Lake Superior Quality Innovation Network serves Michigan, Minnesota, and Wisconsin, under the Centers for Medicare & Medicaid Services Quality Improvement Organization Program. | www.lsqin.org

This material was prepared by Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-MI/MN/WI-C3-19-119 052419

ANXIETY SHARED PATHWAY

TOOLKIT

Anxiety Shared Pathway

TOOLKIT

Anxiety Shared Pathway Toolkit

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TABLE OF CONTENTS

BACKGROUND............................................................................................................................... 2

ASSESSMENT TOOL ..................................................................................................................... 2

FUNDING IDEAS ............................................................................................................................ 4

MODALITY DEFINITIONS .............................................................................................................. 5

INTEGRATIVE HEALING THERAPY MENU .................................................................................. 7

GENERAL RESOURCES ............................................................................................................... 8

ESSENTIAL OIL RESOURCES ...................................................................................................... 9

SUCCESS STORIES .................................................................................................................... 11

TIPS .............................................................................................................................................. 12

OUTCOMES ................................................................................................................................. 13

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BACKGROUND

The Lake Superior Quality Innovation Network Minnesota West Metro Coordination of Care Initiative community developed this toolkit focused on reducing anxiety.

Anxiety is one of the leading causes of hospital readmissions and crosses many diagnoses

Mitigation of anxiety symptoms can be achieved in a variety of care settings

This toolkit is intended for transitional care units and home care agencies to help prepare staff to be able to offer integrative therapy programs to their residents/clients in order to alleviate anxiety, which will ultimately lead to better outcomes.

ASSESSMENT TOOL The GAD-7 is recommended as an anxiety assessment tool. No permission is required to reproduce, translate, display or distribute. Link to GAD-7 screening tool: www.tbh.org/sites/default/files/Generalized_Anxiety_Disorder_Screener_GAD7.pdf

The following information was retrieved from https://www.hiv.uw.edu/page/mental-health-

screening/gad-7:

Interpretation of GAD-7 When screening for anxiety disorders, a score of 8 or greater represents a reasonable cut-point for identifying probable cases of generalized anxiety disorder, further diagnostic assessment is warranted to determine the presence and type of anxiety disorder. Using a cut-off of 8 the GAD-7 has a sensitivity of 92 percent and specificity of 76 percent for diagnosis generalized anxiety disorder.2, 3

The following cut-offs correlate with level of anxiety severity:

Score 0-4: Minimal Anxiety

Score 5-9: Mild Anxiety

Score 10-14: Moderate Anxiety

Score greater than 15: Severe Anxiety

Based on a recent meta-analysis, some experts have recommended considering using a cut-off of 8 in order to optimize sensitivity without compromising specificity2.

Performance as Screening Tool for Anxiety Disorders Although designed as a screening tool for generalized anxiety, the GAD-7 is also performs reasonably well as a screening tool for three other common anxiety disorders—Panic Disorder, Social Anxiety Disorder, and Posttraumatic Stress Disorder.3

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ASSESSMENT TOOL (continued)

Performance of GAD-7 as Screening Tool for Anxiety Disorders3 (Using GAD-7 Score Cut-off of ≥10)

Test Sensitivity Specificity Positive Likelihood Ratio

Generalized Anxiety Disorder 89% 82% 5.1

Panic Disorder 74% 81% 3.9

Social Anxiety Disorder 72% 80% 3.6

Post-Traumatic Stress Disorder 66% 81% 3.5

Any anxiety disorder 68% 88% 5.5

Acknowledgement The GAD-7 was developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute. Sources 1. Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the

GAD-7. Arch Intern Med. 2006;166:1092-7.

2. Plummer F, Manea L, Trepel D, McMillan D. Screening for anxiety disorders with the GAD-7 and GAD-2: a systematic review and diagnostic metaanalysis. Gen Hosp Psychiatry. 2016;39:24-31.

3. Kroenke K, Spitzer RL, Williams JB, Monahan PO, Löwe B. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007;146:317-25.

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FUNDING IDEAS While cost of these various integrative healing techniques can be minimal, there are expenses associated with establishing a program. Here are a few options that could help to offset your costs for training and supplies.

