Content uploaded by Louise Lambert
Author content
All content in this area was uploaded by Louise Lambert on Aug 28, 2015
Content may be subject to copyright.
Happiness intervention decreases pain and
depression, boosts happiness among primary
care patients
Louise T. Lambert D’raven
1
,Nina Moliver
2
and Donna Thompson
1
1
Red Deer Primary Care Network, Alberta, Canada
2
Jamaica Plain, USA
Aim: The aim of the study was to determine whether positive psychological interventions
(PPIs) in a primary health care setting would improve physical and mental health
over time. Background: Most treatments for depression focus on reducing symptoms
rather than on creating positive states of mental health. Empirical studies to verify the
efficacy of PPIs in primary health care are needed. Method: In a six-week pilot program,
we invited patients in a primary health care setting with symptoms of depression to
participate in groups designed to increase levels of happiness. The program involved
interventions such as engaging in good deeds, writing gratitude letters, and introducing
empirical research. Patients completed the SF12v2
®
at the beginning and end of the
program and at three- and six-month follow-up. Measures included physical functioning,
bodily pain, mental health, social functioning, and vitality. Patients also participated in
focus groups to discuss their experiences. Findings: Of the 124 patients who enrolled in
this pilot study, 75 completed the six-week program, and 35 participated in two follow-up
assessments. Among the participants who remained for all follow-up assessments,scores
improved from baseline to 6-month follow-up for health, vitality, mental health, and the
effects of mental and physical health on daily activities. This subset of patients reported
greater energy and more daily accomplishments, along with reductions in functional
limitations. Improvements in mental and physical health and functioning were shown over
a six-month period. The study provides a basis for the further investigation of PPIs in
creating improvements for patients with depression in primary health care.
Key words: depression; happiness interventions; positive psychology; primary health care
Received 8 June 2013; revised 10 November 2013; first published online 22 January 2014
Introduction
Major depression is projected to become the
largest contributor to the disease burden in high-
income nations by 2030 (Mathers and Loncar,
2006). Presently, as many Canadians suffer from
major depression as from other leading chronic
conditions, including diabetes and heart disease
(Canadian Community Health Survey, 2002).
Depression has increased 60% in Canada since
1995, becoming the fastest-rising diagnosis made
by physicians (Mothersill, 2004). Worldwide,
depression is the most costly of all diseases to treat
(World Health Organization, 2008).
Depression is strongly associated with pain (Strigo
et al., 2008; Lee and Tsang, 2009; Narasimhan and
Campbell, 2010). Patients who reported physical
symptoms were 2.5–10 times more likely to be diag-
nosed with a depressive disorder than other patients
(Means-Christensen et al., 2008). The utilization
rates of health care were higher among primary
care patients who reported depression and pain
Correspondence to: Louise T. Lambert D’raven, PhD, c/o Red
Deer Primary Care Network, 5130-47 street, Red Deer,
Alberta, Canada T4N 1R9. Email: ltlamber@yahoo.com
Primary Health Care Research & Development 2015; 16: 114–126 DEVELOPMENT
doi:10.1017/S146342361300056X
© Cambridge University Press 2014
(Katon et al., 2003; Arnow et al., 2009; Narasimhan
and Campbell, 2010) than among non-depressed
patients with comparable levels of physical illness
(Rowan et al., 2002; Katon, 2003).
The World Health Organization (1946) defined
health as ‘a state of optimal physical, mental, and
social well-being, and not merely the absence of
disease and infirmity’. Health goes beyond the
absence of pathology and must be understood in
terms of health enhancement, the development of
strengths, and the maximization of one’s potential
(Duckworth et al., 2005; Becker et al., 2008; 2009).
Positive behaviors offer the best protection against
mental pathology (Duckworth et al., 2005). States
of happiness, manifested by positive emotions
and experiences, contribute significantly to robust
health. Happier individuals had greater social
supports and were more encouraged to engage in
health screenings, physical activity, and self-care
(Ostir et al., 1998; Pressman and Cohen, 2005;
Giltay et al., 2007).
Physical health has been shown to be closely
relatedtomentalhealth(Ryffet al., 2006; Ryff
and Singer, 2008). Positive emotions were found to
mitigate the physiological and cognitive effects of
negative emotions, decrease reactivity to stress, and
improve immune system response (Frederickson
et al., 2000; Segerstrom and Miller, 2004; Fredrickson
and Branigan, 2005; Fredrickson, 2006; Bower
et al., 2009). Happiness appears to have boosted
immunity, reduced stress, and inhibited wear and
tear on the body (Howell et al., 2007), as well as
enabling individuals to make better health deci-
sions and to engage in health-promoting behaviors
(Lyubomirsky et al., 2005; Fredrickson, 2006;
Veenhoven, 2008).
Traditional interventions that focus on minimiz-
ing symptoms of depression can leave individuals
in a languishing state in which they no longer
experience depression (Karwoski et al., 2006;
Layous et al., 2011). In contrast, positive psycholo-
gical interventions (PPIs), empirically derived
activities that promote the building of positive states
(Pawelski, 2009), have been found to promote
physical health (Seligman, 2008; Fowler, 2009;
Aspinwall and Tedeschi, 2010). Building positive
states can have benefits beyond the absence of
negative states, an important point given that a lack
of mental health may result in the same harmful
consequences as the presence of mental illness
(Duckworth et al., 2005; Keyes, 2005). For example,
individuals who declined from a state of flourishing
to moderate mental health were four times as likely
to have a mental illness as those who remained
in a state of flourishing, whereas declining from
moderate to languishing mental health increased the
odds ratio of mental illness 10 years later by 86%
(Keyes, 2010; Keyes et al., 2010).
In clinical samples, the use of PPIs improved
positive mood for over six months (Duckworth
et al., 2005; Lyubomirsky et al., 2011; Mongrain and
Anselmo-Matthews, 2012). Interventions included
counting blessings, planning gratitude visits, and
envisioning a person’s best self. When depressed
individuals engaged in noticing three good things
and using strengths in a new way, depression
remained low for up to six months, whereas writing
a gratitude letter led to an improvement in happi-
ness up to one month later (Seligman et al.,2005).
After six weeks, a treatment group had lower
depression scores and greater life satisfaction com-
pared with a control group and kept its gains one
year later (Seligman et al., 2006). The changes in
depression scores were also higher for the treat-
ment group than for a medicated control group, and
remission rates were higher.
