Mindfulness training reduces the severity of irritable bowel syndrome in women: results of a randomized controlled trial

Interplay of yoga, physical activity, and probiotics in irritable bowel syndrome management: A double-blind randomized study

OBJECTIVES

This study aimed to explore the synergistic impact of online yoga, mindfulness practices, and probiotics on irritable bowel syndrome (IBS) by evaluating changes in physical fitness, mental health, and gut microbiota composition.

DESIGN, SETTING AND INTERVENTIONS

The six-week randomized, double-blinded, placebo-controlled trial included 31 IBS patients categorized into three groups: online yoga with probiotics (EP), online yoga with a placebo (EC), and probiotics only (P). Assessments involved physical fitness tests, subjective questionnaires (IBS-QOL, BSRS-5), and gut microbiome analysis.

MAIN OUTCOME MEASURES

Participants self-collected stool samples and were given a set of questionnaires at baseline and after six weeks of intervention. Their symptoms were measured by changes in the gut microbiota, physical fitness and quality of life, and psychological well-being.

RESULTS

The EP group demonstrated improved cardiovascular endurance (P < 0.001) and a significant reduction in Klebsiella bacterial strains (P < 0.05). Both the EP and EC groups exhibited significantly decreased IBS-QOL scores (P < 0.001 and P < 0.05, respectively), indicating enhanced quality of life. While BSRS-5 scores decreased in both groups, the reduction was statistically insignificant.

CONCLUSION

Integrating online yoga, mindfulness practices, and probiotics demonstrated comprehensive benefits for IBS patients. This intervention improved physical fitness and mental well-being and positively influenced gut microbiota composition. The study highlights the potential of this multifaceted approach in managing IBS symptoms and enhancing overall health, emphasizing the relevance of the gut-muscle-brain axis in understanding and addressing IBS complexities.

TRIAL REGISTRATION

Taiwanese Registry of Institutional Review Board IRBHP210009/CH11000259.

Mindfulness-Based Interventions on Psychological Comorbidities in Patients with Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Inflammatory bowel disease (IBD) is a chronic, lifelong disease, so IBD patients are highly susceptible to negative emotions, such as anxiety and depression, resulting in a reduced quality of life. Mindfulness-based intervention (MBI) is widely used to reduce stress, anxiety and depression in people. Therefore, this study conducted a systematic review of mindfulness-based intervention training on anxiety, depression, and quality of life in patients with IBD through meta-analysis.

METHODS

Search papers in PubMed, Web of Science, Cochrane Library, Google Scholar, CNKI, Wanfang, and Embase databases. The search time limit was from the establishment of the database to May 2023. Randomized controlled trial studies of the effect of mindfulness intervention training on patients with IBD were screened, the included results were integrated and analyzed, and ReviewManager 5.4 was used for meta-analysis.

RESULTS

A total of 14 studies with a total of 1030 IBD patients were included. A total of 10 studies showed that the anxiety of patients in the mindfulness intervention group was significantly reduced by (standard mean difference (SMD) = -0.73, 95% confidence interval (CI): -1.01 to -0.45) compared to the control group. 8 studies showed that the intervention group significantly reduced patients' depression (SMD = -0.60, 95% CI: -0.78 to -0.42). 7 studies showed that the patient's quality of life improved after mindfulness intervention (SMD = 0.66, 95% CI: 0.45-0.87).

CONCLUSION

Mindfulness-based intervention training can improve anxiety, depression, and quality of life in patients with inflammatory bowel disease in the short term, but the long-term effects need to be confirmed by more randomized controlled trials.

Acute and Long-Term Effects of App-Delivered Heartfulness Meditation on Psychological Outcomes and the Endocannabinoid Signaling System in Cyclic Vomiting Syndrome

INTRODUCTION

Cyclic vomiting syndrome (CVS) is a disorder of gut-brain interaction often triggered by stress. Interventions such as meditation may improve psychological outcomes and health-related quality of life (HRQoL), but their efficacy and the underlying mechanism are unknown.

METHODS

We conducted a 6-week single-arm pilot study to assess the effects of heartfulness meditation (HFM) in CVS using a custom-designed meditation app. Primary outcomes included state and trait anxiety and mood state changes pre vs post-meditation, and secondary outcomes were psychological distress, coping, sleep quality, and HRQoL at baseline and at weeks 3 and 6. Serum concentrations of endocannabinoids N -arachidonylethanolamine and 2-arachidonoylglycerol and related lipids were measured pre- and post-HFM at baseline and week 6.

RESULTS

In 30 treatment completers, there was a significant improvement in state anxiety ( P < 0.001), total mood disturbance ( P < 0.001), and other mood states (all P values < 0.05) across the 3 time points. Trait anxiety was also improved at week 6. There was a significant improvement in psychological distress (Global Severity Index), sleep quality (daytime dysfunction), coping (using religion/spirituality), and HRQoL (mental and physical) across the 3 time points (all P < 0.05). Significant increases in N -arachidonylethanolamine and related lipids N -oleoylethanolamine and palmitoylethanolamide post vs pre-HFM were observed at week 6 ( P < 0.001, 0.002, 0.003, respectively). No adverse effects were noted.

DISCUSSION

App-delivered HFM is feasible, safe, and effective and improves psychological outcomes and augments endocannabinoids. This provides insight into the mechanism underlying HFM and has potential for widespread use as a digital therapeutic in CVS and other disorder of gut-brain interaction.

Acceptance and commitment therapy for the treatment of irritable bowel syndrome and inflammatory bowel disease: a narrative review

Background and Objective

Cognitive behavioral therapy (CBT) is a common treatment modality for patients with irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD). CBT may not be a good fit for all patients and some may instead benefit from an acceptance and commitment therapy (ACT) approach. This narrative review presents evidence for the use of ACT in adult patients with IBS or IBD. The authors also suggest instances in which patients with IBS or IBD may benefit from ACT and discuss future directions of research.

Methods

Between August 2023 and January 2024, databases such as Google Scholar, institutional libraries, and PubMed were used to review the literature on ACT in patients with IBS and IBD. A variety of search terms were included. Non-English, pediatric, and studies that did not employ a full ACT protocol were excluded.

Key Content and Findings

ACT for IBS studies typically utilized a self-help book or a one-day workshop intervention, with results indicating reductions in IBS and mood symptoms and improvements in quality of life. Within IBD, three randomized controlled trials (RCTs) tested the impact of ACT, two of which found reductions in stress, depression, and anxiety symptoms.

Conclusions

Despite the limited number of studies testing a full ACT protocol in patient populations with IBS or IBD, results indicate potential efficacy in managing not only symptoms, but also facets of quality of life. Future studies should utilize robust experimental designs and comprehensively test the effectiveness of ACT in IBS and IBD patient populations with both process and outcome measures.

Effect of Brain-Gut Behavioral Treatments on Abdominal Pain in Irritable Bowel Syndrome: Systematic Review and Network Meta-Analysis

BACKGROUND & AIMS

Some brain-gut behavioral treatments (BGBTs) are beneficial for global symptoms in irritable bowel syndrome (IBS). United States management guidelines suggest their use in patients with persistent abdominal pain, but their specific effect on this symptom has not been assessed systematically.

METHODS

We searched the literature through December 16, 2023, for randomized controlled trials (RCTs) assessing efficacy of BGBTs for adults with IBS, compared with each other or a control intervention. Trials provided an assessment of abdominal pain resolution or improvement at treatment completion. We extracted data as intention-to-treat analyses, assuming dropouts to be treatment failures and reporting pooled relative risks (RRs) of abdominal pain not improving with 95% confidence intervals (CIs), ranking therapies according to the P score.

RESULTS

We identified 42 eligible randomized controlled trials comprising 5220 participants. After treatment completion, the BGBTs with the largest numbers of trials and patients recruited demonstrating efficacy for abdominal pain, specifically, included self-guided/minimal contact cognitive behavioral therapy (CBT) (RR, 0.71; 95% CI, 0.54-0.95; P score, 0.58), face-to-face multicomponent behavioral therapy (RR, 0.72; 95% CI, 0.54-0.97; P score, 0.56), and face-to-face gut-directed hypnotherapy (RR, 0.77; 95% CI, 0.61-0.96; P score, 0.49). Among trials recruiting only patients with refractory global IBS symptoms, group CBT was more efficacious than routine care for abdominal pain, but no other significant differences were detected. No trials were low risk of bias across all domains, and there was evidence of funnel plot asymmetry.

CONCLUSIONS

Several BGBTs, including self-guided/minimal contact CBT, face-to-face multicomponent behavioral therapy, and face-to-face gut-directed hypnotherapy may be efficacious for abdominal pain in IBS, although none was superior to another.

Re-examining the Mysterious Role of the Cerebellum in Pain

Pain is considered a multidimensional experience that embodies not merely sensation, but also emotion and perception. As is appropriate for this complexity, pain is represented and processed by an extensive matrix of cortical and subcortical structures. Of these structures, the cerebellum is gaining increasing attention. Although association between the cerebellum and both acute and chronic pain have been extensively detailed in electrophysiological and neuroimaging studies, a deep understanding of what functions are mediated by these associations is lacking. Nevertheless, the available evidence implies that lobules IV-VI and Crus I are especially pertinent to pain processing, and anatomical studies reveal that these regions connect with higher-order structures of sensorimotor, emotional, and cognitive function. Therefore, we speculate that the cerebellum exerts a modulatory role in pain via its communication with sites of sensorimotor, executive, reward, and limbic function. On this basis, in this review, we propose numerous ways in which the cerebellum might contribute to both acute and chronic pain, drawing particular attention to emotional and cognitive elements of pain. In addition, we emphasise the importance of advancing our knowledge about the relationship between the cerebellum and pain by discussing novel therapeutic opportunities that capitalize on this association.

