Journal of Behavioral Medicine, Vol. 29, No. 4, August 2006 ( C© 2006)DOI: 10.1007/s10865-006-9063-6

Effects of Spiritual Mantram Repetition on HIV Outcomes:A Randomized Controlled Trial

Jill E. Bormann,1,2,6 Allen L. Gifford,3 Martha Shively,1,2 Tom L. Smith,1,4

Laura Redwine,4 Ann Kelly,1 Sheryl Becker,1 Madeline Gershwin,1

Patricia Bone,5 and Wendy Belding5

Accepted for publication: June 7, 2006Published online: July 18, 2006

We examined the efficacy of a psycho-spiritual intervention of mantram repetition—a wordor phrase with spiritual associations repeated silently throughout the day–on psychologicaldistress (intrusive thoughts, stress, anxiety, anger, depression), quality of life enjoyment andsatisfaction, and existential spiritual well-being in HIV-infected adults. Using a 2-group by 4-time repeated measures design, 93 participants were randomly assigned to mantram (n = 46)or attention control group (n = 47). Over time, the mantram group improved significantlymore than the control group in reducing trait-anger and increasing spiritual faith and spiri-tual connectedness. Actual mantram practice measured by wrist counters was inversely as-sociated with non-HIV related intrusive thoughts and positively associated with quality oflife, total existential spiritual well-being, meaning/peace, and spiritual faith. Intent-to-treatfindings suggest that a mantram group intervention and actual mantram practice each makeunique contributions for managing psychological distress and enhancing existential spiritualwell-being in adults living with HIV/AIDS.

KEY WORDS: HIV/AIDS; randomized controlled trial; spirituality; spiritual therapy; meditation;mind-body and relaxation techniques; intervention study.

Growing evidence supports the premise thatspirituality is associated with better health outcomes(Seeman et al., 2003) and improved quality of life(Aguirre, 1998; Brady et al., 1999; Paloutzian andEllison, 1982). Both religious and spiritually-basedpractices may buffer the effects of stress (Ironsonet al., 2002; Koenig et al., 2001; Ozsoy and Ernst,1999; Pargament et al., 2004; Reed 1986; Tuck et al.,2001; Sowell et al., 2000; Woods et al., 1999) which

1VA San Diego Healthcare System, 3350 La Jolla Village Drive(118), San Diego, CA 92161, USA.

2School of Nursing, San Diego State University, San Diego, CA92182, USA.

3Bedford VA Medical Center, Bedford, MA 01730, USA.4University of California San Diego, San Diego, CA 92161, USA.5Veterans Medical Research Foundation, San Diego, CA 92161,USA.

6Correspondence should be addressed to e-mail: jill.bormann@va.gov.

are known to impair the immune system (Antoniet al., 2002; Baum and Posluszny, 1999; Kiecolt-Glaser et al., 2002a,b).

Research has demonstrated that forms of medi-tation like Transcendental Meditation (TM), a tech-nique using a “meaningless” mantra assigned bya teacher and repeated silently while sitting qui-etly with eyes closed for 15–20 min, twice a day, isassociated with stress reduction (Alexander et al.,1993). Other health improvements reported in-clude reduced hypertension (Alexander et al., 1996;Alexander et al., 1993; Schneider et al., 2005;Schneider et al., 1995), improved pain management(Mills and Farrow, 1981), improved cerebral bloodflow (Jevning et al., 1996) and EEG changes (Taneliand Krahne, 1987). Findings of these TM studies,however, have been challenged by Canter and Ernst(2003, 2004) who found “700 published research pa-pers on TM, many of which have been produced by

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researchers directly associated with the TM organiza-tion and/or have not been subjected to peer review”(Canter and Ernst, 2003, p. 758).

Bernardi and colleagues found that recitingthe rosary prayer or yoga mantras enhanced car-diovascular rhythms and slowed respirations inhealthy adults (Bernardi et al., 2001). Janowaik andHackman (1994) conducted a randomized controlledtrial comparing a mantra chanting group, yoga relax-ation group, and control group on stress in a sampleof college students and they found the mantra groupdemonstrated significant stress reduction with a largeeffect size. They also found a positive association be-tween mantra chanting and stress reduction. Thesemeditative techniques are believed to reduce stressby initiating the relaxation response, a state of sub-jective and physiological calm opposite to the fight orflight response (Benson, 1983; Benson, 1989; Bensonet al., 1974; Benson et al., 1975; Jacobs, 2001a,b).

Three recent studies have differentiated theeffects of a spiritual versus a secular mantra onstress-related outcomes. In a post-test only quasi-experimental study of college students (N = 84),Wachholtz and Pargament (2005) explored whetherrepeating a so-called spiritual phrase using “God”was associated with greater improvements in healthand spiritual outcomes than either a secular phraseor passive muscle relaxation. The intervention groupwas instructed to choose 1 of 4 spiritual phrases suchas “God is good,” or “God is peace.” The placebogroup chose 1 of 4 secular phrases such as “I amgood,” or “I am peaceful.” All were instructed topractice 20 min per day for 2 weeks and keep trackof frequency. They were measured on anxiety, mood,spiritual health, spiritual experiences, and toleranceto a cold pressor stress test. Results indicated thespiritual group had significant decreases in anxiety,more positive mood, spiritual health, and spiritual ex-periences, and tolerated the pain of the cold pressortest almost twice as long as the other two groups. Au-thors concluded that a spiritual phrase may be moreeffective than either a secular phase or relaxationtechniques on these outcomes.

Wachholtz and Pargament (2006) replicatedtheir study in a sample of migraineurs, randomizingthem to the same spiritual meditation or passive mus-cle relaxation groups, but dividing their secular med-itation group into using “internal-focused” phrasessuch as “I am good” or external-focused phrases suchas “rain is good.” Participants in each group practiced20 min per day for 4 weeks and kept diaries of theirheadache symptoms. Using a series of 4 (group) by

2 (time) analyses, they found that the spiritual med-itation group reported a significant decrease in thenumber of migraine headaches (p < .001), increasedpain tolerance (p < .01), and significant positive im-provements in mental health, headache-related self-efficacy, and spiritual health variables (p < .05 top < .005). They concluded that “spiritually-focusedmeditation may offer enhanced health effects com-pared to secular forms of meditation” (Wachholtzand Pargament, 2006, p. S074).

Wolf and Abell (2003) conducted a randomizedtrial comparing adults assigned to one of 3 groups:(1) intervention chanting the maha mantra (n = 31),(2) placebo chanting a non-sensical mantra (n = 31),and (3) a no-treatment control (n = 31) on stressusing the Index of Clinical Stress (Abell 1991), de-pression using the Generalized Contentment Scale(Hudson and Proctor, 1977), and the Vedic Person-ality Inventory (Wolf, 1999) with subscales on en-lightenment, passion, and inertia. Participants froma southeastern community in the United States wererecruited using newspaper advertisements about astudy testing an “Eastern intervention for stress anddepression.” Participants were block randomized sothat each group had equal numbers of participantswith previous experience in yoga, meditation, or re-lated techniques. Authors did not report on whetheror not participants were Hindu or had any previousassociation with the maha mantra.

