Mindfulness-Based Stress Reduction

Mindfulness-Based Stress Reduction

PEP Topic 
Caregiver Strain and Burden
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 disturbance, and depression (Piet, Würtzen, & Zachariea, 2012). It also has been studied in caregivers of patients with cancer for its effect on caregiver strain and burden.

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Likely to Be Effective

Research Evidence Summaries

Birnie, K., Garland, S.N., & Carlson, L.E. (2010). Psychological benefits for cancer patients and their partners participating in mindfulness-based stress reduction (MBSR). Psycho-Oncology, 19, 1004–1009.

doi: 10.1002/pon.1651
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Study Purpose:

To conduct a preliminary exploration of mindfulness-based stress reduction (MBSR) participation of couples affected by cancer, particularly as participation affects symptoms of stress, mood disturbance, and mindfulness for patients with cancer and their partners

Intervention Characteristics/Basic Study Process:

A convenience sample of 41 couples already enrolled in an MBSR program at a cancer outpatient center agreed to participate by completing the three study measures before the program started and two weeks following program completion. Weekly 90-minute classes held over an eight-week period, plus one weekend retreat lasting three to six hours, comprised the intervention. Of the 41 couples, only 21 completed post-test measures and at least six of eight MBSR classes.

Sample Characteristics:

  • The sample was comprised of 21 couples (95% married).
  • The sample was 52.4% female and 47.6% male.
  • Mean patient age was 62.9 years (SD = 7.37); mean partner age was 62.8 years (SD = 9.34).
  • The most common patient diagnoses were prostate cancer (28.6%), breast cancer (19%), and colorectal cancer (14.3%).
  • Mean time since primary diagnosis for all patients was 2.03 years.
  • Mean educational level for couples was 14.6 years.

Setting:

  • Single site
  • Outpatient setting
  • Cancer center in Calgary, Alberta, Canada

Phase of Care and Clinical Applications:

  • Multiple phases of care
  • Late effects and survivorship

Study Design:

A pretest/post-test design was used.

Measurement Instruments/Methods:

  • Profile of Mood States (POMS): Measures identified mood and change in mood or affective states using a Likert scale with well-established reliability (Kuder-Richardson of six POMS subscales ranged from 0.84 to 0.95.)    
  • Calgary Symptoms of Stress Inventory (C-SOSI): Uses a Likert scale to measure physical and psychologic responses to stress and consists of eight subscales (depression, anger, muscle tension, cardiopulmonary arousal, sympathetic arousal, neurologic/gastrointenstinal, cognitive disorganization, and upper respiratory symptoms). The tool has been validated in the oncology population with convergent and divergent validity (Cronbach's alpha = 0.95).
  • Mindfulness Attention Awareness Scale (MAAS): Uses a Likert scale to  assess individual differences in mindfulness over time and measures the presence or absence of attention and awareness to the present moment. The scale has been validated with patients with cancer (Cronbach's alpha = 0.87).

Results:

Of the couples, 21 provided POMS data, 19 provided C-SOSI data, and 16 provided MAAS data for baseline and postintervention measures. Before MBSR intervention, patients reported significantly higher scores on the POMS fatigue subscale (p = 0.05), while partners reported significantly higher scores on the C-SOSI sympathetic arousal subscale (p < 0.05) than did patients according to t-test analysis. Patients with only baseline data reported significantly higher levels of total mood disturbance before MBSR classes than those who provided complete data (p < 0.05). After program completion, both patients and partners experienced significant reduction in mood disturbance (p < 0.05) and the C-SOSI subscales of muscle tension (p < 0.01), fatigue (p < 0.05), neurologic/GI (p < 0.05), and upper respiratory symptoms (p < 0.01). Both groups significantly increased their mindfulness (p < 0.05) as a result of the intervention. After the MBSR intervention, couples’ scores on the POMS and C-SOSI were more highly correlated with one another. Partners’ mood disturbance scores were positively correlated (p < 0.05) with patients’ symptoms of stress and negatively correlated with patients’ levels of mindfulness (p < 0.05).

Conclusions:

As one of the first studies using a sample of patients with cancer and partners, the MBSR program benefited both patients and their partners by reducing mood disturbance and physical symptoms of stress, psychologically aligning patients and partners during the cancer journey, and increasing levels of mindfulness. Moderate effect sizes were found for both patients and partners on these variables.

Limitations:

  • The sample was small and underpowered, with less than 30 participants.
  • The study had no comparison group.
  • The study had 51% attrition following collection of baseline data from 41 couples.

