positive affect interventions to reduce stress

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POSITIVE AFFECT INTERVENTIONS TO REDUCE STRESS Harnessing the Benefit While Avoiding the Pollyanna LAURA R. SASLOW , MICHAEL COHN, & JUDITH TEDLIE MOSKOWITZ

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tress is a significant concern for most U.S.  adults. In the American Psychological Association’s “Stress in America” 2011 survey (American Psychological Association, 2012), 22  percent of respondents reported experiencing extreme stress levels and 39 percent reported that their stress had increased over the past year. At the same time, only 29 percent reported that they were doing an excellent or very good job at managing the stress in their lives. Forty-four percent reported lying awake at night due to stress (American Psychological Association, 2012). There is clearly a need for effective interventions to help people reduce the stress in their lives. The scientific literature is replete with stress reduction interventions (e.g., Knittle, Maes, & de Gucht, 2010; Martire, Schulz, Helgeson, Small, & Saghafi, 2010; Richardson & Rothstein, 2008; Scott-Sheldon, Kalichman, Carey, & Fielder, 2008), but most of these programs focus on directly reducing distress, sadness, anxiety, and other negative emotions. In the past decade, there has been increasing interest in interventions for creating and enhancing positive emotions as a path for improving psychological and physical well-being and decreasing stress. This approach is based on experimental and prospective observational studies that demonstrate adaptive consequences of positive affect, independent of effects of negative affect, including higher levels of prosocial behavior, better relationships, more creativity, and higher quality of work (Lyubomirsky, King, & Diener, 2005), better physical health (Pressman & Cohen, 2005; Saslow & Moskowitz 2012), and even a lower risk of mortality in a number of healthy and chronically ill samples (Chida & Steptoe, 2008; Moskowitz, 2003; Moskowitz, Epel, & Acree, 2008; Steptoe & Wardle, 2011). A primary hypothesis for positive affect interventions in the context of stress is that targeting positive affect provides a unique pathway to increasing the odds of these beneficial outcomes, independent of the effects of negative affect (Moskowitz et al., 2011).

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A number of studies have demonstrated beneficial psychological and physical health outcomes from a variety of individual positive affect-related intervention techniques, including increasing gratitude (e.g., Lyubomirsky, Sheldon, & Schkade, 2005), acts of kindness (e.g., Dunn, Aknin, & Norton, 2008), and practicing loving-kindness meditation (Fredrickson, Cohn, Coffey, Pek, & Finkel, 2008). In this chapter, we review what we consider a “second generation” of positive affect interventions, which (a) teach multiple positive affect skills from different lines of research and (b) address populations dealing with serious health or socioemotional stressors. Not all of the interventions reviewed were designed with an explicit theoretical focus on positive affect, but all include some form of it (e.g., happiness or life satisfaction) as an outcome. Given our theoretical outlook that positive affect is the primary pathway through which these interventions result in beneficial outcomes, we focus on positive affective outcomes in this review. We also present our recent work that pilot tested a multiple component intervention that aims to reduce the stress of chronic illness and other significant life events via increases in positive affect. We conclude with suggestions to help researchers develop well-defined, easily disseminated interventions tailored to their population of choice.

A NOTE ON EMOTION TERMINOLOGY We define positive affect as the subjective experience of positively valenced feelings, including lower activation feelings like calm or satisfied as well as higher activation feelings like excited or thrilled. In our definition of affect we include both momentary emotional experience and longer-lasting moods. The research literature on positive affect interventions includes a broad range of operationalizations of affect, which vary in the degree to which they overlap with this definition. In our view, the imprecise measurement of affect is one of the key issues that complicate interpretation of the literature. Therefore, we make special note of how the positive affect constructs are measured and labeled as we review each study, and we discuss the issue of affect measurement in more detail at the end of the chapter. In addition, a number of the interventions include broader positive constructs such as life satisfaction (e.g., Seligman, Rashid, & Parks, 2006), purpose in life (e.g. Fava, et al., 1998; Fava & Ruini, 2003), or self-acceptance (e.g., Fava, Rafanelli, Cazzaro, Conti, & Grandi, 1998). Given the early stage of the literature on positive affect interventions, we include these in the review for completeness.