Participants in the treatment and placebo groupswere individually taught how to chant mantras aloudusing a bracelet of 109 beads to count repetitions.They could chant while sitting or walking as long asthey gave chanting their full attention. The assignedmaha mantra was “Hare Krishna, Hare Krishna,Krishna Krishna, Hare Hare, Hare Rama, HareRama, Hare Hare, Rama Rama.” The placebomantra consisted of theoretically non-sensical San-skrit syllables with the same pattern: “Sarva Dasa,Sarva Dasa, Dasa Dasa, Sarva Sarva, Sarva Jana,Sarva Jana, Sarva Sarva, Jana, Jana.” All were topractice at least 3 rounds (20 to 25 min) per day for4 weeks and keep track of their practice rounds. Theywere assessed at pre- and post-intervention, and4 weeks follow-up. The maha mantra group had sig-nificant reductions (p < .05) in stress, depression, andinertia; and improvements in enlightenment com-pared to either placebo or control. There were alsosignificant baseline to 4-week follow-up effects onstress and inertia in the maha mantra group. Limi-tations were a self-selected sample with knowledgethe study was testing an Eastern intervention for

Effects of Spiritual Mantram Repetition on HIV Outcomes 361

stress and depression. There was potential for exper-imenter effects and investigators were not blinded togroups.

Spirituality in HIV/AIDS

Epidemiological evidence suggests spiritualityis an important coping resource for those livingwith HIV/AIDS (Guillory, 1997; Hall, 1998; Mytkoand Knight, 1999; Siegel and Schrimshaw, 2002;Sowell et al., 2000). In a qualitative study on reli-gion/spirituality in 63 medical patients with cancer,cardiac, or HIV disease, participants described spiri-tuality as “a mechanism for connectedness and tran-scendence a person’s relationship to the higher di-mension and divinity within the self” (Woods andIronson, 1999, p. 410).

Spiritual well-being is associated with greaterquality of life in persons with HIV/AIDS (Somlaiand Heckman, 2000; Tsevat et al., 1999; Tuck et al.,2001; Woods and Ironson, 1999), greater longevityand less distress (Ironson et al., 2002), and lower uri-nary cortisol (Ironson et al., 2002). In a sample of 106HIV-infected men and African-American women,Woods and colleagues (1999a) found religiouscoping responses such as I “put my trust in God” or“find comfort in religion” were associated with lowerlevels of depression. Flanelly and Inouye (2001)found a significant relationship between religiousfaith and quality of life in a non-random sample of40 adults with HIV. Siegel and Schrimshaw (2002)found that nearly all 63 non-randomly sampledadults older than 50 reported that religious/spiritualbeliefs helped them cope with HIV/AIDS. Reli-gious/spiritual coping strategies were summarized as(a) positive appraisals of their situation, (b) eitherdeveloping or giving up control, and (c) gettingsocial support and acceptance. Tuck and colleagues(2001) investigated relationships of spirituality andpsychosocial factors in 52 men with HIV/AIDS usingthe Spiritual Well-Being Scale (Paloutzian 2002;Paloutzian and Ellison, 1982). They found positiverelationships between existential spiritual well-beingand social support, appraisal—focused coping, andemotional, social, physical, functional well-being andquality of life. They found negative relationshipsbetween spiritual well-being and uncertainty andemotion-focused coping (Tuck et al., 2001). Allthese studies, although primarily descriptive andcorrelational with non-random samples, suggest theimportance of spirituality and need for developingspiritual interventions for HIV/AIDS.

Some types of meditation have been studied incombination with cognitive and relaxation therapiesin HIV-infected adults. A 10-week (2.5 hours/week)multi-modal cognitive-behavioral stress managementprogram demonstrated significant pre-post reduc-tions in HIV-infected gay men’s (n = 47) self-reported levels of depressed mood, anxiety, anger,perceived stress, and 24-h urine norepinephrine out-put compared to a wait-list control group (n = 26)(Antoni et al., 2002; Antoni, 2000; Antoni et al.,1999). The intervention contained several techniquesincluding meditation, progressive muscle relaxation,guided imagery, breathing, autogenics, informationon stress theory, and cognitive-behavioral techniquesincluding cognitive restructuring, coping skills, as-sertiveness, anger management, and social support(Antoni et al., 2000). This same multi-modal inter-vention demonstrated reductions in herpes simplexvirus type 2 antibody titers and salivary cortisol levelsin 41 gay men compared to a wait list control group(n = 21) (Cruess et al., 2000a,b) and demonstratedincreases in coping strategies and reductions in dys-functional attitudes in 100 HIV-infected gay mencompared to a no-treatment control group (Cruesset al., 2002). A limitation of this study was not havingan attention control group to control for the thera-peutic effects of the group experience.

Robinson and colleagues (2003) evaluated a 10-week Mindfulness Based Stress Reduction program(including sitting meditation, yoga, and Aikido ex-ercises) on psychological and immune markers in asample of 24 HIV-infected adults. Despite a high at-trition rate (48%) and lack of random assignment,there was a significant increase in natural killer cellactivity in the intervention group although no im-provements in psychological or functional healthmeasures.

Spiritual Interventions For HIV/AIDS

Tarakeshwar and colleagues (2005) exam-ined the feasibility and efficacy of an 8-week(90 min/week) spiritual coping group interventionon spirituality, religiosity, and psychological dis-tress in a pilot study of 13 participants living withHIV. They used the Brief Multidimensional Mea-surement of Religiousness-Spirituality scale (Idleret al., 2003), the Center for Epidemiological Stud-ies Depression Scale (CES-D) (Radloff, 1977), andBeck Anxiety Inventory (Beck and Steer, 1990). Se-lected outcomes included private spiritual practices,

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organizational religiousness, forgiveness, self-ratedreligiosity and spirituality, and spiritual coping. Us-ing a one group, pre-posttest design, participants re-ported significantly higher self-rated religiosity, moreuse of positive spiritual coping, lower use of nega-tive spiritual coping, and lower depression. Resultsincluded qualitative evaluation of the interventionusing focus groups that reported spirituality was avaluable coping resource for HIV. Limitations werea small, self-selected sample, no control group, andonly two time-points.

Because evidence indicates that spiritual inter-ventions may enhance the lives of those living withHIV/AIDS, we explored the efficacy of a psycho-spiritual intervention of frequent, silent mantramrepetition—a word or phrase with spiritual associa-tions repeated silently throughout the day or nightusing Easwaran’s (2001) guidelines—on psycholog-ical distress, quality of life, and existential spiritualwell-being in a diverse sample of HIV-infected menand women compared to an attention control group.Repetition of a mantram, as taught in this interven-tion, is not practiced with eyes closed at a specialtime or place but is to be repeated anytime, any-where, throughout the day or night, making it easilyintegrated into daily life (Bormann, 2005; Easwaran,2001; Easwaran, 2005). The hypothesized mecha-nism is one of directing attention away from intru-sive thoughts and toward a chosen word or phrasewith spiritual associations that provides comfort. Itinvolves the same two basic steps as Benson’s re-laxation response: (a) mentally repeating the wordor phrase, and (b) passively disregarding any otherthoughts that intrude (Benson, 1983; Benson, 1993;Benson, 1996) resulting in a physiological state ofrelaxation opposite of the fight or flight response(Benson, 1996; Bernardi et al., 2001).

