College students' perceptions of concussion: Illness beliefs and masculinity norms predict stigma and willingness to seek treatment.

College students' beliefs and attitudes concerning concussion, and masculinity norms, were examined in relation to stigma and willingness to seek treatment for possible concussion. Beliefs were measured using a revised Illness Perception Questionnaire (IPQ). Participants: Participants were 631 undergraduates at a Northeastern university, most of whom were nonathletes with no concussion. Methods: Data were collected online. Regression analysis were performed to identify predictors of stigma and treatment willingness. Results: Beliefs that concussion symptoms reflect malingering, are controllable, and have psychological causes were related to more stigmatizing attitudes, as was endorsement of masculinity norms regarding winning and risk-taking. Believing that concussion symptoms are long-lasting and endorsing competitiveness, pain discounting, and self-reliance predicted willingness to seek treatment. Preliminary structural models showed adequate fit. Conclusions: In addition to beliefs assessed by the IPQ, traditional conceptions of masculinity warrant greater attention in the study of concussion-related stigma and willingness to seek treatment.

Exposure to conflicting COVID-19 information in undergraduates: Implications for pandemic-related information-seeking and concern, attention, and cognitive workload.

Objectives: To examine college students' conflicting COVID-19 information exposure, information-seeking, concern, and cognitive functioning. Participants: 179 undergraduates were recruited in March-April 2020, and 220 in September 2020 (Samples 1 and 2, respectively). Methods: Students completed the Attention Network Test, NASA Task Load Index, and COVID-related questions. Results: In Sample 1, exposure to conflicting information predicted poorer attentional performance and greater COVID-related information-seeking and concern; concern was correlated with workload. In Sample 2, conflicting information was associated with information-seeking. In Sample 1, but not Sample 2, cognitive effects of conflicting information were mediated by information-seeking and virus-related concern. Conclusions: Conflicting COVID-19 information may undermine students' cognitive functions, bearing implications for health, academic performance, and stress. Strategies for countering these effects include enhancing the clarity of institutional messaging, and tailoring course curricula and offering workshops to students, faculty, administrators, and counseling staff to augment students' capacity to comprehend and utilize COVID-related communications.

Associations between the late positive potential and PTSD, anxiety, and depressive symptoms among trauma-exposed undergraduates.

BACKGROUND: The late positive potential (LPP) is a neural marker of attention to emotional stimuli; dysregulations in those attentional processes might contribute to trauma-related psychopathology. Although higher LPP amplitudes to negative images have been found to be associated with anxiety symptoms, results have been mixed regarding depressive and PTSD symptoms, especially among trauma-exposed populations. Further, the relationships between the LPP to positive and neutral images and psychopathology symptoms have been underexamined. The purpose of the current study was to test the effects of image valence, and PTSD, anxiety, and depressive symptoms on LPP amplitude among trauma-exposed undergraduates. METHOD: Seventy-three trauma-exposed undergraduates viewed a series of negative, positive, and neutral images while LPPs were recorded. Self-report measures were used to assess recent PTSD, anxiety, and depressive symptoms. Hierarchical linear modeling tested valence and symptom main effects, as well as Valence by Symptom interactions on LPP amplitude. RESULTS: We found a main effect of valence such that individuals exhibited higher LPP amplitudes to negative images compared to neutral images. We also found a Valence by Depressive Symptoms interaction such that there was an inverse relationship between depressive symptoms and the LPP to neutral images but no associations between depressive symptoms and the LPP for positive or negative images. We found no main effects or interactions for anxiety and PTSD symptoms. CONCLUSION: Depressive symptoms might be related to diminished attention to neutral stimuli among trauma-exposed undergraduates. Further investigation of the relationship between the LPP and psychopathology is needed.

Healthy or not? The impact of conflicting health-related information on attentional resources.

Despite its ubiquity, little is known about the impact of exposure to conflicting health information on cognitive efficiency. We hypothesized that it would reduce attentional capacity, as evidenced by (1) increased response errors during the Attention Network Test (ANT), (2) decreased efficiency of each ANT system (alerting, orienting, execute control), and (3) increased self-reported workload, (4) nutritional confusion and (5) nutritional backlash. A sample of 184 online participants were assigned randomly to read an article containing either congruent or conflicting health information. Subsequently, they completed the ANT and self-report measures of workload, nutritional confusion, and backlash at nutritional recommendations and research. Participants in the conflicting health information condition made more errors, had overall slower reaction times, and reported greater workload, nutritional confusion, and backlash. No differences were found for individual ANT systems. These findings suggest that exposure to conflicting health information can degrade attentional mechanisms responsible for accurate and prompt responding to incoming information.

