What is mindfulness?

Transcription

1 Dr Sheila Hardy

2 What is mindfulness? Mindfulness meditation can be traced back to eastern Buddhist practices though its presence in the western medical and psychological research literature is relatively new 1. There is no need to be religious or spiritual to practise mindfulness 2. It is a technique that helps people to pay attention to the present moment 3 using practices such as yoga, meditation and breathing. It enables people to become more aware of their body sensations and the way they are thinking and feeling. Mindfulness is now considered to have the potential to produce benefits in the treatment of physical and mental illnesses 4 Side-effects are rare but there have been reports of dissociation, anxiety and depression particularly with vulnerable people such as those with PTSD. 1. Krolikowski A. (2013) The effectiveness of internet-based mindfulness interventions for physical and mental illnesses: a narrative review. International Journal of Cyber Behavior, Psychology and Learning. 3 (4) Grossman P, Niemann L, Schmidt S et al. (2004) Mindfulness-based stress reduction and health benefits: a meta-analysis. J Psychosom Res Kabat-Zinn, J. (2003) Mindfulness-based interventions in context: Past, present, future. Clinical Psychology: Science and Practice. 10 (2) Hooker K and Fodor I. (2008) Teaching mindfulness to children. Gestalt Review. 12 (1) *

3 Cognitive-behavioural therapists (CBTs) have adopted mindfulness practices as components of their treatments. There are two types of mindfulness which have evidence to support their use: Mindfulness based cognitive therapy Mindfulness based stress reduction

4 Mindfulness based cognitive therapy Research has shown that mindfulness based cognitive therapy (MBCT) reduces the recurrence rate of depression in people who have experienced three or more previous episodes 1. This use is recommended in the United Kingdom s national guidance for depression 2 as it can be as effective at reducing depression recurrence as antidepressants Crane C, Crane R, Eames C et al. (2014) The effects of amount of home meditation practice in Mindfulness Based Cognitive Therapy on hazard of relapse to depression in the Staying Well after Depression Trial. Behaviour Research and Therapy National Institute for Health and Care Excellence (NICE). (2009) Depression in adults with a chronic physical health problem. London: National Collaborating Centre for Mental Health. 3. Williams J, Crane C, Barnhofer T et al. (2013) Mindfulness-Based Cognitive Therapy for Preventing Relapse in Recurrent Depression: A Randomized Dismantling Trial. Journal of Consulting and Clinical Psychology

5 Mindfulness based stress reduction Mindfulness based stress reduction (MBSR) aims to address prolonged periods of stress which can lead to poor mental and physical health. It was developed in 1979 at the University of Massachusetts. MBSR combines mindfulness meditation and gentle Hatha yoga into a structured clinical programme that can be taught to individuals or in a group format. It was initially intended to assist people to deal with the concerns of their medical illness and help them to manage stress and pain. It is now being applied to a range of health problems and to maintain physical and mental wellbeing.

6 Mindfulness based stress reduction Physiological relaxation is achieved while practicing MBSR but the focus is to develop an awareness of the body and mind 1. Participants are encouraged to observe their thoughts and emotions but to let them pass without judging them or becoming immersed in them 2. This practice of being in the moment and remaining nonreactive, nonevaluative and non-judgmental enables awareness of thoughts and emotions to go quickly. By avoiding distractive or ruminative thoughts, participants are able to notice, understand and integrate their own perception of self and the environment Whitebird R, Kreitzer M and O'Connor P. (2009) Mindfulness-Based Stress Reduction and Diabetes. Diabetes Spectr. 22 (4) Praissman S. (2008) Mindfulness-based stress reduction: a literature review and clinician's guide. J Am Acad Nurse Pract Jain S, Shapiro S, Swanick S et al. (2007) A randomized controlled trial of mindfulness meditation versus relaxation training: effects on distress, positive states of mind, rumination, and distraction. Ann Behav Med

7 Why consider mindfulness for people with diabetes? Have to self-manage their lifestyle behaviours, monitor their blood glucose and take medication as prescribed in order to control their condition effectively 1. Being stressed, anxious or depressed can have an effect on how well they can achieve this. A large study in the US found that people with diabetes were five times more likely to be anxious than the general population 2. Depression is also common 3, with a quarter of people in this group being affected at some time in their lives Funnell M, Anderson R (2004) Empowerment and self-management of diabetes. Clinical Diabetes 22 (3) Li C, Barker L, Ford ES, Zhang X, Strine TW, Mokdad AH (2008) Diabetes and anxiety in US adults: findings from the 2006 Behavioral Risk Factor Surveillance System. Diabet Med 25 (7) Ali S, Stone MA, Peters JL, Davies MJ, Khunti K (2006) The prevalence of co-morbid depression in adults with Type 2 diabetes: a systematic review and meta-analysis. Diabet Med 23 (11) O Connor PJ, Crain AL, Rush WA, Hanson AM, Fischer LR, Kluznik JC (2009) Does diabetes double the risk of depression? Ann Fam Med 7 (4)

