Positive Psychology Interventions and Cardiovascular Health Frequency and Duration to Sustain Cardiovascular Benefits

SUMMARY

PPIs represent an emerging, evidence-based approach to strengthening CV health through psychological well-being. This review indicates that PPIs can bolster CV health across both primary and secondary prevention. Hybrid formats consistently outperformed single-mode delivery, yielding the largest gains in physical activity and adherence behaviors. Defining the optimal parameters for frequency and duration, and confirming effectiveness across diverse populations, will be an essential next step to ensure that benefits are both reproducible and equitable. Larger, long-term RCTs and real-world implementation studies are essential to determine whether and how these benefits translate into sustained reductions in CV events and mortality. As mental health is an essential component of CV health, aligning policy, research, and clinical practice will be key to unlocking the full potential of PPIs in reducing the global burden of CVD.

INTRODUCTION

The interplay between psychological health and cardiovascular disease (CVD) has traditionally been examined through the risk conferred by depression, anxiety, and stress.¹ Increasingly, however, accumulating evidence highlights that positive psychological well-being, reflected through resources such as optimism, positive affect, and emotional vitality act as independent protective factors. Large-scale observational studies, meta-analyses, and a recent American Heart Association scientific statement consistently emphasize that higher levels of psychological well-being are associated with reduced incidence of CVD and lower mortality.^1–4 These associations, replicated across diverse populations, suggest that fostering psychological well-being may present a viable pathway for CVD prevention.²

Positive psychological interventions (PPIs) emerged in the early 2000s as part of the broader positive psychology movement, which expanded the field of psychology beyond the remediation of distress toward the systematic cultivation of well-being, strengths, and human flourishing.⁵ PPIs are defined as structured, theory-driven strategies such as gratitude journaling, mindfulness practice, and strengths identification. These strategies are designed to build psychological resources, including optimism, positive affect, and purpose in life, which are shown to foster optimal functioning across life domains.⁶ Unlike traditional approaches focused on reducing distress, PPIs thus proactively cultivate positive psychological resources, with potential downstream benefits for physical health, including cardiovascular (CV) outcomes.²

Although positive psychological well-being is linked to CV health, intervention studies have rarely defined the adequate dose of PPIs. To date, existing trials offer important insights,^7,8 but they also underscore unresolved questions about the optimal dose (ie, frequency and duration) of PPIs to improve CV health. Clarifying the optimal dose is essential for guiding intervention design, ensuring adherence, and informing implementation in both clinical and community settings. Thus, the narrative article aims to synthesize current evidence on the frequency and duration of PPIs in relation to CV outcomes to clarify effective delivery parameters and highlight considerations for integration into clinical prevention and care. In doing so, it focuses on adults with, or at risk for, CVD. Moreover, consistent with the recent American Heart Association scientific statement,¹ the article includes mindfulness-based interventions within the PPI framework, given their emphasis on cultivating positive states and well-being. In some instances, mindfulness-based interventions are referenced separately to highlight distinctions in mechanism or delivery (eg, attention regulation vs emotion cultivation), but all are examined under the overarching PPI umbrella.

POSITIVE PSYCHOLOGICAL AND MINDFULNESS-BASED INTERVENTIONS

PPIs encompass a range of interventions that focus on enhancing well-being using a strengths-based approach.⁹ Because definitions of well-being vary across disciplines, many PPIs draw on the PERMA model, a widely recognized framework defining well-being across 5 core domains: positive emotion, engagement, relationships, meaning, and accomplishments.¹⁰ Frequently studied PPIs include gratitude exercises, identification of personal strengths, engaging in acts of kindness or prosocial behavior, and mindfulness practices. These interventions typically involve practices that align with specific PERMA domains, such as gratitude journaling to foster positive emotion or time in nature to enhance engagement.¹⁰ Table 1 summarizes the PERMA domains, core psychological resources, representative strategies, and proposed mechanisms targeted by positive psychological and mindfulness-based interventions in adults with or at risk for CVD.

Table 1.

PERMA domains and intervention categories: resources targeted, example strategies and mechanisms of efficacy for adults with or at risk for cardiovascular disease

PERMA Domain/Intervention Category	Primary Psychological Resources Targeted	Representative Strategies/Examples	Proposed Mechanism of Efficacy
Positive emotion	Gratitude, joy, emotion regulation	Daily reflection on positive events (“Three Good Things”), writing gratitude letters, keeping a gratitude journal	Activation of positive emotion broadens cognitive and behavioral repertoires, reduces physiologic stress reactivity
Engagement	Self-efficacy, mastery, flow	Identifying personal strengths, setting small achievable goals, practicing skills that foster absorption and focus	Intrinsic motivation and perceived competence promote sustained behavior change
Relationships	Social connectedness, compassion, belonging	Performing prosocial behaviors (eg, acts of kindness), expressing appreciation, practicing mindful listening in relationships	Strengthened social ties buffer stress responses and enhance parasympathetic regulation
Meaning	Purpose, spirituality, psychological coherence	Writing about life purpose, reflecting on personal values, engaging in spiritually oriented gratitude or prayer	Cultivation of meaning supports cognitive coherence, reduces stress perception, and improves vascular regulation
Accomplishment	Optimism, cognitive flexibility, goal pursuit	Visualizing one’s “best possible self,” setting health-related goals, practicing positive reframing	Reframing and success reinforcement increase expectancy for positive outcomes and motivation
Multicomponent PPIs	Combination of multiple domains above	Blended programs combining gratitude, strengths, and optimism exercises with motivational interviewing	Synergistic activation of multiple positive states enhances resilience and adherence
Mindfulness-based programs (within PPI framework)	Attention regulation, awareness, stress reduction	Guided mindfulness meditation, body scan, mindful breathing, gentle movement (eg, yoga-based practices)	Focused attention and acceptance reduce sympathetic arousal and improve self-regulation

Accumulating evidence underscores the efficacy and versatility of PPIs across populations and delivery contexts (Fig. 1). PPIs, including multiple intervention components that combine strategies such as gratitude practices and acts of kindness, demonstrate meaningful mental health benefits.⁶ A 2020 meta-analysis reports moderate improvements in psychological well-being and small effects in subjective well-being and depressive symptoms.⁶ PPIs are delivered in multiple formats, including individual, self-help, group-based, and digital, and show comparable effects across delivery modes. They are typically evaluated against cognitive behavioral therapy (CBT), active health-education controls, or treatment as usual/waitlist conditions.⁶ Treatment duration varies, from single-session interventions to 20-week programs, with weekly sessions over 6 to 12 weeks most common.⁶

Fig. 1.

