Mindfulness-Based Stress Reduction

Mindfulness-Based Stress Reduction

PEP Topic 
Anxiety
Description 

Mindfulness-based stress reduction (MBSR) is a consciousness discipline that is grounded in eastern philosophy and traditions such as yoga and Buddhism, focusing on awareness of the present moment. It aims to teach people to deal more effectively with experience through awareness of feelings, thoughts, and bodily sensations. Participants learn to engage in mindfulness practices such as body scan, simple yoga exercises, and meditation. MBSR has been studied in patients with cancer for its effect on symptoms of anxiety, cognitive impairment, fatigue, sleep-wake disturbances, and depression. It has also been studied in caregivers of patients with cancer for its effect on caregiver strain and burden.

Likely to Be Effective

Research Evidence Summaries

Garland, S. N., Tamagawa, R., Todd, S. C., Speca, M., & Carlson, L. E. (2013). Increased mindfulness is related to improved stress and mood following participation in a mindfulness-based stress reduction program in individuals with cancer. Integrative Cancer Therapies, 12, 31–40.

doi: 10.1177/1534735412442370
Print

Study Purpose:

To examine the effects of a mindfulness-based stress-reduction therapy (MBSRT) on stress and mood disturbances and to examine the relationship of improved mindfulness and mood changes.

Intervention Characteristics/Basic Study Process:

Hospital staff referred patients to the study or patients self-referred to the study. MBSRT consisted of eight weekly sessions and a six-hour silent retreat held after the sixth session. Classes taught participants about the mind-body connection, principles of mindfulness, and yoga practice. Patients were encouraged to share experiences to generate support from group members. All were given CDs with guided meditation exercises, and all received a program manual. Patients were encouraged to practice meditation and mindful movement at least 45 minutes per day. Patients who did not attend at least five sessions were excluded from the analysis.

Sample Characteristics:

  • The sample was comprised of 268 patients.
  • Mean age was 53.8 years.
  • The sample was 15.7% male and 84% female; 71% were married or partnered.
  • Patients were diagnosed with breast, hematologic, and colon cancer.
  • Average time from diagnosis was zero years, indicating participation close in time to diagnosis.

 

Setting:

  • Single site
  • Outpatient
  • Canada

Phase of Care and Clinical Applications:

Patients were undergoing the transition phase after active treatment.

Study Design:

The study used a pre-/posttest design.

Measurement Instruments/Methods:

  • Mindfulness Attention Awareness Scale (MAAS)
  • Five Facet Mindfulness Questionnaire (FFMQ)
  • Calgary Symptoms of Stress Inventory (C-SOSI)
  • Profile of Mood States (POMS) Questionnaire

Results:

  • The level of mindfulness increased significantly over the course of the program (p < 0.001). 
  • Improvements in stress and mood outcomes were noted, with effects of at least small to moderate size.
  • Change was observed in tension-anxiety (d = 0.52), depression (d = 0.44), and fatigue (d = 0.37) (p < 0.001). 
  • The study revealed no significant or strong correlation between mindfulness change and mood change.

Conclusions:

The findings supported the use of MBSRT approaches for managing the symptoms of anxiety, depression, and fatigue.

Limitations:

  • The study had risks of bias:  the sample consisted mostly of self-referred participants, suggesting that participants may have been predisposed to find therapy effective; and the study lacked a control group, blinding, random assignment, and appropriate attentional control condition. The lack of a control condition is particularly important because anxiety, depression, and fatigue can improve over time with no intervention.
  • The findings were not generalizable.
  • Baseline anxiety and depression scores were not reported, so it is not known if patients had any initial significant mood problems.
  • The authors stated that patients who did not attend at least five sessions were excluded from the analysis, but the authors did not report how many patients, if any, were excluded; therefore, the drop-out rate and final sample size were unclear.
  • The fact that the study revealed no significant correlations between change in mindfulness scores and mood changes may suggest that the mindfulness aspect of the intervention may not be the main effective component—the component may have been yoga or the support group sessions.

