Journal of Happiness Studies

, Volume 17, Issue 5, pp 1985–2006 | Cite as

A Positive Psychology Intervention for Patients with an Acute Coronary Syndrome: Treatment Development and Proof-of-Concept Trial

  • Jeff C. HuffmanEmail author
  • Rachel A. Millstein
  • Carol A. Mastromauro
  • Shannon V. Moore
  • Christopher M. Celano
  • C. Andres Bedoya
  • Laura Suarez
  • Julia K. Boehm
  • James L. Januzzi
Research Paper


Positive psychological constructs are associated with superior outcomes in cardiac patients, but there has been minimal study of positive psychology (PP) interventions in this population. Our objective was to describe the intervention development and pilot testing of an 8-week phone-based PP intervention for patients following an acute coronary syndrome (ACS). Initial intervention development and single-arm proof-of-concept trial, plus comparison of the PP intervention to a subsequently-recruited treatment as usual (TAU) cohort. PP development utilized existing literature, expert input, and qualitative interview data in ACS patients. In the proof-of-concept trial, the primary outcomes were feasibility and acceptability, measured by rates of exercise completion and participant ratings of exercise ease/utility. Secondary outcomes were pre-post changes in psychological outcomes and TAU comparisons, measured using effect sizes (Cohen’s d). The PP intervention and treatment manual were successfully created. In the proof-of-concept trial, 17/23 PP participants (74 %) completed at least 5 of 8 exercises. Participants rated the ease (M = 7.4/10; SD = 2.1) and utility (M = 8.1/10, SD = 1.6) of PP exercises highly. There were moderate pre-post improvements (ds = .46–.69) in positive affect, anxiety, and depression, but minimal effects on dispositional optimism (d = .08). Compared to TAU participants (n = 22), PP participants demonstrated greater improvements in positive affect, anxiety, and depression (ds = . 47–.71), but not optimism. A PP intervention was feasible, well-accepted, and associated with improvements in most psychological measures among cardiac patients. These results provide support for a larger trial focusing on behavioral outcomes.


Myocardial infarction Unstable angina Positive affect Optimism Mental health Intervention 



This work was supported by the National Institutes of Health (NIH) Grant R01HL113272.

Compliance with Ethical Standards

Conflicts of interest

The authors have no conflicts of interest to report and there were no other funding sources.