Mantram repetition, sometimes also referred toas repetition of a Holy Name (Oman and Driskill,2003), was taught using Easwaran’s guidelines(Easwaran, 2001; Easwaran, 2005) and presentedin a 10-week format with face-to-face meetings andautomated phone calls to encourage adherence(Dubbert et al., 2002; Eller, 1999). Pilot studieson the mantram intervention without a controlgroup have demonstrated significant decreases inperceived stress, state-trait anxiety, state-trait angerand significant increases in quality of life and exis-tential spiritual well—being in self-selected samplesof veterans (N = 62) (Bormann et al., 2005) andhealthcare employees (N = 42) (Bormann et al.,2004; Bormann et al., in press; Bormann et al., 2006).

Study Aims

The primary aims of this experimental studywere to explore the efficacy of a mantram repeti-tion intervention on (a) intrusive thoughts, perceivedstress, anxiety, anger, and depression; and (b) qual-ity of life enjoyment and satisfaction and existentialspiritual well-being compared to an attention controlgroup in HIV-infected adults. The secondary aim wasto explore the relationship of actual mantram prac-tice to these same outcomes.

Conceptual Framework

The links between stressful life events, intrusivethoughts, symptoms of psychological distress, andquality of life provide the conceptual framework forthe proposed study (see Fig. 1). In this frameworktaken from a larger theoretical model (Kaplan et al.,1994), stressful life events create response patternsof intrusive thoughts leading to symptoms of psycho-logical distress. We hypothesized that these thoughtswould be interrupted and/or mitigated with frequentmantram repetition and subsequently, psychologicaldistress assessed using measures of perceived stress,trait-anxiety, trait-anger, and depression would de-crease while quality of life and existential spiritualwell-being would increase.

METHOD

Design

We used a 2-group [mantram vs. control] by4-time [pre-intervention (week 1), mid-intervention(week 5), post-intervention (week 10), and follow-up(week 22)] mixed repeated measures design. An at-tention control group was designed to provide a verysimilar group experience as the mantram group us-ing the same co-facilitators and time frame but with-out spiritual or stress management information ortraining.

Participants

We enrolled 93 HIV-infected adults betweenMay 2003 and May 2004 from HIV clinics, com-munity agencies, and referrals from HIV providersin San Diego, California. The study was conducted

Effects of Spiritual Mantram Repetition on HIV Outcomes 363

Fig. 1. Conceptual framework for the current study.

through the VA San Diego Healthcare System(VASDHS) and University of California San Diego(UCSD). Institutional review board approval wasobtained and participants gave informed consent.The study was described as a research study testing“group interventions for HIV stress management”and made no mention of spirituality. Interestedindividuals were telephone-screened for inclusioncriteria: HIV-infected ≥ 6 months, 18 to 65 yearsold, clean and sober from drug/alcohol abuse for≥ 6 months; ability to read, write, and compre-hend English. In-person screening interviews werescheduled to collect demographic data, Mini-MentalStatus Exam (Cockrell and Folstein, 1988), andto assess exclusion criteria consisting of: cognitiveimpairment, dementia, or active psychosis; a score of≤ 25 on Mini-Mental Status Exam; diagnosis affect-ing cortisol levels such as type I diabetes mellitus,cancer, asthma, chronic hepatitis, chronic fatiguesyndrome, or regular use of medications having animmuno-modulary effect (e.g. cytotoxic chemother-apy, corticosteroids, interferon); loss of family, lovedone, or significant other in past 3 months; initiatingthe practice of a new alternative/complementarytherapy in past 3 months; practice of other formsof mantram repetition such as the rosary, chanting,or TM; acute infection or a change in highly activeanti-retroviral therapy (HAART) defined as 3 ormore antiretroviral drugs with at least one being aprotease-inhibitor or non-nucleoside transcriptaseinhibitor. Group and data collections meetings wereheld at the UCSD Medical Center in San Diego,California. Participants did not realize their groupassignment until attending their first group meeting.After learning their assignment, 5% of participantsin the mantram group dropped from the studycompared to 3% who dropped from the controlgroup.

Interventions: Mantram and AttentionControl Group

Both groups consisted of 8 to 15 participantsled by the same two Master’s prepared psychiatric-mental health nurses to control for differences in fa-cilitator characteristics. Both groups attended 5 con-secutive weekly sessions (90 min/week), followed by4 weekly automated phone calls from co-facilitatorsand a final session in week 10. Phone calls tothe mantram group encouraged mantram practicewhereas phone calls to the attention control groupgave study information.

The mantram intervention consisted of infor-mation on choosing and using a mantram. Otherstrategies taught to enhance mantram repetitionwere practicing one-pointed attention or mindfulnesswhile engaging in one task at a time, and intention-ally slowing down mentally and behaviorally whileusing a mantram. Slowing down and mantram repe-tition together were discussed as a means for mak-ing wiser choices, setting priorities, and decreasingstress from hurried behavior. The classes were taughtwith participants sitting in a circle to facilitate groupdiscussions.

Participants were given The Mantram Hand-book (Easwaran 2001; Oman and Driskill, 2003)with weekly reading, a course manual with exercises,and a list of recommended mantrams representingvarious spiritual traditions. Examples included “OmMani Padme Hum” from Buddhism, “Rama, Rama”from Hinduism, “Lord have mercy” from Christian-ity, “Shalom” from Judaism, “Allah” from Islam and“O Wakan Tanka” from Native American spiritualtraditions. For more mantrams, see Bormann (2005)or www.easwaran.org.

Each class consisted of (1) time for questionsand answers on the material presented, (2) reporting

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on homework assignments and sharing strategies forusing mantram repetition, (3) in-class group exercisesto illustrate application of mantram practice, slow-ing down, or one-pointed attention, (4) five minutesof mantram writing or silent, group mantram repeti-tion, and (5) instructions for homework assignments.Participants were especially encouraged to practicemantram repetition during non-stressful times suchas before sleep or while waiting in line in order to re-inforce the mind-body connection of mantram wordswith the relaxation response.

Participants were asked to objectively quan-tify mantram practice using portable wrist counters(FalconwoodTM wrist golf score keeper manufac-tured by ProActive Sports, Inc., Canby, Oregon) torecord their daily and weekly totals of mantram prac-tice. Mantram tracking was done beginning in weeks2 through 10, for a total of eight weeks.

Participants in the attention control groupviewed videotapes on HIV-topics including medica-tions, treatment issues, wasting syndrome, and nutri-tion. Following the videos, co-facilitators led groupdiscussions meant to provide group interaction andattention similar to the mantram group but withoutany specific skills or stress management training.

Procedures

Eligible participants were scheduled for baselineassessment using questionnaires and blood draws forCD4 and HIV-RNA. Psychosocial outcomes were as-sessed at pre-intervention (week 1), mid-intervention(week 5), post-intervention (week 10) and follow-up (week 22). HIV-RNA and CD4 counts were as-sessed only at baseline and follow-up to control forhealth status. Random assignment was done by theproject coordinator using a table of random num-bers and stratifying on CD4 count (<200 or ≥ 200)and HAART (yes or no). Participants were notifiedof group assignment by phone and were compen-sated with food vouchers at data collection meetings,but not at group meetings. Research personnel whoadministered the self-report, paper and pencil ques-tionnaires and the group co-facilitators could not beblinded to group assignment.

Quality Control

To assure that groups were delivered in a stan-dardized way, instructor guidelines for the mantram

group were followed and audio-taped recordings ofboth groups were collected at each meeting. Tapeswere reviewed by an expert psychiatric nurse famil-iar with both groups’ content. Inconsistencies werenoted and group leaders were contacted to correctany deficiencies before the next group meetings.

