Expressive Writing for Depression and Anxiety

(EWMS Trial)

Overseen By Brian P Marx, PhD

Age: 18+

Sex: Any

Trial Phase: Academic

Sponsor: VA Office of Research and Development

Must be taking: Psychotropic

Disqualifiers: Suicidal plan, Unstable mania, Psychosis, Severe substance use, Cognitive impairment

Compensation: Varies

Number of Visits: 4

Duration: 3-4 weeks

85 Participants Needed

Trial Summary

What is the purpose of this trial?

Sexual minority stressors (e.g., sexual minority identity-based discrimination) contribute to greater risk for and severity of depression, anxiety, substance use disorders and suicide among sexual minority Veterans. However, no brief, scalable, one-on-one interventions targeting sexual minority stressor-related distress are available in Veterans Affairs (VA) for sexual minority Veterans. The proposed research will examine the feasibility, acceptability, and preliminary effectiveness of a brief, 3-session expressive writing intervention to target distress related to sexual minority stressor exposure among sexual minority Veterans. The results of this work will advance knowledge about a promising brief and easy to implement intervention focused on reducing depressive and anxiety symptoms among sexual minority Veterans. This proposal aligns with VA's and CSR\&D's commitment to providing equitable services to sexual minority Veterans and the aim of reducing health disparities among underserved Veteran groups.

Do I need to stop my current medications to join the trial?

The trial requires that participants be stable on their psychotropic medication for at least 4 weeks, so you do not need to stop taking your current medications if they are stable.

What data supports the effectiveness of the treatment Expressive Writing for Depression and Anxiety?

Research suggests that culturally-tailored writing interventions can help manage stress and improve mental health outcomes among African Americans by addressing justice and injustice, which may be relevant to the Expressive Writing treatment for depression and anxiety. ^{1 2 3 4 5}

Is expressive writing safe for humans?

The research articles provided do not contain specific safety data for expressive writing interventions, but generally, expressive writing is considered a low-risk activity for most people. ^{2 5 6 7 8}

How does the treatment Expressive Writing for Minority Stressors differ from other treatments for depression and anxiety?

Expressive Writing for Minority Stressors is unique because it involves writing about personal experiences related to minority stress, which can help reduce depression and anxiety by allowing individuals to process and express their emotions. Unlike traditional therapies that may involve direct interaction with a therapist, this treatment can be done privately and may be particularly beneficial for those who are socially inhibited or prefer not to engage in face-to-face therapy. ^{9 10 11 12 13}

Research Team

Kelly L Harper, PhD

Principal Investigator

VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA

Eligibility Criteria

This trial is for sexual minority Veterans experiencing significant depression or anxiety, who have faced discrimination due to their sexuality. They must score above 10 on specific mental health scales and identify as non-heterosexual. Those with severe substance use disorders, cognitive impairments, suicidal plans/intent, or unstable mania/psychosis cannot participate.

Inclusion Criteria

Participants must endorse clinically significant depressive or anxiety symptoms (score above 10 on the PHQ-9 or GAD-7)

Participants will be Veterans who identify as a sexual minority (i.e., identify as gay, lesbian, bisexual, pansexual, queer, or another identity other than heterosexual)

Participants must report a history of sexuality-based minority stressor exposure based on endorsement of at least one item on a modified version of the Everyday Discrimination Scale (EDS) that is contributing to distress per Veteran report ('yes' on EDS item 11)

Exclusion Criteria

Veterans with current substance use disorder, severe (assessed via the Structured Interview for DSM-5)

Veterans with clear and current suicidal plan and/or intent (assessed via the Columbia Suicide Severity Rating Scale)

Veterans with current presentation of unstable mania and/or psychosis (assessed via the Structured Interview for DSM-5)

Timeline

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Treatment

Participants undergo a 3-session expressive writing intervention targeting distress related to sexual minority stressors

3-4 weeks

3 sessions (in-person or remote)

Follow-up

Participants are monitored for safety and effectiveness after treatment

3 months

1 visit (in-person or remote)

Treatment Details

Interventions

• Expressive Writing on Minority Stressors
• Neutral Writing

Trial Overview The study tests a brief expressive writing intervention aimed at reducing distress from sexual minority stressors versus neutral writing. It involves three sessions designed for sexual minority Veterans to see if it can lessen symptoms of depression and anxiety.

