Deployment of a Digital Advance Care Planning Platform at an Accountable Care Organization.

BACKGROUND: Advance care planning (ACP), a process of sharing one's values and preferences for future medical treatments, can improve quality of life, reduce loved ones' anxiety, and decrease unwanted medical utilization and costs. Despite benefits to patients and health care systems, ACP uptake often remains low, due partially to lack of knowledge and difficulty initiating discussions. Digital tools may help reduce these barriers to entry. METHODS: We retrospectively examined data from pilot deployment of Koda Health patient-facing ACP among Houston Methodist Coordinated Care patients, for quality improvement (QI) purposes. Patients referred by nurse navigators could access Koda's digital platform, complete ACP, and share the legal documentation generated. Analyzed measures include usage rates and ACP-related decisions within the platform. RESULTS: Of eligible patients (n = 203), 52.7% voluntarily completed their plan. Engagement and completion rates were similar across demographics. Patients indicated majority preference (66.4%) toward spending the last days of life at home. Most patients indicated wanting no life-support intervention if quality of life became unacceptable (51 to 71% across 4 treatments). Life-support decisions were similar between demographic categories, excepting CPR and dialysis, wherein a greater portion of Black patients than White patients preferred at least trial intervention, rather than none. CONCLUSIONS: As an observational QI analysis, limitations include bounded geographical reach and lack of data on ACP impacts to subsequent health care utilization, which future studies will address. Findings suggest that digital health tools like Koda can effectively facilitate equitable ACP access and may help support health systems and providers in offering comprehensive ACP.

The Mindful Reappraisal of Pain Scale (MRPS): Validation of a New Measure of Psychological Mechanisms of Mindfulness-Based Analgesia.

Objectives: Mindfulness is theorized to decrease the affective amplification of chronic pain by facilitating a shift from emotionally-laden, catastrophic pain appraisals of nociceptive input to reappraising chronic pain as an innocuous sensory signal that does not signify harm. Understanding of these hypothetical psychological mechanisms of mindfulness-based analgesia has been limited by a lack of direct measures. We conducted a series of psychometric and experimental studies to develop and validate the Mindful Reappraisal of Pain Sensations Scale (MPRS). Methods: After item generation, we conducted exploratory and confirmatory factor analyses of the MRPS in samples of opioid-treated chronic pain patients both before (n=450; n=90) and after (n=222) participating in Mindfulness-Oriented Recovery Enhancement (MORE). We then examined the convergent and divergent validity of the MRPS. Finally, in data from a randomized clinical trial (n=250), the MRPS was tested as a mediator of the effects of MORE on reducing chronic pain severity. Results: Exploratory and confirmatory factor analyses demonstrated the single-factor structure of the MRPS. The MRPS also evidenced convergent and divergent validity. Mindfulness training through MORE significantly increased MRPS scores relative to supportive psychotherapy (F4,425.03 = 16.15, p < .001). Changes in MRPS scores statistically mediated the effect of MORE on reducing chronic pain severity through 9-month follow-up. Conclusions: Taken together, these studies demonstrate that the MRPS is a psychometrically sound and valid measure of novel analgesic mechanisms of mindfulness including attentional disengagement from affective pain appraisals and interoceptive exposure to pain sensations.

Association between opioid use disorder and blunted heart rate variability among opioid-treated chronic pain patients.

