CRITICALLY APPRAISED PAPER (CAP) Crain, A. L., Enstad, C. J., Hanson, L. R., Kreitzer, M., Lewis, B. A., & Whitebird, R. R. (2012). Mindfulness-based stress reduction for family caregivers: A randomized controlled trial. The Gerontologist, 53(4), 676-686. http://dx.doi.org/10.1093/geront/gns126 CLINICAL BOTTOM LINE: The purpose of this study was to compare the effects of a mindfulness-based stress reduction (MBSR) program with those of a community caregiver education and support (CCES) program for family caregivers of people with dementia (p. 676). Researchers compared the outcome measures (perceived stress, anxiety, depression, overall mental health, caregiver burden, and social support) of participants in each of the two groups at baseline, post intervention, and at 6 months. Overall, the results of this study were significant and supported the potential of MBSR to reduce stress and improve overall mental health in caregivers for people with dementia. The results indicated clinically significant improvements in overall mental health for the MBSR group. Rapid improvement in levels of stress and depression were seen in the MBSR group and were significantly greater than the CCES group post-intervention. Though the CCES group also had minor improvements in levels of stress and depression, a level comparable to that of the MBSR group was not noted until 6 months post-intervention. Although this gradual improvement eliminated the significant difference between the two groups at the 6-month follow-up, a rapid decrease in symptoms of stress and depression, which occurred in the MBSR group, would still be beneficial to those who are experiencing extreme difficulties as a result of caregiving. All outcomes showed improvement, but not all measures had a statistically significant difference between the two groups to report. Additionally, the improvements seen in mental health and stress did not produce significant improvement in caregiver burden scores, with both groups only showing minor increases in scores. The aspect of caregiver burden would require a more multifaceted approach to address the many dimensions of the caregiving experience, rather than a targeted approach such as MBSR. The clinical implications of this study can be applied to occupational therapy practice. Practitioners not only treat patients, but also educate caregivers. While traditional caregiver education may only include providing instruction as to how to care for the patient, it also potentially could include strategies for self-care. With that in mind, occupational therapy 1
practitioners can incorporate aspects of MBSR in their education, such as recommending strategies that caregivers can use on a daily basis. This would require practitioners first become familiar with MBSR. Another option would be for practitioners to make referrals for MBSR services. If caregivers of people with dementia are in a better state of mental health and reduced stress, they will be able to provide more effective and quality care. RESEARCH OBJECTIVE(S) List study objectives. Determine the feasibility and acceptability of MBSR as an intervention for stress among caregivers with a family member with dementia and to investigate mental health outcomes among participants. DESIGN TYPE AND LEVEL OF EVIDENCE: Level I: Randomized controlled trial SAMPLE SELECTION How were subjects recruited and selected to participate? Please describe. Participants were obtained voluntarily via a health plan and its clinics, community outreach, paid advertising, press coverage, and word of mouth. Researchers screened 156 caregivers, out of whom 112 were eligible to participate. 78 consented to be a part of the study. No other information was reported regarding selection procedures. Inclusion Criteria Inclusion criteria included: being self-identified as a primary caregiver of a community-dwelling family member who had memory loss consistent with dementia; being older than 21 years old; be able to speak English; being able to read the course materials; being willing to attend all group sessions; not having participated in a community caregiver support program; not having practiced meditation, yoga, or tai chi in the previous year; having scored 5 or higher on a single-item measure of self-perceived stress on a scale of 1 10; having no psychiatric hospitalizations or diagnoses of mental illness in the previous 2 years; not having taken antipsychotic or anticonvulsion medication; and having no thoughts of harming themselves in the past 6 months. Exclusion Criteria Exclusion criteria were not reported. However, if one did not meet the inclusion criteria addressed above, he or she was excluded from the study. SAMPLE CHARACTERISTICS N= (Number of participants taking part in the study) 78 2
#/ (%) Male 9 / (11.5%) #/ (%) Female 69 / (88.5%) Ethnicity Non-Hispanic White: 97.4% Hispanic: 1.3% American Indian: 1.3% Disease/disability diagnosis Primary caregiver of a community-dwelling family member with memory loss consistent with dementia INTERVENTION(S) AND CONTROL GROUPS Add groups if necessary Group 1 Brief description of the intervention Participants in the MBSR group received instruction about concepts of mindfulness and practiced meditation and gentle yoga exercises each week. They were instructed on sitting and walking meditation, body scan meditation, and Hatha yoga. They were given stretching exercises, CDs, and written material to help them engage in practice at home. Participants recorded daily MBSR practice in health behavior calendars. The study coordinators conducted weekly telephone support calls during the intervention and then monthly for 6 months. The MBSR coordinator encouraged participants to practice daily and helped those who had difficulties to problem solve their situations. How many participants in the group? Where did the intervention take place? Who delivered? How often? 38 A nonprofit center affiliated with a mixed-model health plan, as well as participants homes An MBSR instructor who was employed by the University of Minnesota Center for Spirituality and Healing and trained in MBSR through the Stress Reduction and Relaxation Clinic at the University of Massachusetts 2.5-hour in-person sessions and telephone conversations once a week, plus an additional 5-hour retreat or wellness day that provided intensive coverage of the same material delivered in the weekly sessions 3
