Why do some people recover after a heart attack while others don’t?

I am a psychiatrist who has spent the last 13 years focusing on improving the mental health of people who have heart disease and other medical conditions. I see a lot of patients in the hospital who have had heart problems, and I generally have a good sense about who will recover successfully and who will not. Some of that is based on factors like weight, diet, smoking and family history, all of which are well-documented in medicine. But I also take into account psychological factors that are not as closely studied. What I have found over the years is that motivation and hope are crucial to recovery.

My current research is zeroing in on what has been identified as one of the most powerful aspects of psychological well-being: gratitude.

We’re finding that gratitude — toward loved ones, health-care providers and even for being alive — can be an important part of recovery. There is growing evidence that being grateful may not only bring good feelings, it could lead to better health.

How gratitude works

You might think that feeling grateful after surviving a major heart event would be common. But not all people experience gratitude in this context. For example, only half of people report experiencing significant gratitude after a heart attack.

It turns out that gratitude is complicated and requires some moderately complicated mental gymnastics.

  • First: Hey, this good thing happened.
  • Second: Hey, the source of this goodness comes not from me, but from some external source.
  • Finally: Boy, I am glad about this external source.

We completed in-depth interviews with heart attack patients in the hospital, and then three months later. We learned how much gratitude can vary — some people are naturally grateful as part of their disposition, while others may not be prone to appreciation but may experience it strongly in certain moments.

We also discovered that the subject of the gratitude can differ. Some feel grateful for their spouse, family and friends; some feel grateful for the doctors and nurses who may have helped or even saved them; and others may feel grateful not for a person but for broader concepts, such as being grateful for health, even grateful to be alive.

Next, we set out to explore whether gratitude makes a difference in terms of health — and taking care of one’s health — after a major medical event like a heart attack.

In our Gratitude Research in Acute Coronary Events (GRACE) study, we enrolled 164 people at Massachusetts General Hospital who had recently suffered a heart attack. After two weeks, we had them answer questions about overall gratitude and specific gratitude related to health. Six months later, we had them wear step counters for a week and gathered additional information about their recovery.

We asked people about overall gratitude as part of their disposition, as well about specific, in-the-moment, health-related gratitude, to learn whether either or both of these kinds of gratitude were linked with better health outcomes.

When we asked about specific gratitude, we asked people to rate their agreement with statements like, “Over the past week, I have been feeling thankful toward my family and friends”; “Over the past week, I have been feeling thankful about my health”; and, “Over the past week, I have been feeling thankful about the doctors, nurses, and other staff who helped to take care of me when I was in the hospital and afterwards.”

We found that people who reported feeling more gratitude after two weeks also reported six months later that they had taken their medication more reliably, maintained a healthier diet, and gotten more exercise than their less grateful counterparts. They also reported better health-related quality of life and lower rates of developing depression and anxiety. These connections were above and beyond the effects of age, gender, heart attack severity and overall medical health.

We also found that in-the-moment gratitude specifically for one’s health had even stronger associations with beneficial outcomes, and this form of gratitude was an independent predictor of heart attack patients becoming more physically active six months later.

How we learn to be grateful

But are grateful people just naturally grateful? Or is it possible to teach gratitude in people with an illness to try to improve their well-being and recovery? We have been testing this for the last several years.

To develop such a program, we adapted exercises that research has found reliably boost well-being. Many of them focused specifically on developing gratitude, such as keeping a gratitude journal and writing a letter of gratitude. We wanted to see whether the exercises would have a measurable impact on health and whether they could build the habits that would improve well-being.

We first tested it out in patients with a recent heart attack. We gave them a treatment manual and asked them to complete writing exercises independently. A study trainer called them every week for eight weeks to review the activity they were assigned, the emotions it provoked and how it affected their daily lives.

In our initial study of 47 patients with heart disease, we found the program was well-accepted, with patients completing more than 80 percent of the exercises. People who were part of the program, compared to those getting standard treatment, experienced improvements in positive affect, anxiety and depression.

“This program helped me realize how lucky I am,” wrote one participant. “There’s definitely a connection between positive emotions and activity levels.” Another said, “It’s given me more confidence; I am stronger emotionally, and that makes me stronger physically.”

In fact, we consistently found in this study that people report the greatest benefit from gratitude-based exercises, especially the gratitude letter. We then expanded the program to a larger group of heart-attack patients and found it was associated with more positive feelings, healthier eating, increased physical activity and less depression and anxiety.

How gratitude can help us stay healthy

Gratitude might influence behavior around self-care — becoming more active, not smoking, eating healthily and taking medication. It’s often the case that gratitude helps patients feel they’re being given a second chance, which can drive them to take advantage of what life has to offer.

That means, for many people, getting and staying healthy, for themselves and also for loved ones. These powerful, grateful feelings can lead to feeling more engaged, energized and motivated. Certainly, that’s what we saw in the GRACE study.

Gratitude might also have beneficial biological effects that help the cardiovascular system and overall health. Studies of various measures of positive psychological well-being, from happiness to optimism to gratitude, have found that experiencing well-being more frequently and more strongly is associated with lower levels of inflammation throughout the bloodstream and the body, a calmer fight-or-flight autonomic nervous system, and other effects that are clearly linked with better prognosis and longer survival.

Beyond momentary happiness or pleasure there is some suggestion that having deeper well-being — satisfaction, gratitude and a sense of purpose — might have much stronger effects on long-term health.

These findings suggest that experiencing gratitude — particularly in-the-moment, specific gratitude — may not only increase your well-being and outlook, it might make you change your behavior and lifestyle, which could in turn help you to live longer and better.

The benefits of gratitude are not just available to the naturally grateful, nor are they reserved just for life’s happiest occasions. Indeed, they are important even during some of our scariest and most challenging moments, like when we find ourselves in a hospital bed, confronting our own mortality.

A version of this piece was originally published in Greater Good Magazine. It has been adapted, with permission, for the Inspired Life blog.

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