The efficacy of mindfulness-based stress reduction in the treatment of sleep disturbance in women with breast cancer: an exploratory study

Mindfulness meditation and cognitive behavioral therapy for insomnia: a naturalistic 12-month follow-up

A unique intervention combining mindfulness meditation with cognitive behavioral therapy for insomnia (CBT-I) has been shown to have acute benefits at posttreatment in an open label study. The aim of the present study was to examine the long-term effects of this integrated intervention on measures of sleep and sleep-related distress in an attempt to characterize the natural course of insomnia following this treatment and to identify predictors of poor long-term outcome. Analyses were conducted on 21 participants, who provided follow-up data at six and 12 months posttreatment. At each time point, participants completed one week of sleep and meditation diaries and questionnaires related to mindfulness, sleep, and sleep-related distress, including the Pre-Sleep Arousal Scale, the Glasgow Sleep Effort Scale, the Kentucky Inventory of Mindfulness Skills, and the Insomnia Episode Questionnaire. Analyses examining the pattern of change across time (baseline, end of treatment, six months, and 12 months) revealed that several sleep-related benefits were maintained during the 12-month follow-up period. Participants who reported at least one insomnia episode (>or=1 month) during the follow-up period had higher scores on the Pre-Sleep Arousal Scale (P < .05) and the Glasgow Sleep Effort Scale (P < .05) at end of treatment compared with those with no insomnia episodes. Correlations between mindfulness skills and insomnia symptoms revealed significant negative correlations (P < .05) between mindfulness skills and daytime sleepiness at each of the three time points but not with nocturnal symptoms of insomnia. These results suggest that most sleep-related benefits of an intervention combining CBT-I and mindfulness meditation were maintained during the 12-month follow-up period, with indications that higher presleep arousal and sleep effort at end of treatment constitute a risk for occurrence of insomnia during the 12 months following treatment.

Theories, models, and frameworks related to sleep-wake disturbances in the context of cancer

The purpose of this article was to review theories, models, and frameworks of sleep disturbances referenced in the cancer literature. Sleep-wake disturbances in cancer are a significant problem that negatively affects quality of life. There is no previously published review of the theories, models, or frameworks used to study sleep-wake disturbances in the context of cancer. Describing existing theories or models and their application in cancer is important to advance knowledge in this area. Two theories and 9 models were identified for review. These have been used to further understand the problem of sleep-wake disturbances as a primary or secondary symptom within the cancer literature. Searches were conducted from January 1, 1970, to July 31, 2008, to find relevant articles using 4 electronic databases: MEDLINE, CINAHL, PubMed, and PsychINFO. On the basis of the search, 73 descriptive or intervention studies were identified and reviewed. Most research was atheoretical, with no identified theory, model, or framework. In studies that did use theory or models, few were applied in more than one study. Although several commonalities across models did emerge, a more comprehensive and widely used model could help guide nursing research to facilitate effective symptom management for this prominent problem in cancer.

Effect of compassion meditation on neuroendocrine, innate immune and behavioral responses to psychosocial stress

Meditation practices may impact physiological pathways that are modulated by stress and relevant to disease. While much attention has been paid to meditation practices that emphasize calming the mind, improving focused attention, or developing mindfulness, less is known about meditation practices that foster compassion. Accordingly, the current study examined the effect of compassion meditation on innate immune, neuroendocrine and behavioral responses to psychosocial stress and evaluated the degree to which engagement in meditation practice influenced stress reactivity. Sixty-one healthy adults were randomized to 6 weeks of training in compassion meditation (n=33) or participation in a health discussion control group (n=28) followed by exposure to a standardized laboratory stressor (Trier social stress test [TSST]). Physiologic and behavioral responses to the TSST were determined by repeated assessments of plasma concentrations of interleukin (IL)-6 and cortisol as well as total distress scores on the Profile of Mood States (POMS). No main effect of group assignment on TSST responses was found for IL-6, cortisol or POMS scores. However, within the meditation group, increased meditation practice was correlated with decreased TSST-induced IL-6 (r(p)=-0.46, p=0.008) and POMS distress scores (r(p)=-0.43, p=0.014). Moreover, individuals with meditation practice times above the median exhibited lower TSST-induced IL-6 and POMS distress scores compared to individuals below the median, who did not differ from controls. These data suggest that engagement in compassion meditation may reduce stress-induced immune and behavioral responses, although future studies are required to determine whether individuals who engage in compassion meditation techniques are more likely to exhibit reduced stress reactivity.

Mind-body medicine and cancer

Mind-body medicine, grounded in a respectful, therapeutic partnership, should be a central element in the care of every person diagnosed with cancer. This article reviews some of the physiologic foundations of mind-body medicine, the introduction of mind-body approaches to cancer care in the 1970s, the specific mind-body approaches that have been used, and the evidence that supports their use. The importance of group support for enhancing the effectiveness of these approaches is discussed. Guidelines are offered for integrating mind-body approaches and perspectives in the care of people who have cancer.