Nursing Implications:

The findings suggested that a stress-reduction intervention involving group support, yoga, and mindfulness may help patients manage the symptoms of anxiety, depression, and fatigue. The various study limitations prevented firm conclusions from being drawn.

Hoffman, C. J., Ersser, S. J., Hopkinson, J. B., Nicholls, P. G., Harrington, J. E., & Thomas, P. W. (2012). Effectiveness of mindfulness-based stress reduction in mood, breast- and endocrine-related quality of life, and well-being in stage 0 to III breast cancer: a randomized, controlled trial. Journal of Clinical Oncology, 30, 1335–1342.

doi: 10.1200/JCO.2010.34.0331
Print

Study Purpose:

  • To assess the effectiveness of a mindfulness-based stress reduction (MBSR) intervention for mood, breast- and endocrine-specific quality of life, and well-being after hospital treatment in women with stage 0 to III breast cancer.
  • To compare MBSR to usual care and its effect on mood and disease-related quality of life.
  • To measure if a dose-related effect was evident with formal, eight-week MBSR practice.

Intervention Characteristics/Basic Study Process:

The intervention consisted of an eight-week MBSR program closely following the Kabat-Zinn method. The intervention involved 2- to 2.25-hour classes and a 6-hour retreat. Home practice was recommended for 45 minutes, six to seven days per week. Outcomes were measured at baseline, weeks 8 to 12, and weeks 12 to 14. A wait-list control group received usual care.

Sample Characteristics:

  • A total of 229 patients (100% female) participated.
  • Mean age was 49 years (SD = 9.26 years) in the treatment group and 50.1 years (SD = 9.14 years) in the control group.
  • Patients had been diagnosed with stage 0 to III breast cancer; 47% had stage II cancer.
  • Participants were recruited from The Haven, a charitable day center that provides free psychosocial services for patients with breast cancer. All patients had received an average of 30 hours of support prior to entering the study.

Setting:

  • Single site
  • Outpatient
  • The Haven, London, England

Phase of Care and Clinical Applications:

  • Patients were undergoing long-term follow-up.
  • The study has clinical applicability for late effects and survivorship.

Study Design:

The study used a randomized, controlled trial design.

Measurement Instruments/Methods:

  • Profile of Mood States (POMS) questionnaire
  • Functional Assessment of Cancer Therapy (FACT)–Breast and Endocrine Symptoms 
  • World Health Organization (WHO) (Five) Well-being Index

Results:

  • The study revealed significant differences between the groups in regard to POMS subscale scores (p < 0.001): depression (p = 0.017), anxiety (p < 0.001), anger (p = 0.005), vigor (p < 0.001), fatigue (p = 0.002), and confusion (p = 0.002).
  • Participants completed a mean of 19.58 hours (standard deviation = 11.49 hours) of home MBSR practice over eight weeks, or 21 minutes per day. Increased hours of MBSR practice improved POMS scores at T3 for overall mood (p = 0.004), vigor (p = 0.02), fatigue (p = 0.03), and anxiety (p = 0.01). POMS scores improved at T2 and T3 for anger (p = 0.005 and 0.02, respectively), confusion (p = 0.04 and 0.001, respectively), and well-being.

Conclusions:

MBSR significantly improved mood and reduced confusion.

Limitations:

  • The study lacked an appropriate control group.
  • The control group was not attention controlled, which limited the interpretation of between-group differences.
  • The setting was unique, and the intervention used many resources, which made implementing and generalizing findings difficult.
  • The study had a risk of bias due to lack of blinding.

Nursing Implications:

Although further study is needed to measure MBSR and its impact on depression and anxiety, in this sample, home-based practice was feasible and improved mood. In practice and education, nurses can promote components of MBSR, such as breathing, yoga, relaxation, meditation, seeking support resources, and gentle stretching.

