Psychological Inflexibility, Depression & Anxiety in Migraine/CVD

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J Contextual Behav Sci. Author manuscript; available in PMC 2020 August 05.
Published in final edited form as:
J Contextual Behav Sci. 2019 July ; 13: 1–6. doi:10.1016/j.jcbs.2019.06.001.
Cross-sectional relations between psychological inflexibility and
symptoms of depression and anxiety among adults reporting
migraines or risk factors for cardiovascular disease
Lilian Dindo, Ph.D.1,2, Charles P. Brandt, Ph.D3, Jess Fiedorowicz, M.D., Ph.D.4
1Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Blvd, Houston, Texas,
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United States
2Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1977 Butler
Blvd, Houston, Texas, United States
3The Houston OCD Program, 708 E. 19th Street, Houston, Texas, United States
4Departments of Psychiatry, Epidemiology, and Internal Medicine, University of Iowa, Iowa City,
Iowa 52242
Abstract
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Psychological inflexibility is a multifaceted construct reflecting a rigid dominance of
psychological reactions over chosen values and contingencies in guiding action. Psychological
inflexibility has been related to depressive and anxiety symptoms and has been studied as a target
of treatment for different forms of psychopathology. This construct, however, remains
understudied among some at-risk groups. To close this gap in knowledge, the current study
examined cross-sectional relations between psychological inflexibility and (1) symptoms of
depression among adults with migraines (n = 2936) and (2) symptoms of anxiety and depression
among adults at-risk for cardiovascular disease (n = 921). Results indicate that psychological
inflexibility significantly related to depressive and anxiety symptoms among these populations.
Results are discussed in terms of treatment implications for such persons.
Keywords
anxiety; depression; migraines; cardiovascular disease; resilience; psychological inflexibility
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*
Correspondence concerning this article should be addressed to Lilian Dindo, (MEDVAMC 152), 2002 Holcombe, Houston, TX,
77030. [email protected].
Compliance with Ethical Standards
There are no conflicts of interest.
Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of
the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable
ethical standards. This study was approved by the (blinde) Institutional Review Board. Prior to completing the screening
questionnaire, participants were informed that completing the screening questionnaire was an indication of consent.
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Nearly half of the adult U.S. population has a chronic health condition, and one in four
adults has more than one chronic health condition (Ward, Schiller, & Goodman, 2014); up to
20% of this population has a co-occurring major depressive or anxiety disorder (Evans et al.,
2005; Merikangas et al., 2007). Migraines and cardiovascular problems are two of the most
common chronic health conditions today, affecting millions annually (Raghupathi &
Raghupathi, 2018; Steiner et al., 2015). Importantly, persons living with migraines have
notably higher rates of anxiety and depressive symptoms than the general population
(Antonaci et al., 2011), and the same is true for persons living with cardiovascular risk
factors (Ormel et al., 2007). The comorbidity of medical and mental health difficulties is of
major public health significance as it results in decreased quality of life, poorer response to
treatments, and overall worse prognosis (Lake, Rains, Penzien & Upchik, 2005; Ormel et al.,
2007; Radat & Swensen, 2005). For example, in 2014 the American Heart Association
released a scientific statement recommending depression be formally considered “a risk
factor for adverse medical outcomes in patients with acute coronary syndrome (Lichtman et
al., 2014, p.1363).” In fact, depression and anxiety are independently associated with
vascular disease generally and are under-addressed in this patient group, due both to poor
recognition and lack of evidence to guide interventions.