Virtual reality-guided mindfulness for chronic pain in cancer survivors: protocol for the virtual mind study-a single-group feasibility trial

Background

Chronic cancer-related pain (CRP) can have a significant negative impact on quality of life. Mindfulness is hypothesized to mitigate chronic CRP by regulating both physical and emotional resistance to pain. In recent years, there has been interest in the use of virtual reality (VR) to deliver mindfulness meditation. VR provides an immersive and engaging environment, which may enhance one's focused attention to present-moment experiences, potentially making mindfulness less effortful and more efficacious for individuals with chronic pain. There has been little research in this area for people with a history of cancer.

Objective

The aim of this mixed methods study is to evaluate the feasibility of a VR-guided mindfulness (VRGM) intervention offered to adult cancer survivors with chronic CRP.

Methods

This mixed methods feasibility study will employ a single-arm, pretest-posttest design with semistructured interviews. In total, 15 cancer survivors will be enrolled in a 6-week home-based intervention that consists of 10-15 min of daily VRGM practice. The primary outcome is feasibility as assessed by accrual rates, retention in the study, intervention adherence, questionnaire completion, and side effect rates. Participants will be assessed on psychosocial outcome measures (i.e., pain, sleep, depressive and anxiety symptoms, fatigue, quality of life, and mindfulness) before and after the intervention, and 6 weeks post intervention (follow-up). Changes in pain will be described in relation to levels of immersion and presence in the virtual environment, trait mindfulness, and amount of VRGM practice. Qualitative information will provide subjective detail on participants' experience with VRGM to complement quantitative data. This study has been approved by the Health Research Ethics Board of Alberta Cancer Committee (HREBA.CC-20-0411).

Conclusions

This novel intervention provides a potential alternative treatment to pharmacological pain management. Results from this study may inform future larger VGRM trials for chronic CRP to help reduce suffering in people with cancer. Study findings will be disseminated through open access publications, traditional conference presentations, professional cancer organizations, and social media platforms.

Understanding the Role of Therapist Quality in Accounting for Heterogeneity of Patient Outcomes in Psychosocial Chronic Pain Treatments

A variety of evidence-based psychosocial treatments now exist for chronic pain. However, on average, effect sizes have tended to be modest and there is a high degree of heterogeneity in treatment response. In this focus article, we explore the potential role that therapist quality in delivering treatment may have in accounting for a degree of this variability in outcome. Therapist quality refers to the skillful delivery of treatment, harnessing both specific and common therapeutic factors during sessions. While recognized as important to assess and report in clinical trials by some reporting guidelines, few randomized controlled trials evaluating psychosocial treatments for chronic pain have reported on therapist factors. We reviewed the clinical trials included in three systematic reviews and meta-analyses of trials of cognitive-behavioral therapy (mainly), mindfulness-based interventions, and acceptance and commitment therapy. We found that of the 134 trials included, only nine assessed and reported therapist quality indicators, with a variety of procedures used. This is concerning as without knowledge of the quality in which treatments are delivered, the estimates of effect sizes reported may be misrepresented. We contextualize this finding by drawing on the broader psychotherapy literature which has shown that more skillful, effective therapists demonstrated ten times better patient response rates. Examination of the characteristics associated with these more effective therapists tends to indicate that skillful engagement of common factors in therapy sessions represents a distinguishing feature. We conclude by providing recommendations for assessing and reporting on therapist quality within clinical trials evaluating psychosocial treatments for chronic pain. PERSPECTIVE: Therapist quality in the delivery of psychosocial treatments for chronic pain has rarely been assessed in clinical trials. We propose that therapist quality indicators are an under-studied mechanism that potentially contributes to the heterogeneity of treatment outcomes. We provide recommendations for assessing and reporting on therapist quality in future trials.

Mediating effect of psychological distress and mindful eating behaviors between orthorexia nervosa and academic self-efficacy among Lebanese university female students

OBJECTIVES

This study examined the mediating effect of psychological distress and mindful eating behaviors between orthorexia nervosa and academic self-efficacy among Lebanese university female students.

METHODS

A total of 769 female participants enrolled in this cross-sectional study (mean age 21.58 ± 3.20 years). A self-administered questionnaire was distributed among university female students. The questionnaire consisted of Mindful Eating Behaviors Scale, ORTO-R, Depression Anxiety Stress Scale, and Arabic version of Academic Self-Efficacy Scale.

RESULTS

The results showed that psychological distress fully mediated the association between orthorexia nervosa and academic self-efficacy; higher orthorexia nervosa was significantly associated with less psychological distress (β= -0.31, p =.05), with more psychological distress significantly associated with lower academic self-efficacy (β= -0.32, p =.09). Focused eating fully mediated the association between orthorexia nervosa and academic self-efficacy; higher orthorexia nervosa was significantly associated with less focused eating (β=-0.09, p =.04), with more focused eating significantly associated with better academic self-efficacy (β = 1.40, p =.10). Orthorexia nervosa was not directly associated with academic self-efficacy in both models.

CONCLUSION

This study shed light on important connections between orthorexia nervosa, psychological distress, mindful eating behaviors, and academic self-efficacy within the Lebanese context. The findings will have practical implications for both educational institutions and healthcare providers striving to support young female adults' overall well-being and academic success.

Mindfulness-Oriented Recovery Enhancement for Veterans and Military Personnel on Long-Term Opioid Therapy for Chronic Pain: A Randomized Clinical Trial

OBJECTIVE

This randomized clinical trial evaluated the efficacy of Mindfulness-Oriented Recovery Enhancement (MORE) among past and present U.S. military personnel with prescriptions for long-term opioid therapy for chronic pain.

METHODS

In this clinical trial, 230 past and present military personnel with prescriptions for long-term opioid therapy were randomized in a 1:1 ratio to MORE or supportive psychotherapy (initially delivered in person and then via videoconferencing after the onset of the COVID-19 pandemic). Primary outcomes were chronic pain, measured by the Brief Pain Inventory, and aberrant drug-related behaviors, measured by the Current Opioid Misuse Measure, through 8 months of follow-up. Opioid dose was a key secondary outcome. Other outcomes included psychiatric symptoms, catastrophizing, positive affect, ecological momentary assessments of opioid craving, and opioid attentional bias.

RESULTS

MORE was superior to supportive psychotherapy through the 8-month follow-up in reducing pain-related functional interference, pain severity, and opioid dose. MORE reduced daily opioid dose by 20.7%, compared with a dose reduction of 3.9% with supportive psychotherapy. Although there was no overall between-group difference in opioid misuse, the in-person MORE intervention outperformed supportive psychotherapy for reducing opioid misuse. MORE reduced anhedonia, pain catastrophizing, craving, and opioid attentional bias and increased positive affect to a greater extent than supportive psychotherapy. MORE also modulated therapeutic processes, including mindful reinterpretation of pain sensations, nonreactivity, savoring, positive attention, and reappraisal.

CONCLUSIONS

Among past and present U.S. military personnel, MORE led to sustained decreases in chronic pain, opioid use, craving, and opioid cue reactivity. MORE facilitated opioid dose reduction while preserving adequate pain control and preventing mood disturbances, suggesting its utility for safe opioid tapering.

Neural correlates of perceived and relative resilience in male and female patients with irritable bowel syndrome

BACKGROUND

Patients with irritable bowel syndrome (IBS) show lower resilience than healthy controls (HCs), associated with greater symptom severity and worse quality of life. However, little is known about affected markers of resilience or the influence of sex. Furthermore, as resilience is complex, a comprehensive assessment, with multiple resilience measures, is needed. Therefore, we aimed to evaluate perceived and relative resilience and their neural correlates in men and women with IBS.

METHODS

In 402 individuals (232 IBS [73.3% women] and 170 HCs [61.2% women]), perceived resilience was assessed by the Connor-Davidson Resilience Scale (CDRISC) and Brief Resilience Scale (BRS); relative resilience was assessed by the standardized residual of the Short Form-12 mental component summary score predicted by the Adverse Childhood Experiences score. Non-rotated partial least squares analysis of region-to-region resting-state connectivity data was used to define resilience-related signatures in HCs. Disease and sex-related differences within these signatures were investigated.

KEY RESULTS

Scores on all resilience measures were lower in IBS than in HCs (p's < 0.05). In all three resilience-related signatures, patients with IBS showed reduced connectivity largely involving the central autonomic network (p's < 0.001). Men with IBS showed lower CDRISC scores than women with IBS, and greater reductions in CDRISC-related connectivity, associated with worse symptom severity (p < 0.05).

CONCLUSIONS AND INFERENCES

Individuals with IBS show reduced perceived and relative resilience, with reduced connectivity suggesting impaired homeostasis maintenance. Men with IBS may show additional impairment in specific aspects of resilience. Treatments aimed at improving resilience may benefit patients with IBS, especially men with IBS.