Given the severity of the ongoing opioid epidemic, it is essential to understand the mechanisms of risk for development and maintenance of opioid use disorder (OUD). The aim of the current large-scale psychophysiological investigation was to test whether patients with OUD had lower resting-state high-frequency heart rate variability (HF-HRV) than those without OUD, controlling for sociodemographic and clinical confounds. Additionally, we tested whether HF-HRV was associated with opioid craving in this population. Participants in this cross-sectional study were 490 chronic pain patients (50.4% female) treated with long-term opioid therapy. OUD diagnosis was determined by psychiatric interview. HF-HRV was measured at resting baseline. We computed the association between OUD and resting-state HF-HRV, controlling for age, gender, race, pain severity, emotional distress and opioid dose. Opioid craving was measured with visual analogue scales to assess whether HF-HRV was associated with craving. Results showed that resting HF-HRV was significantly lower for patients with OUD than for those without OUD (p < 0.001, d = 0.36), indicating deficits in autonomic flexibility. OUD diagnosis (p = 0.002) and OUD severity (p = 0.03) were associated with lower HF-HRV in regression models accounting for a range of confounders. Additionally, lower HF-HRV was significantly (but weakly) correlated with heightened opioid craving (r = -0.166, p < 0.001). Overall, findings suggest that resting-state HF-HRV may serve as a valid biomarker of addiction among people on long-term opioid therapy.

Mindfulness-Oriented Recovery Enhancement for Addictive Behavior, Psychiatric Distress, and Chronic Pain: A Multilevel Meta-Analysis of Randomized Controlled Trials.

Objectives: Mindfulness-Oriented Recovery Enhancement (MORE) is an integrative intervention designed to ameliorate addiction, chronic pain, and psychiatric symptoms. Although multiple randomized controlled trials (RCTs) have examined the clinical efficacy of MORE, no study has quantitatively synthesized this body of research. Thus, we conducted a meta-analysis of RCTs examining the effects of MORE on addictive behaviors, craving, opioid dose, pain, and psychiatric symptoms. Methods: Relevant manuscripts were identified through comprehensive searches of four bibliographic databases. Two- and three-level random-effects models were used to generate synthesized effect size estimates, and meta-regressions were performed to examine whether study and sample characteristics influenced the magnitude of aggregate effect sizes. Results: Our search identified 16 manuscripts reporting data from eight RCTs (N = 816). Moderate to small effects in favor of MORE were observed for addictive behaviors (SMC = - .54, p = .007), craving (SMC = - .42, p = .010), opioid dose (MC = - 17.95, p < .001), chronic pain (SMC = - .60, p < .001), and psychiatric symptoms (SMC = - .34, p < .001). MORE's effects on psychiatric symptoms and craving were not moderated by participant race, gender, age, or income. Conclusions: Study findings provide empirical evidence of MORE's efficacy for a wide diversity of individuals, and as such, MORE should now be disseminated broadly throughout the healthcare system. Supplementary Information: The online version contains supplementary material available at 10.1007/s12671-022-01964-x.

Mindful Lawyering: a Pilot Study on Mindfulness Training for Law Students.

Objectives: Many US law schools are now offering elective courses in mindfulness training to alleviate disproportionately high levels of anxiety, depression, stress, and disordered alcohol use among law students. To date, empirical evidence on the effectiveness of these courses has been lacking. The aim of this pilot study was to explore the feasibility and impact of a 13-week mindfulness course, "Mindful Lawyering," specifically tailored to law students. The primary hypothesis was that mindfulness training would be significantly correlated with improvements in well-being and mindfulness. Methods: The design was a non-randomized, quasi-experimental study involving 64 law students. The mindfulness group was 31 students taking Mindful Lawyering; the comparison group was 33 students taking other law school courses. Outcome measures were the Depression, Anxiety, and Stress Scale; the Positive and Negative Affect Scale; the Alcohol Use Disorders Identification Test; and the Five Facet Mindfulness Questionnaire. Results: Results provide promising evidence to support the hypothesis. The mindfulness group showed significantly greater improvement on measures of stress (p < .001, d = 1.15), anxiety (p < .001, d = . 90), depression (p = .012, d = .66), negative affect (p = .002, d = .81), disordered alcohol use (p = .011, d = .67), and mindfulness (p < .001, d = 1.32) from pre to post relative to the comparison group. The course was well accepted and feasible for law students. Conclusions: Findings from the current study suggest that mindfulness training may occasion improvements in the well-being of law students. More research is needed to replicate these findings in larger, randomized samples of law students. Supplementary Information: The online version contains supplementary material available at 10.1007/s12671-022-01965-w.