Primary Outcome Measures

Intrusive thoughts were measured using theImpact of Events Scale-Revised intrusion subscale(Horowitz et al., 1979) designed to assess current sub-jective distress for one HIV stressor and one non-HIV stressor. The subscale contains 7 items with aweighted Likert scale of 0 (not at all), 1 (rarely), 3(sometimes) and 5 (often) and higher scores indicategreater distress. Sample items include, “I thoughtabout it [named stressor] when I didn’t mean to,”and “Pictures about it popped into my mind.” Test-retest reliability on intrusion in 2 samples reportedin other studies yielded correlation coefficients of .51and .89 (Weiss and Miramar, 1997). Evidence of con-tent, criterion, and construct validity also been re-ported (Briere 1997; Horowitz et al., 1979; Weiss andMiramar, 1997). Cronbach’s alpha for HIV intrusionwas .90 and for non-HIV intrusion was .92.

Stress was measured using the Perceived StressScale, a 10-item questionnaire with 5-point Likertscale ranging from 0 (never) to 4 (very often) (Pbertet al., 1992), (Cohen et al., 1983). Scores range from 0to 40, with higher scores indicating greater perceivedstress. Sample items included “How often have youbeen able to control irritations in your life?” and“How often have you been upset because of some-thing that happened unexpectedly?” Construct valid-ity has been reported as r = .83 (Cohen et al., 1983;Cohen and Williamson 1988). Cronbach’s alpha forthis study was .86.

Anxiety was measured using Spielberger Trait-Anxiety Inventory, a 20-item questionnaire with a4-point Likert scale ranging from 1 (almost never)to 4 (almost always) to measure anxiety as a trait(Spielberger 1972). Scores range from 20 to 80 withhigher scores indicating more anxiety. “Trait” itemswere chosen instead of “state” items to capture howone “generally feels” over time rather than how onefeels “right now” when filling out questionnaires be-cause our pilot studies demonstrated that the “state”items had little variability and floor effects. Sampletrait-anxiety items included “I generally feel nervousand restless,” “I generally have disturbing thoughts,”

Effects of Spiritual Mantram Repetition on HIV Outcomes 365

and “I generally feel content” (reversed). Evidenceof construct, concurrent, convergent, and divergentvalidity have been reported (Spielberger, 1983) andCronbach’s alpha coefficient for internal consistencyreliability in this sample was .91.

Anger was assessed with the Spielberger Trait-Anger Inventory-Short Form, 10 items with a 4-pointLikert scale ranging from 1 (almost never) to 4 (al-most always) that was used to measure anger asan emotional trait (Spielberger et al., 1983). Scoresrange from 10 to 40 with higher scores indicatingmore anger. Sample items included “I generally feelI have a fiery temper,” “When I get mad I say nastythings,” and “I am a hotheaded person.” Concurrentvalidity has been supported by correlations with mea-sures of hostility, neuroticism, and anxiety (Londonand Spielberger, 1983; Spielberger et al., 1983). Forthis study, Cronbach’s alpha was .91.

Depression was assessed with the Center forEpidemiological Study-Depression Scale (CES-D), a20-item Likert scale rating the frequency of gen-eral psychological impairment and depressive symp-toms from 0 (rarely or none) to 3 (most of thetime) (Radloff, 1977; Radloff, 1986). Sample itemsincluded “How often have you felt or behaved thisway in the past 7 days: I had crying spells; I felt de-pressed; I felt fearful; My sleep was restless.” Split-half reliability has been reported from .76 to .85(Radloff and Teri, 1986). Evidence of criterion valid-ity has been reported (Radloff, 1977; Radloff, 1986)and the scale has shown significant differences be-tween respondents who reported needing help foremotional problems and those who did not. Scoreshave varied significantly with the presence of lifeevents (Weissman et al., 1977). Cronbach’s alpha forthis study was .91.

Quality of life was assessed with the Overall-General Activities subscale from the Quality of LifeEnjoyment and Satisfaction Questionnaire (Q-LES-Q), a measure of the degree of enjoyment and sat-isfaction experienced by participants with variousmental and medical disorders in areas of daily func-tioning (Endicott et al., 1993). Fourteen items wereused to assess an overall quality of life score. Eachitem is scored on a 5-point Likert scale from 1 (notat all or never) to 5 (frequently or all the time) withhigher scores indicating greater satisfaction. Sam-ple items included “How satisfied have you beenwith your. . . physical health?. . . mood?. . . social rela-tionships?” Test-retest reliability has been reportedas .74. Validity has been reported using correla-tions with the Clinical Global Impressions Severity of

Illness Rating (r = − 66), the Hamilton Rating Scalefor Depression (r = − .64) and the Beck DepressionInventory (r = − .67) (Endicott et al., 1993). In thisstudy, Cronbach’s alpha was .92.

Existential spiritual well being was assessed us-ing the Functional Assessment of Chronic IllnessTherapy Spiritual Well-being–Expanded (FACIT-SpEx version 4) scale, a 23-item measure that as-sesses three aspects of spiritual well-being: a senseof (a) meaning in life, harmony, peacefulness, (b)strength and comfort from one’s faith, and (c) con-nectedness, compassion, forgiveness (Brady et al.,1999; Mytko and Knight, 1999; Peterman et al., 2002).Each item is scored on a 5-point Likert scale rangingfrom 0 (not at all) to 4 (very much). The total scoreranges from 0 (low)–92 (high). The meaning/peacesubscale contains 8 items such as “I feel peaceful;I have a reason for living,” and ranges from 0 to32. Spiritual faith contains 4 items: “I find comfortin my faith or spiritual beliefs; I find strength in myfaith or spiritual beliefs; My illness has strengthenedmy faith or spiritual beliefs; I know that whateverhappens with my illness, things will be okay,” andranges from 0 to 16. Spiritual connectedness contains11 items such as “I feel connected to other people(or to God/Higher Power); I feel compassion for oth-ers and the difficulties they are facing,” and rangesfrom 0 to 44. Chronbach’s alpha in this study for totalscore was .94, meaning/peace subscale .89, for faithsubscale .94, and for spiritual connectedness .89.

Mantram practice was assessed using daily coun-ters and tracking sheets from weeks 2 to 10. Onecount was recorded each time mantram repetitionswere initiated regardless of how many repetitionsoccurred. One self-report item rating frequency ofmantram use from 1 (never), 2 (sometimes), 3(often), and 4 (routinely) was collected at eachtimepoint.

Statistical Analysis

Groups were compared on demographics (age,years infected with HIV, gender, ethnicity, mari-tal/partner status, sexual orientation, how infected,education, employment, income, identification withreligious group, frequency of religious practice), clin-ical characteristics (CD4, HIV-RNA, and HAARTstatus) and outcome variables. All comparisons wereconducted using Chi-square for categorical vari-ables or t-tests for normally distributed continuousvariables.

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Analyses involved separate sets of 2 (group)by 4 (time) repeated measures ANOVA using theprinciple of intent-to-treat. Data of participants whodropped were found to be missing completely atrandom; therefore, a maximum-likelihood approachwas employed to assign values based on group as-signment using imputation with the Expectation-Maximization (EM) algorithm in SPSS. All statisticaltests were performed with a two-tailed alpha of 0.05using SPSS (SPSS Inc. and Norusis, 2000).