Facing the challenges of hematopoietic stem cell transplantation with mindfulness meditation: a pilot study

The hematopoietic stem cell transplant (HSCT) experience is emotionally and physically stressful for cancer patients who undergo this procedure. Mindfulness-based interventions have been studied in patients with various diagnoses, including cancer, although minimal work has applied this intervention to hospitalized patients. Use of mindfulness meditation has potential to provide HSCT patients with coping skills to deal with unpleasant symptoms and an uncertain future. This exploratory study examined feasibility, physiological arousal, and psychological and physical symptoms in HSCT patients participating in a mindfulness meditation intervention that begins before and continues throughout hospitalization and involves one-on-one guided sessions and daily practice using a 17-minute meditation CD. Of the 20 participants, 78.9% completed the intervention. Statistically significant decreases in heart and respiratory rates and improvements in symptoms immediately before and after each session were found. These findings demonstrate feasibility and preliminary support of a mindfulness meditation intervention with symptomatic, hospitalized cancer patients.

Mindfulness-based stress reduction training for oncology patients: patients' appraisal and changes in well-being

OBJECTIVE

This study explores satisfaction and changes in well-being in cancer patients following mindfulness-based stress reduction training.

METHOD

Data were collected in 47 cancer patients before and after the training, and also 1 year later. Standardized questionnaires were used to measure quality of life, joy in life, mood disturbances (depression, anger, vigor, fatigue, and tension), meaning in life and physical symptoms.

RESULTS

Participants were highly satisfied and said they had reached their goals with the training. The results show that directly after the training patients reported a better quality of life, more joy in life, less tension, and fewer physical symptoms. These effects appeared even stronger at follow-up. A year after the training a decrease was also found in depression, anger, vigor and total mood disturbance. No changes could be established for meaning in life and fatigue. Effect sizes varied between 0.28 and 0.60, indicating small-to-moderate changes.

CONCLUSION

Mindfulness training potentially supports cancer patients in handling the stress due to their life-threatening disease and increases their well-being. Several suggestions for further research are discussed.

PRACTICE IMPLICATIONS

Mindfulness training provides cancer patients with tools to deal with their limitations and worries, both during and after their treatment.

Effects of mindfulness-based stress reduction intervention on psychological well-being and quality of life: is increased mindfulness indeed the mechanism?

Background

Although several studies have reported positive effects of mindfulness-based stress reduction (MBSR) intervention on psychological well-being, it is not known whether these effects are attributable to a change in mindfulness.

Purpose

The aim of this study is to compare the effects of MBSR to a waiting-list control condition in a randomized controlled trial while examining potentially mediating effects of mindfulness.

Methods

Forty women and 20 men from the community with symptoms of distress (mean age 43.6 years, SD = 10.1) were randomized into a group receiving MBSR or a waiting-list control group. Before and after the intervention period, questionnaires were completed on psychological well-being, quality of life, and mindfulness.

Results

Repeated measures multiple analysis of variance (MANCOVAs) showed that, compared with the control group, the intervention resulted in significantly stronger reductions of perceived stress (p = 0.016) and vital exhaustion (p = 0.001) and stronger elevations of positive affect (p = 0.006), quality of life (p = .009), as well as mindfulness (p = 0.001). When mindfulness was included as a covariate in the MANCOVA, the group effects on perceived stress and quality of life were reduced to nonsignificance.

Conclusion

Increased mindfulness may, at least partially, mediate the positive effects of mindfulness-based stress reduction intervention.

Combining mindfulness meditation with cognitive-behavior therapy for insomnia: a treatment-development study

This treatment-development study is a Stage I evaluation of an intervention that combines mindfulness meditation with cognitive-behavior therapy for insomnia (CBT-I). Thirty adults who met research diagnostic criteria for Psychophysiological Insomnia (Edinger et al., 2004) participated in a 6-week, multi-component group intervention using mindfulness meditation, sleep restriction, stimulus control, sleep education, and sleep hygiene. Sleep diaries and self-reported pre-sleep arousal were assessed weekly while secondary measures of insomnia severity, arousal, mindfulness skills, and daytime functioning were assessed at pre-treatment and post-treatment. Data collected on recruitment, retention, compliance, and satisfaction indicate that the treatment protocol is feasible to deliver and is acceptable for individuals seeking treatment for insomnia. The overall patterns of change with treatment demonstrated statistically and clinically significant improvements in several nighttime symptoms of insomnia as well as statistically significant reductions in pre-sleep arousal, sleep effort, and dysfunctional sleep-related cognitions. In addition, a significant correlation was found between the number of meditation sessions and changes on a trait measure of arousal. Together, the findings indicate that mindfulness meditation can be combined with CBT-I and this integrated intervention is associated with reductions in both sleep and sleep-related arousal. Further testing of this intervention using randomized controlled trials is warranted to evaluate the efficacy of the intervention for this population and the specific effects of each component on sleep and both psychological and physiological arousal.

"Does one size fit all?" moderators in psychosocial interventions for breast cancer patients: a meta-analysis

BACKGROUND

A variety of psychosocial interventions have been developed to promote better adjustment to breast cancer (BC) and their efficacy has been demonstrated repeatedly. However, the effect sizes (ES) vary considerably across studies.

PURPOSE

This article intends to shed light on potential moderators of intervention efficacy for BC patients, such as the intervention type (e.g., education, supportive), the composition of the sample (only BC patients or BC mixed with other cancer types), and the practitioner of the intervention (psychologist, nonpsychologist).