Key characteristics of PPIs, including components, delivery formats, comparison arms, and associated mental-health benefits.

Research suggests that the efficacy of PPIs in improving psychological well-being and positive affect is mediated by several key mechanisms. The broaden-and-build theory posits that positive emotions expand “momentary thought-action repertoires,” promoting the development of psychological, social, physical, and intellectual resources that encourage human flourishing or optimal psychological functioning.⁵ For example, feelings of joy can spark curiosity and creativity, while gratitude can strengthen social bonds, both of which contribute to resilience and well-being. Building on strengths and self-efficacy (confidence in one’s ability to carry out specific behaviors successfully) further bolsters well-being by expanding psychological resources and shifting focus from deficits to strengths.¹¹ Positive reframing, including gratitude practices, can support emotional flexibility, psychological adaptation, and social connection.¹² For instance, reflecting on a stressful experience with appreciation for what was learned can transform distress into a sense of growth or meaning. Finally, in alignment with the PERMA model, developing a sense of connection to others and purpose in life represent additional pathways, often expressed through prosocial behaviors such as helping or acts of kindness.¹³ Although not exhaustive, these mechanisms highlight the broad pathways through which PPIs influence outcomes.

RANDOMIZED CONTROLLED TRIALS EVALUATING POSITIVE PSYCHOLOGICAL INTERVENTIONS IN CARDIOVASCULAR HEALTH

Observational evidence from large prospective cohorts such as the Women’s Health Initiative, Health and Retirement Study, and CARDIA consistently links psychological well-being, including optimism and purpose in life, with lower risks of coronary heart disease, stroke, and CV mortality.^14–16 A meta-analysis involving 10 studies similarly shows that higher well-being is associated with reduced odds of CVD and all-cause mortality, independent of sociodemographic and behavioral factors.³ Despite the robustness of these associations, heterogeneity in measurement, residual confounding, and the possibility of reverse causation limit causal inference.¹⁷ To advance causal understanding, this review focuses on randomized controlled trials (RCTs) of positive psychological and mindfulness-based interventions in adults with, or at risk for CVD, synthesizing evidence on the exposure dose (ie, frequency and duration) most likely to improve CV health.

Design and Population Characteristics of Included Randomized Controlled Trials

Included trials examined PPIs, including mindfulness-based approaches, designed to enhance psychological well-being in adults and reporting at least one CV risk factor, such as hypertension, dyslipidemia, high levels of inflammatory markers and physical inactivity, or clinical CV events. For consistency, mindfulness-based interventions are examined within the PPI framework, given their shared focus on cultivating positive psychological states. They are referenced separately when distinctions in mechanism or delivery are relevant; PPIs, such as gratitude journaling and optimism training, emphasize emotion cultivation and cognitive reframing, whereas mindfulness interventions, such as meditation or the body-scan practice, focus on attention regulation and nonjudgmental awareness.

To our knowledge, this review is the largest synthesis to date, encompassing 18 RCTs, including one factorial optimization trial and a 3 arm pilot, as summarized in Table 2. Across these studies, 11 focused on PPIs, and 7 applied mindfulness-based approaches as part of the broader PPI framework.

Table 2.

Summary of RCTs evaluating PPIs and mindfulness-based interventions in adults with or at risk for CVD

