Mindfulness-Based Stress Reduction

Mindfulness-Based Stress Reduction

PEP Topic 
Fatigue
Description 

Mindfulness-based stress reduction (MBSR) is a consciousness discipline 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 also has been studied in caregivers of patients with cancer for its effect on caregiver strain and burden.

Likely to Be Effective

Research Evidence Summaries

Carlson, L.E., & Garland, S.N. (2005). Impact of mindfulness-based stress reduction (MBSR) on sleep, mood, stress and fatigue symptoms in cancer outpatients. International Journal of Behavioral Medicine, 12, 278–285.

doi: 10.1207/s15327558ijbm1204_9
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Intervention Characteristics/Basic Study Process:

The mindfulness-based stress reduction (MBSR) intervention was provided over eight weekly 90-minute group sessions. Details of the intervention have been previously described in Carlson et al. (2003). Participants were asked to complete 45 minutes of meditation homework six days a week and recorded their progress in a homework log. Patient outcomes were assessed at baseline and at week 8.

Sample Characteristics:

  • N = 63
  • MEAN AGE =54 years
  • AGE RANGE = 32–78 years
  • FEMALES: 78%
  • KEY DISEASE CHARACTERISTICS: Patients with cancer—cancer diagnoses were varied, with the most common being breast (59%), followed by prostate, ovarian, and non-Hodgkin lymphoma
  • OTHER KEY SAMPLE CHARACTERISTICS: The majority of participants was married (71%) and well educated (mean = 16 years of formal education)

Setting:

  • LOCATION: Tom Baker Cancer Center

Study Design:

  • Pre-post intervention study

Measurement Instruments/Methods:

  • Profile of Mood States (POMS)

Results:

The MBSR intervention resulted in a statistically significant improvement in fatigue when comparing pre- and post-test outcomes (p < 0.001). Statistically significant relationships also were found between changes in symptoms of stress and fatigue (p < 0.001), as well as changes in mood disturbance and fatigue (p < 0.001). Therefore, with less fatigue, patients also were less stressed and less moody.

Limitations:

  • Lack of a control group
  • Cannot determine which aspects of the intervention led to observed improvements in fatigue because MBSR is delivered in a multimodal format
  • Lack of a specific measure to assess fatigue
  • No follow-up assessment; therefore, long-term effects of MBSR remain unknown

Carlson, L.E., Speca, M., Patel, K.D., & Goodey, E. (2003). Mindfulness-based stress reduction in relation to quality of life, mood, symptoms of stress, and immune parameters in breast and prostate cancer outpatients. Psychosomatic Medicine, 65, 571–581.

doi: 10.1097/01.PSY.0000074003.35911.41
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Intervention Characteristics/Basic Study Process:

Didactic, inductive, and experiential modes of learning were used to implement the intervention and convey information to patients. The intervention was provided over the course of eight weekly 90-minute group sessions (maximum of 15 participants per group) as well as a three-hour silent retreat on Saturday between weeks 6 and 7.

Patients received a booklet containing information about each week’s instructions as well as an audiotape with sensate-focused body scan meditation on one side and a guided sitting meditation on the other.

The program was composed of three primary components.

  1. Theoretical materials related to mindfulness, relaxation, meditation, and the mind-body connection
  2. Experiential practice of meditation and yoga during group meetings and home-based practice
  3. Group process focused on problem-solving concerning obstacles to effective practice, daily applications of mindfulness, and supportive interaction between group members

Sample Characteristics:

  • N = 59
  • MEAN AGE = 54.5 years
  • KEY DISEASE CHARACTERISTICS: 49 women with breast cancer and 10 men with prostate cancer
  • OTHER KEY SAMPLE CHARACTERISTICS: Most patients (N = 42) were married or cohabiting, with a mean of 14.7 years of formal education. Patients had a median cancer diagnosis of 1.1 years prior to study enrollment (range = three months to 20 years). Two-thirds had stage II cancer (62.7%).
  • EXCLUSION CRITERIA: Treatment with chemotherapy, radiation therapy, or hormone therapy currently or within the past three months; psychiatric illness; a concurrent autoimmune disorder; and past participation in a mindfulness-based stress reduction (MBSR) group
  • RECRUITMENT: Patients primarily were recruited with pamphlets and posters around the center, in each of the breast and prostate clinic areas, and were able to self-refer.