Linear effects across all time points were not ex-pected due to the study design involving 5 weeks offace-to-face meetings, 4 weeks of phone calls, a finalmeeting at week 10 and no contact with study per-sonnel from week 10 until follow-up 3 months later(week 22). This was done to assess whether mantrameffects could be sustained without booster sessions.To explore actual mantram repetition (practice ef-fects) apart from the mantram intervention (groupeffects), secondary analyses using partial correla-tions adjusting for baseline values were conducted onmantram practice and outcome measures.

RESULTS

Sample

Of the 112 initially eligible participants who con-sented to enroll in the study, 19 dropped prior torandom assignment due to illness, new job, fam-ily needs, or no transportation. Ninety-three (83%)completed baseline and were randomly assignedto the mantram group (n = 46) or control group(n = 47). As the study progressed, 27 (29%) partici-pants dropped out due to illness, incarceration, lackof transportation, change in job or school schedules(see Fig. 2). Chi-square indicated a larger proportionwho dropped were non-whites (66.7%) versus whites(40.9%) who dropped (χ2 = 5.09, df = 1, p = .03).A larger proportion who dropped also used stimu-lants (22.2% versus 1.5%) as determined by Fisher’sexact test = .002. There were no other significant dif-ferences (p < .05) on any other demographic or clin-ical variables between those who dropped and whocompleted.

For those remaining in the study (see Table I),demographics, clinical, and outcome variables atbaseline were not significantly different betweengroups except on four variables: non-HIV relatedintrusive thoughts, years with HIV, employment,and smoking. Non-HIV related intrusive thoughts

were higher in the control group (19.9 ± 11.16) thanthe mantram group (15.0 ± 11.0), t = 2.13, df = 91,p = .04. Years with HIV were greater in the control(11.1 ± 6.22 years) compared to mantram group(8.4 ± 5.27), t = 2.25, df = 91, p = .03. For employ-ment, there was a larger proportion who workedmore than 20 h/week in the mantram group (41%)compared to the control group (17%), χ2 = 6 .77,df = 2, p = .04. For smoking, a greater proportionsmoked in the mantram group (54%) than those inthe control group (32%), χ2 = 4.77, df = 1, p = .03.Of the 93 randomized, 66 (71%) completed allstudy time-points. The analyses described here wereperformed using intent-to-treat on all 93 partici-pants who were randomly assigned. Adjustmentsin pre-treatment differences between the mantramand control groups were made using analysis ofcovariance with no differences on study outcomes.

Psychological Distress Outcomes

As shown in Table II, there was a significantgroup by time quadratic interaction for non-HIVrelated intrusive thoughts, although the interactionwas not the one predicted. The control group de-creased from baseline to post-intervention and thenincreased at week 22. The mantram group consis-tently decreased slightly over time. Effect sizes weremedium (ηp2 = .05). There were no group by timeinteractions for HIV-related intrusive thoughts, per-ceived stress, trait-anxiety, or depression. These out-comes all had significant main effects for time.

For trait-anger, there was a significant group bytime interaction where the mantram group decreasedduring group meetings and this decrease was main-tained at week 22 follow-up. Effect size was betweensmall to medium (ηp2 = .03). In contrast, there waslittle change in the control group.

Quality of Life and Existential SpiritualWell-Being Outcomes

On quality of life enjoyment and satisfactionsubscale (Q-LES-Q), the mantram group improvedmore during group meetings, whereas the controlgroup improved more at 22-weeks indicated by a sig-nificant group by time interaction (see Table III). Ef-fect size was between small to medium (ηp2 = .03).On the existential spiritual well-being (FACIT-SpEx.v4) scale, there were significant group by time

Effects of Spiritual Mantram Repetition on HIV Outcomes 367

37 Completed Time 2 (Week 5) Assessment

32 Completed Time3 (Week 10) Assessment

Discontinued No show (n=1)

37 Completed Time 2 (Week 5) Assessment

36 Completed Time 3 (Week 10) Assessment

1 Discontinued Control 5 Discontinued Mantram Disruptive-asked to leave (n=2)

2 lost to follow-up

32 completed Time 4 (Week 22) Follow-up

34 completed Time 4 (Week 22) Follow-up

206 Inquired about Study

112 Screened, eligible and consented

93 Randomized by HAART & CD 4Completed Baseline Assessment

Assigned to Control (n = 47) Assigned to Mantram (n=46)

Attended Week 1 Control Session (n=38)

94 not eligible

(total n= 9) sick (n=2) no show (n=4) schedule change (n=1) lost to follow-up (n = 2)

(total n=7) sick (n=1) no show (n=1) schedule change (n=2) lost to follow-up (n=3)

Attended Week 1 Mantram Session (n=39)

Discontinued No show (n=2)

19 dropped due to illness, family needs, or

no transportation

Dropped before meetingsDropped before meetings

Fig. 2. Flow diagram of retention and attrition.

quadratic interactions on 2 of 3 subscales–spiritualfaith and spiritual connectedness. Both groups im-proved on these subscales during the group meet-ings, but the mantram group improved more. Dur-ing the phone calls, the mantram group maintainedthese improvements, whereas the control group didnot. Effect sizes were between small and medium(ηp2 = .04 and .05, respectively). There were signif-icant main effects for time on total existential spir-itual well-being and all subscales. Correlations be-tween quality of life enjoyment and satisfaction andtotal spiritual well-being were significant (p < .001) at

all time points ranging from r = .45 to r = .57 in thetotal sample.

Secondary Analyses on Mantram Practice Effects

Mantram practice using counters was collectedin weeks 2 to 10 from 29 (63%) of the mantram par-ticipants. Frequency distribution indicated one sub-ject’s data were greater than 6 standard deviationsabove the mean. This subject was dropped for pur-poses of computing mean and standard deviations

368 Bormann et al.

Table I. Demographic Characteristics by Group at Baseline (N = 93)

Variable (Range)Mantram

(n = 46) X (SD)Control

(n = 47) X (SD)Both

(N = 93) X (SD) t-test (df) p

Age (19–57) 43.3 (6.56) 42.5 (7.17) 42.9 (6.84) –0.56 (91) .58Years with HIV (0.5–25) 8.4 (5.27) 11.1 (6.22) 9.8 (5.90) 2.25 (91) .03Frequency of CAMa Use (1-never,2-sometimes, 3-often, 4-routinely) 1.4 (0.35) 1.4 (0.49) 1.4 (0.38) 0.95 (91) .10Number of CAMa Therapies (0–15) 5.1 (3.89) 4.8 (4.08) 4.9 (3.97) –0.36 (91) .97

n (%) n (%) n (%) χ 2 (df) p

GenderMale 37 (80.4) 38 (80.9) 75 (80.6) 0.003 (1) .96Female 9 (19.6) 9 (19.1) 18 (19.4)

Ethnicity (χ2 white/non-white)White 25 (54.3) 23 (48.9) 48 (51.6) 0.27 (1) .61Black 16 (34.8) 13 (27.7) 29 (31.2)Hispanic 5 (10.9) 9 (19.1) 14 (15.1)American Indian/Alaskan 0 (0) 2 (4.3) 2 (2.2)

Marital StatusNever Married/Partnered 28 (60.9) 34 (72.3) 62 (66.7) 1.38 (1) .25Ever Been Married/Partnered 18 (39.1) 13 (27.7) 31 (33.3)

Sexual OrientationGay/Lesbian 23 (50.0) 25 (53.2) 48 (51.6) 0.28 (2) .88Heterosexual 17 (37.0) 15 (31.9) 32 (34.4)Other 6 (13.0) 7 (14.9) 13 (14.0)

