This article was downloaded by: [Lakehead University]On: 08 December 2014, At: 13:49Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House,37-41 Mortimer Street, London W1T 3JH, UK

Behavioral MedicinePublication details, including instructions for authors and subscription information:http://www.tandfonline.com/loi/vbmd20

A Classroom Mind/Body Wellness Intervention for OlderAdults With Chronic Illness: Comparing Immediate and1-Year BenefitsBruce Rybarczyk PhD , Gail DeMarco PhD , Marco DeLaCruz MD , Stan Lapidos MS & BarryFortner PhDPublished online: 25 Mar 2010.

To cite this article: Bruce Rybarczyk PhD , Gail DeMarco PhD , Marco DeLaCruz MD , Stan Lapidos MS & Barry Fortner PhD(2001) A Classroom Mind/Body Wellness Intervention for Older Adults With Chronic Illness: Comparing Immediate and 1-YearBenefits, Behavioral Medicine, 27:1, 15-27

To link to this article: http://dx.doi.org/10.1080/08964280109595768

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) containedin the publications on our platform. However, Taylor & Francis, our agents, and our licensors make norepresentations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of theContent. Any opinions and views expressed in this publication are the opinions and views of the authors, andare not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon andshould be independently verified with primary sources of information. Taylor and Francis shall not be liable forany losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoeveror howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use ofthe Content.

This article may be used for research, teaching, and private study purposes. Any substantial or systematicreproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in anyform to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

A Classroom Mind/Body Wellness Intervention for Older Adults With Chronic Illness:

Comparing Immediate and 1-Year Benefits Bruce Rybarczyk, PhD; Gail DeMarco, PhD; Marco DeLaCruz, MD;

Stan Lapidos, MS; Barry Fortner, PhD

The authors tested the eficacy of a mindbody wellness intervention for older adults with chronic illness. They randomly assigned 243 physician-referred patients from an urban H M O to a classroom intervention or a wait-list con- trol group. The intervention provided instruction on mind/body relationships; relacition training; cognitive restructuring; problem-solving; communica- tion; and behavioral treatment for insomniu, nutrition, and exercise. At post- treatment, the intervention group had signijicant decreases in self-reported sleep dificulties, pain, anxiety, and depression symptoms compared with con- trols. The intervention also led to a significant decrease in “chance” and “powerful others” heizlth locus of control beliefs. At I -year follow-up, the intervention group maintained benefits in sleep and health locus of control and also reported a signijkant increase in health behaviors compared with controls. Pain, anxier); and depression benefits were not maintained. This type of classroom intervention appears to have some lasting effects on health behaviors and beliefs.

Index Terms: health behaviors. insomnia, locus of control, mindbody well- ness, older persons, puin

Group interventions to facilitate coping and increase self- management of chronic health problems have become an increasingly popular treatment modality and research area in behavioral medicine.lV2 One line of research has empha- sized a specific intervention approach, such as teaching mindfulness meditation,’ providing traditional group psy- ~hotherapy,~ or changing specific health behavior^.^ A sec- ond line of research has employed a multicomponent approach to intervention by providing a combination of self-help skills and information.”Is These multicomponent interventions typically include several of the following: instruction on the mindhody connection; relaxation train- ing; cognitive-behavioral approaches to managing pain, anxiety, and depression; problem solving; effective commu- nication; and information on nutrition, sleep, exercise, and disease-specific topics. Although different terms have been

applied to these intervention programs (eg, mind/body, lifestyle management, self-care, cognitive-behavioral, cop- ing enhancement), we refer to them collectively as group multicomponent wellness (GMW) interventions.

Studies have shown that GMW interventions are effective in improving quality of life and reducing symptoms among patients with a wide variety of medical cunditions. These conditions include chronic pain,12.” cancer, cardiovascular disease,’-9 arthritis,l4.l5 chronic fatigue syndrome,l” and psy- chosomatic complaints.” In many cases, these interventions have demonstrated stronger treatment effects than tradition- al health-education interventions for these same medical problems.Ih Moreover, in two cases these intervention pro- grams were provided in HMO settings, and clinicians were able to measure and demonstrate significant reductions in patients’ use of medical services.’.” Reduced healthcare

15

Dow

nloa

ded

by [

Lak

ehea

d U

nive

rsity

] at

13:

49 0

8 D

ecem

ber

2014

CLASSROOM MINDBODY WELLNESS

costs were also demonstrated in a third study” that relied on self-reported measures of use. The goal of developing cost- effective interventions is a primary reason why behavioral medicine researchers continue to emphasize group interven- tions over individual approaches.

Because research on GMW interventions is in an early stage, several important issues have yet to be adequately studied. One such issue is whether these interventions can effectively treat individuals with a range of chronic diseases that share a common set of coping tasks. Previous interven- tion studies have tested disease-specific programs. An exception was a recent study by Long and colleague^'^ that provided a 7-week mind/body wellness program to a group of patients with diagnoses of heart disease, lung disease, stroke, or arthritis. Compared with patients randomly assigned to the control condition, participants in that study demonstrated improvements at 6-month follow-up in exer- cise, communication with physicians, self-reported health, health distress, fatigue, disability, and social-role limita- tions. No changes were found for pain and discomfort, shortness of breath, or psychological distress. GMW pro- grams designed for patients with a range of medical condi- tions are critical for older adults because many people in this age group have multiple chronic medical conditions.’*

Another issue that needs to be addressed is the generaliz- ability of GMW interventions to underserved and at-risk demographic groups. A 1994 national conference on New Research Frontiers in Behavioral Medicine concluded that older adults should be given priority in future research.I9 Persons in the current cohort of older adults are a good fit with GMW interventions because of the higher prevalence of psychosomatic symptomsz0 and documented preference for mental health treatments that are integrated into prima- ry care settings.2’ We hypothesize that self-help techniques are uniquely effective in enhancing older adults’ coping with chronic illness in a manner that is compatible with the current cohort’s emphasis on self-reliance. African Ameri- cans are another underserved and at-risk group who should be given priority in future GMW studies.I9 African Ameri- cans, compared with nonminority populations, have higher rates of chronic as well as higher rates of specif-

ic psychosocial factors (eg, less education, lower incomes) that may exacerbate these conditions.z3~z4

A final issue that needs to be addressed more thoroughly is the long-term durability of the effects of participation in GMW interventions. A majority of studies have not exam- ined long-term benefits or have assessed these effects at fol- low-up periods of 6 months’ duration or less. Assessing longer term benefits is essential because of the assumption that these programs provide tertiary prevention, helping patients manage their diseases themselves and cope more effectively over time. Thus, benefits from participation should remain the same or accrue over time, and outcomes should reflect this trend. For example, two studies that did measure outcomes from GMW interventions for cardiac patients at two or more follow-up intervals found that improved psychological functioning relative to controls appeared at the I-year follow-up but not at the earlier assessment^.'^.'^ By contrast, in a study of arthritis patients, Lorig and colleague^'^ found that pain and disability decreased at 4 months postintervention and were either sig- nificantly diminished or were not maintained at a 20-month follow-up assessment.