8 Diabetes, stress, anxiety, depression and pain People with both diabetes and depression are more likely to have poor control of their glycated haemoglobin (HbA1c) and are less likely to eat a healthy diet, exercise and take their prescribed medication 1,2,3. More at risk of developing adverse complications of diabetes, including microvascular and macrovascular disease 4,5. Treatments for depression have been found to be less effective in people with diabetes compared with those who do not have diabetes 6,7. Anxiety and depression in diabetes may be caused by the stress of adapting to and managing a chronic illness 8 or the fact that it can interfere with the person s social interactions and relationships 9. The major complications of diabetes add stress and further increase the risk of depression, anxiety and poor quality of life 10,11. A systematic review of the prevalence of pain found it was 10 20% in patients with diabetes and 40 50% in those with diabetic neuropathy 12. Pain is associated with depression, anxiety and sleep disturbances, and patients with chronic neuropathic pain experience lower health related quality of life Gonzalez JS, Peyrot M, McCarl LA et al (2008) Depression and diabetes treatment nonadherence: a meta-analysis. Diabetes Care 31 (12) Bogner HR, de Vries HF, O Donnell AJ, Morales KH (2013) Measuring concurrent oral hypoglycemic and antidepressant adherence and clinical outcomes. Am J Manag Care 19 (3) e Rotella F, Mannucci E (2013) Depression as a risk factor for diabetes: a meta-analysis of longitudinal studies. J Clin Psychiatry 74 (1) Carnethon MR, Kinder LS, Fair JM, Stafford RS, Fortmann SP (2003) Symptoms of depression as a risk factor for incident diabetes: findings from the National Health and Nutrition Examination Epidemiologic Follow-up Study, Mezuk B, Eaton WW, Albrecht S, Golden SH (2008) Depression and type 2 diabetes over the lifespan: a meta-analysis. Diabetes Care 31 (12) Katon W, Russo J, Frank E et al (2002) Predictors of nonresponse to treatment in primary care patients with dysthymia. Gen Hosp Psychiatry 24 (1) Lustman PJ, Clouse RE (2005) Depression in diabetic patients: the relationship between mood and glycemic control. J Diabetes Complications 19 (2) Whitebird R, Kreitzer M and O'Connor P. (2009) Mindfulness-Based Stress Reduction and Diabetes. Diabetes Spectr. 22 (4) Tak-Ying Shiu A, Kwan JJ, Wong RY (2003) Social stigma as a barrier to diabetes self-management: implications for multi-level interventions. J Clin Nurs 12 (1) Kautzky-Willer A, Handisurya A (2009) Metabolic diseases and associated complications: sex and gender matter! Eur J Clin Invest 39 (8) Oliveira AF, Valente JG, Leite Ida C, Schramm JM, Azevedo AS, Gadelha AM (2009) Global burden of disease attributable to diabetes mellitus in Brazil. Cad Saude Publica 25 (6) Veves A, Backonja M, Malik RA (2008) Painful diabetic neuropathy: epidemiology, natural history, early diagnosis, and treatment options. Pain Med 9 (6) Langley PC, Van Litsenburg C, Cappelleri JC, Carroll D (2013) The burden associated with neuropathic pain in Western Europe. J Med Econ 16 (1)

9 Mindfulness based stress reduction - does it work? There have been a number of studies on the use of MBSR with healthy people (for stress reduction and to assist with behavioural lifestyle changes) and those with long-term conditions. They have shown decreases in medical symptom, improved functioning and quality of life, reductions in psychological distress and decreases in mood disturbances such as depression and anxiety 1. A study of patients with cancer found that MBSR can have a significant impact on reducing sleep disturbance and improving sleep quality 2. There is also research which has established that regular practice of mindfulness meditation has the potential to reduce systolic and diastolic blood pressure, which can subsequently reduce the risk of hypertension, heart attack and stroke 3,4,5. 1. Whitebird R, Kreitzer M and O'Connor P. (2009) Mindfulness-Based Stress Reduction and Diabetes. Diabetes Spectr. 22 (4) Carlson L and Garland S. (2005) Impact of mindfulness-based stress reduction (MBSR) on sleep, mood, stress and fatigue symptoms in cancer outpatients. Int J Behav Med. 12 (4) Barnes V, Davis H, Murzynowski J et al. (2004) Impact of meditation on resting and ambulatory blood pressure and heart rate in youth. Psychosom Med Anderson J, Liu C, Kryscio R. (2008) Blood pressure response to transcendental meditation: a meta-analysis. Am J Hypertens. 21 (3) Dhar H. (2009) Meditation Therapy in Cardiovascular and Metabolic Disorders Special Reference to coronary Artery Disease and Diabetes. Bombay Hospital Journal. 51 (4)