How Infected(χ2 homosexual vs. other)

Homosexual contact 24 (52.2) 26 (55.3) 50 (53.8) .007 (1) .94Injecting drugs 7 (15.2) 9 (19.1) 16 (17.2)

Homosexual & injecting drugs 3 (6.5) 2 (4.3) 5 (5.4)Heterosexual contact 7 (15.2) 5 (10.6) 12 (12.9)Blood transfusion 1 (2.2) 1 (2.1) 2 (2.2)Unknown 4 (8.7) 4 (8.5) 8 (8.6)

EducationHigh school or less 11 (23.9) 18 (38.3) 29 (31.2) 2.45 (2) .29Some college/no degree 21 (52.5) 19 (47.5) 40 (43.0)College degree or higher 14 (30.4) 10 (41.7) 24 (25.8)

EmploymentNone 15 (32.6) 20 (42.6) 35 (37.6) 6.77 (2) .04< 20 hrs/wk 12 (26.1) 19 (40.4) 31 (33.3)≥ 20 hrs/wk 19 (41.3) 8 (17.0) 27 (29.0)

Identifies with Religious GroupYes 29 (63.0) 31 (66.0) 60 (64.5) 0.09 (1) .77

Frequency of Religious PracticeNot Applicable 18 (39.1) 17 (36.2) 35 (37.6) 0.12 (2) .95Infrequently 9 (19.6) 9 (19.1) 18 (19.4)Frequently 19 (41.3) 21 (44.7) 40 (43.0)

Income< $5,000 7 (15.2) 9 (17.0) 15 (16.1) 1.47 (2) .48$5,001–17,000 23 (50.0) 28 (59.6) 51 (54.8)> $17,001 16 (34.8) 11 (23.4) 27 (29.0)

aCAM = Complementary and Alternative Medicine.

for the next steps. All outliers beyond 3 standarddeviations of the mean were set to the next high-est subject’s value. For subjects with missing data,a maximum-likelihood approach using Expectation-

Maximization (EM) algorithm in SPSS was em-ployed to assign values for the intent-to-treat analy-ses. The mantram frequency distribution from weeks2 to 10 was positively skewed so a natural log

Effects of Spiritual Mantram Repetition on HIV Outcomes 369

Table II. Intrusive Thoughts, Perceived Stress, Trait-Anxiety, Trait-Anger and Depression: 2 (Group) by 4 (Time) Repeated MeasuresANOVA (N = 93)

Mantram Control F F FVariables (Range) n = 46 X (SD) n = 47 X (SD) Group p Time p Group × Time p bη p2

Non-HIV Intrusiveness (0–35)Time 1 15.0 (11.10) 19.9 (11.16)Time 2 missing missing 4.41 .04 3.57 .03 2.13 .13 .023Time 3 14.4 (8.61) 15.0 (7.74) ∗Q = 4.75 .04 .050Time 4 13.2 (9.18) 17.2 (9.17)

HIV-Related Intrusiveness (0–35)Time 1 11.9 (10.20) 12.5 (8.60) 0.13 .72 5.56 .001 .17 .92 .002Time 2 11.0 (8.99) 11.5 (7.96)Time 3 9.8 (7.69) 10.9 (7.52)Time 4 9.7 (8.29) 9.9 (8.13)

Perceived Stress Scale (0–40)Time 1 16.6 (7.39) 17.6 (6.55) 1.77 .19 9.34 .003 .02 .89 .000Time 2 15.5 (6.23) 17.8 (6.03)Time 3 14.6 (6.06) 15.8 (6.21)Time 4 15.0 (5.83) 16.5 (5.93)

Trait Anxiety (20–80)Time 1 44.1 (11.13) 44.9 (10.37) 1.22 .27 12.0 .001 1.77 .15 .02Time 2 40.7 (9.62) 43.1 (9.63)Time 3 40.2 (9.74) 43.7 (9.32)Time 4 40.3 (10.46) 42.1 (9.74)

Trait Anger (10–40)Time 1 19.3 (6.58) 19.9 (6.82) 2.84 .10 8.19 .001 2.74 .05a .03Time 2 17.3 (5.97) 19.5 (6.03)Time 3 16.8 (4.73) 19.5 (6.52)Time 4 16.7 (5.41) 19.1 (6.49)

Depression (0–60)Time 1 18.4 (10.99) 22.3 (11.59) 1.56 .21 14.9 .001 2.43 .07 .03Time 2 17.9 (10.03) 20.2 (10.46)Time 3 16.0 (9.82) 19.6 (10.97)Time 4 17.0 (10.28) 17.2 (10.03)

∗Q = Quadratic Interaction Effect.aFindings were replicated using a mixed-model approach with similar results.bPartial eta squared values are for the interactions only. Effect sizes: Small = .01, Medium = .06, Large = .15.

transformation was performed. A second analysis us-ing the non-imputed (original raw) mantram data(n = 29) was also done. The pattern of results fromthis second analysis was essentially the same as theintent-to-treat findings, except for changes in somep-values as a function of differential power.

The overall average daytime mantram prac-tice using counters after imputation was M = 13.0(SD = 9.33), median = 13.03, ranging from 1 to 40mantram cycles (initiations of repetitions) per day.To determine if frequency of mantram practice wasrelated to religious involvement or frequency of re-ligious practice, mantram users were divided at themedian into high mantram users (n = 25) and lowmantram users (n = 21). Chi-square and t-tests wererun on all demographic, clinical, and outcome vari-ables between the high and low mantram users re-sulting in no significant differences.

We then evaluated outcomes using a 3 group(high mantram use, low mantram use, no mantramcontrol) by 4 time repeated measures ANOVAsand found significant group by time interactions forspiritual faith (see Fig. 3) and similar patterns to therepeated measures ANOVAs shown in Tables IIand III. To further assess the effect of high and lowmantram use in the mantram group alone, additional2-group (high and low users determined by mediansplit) by 4-time repeated measures ANOVA wasconducted on all outcomes. For spiritual faith, agroup by time interaction, F(3,132) = 3.63, p = .02,indicated that high mantram users improved signif-icantly more on spiritual faith than low mantramusers. This yielded between a medium to large effect(ηp2 = .08). For trait-anger, a 2-group by 4-timeinteraction, F(3,132) = 3.04, p = .04, indicated thatlow mantram users improved significantly more on

370 Bormann et al.

Table III. Quality of Life Enjoyment and Satisfaction and Existential Spiritual Well-Being: 2 (Group) by 4 (Time) Repeated MeasuresANOVA (N = 93)

Variables (Range)Mantram

n = 46 X (SD)Control

n = 47 X (SD)F

Group pF

Time pF

Group × Time p aη p2

Quality of Life Q-LES-Qb (14–70)Time 1 47.3 (11.55) 46.6 (10.11) 0.001 .99 15.5 .001 3.01 .04 .03Time 2 49.5 (10.55) 47.6 (11.55)Time 3 50.4 (9.88) 50.8 (9.00)Time 4 50.3 (10.30) 52.7 (8.58)

Existential SWB FACITc (0–92)Time 1 64.7 (18.52) 59.6 (17.97) 3.93 .05 7.20 .001 1.60 .19 .02Time 2 68.9 (14.64) 62.6 (17.70)Time 3 70.7 (15.32) 61.7 (16.54)Time 4 68.9 (15.30) 64.2 (16.02)