Comparison of the Effectiveness of Mindfulness-Based Stress Reduction and Compassion-Focused Treatment on the Severity of Gastrointestinal Symptoms in Patients with Irritable Bowel Syndrome

Background

The aim of this research was to compare the effectiveness of mindfulness-based stress reduction and compassion-focused on the severity of digestive symptoms in patients with irritable bowel syndrome (IBS).

Methods

The research method was of semi-experimental type with pre-test, post-test, follow-up, and experimental and control groups. The population included patients with IBS in Isfahan city, 45 of them were selected by convenience sampling method and randomly assigned to three groups (15 in each group). Then, the patients of one experimental group received eight sessions of 90 minutes of a mindfulness-based stress reduction program, while the other experimental group received eight sessions of 90 minutes of compassion-focused therapy. The measurement tools included the severity of IBS scale and a short clinical interview. Research data were analyzed using variance analysis with repeated measures on one factor (mixed design).

Results

The results showed that both methods of intervention had been equally effective on the severity of disease symptoms (P<0.01).

Conclusion

Both intervention methods can be used as a complementary treatment for patients with IBS.

Comparing the effectiveness of online individualized transdiagnostic treatment with acceptance and commitment therapy on medication adherence, gastrointestinal symptoms and perceived stress of patients with irritable bowel syndrome

Aim

This study aimed to investigate whether transdiagnostic treatment as well as acceptance and commitment therapy (ACT) could improve treatment adherence and alleviate gastrointestinal symptoms plus perceived stress in patients suffering from irritable bowel syndrome.

Background

Research has shown that people with chronic diseases often have negative attitudes toward medications, especially when they also have psychiatric disorders. This, along with the complex dosing requirements and inadequate knowledge about medication adherence among irritable bowel syndrome patients, can affect the treatment efficacy.

Methods

A randomized clinical trial was conducted using a pre-test-post-test design. The statistical population included patients with irritable bowel syndrome referring to Taleghani Hospital in Tehran between winter 2021 and spring 2022. Convenience sampling was used to select 30 individuals, with 15 people assigned to each group. Two types of psychotherapy were provided online and individually to the participants. The desired treatments were given to the transdiagnostic treatment and ACT groups in eight weekly sessions of 45-60 minutes.

Results

There was no significant difference between the transdiagnostic treatment pre-test and ACT regarding perceived stress, medication adherence, and gastrointestinal symptoms (P>0.05). There was no significant difference either between the transdiagnostic treatment and ACT post-test. However, there was a significant difference between the pre-test and post-test phases of ACT regarding adherence, gastrointestinal symptoms, plus perceived stress (P<0.05) and transdiagnostic treatment regarding gastrointestinal symptoms (P<0.05).

Conclusion

Specialists may use transdiagnostic treatment and ACT as effective psychological treatments to alleviate gastrointestinal symptoms and perceived stress, thereby increasing treatment adherence in patients with irritable bowel syndrome.

Mindfulness for academic performance in health professions students: a systematic review

OBJECTIVES

To systematically review the impact of mindfulness-based interventions (MBIs) on the academic performance of undergraduate medicine, nursing and allied health students.

METHODS

Randomised controlled trials that examined the effects of MBIs in medicine, nursing and allied health students on academic performance were eligible for inclusion. Electronic database searches were conducted across Medline, Embase, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature (CINAHL Plus), PsycINFO and ERIC databases. Two authors independently reviewed citations, extracted data and assessed the quality of evidence using the Cochrane Collaboration's risk of bias tool. A descriptive analysis of included studies and a meta-analysis using a random-effects model of standardised mean difference were performed.

RESULTS

A total of 267 studies were returned from the search, of which 2 met the inclusion criteria. The overall risk of bias was assessed as unclear risk of bias for one study and high risk of bias for second included study. A meta-analysis of MBIs on student academic performance as measured by marks in written examination indicated no statistical difference between interventions (Standardised Mean Difference (SMD)=0.43, 95% CI -1.77 to 2.62, I2=96%).

DISCUSSION

Our systematic review highlights a lack of evidence to either support, or refute, the use of mindfulness interventions on the academic performance of undergraduate medical students. We encourage that future randomised controlled trials pay heed to the dosing of mindfulness and include a measurement of mindfulness to enable us to draw a clearer causal relationship.

Managing pain in irritable bowel syndrome: current perspectives and best practice

INTRODUCTION

Irritable bowel syndrome (IBS) is characterized by chronic symptoms (>6 months) of abdominal pain in combination with a disturbed bowel habit. There is an association between the intensity of abdominal pain and the need for health care utilization. A bidirectionally disordered gut-brain interaction is central in the pathophysiology of IBS where a number of factors, gastrointestinal and non-gastrointestinal, can contribute to the illness experience. In order to treat abdominal pain in IBS, mapping these factors in a multidimensional clinical profile is helpful.

AREAS COVERED

This review covers basic epidemiology and pathophysiology of abdominal pain in IBS, the diagnostic approach, and a multidimensional treatment model where the management of abdominal pain is in focus.

EXPERT OPINION

A personalized treatment of abdominal pain in IBS is possible in patients who understand the diagnosis, the potential of therapies used, and where a good continuity in the patient-doctor relationship is established.

Bladder Pain Sensitivity Is a Potential Risk Factor for Irritable Bowel Syndrome

BACKGROUND

Although dysmenorrhea is a highly prevalent risk factor for irritable bowel syndrome (IBS), the factors underlying this risk are not fully understood. Prior studies support a hypothesis that repeated distressing menstrual pain promotes cross-organ pelvic sensitization with heightened visceral sensitivity.

AIMS

To further explore cross-organ pelvic sensitization we examined the association of dysmenorrhea, provoked bladder pain, and other putative factors with self-reported IBS-domain pain frequency and new onset after 1-year follow up.

METHODS

We measured visceral pain sensitivity with a noninvasive provoked bladder pain test in a cohort of reproductive-aged women, enriched for those reporting moderate-to-severe menstrual pain intensity but without any prior IBS diagnosis (n = 190). We analyzed the relationship between menstrual pain, provoked bladder pain, pain catastrophizing, anxiety, and depression with primary outcomes: (1) frequency of self-reported IBS-domain pain and (2) new onset of IBS-domain pain after 1-year follow up.

RESULTS

All hypothesized factors correlated with the frequency of IBS-domain pain (p's ≤ 0.038). In a cross-sectional model, only menstrual pain (standardized adjusted odds ratio 2.07), provoked bladder pain (1.49), and anxiety (1.90) were independently associated with IBS-domain pain ≥ 2 days/month (C statistic = 0.79). One year later, provoked bladder pain (3.12) was the only significant predictor of new onset IBS-domain pain (C statistic = 0.87).

CONCLUSION

Increased visceral sensitivity among women with dysmenorrhea could lead to IBS. Because provoked bladder pain predicted subsequent IBS, prospective studies should be performed to see if the early treatment of visceral hypersensitivity mitigates IBS.

Impact of mindfulness tendency and physical activity on brain-gut interactions

BACKGROUND

Irritable bowel syndrome (IBS) is a disorder of brain-gut interactions characterized by abdominal pain and bowel dysfunction. Exercise and mindfulness have been reported to be effective on IBS, but there has been no study of their interaction. In this study, we hypothesized that exercise and mindfulness interactively affect the severity of IBS symptoms.

METHODS

Subjects were 703 adolescents with 590 women and 113 men. Their IBS status was evaluated with Rome III Diagnostic Questionnaire and IBS Severity Index (IBS-SI). They also fulfilled past exercise experience, athletic performance and exercise enthusiasm, International Physical Activity Questionnaire (IPAQ), Mindful Attention Awareness Scale (MAAS), Kessler 6 Scale (K6), and Perceived Stress Scale (PSS). Statistical analysis was performed using SPSS v25.

RESULTS

In this population, 184 (158 women and 26 men, 14.1%) subjects had Rome III IBS symptoms. IBS subjects scored significantly less in exercise enthusiasm at high school (p = 0.017) and MAAS (p < 0.001) and significantly more K6 (p < 0.001) and PSS (p < 0.001) than non-IBS. The two-way ANOVA on IBS-SI showed a significant main effect of MAAS (p < 0.001) and interaction between MAAS and IPAQ (p = 0.008).

CONCLUSION

It is suggested that mindfulness per se decreases IBS severity, but that mindfulness and physical activity interactively affect the severity. Further studies on how to design interventional trials for IBS patients with mindfulness and physical exercise are warranted.

Efficacy of mindfulness- and acceptance-based cognitive-behavioral therapies for bodily distress in adults: a meta-analysis

Objective

Bodily distress, i.e., somatoform disorders and associated functional somatic syndromes, is highly prevalent, often persistent and highly disabling. It has been proposed that "third wave" therapies may be beneficial variants of cognitive behavioral treatments. However, evidence on their efficacy is scarce. This meta-analysis examines the efficacy of "third wave" psychotherapies (mindfulness-based cognitive therapy [MBCT], mindfulness-based stress reduction [MBSR], and acceptance and commitment therapy [ACT]) in adults with bodily distress.