METHODS

Fifty-six randomized-controlled studies investigating the effectiveness of psychosocial interventions with adult BC patients were meta-analytically reviewed.

RESULTS

The overall ES of d = 0.26 was similar to previous meta-analyses and moderated by several variables. The ES varied notably based on the composition of the sample, the profession offering the intervention, and the type of intervention. Studies with samples consisting of only BC patients and studies with nonpsychologist-led interventions showed lower ES. Psychoeducation yielded the strongest ES. These moderators maintained their significance even when controlling for the nature of the control group, the format of the intervention, the timing of the intervention, or the stage of disease.

CONCLUSIONS

These results suggest that among current interventions, psychoeducation is a treatment of choice for BC patients, preferably prior to surgery and led by individuals with a medical expertise. Other psychosocial interventions appear most effective when administered individually and led by a psychologist. In addition, there is a need for improved psychosocial interventions to enhance the present ES for women with BC.

The effects of mindfulness-based stress reduction on sleep disturbance: a systematic review

INTRODUCTION

Sleep disturbance is common and associated with compromised health status. Cognitive processes characterized by stress and worry can cause, or contribute to, sleep complaints. This study systematically evaluated the evidence that sleep can be improved by mindfulness-based stress reduction (MBSR), a formalized psychoeducational intervention that helps individuals self-manage and reframe worrisome and intrusive thoughts.

METHODS

Articles were identified from searches of Medline, Allied and Complementary Medicine Database, CINAHL, PsycINFO, Digital Dissertations, and the Cochrane Central Register of Controlled Trials. Eligible for inclusion were English language clinical trials of MBSR that reported preintervention and postintervention measures of sleep quality or duration. Studies employing multicomponent interventions were excluded. Studies were reviewed independently by the first and second authors.

RESULTS

Thirty-eight articles were identified for review. Seven met inclusion criteria. Lack of standardized outcome measures precluded pooling of results for quantitative data analysis. Sleep report measures varied (standardized scales, single item, sleep diaries). Four studies (all uncontrolled) found that MBSR significantly improved measures of sleep quality or duration. The remaining studies found no statistically significant difference between treatment and control conditions.

CONCLUSIONS

To date, controlled studies have not clearly demonstrated the positive effects of MBSR on sleep quality and duration. However, there is some evidence to suggest that increased practice of mindfulness techniques is associated with improved sleep and that MBSR participants experience a decrease in sleep-interfering cognitive processes (eg, worry). More research is needed using standardized sleep scales and methods, with particular attention to the importance of MBSR home practice.

Behavioral symptoms in patients with breast cancer and survivors

Behavioral symptoms are a common adverse effect of breast cancer diagnosis and treatment and include disturbances in energy, sleep, mood, and cognition. These symptoms cause serious disruption in patients' quality of life and may persist for years after treatment. Patients need accurate information about the occurrence of these adverse effects as well as assistance with symptom management. This review considers four of the most common behavioral sequelae of breast cancer, namely fatigue, sleep disturbance, depression, and cognitive impairment. Research on the prevalence, mechanisms, and treatment of each symptom is described, concluding with recommendations for future studies.

An initial evaluation of a mindful parenting program

A growing number of children are experiencing marital transition. The effects of divorce on children have typically been considered deleterious, although factors can buffer the difficulty of postdivorce adjustment. One of these factors is a positive relationship with a parental figure. Unfortunately, divorce often overwhelms parents with a series of changes that compromise their parenting skills. One new approach to improving parenting after divorce is mindful parenting, which aims to enhance interpersonal and emotional connection in the parent-child relationship. This program is intended to facilitate parents' self-awareness, their mindfulness, and their intentionality in responding to their child's needs. The present study reports on the implementation of the Mindful Parenting Program, delivered in two groups to 12 recently divorced parents with preschool-aged children. Program effectiveness was conducted on two levels. First, mindfulness measured by the Toronto Mindfulness Scale revealed significant increases over the intervention and posttest period. Second, in-home behavioral observations conducted pre- and postintervention revealed no changes in parent-child relationships. These findings are discussed within the larger context of facilitating effective parenting postdivorce.

Randomized trial of a cognitive-behavioral intervention for insomnia in breast cancer survivors

PURPOSE/OBJECTIVES

To determine the efficacy of a cognitive-behavioral intervention for treating insomnia in breast cancer survivors.

DESIGN

Randomized controlled trial.

SETTING

University and medical center settings.

SAMPLE

72 women at least three months after primary treatment for breast cancer with sleep-onset or sleep maintenance insomnia at least three nights per week for at least three months as determined through daily sleep diaries.

METHODS

Random assignment to a multicomponent intervention (stimulus control instructions, sleep restriction, and sleep education and hygiene) or a single-component control group (sleep education and hygiene).

MAIN RESEARCH VARIABLES

Sleep-onset latency, wake after sleep onset, total sleep time, time in bed, sleep efficiency, and sleep quality.

FINDINGS

After the intervention, both groups improved on sleep-onset latency, wake after sleep onset, total sleep time, time in bed, sleep efficiency, and sleep quality based on daily sleep diaries. A between-group difference existed for time in bed. Wrist actigraph data showed significant pre- to postintervention changes for sleep-onset latency, wake after sleep onset, total sleep time, and time in bed. When compared to the control group, the multicomponent intervention group rated overall sleep as more improved.