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Given the high prevalence, and detrimental impact, of comorbidity between mental health
symptoms and chronic illness, it is important to understand the mechanisms that underpin
these relations. One psychological construct that has been associated with, and predictive of,
the onset of mood and anxiety disorders is psychological inflexibility (Dimidjian et al.,
2016; Spinhoven, Drost, de Rooij, van Hemert, & Penninx, 2016; Kashdan, Barrios, Forsyth,
& Steger, 2006; Kashdan & Rottenberg, 2010). Psychological inflexibility is a
transdiagnostic process reflecting a “rigid dominance of psychological reactions over chosen
values and contingencies in guiding action” (p. 678) (Bond et al., 2011). This multifaceted
construct is composed of six core skills: 1) preoccupation with past or future events (versus
present moment focus); 2) poor perspective-taking skills (versus keeping broad perspective
on thinking and feeling); 3) not knowing what matters most (versus strengthening
connection to what really matters); 4) not doing what it takes to pursue a valued life (versus
engaging in the behaviors that our values require); 5) escaping from, avoiding, or trying to
control difficult internal experiences (versus being willing to have the thoughts, emotions,
memories, and physical sensations that show up when moving towards a valued life); and 6)
treating thoughts as “truths” that dictate behavior choices (versus defusion, or stepping back
from thoughts and noticing them as thoughts that need not determine one’s behaviors)
(Hayes, Levin, Plumb-Vilardaga, Villatte, & Pistorello, 2013). Of note, different measures of
psychological inflexibility exist; to date, however, measurement of this complex construct
remains a challenge and a matter of debate (Renshaw, 2018).
Overall, persons with high levels of psychological inflexibility exhibit difficulty engaging in
values-based behavior when internal (e.g., emotions, thoughts, pain) and external obstacles
are present. For example, among individuals with high anxiety, avoidance of distressing
experiences (e.g., going out with new people) reduces immediate contact with the distressing
experiences, delivering short-term relief. Long-term, however, it leads to greater dysfunction
and increased distress. Among people living with medical illness, one pathway towards
elevated depressive or anxiety symptoms may involve avoidance of meaningful life activities
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and relationships as an attempt to cope with illness-related thoughts or fears (“I can’t go out
because I may get a headache”). Avoiding meaningful activities can increase disconnection,
reinforce more avoidance, and decrease one’s sense of meaning and personal choice.
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Psychological inflexibility is related to both mental health difficulties and to negative
physical health outcomes such as greater pain intensity and pain-related disability
(Dimidjian et al., 2016; McCracken, Vowles, & Eccleston, 2004). However, there have been
only a small number of studies examining relations between psychological inflexibility and
anxiety and depressive symptoms among persons with chronic health conditions. To date, no
studies have examined relations between psychological inflexibility and distress in patients
at risk for cardiovascular disease. Among persons with migraine, one study found that
psychological inflexibility was associated with depressive symptoms (Almarzooqi, Chilcot,
& McCracken, 2017). A better understanding of processes related to depressive and anxiety
symptoms within the context of specific medical problems can lead to increasingly targeted
behavioral interventions.
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The current study examined relations between psychological inflexibility and depressive
symptoms among persons with migraines and between psychological inflexibility and
depressive/anxiety symptoms among persons at risk for cardiovascular disease. Specifically,
it was hypothesized that greater psychological inflexibility would be associated with higher
rates of anxiety and depressive symptoms after controlling for relevant variables, such as
number of migraines in previous month and history of heart attack/stroke among large
samples of community-dwelling adults. The data reported in this manuscript were gathered
from participants being screened for two separate treatment trials; one examining the effect
of an Acceptance and Commitment Therapy (ACT) intervention on depressive symptoms
among individuals with migraine and one examining the effect of an ACT intervention on
depressive and anxiety symptoms among individuals at risk for cardiovascular disease.
Study 1: Adults with Self-reported Migraine
Methods
This project and the following study were approved by the University Institutional Review
Boards.
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Recruitment—Participants were recruited via flyers distributed in the community and
medical clinics, print ads, and other advertisements. Patients who were interested in a
clinical trial for adults with migraine were invited to complete online screening
questionnaires to assess eligibility for the treatment study. These self-report screening
questionnaire data were used for the analyses reported. Participants provided these data prior
to treatment assignment and prior to the intervention (between 2012–2016). Details of the
treatment trial have been published previously (Dindo, Recober, Marchman, O’Hara &
Turvey, 2014; Dindo, Recober, Marchman, Turvey & O’Hara, 2012).
