Publications by authors named "Sean R Legler"

5 Publications

  • Page 1 of 1

An Adaptive Text Message Intervention to Promote Well-Being and Health Behavior Adherence for Patients With Cardiovascular Disease: Intervention Design and Preliminary Results.

J Acad Consult Liaison Psychiatry 2021 Jun 8. Epub 2021 Jun 8.

Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Department of Psychiatry, Harvard Medical School, Boston, MA. Electronic address:

Background: Most individuals with heart disease struggle to adhere to cardiovascular health behaviors, despite their known health benefits. Text message interventions (TMIs) are a promising treatment modality for health behavior promotion, but existing TMIs typically deliver a fixed set of messages and do not target well-being constructs associated with adherence and cardiovascular health.

Objective: To develop a 4-week TMI, which delivers daily messages to promote well-being and adherence to health behaviors and dynamically adapts based on participant feedback to deliver increasingly customized messages; and to assess its feasibility, acceptability, and preliminary efficacy in a single-arm, proof-of-concept trial in 14 individuals with coronary artery disease (age mean = 67.9, standard deviation = 8.7).

Methods: Participants received daily text messages related to well-being, physical activity, or diet, rated each message's utility, and these ratings informed the TMI's choice of future text messages. Feasibility was assessed by the proportion of messages successfully sent, and acceptability was assessed by participant ratings of intervention burden and text message utility. Finally, the intervention's preliminary efficacy was explored by measuring pre-post changes in psychologic and behavioral outcomes.

Results: The TMI was both feasible (93% of participants received all messages) and well-accepted (mean text message utility: 7.0 of 10 [standard deviation 2.5]; mean intervention utility: 6.4 of 10 [standard deviation 0.9]; mean intervention burden: 0.5 of 10 [standard deviation 0.9]). Participants reported that messages related to well-being were particularly helpful and that most messages led to an action (e.g., eating more vegetables, being kind to others). The TMI led to nonsignificant, small-to-medium effect size improvements in happiness, optimism, determination, depression, anxiety, self-rated health, and diet (d = 0.19-0.48), and, unexpectedly, small reductions in activity and physical function (d = -0.20 and -0.32).

Conclusions: The adaptive TMI was feasible, well-accepted, and associated with nonsignificant improvements in psychologic outcomes and mixed effects on behavioral outcomes. Larger, well-powered studies are needed to determine whether this TMI will be able to improve well-being and health-related outcomes in this high-risk population.
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June 2021

State Gratitude for One's Life and Health after an Acute Coronary Syndrome: Prospective Associations with Physical Activity, Medical Adherence and Re-hospitalizations.

J Posit Psychol 2019 4;14(3):283-291. Epub 2018 Jan 4.

Harvard Medical School, Boston, MA, United States of America.

Gratitude may be associated with beneficial health outcomes, but studies of this association have been mixed, and in these studies gratitude has often been conceptualized as a stable, unidimensional trait. We used four specific items to examine the prospective association of state- and domain-specific gratitude with medical outcomes among 152 patients with a recent acute coronary syndrome. State gratitude for one's health 2 weeks post-event was associated with increased physical activity (measured via accelerometer) 6 months later, controlling for relevant demographic, social, medical and psychological factors (β=340.9; 95% confidence interval=53.4-628.4; p=.020). Gratitude for one's life was associated with increased self-reported medical adherence at 6 months on the maximally adjusted model (β=.60; 95% confidence interval=.16-1.04; p=.008); no gratitude items were associated with rehospitalizations. In contrast, dispositional gratitude, measured by the Gratitude Questionnaire-6, was less dynamic and responsive to change over the 6-month period and was not associated with physical activity.
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January 2018

Development of the State Optimism Measure.

Gen Hosp Psychiatry 2019 May - Jun;58:83-93. Epub 2019 Apr 4.

Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.

Background: Optimism, or positive expectations about the future, is associated with better health. It is commonly assessed as a trait, but it may change over time and circumstance. Accordingly, we developed a measure of state optimism.

