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An everyday activity as a treatment for depression: The benefits of expressive writing for people diagnosed with major depressive disorder



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An everyday activity as a treatment for depression: The benefits
of expressive writing for people diagnosed with major
depressive disorder
Katherine M. Krpana,*, Ethan Krossa, Marc G. Bermanb, Patricia J. Deldina, Mary K.
Askrenc, and John Jonidesa
Katherine M. Krpan:
aDepartment of Psychology, University of Michigan, Ann Arbor, MI, USA
bDepartment of Psychology, University of South Carolina, Columbia, SC, USA
cIntegrated Brain Imaging Center, Department of Radiology, University of Washington, Seattle,
Background—The benefits of expressive writing have been well documented among several
populations, but particularly among those who report feelings of dysphoria. It is not known,
however, if those diagnosed with Major Depressive Disorder (MDD) would also benefit from
expressive writing.
Methods—Forty people diagnosed with current MDD by the Structured Clinical Interview for
DSM-IV participated in the study. On day 1 of testing, participants completed a series of
questionnaires and cognitive tasks. Participants were then randomly assigned to either an
expressive writing condition in which they wrote for 20 min over three consecutive days about
their deepest thoughts and feelings surrounding an emotional event (
=20), or to a control
condition (
=20) in which they wrote about non-emotional daily events each day. On day 5 of
testing, participants completed another series of questionnaires and cognitive measures. These
measures were repeated again 4 weeks later.
Results—People diagnosed with MDD in the expressive writing condition showed significant
decreases in depression scores (Beck Depression Inventory and Patient Health Questionnaire-9
scores) immediately after the experimental manipulation (Day 5). These benefits persisted at the
4-week follow-up.
Limitations—Self-selected sample.
Conclusions—This is the first study to demonstrate the efficacy of expressive writing among
people formally diagnosed with current MDD. These data suggest that expressive writing may be
a useful supplement to existing interventions for depression.
Expressive writing; Major depressive disorder; Intervention; Written emotional disclosure
© 2013 Elsevier B.V. All rights reserved
*Corresponding author. Tel.: +1 734 647 6249.
Conflict of interest: The authors' have no conflicts of interest to report.
NIH Public Access
Author Manuscript
J Affect Disord
. Author manuscript; available in PMC 2014 September 25.
Published in final edited form as:
J Affect Disord
. 2013 September 25; 150(3): 1148–1151. doi:10.1016/j.jad.2013.05.065.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
1. Introduction
Expressive writing is a technique whereby individuals engage in deep and meaningful
writing about a traumatic or troubling event (Pennebaker and Beall, 1986). Over the past 25
years, a vast literature has documented robust physical and psychological benefits associated
with expressive writing among several populations (e.g., undergraduate students, inmates,
victims of partner abuse), that extend up to 6 months following intervention (Gortner et al.,
2006; Koopman et al., 2005; Pennebaker and Francis, 1996; Richards et al., 2000).
Compared to groups assigned to write about trivial or non-traumatic events, people who
engage in expressive writing experience reduced medical visits (Pennebaker and Francis,
1996), improvements in immune function (Pennebaker et al., 1988), increases in antibody
production (Petrie et al., 1995), increases in psychological wellbeing (Lepore, 1997; Murray
and Segal, 1994) reduced anxiety (Sloan et al., 2005, 2007), and reduced depressive
symptoms among both control and psychologically at-risk populations (Gortner et al., 2006;
Graf et al., 2008; Koopman et al., 2005; Pennebaker and Chung, 2011; Sloan and Marx,
2004; Sloan et al., 2005, 2007, 2008; Stice et al., 2007). Of particular interest is that the
mood-related benefits of expressive writing seem to be particularly notable among people
who report higher levels of depression and anxiety (Baikie et al., 2012; Gortner et al., 2006;
Koopman et al., 2005; Sloan et al., 2007). For example, women with high baseline
depression, people scoring highly on suppression measures, and people who are likely to be
suffering from mood disorders, especially benefit from expressive writing (Baikie et al.,
2012; Gortner et al., 2006; Koopman et al., 2005). At this time, however, there has been no
research examining the therapeutic qualities of expressive writing among people who have
been formally diagnosed with current Major Depressive Disorder (MDD). The potential
value of expressive writing as a supplement for existing treatments for depression is
significant. Expressive writing is an activity that could be implemented by most any willing
participant. Moreover, it is grounded in a rigorous, and comprehensive scientific tradition
(Klein and Boals, 2001; Pennebaker and Beall, 1986; Sloan and Marx, 2004; Sloan et al.,
2005). The sizable and meaningful effects observed in other populations (Smyth, 1998)
suggest that expressive writing may well be an effective, time- and cost-efficient therapy to
supplement existing treatments for depression (see Kazdin and Blase, 2011).
