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Robison R, Brendle M, Moore C, Cross H, Helm L, Darling S, Thayer S, Thielking P, Shannon S. Ketamine-Assisted Group Psychotherapy for Frontline Healthcare Workers with COVID-19-Related Burnout and PTSD: A Case Series of Effectiveness/Safety for 10 Participants. J Psychoactive Drugs 2024; 56:23-32. [PMID: 36862829 DOI: 10.1080/02791072.2023.2186285] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 12/01/2022] [Accepted: 12/14/2022] [Indexed: 03/04/2023]
Abstract
This study reports on 10 frontline healthcare workers, employed during the COVID-19 pandemic and experiencing symptoms of burnout and PTSD, treated with group ketamine-assisted psychotherapy (KAP) in a private outpatient clinic setting. Participants attended 6 sessions once weekly. These included 1 preparation session, 3 ketamine sessions (2 sublingual, 1 intramuscular), 2 integration sessions. Measures of PTSD (PCL-5), depression (PHQ-9), and anxiety (GAD-7) were administered at baseline and post-treatment. During ketamine sessions, the Emotional Breakthrough Inventory (EBI) and the 30-item Mystical Experience Questionnaire (MEQ-30) were recorded. Participant feedback was gathered 1-month post-treatment. We observed improvements in participants' average PCL-5 (59% reduction), PHQ-9 (58% reduction), and GAD-7 (36% reduction) scores from pre- to post-treatment. At post-treatment, 100% of participants screened negative for PTSD, 90% had minimal/mild depression or clinically significant improvement, and 60% had minimal/mild anxiety or clinically significant improvement. MEQ and EBI scores had large variations among participants at each ketamine session. Ketamine was well tolerated, and no significant adverse events were reported. Participant feedback corroborated findings of improvements observed in mental health symptoms. We found immediate improvements treating 10 frontline healthcare workers experiencing burnout, PTSD, depression, and anxiety using weekly group KAP and integration.
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Affiliation(s)
- Reid Robison
- Numinus Wellness, Draper, UT, USA
- University of Utah School of Medicine, SL, UT, USA
| | - Madeline Brendle
- Numinus Wellness, Draper, UT, USA
- Department of Pharmacotherapy, University of Utah College of Pharmacy, SLC, UT, USA
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2
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Montague R, Canning SE, Thielking P, Qeadan F. Adverse childhood experiences and psychotropic medication prescription among cancer patients. J Psychosoc Oncol 2023:1-15. [PMID: 38127059 DOI: 10.1080/07347332.2023.2296040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
BACKGROUND This study aimed at identifying and characterizing adverse childhood experiences (ACEs) in a sample of cancer patients and subsequently evaluating the relationship between ACEs and prescription of psychotropic medication among them. Individuals with ACEs have a higher risk of mental health conditions and are more likely to be prescribed psychotropic medications. METHODS A sample of 178 adult patients receiving Supportive Oncology & Survivorship (SOS) services at Huntsman Cancer Hospital in Utah was obtained. ACEs and Brief Resilient Coping Scale (BRCS) questionnaires were administered confidentially. A multivariable mixed effect model, adjusting for sex, age, and insurance type while controlling for zip-codes clustering were employed. RESULTS Compared to the prevalence of ACEs in the general population, from the CDC-Kaiser Permanente ACEs Study, we found no significant difference in the prevalence of people who had experienced an adverse childhood event (ACEs score > = 1) between our study of cancer patients and the CDC-Kaiser study (67.4% vs. 63.6%, p = 0.29372), but found a significant difference in the prevalence of people who had experienced severe adverse childhood experiences (ACES score > =4) (25.3% vs. 12.1%, p < 0.00001). Furthermore, this study reveals a significant association between an increase of one unit in the total ACEs score and the odds of psychotropic medication prescription in the past 12 months (OR: 1.233; 95% CI: 1.025, 1.483). Those with a total ACEs score of three or more were found to have 280% higher odds of being prescribed psychotropic medication compared to those with ACEs ≤ 2 (OR: 3.822; 95% CI: 1.404,10.407). CONCLUSION A significant proportion of cancer patients have a history of ACEs, and thus trauma-informed care approach is essential during their treatment.