Nursing Implications:

MBSR programs for patients with cancer and their partners may buffer physical and psychological challenges during their cancer journey. Nurses, as members of the healthcare team, may suggest these increasingly evidence-based programs as a complementary intervention for patients and partners who seek additional nonmedical ways to cope with the cancer illness. Validation of MBSR will enhance couples’ willingness to seek out MBSR that may respond to psychosocial gaps in care of patients with cancer and their partners who struggle with predominant high-technology approaches to oncology care. Further examination is also needed to identify cost-effective ways of meeting healthcare system goals for person-centered care in diverse populations of families facing cancer.

Fegg, M.J., Brandstatter, M., Kogler, M., Hauke, G., Rechenberg-Winter, P., Fensterer, V., . . . Borasio, G.D. (2013). Existential behavioural therapy for informal caregivers of palliative patients: A randomised controlled trial. Psycho-Oncology, 22, 2079–2086.

doi:10.1002/pon.3260
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Study Purpose:

To evaluate the applicability and effectiveness of existential behavioral therapy (EBT)  to informal caregivers of palliative care patients with regards to psychological distress and quality of life when compared with treatment as usual

Intervention Characteristics/Basic Study Process:

The intervention was six group sessions totaling 22 hours. The sessions focused on introductions and mindfulness, death, bereavement and mindfulness, activating resources, finding meaning, self-care and stress management, personal values for (re-)orientation, and moving forward. Sessions were administered in small (10 participants or fewer), closed groups by a trained behavioral therapist following a study manual. Evaluations occurred at baseline, pre- and post-intervention, and at 3- and 12-month follow-up (five time points).

Sample Characteristics:

  • N = 133  
  • MEAN AGE = 54.5 years (13.2 years)
  • MALES: 30.1%, FEMALES: 69.9%
  • KEY DISEASE CHARACTERISTICS: Primarily (92.7%) various cancer diagnoses and neurological diseases; six months or less to live; currently in an inpatient palliative care unit
  • OTHER KEY SAMPLE CHARACTERISTICS: German speaking; 61.7% identified as partners, 26.3% as parents, 4% as children, and 12% as other

Setting:

  • SITE: Multi-site    
  • SETTING TYPE: Inpatient  
  • LOCATION: Munich, Germany

Phase of Care and Clinical Applications:

  • PHASE OF CARE: End-of-life care
  • APPLICATIONS: Palliative care 

Study Design:

  • RCT

Measurement Instruments/Methods:

  • Brief Symptom Inventory (BSI) subscales—somatization, anxiety, and depression
  • Quality of life
    • Satisfaction With Life Scale (SWLS)—cognitive aspects
    • World Health Organization Quality of Life (WHOQOL)-BREF
    • Numeric rating scale for quality of life—QOL-NRS (single-item, scale of 1–10)
  • Positive and Negative Affect Scale (PANAS)

Results:

EBT showed medium effects at the pre-/immediate post-test evaluation with improvement in anxiety (p 0.006) and on all measures of quality of life (p 0.009, 0.007, < 0.001). At the three-month evaluation, EBT showed no significant effects, with only small effect sizes on one-third of the quality-of-life measure SWLS (p 0.04). However, at the 12-month evaluation, EBT demonstrated medium effects on depression (p 0.04) and QOL-NRS (p 0.002). Interestingly, similar patterns resulted when examining secondary outcomes of affect, with significantly less negative affect demonstrated at post-test (p 0.003), which then was not noted at the three-month evaluation, and at 12 months, significantly less negative affect was measured again (p 0.003). Positive affect, although never significant, always was trending more positive than when compared with controls. High level of satisfaction existed with the group, the therapist, information, mindfulness, and values.

Conclusions:

EBT shows promise as an intervention to improve psychological distress and quality of life for carers of patients with cancer at end of life. The effect is greatest immediately following the intervention. Additional work is required with attentional control groups and outpatient patient populations to further support the benefits of this intervention.

Limitations:

  • Risk of bias (no appropriate attentional control condition)  
  • Risk of bias (sample characteristics)
  • Intervention expensive, impractical, or training needs
  • Other limitations/explanation: Heterogeneous sample—variety of care types, partners versus relatives and carers of living and dead patients were included in the same groups, meaning that for some, they already were in the grieving process at the start of the intervention. When compared to treatment as usual, which is no intervention, whether EBT or just being part of a group, or having attention of the therapist accounted for the improved outcomes is unclear. Intervention included specially trained behavioral therapist, not nurses.

Nursing Implications:

Interventions such as EBT that target informal carers of patients with cancer have the potential to relieve distress and improve quality of life for the carer and the patient.


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