  1. Aspinwall, L. G., & Tedeschi, R. G. (2010). The value of positive psychology for health psychology: Progress and pitfalls in examining the relation of positive phenomena to health. Annals of Behavioral Medicine, 39(1), 4–15.CrossRefGoogle Scholar
  2. Auer, R., Gaume, J., Rodondi, N., Cornuz, J., & Ghali, W. A. (2008). Efficacy of in-hospital multidimensional interventions of secondary prevention after acute coronary syndrome: A systematic review and meta-analysis. Circulation, 117(24), 3109–3117.CrossRefGoogle Scholar
  3. Barth, J., Schumacher, M., & Herrmann-Lingen, C. (2004). Depression as a risk factor for mortality in patients with coronary heart disease: A meta-analysis. Psychosomatic Medicine, 66(6), 802–813.CrossRefGoogle Scholar
  4. Bauer, L. K., Caro, M. A., Beach, S. R., Mastromauro, C. A., Lenihan, E., Januzzi, J. L., et al. (2012). Effects of depression and anxiety improvement on adherence to medication and health behaviors in recently hospitalized cardiac patients. American Journal of Cardiology, 109(9), 1266–1271.CrossRefGoogle Scholar
  5. Berkman, L. F., Blumenthal, J., Burg, M., Carney, R. M., Catellier, D., Cowan, M. J., et al. (2003). Effects of treating depression and low perceived social support on clinical events after myocardial infarction: The Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Randomized Trial. Journal of the American Medical Association, 289(23), 3106–3116.CrossRefGoogle Scholar
  6. Bjelland, I., Dahl, A. A., Haug, T. T., & Neckelmann, D. (2002). The validity of the Hospital Anxiety and Depression Scale. An updated literature review. Journal of Psychosomatic Research, 52(2), 69–77.CrossRefGoogle Scholar
  7. Boehm, J. K., & Kubzansky, L. D. (2012). The heart’s content: The association between positive psychological well-being and cardiovascular health. Psychological Bulletin, 138(4), 655–691.CrossRefGoogle Scholar
  8. Boehm, J. K., Williams, D. R., Rimm, E. B., Ryff, C., & Kubzansky, L. D. (2013). Association between optimism and serum antioxidants in the midlife in the United States study. Psychosomatic Medicine, 75(1), 2–10.CrossRefGoogle Scholar
  9. Bolier, L., Haverman, M., Westerhof, G. J., Riper, H., Smit, F., & Bohlmeijer, E. (2013). Positive psychology interventions: A meta-analysis of randomized controlled studies. BMC Public Health, 13, 119.CrossRefGoogle Scholar
  10. Brouwers, C., Mommersteeg, P. M., Nyklicek, I., Pelle, A. J., Westerhuis, B. L., Szabo, B. M., et al. (2013). Positive affect dimensions and their association with inflammatory biomarkers in patients with chronic heart failure. Biological Psychology, 92(2), 220–226.CrossRefGoogle Scholar
  11. Browning, C., Sims, J., Kendig, H., & Teshuva, K. (2009). Predictors of physical activity behavior in older community-dwelling adults. Journal of Allied Health, 38(1), 8–17.Google Scholar
  12. Callahan, C. M., Unverzagt, F. W., Hui, S. L., Perkins, A. J., & Hendrie, H. C. (2002). Six-item screener to identify cognitive impairment among potential subjects for clinical research. Medical Care, 40(9), 771–781.CrossRefGoogle Scholar
  13. Carroll, A. E., Rivara, F. P., Ebel, B., Zimmerman, F. J., & Christakis, D. A. (2005). Household computer and internet access: The digital divide in a pediatric clinic population. In AMIA annual symposium proceedings, pp. 111–115.Google Scholar
  14. Celano, C. M., & Huffman, J. C. (2011). Depression and cardiac disease: A review. Cardiology in Review, 19(3), 130–142.CrossRefGoogle Scholar
  15. Charlson, M. E., Boutin-Foster, C., Mancuso, C. A., Peterson, J. C., Ogedegbe, G., Briggs, W. M., et al. (2007). Randomized controlled trials of positive affect and self-affirmation to facilitate healthy behaviors in patients with cardiopulmonary diseases: Rationale, trial design, and methods. Contemporary Clinical Trials, 28(6), 748–762.CrossRefGoogle Scholar
