Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1694841292482.pdf (Liberia)
Spirituality in Clinical Practice 2015, Vol.

2, No.

1, 5–17 2326-4500/15/$12.00 © 2015 American Psychological Association http://dx.doi.org/10.1037/scp0000050 The Role of Gratitude in Spiritual Well-Being in Asymptomatic Heart Failure Patients Paul J.
Mills, Laura Redwine, Kathleen Wilson, Meredith A. Pung, Kelly Chinh, Barry H. Greenberg, Ottar Lunde, Alan Maisel, and Ajit Raisinghani University of California, San Diego Alex Wood University of Stirling Deepak Chopra University of California, San Diego, and Chopra Center for Wellbeing, Carlsbad, California Spirituality and gratitude are associated with well-being.
Few if any studies have examined the role of gratitude in heart failure (HF) patients or whether it is a mechanism through which spirituality may exert its beneﬁcial effects on physical and mental health in this clinical population.

This study examined associations between gratitude, spiritual well-being, sleep, mood, fatigue, cardiac-speciﬁc self- efﬁcacy, and inﬂammation in 186 men and women with Stage B asymptomatic HF (age 66.5 years 10).
In correlational analysis, gratitude was associated with better sleep (r .25, p .01), less depressed mood (r .41, p .01), less fatigue (r .46, p .01), and better self-efﬁcacy to maintain cardiac function (r .42, p .01).

Patients expressing more gratitude also had lower levels of inﬂammatory biomarkers (r .17, p .05).
We further explored relationships among these variables by examining a putative pathway to determine whether spirituality exerts its beneﬁcial effects through gratitude.

We found that gratitude fully mediated the relationship between spiritual well-being and sleep quality (z 2.35, SE .03, p .02) and also the relationship between spiritual well-being and depressed mood (z 4.00, SE .075, p .001).
Gratitude also partially mediated the relation- ships between spiritual well-being and fatigue (z 3.85, SE .18, p .001) and between spiritual well-being and self-efﬁcacy (z 2.91, SE .04, p .003).

In sum, we report that gratitude and spiritual well-being are related to better mood and sleep, less fatigue, and more self-efﬁcacy, and that gratitude fully or partially mediates the beneﬁcial effects of spiritual well-being on these endpoints.
Efforts to increase gratitude may be a treatment for improving well-being in HF patients’ lives and be of potential clinical value.

Keywords: heart failure, gratitude, spiritual well-being, inﬂammation Paul J.
Mills, Department of Family Medicine and Public Health, Department of Psychiatry, and UC San Diego Center of Excellence for Research and Training in Global Integrative Health, University of California, San Diego, and Chopra Center for Wellbeing, Carlsbad, Cal- ifornia; Laura Redwine, Department of Psychiatry and UC San Diego Center of Excellence for Research and Training in Global Integrative Health, University of California, San Diego; Kathleen Wilson and Meredith A. Pung, Department of Family Medicine and Public Health, University of California, San Diego; Kelly Chinh, Department of Psychiatry, University of Califor- nia, San Diego; Barry H. Greenberg, Ottar Lunde, Alan Maisel, and Ajit Raisinghani, Department of Medicine, University of California, San Diego; Alex Wood, De- partment of Behavioral Science, University of Stirling; Deepak Chopra, Department of Family Medicine and Public Health, University of California, San Diego, and Chopra Center for Wellbeing.
This work was supported by Grants HL-073355, HL- 096784, and 1UL1RR031980-01 from the National Insti- tutes of Health and a grant from the Greater Good Science Center, Berkeley, CA.

Correspondence concerning this article should be ad- dressed to Paul J.

Mills, UCSD, 9500 Gilman Drive #0725, La Jolla, CA 92093-0725.

E-mail: pmills@ucsd.edu 5 6 MILLS ET AL.

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Gratitude unlocks the fullness of life.

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Itturns denial into acceptance, chaos into order, confusion into clar- ity.
success, and mistakes into important events.

Gratitude makes sense of our past, brings peace for today, and creates a vision for tomorrow.

