Insurance-Reimbursable Mindfulness for Safety-Net Primary Care Patients: A Pilot Randomized Controlled Trial

Body listening in the link between symptoms and self-care management in cardiovascular disease: A cross-sectional correlational descriptive study

OBJECTIVE

The aim of this study was to quantify relationships among symptoms, interoceptive sensibility (i.e. the conscious level of sensing, interpreting and integrating signals from the body), and self-care management behaviors (i.e. the response to symptoms when they occur) among adults with cardiovascular disease. We hypothesized that better interoceptive sensibility would increase the positive behavior-driving effects of symptoms on self-care management.

METHODS

Adult patients with cardiovascular disease who experienced recent symptoms were recruited to participate in this cross-sectional correlational descriptive study. Patient-Reported Outcomes Measurement Information System measures were used to capture dyspnea, pain interference, fatigue, sleep disturbances, nausea and vomiting, anxiety and depressive symptoms. Interoceptive sensibility was measured using the Multidimensional Assessment of Interoceptive Awareness Version 2. The Self-Care of Chronic Illness Inventory was used to measure self-care management. Network analysis was used to identify domains of interoceptive sensibility that were most central. Linear regression with interaction terms was used to test the moderating effect of interoceptive sensibility on the relationship between symptoms and self-care management.

RESULTS

The age of participants in the sample (n = 387) ranged from 18 to 88 years, a slight majority (53.5 %) were female, and a majority were Caucasian (66.4 %) or African American (32.0 %). Hypertension was the most common disorder (n = 238 (61.5 %)), followed by rhythm disorders (n = 124 (32.0 %)), coronary artery disease (n = 94 (24.3 %)), heart failure (n = 89 (23.0 %)), valve disease (n = 69 (17.8 %)), stroke (n = 62 (16.0 %)) and peripheral vascular disease (n = 49 (12.7 %)). Based on network analysis, body listening (i.e. active listening to the body for insights) was the most central interoceptive domain, and distracting (i.e. tendency to ignore or distract oneself from sensations of discomfort) was the least central. Noticing (i.e. greater awareness of body sensations), distracting, and body listening were significant in moderating relationships between dyspnea, sleep disturbances and anxiety and the outcome of self-care management behaviors (all p < 0.001). Better noticing and body listening were associated with better self-care management across symptoms, whereas ignoring or distracting oneself from discomfort was associated with worse self-care management behaviors.

CONCLUSION

Among adults with cardiovascular disease, interventions designed to augment the identified interoceptive sensibility domains like body listening, and mitigate the tendency to ignore or distract oneself from discomfort may support adults with cardiovascular disease through the development of future interventions that optimize patient behaviors in response to symptoms when they occur.

Integrating choice points into mindfulness training for the dissociative subtype of PTSD: A case report

Approximately 15-30 % of individuals diagnosed with PTSD experience high levels of dissociation, a condition categorized in the DSM-V as a dissociative subtype of PTSD (PTSD-D). Despite the rising number of studies supporting mindfulness-based interventions (MBIs) for the treatment of PTSD, literature on mindfulness and dissociation remains scarce and discording. While best practices for offering mindfulness for dissociative patients remain unclear, integrating choice points into MBIs may be aligned with trauma-informed principles and effective in countering loss of self-agency associated with trauma. In this article, we present a case study from a larger randomized controlled trial of an individual with PTSD-D who successfully completed an 8-week MBI while displaying active dissociation symptoms throughout the group. Follow-up interviews with stakeholders in the patient's care as well as pre-and post-intervention assessments indicate that the patient had a positive experience with the mindfulness training and improved self-regulation. Analysis of the case study suggests that the mindfulness training may have been safe and effective for this patient due to the integration of choice points throughout the mindfulness training and promotion of structural safety. We expand on this by further discussing six influencing factors that contributed to the outcome of the case study and can serve as a reference for clinicians, researchers, and instructors who wish to offer MBIs safely to patients with PTSD-D.

