Mindfulness-based stress reduction to improve depression, pain and high patient global assessment in controlled rheumatoid arthritis.

Objective: The aim was to improve distressing patient-reported outcomes (PROs) that persisted in RA patients with clinically controlled inflammation (controlled RA). Methods: In a pragmatic pilot study, we offered mindfulness-based stress reduction (MBSR), a group intervention, to controlled RA patients who had high (≥16) Centre for Evaluation Studies depression (CES-D) scores and/or patient general assessment of disease activity (PGA) at least 2/10 larger than evaluator general assessment (EGA) (PGA-EGA: Delta). Evaluations before, 6 and 12 months after MBSR included CES-D, PGA, modified HAQ, simple disease activity index (SDAI), anxiety (general anxiety disorder 7; GAD-7), coping strategies (coping with health injuries and problems; CHIP), sleep disturbance and pain. Facilitators and obstacles to recruitment and participation were identified. A subset of patients was interviewed for qualitative analysis of their experience. Results: Out of 306 screened patients, 65 were referred, 39 (60%) agreed and 28 (43%) completed MBSR. Anticipated burden, timing and frequency of group meetings, commuting issues, age extremes and co-morbidities were barriers to participation. Up to 12 months after MBSR, anxiety, depression, emotion-oriented coping, sleep and function significantly improved. Nonetheless, no significant impact was observed on pain, PGA, Delta or SDAI. The interviews revealed that benefits, including integration of effective coping strategies, were maintained. Conclusion: We addressed MBSR feasibility issues and selection of outcomes in controlled RA patients with distressing PROs. For patients who chose to participate in MBSR, lasting benefits were evident for anxiety, depression, sleep and function. Larger studies are required to evaluate the weaker impact of MBSR on RA-related pain and PGA.

Mindfulness-based Intervention for Female Adolescents with Chronic Pain: A Pilot Randomized Trial.

OBJECTIVE: To test the feasibility of a randomized-controlled trial measuring the impact of an adapted mindfulness-based intervention (MBI) in female adolescents with chronic pain. METHODS: This was a single center, single-blind, prospective, experimental, longitudinal trial conducted in a pediatric tertiary care center. Participants had a history of chronic pain during at least three months. They were randomized into an intervention group or a wait-list control group. Both groups successively followed an adapted eight-week MBI designed specifically for adolescents with chronic pain. Pre-determined criteria were established to assess the feasibility, validity and acceptability of the study model. Data evaluating changes in quality of life, depression, anxiety, pain perception, psychological distress and salivary cortisol were collected throughout the 4-month study period. RESULTS: Nineteen female participants completed the study and had a mean age of 15.8 years (range 13.9 -17.8). Attrition rate was low (17%). Attendance to mindfulness sessions (84%) and compliance to study protocol (100%) were high. All participants reported a positive change in the way they coped with pain. No changes in quality of life, depression, anxiety, pain perception, and psychological distress were detected. Significant reductions in pre-and post-mindfulness session salivary cortisol levels were observed (p<0.001). CONCLUSIONS: Mindfulness is a promising therapeutic approach for which limited data exist in adolescents with chronic pain. Our study indicates the feasibility of conducting such interventions in teenage girls. A large trial is needed to demonstrate the efficacy and bio-physiological impacts of MBIs in teenagers with chronic pain.

OBJECTIF: Vérifier la faisabilité d'un essai randomisé contrôlé qui mesure l'effet d'une intervention de pleine conscience (IPC) adaptée chez des adolescentes souffrant de douleur chronique. MÉTHODES: Il s'agissait d'un essai monocentrique, à l'insu, prospectif, expérimental, longitudinal mené dans un centre soins tertiaires pédiatriques. Les participantes avaient des antécédents de douleur chronique durant au moins trois mois. Elles ont été randomisées soit dans un groupe d'intervention, soit dans un groupe témoin placé sur une liste d'attente. Les deux groupes ont suivi successivement une IPC adaptée de 8 semaines, conçue spécifiquement pour les adolescentes souffrant de douleur chronique. Des critères prédéterminés ont été établis pour évaluer la faisabilité, la validité et l'acceptabilité du modèle d'étude. Les données évaluant les changements touchant la qualité de vie, la dépression, l'anxiété, la perception de la douleur, la détresse psychologique et le cortisol salivaire ont été recueillies durant la période de 4 mois de l'étude. RÉSULTATS: Dix-neuf participantes ont participé à l'étude et leur âge moyen était de 15,8 ans (écart de 13,9 à 17,8). Le taux d'attrition était faible (17 %). L'assistance aux séances de pleine conscience (84 %) et l'observance du protocole de l'étude (100 %) étaient élevées. Toutes les participantes ont déclaré un changement positif de la façon dont elles traitaient avec la douleur. Aucun changement n'a été détecté en ce qui concerne la qualité de vie, la dépression, l'anxiété, la perception de la douleur, et la détresse psychologique. Des réductions significatives des taux de cortisol salivaire avant et après les séances de pleine conscience ont été observées (p < 0,001). CONCLUSIONS: La pleine conscience est une approche thérapeutique prometteuse pour laquelle il n'existe que des données limitées pour les adolescentes souffrant de douleur chronique. Notre étude indique la faisabilité de mener ces interventions auprès d'adolescentes. Il faut un vaste essai pour démontrer l'efficacité et les effets biophysiologiques des IPC chez les adolescentes souffrant de douleur chronique.