Biological causal beliefs and depression stigma: the moderating effects of first- and second-hand experience with depression.

BACKGROUND: Essentialist theory (ET) links biological attributions for mental illnesses to pessimistic prognostic beliefs and stigma. The commonsense model (CSM) provides a nuanced framework for studying illness beliefs as shaped by experience. AIMS: ET-informed hypotheses linking causal and prognostic beliefs and stigmatizing attitudes concerning depression were tested using CSM constructs with a focus on the moderating effects of self-reported experience with this disorder. METHODS: U.S. adults (N = 319) completed online questionnaires assessing depression-related beliefs, attitudes and experience. Multiple regression analysis focused on predictive effects of neurobiological and genetic attributions. Potential mediators (prognosis) and moderators (experience) of the biological attribution-stigma link also were tested. RESULTS: Neurobiological attributions predicted viewing depression as more consequential, longer lasting, and unexpectedly, more treatable. Neurobiological attributions were inversely related to stigma, a link partially mediated by beliefs about depression's consequences and duration. However, both biological attributions' relationships to stigma were moderated by experience. Stronger biological attributions predicted less stigma specifically among participants reporting first- or second-hand experience with depression. CONCLUSION: Experience with depression may shape the relationships of specific causal and prognostic beliefs with depression stigma. Psychoeducation in clinical and public health contexts may be informed by further research using CSM constructs.

Lay beliefs about the causes and treatment of depression: Tests of measurement models and associations.

BACKGROUND: There is reason to expect beliefs about depression's causes and treatment to influence use of psychotherapy, but the literature is marked by theoretical, methodological, and empirical inconsistencies. This study assessed the factorial validity of measures of beliefs about depression's causes and formal treatment versus self-management. It also tested the links of causal attributions to general treatment/self-management beliefs and endorsement of specific interventions. METHODS: The revised Illness Perception Questionnaire (IPQ-R) adapted for depression was administered online to a non-patient, U.S. sample (N = 319). RESULTS: Confirmatory factor analyses yielded three causal dimensions, Environmental Stressors, Biological Factors, and Personal Attributes, and two control dimensions, (Formal) Treatment and Personal. Both models fit irrespective of whether respondents believed they had ever experienced depression. A structural equation model (SEM) showed a positive relationship for Environmental and Biological attributions, and an inverse relationship for Personal attributions, in predicting general preferences for Formal Treatment. A second SEM, focusing on specific interventions, linked Environmental causation to endorsement of psychotherapy, dietary changes, and self-help, and Biological causation to endorsement of medication and exercise, with Personal causation inversely associated with endorsement of psychotherapy. LIMITATIONS: A cross-sectional, correlational design precludes causal inferences. Potential sociocultural influences were not assessed. CONCLUSIONS: Modifications to the IPQ-R suggested by this study improved its psychometric properties, validated its distinction between Treatment and Personal Control beliefs, and supported examination of both general and specific beliefs about ways to deal with depression. Relationships linking cause and treatment beliefs warrant further investigation as potential intervention targets to increase treatment utilization.

Pathways from exposure to racial/ethnic discrimination to depression: Testing a social-cognitive model.