Methods: An initial 29-item pool was generated based on literature reviews and expert consultations. It was administered to three samples: sample 1 was a general healthy population (n = 136), sample 2 was people with cardiac disease (n = 96), and sample 3 was persons recovering from problematic substance use (n = 265). Exploratory factor analysis and item-level descriptive statistics were used to select items to form a unidimensional State Optimism Measure (SOM). Confirmatory factor analysis (CFA) was performed to test fit.

Results: The selected seven SOM items demonstrated acceptable to high factor loadings on a single dominant factor (loadings: 0.64-0.93). There was high internal reliability across samples (Cronbach's alphas: 0.92-0.96), and strong convergent validity correlations in hypothesized directions. The SOM's correlations with other optimism measures indicate preliminary construct validity. CFA statistics indicated acceptable fit of the SOM model.

Conclusions: We developed a psychometrically-sound measure of state optimism that can be used in various settings. Predictive and criterion validity will be tested in future studies.
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January 2020

Optimizing a Positive Psychology Intervention to Promote Health Behaviors After an Acute Coronary Syndrome: The Positive Emotions After Acute Coronary Events III (PEACE-III) Randomized Factorial Trial.

Psychosom Med 2018 Jul/Aug;80(6):526-534

From the Harvard Medical School (Celano, Millstein, Chung, Campbell, Legler, Park, Healy, Januzzi, Huffman); Departments of Psychiatry (Celano, Albanese, Millstein, Mastromauro, Chung, Campbell, Legler, Park, Huffman) and Neurology (Healy), Massachusetts General Hospital, Boston; The Methodology Center and Department of Human Development and Family Studies (Collins), Pennsylvania State University, University Park; and Division of Cardiology (Januzzi), Department of Medicine, Massachusetts General Hospital and Cardiometabolic Trials, Baim Institute for Clinical Research, Boston.

Objective: Despite the clear benefits of physical activity and related behaviors on prognosis, most patients experiencing an acute coronary syndrome (ACS) remain nonadherent to these behaviors. Deficits in positive psychological constructs (e.g., optimism) are linked to reduced participation in health behaviors, supporting the potential utility of a positive psychology (PP)-based intervention in post-ACS patients. Accordingly, we aimed to identify optimal components of a PP-based intervention to promote post-ACS physical activity.

Methods: As part of a multiphase optimization strategy, we completed a randomized factorial trial with eight conditions in 128 post-ACS patients to efficiently identify best-performing intervention components. All participants received a PP-based intervention, with conditions varying in duration (presence/absence of booster sessions), intensity (weekly/daily PP exercises), and content (PP alone or combined with motivational interviewing), allowing three concurrent comparisons within the trial. The study aims included assessments of the overall feasibility, acceptability, and impact of the intervention, along with the primary aim of determining which components were associated with objectively measured physical activity and self-reported health behavior adherence at 16 weeks, assessed using longitudinal models.

Results: The intervention was well accepted and associated with substantial improvements in behavioral and psychological outcomes. Booster sessions were associated with greater activity to a nearly significant degree (β = 8.58, 95% confidence interval = -0.49-17.65, effect size difference = .43, p = .064), motivational interviewing was associated with overall adherence (β = 0.95, 95% confidence interval = 0.02-1.87, effect size difference = .39, p = .044), and weekly exercise completion was generally superior to daily.

Conclusions: These findings will enable optimization of the PP-based intervention in preparation for a well-powered controlled trial.

Clinical Trial Registration:, NCT02754895.
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June 2019

Positive psychological well-being and health in patients with heart disease: a brief review.

Future Cardiol 2017 Sep 22;13(5):443-450. Epub 2017 Aug 22.

Department of Psychology, Chapman University, Orange, CA 92866, USA.

Poor psychological health (e.g., depression and anxiety) is prospectively associated with adverse cardiac outcomes. In contrast, there is increasing evidence that positive psychological constructs like happiness, optimism and gratitude are independently and prospectively linked to better health behaviors and superior cardiac prognosis in people with and without heart disease. However, a critical question is whether such positive states and traits are modifiable. Recent studies of systematic positive psychology interventions designed to promote well-being have shown promise in patients with heart disease, and more data are needed to learn whether these interventions are effective and whether they can be broadly applied to impact public health.
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September 2017