1.1. The current study
The purpose of this study was to determine if people diagnosed with current MDD would
benefit from expressive writing just as non-clinical populations have been shown to benefit
in the past. In addressing this question, the dependent measure we focused on was change in
depressive symptoms over time—precisely the outcome that one would hope to see an
effective intervention for depression influence over time. We tested whether three
consecutive days of expressive writing would significantly reduce depression as indexed by
the Beck Depression Inventory (BDI; Beck et al., 1996) and the Patient Health
Questionnaire-9 (PHQ; Spitzer et al., 1999), two canonical and widely used measures of
depressive symptoms.
2. Methods
2.1. Participants
Forty-four people diagnosed with current MDD were recruited for the study. Four
participants (3 in the expressive group and 1 in the control group) dropped out of the study
before its completion, leaving a total of 20 participants in each group. Twenty people were
randomly assigned to the Expressive Writing (EW) group (15 females, 5 males, mean
age=28 years), and 20 to the Control Writing (CW) group (16 females, 4 males, mean
age=29 years). Data on ethnicity and socioeconomic status was not collected. Each
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participant underwent a Structured Clinical Interview for DSM IV (SCID; Fist and Gibbons,
1996) with a trained, advanced graduate student or Ph.D. level clinician, and was diagnosed
with current MDD. Participants were recruited from the University of Michigan and the
greater Ann Arbor area through advertisements posted on campus and in the surrounding
community, and also on Craigslist and Facebook. Advertisements asked potential
participants if they were feeling sad, down, or depressed; if they were interested in
participating in research, they were asked to contact our lab via telephone or e-mail.
Participants met inclusion criteria if they were diagnosed with current MDD according to the
SCID, and had no history of psychotic or bipolar disorder. All participants were tested in the
experiment within 2 weeks of completing the SCID to ensure their diagnosis was current.
Twenty-seven participants had co-morbid diagnoses (e.g., anxiety, phobia), and 15 were on
medication for depression at the time of study (6 in EW; 9 in CW). All participants provided
informed written consent as administered by the Institutional Review Board of the
University of Michigan, and were compensated a total of $160 dollars for their time.
2.2. Procedure
Testing always began on a Monday (referred to as “Pre”) with participants completing a
series of questionnaires and cognitive measures including the Beck Depression Inventory
(BDI; Beck et al., 1996) and the Patient Health Questionnaire-9 (PHQ) (Spitzer et al., 1999).
On Tuesday through Thursday (Days 2–4 of testing), participants engaged in either
expressive or control writing for a total of 20 min. The instructions for EW were
administered following previous work (Pennebaker and Beall, 1986). Briefly, participants
were asked to write about their deepest thoughts and feelings about an extremely important
emotional issue that had affected them and their life. They were free to write about the same
event on each day, or to write about different events. People in the control group were asked
to write about how they organized their day. On the Friday (Day 5: Referred to as “Post”),
participants repeated the questionnaire and cognitive measures (in alternate forms, where
appropriate) that were administered on Day 1. These measures were again administered 4-
weeks later (referred to as “Follow-up”). For the purposes of this communication, we only
examined changes in depression scores on the BDI and PHQ.
2.3. Analysis parameters
A 2 (Group: EW vs. CW) × 3 (Time: Pre vs. Post vs. Follow-up) repeated measures analysis
of variance (ANOVA) were performed on the scores from the BDI and PHQ. Post-hoc
analyses were performed where appropriate.
3. Results
3.1. BDI
Relative to people in the CW condition, people in the EW group showed decreases in BDI
depression scores immediately post test, and at 4-weeks post intervention. As seen in Fig. 1,
repeated measures ANOVA on BDI scores revealed a significant effect of Time
(2, 38) =
< .001,
2 = .21, and Condition
(1, 38) = 6.41,
2 = .14, but no
significant Interaction (
=.36). To further investigate the effect of time, repeated
measures ANOVAs were run separately for the EW and CW groups. These analyses
revealed that the effect of time was primarily driven by the EW group (EW group:
(2, 38)
= 7.7,
2 = .29 CW group
(2, 38)=3.1,
> .05,
2 = .14). Follow-up univariate
analyses further examining group differences on BDI scores revealed no differences at
baseline (
(1, 38)=2.17, p=.15,
2 = .05) but significant group differences post intervention
(1, 38) = 6.37,
= .016,
2 = .14), and at follow-up (
(1, 38) = 5.01,
2 = .12).
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Notably, by follow-up, people in the EW group, but not the CW group, had subclinical
levels of depression as indexed by the BDI (<21). The same pattern of results was present
when evaluating participants both on and off medication.
3.2. PHQ
People in both the EW and CW groups showed decreases in PHQ depression scores post
intervention, and 4-weeks follow-up. However, people in the EW group were significantly
less depressed than their CW counterparts. As seen in Fig. 2, repeated measures ANOVA
revealed a significant effect of Time
(2, 38)=13.92, p < .011,
2 =.27, and Condition
2=.15, but no Interaction (
=.31). To further explore the effect
of Time, repeated measures ANOVAs were run for the EW and CW groups separately.