Effects of live-online, group mindfulness training on opioid use and anxiety during buprenorphine treatment: A comparative effectiveness RCT

BACKGROUND

Office-based opioid treatment with buprenorphine has emerged as a popular evidence-based treatment for opioid use disorder. Unfortunately, psychosocial stress, anxiety, pain, and co-morbid substance use increase patients' risk for relapse. We designed this study to compare the effects of complementing buprenorphine treatment with 24 weeks of a live-online Mindful Recovery Opioid Care Continuum (M-ROCC) group to a time and attention-matched, live-online Recovery Support Group (RSG) active control condition.

METHODS

We plan to enroll a maximum of N = 280 and randomize at least N = 192 patients prescribed buprenorphine through referrals from office-based and telemedicine buprenorphine treatment providers and social media advertisements. Participants will be randomly assigned to M-ROCC or RSG and will be blinded to their treatment condition. The primary outcome for this study will be biochemically confirmed periods of abstinence from illicit opioids, as measured by self-reported use and randomly collected, video-observed oral fluid toxicology testing during the final 12 weeks of study participation. Secondary outcomes include changes in Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety and pain interference scores between baseline and week 24.

RESULTS

The trial was funded by the National Institutes of Health, HEAL Initiative through NCCIH (R33AT010125). Data collection is projected to end by September 2023, and we expect publication of results in 2024.

CONCLUSION

If the M-ROCC intervention is found to be effective in this format, it will demonstrate that live-online mindfulness groups can improve outcomes and address common co-morbidities like anxiety and pain during buprenorphine treatment.

Impact of warm mindfulness on emotion regulation: A randomized controlled effectiveness trial

OBJECTIVE

To determine the effects of mindfulness training for primary care (MTPC), an integrated warm mindfulness training program, on emotion regulation and its relationship with health behavior change. Interventions that improve self-regulation, particularly emotion regulation, are needed for the self-management of comorbid chronic physical and mental illnesses. Mindfulness-based interventions (MBIs) may impact self-regulation and facilitate health behavior change.

METHOD

A randomized controlled comparative effectiveness trial was conducted in a population of adult primary care patients to evaluate the impact of MTPC versus a low-dose mindfulness comparator (LDC) on self-reported difficulties in emotion regulation (DERS) total score and other assays of self-regulation at baseline, Weeks 8 and 24. Self-reported action plan initiation was reported between Weeks 8 and 10. Participants had diagnoses of anxiety, depression, or stress-related disorders. MTPC is an 8-week insurance-reimbursable warm MBI designed to cultivate mindfulness and self-compassion and to catalyze chronic illness self-management related health behavior change.

RESULTS

Compared to LDC, MTPC participants had statistically significant reductions in DERS total score at 8 weeks (d = -0.59, β = -12.98, 95% CI [-23.3 to -2.6]; p = .01) and 24 weeks (d = -0.61, β = -13.35, [-24.3, -2.4]; p = .02). Compared to 38% for LDC, 63% of MTPC participants successfully initiated their action plan within 3 weeks (OR = 2.87, [1.1, 7.9]; p = .04).

CONCLUSIONS

This randomized controlled trial demonstrated MTPC enhanced emotion regulation and facilitated initiation of chronic illness self-management and health behavior change among primary care patients with anxiety, depression, and stress-related disorders, replicating previous reports. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Effects of a trauma‐informed mindful recovery program on comorbid pain, anxiety, and substance use during primary care buprenorphine treatment: A proof‐of‐concept study

BACKGROUND

A mindfulness-based intervention that reduces comorbid pain, anxiety, and substance use during office-based opioid treatment (OBOT) could enhance retention and prevent overdose. We conducted a pilot study of the Mindful Recovery OUD Care Continuum (M-ROCC), a 24-week trauma-informed program with a motivationally-sensitive curriculum.