Meaning/Peace Subscale (0–32)Time 1 22.0 (7.07) 19.2 (7.11) 2.93 .09 10.84 .001 .94 .43 .01Time 2 22.7 (6.33) 20.7 (6.48)Time 3 23.4 (6.03) 21.2 (6.53)Time 4 23.7 (6.30) 22.3 (6.13)

Spiritual Faith Subscale (0–16)Time 1 10.7 (4.69) 9.9 (4.66) 2.99 .09 3.67 .013 1.98 .12 .02Time 2 12.1 (3.73) 10.3 (4.81)Time 3 12.0 (3.97) 9.9 (4.78) ∗Q = 4.69 .04d .05Time 4 11.5 (4.15) 10.2 (4.83)

Spiritual Connectedness (0–44)Time 1 32.0 (8.82) 30.6 (8.20) 3.53 .07 3.34 .02 2.57 .06 .03Time 2 34.0 (6.90) 31.6 (8.17)Time 3 35.2 (6.73) 30.6 (7.66) ∗Q = 4.11 .05d .04Time 4 33.8 (7.08) 31.7 (7.26)

∗Q = Quadratic Interaction Effect.aPartial eta squared values are for the interactions only. Effect sizes: Small = .01, Medium = .06, Large .15.bQuality of Life Enjoyment and Satisfaction Questionnaire-General Activity Subscale (Q-LES-Q).cExistential Spiritual Well-Being (SWB) using Functional Assessment of Chronic Illness-Spirituality-Expanded (FACIT-SpEx).dFindings were replicated using a mixed-model approach with similar results.

trait-anger at week 22 than high mantram users andyielded a medium effect (ηp2 = .06).

To assess effects of actual mantram practice us-ing mantram counters and self-report, we conductedpartial correlations to control for baseline outcomesvalues. These results are shown in Table IV. Fre-quency of mantram practice using counters (weeks2 to 10) at post-intervention was inversely associ-ated with non-HIV related intrusive thoughts andpositively associated with quality of life enjoymentand satisfaction, total existential spiritual well-being,and spiritual subscales of meaning/peace and spiri-tual faith.

Mantram practice measured by the one self-report item asking, “Have you used a mantram?”ranging from 1 (never), 2 (sometimes), 3 (often)and 4 (routinely) did not significantly correlate withcounter mantram data at week 10. Partial correla-tions for both mantram counter data and self-reportmantram practice at week 10 are shown in Table IVand there were different results between counter ver-

sus self-report mantram practice data. Three out-comes were significant using both types of mantrampractice data (counter and self-report): quality of lifeenjoyment and satisfaction, total existential spiritualwell-being, and the meaning/peace subscale. Therewere significant inverse relationships between self-report practice and HIV-intrusive thoughts, trait-anxiety, depression, and quality of life.

DISCUSSION

There is growing literature that mind-bodytherapies including spiritually-based interven-tions are gaining popularity and accruing em-pirical evidence (Astin et al., 2003; Barrowsand Jacobs, 2002; Harris et al., 1999). Further,spiritual interventions for HIV/AIDS are beingdeveloped (Pargament, 1999; Pargament et al., 2004;Tuck et al., 2001) and tested (Tarakeshwar et al.,2005). In this study, we examined the efficacy of

Effects of Spiritual Mantram Repetition on HIV Outcomes 371

0

2

4

6

8

10

12

14

16

Week 1 Week 5 Week 10 Week 22

High Mantram Use Group (n = 25)

Low Mantram Use Group (n = 21)

No Mantram Control Group (n = 47)

Fig. 3. Frequency of Mantram Practice and Spiritual Faith: A3 (Group) by 4 (Time) Repeated Measures ANOVA. F = 3.01(3,273) p = .04 (η p2 = .06 medium effect).

frequent mantram repetition on psychologicaldistress, quality of life, and existential spiritual well-being in HIV/AIDS using a robust experimentaldesign to control for therapeutic group effects.

Intrusive Thoughts

We found neither the mantram nor atten-tion control group were associated with reduc-tions in HIV-related intrusive thoughts. This mightbe explained by the number of years this sam-ple had been living with HIV (average of 10 ± 5.90years) and therefore, they may have had ample

time to successfully manage or reduce HIV-relatedthoughts.

There were greater reductions in non-HIV re-lated intrusive thoughts in the attention controlgroup at post-intervention but they had significantlyhigher levels of intrusiveness to begin with. Reduc-tions in non-HIV related intrusive thoughts in thecontrol group were not maintained at follow-up. Themantram group, however, had a steady decline innon-HIV related intrusive thoughts over time, al-though not significant.

Perceived Stress, Trait-Anxiety, Trait-Angerand Depression

Surprisingly, there were no group interaction ef-fects for perceived stress or trait-anxiety as found inour pilot studies, nor for depression, although theseall decreased over time. This might be explained bythe social support and opportunity for emotional ex-pression that was provided in both groups and hasbeen helpful for psychosocial adjustment to HIV(Ironson et al., 1995). Research shows that grouptherapy alone is an effective, therapeutic interven-tion (Burlingame et al., 2003).

Similar to our pilot studies, the mantram groupsignificantly reduced trait-anger. Those first learn-ing of their HIV status often react with anxiety, de-pression, and anger (Emmelkamp, 1996; Mulder andAntoni, 1994; Perdices et al., 1992) and there is ev-idence that hostility and chronic anger negativelyimpact health (Kiecolt-Glaser et al., 2002a) and en-hance HIV disease progression (Ironson et al., 2002).

Table IV. Mantram Practice Comparing Counters and Self-Report at Post-Intervention: Intent to Treat Analysis UsingPartial Correlations Adjusting for Baseline Values

Outcomes Intent to Treat (n = 46)Mantram Practice Using Counters

Weeks 2–10 Partial rMantram Practice Using Self-Report

at Week 10 Partial r

Non-HIV Related Intrusive Thoughts –.32∗ –.09HIV-Related Intrusive Thoughts .11 –.58∗∗∗Perceived Stress .01 –.21Trait-Anxiety –.09 –.56∗∗∗Trait-Anger –.07 –.07Depression –.20 –.47∗∗∗Quality of Life (Q-LES-Q) .31∗ .49∗∗∗Total Spiritual Well-Being (FACIT) .43∗∗ .32∗Meaning/Peace .42∗∗ .33∗Spiritual Faith .52∗∗∗ .15Spiritual Concerns .24 .28∗p < .05.∗∗p < .01.∗∗∗p < .001.

372 Bormann et al.

Hostility is also a high risk factor for chronic heartdisease, all-cause mortality (Miller et al., 1996), andlong-term hypertension (Yan et al., 2003).

Quality of Life Enjoyment and Satisfactionand Existential Spiritual Well-Being

We found a positive association between qualityof life and spiritual well—being as previously shownin the literature (Somlai and Heckman, 2000; Tsevatet al., 1999; Tuck et al., 2001; Woods and Ironson,1999). Although the mantram group improvedslightly more in quality of life during group meet-ings, the control group’s quality of life increasedsignificantly more at follow-up which gives supportto the value of HIV education. Although there wasnot a direct relationship between the mantram groupand quality of life, there may be an indirect effectwhereby the mantram intervention is associated withspiritual faith and connectedness which, in turn, isrelated to quality of life enjoyment and satisfaction.A mediational model is required to establish thisrelationship.