Participants—Flyers called for adults ages 18–75 living with migraines. Included in this
report are the 2,936 individuals who screened positive for migraine (i.e., a score ≥ 2) on the
ID Migraine, a self-administered, highly sensitive, three-item screen for migraine. The ID-
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Migraine is a widely used screening instrument for migraine headaches in primary care
settings (Dindo et al., 2015). It has a sensitivity of 81%, a specificity of 75%, and a positive
predictive value of 93%. The sensitivity and specificity of the screener are not impacted by
age or sex (Cousins, Hijazze, Van de Laar, & Fahey, 2011). All individuals in the current
manuscript reported one or more migraines in the previous month. The average number of
migraines in the past month reported by the participants was 3.81 migraines (SD = 1.47).
Measures—The following self-reported information was obtained:
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Psychological Inflexibility: The Acceptance and Action Questionnaire-II (AAQ-II; Bond et
al., 2011) was used to assess psychological inflexibility. The AAQ-II is a seven-item selfreport measure. Items are rated on a 7-point scale, ranging from 1 (“never true”) to 7
(“always true”), with higher scores reflecting greater inflexibility. Example items include,
“Emotions cause problems in my life,” and “My painful memories prevent me from having a
fulfilling life.” The AAQ-II exhibits good internal consistency (α=.93), test-retest reliability
(0.81 at three months) (Bond et al., 2011) and independent construct validity when
compared to related constructs, including pain-related anxiety, depression, alexithymia, and
mindfulness (Duarte, Pinto-Gouveia, & Ferreira, 2017; McCracken & Zhao-O’Brien, 2010).
The AAQ-II has been used in adults with chronic health problems, including cancer (Swash,
Bramwell, & Hulbert-Williams, 2017), athletes recovering from sport-related injuries
(DeGaetano, Wolanin, Marks, & Eastin, 2016), and persons with traumatic brain injuries
(Whiting, Deane, Simpson, McLeod, & Ciarrochi, 2017). Internal consistency in this sample
of adults with migraine was excellent (α = 0.93).
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Symptoms of Depression: The Patient Health Questionnaire-8 (PHQ-8 (Gilbody, Richards,
Brealey, & Hewitt, 2007) was used to assess depressive symptoms in the current study. The
PHQ-8 is a self-report, eight-item scale assessing depressive symptoms (e.g., “How often
during the past two weeks were you bothered by little interest or pleasure in doing things?”)
on a 4-point Likert-type scale (0 = not at all, 3 = nearly every day). The PHQ-8 is
established as a valid diagnostic and severity measure for depressive disorders in clinical and
population studies (Kroenke, et al., 2009). In the current study, the PHQ-8 exhibited good
internal consistency in the migraine sample (α = .89).
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Self-Reported Number of Migraines: Participants were asked to self-report the total
number of migraines they had experienced in the past 30 days. Those reporting 1or more
migraine in the previous month were included in the analyses. Report of migraine frequency
based on patient recollection is consistent with data obtained from daily diaries. Thus, this
single-item assessment is considered valid (McKenzie & Cutrer, 2009).
Self-Reported History of Brain Injury: Participants self-reported, dichotomously, a
“history of brain injury” (yes/no). If yes, participants were asked to explain their brain injury
history.
Self-Reported Psychiatric Illness: Participants self-reported, dichotomously, lifetime
diagnosis of a psychiatric disorder (yes/no). If yes, participants were asked to specify their
diagnosis.
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Self-Reported Psychotherapy Involvement: Participants were asked if they were currently
receiving “counseling or therapy.” Results were coded dichotomously (yes/no).
Self-Reported History of Serious Medical Illness: Participants self-reported,
dichotomously, whether they had ever “been diagnosed with a serious medical illness” (yes/
no). If yes, participants were asked to provide additional details regarding their illness.