METHODS

Patients prescribed buprenorphine (N = 18) enrolled in M-ROCC. We collected urine toxicology biweekly. At 0, 4, and 24 weeks, participants completed PROMIS-Pain, PROMIS-Anxiety, Mindfulness (FFMQ), Experiential Avoidance (BEAQ), Interoceptive Awareness (MAIA), and Self-Compassion (SCS-SF) scales. We estimated changes over time using mixed models. Participants completed qualitative interviews at 4 and 24 weeks.

RESULTS

Positive urine toxicology decreased over time for cocaine (β = -.266, p = .008) and benzodiazepines (β = -.208, p = .028). M-ROCC reduced PROMIS-Pain (Z = -2.29; p = .022), BEAQ (Z = -2.83; p = .0005), and increased FFMQ (Z = 3.51; p < .001), MAIA (Z = 3.40; p = .001), and SCS-SF (Z = 2.29; p = .022). Participants with co-morbid anxiety had decreased PROMIS-Anxiety (Z = -2.53; p = .012). Interviewed participants commonly used mindfulness practices for stress and anxiety (12/12, 100%), and to reduce pain catastrophizing and rumination (7/12, 58%).

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

This is the first study to report the effects of a 24-week mindfulness program during buprenorphine treatment on common comorbidities, including pain interference, anxiety, cocaine, and benzodiazepine use. The findings that M-ROCC is associated with reduced experiential avoidance, as well as increased interoceptive awareness and self-compassion, align with proposed mechanisms that are now extended to OUD treatment. Future larger randomized controlled trials are needed before effectiveness can be established and the role of these mechanisms can be confirmed.

Increased insula response to interoceptive attention following mindfulness training is associated with increased body trusting among patients with depression

Interoceptive dysfunction is often present in anxiety and depression. We investigated the effects of an 8-week intervention, Mindfulness Training for Primary Care (MTPC), on brain mechanisms of interoceptive attention among patients with anxiety and/or depression. We hypothesized that fMRI brain response to interoception in the insula, a region known for interoceptive processing, would increase following the MTPC intervention, and that such increases would be associated with post-intervention changes in self-reported measures of interoceptive awareness. Adults (n = 28) with anxiety and/or depression completed baseline and post-intervention fMRI visits, including a task in which they alternated between focusing on their heartbeat (interoception (INT)) and a control visual attention task (exteroception (EXT)). Following MTPC, we observed increased evoked fMRI response (relative to baseline) in left anterior insula during the INT-EXT task contrast (z > 3.1, p < 0.001 corrected). In patients with moderate-to-severe depression as defined by the Patient Reported Outcomes Measurement Information System (PROMIS), increased post-intervention insula response was associated with increased Body Trusting, a subscale of the Multidimensional Assessment of Interoceptive Awareness (z > 3.1, p = 0.007 corrected). This study demonstrates that patients with mood disorders may respond differentially to mindfulness-based treatment depending on depression severity, and that among those who are more depressed, increased trusting in one's own body sensations and experiencing the body as a safe place to attend to may be necessary components of positive responses to mindfulness-based interventions.

Exploring health coaching and mindfulness as levers for transformation in health: stakeholder perspectives

BACKGROUND

Health coaching (HC) and mindfulness (MFN) are proven interventions for mobilizing patients' inner resources and are slowly being integrated into public primary care. Since 2015 the medical community in Gibsons BC has integrated physician-led HC and MFN-based programs into team-based care. This exploratory study aimed to understand the mechanisms by which these rural programs helped both patients and clinicians, and to elicit priorities for future study in these fields.

METHODS

Using a qualitative participant-engaged constructivist approach in focus groups and large-group graphic facilitation, we elicited perspectives from patients and their physicians during a 1-day event held in September 2018. Thematic analysis of transcripts using Nvivo identified emergent themes that were regularly reviewed with coresearchers, and member checked with participants via online videoconferences held at 6 weeks and 4 months postevent.

RESULTS

We identified six main themes relating to the successful implementation of these programs: (i) accessibility and affordability, (ii) offering a toolbox of practical skills, (iii) providing attuned and openhearted care, (iv) generating hope and self-efficacy, (v) experiencing a shared humanity and connection, and (vi) addressing the health of the whole person.