Lengacher, C. A., Reich, R. R., Post-White, J., Moscoso, M., Shelton, M. M., Barta, M., . . . Budhrani, P. (2012). Mindfulness based stress reduction in post-treatment breast cancer patients: an examination of symptoms and symptom clusters. Journal of Behavioral Medicine, 35, 86–94.

doi: 10.1007/s10865-011-9346-4
Print

Study Purpose:

To compare the prevalence and severity of symptoms and symptom clusters in patients with breast cancer who participated in a mindfulness-based stress reduction (MBSR) program to the symptoms and symptom clusters in patients who received usual care.

Intervention Characteristics/Basic Study Process:

Women who expressed interest in participating in the study were randomly assigned to MBSR or usual care. The MBSR program lasted six weeks and included educational material, meditation practice in weekly group settings and homework, group discussion on barriers to meditation, application of mindfulness in daily life, and group support interactions. Meditation training consisted of sitting and walking meditation, body scan, and gentle Hatha yoga. Researchers obtained study measures at baseline and within two weeks of program conclusion. Hierarchical-cluster analysis was used to identify symptom clusters. Researchers compared each group's symptom clusters and individual symptoms to those of the other group.

Sample Characteristics:

  • In total, 84 participants (100% female) were included.
  • Mean patient age was 58 years (standard deviation = 9.4 years).
  • Median time since diagnosis of breast cancer was 11 to 15 weeks.
     

Setting:

  • Single site
  • Outpatient
  • Florida

Study Design:

This was a randomized, controlled trial.

Measurement Instruments/Methods:

MD Anderson Symptom Inventory

Results:

Severity of symptoms declined in both groups from baseline to the end of the study. Fatigue and drowsiness declined more in the MBSR group (p = 0.05). Interference scores for mood and relationships also declined more in the MBSR group (p ≤ 0.05). Analysis of changes in symptom clusters showed no differences between groups. Clusters identified were gastrointestinal (nausea, vomiting, anorexia, shortness of breath, dry mouth, numbness), cognitive or psychological (distress, sadness, pain, remembering), and fatigue (fatigue, disturbed sleep, drowsiness). Cluster scores declined in both groups.

Conclusions:

Findings suggested that MBSR interventions may benefit women with breast cancer who are managing fatigue or mood.

Limitations:

  • The study had a small sample size, with less than 100 participants.    
  • Baseline sample/group differences were of import.
  • The study had risks of bias due to no blinding and no appropriate attentional control condition.
  • The control group included significantly more black patients than did the MBSR group. Ethnic and cultural differences could impact the findings.
  • The study did not state whether any patients were receiving antitumor treatment or if any patients had undergone surgery.
  • The gastrointestinal cluster did not make clinical sense as a cluster. 
  • Enrollment occurred by means of patient self-selection.
  • Symptom severity scores at baseline were low in all patients (less than 4 on a 10-point scale).
 

Nursing Implications:

Findings suggested that MBSR may be helpful, to some patients with breast cancer, as a means of combating fatigue and mood changes. Study limitations limited the strength of these findings.

Monti, D.A., Kash, K.M., Kunkel, E.J., Brainard, G., Wintering, N., Moss, A.S., . . . Newberg, A.B. (2012). Changes in cerebral blood flow and anxiety associated with an 8-week mindfulness programme in women with breast cancer. Stress and Health, 28, 397–407.

doi: 10.1002/smi.2470
Print

Study Purpose:

To evaluate changes in cerebral blood associated with a mindfulness-based art therapy program (employing functional magnetic resonance imaging) and correlate such changes to stress and anxiety in women with breast cancer

Intervention Characteristics/Basic Study Process:

The Mindfulness-based Art Therapy (MBAT) intervention arm consisted of the basic mindfulness-based stress reduction (MBSR) curriculum paired with expressive art tasks. The design of MBAT was intended to provide opportunities for self-expression, facilitate coping strategies, and improve self-regulation. The MBSR aspect of the MBAT intervention provided standardized tools to help participants observe, assess, and negotiate their objective and subjective experiences of the illness process. A variety of mindfulness meditation techniques were taught during the eight-week program, including body scan, awareness of breathing, awareness of emotions, and mindful yoga, walking, eating, and listening.

