had been recruited to participate in the resilience study, and who gave permission to be contacted about future studies, were telephoned and informed about the nature of the new project, and appropriately consented. All materials for the project were translated into Spanish, and then back-translated into English. Interactions with Spanish-speaking participants were conducted in Spanish by a Spanishspeaking staff member. In brief, participants were told that the study was intended to test the effectiveness of brief, daily training to promote well-being in community residents. They then completed the CES-D via telephone to determine their

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Zautra et al. Assessed for eligibility n= 162

Total excluded prior to randomiza
on: n =80 Not mee
ng inclusion criteria: n = 37

Enrollment

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Randomized: n = 82

Refused to par
cipate: n = 43

Alloca
on

Mindfulness-Acceptance (MA): n = 29

Mastery-Control (MC): n = 29

Health Tips (HT aen
on control): n = 24

Course of Treatment: Total of 31 Daily diaries-- 2 diaries prior to and 29 diaries following start of treatment

Incomplete interven
on: n = 2

Incomplete interven
on: n = 3

Incomplete interven
on: n = 0

Interven
on was incomplete if less than 50% of interven
on messages were retrieved

Interven
on was incomplete if less than 50% of interven
on messages were retrieved

Interven
on was incomplete if less than 50% of interven
on messages were retrieved

31 Day Analyses:

Analyzed: n= 25

Analyzed: n= 25

Analyzed: n= 23

Excluded from analysis: n= 4

Excluded from analysis: n= 4

Excluded from analysis: n= 1

Completed fewer than 3/31 diary reports

Completed fewer than 3/31 diary reports

Completed fewer than 3/31 diary reports

Figure 1. Consort diagram.

level of depressive symptoms (Aneshensel, Frerichs, Clark, & Yokopenic, 1982), and those who achieved a CES-D score of 16 or greater (FechnerBates, Coyne, & Schwenk, 1994) were scheduled for an in-person visit by project personnel. The participants then were randomly assigned to one of the three intervention groups of the design: MC, MA, or HT. The next step was an in-person meeting at the participant’s home, where an undergraduate research assistant gave the participant an explanation of the procedures to be followed for both the daily telephone calls and diary reports. All information provided by the research assistants to the participants was scripted to assure that all participants within an intervention group received identical instructions. Participants in all three conditions received the initial home visit, which was approximately 20 minutes in

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length. The research assistants were blinded to the hypotheses of the study and did not have access to the daily diary data of the participants at any time during the study. During the first two days of diary participation, participants completed online diaries at the end of each day to provide pretreatment baseline data. Telephone contacts commenced on Day 3 and continued for 27 days. On each of the 27 days, participants received a morning telephone call with a prerecorded message delivering the intervention, and reported on their daily activities online prior to retiring for the night. Participants were given a unique identification (ID) number and were required to enter that ID, and the day and month of their birth to receive each day’s message. Following 27 days of intervention calls, participants completed two additional days of diaries. Participants received up to $140 for their participation: an initial payment of $25 for completing an initial questionnaire, and a final payment of up to $115 depending upon the number of daily diaries completed. Participants were not paid based on their adherence to the intervention telephone calls.

Intervention and Control Conditions

Personal Control/Mastery Intervention (MC) At the initial in-home contact, the participant was presented with concepts and examples of daily and major life events in which a person had a causal role and those in which event occurrences arise from outside of personal causation (e.g., Seligman, 2007). Crossed with those categories were concepts and examples of positive, negative, and neutral events. These examples illustrated how our feelings about the events in our lives can create very different effects on our well-being. Personal examples from the participant’s own life were also solicited and grouped into controllable and uncontrollable categories. Some examples provided to the participant to stimulate developing his or her own list of events were: 1) Personally Controllable Positive (e.g., “You bought yourself some ice cream” and “You went to a movie”); 2) Personally Controllable Negative (e.g., “You did not get a flu shot” and “You were critical of someone”); 3) Personally Controllable Neutral (e.g., “You read a news item” and “You drove to work”); 4) Personally Uncontrollable Positive (e.g., “Someone gave you ice cream” and “Someone smiled nicely at you”); 5) Personally Uncontrollable Negative (e.g., “You had a flat tire” and “Someone was critical of you”); and 6) Personally Uncontrollable Neutral (e.g., “Someone started a conversation” and “Someone told you a news item”).