Nonetheless, successes are modest. For instance,
Sin and Lyubomirsky (2009) reviewed 51 interven-
tions in a meta-analysis and showed that these
indeed improved well-being (r=0.29) and helped to
reduce depressive symptoms (r=0.31) albeit with
small effect sizes. A more recent meta-analysis
of positive interventions conducted by Bolier et al.
(2013) had stricter inclusion guidelines (n=39
studies with over 6139 participants) and showed
the effect sizes to be smaller but nonetheless
significant and sustainable over time. Specifically,
subjective well-being (r=0.34), psychological well-
being (r=0.20), and depression (r=0.23) were
positively affected by PPIs with the gains main-
tained at three and six months.
PPIs can be delivered in psycho-educational
groups with quick gains (Layous et al.,2011),and
are cost effective, easy to deliver, and lack side
effects. Because the focus is on well-being, PPIs
are also less stigmatizing (Layous et al.,2011).
Nonetheless, criticisms abound. Interventions have
been cited as individualistic and based on Western
definitions of happiness (Lu and Gilmour, 2006;
Christopher and Hickinbottom, 2008; Delle Fave
et al., 2011; Uchida and Ogihara,2012). Further, the
field has only recently acknowledged that happiness
Happiness program boosts happiness decreases pain 115
Primary Health Care Research & Development 2015; 16: 114–126
can be pursued through relationships and may be
less important than religion, family, or culture
(Pedrotti, 2007; Richardson and Guignon, 2008).
Proscribing Western PPIs in more collective socie-
ties may have negative implications. For instance,
pursuing individual happiness may be harmful to
relationships (Ahuvia, 2002; Uchida et al.,2004),
especially when happiness is understood as an inter-
subjective state defined by reciprocal support.
Culture, goals, and personality must be considered
(Schueller, 2011; Sergeant and Mongrain, 2011;
Schueller and Parks, 2012; Lyubomirsky and
Layous, 2013). Thus, a uniform approach is ill
advised and practitioners should be mindful not
to implement PPIs indiscriminately or to proclaim
benefits beyond what the data suggests (Kashdan
and Steger, 2011).
The use of PPIs is still in its infancy and even
more so in the field of primary health care. The
incorporation of PPIs into this domain would
improve individual skills and lead to greater states
of physical and mental health in the overall popu-
lation (Insel and Scolnick, 2006; Seligman, 2008;
Keyes, 2010; Kobau et al., 2011). Indeed, recent
studies have shown that the experience of happi-
ness significantly enhances the chances of recovery
from a mental disorder such as depression
(Bergsma et al., 2011). Thus, empirical studies to
verify the efficacy of these interventions in primary
health care settings are therefore needed.
Method
The purpose of this pilot study was to evaluate
changes in quality of life and perceptions of
happiness among primary health care adults after
participating in Happiness 101, a six-week PPI
program designed to treat depression and increase
well-being. The primary author (Lambert, 2009/
2012) developed the program and oversaw its
implementation within the Red Deer Primary
Care Network, a primary health care organization
in Red Deer, Alberta, Canada. The rationale for
this study was predicated on the need to deliver
effective and low-cost services that translated into
tangible immediate and sustainable mental and
physical results.
Participants were primary health care patients
over the age of 18 years. Referrals came from
primary health care physicians, mental health
counselors, or patients themselves. The program was
voluntary and offered at no cost. The Ethics Review
Board of Red Deer College granted approval to
conduct the study and all participants gave informed
consent. The study was conducted between
November 2010 and March 2012 where three six-
week programs within each calendar quarter were
offered. The study involved a quasi-experimental
quantitative evaluation and a qualitative assessment
involving focus groups. The first author was the lead
facilitator. Up to 25 participants were allowed into
each intake.
The Health-Related Quality of Life Assessment
Tool (SF12v2
®
;Wareet al., 2002), a self-administered,
12-item health measurement scale, was used. The
SF12v2
®
measures health-related quality of life
and has been extensively evaluated in patient
populations, including those with mental health
conditions. The questionnaire includes dimensions
for both physical and mental health. Domains for
physical health include (a) physical functioning,
(b) effect of physical health on routine activities
(referred to as role physical), (c) bodily pain, and
(d) overall physical health. Mental health domains
include (a) vitality, (b) social functioning, (c) effect of
mental health on daily activities (referred to as role
emotional), and (d) overall mental health. There is
also a summary component for both domains.
Norm based, each dimension of the SF12v2
®
has
a mean of 50 and a standard deviation (SD) of 10 in
the general US population. Each 1-point differ-
ence equals 1/10 of a SD, or an effect size of 0.10.
Scores below 50 reflect a health status below the
population average (Ware et al., 2002), with higher
scores representing better health. The instrument
has been proved reliable and valid with estimates
of internal consistency reliability for physical
health of 0.91 and for mental health of 0.87. The
SF12v2
®
has been useful in comparing the relative
burden of diseases and in differentiating the health
benefits produced by a range of treatments
(Cheak-Zamora et al., 2009).
Study participants scored in the mild to moder-
ate depression range and a score of <42 for the
mental health component of the instrument was
considered a screening cutoff for depression
(Ware et al., 2002). Most participants reported
feelings of depression, but some sought the inter-
vention as a way of preventing relapse and living
more fully and were not considered depressed.
Participants were screened for suicidal ideation,
116 Louise T. Lambert D’raven, Nina Moliver and Donna Thompson
Primary Health Care Research & Development 2015; 16: 114–126
other mental health issues, and possible substance
abuse. If present, mental health counselors worked
individually with patients until the risk was mini-
mized, after which the patient was free to enter the
program. Some continued to access services for
unrelated issues (ie, parenting, workplace conflicts,
smoking). A number of more severely depressed
patients were on antidepressant medication, but
data were not collected to this effect. Participants
self-reported energy levels, accomplishment of
tasks, perceptions of pain and its interference in
daily tasks, limitations in social activities, feelings
of being downhearted or depressed, and overall
health. These outcomes were measured at baseline,
at the end of the six-week program, and at three-
and six-month follow-up.
During 2-h weekly sessions, participants listened
to presentations from the empirical literature
about the science of well-being. Topics included
adaptation (Lyubomirsky, 2011), orientations to
happiness pathways (Peterson et al., 2005), flow
(Csikszentmihalyi, 1990), the broaden and build
model (Fredrickson, 2006), and the architecture of
sustainable happiness (Lyubomirsky et al., 2005).
The sessions also focused on the importance of
physical activity. To place the sessions in context, a
segment on the development of positive psycho-
logy was included so that patients could under-
stand the type of treatment they were receiving.