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Itturns problems into gifts, failures into ––Melodie Beattie Heart failure (HF) is a major public health concern, affecting over 6 million Americans, with rates expected to nearly triple over the next few decades as the population ages (Krum & Stewart, 2006).
It is the end stage of most car- diac anomalies, with the annual number of hos- pitalizations exceeding 1 million, and direct costs in the United States exceeding $40 billion/ year (Desai & Stevenson, 2012; Wang, Zhang, Ayala, Wall, & Fang, 2010).
In the ﬁeld of behavioral cardiology (Rozan- ski, 2014), there is increasing interest in exam- ining associations between positive psycholog- ical attributes such as spirituality and gratitude, potential mechanisms of their action, and im- portantly, associations with clinical outcomes (Dubois et al., 2012; Huffman et al., 2011; Sacco, Park, Suresh, & Bliss, 2014).

In many populations, spirituality or religious wellness are associated with better mental and physical health.
In a recent meta-analytic review, for example, Bonelli and Koenig (2013) reported that religious–spiritual is corre- lated with better mental health, including less depression (Bonelli & Koenig, 2013), although such associations are not always observed (Morgenstern et al., 2011).

In patients with symptomatic HF, there is a positive correlation between spiritual well-being and better mental health (Whelan-Gales, Quinn Grifﬁn, Maloni, & Fitzpatrick, 2009).
In addition, symptomatic HF patients with higher measures of spiritual well-being have better HF-related health status (Bekelman et al., 2009).

involvement Therapeutically, there is increasing recogni- tion of the value of embracing multidisciplinary therapeutic approaches in HF that include spiritu- ality as part of more routine psychosocial support (Naghi, Philip, Phan, Cleenewerck, & Schwarz, 2012).
Spirituality-based interventions for im- proving mood and well-being in cardiovascular disease populations have shown promising out- comes and demonstrated good adherence in sev- eral pilot studies.

For example, Delaney, Barrere, and Helming (2011) reported reduced depression scores among community-dwelling patients with cardiovascular disease following an individual- ized 1-month spirituality-based intervention on health-related outcomes.

Warber et al.
Warber et al.

(2011) ex- amined the effects of a nondenominational spiri- tual retreat on depression and other measures of well-being in postacute coronary syndrome pa- tients.

A 4-day spiritual retreat intervention in- cluded guided imagery, meditation, drumming, journal writing, and nature-based activities.

A control intervention included nutrition education, exercise, and stress management.

Both retreat groups received follow-up phone coaching bi- weekly for up to 3 months.
Compared with the control group, patients assigned to the spiritual retreat group had signiﬁcantly lower depression scores postintervention, which were maintained 3 months later.

Gratitude is considered a positive psycholog- ical factor that has also been associated with well-being in some populations.

According to Büssing et al.


(2014), in clinical populations feelings of gratitude and awe facilitate percep- tions and cognitions that go beyond the focus of the illness and include positive aspects of one’s personal and interpersonal reality, even in the face of disease.

According to Wood, Froh, and Geraghty (2010), gratitude is part of a wider life orientation toward noticing and appreciating the positive aspects of life.
Gratitude can be attrib- uted to an external source such as an animal, person, or nonhuman (e.g., God, the cosmos), and may be part of a vaster perspective of noticing and appreciating the positive in the world (Wood et al., 2010).
There are individual differences in dispositional gratitude, which en- tails how frequently and intensely people expe- rience the emotion of gratitude, the range of events which elicit the emotion, and in the in- terpretation of social situations (McCullough, Emmons, & Tsang, 2002; Wood, Maltby, Stew- art, Linley, & Joseph, 2008).
Longitudinal stud- ies suggest that higher levels of gratitude are directly linked to improvements in perceived social support as well as reduced stress and depression, and that these direct effects are not explained by personality factors (Wood et al., 2008).

Gratitude has theological origins and the im- portance of its development and practice is em- phasized in the majority of world religions.
Prayer frequency has been found to increase gratitude (Lambert, Graham, & Fincham, 2009), and in this way gratitude may serve as a ROLE OF GRATITUDE IN SPIRITUAL WELL-BEING 7 pathway through which spirituality exerts its known positive effects on physical and mental health.

