Codie R. Rouleau

The impact of mindfulness-based interventions on symptom burden, positive psychological outcomes, and biomarkers in cancer patients

Research on the use of mindfulness-based stress reduction and related mindfulness-based interventions (MBIs) in cancer care has proliferated over the past decade. MBIs have aimed to facilitate physical and emotional adjustment to life with cancer through the cultivation and practice of mindfulness (ie, purposeful, nonjudgmental, moment-to-moment awareness). This descriptive review highlights three categories of outcomes that have been evaluated in MBI research with cancer patients – namely, symptom reduction, positive psychological growth, and biological outcomes. We also examine the clinical relevance of each targeted outcome, while describing recently published original studies to highlight novel applications of MBIs tailored to individuals with cancer. Accumulating evidence suggests that participation in a MBI contributes to reductions in psychological distress, sleep disturbance, and fatigue, and promotes personal growth in areas such as quality of life and spirituality. MBIs may also influence markers of immune function, hypothalamic–pituitary–adrenal axis regulation, and autonomic nervous system activity, though it remains unclear whether these biological changes translate to clinically important health benefits. We conclude by discussing methodological limitations of the extant literature, and implications of matching MBIs to the needs and preferences of cancer patients. Overall, the growing popularity of MBIs in cancer care must be balanced against scientific evidence for their impact on specific clinical outcomes.

THE COMPARATIVE IMPACT OF MINDFULNESS-BASED CANCER RECOVERY (MBCR) AND COGNITIVE BEHAVIOR THERAPY FOR INSOMNIA (CBT-I) ON SLEEP AND MINDFULNESS IN CANCER PATIENTS

BACKGROUND Insomnia is an important but often overlooked side effect of cancer. Dysfunctional sleep beliefs have been identified as an important perpetuating factor for insomnia. Mindfulness practice has been demonstrated to improve sleep quality but it is unknown whether these effects relate to changes in dysfunctional sleep beliefs. PURPOSE This study is a secondary analysis of a randomized controlled trial comparing mindfulness-based cancer recovery (MBCR) to cognitive behavior therapy for insomnia (CBT-I) in cancer patients with insomnia. This present analysis compares program impact on mindfulness, dysfunctional sleep beliefs, and insomnia severity clinical cutoffs. METHODS Patients (MBCR, n = 32; CBT-I, n = 40) were assessed at baseline, post-program, and 3-month follow-up. RESULTS Across both groups, patients showed improvements over time in acting with awareness (P = .021) and not judging experiences (P = .023). Changes in dysfunctional sleep beliefs produced by the CBT-I group exceeded those produced by MBCR at post-program and follow-up (P < .001). Acting with awareness, non-judging, and non-reacting were the facets of mindfulness associated with an overall reduction in dysfunctional sleep beliefs. There were no significant differences between the MBCR and CBT-I groups in the percentage of patients exceeding insomnia severity clinical cutoffs at post-program or follow-up. CONCLUSIONS This study supports the use of both CBT-I and MBCR to reduce insomnia severity and suggests the development of mindfulness facets as a method of reducing dysfunctional sleep beliefs.

An investigation of the benefits of stress management within a cardiac rehabilitation population

PURPOSE: Research describing whether stress management can improve clinical outcomes for patients in cardiac rehabilitation (CR) has yielded equivocal findings. METHODS: The present investigation retrospectively examined the incremental impact of exercise and stress management (n = 188), relative to exercise only (n = 1389), on psychosocial and physical health outcomes following a 12-week CR program. RESULTS: Participation in stress management and exercise was associated with greater reductions in waist circumference and systolic blood pressure, relative to exercise alone, for patients with baseline clinical elevations on these measures. The stress management group had more depressive symptoms (as measured by the Hospital Anxiety and Depression Scale; t[1] = 3.81, P < .001) and lower physical quality of life (as measured by the 12-Item Short Form Health Survey Physical Component; t[1] = 3.00, P = .003) than the exercise-only group at baseline, but there were no differences between the groups at 12 weeks in terms of depressive symptoms (t[1] = 1.74, P = .082) or physical quality of life (t[1] = 1.56, P = .120). CONCLUSION: These findings suggest that stress management may offer additional benefits in selected patients over and above exercise in CR.