Group discussions, along with written or verbal
in-class activities and prescribed homework,
facilitated the delivery of information. Thirteen
PPIs were introduced, all of which were based on
available literature. Examples include engaging in
three good deeds and writing a gratitude letter
(Duckworth et al., 2005; Seligman et al., 2005),
using mindfulness (Brown et al., 2007), and savor-
ing (Bryant and Veroff, 2006). Table 1 shows the
full set of weekly interventions. The program
concluded with a social event to which all past and
present participants were invited.
Quantitative assessments were based on the
results of the SF12v2
®
administered at baseline,
end of program, three- and six-month follow-up.
Analyses of variances (ANOVAs) were used to
compare baseline scores between individuals
who left the study before the end of the program,
those who completed the program but did not
participate in follow-up assessments, and those who
completed follow-up assessments. Changes for each
subscale of the instrument were also evaluated. The
distribution of the scores for individuals who com-
pleted the full follow-up assessments was sufficiently
normal for the performance of parametric statistical
analyses. Therefore, repeated-measures ANOVAs
with an αsignificance level of 0.05 were used to
evaluate the changes over time. Pairwise analyses for
multiple comparisons were conducted. Bonferroni
corrections were not performed because of the
nature of the analysis and the number of sub-
scales used (Stanovich, 1988). After baseline scores
were compared, the statistical analysis included
only the 35 participants who completed all four
assessments.
For the qualitative evaluation, two focus groups
from the first six intakes were conducted to dis-
cover how participants experienced Happiness 101
and how they compared the intervention with
other therapies. An independent facilitator was
enlisted for this purpose in November 2010 and
again in February 2011. Both focus groups took
place before the final social event at the conclusion
Table 1 Weekly interventions
Week Intervention Empirical source
1 Mindfulness Brown et al. (2007)
Time control Flaherty (2003)
2 Goal setting; reducing over-thinking Lyubomirsky et al. (2006), Lyubomirsky and Tkach (2003)
3 Three good deeds; self-talk; optimism Carver et al. (2010), Hardy et al. (2001), Lambert (2009/2012)
4 Writing and thinking about positive experiences Burton and King (2004)
Savoring Bryant and Veroff (2006)
Gratitude letter and visit Duckworth et al. (2005), Seligman et al. (2005)
5 Best possible self Kurtz and Lyubomirsky (2008), Sheldon and Lyubomirsky (2006)
Planning a date Lambert (2009/2012)
6 Counting blessings and three good things Seligman et al. (2005)
Happiness program boosts happiness decreases pain 117
Primary Health Care Research & Development 2015; 16: 114–126
of the six-week program. All comments were
audiorecorded and transcribed verbatim.
Results
Between November 2010 and March 2012, 665
referrals were received into the program, including
133 males (20%). The mean age was 45 years. Of
referred patients, 318 (48%) were registered into a
session. The program completion rate was 71%.
Of the six classes offered for each program, parti-
cipants attended an average of 3.6 classes. One
hundred and twenty-four participants completed
baseline questionnaires. We then conducted
assessments at six weeks (n=75), three months
(n=36), and six months (n=35). Table 2 shows
the gender and age distributions for each stage of
the program.
Quantitative measures
At baseline, all mean scores for mental and
physical health were below the US norm of 50. The
lowest scores were for role emotional (ie, the effect
of mental health on daily activities), overall mental
health, and social function. The highest scores
were for physical functioning. Table 3 shows the
mean scores for mental and physical health at each
assessment interval. Table 4 shows the inter-
correlations for all outcome measures at six-month
follow-up.
Three groups were considered in baseline com-
parisons: participants who withdrew before the
end of the study, participants who completed the
study but either declined or were unavailable to
participate in the three-month follow-up assess-
ment, and participants who completed all follow-up
assessments. There were no significant differences
in any baseline measures between these three
groups, although the large rate of attrition, further
identified in the limitations section, may be sugges-
tive of some differences. When participants who
completed the six-week study were compared with
all other participants, regardless of whether they
completed the follow-up assessments, there were no
significant differences in any baseline scores.
The percentage of at-risk patients declined from
67% at baseline to 26% at six-month follow-up
Table 3 Physical and mental health, mean scores at assessment intervals
Dimension Baseline Six weeks Three months Six months
Physical function 44.44 ± 13.37 45.43± 11.14 46.89 ± 11.37 47.39 ± 10.19
Role physical 39.14 ± 13.14 44.41± 10.25 44.54 ± 10.97 47.61 ± 9.73
Body pain 41.13 ± 14.68 47.25± 11.33 46.09 ± 10.99 47.25 ± 11.59
General health 39.82 ± 10.82 43.33± 10.09 46.71 ± 11.01 46.59 ± 8.63
Physical health summary 43.71± 14.34 46.29 ± 11.01 46.72 ± 10.98 47.98 ± 11.09
Vitality 40.85 ± 10.57 47.46 ± 10.77 50.34 ± 10.45 48.04 ± 9.29
Social function 38.67 ± 11.52 44.45 ± 11.44 44.45 ± 10.34 45.90 ± 11.98
Role emotional 35.79 ± 10.43 40.10 ± 11.91 43.45 ± 10.88 46.55 ± 9.35
Mental health 38.24 ± 10.84 46.08 ± 10.08 46.78 ± 9.51 45.38 ± 7.84
Mental health summary 36.53 ± 11.28 43.83 ± 12.27 46.00 ± 9.88 45.91 ± 9.76
n=35. Figures are given as M± SD.
Table 2 Gender and age distributions of participants at each stage of program
Time nFemales Males Mean age Age range
Baseline 124 101 (81%) 23 (19%) 48 19–79
End of program (six weeks) 75 60 (80%) 15 (20%) 50 19–79
Three-month follow-up 36 27 (75%) 9 (25%) 54 19–79
Six-month follow-up 35 27 (77%) 8 (23%) 53 19–79
118 Louise T. Lambert D’raven, Nina Moliver and Donna Thompson
Primary Health Care Research & Development 2015; 16: 114–126
using 42 as the cutoff score for identifying patients
at risk for depression. This decline was clinically as
well as statistically significant. Declines were
greater among males than among females. Among
the general US population, 20% are considered at
risk for depression. Figure 1 shows the change in
the percentage of participants at risk from baseline
to follow-up.
The power of the study was β=0.94, assuming
a medium effect size. The results of repeated-
measures ANOVAs showed significant differences
in scores of role physical, general health, vitality,
role emotional, mental health, and mental health
summary over the three time intervals. Table 5
shows the test statistics for dimensions with signi-
ficant changes over time.