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Behavioral activation was woven into the mastery program. Participants were given suggestions to increase the frequency of positive events in their lives, to avoid negative events, and to be aware that some events are common but neutral in impact on their feelings. These actions helped elaborate for them the concepts of controllable and uncontrollable positive, negative, and neutral occurrences during the course of an average day. The research assistant explained that the daily telephone contacts were intended to increase the range and frequency of the participant’s actions and self-efficacy cognitions involved in achieving greater control and mastery in their daily living over the course of the upcoming month. Mindful Awareness and Acceptance Intervention (MA) The orientation to the MA intervention conducted at the initial in-home contact followed a uniform script. That script included information about the potential benefits of increasing mindful attention to and acceptance of experiences in daily life. Participants were told that being better able to focus on the present moment mindfully and without judgment would increase their ability to manage their strong emotions without getting caught in them, to interrupt patterns of thinking that are self-critical and ruminative, and to act in ways that are concordant with their values and interests. As part of the orientation, individuals were introduced to several basic techniques that they could practice on a daily basis to increase mindful awareness and acceptance, and were guided by a research assistant through two brief exercises. One exercise was a meditation focused on attending to the breath, and the second was a visualization exercise that focused on fostering compassion for self and others. During the 27 days of the automated phone calls, individuals were guided each morning through a brief meditation similar to those included in the orientation, and encouraged to find a way to engage in one or more experiential practices in their day’s activities. The meditations during the first week of the intervention focused on being mindful of the breath, body sensations, and other sensory experiences; the second week centered on noticing and recognizing thoughts as transitory experiences; the third week consisted of meditations on compassion and nonjudgment for self and others; and the final week of meditations included guidance on gently attending to aversive experiences with wisdom and nonjudgment, and attending to positive experiences. Attention Control: Health Tips (HT) This condition was intended to control for exposure of the automated telephone delivery technology and the effects of reporting one’s daily expe-

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riences by providing some useful information on daily habits of healthy living to engage the participants while avoiding any manipulation to enhance mastery or mindful awareness and acceptance. The HT participants were given health behavior tips each morning for the 27 days using the automated system. Each day a separate health behavior concern was introduced, and participants in this condition were advised on what constituted a healthy course of action to follow in their daily lives. The 27 topics included health behaviors related to diet, exercise, sleep hygiene, and common chronic illnesses such as diabetes, cancer, and cardiovascular disease.

End-of-Day Assessment Each evening, participants in the MC, MA, and HT groups responded to a series of questions about their daily life presented online (three participants without Internet service filled out paper diaries). These measures constituted the outcome measures for the current study. Daily emotional health was assessed with four measures: 1) the 10-item positive affect (current sample ␣ reliability ⫽ .949) and the 10-item negative affect (␣ ⫽ .937) scales (Watson, Clark, & Tellegen, 1988); 2) a 3-item daily depression scale including two items from Whooley, Avins, Miranda, and Brownder (1997) and a third item, “ I felt unable to enjoy life,” tapping an additional common feeling associated with depression (␣ ⫽ .812); and 3) three items taken from the SF-36 Role-emotional subscale (Ware, Snow, Kosinski, & Gnadek, 1993; ␣ ⫽ .839). Daily physical health was assessed with three measures: 1) four items from the Role-physical subscale of the SF-36 (␣ ⫽ .915); 2) a 0 –100 numeric bodily pain item (Jensen, Karoly, & Braver, 1986); and 3) a 10-item physical symptom checklist drawn from prior studies in our research lab (Zautra et al., 2008; ␣ ⫽ .71) containing items such as “Had difficulty falling asleep last night,” and “Suffered a minor physical injury (minor sprain, pulled muscle, cut or bruise).” Three measures assessed cognitive adjustment and daily stress: 1) five items taken from the Hope scale (Snyder et al., 1996; ␣ ⫽ .873); 2) two items to assess catastrophizing (Keefe, Brown, Wallston, & Caldwell, 1989; ␣ ⫽ .925); and 3) a measure of perceived stress in daily life (Zautra, Guarnaccia, & Dohrenwend, 1986; ␣ ⫽ .602). The perceived stress measure was formed as the average of five ratings of the “stressfulness” following inquiries into the daily occurrence of stressful events in finances (seven items), friendship (seven items), spouse/significant other relations (five items) and work life (six items).