Author, Year, Journal	Population (Sample Condition)	PPI Type	Control Arm	N	Delivery Mode	Frequency (min/h per Session)	Duration	Post-Test Timepoint	Follow-up Timepoint	Relevant Outcome(s)	Main Findings	Notes on Sustainability	Limitations/Quality
Ogedegbe et al,18 2012	Hypertension (African American)	Positive affect and self-affirmation adjunct	Education only	256	Clinic and structured phone contacts	Bimonthly (uncertain)	12 mo	12 mo	None	Medication adherence; clinic BP	↑ Adherence ~6 pp (OR ~1.5); BP change NS	Behavior change maintained through 12 mo	Multicomponent; adherence primary
Parswani et al,19 2013	Coronary heart disease, Manipal Hospital (Bangalore, India)	MBSR	Usual care and lone health education session	30	Group sessions and home practice	Weekly sessions (2.5 h) and daily practice	8 wk	8 wk	3 mo	BP, BMI	↓ Anxiety, depression, stress; ↓ BMI and BP	Hospital-based group program, feasible and low-cost adjunct	Small N, single site, short follow-up, limited generalizability
Younge et al,20 2015	CHD	Web-based mindfulness intervention	Usual care/waitlist	324	Web-based, self-guided modules	Self-paced weekly modules (~30–60 min)	8 wk	8 wk	3 mo	6MWT, HR, BP, weight, lipids, HbA1c	Borderline ↑ 6MWT; ↓ resting HR; no BP/lab effects	Scalable online model; variable adherence	Low adherence; small effects; short follow-up
Redwine et al,21 2016	Stage B (asymptomatic) HF	Gratitude journaling	Usual care	70	Self-journal and check-ins	Daily (uncertain)	8 wk	8 wk	None	HRV response; inflammatory biomarkers	↑ Gratitude; ↓ Inflammation; ↑ HF-HRV (gratitude task)	Low-cost, self-directed	Single site; small N
Nikrahan et al,22 2016	Postrevascularization (CABG/PCI)	PP (gratitude, optimism, strengths)	Wait-list control	69	In-person group	Weekly (uncertain)	6 wk	7 wk	15 wk	hs-CRP; IL-6; fibrinogen	↓ hs-CRP; ↓ cortisol awakening response	Manualized, feasible group delivery	Modest N; exploratory
Celano et al,23 2018	Post-acute coronary syndrome (ACS)	Factorial PP optimization	8 component combinations	128	One in-person session with interventionist, phone and microtasks	Weekly (15–20 min) and daily boosters	8 wk	8 wk	16 wk	PA (Accel); diet, med adherence, self-report PA	Weekly>daily; motivation interviewing ↑ Adherence; boosters trend	Directly informs dose	No external control
Mohammadi et al,24 2018	Chronic CHD, outpatients	Optimism training (group)	Attention-matched educational control	61	In-person group	Weekly (2 h)	8 wk	8 wk	16 wk	No cardiovascular outcome	↑ Optimism, life satisfaction, hope; ↓ Anxiety; no effect on affect	Small, single-site; short followup limits sustainability	Small N; single site; limited measures
Huffman et al,25 2019	Post-ACS	PP and motivational interviewing	Attention-matched MI-based health education	47	Phone sessions	Weekly (30–45 min)	12 wk	12 wk	24 wk	Accelerometer-measured PA	↑ Steps (~1842/d); ↑ Positive Affect EMD (3.9, 7.3); ↑ Moderate to vigorous PA	Some PA gains persisted at 24 wk	Single site; behavior primary
Nijjar et al,26 2019	Eligibility for cardiac rehabilitation	MBSR group	Usual care	47	In-person, group format	Weekly (2.5 h/session) and retreat (6.5 h)	8 wk	8 wk	3 mo (short term) and 9 mo (long term)	HbA1c, lipids, CRP, BP; HRV	↑ Reg & well-being (↓ anx/dep) 3 mo; ↑ biomarkers in PHQ ≥5 at 3 and 9 mo	Effects ↓ by 9 mo (re-dose suggested); 3 mo PHQ-9/ GAD-7 tied to worse 9 mo biomarkers	Small pilot (n = 47); single site; 2:1; ↓ effects 9 mo (booster); underpowered; ~15% attrition
Celano et al,27 2020	HF and suboptimal adherence	PP and motivational interviewing	MI only; usual care	45	Phone	Weekly (uncertain)	12 wk	12 wk	24 wk	PA, diet, adherence, BNP	↑ Moderate to vigorous PA, med adherence; ↑ affect	Scalable	Small pilot; behavioral and psych/clinical endpoints
Mohammadi et al,28 2020	CAD	Optimism training (group)	Attention-matched educational control	61	In-person group	Weekly (2 h)	8 wk	8 wk	16 wk	hs-CRP, IL-6, irisin, fibrinogen	↓ hs-CRP, fibrinogen; ↑ irisin (8 wk); sustained 16 wk; ↓ IL-6	Brief training; potential scalability; long-term effects unclear	Small N, single site; short follow-up; biomarker focus only
Sadlonova et al,29 2022	CHD; cardiac rehab	Group multicomponent PPI	Group CBT; usual care	84	In-person group	Weekly (90 min)	8 wk	9 wk	15 wk	CRP	No consistent effect; small-medium psych improvements (ns)	Works in rehab context	Short follow-up; modest N
Saban et al,30 2022	At risk for CVD (Women Veterans)	MBSR	Health education (active control)	164	In-person group	Weekly (2.5 h) and retreat and daily practice (45 min)	8 wk	8 wk	6 mo	Diurnal salivary cortisol, IL-6, IFN-γ	↑ Mindfulness (5FM); ↓ Stress; ↓ Loneliness; ↓ Diurnal cortisol	Cortisol ↓ maintained 6 mo; 54% ≥6 sessions	54% participation/retained
Cavalcante et al,31 2023	HF	SMART®-based Coping, mindfulness and Dharma tools	Usual care	38	Facilitator-led group	Weekly (2 h) and daily (45 min) and retreat (450 min)	8 wk	8 wk	None	6MWT (function), NT-proBNP	↑ Mindfulness (FMI) ↓Perceived stress ↑ QOL (MLHFQ) ↑ sleep (PSQI) ↑ 6MWT	Longer protocols may be needed to impact clinical outcomes (ESR, CRP, NT-proBNP)	Small N; 16% attrition; single site; short follow-up; no blinding; underpowered biomarkers
Loucks et al,32 2023	Hypertension	Modified MBSR	Enhanced usual care: AHA brochure and BP cuff/instructions	201	Group sessions (in-person/online hybrid)	Weekly (2.5 h) and daily (45 min)	8 wk	12 wk	6 mo	Office systolic BP, medication use	↑Mindfulness; ↓SBP at 6 mo; ↓Sedentary time; ↑Diet quality	Session adherence strong (~83% attended ≥7 of 10 sessions)	6 mo follow-up; some data pandemic affected; limited to elevated BP
Zou et al,33 2024	ACS	Mindfulness and health education and lifestyle modification	Usual care and attention control	178	1 in-person and 5 virtual (WeChat)	Weekly (1 h)	6 wk	6 wk	12 wk	Adherence, lifestyle	↓Stress ↑Health-related QOL ↑Improved diet ↑PA ↓SBP	76% completed; abbreviated, flexible dosing improved feasibility	Self-reported behaviors; social media context may limit generalizability
Celano et al,34 2024	HTN, hyperlipidemia, or T2D	Adaptive text message intervention (PP and behavior)	Enhanced usual care	60	Text and phone	Daily texts and weekly goals and monthly calls (uncertain)	12 wk	12 wk	None	PA, physical function	↑PA and MVPA, ↑Optimism, ↑ Self-efficacy, ↑Function, ↓Anxiety (small effects, 12 wk)	Scalable, low-cost digital	Small N; short duration; no biomarkers
Teixeira et al,35 2025	Stage I-II hypertension	Spirituality-based PPI via WhatsApp	Usual care	100	Digital (WhatsApp)	Daily (≤5 min) and call	12 wk	12 wk	None	SBP (office/central); endothelial function (FMD)	−7.6 mm Hg office SBP; −4.1 mm Hg central SBP; ↑ FMD by 4–8 pp; no HBPM effect	Low cost, high reach	Single center; short follow-up