For health dimensions with significant overall
changes, pairwise analyses were performed to
determine the significance of the changes over each
time interval. Table 6 demonstrates the results of
the pairwise analyses. Of note, with the exception
of a significant change in role emotional between
six weeks and six-month follow-up, all significant
changes occurred only with respect to baseline
scores. Significant improvements occurred for all six
dimensions between baseline and six-month follow-
up, and for five of the six dimensions (with the
exception of role physical) between baseline and
three-month follow-up. Significant improvements
occurred for vitality, mental health, and mental
health summary between baseline and six weeks.
Although the overall change for social function
was not significant, P=0.10, pairwise analyses
showed a significant increase in social function
between baseline and three-month follow-up,
P=0.04, and between baseline and six-month
follow-up, P=0.01. There was a significant inverse
Table 4 Intercorrelations for outcome variables at six-month follow-up
Measures Physical
function
Role
physical
Body
pain
General
health
Vitality Social
function
Role
emotional
Role physical 0.65*** –––
Body pain 0.59*** 0.47** ––
General health 0.46** 0.62*** 0.34* –
Vitality 0.46** 0.64*** 0.45** 0.65***
Social function 0.56*** 0.57*** 0.33 0.46** 0.56***
Role emotional 0.14 0.38* −0.18 0.16 0.42* 0.48**
Mental health 0.09 0.23 0.06 0.02 0.47** 0.50** 0.64***
n=35.
*P<0.05.
**P<0.01.
***P<0.001.
Figure 1 Comparison of percentage of participants at
risk for depression from baseline to follow-up
Table 5 Multivariate analysis of health dimensions with
significant changes over time
Dimensions Wilks’λF
(3,32)
P-value
Role physical 0.78 2.97 0.047
General health 0.78 3.01 0.044
Vitality 0.64 5.93 0.002
Role emotional 0.51 10.32 <0.001
Mental health 0.71 4.42 0.010
Mental health summary 0.61 6.98 0.001
n=35.
Happiness program boosts happiness decreases pain 119
Primary Health Care Research & Development 2015; 16: 114–126
correlation between the physical health summary
score and the mental health summary score at
baseline, n=124, r(122) =−0.19, P=0.03. How-
ever, these two scores were not significantly corre-
lated at the other three time points.
Focus groups
Focus groups were conducted with 24 partici-
pants from the first six Happiness 101 intakes. The
first question presented to focus group participants
was, ‘What was your experience of Happiness 101?
What was it like?’Overall, patients reported the
Happiness 101 program to be a very positive
experience, in sharp contrast to previous types of
therapies they had received in the past for
depression. Comments were as follows:
∙Looking at the ‘positive side’in teaching us how
to move forward rather than ‘focusing on the
past’has been revolutionary –a wow moment…
This is what we need do within society as a
whole. (Participant #3, female, age 49)
∙The program was an enlightening ‘mind frame’
change from previous groups that delved into
past experiences. This was forward thinking.
(Participant #7, female, age 49)
∙It was a joy to come each week. I looked forward
to homework and had a desire to get better.
I needed new tools to get better. I needed to
reach out and learn new ways to help myself.
I had been down too long. (Participant #8,
female, age 51)
∙I didn’t know that a course like this existed. The
course went way beyond my expectations.
(Participant #12, male, age 31)
∙I got very depressed when I became ill and I was
referred to a psychiatrist. My treatment was
entirely focused on my depression, and this
course was focused entirely on my happiness.
I always left my psychiatrist feeling worse than
when I went (Participant #17, female, age 46)
As participants learned and used the 13 PPIs,
they were asked what they retained from the pro-
gram and which (if any) techniques they continued
to use by asking, ‘What are you doing differently as
a result of participating in this program? How have
you learned to sustain these changes?’Answers
included the following:
∙Mindfulness –This was pivotal. I try to do this
several times a day. Applying mindfulness is a
new technique. Being able to switch to focus on
what’s happening around me has been different.
(Participant #3, female, age 49)
∙Journaling…I now write about more action-
oriented items, plan ahead, and reflect on the
Table 6 Significance of changes over time, pairwise analyses
Health dimensions Time measure Baseline Six weeks Three months
Role physical Six weeks 0.09 ––
Three months 0.06 0.96 –
Six months 0.004 0.19 0.22
General health Six weeks 0.20 ––
Three months 0.02 0.20 –
Six months 0.008 0.13 0.96
Vitality Six weeks 0.02 ––
Three months <0.001 0.33 –
Six months 0.006 0.82 0.35
Role emotional Six weeks 0.14 ––
Three months 0.002 0.24 –
Six months <0.001 0.02 0.20
Mental health Six weeks 0.009 ––
Three months 0.004 0.76 –
Six months 0.001 0.74 0.55
Mental health summary Six weeks 0.03 ––
Three months 0.001 0.44 –
Six months <0.001 0.42 0.97
n=35. Significant differences are in boldface, α=0.05.
120 Louise T. Lambert D’raven, Nina Moliver and Donna Thompson
Primary Health Care Research & Development 2015; 16: 114–126
positive. I often think and write about the three
good things that have happened to me today.
(Participant #7, female, age 49)
∙I stopped over-thinking. I learned to make a
decision and stick to it. I always went over and
over my decisions and ended up with stomach
pains. I catch myself and purposefully think
about something else that doesn’t stress me out.
(Participant #4, male, age 20)
∙Setting goals…I had never set goals. I attained
things by chance in the past. If I needed a job,
I got one, and things worked out. This had been
a stressful year, with situations not working out,
and setting small goals that are attainable will
work for me. This was a big learning. (Partici-
pant #12, male, age 31)
∙I was a ‘wallower’. I have learned to be proactive
and am now doing things. I am more active…
getting up and doing small projects. This is
working for me. (Participant #19, male, age 53)
∙I did my homework every week...that’s how
committed I was. Practicing what I learned was
important. (Participant #20, female, age 44)
∙I am healthier because of my positivity. I haven’t
caught a cold lately, and I usually do. (Partici-
pant #8, female, age 51)
∙I smile more and have been told this. (Partici-
pant #17, female, age 46)
Of particular interest were the experiences of
some participants who were taking antidepressant
medication before or during the program. Some
participants felt they still required pharmaceutical
intervention, as the group did not meet all of their
needs, whereas others reported feeling that medi-
cation was complementary to their treatment. A
third view was that medication or hospitalization
was not sufficient and that learning the skills to
be happy was essential. Overall, participant state-
ments suggested that a balanced and careful
response to the use of medication should involve
the patient’s wishes as well as the acquisition of
skills to generate well-being. Comments included
the following:
∙I am on medication and have been to counsel-
ling. My medication has been increased and may
be at the right level now. I was having problems
with memory. Mindfulness intervention has
helped me to be more focused. I am more
relaxed. I can gather my thoughts better. I think
the medication and Happiness Group strategies
are working complementarily. (Participant #20,
female, age 44)
∙I have just started medication this past weekend.