Our present study tested a GMW intervention designed for older adults (age > 50 y) with at least one chronic ill- ness. We pilot tested the classroom intervention we used, which resulted in reduced depression and medical symp- toms and improved health behaviors and life satisfaction in 47 older adult HMO membersz5 with a range of chronic ill- nesses. The study also included three other components not employed in previous studies: implementation of the pro- gram in urban HMO offices with a large African American patient base, physician referral rather than self-referral of participants, and assessment of both immediate and 1-year outcomes. A previous publication compared the immediate benefits of the intervention for half of the participants in the present study to a third group who had received a compara- ble intervention in a home course.26 Results showed an array of comparable positive benefits across the two inter- vention groups. Limitations on funding did not permit con- tinued randomization and follow-up with the home-course group in the present study.

METHOD Participants Dr Rybarcuk is an associate professor in the Departments of Psy-

chology and Physical Medicine and Rehabilitation, Rush Universi-

ment of Family Medicine, and Mr Lupkios is the coordinator of the Geriatric Interdisciplina~ Team Training Program. Dr Fortner is director of Psychology and Cancer Symptom Research at West Cancer Clinic in Memphis, and Dr DeMarco is staff psychologist at Community Health Center in Middletown, Connecticut.

We obtained participants through a multistep screening,

boards involved approved the study, and we obtained in- formed consent from each participant. Using the patient database of an urban staff-model HMO office, we compiled a list of members who were at least 50 years old who had 6

& where Dr DeLacmz is an instructor in the Depan- referral, and recruitment procedure. The institutional review

16 Behavioral Medicine

Dow

nloa

ded

by [

Lak

ehea

d U

nive

rsity

] at

13:

49 0

8 D

ecem

ber

2014

RYBARCZYK ET AL

or more primary care visits in the preceding year. We divid- ed the 13, 378 patients into separate lists of patients assigned to each of the 29 internists and family practice physicians at the HMO office. We gave the physicians an in-service pre- sentation on the intervention program, then provided them with their patient lists. We asked them to refer patients who met the following criteria: (a) diagnosis of at least one chronic illness, (b) cognitive functioning grossly within the normal range, and (c) the presence of “a significant psy- chosocial component to their chronic illness.” We based the division on clinical judgment. To assist physicians in mak- ing the latter judgment, we provided specific examples of psychosocial problems that occur frequently with chronic illness (eg, depression or anxiety symptoms, insomnia, excessive pain complaints, somatization, relationship prob- lems, and psychological dependency on healthcare providers). To meet an additional research funding priority of including a large subset of women with cardiovascular disease, we asked the physicians to give preference to women when making referrals. The physicians referred a total of 905 patients.

To assign referred patients to the two groups, we used random stratification by age and primary care use. A research assistant then telephoned patients individually and invited them to participate in the program. Patients were told that their physicians, who felt they might benefit from this type of wellness program, had recommended them. The program was free, but patients were asked to fill out ques- tionnaires at three different times for research purposes. We also invited control group patients to complete the question- naires in exchange for participating in a classroom program the following year.

Classroom participants completed the pretreatment and posttreatment questionnaire at the beginning of the first and end of the last class meeting, respectively. All other question- naires were mailed to subjects and returned in a postpaid envelope. If a classroom participant was not present at the last class, we mailed the questionnaires. Control group partici- pants completed their questionnaires at time intervals that were matched to the intervention group. Patients were assured that all answers would remain confidential and would not be shared with physicians or with other HMO staff.

Of the initial randomized pool of potential patients, 379 persons agreed to participate. Those who did not agree did so for the following reasons: (a) they could not be reached or did not return a call to the study coordinator after a mes- sage was left about the study (42.2%), (b) daytime employ- ment (3 1.4%). (c) difficulties in getting transportation to class (5.8‘%), (c) health problems that prohibited regular attendance (6.9%), (d) anticipated travel during the time of

the intervention (4.7%), (e) not interested (7.6%), (fl day- time caregiver responsibilities (0.4%). and various other reasons ( I . 1 %-eg, English was not their primary language or they were no longer in the health plan).

Three hundred two patients completed the pretreatment questionnaires. Subsequent attrition during the 8-week treat- ment phase of the study was 19% in the classroom group and 20% in the control group. We included intervention partici- pants in the data analysis if they attended at least half of the classes. The mean number of classes attended was 6.6, with the following attendance levels: 9 participants attended fewer than 4 classes, 5 attended 4 classes, 14 attended 5 classes. 33 attended 6 classes, 36 attended 7 classes, and 28 attended 8 classes. When participants missed a class, we offered them a make-up audiotape of the class to review as a way of mitigating the effect of a missed class.

Although the groups started out as equivalent in age and use of care after randomization, the treatment group was sig- nificantly ofder than the control group, t(241) = 2.25, p < 0 5 , at the posttreatment assessment because of differential attri- tion. We had anecdotal evidence that younger patients drop- ped out of the treatment group more frequently than older patients because of the difficulties associated with a busy schedule. The two groups were not significantly different o n any other demographic variable or pretreatment dependent variable. See Table 1 for a summary of the demographic pro- files of the two groups at the posttreatment interval.

We retained 243 patients in the pretreatment and posttreat- ment portions of the study. The typical participant was “young old” ( M = 66.1 y, range = 50-93); an African Amer-

TABLE 1 Demographic Characteristics of Participants,

by Group

Wait-list Classroom control (n = 113) ( n = 130)

Variable M SD M SII

Age ( Y ) 67.6 9.3 64.8 9.6 Office visits 12.1 6.5 10.9 5.5 Education (y) 12.7 2.9 13.3 3.1 Gender

Race

Marital status

Women (%) 80.4 80.7

African American (%) 66.0 64.6

Married (%) 53.6 48.5

Vol 27, Spring 2001 17

Dow

nloa

ded

by [

Lak

ehea

d U

nive

rsity

] at

13:

49 0

8 D

ecem

ber

2014

CLASSROOM MINDBODY WELLNESS

ican (65), non-Hispanic White (31%), Hispanic (2%), other (2%); was married (5 1 %), divorced, or separated (1 7%); wid- owed (25%); single (7%); female (81%) with a high school education (18% less than a high school education, 37% high school graduate, 22% less than 4 years of college, 23% 4 or more years of college). Comorbid chronic illness was com- mon, with the most frequent conditions being hypertension (8 1 %), diabetes (30%), osteoarthntishheumatoid arthntis (27%); cardiovascular disease (25%), spinal stenosisilow back pain (1 1 %); and hypercholesterolemia (12%). The mean number of primary care office visits in the year pre- ceding the study was 10.75 (range = 6-31).