The American College of Cardiology/ American Heart Association (ACC/AHA) HF staging system denotes Stage B patients as asymptomatic but at high risk for developing symptomatic (Stage C) HF (Hunt et al., 2005a).
Stage B consists of patients who have devel- oped structural heart disease (e.g., previous myocardial infarction, asymptomatic valvular disease) with speciﬁc left ventricular (LV) dys- function that is associated with inﬂammation and the development of HF but who have never shown signs or symptoms of HF.
Stage C HF further includes both structural or functional abnormality, increased inﬂammation, and exer- cise limitation from dyspnea or fatigue, whereas Stage D includes severe “end-stage” HF (Eisen, Benderly, Behar, Goldbourt, & Haim, 2014; Viganego & Le Jemtel, 2007).

The ACC/AHA HF staging system emphasizes both the evolu- tion and the progression of chronic HF and seeks to identify and implement early therapeu- tic interventions to ultimately reduce morbidity and mortality (Hunt et al., 2005b).
The Stage B level of disease presents an important therapeu- tic window into potentially halting disease pro- gression and improving quality of life.

Progres- sion from Stage B HF to symptomatic HF is associated with a ﬁvefold increase in mortality risk (Ammar et al., 2007).
Within the growing ﬁeld of studying relation- ships between gratitude and well-being, few studies have examined HF populations, and this is despite recent studies describing the impor- tance of psychosocial resources such as grati- tude in alleviating the struggles associated with living with symptomatic HF (Sacco et al., 2014).
The purpose of this study therefore was to examine associations between spiritual well- being, gratitude, and physical and mental health in Stage B HF patients and to examine a poten- tial pathway (i.e., gratitude) through which spir- itual well-being may promote physical and mental health beneﬁts.

Method Participants The sample consisted of 186 men and women with AHA/ACC classiﬁcation Stage B HF with a diagnosis for at least 3 months.
Patients were recruited from the cardiology clinics at the Uni- versity of California San Diego Medical Cen- ters and the Veterans Affairs San Diego Health care System (VASDHS).
Presence of Stage B HF was deﬁned as structural heart disease based on recommendations and cut-points from the American Society of Echocardiog- raphy guidelines (Lang et al., 2005), includ- ing LV hypertrophy (deﬁned as mean LV wall thickness of septum and posterior wall 12 mm), LV enlargement (at least moderate in severity, deﬁned as LV end diastolic diame- ter 64 mm in men or 58 mm in women, or LV mass index 132 in men or 109 in women), LV systolic dysfunction (deﬁned as LV ejection fraction 55% or wall motion abnormality), LV diastolic dysfunction, asymptomatic valvular heart disease of at least moderate severity, or previous myocar- dial infarction, but without signs or symptoms of HF.
Left ventricular ejection fraction (%LVEF) was assessed by echocardiography as part of the patient’s routine medical eval- uation.

Protocol The protocol was approved by the UCSD and VASDHS Institutional Review Boards and par- ticipants gave written informed consent.

The study was carried out in accordance with the Declaration of Helsinki principles.
On presen- tation to the laboratory, a blood draw was ob- tained using a 21- or 23-gauge butterﬂy needle and participants completed a packet of psycho- social questionnaires.

Measures Gratitude.

Gratitude was assessed with the GQ– 6 (Froh et al., 2011; McCullough et al., 2002).

The GQ– 6 is a psychometrically sound self-administered 6-item scale designed to mea- sure trait gratitude.

Internal consistency of the GQ– 6 in this cardiac population was high, with a Cronbach’s alpha of 0.92.
Spiritual well-being.

The Functional As- sessment of Chronic Illness Therapy Spiritual Well-Being Scale (FACIT–SP12) was used to as- sess spiritual well-being (Peterman, Fitchett, Brady, Hernandez, & Cella, 2002).

The FACIT– SP12 is a 12-item scale designed to measure the extent to which patients experienced spiritual 8 MILLS ET AL.

well-being over the previous week.


Internal con- sistency reliability coefﬁcients have ranged from .81 to .88, and convergent validity estimates show moderate to strong correlations with other mea- sures of spirituality and religiousness (Peterman et al., 2002).

In this cohort, Cronbach’s alpha for the FACIT–SP12 was 0.85.

Depressive symptom severity.


Symptoms of depression were assessed with the 21-item Beck Depression Inventory (BDI–IA), where scores 10 indicate possible clinical depression (Beck, 1978).