  16. Chida, Y., & Steptoe, A. (2008). Positive psychological well-being and mortality: A quantitative review of prospective observational studies. Psychosomatic Medicine, 70(7), 741–756.CrossRefGoogle Scholar
  17. Chiu, C. J., & Wray, L. A. (2011). Gender differences in functional limitations in adults living with type 2 diabetes: Biobehavioral and psychosocial mediators. Annals of Behavioral Medicine, 41(1), 71–82.CrossRefGoogle Scholar
  18. Chocron, S., Etievent, J. P., Viel, J. F., Dussaucy, A., Clement, F., Kaili, D., et al. (2000). Preoperative quality of life as a predictive factor of 3-year survival after open heart operations. Annals of Thoracic Surgery, 69(3), 722–727.CrossRefGoogle Scholar
  19. Chow, C. K., Jolly, S., Rao-Melacini, P., Fox, K. A., Anand, S. S., & Yusuf, S. (2010). Association of diet, exercise, and smoking modification with risk of early cardiovascular events after acute coronary syndromes. Circulation, 121(6), 750–758.CrossRefGoogle Scholar
  20. Cohn, M. A., Pietrucha, M. E., Saslow, L. R., Hult, J. R., & Moskowitz, J. T. (2014). An online positive affect skills intervention reduces depression in adults with type 2 diabetes. Journal of Positive Psychology, 9(6), 523–534.CrossRefGoogle Scholar
  21. DiMatteo, M. R., Hays, R. D., & Sherbourne, C. D. (1992). Adherence to cancer regimens: Implications for treating the older patient. Oncology, 6(2 Suppl), 50–57.Google Scholar
  22. DuBois, C. M., Beach, S. R., Kashdan, T. B., Nyer, M. B., Park, E. R., Celano, C. M., et al. (2012). Positive psychological attributes and cardiac outcomes: Associations, mechanisms, and interventions. Psychosomatics, 53(4), 303–318.CrossRefGoogle Scholar
  23. DuBois, C. M., Lopez, O. V., Beale, E. E., Healy, B. C., Boehm, J. K., & Huffman, J. C. (2015). Relationships between positive psychological constructs and health outcomes in patients with cardiovascular disease: A systematic review. International Journal of Cardiology, 195, 265–280.CrossRefGoogle Scholar
  24. Fishbach, A., & Labroo, A. A. (2007). Be better or be merry: How mood affects self-control. Journal of Personality and Social Psychology, 93(2), 158–173.CrossRefGoogle Scholar
  25. Gander, F., Proyer, R. T., Ruch, W., & Wyss, T. (2013). Strength-based positive interventions: Further evidence for their potential in enhancing well-being and alleviating depression [Peer Reviewed]. Journal of Happiness Studies, 14(4), 1241–1259.CrossRefGoogle Scholar
  26. Gehi, A. K., Ali, S., Na, B., & Whooley, M. A. (2007). Self-reported medication adherence and cardiovascular events in patients with stable coronary heart disease: The heart and soul study. Archives of Internal Medicine, 167(16), 1798–1803.CrossRefGoogle Scholar
  27. Giltay, E. J., Geleijnse, J. M., Zitman, F. G., Buijsse, B., & Kromhout, D. (2007). Lifestyle and dietary correlates of dispositional optimism in men: The Zutphen Elderly Study. Journal of Psychosomatic Research, 63(5), 483–490.CrossRefGoogle Scholar
  28. Glassman, A. H., O’Connor, C. M., Califf, R. M., Swedberg, K., Schwartz, P., Bigger, J. T, Jr, et al. (2002). Sertraline treatment of major depression in patients with acute MI or unstable angina. JAMA, 288(6), 701–709.CrossRefGoogle Scholar
  29. Hare, D. L., Toukhsati, S. R., Johansson, P., & Jaarsma, T. (2014). Depression and cardiovascular disease: A clinical review. European Heart Journal, 35(21), 1365–1372.CrossRefGoogle Scholar
  30. Hevey, D., McGee, H. M., & Horgan, J. H. (2014). Comparative optimism among patients with coronary heart disease (CHD) is associated with fewer adverse clinical events 12 months later. Journal of Behavioral Medicine, 37(2), 300–307.CrossRefGoogle Scholar