Abbreviations: ACS, acute coronary syndrome; AHA, American Heart Association; BNP, B-type natriuretic peptide; BP, blood pressure; CABG, coronary artery bypas s graft; CHD, coronary heart disease; CRP, C-reactive protein; EMD, estimated mean difference; ESR, erythrocyte sedimentation rate; FMI, Freiburg mindfulness inventory; FMD, flow-mediated dilation; GAD-7, generalized anxiety disorder-7 scale; HbA1c, hemoglobin A1c; HBPM, home blood pressure monitoring; HF, heart failure; HR, heart rate; HTN, hypertension; IL-6, interleukin-6; MBSR, Mindfulness-Based Stress Reduction; MI, motivational interviewing; MLHFQ, Minnesota living with heart failure questionnaire; MVPA, moderate-to-vigorous physical activity; PA, physical activity; PCI, percutaneous coronary intervention; PHQ-9, Patient Health Questionnaire-9; PP, positive psychology; PSQI, Pittsburgh sleep quality index; QOL, quality of life; SBP, systolic blood pressure; T2D, type 2 diabetes.

Participants

Across the included trials, adults with elevated CV risk (most commonly uncontrolled hypertension) or established CVD (eg, heart failure, post-acute coronary syndrome, coronary heart disease) were enrolled. Sample sizes ranged from 30 to 324, with most studies enrolling 50 to 200 participants. Mean ages typically fell in the late 50s to mid-60s, and when reported, women comprised approximately 35% to 55% of samples.

Location

Trials were conducted primarily in the United States,^{18,21,23,25,27,29,30,32,34} with additional studies in Brazil,^31,35 Iran,^22,24,28 India,¹⁹ China,³³ Canada,²⁶ and the Netherlands.²⁰

Control arms

Control arms included education-only,¹⁸ health education,^25,30,28,19 usual care,^{21,27,31,32,34,35,19,20,26,33} attention control,²⁴ motivational interviewing,²³ group-based CBT,²⁹ and wait list.^22,20

Delivery mode

Modes of delivery can be categorized into 2 broad approaches. Individually delivered interventions used one-on-one formats such as structured telephone sessions, self-directed journaling with brief check-ins,²¹ and digital platforms (eg, app-based content, text messaging, or asynchronous messaging).^{18,23,25,27,34,35,20} Group-based interventions were delivered in interactive group settings, including in-person group sessions,^{29,30,32,31,19,22,24,28,26} hybrid in-person/online formats,^32,33,36 and synchronous virtual meetings.^{18,23,25,27,34}

Frequency and duration

Studies varied widely in how intervention “dose” was defined and delivered. In individual trials, frequency was defined as planned cadence of intervention activities, such as daily journaling,²¹ microinterventions (brief, structured therapeutic activities targeting a specific psychological process such as gratitude, mindfulness, or positive affect), or weekly sessions. Digital formats primarily relied on daily prompts to deliver intervention content.^35,20 Duration was defined as the total length of the active intervention phase.

Across the 18 RCTs, duration ranged from 6 weeks to 12 months, although most interventions lasted 6 to 12 weeks. Contact intensity varied from daily microinterventions or text-based tasks to weekly 60 to 150 minute sessions, occasionally supplemented by day-long retreats. Some trials reported total contact time (minutes per session × number of sessions)^32,31 or dose density (contacts per week),¹⁸ while others focused on adherence (proportion of assigned tasks completed).^21,23 Most interventions incorporated weekly sessions, reinforced through structured home assignments or microtasks³⁴ (short, self-directed practice activities completed between sessions to reinforce intervention skills, such as a 1 minute gratitude reflection or a brief breathing prompt).

For the purpose of this review, frequency and duration are defined according to the frequency of intervention activities and the total length of the active intervention phase, respectively, to facilitate comparison across trials, as summarized in Table 2.

Cardiovascular disease outcomes

Outcomes spanned clinical CV risk factors (eg, blood pressure, endothelial function, inflammatory biomarkers, heart-rate variability [HRV], cortisol and lipid levels),^{18,21,29,30,31,28,26,20} health behaviors (dietary adherence, accelerometer-measured physical activity and medication adherence),²³ and functional outcomes (6 minute walk test [6MWT]).²⁰

Results: Intervention Frequency and Duration for Cardiovascular Effects

Short-term cardiovascular effects (≤3 months)

Across 18 RCTs, positive psychological and mindfulness-based interventions produced modest but favorable effects on CV risk. Of these, 12 trials evaluated outcomes within 3 months (see Table 2), providing the most direct evidence of short-term physiologic and behavioral change.