These results revealed an effect of time in both groups (EW group:
(2, 38)=8.7,
2=.32; CW group:
(2, 38)=5.8,
2=.24). Follow-up univariate analyses further
examining group differences in PHQ scores revealed no differences in depression at baseline
(1, 38)=2.02,
2=.05), but significant group differences post (
(1, 38)= 8.07,
2=.17), and at follow-up (
(1, 38)=4.85,
2=.12). Again, people in the EW
group had subclinical depression scores on the PHQ by the end of the study (<10). The same
patterns of results were found when evaluating those both on, and off medication.
3.3. Summary
In summary, analysis of both the BDI and PHQ data revealed that the EW group had lower
depression scores immediately following the intervention, and that this persisted to the 4-
week follow-up. The BDI data also revealed a significant effect of time, which was driven
by the EW group. While the effect of time was present for both the EW and CW group in
the PHQ data, the effect-size was larger in the EW group.
4. Discussion
To our knowledge, this is the first study to examine the effects of expressive writing among
people formally diagnosed with current Major Depressive Disorder. It was unclear a priori
whether having people write expressively and explore their private thoughts and feelings
would reduce depressive symptoms, as it does in populations of dysphoric individuals, or
propel the ruminative process and worsen the depression. Consistent with earlier work,
expressive writing reduced depression scores among people diagnosed with current MDD.
Compared to a group assigned to write about daily events, people with MDD in the EW
group showed significant reductions in depression scores on both the BDI and the PHQ
immediately following 3 days of writing, and these differences persisted 4-weeks later.
Importantly, there were no baseline differences between EW and CW group in age, gender
or severity of depression.
Examination of our BDI data showed an effect of Time that was driven by the EW group.
The effect of Time was also present in the PHQ data, but in this case both groups showed a
significant effect, although it was stronger in the EW group (EW
2=.31 vs. CW
Considering that the EW group had significantly lower depression scores than the CW group
immediately following the intervention, and again at 4-weeks post intervention, we interpret
this effect of Time in the CW group to reflect the standard course of depression. Symptoms
gradually worsen and remediate even when untreated.
These data are clinically meaningful. On average, the EW group dropped to nearly 9 points
on the BDI, and over 5 points on the PHQ. Indeed, by the end of the study, people in the EW
group had subclinical scores on both of these measures. Anecdotally, participants remarked
about feeling better. On the final day of expressive writing, one participant even wrote about
how much better she felt, and wondered if these few days of writing really could possibly
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have had an impact. Both the statistical significance and anecdotal evidence strongly support
the possibility that incorporating expressive writing into a treatment plan for MDD could
positively impact outcomes. Moreover, a recent paper Kazdin and Blase (2011) highlighted
the necessity of developing simple and cost-efficient methods to treat anxiety and
depression. Expressive writing does exactly this: it is readily accepted by patients, and is
also time- and cost-effective. Moreover, for the first time, the data presented in this paper
provide experimental support for the efficacy of expressive writing among those with MDD.
These preliminary data are encouraging, but more work is needed not only to replicate these
results, but to examine individual differences in susceptibility to EW effects. Our data
suggest that at the group level, expressive writing is effective in MDD. It may be, however,
that some patients are more or less likely to respond to expressive writing. From a clinical
perspective, this knowledge is important.
Finally, the mechanisms of expressive writing are unknown at this time. Others have
hypothesized expressive writing to be driven by individual and social disinhibition,
habituation to emotional stimuli, catharsis, the translation of emotions into language, and
changes in working memory (for review, see Pennebaker and Chung, 2011). Future work
examining the mechanisms of individual differences in MDD may prove insightful from an
academic and clinical perspective.
4.1. Limitations
While these preliminary data are encouraging, there are some limitations. The sample size
was modest and self-selected, and many participants had co-morbidities and were taking
medications. Our sample is also primarily female. While both the EW and CW group
contained similar numbers of males (5 and 4, respectively) it is possible that gender is an
important factor in the efficacy of expressive writing in MDD.
4.2. Conclusion
This is the first study to demonstrate that the benefits of expressive writing extend to people
diagnosed with current MDD. In our study, there were no baseline group differences in
severity of depression. Importantly, people in the EW group, who wrote for just 20-min a
day for three consecutive days, had significantly lower depression scores than their control
counterparts just one day after the intervention. Moreover, 4-weeks later, the EW group still
had significantly lower (and subclinical) depression scores than the control group. These
data suggest that expressive writing could be used to supplement existing interventions of
depression. It is time- and cost-efficient, and is accessible to any person capable of
expressive output.
We would especially like to thank all the people who participated in the study. We also thank Alexa Erickson and
Catherine Cherny for their help with data collection; Sue Li for her help in processing data; Phillip Cheng, Hyang
Sook Kim, Teresa Nguyen and Savanna Mueller for diagnostic interviewing.