Depressive symptoms predict future simple disease activity index scores and simple disease activity index remission in a prospective cohort of patients with early inflammatory polyarthritis.

OBJECTIVE: To determine whether depressive symptoms assessed in treated patients with early inflammatory polyarthritis (EPA) influence disease activity during follow-up. METHODS: Consecutively recruited EPA patients were actively treated to remission. Simple disease activity index (SDAI) and Center for Epidemiologic Studies Depression Scale (CES-D) scores were calculated at inclusion and up to 42 months into disease. SDAI scores were log-transformed to compute univariate and multivariate linear regressions. Parametric interval-censored Kaplan-Meier and survival regressions using Weibull distribution were used to assess time to and predictors of SDAI remission. RESULTS: A total of 275 EPA patients were recruited at a median of 4 months into disease. In multivariate linear regression models, accounting for baseline demographic, clinical, serological and functional variables and 12-month inflammation markers, CES-D scores at 12 months into disease were correlated (r(2) = 0.14) with subsequent SDAI scores. Patients with 12-month high CES-D (≥19; suggestive of depression) had a lower proportion of SDAI remission (31.3% vs 84.3%; P < 0.001) and reached SDAI remission less rapidly [hazard ratio = 0.25 (95% CI 0.12, 0.53); P < 0.001]. CONCLUSION: Each follow-up SDAI correlated significantly with 12-month depressive symptoms, a median of 7 months after initiation of treatment. CES-D scores suggestive of depression at 12 months were strongly correlated with delay and failure to reach remission later on. Depressive symptoms in treated EPA patients represent important clinical issues with long-term association with disease activity. Interventions to alleviate persistent depressive symptoms in treated EPA warrant careful evaluation of their potential to improve disease remission rates.

Being a mindful clinical teacher: can mindfulness enhance education in a clinical setting?

Mindfulness may be viewed as a vehicle to promote the healer's role in medicine. This role addresses the way in which a medical practitioner interacts with patients. The aim of this article is to highlight how mindful qualities may also enhance teaching in clinical settings. Challenges to being a mindful clinical teacher are presented along with creative ways to accommodate them. Residents play an important role in training medical students. Examples of how mindfulness influenced a psychiatric resident's teaching experiences are presented to illustrate the concepts discussed herein. The dimension of "being" in medicine, based on the humanist philosophy of Dr Karl Jaspers, is provided as a framework for this article.

Teaching mindfulness in medical school: where are we now and where are we going?

OBJECTIVES: Mindfulness has the potential to prevent compassion fatigue and burnout in that the doctor who is self-aware is more likely to engage in self-care activities and to manage stress better. Moreover, well doctors are better equipped to foster wellness in their patients. Teaching mindfulness in medical school is gaining momentum; we examined the literature and related websites to determine the extent to which this work is carried out with medical students and residents. METHODS: A literature search revealed that 14 medical schools teach mindfulness to medical and dental students and residents. RESULTS: A wide range of formats are used in teaching mindfulness. These include simple lectures, 1-day workshops and 8-10-week programmes in mindfulness-based stress reduction. Two medical schools stand out because they have integrated mindfulness into their curricula: the University of Rochester School of Medicine and Dentistry (USA) and Monash Medical School (Australia). Studies show that students who follow these programmes experience decreased psychological distress and an improved quality of life. CONCLUSIONS: Although the evidence points to the usefulness of teaching mindful practices, various issues remain to be considered. When is it best to teach mindfulness in the trajectory of a doctor's career? What format works best, when and for whom? How can what is learned be maintained over time? Should mindfulness training be integrated into the medical school core curriculum?