For how long? Weekly sessions and telephone conversations for 8 weeks and monthly telephone conversations for 6 months Group 2 Brief description of the intervention CCES participants were educated about issues affecting family caregivers as well as group social and emotional support. Topics such as dementia, legal and financial issues, community resources, communication, self-care, grief, and loss were covered each week. They also participated in group-based discussions facilitated by the instructor about their experience as caregivers. The study coordinators conducted weekly telephone support calls during the intervention period and then monthly for 6 months. The CCES coordinator encouraged participants to practice or implement what they were learning in their group. How many participants in the group? Where did the intervention take place? Who delivered? 40 A nonprofit center affiliated with a mixed-model health plan, as well as participants homes A CCES instructor who was an experienced licensed social worker provided through a local nonprofit organization that has provided caregiver programs and services in the community for 30 years How often? For how long? 2.5-hour in-person sessions and telephone conversations once a week, plus an additional 5-hour retreat or wellness day that provided intensive coverage of the same material delivered in the weekly sessions Weekly sessions and telephone conversations for 8 weeks and monthly telephone conversations for 6 months Intervention Biases: Check yes, no, or NR and explain, if needed. Contamination: Both groups were from the same location; therefore, the risk of participants from either group encountering or already knowing each other was present, especially because word of mouth was one method of recruitment. There was no way to control for the possibility of participants exchanging information between groups. 4
Co-intervention: Although there were inclusion criteria regarding participants mental health status and other specific factors, it is unknown if participants were receiving other medications or treatments for unrelated conditions that could have affected their functioning and thus their performance during the study. Timing: Five waves of intervention groups were conducted, but the authors did not specify whether they occurred concurrently or back-to-back. It may be implied that one group occurred at a time due to the fact that the study was conducted from 2007 to 2010, but, because the authors did not clarify, that is only speculation. Site: It is unknown if both groups received their interventions in the exact same location within the research center. A portion of the interventions also occurred in participants homes, which could have provided a higher level of satisfaction for certain participants than for others. Use of different therapists to provide intervention: There was a different instructor for each group, leading to the possibility that one was more motivating and encouraging than the other. For example, the MBSR instructor provided additional support by helping those who were facing difficulties problem solving, while the CCES instructor only encouraged participants to practice or implement what they were learning. This leads us to question whether the follow-up phone calls were consistent with each other in content and quality, which may have caused the MBSR participants to perform better. MEASURES AND OUTCOMES Complete for each measure relevant to occupational therapy: Measure 1: Perceived Stress Scale 10-item version A self-reported measure of the degree to which situations in the prior month were considered stressful Perceived stress 5
Is the measure reliable? Is the measure valid? Measure 2: Center for Epidemiologic Studies Depression Scale, 20-item measure Depression Is the measure reliable? Is the measure valid? YES NR Measure 3: State-Trait Anxiety Inventory (STAI) State Version Y subscale Anxiety Is the measure reliable? YES NR Is the measure valid? YES NR Measure 4: Short-Form-12 Health Survey (SF-12) Overall mental health. Includes two separate scores, one for mental health and one for physical health Is the measure reliable? YES NR 6
Is the measure valid? YES NR Measure 5: Montgomery Borgatta Caregiver Burden Scale Caregiver burden: This scale contains three subscales: objective burden, subjective demand burden, and subjective stress burden. Objective burden measures the level of interference on or disruption of tangible aspects of the caregiver s life. Subjective demand burden measures the degree to which the caregiver perceives care to be excessively demanding. Subjective stress burden measures the influence that caregiving responsibilities has on emotions. Is the measure reliable? YES NR Is the measure valid? YES NR Measure 6: Medical Outcomes Study Social Support Survey Social support covers four categories: emotional or informational support, tangible support, positive social interaction, and affectionate support Is the measure reliable? YES NR Is the measure valid? YES NR Measurement Biases Were the evaluators blind to treatment status? Check yes, no, or NR, and if no, explain. 7
