ONLINE RESOURCE: ELECTRONIC SUPPLEMENTAL MATERIALS
Mantram Repetition Fosters Self-Efficacy
Supplemental Materials
Mantram Repetition Fosters Self-Efficacy in Veterans for Managing PTSD: A Randomized Trial
by D. Oman, 2014, Psychology of Religion and Spirituality
http://dx.doi.org/10.1037/a0037994
Electronic Supplemental Materials
This file is the Online Resource (electronic supplemental materials) for the paper “Mantram Repetition Fosters Self-Efficacy in Veterans for Managing PTSD: A Randomized Trial,” by Doug Oman, to be published in the Psychology of Religion and Spirituality.
This material is offered as potentially useful to readers who may have specific interests, but is not deemed as essential to understanding the main concepts or findings of the article.
CONTENTS
PageAppendix A: Additional Information on Intervention & Weekly Questions / 2
Appendix B: Additional Information on Statistical Analyses / 4
Appendix C: Additional Results / 5
Appendix D: Additional Narrative Reports by Intervention Participants / 6
Appendix A: Additional Information on Conditions (Intervention, Control) &Weekly Questions
Participants received either case management alone (control group), or MRP plus case management (treatment group). The manualized MRP intervention was delivered in 6 weekly sessions, 90-minutes per week, by two Masters level psychiatric nurses. Veterans attended in groups that ranged from 3 to 9 members. Each class included lecture, sharing, and home work assignments. In the first session, veterans received a brief review of PTSD signs and symptoms followed by instructions on how to choose and silently repeat a mantram to train attention. Although participants were encouraged to choose a mantram from a spiritual tradition, they were permitted to use words they regarded as more acceptable, such as the word “one” (see Bormann, Oman et al., 2005; Benson & Stark, 1996). The second session introduced the concept of the stress response, and addressed barriers and resistance to using a mantram and ways to repeat a mantram for symptom management. In the third session, mantram repetition was taught as a means of slowing down thoughts and reactivity. The fourth session introduced the skill of one-pointed attention or mindfulness in doing one thing at a time. The last two sessions reviewed course content, outlined ways to use all three strategies synergistically and keep practice going. Every week, participants were encouraged to increase daily mantram practice. There were no reported adverse events or side effects (Bormann et al, 2013).
Regarding treatment fidelity, the two cofacilitators followed written guidelines. Two of every six classes within each cohort were randomly selected and reviewed by two quality control experts who were master’s-level nurses with MRP experience. They used a checklist to evaluate content conformity. Recordings from one cohort were missing due to equipment failure. Audiotapes were reviewed for the remaining 11 out of the 12 total cohorts. Of the 22 classes that were rated, there was 86% agreement that the course content was addressed adequately (Bormann et al, 2013).
Case Management Component of Each Condition (Treatment, Control)
When each participating veteran was enrolled in the present study, he/she had already been assigned to a “case manager” who was responsible to coordinate that veteran's treatment. Care was individually determined. Any case manager could have individual weekly sessions with the veteran, like individual therapy, if deemed necessary. However, due to heavy case loads, individual therapy was rare for veterans at the large VA facility that hosted the present study. At this facility, most PTSD treatments of all types were delivered in groups. The case manager would recommend the next type of group therapy they thought their veterans would need, and veterans often had to wait until a group therapy was available. The case manager was also available to see the Veteran for any medication changes. Case managers could be any type of healthcare professional (social worker, psychologist, psychology intern, psychiatric/clinical nurse, or psychiatrist/MD). None of the case managers were affiliated with the study (e.g., none served as study personnel).
Thus, because a PTSD diagnosis was a study inclusion criterion, every participant in both the MRP condition and the control condition had a case manager and was receiving case management. Because of random assignment, the baseline features of case management should have been equivalent between conditions (treatment or control). To monitor the ongoing equivalence between conditions of the case management received by participants, data related to the number of provider visits per week and changes in medications (yes or no) were collected in questions completed by participants, validated by chart review. There were no statistically significant differences in numbers of provider visits between the treatment and control groups (p=.67 in rank sum test of mean visits/week; p=.62 in poisson mixed model), which from Week 1 to Week 6 amounted to a mean of 4.38 across all participants (N=132, SD=3.97), and means of 4.22 in the control group (N=69, SD=3.83), and 4.56 in the treatment group (N=63, SD=4.14). Medical records were also reviewed to identify medication changes that could plausibly alter PTSD symptoms (e.g., SSRIs or other mood stabilizers). The numbers of psychotropic medication changes (types and dosages) were evaluated each week using chi-square and t tests, and found to be equivalent. More specifically, during the 6 weeks of active treatment, there were medication changes for 16 subjects in the case management condition and 20 subjects in the MRP + case management condition (Bormann, Thorp et al, 2013, p. 263), with 25% of participants overall experiencing a change (21% of controls and 29% of treatment, p=.33 for difference).