Method

We included randomized controlled trials (RCTs) treating adults with bodily distress using MBCT, MBSR, and ACT compared to inactive and non-specific control groups. A random effects model was used. The primary outcome was somatic symptom severity. Secondary outcomes were degrees of depression and of anxiety, health anxiety, perceived health status, mindfulness, psychological inflexibility, and pain acceptance.

Results

Sixteen RCTs with 1,288 participants were included in the analysis (k = 4 MBCT, k = 7 MBSR, k = 5 ACT; k = 7 fibromyalgia, k = 5 irritable bowel syndrome, k = 1 chronic fatigue syndrome, k = 2 bodily distress, k = 1 medically unexplained symptoms). However, not all studies provided data for each of the relevant outcomes. The analyses revealed that "third wave" therapies were more effective than control conditions in reducing somatic symptom severity (k = 15, n = 1,100, g = -0.51, 95%CI -0.69; -0.32). Heterogeneity was moderate (I ² = 52.8%, 95%CI 15.1 to 73.8). Effects for secondary outcomes were small to moderate with varying degrees of heterogeneity. We did not find differences between the different therapy approaches (mindfulness- vs. acceptance-based therapies); neither therapy dosis (i.e., total duration of therapy sessions) nor number of sessions were significant moderators of efficacy.

Conclusions

The therapies addressing mindfulness and acceptance proved to be more effective than control conditions. Hence, they are promising treatment approaches for bodily distress. However, there is still need for research on which patient groups may benefit from these psychological approaches.

Systematic review registration

https://osf.io/g7hby, identifier: 10.17605/OSF.IO/4RZGC.

Meditation and Irritable Bowel Syndrome, a Systematic Review and Meta-Analysis

Mind-body interventions have shown efficacy in many conditions that have psychosomatic mechanisms, as well as for other pathologies. The aim of this study was to assess the effectiveness of meditation/mindfulness at improving the symptoms severity, quality of life and other associated mood and mental conditions, measured in patients with irritable bowel syndrome (IBS). A systematic review of randomized controlled trials in adult participants with IBS was conducted. Eight databases were searched for articles. We performed a meta-analysis evaluating the effects of meditation-based therapy on symptomatology, quality of life, anxiety and depression. Out of 604 articles screened, six were selected for quantitative review. The standardized mean difference (SMD) of the mindfulness group and the control group was of -36.95 (95% CI -74.61-0.7), p = 0.054 regarding the IBS symptom score; of 12.58 (95% CI 4.42-20.74), p = 0.003 regarding the IBS quality of life; SMD = 2.8 (95% CI 1.01-4.6), p = 0.002 for spiritual scale; and of 15.49 (95% CI -28.43--2.55), p = 0.019 regarding the pain score in IBS. Our study found that the quality of life and the spiritual scale scores (i.e., mindful awareness) were statistically significantly higher in the mindfulness group, while the pain score was statistically significantly lower in the mindfulness group.

Heart Rate Variability-An Index of the Efficacy of Complementary Therapies in Irritable Bowel Syndrome: A Systematic Review

Irritable bowel syndrome (IBS), as a functional and psychosomatic disease, reduces the quality of life and increases the risk of developing mental disorders. Deregulation of the autonomic nervous system (ANS) is one of the main causes of the disease. The objective of the present study was to identify the studies in which measurements of heart rate variability (HRV) were performed before and after therapeutic intervention, and to evaluate the effectiveness of IBS therapy in terms of a reduction of IBS symptoms and changes in autonomic tone. A systematic review of the literature was carried out in accordance with PRISMA standards. Six databases were searched for articles published before 2022: PubMed®, MEDLINE®, EBSCO, Cochrane, Scopus, and Web of Science. Inclusion criteria were experimental design, diagnosis of IBS (medical and/or diagnosis in accordance with the Rome Criteria), non-pharmacological intervention, and HRV measurement before and after the intervention. The quality of the studies was assessed by JBI Critical appraisal. In total, 455 studies were identified, of which, sixwere included in the review. Expected changes in HRV (increase in parasympathetic activity) were observed in four of the six studies (interventions studied: ear acupressure, transcutaneous auricular vagusnerve stimulation, cognitive behavioral therapy with relaxation elements, yoga). In the same studies, therapeutic interventions significantly reduced the symptoms of IBS. The present review indicated that interventions under investigation improve the efficiency of the ANS and reduce the symptoms of IBS. It is advisable to include HRV measurements as a measure of the effectiveness of interventions in IBS therapy, and to assess autonomic changes as a moderator of the effectiveness of IBS therapy.

Belgian consensus on irritable bowel syndrome

BACKGROUND

Irritable bowel syndrome (IBS) is characterised by recurrent abdominal pain related to defaecation or associated with altered stool frequency or consistency. Despite its prevalence, major uncertainties in the diagnostic and therapeutic management persist in clinical practice.

METHODS

A Delphi consensus was conducted by 20 experts from Belgium, and consisted of literature review and voting process on 78 statements. Grading of recommendations, assessment, development and evaluation criteria were applied to evaluate the quality of evidence. Consensus was defined as > 80 % agreement.

RESULTS

Consensus was reached for 50 statements. The Belgian consensus agreed as to the multifactorial aetiology of IBS. According to the consensus abdominal discomfort also represents a cardinal symptom, while bloating and abdominal distension often coexist. IBS needs subtyping based on stool pattern. The importance of a positive diagnosis, relying on history and clinical examination is underlined, while additional testing should remain limited, except when alarm features are present. Explanation of IBS represents a crucial part of patient management. Lifestyle modification, spasmolytics and water-solube fibres are considered first-line agents. The low FODMAP diet, selected probiotics, cognitive behavioural therapy and specific treatments targeting diarrhoea and constipation are considered appropriate. There is a consensus to restrict faecal microbiota transplantation and gluten-free diet, while other treatments are strongly discouraged.

CONCLUSIONS

A panel of Belgian gastroenterologists summarised the current evidence on the aetiology, symptoms, diagnosis and treatment of IBS with attention for the specificities of the Belgian healthcare system.

Mindfulness-Oriented Recovery Enhancement vs Supportive Group Therapy for Co-occurring Opioid Misuse and Chronic Pain in Primary Care: A Randomized Clinical Trial

IMPORTANCE

Successful treatment of opioid misuse among people with chronic pain has proven elusive. Guidelines recommend nonopioid therapies, but the efficacy of mindfulness-based interventions for opioid misuse is uncertain.

OBJECTIVE

To evaluate the efficacy of Mindfulness-Oriented Recovery Enhancement (MORE) for the reduction of opioid misuse and chronic pain.

DESIGN, SETTING, AND PARTICIPANTS

This interviewer-blinded randomized clinical trial enrolled patients from primary care clinics in Utah between January 4, 2016, and January 16, 2020. The study included 250 adults with chronic pain receiving long-term opioid therapy who were misusing opioid medications.

INTERVENTIONS

Treatment with MORE (comprising training in mindfulness, reappraisal, and savoring positive experiences) or supportive group psychotherapy (control condition) across 8 weekly 2-hour group sessions.

MAIN OUTCOMES AND MEASURES

Primary outcomes were (1) opioid misuse assessed by the Drug Misuse Index (self-report, interview, and urine screen) and (2) pain severity and pain-related functional interference, assessed by subscale scores on the Brief Pain Inventory through 9 months of follow-up. Secondary outcomes were opioid dose, emotional distress, and ecological momentary assessments of opioid craving. The minimum intervention dose was defined as 4 or more completed sessions of MORE or supportive group psychotherapy.

RESULTS

Among 250 participants (159 women [63.6%]; mean [SD] age, 51.8 [11.9] years), 129 were randomized to the MORE group and 121 to the supportive psychotherapy group. Overall, 17 participants (6.8%) were Hispanic or Latino, 218 (87.2%) were White, and 15 (6.0%) were of other races and/or ethnicities (2 American Indian, 3 Asian, 1 Black, 2 Pacific Islander, and 7 did not specify). At baseline, the mean duration of pain was 14.7 years (range, 1-60 years), and the mean (SD) morphine-equivalent opioid dose was 101.0 (266.3) mg (IQR, 16.0-90.0 mg). A total of 203 participants (81.2%) received the minimum intervention dose (mean [SD], 5.7 [2.2] sessions); at 9 months, 92 of 250 participants (36.8%) discontinued the study. The overall odds ratio for reduction in opioid misuse through the 9-month follow-up period in the MORE group compared with the supportive psychotherapy group was 2.06 (95% CI, 1.17-3.61; P = .01). At 9 months, 36 of 80 participants (45.0%) in the MORE group were no longer misusing opioids compared with 19 of 78 participants (24.4%) in the supportive psychotherapy group. Mixed models demonstrated that MORE was superior to supportive psychotherapy through 9 months of follow-up for pain severity (between-group effect: 0.49; 95% CI, 0.17-0.81; P = .003) and pain-related functional interference (between-group effect: 1.07; 95% CI, 0.64-1.50; P < .001). Participants in the MORE group reduced their opioid dose to a greater extent than those in the supportive psychotherapy group. The MORE group also had lower emotional distress and opioid craving.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, among adult participants in a primary care setting, the MORE intervention led to sustained improvements in opioid misuse and chronic pain symptoms and reductions in opioid dosing, emotional distress, and opioid craving compared with supportive group psychotherapy. Despite attrition caused by the COVID-19 pandemic and the vulnerability of the sample, MORE appeared to be efficacious for reducing opioid misuse among adults with chronic pain.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02602535.