The attrition rate during the 1 -year follow-up period was 16%, with nearly identical rates for both groups (ie, 15% for treatment and 17% for control). Reasons for attrition included patient could not be reached (6.2%), patient had health problems precluding participation (3.6%), patient was no longer interested in participating (2.7%), patient developed new cognitive limitations that precluded partici- pation (1.8%), patient was spending the season in another state (l%), and the patient had died (1%). Patients who were not included in the 1-year follow-up assessment were not significantly different on any pretreatment or posttreat- ment measures from those who remained in the study.

Measures We selected or constructed brief instruments and abbre-

viated versions of longer scales to use as outcome measures so that the full questionnaire would take no longer than 30 minutes to complete. Brevity was particularly important for control participants, who were being asked to complete forms in exchange for a course that would be offered a full year later. Changes that the authors made to instruments were based on a pilot

Medical Symptoms Checklist (MSCL)

The MSCL has been used to evaluate the outcome of a similar mindhody wellness intervention. * It includes 25 common physical symptoms (eg, headache, numbness) that are rated on frequency of occurrence. To simplify the ques- tionnaire, we reduced the ratings to a 6-point scale of how often a medical symptom was experienced, ranging from 0 (never or almost never) through 1 (a few times a month), 2 (once a week), 3 (several times a week), 4 (once a day), and to 5 (more than once a day). We expanded the scale to 29 items by adding symptoms that are more common to older adults with chronic illnesses (eg, constipation, fatigue). The instructions did not provide a specific time period to con- sider, but the answer format implied that the frame of refer- ence is relatively long range. Scores for the instrument can

range between 0 and 145, and Cronbach’s alpha for the present study was 0.88.

Frequency of Sleep Dificulties

Because of its importance to health and because it is a com- bined psychological and physical health variable, we ana- lyzed the frequency of sleep difficulties item from the MSCL separately and did not use it in the MSCL total score analy- ses. As noted above, answers can range between 0 and 5 .

Pain and General Health Perception Ratings

From the Short Form-36 Health S u ~ e y , ~ ’ we adopted two items assessing pain and general health perception. Both items have demonstrated good validity and reliability. The pain item asks respondents to rate “How much bodily pain you have had during the past 4 weeks” on a 6-point scale from none (1) through very mild (2), mild (3), moderate (4), severe (3, to very severe (6). In addition, patients are asked to respond to a series of health perception items by respond- ing to “ In general, would you say your health is. . . ” using a 5-point scale: from 1 (excellent) through 2 (very good) , 3 (good), 4 (fair) to 5 @our) .

Short-Form McGill Pain Questionnaire (SF-MPQ)

The SF-MPQ was designed as a brief version of the long- form MPQ, which has been widely used for measurement and study of the qualitative dimensions of pain.28929 It includes 16 adjectives describing pain sensations (eg, throb- bing, splitting, and punishing-cruel) and asks respondents to rate how much they have experienced each of these sen- sations on the following 4-point scale: 0 (none), 1 (mild), 2 (moderate), 3 (severe). Total scores can range between 0 and 48. The SF-MPQ total score has been shown to corre- late highly with the standard MPQ. To adapt the scale to the assessment of both intermittent and chronic pain, we instructed patients to rate any pain experienced during the past week. Cronbach’s alpha for the modified scale used in present study was 0.88. Because the SF-MPQ was added to the study after the first treatment class, data for this measure were obtained only for a subset of 188 participants.

Beck Anxiety Inventory (BAI)

The BAI is a 21-item scale designed to measure the severity of anxiety with minimal confounding from the symptoms of depres~ion .~~ Respondents rate how much they have been bothered during the past week by each anxiety symptom, using a 4-point scale: 0 (not at all) to 3 (severe- ly). Scores can range between 0 and 63. The scale has demonstrated good internal consistency and reliability, high concurrent validity with other measures of anxiety, and the

18 Behavioral Medicine

Dow

nloa

ded

by [

Lak

ehea

d U

nive

rsity

] at

13:

49 0

8 D

ecem

ber

2014

RY BARCZY K ET AL

ability to discriminate anxiety disorders from other nonaf- fective psychiatric disorder^.^' Cutoff scores have been established for mild (> 9), moderate (> 16), and severe (> 29) symptoms of an~iety.~’ Cronbach’s alpha for this scale in the present study was 0.88.

Center for Epidemiologic Studies Depression Scale (CES-D)

The CES-D32 is a widely used 20-item depression scale that has established validity and reliability with a wide range of populations and is not compromised by the effects of age, gender, medical illness, functional impairment, cog- nitive impairment. or social de~irabil i ty.~~ To simplify the questionnaire, we used a modified version of the CES-D that employs a yes-no answer format in lieu of a 4-point fre- quency rating for each item.32 In the modified version, each item remains in the same statement form (eg, “I felt depressed”) as do the instructions inquiring whether it applied during the past week. Scores can range from 0 to 20. A large-scale study demonstrated that the yes-no format yields scores that are comparable to the original scale.34 For discriminating clinically significant levels of depression, we found that a score of 9 was equivalent to the cutoff score of 16 on the original scale. Cronbach’s alpha for the modified scale used in the present study was 0.87.

Life Satisfaction Index-Short Form (U) Bigot35 developed an &item version of the original 18-

item LSI-A36 to measure subjective well-being. This version of the scale yields a global score of life satisfaction with adequate levels of reliability and validity. Respondents are asked to what extent they agree: 0 (agree) 2 (disagree) 1 (not sure) with a series of statements (eg, ‘‘My life could be happier than it is now”). Scores can range between 0 and 16. The construct of subjective well-being has been used frequently in studies of older adults and individuals with medical illness and di~ability;~’ Cronbach’s alpha for this scale in the present study was 0.74.

Abbreviated Health-Promoting Lifestyle Profile (HPLP)

The HPLP is a 48-item measure of health behaviors.38 Respondents rate how frequently they engage in a health behavior (eg, take some time for relaxation each day, par- ticipate in supervised exercise programs or activities) on a 4-point scale: 1 = never to 4 = routinely. We did not provide a time frame in the instructions. For the present study, we used 15 items that assessed health behaviors that were both appropriate to this population and were targeted for modifi- cation in the intervention. We included items related to the following constructs from each of the 6 subscales of the full HPLP: self-actualization, health responsibility, exercise,

nutrition, interpersonal support, and stress management. This shortened version served as a responsive outcome measure in our two previous GMW intervention s t u d i e ~ ; ~ ~ . ~ ~ for the abbreviated scale we used in this study, scores could range between 15 and 60, with Cronbach’s alpha 0.83 for our respondents

Multidimensional Health Locus of Control Scale (MHLC)

The MHLC is an 1 %item instrument that measures three dimensions of health locus of control.39 We selected it because the intervention was partly aimed at encouraging participants to change their beliefs about their ability to control their health by controlling nonmedical factors, such as stress level and coping. The MHLC, in turn, has been cor- related with a wide range of health outcomes.40 Respondents rate how much they agree with a statement about factors determining health outcomes (eg, “Health professionals con- trol my health” and “No matter what I do, if I am going to get sick, I will get sick”). The measure yields three scale scores for internality, powerful others, and chance locus of control. The MHLC scales have been shown to have good criterion validity. concurrent validity, and reliability.” To simplify the answer format, we reduced the 6-point scale of agreement to a 4-point scale, eliminating slightly agree and slightly dis- agree. Scores for each scale could range between 0 and 18. Cronbach’s alphas for the internality, powerful others, and chance scales were 0.53,0.56, and 0.62, respectively.