The Minnesota Council of Nonprofits has a lot of great information on fundraising resources. Foundation grants that support innovation in health care delivery might be a great opportunity https://www.minnesotanonprofits.org/resources-tools/principles-practices-for-nonprofit-excellence/fundraising

If you are a Nursing Home, the Minnesota Department of Human Services (DHS) has a program for Nursing Facilities called Performance-Based Incentive Payment Program (PIPP). This program looks to support innovative work that improves quality for nursing home residents. More about the program can be found on the MN DHS Nursing Facility Provider Portal: https://nfportal.dhs.state.mn.us/PortalLogin.aspx?ReturnUrl=%2fMNQI%2fDefault.aspx

Examples of previous rounds of PIPP proposals can be found at: https://mn.gov/dhs/partners-and-providers/grants-rfps/pipp/

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MODALITY DEFINITIONS Clinical Aromatherapy: Use of specific essential oils to address specific symptoms of mind and body for measurable outcomes. Aromatherapy can offer symptom support of anxiety, nausea, pain, and support relaxation and sense of well-being.

Resources:

https://nccih.nih.gov/

https://tisserandinstitute.org/essential-oils-in-hospitals/

https://www.alliance-aromatherapists.org/

https://www.coursera.org/learn/aromatherapy-clinical-use-essential-oils

https://www.rjbuckle.com/clinicalaromatherapy.html

https://www.takingcharge.csh.umn.edu/aromatherapy

Breathing:

Breathing improves our flow of oxygen to the brain and body, increases relaxation, and may decrease pain.

Close your eyes and pay attention to how you are breathing.

Place a hand on your stomach and your chest and focus your awareness on the rise and fall of your stomach.

Slow your breath down, inhale through your nostrils, feel the air touch the back of your tongue and throat, pause at the top of your inhale and exhale like you are blowing out a candle.

Set a timer for 1-10 minutes and focus on your breath.

Add a message while breathing, inhale “peace”, exhale “release”.

Smartphone apps for support: Breathe, Calm, Stop Breathe & Think.

Daily Exercise:

Exercise can improve mood, blood flow, strength, and flexibility. Talk to your physician about an exercise plan appropriate to your needs. This could include stretching exercises, yoga, tai chi, and other options.

o https://nccih.nih.gov/health

o https://www.csh.umn.edu/education/online-modules-and-resources/learning-modules-healthcare-professionals

o https://www.takingcharge.csh.umn.edu/physical-activity-fitness

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MODALITY DEFINITIONS (continued) Energy Therapies:

Energy therapies including Healing Touch and Reiki focus on the body’s energy field to promote health and well-being. Many hospitals and other health care settings may offer energy therapies to patients. o https://nccih.nih.gov/health/reiki-info

o https://www.csh.umn.edu/education/online-modules-and-resources/learning-modules-healthcare-professionals

Faith Communities:

If you belong to a faith community, there may be opportunities for support including volunteers or visits from the spiritual care staff or access to technology to support your faith community involvement. Keeping connected to your faith community can support your mind, body, and spirit. Some faith communities have parish nurse support.

Gratitude Practice:

The practice of gratitude has demonstrated to support mood and focus attention on the positive aspects of our lives. The practice includes writing three positive things each day that you have experienced. The tools needed are a journal or notebook, pen, and just a few minutes of your time. o https://emmons.faculty.ucdavis.edu/gratitude-and-well-being/

o https://today.duke.edu/2016/02/resilience Massage:

There are several different types of massage ranging from hand/foot massage to full body. o https://nccih.nih.gov/health/massage

o https://www.csh.umn.edu/education/online-modules-and-resources/learning-modules-healthcare-professionals

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INTEGRATIVE HEALING THERAPY MENU

Anxiety

Aromatherapy (Lavender, Mandarin, Ginger)

Breathing

Energy Therapy

Gratitude Practice

Herbal Tea

Lotion

Massage

Meditation

Movement as directed (Yoga, Tai Chi, Walking)

Music

Nature

Prayer

Support Groups

Therapy/Health-coaching

Nausea*

Acupressure/Acuband

Aromatherapy (Ginger, Mandarin)

Breathing

Energy Therapy

Ginger Chews

Ginger Tea

Gratitude Practice

Herbal Tea

Meditation

Music

Peppermints

Prayer

Pain

Aromatherapy (Lavender, Mandarin)

Breathing

Daily Exercise

Energy Therapy

Gratitude Practice

Ice/Heat

Laughter

Massage

Meditation

Movement as directed

Music

Nature

Pain Journal

Prayer

Support Group

Therapy/Health-coaching

Sleep*

Aromatherapy (Lavender)

Breathing

Gratitude Practice

Herbal Tea

Lotion

Meditation

Movement as directed

Music

Prayer

Sleep Environment (Dim Lights, Warm Milk Eye Mask, Massage Limit TV/Technology)

Tea

*Although this toolkit was created as a resource to treat anxiety, it can also be used for treatment for other purposes listed above.

