PURPOSE: Stress Management Intervention (SMI) was one of seven nonpharmacologic approaches evaluated in Phase I Trials of Hypertension Prevention (TOHP-I) for efficacy in lowering diastolic blood pressure (BP) in healthy men and women aged 30 to 54 years with diastolic BP 80-89 mm Hg.METHODS: A total of 242 and 320 participants were randomized to SMI or an assessment only" SMI Control, respectively, at four clinical centers. The SMI consisted of 37 contact hours in 21 group and two individual meetings over 18 months and included: training in four relaxation methods, techniques to reduce stress reactions, cognitive approaches, communication skills, time management, and anger management within a general problem-solving format. Standardized protocols detailed methods and timing for collecting BP, psychosocial measures, and urinary samples from both SMI and SMI Control participants.RESULTS: In intention-to-treat analyses, although significant baseline to termination BP reductions were observed in both groups, net differences between the SMI and SMI Control groups' BP changes (mean (95% CI)) were not significant: -0.82 (-1.86, 0.22) for diastolic BP, and -0.41 (-1.96, 1.01) for systolic BP. Extensive adherence sub-group analyses found one effect: a significant 1.36 mm Hg (p = 0.01) reduction in diastolic BP relative to SMI Controls at the end of the trial for SMI participants who completed 61% or more of intervention sessions.CONCLUSIONS: While the TOHP-I SMI was acceptable to participants as evident from high levels of session completion, the absence of demonstrated BP lowering efficacy in intention-to-treat analyses suggests that the TOHP-I SMI is an unlikely candidate for primary prevention of hypertension in a general population sample similar to study participants. The isolated finding of significant diastolic BP lowering in SMI participants with higher adherence provides very weak evidence of SMI BP lowering efficacy and may be a chance finding. Whether similar or other stress management interventions can produce significant BP lowering in populations selected for higher levels of BP, stress, or intervention adherence remains to be demonstrated. Ann Epidemiol 2000;10:45-58. Published by Elsevier Science Inc.

Investigations suggesting that the order of obtaining resting and cardiovascular reactivity measurements moderates values have provided inconsistent results and have not analyzed data from children; the generalizability of results is uncertain. In this investigation, all children enrolled in the eighth-grade classrooms of the public schools of an entire county (n = 451) participated in standardized reactivity assessments. The order of resting and reactivity measurements was randomized by examination day (a total of 19 days). Analyses indicated that all comparisons of order effects on mean resting blood pressure and heart rate, as well as reactivity (both change from resting and absolute values and both mean and maximal values), were nonsignificant. Results indicate that measurement order is not always a necessary consideration in studies of reactivity; the conditions under which measurement order is a consideration requires clarification.

Blood pressure and heart rate were measured at rest and during a television video game in 399 healthy children. At the first assessment, children were in third grade and at the 2-year follow-up, they were in fifth grade. Children were classified according to race (black/white), gender (boy/girl), body mass index (light/heavy), and video game performance (low score/high score). Correlational analysis indicated that irrespective of the classification variable, absolute reactivity values, e.g., a heart rate of 110 bpm, tended to be more stable than change reactivity values, e.g., a heart rate change of 10 bpm. The greater stability of absolute values was most pronounced with systolic blood pressure. Absolute values were at least as stable as resting values and frequently demonstrated greater stability. Mean and maximal reactivities were correlated comparably. We conclude that children's reactivity is a stable characteristic and that, unless indicated by a priori hypotheses, the use of absolute values is preferable to the use of change values.

Cardiovascular reactivity is the change in blood pressure, pulse, and other parameters of cardiovascular function in response to a challenging task. During the conduct of cardiovascular reactivity protocols, researchers frequently use automated blood pressure devices to measure blood pressure reactivity. However, the accuracy of automated devices in measuring blood pressure reactivity is unknown. To investigate the accuracy and precision of the Dinamap 1846 SXP and the VitaStat 2600B in the measurement of blood pressure reactivity, we compared blood pressure reactivity recorded by the VitaStat and Dinamap with that obtained by observers using a conventional mercury sphygmomanometer. At three sites, 159 normotensive subjects performed the same task twice, once with blood pressure reactivity measured by the manual observers and once by the VitaStat (n = 79) or Dinamap (n = 80), with the order determined at random. Ratios (VitaStat/Dinamap) of aggregate within-person variance for baseline and task, systolic and diastolic blood pressures ranged from 1.53 to 4.93 (all P < 0.01), suggesting that the Dinamap has better precision than the VitaStat. For both diastolic and systolic blood pressure reactivity and for both types of automated devices, the mean differences in blood pressure reactivity between manual and automated measurements were small (range, −1.8 to 0.8 mm Hg). However, the VitaStat versus manual scatter plot of diastolic blood pressure reactivity showed greater dispersion (correlation coefficient r = 0.16, P = 0.15) than the Dinamap versus manual scatter plot (r = 0.36, P = 0.001). For systolic blood pressure reactivity, the VitaStat versus manual and Dinamap versus manual scatter plots were similar. Our data indicate that the Dinamap is superior to the VitaStat in the measurement of blood pressure reactivity. The substantial performance differences between the VitaStat and Dinamap suggest that other automated blood pressure monitors must be evaluated prior to use in cardiovascular reactivity studies.

The present study investigated professional perceptions of utility and the actual predictive validity of the MMPI and the Millon Behavioral Health Inventory (MBHI) in a sample of chronic pain patients. Overall results indicated statistical preference for the MBHI on nine of the ten dimensions of clinical utility. In addition, patient prognosis was rated as more favorable based upon the MBHI report. The differences noted between raters of different professional capacities were hypothesized to reflect differences in familiarity with assessing pain patients from a psychological perspective. However, over the course of a one year follow-up, neither instrument significantly predicted such behaviors as hospital usage, medication usage or general status. Rather, the psychologists who wrote the original consultations (which were not rated for utility) were more accurate than either the MMPI or the MBHI in predicting these health related behaviors.

The purpose of the present study was to perform a multimeihod assessment of the Type A behavior pattern in a sample of patients with coronary artery disease (CAD) participating in a cardiac rehabilitation program and to examine the relationship between Type A behavior and the severity of previously determined CAD. Results, based on the Structured Interview, indicated a preponderance of Type A behavior among the 52 patients. Other Type A measures, the jenkins Activity Survey. Framingham Type A Scale, and Bortner Type A Rating Scale, showed more normal distributions of patient scores. The relationship between the behavior pattern and CAD was affected by the method of determining Type A behavior and the method of determining CAD severity. Type A behavior, assessed by the Structured Interview, demonstrated a significant association with CAD severity only with adjustment for additional CAD risk factors. Thus, discrepancies in previous investigations may be explicable in terms of the measurement of both Type A and CAD as well as the presence or absence of more traditional risk factors. Finally, Type A behavior may be a CAD risk factor throughout adulthood.