Predictors of pain for patients with early inflammatory polyarthritis.

OBJECTIVE: To identify predictors of pain at 1 year in patients with early inflammatory polyarthritis (EIP). METHODS: Using a prospective design, patients were examined by a rheumatologist and completed questionnaires at baseline and at 1 year after symptom onset. Separate regression analyses were run for pain intensity, sensory pain, and affective pain. Age and sex were adjusted in cross-sectional and longitudinal analyses; baseline potential predictors consisted of measures for corresponding pain values and disease activity, depression, coping scores, medication use, rheumatoid arthritis criteria being met, and duration of symptoms. RESULTS: A total of 211 patients were enrolled in the study (mean ± SD age 58.8 ± 14.2 years, 63% women). There were significant improvements at 1 year for disease activity, instrumental coping, emotional coping, depression, and all 3 pain measures. At baseline, disease activity and depression were positively associated with all types of pain; in addition, instrumental coping was positively associated with sensory pain and palliative coping was positively associated with affective pain. At 1 year, pain intensity was predicted by baseline pain intensity, duration of symptoms, use of disease-modifying antirheumatic drugs (DMARDs), and emotional coping. Sensory pain was predicted by baseline sensory pain and DMARD use. Affective pain was predicted by baseline affective pain, DMARD use, and emotional coping. CONCLUSION: The majority of treated EIP patients can expect improvements in clinical and psychosocial variables over the first year of their illness. Emotional coping at baseline may contribute to pain in the future, and therefore it may be useful for patients to learn other means of dealing with this chronic disease.

Changes in the cortisol awakening response (CAR) following participation in mindfulness-based stress reduction in women who completed treatment for breast cancer.

BACKGROUND: Changes in the cortisol awakening response (CAR) were studied in women participating in a Mindfulness-Based Stress Reduction (MBSR) program after completion of their medical treatment for breast cancer. METHOD: Thirty-three women completed questionnaires pre- and post-MBSR pertaining to: stress, depressive symptomatology, and medical symptoms. The CAR was assessed on 3 days pre- and 3 days post-MBSR as a biological marker of stress. RESULTS: A significant effect on the CAR was found, with cortisol levels showing a prolonged increase after awakening at the post-MBSR assessment period. This was accompanied by significant improvements in self-reported stress levels, depressive symptomatology, and medical symptoms. Furthermore, the change in medical symptoms was negatively correlated with the area under the curve (AUC) at study onset (r = -.52, p < .002); i.e., the greater the AUC of the CAR before MBSR, the greater the reduction in medical symptoms after the program. CONCLUSIONS: These results suggest the potential usefulness of employing the CAR as a biological marker in women with breast cancer participating in an MBSR program.

Increased mindfulness--the active component of the mindfulness-based stress reduction program?

While there is growing consensus that Mindfulness-Based Stress Reduction (MBSR) is an effective program for patients with a wide range of health problems, little is known with regard to the processes underlying benefits seen following the program. Herein we examined the relationship between increases in mindfulness and improvements in patient outcomes. We sought to determine if there was a relationship between the practice of various types of meditation taught during the program and post-MBSR results. Eighty-three chronic ill patients provided pre- and post-MBSR data. An increase in mindfulness was significantly related to reductions in depressive symptoms, stress, medical symptoms and an increase in overall sense of coherence. However, the relationship between practice and outcomes was less evident. Future research is needed to identify which factors lead to an increase in mindfulness.

Fear of pain in patients with advanced cancer or in patients with chronic noncancer pain.

OBJECTIVES: pain is one of the most prevalent symptoms in patients with advanced cancer and, according to anecdotal reports, perhaps the most feared. Surprisingly, fear of pain has been the subject of little research within cancer care. The literature on chronic noncancer pain, however, suggests that fear of pain contributes to limitations in function in populations with diverse chronic illness. Little is known about the extent to which such findings might generalize from patients with chronic noncancer pain to those with chronic cancer pain. Therefore, this research examined the extent to which fear of pain is associated with limitations in function in patients with advanced cancer and also compared patients with chronic cancer and noncancer pain. METHODS: we recruited 117 patients with advanced cancer who received a referral for pain management and 118 patients with a primary complaint of chronic noncancer pain. Participants completed self-report questionnaires. RESULTS: findings revealed similarities between the groups for fear of pain and limitations in function, but they differed on level of depression and pain severity (patients with noncancer pain were more depressed and reported higher pain severity). Fear of pain independently predicted limitations in function in both groups controlling for demographic variables and pain severity. When depression and physical symptoms were controlled, fear of pain predicted limitations in function only in patients with advanced cancer. DISCUSSION: the findings emphasize the importance of psychological dimensions of pain in patients with advanced cancer, as well as the similarities and differences between the 2 groups of patients suffering from chronic pain.