CONCLUSIONS

A nonpharmacologic intervention is effective in the treatment of insomnia in breast cancer survivors.

IMPLICATIONS FOR NURSING

Breast cancer survivors can benefit from a cognitive-behavioral intervention for chronic insomnia. Sleep education and hygiene, a less complex treatment than a multicomponent intervention, also is effective in treating insomnia.

Measuring the psychological impact of mindfulness meditation on health among patients with cancer: a literature review

PURPOSE/OBJECTIVES

To describe the construct of mindfulness meditation and systematically review instruments measuring the psychological impact of mindfulness-based stress reduction (MBSR) on health among patients with cancer.

DATA SOURCES

PubMed, CINAHL, PsycINFO, ISI Web of Knowledge, EBSCO, and published literature (1987-2006).

DATA SYNTHESIS

13 psychological instruments used in seven studies (2000-2005) to measure effects of MBSR on health in patients with cancer were reviewed. Most studies used a one-group pre- and post-test design. The post-MBSR outcomes for each instrument varied, suggesting different yet promising relationships. For some instruments, data were insufficient to conclude sufficiently whether any were strong or appropriate to use in future intervention studies.

CONCLUSIONS

To enhance knowledge of MBSR, more intervention research studies of MBSR in patients with cancer and reexamination of specific instruments are needed.

IMPLICATIONS FOR NURSING

Based on the review, instruments can measure MBSR effects and found MBSR to be a potentially beneficial oncology nursing intervention.

Complementary therapies and integrative oncology in lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition)

BACKGROUND

This chapter aims to differentiate between "alternative" therapies, often promoted falsely as viable options to mainstream lung cancer treatment, and complementary therapies, adjunctive, effective techniques that treat symptoms associated with cancer and its mainstream treatment, and to describe the evidence base for use of complementary therapies.

METHODS AND DESIGN

A multidisciplinary panel of experts in oncology and integrative medicine evaluated the evidence for complementary (not alternative) therapies in the care of patients with lung cancer. Because few complementary modalities are geared to patients with only a single cancer diagnosis, symptom-control research conducted with other groups of patients with cancer was also included. Data on complementary therapies such as acupuncture, massage therapy, mind-body therapies, herbs and other botanicals, and exercise were evaluated. Recommendations were based on the strength of evidence and the risk-to-benefit ratio.

RESULTS

Patients with lung and other poor-outlook cancers are particularly vulnerable to heavily promoted claims for unproved or disproved "alternatives." Inquiring about patients' use of these therapies should be routine because these practices may be harmful and can delay or impair treatment. Mind-body modalities and massage therapy can reduce anxiety, mood disturbance, and chronic pain. Acupuncture assists the control of pain and other side effects and helps reduce levels of pain medication required. Trials of acupuncture for chemotherapy-induced neuropathy and postthoracotomy pain show promising results. Herbal products and other dietary supplements should be evaluated for side effects and potential interactions with chemotherapy and other medications.

CONCLUSIONS

Complementary therapies have an increasingly important role in the control of symptoms associated with cancer and cancer treatment.

Putting evidence into practice: evidence-based interventions for fatigue during and following cancer and its treatment

Cancer-related fatigue has a significant impact on patients' physical and psychosocial functioning, symptom distress, and quality of life, yet it remains under-recognized and undertreated. The Oncology Nursing Society's Putting Evidence Into Practice initiative sought to improve patient outcomes relative to this important problem by critically examining and summarizing the evidence base for interventions to prevent and manage fatigue during and following treatment. This article critically reviews and summarizes the available empirical evidence regarding interventions for cancer-related fatigue. In addition to offering patients and clinicians a tool to facilitate effective management of the distressing symptom, this evidence-based review identifies gaps in knowledge and research opportunities.

Melatonin, environmental light, and breast cancer

Although many factors have been suggested as causes for breast cancer, the increased incidence of the disease seen in women working in night shifts led to the hypothesis that the suppression of melatonin by light or melatonin deficiency plays a major role in cancer development. Studies on the 7,12-dimethylbenz[a]anthracene and N-methyl-N-nitrosourea experimental models of human breast cancer indicate that melatonin is effective in reducing cancer development. In vitro studies in MCF-7 human breast cancer cell line have shown that melatonin exerts its anticarcinogenic actions through a variety of mechanisms, and that it is most effective in estrogen receptor (ER) alpha-positive breast cancer cells. Melatonin suppresses ER gene, modulates several estrogen dependent regulatory proteins and pro-oncogenes, inhibits cell proliferation, and impairs the metastatic capacity of MCF-7 human breast cancer cells. The anticarcinogenic action on MCF-7 cells has been demonstrated at the physiological concentrations of melatonin attained at night, suggesting thereby that melatonin acts like an endogenous antiestrogen. Melatonin also decreases the formation of estrogens from androgens via aromatase inhibition. Circulating melatonin levels are abnormally low in ER-positive breast cancer patients thereby supporting the melatonin hypothesis for breast cancer in shift working women. It has been postulated that enhanced endogenous melatonin secretion is responsible for the beneficial effects of meditation as a form of psychosocial intervention that helps breast cancer patients.