Sample Characteristics:

  • The study reported on 18 female patients with breast cancer.
  • Mean patient age was 55 years (range = 45–67).
  • Patients received their breast cancer diagnosis between 6 months and three years prior to enrollment and were not in active treatment.

Setting:

  • Urban setting
  • Thomas Jefferson University, Philadelphia, PA

Phase of Care and Clinical Applications:

  • Patients were not receiving active treatment.
  • The study has clinical applicability for elder care and palliative care.

Study Design:

A randomized, qualitative study design was used.

Measurement Instruments/Methods:

Response to the program was evaluated using the Symptom Checklist-90 Revised (SCL-90-R) as a way to rate behavior. The SCL-90-R was obtained pre- and post-MBAT and within one week of the pre- and post-functional MRI scans. The SCL-90-R is a 90-item inventory that assesses nine symptom dimensions and a summary score, the Global Severity Index. Functional MRI scans were also obtained as a way to correlate scores on the SCL-90-R with results of the functional MRI.

Results:

Overall, the study showed significant differences in cerebral blood flow in the insula, caudate, and amygdala in patients who underwent an eight-week MBAT program. Given the improvements in anxiety levels (lower scores on the SCL-90-R), these findings suggest that at the level of these brain structures, the MBAT intervention may help to mediate emotional responses in women with breast cancer.

Conclusions:

Women who used MBAT techniques had lower scores on the anxiety scale, and also a difference in cerebral blood flow in the insula, caudate, and amygdala regions shown through functional MRI studies. These areas have known correlations with stress and anxiety.

Limitations:

  • The study had a small sample, with less than 30 participants.
  • The study had risk of bias due to lack of blinding.
  • Findings are not generalizable.
  • The intervention was expensive, impractical, or required training needs.
  • Functional MRI is prohibitively expensive and only available in university settings.

Nursing Implications:

Brief guided imagery or simple meditation techniques could be employed by nurses to relieve patients’ stress and anxiety. Guiding patients toward reading about meditation and guided imagery and encouraging them to try these techniques on their own may also be useful.

Sharplin, G.R., Jones, S.B., Hancock, B., Knott, V.E., Bowden, J.A., & Whitford, H.S. (2010). Mindfulness-based cognitive therapy: An efficacious community-based group intervention for depression and anxiety in a sample of cancer patients. Medical Journal of Australia, 193(5 Suppl.), S79–82.

doi: PMid:21542452
Print

Study Purpose:

To assess the impact of an eight-week mindfulness-based cognitive therapy program on individuals experiencing distress as a consequence of cancer 

Intervention Characteristics/Basic Study Process:

Participants included people with a history of cancer and those the study defined as carers. Participants were people who called the Cancer Council South Australia Helpline. They were assessed for anxiety and depression before and after a course of mindfulness-based cognitive therapy (MBCT). The MBCT program consisted of eight weekly two-hour sessions facilitated by an experienced counselor. The program sessions included these topics: stepping out of automatic pilot; dealing with barriers; mindfulness of one’s breath; staying present; acceptance; holding, allowing, letting be; thoughts are not facts; how to best take care of oneself; and using learned skills to control future mood. An optional three-hour follow-up session occurred six weeks after program completion, to reinforce mindfulness principles.

Sample Characteristics:

  • The sample (N = 21) included 16 cancer survivors and five carers.
  • Mean participant age was 52 years, with a range of 34–69 years.
  • The sample was 14% male and 86% female.
  • The largest number of participants had breast cancer; glioblastoma multiforme, adenoid cystic carcinoma, acute myeloid leukemia, lymphoma, liver cancer, bladder cancer, ovarian cancer, and prostate cancer were represented.
  • Time since diagnosis was 3–120 months.

Setting:

  • Single site  
  • Adelaide, South Australia, Australia

Phase of Care and Clinical Applications:

  • Patients were in the transition phase after initial treatment.
  • The study has clinical applicability for late effects and survivorship.