The BDI–IA assesses symptoms related to sadness, feelings of guilt, suicidal ideation, and changes in appetite and body weight, among other characteristics.
The BDI–IA shows high reliability and structural validity and capacity to discriminate between depressed and nondepressed participants with broad applicability for research and clinical practice worldwide (Wang & Gorenstein, 2013).

The BDI–IA Cronbach’s alpha for this sample was 0.85.

Sleep quality.

The Pittsburgh Sleep Qual- ity Index (PSQI) was used to assess sleep quality (Smyth, 2000).
The PSQI is widely used in sleep research and measures sleep disturbance and usual sleep habits and has high internal reliability and construct validity (Carpenter & Andrykowski, 1998).

In addi- tion to component scores in domains of sub- jective sleep quality, latency and duration, habitual sleep efﬁciency, sleep disturbances, use of sleeping medication, and daytime dys- function, the PSQI also yields a global score (Buysse, Reynolds, Monk, Berman, & Kup- fer, 1989).
Cronbach’s alpha for the PSQI global score was 0.83.

Fatigue.

The Multidimensional Fatigue Symptom Inventory–Short Form (MFSI) was used to assess total fatigue (Stein, Jacobsen, Blanchard, & Thors, 2004).

The MFSI has strong psychometric properties and is useful in medically ill and nonmedically ill individuals (Donovan et al., 2014).

Cronbach’s alpha for the MFSI was 0.87.

Self-efﬁcacy.
Self-efﬁcacy.

The Cardiac Self-Efﬁcacy Questionnaire (CSEQ) examines the role of patient self-efﬁcacy for patients with coro- nary heart disease.

The CSEQ has two factors (control symptoms and maintain function) and has high internal consistency and good con- vergent and discriminant validity (Sullivan, LaCroix, Russo, & Katon, 1998).

We used the CSEQ-Maintain Function subscale, and Cron- bach’s alpha was 0.85.

Inﬂammatory markers.


Inﬂammation is implicated in the pathogenesis of HF and in- ﬂammatory biomarkers are used for risk strat- iﬁcation and prognosis (Bouras et al., 2014).
We therefore assessed a relevant panel of inﬂammatory biomarkers known to be in- volved in adverse remodeling of the heart and the progression to heart failure, including CRP, TNF-, IL-6, IFN-gamma & ST2 (Co- sper, Harvey, & Leinwand, 2012; Huang, Yang, Xiang, & Wang, 2014; Seljeﬂot, Nilsson, Westheim, Bratseth, & Arnesen, 2011; Sun et al., 2014).

Whole blood was preserved with EDTA, and following centrif- ugation, the plasma was stored at 80 °C until assay.
Circulating levels of these bio- markers were determined by commercial ELISA (Meso Scale Discovery, Rockville, MD).

Intra- and interassay coefﬁcients were 5%.

Statistical Analyses Prior to statistical analyses all data were tested for normality and homogeneity of vari- ance using the Kolmogorov–Smirnov test; no transformations were conducted.

Correla- tional and mediation analyses were run using SPSS software packages (Version 22.0; IBM, Armonk, NY).
The SPSS Dimension Reduc- tion factor analysis program was used to cal- culate a composite inﬂammatory index score comprised of circulating levels of CRP, TNF-, IL-6, IFN-gamma & ST2.

The resul- tant factor score Eigenvalue was 3.23, ac- counting for 53.8% of inﬂammatory variance.

We examined mediation using the approach outlined by Baron and Kenny (1986).
Using this mediation strategy, we ran a series of regression analyses were run: ﬁrst regressing the dependent variable on the independent variable (Step 1/Path c), next regressing the mediating variable on the independent vari- able (Step 2/Path a), and last regressing the dependent variable on both the mediating variable (Step 3/Path b) and the independent variable (Step 4/Path c’).
We further exam- ined the signiﬁcance of the product of the path coefﬁcients [(ab) an estimate of the indirect effect] using the Sobel test (Sobel, 1982).

ROLE OF GRATITUDE IN SPIRITUAL WELL-BEING 9 Results Table 1 presents biological, medical, psycho- social, and inﬂammatory biomarker characteris- tics of the patients.
Correlational Analyses Gratitude was associated with better sleep (p .01), less depressed mood (p .01), less fatigue (p .01), and better self-efﬁcacy to maintain cardiac function (p .01).