Putting evidence into practice: evidence-based interventions for sleep-wake disturbances

Symptom management is a vital aspect of the practice of oncology nursing. The Oncology Nursing Society has identified outcomes sensitive to nursing intervention, known as nursing-sensitive patient outcomes. This article presents information about sleep-wake disturbances that occur in patients with cancer and makes recommendations for evidence-based interventions to improve sleep for patients. Sleep-wake disturbances occur in 30%-75% of people with cancer and have a negative impact on other symptoms and quality of life. Despite the frequency and severity of sleep-wake disturbances, limited research has tested interventions to improve sleep-wake outcomes. Although no interventions currently receive the highest recommendations for implementation into practice, several nonpharmacologic interventions show initial positive findings in promoting high-quality sleep and daytime functioning. Oncology nurses can screen for sleep-wake disturbances and suggest tailored interventions. Four categories of promising interventions are cognitive-behavioral therapy, complementary therapies, psychoeducation and information, and exercise. Clinicians can use the Putting Evidence Into Practice (PEP) card and PEP resources at www.ons.org/outcomes to improve sleep-wake outcomes.

Associations among Salivary Cortisol, Melatonin, Catecholamines, Sleep Quality and Stress in Women with Breast Cancer and Healthy Controls

Dysregulations in several biological systems in breast cancer patients have been reported, including abnormalities in endocrine and sympathetic nervous system indices, as well as psychological disturbances and sleep disorders. The purpose of this exploratory study was to compare women with breast cancer to healthy control women on measures of salivary cortisol, urinary catecholamines, overnight urinary melatonin, and self-reported sleep quality, symptoms of stress, depression, anxiety and mood disturbance, to determine if discernable patterns of dysregulations across systems were apparent. Thirty-three women were tested in each group, with an average age of approximately 52 years, primarily Caucasian and well-educated. Forty percent of the women with breast cancer had stage 2 disease and they were an average of 1.36 years post-diagnosis. Women with breast cancer had significantly higher levels of disturbance on all the psychological indices, but there were no differences between groups on any of the biological measures, with the exception that the control women had higher dopamine values than the participants with breast cancer. None of the psychological scores were correlated with the biological measures. These results are consistent with other studies of early-stage breast cancer and highlight the importance of considering disease characteristics when investigating endocrine and sympathetic nervous system functioning.

Effect of Mindfulness-Based stress reduction in rheumatoid arthritis patients

OBJECTIVE

To assess the effect of a meditation training program, Mindfulness-Based Stress Reduction (MBSR), on depressive symptoms, psychological status, and disease activity in patients with rheumatoid arthritis (RA) through a randomized, waitlist-controlled pilot study.

METHODS

Participants were randomized to either an MBSR group, where they attended an 8-week course and 4-month maintenance program, or to a waitlist control group, where they attended all assessment visits and received MBSR free of charge after study end. Participants received usual care from their rheumatologists throughout the trial. Self-report questionnaires were used to evaluate depressive symptoms, psychological distress, well-being, and mindfulness. Evaluation of RA disease activity (by Disease Activity Score in 28 joints) included examination by a physician masked to treatment status. Adjusted means and mean changes in outcomes were estimated in mixed model repeated measures analyses.

RESULTS

Sixty-three participants were randomized: 31 to MBSR and 32 to control. At 2 months, there were no statistically significant differences between groups in any outcomes. At 6 months, there was significant improvement in psychological distress and well-being (P = 0.04 and P = 0.03, respectively), and marginally significant improvement in depressive symptoms and mindfulness (P = 0.08 and P = 0.09, respectively). There was a 35% reduction in psychological distress among those treated. The intervention had no impact on RA disease activity.

CONCLUSION

An 8-week MBSR class was not associated with change in depressive symptoms or other outcomes at 2-month followup. Significant improvements in psychological distress and well-being were observed following MBSR plus a 4-month program of continued reinforcement. Mindfulness meditation may complement medical disease management by improving psychological distress and strengthening well-being in patients with RA.

Mindfulness meditation alleviates depressive symptoms in women with fibromyalgia: Results of a randomized clinical trial

OBJECTIVE

Depressive symptoms are common among patients with fibromyalgia, and behavioral intervention has been recommended as a major treatment component for this illness. The objective of this study was to test the effects of the Mindfulness-Based Stress Reduction (MBSR) intervention on depressive symptoms in patients with fibromyalgia.

METHODS

This randomized controlled trial examined effects of the 8-week MBSR intervention on depressive symptoms in 91 women with fibromyalgia who were randomly assigned to treatment (n = 51) or a waiting-list control group (n = 40). Eligible patients were at least 18 years old, willing to participate in a weekly group, and able to provide physician verification of a fibromyalgia diagnosis. Of 166 eligible participants who responded to local television news publicizing, 49 did not appear for a scheduled intake, 24 enrolled but did not provide baseline data, and 2 were excluded due to severe mental illness, leaving 91 participants. The sample averaged 48 years of age and had 14.7 years of education. The typical participant was white, married, and employed. Patients randomly assigned to treatment received MBSR. Eight weekly 2.5-hour sessions were led by a licensed clinical psychologist with mindfulness training. Somatic and cognitive symptoms of depression were assessed using the Beck Depression Inventory administered at baseline, immediately postprogram, and at followup 2 months after the conclusion of the intervention.