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Manipulation Checks The number of days members in each treatment condition signed on to receive the telephone messages was recorded automatically. In addition to the outcome measures, participants were asked in each evening’s diary how much time they devoted that day to following the recommendations included in the prompt that morning.

Data Analytic Strategy

The study used a multilevel design to test differential treatment effects with daily repeated measures over time. Data were coded by day, and 31 daily scores were clustered to provide summary scores and reduce arbitrary inflation of power to detect effects. The first two days constituted cluster 1 and reflected preintervention daily assessment; the remaining days were grouped into clusters of three days each, resulting in Clusters 2–11. The interaction of Day cluster by Treatment group provided evidence of differential effects over time due to group assignment; differences in linear trends were predicted to favor the active treatment conditions. The analyses proceeded in stages, beginning with analyses of linear effects across day clusters of each group. The second stage of analysis involved identifying significant differences between the three conditions on dependent measures across time. Multilevel modeling was used as the primary data-analytic tool. This method is particularly useful for the linear analysis of data that have a nested hierarchical structure with both between-subjects and within-subject predictions of differential change over time with many observations per subject. All multilevel analyses were conducted using SAS PROC MIXED (Littell, Milliken, Strong, & Wolfinger, 1996). The MIXED procedure is particularly useful when participants have varying amounts of missing data. As a result, all 73 participants were included in multilevel analyses. To illustrate, a basic equation to assess daily depressive symptoms would be as follows: Depressive symptoms ⫽ b0 ⫹ b1 Day Cluster ⫹ b2 Treatment Contrast MC versus HT ⫹ b3 Treatment Contrast MC versus HT ⫻ Day Cluster ⫹ r. Day Cluster was coded 1–11 to permit examination of linear trends, and Treatment effects were estimated with dummy coded contrasts (e.g., MC vs. HT; MC vs. HT). All analyses were conducted with an ARH (1) error structure to model significant heterogeneity in the autocorrelation between adjacent day cluster scores (Littell et al., 1996). Effect sizes for multilevel models were computed as separate estimates of proportional reduction of variance (PRV) from a null model (modeling only the intercept as a predictor of the outcome variable) to a full model, including both the intercept and the

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predictors of interest in each path (Peugh, 2010). Computing effect sizes using this approach yielded estimates of the proportional reduction of variance for level-1 variances for each group across observations. They are reported in Table 1.

RESULTS Preliminary Comparisons of Groups

Treatment groups were similar in age, F(2, 79) ⫽ .37, ns and in their proportion of women, Hispanics, and Spanish-language speakers (␹2(2) ⬍ 2.802, ns). Importantly, groups also reported largely comparable levels of emotional and physical health across the first two diary reports (all ps ⬎ .05). Groups also received a similar “dose” of their respective interventions, accessing an average of 23.60 (SD ⫽ 5.31) of 27 possible daily messages, F(2, 79) ⫽ 2.44, ns. Groups did show differences in the extent to which they reported that they applied intervention skills or information daily, F(2, 77) ⫽ 7.90, p ⫽ .001. The HT group reported the lowest level of daily application Table 1. Intervention Effects on Outcomes of Emotional Health, Physical Health, and Cognitive Adjustment/Daily Stress Fixed effects by groupa Outcome Emotional health Depressive symptoms Negative affect Positive affect Role-emotional Physical health Average pain Role-physical

MC

MA

HT

⫺.065 (.145)ⴱⴱⴱ

⫺.052 (.099)ⴱⴱⴱ

⫺.047 (.007)ⴱⴱ

⫺.037 (.154)ⴱⴱⴱ

⫺.024 (.020)ⴱ

.017 (.000) ⴱ

.058 (.130)ⴱⴱⴱ ⴱⴱ

.002 (.000) .013 (.000)

1.397 (.027)

1.586 (.045)

1.017 (.000)

⫺.376 (.008) .357 (.000)

⫺.519 (.000) 1.488 (.115)ⴱⴱ

.137 (.000) .139 (.000)

Health complaints

.011 (.000)

⫺.072 (.186)ⴱⴱⴱ

⫺.001 (.002)

Cognitive adjustment/ daily stress Catastrophizing

⫺.072 (.202)ⴱ

⫺.053 (.132)ⴱⴱ

⫺.005 (.000)

.008 (.000) .003 (.000)

.046 (.032)ⴱⴱ ⫺.016 (.040)ⴱ

⫺.010 (.001) .018 (.000)ⴱ

Hope Interpersonal stress a †

beta coefficient (effect sizes given in parentheses). p ⬍ .10. ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001.