The Happiness Group was not enough. (Partici-
pant #4, male, age 20)
∙I am still on my medication and will be for some
time, but this really helped bring perspective to
my unhappiness. (Participant #7, female, age 49)
∙My psychiatrist wanted me to take pills for
my depression…I was never offered a choice and
I absolutely wanted another alternative to
medication. I went back to my family physician
and was then referred to this course. (Participant
#17, female, age 46)
∙I need my medication because I was suicidal.
[But] my doctor emphasized that I needed to
look beyond medication in helping myself get
better. This course gave me a different perspec-
tive other than the information I was receiving in
the hospital where I was admitted with depres-
sion. I left the hospital on my own…I received so
much more from this course. (Participant #19,
male, age 53)
Many patients had been in previous forms
of counseling before attending Happiness 101.
How Happiness 101 differed from other types of
counseling and in what ways was sought. Almost
all participants agreed that the positive psycho-
logical approach was dramatically different and
that the group offered unexpected, yet highly
welcomed, benefits.
∙I got tired of always answering question in other
therapy: Why do you think this happened to
you? (Participant #20, female, age 44)
∙I was excited to go home from class and try
lessons, and I looked forward to coming back.
Some classes I have attended have depleted
your energy and made you feel more depressed.
The class was energizing. (Participant #3, female,
age 49)
∙When I was first referred to this class, I didn’t
want to go to another group therapy class. I had
a bad experience previously where I just listened
to other people’s problems. This view only lent
itself to my feeling more depressed. It was
different to have people share things that made
them happy and not sad. (Participant #7, female,
age 49)
Happiness program boosts happiness decreases pain 121
Primary Health Care Research & Development 2015; 16: 114–126
∙There was too much focus in other groups as to
what is making you sad…this was about becom-
ing happy. (Participant #12, male, age 31)
∙I was convinced that I needed to fix the things
from the past that bothered me…I was forced to
relive past experiences, rather than moving on.
Why do I have to deal with old issues? I found
out this is not the case anymore. (Participant #10,
female, age 60)
∙In past group experiences, I just cried the whole
time. (Participant #8, female, age 51)
∙This was my first group experience, but in
individual therapy I cried the whole time. Louise
emphasized that we didn’t need to cry. I am
learning to be happy about my husband
and children and not to think of them as
sources of unhappiness. (Participant #13, female,
age 42)
∙I don’t like a group situation, but I started to
enjoy coming to these groups because I was
learning so much. (Participant #19, male, age 53)
∙This perspective doesn’t bring you down. It lifts
you up. You want to return to class. You feel
good when you leave class. It’s informative and
problem solving rather than problem finding.
(Participant #22, female, age 29)
Many participants believed that the program
taught skills that would be useful for other popu-
lations, such as schools, couples, and workplaces.
People clearly recognized the applicability of
happiness skills, and the openness to recommend-
ing the program to others suggested that there was
little stigma to attending the group. Furthermore,
the benefits of being happier were evident across
participant responses (eg, got a job, spent more
time with children, felt better physically). The
universal appeal of happiness and a focus on the
positive and the future appeared to be important.
When participants were asked participants if they
would recommend the program and a positive
psychological approach to others, and why,
responses included the following:
∙Absolutely. This should bea mandatory Grade 12
class to learn skills for lifetime happiness and
coping. These skills need to be learned early in
life. (Participant #3, female, age 49).
∙The elderly need this as well. It’s a phenomenon
how people turn negative when they get older,
and this would be very good to change their
perspective on life. Take it to care facilities for
old folks. People don’t need to be negative when
they get old. (Participant #24, male, age 55)
∙It’s hard to put on a happiness face when you are
feeling down. It gets harder and harder to be
someone that you aren’t. I just started to stay
home and not go out. It’s too hard to be happy,
and you don’t want people seeing you sad. Now
I have started to go out. I started to feel so much
better, and I went out and got a job. I needed to
get out, as the walls were talking back to me in
the house. This group was the ‘positive change’
I needed. Amen! (Participant #20, female, age 44)
∙The mind frame has become important to me,
and I have made an effort to get off the couch to
play with the kids. Making this effort gets easier
all the time. I am having fun. (Participant #19,
male, age 53)
∙I now have a desire to get up in morning, shower,
and get dressed even if I’m not going anywhere.
This is a new habit for me. I need to appreciate
each day. (Participant #4, male, age 20).
∙I liked the fact that the class wasn’t targeted
entirely to clinical depression –if you are just
down, you could benefit from this class. Just
come to learn and apply a different perspective.
This is a course that applies to everyone!
(Participant #8, female, age 51)
Discussion and conclusions
The results of the happiness intervention showed
that for the subset of patients who remained in
the program for six weeks and participated in
follow-up assessments, the repeated use of PPIs
was associated with decreased depression and
perceptions of pain and increased social function-
ing, subjective vitality, and overall mental health
over time. The most notable improvements on
indicators of the SF12v2
®
occurred over the course
of the initial study. All significant improvements
were sustained during the follow-up period. The
effects of mental health on daily activities continued
to improve after the end of the study session, perhaps
reflecting positive feedback loops as individuals
interacted with their environments from a founda-
tion of improved affect.
The findings were consistent with results from
previous studies (eg, Duckworth et al., 2005; Seligman
et al., 2005; 2006; Sin and Lyubomirsky, 2009;
Lyubomirsky et al., 2011; Mongrain and Anselmo-
122 Louise T. Lambert D’raven, Nina Moliver and Donna Thompson
Primary Health Care Research & Development 2015; 16: 114–126
Matthews, 2012). Verbal responses also reflected
physical, mental, and social improvements such as
obtaining employment, resisting a cold, enjoying
work more, spending more time with children
and spouses, being grateful for every day, and
expecting and planning for a bright future.
Several limitations may have affected the find-
ings of this study. The attrition rate from baseline
to follow-up was high. One hundred and twenty-
four patients participated in the study initially and
75 remained at the end of the program. Further
attrition resulted in 36 participants responding to
follow-up assessment at three months, and 35 at
the final assessment mark. Individuals whose well-
being did not improve from the intervention may
have left the program. Conversely, individuals who
remained in the program may have been highly
motivated, receptive, or committed to the style of
intervention. Other participants may not have
perceived the need to continue with the follow-up
measures, while others were unavailable (ie, moved
away, change in contact information, etc.). Thus,
conclusions can be drawn only on the subset of self-
selected individuals who remained in the program,
and the results of this study cannot be generalized
to other primary health care patients. Instead, the
results have shown that a PPI may be considered as
apotentiallybeneficial intervention in alleviating
depression among a selected subset of primary
health care patients who, for undetermined reasons,
may be well suited to the effects of a PPI.