MULTI-COMPONENT POSITIVE AFFECT INTERVENTIONS In this section we review a number of multi-component positive affect interventions. For each intervention we discuss details of content, format, control conditions, and measurement of positive affect in order to better understand the conclusions that can be drawn at this comparatively early point in the development of the literature. Fordyce’s Happiness Intervention. One of the earliest programs that specifically targeted positive affect was developed by Michael Fordyce (Fordyce, 1981, 1983). His intervention covered 14 different skills which he grouped into three different areas: lifestyle skills based on the daily living

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style of happy people (“keep busy and be more active,” “spend more time socializing,” “be productive at meaningful work,” “get better organized and plan things out,” and “close relationships are the number one source of happiness”), five attitudes and values skills based on the attitude patterns of happy people (“stop worrying,” “lower your expectations and aspirations,” “develop positive, optimistic thinking,” “become present oriented,” and “put happiness as your most important priority”), and four personality skills based on the personality of happy people (“work on a healthy personality,” “develop an outgoing, social personality,” “be yourself,” and “eliminate negative feelings and problems”). The interventions were group-based, with one hour-long lecture for each of the 14 skills. For all studies, participants were college students and the lectures were delivered as part of a class. Participants were provided detailed instructions about each skill, including the theory and research behind it. They were exposed to the skills, but not required to practice or use them. A variety of control groups were used across the various studies: receiving only introductory information about the happiness skills, receiving introductory information and instructions on how to practice several (but not all) of the skills, or being told that their happiness would likely increase (Fordyce, 1983). In these interventions, positive affect was assessed with several open-ended questions and the Happiness Measure (Fordyce, 1988)  that asks, for example:  “On the average, the percent of time I feel happy ___ %. On the average, the percent of time I feel unhappy ___ %. On the average, the percent of time I feel neutral ___ %.” Results generally supported the efficacy of the intervention for increasing positive affect (happiness). For example, in one set of studies, the intervention group reported feeling happy a significantly higher percentage of time compared to the control group (Fordyce, 1983). After the interventions ended, participants were asked to rate whether their happiness improved as a function of the intervention. Across studies, at least three-fourths of individuals felt that the interventions helped them become happier. According to participants’ ratings at the end of the intervention, across studies the most helpful skills were “stop worrying,” “be yourself,” “develop positive, optimistic thinking,” and “spend more time socializing.” Although Fordyce did not work with a chronically high stress sample, many of the skills included in this early positive affect intervention were adopted in subsequent interventions developed for people experiencing significant life stress. Well-being Therapy. Another approach that specifically aimed to increase positive affect using a variety of skills is well-being therapy, developed by Giovanna Fava and colleagues (Fava, et al., 1998; Fava & Ruini, 2003). The skills covered include: (a) noting episodes of well-being, (b)  identifying thoughts that interrupt feelings of well-being, and (c)  helping participants achieve a variety of types of well-being, based on Carol Ryff ’s theories: self-acceptance, warm relationships with others, the ability to be independent and self-determining, feeling mastery over one’s environment in order to attend to one’s needs, pursuing meaningful goals, and feeling that one is growing and developing as a person (Ryff, 1989). Participants were taught a variety of approaches including cognitive restructuring (changing the way one thinks about an issue), scheduling activities, and problem solving. In eight 40-minute sessions every other week, the intervention was provided in one-on-one sessions with a therapist. In a pilot study of the intervention with individuals with affective disorders, participants were either randomly assigned to well-being therapy (10 individuals) or cognitive-behavioral therapy (10 individuals). The primary outcome at the end of treatment was well-being as measured by Ryff ’s (1989) scale, which taps six dimensions including purpose in life, self-acceptance, and personal growth as well as Kellner’s symptom questionnaire which measures four dimensions of well-being including relaxation, contentment, physical well-being, and friendliness. (Kellner, 1987).