RATIONALE AND OBJECTIVE: Interpersonal racial/ethnic discrimination is a risk factor for depression across the lifespan in minoritized racial/ethnic groups. This study tests a model proposing that social cognitive processes, including relational schemas, mediate the link between discrimination and depression. Relational schemas enable individuals to form mental representations of others, reflecting prior social learning and generating expectations about future social relations. Racism-related relational schemas include, among others, concerns about being rejected or invalidated, concerns about confirming negative stereotypes held by others, and cynical mistrust of others. Prior studies have typically examined the mediating role of one or two relational schemas in the association between discrimination and depression; less is known about the unique and combined effects of multiple dimensions of racism-related social cognition. METHODS: The model was tested in a convenience sample of ethnically diverse, non-white participants recruited from two sites, a community medical center (N = 136; Mage = 38, SD = 13.0) and a private university (N = 120; Mage = 19.4, SD = 1.3), yielding a consolidated sample of 256 participants (64% women). Data were collected between September 2016 and April 2018. Participants completed paper-and-pencil self-report measures of exposure to interpersonal discrimination, depressive symptoms, and eight measures of relational schemas. RESULTS: Confirmatory factor analysis indicated that the eight relational schemas defined three primary dimensions: concerns about rejection and invalidation, social vigilance, and mistrust. A structural equation model in which the association between exposure to discrimination and depressive symptoms operates through latent factors representing three social-cognitive dimensions demonstrated adequate fit (CFI = 0.96, RMSEA = 0.06, SRMR = 0.04). A significant mediational effect was found only for concerns about rejection and invalidation. CONCLUSION: The conceptual model supported by this study may help inform psychological interventions aimed at mitigating the detrimental effects of racial/ethnic discrimination on mental health.

Psychosocial predictors of virus and social distancing fears in undergraduate students living in a US COVID-19 "hotspot".

The COVID-19 pandemic is positioned to exact a substantial mental health toll on the global population. Heightened fears of viral contamination and fears of the negative consequences of social distancing (e.g., fears related to home confinement, fears of loneliness and isolation) might contribute to the distress caused by the pandemic. Cross-sectional data were collected from undergraduates (N = 608) residing in a U.S. pandemic "hotspot" at the time of data collection (between 7 April to 9 May, 2020). Outcome variables included viral contamination fears and social distancing fears. Predictor variables included biological sex, underlying medical vulnerability, number of recent viral symptoms, presence of positive COVID-19 test in social network, anxiety, depression, stress, emotion dysregulation, intolerance of uncertainty, body vigilance, and health anxiety. Female sex, anxiety severity, intolerance of uncertainty, and health anxiety uniquely predicted fears of viral contamination. Female sex and depression severity uniquely predicted fears of social distancing. Multiple anxiety-related vulnerabilities are potential intervention targets for reducing viral contamination fears. Depression is a potential intervention target for social distancing fears. Females might be at greater risk for both types of fears.

Dispositional Optimism and Cardiovascular Reactivity Accompanying Anger and Sadness in Young Adults.

BACKGROUND: Dispositional optimism, a generalized expectation for positive outcomes, appears to promote physical health and well-being, including positive effects on cardiovascular disease outcomes. Mechanisms may involve adaptive responses to psychological stressors that dampen their physiological impact. PURPOSE: This study investigated (i) whether individual differences in optimism are associated with attenuated cardiovascular reactivity (CVR); (ii) whether the CVR moderating effect of optimism differs for two stress emotions, anger and sadness; and (iii) whether separate measures of optimism and pessimism, and the more commonly used measure that combines them, differ in their relationships with CVR. METHODS: The Life Orientation Test-Revised (LOT-R) was used to provide an overall dispositional optimism score and subscale scores separately assessing optimism and pessimism. These predictors were examined in relation to cardiovascular responses evoked by a stressful autobiographical recall task. Task instructions were manipulated within subjects to produce anger and sadness. CVR measures were systolic and diastolic blood pressure (SBP and DBP) and heart rate (HR). RESULTS: Dispositional optimism was inversely associated with SBP and HR (but not DBP) elevations while participants related both anger- and sadness-inducing events. There was some indication that these associations were stronger for sadness than for anger, and that the LOT-R optimism subscale was a better predictor of CVR than its pessimism subscale. CONCLUSIONS: These findings add to the understanding of health-promoting effects of dispositional optimism by addressing relationships of optimism and pessimism with cardiovascular concomitants of anger and sadness that are thought to contribute to heart disease.

Poincaré plot indices as measures of sympathetic cardiac regulation: Responses to psychological stress and associations with pre-ejection period.