In hypertension and post-acute coronary syndrome cohorts, mindfulness-based programs delivered over 8 weeks reduced systolic blood pressure by 4 to 8 mm Hg^32,35 and lowered inflammatory markers such as high-sensitivity C-reactive protein (hs-CRP) and fibrinogen,^21,28 while a spirituality-focused digital intervention delivered over 12 weeks produced comparable blood pressure reductions and improved endothelial function by 4% to 8% points.³⁵ In cardiac populations, PPIs conducted over 8 to 12 weeks increased physical activity by roughly 1800 steps per day (observed in a positive psychology plus motivational interviewing program) and improved medication adherence,^23,25,27,34 whereas mindfulness programs of comparable length reduced sedentary time and improved diet.³³ The 12 week WhatsApp-based spirituality program achieved one of the largest blood pressure reductions of 7.6 mm Hg in office systolic blood pressure and 4.1 mm Hg in central systolic blood pressure³⁵; a factorial optimization trial combining weekly sessions with daily micro-tasks over 8 weeks produced the strongest behavioral improvements, which included greater physical activity, healthier diet patterns, and improved medication adherence.²³ These findings suggest that digitally supported or reinforced protocols can deliver meaningful CV and behavioral benefits within relatively brief intervention windows.

Across studies, contact schedules ranged from daily self-directed digital practice to weekly 60 to 150 minute sessions, with most interventions spanning 8 to 12 weeks and averaging 1 to 2 structured contacts per week.²⁶ Higher-frequency contact within this period produced the most consistent physiologic benefits.²⁶ Small pilot studies also showed reductions in hs-CRP, improved HRV, and favorable neuroendocrine changes.^25,26 Complementary nonrandomized studies reported similar short-term physiologic gains with 8 to 12 week interventions^37,38 and helped define optimal exposure parameters. Table 3 summarizes complementary non-RCT evidence on positive psychological and mindfulness-based interventions in CV populations. The 2021 American Heart Association Scientific Statement likewise emphasizes the need for rigorous trials with explicit reporting of intervention frequency and duration.¹ Collectively, short-term evidence supports the biological plausibility of CV benefits, with most consistent physiologic gains observed in programs that provide high-frequency engagement over 8 to 12 weeks.^26,37,38 Larger, adequately powered trials with clinical endpoints remain needed to confirm these effects.

Table 3.

Single-arm pilot studies and systematic reviews/meta-analysis of positive psychology and mindfulness interventions in cardiovascular populations

Study Type	Study, Year	Population	PPI Type	N	Delivery	Frequency (min/hours per Session)	Duration	Post-test and Follow-up	Outcomes	Dose Notes/Takeaways
Single-arm pilot (proof-of-concept)	Huffman et al,37 2016	Post-acute coronary syndrome (ACS)	Phone-based multicomponent PPI (gratitude, strengths, optimism tasks)	23	Phone and at-home practice	Weekly sessions and brief daily tasks	8 wk	Post-intervention at 8 wk	Feasible; ↑ affect; ↓ anxiety/depression; little optimism change; no behavioral/clinical effects	Weekly calls and daily tasks feasible; short-term psychological gains only
Systematic review & meta-analysis (RCTs)	Gathright et al,39 2019	CVD (9 RCTs)	Transcendental meditation (TM)	851 (9 studies)	In-person and check-ins and home practice	4 wk (90 min) and 11 wk (60 min) and daily (20 min)	12–281 wk (median 20 wk)	Median 20 wk postintervention	No group effects; TM showed within-group ↓SBP/DBP	TM may aid BP in CVD, but not standalone (AHA-aligned)
Optimization trial (multiphase development)	Huffman et al,38 2020	Post-ACS	Positive psychology-motivational interviewing (PP-MI) to promote health behaviors	255 (qualitative, factorial, pilot)	Phone and at-home microtasks	Weekly and near-daily microtasks (optimized)	12 wk (final optimized program)	Post-intervention at 12 wk	Feasibility/acceptability; well-being; PA signals	12 wk weekly calls and microtasks feasible; guided evaluative phase
Systematic review & meta-analysis	Scott-Sheldon et al,40 2020	CVD	Mindfulness-based interventions (MBIs)	1476 (14 RCTs and 2 quasi-experiments)	Mostly group-based sessions	Weekly (~9 × 60 min) and daily (30 min)	6–12 wk per intervention	Up to 44 wk (5 studies with follow-up)	↓Psychological distress (anxiety, depression, perceived stress) ↓Systolic BP (SBP)	11/14 group-based; effects post-only, not sustained ≤44 wk
Scientific statement (guideline context)	Levine et al,1 2021	At risk for cardiovascular disease	Psychological health and well-being (conceptual integration, not a single intervention)	Not applicable (literature synthesis/expert consensus)	Not applicable	Not applicable	Not applicable	Not applicable	Evidence linking psych health/well-being to CVD; supports integrating psych care in prevention/treatment	Positions psych health as central to CVD care; calls for research on mechanisms, dose, implementation
Single-arm pilot (pre-post)	Salmoirago-Blotcher et al,41 2022	Chronic heart failure	Phone-delivered mindfulness training (based on MBSR)	33	Individual sessions via phone	Weekly (30 min) and daily (20 min)	8 wk	Postintervention	↑Mindfulness, ↑6MWT, ↑Cognition; 91% attendance; ~12 min/d practice	Evidence for lower dose protocol compared to standard MBSR
Systematic review & meta-analysis	Tonis et al,42 2023	CVD (various cohorts across studies)	PPI (gratitude, optimism, strengths, well-being; various formats)	1222 (20 studies)	Mixed: in-person, phone, app, written, group	Varied (ranged from singlesession to multiweek programs)	Varied (most between 4–12 wk)	Post-intervention (most); some longer	Small-moderate gains in wellbeing, reduced distress in CVD	↑ Multi-week PPIs more effective; need standard dosing and long-term follow-up
Systematic review and meta-analysis	Wang et al,43 2023	CVD (mix of clinical/related cohorts across included RCTs)	Gratitude interventions (journaling, letters, exercises)	2951 (19 studies)	Mixed: self-guided writing, group/phone/app	Varied; often daily practice or regular prompts	1–12 wk (most 4–8)	Mostly postintervention; limited longer term	↑ Well-being/adherence; signals on HRV and BP	Multiweek practice better; need standardization and follow-up
Systematic review and meta-analysis	Mir et al,44 2024	Hypertension	Mindfulness-based meditation (Kabat-Zinn definition)*	543 (9 RCTs)	Mainly group sessions and some individual practice	Typically weekly (90–150 min) and daily home practice	6–8 wk	Limited; few studies with follow-up	↓SBP (5/9); ↓DBP (4/9); MBM effects: SBP d = 0.14–2.86, DBP d = 0.05– 1.21	MBM may aid HTN; BP gains greatest with meds and PA

Abbreviations: AHA, American Heart Association; DBP, diastolic blood pressure; HTN, hypertension; MBM, mindfulness-based meditation.