The Relationship between FFMQ Mindfulness and Harmony in Life among Patients with Celiac Disease

Background

Patients with Celiac Disease (CD) experience psychological disorders and emotion-regulation disruptions. Although following a gluten-free diet alleviates their symptoms, these patients report social relationship problems.

Objective

The first aim of this study was to analyze the level of FFMQ mindfulness (describing emotions, acting with awareness, observing, non-judging of inner experience, and non-reactivity to inner experience) and harmony in life (HiL) in patients with CD. The second goal was to examine the relationship between the FFMQ and HiL scales in patients with CD. The third was to detect the effects of the duration of the illness, education level, and employment status on FFMQ-measured mindfulness and HiL.

Design

The study involved 111 Turkish patients with CD (N Females = 75, 67.6%) living in Turkey. The patients filled out the FFMQ and HiL questionnaires via a google form survey. The duration of their diagnosis, age, employment status, and education level were nominal variables. A Pearsons' correlation test, independent t-test, multiple linear regression, and one-way ANO VA were implemented.

Results

The results showed that patients with CD had a low level of HiL. The total FFMQ score was positively related to the HiL scale. Education and duration of diagnosis had a significant impact on the FFMQ and HiL scores. Age affected the level of describing emotions, and employment status had a strong effect on acting with awareness. However, gender affected neither the FFMQ nor HiL levels.

Conclusion

The results showed that patients with CD expressed a low level of HiL. Non-reactivity to inner experience, observing, and acting with awareness were positive predictors of the HiL scores. Moreover, since the HiL and FFMQ scales showed high internal consistency, the FFMQ and HiL questionnaires can be used in further studies of patients with CD.

A Rome Working Team Report on Brain-Gut Behavior Therapies for Disorders of Gut-Brain Interaction

BACKGROUND AND AIMS

This Rome Foundation Working Team Report reflects the consensus of an international interdisciplinary team of experts regarding the use of behavioral interventions, specifically brain-gut behavior therapies (BGBTs), in patients with disorders of gut-brain interaction (DGBIs).

METHODS

The committee members reviewed the extant scientific literature and, when possible, addressed gaps in this literature through the lens of their clinical and scientific expertise. The Delphi method was used to create consensus on the goals, structure, and framework before writing the report. The report is broken into 5 parts: 1) definition and evidence for BGBT, 2) the gut-brain axis as the mechanistic basis for BGBT, 3) targets of BGBTs, 4) common and unique therapeutic techniques seen in BGBT, and 5) who and how to refer for BGBT.

RESULTS

We chose to not only review for the reader the 5 existing classes of BGBT and their evidence, but to connect DGBI-specific behavioral targets and techniques as they relate directly, or in some cases indirectly, to the gut-brain axis. In doing so, we expect to increase gastrointestinal providers' confidence in identifying and referring appropriate candidates for BGBT and to support clinical decision making for mental health professionals providing BGBT.

CONCLUSIONS

Both gastrointestinal medical providers and behavioral health providers have an opportunity to optimize care for DGBIs through a collaborative integrated approach that begins with an effective patient-provider relationship, thoughtful communication about the brain-gut axis and, when appropriate, a well communicated referral to BGBT.

Pain in irritable bowel syndrome: Does anything really help?

Pain relief remains a significant challenge in the management of irritable bowel syndrome (IBS): "Does anything really help relieve the pain in patients with IBS?". Interventions aimed at pain relief in patients with IBS include diet, probiotics or antibiotics, antidepressants, antispasmodics, and drugs targeting specific gastrointestinal receptors such as opioid or histamine receptors. In the systematic review and meta-analysis published in this journal, Lambarth et al. examined the literature on the role of oral and parenteral anti-neuropathic agents in the management of pain in patients with IBS. This review article appraises their assessment of the efficacy of the anti-neuropathic agents amitriptyline, pregabalin, gabapentin, and duloxetine in the relief of abdominal pain or discomfort, and impact on overall IBS severity and quality of life. This commentary provides an update of current evidence on the efficacy of the dietary and pharmacological treatments that are available or in development, as well psychological and cognitive behavioral therapy for pain in IBS. Advances in recent years augur well for efficacious treatments that may expand the therapeutic arsenal for pain in IBS.

A Coached Digital Cognitive Behavioral Intervention Reduces Anxiety and Depression in Adults With Functional Gastrointestinal Disorders

INTRODUCTION

Traditional cognitive behavioral interventions (CBIs) improve mood and gastrointestinal symptom severity in patients with functional gastrointestinal disorders (FGIDs) but face substantial barriers to implementation. Integrating behavioral health technology into medical clinic workflows could overcome these barriers. We evaluated the feasibility and impact of a coached digital CBI (dCBI) as a first-line intervention in a prospective cohort of emotionally distressed patients with FGID.

METHODS

Patients with anxiety and/or depressive symptoms were offered a dCBI (an app called RxWell) during routine clinic visits. RxWell provides cognitive behavioral techniques enhanced by within-app text messaging with a health coach. Both gastroenterology and behavioral health-care providers electronically prescribed RxWell. We tracked patient interactions with RxWell, and patients completed anxiety (General Anxiety Disorder-7) and depression (Personal Health Questionniare Depression Scale) measures through the app. Our primary study outcome was the change in General Anxiety Disorder-7 and Personal Health Questionniare Depression Scale scores.

RESULTS

Of 364 patients with FGID (mean age 43 years [SD 16 years]; 73.1% women) prescribed the dCBI, 48.4% enrolled (median use, 3 techniques [interquartile range 1-14]). About half of RxWell enrollees communicated with health coaches. The mean baseline anxiety score was 11.4 (SD 5.5), and the depression score was 11.5 (SD 6.1). RxWell users experienced improvements in anxiety (mean change 2.71 [t = 3.7, df = 58; P < 0.001]) and depression (mean change 2.9 [t = 4.2, df = 45; P < 0.001]) at 4 months.

DISCUSSION

Patients with FGIDs and moderately severe anxiety and depressive symptoms are willing to use dCBI tools recommended by their providers. Our pilot data demonstrate that dCBI usage is associated with clinically and statistically significant mood symptom reductions.

The Mindful Lawyer: Investigating the Effects of Two Online Mindfulness Programs on Self-Reported Well-Being in the Legal Profession

OBJECTIVES

Two studies were conducted to determine whether mindfulness meditation could be an effective tool for improving well-being among legal professionals-a population plagued by high rates of depression, anxiety, and stress.

METHODS

Study 1. Legal professionals completed questionnaires before and after an 8-week mindfulness program. Study 2. Lawyers were randomly assigned to either an experimental or waitlist condition. Questionnaires were administered at the beginning of the study and after experimental participants had completed a 30-day intervention.

RESULTS

Study 1. Participants reported significant improvements in mood, resilience, trait mindfulness, stress, anxiety, and depression over time. Study 2. Post-intervention, experimental participants reported better mood, lower levels of stress, and higher levels of non-reactivity and observing than waitlist participants.

CONCLUSIONS

Mindfulness and meditation may effectively improve well-being among legal professionals.

The Role of Resilience in Irritable Bowel Syndrome, Other Chronic Gastrointestinal Conditions, and the General Population

BACKGROUND & AIMS

Resilience is the ability to adapt positively to stress and adversity. It is a potential therapeutic target as it is reduced in irritable bowel syndrome (IBS) compared to healthy controls and associated with worse symptom severity and poorer quality of life. The aim of this study was to examine if these findings are generalizable by comparing resilience between IBS versus the general population and other chronic gastrointestinal (GI) conditions.

METHODS

Participants in the general population completed an online survey containing questionnaires measuring demographics, diagnosis of IBS and other GI conditions, symptom severity, psychological symptoms, resilience, and early adverse life events (EALs). IBS was defined as having a physician diagnosis of IBS and/or meeting Rome criteria without co-morbid GI disease. All others were included in the general population group. The chronic GI conditions group included those with inflammatory bowel disease, celiac disease and/or microscopic colitis.

RESULTS

Resilience was lower in IBS (n = 820) than the general population (n = 1026; p < 0.001) and associated with worse IBS symptom severity (p < 0.05). Global mental health affected resilience differently in IBS compared to the general population (all p's < 0.05). EALs were associated with decreased ability to bounce back from adversity in both IBS and the general population (p < 0.001). Resilience scores were similar in IBS and other chronic GI conditions that present with similar symptoms.

CONCLUSIONS

Resilience is lower compared to the general U.S. population but does not appear to be specific to IBS as it is comparable to other chronic GI conditions. Low resilience negatively affects symptom severity and mental health and thus, may serve as a novel therapeutic target.

AGA Clinical Practice Update on Management of Chronic Gastrointestinal Pain in Disorders of Gut-Brain Interaction: Expert Review

DESCRIPTION

This expert review summarizes approaches to management of pain in disorders of gut-brain interaction. This review focuses specifically on approaches to pain that persist if first-line therapies aimed at addressing visceral causes of pain are unsuccessful. The roles of a therapeutic patient-provider relationship, nonpharmacologic and pharmacologic therapies, and avoidance of opioids are discussed.