Group comparisons MC ⬍ HTⴱ, MA ⬍ HT† MC ⬍ HTⴱ, MA ⬍ HT† MA ⬎ MC†, MA ⬎ HTⴱ No significant contrasts MA MA MA MA MA

⬍ ⬎ ⬎ ⬍ ⬍

HTⴱ MCⴱ, HTⴱⴱ MCⴱⴱⴱ, HTⴱⴱⴱ

MC ⬍ HTⴱ, MA ⬍ HT† MA ⬎ HTⴱⴱ MA ⬍ HTⴱ

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on the 0 –3 scale (M ⫽ 1.98, SD ⫽ .56), whereas the MC group and the MA groups were comparable in their level of daily practice (M ⫽ 2.59, SD ⫽ .41 for MC vs. M ⫽ 2.40, SD ⫽ .63 for MA). Both intervention groups reported higher levels of practice across the diaries than did the control group (ps ⬍ .023), which was expected given the substance of the interventions. A review of comments offered voluntarily by participants at the conclusion of the study suggested the three conditions were each viewed in a highly favorable light.

Group Effects on Outcomes

Emotional Health Intervention effects on emotional health were examined first within each group by testing for linear effects across time on depressive symptoms, positive affect, negative affect, and SF-36 Role-emotional subscale. Both intervention groups showed improvements in most markers of emotional health. The MC group reported decreasing levels of depression and negative affect (ts ⬍ ⫺3.56, ps ⬍ .0005) and significant increases in SF-36 Roleemotional scores (t ⫽ 2.07, p ⫽ .04) over time. The MA group likewise reported decreases in depression and negative affect (ts ⬍ ⫺2.33, ps ⬍ .021), and showed significant improvements on the SF-36 Role-emotional subscale as well as in positive affect (ts ⬎ 2.62, ps ⬍ .010). In contrast to the broader effects of both intervention groups, the HT group showed only one change over days in indicators of emotional health, decreases in depression, t ⫽ ⫺3.14, p ⬍ .002, suggesting some regression effects for this variable. Table 1 displays the results overall and follow-up analyses of contrasts between groups. Comparisons between groups indicated that improvements on all markers of emotional health were similar between the MC and MA groups. Changes in depression and negative affect were significantly larger in the MC group and marginally larger in the MA group, compared to the HT group (see Figure 2). Improvements in positive affect were also greater in the MA group compared to HT controls, with a marginally significant difference between MC and HT (see Figure 3). Finally, SF-36 Role-emotional scores over days did not differ between any of the groups (see Figure 4).

Physical Health Intervention effects on physical health were examined within each group by testing for linear effects across time on physical symptoms, SF-36 Rolephysical subscale scores, and pain. Evaluation of within-group change over

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Figure 2. Depressive symptoms reports across time for Health Tips (HT), Mastery-Control

(MC), and Mindfulness Awareness (MA) intervention groups.

time revealed that the MA group showed improvements over days in two of the three markers of physical health: Physical symptoms and SF-36 Rolephysical subscale scores (ts ⬎ 3.13, ps ⬍ .002; see Figure 3). In contrast, the MC and HT groups did not show significant improvement on any physical health measure (ts ⬍ 1.38, ns). Table 1 displays the results overall and follow-up analyses of contrasts between groups. Comparisons between groups indicated that changes in physical symptoms and SF-36 Role-physical subscale scores were more pronounced for the MA group than for the MC and HT groups, which did not differ from one another on any physical health measure. Moreover, the MA group showed more pronounced changes in pain than did the HT group.