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GENERAL RESOURCES All staff that will be introducing and providing therapies should complete training for each therapy provided. Online training can be found at the links below:

Integrative therapy module page: https://www.csh.umn.edu/education/online-modules-and-resources/learning-modules-healthcare-professionals

The University of Minnesota specialization course for health care professionals, “Integrative

Health and Medicine Specialization Course for Health Professionals”, includes aromatherapy,

guided imagery, herbal medicine, and mindfulness in integrative healthcare. The course can be

accessed at the link below:

https://www.coursera.org/specializations/integrative-health-and-medicine

Smartphone apps for support with relaxation, meditation and sleep:

Calm

Head Space

Stop Breathe & Think Other resources:

Earl E. Bakken Center for Spirituality & Healing at the University of Minnesota

Pathways, Minneapolis

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ESSENTIAL OIL RESOURCES

Aromatherapy:

Alliance of International Aromatherapists

https://www.alliance-aromatherapists.org/

Healing Alchemy https://store.naturalmentalhealth.com/healing-alchemy-aromatherapy/ patricia@haaromatherapy.com

Jodi Baglien

https://www.jodibaglien.com/

Plant Extracts International

https://plantextractsinc.com/

Healing Concepts

www.healingconceptsEOT.com

Recommendations for products to include in your tool kit:

Contact one of the companies listed above or alternate company who has experience

providing aromatherapy in a health care setting.

Identify your budget for essential oils; look within your system for an Aromatherapy Policy

and Procedure; determine your plan for clinician and patient/caregiver education and

internal ordering process.

Discuss your population, need and environment with the aromatherapy contact person.

Begin with a small number of products that can address multiple symptoms such as:

anxiety, nausea, pain, and sleep.

Discuss with provider the options for patient use: inhalation tube, essential oil bottles for

multi-patient use, patches, diffusion, and massage oils.

Request information data sheets, safety and educational materials on the essential oils you

will be using.

Inquire if training is available through the provider.

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ESSENTIAL OIL RESOURCES (continued)

Treatment of Symptoms with Essential Oils: Discuss with your specific essential oil provider about recommended oils for specific symptoms. The provider will have essential oil blends for your population needs. In general:

Pain: Lavender, (Calming, Healing Alchemy), (Orthopedic Blend)

Nausea: Ginger, (Plant Extracts Un-Nausea or Tum-ease) Mandarin, Spearmint, Peppermint (if no contraindications), (Soothing, Healing Alchemy)

Stress/Anxiety/ Insomnia: Lavender, (Calming, Healing Alchemy), (Healing Concepts, Support your Healing)

Contraindications:

Pregnancy: Avoid all oils (exception in third trimester, use of ginger and mandarin)

Pediatrics: Avoid all oils under six years old and then work with clinical aromatherapist for recommendations

Peppermint: Contraindications include pediatrics, pregnancy, high blood pressure, high heart rate, seizures, TBI, stroke, aneurysm

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SUCCESS STORIES

The Senior Care Communities organization in the Twin Cities metro area of Minnesota launched an Integrative Health and Wellness Program at its Woodbury Senior Living campus in the spring of 2013. The organization consulted with the Earl E. Bakken Center for Spirituality & Healing at the University of Minnesota, where three Doctor of Nursing Practice students in integrative health and healing completed a needs assessment and proposed recommendations for the Woodbury Senior Living facility, a 300-bed full-spectrum senior living campus offering transitional care, assisted living, and skilled long-term nursing care. The organization set out to foster a healing environment through a new integrative health and wellness department, hiring an integrative nurse clinician to build the initiative. At a time when senior living options are flourishing with the increased building of new facilities with new decor and amenities, having an integrative model was seen as not only beneficial to residents but also as a valuable asset to stay competitive.