Healthcare Use

To assess the impact of the intervention on healthcare use, we collected data on the number of primary care office visits, specialistkonsultant office visits, and hospitaliza- tions. These three variables have been used in previous ~ t u d i e s ~ . ” , ’ ~ and generally reflect three levels of use. Because all patients in our study were members of the HMO, virtually all of their care was conducted within the system and records were retrievable. We selected the time intervals of 9 months pre- and posttreatment because a change in the data management system of the HMO ren- dered unreliable any data 9 months before the first inter- vention group. Twenty-two participants (9% of the sample) left the health plan or died during the follow-up period and therefore were not included in the analyses of the utilization variables.

Intervention Participants attended eight 2-hour classes presented

jointly by a clinical psychologist (B. Rybarczyk) and a pri- mary care physician (M. DeLaCruz), both of whom had training and experience in leading mindhody wellness pro-

Vol 27, Spring 2001 19

Dow

nloa

ded

by [

Lak

ehea

d U

nive

rsity

] at

13:

49 0

8 D

ecem

ber

2014

CLASSROOM MIND/BODY WELLNESS

grams. The instruction focused on topics and techniques that have been covered in other mindhody wellness inter- ventions. The specific topics, in order of presentation, were an overview of the mindhody relationship;’ I relaxation training, including breathing, progressive muscle exercise, autogenic training and imagery;4’ cognitive approaches to stress, anxiety, and depression;424 the rational-emotive therapy approach to procrastinati~n;~~ problem-solving technique^;^^ effective communication and assertiveness training;47 sleep hygiene and behavioral approaches to insomnia;48 setting up an exercise plan and unique exercise issues for older adults;49 nutrition; mindfulness meditation;3 and spirituality and ~ e l l n e s s . ~ ~

The presentations included instructor-led relaxation exer- cises and a guest presentation by a nutritionist and a 75- year-old, self-taught fitness instructor. To accommodate space limitations and because the participants were from three different HMO offices, we divided the classroom group into four separate classes.

To supplement the presentations by the instructors, we provided participants with a bound set of companion read- ings (237 pages) matched to each of the topics. These read- ings included unpublished writings by the instructors as well as excerpts from a wide range of and unpub- lished sources, emphasizing topics specific to older adults with chronic illnesses. We also gave each participant three relaxation audiotapes to use at home. We based our approach on research showing that relaxation-training programs are more effective when instruction is supplemented with audio- t a p e ~ . ~ ~ One tape was produced specifically for the study and included four commonly used modalities: deep breathing, progressive muscle relaxation, autogenic training, and imagery. A second tape, Inner Health: Natural Relaxation I, consisted of a “nature walk” with three-dimensional sound effects and narration employing several types of relaxation modalities.“ The third tape, Inner Health: Natural Sleep, was similar to the second tape and was designed to lead the listener from relaxation into The latter two tapes were recommended for use with earphones to obtain the full three-dimensional sound effects. We asked participants to try each tape at least once and encouraged them to learn to do the relaxation procedures without the aid of a tape.

Data Analyses To increase power for detecting outcomes that were sig-

nificant at posttreatment but not significant at 1 -year fol- low-up and vice versa, we analyzed posttreatment and 1- year follow-up data separately. To test for overall differences at posttreatment between the intervention and control groups, we conducted a 2 x 2 repeated measures

multianalysis of variance (MANOVA), examining the Group x Time interaction for 12 dependent measures. We conducted a similar MANOVA test to examine the Group x Time interaction for all 12 pretreatment and 1 -year follow- up scores. If we found an overall Group x Time interaction effect, we conducted separate repeated measure analyses of variance (ANOVAs) for each dependent measure to test for group differences in pretreatment and posttreatment and I - year follow-up.

For each significant difference, we calculated an effect size (4, using the Cohen formulas’ for difference scores to communicate the magnitude of the treatment effect. For the three measures of healthcare use, we conducted individual repeated measures ANOVAs, comparing groups on 9- months pretreatment and 9-months posttreatment.

It should be noted that because the final intervention group was older than the control group, we considered a multivari- ate analysis of covariance (MANCOVA) with follow-up ANCOVA tests with age as a covariate, However, we deter- mined that this was unnecessary because age was not signifi- cantly correlated with change score on any outcome measure.

RESULTS We found a significant Group x Time interaction effect in

the MANOVA analysis for the 12 dependent measures pre- treatment and posttreatment scores, Wilks Lambda ( I I , 23 1) = 2.80, p < .002, and pretreatment and I-year follow- up scores, Wilks Lambda (1 1, 185) = 2.67, p < .002. Tables 2 , 3 , and 4 provide a summary of pretreatment, posttreat- ment and 1-year follow-up means and standard deviations for the three groups of outcome variables (medical symp- toms, health behaviors and beliefs, and psychological adjustment), by group. Significant differences between groups are noted by asterisks and effect sizes are reported where there are significant differences. Specific statistical findings for each of the dependent variables as well as patients’ ratings of the content follow.

Medical Symptoms

Repeated measures ANOVAs revealed a significant Group x Time effect, indicating greater improvement at posttreatment for intervention participants, compared with controls on the following variables: the McGill Pain Questionnaire, F( 1, 186) = 4.2 1 , p < .05, pain quantity rat- ing, F( 1, 241) = 4.32, p < .05, and sleep difficulties rating, F( 1, 241) = 7.14 , p < .01. A trend toward a significant Group x Time effect, F( 1, 241) = 3.64, p = .058, was also found, indicating that a reduction in MSCL medical symptom frequency in treatment participants was com- pared with that of controls. There was no significant

20 Behavioral Medicine

Dow

nloa

ded

by [

Lak

ehea

d U

nive

rsity

] at

13:

49 0

8 D

ecem

ber

2014

RYBARCZYK ET AL

TABLE 2 Summary of Self-Report of Health Variables (M and SD)

1 -year follow-up

Pretreatment Posttreatment (n = 205) M SD M SD M SD

MSCL-Symptom Frequency Classroom Control Intervention effect size 16)

Classroom Control Intervention effect siz,e (6)

Classroom Control Intervention effect size :6)

Classroom Control Intervention eflect size (d)

Classroom Control

McGill pain questionnaire

Pain quantity rating

Sleep difficulties rating

General health rating

26.5 28.2

8.3 9.5

2.9 3.0

1.6 1.4

3.2 3.2

16.7 21.6

8.3 9. I

1 .o 0.9

I .5 1.6

0.8 1 .0

22.2 15.1" 26.3 22.0$:

0.24

6.4 7.3** 9.3 9.4**

0.30

2.7 1 . 1 * * 3.0 I .o**

0.25

I .3 1.4** 1 .5 1.6**

0.29

3.0 0.9 3.1 1 .0

24.3 17.0 25.6 20.8

8.5 9.3 8.4 8.7

2.8 1 . 1 2.9 1 . 1

I .2 I .4** I .4 I .6**

0.24

3.0 0.9 3.0 1 .o

Noir. MSCL = Medical Symptoms Check List." Significant difference in change from pretreatment score between groups: *p = .os. **p < .os.