Were the evaluators blind to treatment status? Check yes, no, or NR, and if no, explain. Recall or memory bias. Check yes, no, or NR, and if yes, explain. Others (list and explain): NR RESULTS List key findings based on study objectives Include statistical significance where appropriate (p<0.05) Include effect size if reported Treatment effects were evaluated at 2 months and 6 months using the SAS PROC MIXED, a general linear mixed model, to determine the differences between the outcomes of each group and the baseline measurements at the start of the study. Perceived Stress: The MBSR and CCES groups were similar at baseline in their reports of perceived stress (p =.99). At post intervention (2 months), the MBSR participants had significant improvement (p =.007) compared to the CCES group. However, the CCES group gradually improved so that at 6 months, the two groups were no longer statistically distinguishable (p =.07). Anxiety: The baseline differences (p =.01) in anxiety between MBSR and CCES participants remained stable at 2 months (p =.01) and 6 months (p =.02) as both groups steadily improved over time. Depression: The MBSR and CCES groups did not significantly differ at baseline in their reports of depression (p =.58). At 2 months, the MBSR participants had a significant decrease in depressive symptoms (p =.005) in comparison with the CCES participants. At 6 months, there was no longer a significant difference (p =.16) as the CCES group had progressively improved. Overall Mental health: There was no statistical significance in mental health outcomes at baseline (p =.10). At 2 months, MBSR participants reported immediate improvement in outcomes whereas CCES participants reported very little change (p = 007). MBSR participants maintained this improvement at 6 months while CCES participants steadily improved over time, which resulted in similar outcomes at the 6-month follow-up (p =.04). 8
Physical health: There were baseline differences in physical health between the CCES and MBSR groups (p =.04). However, these diminished post intervention (p =.36) and at 6 months (p =.26) as MBSR participants physical health improved slightly. Caregiver burden and social support: MBSR and CCES participants reported improvement steadily over time (i.e., objective burden; p =.58, p =.67); subjective demand (p =.24, p =.09); subjective stress (p =.32, p =.26); social support (p =.66, p =.84) such that there were no significant differences between MBSR and CCES participants at post intervention or 6 months. Was this study adequately powered (large enough to show a difference)? Check yes, no, or NR, and if no, explain. YES NR Were appropriate analytic methods Check yes, no, or NR, and if no, explain. YES NR Were statistics appropriately reported (in written or table format)? Check yes or no, and if no, explain. YES Was the percent/number of subjects/participants who dropped out of the study reported? YES Limitations: What are the overall study limitations? This study neglected to establish long-term benefits of MBSR, which the authors suggest be researched further. It is important to consider that it can be difficult to continue practicing MBSR on a daily basis. Finding proper support for this continued practice, as well as enough MBSR instructors trained for this population, is necessary in order to determine any possible extended outcomes. Another limitation was the perception that mind-body interventions can be difficult for caregivers to accept as a means to reduce stress. The authors experienced difficulty with recruitment, with resistance seen especially in minorities, due to this view. The trouble with recruitment led to the participants of the study being predominantly White; therefore, the caregiver experiences of minorities were possibly not reflected. 9
CONCLUSIONS This study revealed that implementing MBSR produces positive changes in the mental health of caregivers for people with dementia. Results show that MBSR was more effective than CCES at improving overall mental health post-intervention and at 6 months, while also being more effective at lowering levels of stress and depression immediately following intervention. There were no statistically significant differences for the remaining outcomes. Both groups reported immediate improvement in levels of anxiety post-intervention, and both groups showed gradual improvement regarding caregiver burden and social support over time. Improving mental health and overall well-being of caregivers for people with dementia is critical, considering the increase in the number of families affected by dementia and the negative effects that often result from caregiving. These can include poor health; diminished psychological, social, and emotional health; and increased mortality (681). Stress is a prominent cause of declining mental health and well-being, especially among dementia caregivers in whom stress can become chronic, thus leading to long-term declines in health. This was seen in both intervention groups, in that they reported high levels of stress, depression, and anxiety symptoms. Each of these outcomes then displayed significant improvement as a result of the intervention. Based on these results, the authors concluded that MBSR not only can be considered a feasible intervention to help manage the daily stressors and emotional challenges experiencing by caregivers for people with dementia, but also has the potential to provide long-term benefits by reducing chronic stress and improving overall mental health. This work is based on the evidence-based literature review completed by Jennifer Mehesy, OTS; Jennifer Scrivani, OTS; and Megan Foti, DOT, MS, OTR, Faculty Advisor, The Richard Stockton College of New Jersey. CAP Worksheet adapted from Critical Review Form--Quantitative Studies. Copyright 1998, by M. Law, D. Stewart, N. Pollack, L. Letts, J. Bosch, & M. Westmorland, McMaster University. Used with permission. For personal or educational use only. All other uses require permission from AOTA. Contact: www.copyright.com 10
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