There was no control group to assess whether
positive changes in affect were attributable to the
intervention. The gains discovered in the study
may have been attributable to the passage of time.
All participants expected to feel happier and less
depressed through their participation in the pro-
gram. The expectation of feeling happier may have
functioned as a placebo and contributed to initial
gains. Gains may also have been attributable to
nonspecific factors such as the support of group
leaders, participation in the groups themselves, or
the benefits from the social event held before the
final follow-up evaluations. The presentation of
empirical literature may have had a persuasive
effect on the participants as the mere expectation
that PPIs will work has been shown to increase
their efficacy (Boehm and Lyubomirsky, 2009;
Sin and Lyubomirsky, 2009; Sheldon et al., 2010;
Lyubomirsky et al., 2011). Some patients were
receiving pharmaceutical treatment during the
program and these benefits were not accounted
for. The Hawthorne effect, according to which
individuals improve their behavior when they
know they are being studied, may also explain
some of the findings.
The self-selection of some participants may
also have contributed to an initial placebo effect,
as has been noted for many PPIs (Lyubomirsky
et al., 2011). However, most positive indicators
were maintained or improved at follow-up indi-
cating that a placebo effect was not an adequate
explanation for all improvements. Finally, as parti-
cipants are often eager to share their positive
improvements, the self-reports may have been
positively biased. We minimized this risk by enlist-
ing an independent interviewer for the focus groups.
Of note, self-reports are generally assumed to be
valid for positive as well as for negative experiences
(Peterson, 2006; Baumeister et al., 2007; Park and
Peterson, 2009).
The current study was a pilot study. The data
does not permit definitive conclusions to be drawn
regarding the benefits of PPIs in a primary health
care setting, because of both the absence of a
control group and the high rate of attrition.
Follow-up studies are recommended with a control
group to assess whether improvements in well-
being can be attributed to the intervention, or
other moderating factors such as anti-depressant
medication, the passage of time, or participant
expectations. In future research, data should
be analyzed to determine reasons that patients
withdraw from a PPI or choose not to participate
in follow-up assessments.
PPIs have not been used widely in primary health
care and this intervention represents an initial
foray into the field. By targeting primary health
care patients, this low-cost, non-stigmatizing and
brief pilot intervention was oriented equally to the
treatment of mental distress and to the preven-
tion and promotion of positive mental health. The
reduction of physical symptoms of pain through
PPIs may further help to reduce the health care
costs and dependency associated with depression
and its treatment, as well as the costs associated
with poorer functioning and time lost from pro-
ductive work. Using PPIs in a primary health care
setting may lead to new applications and future
research designed to improve health and function-
ing in both the physical and mental domains. A
focus on the positive may be the most powerful
Happiness program boosts happiness decreases pain 123
Primary Health Care Research & Development 2015; 16: 114–126
medicine in increasing levels of well-being and in
providing participants with the skills to help them
manage themselves.
Acknowledgments
Thank you to the Red Deer Primary Care Network.
Financial Support
This research received no specific grant from any
funding agency, commercial, or not-for-profit sectors.
Conflicts of Interest
None.
References
Ahuvia, A.C. 2002: Individualism/collectivism and cultures of
happiness: a theoretical conjecture on the relationship
between consumption, culture and subjective well-being at
the national level. Journal of Happiness Studies 3, 23–36.
Arnow, B., Blasey, C., Lee, J., Fireman, B., Hunkeler, E. and
Dea, R. 2009: Relationships among depression, chronic
pain, chronic disabling pain, and medical costs. Psychiatric
Services 60, 344–50.
Aspinwall, L. and Tedeschi, R. 2010: The value of positive
psychology for health psychology: progress and pitfalls in
examining the relation of positive phenomena to health.
Annals of Behavioral Medicine 39, 4–15.
Baumeister, R., Vohs, K. and Funder, D. 2007: Psychology as
the science of self-reports and finger movements: whatever
happened to actual behavior? Perspectives on Psychological
Science 2, 396–403.
Becker, C., Dolbier, C., Durham, T., Glascoff, M. and Adams, T.
2008: Development and preliminary evaluation of a positive
health scale. American Journal of Health Education 39, 34–41.
Becker, C., Moore, J., Whetstone, L., Glascoff, M., Chaney, E.,
Felts, M. and Anderson, L. 2009: Validity evidence for the
Salutogenic Wellness Promotion Scale (SWPS). American
Journal of Health Behavior 33, 455–65.
Bergsma, A., Ten Have, M., Veenhoven, R. and De Graaf, R.
2011: Mental disorders and happiness; a 3-year follow-up in
the Dutch general population. The Journal of Positive
Psychology 6, 253–59.
Boehm, J.K. and Lyubomirsky, S. 2009: The promise of
sustainable happiness. In Lopez S.J., editor, Handbook of
positive psychology. Oxford:Oxford UniversityPress, 667–77.
Bolier, L., Haverman, M., Westerhof, G., Riper, H., Smit, F.
and Bohlmeijer, E. 2013: Positive psychology interventions:
a meta-analysis of randomized controlled studies. BMC
Public Health 13, 119.
Bower, J., Moskowitz, J. and Epel, E. 2009: Is benefitfinding
good for your health? Pathways linking positive life changes
after stress and physical health outcomes. Current Directions
in Psychological Science 18, 337–41.
Brown, K., Ryan, R. and Creswell, J. 2007: Addressing
fundamental questions about mindfulness. Psychological
Inquiry 18, 272–81.
Bryant, F. and Veroff, J. 2006: Savoring: a new model of positive
experience. Mahwah, NJ: Erlbaum.
Burton, C. and King, L. 2004: The health benefits of writing
about intensely positive experiences. Journal of Research in
Personality 38, 150–63.
Carver, C., Scheier, M. and Segerstrom, S. 2010: Optimism.
Clinical Psychology Review 30, 879–89.
Cheak-Zamora, N., Wyrwich, K. and McBride, T. 2009:
Reliability and validity of the SF-12v2 in the medical
expenditure panel survey. Quality of Life Research 18, 727–35.
Christopher, J. and Hickinbottom, S. 2008: Positive psychology,
ethnocentrism, and the disguised ideology of individualism.