Group x Time effect for the General Health Rating at the posttreatment assessment.

At the I-year follow-up, the significant Group x Time effect, indicating a reduction on the Sleep Disturbance Rat- ing for intervention participants compared with controls, was sustained, F( I , 203) = 4.42, p < .05. None of the other reductions at posttreatment remained significant at 1 -year follow-up.

Psychologicul Adjustment

Repeated measures ANOVAs resulted i n a significant Group x Time interaction for the CES-D depression score, F ( I , 241) = 3.56, p < .0001, and BAI anxiety score. F(1, 24 I ) = 3.94, p < .OS, indicating greater improvement at post- treatment for intervention participants compared with con- trols on both measures. However, at the I-year follow-up assessment, these effects were not sustained. There was no significant Group x Time interaction for the Life Satisfac- tion Index at both posttreatment and I -year fiAlow-up.

Health Behaviors und Beliefs

Repeated measures ANOVAs resulted in a significant Group x Time interaction at posttreatment for the Chance scale, F(1 , 241) = 7.00, p < .01, and the Powerful Others scale, F(1, 241) = 7.52, p < .01, indicating favorable improvements at posttreatment for intervention participants compared with controls. A significant Group x Time inter- action was not obtained for the Internal Locus of Control scale of the MHLC or the abbreviated Health Promoting Lifestyle Profile at posttreatment.

At the I-year follow-up, the significant Group x Time interactions for the MHLC Chance scale. F( I . 203) = 6.40, p < .OS, and Powerful Others scale, F( I , 203) = 4.70, p < .05, were sustained. In addition, we found a Group x Time interaction for the abbreviated Health Promoting Lifestyle Profile. F(1 , 203) = 15.49, p < .0001, indicating a larger increase in health behaviors for intervention participants compared with controls.

Vol 27, Spring 2001 21

Dow

nloa

ded

by [

Lak

ehea

d U

nive

rsity

] at

13:

49 0

8 D

ecem

ber

2014

CLASSROOM MINDmODY WELLNESS

~ ~ ~~~ ~ ~

TABLE 3 Summary of Self-Reported Psychological Adjustment Variables

1 -year follow-up

Pretreatment Posttreatment (n = 205) Variable M SD M SD M SD

Beck Anxiety Inventory Classroom 8.4 7.9 6.5 6.4** 7.1 6.9 Control 9.9 9.1 9.6 10.4** 8.7 9.3 Intervention effect size (d) 0.25

Center for Epidemiologic Studies-Depression

Classroom 4.9 4.5 3.0 3.3***** 4.1 5.0 Control 4.8 4.9 4.6 4.9***** 4.8 4.8 Intervention effect size (d) 0.45

Classroom 8.6 4.1 9.6 4.2 9.4 4.1 Control 8.8 4.3 9.1 4.1 8.9 4.3

Life satisfaction

Significant difference in change from pretreatment score between groups: **p < .05. *****p < .OOOl.

TABLE 4 Summary of Self-Reported Health Variables (M and SD)

1 -year follow-up

Pretreatment Posttreatment (n = 205) M SD M SD M SD

Abbreviated Health Promoting Lifestyle Profile

Classroom Control Intervention effect size (d)

Classroom Control

Classroom Control Intervention effect size (6)

MHLC Powerful Others scale Classroom Control Intervention effect size (6)

MHLC Internal Locus scale

MHLC Chance scale

40.3 8.2 39.5 6.5

17.4 2.7 16.6 4.6

12.9 3.7 12.8 3.3

15.9 4.9 15.0 4.2

42.4 7.7 41.0 7.9

18.2 3.1 16.9 3.3

12.4 3.8*** 13.5 3.5***

0.34

14.7 4.1**** 15.2 3.8****

0.35

43.9 7.8***** 39.8 7.1*****

0.52

18.0 3.0 16.2 3.8

11.8 3.2** 12.9 3.2**

0.32

14.4 3.5** 14.7 3.5**

0.30

Nore. MHCL = Multidimensional Health Locus of Control. Significant difference in change from pretreatment score between groups: **p < .05. ***p < .01. ****p < ,001. *****p < .OOO1.

22 Behavioral Medicine

Dow

nloa

ded

by [

Lak

ehea

d U

nive

rsity

] at

13:

49 0

8 D

ecem

ber

2014

RYBARCZYK ET AL

Healthcure Use

We found no significant differences between groups in any of the three use measures (primary care office visits, specialistkonsultant visits, and hospital admissions) when we compared 9 months before the study with 9 months after the study. A 20% reduction in primary care visits in the treatment group was offset by a nearly identical reduction in the control group.

Correlutions Between Subject Variables and Change Scores in the Classroom Intervention Group

We calculated a series of correlations for 6 different par- ticipant variables (age, race, gender, education, attendance, and primary care visits) and change scores between pre- treatment and posttreatment on the 12 outcome measures for the classroom intervention group. Among the 72 corre- lations, only 3 were significant, but none war greater than r = .30. Because of the probability of Type I error with this large number of correlations, we concluded there was no significant relationship between the measurt:d participant variables and outcomes from the intervention.

Participant Ratings of Content and Audiotape Preferences

Classroom participants rated each component of the course for its usefulness on a 5-point scale (0 == not useful to 4 = extremely useful). The data in Table 5 show a rank-order list of participants’ ratings of the usefulness of the different aspects of the intervention. The components of’ the interven- tion were written in lay language and grouped into similar content areas to make the rating process easy for partici- pants. The table also includes the percentages of partici- pants who chose that topic as their “favorite” and “least favorite.” A separate posttreatment question regarding par- ticipants’ audiotape preferences showed that the nature walk tape was preferred by 45% of participants, the noncommer- cial tape by 29%, and the natural sleep tape by 26%.