Study Design:

Prospective, one-group, pre/post-test design

Measurement Instruments/Methods:

  • Beck Depression Inventory (BDI)    
  • State-Trait Anxiety Inventory (STAI)
  • Freiburg Mindfulness Inventory (FMI)

Results:

  • Mean depression scores decreased from mild (mean: 15.0; SD = 9.07) to minimal (mean: 10.37; SD = 5.92) and for anxiety levels from clinical (mean: 43.17; SD = 13.25) to nonclinical (mean, 31.39; SD = 9.61). 
  • At the three-month follow-up, depression levels remained roughly the same as they had been at baseline. Compared to pretreatment levels of mean anxiety, at three months researchers noted a slight but nonsignificant increase.
  • Mindfulness level at each time point had significant negative correlations with depression and anxiety.

Conclusions:

Poor study design and small sample prevent drawing a valid conclustion about the effect of the intervention.

Limitations:

  • The study had a small sample size (particularly in regard to carers), with fewer than 30 participants. This fact limits generalizability.
  • The study did not include an appropriate control group.
  • The authors' recruitment method, using those who had called a helpline as the recruitment pool, was unusual. 
  • Defining and measuring the concept of mindfulness is difficult.
  • Measurement and intervention time points, in relation to cancer treatments, were unjustified; thus, the findings may have been the result of natural changes over time.
     

Nursing Implications:

MBCT may be an effective intervention for cancer survivors and carers who are willing to make a time commitment for sessions and homework. Further research is warranted.

Würtzen, H., Dalton, S.O., Elsass, P., Sumbundu, A.D., Steding-Jensen, M., Karlsen, R.V., . . . Johansen, C. (2013). Mindfulness significantly reduces self-reported levels of anxiety and depression: Results of a randomised controlled trial among 336 Danish women treated for stage I–III breast cancer. European Journal of Cancer 49,1365–1373.

doi: 10.1016/j.ejca.2012.10.030
Print

Study Purpose:

To test, in a randomized controlled study, the effect of a structured eight-week group mindfulness-based stress-reduction program on anxiety and depression among women with breast cancer

Intervention Characteristics/Basic Study Process:

The mindfulness-based stress-reduction program consisted of eight weekly two-hour group sessions. The program included guided meditation, yoga and psychoeducational advice on stress and stress reactions, and group dialog about the integration of mindfulness practice into daily life. Three experienced clinical psychologists provided the program. The control group received usual care. Data were collected before randomization and at 6 and 12 months after the intervention.

Sample Characteristics:

  • The study reported on 336 female patients (168 in the experimental group, 168 in the control group).
  • Mean patient age was 54.14 years (SD = 10.30 years).
  • Patients had stage I–III breast cancer (97% had stage I or II).
  • Recruitment was of patients who had received surgery within 3–18 months. Patients underwent various treatments during the study.

Setting:

  • Multisite
  • Outpatient setting
  • Hospitals associated with University of Copenhagen, Denmark

Phase of Care and Clinical Applications:

  • Patients were undergoing active antitumor treatment.
  • The study has clinical applicability for elder care and palliative care.

Study Design:

A randomized controlled trial design was used.

Measurement Instruments/Methods:

  • Symptom Checklist-90 Revised (SCL-90-R), Danish version: 13 items relating to the depression subscale and 10 items relating to the anxiety subscale
  • Center for Epidemiologic Studies Depression Scale (CESD): 21 items focusing primarily on cognitive and affective, rather than physical, manifestations of depression

Results:

  • At baseline, researchers noted no difference between groups in regard to clinical or demographic characteristics, depression, or anxiety.
  • After intervention, analysis revealed a statistically significant between-group difference regarding CESD scores (p = 0.001). At six months, analysis revealed a significant between-group difference regarding anxiety scores (p = 0.05) and for both depression measures (SCL-90-R, p = 0.01; CESD, p = 0.03). After 12 months, researchers noted a significant difference between groups in regard to SCL-90-R depression and CESD scores. After 12 months, intention-to-treat analyses showed differences between groups in levels of anxiety (p = 0.0002) and depression (SCL-90-R, p < 0.0001; CESD, p = 0.0367).
  • The intervention was more effective for those with higher levels of anxiety and depression at baseline.