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Analyses—First, correlations between study variables were examined. Pearson
correlations are reported for associations between continuous variables. Point biserial
correlations are reported for relations between continuous variables and dichotomous
variables. Next, nested linear regression models were used to examine the unique effect of
psychological inflexibility on depression among participants with migraines. Covariates
included number of migraines in the past month, history of brain injury, lifetime psychiatric
illness, and history of serious medical illness. These covariates were included in the base
regression model; and the exposure of interest, the AAQ-II total score, was subsequently
added to a hierarchical model to examine its effects adjusting for important confounding
variables. The Variance Inflation Factor was estimated to assess for any issues with
multicollinearity. Standardized parameter estimates (β) are reported for continuous variables
only. SPSS version 24 (IBM Corporation, Armonk, NY) and SAS 9.4 (SAS Institute, Cary,
NC) were used for all analyses.
Results
Correlations—As shown in Table 1, psychological inflexibility was significantly
positively correlated with depressive symptoms (r = .51, p < .001).
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Role of Psychological Inflexibility on Depressive Symptoms—In Step 1 of a
regression analysis, theoretically relevant covariates accounted for 12.5% of the variance in
depressive symptoms; number of migraines in the past month (B = 1.03, p <.001), history of
brain injury (B = 0.88, p =.004), psychiatric illness (B = 2.43, p <.001), and serious medical
illness (B = 0.82, p =.001) were all significant predictors (Table 2). Psychological
inflexibility (as measured by the AAQ-II), entered in Step 2 accounted for an additional
41.5% of variance in depressive symptoms (β = 0.69, p <.001; Table 2).
Study 2: Adults with Self-Reported Risk Factors for Cardiovascular Disease
Methods
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The second study was similar to the first in many ways, except for a different sample and the
use of some different instruments.
Recruitment—Participants were recruited via flyers distributed in the community and
medical clinics, print ads, and other advertisements. Patients who were interested in a
clinical trial for adults with vascular risk factors (hypertension, diabetes mellitus or impaired
fasting glucose, dyslipidemia or obesity) were invited to complete online screening
questionnaires to assess eligibility for these studies. These self-report screening
questionnaire data were used for the analyses reported. Participants provided these data prior
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to treatment assignment and prior to the intervention (between 2013–2014). Details of the
treatment trial have been published previously (Dindo et al., 2015).
Participants—Flyers called for adults age 18–75 with high blood pressure, high
cholesterol, high blood glucose, diabetes mellitus, or excess weight. Included in this report
are 921 persons who reported having one or more of these cardiovascular risk factors.
Measures—The AAQ-II (described in Study 1) was used to assess psychological
inflexibility. The PHQ-8 (also described in Study 1) was used to assess symptoms of
depression. The PHQ-8 exhibited good internal consistency in the cardiovascular (α = .87)
sample.
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Symptoms of Anxiety: The Generalized Anxiety Disorder Seven-item scale (GAD-7;
Spitzer, Kroenke, Williams, & Lowe, 2006)) was used to assess anxiety symptom severity in
the current study. The GAD-7 is a seven-item self-report scale on which respondents
indicate feelings related to anxiety and worry in the past two weeks (e.g., “feeling nervous,
anxious, or on edge”) on a 4-point Likert-type scale (0 = not at all, 3 = nearly every day).
Evidence supports the validity of the GAD-7 as a measure of anxiety symptoms in clinical
and population samples (Löwe et al., 2008). In this sample, the GAD-7 exhibited good
internal consistency (α = .90).
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Self-Reported History of Cardiovascular Risk Factors: Using questions from the
National Comorbidity Survey – Replication, participants self-reported a lifetime history of
heart attack and/or stroke at any point in their life. They were also asked if a “doctor or other
health professional” ever told them that they had: heart disease?, high blood pressure?,
diabetes or high blood sugar?, or high cholesterol or triglycerides? The latter screen for
hyperlipidemia was not part of the NCS-R and was added by the authors for this survey.
Other: Self-reported history of psychiatric Illness, therapy involvement, history of brain
injury, and history of serious medical illness were also assessed, as described in Study 1.