The mantram group, as predicted, significantlyincreased spiritual faith and spiritual connectednesswhich are positively associated with quality of lifeand have been cited as valuable coping resourcesin persons with HIV/AIDS (Guillory et al., 1997;Hall, 1998; Mytko and Knight, 1999; Siegel andSchrimshaw, 2002; Sowell et al., 2000). These re-lationships cannot be explained by demographics,involvement in a religious group, frequency of reli-gious practice, or having higher levels of existentialspiritual well-being to begin with, and therefore,are most likely explained by the mantram interven-tion. This finding provides evidence that mantramrepetition does have an effect on some aspectsof spiritual well-being. Additional evidence wasprovided by finding that high mantram users had sig-nificantly greater improvements in spiritual faith atpost-intervention than low mantram users, althoughthis difference faded at follow-up without boostersessions or phone call encouragement to practice.It should be kept in mind, however, that generatinggroups of high and low mantram users deviates fromexperimental design of random assignment.

Mantram Group versus Mantram Practice Effects

Despite the lack of predicted mantram group ef-fects on intrusive thoughts, anger, and depression,

mantram practice using counters or self-report wereinversely related to these outcomes indicating thatmantram practice may have a valuable, therapeuticeffect on psychological distress. Similarly, there wereno mantram group effects on quality of life, total ex-istential spiritual well-being, and meaning/peace, yetmantram practice using counters was positively re-lated to all of these. These mixed findings suggestthere may be unique contributions from the mantramgroup “experience” (Burlingame et al., 2003; Yalom,1995) apart from actual mantram repetition “prac-tice” itself. Discussion and social support in the groupmeetings may explain these outcomes or perhaps alarger sample size is needed to increase power. Al-though the mantram practice findings do support ourhypothesis that mantram repetition improves somehealth outcomes, this interpretation must be viewedwith caution because those practicing more were self-selected.

Because participants chose their own mantrams,they may have had more belief in them comparedto secular words, demonstrating what Benson (1996)and Koenig (2000) call the “faith factor.” Those withfaith, according to Benson (1996), are more moti-vated to practice and thereby, gain greater healthoutcomes. Although the mantram group did not sig-nificantly improve feelings of meaning/peace, therewas a positive relationship between mantram prac-tice and meaning/peace. This may be explained byOman and Driskill’s (2003) description of the devo-tional nature of mantram repetition and its conse-quential centering, peaceful effects.

The fact that self-reported mantram prac-tice was not significantly correlated with countermantram data suggests the need for further researchin this area. One explanation may be the poten-tially wide interpretation of rating frequency from‘never,’ ‘sometimes,’ ‘often,’ to ‘routinely.’ Addi-tional methods of assessing frequency of mantramrepetition and more specific self-report items areneeded. Measuring adherence to mind-body inter-ventions is difficult and clearly requires furtherinvestigation.

To assess generalizability of results, participantsin this study were compared to another study of100 HIV infected adults (Chesney et al., 2003).Both samples had higher levels of both trait-anxietyand trait-anger (Spielberger, 1983; Spielberger et al.,1983; Spielberger et al., 1999) and lower levels ofquality of life enjoyment and satisfaction (Gelfinet al., 1998) compared to population norms. Thissuggests our study participants are similar to other

Effects of Spiritual Mantram Repetition on HIV Outcomes 373

HIV/AIDS samples and perhaps our findings wouldbe generalizable as well.

LIMITATIONS

Although participants were randomly assigned,a limitation of this study was having a self-selectedsample from southern California, making resultsless generalizable to the larger HIV population orthose from different geographical areas. Anotherlimitation was the number of participants whodropped out; however, other HIV-interventionstudies have reported similar attrition rates (Cruesset al., 2002; Eller, 1995; Eller, 1999; McCain et al.,2003; Robinson et al., 2003). Another limitationwas not blinding group leaders or those collectingquestionnaire data. Group leaders taught both armsof the study to control for instructor characteristicsbut they may have shown bias toward the mantramgroup. Finally, there may have been some threats tointernal validity due to contamination. Some partici-pants were partners assigned to different groups andindicated they shared group content despite beinginstructed not to. Also, providing HIV informationalvideos may have created a stronger attention controlgroup than planned.

CONCLUSIONS

Using a strong experimental, prospective de-sign, we found that mantram repetition—a psycho-spiritual practice that is easily integrated into dailylife–can significantly decrease the psychological dis-tress of anger and increase spiritual faith which is as-sociated with quality of life in HIV-infected adults.As is commonly found in clinical practice, there weregreater improvements in outcomes during the face-to-face meetings, but without 3-month follow-up con-tact and encouragement to practice, improvementsreturned to near baseline on most measures. This in-dicates the need for refresher phone calls or boosterfollow-up meetings to support mantram repetitionover time. Nevertheless, it is noteworthy that im-provements in some outcomes were found with only5-weeks of the face-to-face mantram group interven-tion as compared to typically longer stress manage-ment interventions that range from 10 to 16 weeks(Antoni, 2000).

These findings support the need for more re-search on mantram repetition using larger random-

ized trials, more face-to-face intervention meetingsor exploring other modes of delivery, more practicetime with follow-up refreshers, and other measuresof intrusive thoughts (e.g., the arousal subscale ofthe Impact of Events Scale-Revised) to enhance ourunderstanding of how mantram repetition works. Itmay also be useful to assess mantram repetition in anewly diagnosed HIV sample or in participants whohave lived with HIV for 5 years or less.

Because of its simplicity, mantram repetitionhas a wide variety of applications (Bormann et al.,2005; Bormann et al., 2006; Bormann et al., inpress; Easwaran, 2001; Easwaran, 2005; Oman andDriskill, 2003). Future studies are aimed at testinga longer intervention period (8-weeks) with follow-up support in persons with HIV/AIDS as well as inother samples including veterans with posttraumaticstress disorder and family caregivers of people withAlzheimer’s or other debilitating diseases.

ACKNOWLEDGMENTS

This study was conducted with core supportfrom the National Center of Complementary andAlternative Medicine, National Institutes of Health(NCCAM/NIH) grant # R21AT01159-01A1 and withindirect support from the Office of Research andDevelopment, Health Services Research and De-velopment Service, Department of Veterans Af-fairs and the Health Services Research Unit ofthe VA San Diego Healthcare System; San DiegoVeterans Medical Research Foundation; Universityof California San Diego (UCSD) General Clin-ical Research Center (#1637), National Institutesof Health/National Center for Research Resources(M01RR008); UCSD Center for AIDS Research(CFAR 5P30 AI 36214) and the UCSD Antiretrovi-ral Research Center (AVRC); San Diego State Uni-versity School of Nursing’s Institute of Nursing Re-search (#900521); and Sigma Theta Tau InternationalHonor Society-Gamma Gamma Chapter. Portions ofthis study were presented at the 17th Annual Asso-ciation of Nurses in AIDS Care Conference, NewOrleans, LA, November 15-18, 2004; the Society ofBehavioral Medicine Annual Meetings in Boston,MA, April 13-15, 2005 and in San Francisco, CA,March 22-25, 2006; and the Veterans Affairs HealthServices Research and Development Annual Meet-ing in Arlington, VA, February 17, 2006.

The views expressed in this article are thoseof the authors and do not necessarily represent the

374 Bormann et al.

official views of the Department of Veterans Af-fairs or the National Center for Complementaryand Alternative Medicine, National Institutes ofHealth.

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