Role of funding source: This work was supported by NIMH grant MH060665 to John Jonides. This work was also
supported by the University of Michigan Advanced Rehabilitation Research Training Program (Grant
#H133P090008) funded by the National Institute on Disability Rehabilitation Research (NIDRR), Office of Special
Education and Rehabilitation Services (OSERS) of the U.S. Department of Education, Washington, DC. The grants
were used to pay the post-doctoral fellow's stipend (Katherine M. Krpan), research assistants' salary, and the cost of
running the experiment.
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Fig. 1.
Mean (± SEM) Beck Depression Inventory (BDI) scores before the intervention (pre), one
day following the intervention (post), and 4 weeks after the intervention (follow-up).
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Fig. 2.
Mean (± SEM) Patient Health Questionnaire-9 (PHQ) scores before the intervention (pre),
one day following the intervention (post), and 4 weeks after the intervention (follow-up).
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... Studies examine physical health changes by assessing individuals' blood pressure, heart rate, and cortisol levels (21, 33,34). Psychological health changes were mainly studied in relation about the reduction of negative emotions such as depression and anxiety (18,22,(35)(36)(37)(38)(39)(40)(41). General functioning changes were investigated through an assessment of the rate of absenteeism (42), academic performance (34,43,44), and working memory (45). ...
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Introduction Expressive Writing (EW) is an intervention that focuses on individuals’ writing down their thoughts and feelings about trauma or stressful events. Meta-analyses on EW studies have confirmed that EW has a positive effect. However, the heterogeneity of studies is high, so many studies have investigated boundary conditions and moderators. One of these moderators is the cultural difference in emotional suppression. Since EW focuses on the expression of suppressed thoughts and emotions, its effect might be slightly different for people in Asian cultures who show a high tendency to suppress their emotions. This study attempted to confirm the effect size of the EW interventions in Korea and examine whether these studies have different effect size from those based on Western cultures. Method A total of 29 studies published in Korea until 2021 were analyzed. The effect size was calculated using the “dmetar,” “meta,” and “metafor” packages of the statistical program R 4.0.4. Results The results were as follows. First, the effect size of EW intervention was 0.16, and we found that studies in the Korean context showed no significant difference from studies based on western meta-analysis. Second, the moderating variables that influenced the EW intervention were the writing type, the number of sessions, the time per session, and the measurement time. Discussion The results of this study suggest that EW interventions benefit Koreans. And it is at least harmless and has a positive effect considering the efficiency and conciseness of interventions. Furthermore, the finding shows that EW interventions can be helpful even in the general population without apparent psychological problems. By considering moderators, we could structure more effective form of EW interventions for Koreans.
... Some studies have even suggested that the intervention has potential when administered online (Dean et al., 2016;Won Lee et al., 2016). In clinical populations, EW interventions reduce depressive symptoms compared to controls if the writing was emotion rich (Baikie et al., 2012;Krpan et al., 2013). However, it is of note that Baikie et al. (2012) only observed lowered depressive symptoms in participants who were mild to moderately depressed, with no reduction in depressive symptoms among those more severely depressed, due to difficulties with concentration, motivation, and increased level of self-critical thoughts. ...
... The rehabilitating impact of art on both mental health and life satisfaction is well-studied (14)(15)(16)(17). This can be in the form of music (16,18), visual arts (19), dance and movement programs (20), expressive writing such as journaling (21), and other alternatives. ...
... In a meta-analysis of 39 randomized controlled trials, Reinhold et al. [10] found that expressive writing exerted only limited effects in reducing depressive symptoms, and sometimes exacerbated results in unpredictable ways. In unsupervised settings, expressive writing can occasionally increase psychological distress [11,12], even to the point of causing patients to discontinue their treatment [13,14]. These conflicting findings indicate that, despite the efficacy and convenience of expressive writing for emotion regulation, care should be taken when deploying this approach in self-directed practices. ...
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Conventional writing therapies are versatile, accessible and easy to facilitate online, but often require participants to self-disclose traumatic experiences. To make expressive writing therapies safer for online, unsupervised environments, we explored the use of text-to-image generation as a means to downregulate negative emotions during a fictional writing exercise. We developed a writing tool, StoryWriter, that uses Generative Adversarial Network models to generate artwork from users’ narratives in real time. These images were intended to positively distract users from their negative emotions throughout the writing task. In this paper, we report the outcomes of two user studies: Study 1 ( N = 388), which experimentally examined the efficacy of this application via negative versus neutral emotion induction and image generation versus no image generation control groups; and Study 2 ( N = 54), which qualitatively examined open-ended feedback. Our results are heterogeneous: both studies suggested that StoryWriter somewhat contributed to improved emotion outcomes for participants with pre-existing negative emotions, but users’ open-ended responses indicated that these outcomes may be adversely modulated by the generated images, which could undermine the therapeutic benefits of the writing task itself.