METHODS

This was not a formal systematic review but was based on a review of the literature to provide best practice advice statements. No formal rating of the quality of evidence or strength of recommendation was performed. BEST PRACTICE ADVICE 1: Effective management of persistent pain in disorders of gut-brain interaction requires a collaborative, empathic, culturally sensitive, patient-provider relationship. BEST PRACTICE ADVICE 2: Providers should master patient-friendly language about the pathogenesis of pain, leveraging advances in neuroscience and behavioral science. Providers also must understand the psychological contexts in which pain is perpetuated. BEST PRACTICE ADVICE 3: Opioids should not be prescribed for chronic gastrointestinal pain because of a disorder of gut-brain interaction. If patients are referred on opioids, these medications should be prescribed responsibly, via multidisciplinary collaboration, until they can be discontinued. BEST PRACTICE ADVICE 4: Nonpharmacologic therapies should be considered routinely as part of comprehensive pain management, and ideally brought up early on in care. BEST PRACTICE ADVICE 5: Providers should optimize medical therapies that are known to modulate pain and be able to differentiate when gastrointestinal pain is triggered by visceral factors vs centrally mediated factors. BEST PRACTICE ADVICE 6: Providers should familiarize themselves with a few effective neuromodulators, knowing the dosing, side effects, and targets of each and be able to explain to the patient why these drugs are used for the management of persistent pain.

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 ± 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 (β = 0.310, p = 0.008) and by the self-regulation MAIA subscale (β = 0.335, p = 0.001). The effect of MORE on treatment-induced increases in reappraisal was mediated by increased interoceptive self-regulation (indirect effect: β = 0.110, p = 0.030). In turn, decreases in distress through 3-month follow-up were mediated by increases in reappraisal (indirect: β = -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.

Mindfulness-based cognitive therapy in functional dyspepsia: A pilot randomized trial

BACKGROUND AND AIM

Patients with functional dyspepsia (FD) often have concomitant anxiety and depression. Mindfulness-based cognitive therapy (MBCT) combines the principles of cognitive behavioral therapy and mindfulness. It is a group-based therapy and has been shown to be efficacious in functional gastrointestinal disorders. There are no randomized controlled trials (RCTs) evaluating MBCT in FD. We aimed to evaluate feasibility and efficacy of MBCT in FD management.

METHODS

We performed a mixed-method single-center pilot randomized trial of 28 patients fulfilling ROME-III criteria for FD. Fifteen patients were randomized to an 8-week MBCT program while 13 underwent treatment-as-usual (TAU). Patients completed questionnaires at baseline and at week 8. Two focus-groups were conducted. Feasibility of recruitment, acceptability of randomization, procedures and intervention, handout compliance and feasibility of quantitative measures were assessed. The primary outcome was subjective-clinical-assessment of FD symptoms (SCA-FD). Secondary outcome measures included Short-form Nepean Dyspepsia Index (SF-NDI), subjective-clinical-assessment of general health (SCA-GH), EuroQoL-Visual Analog Scale (EuroQoL-VAS), and Depression, Anxiety and Stress Scale-21 Items (DASS-21).

RESULTS

Twelve of 15 patients in the MBCT group completed the program. There was a trend towards symptom improvement, with 90% in the MBCT group reporting improvement in SCA-FD compared with 45% in TAU(P = 0.063). Patients who underwent MBCT reported greater improvement in SF-NDI (mean change: -8.8 (SD: 7.5) vs -0.7 (7.2), P = 0.018) and DASS-21 (-19.8 (29.5) vs -5.5 (6.6) P = 0.13) compared with TAU. There was no difference in SCA-GH and EuroQoL-VAS. Based on SCA-FD improvement, the eventual RCT will require 50 patients (25 in each group).

CONCLUSIONS

Mindfulness-based cognitive therapy is likely efficacious for FD, and it would be feasible to conduct a RCT.

Potential Benefit With Complementary and Alternative Medicine in Irritable Bowel Syndrome: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

Patients with irritable bowel syndrome (IBS) may pursue complementary and alternative medicine (CAM). We conducted a comprehensive systematic review and meta-analysis examining efficacy of CAM vs. placebo or sham in adults with IBS.

METHODS

Publication databases were searched for randomized controlled trials of CAM therapies (herbal therapy, dietary supplements, mind-body based, body-based, and energy-healing) in adults with IBS. Data were extracted to obtain pooled estimates of mean improvement in abdominal pain (standardized mean difference [SMD]) and relative risk (RR) of overall response using random effects models. Sensitivity and subgroup analyses along with quality assessments were completed.

RESULTS

Among 2825 articles identified, 66 were included. Herbal therapy (SMD=0.47, 95% CI: 0.20 to 0.75, I²=82%) demonstrated significant benefit over placebo for abdominal pain (low confidence in estimates). Benefit with mind-body based therapy for abdominal pain was of borderline significance (SMD=0.29, 95% CI: -0.01 to 0.59, I²=78%). Herbal therapy (RR=1.57, 95% CI: 1.31 to 1.88, I²=77%), dietary supplements (RR=1.95, 95% CI: 1.02 to 3.73, I²=75%), and mind-body based therapy (RR=1.67, 95% CI: 1.13 to 2.49, I²=63%) showed benefit for overall response compared to placebo (low confidence in estimates). Body-based and energy healing therapies demonstrated no significant benefit over placebo or sham for abdominal pain or overall response.

CONCLUSIONS

CAM therapies such as herbal or dietary supplements and mind-body based approaches may be beneficial for abdominal pain and overall response in IBS. However, overall quality of evidence is low. Rigorous, high quality clinical trials are warranted to investigate CAM in IBS.

Assessing the post-treatment therapeutic effect of pinaverium in irritable bowel syndrome: a randomized controlled trial

Irritable bowel syndrome (IBS) is the most common gastrointestinal disorder significantly decreasing patients' lives of quality and placing huge economic burden on our society. Existing studies indicated that the therapeutic effects maintained for a period of time after the treatments were discontinued. It is clinically important to assess these post-treatment therapeutic effects (PTTE), which prevent IBS from relapsing. To assess the PTTE in pinaverium treatment and obtain high-quality evidence to justify the use of PTTE for long-term IBS management, we performed this controlled, double blind study on patients with IBS who were randomized to pinaverium 50 mg (n = 132) or placebo (n = 132), three times daily, for 4 weeks, and were followed up for 57 weeks after the treatments. The primary endpoints were abdominal pain and stool consistency. The secondary endpoints were pain frequency and stool frequency. The tertiary endpoints were global overall symptom and adverse events. Three days after pinaverium was discontinued, endpoints rebounded only 23.2-42.8% (P < 0.015 cf. placebo). The PTTE (P < 0.05 cf. placebo) lasted 9-17 weeks, which is similar to other antispasmodics with a 15-week treatment in striking contrast to ≥ 1 year PTTE in cognitive behavior therapy and < 1 week PTTE in serotonin antagonist treatment indicating that PTTE length markedly depends on the medication class used for the treatment and less depends on treatment length. After 17 weeks, the stage could be considered as an IBS natural history [no significant differences between pinaverium and placebo (all endpoints' P's > 0.05)], during which an average of 51.5-56.4% of patients (pool pinaverium and placebo data together) had IBS symptoms. These results provide clinical insights into efficient and cost-effective management of refractory IBS, and lend support to the IBS management that the selection of a therapy should consider both its effectiveness during treatment and its PTTE after the treatment.Trial registration number: NCT02330029 (16/08/2016).

Effects of Mindfulness-Based Stress Reduction on Experimental Pain Sensitivity and Cortisol Responses in Women With Early Life Abuse: A Randomized Controlled Trial

OBJECTIVE

Early life abuse (ELAb) initiates pathophysiological cascades resulting in long-term maladaptive stress responsivity, hyperalgesia, and an increased risk of psychopathology. Mindfulness-based stress reduction (MBSR) is effective in modifying psychological and somatic symptoms; thus, we predicted that MBSR would be particularly efficacious for women with ELAb.

METHOD

Medically healthy women (mean age = 31 years) with or without a history of early (≤13 years) physical or sexual abuse provided self-report measures and were tested in the laboratory before and after randomization to standard MBSR (n = 52) or social support (SSG) (n = 60) for 8 weeks. The laboratory procedure involved pain testing using the cold pressor and temporal summation of heat pain (indexing central sensitization) procedures, and exposure to the Trier Social Stress Test. Plasma cortisol in response to the experimental protocol was assessed as area under the curve (AUC).

RESULTS

The interventions differentially impacted pain sensitivity and cortisol AUC for women with ELAb, as MBSR increased the temporal summation of heat pain intensity ratings (p = .024) and reduced cortisol AUC (p = .004). For women without ELAb, MBSR decreased cold pressor tolerance (p = .045) and decreased the temporal summation of heat pain intensity ratings relative to SSG (p = .024). Both MBSR and SSG improved depression symptoms and emotion regulation abilities (p values < .001); however, MBSR was associated with greater benefits in describing emotions (p = .008) and impulse control (p = .017) for women with ELAb.

CONCLUSIONS

Women with ELAb benefited from MBSR-specific improvements in central sensitization, mindfulness skills, and emotion regulation abilities. This is the first study to examine the efficacy of MBSR in modifying affective and somatic symptoms based on ELAb status and provides evidence for considering ELAb in tailoring treatment approaches.Trial Registration: ClinicalTrials.gov Identifier: NCT01995916; https://clinicaltrials.gov/ct2/show/NCT01995916.