Cognitive Adjustment and Daily Stress Analyses to evaluate within-group change in catastrophizing revealed that the MC and MA groups showed significant declines in catastrophizing (ts ⬍ ⫺2.55, ps ⬍ .012), whereas the HT group remained unchanged over the course of the study, t ⫽ ⫺.26, ns. Comparisons of the extent of change of groups revealed that improvements in catastrophizing were comparable in the

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Figure 3. Positive Affect across time for Health Tips (HT), Mastery-Control (MC), and

Mindfulness Awareness (MA) intervention groups.

MC and MA groups, but were significantly better in the MC group and marginally better in the MA group than in the HT group (see Table 1). Improvements in hope were significant for the MA group, t ⫽ 2.98, p ⬍ .004 but not for the MC or HT groups (ts ⬍ .77, ns). The magnitude of the increase was greater in the MA group than in the HT group (see Table 1). Participants’ ratings of the stress in their everyday lives also changed over time within groups. Daily stress decreased in the MA group, t ⫽ ⫺2.04, p ⬍ .043, increased in the HT group, t ⫽ 2.34, p ⬍ .021, and remained unchanged in the MC group, t ⫽ ⫺.30, ns. The difference in extent of change in stress between the MA and HT groups was significant, but no other difference between groups emerged (see Table 1).

Moderators of Treatment Effects

We tested whether the extent to which demographic (i.e., age, gender, Hispanic ethnicity), CES-D scores at screening, or treatment factors (i.e., dose of treatment) moderated responsiveness to treatment. The base multilevel models described above were repeated including a potential moderator

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Figure 4. Physical functioning across time for Health Tips (HT), Mastery-Control (MC), and Mindfulness Awareness (MA) intervention groups.

in the model for each of the 10 outcomes. Two significant effects emerged, one involving age and one involving depressive symptoms at screening. Age moderated group effects on pain over the course of the treatment (Age ⫻ Time ⫻ Group slope estimate ⫽ ⫺.071, SE slope estimate ⫽ 0.023, t ⫽ 3.11, p ⬍ .002). Examination of time effects within age and treatment groups revealed that for older participants, both MC and MA yielded improvements in pain, whereas the HT condition did not change pain over time. For younger participants, group assignment has no relation to changes in pain over time. Analyses of the moderating effects of depressive symptoms revealed that the benefits of MA on hope compared with other groups were only evident for those participants with lower levels of depressive symptoms (Depression ⫻ Time ⫻ Group, F ⫽ 3.73, p ⬍ .02). DISCUSSION

This randomized controlled trial compared the health effects of two distinct interventions targeting either mastery or mindfulness/acceptance skills to those of an education condition in distressed middle-aged adults. The most novel aspect of our method, however, was that the treatment was

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delivered via 5-min automated phone messages each day over a 4-week interval. The findings indicate that both active treatments yielded benefits versus the control condition, and that mindfulness treatment had broader effects than did the mastery treatment. Both interventions resulted in improvements in depressive symptoms and negative affect as well as catastrophizing, consistent with the effects of widely accepted empirically validated behavioral therapies (Teasdale et al., 2002). The mindfulness treatment, however, yielded additional gains in daily positive affect, a key aspect of quality of life that is sometimes overlooked in the evaluation of treatment outcomes. Although low positive affect or anhedonia is a feature of depression, it appears to be important in its own right, predicting health outcomes over and above the contribution of negative affective states (Moskowitz, 2003; Ong, 2010). Individuals in the mindfulness group also reported lowered perceived stress in interpersonal relations and improved self-reports of physical health over the course of treatment. Moreover, both active treatments improved pain reports among older (but not younger) participants. Thus, mastery and mindfulness showed comparable benefits across negative affective, cognitive outcomes, and pain outcomes, whereas mindfulness also improved daily reports of positive emotion, lowered interpersonal stress, and improved self-reports of physical health consistent with Martin’s (1997) contention that mindfulness is a core therapeutic process with broad applicability across a range of emotional difficulties. More generally, the interventions tested here are representative of “action” theory-oriented approaches (Shahar, 2004). Both rely on the principal that people are active agents, shaping their environments and encourage agentic action: Through selfawareness with mindfulness, and enhanced efficacy expectations with personal mastery instruction. Somewhat hidden from view, but embedded within each intervention, are interpersonal themes as well, consistent with relationship-oriented therapies (Weissman, Markowiz, & Klerman, 2000). In the mastery condition, participants are given instructions to interact on more positive ways with others. The mindfulness practice leads to greater awareness and acceptance of emotions, many of which arise from social interactions. Further, explicit attention is given to positive feelings toward others in the mindfulness condition. Other investigations have tested adaptations of behavioral treatments for depression so that they can be more easily delivered using electronic technologies (e.g., García-Lizana & Munoz-Mayorga, 2010; Spek et al., 2007). Our work builds on the existing research on electronic adaptations by demonstrating that the benefits of specific components of automated telephone-assisted treatments may be examined separately prior to building a multicomponent intervention. The current investigation had several noteworthy strengths. First, we assessed intervention effects on a range of affective, cognitive, and physical