RESULTS

Change in depressive symptoms was assessed using slopes analyses of intervention effects over time. Depressive symptoms improved significantly in treatment versus control participants over the 3 assessments.

CONCLUSION

This meditation-based intervention alleviated depressive symptoms among patients with fibromyalgia.

A longitudinal study of depression, pain, and stress as predictors of sleep disturbance among women with metastatic breast cancer

OBJECTIVE

Sleep disturbances are common among women with breast cancer and can have serious consequences. The present study examined depression, pain, life stress, and participation in group therapy in relation to sleep disturbances in a sample of women with metastatic breast cancer.

METHODS

Ninety-three women with metastatic breast cancer participated in a large intervention trial examining the effect of the group therapy on their symptoms. They completed measures of depression, pain, life stress, and sleep disturbance at baseline, 4, 8 and 12 months.

RESULTS

The results showed that higher initial levels of depression at baseline predicted problems associated with getting up in the morning, waking up during the night, and daytime sleepiness. Increases in depression over the course of 12 months were associated with fewer hours of sleep, more problems with waking up during the night and more daytime sleepiness. Higher levels of pain at baseline predicted more problems getting to sleep. Increases in pain predicted more difficulty getting to sleep and more problems waking up during the night. Greater life stress at baseline predicted more problems getting to sleep and more daytime sleepiness.

CONCLUSIONS

Depression, pain, and life stress scores were each associated with different types of negative change in self-reported sleep disturbances. Depression, especially worsening depression, was associated with the greatest number of types of negative change. The relationships found between sleep disturbance and depression, pain, and life stress suggest specific ways to address the problem of sleep disturbance for women with metastatic breast cancer and show how different types of disturbed sleep may be clinical markers for depression, pain, or life stress in this population.

Mindfulness meditation for oncology patients: a discussion and critical review

The purpose of this article is to (1) provide a comprehensive over view and discussion of mindfulness meditation and its clinical applicability in oncology and (2) report and critically evaluate the existing and emerging research on mindfulness meditation as an intervention for cancer patients. Using relevant keywords, a comprehensive search of MEDLINE, PsycInfo, and Ovid was completed along with a review of published abstracts from the annual conferences sponsored by the Center for Mindfulness in Medicine, Health Care, and Society and the American Psychosocial Oncology Society. Each article and abstract was critiqued and systematically assessed for purpose statement or research questions,

STUDY DESIGN

The search produced 9 research articles published in the past 5 years and 5 conference abstracts published in 2004. Most studies were conducted with breast and prostate cancer patients, and the mindfulness intervention was done in a clinic-based group setting. Consistent benefits--improved psychological functioning, reduction of stress symptoms, enhanced coping and well-being in cancer outpatients--were found. More research in this area is warranted: using randomized, controlled designs, rigorous methods, and different cancer diagnoses and treatment settings; expanding outcomes to include quality of life, physiological, health care use, and health-related outcomes; exploring mediating factors; and discerning dose effects and optimal frequency and length of home practice. Mindfulness meditation has clinically relevant implications to alleviate psychological and physical suffering of persons living with cancer. Use of this behavioral intervention for oncology patients is an area of burgeoning interest to clinicians and researchers.

Methodological quality of patient-reported outcome research was low in complementary and alternative medicine in oncology

OBJECTIVE

To evaluate the methodological robustness of patient-reported outcomes (PROs) evaluation in complementary and alternative medicine (CAM) randomized controlled trials (RCTs) in oncology.

STUDY DESIGN AND SETTING

CAM RCTs with a PRO endpoint were retrieved from a number of electronic databases. CAM interventions were defined according to the five major categories of the National Center for Complementary and Alternative Medicine. The "Minimum Standard Checklist for Evaluating HRQOL Outcomes in Cancer Clinical Trials" was used to assess the quality of the PRO reporting in these trials.

RESULTS

Forty-four RCTs enrolling 4,912 patients were identified: six studies involved alternative medical systems, 14 involved mind body interventions, 15 dealt with biologically-based therapies, seven involved manipulative and body-based methods, and two energy therapies. Eighty-nine percent of studies used a PRO as a primary endpoint and 59% documented PRO missing data. Although 84% of the studies used a validated PRO questionnaire, only 37% stated an a priori hypothesis and 20% addressed clinical significance of the outcomes. Overall, 64% of the studies analyzed exhibited a number of methodological drawbacks.

CONCLUSIONS

To facilitate the interpretation of results from such CAM RCTs, investigators are encouraged to pay greater attention to key methodological issues as identified in this study.

Yoga for depression: the research evidence

BACKGROUND

Yoga-based interventions may prove to be an attractive option for the treatment of depression. The aim of this study is to systematically review the research evidence on the effectiveness of yoga for this indication.

METHODS

Searches of the major biomedical databases including MEDLINE, EMBASE, ClNAHL, PsycINFO and the Cochrane Library were conducted. Specialist complementary and alternative medicine (CAM) and the IndMED databases were also searched and efforts made to identify unpublished and ongoing research. Searches were conducted between January and June 2004. Relevant research was categorised by study type and appraised. Clinical commentaries were obtained for studies reporting clinical outcomes.