Setting:

  • LOCATION: Tom Baker Cancer Center

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Active treatment

Study Design:

  • Pre-post intervention study

Measurement Instruments/Methods:

  • European Organization for Research and Treatment in Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30)
  • Profile of Mood States (POMS)

Results:

The MBSR intervention did not result in a significant difference for fatigue outcomes between pre- and post-intervention time points. Only 42 patients had complete data for both time points. When comparing the 17 patients with incomplete data to the rest of the sample, participants with complete data were more likely to be married or cohabitating. Non-completers had higher scores than completers on several of the baseline measures for POMS subscale, including depression, anger, and confusion.

Limitations:

  • Lack of a neutral comparison group
  • Lack of correction for multiple comparisons during statistical analysis

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
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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
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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.

Kieviet-Stijnen, A., Visser, A., Garssen, B., & Hudig, W. (2008). Mindfulness-based stress reduction training for oncology patients: Patients’ appraisal and changes in well-being. Patient Education and Counseling, 72, 436–442.

doi: 10.1016/j.pec.2008.05.015
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Intervention Characteristics/Basic Study Process:

The MBSR intervention emphasized the following.

  • Learning to meditate
  • Systematic monitoring of the body
  • Exploring one’s limits and trying to shift these limits
  • Recognizing and investigating thoughts and cognitions
  • Recognizing daily stress inducing conditions and their emotional impact
  • Learning more ways to handle daily stress

The intervention was offered in eight weekly sessions that were each 2.5 hours in length. Participants were encouraged to practice at home for 45 minutes using an exercise CD and other homework assignments. Each training group was guided by two therapists experienced in working with patients with cancer. Outcomes were assessed at baseline, at week 8, and a year after intervention.

The intervention was modeled after the MBSR program at the Stress Reduction and Relaxation Clinic, Massachusetts Medical Center as described by Kabat-Zinn (1990).

Sample Characteristics:

  • N = 47
  • MEAN AGE = 48.4 years
  • AGE RANGE = 31–65 years
  • MALES: 72%
  • KEY DISEASE CHARACTERISTICS: Patients with cancer with multiple diagnoses, the most common being breast cancer (40%)
  • OTHER KEY SAMPLE CHARACTERISTICS: Undergoing treatment (e.g., chemotherapy, hormonal therapy, radiation treatment, surveillance, alternative/complementary) throughout the intervention period.

Setting:

Not described

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Active treatment

Study Design:

  • Pre-post intervention study

Measurement Instruments/Methods:

  • Profile of Mood States (POMS)

Results:

The MBSR intervention did not significantly improve fatigue outcomes for patients at the eight-week intervention end-point or at one-year follow-up.

Limitations:

  • Lack of a neutral comparison group
  • Observed changes in quality of life may be a consequence of the passage of time.
  • Participants were self-referred to program.
  • High dropout rate observed throughout the study (no significant differences in demographic characteristics, disease variables, and well-being scores observed between completers and non-completers)

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
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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.

Speca, M., Carlson, L.E., Goodey, E., & Angen, M. (2000). A randomized, wait-list controlled clinical trial: The effect of a mindfulness meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients. Psychosomatic Medicine, 62, 613–622.

doi: 10.1097/00006842-200009000-00004
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Intervention Characteristics/Basic Study Process:

The mindfulness based stress reduction (MBSR) intervention was based on the main principle that purposeful management of awareness can be used repeatedly in the ongoing process of adapting to illness once experiential knowledge of key processes in the stress-response cycle is mastered. Objectives of program were to

  1. Provide an opportunity to develop an understanding of one’s personal responses to stress and a means to modify them
  2. Allow group member to take an active role in their healing process
  3. Teach options for self-care that promote feelings of competence and mastery
  4. Enhance feelings of well-being
  5. Provide a safe and supportive group environment.

The intervention consisted of seven 90-minute weekly sessions. Patient outcomes were evaluated at baseline and at week 7 (end of intervention).

Sample Characteristics:

  • N = 90 
  • MEAN AGE = 51 years
  • KEY DISEASE CHARACTERISTICS: Patients with cancer with multiple diagnoses and stages, with breast cancer being the most common (38%)
  • OTHER KEY SAMPLE CHARACTERISTICS: Well educated with a mean of 15 years of formal education, convenience sample

Study Design:

  • Randomized wait-list control design
    • MBSR (N = 53)
    • Wait-list control (N = 37)

Measurement Instruments/Methods:

  • Profile of Mood States (POMS)

Results:

The MBSR intervention did not have a significant effect on improving fatigue outcomes for patients. When comparing pre- and post-test intervention scores, both the control and intervention groups experienced a decline in fatigue scores from baseline to week 7; however, this difference did not reach significance for either group.