Mindfulness-Based Interventions for Perioperative Pain Management and Opioid Risk Reduction Following Surgery: A Stepped Care Approach.

Surgical procedures often improve health and function but can sometimes also result in iatrogenic effects, including chronic pain and opioid misuse. Due to the known risks of opioids and the physical, emotional, and financial suffering that often accompanies chronic pain, there has been a call for greater use of complementary non-pharmacological treatments like mindfulness-based interventions. Mindfulness can be broadly described as an attentional state involving moment-by-moment meta-awareness of thoughts, emotions, and body sensations. An expanding number of randomized clinical trials have found strong evidence for the value of mindfulness techniques in alleviating clinical symptomology relevant to surgical contexts. The purpose of this review is to examine the empirical evidence for the perioperative use of mindfulness interventions. We present a mindfulness-based stepped care approach that first involves brief mindfulness to treat preoperative pain and anxiety and prevent development of postoperative chronic pain or opioid misuse. More extensive mindfulness-based interventions are then provided to patients who continue to experience high pain levels or prolonged opioid use after surgery. Finally, we review psychophysiological mechanisms of action that may be integral to the analgesic and opioid sparing effects of mindfulness.

Willingness and Accessibility of a Hypnosis Intervention for Anxiety Among a Low Socioeconomic Status Population.

Objective: This survey study aimed to investigate the willingness and accessibility of a hypnosis intervention for anxiety among low socioeconomic status patients in a primary care setting. Methods: Participants were asked to complete a one-page survey during a scheduled office visit with their primary care provider. Survey questions included participants' interest in hypnosis as a treatment for anxiety, how many sessions they would be willing/able to attend, how they would prefer access to a recorded hypnosis intervention, and items relating to anxiety, including the Generalized Anxiety Disorder-7 measure. Results: Two hundred participants (71.5% female) completed the survey with a mean age of 43.16 (standard deviation = 15.78). Over half (54.6%) of the survey participants reported that they experience anxiety, and 74% of the participants indicated that they would be interested in hypnosis if it were recommended by their provider for anxiety. Discussion: Given the high prevalence of anxiety among survey participants, there exists a clear need for effective and accessible treatment options. These results demonstrate the willingness of individuals to use hypnosis for anxiety and to engage in remote hypnosis interventions.

Hypnotizability Norms may not be Representative of the General Population: Potential Sample and Self-Selection Bias Considerations.

The analysis of the methods sections of 66 normalization tests of hypnotizability scales reveals that out of 33,338 subjects, 58.57% were college and university students, and the majority of these were students of psychology. Of all subjects, 7.45% were younger school children, 27.63% were patients treated with hypnosis, and out of these, 85.26% were patients of 1 single therapist. Only 0.51% were trainees of dental or nursing schools, 0.13% were prisoners, and 5.71% were other adults. These figures suggest a sample-selection bias. As 83.08% of these subjects were told beforehand that they were to undergo a hypnosis study, a self-selection bias is also implied in the data. It can be presumed that those interested in hypnosis participated, whereas others who had no interest in hypnosis may have refrained. It is concluded that some of the published norms of hypnotizability tests may not be adequately representative of the general population. Many hypnosis studies, whether clinical or experimental, which are based on hypnotizability, may be afflicted by these biases.

Mindfulness-oriented recovery enhancement improves negative emotion regulation among opioid-treated chronic pain patients by increasing interoceptive awareness.