RESULTS

Five randomised controlled trials were located, each of which utilised different forms of yoga interventions and in which the severity of the condition ranged from mild to severe. All trials reported positive findings but methodological details such as method of randomisation, compliance and attrition rates were missing. No adverse effects were reported with the exception of fatigue and breathlessness in participants in one study.

LIMITATIONS

No language restrictions were imposed on the searches conducted but no searches of databases in languages other than English were included.

CONCLUSIONS

Overall, the initial indications are of potentially beneficial effects of yoga interventions on depressive disorders. Variation in interventions, severity and reporting of trial methodology suggests that the findings must be interpreted with caution. Several of the interventions may not be feasible in those with reduced or impaired mobility. Nevertheless, further investigation of yoga as a therapeutic intervention is warranted.

Impact of mindfulness-based stress reduction (MBSR) on sleep, mood, stress and fatigue symptoms in cancer outpatients

Sleep disturbance is a very common problem for cancer patients that has largely not been addressed in the clinical intervention literature. Mindfulness meditation has demonstrated clinical benefits for a variety of patient populations in other areas of functioning. This study examined the effects of an 8-week Mindfulness-Based Stress Reduction (MBSR) program on the sleep quality of a heterogeneous sample of 63 cancer patients. Overall sleep disturbance was significantly reduced (p < .001) and participants reported that their sleep quality had improved (p .001). There was also a significant reduction in stress (p < .001), mood disturbance (p = .001), and fatigue (p < .001). The associations among these changes and implications for improving quality of life of cancer patients are discussed.

Yoga for cancer patients and survivors

BACKGROUND

Yoga has been practiced for thousands of years to improve physical and emotional well-being. Empirical research on yoga has been ongoing for several decades, including several recent studies conducted with cancer patients and survivors.

METHODS

This review provides a general introduction to yoga and a detailed review of yoga research in cancer.

RESULTS

Nine studies conducted with cancer patients and survivors yielded modest improvements in sleep quality, mood, stress, cancer-related distress, cancer-related symptoms, and overall quality of life. Studies conducted in other patient populations and healthy individuals have shown beneficial effects on psychological and somatic symptoms, as well as other aspects of physical function.

CONCLUSIONS

Results from the emerging literature on yoga and cancer provide preliminary support for the feasibility and efficacy of yoga interventions for cancer patients, although controlled trials are lacking. Further research is required to determine the reliability of these effects and to identify their underlying mechanisms.

Sleep wake disturbances in people with cancer and their caregivers: state of the science

PURPOSE/OBJECTIVES

To review the state of the science on sleep/wake disturbances in people with cancer and their caregivers.

DATA SOURCES

Published articles, books and book chapters, conference proceedings, and MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, PsycINFO, and the Cochrane Library computerized databases.

DATA SYNTHESIS

Scientists have initiated studies on the prevalence of sleep/wake disturbances and the etiology of sleep disturbances specific to cancer. Measurement has been limited by lack of clear definitions of sleep/wake variables, use of a variety of instruments, and inconsistent reporting of sleep parameters. Findings related to use of nonpharmacologic interventions were limited to 20 studies, and the quality of the evidence remains poor. Few pharmacologic approaches have been studied, and evidence for use of herbal and complementary supplements is almost nonexistent.

CONCLUSIONS

Current knowledge indicates that sleep/wake disturbances are prevalent in cancer populations. Few instruments have been validated in this population. Nonpharmacologic interventions show positive outcomes, but design issues and small samples limit generalizability. Little is known regarding use of pharmacologic and herbal and complementary supplements and potential adverse outcomes or interactions with cancer therapies.

IMPLICATIONS FOR NURSING

All patients and caregivers need initial and ongoing screening for sleep/wake disturbances. When disturbed sleep/wakefulness is evident, further assessment and treatment are warranted. Nursing educational programs should include content regarding healthy and disrupted sleep/wake patterns. Research on sleep/wake disturbances in people with cancer should have high priority.

Mindfulness-Based Stress Reduction as supportive therapy in cancer care: systematic review

AIM

This paper reports a systematic review and critical appraisal of the evidence on the effectiveness of Mindfulness-Based Stress Reduction for cancer supportive care.

BACKGROUND

The experience of cancer can have a negative impact on both psychological and physical health and on quality of life. Mindfulness-Based Stress Reduction is a therapy package that has been used with patients with a variety of conditions. In order to draw conclusions on its effectiveness for cancer patients, the evidence requires systematic assessment.

METHODS

A comprehensive search of major biomedical and specialist complementary medicine databases was conducted. Additionally, efforts were made to identify unpublished and ongoing research. Relevant research was categorized by study type and appraised according to study design. Clinical commentaries were obtained for each study and included in the review.

RESULTS

Three randomized controlled clinical trials and seven uncontrolled clinical trials were found. A lack of relevant qualitative research studies was identified. Studies report positive results, including improvements in mood, sleep quality and reductions in stress. A dose-response effect has been observed between practice of Mindfulness-Based Stress Reduction and improved outcome. A number of methodological limitations were identified. Modifications to the traditional Mindfulness-Based Stress Reduction programme make comparison between studies difficult and a lack of controlled studies precludes any firm conclusion on efficacy.