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Results for well-being therapy groups suggested a reduction in symptoms of depression and improvements in some markers that reflect positive affect (Fava, et al., 1998). For example, in the well-being therapy group, participants increased their level of personal growth (Ryff scale) and contentment (Kellner scale). In the cognitive behavioral therapy group, participants increased their purpose in life and self-acceptance (both from the Ryff scale). The work of Fava and colleagues was among the first that specifically targeted positive affect in people coping with the significant stress of mental illness. The finding that the well-being therapy had different effects compared to cognitive behavioral therapy argues for incorporation of positive affect skills into more established forms of psychological therapy. Positive Psychotherapy. Martin Seligman, one of the founders of positive psychology, and his colleagues have also created a multi-skill well-being intervention for people with depression, which they call positive psychotherapy (Seligman, et al., 2006). There is a version delivered in groups and a slightly different version for one-on-one delivery. The group version of positive psychotherapy focuses on six topics: (a) using strengths: participants take a questionnaire that identifies their top five strengths which they then use more in their everyday lives; (b)  gratitude:  daily for a week, participants write down three good things that happened to them and why they think that they occurred; (c) ideal life: participants write a short essay about what they wish their obituary would say, what they would like to be remembered for the most, (d) gratitude (second time): participants write and deliver a letter to someone to whom they are grateful and have never thanked properly, (e) active, constructive responding: to increase the warmth and positivity of relationships, participants are taught to react positively and enthusiastically to others’ good news, and (f) savoring: participants take the time to slow down and enjoy something, reflecting on how the new, slower approach compared to their typical approach. The individually delivered (one-on-one) program also covers using strengths, gratitude, active constructive responding, and savoring. In addition, there are sessions that cover (a)  the idea that holding on to anger and bitterness can increase levels of depression; (b) forgiveness: participants learn about forgiveness and consider forgiving a transgressor, if appropriate; (c) satisficing versus maximizing: participants practice having standards that are good enough, rather than aiming for perfection; and (d) acts of kindness: using one’s signature strengths to give time to others. In the test of the group version of positive psychotherapy, participants were depressed students. The intervention was provided by a clinical psychologist or clinical psychology student in six weekly two-hour sessions. Classes involved discussing the previous week’s topic and a lecture on the current week’s topic. The final session discussed maintaining the skills and customizing the exercises. The control group received no treatment. Positive affect was measured using the Satisfaction with Life Scale (Diener, Emmons, Larsen, & Griffin, 1985). Items include “In most ways my life is close to my ideal” and “I am satisfied with life.” In the test of the one-on-one version of the intervention, a therapist provided approximately 14 one-hour visits over about 12 weeks. Participants were asked to do homework exercises. The control group was assigned to treatment as usual, therapy through the University of Pennsylvania’s counseling center. Positive affect was measured using the Satisfaction with Life Scale (Diener, et al., 1985) and the Positive Psychotherapy Inventory, which asks questions about positive mood, feeling that life has meaning, and knowing and using personal strengths (described in Guney, 2011). Results for both the group and individually-delivered version of positive psychotherapy suggest efficacy for this approach. In a pilot study of the group-delivered intervention with college students with mild to moderate depression, 19 participants were randomly assigned to

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positive psychotherapy and 21 to a no-treatment control group. Follow-up assessments at 3, 6, and 12 months showed that individuals in the positive psychotherapy condition had significantly higher levels of life satisfaction than individuals who had been assigned to the control group. In the pilot study of the individually-delivered intervention, individuals with unipolar depression seeking treatment at a counseling center were either assigned to positive psychotherapy (13 individuals) or treatment as usual (15 individuals). Pre- and post-treatment effects showed that individuals in the positive psychotherapy condition became happier (as measured with the Positive Psychotherapy Inventory) but did not have increased levels of life satisfaction. A third group was a nonrandomized, matched group receiving treatment as usual and antidepressant medications (17 individuals). Positive psychotherapy also outperformed this group; those given positive psychotherapy were happier (as measured with the Positive Psychotherapy Inventory) after the intervention than those given treatment as usual and antidepressants. As with Well-Being therapy (described above), the data from studies of Positive Psychotherapy suggest that incorporating positive affect skills into therapy for depression may significantly augment more traditional therapies. Mindfulness Meditation and Emotion Regulation Therapy to Cope with Chronic Illness. A number of recent studies have included some form of meditation in a multi-component positive affect intervention. Zautra and colleagues (Zautra et al., 2008), designed an intervention specifically for people living with rheumatoid arthritis which covered a variety of skills in order to diminish the harmful effects of stress and illness and increase the ability to maintain positive emotions and behaviors even in the face of stress. Specific skills taught included (a) mindfulness, particularly awareness and acceptance of the full range of negative and positive emotions; (b) noticing and enhancing positive emotions by scheduling and enjoying positive events; and (c) learning to improve and better enjoy one’s social relationships. The intervention was provided by a therapist in a group format, in eight weekly two-hour sessions. Classes involved a lecture on the current week’s topic, discussing the previous week’s topic, and teaching skill-related exercises. Participants were asked to do weekly homework exercises, which included meditating for 10 minutes a day. The control groups were cognitive behavioral therapy for pain (covering relaxation training and ways to manage pain) or an education-only attention placebo control group (omitting coping information but providing information about rheumatoid arthritis such as medication and natural remedies). Positive affect was measured using an aggregation of 30 daily diaries of the positive subscale of the Positive and Negative Affect Schedule (Watson, Clark, & Tellegen, 1988), which participants were asked to fill out 30 minutes before the end of the day. The daily diaries were filled out for 30 days prior to and after the intervention. Results indicate that a multi-component intervention that includes the positive affect skills of mindfulness and emotion regulation significantly increases positive affect. In a randomized controlled trial of the intervention, participants in either the mindfulness or cognitive behavioral groups had a statistically significant increase in positive affect over time compared to the education-only control condition. Participants with a history of recurrent depression appeared to benefit most from the mindfulness and emotion regulation group, as compared to the other two groups. Meditation and Emotion Regulation Training Intervention. Margaret Kemeny and colleagues have created a multicomponent meditation and emotion regulation training intervention (Kemeny et  al., 2011)  which covers a variety of skills in order to diminish the harmful effects of emotions and improve participants’ ability to respond to others with compassion and