Patients expressing more gratitude also had lower levels of the inﬂammatory biomarker index (p .05).
Spiritual well-being was associated with better sleep p .01), less depressed mood (p .01), less fatigue (p .01), and better self-efﬁcacy to maintain cardiac function (p .01; see Table 2).

Gratitude as a Mediator of the Relationship Between Spirituality and Physical and Mental Health Mediation analyses were conducted to exam- ine whether gratitude mediates the relationship between spiritual well-being and aspects of physical and mental health.
These effects were as follows (Figures 1 and 2): Table 1 Sociodemographic, Medical, Psychosocial, and Inﬂammatory Biomarker Characteristics of Study Participants (N 186) Characteristic Age (in years) Body mass index (kg/m2) Gender (men) Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) Left ventricular ejection fraction Concomitant disease Diabetes mellitus Myocardial infarction Medications ACE inhibitors Beta blockers Calcium channel blockers score Statin Aspirin Diuretics Anti-arrhythmic Warfarin Digoxin Psychosocial Gratitude Questionnaire (GQ–6) Functional Assessment of Chronic Illness Therapy Spiritual Well-Being Scale (FACIT–SP12) Beck Depression Inventory (BDI–IA) Pittsburgh Sleep Quality Index (PSQI) Multidimensional Fatigue Symptom Inventory––Short Form (MFSI-SF) Cardiac Self-Efﬁcacy Questionnaire–– Maintain Function subscale Inﬂammatory biomarkers CRP (mg/dl) IL-6 (pg/ml) TNF- (pg/ml) IFN-gamma (ng/ml) ST-2 (pg/ml) M/% (SD) 66.4 (10.3) 30.2 (5.6) 95.3% 134.2 (18.8) 77.1 (11.9) 64.8% (8.95) 30.4% 17% 39.1% 44.2% 20.1% 55.0% 39.0% 32.1% 3.9% 10.6% 2.0% 5.65 1.09 12.07 5.71 8.84 8.14 8.92 3.32 29.69 21 16.08 4.94 6.04 (9.2) 2.21 (2.1) 4.25 (3.0) 2.39 (5.3) 17.9 (8.2) Sleep.
In Step 1 of the mediation model, the regression of subjective sleep quality (PSQI) on spiritual well-being (FACIT–SP12) was sig- niﬁcant (R2 .08, .284), t(166) 3.82, p .001.

Step 2 showed that the regres- sion of spiritual well-being (FACIT–SP12) on the mediator, trait gratitude (GQ– 6), was also signiﬁcant (R2 .31, .552), t(169) 8.58, p .001.
Step 3 of the mediation process showed that the mediator, trait gratitude (GQ– 6), controlling spiritual well-being (FACIT– SP12), was signiﬁcantly related to sleep quality (PSQI; R2 .11, .213), t(167) 2.42, p .02.
Step 4 of the analyses revealed that, when controlling for trait gratitude (GQ– 6), spiritual well-being (FACIT–SP12) no longer remained a signiﬁcant predictor of subjective sleep quality (PSQI; R2 .11, .167), t(167) 1.89, p .06, indicating that the beneﬁcial effect of spirituality on sleep exerts its effect through gratitude.
We further exam- ined the strength of the indirect or mediated effect using the Sobel test and conﬁrmed its signiﬁcance (z 2.35, SE .03, p .02).

In Step 1, we regressed depressed mood (BDI–IA) on spiritual well- being (FACIT–SP12) and this relationship was signiﬁcant (R2 .13, .355), t(157) 4.765, p .001.

Step 2 outputs are the same in all four mediation models.
Step 3 demon- strated that the mediator, trait gratitude (GQ– 6) was related to depressed mood (BDI–IA) when controlling for spiritual well-being (FACIT– SP12; R2 .23, 3.84), t(158) 4.536, p .001.

Step 4 indicated that when controlling for trait gratitude (GQ– 6), the relationship be- tween spiritual well-being (FACIT–SP12) and depressed mood (BDI–IA) is no longer signiﬁ- Depressed mood.