OBJECTIVE: Long-term opioid therapy presents health risks for people with chronic pain. Some chronic pain patients escalate their opioid dose to regulate negative emotions. Therefore, emotion regulatory strategies like reappraisal are key treatment targets for this population. Mindfulness has been shown to enhance reappraisal, but the mechanisms of action are unknown. This study was a secondary analysis of data from a randomized, controlled trial of Mindfulness-Oriented Recovery Enhancement (MORE) to test a specific postulate of the Mindfulness-to-Meaning Theory: that mindfulness-based interventions promote reappraisal, via interoceptive self-regulation, as a means of decreasing emotional distress. METHODS: Ninety-five patients with opioid-treated chronic pain (age = 56.8 ±â€¯11.7, 66% female) were randomized to 8 weeks of MORE or Support Group (SG) psychotherapy. An interoceptive awareness latent variable was constructed from the Multidimensional Assessment of Interoceptive Awareness (MAIA). Next, interoceptive self-regulation was assessed as a mediator of the effect of MORE on post-treatment reappraisal, and then reappraisal was examined as a mediator of change in distress through 3-month follow-up. RESULTS: MORE participants had greater improvements in interoceptive awareness than the SG as measured by the interoceptive awareness latent variable (ß = 0.310, p = 0.008) and by the self-regulation MAIA subscale (ß = 0.335, p = 0.001). The effect of MORE on treatment-induced increases in reappraisal was mediated by increased interoceptive self-regulation (indirect effect: ß = 0.110, p = 0.030). In turn, decreases in distress through 3-month follow-up were mediated by increases in reappraisal (indirect: ß = -0.136, p = 0.031). CONCLUSION: MORE facilitated reappraisal of distress by enhancing interoceptive self-regulation, supporting a central mechanistic causal pathway specified by the Mindfulness-to-Meaning Theory.

Effect of Hypnosis on Anxiety: Results from a Randomized Controlled Trial with Women in Postmenopause.

Anxiety is common, yet often under-treated, among women in postmenopause. This study examined the effect of a hypnotic intervention designed to reduce hot flashes, on anxiety levels of postmenopausal women. Anxiety was assessed using the State-Trait Anxiety Inventory, the Hospital Anxiety and Depression Scale-Anxiety subscale, and a visual analog scale. Additionally, hypnotizability was tested as a moderator of anxiety reductions. Significant reductions in anxiety were found from baseline to endpoint and follow-up and hypnosis was superior to the control condition. Additionally, ratings of Current Anxiety decreased from pre-session to post-session at each weekly visit and the pre-session scores reduced continuously. Hypnotizability was found to moderate anxiety reductions, but regardless of hypnotizability level participants, on average, experienced significant symptom improvement from baseline scores. These data provide initial support for the use of hypnosis to reduce symptoms of anxiety among postmenopausal women.Trial registration: This study was registered at ClinicalTrials.gov on February 11, 2011 under Identifier number NCT01293695 ( https://clinicaltrials.gov/ct2/show/NCT01293695?term=Elkins&cond=hot+flashes&draw=2&rank=2 ).

Rapid eye movement sleep mediates age-related decline in prospective memory consolidation.

STUDY OBJECTIVES: Prospective memory, or remembering to execute future intentions, accounts for half of everyday forgetting in older adults. Sleep intervals benefit prospective memory consolidation in young adults, but it is unknown whether age-related changes in slow wave activity, sleep spindles, and/or rapid eye movement (REM) sleep mediate hypothesized effects of aging on prospective memory consolidation. METHODS: After an adaptation night, 76 adults aged 18-84 completed two experimental nights of in-laboratory polysomnography recording. In the evening, participants encoded and practiced a prospective memory task and were tested the next morning. On a counterbalanced night, they encoded and practiced a control task, and were tested the following morning. RESULTS: Increasing age predicted worse prospective memory consolidation (r = -.34), even when controlling for encoding, speed, and control-task performance (all ps < .05). Frontal delta power, slow oscillations, and spindle density were not related to prospective memory consolidation. REM sleep duration, however, explained significant variance in prospective memory consolidation when controlling for age (∆R2 = .10). Bootstrapping mediation showed that less REM sleep significantly mediated the aging effect on prospective memory consolidation [b = -.0016, SE = 0.0009 (95% confidence interval [CI] = -0.0042 to -0.0004)]. REM sleep continued to mediate 24.29% of the total effect of age on prospective memory after controlling for numerous demographic, cognitive, mental health, and sleep variables. CONCLUSION: Age-related variance in REM sleep is informative to how prospective memory consolidation changes with increasing age. Future work should consider how both REM sleep and slow wave activity contribute, perhaps in a sequential or dynamic manner, to preserving cognitive functioning with increasing age.