All new residents arriving at the Transitional Care Unit received a visit from the integrative nurse clinician, who assesses comfort and relaxation, sleep, nutritional status, and general wellbeing. If the resident is interested, he or she receives a hand or foot massage, essential oils, a short energy healing session (Healing Touch or Reiki), healing music, and/or guided imagery. The music provided is often from the C.A.R.E. Channel (Continuous Ambient Relaxation Environment). With nature imagery and original instrumental music, this channel fosters a healing environment and can be very beneficial to help shift the mood in a room and support relaxation. At the end of the integrative session, remarks from residents most always reflect that there has been some improvement in mood and comfort. When asked how the integrative therapy visits have helped him, one resident remarked, “It has made my life more bearable, definitely. It’s added quality to my life. I don’t feel worthless anymore.”

New employees at Woodbury Senior Living receive an overview of the Integrative Health and Wellness Program during their orientation to the facility. Along with a review of the integrative therapies that are used in the program, the concept of “presence” and self-care are discussed. Staff is encouraged to take responsibility for the energy brought into every resident’s room during a shift and build caring relationships with the residents under their care. The staff also attends an in-service on the essential oils used in the program, so that the nursing staff is ready to be able to offer essential oils to residents for pain, anxiety, nausea, insomnia, and general wellbeing. The staff at Woodbury Senior Living has found that using integrative therapies helps break the cycle of pain and anxiety - the feedback loop that heightens pain and anxiety as each contributes to the other. Being able to promote relaxation for a resident in pain often facilitates the reduction of both pain and anxiety. Source: Kirk, L. N., Trelstad Porter, R., Quarberg, A., & Halcon, L. (2018). Integrative Nursing in Senior Living. In M.J. Kreitzer & M. Koithan (Eds.), Integrative Nursing (2nd ed., pp. 483-484). New York, NY: Oxford University Press. (Reprinted with permission from M.J. Kreitzer.)

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TIPS Tips for Building an Integrative Nursing Program in a Senior Living Facility

Complete a needs assessment of your organization to identify opportunities for integrative programming. Consult other organizations with integrative offerings to find out what has been successful for them.

Create a vision for the program that staff will get excited about, and leadership can support.

Establish buy-in by key stakeholders, including board members, leadership within the organization, and medical team. Create ways to quantify and track before and after scores of pain, stress, nausea, and present findings to key stakeholders.

Start with self-care for the staff using the therapies you will be teaching them later. By nurturing the caregivers and creating experiences they enjoy, you will reinforce the value of what they will be learning and build interest. This also is a great way to have one-to-one time with staff to deepen rapport and answer questions or concerns.

Create the infrastructure for the program. Develop procedures and documentation tools, establish vendors, and order supplies and staff resources.

Set up and lead mandatory education classes for staff to learn how to safely offer, deliver, and document integrative therapies, including the value of presence. Address concerns and issues that staff have upfront and reframe them. For example, “We have no time” is reframed by showing how these tools can actually save time when you help someone feel better and create more job satisfaction in the process. Share stories of success, like when one night nurse said, “Lavender sure beats the heck out of Ativan.”

Sustaining the program requires ongoing education at orientation and mentoring of staff on the units. Hold staff accountable and keep it at the forefront of the care they provide by talking about ways integrative therapies could address resident issues at morning meetings and care rounds. Adding a volunteer team to offer energy work and hand/foot massages is a helpful and cost-effective way to deliver care staff may not be trained in or have the ability to do.

Source: Kirk, L. N., Trelstad Porter, R., Quarberg, A., & Halcon, L. (2018). Integrative Nursing in Senior Living. In M.J.

Kreitzer & M. Koithan (Eds.), Integrative Nursing (2nd ed., pp. 483-484). New York, NY: Oxford University Press.

(Reprinted with permission from M.J. Kreitzer.)

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OUTCOMES Introduction Integrative treatment approaches are becoming increasingly important. This is especially the case in treating chronic diseases; long-term conditions that develop slowly over time often progress in severity and rarely can be cured. Treating such diseases, including musculoskeletal, cardiovascular, digestive, and metabolic disorders, uses up nearly 80 percent of nations’ health budgets and imposes immense individual burdens. Chronic diseases impair physical and mental health and reduce one’s ability to carry out activities of daily living. For example, studies have shown that physical illness is an important risk factor for anxiety and depression and that depression is a risk factor for physical illness.