COMMENT

Our present study provides evidence that a classroom multicomponent group wellness intervention for older adults with chronic illness was effective in reducing self- reported sleep difficulties, pain, anxiety, and depression symptoms, as well as chance and powerful others health locus of control beliefs during the period of treatment. Improvements in sleep, health locus of control beliefs, and health behaviors were observed 1 year after the interven- tion. Most of these intervention effects were in the small-to- moderate range (d = 0.2 - 0.5). If these modest changes in behaviors and attitude continue, they would probably have

TABLE 5 Participants’ Ratings of Program Content: Degree of

Usefulness, Favorite, and Least Favorite Topics

I Least Usefulness Favorite favorite M SD (%) (%) --

Relaxation training 3.47 0.96 25.3 0.0 Exercise and nutrition 3.19 1.05 9.3 10.8 Problem-solving

techniques 3.14 1.04 8.0 8.1 Mindfulness meditation

& Spirituality/wellness 3.12 1.22 28.0 21.6 Skills for effective

communication 3.06 1.00 14.7 18.9 Overview of mindhody

relationship 3.03 1.13 8.0 13.5 Cognitive approaches 2.97 1.12 6.7 27.0

long-range effects on participants’ health status, given that both health behaviors and internal health locus of control beliefs predict a wide array of positive health outcomes.40

Stronger beliefs about the controllability of health out- comes lead individuals to take greater responsibility for their own health and increase positive health behaviors. These types of benefits need to be assessed with an even longer follow-up period and with more direct measures of health status than those we employed in the present study.

Our findings parallel those of previous studies, showing that similar programs were effective in enhancing coping and quality of life among individuals with a variety of med- ical conditions.6-’s However, only a few of these studies have tested the degree to which benefits are maintained over a period of time longer than 6 m ~ n t h s . ~ ~ ~ . ’ ” ’ ~ We found that approximately half of the effects were short-term only, and half were robust enough to be sustained over 1 year. One effect did not appear until the I-year follow-up (ie, health behaviors). Thus, the findings of the present study qualify the findings of other GMW studies that did not include suf- ficient follow-up periods. In fact, the inferences made in our previously published study regarding the efficacy of the same intervention for treating pain, anxiety, and depressive symptoms, as well as the lack of efficacy in increasing health behaviors, are revised by current results.26

The increase in health behaviors, as measured by the HPLP, was the largest effect in the study (d = 0.52), paral- leling the results of our pilot study outcome at 6 months p~st t reatment .~~ The findings of both studies are in con- trast to the findings of Lorig and Holman,14 who reported

Vol 27, Spring 2001 23

Dow

nloa

ded

by [

Lak

ehea

d U

nive

rsity

] at

13:

49 0

8 D

ecem

ber

2014

CLASSROOM MINDIBODY WELLNESS

that health behavior changes were not a significant long- term outcome of their GMW interventions with arthritis patients and led them to conclude that attitudinal changes (ie, self-efficacy), rather than actual behavioral changes, are the most important outcome of GMW interventions. However, it should be noted that we measured a wider array of health behaviors (eg, diet, exercise, stress man- agement) whereas the Lorig studiesI4 used specific health behavior measures. This may account for the discrepant findings; future studies should employ the full 48-item version of the HPLP so that intervention effects on specif- ic subscales can be tested.

Limitations Several limitations of our methods need to be under-

scored. One issue that affects generalizability is the sample bias introduced by the high level of attrition (70%) during the recruitment process. Those who agreed to participate may have had more motivation, greater previous exposure to self-help techniques, fewer psychological problems, or other important differences compared with those who did not agree to participate. A second limitation was the lack of an active control group (“attention placebo”), which might have provided some health information without the training in specific skills.“ This type of control group, although rarely used, allows for an assessment of the benefits obtained from simply providing any type of treatment pro- gram. Similarly, the demand characteristics that may have been associated with completing the posttreatment ques- tionnaire in the classroom setting were not controlled for and may have influenced patients’ responses.

In addition, the study did not include any assessment of the degree to which the patients implemented and practiced the self-help techniques that were presented, nor did it allow for a direct evaluation of the relative efficacy of the individ- ual components of the program. Interestingly, patient rat- ings showed roughly equivalent assessments of usefulness for the individual components in the intervention (see Table 5). It may be that multicomponent programs will yield ben- efits for a greater number of participants by providing something for everybody. Offering breadth at the expense of depth may be particularly relevant when providing inter- ventions to medical patients with a variety of chronic ill- nesses. Note that the favorite topic for many individuals (ie, mindfulness meditation/spirituality and wellness) was the least favorite topic for an equally large group. Future stud- ies need to compare previously validated multicomponent approaches with singular approaches in randomized studies that allow for the evaluation of relative effects of treatments by problems within patients.

Implications

The lack of durability of the reductions in psychological distress and pain raises questions about whether GMW pro- grams provide enough specific skills to combat these prob- lems on a long-term basis. In fact, a recent meta-analysis of outcomes from psychosocial interventions for cardiac dis- ease patients found that increased psychosocial adjustment is not a significant outcome.54 This was in contrast to a wide array of other positive health benefits that are obtained from these interventions. These collective findings support the contention that clinically significant levels of anxiety and depression are disorders that need to be remedied by empir- ically tested mental health treatments (eg, cognitive-behav- ioral therapy) to obtain lasting effects. Similarly, our find- ings regarding the lack of durability in the pain reduction outcome raise questions about whether multicomponent programs that address a wide range of wellness issues are appropriate for individuals with significant pain problems.

In contrast to the recent Lorig study,” which provided a similar GMW intervention to older adults with chronic ill- nesses, our intervention did not yield benefits in reduced use of healthcare. One possible explanation for the differ- ence in outcome may be that our intervention was simply not as effective. The Lorig program has been systematical- ly developed and tested over a period of several years, using empirically based refinements. For example, because the program was going to be a modified version of an original one designed for arthritis patients, they conducted a needs assessment with 1 1 focus groups consisting of patients with a wide range of chronic illnesses. As a result, the interven- tion included some units with more practical information, such as tips on the proper use of medications, effective com- munication with physicians, and community resources. Our intervention, by contrast, had been revised once on the basis of a single pilot

A second explanation may be found in the type of partic- ipants recruited for the Lorig study. The participants in their study were self-referred from the community whereas par- ticipants in our study were physician referred. As a conse- quence, their patients may have been more motivated and resourceful and, therefore, able to get more benefits from the program.ss Their patients were also more educated by an average of 3 years, and 90% were White. A final expla- nation may be that the Lorig study relied on self-reports of use rather than the insurance plan data employed in our study. This may have created demand characteristics that led program participants to underreport their ofice visits after the intervention.