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empathy. Specific skills taught included (a) help concentrating, (b) training in mindfulness meditation, (c) the role of meditation in increasing feelings of compassion and empathy, (d) yoga, (e) information about the relationship between thoughts and emotions and (f) learning to be better aware of emotions in oneself and others. The interventions were provided in a group format with two trainers, in four all-day sessions and four evening sessions over eight weeks. Participants were asked to meditate for 25 minutes a day. The intervention group was compared to a wait-list control group. Positive affect was measured using the Positive and Negative Affect Schedule over the last few weeks (Watson, et al., 1988). Results suggested that this multi-component intervention significantly influenced positive affect. In a randomized controlled trial of the intervention with 82 female schoolteachers, participants were randomly assigned to the meditation and emotion regulation training intervention or the wait-list control group. Those assigned to the meditation and emotion regulation group had statistically higher positive affect at the end of the intervention than those assigned to the control group. Telemedicine Positive Psychology Intervention. Sonja Lyubomirsky, an early and important contributor to research on positive psychology, with her colleagues has created a telemedicine multicomponent positive psychology intervention for patients hospitalized for acute coronary syndrome or heart failure (Huffman et al., 2011). The skills involved include (a) gratitude:  participants write about three events over the past week for which they feel grateful; (b) gratitude (second time): participants write a letter to thanking someone for their kindness; (c) best possible self: participants write about their best possible future first with respect to their social relationships, and the next week with respect to their health, each time considering what steps they can take to bring about this future; and (d) acts of kindness: participants do three kind things for others in one day. Participants are also given time to repeat past activities. Over eight approximately 20-minute weekly one-on-one discussions, the intervention was provided by a social worker. Participants were asked to do homework exercises. In general, the first discussion was provided in-person and the rest of the sessions were provided over the phone. There were two control conditions. In the first, participants were taught and then encouraged to use a 20-minute relaxation exercise in addition to weekly phone calls to provide extra help. In the second control condition, participants were asked to neutrally recall their daily events and given weekly phone calls to provide extra help. Positive affect was measured with items from the Center for Epidemiological Studies— Depression Scale (Radloff, 1977; Roberts & Vernon, 1983), which asks about how much people have felt hopeful, happy, and as good as others, as well as asking how much they have enjoyed their lives. Positive affect was also measured with the Subjective Happiness Scale (Lyubomirsky & Lepper, 1999)  which includes items such as:  “Some people are generally very happy. They enjoy life regardless of what is going on, getting the most out of everything. To what extent does this characterization describe you?” Participants were assigned to one of the three eight-week conditions: the positive psychology program, a Relaxation Response active control group (Benson, Greenwood, & Klemchuk, 1975), and an attention control group. Although none of the differences were statistically significant, pre- and post-treatment effects showed that individuals in the positive psychology program had increases in positive affect, as measured by the CES-D subscale, compared to the other two groups. When measuring positive affect with the Subjective Happiness Scale, however, the relaxation response control group became happier, whereas the intervention group and the attention control group did not appear to change.