Conclusions:

The mindfulness-based stress-reduction program was effective in reducing anxiety and depression over time in the patients studied. The intervention was most effective for those who had higher levels of anxiety and depression at baseline.

Limitations:

  • The study had risk of bias due to lack of appropriate attentional control.
  • Key differences between the sample groups could have influenced results.
  • The intervention is expensive, impractical to implement, and presents training needs.
  • Researchers paid insufficient attention to the control group and provided no blind.
  • Patients may have been at different time points in relation to treatment (e.g., chemotherapy, radiation treatment). This may decrease the reliability of study findings.

Nursing Implications:

The intervention appears to be effective. It does, however, require that the facilitator receive special training, which is an extra cost, and the intervention may be difficult to implement in the practice setting. The study does not address whether the effectiveness of the intervention varies with phase of care. As with other types of intervention, the mindfulness-based stress-reduction program appeared to be most effective for patients who had higher levels of anxiety and depression at the beginning of treatment, suggesting that appropriate patient selection for such an intervention can be beneficial. This study was limited by the lack of attentional control; providing attention alone may positively affect the anxiety and depression of patients with cancer.

Systematic Review/Meta-Analysis

Piet, J., Würtzen, H., & Zachariae, R. (2012). The effect of mindfulness-based therapy on symptoms of anxiety and depression in adult cancer patients and survivors: A systematic review and meta-analysis. Journal of Consulting and Clinical Psychology, 80, 1007–1020.

doi: 10.1037/a0028329
Print

Purpose:

To evaluate current evidence regarding the effect of mindfulness-based therapy (MBT) on symptoms of anxiety and depression in patients with cancer

Search Strategy:

  • Databases used in the search were EMBASE, PubMed, PsycINFO, Web of Science, Scopus, and Cochrane Collaboration.
  • Search keywords were mindfulness, MBT, MBSR, and cancer.
  • Inclusion criteria were English-language studies reporting on adult patients with a current or former diagnosis of cancer who were receiving MBT or mindfulness-based stress reduction (MBSR) as an intervention. Studies included pre- and postintervention valid continuous measures of anxiety or depression symptoms.
  • Exclusion criteria were unspecified.

Literature Evaluated:

  • The study included 670 references.
  • Authors used the Jadad scale to evaluate and comment on the literature.

Sample Characteristics:

  • A final number of 22 studies were included in the review.   
  • Sample range across studies was 1,409 participants, with a range of 12–287.
  • Mean participant age was 55 years.
  • Women with breast cancer represented 86% of the sample.

Phase of Care and Clinical Applications:

Multiple phases of care

Results:

Among nonrandomized studies, overall effect size for anxiety was 0.60 (Hedges’s g, p < 0.001) and 0.42 (p < 0.001) for depression. Among randomized controlled trials, effect size for anxiety was 0.37 and 0.44 (p < 0.001) for depression. Most studies used the Profile of Mood States scale or the State-Trait Anxiety Inventory. The range of Jadad quality scores was 0–4, with only six studies having scores greater than 2. This score indicates low quality. Heterogeneity among studies was moderate.

Conclusions:

Findings demonstrate a low to moderately significant effect of MBT in reducing anxiety and symptoms of depression among patients with cancer. Heterogeneity among studies suggests that findings be viewed with caution.

Limitations:

  • Most participants were women with breast cancer. Findings may not be generalizable to males and to other diseases.
  • The quality of many of the assessed studies was low. 
  • Most studies did not include patients with clinically significant levels of anxiety or depression at baseline.
  • Studies were done at various phases in the cancer trajectory, so how the phase of care may have influenced findings is unclear. 
  • In general, anxiety and depression symptoms improve over time with no intervention. The research did not consider this fact.

Nursing Implications:

MBT may benefit patients with cancer by reducing anxiety and symptoms of depression. The use of MBT appears to be feasible in cancer care. The low quality of studies in this analysis points to the need for well-designed research on the effects of MBT.


Menu