CONCLUSION

Mindfulness-Based Stress Reduction has potential as a clinically valuable self-administered intervention for cancer patients. Further research into its efficacy, feasibility and safety for cancer patients in the nursing context is recommended.

Adolescents, substance abuse, and the treatment of insomnia and daytime sleepiness

Adolescence is a time of change that can be both exciting and stressful. In this review, we focus on the central role that disturbed sleep and daytime sleepiness occupies in interactions involving substance abuse and negative health, social, and emotional outcomes. As a means of improving sleep and lowering risk for recidivism of substance abuse, we developed and implemented a six-session group treatment to treat sleep disturbances in adolescents who have received treatment for substance abuse. The components of the treatment are stimulus control instructions, use of bright light to regularize sleep, sleep hygiene education, cognitive therapy, and Mindfulness-Based Stress Reduction. Preliminary evidence indicates that participants who completed four or more sessions in the treatment program showed improved sleep and that improving sleep may lead to a reduction in substance abuse problems at the 12-month follow-up.

Treating Anxiety With Mindfulness: An Open Trial of Mindfulness Training for Anxious Children

This study is an open clinical trial that examined the feasibility and acceptability of a mindfulness training program for anxious children. We based this pilot initiative on a cognitively oriented model, which suggests that, since impaired attention is a core symptom of anxiety, enhancing self-management of attention should effect reductions in anxiety. Mindfulness practices are essentially attention enhancing techniques that have shown promise as clinical treatments for adult anxiety and depression (Baer, 2003). However, little research explores the potential benefits of mindfulness to treat anxious children. The present study provided preliminary support for our model of treating childhood anxiety with mindfulness. A 6-week trial was conducted with five anxious children aged 7 to 8 years old. The results of this study suggest that mindfulness can be taught to children and holds promise as an intervention for anxiety symptoms. Results suggest that clinical improvements may be related to initial levels of attention.

Sleep Deprivation and Psychosocial Impact in Acutely Ill Cancer Patients

Sleep is an important factor related to health and quality of life for all individuals. For people with cancer, sleep disturbances are common and are a source of distress. This article summarizes the problems and reviews the types, prevalence, etiology, risk factors, clinical sequelae, and management of sleep disturbances experienced by cancer patients. A comprehensive review of the literature is presented, along with direction for nursing practice and research.

The Role of Acceptance and Mindfulness in the Treatment of Insomnia

The present article explores possible reasons why acceptance and mindfulness techniques may be beneficial in the treatment of insomnia. First, it is argued that sleep is facilitated by cognitive deactivation, with less controlled information processing as compared with daytime functioning, and correspondingly more acceptance of spontaneously occurring physiological and mental processes. Second, it is argued that mindfulness practice, in the form of nonjudgmental observation of spontaneously occurring physical and psychological processes, may be an effective way of training the skills of cognitive deactivation. As a complement, psychoeducational methods are advocated to help the client develop a more functional schematic model of sleep and sleeplessness.

Using mindfulness-based therapeutic interventions in psychiatric nursing practice--part I: Description and empirical support for mindfulness-based interventions

Finding effective nursing interventions for the treatment of mental illness is a major concern for advanced practice psychiatric nurses (APPN). Increasingly, innovative psychotherapeutic treatment modalities are being used for the treatment of individuals with serious mental illness. One such innovative approach, mindfulness-based therapeutic interventions, has been shown to relieve distress for individuals with medical and psychiatric illnesses. In part one of this two-part article, the investigators describe principle concepts of mindfulness, review current research in the usefulness of mindfulness practice for treatment of psychiatric illnesses, and outline the theoretical basis for this treatment modality, including mindfulness-based cognitive therapy (MBCT). In Part II, the writers detail the therapy phases of MBCT and present a clinical case in which an advance practice psychiatric nurse integrates mindfulness-based psychotherapeutic approaches into her treatment. This clinical case may inform future clinical nursing research and advanced psychiatric nursing practice.

Sleep-wake disturbances in people with cancer part II: evaluating the evidence for clinical decision making

PURPOSE/OBJECTIVES

To evaluate the quality of evidence on sleep-wake disturbances in people with cancer as a basis for clinical decision making and to discuss implications of the evidence for oncology clinicians, educators, and researchers.

DATA SOURCES

Published, peer-reviewed articles.

DATA SYNTHESIS

Members of the 2001 Oncology Nursing Society (ONS) Advanced Practice Nurse Retreat Evidence-Based Practice Sleep Working Group selected and evaluated data sources using criteria and processes outlined by ONS.

CONCLUSIONS

The development of nursing science related to sleep-wake disturbances among people with cancer and the application of research findings to clinical decision making are limited by the quantity and quality of published evidence.

IMPLICATIONS FOR NURSING

Clinicians are challenged to develop a plan of care that includes the assessment of sleep-wake disturbances and interventions to address them. Nurse educators are challenged to include sleep-wake content and skills to evaluate empirical data and interventions for sleep-wake disturbances in degree and continuing education curricula. Nurse researchers are challenged to specify consistent conceptual and operational definitions of key variables in sleep-wake models, use measurement instruments with evidence of reliability and validity, and design clinical trials to test interventions for sleep-wake disturbances among people with cancer.