Theory & Psychology 18, 563–89.
Csikszentmihalyi, M. 1990: Flow: the psychology of optimal
experience. New York, NY: Harper & Row.
Delle Fave, A., Brdar, I., Freire, T., Vella-Brodrick, D.
and Wissing, M.P. 2011: The eudaimonic and hedonic
components of happiness: qualitative and quantitative
findings. Social Indicators Research 100, 185–207.
Duckworth, A., Steen, T. and Seligman, M. 2005: Positive
psychology in clinical practice. Annual Review of Clinical
Psychology 1, 629–51.
Flaherty, M. 2003: Time work: customizing temporal experi-
ence. Social Psychology Quarterly 66, 17–33.
Fowler, R. 2009: Positive health: how to die young as late as
possible. Symposium conducted at the International Posi-
tive Psychology Association, First World Congress on
Positive Psychology, Philadelphia, PA.
Fredrickson, B. 2006: The broaden-and-build theory of positive
emotions. In Csikszentmihalyi, M. and Csikszentmihalyi, I.,
editors, A life worth living: Contributions to positive psychology.
New York, NY: Oxford University Press, 85–103.
Fredrickson, B. and Branigan, C. 2005: Positive emotions
broaden the scope of attention and thought-action reper-
toires. Cognition and Emotion 19, 313–32.
Fredrickson, B., Mancuso, R., Branigan, C. and Tugade, M.
2000: The undoing effect of positive emotions. Motivation
and Emotion 24, 237–58.
Giltay, E., Geleijnse, J., Zitman, F., Buijsse, B. and Kromhout,
D. 2007: Lifestyle and dietary correlates of dispositional
optimism in men: The Zutphen Elderly Study. Journal of
Psychosomatic Research 63, 483–90.
Hardy, J., Hall, C. and Alexander, M. 2001: Exploring self-talk
and affective states in sport. Journal of Sports Sciences 19,
469–75.
Howell, R., Kern, M. and Lyubomirsky, S. 2007: Health
benefits: meta-analytically determining the impact of
well-being on objective health outcomes. Health Psychology
Review 1, 83–136.
124 Louise T. Lambert D’raven, Nina Moliver and Donna Thompson
Primary Health Care Research & Development 2015; 16: 114–126
Insel, T. and Scolnik, E. 2006: Cure therapeutics and strategic
prevention: raising the bar for mental health research.
Molecular Psychiatry 11, 11–17.
Karwoski, L., Garratt, G. and Ilardi, S. 2006: On the integration
of positive psychology with cognitive-behavioral therapy for
depression. Journal of Cognitive Psychotherapy 20, 159–70.
Kashdan, T.B. and Steger, M.F. 2011: Challenges, pitfalls
and aspirations for positive psychology. In Sheldon, K.,
Kashdan, T.B. and Steger, M.F., editors, Designing positive
psychology: taking stock and moving forward. Oxford, UK:
Oxford University Press, 9–21.
Katon, W. 2003: Clinical and health services relationships
between major depression, depressive symptoms, and
general medical illness. Biological Psychiatry 54, 216–26.
Katon, W., Lin, E., Russo, J. and Unutzer, J. 2003: Increased
medical costs of a population-based sample of depressed
elderly patients. Archives of General Psychiatry 60, 897–903.
Keyes, C. 2005: Mental illness and/or mental health? Investigat-
ing axioms of the complete state model of health. Journal of
Consulting and Clinical Psychology 73, 539–48.
Keyes, C. 2010: The next steps in the promotion and protection
of positive mental health. Canadian Journal of Nursing
Research 42, 17–28.
Keyes, C., Dhingra, S. and Simoes, E. 2010: Change in level of
positive mental health as a predictor of future risk of mental
illness. American Journal of Public Health 100, 2366–71.
Kobau, R., Seligman, M., Peterson, C., Diener, E., Zack, M.,
Chapman, D. and Thompson, W. 2011: Mental health
promotion in public health: perspectives and strategies
from positive psychology. American Journal of Public
Health 101, e1–9.
Kurtz, J. and Lyubomirsky, S. 2008: Toward a durable
happiness. In Lopez, S. and Rettew, J. editors, The positive
psychology perspective series. Volume 4. Westport, CT:
Greenwood Publishing Group, 21–36.
Lambert, L. 2009/2012: Happiness 101: a how-to guide in positive
psychology for people who are depressed, languishing, or
flourishing (the facilitator guide). Bloomington, IN: Xlibris
Corporation.
Layous, K., Chancellor, J., Lyubomirsky, S., Wang, L. and
Doraiswamy, P. 2011: Delivering happiness: translating
positive psychology intervention research for treating major
and minor depressive disorders. The Journal of Alternative
and Complementary Medicine 17, 675–83.
Lee, S. and Tsang, A. 2009: A population-based study of
depression and three kinds of frequent pain condi-
tions and depression in Hong Kong. Pain Medicine 10,
155–63.
Lu, L. and Gilmour, R. 2006: Individual oriented and socially
oriented cultural conceptions of subjective well-being:
conceptual analysis and scale development. Asian Journal
of Social Psychology 9, 36–49.
Lyubomirsky, S. 2011: Hedonic adaptation to positive and
negative experiences. In Folkman, S., editor, Oxford
handbook of stress, health, and coping. New York, NY:
Oxford University Press, 200–24.
Lyubomirsky, S., Dickerhoof, R., Boehm, J. and Sheldon, K.
2011: Becoming happier takes both a will and a proper
way: an experimental longitudinal intervention to boost
well-being. Emotion 11, 391–402.
Lyubomirsky, S., King, L. and Diener, E. 2005: The benefits of
frequent positive affect. Psychological Bulletin 131, 803–55.
Lyubomirsky, S., Sousa, L. and Dickerhoof, R. 2006: The costs
and benefits of writing, talking, and thinking about life’s
triumphs and defeats. Journal of Personality and Social
Psychology 90, 692–708.
Lyubomirsky, S. and Layous, K. 2013: How do simple posi-
tive activities increase well-being? Current Directions in
Psychological Science 22, 57–62.
Lyubomirsky, S. and Tkach, C. 2003: The consequences of
dysphoric rumination. In Papageorgiou, C. and Wells, A.,
editors, Rumination: nature, theory, and treatment of
negative thinking in depression. Chichester, England: John
Wiley & Sons, 21–41.
Mathers, C. and Loncar, D. 2006: Projections of global
mortality and burden of disease from 2002 to 2030. PLoS
Medicine 3, e442.