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Positive Affect-Enhanced Patient Education Intervention. Several recent papers by Alice Isen and colleagues examined the effects of a patient education intervention enhanced with positive affect and self-affirmation (Mancuso et al., 2012; Ogedegbe et al., 2012; Peterson, Charlson et al., 2012; Peterson, Czajkowski, et al., 2012). Across studies, participants in the positive affect group received patient education information as well as a positive affect induction (small gifts were mailed to the participants) and telephone calls and information to help them foster their feelings of positive affect and self-affirmation. For example, to increase feelings of positive affect, participants were encouraged to think about things that made them feel good during their everyday lives. To increase self-affirmation, participants were encouraged to think about things that made them feel proud of themselves when they were working on other activities related to the intervention that might be challenging. The intervention was individually delivered over the phone. A member of the research team called the participants every two months for a year. In addition, at the same time interval, staff from the study mailed small gifts to each participant. The control groups were patient education groups. Participants received a workbook to increase their knowledge about their physical ailment in order to encourage effective self-management, and they created a behavioral contract for an activity related to the intervention (taking medication, exercising). In the two studies on exercise, participants received a pedometer, which was designed to provide them feedback about their behaviors. Positive affect was measured using the PANAS (Watson, et al., 1988). The aims of the interventions were diverse: to increase physical activity in asthma patients (Mancuso et al., 2012), to increase physical activity after participants underwent percutaneous coronary intervention (Peterson, Charlson, et al., 2012), or to increase medication adherence in hypertensive African Americans (Ogedegbe et al., 2012). Some of these aims were achieved. The positive affect intervention was associated with increased adherence to hypertension medication (Mancuso et al., 2012) and increased exercise following heart surgery (Peterson, Charlson, et  al., 2012)  relative to control conditions. In a fourth paper that combined the results from the three individual studies, the researchers report that across intervention and control groups, those participants who reported at least a one-standard-deviation decline in PANAS positive from baseline to 12 months were less likely to maintain their behavior change. This suggests that positive affect may play an important role in the adherence to medical recommendations. However, the research did not directly report on whether the positive affect and self-affirmation intervention was more effective at increasing positive affect, the hypothesized mediator of the beneficial effects of the intervention on health behaviors (Peterson, Czajkowski, et al., 2012). Positive Affect Intervention for Coping with Stress. Based on revised Stress and Coping Theory (Folkman, 1997, 2008)  and the Broaden-and-Build theory of positive emotion (Fredrickson, 1998), our multicomponent intervention consists of eight behavioral and cognitive “skills” for increasing positive affect: (a) noting daily positive events, (b) capitalizing on or savoring positive events, (c) gratitude, (d) mindfulness, (e) positive reappraisal, (f) focusing on personal strengths, (g)  setting and working toward attainable goals, and (h)  acts of kindness (Moskowitz et al., 2012 Moskowitz, 2010). As we develop the intervention and tailor it for different types of health-related and life stress, we have completed five pilot studies in adults. Details of each pilot sample are in Table  27.1. Skills were taught in either four or five weekly sessions. Most were individually administered, in person, but we have conducted one pilot in which the skills were delivered in a group format (RESTORE; see Table 27.1). Positive and negative affect were measured with the modified Differential Emotions Scale (Fredrickson, Tugade, Waugh, & Larkin, 2003) in which

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Table 27.1: Description of positive affect skills pilot studies Study Participants

N

Control condition

ARTEMIS: Men undergoing treatment for methamphetamine addiction DAISY: Patients with type 2 diabetes IRISS: People newly diagnosed with HIV LEAF: Caregivers of dementia patients RESTORE: University Employees

17

Attention Control (Interviews)

13 10 19 28

Attention Control (Interviews) None Attention Control (Interviews) Waitlist Control

participants are asked the extent to which, over the past week, they experienced a number of positive and negative affects which are presented in sets of three synonyms. Negative affect consisted of angry/irritated/annoyed, ashamed/humiliated/disgraced, contemptuous/scornful/ disdainful, embarrassed/self-conscious/blushing, sad/downhearted/unhappy, and scared/fearful/ afraid. Positive affect consisted of amused/fun loving/silly, awe/wonder/amazement, content/ serene/peaceful, glad/happy/joyful, grateful/appreciative/thankful, hopeful/optimistic/encouraged, interested/alert/curious, love/closeness/trust, and proud/confident/self-assured. Participants were asked to report how frequently they experienced each of the listed emotion triplets in the past week from 0  =  never to 4  =  most of the time. Participants were assessed at baseline, post-intervention, and at a one-month follow-up after completion of the intervention. In total, 87 individuals participated across the five pilot studies (Table  27.1). Using meta-analysis, we first looked at the overall change in positive and negative affect, excluding participants who were in the control condition. Looking at change in positive and negative affect in the intervention conditions only, there was a marginally significant increase in overall positive affect (weighted mean change in the DES positive = .17, 95% confidence interval = [-.03,0.36]; See Figure 27.1) and a significant decrease in negative affect (weighted mean change in DES