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Affiliation(s)
| | - Sarah Elise Canning
- Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT, USA
| | - Paul Thielking
- Novamind, Toronto, Canada, and Cedarpsychiatry, Murray, UT, USA
| | - Fares Qeadan
- Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Maywood, IL, USA
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3
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Lewis BR, Garland EL, Byrne K, Durns T, Hendrick J, Beck A, Thielking P. HOPE: A Pilot Study of Psilocybin Enhanced Group Psychotherapy in Patients With Cancer. J Pain Symptom Manage 2023; 66:258-269. [PMID: 37302533 DOI: 10.1016/j.jpainsymman.2023.06.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/03/2023] [Accepted: 06/06/2023] [Indexed: 06/13/2023]
Abstract
CONTEXT/OBJECTIVES Psilocybin-assisted psychotherapy shows promise in treating depression and existential distress in people with serious medical illness. However, its individual-based methodology poses challenges for scaling and resource availability. The HOPE trial (A Pilot Study of Psilocybin Enhanced Group Psychotherapy in Patients with Cancer) is an Institutional Review Boards-approved open-label feasibility and safety pilot study examining psilocybin-assisted group therapy in cancer patients with a DSM-5 depressive disorder (including major depressive disorder as well as adjustment disorder with depressed mood). We report here the safety and clinical outcome measures including six-months follow up data. METHODS Outcome measures were collected at baseline, two-weeks and 26-weeks postintervention. The study involved three group preparatory sessions, one high-dose (25 mg) group psilocybin session, and three group integration sessions with cohorts of four participants over a three-week intervention. RESULTS Twelve participants completed the trial. no serious adverse events attributed to psilocybin occurred. The primary clinical outcome measures of change in symptoms of depression on the clinician administered 17-item-HAM-D showed clinically substantial decrease in HAM-D scores from baseline to the two-week timepoint (21.5-10.09, P < 0.001) and the 26-week timepoint (21.5-14.83, P = 0.006). Six out of 12 participants met criteria for remission at two weeks, as defined by HAM-D < 7, three out 12 demonstrated a clinically significant change (4-6 points), and eight out of twelve demonstrated a clinically substantial change (7-12 points). CONCLUSION This pilot study demonstrated the safety, feasibility, and possible efficacy of psilocybin-assisted group therapy for cancer patients dealing with depressive symptoms. Based on demonstrated efficacy and significant reductions in therapist time, future investigations with the group therapy model are warranted.
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Affiliation(s)
- Benjamin R Lewis
- Huntsman Mental Health Institute (B.R.L., K.B., T.D.), University of Utah, Salt Lake City, Utah, USA.
| | - Eric L Garland
- Department of Social Work (E.L.G.), University of Utah, Salt Lake City, Utah, USA
| | - Kevin Byrne
- Huntsman Mental Health Institute (B.R.L., K.B., T.D.), University of Utah, Salt Lake City, Utah, USA
| | - Tyler Durns
- Huntsman Mental Health Institute (B.R.L., K.B., T.D.), University of Utah, Salt Lake City, Utah, USA
| | - John Hendrick
- Department of Emergency Medicine (J.H.), University of Utah, Salt Lake City, Utah, USA
| | - Anna Beck
- Huntsman Cancer Institute (A.B.), University of Utah, Salt Lake City, Utah, USA
| | - Paul Thielking
- Huntsman Mental Health Institute (P.T.), University of Utah, Salt Lake City, Utah, USA
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Argento E, Omene E, Jaeger AH, Kertes A, Mitchell KA, Necyk C, Thielking P, Lewis EC. Case report: Improvement in refractory functional seizures, depression, and quality of life with ketamine-assisted therapy. Front Neurosci 2023; 17:1197409. [PMID: 37378010 PMCID: PMC10291615 DOI: 10.3389/fnins.2023.1197409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 05/17/2023] [Indexed: 06/29/2023] Open
Abstract
Functional seizures, a primary subtype of functional neurological disorder (FND), are a known cause of serious neurological disability with an increasing awareness of their impact amongst the neuroscience community. Situated at the intersection of neurology and psychiatry, FND is characterized by a range of alterations in motor, sensory or cognitive performance, such as abnormal movements, limb weakness, and dissociative, seizure-like episodes. Functional seizures are known, in part, to have psychological underpinnings; however, the lack of effective and consistent treatment options requires research and novel approaches to better understand the etiology, diagnosis and what constitutes a successful intervention. Ketamine, a selective blocker of the N-methyl-D-aspartate receptor, has a well-established safety and efficacy profile. In recent years, ketamine-assisted therapy has shown increasing potential for treating a broad range of psychiatric conditions, building on its demonstrated rapid-acting antidepressant effects. Here we present a 51-year-old female with refractory daily functional seizures leading to significant disability and a medical history significant for major depressive disorder (MDD) and posttraumatic stress disorder (PTSD). After unsuccessful treatment attempts, the patient underwent a novel protocol with ketamine-assisted therapy. After 3 weeks of ketamine-assisted therapy followed by 20 weeks of intermittent ketamine treatment and ongoing integrative psychotherapy, the patient's seizures were significantly reduced in frequency and severity. She experienced significant improvements in depressive symptoms and functional ability scores. To our knowledge, this is the first reported case describing improvement in functional seizures following ketamine-assisted therapy. While rigorous studies are needed, this case report encourages further investigation of ketamine-assisted therapy for functional seizures and other functional neurological symptoms.