Cortisol as a marker for improvement in mindfulness-based stress reduction.

While much attention has been devoted to examining the beneficial effects of Mindfulness-Based Stress Reduction programs on patients' ability to cope with various chronic medical conditions, most studies have relied on self-report measures of improvement. Given that these measures may not accurately reflect physiological conditions, there is a need for an objective marker of improvement in research evaluating the beneficial effects of stress management programs. Cortisol is the major stress hormone in the human organism and as such is a promising candidate measure in the study of the effects of Mindfulness-Based Stress Reduction programs. In conjunction with other biological measures, the use of cortisol levels as a physiological marker of stress may be useful to validate self-reported benefits attributed to this program. In the current manuscript, we review the available literature on the role of cortisol as a physiological marker for improvement with regards to mindfulness practice, and make recommendations for future study designs.

Predictors of disability and pain six months after the end of treatment for fibromyalgia.

OBJECTIVES: The goal of this study was to identify factors associated with decreased disability and lower pain scores 6 months after a multimodal treatment program for fibromyalgia (FM). METHODS: Forty-six patients with FM were assessed after having participated in a 3-month outpatient program integrating physiotherapy, occupational therapy, nursing, and cognitive-behavior therapy. A physician examined the patients before treatment and patients who completed a battery of psychosocial questionnaires at baseline, during treatment, at the end of treatment, and 3 and 6 months after the end of treatment. Two separate multivariable linear regression models were built to identify predictors of improvements in disability and pain. RESULTS: Two predictors for improvement in disability were found: an increase in self-efficacy for pain during treatment and better general adherence during treatment. Similarly, one predictor for improvement in pain intensity was found: an increase in self-efficacy for pain during treatment. DISCUSSION: Self-efficacy and adherence are 2 modifiable factors that influence disability and pain intensity in FM. These psychosocial factors need to be addressed in FM treatment programs to assist patients in maintaining posttreatment improvements.

Preliminary validity of the barriers to treatment adherence questionnaire in fibromyalgia: combining quantitative and focus group data.

The goals of this study were to (1) provide preliminary reliability and validity of the Barriers to Treatment Adherence Questionnaire, developed for patients with fibromyalgia, and (2) examine barriers to adherence and general adherence to multimodal treatment during a 3-mo. period. A secondary goal was to explore in a focus discussion group format patients' perceptions of the adherence process and ways of managing the treatment program. 39 fibromyalgia patients were followed while participating in a combined outpatient program of physiotherapy, occupational therapy, nursing, and cognitive behavioral therapy. The Barriers to Treatment Adherence Questionnaire demonstrated good reliability. Construct validity of the Barriers to Treatment Adherence Questionnaire was supported through significant positive correlations with the General Adherence Scale at Months 1 and 3. In addition, a significant change was observed in scores on the Barriers to Treatment Adherence Questionnaire for the physiotherapy component of treatment, with scores decreasing between Months 2 and 3. Addressing barriers to improve adherence may maximize the benefit of treatment programs.

Cultivating mindfulness in health care professionals: a review of empirical studies of mindfulness-based stress reduction (MBSR).

Demands faced by health care professionals include heavy caseloads, limited control over the work environment, long hours, as well as organizational structures and systems in transition. Such conditions have been directly linked to increased stress and symptoms of burnout, which in turn, have adverse consequences for clinicians and the quality of care that is provided to patients. Consequently, there exists an impetus for the development of curriculum aimed at fostering wellness and the necessary self-care skills for clinicians. This review will examine the potential benefits of mindfulness-based stress reduction (MBSR) programs aimed at enhancing well-being and coping with stress in this population. Empirical evidence indicates that participation in MBSR yields benefits for clinicians in the domains of physical and mental health. Conceptual and methodological limitations of the existing studies and suggestions for future research are discussed.