^*Mindfulness-based meditation refers to interventions grounded in the Kabat-Zinn definition of mindfulness, emphasizing present-moment, nonjudgmental awareness, and typically delivered using Mindfulness-Based Stress Reduction (MBSR) or closely related protocols.

Long-term cardiovascular effects (>3 months)

Long-term data remain limited. Six RCTs extended follow-up beyond the immediate postintervention period, including several with assessments between 3 and 6 months^25,27,30,32 and 2 with outcomes at 9 to 12 months.^18,26 The only year-long RCT, conducted among African American adults with uncontrolled hypertension, provided bimonthly clinic visits supplemented by structured telephone contacts over 12 months using a positive affect and self-affirmation approach.¹⁸ Although blood pressure did not significantly change, medication adherence was approximately 6% higher in the intervention group, and this benefit was maintained over 12 months. The extended duration, even with fewer and less frequent contacts, was sufficient to sustain adherence, suggesting that durability may depend more on reinforcement over time (ie, such as occasional booster sessions or re-engagement with key intervention skills) than on high contact frequency (ie, such as completing intervention activities multiple times per week). Other trials with 6 to 9 month follow-up showed partial maintenance of behavioral gains, such as continued improvements in physical activity and medication adherence, and selective persistence of physiologic benefits, including sustained systolic blood pressure reduction at 6 months in a mindfulness-based program and continued cortisol improvement among women veterans.^{25,27,30,32,26} Collectively, these findings suggest that booster contacts and hybrid delivery formats may be important to preserve long-term effects.

Summary: dose–response relationship across short- and long-term interventions

Taken together, convergent findings from the 18 RCTs indicate a dose–response relationship. Short-term physiologic improvements generally require high-frequency contact sustained for at least 8 weeks, whereas long-term adherence can be maintained with lower density but extended engagement, including digital formats that reduce participant burden. Table 4 summarizes the frequency, duration, types and modalities, as well as key outcomes of positive psychological and mindfulness-based interventions, offering practical reference points for dosing across physiologic, behavioral, and psychological domains.

Table 4.

Intervention frequency, duration, types, modalities and outcomes of positive psychological and mindfulness interventions in cardiovascular populations

Target Outcome	Recommended Frequency	Recommended Duration	Common Intervention Types	Delivery Modalities with Evidence	Representative Effect Sizes
Physiologic risk markers (blood pressure, endothelial function, inflammatory indices)	Daily microtasks (eg, a 1 min gratitude prompt or a brief reflection text) plus ≥1 structured session per week	8–12 wk (active phase)	Gratitude journaling, optimism/strengths training, spirituality-based PPIs, MBSR	In-person group with home practice; hybrid (weekly sessions and daily tasks); digital prompts reinforced by clinician contact	SBP ↓ 5–8 mm Hg; FMD ↑ 4–8 pp; hs-CRP, IL-6 ↓ ~15%-20%
Health behaviors (medication adherence, physical activity (PA))	Weekly or biweekly structured contact	≥6–12 mo for sustained effect	Positive affect and self-affirmation; PP and MI; multicomponent PPIs	Telephone/clinic follow-up; group with reinforcement; hybrid formats	Adherence ↑ 10–15 pp; PA ↑ ~900–1800 steps/day
Psychological outcomes (depression, anxiety, stress, well-being)	Weekly sessions with daily practice or prompts	6–8 wk (active phase)	Gratitude journaling, optimism training, MBSR, multicomponent skills	In-person groups; digital (apps, messaging); phone-based sessions	Moderate-large reductions in anxiety, depression, perceived stress; HRQoL ↑
Maintenance after active phase	Brief booster contacts or periodic digital prompts	3–6 mo postintervention (to sustain gains)	Gratitude journaling, optimism/strengths training, spirituality-based PPIs, MBSR, and multicomponent PPIs (continued in maintenance format)	Digital reminders; brief phone/clinic check-ins	Adherence maintained up to 12 mo; physiologic gains diminish without continued exposure

Abbreviations: BP, blood pressure; FMD, flow-mediated dilation (measure of endothelial function); HRQoL, health-related quality of life; hs-CRP, high-sensitivity C-reactive protein; IL-6, interleukin-6; MBSR, Mindfulness-Based Stress Reduction; MI, motivational interviewing; mo, months; PA, physical activity; pp, percentage points.

Persistence of Benefits Following Intervention Completion

Only a subset of trials assessed outcomes beyond the active intervention phase. Behavioral improvements, including medication adherence and physical activity, often persisted for 3 to 6 months without additional contact,^23,25,27,33 suggesting that behavioral skills acquired during the intervention may carry forward without further reinforcement. In contrast, physiologic improvements were less durable when all contact stopped.²⁶ In Ogedegbe and colleagues,¹⁸ medication adherence showed an ≈6% absolute increase in the positive-affect/self-affirmation group and was sustained over 12 months, supported by brief clinic and scheduled telephone touchpoints, although blood pressure remained unchanged. Trials with follow-up beyond 3 months showed that psychological and biomarker improvements were more likely to persist when some form of postintervention reinforcement occurred and tended to attenuate when contact ceased.^30,32,26 Two trials represent an exception to this pattern: In Saban and colleagues,³⁰ reductions in diurnal cortisol were sustained at 6 months, and in Loucks and colleagues,³² systolic blood pressure reductions persisted through 6 months, despite no additional contact after the intervention. In contrast, in Nijjar and colleagues,²⁶ gains in well-being and inflammatory markers at 3 months dissipated by 9 months. Digital and hybrid formats (eg, text-based³⁴ or spirituality-based interventions)³⁵ produced short-term improvements in physical activity and blood pressure with modest adherence through ≈3 months, but longer-term outcomes were not evaluated. Overall, behavioral maintenance appears achievable with minimal reinforcement, whereas physiologic gains are less consistent; some persist without further contact, while others diminish, indicating that sustained benefit may require continued engagement or extended intervention duration.