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Affiliation(s)
- Elena Argento
- Numinus Wellness Inc., Vancouver, BC, Canada
- Faculty of Medicine, British Columbia Centre on Substance Use, University of British Columbia, Vancouver, BC, Canada
| | - Egiroh Omene
- Neurology Centre of Toronto by Numinus, Toronto, ON, Canada
| | | | - Angela Kertes
- Neurology Centre of Toronto by Numinus, Toronto, ON, Canada
- North Toronto Psychology, Toronto, ON, Canada
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Lewis BR, Byrne K, Hendrick J, Garland EL, Thielking P, Beck A. Group format psychedelic-assisted therapy interventions: Observations and impressions from the HOPE trial. JPS 2023. [DOI: 10.1556/2054.2022.00222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
AbstractBackgroundPsilocybin-assisted psychotherapy has demonstrated significant promise as a treatment for depression, anxiety, and existential distress associated with serious medical illness and has generally been employed on an individual basis, which presents challenges for scaling and resource availability. There are also compelling theoretical reasons to suggest that group-based formats-if utilized in a thoughtful fashion-might offer unique or enhanced therapeutic benefits for certain conditions or populations. The HOPE trial is an IRB-approved open-label feasibility and safety pilot study of psilocybin enhanced group therapy in patients with a DSM-5 depressive disorder associated with a cancer diagnosis completed at the Huntsman Cancer Institute (HCI) in Salt Lake City, Utah (HOPE: A Pilot Study of Psilocybin Enhanced Group Psychotherapy in Patients with Cancer). We report here qualitative survey-based data, impressions, and suggestions for group-based psychedelic-assisted therapy interventions based on our observations to inform future studies.MethodsPatients with a DSM-5 depressive disorder with an underlying cancer diagnosis were recruited from HCI by referral from oncology providers, palliative care, and social work. Following screening and consenting, 4-6 participants per cohort (with three total cohorts) were enrolled in a protocol involving 3 120 min group preparatory sessions, a single high-dose (25 mg) group psilocybin session, and 3 subsequent group integration sessions. Primary clinical outcomes are still in process of data collection and analysis. Qualitative data was gathered from patient written reports and a survey administered at 2 weeks post intervention. Qualitative reports were also gathered from the therapist team at a post-study group process session.FindingsWe report here results from a qualitative survey of participant experiences with group format study design, as well as impressions and guidelines for group format and group psychotherapeutic process to inform other studies pursuing group-based interventions in psychedelic therapy. Suggestions are provided for protocol design, screening processes, space considerations, therapist team structure, group process, music, timeline, as well as potential issues and challenges.
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Brendle M, Ahuja S, Valle MD, Moore C, Thielking P, Malone DC, Robison R. Safety and effectiveness of intranasal esketamine for treatment-resistant depression: a real-world retrospective study. J Comp Eff Res 2022; 11:1323-1336. [PMID: 36331048 DOI: 10.2217/cer-2022-0149] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Aim: There is limited real-world evidence for patients with treatment-resistant depression (TRD) receiving esketamine nasal spray. Methods: This retrospective cohort study used data collected from a psychiatric clinic's EHR system. Results: A total of 171 TRD patients received esketamine July 2019-June 2021. This predominantly female, white population had several mental health comorbidities and high exposure to psychiatric medications. We observed significant reductions (p < 0.001) in average PHQ-9 and GAD-7 scores from baseline (PHQ-9: mean: 16.7; SD: 5.8; GAD-7: mean: 12.0; SD: 5.8) to last available treatment (PHQ-9: mean: 12.0; SD: 6.4; GAD-7: mean: 8.7; SD: 5.6). There were no reports of serious adverse events. Conclusion: This study found a significant disease burden for patients with TRD. Esketamine appears to be well tolerated and effective in improving depression and anxiety.