  31. Hoen, P. W., Denollet, J., de Jonge, P., & Whooley, M. A. (2013). Positive affect and survival in patients with stable coronary heart disease: Findings from the Heart and Soul Study. Journal of Clinical Psychiatry, 74(7), 716–722.CrossRefGoogle Scholar
  32. Huffman, J. C., DuBois, C. M., Healy, B. C., Boehm, J. K., Kashdan, T. B., Celano, C. M., et al. (2014a). Feasibility and utility of positive psychology exercises for suicidal inpatients. General Hospital Psychiatry, 36(1), 88–94.CrossRefGoogle Scholar
  33. Huffman, J. C., DuBois, C. M., Mastromauro, C. A., Moore, S. V., Suarez, L., & Park, E. R. (2014b). Positive psychological states and health behaviors in acute coronary syndrome patients: A qualitative study. Journal of Health Psychology. Google Scholar
  34. Huffman, J. C., Mastromauro, C. A., Boehm, J. K., Seabrook, R., Fricchione, G. L., Denninger, J. W., et al. (2011). Development of a positive psychology intervention for patients with acute cardiovascular disease. Heart International, 6(2), e14.CrossRefGoogle Scholar
  35. Huffman, J. C., Moore, S. V., DuBois, C. M., Mastromauro, C. A., Suarez, L., & Park, E. R. (2015). An exploratory mixed methods analysis of adherence predictors following acute coronary syndrome. Psychol Health Med, 20(5), 541–550.CrossRefGoogle Scholar
  36. Ikeda, A., Schwartz, J., Peters, J. L., Fang, S., Spiro, A, 3rd, Sparrow, D., et al. (2011). Optimism in relation to inflammation and endothelial dysfunction in older men: the VA Normative Aging Study. Psychosomatic Medicine, 73(8), 664–671.CrossRefGoogle Scholar
  37. Jiang, W., O’Connor, C., Silva, S. G., Kuchibhatla, M., Cuffe, M. S., Callwood, D. D., et al. (2008). Safety and efficacy of sertraline for depression in patients with CHF (SADHART-CHF): A randomized, double-blind, placebo-controlled trial of sertraline for major depression with congestive heart failure. American Heart Journal, 156(3), 437–444.CrossRefGoogle Scholar
  38. Katz, D. A., Graber, M., Birrer, E., Lounsbury, P., Baldwin, A., Hillis, S. L., et al. (2009). Health beliefs toward cardiovascular risk reduction in patients admitted to chest pain observation units. Academic Emergency Medicine, 16(5), 379–387.CrossRefGoogle Scholar
  39. Kelloniemi, H., Ek, E., & Laitinen, J. (2005). Optimism, dietary habits, body mass index and smoking among young Finnish adults. Appetite, 45(2), 169–176.CrossRefGoogle Scholar
  40. Khoza, S. R., & Kortenbout, W. (1995). An investigation of compliance in type II diabetic patients attending clinic at Church of Scotland hospital. Curationis, 18(4), 10–14.CrossRefGoogle Scholar
  41. Kind, T., Huang, Z. J., Farr, D., & Pomerantz, K. L. (2005). Internet and computer access and use for health information in an underserved community. Ambulatory Pediatrics, 5(2), 117–121.CrossRefGoogle Scholar
  42. Kolansky, D. M. (2009). Acute coronary syndromes: morbidity, mortality, and pharmacoeconomic burden. American Journal of Managed Care, 15(2 Suppl), S36–S41.Google Scholar
  43. Konstam, V., Salem, D., Pouleur, H., Kostis, J., Gorkin, L., Shumaker, S., et al. (1996). Baseline quality of life as a predictor of mortality and hospitalization in 5,025 patients with congestive heart failure. SOLVD Investigations. Studies of Left Ventricular Dysfunction Investigators. American Journal of Cardiology, 78(8), 890–895.CrossRefGoogle Scholar
  44. Krumholz, H. M., Peterson, E. D., Ayanian, J. Z., Chin, M. H., DeBusk, R. F., Goldman, L., et al. (2005). Report of the National Heart, Lung, and Blood Institute working group on outcomes research in cardiovascular disease. Circulation, 111(23), 3158–3166.CrossRefGoogle Scholar
  45. Laerum, E., Johnsen, N., Smith, P., & Larsen, S. (1988). Myocardial infarction may induce positive changes in life-style and in the quality of life. Scandinavian Journal of Primary Health Care, 6(2), 67–71.CrossRefGoogle Scholar