Sleeping for Two: An Open-Pilot Study of Cognitive Behavioral Therapy for Insomnia in Pregnancy

Insomnia and disturbed sleep are common during pregnancy. This study investigated the effectiveness of group cognitive-behavioral therapy for insomnia (CBT-I) delivered in pregnancy. Thirteen pregnant women with insomnia participated in five weekly CBT-I group sessions. All participants completed the study and provided baseline and follow-up data. Significant reductions in insomnia symptoms and increases in subjective sleep quality were observed over the course of the study. Diary and actigraphy assessments of sleep also changed, such that participants reported less time in bed (TIB), shorter sleep onset latency (SOL), increased sleep efficiency (SE), and increased subjective total sleep time (TST). Additionally, symptoms of depression, pregnancy-specific anxiety, and fatigue all decreased over the course of treatment. Effect sizes ranged from medium to large. CBT-I delivered during pregnancy was associated with significant improvements in sleep and mood. The next step in this area of inquiry is to better establish effectiveness via a randomized controlled trial.

Training Healthcare Providers in Motivational Communication for Promoting Physical Activity and Exercise in Cardiometabolic Health Settings: Do We Know What We Are Doing?

Regular physical activity (PA) is essential for secondary and tertiary prevention of cardiometabolic risk factors and disease, but low adherence to PA recommendations is common. Motivational communication (MC) represents a collection of evidence-based behavior change strategies drawn from motivational interviewing, cognitive-behavioral techniques, and behavior change theories that show promise for promoting PA adherence. However, dissemination of MC strategies in cardiometabolic healthcare settings has been limited by inconsistent reporting of training fidelity in intervention research, making it unclear how to optimally train healthcare providers. We discuss preliminary considerations for training individuals in the use of MC, including: being relatively intensive with more than self-directed learning, covering an array of behavior change strategies, offering ongoing mentorship and support, and being delivered by a skilled trainer who addresses diverse trainee needs. Future work is needed to expand upon these considerations and establish what constitutes competent MC training to impact cardiometabolic health outcomes.

Ethical issues in the psychosocial assessment of bariatric surgery candidates

Psychosocial evaluation is recommended prior to bariatric surgery. Practice guidelines have been published on assessment methods for bariatric surgery candidates, but they have not emphasized ethical issues with this population. This review outlines ethical and professional considerations for behavioral healthcare providers who conduct pre-surgical assessments of bariatric surgery candidates by merging ethical principles for mental health professionals with current practices in pre-surgical assessments. Issues discussed include the following: (a) establishing and maintaining competence, (b) obtaining informed consent, (c) respecting confidentiality, (d) avoiding bias and discrimination, (e) avoiding and addressing dual roles, (f) selecting and using psychological tests, and (g) acknowledging limitations of psychosocial assessments.

A qualitative study exploring factors that influence enrollment in outpatient cardiac rehabilitation.

Abstract Purpose: This study explored patients’ decision-making about whether or not to enroll in cardiac rehabilitation (CR), an underutilized program that is associated with significantly improved health outcomes. Method: Face-to-face interviews were conducted with acute coronary syndrome patients (n = 14) after referral to a local CR center, but prior to program enrollment. Thematic analysis was used to derive themes from interview transcripts. Results: Three themes emerged including anticipated benefit, perceived ability, and contextual influences. Participants believed key benefits of CR would be access to specialist health care providers, improved longevity, reduced cardiovascular risk, as well as improved motivation, accountability, learning opportunities, and general fitness. Participants were concerned about their ability to engage in and travel to exercise sessions, pay the program fee, and manage scheduling conflicts. Contextual influences on decision-making included health care provider recommendation, first impressions of the CR center, knowledge gaps about what CR entails, input from family and peers, and psychological distress. Conclusion: The period following CR referral but prior to enrollment represents an optimal opportunity to promote in-the-moment decisions in favor of CR. Patients report both positive and negative aspects of CR, suggesting individualized efforts to resolve ambivalence may increase program participation. Implications for Rehabilitation Cardiovascular disease is a leading cause of mortality worldwide. Cardiac rehabilitation (CR) is an effective secondary prevention strategy to improve cardiovascular morbidity and mortality, but only a subset of eligible patients enroll. After referral but prior to enrollment, patients anticipate both positive and negative aspects of CR participation. Individualized efforts to resolve ambivalence, address knowledge gaps, and problem-solve barriers may increase uptake into CR programs.