Although much progress has been made to-date in drug development and medical technology, patients and their psychosocial needs are less often involved in the therapeutic process. Despite the effect that psychological health and lifestyle factors are known to have on health and disease in patients with chronic health conditions, few change their lifestyles. Empowering patients to adopt healthy lifestyles may enhance the effects of any treatments received and reduce future health risks.

The Department for Internal and Integrative Medicine at Kliniken Essen-Mitte, the University of Duisburg-Essen’s academic teaching hospital, was established in 1999. The Clinic combines conventional medicine, complementary medicine, and Mind/Body therapies to treat patients with chronic diseases. The Mind/Body therapies were added specifically to promote patients’ active participation in their care. Mind/Body therapies are defined as “practices that focus on the interactions between the brain, mind, body, and behavior, with the intention of using the mind to affect physical functioning and promote health.” Such therapies include lifestyle education: seeking to enhance patients’ capacity for self-care through such elements as exercise, good nutrition, relaxation, and self-help. Although Mind/Body programs are not overtly psychotherapeutic, aspects of cognitive behavioral therapy are used to enhance patients’ ability to cope with their condition, and its impact on daily life, and to live a healthy lifestyle.

Research shows such programs’ effectiveness for conditions including coronary heart disease, inflammatory bowel disease, and cancer. Patients’ control beliefs are also considered key in ensuring long-term treatment effectiveness. Patients who have an internal locus of control (believe that they can improve their health) should use active coping strategies more often than other patients.

This observational study was conducted to explore the influence of a 2-week integrative treatment program on patients’ quality of life, psychological symptoms, and locus of control and to determine the factors predicting improved quality of life.

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OUTCOMES (continued)

Intervention Patients received two weeks of integrative inpatient hospital treatment; following individual treatment plans developed from extensive anamneses by physicians, nurses, and mind/body therapists. Treatments included conventional diagnostic and interventional medical approaches, including physiotherapy, and the use of complementary techniques. Patients also received several mind/body therapy sessions, focusing on exercise, stress-reduction, diet, and self-help, to empower them to adopt healthy lifestyles. These sessions were based on Harvard Medical School’s Benson-Henry Institute for Mind/Body Medicine Program and the University of Massachusetts’ Mindfulness-Based Stress Reduction Program. Elements of cognitive restructuring were also added in this study.

Primary Outcome Measures Health-Related Quality of Life (SF-36) Patients’ health-related quality of life was assessed using the short form 36 of the health survey questionnaire (SF-36). This tool measures individuals’ quality of life on eight dimensions and two main component scales (physical, mental). It has proven validity and reliability. Each scale ranges from 0 to 100, with higher scores indicating higher quality of life. In this study, only the main component summaries were analyzed; comparing the outcome with age- and gender-matched values from the German general population. The differences found are presented as z-scores, with 0 representing the mean and 1 the standard deviation of the population. The SF-36 assesses quality of life by means of daily living activities, making its use inappropriate in a hospital setting. The SF-36 was, therefore administered at ADM, FU3, FU6, and FU12, but not at discharge, in this study.

(ADM – admission; FU3 - 3 months follow up; FU6 - 6 months follow up; and FU12 – 12 months

follow up.)

Secondary Outcome Measures

Anxiety and Depression (HADS) Changes in patients’ psychological symptoms were measured using the Hospital Anxiety and Depression Scale (HADS). This tool has 14 items, scored on 4-point Likert scales. Higher scores indicate more severe symptoms. For both dimensions, cut-off scores have been introduced to indicate possible sub-syndromal (≥8) or clinically relevant (≥11) anxiety or depression. Study patients completed the HADS at admission, discharge, and follow-up.

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OUTCOMES (continued)

Health Locus of Control (GKÜ) Patients’ health locus of control was measured using the GKÜ, a short version in German of the Multidimensional Health Locus of Control Questionnaire (MHLC). The GKÜ is a 9-item questionnaire which assesses three dimensions of patients’ control beliefs: internal, external-social, and external-fatalistic. The more internal control patients perceive, the more they feel able to influence their health. By contrast, the more control that patients attribute to others (external-social), or luck or destiny (external-fatalistic), the less they feel able to influence their health. The GKÜ was originally devised for use with patients with cancer but has since been adapted for use with other patients, such as those with back pain. A previous study reported problems with one item on the GKÜ. A factor analysis undertaken with the present study data showed that this item loaded on two factors equally. It was therefore deleted from the analysis. Patients completed the GKÜ at admission, discharge, and follow-up.