Analyses—The same statistical analytic strategies used in Study 1 were applied for this
study. In the regression analyses, age, history of psychiatric illness, history of heart attack or
stroke, and current psychological counseling/therapy were used as covariates that might
explain the relation between psychological inflexibility and anxiety/depression among adults
at risk for cardiovascular disease.
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Results—As shown in Table 3, psychological inflexibility was significantly positively
correlated with depressive symptoms (r = .67, p < .001) and anxiety symptoms (r = .71, p
< .001).
Role of Psychological Inflexibility in Depressive Symptoms: The first step of the
regression analysis included theoretically relevant covariates and accounted for 16.5% of the
variance in depressive symptom scores, with age (β = −.21, p <.001), psychiatric illness (B =
3.06, p <.001), heart attack/stroke history (B = 2.38, p =.008), and current (past year)
psychological therapy (B = 1.65, p <.001) each being a significant predictor. Psychological
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inflexibility, entered in Step 2, accounted for an additional 29.0% of variance in depressive
symptoms (B = .61, p <.001). See Table 4.
Role of Psychological Inflexibility on Anxiety Symptoms: The first step of the regression
analysis accounted for 12.6% of the variance on anxiety symptoms scores, with age (β =
−.23, p <.001), history of psychiatric illness (B = 1.87, p <.001), and current (past year)
psychological therapy (B = 1.70, p <.001) each being significant predictors. Psychological
inflexibility, entered in Step 2, accounted for an additional 37.5% of variance y (B = .70, p
<.001) being a significant predictor.
Discussion
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Results indicated that psychological inflexibility, as measured by the AAQ-II, was
significantly correlated to symptoms of distress among adults with migraines and among
adults at risk for cardiovascular disease. Psychological inflexibility explained a significant
amount of the variance in depressive symptoms in patients with migraine, even after
controlling for other relevant medical variables (ΔR2 = .40). Similarly, psychological
inflexibility significantly related to depressive (ΔR2 = .29) and anxiety (ΔR2 = .38)
symptoms in patients at risk for cardiovascular disease, after controlling for a range of
medical variables.
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These results support the continued examination of psychological inflexibility as a potential
therapeutic target for decreasing distress in these populations. ACT is a transdiagnostic
treatment intervention aimed at targeting psychological inflexibility. ACT treatment studies
have shown that decreases in psychological inflexibility can lead to improvements in
important outcomes (see Hayes et al., 2013 for summary); for example, ACT has led to
reductions in psychological distress among persons with chronic illnesses (McCracken &
Vowles, 2014), including among adults with migraine (Dindo, et al., 2012) and adults at risk
for cardiovascular disease (Dindo, et al., 2015). As such, ACT represents a promising way to
meet the heterogeneous needs of patients with a broad range of problems, including mental
health and physical health symptoms (Dindo, Van Liew, & Arch, 2017).
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Of note, however, the AAQ is simply one measure of psychological flexibility; and some
have argued that it overlaps with measures of distress (Wolgast, 2014; Rochefort, Baldwin,
& Chmielewski, 2018) and does not uniquely measure processes targeted by ACT. Others,
however, have shown that the AAQ-II is associated with depression after controlling for
depressive symptoms (Kato, 2016) and that it predicts outcomes above and beyond other
measures of psychopathology (Gloster, Klotsche, Chaker, Hummel, & Hoyer, 2011),
suggesting that the AAQ-II might help to explain some kinds of dysfunction above and
beyond other measures of depression and anxiety. Consequently, future research is needed to
clarify whether the AAQ-II has sufficient discriminant validity from psychological distress,
particularly depressive and anxiety symptoms, to serve as a useful measure of an ACT
process. Studies using multiple ways of measuring this construct, including self-report
(AAQ-II and other questionnaires), experimental tasks, and experience-sampling methods
(Kashdan & Rottenberg, 2010), as well as longitudinal designs that examine the mediating
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role of psychological flexibility, are needed to more fully delineate the value of the AAQ-II
and other measures of psychological inflexibility (Spinhoven et al., 2016).