10 MILLS ET AL.
10 MILLS ET AL.

Table 2 Correlations Among Administered Questionnaires Instrument Gratitude Questionnaire (GQ–6) Spiritual Well-Being Scale (FACIT–SP12) Beck Depression Inventory (BDI–IA) Pittsburgh Sleep Quality Index (PSQI) Multidimensional Fatigue Symptom Inventory—Short Form (MFSI-SF) Cardiac Self-Efﬁcacy Questionnaire–Maintain Function subscale (CSEQ-MF) Inﬂammatory Index (CRP, TNF-, IL-6, IFN-gamma & ST2) p .05.

 p .001.
p .001.

 p .01.
p .01.

Gratitude Questionnaire (GQ–6) Spiritual Well- Being Scale (FACIT–SP12) .55 –.46 –.32 –.50 .43 –.17 –.35 –.28 –.50 .46 –.10 cant (R2 .23, .384), t(156) 1.663, p .10, indicating that gratitude fully mediates the relationship between spiritual well-being and depressed mood.
We again conﬁrmed the signiﬁcance of the mediation using the Sobel test (z 4.00, SE .075, p .001).

Fatigue.
Fatigue.

When examining fatigue (MFSI), there was again evidence of relationship with spiritual well-being (FACIT–SP12; R2 .25, .499), t(163) 7.342, p .001, in Step 1, and Step 3 again demonstrated a rela- tionship between trait gratitude (GQ– 6) and fatigue (MFSI) when controlling for spiritual well-being (FACIT–SP12; R2 .33, .335), t(162) 4.318, p .001.
However, Step 4 revealed that the relationship between A a = .10 (.01)** Gratitude b = –.66 (.27)* Spiritual Well-being Sleep Quality c1 = –.09 (.05) [c = –.16 (.04)]** B a = .10 (.01)** Gratitude b = –2.95 (.65)** Spiritual Well-being Depressed Mood c1 = –.208 (.12) [c = –.50 (.11)]** Figure 1.

Trait gratitude signiﬁcantly mediated the relationships between spiritual well- being and sleep quality and spiritual well-being and depressed mood.
Path values are unstandardized regression coefﬁcients with standard errors in parentheses.

Mediated (indirect) effects were derived from the product of paths a and b and examined using the Sobel test (1982).

Panel A: Trait gratitude fully mediated the relationship between spiritual well-being and sleep quality (z 2.45, SE .03, p .02).
Panel B: Trait gratitude fully mediated the relationship between spiritual well-being and depressed mood (z 4.00, SE .08, p .001).

 p .05.

 p .01.
p .01.

ROLE OF GRATITUDE IN SPIRITUAL WELL-BEING 11 A a = .10 (.01)** Gratitude b = –6.64 (1.54)** Spiritual Well-being Fatigue c1 = –1.14 (.28)** [c = –1.82 (.25)]** B a = .10 (.01)** Gratitude b = 1.17 (.38)* Spiritual Well-being Self-Efficacy to Maintain Cardiac Function c1 = .27 (.07)** [c = .40 (.06)]** Figure 2.
Trait gratitude signiﬁcantly mediated the relationships between spiritual well- being and fatigue and spiritual well-being and self-efﬁcacy to maintain cardiac function.

Path values are unstandardized regression coefﬁcients with standard errors in parentheses.

Medi- ated (indirect) effects were derived from the product of paths a and b and examined using the Sobel test (1982).
Panel A: Trait gratitude partially mediated the relationship between spiritual well-being and fatigue (z 3.849, SE .18, p .001).

Panel B: Trait gratitude partially mediated the relationship between spiritual well-being and cardiac-speciﬁc self-efﬁcacy (z 2.91, SE .04, p .01).

 p .05.
p .05.

 p .01. spiritual well-being (FACIT–SP12) and fatigue (MFSI) remains signiﬁcant controlling for the putative mediator, gratitude (GQ– 6; R2 .33, .312), t(162) 4.020, p .001.
Al- though the c1 path remains signiﬁcant, the Sobel test of the indirect or mediated pathway was also signiﬁcant (z 3.85, SE .18, p .001), providing evidence to suggest that grati- tude partially mediates the relationship between spiritual well-being and fatigue.

Self-efﬁcacy to maintain cardiac function.