Weekly Questions on Self-Efficacy, Provider Visits, and Medication Changes
From Weeks 2 through 12, participants in each condition completed questions that tracked 3 weekly variables of interest (data for Weeks 7 to 11 were unanalyzed in this study). These variables were 1) PTSD symptom management self-efficacy (as described in the main manuscript), 2) Provider visits, if any, and 3) Changes in medications, if any. Questions were worded identically for all participants in both groups. Each question referred to perceptions or events of the previous week. From Weeks 2 through 6, MRP group participants completed the questions at the beginning of their group meetings, and handed them in. The case management group received a packet of weekly questions at baseline, with instructions to complete each week’s questions on a specified day (which corresponded to the MRP group meetings). From Weeks 2 through 6, these case management participants received telephone reminders to complete their questions on the specified day, and all questions were collected beginning at week 7 when they (as a “wait-list” group) met to begin their own receipt of the MRP intervention. At Week 7 after completing the MRP, the MRP group received a packet of questions, and the methods of collecting the questions were reversed between the two treatment conditions: Questions were eventually collected from the original MRP participants at Week 12 as they visited the clinic to complete another package of assessments (which were unanalyzed in the present study), and from the original case management participants when they had their final meeting at Week 12.
References for Appendix A
Benson, H., & Stark, M. (1997). Timeless Healing: the Power and Biology of Belief. New York: Fireside.
Bormann, J. E., Oman, D., Kemppainen, J. K., Becker, S., Gershwin, M., & Kelly, A. (2006). Mantram repetition for stress management in veterans and employees: A critical incident study. Journal of Advanced Nursing, 53(5), 502-512. doi: 10.1111/j.1365-2648.2006.03752.x
Bormann, J. E., Thorp, S. R., Wetherell, J. L., Golshan, S., & Lang, A. J. (2013). Meditation-based mantram intervention for veterans with posttraumatic stress disorder: A randomized trial. Psychological Trauma: Theory, Research, Practice, and Policy, 5(3), 259-267. doi: 10.1037/a0027522
Appendix B: Additional Information Relevant to Statistical Analyses
Effects of treatment were analyzed in hierarchical linear models (HLM), sometimes called linear mixed models (Singer, 1998), which are increasingly a tool of choice for analyzing longitudinal data. Compared to more conventional methods such as ANOVA, HLM allows improved handling of unbalanced designs and missing data, and more flexible analyses of data gathered at multiple timepoints. In HLM terminology (Raudenbush & Bryk, 2002), we used the following model for our primary tests for treatment effects at Week 6, based on data from only Weeks 1 and 6:
Yk(i),t = c0 + βTXIk,t + Rk(i) + Gk + Tt + ek(i),t
In this formula, Yk(i),t represents the outcome for the ith individual within the kth treatment condition (k = 1 or 2) at Week t (t = 1 or 6). The Week 6 treatment effect is represented by βTX, which is the coefficient of Ik,t, a “Level 1” predictor that is 1 for the treatment group at Week 6, and 0 otherwise. Thus, Ik,t represents whether an individual at time t has received the treatment. The other terms in the model represent adjustments and an error term. Adjustment for preexisting individual differences in outcome level is included as a “Level 2” random effect, represented by Rk(i). Adjustment for group assignment (e.g., baseline group differences, despite their lack of statistical significance) is included as a Level 2 fixed effect, represented by Gk. Adjustment for temporal trends that affect all participants equally is included as a Level 1 fixed effect, represented by Tt, the change since baseline for each week t > 1. Residual error, the discrepancy between the observed and expected outcome of individual k(i) at Week t, is represented by the Level 2 random effect ek(i),t, assumed to be independent and normally distributed with mean of zero and a variance of σ2. The global intercept is represented by c0.
Variations of this model were used to explore additional questions. One application involved estimating treatment effects based on a prorated treatment effects model in which the effect of treatment is postulated as growing from 0% at Week 1 to 20% of its ultimate size at Week 2, to 40% at Week 3, and to 60%, 80%, and 100% at Weeks 4, 5, and 6, respectively. This model was represented by replacing βTXIk,t with βTXJk,t, where Jk,t represents the proportion of treatment that group k will have experienced by Week t. To model treatment as linearly prorated, we used Jk,t.= ((t-1)/5)Ik,t. As in the first equation displayed above, βTX represents the treatment effect after Week 6. Additional applications involved tests of mediation, and sensitivity analyses for incorporating individuals with partial data.