Impact of Psychological Comorbidity on the Prognosis of Irritable Bowel Syndrome

INTRODUCTION

Psychological comorbidities are associated with irritable bowel syndrome (IBS), but little is known about their cumulative effect on its prognosis. We examined this issue in a longitudinal 12-month follow-up study.

METHODS

We collected complete demographic, symptom, and psychological comorbidity data (anxiety, depression, somatic symptom disorder, perceived stress, and gastrointestinal symptom-specific anxiety) at baseline from 807 adults who met Rome IV criteria for IBS. At 12 months, we collected data regarding IBS symptom severity and impact, consultation behavior, and treatments commenced from 452 individuals successfully followed up. We examined the cumulative effects of psychological comorbidities at baseline on subsequent IBS disease behavior.

RESULTS

At baseline, among the 807 participants, 177 (21.9%) had 1, 139 (17.2%) 2, 103 (12.8%) 3, 89 (11.0%) 4, and 54 (6.7%) 5 psychological comorbidities. IBS symptom severity at baseline increased significantly with the number of psychological comorbidities (72.2% of those with 5 psychological comorbidities reported severe symptoms, vs 29.1% of those with none, P < 0.001). Among 452 (56.0%) participants followed up at 12 months, those with a higher number of psychological comorbidities at baseline were significantly more likely to have seen a gastroenterologist (33.3% of those with 5 psychological comorbidities, vs 21.4% of those with none, P = 0.001), cycle through more treatments (P < 0.0001), to report more severe IBS symptoms (66.7% with 5, vs 24.4% with none, P < 0.001) and continuous abdominal pain (22.1% with none, vs 61.9% with 5, P < 0.001), and to report that symptoms impacted on daily activities ≥50% of the time (90.5% with 5, vs 41.2% with none, P < 0.001).

DISCUSSION

The prognosis of individuals with Rome IV-defined IBS worsens according to incremental increases in psychological comorbidity. This has important clinical and research implications.

The Mindful Path to Nursing Accuracy: A Quasi-Experimental Study on Minimizing Medication Administration Errors

Achieving error-free health care is critically vital and includes freedom from the occurrence of medication errors, which, as yet, is an unrealized goal in the United States. The purpose of this study was to minimize or potentially eliminate medication errors by adding training in mindfulness thinking to the current system protocol. The goal of this quantitative, quasi-experimental study was to determine whether training nurses in mindfulness thinking founded on the Dossey Integral Theory changed the frequency and severity of medication administration errors. Data analysis included the following steps: recording of data using the NCC MERP (National Coordinating Council for Medication Error Reporting) instrument, statistical analysis using paired t test, and a logistical interpretation of descriptive statistics. An error reduction of 73.3% between pre- and posttraining mean for the experimental group was observed. This study may add to the limited body of research related to mindfulness and the resultant reduction in medication errors.

Health-Related Quality of Life in Irritable Bowel Syndrome: A Systematic Review and Meta-analysis

Irritable bowel syndrome (IBS) affects up to 20% of the global population and is associated with impaired health-related quality of life (HRQoL). This systematic review and meta-analysis aimed to investigate differences in HRQoL of those with IBS compared with healthy controls and to examine whether HRQoL improves following psychological intervention. Online databases were searched for articles from 2002 to 2017. Studies were screened and data extracted according to predetermined criteria. A total of 4,154 citations were identified from which 36 were eligible for inclusion. Eight studies compared HRQoL of those with IBS (n = 822) with that of healthy individuals (n = 3,809). Those with IBS suffered significant impairment across all HRQoL domains compared with healthy individuals, with the majority of effects (Cohen's d) being moderate to large. Twenty-eight studies investigated HRQoL in IBS following psychological intervention (n = 1,308) relative to controls (n = 1,006). All HRQoL domains improved with large effects following treatment; however, maintenance of these effects was inconsistent. Those with IBS experience poorer HRQoL than the wider community; nevertheless, psychological interventions are associated with improved HRQoL across all domains. High-quality studies are needed to better inform gastroenterological nurses of which interventions are most efficacious in alleviating the burden of IBS, and which IBS subpopulations would benefit.

[A Meta-Analysis on the Effects of Mind-Body Therapy on Patients with Irritable Bowel Syndrome]

PURPOSE

Previous randomized controlled trials (RCT) found that mind-body therapy can improve the health outcomes of patients with irritable bowel syndrome (IBS). The purpose of this meta-analysis was to identify the combined effects of mind-body therapy on patients' IBS symptoms, quality of life, anxiety, and depression.

METHODS

A systematic literature search was conducted using various databases such as PubMed, EMBASE, CINAHL CENTRAL, DBpia, RISS, and KISS. The primary outcome variables were IBS symptoms and quality of life; the secondary outcome variables were anxiety and depression. Comprehensive Meta-Analysis version 3.0 was used to analyze the extracted data. The effect size was calculated using standardized mean difference (SMD) and 95% confidence interval (CI).

RESULTS

Eleven final RCTs were used for this meta-analysis. Mind-body therapy was found to have a significant effect on the IBS patients' symptoms (SMD, -0.63; 95% CI, -0.77 to -0.48), quality of life (SMD, 1.03; 95% CI, 0.40 to 1.66), anxiety (SMD, -0.28; 95% CI, -0.47 to -0.09), and depression (SMD, -0.31; 95% CI, -0.06 to -0.12).

CONCLUSION

This meta-analysis reveals that mind-body therapy significantly improves IBS patients' symptoms, quality of life, anxiety, and depression. The results suggest that, in the future, appropriate mind-body therapy should be applied to Koreans suffering from IBS. Moreover, the therapy's long-term effects should be assessed.

Effects of Combining Meditation Techniques on Short-Term Memory, Attention, and Affect in Healthy College Students

Meditation refers to a family of self-regulation practices that focuses on training attention and awareness to foster psycho-emotional well-being and to develop specific capacities such as calmness, clarity, and concentration. We report a prospective convenience-controlled study in which we analyzed the effect of two components of Preksha Dhyāna – buzzing bee sound meditation (Mahapran dhvani) and color meditation (leśyā dhyāna) on healthy college students. Mahapran and leśya dhyāna are two Preksha Dhyāna practices that are based on sound and green color, respectively. The study population represents a suitable target as college students experience different stress factors during the school year. This study measures the individual and combined effects of two techniques (one focusing on sound and one focusing on color), on short-term memory, attention, and affect, in novice meditators. We used a battery of cognitive, performance, and compared results with baseline and control values. We found improved cognition, especially attention, short-term memory, and affect in terms of positivity and reduced negativity. Overall, the two techniques produced variable benefits and subjects showed improved scores over baseline for short-term memory, cognitive function, and overall wellbeing. Further studies are required to understand underlying mechanisms for the observed differences between the two techniques and to elucidate mechanisms underlying the more pronounced and global benefits observed with the combined techniques. These results underscore a need to examine individual components of meditation practices in order to individualize treatment approaches for attention disorders in young adults.

Clinical Trail Registration:ClinicalTrials.gov Identifier: NCT03779269.

Importance of Non-pharmacological Approaches for Treating Irritable Bowel Syndrome: Mechanisms and Clinical Relevance

Chronic visceral pain represents a major unmet clinical need with the severity of pain ranging from mild to so severe as to prevent individuals from participating in day-to-day activities and detrimentally affecting their quality of life. Although chronic visceral pain can be multifactorial with many different biological and psychological systems contributing to the onset and severity of symptoms, one of the major triggers for visceral pain is the exposure to emotional and physical stress. Chronic visceral pain that is worsened by stress is a hallmark feature of functional gastrointestinal disorders such as irritable bowel syndrome (IBS). Current pharmacological interventions for patients with chronic visceral pain generally lack efficacy and many are fraught with unwanted side effects. Cognitive behavioral therapy (CBT) has emerged as a psychotherapy that shows efficacy at ameliorating stress-induced chronic visceral pain; however, the molecular mechanisms underlying CBT remain incompletely understood. Preclinical studies in experimental models of stress-induced visceral pain employing environmental enrichment (EE) as an animal model surrogate for CBT are unraveling the mechanism by which environmental signals can lead to long-lasting changes in gene expression and behavior. Evidence suggests that EE signaling interacts with stress and nociceptive signaling. This review will (1) critically evaluate the behavioral and molecular changes that lead to chronic pain in IBS, (2) summarize the pharmacological and non-pharmacological approaches used to treat IBS patients, and (3) provide experimental evidence supporting the potential mechanisms by which CBT ameliorates stress-induced visceral pain.

Behavioral and Diet Therapies in Integrated Care for Patients With Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a common, symptom-based condition that has negative effects on quality of life and costs health care systems billions of dollars each year. Until recently, management of IBS has focused on over-the-counter and prescription medications that reduce symptoms in fewer than one-half of patients. Patients have increasingly sought natural solutions for their IBS symptoms. However, behavioral techniques and dietary modifications can be effective in treatment of IBS. Behavioral interventions include gastrointestinal-focused cognitive behavioral therapy and gut-directed hypnotherapy to modify interactions between the gut and the brain. In this pathway, benign sensations from the gut induce maladaptive cognitive or affective processes that amplify symptom perception. Symptoms occur in response to cognitive and affective factors that trigger fear of symptoms or lack of acceptance of disease, or from stressors in the external environment. Among the many dietary interventions used to treat patients with IBS, a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols is the most commonly recommended by health care providers and has the most evidence for efficacy. Patient with IBS who choose to follow a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols should be aware of its 3 phases: restriction, reintroduction, and personalization. Management of IBS should include an integrated care model in which behavioral interventions, dietary modification, and medications are considered as equal partners. This approach offers the greatest likelihood for success in management of patients with IBS.