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Affiliation(s)
- Madeline Brendle
- Department of Pharmacotherapy, University of Utah College of Pharmacy, UT 84112, USA.,Numinus Wellness, UT 84020, USA
| | | | | | | | | | - Daniel C Malone
- Department of Pharmacotherapy, University of Utah College of Pharmacy, UT 84112, USA
| | - Reid Robison
- Numinus Wellness, UT 84020, USA.,University of Utah School of Medicine, UT 84132, USA
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Ahuja S, Brendle M, Smart L, Moore C, Thielking P, Robison R. Real-world depression, anxiety and safety outcomes of intramuscular ketamine treatment: a retrospective descriptive cohort study. BMC Psychiatry 2022; 22:634. [PMID: 36192794 PMCID: PMC9528178 DOI: 10.1186/s12888-022-04268-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 09/20/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Ketamine has emerged as a promising pharmacotherapy for depression and other mental illnesses, and the intramuscular (IM) administration of ketamine is now offered at many North American outpatient psychiatric clinics. However, a characterization of the outpatient population receiving IM ketamine treatment and an evaluation of the real-world depression, anxiety, and safety outcomes of long-term psychiatric IM ketamine treatment has not been reported. This study aimed to evaluate the clinical characteristics, treatment patterns, clinical outcomes, and adverse events of patients receiving IM ketamine treatment. METHODS Patient data from the electronic health records of a private outpatient psychiatric clinic network in the United States were collected and analyzed retrospectively. Adults with any psychiatric diagnosis who received ketamine treatment only by IM administration from January 2018 to June 2021 were included. A total of 452 patients were included in the cohort. RESULTS Patients receiving IM ketamine treatment had a mean of 2.8 (SD 1.4) psychiatric diagnoses. 420 (93%) patients had a diagnosis of major depressive disorder, 243 (54%) patients had a diagnosis of generalized anxiety disorder, and 126 (28%) patients had a diagnosis of post-traumatic stress disorder. Patients received a median of 4 (range 1-48) IM ketamine treatments. Median depression scores (PHQ-9) improved 38% from 16.0 (IQR 11.3-21.8) at baseline to 10.0 (IQR 6.0-15.0) at last treatment (p < .001). Median anxiety scores (GAD-7) improved 50% from 14.0 (IQR 8.0-17.0) at baseline to 7.0 (IQR 4.3-11.8) at last treatment (p < .001). With maintenance ketamine treatments, average improvements in depression (PHQ-9) and anxiety (GAD-7) scores of at least 4.7 and 4.9 points were maintained for over 7 months. An adverse event occurred during 59 of 2532 treatments (2.3%). CONCLUSIONS IM ketamine is being utilized to treat psychiatric outpatients with multiple mental illnesses not limited to depression. Average depression and anxiety levels significantly improve throughout IM ketamine treatment and do not regress to baseline during patients' maintenance treatment phase. Prospective studies are recommended to confirm the long-term effectiveness and safety of IM ketamine.
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Affiliation(s)
| | - Madeline Brendle
- Cedar Psychiatry, Springville, UT USA ,grid.223827.e0000 0001 2193 0096Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT USA
| | - Leo Smart
- Cedar Psychiatry, Springville, UT USA
| | - Claire Moore
- Cedar Psychiatry, Springville, UT USA ,Numinus Wellness, Vancouver, British Columbia Canada
| | - Paul Thielking
- Cedar Psychiatry, Springville, UT USA ,Numinus Wellness, Vancouver, British Columbia Canada ,grid.223827.e0000 0001 2193 0096University of Utah School of Medicine, DraperSalt Lake City, UT 721 E 12200 S, 84020 USA
| | - Reid Robison
- Cedar Psychiatry, Springville, UT, USA. .,Numinus Wellness, Vancouver, British Columbia, Canada. .,University of Utah School of Medicine, DraperSalt Lake City, UT, 721 E 12200 S, 84020, USA.