... In another study, Krpan et al. (2013) shows that expressive writing is beneficial for both physical and mental health, and that people instinctively seek to understand themselves and their experiences, and seek understanding from others Just as students seek academic success, they seek understanding of themselves and the world, especially after a global pandemic. Thus, introducing expressive writing into first-year writing classes is a step towards helping students achieve both and achieve more. ...
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Expressive writing alludes to composing in which a person depicts profound considerations and sentiments encompassing the important event, the topic, or the area. As the world suffers from the COVID-19 pandemic, school and universities changed their teaching modalities from face-to-face teaching-learning process to online classes. Students were affected especially from lower socioeconomic localities of their limited financial ability to acquire the necessary equipment for learning and internet connection. In addition, they felt social isolation, lack of interaction with fellow students and the uncertainty of when the pandemic will be over. Hence, the study aimed to determine the effect of expressive writing on the psychological and physical conditions of the college students. The study used experimental design with pre-test and post-test and randomly assigned the respondents into the control group writing about their daily activities and the experimental group using expressive writing with each group has 60 respondents. The results showed that there is a significant difference in the health conditions between the experimental group treated with expressive writing and the control group treated with neutral condition. In conclusion, using expressive writing can overcome traumas and emotional upheavals thus resolves issues and improves health conditions.
Students with learning disabilities face more educational and even adult life difficulties than their counterparts without such disabilities, because of their poorer executive functioning. This study explored the effects of a disclosure program for expressive writing about emotions on the 3 executive functions of working memory, planning/organizing, and cognitive flexibility in an Iranian context. In so doing, 40 third to fifth graders with learning disabilities were recruited and assigned to either experimental or control groups through certain recognition tests and interviews. The effects of the treatment on executive functions were stable after 2 months. It was concluded that such disclosure programs can reduce executive functioning impairments of students with learning disabilities.
Club Itaca è un servizio offerto da Progetto Itaca Onlus, basato sul modello di Clubhouse International, di riabilitazione psicosociale psichiatrica per persone affette da disturbi di salute mentale Progetto Itaca e Atstrat hanno sviluppato "Storie di Rinascita", una metodologia di intervento volta ad aiutare le persone affette da disturbi della Salute Mentale ad acquisire consapevolezza e ad accettare la propria condizione, progredendo nel percorso di recovery attraverso la scrittura espressiva strutturata in tre atti: "come ero" (passato); "come sono" (presente); "cosa mi ha aiutato a cambiare" (fattori di rinascita). Scopo. L'obiettivo del presente studio è quello di indagare l'espressione emotiva delle narrative di Storie di Rinascita e di individuare gli elementi di rinascita riferiti dalle persone affette da disturbi della Salute Mentale. Metodi. 62 narrative sono state analizzate utilizzando la Sentiment Analysis e la Topic Analysis. Risultati. L'analisi del sentiment evidenzia una media dell'intensità delle parole polarizzate negativamente più elevata nel passato (µ = 1.71 ± 1.28) rispetto al presente (µ = 1.56 ± 0.93); si nota invece un aumento dell'intensità globale positiva da passato (µ = 1.29 ± 0.71) a presente (µ = 1.34 ± 0.80). Rispetto alle emozioni, le parole relative a rabbia, disgusto, paura e tristezza risultano meno intense nel presente (rispettivamente µ = 1.63 ± 1.06; µ = 1.40 ± 0.49; µ = 1.53 ± 0.94; µ = 1.76 ± 1.25), rispetto al passato (rispettivamente µ = 1.31 ± 0.63; µ = 1.12 ± 0.32; µ = 1.42 ± 0.63; µ = 1.47 ± 0.79). La media dell'intensità di gioia, sorpresa e fiducia è invece simile nelle due tipologie di narrazioni. L'Analisi dei Topic ha permesso di individuare i seguenti tre topic relativi ai fattori di rinascita: 1) il Club Itaca, 2) la Rete Sociale e 3) i Fattori Personali. Discussione e conclusione. L'utilizzo di un linguaggio emotivo meno negativo e più positivo quando si riferiscono al presente rispetto a quando parlano del loro passato permette di ipotizzare un miglioramento nella condizione delle persone affette da disturbi della Salute Mentale e una elaborazione positiva delle esperienze difficoltose sperimentate nel passato. Tali cambiamenti sembrano essere favoriti da Club Itaca, dal supporto della rete sociale e dalle proprie capacità personali. Storie di Rinascita risulta un utile strumento per favorire una rielaborazione della condizione di malattia e far prendere coscienza alle persone dei propri progressi.
