title: Relaxation response and spirituality: Pathways to improve psychological outcomes in cardiac rehabilitation.
abstract: OBJECTIVE
  Studies have shown beneficial effects from practicing the relaxation response (RR). Various pathways for these effects have been investigated. Previous small studies suggest that spirituality might be a pathway for the health effects of the RR. In this study, we tested the hypothesis that increased spiritual well-being by eliciting the RR is one pathway resulting in improved psychological outcomes.
  
  
  METHODS
  This observational study included 845 outpatients who completed a 13-week mind/body Cardiac Rehabilitation Program. Patients self-reported RR practice time in a questionnaire before and after the 13-week program. Similarly, data on spiritual well-being, measured by the subscale of Spiritual Growth of the Health-Promoting Lifestyle Profile II, were collected. The psychological distress levels were measured by the Symptom Checklist-90-Revised. We tested the mediation effect of spiritual well-being using regression analyses.
  
  
  RESULTS
  Significant increases in RR practice time (75 min/week, effect size/ES=1.05) and spiritual well-being scores (ES=0.71) were observed after participants completed the program (P<.0001). Patients also improved on measures of depression, anxiety, hostility and the global severity index with medium effect sizes (0.25 to 0.48, P<.0001). Greater increases in RR practice time were associated with enhanced spiritual well-being (beta=.08, P=.01); and enhanced spiritual well-being was associated with improvements in psychological outcomes (beta=-0.14 to -0.22, P<.0001).
  
  
  CONCLUSIONS
  Our data demonstrated a possible dose-response relationship among RR practice, spiritual and psychological well-being. Furthermore, the data support the hypothesis that spiritual well-being may serve as a pathway of how RR elicitation improves psychological outcomes. These findings might contribute to improved psychological care of cardiac patients.
authors.affiliation: Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, USA. bhchang@bu.edu
authors.forename: Bei-Hung
authors.initials: BH
authors.lastname: Chang
authors.forename: Aggie
authors.initials: A
authors.lastname: Casey
authors.forename: Jeffery A
authors.initials: JA
authors.lastname: Dusek
authors.forename: Herbert
authors.initials: H
authors.lastname: Benson
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001007:Anxiety / Q000175:diagnosis / Q000523:psychology; D057189:Checklist; D003863:Depression / Q000175:diagnosis / Q000523:psychology; D005260:Female; D015438:Health Behavior; D006331:Heart Diseases / Q000451:nursing / Q000523:psychology* / Q000534:rehabilitation*; D006791:Hostility; D006801:Humans; D008297:Male; D008875:Middle Aged; D019222:Mind-Body Relations, Metaphysical; D009720:Nurse Clinicians; D010349:Patient Compliance / Q000523:psychology; D010555:Personality Inventory / Q000706:statistics & numerical data; D011594:Psychometrics; D011788:Quality of Life / Q000523:psychology; D012064:Relaxation Therapy; D029181:Spirituality; D011795:Surveys and Questionnaires