CONCLUSION

These themes highlight critical qualities of HC and MFN programs when implemented in a Medicare system. Key features include reducing stigma around mental health through making programs physician-led and a natural part of primary care, enriching accessibility through public funding, and enhancing patient agency through cultivating embodied awareness, self-compassion, and interpersonal skills. These themes inform the next steps to support upscaling these programs to other communities.

Meditative and Mindfulness-Focused Interventions in Neurology: Principles, Science, and Patient Selection

A growing body of research suggests that meditative- and mindfulness-focused interventions may improve neuropsychiatric symptoms that commonly occur in a range of neurological disorders. In this article, the principles of meditation and mindfulness are first defined, as well as briefly describing the neurobiological mechanisms implicated in these interventions. Thereafter, a range of meditative- and mindfulness-focused interventions are detailed, along with their supporting evidence to treat neuropsychiatric symptoms in neurological conditions (e.g., headache, movement disorders, chronic pain, etc.). Overall, these interventions warrant further investigation among individuals with neurological conditions. When recommending these interventions, health care professionals must consider a combination of structural (e.g., insurance reimbursement) and patient factors (e.g., ability to tolerate a group setting).

Effects of Mindfulness Meditation on Doctors' Mindfulness, Patient Safety Culture, Patient Safety Competency and Adverse Event

Objective: This study investigated the effects of mindfulness meditation on doctors’ mindfulness, patient safety culture, patient safety competency, and adverse events. Methods: We recruited 91 doctors from a hospital in China and randomized them to mindfulness meditation group (n = 46) and a waiting control group (n = 45). The mindfulness meditation group underwent an 8-week mindfulness meditation intervention, while the control group underwent no intervention. We measured four main variables (mindfulness, patient safety culture, patient safety competency, and adverse event) before and after the mindfulness meditation intervention. Results: In the experimental group, mindfulness, patient safety culture and patient safety competency were significantly higher compared with those of the control group. In the control group, there were no significant differences in any of the three variables between the pre-test and post-test. Adverse events in the experimental group were significantly lower than in the control group. Conclusions: The intervention of mindfulness meditation significantly improved the level of mindfulness, patient safety culture and patient safety competency. During the mindfulness meditation intervention, the rate of adverse events in the meditation group was also significantly lower than in the control group. As a simple and effective intervention, mindfulness meditation plays a positive role in improving patient safety and has certain promotional value.

A Conceptual Model of the Influence of Mindfulness-Based Interventions on Stress and Quality of Life in Patients With Chronic Conditions

Individuals with chronic conditions are susceptible to stress-related health complications. Left unattended, chronic stress exacerbates inflammation, diminishes quality of life (QOL), and increases all-cause mortality. Here, we suggest a theoretical framework promoting the use of mindfulness-based interventions (MBIs) in patients with chronic conditions and a conceptual model of how MBIs may influence stress and QOL.

Feasibility and acceptability of mindful recovery opioid use care continuum (M-ROCC): A concurrent mixed methods study

As opioid overdose deaths increase, buprenorphine/naloxone (B/N) treatment is expanding, yet almost half of patients are not retained in B/N treatment. Mindfulness-based interventions (MBIs) designed to promote non-judgmental awareness of present moment experience may be complementary to B/N treatment and offer the potential to enhance retention by reducing substance use and addressing comorbid symptoms. In this pilot study, we examined the feasibility and acceptability of the Mindful Recovery OUD Care Continuum (M-ROCC), a trauma-informed, motivationally sensitive, 24-week MBI. Participants (N = 18) were adults with Opioid Use Disorder prescribed B/N. The study team conducted assessments of satisfaction, mindfulness levels, and home practice, as well as qualitative interviews at 4 and 24-weeks. M-ROCC was feasible in a sample with high rates of childhood trauma and comorbid psychiatric diagnoses with 89% of participants retained at 4-weeks and 72% at 24-weeks. Positive qualitative interview responses and a high rate of participants willing to refer a friend (100%) demonstrates program acceptability. Participant mindfulness increased from baseline to 24-weeks (β = 0.24, p = 0.001, d = 0.51), and increases were correlated with informal mindfulness practice frequency (r = 0.7, p < 0.01). Although limited by small sample size, this pilot study highlights the feasibility and acceptability of integrating MBIs into standard primary care Office-Based Opioid Treatment (OBOT) among a population with substantial trauma history.