Additionally, psychological inflexibility is theorized to be the product of six subprocesses:
experiental avoidance, cognitive fusion, inflexible self content, preoccupation with the past
and/or future, lack of clarity of values, and inaction on valued domains. However, the AAQII may not provide a balanced measurement of all aspects of the construct, Thus, future
research might benefit from examining the impact, on distress and disability, of each of these
subprocesses among these groups. This would provide important information about which
therapeutic processes and/or techniques may be particularly useful in treatments.
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The present studies have a number of limitations. First, the data used were gathered from
participants who were being recruited for clinical trials. A random sample of community
members might provide more generalizable results. Second, we used only self-report
questionnaires for these studies, and we did not use other methods of assessment to validate
these findings (physician-rated measures, symptom diaries). Additionally, the screening
surveys provided limited sociodemographic and clinical information to further characterize
the sample. Future studies could include multimethod assessment approaches and more
detailed demographic information about the participants. Third, the studies are crosssectional in design and do not allow assessment of temporal relations. Thus, we cannot infer
the directionality of psychological inflexibility and anxiety and depressive symptoms. Future
work may test these relations prospectively to understand their directional effects. Finally, it
is possible that other variables are partially responsible for the relation between
psychological inflexibility and distress. For example, in a study of patients with
musculoskeletal illness, the relation between psychological inflexibility and pain was
partially mediated by pain catastrophizing (Talaei-Khoei, Fischerauer, Lee, Ring, &
Vranceanu, 2017). In another study, sleep difficulties partially mediated the relationship
between psychological inflexibility and depression in college students (Kato, 2016). Work is
also increasingly being done to examine relations between psychological inflexibility,
psychological difficulties, and other variables such as self-compassion (Woodruff et al.,
2013). Thus, investigating the role of other constructs in psychological inflexibility and their
associations with distress could provide valuable information and opportunities to address
any residual confounding.
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In summary, persons living with chronic disease are at significantly increased risk for
anxiety and depressive symptoms. The current study suggests that psychological inflexibility
is related to the expression of these symptoms in adults with migraine and adults at risk for
cardiovascular disease, two of the most common chronic health conditions. If replicated with
different measures of psychological inflexibility and among distressed patients with different
chronic health problems, this transdiagnostic construct could be an important target in
psychological treatments.
Acknowledgments
Funding
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This work was made possible by grant number K23MH097827 from the National Institute of Mental Health
awarded to Lilian N Dindo: and was partially supported by the use and resources of the Houston VA HSR&D
Center for Innovations in Quality, Effectiveness and Safety (CIN13-413). Dr. Fiedorowicz was supported by
K23MH083695. This work was also supported by a grant from the Department of Psychiatry at the University of
Iowa to Lilian Dindo and Jess Fiedorowicz. Dr. Fiedorowicz has since received funding for research and as a
consultant from Myriad Genetics, Inc.
The content is solely the responsibility of the authors and does not necessarily represent the official views of the
funding agencies, the Department of Veterans Affairs, the U.S. government, or Baylor College of Medicine. The
funding agencies had no role in the design and conduct of the study; the collection, management, analysis, and
interpretation of the data; or the preparation, review or approval of the manuscript. The authors are grateful for the
contributions of the participants and their families as well as for those of the research team.
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Highlights
•
Nearly half of the US population has a chronic medical condition
•
Depression and anxiety are common among patients with chronic medical
conditions
•
Psychological inflexibility is significantly related to depressive symptoms in
migraineurs
•
Psychological inflexibility is significantly related to distress in patients with
cardiovascular disease risk
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Table 1:
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Zero-order Correlations among study variables for adults with migraine
1) Number of Migraines
1
2
3
4
5
6
--
.04**
.07**
.11**
.28**
.14**
--
.04
.09**
.07**
.06**
--
.18**
.23**
.32**
--
.13**
.08**
--
.71**
2) History of Brain Injury
3) Psychiatric Illness
4) Medical Illness
5) Depressive Symptoms
6) Acceptance and Action
--
Descriptive
Mean (n)
4.04
(344)
(947)
(527)
15.40
19.20
Statistics
SD (%)
1.37
(11.7)
(32.3)
(18.0)
5.53
9.49
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Note: Number of Migraines in the last month coded 0 = <4, 1 = 5 or more; History of Brain Injury coded 1 = yes, 0 = no, Psychiatric Illness coded
1= yes, 0 = no; Medical Illness coded 1 = yes, 0 = no; Depressive Symptoms = PHQ-8 total score; Acceptance and Action = AAQ total score.