Effect Modifiers: Delivery Formats, Intervention Type, and Population

Outcomes were shaped by delivery format, intervention type, and population risk. Most RCTs were delivered through in-person group-based formats.^{29,30,31,19,22,24,28,26} Several trials used telephone-based delivery through weekly calls with brief self-directed practice.^18,23,25,27 A smaller set employed hybrid models that incorporated in-person or telephone sessions with digital or virtual components, such as app-based reinforcement or videoconferencing.^32,34,33 Finally, a subset of studies relied on fully digital or text-based programs.^21,35,20

Digital and text-based programs with daily prompts improved self-efficacy, psychological stress, and quality of life, and in some cases reduced blood pressure and improved endothelial function.^34,35,33 These gains were achieved with per-contact times of 1 to 5 minutes for daily messages, occasionally supplemented by brief calls or weekly sessions, underscoring the scalability of such approaches in lower-resource settings. Weekly in-person group interventions, often multi-component or optimism-focused, were evaluated in several small single-site trials and were associated with reductions in inflammatory biomarkers when paired with structured between-session practice.^{29,30,32,31,28} Hybrid approaches that combined synchronous sessions with ongoing microtasks consistently outperformed single-mode delivery, with weekly sessions plus daily assignments yielding the largest gains in physical activity.²³

Intervention type and population type also mattered. Single-component PPIs such as gratitude journaling or optimism training, typically tested in smaller or lower-risk populations, showed preliminary improvements in inflammatory and autonomic markers when delivered intensively (eg, through daily practice or frequent structured sessions).^21,28 Multicomponent and spirituality-based PPIs were preferentially deployed in higher-risk populations, such as in patients with post-acute coronary syndrome, chronic coronary heart disease, or uncontrolled hypertension, where ongoing engagement appeared necessary for sustained behavioral and physiologic benefits.^18,32,35

Summary of Effect Modifiers: Implications for Dosing Parameters

Taken together, data suggest that digital programs improve psychological well-being and health behaviors in lower-risk groups and may be scalable. Conversely, populations with higher CV risk more often require multicomponent, mindfulness or spirituality-based interventions delivered with higher contact frequency and repeated reinforcement to achieve and sustain physiologic benefits. Hybrid formats that combine structured sessions with ongoing digital engagement appear to encourage both scalability and efficacy.

LIMITATIONS AND FUTURE DIRECTIONS

Current intervention studies of PPIs are constrained by important methodological limitations.

Dosing and Trial Design

Few trials clearly operationalize “dose,”²³ making it difficult to compare across protocols or establish frequency–duration thresholds. Delivery formats remain heterogeneous, ranging from daily text prompts to weekly group sessions, yet these variations are rarely analyzed for dose–response effects. In a pilot study of gratitude journaling for heart failure, researchers note the need to define optimal frequency and duration.²¹ Future research should establish standardized dosing parameters and assess durability through extended follow-up, enabling identification of frequency–duration thresholds and advancing the reproducibility of findings.

Endpoints and Duration

Most outcomes center on psychological or behavioral change,^{23,27,31,32,34,24,33,26} while data on CV events, hospitalizations, or mortality are lacking. Trials are typically short in duration,^{21,27,29,34,19,22,24,28,26} restricting the ability to assess sustained benefits or long-term adherence. Future studies should extend follow-up beyond the active phase and incorporate hard CV endpoints alongside validated behavioral and biomarker measures to determine clinical impact.

Standardization and Intervention Fidelity

The absence of standardized intervention protocols and consensus on core components hinders reproducibility and comparison across studies. Systematization will be critical to distinguish comprehensive, multicomponent PPIs from modular, single-practice formats such as optimism training, guided by empirical evidence. The rise of artificial intelligence (AI) offers an opportunity to address these gaps. Machine learning models that integrate psychosocial, clinical, and biomarker data could identify the intervention components most likely to benefit individual patients, informing tailored care plans. Ensuring equity through diverse training data will be essential to avoid algorithmic bias, but such approaches may enable clinicians to optimize the content, duration, and frequency of PPIs for precision behavioral medicine. The field should lead in applying digital platforms, mobile health, and AI to accelerate discovery, personalize care, and realize the promise of PPIs in practice.

Generalizability

Evidence largely reflects small, demographically homogenous samples. Most trials were conducted in Western, educated, industrialized, rich, and democratic (WEIRD) contexts, largely enrolling White, middle to upper-income participants.^27,45 Approximately 72% of studies occurred in Western countries. Within this homogenous evidence base, the year-long trial by Ogedegbe and colleagues¹⁸ uniquely enrolled African American adults with uncontrolled hypertension, yet single studies remain insufficient to establish external validity. Future research should test culturally adapted PPIs in diverse and low-resource populations, leveraging community partnerships and digital platforms to enhance equity and reach.