In our analyses examining self-efﬁcacy to main- tain cardiac function (CSEQ), in Step 1 there was a signiﬁcant relationship with spiritual well-being (FACIT–SP12; R2 .21, .456), t(159) 6.453, p .001.
In Step 3, there was evidence of a relationship between trait grati- tude (GQ– 6) and self-efﬁcacy to maintain car- diac function (CSEQ) when controlling for spir- itual well-being (FACIT–SP12; R2 .25, .256), t(158) 3.10, p .002.
In Step 4, the relationship between spiritual well-being (FACIT–SP12) and self-efﬁcacy to maintain cardiac function (CSEQ) remains signiﬁcant when controlling for our hypothesized media- tor, gratitude (GQ– 6; R2 .25, .314), t(158) 3.087, p .001.
Again though, the Sobel test of the indirect or mediated pathway was also signiﬁcant (z 2.91, SE .04, p .003), suggesting that gratitude partially medi- ates the relationship between spirituality and cardiac-speciﬁc self-efﬁcacy.

Inﬂammatory index.

In our mediation analyses examining inﬂammation, there was no 12 MILLS ET AL.

relationship between spiritual well-being and the inﬂammatory index (R2 .01, 1.02), t(140) 1.21, p 23.
Similarly, Steps 3 and 4 of the mediation analyses were not signiﬁcant and consequently no relationship between spir- ituality and inﬂammation for gratitude to poten- tially mediate.

Discussion In Stage B asymptomatic HF patients, we found that gratitude was related to better mood and sleep, more self-efﬁcacy, and lower fatigue and inﬂammation.

Spiritual well- being was related to each of these as well, with the exception of the inﬂammatory index.
When examining these relationships in more depth, we found that gratitude fully mediated the beneﬁcial effects of spiritual well-being on sleep and depressed mood and partially mediated the relationships between spiritual well-being and fatigue and spiritual well- being and cardiac-speciﬁc self-efﬁcacy.
Stage B patients are asymptomatic but at high risk for developing symptomatic (Stage C) HF, and thus present an opportunity to implement early therapeutic interventions to ultimately reduce morbidity and mortality (Hunt et al., 2005b).

Interventions designed to increase gratitude do improve psychological well- being (Wood et al., 2010).
Research ﬁndings from gratitude studies suggest that gratitude, because of its orienta- tion toward positive appraisal, is likely in- compatible with the “negative triad” of be- liefs associated with depression (Evans et al., 2005).
Indeed, gratitude is related to both hedonic well-being (i.e., subjective well- being, which is characterized by higher posi- tive affect, lower negative affect, and life satisfaction) and eudaimonic well-being (i.e., psychological well-being, which is character- ized by aspects such as environmental mas- tery, personal autonomy, purpose in life, pos- itive relations with others, and personal growth (Evans et al., 2005; Ryff & Keyes, 1995).
In turn, both hedonic and eudaimonic well-being have been linked to reduced like- lihood of depression (e.g., Pressman & Co- hen, 2005; Wood et al., 2008), as well as alterations in immune function associated with improved health (Ryff, Singer, & Dien- berg Love, 2004).

Thus one potential pathway by which gratitude may promote well-being, as well as better cardiovascular health in HF, is through the enhancement of both subjective (hedonic) and psychological (eudaimonic) well-being (Wood et al., 2010).
It is important to note that a recent review reports that well- being is associated with improved cardiovas- cular health, with hedonic well-being noted to be associated with improved biological func- tion and restorative health behaviors; the au- thors noted a need for more data on the po- tential impact of eudaimonic well-being on cardiovascular outcomes (Boehm & Kubzan- sky, 2012).
Another potential pathway by which grati- tude may enhance health is via shifts in af- fective perceptions of daily life events from negative to positive.

The chronic hassles and uplifts scale is an index of daily perceptions of events as either hassles (negative) or up- lifts (positive), and has been found to corre- late with mood, health, and positive affect (Folkman & Lazarus, 1988).
In a study by our group, we reported independent relationships of uplifts (frequency and intensity) and in- ﬂammatory markers that were independent of sociodemographic, behavioral, medical and psychological variables such as hassles, de- pression, and perceived stress.