The Poincaré plot is a visual representation of the R-R time series within a Cartesian plane constructed by plotting each R-R interval as a function of the previous one. The plot can be characterized by parameters that quantify the standard deviation (SD) of short- and long-term R-R interval variability (SD1 and SD2, respectively). Claims regarding the use of Poincaré plot analysis as an alternative to conventional time-domain and spectral analytic measures of parasympathetic contributions to heart rate variability (HRV) have been evaluated somewhat extensively. However, its proposed utility for characterizing sympathetic influences on HRV during periods of acute mental stress, using SD2 and the SD1/SD2 ratio, has received minimal attention. In the present study, the electrocardiogram was used to record R-R interval variability in healthy participants during a resting baseline period, while they performed a challenging reaction time task, and then during a recovery period. Simultaneously, the thoracic impedance cardiogram was used to derive the pre-ejection period (PEP), which reflects sympathetic cardiac control. HRV was quantified using time-domain, spectral analytic, and Poincaré plot indices. Task performance elicited significant reductions in HRV and PEP parameters, indicating withdrawal of parasympathetic tone with concomitant sympathetic activation. Following cessation of task performance, all HRV and impedance measures returned to baseline levels, signaling resumption of parasympathetic dominance. Bivariate associations linking SD2 and the SD1/SD2 ratio to PEP were observed; however, these were not large in magnitude, were exceeded in size by associations between the Poincaré metrics and conventional HRV markers of parasympathetic cardiac influences, and were eliminated when the latter were controlled statistically. These observations challenge the proposal that the Poincaré SD2 and SD1/SD2 metrics are suitable markers of sympathetic cardiac regulation in research concerned with mental and physical health.

Integrating affective and cognitive correlates of heart rate variability: A structural equation modeling approach.

High frequency heart rate variability (HRV) is a measure of neurocardiac communication thought to reflect predominantly parasympathetic cardiac regulation. Low HRV has been associated empirically with clinical and subclinical levels of anxiety and depression and, more recently, high levels of HRV have been associated with better performance on some measures of executive functioning (EF). These findings have offered support for theories proposing HRV as an index measure of a broad, self-regulatory capacity underlying aspects of emotion regulation and executive control. This study sought to test that proposition by using a structural equation modeling approach to examine the relationships of HRV to negative affect (NA) and EF in a large sample of U.S. adults ages 30s-80s. HRV was modeled as a predictor of an NA factor (self-reported trait anxiety and depression symptoms) and an EF factor (performance on three neuropsychological tests tapping facets of executive abilities). Alternative models also were tested to determine the utility of HRV for predicting NA and EF, with and without statistical control of demographic and health-related covariates. In the initial structural model, HRV showed a significant positive relationship to EF and a nonsignificant relationship to NA. In a covariate-adjusted model, HRV's associations with both constructs were nonsignificant. Age emerged as the only significant predictor of NA and EF in the final model, showing inverse relationships to both. Findings may reflect population and methodological differences from prior research; they also suggest refinements to the interpretations of earlier findings and theoretical claims regarding HRV.

Self-rated health is associated with the length of stay at the intensive care unit and hospital following cardiac surgery.

BACKGROUND: Recently, a considerable amount of evidence suggested that anxiety, depression and other psychosocial variables might influence the outcomes of cardiac surgery. This study investigated the relationship between length of stay at the intensive care unit (ICU) and hospital after surgery and different psychosocial variables (e.g. depression, anxiety, self rated health, happiness, satisfaction). METHODS: We enrolled prospective patients who were waiting for elective cardiac surgery (N = 267) and consented to take part in the study. We collected data of sociodemographic, medical and perioperative factors as well as psychosocial questionnaires completed 1.56 days (standard deviation [SD] = 0.7) before surgery. The primary clinical endpoint was an ICU stay of at least 3 days and the secondary was hospital stay of at least 10 days. RESULTS: Two hundred sixty-seven patients participated in this study. Four patients (1.5%) died in the hospital and 38 patients (14.5%) spent more than 3 days in the ICU and 62 patients (23.2%) spent more than 10 days in the hospital. After controlling for medical and sociodemographic factors, lower self rated health (Adjusted Odds Ratio [AOR]: 0.51, 95% confidence interval [CI]: 0.28-0.95; p = 0.03), lower rate of happiness (AOR: 0.76, 95% CI: 0.59-0.97, p = 0.03), postoperative cardiac failure (AOR: 7.09, 95% CI:1.21-41.54; p = 0.03) and postoperative complications (AOR: 9.52, 95% CI: 3.76-24.11; p < 0.001) were associated with longer ICU stay. More than 10 days of hospital stay was associated with higher occurrence of COPD (AOR 4.56, CI: 1.95-10.67, p < 0.001), NYHA stage (AOR 6.76, CI: 2.57-17.79, p < 0.001), operation time (AOR 1.45, CI: 1.19-1.76, p < 0.001), female gender (AOR 2.16, CI: 1.06-4.40, p = 0.034) and lower self-rated health (AOR 0.63, CI: 0.41-0.99, p = 0.044). CONCLUSIONS: Lower happiness and self-rated health may influence the outcome of cardiac surgery. Therefore, these variables should be assessed in patients.