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Table 2.
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Main Effect of AAQ on Symptoms of Depression In Patients with Migraine Headache
B (β)
p
Sr2
# of Migraines Past Month
1.03
<.001
0.06
History of Brain Injury
0.88
.004
0.003
Psychiatric Illness
2.43
<.001
0.04
Serious Medical Illness
0.82
.001
0.004
0.40 (0.69)
<.001
0.47
Parameter
1
PHQ-8
Step 1 (R2=0.13, p<.001)
Step 2 (ΔR2=0.42, p<.001)
AAQ-Total
2
Not sr2 is the squared partial correlation coefficient.
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1
Patient Health Questionnaire-8 (Spitzer et al. 2000).
2
Acceptance and Avoidance Questionnaire (Bond et al., 2011).
B = unstandardized regression coefficient, β = standardized regression coefficient (reported only for continuous variables).
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Table 3:
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Zero-order Correlations Among Study Variables for Cardiovascular Patients
1)Age
1
2
3
4
5
6
7
--
−.02
.18**
−.07*
−.21**
−.25**
−.27**
--
.001
.35**
.33**
.25**
.37**
--
−.04
.04
−.02
−.01
--
.23**
.21**
.31**
--
.75**
.67**
--
.71**
2) Psychiatric Illness
3) Heart Attack/Stroke
4) Psychotherapy
5) Depressive Symptoms
6) Anxiety Symptoms
7) Acceptance and Action
--
Descriptive
Mean (n)
44.20
(262)
(27)
(141)
6.15
4.46
17.47
Statistics
SD (%)
14.84
(28.4)
(2.9)
(15.3)
4.95
4.52
9.41
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Note: Psychiatric Illness coded 1= yes, 0 = no; Heart Attack/Stroke coded 1 = yes, 0 = no; Psychiatric Therapy coded 1 = yes, 0 = no; Depressive
Symptoms = PHQ-8 total score; Anxiety Symptoms = GAD-7 total score; Acceptance and Action = AAQ total score.
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Table 4.
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Main Effect of AAQ on Symptoms of Depression and Anxiety in Patients with Cardiovascular Risk Factors
B (β)
p
Sr2
−0.07 (−0.21)
<.001
0.05
Psychiatric Illness
3.06
<.001
0.08
Heart Attack/Stroke
2.38
.008
0.01
Psychotherapy
1.65
<.001
0.02
0.32 (0.61)
<.001
0.35
Parameter
1
PHQ-8
Step 1 (R2=0.17, p<.001)
Age
Step 2 (ΔR2=0.29, p<.001)
AAQ-Total
3
2
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GAD-7
Step 1 (R2=0.13, p<.001)
Age
−0.07 (−0.23)
<.001
0.05
Psychiatric Illness
1.87
<.001
0.03
Heart Attack/Stroke
0.7
.41
0.001
Psychotherapy
1.7
<.001
0.02
0.33 (0.70)
<.001
0.43
Step 2 (ΔR2=0.37, p<.001)
AAQ-Total
3
Not sr2 is the squared partial correlation coefficient.
1
Patient Health Questionnaire-8 (Spitzer et al. 2000).
2
The Generalized Anxiety Disorder 7-item scale (Spitzer et al., 2006).
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3
Acceptance and Avoidance Questionnaire (Bond et al., 2011).
B = unstandardized regression coefficient, β = standardized regression coefficient (reported only for continuous variables).
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J Contextual Behav Sci. Author manuscript; available in PMC 2020 August 05.