Adults living with irritable bowel syndrome (IBS): A qualitative systematic review

OBJECTIVE

To consolidate existing qualitative studies which examined the experiences and needs of adults living with IBS, and to gather a holistic insight for future directions and avenues to support these adults.

METHODS

A qualitative systematic review was conducted and six databases were searched for qualitative studies, beginning from each database's inception to July 2020. The qualitative data were meta-synthesised and thematic analysis was adopted. Any discrepancies that arose were discussed between the reviewers until a consensus was reached throughout the process of data screening, selection, critical appraisal and synthesis.

RESULTS

Seventeen studies with a total of 299 adults diagnosed with IBS were included. Four themes were identified: (1) physical, psychological, and social consequences; (2) impact of IBS on working adults; (3) dealing with IBS; and (4) sources of support and support needs.

CONCLUSION

Future research across geographically diverse locations are needed to gather a thorough perspective of the experiences and needs of adults living with IBS. The development and evaluation of technology-based, trained peer-led volunteers, and interventions that adopt mindfulness, active coping strategies, cognitive behavioural therapy and acceptance, and commitment therapy are needed. Ultimately, the collaboration between the relevant stakeholders is essential for standardised instruments and materials for accurate testing, diagnosis, assessment, treatment and management of IBS.

A systematic review and meta-analysis of mindfulness- and acceptance-based interventions for affect intolerance/sensitivity

Affect intolerance/sensitivity, defined as one's sensitivity to, or inability to tolerate, affective states, is a transdiagnostic process implicated in the development and maintenance of numerous forms of psychopathology. Mindfulness and acceptance interventions are posited to improve affect intolerance/sensitivity; however, there has been no quantitative synthesis of this research to date. Seven electronic databases were searched up until November 2018. Hedges' g values, 95% confidence intervals, p-values, and Q-values were calculated for a series of random-effects models. Twenty-five studies (pooled N = 1778) met eligibility criteria and were included in the qualitative synthesis (n = 22 included in the meta-analysis). There was a small, significant effect of mindfulness and acceptance interventions on improving affect intolerance/sensitivity from pre-to post-intervention (Hedges' g = -0.37, 95% CI = -0.52 to -0.23, p < .001), with effects maintained up to 6-months (Hedges' g = -0.35, 95% CI = -0.61 to -0.09, p < .01). There was a significantly larger effect for studies with inactive compared to active controls. No significant effect size differences were found for intervention length (<8 vs. ≥ 8 sessions), intervention type (mindfulness vs. acceptance) or sample type (clinical vs. non-clinical). Mindfulness and acceptance interventions modestly improve affect intolerance/sensitivity.

The Role of Distress Tolerance as a Potential Mechanism Between Anxiety Sensitivity and Gut-Specific Anxiety

BACKGROUND

The link between anxiety/fear and gut dysfunction has been robustly documented in both physical and mental health literatures. The current study explored distress tolerance as a potential mechanism in the relation between anxiety sensitivity and gut-specific anxiety.

METHOD

A cross-sectional sample of 828 adults completed measures of distress tolerance, gut-specific anxiety, and anxiety sensitivity. Multiple linear regression analyses were conducted to determine variable associations, including potential mediating factors.

RESULTS

The results demonstrated a bidirectional relation between anxiety sensitivity and gut-specific anxiety (ß = 0.23, p < 0.001; ß = 0.22, p < 0.001). Findings suggest distress tolerance is a significant mediator that may partially explain the relation between gut-specific anxiety and anxiety sensitivity more broadly (ß = 0.11, CI [0.07-0.14]). Mediation results were consistent when individual subscales of distress tolerance or anxiety sensitivity were incorporated.

CONCLUSION

The outcome of the present study merits additional examination of the psychosomatic nature of distress tolerance as a potential clinical target for individuals with both anxiety and gut-related disorders.

Effects of Mindfulness-Oriented Recovery Enhancement Versus Social Support on Negative Affective Interference During Inhibitory Control Among Opioid-Treated Chronic Pain Patients: A Pilot Mechanistic Study

BACKGROUND

Among opioid-treated chronic pain patients, deficient response inhibition in the context of emotional distress may contribute to maladaptive pain coping and prescription opioid misuse. Interventions that aim to bolster cognitive control and reduce emotional reactivity (e.g., mindfulness) may remediate response inhibition deficits, with consequent clinical benefits.

PURPOSE

To test the hypothesis that a mindfulness-based intervention, Mindfulness-Oriented Recovery Enhancement (MORE), can reduce the impact of clinically relevant, negative affective interference on response inhibition function in an opioid-treated chronic pain sample.

METHODS

We examined data from a controlled trial comparing adults with chronic pain and long-term prescription opioid use randomized to either MORE (n = 27) treatment or to an active support group comparison condition (n = 30). Participants completed an Emotional Go/NoGo Task at pre- and post-treatment, which measured response inhibition in neutral and clinically relevant, negative affective contexts (i.e., exposure to pain-related visual stimuli).

RESULTS

Repeated-measures analysis of variance indicated that compared with the support group, participants in MORE evidenced significantly greater reductions from pre- to post-treatment in errors of commission on trials with pain-related distractors relative to trials with neutral distractors, group × time × condition F(1,55) = 4.14, p = .047, η2partial = .07. Mindfulness practice minutes and increased nonreactivity significantly predicted greater emotional response inhibition. A significant inverse association was observed between improvements in emotional response inhibition and treatment-related reductions in pain severity by 3-month follow-up.

CONCLUSIONS

Study results provide preliminary evidence that MORE enhances inhibitory control function in the context of negative emotional interference.

Mindfulness-based stress reduction improves irritable bowel syndrome (IBS) symptoms via specific aspects of mindfulness

BACKGROUND

Irritable bowel syndrome (IBS) is a common and often debilitating chronic gastrointestinal disorder characterized by abdominal pain and altered bowel habits. Pharmacological treatments are often ineffective, leading to the development of a variety of behavioral interventions. Mindfulness-based stress reduction (MBSR) is one such program that has shown efficacy in reducing gastrointestinal (GI) symptoms and improving quality of life (QOL). This single-arm intervention study examines the association of clinical outcomes with changes in specific aspects of mindfulness.

METHODS

Adults with IBS (53 women, 15 men) participated in an 8-week MBSR class. Primary outcomes of GI symptom severity, quality of life, and GI-specific anxiety, as well as specific aspects of mindfulness using the Five Factor Mindfulness Questionnaire (FFMQ), were assessed at baseline, post-treatment, and 6-month follow-up.

KEY RESULTS

Gastrointestinal symptom responder rate was 71%, and there was a significant pre-post treatment change for three of the five FFMQ scales. Regression analysis indicated that change in the Act with Awareness (P = .02) facet of mindfulness was the strongest predictor of GI symptom and QOL improvement.

CONCLUSIONS & INFERENCES

Mindfulness-based stress reduction training was associated with robust improvements in GI symptoms and associated problems in participants with IBS. Although significant increases in 3 of the 5 measured facets of mindfulness were found, regression analyses suggest that increases in the ability to retain present moment focus and act with awareness may be particularly important for improving outcomes in individuals with IBS. These results may inform the refinement of mindfulness-based protocols specifically for treatment of IBS.

Mindfulness-oriented recovery enhancement reduces opioid dose in primary care by strengthening autonomic regulation during meditation

The current opioid crisis was fueled by escalation of opioid dosing among patients with chronic pain. Yet, there are few evidence-based psychological interventions for opioid dose reduction among chronic pain patients treated with long-term opioid analgesics. Mindfulness-Oriented Recovery Enhancement (MORE), which was designed to target mechanisms underpinning chronic pain and opioid misuse, has shown promising results in 2 randomized clinical trials (RCTs) and could facilitate opioid sparing and tapering by bolstering self-regulation. Here we tested this hypothesis with secondary analyses of data from a Stage 2 RCT. Chronic pain patients (N = 95) on long-term opioid therapy were randomized to 8 weeks of MORE or a support group (SG) control delivered in primary care. Opioid dose was assessed with the Timeline Followback through 3-month follow-up. Heart rate variability (HRV) during mindfulness meditation was quantified as an indicator of self-regulatory capacity. Participants in MORE evidenced a greater decrease in opioid dosing (a 32% decrease) by follow-up than did the SG, F(2, 129.77) = 5.35, p = .006, d = 1.07. MORE was associated with a significantly greater increase in HRV during meditation than was the SG. Meditation-induced change in HRV partially mediated the effect of MORE on opioid dose reduction (p = .034). MORE may boost self-regulatory strength via mindfulness and thereby facilitate self-control over opioid use, leading to opioid dose reduction in people with chronic pain. (PsycInfo Database Record (c) 2020 APA, all rights reserved).