Mindful Self-Hypnosis for Self-Care: An Integrative Model and Illustrative Case Example.

The combination of mindfulness and self-hypnosis could provide a tool that is easily implemented by individuals who want to care for their well-being in times of high stress. Each discipline has been shown to be effective in relieving stress, and integration could further facilitate change while creating a tool that is highly accessible. There are many similarities between the two practices, such as focusing of attention and the emphasis on mind-body connection. However, important distinctions in psychological (e.g., self-monitoring) and neural (e.g., functional connectivity) elements are noted. A theory of how integrated mindful self-hypnosis may create change is presented. An illustrative case example of mindful self-hypnosis practice and a self-hypnosis transcript are provided.

Brief Report: Knowledge of, Interest in, and Willingness to Try Behavioral Interventions in Individuals With Parkinson's Disease.

Purpose/Objective • Behavioral interventions hold enormous promise for managing a variety of motor and nonmotor symptoms in Parkinson's disease (PD). Despite this, prior studies have suggested that the utilization of these interventions is relatively low. The current study seeks to understand factors that could relate to the utilization of PD behavioral strategies. Specifically, the study evaluates the self-described knowledge of, interest in, and willingness to participate in behavioral interventions in a community-dwelling sample of individuals with PD. Research Method/Design • Forty-five individuals with PD completed a survey that assessed knowledge, interest, and willingness to participate in 5 behavioral interventions: hypnosis, relaxation training, mindfulness/meditation, computerized "brain games," and counseling. In addition, participants self-reported their quality of life across several domains; these domain scores were correlated with overall ratings of interest and willingness to participate in behavioral interventions. Results • Self-reported knowledge of behavioral interventions was low, but interest and willingness to participate was moderate to high across modalities. Statistically significant correlations were noted between perceived knowledge of the techniques and interest (r = 0.29, P = .05) as well as willingness to participate (r = 0.32, P = .03) in these techniques. Interest and willingness were also correlated with self-reported bodily discomfort (r = 0.36, P = .02). Conclusions/Implications • The participants of the current sample were interested and willing to participate in behavioral interventions but had limited knowledge of the potential for these techniques to manage their symptoms. The reported high level of willingness to participate in behavioral interventions suggests that it is feasible to provide behavioral interventions in this population.

Hypnosis for Hot Flashes and Associated Symptomsin Women with Breast Cancer.

Women with breast cancer experience a host of physical and psychological symptoms, including hot flashes, sleep difficulties, anxiety, and depression. Therefore, treatment for women with breast cancer should target these symptoms and be individualized to patients' specific presentations. The current article reviews the common symptoms associated with breast cancer in women, then examines clinical hypnosis as a treatment for addressing these symptoms and improving the quality of life of women with breast cancer. Clinical hypnosis is an effective, nonpharmaceutical treatment for hot flashes and addressing many symptoms typically experienced by breast cancer patients. A case example is provided to illustrate the use of clinical hypnosis for the treatment of hot flashes with a patient with breast cancer.

Feasibility of Music and Hypnotic Suggestion to Manage Chronic Pain.

The authors investigated the feasibility and possible effects of hypnotic suggestion and music for chronic pain. Ten people completed the 2-week intervention that consisted of daily listening to hypnotic suggestions combined with music. Averaged subjective pain intensity, pain bothersomeness, overall distress, anxiety, and depression decreased from baseline to endpoint. Participants rated pre- and postlistening pain intensity and pain bothersomeness decreased for each session. Information provided during end-of-study interviews indicated all participants were satisfied with treatment and felt they benefited from being in the study. Means and standard deviations are reported for outcome measures and a case study is provided. This preliminary study supports the use of a combined hypnotic suggestion and music intervention for chronic pain.