References for Appendix B
Singer, J. D. (1998). Using SAS PROC MIXED to fit multilevel models, hierarchical models, and individual growth models. Journal of Educational and Behavioral Statistics, 23, 323-355. doi:10.2307/1165280
Raudenbush, S. W., & Bryk, A. S. (2002). Hierarchical linear models: Applications and data analysis methods. Sage, Thousand Oaks, CA.
Appendix C: Additional Results
Post-hoc exploratory analyses compared self-efficacy and spiritual well-being as potential mediators of treatment effects on PTSD symptoms, depression, and mental health. These analyses suggested that spiritual well-being was statistically more powerful, but that the mediating effects of self-efficacy and spiritual well-being were at least partially independent of each other. More specifically, inserting self-efficacy alone as a predictor in the HLM model reduced each treatment effect to between 56% and 82% of its original size (to 64, 56, 67, 82, and 64 percent, respectively, for CAPS, PCL, depression, mental health, and physical health satisfaction), although treatment effects remained significant for depression and mental health (“partial mediation”). Inserting spiritual well-being instead of self-efficacy diminished treatment effects more strongly, to between 6% and 31% of their original sizes (31, 17, 6, 21, and 25 percent, respectively), reducing treatment effect to nonsignificance in each case (“full mediation”). But when both mediators were inserted together as predictors in the HLM model, self-efficacy and spiritual well-being each remained independently statistically significant in predicting each outcome (p1s < .05), and estimated treatment effects were further reduced in magnitude for 4 of the 5 outcomes, in comparison to using either mediator alone (12, -5, -7, 15, and 8 percent, respectively). Finally, when spiritual well-being was controlled at each step, Sobel tests for indirect effects through self-efficacy indicated that self-efficacy remained marginally significant as a mediator of treatment effects on 4 of the 5 outcomes (Sobel test p1s = .07, .06, .07, .11, and .08, respectively).
When tests of mediation are performed using 2-tailed tests (rather than one-tailed tests as reported in the main text), all the Baron and Kenny mediation criteria for all outcomes were satisfied at least marginally (i.e., p2<.10). The least significant of the four criteria (Sobel test, treatment predicts outcome, self-efficacy predicts outcome, and treatment predicts self-efficacy) are as follows: CAPS, p2=.07 (marginal); PCL, p2=.02; Depression, p2=.02; Mental health, p2=.06 (marginal); physical health satisfaction, p2=.08 (marginal); spiritual well-being, p=.04. Thus, mediation is significant (p2<.05) for two of the five outcomes, and marginal (p2<.10) for the other two.
Appendix D: Additional Narrative Reports by Intervention Participants
A video available online provides additional narrative reports by veterans of how they use the mantram to manage symptoms. This video is an April 2012 news segment from KPBS television (San Diego, California). The video illustrates how several veterans who used the mantram had high levels of self-efficacy for managing symptoms. The video may be found at URL:
http://www.kpbs.org/news/2012/apr/03/vets-find-mantram-repetition-helps-ptsd-symptoms/
Other published sources of narrative reports from different populations about the effects of mantram repetition include:
• Bormann, J. E., Hurst, S., & Kelly, A. (2013). Responses to mantram repetition program from veterans with posttraumatic stress disorder: A qualitative analysis. Journal of Rehabilitation Research and Development, 50, in press. doi:10.1682/JRRD.2012.06.0118
• Bormann, J. E., Oman, D., Kemppainen, J. K., Becker, S., Gershwin, M., & Kelly, A. (2006). Mantram repetition for stress management in veterans and employees: A critical incident study. Journal of Advanced Nursing 53, 502-512. doi:10.1111/j.1365-2648.2006.03752.x
• Bormann, J., Warren, K. A., Regalbuto, L., Glaser, D., Kelly, A., Schnack, J., & Hinton, L. (2009). A spiritually based caregiver intervention with telephone delivery for family caregivers of veterans with dementia. Family & Community Health 32, 345-353. doi:10.1097/FCH.0b013e3181b91fd6
• Hunter, L., Bormann, J., Belding, W., Sobo, E. J., Axman, L., Reseter, B. K.... Anderson, V. M. (2011). Satisfaction and use of a spiritually based mantram intervention for childbirth-related fears in couples. Applied Nursing Research 24, 138-146. doi:10.1016/j.apnr.2009.06.002