  46. Lawton, J., Parry, O., Peel, E., & Douglas, M. (2005). Diabetes service provision: A qualitative study of newly diagnosed type 2 diabetes patients’ experiences and views. Diabetic Medicine, 22(9), 1246–1251.CrossRefGoogle Scholar
  47. Lesperance, F., Frasure-Smith, N., Koszycki, D., Laliberte, M. A., van Zyl, L. T., Baker, B., et al. (2007). Effects of citalopram and interpersonal psychotherapy on depression in patients with coronary artery disease: The Canadian Cardiac Randomized Evaluation of Antidepressant and Psychotherapy Efficacy (CREATE) trial. Journal of the American Medical Association, 297(4), 367–379.CrossRefGoogle Scholar
  48. Lett, H. S., Blumenthal, J. A., Babyak, M. A., Sherwood, A., Strauman, T., Robins, C., et al. (2004). Depression as a risk factor for coronary artery disease: Evidence, mechanisms, and treatment. Psychosomatic Medicine, 66(3), 305–315.Google Scholar
  49. Lichtman, J. H., Froelicher, E. S., Blumenthal, J. A., Carney, R. M., Doering, L. V., Frasure-Smith, N., et al. (2014). Depression as a risk factor for poor prognosis among patients with acute coronary syndrome: Systematic review and recommendations: A scientific statement from the American Heart Association. Circulation, 129(12), 1350–1369.CrossRefGoogle Scholar
  50. Lyubomirsky, S., & Layous, K. (2013). How do simple positive activities increase well-being? [Peer Reviewed]. Current Directions in Psychological Science, 22(1), 57–62.CrossRefGoogle Scholar
  51. Lyubomirsky, S., Sheldon, K. M., & Schkade, D. (2005). Pursuing happiness: The architecture of sustainable change. Review of General Psychology, 9, 111–131.CrossRefGoogle Scholar
  52. Mancuso, C. A., Choi, T. N., Westermann, H., Wenderoth, S., Hollenberg, J. P., Wells, M. T., et al. (2012). Increasing physical activity in patients with asthma through positive affect and self-affirmation: A randomized trial. Archives of Internal Medicine, 172(4), 337–343.CrossRefGoogle Scholar
  53. Menzin, J., Wygant, G., Hauch, O., Jackel, J., & Friedman, M. (2008). One-year costs of ischemic heart disease among patients with acute coronary syndromes: Findings from a multi-employer claims database. Current Medical Research and Opinion, 24(2), 461–468.CrossRefGoogle Scholar
  54. Miniwatts. (2015). Internet world statistics, 2014; Internet usage statistics: The internet big picture., August 11, 2015.
  55. Moskowitz, J. T., Hult, J. R., Duncan, L. G., Cohn, M. A., Maurer, S., Bussolari, C., et al. (2012). A positive affect intervention for people experiencing health-related stress: Development and non-randomized pilot test. J Health Psychol, 17(5), 676–692.CrossRefGoogle Scholar
  56. Mozaffarian, D., Benjamin, E. J., Go, A. S., Arnett, D. K., Blaha, M. J., Cushman, M., et al. (2015). Heart disease and stroke statistics—2015 update: A report from the American Heart Association. Circulation, 131(4), e29–322.CrossRefGoogle Scholar
  57. Ogedegbe, G. O., Boutin-Foster, C., Wells, M. T., Allegrante, J. P., Isen, A. M., Jobe, J. B., et al. (2012). A randomized controlled trial of positive-affect intervention and medication adherence in hypertensive African Americans. Archives of Internal Medicine, 172(4), 322–326.CrossRefGoogle Scholar
  58. Peterson, J. C., Charlson, M. E., Hoffman, Z., Wells, M. T., Wong, S. C., Hollenberg, J. P., et al. (2012). A randomized controlled trial of positive-affect induction to promote physical activity after percutaneous coronary intervention. Archives of Internal Medicine, 172(4), 329–336.CrossRefGoogle Scholar
  59. Pressman, S., & Cohen, S. (2005). Does positive affect influence health? Psychological Bulletin, 131(6), 925–971.CrossRefGoogle Scholar