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health outcomes, as well as relationship stress via electronic daily diary surveys. These reports allowed us to capture “life as it is lived,” giving us a snapshot of day-to-day improvements across outcomes over the course of the treatment. The capacity to electronically verify the timing of diary completion increases the validity of the changes we observed in groups over time. A second strength of the study was the inclusion of intervention and control conditions that were comparable in their ability to engage participants. All three intervention groups received more than 80% of the treatment segments, an access rate that was recorded electronically. Thus, we have guarded confidence that the beneficial changes that we observed in the mastery and mindfulness groups did not simply reflect differential palatability of treatments, expectancy effects, or the passage of time. The automated delivery of the skills training and control messages, also minimizes “therapist” or other nonspecific factors as an explanation for the findings. The diversity of sample, which included both Caucasians and Latinos, with English- and Spanish-speakers, represents a third strength of the investigation. We explored whether treatment effects varied by demographic group, but there was little indication that interventions were differentially effective for men versus women or for Latinos versus Caucasians. Age was the single moderator of any treatment effects, moderation that held only for changes in physical pain. Older adults showed a greater reduction in pain when receiving the active treatments, perhaps because pain was in greater evidence in their daily lives than younger participants. Only evaluation of the treatments in a sample that is sufficiently powered to test for moderation, however, can assure that there are not more subtle group differences in responsiveness to treatments. Several limitations of the study also deserve comment. First, the generalizability of our findings is untested. We constrained our sample to individuals who were middle-aged and experiencing depressive symptoms, but who did not evidence suicidal ideation. As a result, we cannot comment on the applicability of the findings to older (or younger) individuals, or to those with a different symptom profile. The recruitment methods also contained monetary incentives that may have attracted a select sample. Most public health programs do not provide such incentives. Second, because intervention effects were assessed only during the treatment period, we do not know whether the benefits of the interventions were sustained over time, or whether the changes observed would reach the standard of clinical significance. Through the results are promising, inferences of the interventions’ value should be limited to what was measured in this study: daily functioning during and just after the telephone calls. Future efforts to examine whether treatment effects persist could include testing the utility of “booster” doses of the interventions. Given the ease of treatment delivery, such boosters could

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provide an avenue for cost-effective ongoing care, akin to the approach that characterizes psychopharmacologic treatment of depression. A third limitation of the study is that all outcome measures were self-report; additional data derived from observer/collateral ratings of functional health and performance-based measures would provide a more comprehensive picture of the extent and impact of treatment effects. For example, it is unlikely that substantial changes in objective markers of physical health occurred over a 30-day period, but rather helped individuals attend less to somatic symptoms. Finally, we did not examine the mechanisms by which the interventions had their effects. Mastery instructions emphasized behavioral activation for practical gains in a sense of control over daily life, whereas mindfulness provided greater guidance over the management of daily experiences that were uncontrollable. If the interventions operated via distinct yet compatible mechanisms, as we suspect, the combination of mastery with mindfulness/acceptance training may yield more substantial gains than either treatment alone. The potential impact on public health of interventions that are widely available, easy to implement, and readily adopted by depressed adults of diverse backgrounds is substantial. The current study provides evidence that two components of treatments for depression, mastery and mindfulness/ acceptance skills training, can be effectively disseminated to Caucasian and Latino adults, including those who are Spanish-speaking. We hope these findings will lead to future efforts to find the means to broaden the reach of valuable treatments to a wider range of adults in the community who would benefit from cognitive– behavioral interventions.

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Received December 26, 2011 Revision received April 10, 2012 Accepted May 3, 2012 䡲