Positive affect change (95% CI)

Study

0.30 (–0.35, 0.94)

ARTEMIS DAISY

–0.10 (–0.42, 0.22)

IRISS

0.43 (–0.01, 0.87)

LEAF

0.18 (–0.33, 0.68)

RESTORE I

0.50 (–0.14, 1.15)

RESTORE II

0.17 (–0.40, 0.74)

Overall intervention effect

0.17 (–0.03, 0.36)

0 1 Positive affect change (points on DES scale) FIGURE 27.1: Intervention effect on positive affect, pre- to post-, intervention only.

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negative affect  =  -.36, 95% CI  =  [-.58, -.14]) from baseline to post intervention. In terms of change from baseline to one-month follow-up, there was a significant increase in overall positive affect (0.38, 95% CI = [0.14, 0.61]; See Figure 27.2) and a significant decrease in overall negative affect (-.44, 95% CI = [-.67, -.22]). Our measure of positive affect was made up of nine individual triplet items as described above. We were interested in whether the intervention was especially effective for particular positive affects. For example, given the focus on gratitude as part of the intervention, perhaps grateful/appreciative/thankful was especially influenced by the intervention. Meta-analysis of each individual positive affect across the five pilot studies indicated that content/serene/peaceful, glad/happy/joyful, grateful/appreciative/thankful, and hopeful/optimistic/encouraged, increased significantly from pre- to post-intervention and those significant increases were maintained at one-month follow-up. In addition, awe/wonder/amazement and proud/confident/self-assured increased significantly from baseline to the follow up (Table 27.2). The pre-post changes are supportive of the efficacy of the intervention. However, without control conditions, it is impossible to disentangle the effect of the intervention from nonspecific effects of being in the study (e.g., the effect of reporting one’s emotions, attention from interviewers, etc.). In four of our pilot studies we had either an attention-matched (ARTEMIS, DAISY, LEAF) or waitlist control condition (RESTORE). We calculated the changes in positive and negative affect in intervention compared to control conditions and then estimated the overall differences in positive and negative affect by combining studies using meta-analysis. Although the effects did not reach statistical significance, intervention conditions increased more than control on positive affect. The weighted mean difference between intervention and control condition in pre-post change on DES positive = .23; 95% CI = [-.01,.48], indicating that the intervention group increased relative to the control (See Figure 27.3.) The weighted mean difference between intervention and control condition in pre-post change on DES negative was -.06; 95% CI = [-.35,.22], an effect which did not approach statistical significance. The magnitude of change was approximately the same for the pre- to one-month follow up (for positive

Positive affect change (95% CI)

Study ARTEMIS

0.20 (–0.36, 0.76)

DAISY

0.10 (–0.62, 0.81)

IRISS

0.58 (0.02, 1.13)

LEAF

0.43 (–0.06, 0.92)

RESTORE I

0.83 (0.21, 1.44)

RESTORE II

0.09 (–0.49, 0.66)

Overall intervention effect

0.38 (0.14, 0.61)

0

1

Positive affect change (points on DES scale) FIGURE 27.2: Intervention effect on positive affect, pre- to follow-up, intervention only.

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Table 27.2: Estimates for change on DES-positive individual items (with 95% confidence intervals) based on meta analysis across fi ve pilot studies. Affect Amused Awe Glad/Happy/Joyful Grateful/ Hopeful Interested Love Proud Content

Baseline to post-intervention

Baseline to one-month follow-up

–.07 (–.37,0.23) .05 (–.33,.42) .40 (.13,.68) .29 (.01, 0.58) 0.75 (0.46,1.04) .05 (–.24,.34) –.02 (–.30,.26) .16 (–.16, 0.47) .43 (0.12, 0.75)

.14 (–.16,.45) .44 (.08,.80) .45 (0.15, 0.75) .32 (0.02, 0.62) .73 (0.42, 1.03) .27 (–.02, 0.56) 0.06(–.27,0.39) .35 (.02,.68) .57 (0.23, 0.92)

Note: Values in bold are statistically significant at p 

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