  60. Ryff, C. D., Singer, B. H., & Dienberg Love, G. (2004). Positive health: Connecting well-being with biology. Philosophical Transactions of the Royal Society of London. Series B, Biological Sciences, 359(1449), 1383–1394.CrossRefGoogle Scholar
  61. Scheier, M. F., Carver, C. S., & Bridges, M. W. (1994). Distinguishing optimism from neuroticism (and trait anxiety, self-mastery, and self-esteem): A reevaluation of the Life Orientation Test. Journal of Personality and Social Psychology, 67(6), 1063–1078.CrossRefGoogle Scholar
  62. Scheier, M. F., Matthews, K. A., Owens, J. F., Schulz, R., Bridges, M. W., Magovern, G. J., et al. (1999). Optimism and rehospitalization after coronary artery bypass graft surgery. Archives of Internal Medicine, 159(8), 829–835.CrossRefGoogle Scholar
  63. Schou, I., Ekeberg, O., Sandvik, L., & Ruland, C. M. (2005). Stability in optimism-pessimism in relation to bad news: A study of women with breast cancer. Journal of Personality Assessment, 84(2), 148–154.CrossRefGoogle Scholar
  64. Seligman, M. E., Steen, T. A., Park, N., & Peterson, C. (2005). Positive psychology progress: Empirical validation of interventions. American Psychologist, 60(5), 410–421.CrossRefGoogle Scholar
  65. Shepperd, J. A., Maroto, J. J., & Pbert, L. A. (1996). Dispositional optimism as a predictor of health changes among cardiac patients. Journal of Research in Personality, 10, 34–42.Google Scholar
  66. Sin, N. L., & Lyubomirsky, S. (2009). Enhancing well-being and alleviating depressive symptoms with positive psychology interventions: A practice-friendly meta-analysis. Journal of Clinical Psychology, 65(5), 467–487.CrossRefGoogle Scholar
  67. Steptoe, A., Dockray, S., & Wardle, J. (2009). Positive affect and psychobiological processes relevant to health. Journal of Personality, 77(6), 1747–1776.CrossRefGoogle Scholar
  68. Steptoe, A., Wright, C., Kunz-Ebrecht, S. R., & Iliffe, S. (2006). Dispositional optimism and health behaviour in community-dwelling older people: Associations with healthy ageing. British Journal of Health Psychology, 11(Pt 1), 71–84.CrossRefGoogle Scholar
  69. Sud, A., Kline-Rogers, E. M., Eagle, K. A., Fang, J., Armstrong, D. F., Rangarajan, K., et al. (2005). Adherence to medications by patients after acute coronary syndromes. Annals of Pharmacotherapy, 39(11), 1792–1797.CrossRefGoogle Scholar
  70. Tindle, H., Belnap, B. H., Houck, P. R., Mazumdar, S., Scheier, M. F., Matthews, K. A., et al. (2012). Optimism, response to treatment of depression, and rehospitalization after coronary artery bypass graft surgery. Psychosomatic Medicine, 74(2), 200–207.CrossRefGoogle Scholar
  71. Watson, D., Clark, L. A., & Tellegen, A. (1988). Development and validation of brief measures of positive and negative affect: The PANAS scales. Journal of Personality and Social Psychology, 54(6), 1063–1070.CrossRefGoogle Scholar
  72. Ziegelstein, R. C., Fauerbach, J. A., Stevens, S. S., Romanelli, J., Richter, D. P., & Bush, D. E. (2000). Patients with depression are less likely to follow recommendations to reduce cardiac risk during recovery from a myocardial infarction. Archives of Internal Medicine, 160(12), 1818–1823.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2015

Authors and Affiliations

  • Jeff C. Huffman
    • 1
    • 2
    Email author
  • Rachel A. Millstein
    • 1
    • 2
  • Carol A. Mastromauro
    • 1
    • 2
  • Shannon V. Moore
    • 1
    • 2
  • Christopher M. Celano
    • 1
    • 2
  • C. Andres Bedoya
    • 1
    • 2
  • Laura Suarez
    • 1
    • 2
  • Julia K. Boehm
    • 3
  • James L. Januzzi
    • 1
    • 4
  1. 1.Department of PsychiatryMassachusetts General HospitalBostonUSA
  2. 2.Department of PsychiatryHarvard Medical SchoolBostonUSA
  3. 3.Department of PsychologyChapman UniversityOrangeUSA
  4. 4.Division of Cardiology, Department of MedicineMassachusetts General HospitalBostonUSA

Personalised recommendations