Participant Groups

Group I: Expressive Writing on Minority Stressors Experimental Treatment 1 Intervention

The EWMS protocol will consist of 3 sessions delivered by a therapist (either in-person or remotely via telehealth platform) to sexual minority Veterans. The intervention will begin with an overview of the intervention, brief psychoeducation about expressive writing, and a review of the potential benefits of expressive writing. The initial session will also consist of psychoeducation on sexual minority stressors and common reactions to these stressors (i.e., universal stress reactions and minority-identity specific reactions) and how this relates to psychological outcomes, such as depression and anxiety, and high-risk behaviors, such as substance use and suicidal ideation. The initial session will be 60 minutes (introduction, psychoeducation, and first writing exercise) and the following two sessions (feedback, writing exercises, and check-ins) will take approximately 40 minutes.

Group II: Neutral Writing Placebo Group 1 Intervention

To be comparable to EWMS, the control intervention will also be a 3-session individual intervention involving engaging in a writing exercise per session. For the control writing exercises, participants will be asked to write for 30 minutes about their daily activities since waking up that day based on Pennebaker's standard writing paradigm (Pennebaker \& Beall, 1987). Individuals in the control condition will also be given information about the purpose of the writing exercises to be comparable to the psychoeducation information provided in EWMS. Similar to EWMS, the clinician will check in with the participant about the writing session, such as asking how the session went and how it felt to do the writing, following the 30 minutes of writing.

Who Is Running the Clinical Trial?

VA Office of Research and Development

Lead Sponsor

Trials

1,691

Recruited

3,759,000+

Findings from Research

The concept of 'culturally compelled coping' is introduced to describe how Black Americans use controlled coping strategies, such as emotional suppression and hypervigilance, as adaptive responses to systemic racism, rather than simply labeling them as overcontrolled coping.

This new model emphasizes the importance of understanding emotion regulation in the context of racism, suggesting that these coping strategies can have significant implications for the health and well-being of Black Americans.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

How Racism "Gets Under the Skin": An Examination of the Physical- and Mental-Health Costs of Culturally Compelled Coping. Brownlow, BN.[2023]

The study developed two brief writing interventions focused on justice and injustice, showing that these prompts can significantly influence how African Americans respond to acute social stress, particularly during a stress test.

Results indicated that men benefited from the personal justice-only condition with improved emotional responses and lower blood pressure reactivity, while women showed more negative emotional responses and poorer performance, highlighting the need to consider gender differences in stress coping strategies.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Writing about justice and injustice: Complex effects on affect, performance, threat, and biological responses to acute social stress among african American women and men. Lucas, T., Yamin, JB., Krohner, S., et al.[2023]

The 'healing attempt' is a brief digital music-based mindfulness intervention that shows promise in reducing race-based anxiety within the Black community.

This study not only replicates previous findings but also suggests that this intervention is both feasible and potentially effective, indicating a new approach to addressing mental health concerns related to racial anxiety.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

A Digital Music-Based Mindfulness Intervention ("healing attempt") for Race-Based Anxiety in Black Americans. Jones, G., Castro-Ramirez, F., McGuire, T., et al.[2023]

Racial discrimination has significant negative psychological effects on Black Americans, leading to racial stress and trauma (RST) that adversely impacts the wellness of Black youth and families.