In the initial sample of 109 patients enrolled in the study, 19 dropped out. A dropout analysis was performed, and initial POMS scores of dropouts were found to have significantly more mood disturbance on the subscales of anxiety, depression, fatigue, and total mood disturbance (p < 0.05).

Limitations:

  • Because MBSR was a multi-component intervention, it is difficult to isolate the mechanisms of action or specific techniques they contributed to the improvements observed.
  • It is possible that those assigned to the waitlist control group felt disappointment and may not have improved as much spontaneously over time as they would have otherwise.
  • Because the dropout group demonstrated higher mood disturbance, the MBSR program may not be sufficient to treat patients with more serious disturbances.

van der Lee, M. L., & Garssen, B. (2012). Mindfulness-based cognitive therapy reduces chronic cancer-related fatigue: a treatment study. Psycho-Oncology, 21, 264–272.

doi: 10.1002/pon.1890
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Study Purpose:

To evaluate the efficacy of group mindfulness-based cognitive therapy (MBCT) in reducing fatigue in cancer survivors with mixed diagnoses.

Intervention Characteristics/Basic Study Process:

Randomization and assignment to either the intervention condition or the wait-list condition was performed one week prior to the start of each group. Fatigue severity (Checklist Individual Strength [CIS]), functional impairment (Sickness Impact Profile [SIP]), and well-being (Health and Disease Inventory) were assessed before and after the nine-week intervention. The intervention group had a follow-up six months after the intervention.

Sample Characteristics:

Eighty-three patients (32% male, 68% female) were included. All cancer types were included; more than half of the patients had breast cancer. Three patients had a history of two types of cancer. 

Patients were included if 

  • Completion of their last anticancer treatment (all cancer types accepted) was at least one year prior
  • They were curatively treated
  • They were 18 years or older
  • They scored 35 or greater on the severity of fatigue subscale of the self-report CIS
  • There was no other somatic disease or medicine use that could explain or influence fatigue. 

Patients were excluded if they were seen on intake by one of two therapists for assessment of psychiatric morbidity or if they were identified to be at risk for psychosis or severe depression.

Setting:

  • Single site   
  • Helen Dowling Institute, Netherlands

Phase of Care and Clinical Applications:

  • Patients were undergoing the long-term follow-up phase of care.
  • The study has applicability for late effects and survivorship.

Study Design:

The study used a pre- and postrandomized, controlled trial design.

Measurement Instruments/Methods:

  • CIS   
  • SIP
  • Health and Disease Inventory
  • Sleep Quality Scale (SQS)
  • Hospital Anxiety and Depression Scale (HADS)
     

Results:

Ninety-one percent of all participants attended at least seven sessions; the mean number of sessions attended was eight. One-third (30.6%) of all participants suffered from sleep disturbances at follow-up, and 39% in the intervention group showed clinically relevant improvement in fatigue severity. Fatigue severity postintervention was 35.7 in the intervention group compared to 43.4 in the control group (p = 0.00). The effect size for fatigue was 0.74 (d) (no confidence interval was provided for effect size). The mean well-being score at postmeasurement was significantly higher in the intervention group than in the wait-list group. Six months after the intervention, participants in both groups reported significantly less fatigue severity. There was no difference between groups in fatigue at six months.

Conclusions:

MBCT was effective in the short term for chronic cancer-related fatigue (CCRF). Longer-term follow-up showed no differences with mindfulness-based stress reduction versus the controls.

Limitations:

  • The study lacked an appropriate control group.
  • The study had limited generalizability to other therapists, as the same two therapists led all groups.
  • The protocol that the therapists used was not assessed for adherence.
  • There were unequal numbers of participants in the two condition groups.
  • Heterogenicity of the sample and the small sample size limited the control of confounding medical variables.
  • Limited economic resources exist for program development in support of a standardized practice for therapist-led sessions at local cancer centers. 
  • The study lacked an attentional control. 
  • Timing of the first posttest measure was not stated, so it was not clear if any effects were lasting.

Nursing Implications:

MBCT is an acceptable and potentially effective treatment for CCRF. Additional better randomized, controlled trials of the intervention should be conducted prior to routinely referring to MBCT therapists.


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