Means-Christensen, A., Roy-Byrne, P., Sherbourne, C.,
Craske, M. and Stein, M. 2008: Relationships among pain,
anxiety, and depression in primary care. Depression and
Anxiety 25, 593–600.
Mongrain, M. and Anselmo-Matthews, T. 2012: Do positive
psychology exercises work? A replication of Seligman
et al. (2005). Journal of Clinical Psychology 68, 382–89.
Mothersill, K. 2004: The effectiveness of psychological services
within healthcare teams. In Calgary Health Region, Uni-
versity of Calgary Joint Conference, Calgary, Canada,
22 April 2004.
Narasimhan, M. and Campbell, N. 2010: A tale of two
comorbidities: understanding the neurobiology of depres-
sion and pain. Indian Journal of Psychiatry 52, 127–30.
Ostir, G., Markides, K., Black, S. and Goodwin, J. 1998: Lower
body functioning as a predictor of subsequent disability
among older Mexican Americans. Journal of Gerontology
and Medical Science 53, M491–95.
Park, N. and Peterson, C. 2009: Achieving and sustaining a
good life. Perspectives on Psychological Sciences 4, 422–28.
Pawelski, J. 2009: Positive interventions: theory, research and
practice. Symposium conducted at the International Positive
Psychology Association, First World Congress on Positive
Psychology, Philadelphia, PA.
Pedrotti, J.T. 2007: Eastern perspectives on positive psycho-
logy. In Snyder, C.R. and Lopez, S.J., editors, Positive
psychology: the scientific and practical explorations of human
strengths. Thousand Oaks, CA: Sage, 37–50.
Peterson, C. 2006: The values in action (VIA) classification of
strengths. In Csikszentmihalyi, M. and Csikszentmihalyi, I.,
editors, A life worth living: contributions to positive psycho-
logy. New York, NY: Oxford University Press, 29–48.
Peterson, C., Park, N. and Seligman, M. 2005: Orientations
to happiness and life satisfaction: the full life versus the
empty life. Journal of Happiness Studies 6, 25–41.
Happiness program boosts happiness decreases pain 125
Primary Health Care Research & Development 2015; 16: 114–126
Pressman, S. and Cohen, S. 2005: Does positive affect influence
health? Psychological Bulletin 131, 925–71.
Richardson, F. and Guignon, C. 2008: Positive psychology
and philosophy of social science. Theory and Psychology 18,
605–27.
Rowan, P., Davidson, K., Campbell, J., Dobrez, D. and
MacLean, D. 2002: Depressive symptoms predict medical
care utilization in a population-based sample. Psychological
Medicine 32, 903–08.
Ryff, C., Love, G., Urry, H., Muller, D., Rosenkranz, M.,
Friedman, E., Davidson, R.J. and Singer, B. 2006: Psycho-
logical well-being and ill-being: do they have distinct
or mirrored biological correlates? Psychotherapy and
Psychosomatics 75, 85–95.
Ryff, C. and Singer, B. 2008: Know thyself and become what
you are: a eudaemonic approach to psychological well-
being. Journal of Happiness Studies 9, 13–39.
Schueller, S.M. 2011: To each his own well-being boosting
intervention: using preference to guide selection. The
Journal of Positive Psychology 6, 300–13.
Schueller, S.M. and Parks, A.C. 2012: Disseminating self-help:
positive psychology exercises in an online trial. Journal of
Medical Internet Research 14(3), e63.
Segerstrom, S. and Miller, G. 2004: Psychological stress
and the human immune system: a meta-analytic study of
30 years of inquiry. Psychological Bulletin 104, 601–30.
Seligman, M. 2008: Positive health. Applied Psychology 57, 3–18.
Seligman, M., Rashid, T. and Parks, A. 2006: Positive
psychotherapy. American Psychologist 61, 774–88.
Seligman, M., Steen, T., Park, N. and Peterson, C. 2005:
Positive psychology progress: empirical validation of inter-
ventions. American Psychologist 60, 410–21.
Sergeant, S. and Mongrain, M. 2011: Are positive psychology
exercises helpful for people with depressive personality
styles? Journal of Positive Psychology 6, 260–72.
Sheldon, K. and Lyubomirsky, S. 2006: How to increase and
sustain positive emotion: the effects of expressing gratitude
and visualizing best possible selves. The Journal of Positive
Psychology 1, 73–82.
Sheldon, K.M., Abad, N., Ferguson, Y., Gunz, A., Houser-
Marko, L., Nichols, C.P. and Lyubomirsky, S. 2010:
Persistent pursuit of need-satisfying goals leads to increased
happiness: A 6-month experimental longitudinal study.
Motivation and Emotion 34, 39–48.
Sin, N. and Lyubomirsky, S. 2009: Enhancing well-being and
alleviating depressive symptoms with positive psychology
interventions: a practice-friendly meta-analysis. Journal of
Clinical Psychology 65, 467–87.
Stanovich, K. 1988: Cautions regarding Bonferroni corrections:
a response to Davies and Goldsmith. Reading Research
Quarterly 23, 380–81.
Strigo, I., Simmons, A., Matthews, S., Craig, A. and
Paulus, M. 2008: Major depressive disorder is associated
with altered functional brain response during anticipation
and processing of heat pain. Archives of General Psychiatry
65, 1275–84.
Uchida, Y., Norasakkunkit, V. and Kitayama, S. 2004: Cultural
constructions of happiness: theory and empirical evidence.
Journal of Happiness Studies 5, 223–39.
Uchida, Y. and Ogihara, Y. 2012: Personal or interpersonal
construal of happiness: a cultural psychological perspective.
International Journal of Wellbeing 2, 354–69.
Veenhoven, R. 2008: Healthy happiness: effects of happiness
on physical health and the consequences for preventive
health care. Journal of Happiness Studies 9, 449–69.
Ware, J., Kosinski, M., Turner-Bowker, D. and Gandek, B.
2002: SF-12v2™: how to score Version 2 of the
SF-12
®
health survey. Lincoln, RI: Quality Metric
Incorporated.
World Health Organization. 1946: Preamble to the Constitution
of the World Health Organization as adopted by the
International Health Conference, New York, 19–22 June
1946. Retrieved 10 July 2012 from http://www.who.int/
suggestions/faq/en/print.html
World Health Organization. 2008: Global burden of disease:
2004 (Update 2008). Retrieved 3 March 2012 from http://
www.who.int/healthinfo/global_burden_disease/GBD_report_
2004update_full.pdf
126 Louise T. Lambert D’raven, Nina Moliver and Donna Thompson
Primary Health Care Research & Development 2015; 16: 114–126