Population and Outcome Heterogeneity

Variability in study populations and CV endpoints constrains disease-stage-specific guidance.⁴² Most trials have enrolled adults with existing CVD or elevated risk factors,^18–35 yielding stronger evidence for secondary and tertiary prevention than for primary prevention. Behavioral and intermediate outcomes are consistent, but data on incident events are scarce. Future studies should stratify by disease stage and risk level to determine where PPIs exert the greatest preventive benefit. To refine intervention delivery and efficacy, they should further apply optimization frameworks, such as the Multiphase Optimization Strategy.⁴⁶

Integration into Clinical Practice

PPIs for CV health have been tested largely in controlled research settings, with limited evidence of integration into clinical services.⁴⁵ Few RCTs have examined how, and by whom, these PPIs can be delivered in busy clinical settings or community contexts, or how costs and reimbursement might be addressed.^1,45 Brief, skills-focused PPIs may be delivered by existing members of the care team, such as nurses or medical assistants,^45,47 consistent with Centers for Medicare and Medicaid Services reimbursement models for behavioral counseling.⁴⁷ However, because most trials have been conducted in research settings, the impact of provider background or training on intervention delivery remains uncertain. With research showing improved mental and physical well-being with adjunct psychological interventions, integration within cardiac rehabilitation may also provide a suitable setting for delivery. PPIs thus represent a low-cost, scalable strategy that may enhance standard clinical care.

Digital Innovation and Equitable Implementation

Emerging digital and mobile health platforms represent a critical need for extending reach and supporting adherence beyond clinical settings. As emphasized in a 2025 American Heart Association scientific statement, attention to digital determinants of health, such as device access, connectivity, and literacy, will be critical.⁴⁸ Virtual reality offers one promising example, providing immersive environments for practicing mindfulness or gratitude in real time.^49–51 When paired with adaptive AI systems, these tools could deliver multilingual, context-aware interventions tailored to user needs and preferences. As the field advances, alignment with evolving policy initiatives such as the 2024 Mental Health Parity and Addiction Equity Act, which expands behavioral health coverage and reimbursement, will create a timely opportunity to embed PPIs equitably in CV care.^52,53

CLINICAL IMPLICATIONS

Findings suggest that high-frequency delivery of PPIs sustained for at least 8 weeks is optimal for short-term risk reduction among patients with CVD, emphasizing the potential for collaboration among CV practitioners (eg, cardiologists, advanced practice providers, cardiac nurses) and behavioral health professionals, such as clinical psychologists, behavioral medicine specialists, or licensed social workers (Fig. 2). Unfortunately, few institutions have such embedded professionals, and nearly none have the resources to provide such regular sessions without insurance reimbursement.⁵⁴ External referrals to qualified positive psychology practitioners or community-based mental health programs may therefore represent the most practical approach for patient access to PPIs in the current clinical environment.

Fig. 2.

Clinical implications: framework for collaborative care and optimal dosing pathway for PPIs in cardiovascular practice. CMS, centers for Medicare and Medicaid services; VR, virtual reality.

Even without formal programs, clinicians can integrate brief strengths-based discussions that encourage gratitude or optimism to support patient engagement and well-being. Kubzansky and colleagues⁵⁵ offer concise questions and short scripts for routine encounters that promote psychological well-being and target characteristics such as optimism, positive affect, and life satisfaction. These prompts invite patients to reflect on future expectations, sources of enjoyment, and past successes, for example, by asking what they feel grateful for or how they have used their strengths in the past, paired with supportive statements that reinforce resilience and encourage health-promoting behaviors. Examples of supportive statements include, “Staying connected to people who care about you can be a real source of strength,” and “The small steps you are taking, such as being consistent with your medications, can make a meaningful difference for your heart.” Together, these approaches underscore the feasibility of embedding well-being-focused practices within standard clinical care.

KEY POINTS.

• Positive psychological well-being, including optimism, positive affect, and emotional vitality, is associated with lower cardiovascular morbidity and mortality.

• Positive psychological interventions such as gratitude exercises, optimism training, and mindfulness-based practices show consistent improvements in cardiovascular risk factors and health behaviors, although long-term outcomes remain untested.

• Therapeutic dosing generally involves high-frequency engagement over 8 to 12 weeks for short-term physiologic benefits, with ongoing, less intensive reinforcement required to sustain behavior change.

• Evidence remains constrained by small, homogeneous samples and lack of standardized dosing protocols.

• Scalable digital delivery and implementation strategies are needed to integrate these interventions into cardiovascular prevention and care.

CLINICS CARE POINTS.

• Positive psychological well-being matters for CV outcomes. Higher levels of psychological resources, such as optimism and emotional vitality, are associated with lower CV morbidity and mortality. Clinicians can acknowledge these psychological resources during routine clinical encounters and frame them as complementary to standard guideline-directed risk management.

• A consistent delivery pattern emerges across trials. Daily practice reinforced by weekly sessions over 8 to 12 weeks represents the therapeutic dose most consistently linked to improvements in blood pressure, inflammation, and endothelial function. Clinicians should encourage patients to try brief journaling, mindfulness, or gratitude exercises, and when appropriate, refer to clinical psychologists, licensed social workers, or behavioral medicine professionals, cardiac rehabilitation, or community-based mindfulness/positive psychology programs.

• Maintenance can be supported with minimal but continued contact. Medication adherence and physical activity can be sustained with less intensive but ongoing contact. Nurse-led check-ins, brief phone calls, monthly touchpoints, or app-based reminders help maintain gains beyond the active intervention period.

• Hybrid models may enhance reach. Interventions that combine structured sessions with digital prompts or text messages have shown stronger patient engagement and may offer a scalable option. Clinicians should assess patients’ access to and comfort with digital tools to ensure equitable delivery.

Abbreviations

6MWT

6 minute walk test

AI

artificial intelligence

CBT

cognitive behavioral therapy

CV

cardiovascular

CVD

cardiovascular disease

HRV

heart-rate variability

hs-CRP

high-sensitivity C-reactive protein

PPI

positive psychological intervention

RCT

randomized controlled trial