Assessing the Value of Moving More-The Integral Role of Qualified Health Professionals

Being physically active or, in a broader sense, simply moving more throughout each day is one of the most important components of an individuals health plan. In conjunction with regular exercise training, taking more steps in a day and sitting less are also important components of ones movement portfolio. Given this priority, health care professionals must develop enhanced skills for prescribing and guiding individualized movement programs for all their patients. An important component of a health care professionals ability to prescribe movement as medicine is competency in assessing an individuals risk for untoward events if physical exertion was increased. The ability to appropriately assess ones risk before advising an individual to move more is integral to clinical decision-making related to subsequent testing if needed, exercise prescription, and level of supervision with exercise training. At present, there is a lack of clarity pertaining to how a health care professional should go about assessing an individuals readiness to move more on a daily basis in a safe manner. Therefore, this perspectives article clarifies key issues related to prescribing movement as medicine and presents a new process for clinical assessment before prescribing an individualized movement program.

The role of maternal cardiac vagal control in the association between depressive symptoms and gestational hypertension

Reduced cardiac vagal control, indexed by relatively lower high-frequency heart rate variability (HF-HRV), is implicated in depressed mood and hypertensive disorders among non-pregnant adults whereas research in pregnancy is limited. This study examined whether maternal HF-HRV during pregnancy mediates the association between depressed mood and gestational hypertension. Depressive symptoms (Edinburgh Depression Scale) and HF-HRV were measured during early (M=14.9 weeks) and late (M=32.4 weeks) pregnancy in 287 women. Gestational hypertension was determined by chart review. Depressive symptoms were associated with less HF-HRV (b=-0.02, p=.001). There was an indirect effect of depressed mood on gestational hypertension through late pregnancy HF-HRV (b=0.04, 95% CI 0.0038, 0.1028) after accounting for heart rate. These findings suggest cardiac vagal control is a possible pathway through which prenatal depressed mood is associated with gestational hypertension, though causal ordering remains uncertain.

The Association Between Insomnia Symptoms and Mood Changes During Exercise Among Patients Enrolled in Cardiac Rehabilitation.

PURPOSE: Insomnia symptoms (ie, difficulty falling asleep, difficulty staying asleep, and early awakenings) are common among patients with cardiovascular disease and may interfere with the beneficial impact of exercise on mood state. This study investigated the association of insomnia symptom severity with mood disturbance and with changes in mood state during exercise in a cardiac rehabilitation (CR) population. METHODS: Insomnia symptom severity was measured using the Insomnia Severity Index upon admission to a 12-week CR program (n = 57). The Physical Activity Affect Scale was administered before and during a single bout of moderate intensity exercise to measure changes in mood state. Indices of mood disturbance included depressive symptoms (Hospital Anxiety and Depression Scale) and pre-exercise mood state (Physical Activity Affect Scale). RESULTS: Greater severity of insomnia symptoms was associated with less pleasant mood overall (r = −0.45, P < .001), including less tranquility (r = −0.37, P = .005), lower positive affect (r = −0.39, P = .003), and worse fatigue (r = 0.36, P = .005); greater insomnia symptom severity also predicted greater improvements during exercise in both overall mood state (b = 0.26, standard error = 0.10, P = .009) and tranquility (b = 0.09, standard error = 0.04, P = .04), following statistical adjustment for demographic variables and pre-exercise mood state. CONCLUSIONS: Although CR patients reporting insomnia symptoms tend to experience daytime mood disturbance, they may benefit from mood-elevating properties of exercise. Future research is needed to help optimize mood during exercise, which may have implications for improving psychological distress and CR adherence.