Satisfaction with Health and Life in General Patients’ satisfaction with their health and lives in general was measured using two 5-point Likert items from the Life Satisfaction Questionnaire at admission, discharge, and follow-up. The scale used ranged from 1 = very dissatisfied to 5 = very satisfied, with higher scores indicating patients’ greater satisfaction with their health and lives in general.

Demand on Medical Services The study questionnaire also asked patients to record how many doctors’ visits they had made during the previous month. Patients were also asked, at admission and 12-month follow-up, how many days they had been admitted for hospital inpatient treatment and how many days they had missed work (where appropriate) over the previous year.

Improvement in Disease-Related Symptoms At discharge and each follow-up, patients compared their main disease-related symptoms with before they entered treatment, using a 5-point Likert scale that ranged from “much worse” to “much improved.”

Summary of the Results This observational study investigated changes occurring in patients with chronic conditions following a 2-week inpatient integrative program. The latter combined conventional medicine, complementary medicine, and mind/body therapies aimed at empowering patients to adopt a healthy lifestyle. The results revealed a small-to-moderate, but sustained improvement in patients’ perceived quality of life, with regard to both its physical and mental health aspects. Patients also reported reduced anxiety and depression, as measured on the Hospital Anxiety and Depression Scale (HADS). At the same time, patients’ internal locus of control increased, and their external-social control beliefs diminished.

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OUTCOMES (continued)

On the other hand, patients’ external-fatalistic control beliefs rose significantly over time. Patients’

satisfaction with their health and lives in general increased. Employed patients reported fewer

days’ absenteeism, and all patients made fewer doctors’ visits during the posttreatment year.

Altogether, patients reported substantial benefit from their two weeks of integrated inpatient

treatment.

Author: Trinette McLain-Wesseh, AGNP, DNP Student

Sources:

Benson, H. & and Stuart, M. (1999). The Wellness Book. Mind-Body Medicine, Fireside, New York, NY, USA.

Buss, H. U. & Snaith, R. (1995). Hospital Anxiety and Depression Scale—Deutsche Version (HADS-D). Manual, Hans Huber, Bern, Switzerland.

Clarke, D. M. & Currie, K. (2009). “Depression, anxiety and their relationship with chronic diseases: a review of the epidemiology, risk and treatment evidence,” Medical Journal of Australia, 190 (7), pp. S54–S60.

Ellis, A. & Dryden, W. (2007). The Practice of Rational Emotive Behavior Therapy, Springer, New York, NY, USA, 2nd edition.

Herrmann, C. (1997). “International experiences with the hospital anxiety and depression scale - a review of validation data and clinical results,” Journal of Psychosomatic Research, 42 (1), 17–41.

Kabat-Zinn, J. (1982). “An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: theoretical considerations and preliminary results,” General Hospital Psychiatry,” 4, (1) 33–47.

Kabat-Zinn, J. (1990). Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness, Delacorte, New York, NY, USA.

Keles, H., Ekici, A., Ekici, M. Bulcun, E, and Altinkaya, V. (2007). “Effect of chronic diseases and associated psychological distress on health-related quality of life,” Internal Medicine Journal, 37, (1), 6–11.

Michalsen, A. & Grossman, P. and Lehmann, N. et al. (2005). “Psychological and quality-of-life outcomes from a comprehensive stress reduction and lifestyle program in patients with coronary artery disease: results of a randomized trial,” Psychotherapy and Psychosomatics, 74(6), 344–352.

Romy Lauche, Holger Cramer, Susanne Moebus, et al., “Results of a 2-Week Inpatient Stay at the Department for Internal and Integrative Medicine: An Observational Study,” Evidence- Based Complementary and Alternative Medicine, vol. 2012, Article ID 875874, 10 pages, 2012. https://doi.org/10.1155/2012/875874.

Wallston, K. A. & Wallston, B. (1981). “Health locus of control scales,” in Research with the Locus of Control Construct, H. M. Lefcourt, Ed., pp. 189–243, Academic press, New York, NY, USA.