Il trauma è una "ferita dell'anima", un'esperienza destabilizzante rispetto alla consuetudine, che disorganizza la mente di chi lo vive. I ricordi non trattati di un trauma sono spesso frammentati, disorganizzati e possono essere facilmente attivati sotto forma di pensieri intrusivi per cui i soggetti traumatizzati sperimentano varie forme di disagio psicologico. L'intervento di scrittura espressiva si è dimostrato essere un valido strumento come supporto nelle situazioni di stress evidenziando un generalizzato effetto positivo sulla salute. La scrittura espressiva, traducendo i pensieri e le emozioni traumatiche in linguaggio, aiuta i soggetti traumatizzati a dare un senso agli eventi sconvolgenti, a gestire le emozioni negative e migliora le loro connessioni con il mondo sociale. Questa ricerca si è posta l'obiettivo di verificare l'effetto di un protocollo di scrittura espressiva in un contesto non clinico, rappresentato da un campione di giovani adulti studenti universitari ed in particolare, ha inteso studiare gli effetti della scrittura espressiva nel mitigare eventuali problematiche psicologiche legate a eventi stressanti e/o traumatici.I risultati hanno confermato una discreta efficacia del protocollo di scrittura espressiva soprattutto nel sostenere un potenziamento delle risorse di coping personali e di adattamento rispetto agli esiti degli eventi stressanti vissuti.
Background Self-disclosure may enhance positive illness perceptions, whereas patients with systemic lupus erythematosus (SLE) always facing negative illness perceptions due to multiple reasons, so elucidation of factors affecting self-disclosure may facilitate the development of quality of life. Methods A total of 161 hospitalized patients with SLE were recruited. Scales on demographic and clinical characteristics, self-disclosure, psychosocial status (e.g. Social Support Rating Scale – SSRS) and quality of life were used to collect related information from clients. Univariate analysis was performed by Kruskal–Wallis rank-sum test or chi-square test, and multivariate analysis by ordinal logistic regression. Results Social support, drinking, depression and cause of hospitalization were found to be influencing factors of self-disclosure. Multiple logistic regression analyses revealed that the significant and independent factors associated with self-disclosure in patients with SLE were social support, drinking and depression. Domains of LupusQoL, except physical health and fatigue, were positively correlated with self-disclosure. Conclusions With the increase of social support, the level of self-disclosure become worse, drinking, depression and cause of hospitalization are risk factors for it. Moreover, the level of self-disclosure is positively related to the LupusQoL. Medical staff should formulate effective measures according to the results to improve self-disclosure in patients with SLE and promote their quality of life.
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Context The Primary Care Evaluation of Mental Disorders (PRIME-MD) was developed as a screening instrument but its administration time has limited its clinical usefulness.Objective To determine if the self-administered PRIME-MD Patient Health Questionnaire (PHQ) has validity and utility for diagnosing mental disorders in primary care comparable to the original clinician-administered PRIME-MD.Design Criterion standard study undertaken between May 1997 and November 1998.Setting Eight primary care clinics in the United States.Participants Of a total of 3000 adult patients (selected by site-specific methods to avoid sampling bias) assessed by 62 primary care physicians (21 general internal medicine, 41 family practice), 585 patients had an interview with a mental health professional within 48 hours of completing the PHQ.Main Outcome Measures Patient Health Questionnaire diagnoses compared with independent diagnoses made by mental health professionals; functional status measures; disability days; health care use; and treatment/referral decisions.Results A total of 825 (28%) of the 3000 individuals and 170 (29%) of the 585 had a PHQ diagnosis. There was good agreement between PHQ diagnoses and those of independent mental health professionals (for the diagnosis of any 1 or more PHQ disorder, κ = 0.65; overall accuracy, 85%; sensitivity, 75%; specificity, 90%), similar to the original PRIME-MD. Patients with PHQ diagnoses had more functional impairment, disability days, and health care use than did patients without PHQ diagnoses (for all group main effects, P<.001). The average time required of the physician to review the PHQ was far less than to administer the original PRIME-MD (<3 minutes for 85% vs 16% of the cases). Although 80% of the physicians reported that routine use of the PHQ would be useful, new management actions were initiated or planned for only 117 (32%) of the 363 patients with 1 or more PHQ diagnoses not previously recognized.Conclusion Our study suggests that the PHQ has diagnostic validity comparable to the original clinician-administered PRIME-MD, and is more efficient to use. Figures in this Article Mental disorders in primary care are common, disabling, costly, and treatable.1- 5 However, they are frequently unrecognized and therefore not treated.2- 6 Although there have been many screening instruments developed,7- 8 PRIME-MD (Primary Care Evaluation of Mental Disorders)5 was the first instrument designed for use in primary care that actually diagnoses specific disorders using diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition9(DSM-III-R) and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition10(DSM-IV). PRIME-MD is a 2-stage system in which the patient first completes a 26-item self-administered questionnaire that screens for 5 of the most common groups of disorders in primary