The EMBRace intervention, guided by the Racial Encounter Coping Appraisal and Socialization Theory (RECAST), aims to enhance racial socialization practices within Black families to help cope with RST, promoting positive outcomes through psychoeducation and stress management.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

EMBRace: Developing a Racial Socialization Intervention to Reduce Racial Stress and Enhance Racial Coping among Black Parents and Adolescents. Anderson, RE., McKenny, MC., Stevenson, HC.[2023]

Racial stress and trauma are significant issues that can lead to psychological distress, but many therapists lack the training and resources to effectively address these concerns.

The article introduces the Healing Racial Trauma protocol, a cognitive-behavioral approach that includes evidence-based techniques for treating racial stress, emphasizing the importance of an anti-racist and empathy-centered therapeutic relationship.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

An Evidence-Based Approach for Treating Stress and Trauma due to Racism. Williams, MT., Holmes, S., Zare, M., et al.[2023]

In a study comparing treatment outcomes of cognitive behavioral therapy (CBT) for participants of color (n = 43) and White participants (n = 136), there were no significant differences in treatment retention or symptom outcomes, indicating that CBT is equally effective across these groups.

Participants of color, including Black, Latinx, and Asian American individuals, showed moderate to large improvements in anxiety and depression symptoms after CBT, suggesting that this treatment is effective for historically excluded racial and ethnic groups.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Outcomes of People of Color in an Efficacy Trial of Cognitive-Behavioral Treatments for Anxiety, Depression, and Related Disorders: Preliminary Evidence. Cardona, ND., Ametaj, AA., Cassiello-Robbins, C., et al.[2023]

In a longitudinal study of 291 adults (139 Latinx and 152 African American) with anxiety disorders, remission rates for PTSD were notably low, at 35% for African Americans and only 15% for Latinx individuals over 5 years, indicating a chronic course of PTSD in these populations.

Experiences with discrimination were found to significantly predict PTSD diagnosis in these groups, suggesting that racial and ethnic discrimination may play a critical role in the development and persistence of PTSD, highlighting the need for tailored assessment and treatment strategies that address these sociocultural factors.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Posttraumatic stress disorder in African American and Latinx adults: Clinical course and the role of racial and ethnic discrimination. Sibrava, NJ., Bjornsson, AS., Pérez Benítez, ACI., et al.[2022]

The pilot randomized controlled trial will assess the feasibility and acceptability of the Race-Based Stress and Trauma Empowerment (RBSTE) intervention among 48 Veterans of Color experiencing perceived discrimination and stress, comparing it to an active control group receiving Present-Centered Therapy (PCT).

Outcomes will focus on psychological distress, discrimination, ethnoracial identity, holistic wellness, and allostatic load, aiming to provide insights into effective interventions for addressing the health impacts of racism in the Veteran population.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Mitigating the health effects of systemic racism: Evaluation of the Race-Based Stress and Trauma Empowerment intervention. Wang, C., Malaktaris, A., McLean, CL., et al.[2023]

In a systematic review of 24 randomized controlled trials involving 1558 participants, positive writing (PW) was found to improve mood more effectively than expressive writing (EW) in the general population.

For patients, while PW was better at generating positive emotions, EW was more effective in stimulating cognitive changes, suggesting that both writing techniques can be beneficial depending on the population's needs.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Efficacy of expressive writing versus positive writing in different populations: Systematic review and meta-analysis. Lai, J., Song, H., Wang, Y., et al.[2023]

College students vulnerable to depression who engaged in expressive writing for three consecutive days showed significantly lower depression symptoms after six months compared to those in a control condition, particularly if they had high levels of emotional suppression.

The benefits of expressive writing were linked to reductions in brooding, a type of negative rumination, but not reflection, indicating that addressing specific thought patterns can enhance the effectiveness of this therapeutic approach.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Benefits of expressive writing in lowering rumination and depressive symptoms. Gortner, EM., Rude, SS., Pennebaker, JW.[2022]

Participants with mood disorders who engaged in expressive writing, positive writing, or control writing all reported significant improvements in mental and physical health symptoms for at least 4 months after the writing sessions.