Mindfulness and Behavior Change

Initiating and maintaining behavior change is key to the prevention and treatment of most preventable chronic medical and psychiatric illnesses. The cultivation of mindfulness, involving acceptance and nonjudgment of present-moment experience, often results in transformative health behavior change. Neural systems involved in motivation and learning have an important role to play. A theoretical model of mindfulness that integrates these mechanisms with the cognitive, emotional, and self-related processes commonly described, while applying an integrated model to health behavior change, is needed. This integrative review (1) defines mindfulness and describes the mindfulness-based intervention movement, (2) synthesizes the neuroscience of mindfulness and integrates motivation and learning mechanisms within a mindful self-regulation model for understanding the complex effects of mindfulness on behavior change, and (3) synthesizes current clinical research evaluating the effects of mindfulness-based interventions targeting health behaviors relevant to psychiatric care. The review provides insight into the limitations of current research and proposes potential mechanisms to be tested in future research and targeted in clinical practice to enhance the impact of mindfulness on behavior change.

Mindfulness Training for Primary Care for Portuguese-Speaking Immigrants: A Pilot Study

Background: Portuguese-speaking immigrants are a growing underserved population in the Unites States who experience high levels of psychological distress and increased vulnerability to mental health disorders such as depression and anxiety. Current evidence shows that mindfulness-based interventions (MBIs) are effective to promote physical and mental health among educated English speakers; nonetheless, the lack of diversity in the mindfulness literature is a considerable limitation. To our knowledge, the feasibility and acceptability of MBIs among Portuguese-speaking immigrants have not yet been investigated. Methods: This single-arm pilot study (N = 30) explored the feasibility, acceptability, and cultural aspects of Mindfulness Training for Primary Care (MTPC)-Portuguese among Portuguese-speaking immigrants in the Boston area. MTPC is an 8-week, primary care-adapted, referral-based, insurance-reimbursable, trauma-informed MBI that is fully integrated into a healthcare system. The study also examined intervention preliminary effectiveness on mental health outcomes (depression and anxiety symptoms) and self-regulation (emotional regulation, mindfulness, self-compassion, interoceptive awareness), and initiation of health behavior was explored. Results: Primary care providers referred 129 patients from 2018 to 2020. Main DSM-5 primary diagnoses were depression (76.3%) and anxiety disorders (6.7%). Participants (N = 30) attended a mean of 6.1 (SD 1.92) sessions and reported a mean of 213.7 (SD = 124.3) min of practice per week. All survey finishers would recommend the program to a friend, found the program helpful, and rated the overall program as "very good" or "excellent," and 93% would participate again, with satisfaction mean scores between 4.6 and 5 (Likert scale 0-5). Participants and group leaders provided feedback to refine MTPC-Portuguese culturally responsiveness regarding materials language, settings, time, food, and community building. Patients exhibited reductions in depression (d = 0.67; p < 0.001) and anxiety (d = 0.48; p = 0.011) symptoms, as well as enhanced emotional regulation (d = 0.45; p = 0.009), and among survey finishers, 50% initiated health behavior change through action plan initiation. Conclusion: This pilot study suggests that MTPC-Portuguese is feasible, acceptable, and culturally appropriate among Portuguese-speaking patients in the Boston area. Furthermore, the intervention might potentially decrease depression and anxiety symptoms, facilitate health behavior change, and improve emotional regulation. MTPC-Portuguese investigation with larger samples in controlled studies is warranted to support its dissemination and implementation in the healthcare system. Clinical Trial Registration: Identifier: NCT04268355.