Mending broken hearts: marriage and survival following cardiac surgery.

Marriage has long been linked to lower risk for adult mortality in population and clinical studies. In a regional sample of patients (n = 569) undergoing cardiac surgery, we compared 5-year hazards of mortality for married persons with those of widowed, separated or divorced, and never married persons using data from medical records and psychosocial interviews. After adjusting for demographics and pre- and postsurgical health, unmarried persons had 1.90 times the hazard of mortality of married persons; the disaggregated widowed, never married, and divorced or separated groups had similar hazards, as did men and women. The adjusted hazard for immediate postsurgical mortality was 3.33; the adjusted hazard for long-term mortality was 1.71, and this was mediated by married persons' lower smoking rates. The findings underscore the role of spouses (both male and female) in caregiving during health crises and the social control of health behaviors.

Factor structure and longitudinal invariance of the Medical Adherence Report Scale-Asthma.

Adequate assessment of adherence to medical treatment is critical for both research purposes and clinical practice. This study examined the factor structure and longitudinal invariance of the Medication Adherence Report Scale (MARS-A10) in a sample of asthmatic patients. We examined longitudinal data from 294 inner-city, adult participants with moderate to severe asthma. Because of ambiguous evidence regarding the dimensionality of the MARS-A10, the data was analysed with exploratory structural equation modelling. We first proceeded by determining the dimensionality of the scale at baseline and examined whether the structure, loadings, intercepts and errors were invariant over the four assessments points. Results indicated that a two-factor structure (factor 1: non-adherence based on experiential changes; factor 2: non-adherence based on intentional medication avoidance) had the best fit to the data (χ(2)(25)=37.69, p=0.05). Longitudinal analyses revealed that the nine items assessing intentional non-adherence were invariant over time. The evidence from the factor analysis suggests that intentional non-adherence is a multidimensional construct. Additionally, longitudinal data provided strong evidence that the items examining intentional non-adherence are invariant over time, indicating that changes in non-adherence scores can be validly attributed to changes in behaviour.

Depressive symptoms, trait aggression, and cardiovascular reactivity to a laboratory stressor.

BACKGROUND: Depression and anger/aggression-related traits are thought to promote coronary disease, at least in part, through their associations with stress-related cardiovascular processes. It is unclear whether the effects of these factors on cardiovascular reactivity (CVR) are redundant, additive, or synergistic. PURPOSE: The main goal of this study was to examine the independent and interactive effects of depressive symptoms and anger/aggression-related traits in promoting CVR. METHODS: Participants were 63 healthy females who completed the Beck Depression Inventory and Buss-Perry Aggression Questionnaire and performed a stressful speaking task. Systolic and diastolic blood pressure (SBP and DBP) and heart rate were recorded. RESULTS: Significant interaction effects indicated that depressive symptoms were positively associated with SBP and DBP reactivity among women high in verbal aggression but not among those low in verbal aggression. CONCLUSIONS: Depressive symptoms and verbal aggression may interact to promote exaggerated blood pressure responses to stressors, a possible marker for mechanisms that contribute to heart disease.

Trait hostility and ambulatory blood pressure among traffic enforcement agents: the effects of stressful social interactions.

This study investigated the hypothesis that trait hostility is associated with heightened cardiovascular reactivity to potentially stressful social interactions but not to nonsocial activities in the workplace. Participants were 73 (39 women) New York City traffic enforcement agents (TEAs) who patrol the streets and issue summonses for vehicular and parking violations. During their patrols, TEAs face potentially stressful interactions when they encounter motorists and pedestrians who may be angry about receiving summonses. Mood and ambulatory blood pressure were initially measured when TEAs were recently hired and attending classes at the training academy (Time 1), and were subsequently assessed again once the TEAs began independently patrolling the city streets (Time 2). Random effects regression models yielded a significant interaction of hostility and work activity on ambulatory systolic blood pressure at Time 2. For those high in hostility, but not for those low in hostility, systolic blood pressure levels were higher while interacting with members of the public than during nonsocial work activities. The findings support the notion that situational factors affect the association of hostility to cardiovascular reactivity, and that interpersonal stressors in the workplace elicit cardiovascular activation among those high in hostility.