Combining expressive and positive writing into an 'emotional writing group' resulted in significantly lower stress levels compared to the control group, suggesting that writing about emotions can be beneficial for mental health.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Expressive writing and positive writing for participants with mood disorders: an online randomized controlled trial. Baikie, KA., Geerligs, L., Wilhelm, K.[2018]

In a study of 72 individuals with high negative affectivity, those who engaged in positive emotional writing online showed significant reductions in depression and perceived stress reactivity four weeks later, compared to those who wrote about neutral topics.

The findings suggest that online therapeutic writing can be particularly beneficial for socially inhibited individuals, providing a safe and effective way to improve psychological health without the need for direct interaction with therapists.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Online writing about positive life experiences reduces depression and perceived stress reactivity in socially inhibited individuals. Allen, SF., Wetherell, MA., Smith, MA.[2020]

A study involving 136 Chinese American breast cancer survivors found that an enhanced self-regulation expressive writing intervention significantly reduced depressive and anxiety symptoms compared to a control group, with benefits lasting up to 6 months.

The effectiveness of the intervention was linked to reductions in perceived stress, highlighting the importance of culturally adapting therapeutic approaches to better serve minoritized groups.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

The effects of culturally adapted expressive writing interventions on depressive and anxiety symptoms among Chinese American breast cancer survivors: A randomized controlled trial. Lu, Q., Yeung, NCY., Tsai, W., et al.[2023]

References

1. United States pubmed.ncbi.nlm.nih.gov

How Racism "Gets Under the Skin": An Examination of the Physical- and Mental-Health Costs of Culturally Compelled Coping. [2023]

2. England pubmed.ncbi.nlm.nih.gov

Writing about justice and injustice: Complex effects on affect, performance, threat, and biological responses to acute social stress among african American women and men. [2023]

3. Canada pubmed.ncbi.nlm.nih.gov

A Digital Music-Based Mindfulness Intervention ("healing attempt") for Race-Based Anxiety in Black Americans. [2023]

4. United States pubmed.ncbi.nlm.nih.gov

EMBRace: Developing a Racial Socialization Intervention to Reduce Racial Stress and Enhance Racial Coping among Black Parents and Adolescents. [2023]

5. United States pubmed.ncbi.nlm.nih.gov

An Evidence-Based Approach for Treating Stress and Trauma due to Racism. [2023]

6. United States pubmed.ncbi.nlm.nih.gov

Outcomes of People of Color in an Efficacy Trial of Cognitive-Behavioral Treatments for Anxiety, Depression, and Related Disorders: Preliminary Evidence. [2023]

7. United States pubmed.ncbi.nlm.nih.gov

Posttraumatic stress disorder in African American and Latinx adults: Clinical course and the role of racial and ethnic discrimination. [2022]

8. United States pubmed.ncbi.nlm.nih.gov

Mitigating the health effects of systemic racism: Evaluation of the Race-Based Stress and Trauma Empowerment intervention. [2023]

9. United States pubmed.ncbi.nlm.nih.gov

Efficacy of expressive writing versus positive writing in different populations: Systematic review and meta-analysis. [2023]

10. England pubmed.ncbi.nlm.nih.gov

Benefits of expressive writing in lowering rumination and depressive symptoms. [2022]

11. Netherlands pubmed.ncbi.nlm.nih.gov

Expressive writing and positive writing for participants with mood disorders: an online randomized controlled trial. [2018]

12. Ireland pubmed.ncbi.nlm.nih.gov

Online writing about positive life experiences reduces depression and perceived stress reactivity in socially inhibited individuals. [2020]

13. England pubmed.ncbi.nlm.nih.gov

The effects of culturally adapted expressive writing interventions on depressive and anxiety symptoms among Chinese American breast cancer survivors: A randomized controlled trial. [2023]