(Jain, Mills, von Kanel, Hong, & Dimsdale, 2007), sug- gesting that positive perceptions of daily life events is uniquely associated with inﬂamma- tion.
Gratitude may reduce inﬂammatory markers in Stage B HF patients through changes in affective perceptions of daily life.

Gratitude was associated with lower de- pressed mood scores in these patients, and mediated the relationship between spiritual well-being and mood.

Prior studies report that self-rated spiritual well-being is strongly and independently associated with fewer depres- sive symptoms in stage B HF patients (Peter- man et al., 2002).
This is clinically signiﬁcant since the presence of depressive symptoms in cardiovascular diseases such as HF is associ- ated with increased risk of cardiovascular hospitalization and mortality (Johnson et al., 2012; Kato et al., 2012; Rutledge, Reis, Linke, Greenberg, & Mills, 2006).
Typical risk factors associated with depression in HF include increasing age, poor physical ﬁtness, poor sleep, fatigue, and inﬂammation (Alosco et al., 2013; Jimenez & Mills, 2012; Kupper, ROLE OF GRATITUDE IN SPIRITUAL WELL-BEING 13 Widdershoven, & Pedersen, 2012; Mills et al., 2009; Shimizu, Suzuki, Okumura, & Yamada, 2013; Sin, 2012; Tang, Yu, & Yeh, 2010).
For Stage B HF patients, ﬁnding cor- relates of depressive symptoms is particularly important as an avenue for potentially fore- stalling development of symptomatic Stage C disease, which is signiﬁcantly associated with poorer quality of life and increased morbidity and mortality (Ammar et al., 2007).
In terms of gratitude interventions, in a recent double-blind randomized controlled trial in health care practitioners, Cheng, Tsui, and Lam (2014) showed that a 4-week grati- tude journaling intervention, as compared with journaling about hassles, led to a signif- icant reduction in stress and improved mood.

Other interventions focusing on “thoughts of gratitude” reveal that gratitude interventions have a signiﬁcant effect on improving daily positive emotions (Ouweneel, Le Blanc, & Schaufeli, 2014).
Few studies, however, have examined the potential beneﬁts of gratitude interventions for HF despite studies describ- ing the importance of gratitude in alleviating the struggles associated with living with HF (Sacco et al., 2014).

Sacco et al.
Sacco et al.

developed an 8-week phone-based positive psychology in- tervention for patients hospitalized with acute cardiac disease (acute coronary syndrome or decompensated heart failure), which com- prised positive psychology exercises adapted for this population with a focus on gratitude, optimism, and kindness.

Their initial ﬁndings include that the intervention is well accepted in cardiac patients; further outcome data are pending (Sacco et al., 2014).
It is worth noting that though gratitude is considered a positive psychological factor, it is not necessarily good for all people under all circumstances, for example, displaced grati- tude under conditions of exploitation; grati- tude with discernment is worth cultivating.
As far as the scientiﬁc literature, the vast major- ity of research demonstrates positive, not neg- ative, consequences of gratitude and that cul- tivating gratitude doesn’t necessarily reduce seeing the negative features of life but rather offers or encourages seeing the positive in life (Eaton, Bradley, & Morrissey, 2014; Wood et al., 2008).

Summary Gratitude and spiritual well-being are key positive factors to consider in this population.
We documented that an attitude of gratitude is related to better mood and sleep, less fatigue, more self-efﬁcacy, and a lower cellular inﬂam- matory index.

Untangling these relationships further, we found that higher trait gratitude me- diates spiritual well-being’s positive effects on better sleep and less depressed mood (and to a lesser degree fatigue and cardiac-speciﬁc self- efﬁcacy).
These are potentially important obser- vations because depressed mood and poor sleep are associated with worse prognosis in HF as well as other cardiac populations, and therefore interventions that increase levels of gratitude may have clinical implications for improving health outcomes (Canivet, Nilsson, Lindeberg, Karasek, & Ostergren, 2014; Huffman, Celano, Beach, Motiwala, & Januzzi, 2013; Rutledge et al., 2006).
Given that interventions to increase gratitude are relatively simple and of low cost, efforts to increase gratitude in HF patients’ lives may be of potential clinical value and represent a treatment target for improving well-being.

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