Demonstrating reductions in use has been an important

24 Behavioral Medicine

Dow

nloa

ded

by [

Lak

ehea

d U

nive

rsity

] at

13:

49 0

8 D

ecem

ber

2014

RYBARCZYK ET AL

objective for researchers so that the cost-effectiveness of these interventions can be demonstrated to managed-care companies and third-party payers. However, demonstrating reductions in use in a managed-care study can be more dif- ficult than in studies using patients in a more traditional insurance plan because of the multitude of ongoing policy and procedure changes in managed-care organizations. Fur- thermore, a recent report has documented the reluctance of managed-care cotnpanies to put GMW interventions into effect, even though existing research substantiates their cost

s5 A primary reason for the reluctance to adopt such programs is the perception that benefits accrue over time and that the payoffs therefore do not occur within the proper time frame (ie, an average of 16% of membership change to another plan each year).s6 In addition, it is com- monly believed that if plans adopt exemplary programs for individuals with chronic illnesses they will attract more of these costly patients to their plan.5h

Another interesting implication of this study for group intervention programs for medical patients was the modest but significant reduction in sleep difficu1tit:s reported by intervention participants. The finding suggests that standard behavioral instruction for improving sleep can have a small but beneficial effect for older adults with chronic illness. Sleep researchers have previously conjectured that behav- ioral treatments for geriatric insomnia are not effective for individuals who have insomnia that is secontlary to a med- ical condition (eg, pain, frequent urination, and a ~ n e a ) . ~ ’

On the strength of this finding, the first author of this study and colleagues have been undertaking a series of stud- ies of classroom behavioral treatments for geriatric insom- nia that is comorbid with chronic illness. Prehminary results show highly significant initial changes in self-reports of sleep quantity and quality among participants when com- pared with a no-treatment control Insomnia is a common problem among older adults with (chronic illness and has been shown to have a significant effect on quality of life in this group.sy Sleep quality may also prove to be an important mediating factor in the relationship between stress and health outcomes.

Some researchers in the area of GMW interventions have speculated that an essential component of their intervention program is the social support that is provided.8 However, one researcher has emphasized the opposite concern- that group wellness intervention programs can pose a risk by fos- tering dependency on a social group that may inadvertently limit the development of self-directed wellness behaviors.h0 Fortunately, our previously published study allowed us to separate the effect of social support from the actual content of the intervention.2h We compared the classroom interven-

tion of the present study with a parallel audio-video home course intervention. The home course intervention and the classroom intervention yielded comparable benefits (also similar to those obtained at the posttreatment interval in the present study). Thus, the findings from the previous study indicate that the social support element is not essential to the overall effectiveness of a GMW intervention.

Overall, these findings are consistent with the notion that mindhody wellness programs can provide significant and lasting benefits to at-risk and underserved groups. These benefits are modest but need to be evaluated in light of the low cost of implementing such programs. We also hypothe- size that future studies of these interventions that employ longer term follow-up and more objective health measures would yield modest but significant health improvements and eventual savings in the cost of healthcare. A critical aspect of the present study was the inclusion of older adults who were predominately African Americans with moderate to lower levels of education and income. This demographic group has been underrepresented in behavioral medicine research in general and in GMW intervention studies in par- ticular. The positive findings in this study challenge any perception that having postsecondary education, having economic resources, or being in a younger cohort are pre- requisites for successful participation in a program that emphasizes holistic, nonconventional approaches to health.

NOTE This study was supported with a grant from the American Asso-

ciation of Retired Persons (AARP) Andrus Foundation. In addi- tion, a portion of the research was presented as a poster at the annual meeting of the Society for Behavioral Medicine in San Francisco, April 17, 1997.

For further information, please address correspondence to Bruce Rybarczyk, PhD, associate professor, Departments of Psy- chology and Physical Medicine and Rehabilitation, Rush Univer- sity, 1653 West Congress Parkway, Chicago, IL 60612 (e-mail: brybarcz@rush.edu).

REFERENCES 1. Andrykowski MA. Group interventions for cancer patients:

Psychological, immune and health effects. Symposium at the American Psychological Association meeting in Chicago, 1997.

2. Spira JL, ed. Group Therapy for Medically 111 Parienrs. New York: Guilford; 1997.

3. Kabat-Zinn J , Lipworth L, Burney R, Sellers W. Four-year follow-up of a meditation-based program for the self-regula- tion of chronic pain: Treatment outcomes and compliance. Clin J Pain. 1987;2:159-173.

4. Spiegel D, Kraemer HC, Bloom JR, Gottheil E. Effects of psychosocial treatment on survival of patients with metastat- ic breast cancer. Lancer. 1989;2:888-89 I .

Vol 27, Spring 2001 25

Dow

nloa

ded

by [

Lak

ehea

d U

nive

rsity

] at

13:

49 0

8 D

ecem

ber

2014

CLASSROOM MINDBODY WELLNESS

5. Ornish D, Brown SE, Schenvitz LW, et al. Can lifestyle changes reverse coronary artery disease? Lancet. 1990; 336:129-132.

6. Fawzy FI, Fawzy NW, Hyun CS, et al. Malignant melanoma: Effect of an early structured psychiatric intervention, coping, and affective state on recurrence and survival 6 years later. Arch Gen Psychiatry. 1993;50:681-689.

7. Turner L, Linden W, van der Wal R, Schamberger W. Stress management for patients with heart disease: A pilot study. Heart Lung. 1995;24: 145-153.

8. Clark NM, Janz NK, Becker MH, et al. Impact of self-man- agement education on the functional health status of older adults with heart disease. Gerontologist. 1992;32:438443.

9. Lewin B, Robertson IH, Cay EL, Irving JB, Cambell L. Effects of self-help post-myocardial-infarction rehabilitation on psychological adjustment and use of health services. Lancet. 1992;339: 1036-1040.

10. Ross L. Efficacy of chronic fatigue syndrome lifestyle man- agement group treatment program. Presented at the Society for Behavioral Medicine meeting in San Francisco, 1997.

11. Hellman CJC, Budd M, Borysenko J, et al. A study of the effectiveness of two behavioral medicine group interventions for patients with psychosomatic complaints. Behav Med.

12. Caudill M, Schnabel R, Zuttermeister P, et al. Decreased clin- ic use by chronic pain patients: Response to behavioral med- icine intervention. Clin J Pain. 1991;7:305-310.

13. Von Korff M, Moore JE, Lorig K, et al. Randomized trial of lay person-led self-management intervention for back pain patients in primary care. Spine. 1998;23:2608-2615.

14. Long K, Holman HR. Arthritis self-management studies: A twelve-year review. Health Education Quarterly. 1993;20:

15. Long K, Lubeck D, Kraines RG, Seleznick M, Holman HR. Outcomes of self-help education for patients with arthritis. Arthritis Rheum. 1985;8:68M85.

16. Cohen JE, Vivek G, Frank JW, et al. Group education inter- ventions for people with low back pain. Spine. 1994;19: 12 14-1 222.

17. Long KR, Sobel DS, Stewart AL, et al. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: A randomized trial. Med Care. 1999;37:514.

18. Rothenberg RB, Koplan JP. Chronic disease in the 1990s. Annu Rev Public Health. 1990; 1 1 :267-296.

19. New research frontiers in behavioral medicine. Washington: National Institute of Mental Health, 1994; Government Print- ing Office: 207.

20. Koenig HG, Cohen HJ, Blazer DG, Krishnan KR, Sibert TE. Profile of depressive symptoms in younger and older medical inpatients with major depression. J Am Geriatr SOC.