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Garland EL, Thielking P, Thomas EA, Coombs M, White S, Lombardi J, Beck A. Linking dispositional mindfulness and positive psychological processes in cancer survivorship: a multivariate path analytic test of the mindfulness-to-meaning theory. Psychooncology 2016; 26:686-692. [PMID: 26799620 DOI: 10.1002/pon.4065] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Revised: 11/10/2015] [Accepted: 12/09/2015] [Indexed: 12/23/2022]
Abstract
BACKGROUND Research indicates that dispositional mindfulness is associated with positive psychological functioning. Although this disposition has been linked with beneficial outcomes in the broader mental health literature, less is known about dispositional mindfulness in cancer survivors and how it may be linked with indices of psychological and physical health relevant to cancer survivorship. METHODS We conducted a multivariate path analysis of data from a heterogeneous sample of cancer patients (N = 97) to test the Mindfulness-to-Meaning Theory, an extended process model of emotion regulation linking dispositional mindfulness with cancer-related quality of life via positive psychological processes. RESULTS We found that patients endorsing higher levels of dispositional mindfulness were more likely to pay attention to positive experiences (β = .56), a tendency which was associated with positive reappraisal of stressful life events (β = .51). Patients who engaged in more frequent positive reappraisal had a greater sense of meaning in life (β = .43) and tended to savor rewarding or life affirming events (β = .50). In turn, those who engaged in high levels of savoring had better quality of life (β = .33) and suffered less from emotional distress (β = -.54). CONCLUSIONS Findings provide support for the Mindfulness-to-Meaning Theory and help explicate the processes by which mindfulness promotes psychological flourishing in the face of cancer. IMPLICATIONS FOR CANCER SURVIVORSHIP Cancer survivors may benefit from enhancing mindfulness, reappraisal, and savoring. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Eric L Garland
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.,College of Social Work, University of Utah, Salt Lake City, UT, USA
| | - Paul Thielking
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | | | - Mary Coombs
- College of Social Work, University of Utah, Salt Lake City, UT, USA
| | - Shelley White
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Joy Lombardi
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Anna Beck
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
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Beck AC, Garland E, Thielking P, White S. Linking dispositional mindfulness and positive psychological processes in cancer survivorship: A multivariate path analysis. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.31_suppl.237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
237 Background: Research indicates dispositional mindfulness is linked with positive psychological outcomes. This disposition, which is malleable through training, is characterized by the tendency exhibit nonjudgmental and nonreactive awareness of one’s thoughts, emotions, and present moment sensory-perceptual experience. Although this trait has been linked with salutary outcomes in the broader mental health literature, less is known about the trait of mindfulness in cancer survivors and how it may be linked with indices of psychological and physical health relevant to cancer survivorship. Methods: We conducted a multivariate path analysis of cross-sectional data from a heterogenous sample of cancer patients (N = 97) to test a conceptual model linking dispositional mindfulness with cancer-related quality of life via positive psychological processes. Results: We found that patients with higher levels of dispositional mindfulness were more likely to pay attention to positive experiences (β = 0.47), a propensity which was associated with positive reappraisal of stressful life events (β = 0.46). Patients who endorsed more frequent positive reappraisal had a greater sense of sense of meaning in life (β = 0.43) and savored rewarding or life affirming events (β = 0.45). In turn, those who engaged in high levels of savoring had better quality of life (β = 0.33) and suffered from less emotional distress (β = -0.54). Overall model fit was excellent, χ2/df= 1.18; CFI = 0.99; RMSEA = 0.04 (0.00, 0.12). Conclusions: The data support our hypothetical model of the processes by which mindfulness promotes psychological flourishing in the face of cancer. Dispositional mindfulness appears to broaden attention from a myopic focus on illness to encompass previously unattended positive features of the social and natural environment. With this broader set of information from which new, more adaptive situational appraisals may be generated, mindfulness may engender positive reappraisals of stressful life events and promote sense of meaning in life. When sustained over time, these processes may propel an upward spiral of positive cognition-emotion interactions with salutary consequences for cancer survivorship.
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Affiliation(s)
| | - Eric Garland
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Paul Thielking
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Shelley White
- Huntsman Cancer Hospital Wellness & Survivorship Center, Salt Lake City, UT
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Jeronimo SM, Teixeira MJ, Sousa AD, Thielking P, Pearson RD, Evans TG. Natural history of Leishmania (Leishmania) chagasi infection in Northeastern Brazil: long-term follow-up. Clin Infect Dis 2000; 30:608-9. [PMID: 10722458 DOI: 10.1086/313697] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- S M Jeronimo
- Department of Biochemistry, Universidade Federal do Rio Grande do Norte, Natal, Brazil
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