Measurement invariance of the Mini Asthma Quality of Life Questionnaire across African-American and Latino adult asthma patients.

PURPOSE: This study tested the factorial and measurement invariance of the Mini Asthma Quality of Life Questionnaire (MiniAQLQ) in a sample of Latino and African-American asthmatic patients. METHODS: We used confirmatory factor analyses (CFA) to examine data from adult outpatients diagnosed with asthma (n = 265). We proceeded by examining the original factor structure of the MiniAQLQ in the whole sample. We then determined whether the factor structure supported by the data was invariant across African-American and Latino patients by testing a series of nested models. RESULTS: Results revealed that a three-factor structure model that combined the emotional function and symptom domains had the best fit to the whole sample (chi (2)(91) = 99.83, P = 0.08). Analysis using a MIMIC model among Latino participants indicated that survey language did not influence item functioning (chi (2)(93) = 103.29, P = 0.22). Multi-group CFA showed that both the structure and the meaning of the items were invariant across Africa-American and Latino participants. Scalar and strict measurement invariance was supported for 11 out of 15 items. CONCLUSION: These data suggest that structure of the MiniAQLQ needs to be reassessed. Additional research needs to examine whether elimination of current items or inclusion of new items can ensure that constructs are measured without bias across different ethnic groups.

Looking Inside the Black Box of "Attendance at Services": New Measures for Exploring an Old Dimension in Religion and Health Research.

Research in religion and health has spurred new interest in measuring religiousness. Measurement efforts have focused on subjective facets of religiousness such as spirituality and beliefs, and less attention has been paid to congregate aspects, beyond the single item measuring attendance at services. We evaluate some new measures for religious experiences occurring during congregational worship services. Respondents (N=576) were religiously-diverse community-dwelling adults interviewed prior to cardiac surgery. Exploratory factor analysis of the new items with a pool of standard items yielded a readily interpretable solution, involving seven correlated but distinct factors and one index variable, with high levels of internal consistency. We describe religious affiliation and demographic differences in these measures. Attendance at religious services provides multifaceted physical, emotional, social, and spiritual experiences that may promote physical health through multiple pathways.

Coping with racism: a selective review of the literature and a theoretical and methodological critique.

Racism is a stressor that contributes to racial/ethnic disparities in mental and physical health and to variations in these outcomes within racial and ethnic minority groups. The aim of this paper is to identify and discuss key issues in the study of individual-level strategies for coping with interpersonal racism. We begin with a discussion of the ways in which racism acts as a stressor and requires the mobilization of coping resources. Next, we examine available models for describing and conceptualizing strategies for coping with racism. Third, we discuss three major forms of coping: racial identity development, social support seeking and anger suppression and expression. We examine empirical support for the role of these coping strategies in buffering the impact of racism on specific health-related outcomes, including mental health (i.e., specifically, self-reported psychological distress and depressive symptoms), self-reported physical health, resting blood pressure levels, and cardiovascular reactivity to stressors. Careful examination of the effectiveness of individual-level coping strategies can guide future interventions on both the individual and community levels.

Framing written emotional expression from a religious perspective: effects on depressive symptoms.

OBJECTIVE: Previous research has found an inverse association between exposure to emotional trauma and well-being. More recently, studies on written emotional expression found that repeated expression of a traumatic experience is beneficial to physical health. However, possible mechanisms through which written emotional expression may work to influence health are still under investigation. Recent research on psychological stress has also found associations among religion, meaning, and health. This study evaluated the effects of taking a religious perspective while engaged in written emotional expression. METHOD: Participants included 215 college students, who were assigned randomly to one of three experimental groups. One was given conventional written emotional expression instructions for writing about a traumatic experience; another was instructed to write about the trauma from a religious/spiritual perspective; a control group wrote about a trivial topic. RESULTS: Compared with control participants, those in the trauma-religion condition experienced significantly greater reductions in depressive symptoms at 1-month follow-up. Conventional trauma writing had no effect on dependent measures. CONCLUSION: These findings encourage further investigation of religion as a factor that may augment the health-promoting effects of written emotional expression.