care: depressive, anxiety, alcohol, somatoform, and eating disorders. In the original study,5 the average amount of time spent by the physician to administer the clinician evaluation guide to patients who scored positively on the patient questionnaire was 8.4 minutes. However, this is still a considerable amount of time in the primary care setting, where most visits are 15 minutes or less.11 Therefore, although PRIME-MD has been widely used in clinical research,12- 28 its use in clinical settings has apparently been limited. This article describes the development, validation, and utility of a fully self-administered version of the original PRIME-MD, called the PRIME-MD Patient Health Questionnaire (henceforth referred to as the PHQ). DESCRIPTION OF PRIME-MD PHQ ABSTRACT | DESCRIPTION OF PRIME-MD PHQ | STUDY PURPOSE | METHODS | RESULTS | COMMENT | REFERENCES The 2 components of the original PRIME-MD, the patient questionnaire and the clinician evaluation guide, were combined into a single, 3-page questionnaire that can be entirely self-administered by the patient (it can also be read to the patient, if necessary). The clinician scans the completed questionnaire, verifies positive responses, and applies diagnostic algorithms that are abbreviated at the bottom of each page. In this study, the data from the questionnaire were entered into a computer program that applied the diagnostic algorithms (written in SPSS 8.0 for Windows [SPSS Inc, Chicago, Ill]). The computer program does not include the diagnosis of somatoform disorder, because this diagnosis requires a clinical judgment regarding the adequacy of a biological explanation for physical symptoms that the patient has noted. A fourth page has been added to the PHQ that includes questions about menstruation, pregnancy and childbirth, and recent psychosocial stressors. This report covers only data from the diagnostic portion (first 3 pages) of the PHQ. Users of the PHQ have the choice of using the entire 4-page instrument, just the 3-page diagnostic portion, a 2-page version (Brief PHQ) that covers mood and panic disorders and the nondiagnostic information described above, or only the first page of the 2-page version (covering only mood and panic disorders) (Figure 1). Figure 1. First Page of Primary Care Evaluation of Mental Disorders Brief Patient Health QuestionnaireGrahic Jump Location+View Large | Save Figure | Download Slide (.ppt) | View in Article ContextCopyright held by Pfizer Inc, but may be photocopied ad libitum. For office coding, see the end of the article. The original PRIME-MD assessed 18 current mental disorders. By grouping several specific mood, anxiety, and somatoform categories into larger rubrics, the PHQ greatly simplifies the differential diagnosis by assessing only 8 disorders. Like the original PRIME-MD, these disorders are divided into threshold disorders (corresponding to specific DSM-IV diagnoses, such as major depressive disorder, panic disorder, other anxiety disorder, and bulimia nervosa) and subthreshold disorders (in which the criteria for disorders encompass fewer symptoms than are required for any specific DSM-IV diagnoses: other depressive disorder, probable alcohol abuse or dependence, and somatoform and binge eating disorders). One important modification was made in the response categories for depressive and somatoform symptoms that, in the original PRIME-MD, were dichotomous (yes/no). In the PHQ, response categories are expanded. Patients indicate for each of the 9 depressive symptoms whether, during the previous 2 weeks, the symptom has bothered them "not at all," "several days," "more than half the days," or "nearly every day." This change allows the PHQ to be not only a diagnostic instrument but also to yield a measure of depression severity that can be of aid in initial treatment decisions as well as in monitoring outcomes over time. Patients indicate for each of the 13 physical symptoms whether, during the previous month, they have been "not bothered," "bothered a little," or "bothered a lot" by the symptom. Because physical symptoms are so common in primary care, the original PRIME-MD dichotomous-response categories often led patients to endorse physical symptoms that were not clinically significant. An item was added to the end of the diagnostic portion of the PHQ asking the patient if he or she had checked off any problems on the questionnaire: "How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?" As with the original PRIME-MD, before making a final diagnosis, the clinician is expected to rule out physical causes of depression, anxiety and physical symptoms, and, in the case of depression, normal bereavement and history of a manic episode. STUDY PURPOSE ABSTRACT | DESCRIPTION OF PRIME-MD PHQ | STUDY PURPOSE | METHODS | RESULTS | COMMENT | REFERENCES Our major purpose was to test the validity and utility of the PHQ in a multisite sample of family practice and general internal medicine patients by answering the following questions: Are diagnoses made by the PHQ as accurate as diagnoses made by the original PRIME-MD, using independent diagnoses made by mental health professionals (MHPs) as the criterion standard?Are the frequencies of mental disorders found by the PHQ comparable to those obtained in other primary care studies?Is the construct validity of the PHQ comparable to the original PRIME-MD in terms of functional impairment and health care use?Is the PHQ as effective as the original PRIME-MD in increasing the recognition of mental disorders in primary care patients?How valuable do primary care physicians find the diagnostic information in the PHQ?How comfortable are patients in answering the questions on the PHQ, and how often do they believe that their answers will be helpful to their physicians in understanding and treating their problems?