21. Unutzer J, Katon W, Sullivan M, Miranda J. The effectiveness of treatments for depressed older adults in primary care. Pre- sented at Exploring Opportunities to Advance Mental Health-

1990; 16: 165-173.

17-28.

1993,41:1169-1176.

care for an Aging Population, sponsored by the John A. Hart- ford Foundation, Rockville, MD; November 6, 1997.

22. Office of Minority Health. Closing the gap-Heart disease, stroke and minorities. Washington, DC: Public Health Ser- vices, Dept of Health and Human Services; 1987.

23. Dutton DB. Explaining the use of health services by the poor: Costs, attitudes, or delivery systems? American Sociological Review. 1978;43:348.

24. Cobum D, Pope CR. Socioeconomic status and preventive health behavior. J Health Soc Behav. 1974567.

25. Rybarczyk B, Boutelle K, DeLaCruz M, Lapidos S. A well- ness program for at-risk elderly in an HMO: Psychological, medical and utilization benefits. Presented at the Society for Behavioral Medicine, San Diego; 1995.

26. Rybarczyk B. DeMarco G. DeLaCruz M. Lapidos S. Com- paring mindhody wellness interventions for older adults with chronic illness: Classroom versus home instruction. Behav Med. 1999;24: 18 1-1 90.

27. Ware JE, Sherbourne CD. The MOS-36-item Short-Form Health Survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992;30473433.

28. Melzack R. The McGill Pain Questionnaire: Major properties and scoring methods. Pain. 1975; 1 :275-299.

29. Melzack R. The short-form McGill Pain Questionnaire. Pain. 1987;30: 191-197.

30. Beck AT, Steer RA. Manual f o r the Beck Anxiety Inventory. San Antonio, TX: Psychological Corporation; 1990.

3 1. Steer RA, Ranieri WF, Beck AT, Clark DA. Further evidence for the validity of the Beck Anxiety inventory with psychi- atric outpatients. J Anxiety Disord. 1993;7: 195-205.

32. Radloff LS. The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement. 1977; 1:385-401.

33. Lewinsohn PM, Seeley JR, Roberts RE, Allen NB. Center for Epidemiologic Studies Depression Scale (CES-D) as a screening instrument for depression among community- residing older adults. Psycho1 Aging. 1997; 12:277-287.

34. Blazer D, Burchett B, Service C, George LK. The association of age and depression among the elderly: An epidemiologic exploration. J Gerontol.ogy. 1991;46:M21&M215.

35. Bigot A. The relevance of American life satisfaction indices for research on British subjects before and after retirement. Age Ageing. 1974;3:113-121.

36. Neugarten BL, Havinghurst RJ, Tobin SS. The measurement of life satisfaction. J Gerontol 1961;16:134-143.

37. Mossey JM. Importance of self-perceptions for health status among older persons. In: Gatz M, ed. Emerging Issues in Mental Health and Aging. Washington, DC: American Psy- chological Association; 1995: 124-162.

38. Walker S , Sechrist K, Pender NJ. The Health-Promoting Lifestyle Profile: Development and psychometric characteris- tics. Nurs Res. 1987;36:768 1.

39. Norman P, Bennett P. Health locus of control. In: Conner M, Norman P, et al, eds. Predicting Health Behaviour: Research

26 Behavioral Medicine

Dow

nloa

ded

by [

Lak

ehea

d U

nive

rsity

] at

13:

49 0

8 D

ecem

ber

2014

RYBARCZYK ET AL

40.

41.

42.

43.

44.

45

46

47

48

and Practice With Social Cognition Model3 . Buckingham, England: Open University Press; 1996:62-94 Wallston KA, Wallston BS, DeVellis R. Devdopment of the Multidimensional Health Locus of Control (MHLC) Scales. Health Education Monographs. 1978:6: 160-1 70. Bemstein DA, Borkovec TD. Progressive Relaxation Train- ing. Champaign, IL: Research Press; 1973. Beck A. Cognitive Therapy and the Emotional Disorders. New York: International Universities Press; 1976. Bourne EJ. The Anxiety and Phobia Workbook. Oakland, CA: New Harbinger Publications; 1995. Lewinsohn PM, Munoz RF, Youngren MS, Zeiss AM. Control Your Depression. New York; NY Prentice Hall Press; 1986. Knaus WJ. Overcoming procrastination. Rational Living.

D’Zurrilla TJ. Problem-solving training for effective stress management and prevention. Journal of Cognitive Psy- chotherapy: An International Quarterly. 1990;4:327-354. McKay M, Davis M, Fanning P. Messages: The Communica- tion Skills Book. Oakland, CA: New Harbinger; 1995. Morin C. Insomnia: Psychological Assessment and Manage- ment. New York: Guilford; 1993.

1 973 ;8 2-7.

49. lvans W, Rosenberg I. Biomarkers: The Ten Key Ways to Pro- longing vitality. New York; Fireside: 1991.

50. Carlson CR, Hoyle RH. Efficacy of abbreviated muscle relax- ation training: A quantitative review of behavioral medicine research. J Consult Clin Psychol. 1993;61:1059-1067.

5 1 . Inner Health, Natural Relaxation I [audiotape.]. San Diego,

CA: Inner Health; 1994.

Inner Health; 1990.

ences. New York: Academic Press; 1977.

52. Inner Health. Natural Sleep [audiotape]. San Diego, CA:

53. Cohen J. Statistical Power Analysis for the Behavioral Sci-

54.

55 .

56.

57.

58.

59.

60.

Dusseldorp E, van Elderen T, Maes T, Meulman J, Kraaij V. A meta-analysis of psychoeducational programs for coronary heart disease patients. Health Psychol. 1999; 18:506-5 19.

Garfield SL. Research on client variables in psychotherapy. In: Bergin AE, Garfield SL, eds. Handbook of Psychotherapy and Behavior Change. 4th ed. New York: Wiley; 1994:310-333.

Patients as Effective Collaborators in Managing Chronic Conditions. New York: Center for the Advancement of Health, Milbank Memorial Fund; 1999.

Culebras A. Clinical Handbook of Sleep Disorders. Boston: Butterworth-Heinemann; 1996.

Rybarczyk B, Lopez M, Stepanski E, Benson R, Rubin A. Evaluating a behavioral treatment for insomnia in older adults with comorbid chronic illness. Poster presented at the Annual Meeting of the Society for Behavioral Medicine, Nashville; April 2000. Katz DA, McHomey C. The impact of insomnia on quality of life in patients with chronic illness. Med Decis Making. 1996: 16:455.

Kabat-Zinn J. An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation. Gen Hosp Psychiatly. 1982;4:3347.

Vol 27, Spring 2001 27

Dow

nloa

ded

by [

Lak

ehea

d U

nive

rsity

] at

13:

49 0

8 D

ecem

ber

2014