10 Mindfulness based stress reduction - does it work? Mindfulness and diabetes One study of 14 patients with type 2 diabetes looked at the effects of MBSR on physical and psychological outcomes 1. This uncontrolled study found a reduction in HbA1C of 0.5% and reduced mean arterial pressure of 6 mmhg in patients completing the programme. Additionally, decreases in depression, anxiety, and general psychological distress were also observed. Another study of 81 patients with type 2 diabetes 2 provided a one-day education workshop as part of their diabetes medical management; they were randomly assigned either to education alone or to a combination of education and acceptance and mindfulness skills. The results indicated that changes in acceptance coping and self-management behaviour facilitated the improvement in HbA1C. 1. Rosenzweig S, Reibel D, Greeson J et al. (2007) Mindfulness-based stress reduction is associated with improved glycemic control in type 2 diabetes mellitus: a pilot study. Altern Ther Health Med Gregg J, Callaghan G, Hayes S et al. (2007) Improving diabetes self-management through acceptance, mindfulness, and values: a randomized controlled trial. J Consult Clin Psychol

11 Mindfulness based stress reduction - does it work? Mindfulness and pain Mindfulness provides people who have chronic pain with the opportunity to contemplate and change their unhelpful responses. For example, a person who has neuropathic pain may consistently but unsuccessfully try to avoid the pain. These avoidant reactions essentially prolong and increase the amount of distress associated with experiencing the pain. Taking part in a mindfulness-based treatment can help the person to build present-focused awareness of the pain, which empowers them to change their conditioned responses to the pain (avoiding or exacerbating) in favour of less reactive, acceptance-based responses Hooker K and Fodor I. (2008) Teaching mindfulness to children. Gestalt Review. 12 (1)

12 How can you facilitate mindfulness for the patients you see? There are three different ways to practice mindfulness: Following everyday mindful practices Virtual applications Formal group courses.

13 Everyday mindful practices You can advise patients to: Pick a time, for example on the journey to work Try new things, such as taking a different route or going somewhere new to buy groceries Take notice of their thoughts and feelings. Silently naming them and letting them go can be helpful, e.g. Here is the thought that or This is anxiety Notice the sensations of things, for instance, the food they eat, the wind in their hair, the rain on their skin Observe their own thoughts, stand back and watch them floating past, like leaves on a stream

14 Virtual applications Patients can choose from the following options: Getting a mindfulness app for their tablet or phone. There are three that have been advocated by the Mindfulness Organisation Stop, Breathe & Think: Calm: The Mindfulness Training App: Signing up for an online course where the person learns through selfdirected practice at home. A free course is available modelled on the MBSR program founded by Jon Kabat-Zinn at the University of Massachusetts. There may be courses commissioned in some areas for NHS patients. Online Mindfulness-Based Stress Reduction course:

15 Virtual applications Online Mindfulness-Based Stress Reduction course: Welcome Introduction Getting Started MBSR Manual Week 1 - Simple Awareness Introduction to the Body Scan Week 2 - Attention & The Brain Introduction to Sitting Meditation Week 3 - Dealing with Thoughts Introduction to Yoga - Yoga 1 Week 4 - Stress: Responding vs. Reacting STOP: One-Minute Breathing Space and Yoga 2 Week 5 - Dealing with Difficult Emotions/Sensations Soften, Soothe, Allow Week 5b - Special Instructions for Physical Pain The Five-Step PAIN process Week 6 - Mindfulness and Communication Mountain Meditation and Lake Meditation Week 7 - Mindfulness and Compassion Lovingkindness Meditation Week 8 - Conclusion Developing a practice of your own Certificate of Completion

16 Formal mindfulness practices Formal mindful practices that are readily available for the general population include: Meditation classes Yoga Tai-chi MBSR is currently not a standard treatment on the NHS, but there may be courses commissioned in some areas. Other resources: - free resources e.g. Report_Mindful-Nation-UK_Oct2015.pdf - parliamentary report

17 Using mindfulness in practice Mary is 57 years old and has had type 2 diabetes for 12 years. She usually manages her condition very well but has recently been quite stressed as she has been worrying about her daughter s wedding, which is planned for 8 months time. This has led to her snacking and preparing junk food instead of her usual reasonably healthy diet. Mary has attended for her annual review, her HbA1c has gone up to 64 mmol/mol. Could mindfulness be helpful for Mary? If so, how would you go about recommending it?

18 Using mindfulness in practice Jim is 36 years old and has had type 2 diabetes for 8 years. He also has bipolar disorder. He usually manages his condition quite well but has recently stopped walking because he has started to feel really anxious which has made him feel incredibly tired. Jim has attended for his annual review, he has put on 6 kilograms. Could mindfulness be helpful for Jim? If so, how would you go about recommending it?

19 Mindfulness is a technique that can enable a person to focus on the present moment Mindfulness helps some people to accept the way they are feeling Mindfulness can enhance mental and physical wellbeing Mindfulness has been shown to be effective in supporting diabetes management as it can assist with the improvement of stress and its prevention, depression and anxiety, raised blood pressure, raised blood glucose, pain and sleep.