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This study investigated whether emotional expression of traumatic experiences influenced the immune response to a hepatitis B vaccination program. Forty medical students who tested negative for hepatitis B antibodies were randomly assigned to write about personal traumatic events or control topics during 4 consecutive daily sessions. The day after completion of the writing, participants were given their first hepatitis B vaccination, with booster injections at 1 and 4 months after the writing. Blood was collected before each vaccination and at a 6-month follow-up. Compared with the control group, participants in the emotional expression group showed significantly higher antibody levels against hepatitis B at the 4 and 6-month follow-up periods. Other immune changes evident immediately after writing were significantly lower numbers of circulating T helper lymphocytes and basophils in the treatment group. The finding that a writing intervention influences immune response provides further support for a link between emotional disclosure and health. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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The purpose of this study was to compare vocal and written expression of feeling about interpersonal traumatic and trivial events in 20-min sessions over a 4-day period. Similar emotional processing was produced by vocal and written expression of feeling about traumatic events. The painfulness of the topic decreased steadily over the 4 days. At the end, both groups felt better about their topics and themselves and also reported positive cognitive changes. A content analysis of the sessions suggested greater overt expression of emotion and related changes in the vocal condition. Finally, there was an upsurge in negative emotion after each session of either vocal or written expression. These results suggest that previous findings that psychotherapy ameliorated this negative mood upsurge could not be attributed to the vocal character of psychotherapy.
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Can psychotherapy reduce the incidence of health problems? A general model of psychosomatics assumes that inhibiting or holding back one's thoughts, feelings, and behaviors is associated with long-term stress and disease. Actively confronting upsetting experiences--through writing or talk- ing-is hypothesized to reduce the negative effects of inhibition. Fifty healthy undergraduates were assigned to write about either traumatic experiences or superficial topics for 4 consecutive days. Two measures of cellular immune-system function and health center visits suggested that confronting traumatic experiences was physically beneficial. The implications for psychotherapy as a preventive treatment for health problems are discussed. There is little doubt that psychotherapy reduces subjective distress and yields positive behavioral outcomes. In recent years, a small group of researchers has sought to learn whether psychotherapy can also reduce health problems. Two promising reviews have indicated that the use of mental health services is associated with fewer medical visits, fewer days of hospitaliza- tion, and lower overall medical costs. In a summary of 15 stud- ies published between 1965 and 1980, Mumford, Schlesinger, and Glass (1981) found that individuals who underwent psy- chotherapy evidenced a 13% decrease in medical utilization rel- ative to nonpsychotherapy control subjects. Similarly, in a re- view of 13 studies of mental health services that were intro- duced into organizations, Jones and Vischi (1980) found that psychotherapy was associated with a 20% drop in medical utili- zation.
Previous studies have found that writing about upsetting experiences can improve physical health. In an attempt to explain this phenomenon, 72 first-year college students were randomly assigned to write about either their thoughts and feelings about coming to college or about superficial topics for three consecutive days. Measures of language use within the writing samples and cognitive measures of accessibility and schematic organisation were collected in the weeks before and after writing. As in previous studies, writing about college was found to reduce health centre visits for illness and to improve subjects' grade point average. Text analyses indicated that the use of positive emotion words and changes in words suggestive of causal and insightful thinking were linked to health change. Improved grades, although not linked to these language dimensions, were found to correlate with measures of schematic organisation of college-relevant themes. Implications for using written language to understand cognitive and health processes are discussed.
Psychological interventions to treat mental health issues have developed remarkably in the past few decades. Yet this progress often neglects a central goal-namely, to reduce the burden of mental illness and related conditions. The need for psychological services is enormous, and only a small proportion of individuals in need actually receive treatment. Individual psychotherapy, the dominant model of treatment delivery, is not likely to be able to meet this need. Despite advances, mental health professionals are not likely to reduce the prevalence, incidence, and burden of mental illness without a major shift in intervention research and clinical practice. A portfolio of models of delivery will be needed. We illustrate various models of delivery to convey opportunities provided by technology, special settings and nontraditional service providers, self-help interventions, and the media. Decreasing the burden of mental illness also will depend on integrating prevention and treatment, developing assessment and a national database for monitoring mental illness and its burdens, considering contextual issues that influence delivery of treatment, and addressing potential tensions within the mental health professions. Finally, opportunities for multidisciplinary collaborations are discussed as key considerations for reducing the burden of mental illness. © The Author(s) 2011.
The current study investigated the extent to which outpatient psychotherapy clients benefited from Pennebaker's expressive writing protocol (Pennebaker & Beall, 1986) adapted for use as a homework intervention. Participants were randomly assigned to written emotional disclosure or writing control conditions. Pre- and postintervention outcome measures were collected for three consecutive therapy sessions. Clients in the written emotional disclosure group showed significantly greater reductions in anxiety and depressive symptoms as well as greater overall progress in psychotherapy in comparison to the writing control group. Results suggest that emotional disclosure writing homework, in conjunction with outpatient psychotherapy, facilitates therapeutic process and outcome.