[show abstract][hide abstract] ABSTRACT: Our study examined whether mindfulness-based stress reduction (MBSR) is noninferior to cognitive behavioral therapy for insomnia (CBT-I) for the treatment of insomnia in patients with cancer.
This was a randomized, partially blinded, noninferiority trial involving patients with cancer with insomnia recruited from a tertiary cancer center in Calgary, Alberta, Canada, from September 2008 to March 2011. Assessments were conducted at baseline, after the program, and after 3 months of follow-up. The noninferiority margin was 4 points measured by the Insomnia Severity Index. Sleep diaries and actigraphy measured sleep onset latency (SOL), wake after sleep onset (WASO), total sleep time (TST), and sleep efficiency. Secondary outcomes included sleep quality, sleep beliefs, mood, and stress.
Of 327 patients screened, 111 were randomly assigned (CBT-I, n = 47; MBSR, n = 64). MBSR was inferior to CBT-I for improving insomnia severity immediately after the program (P = .35), but MBSR demonstrated noninferiority at follow-up (P = .02). Sleep diary-measured SOL was reduced by 22 minutes in the CBT-I group and by 14 minutes in the MBSR group at follow-up. Similar reductions in WASO were observed for both groups. TST increased by 0.60 hours for CBT-I and 0.75 hours for MBSR. CBT-I improved sleep quality (P < .001) and dysfunctional sleep beliefs (P < .001), whereas both groups experienced reduced stress (P < .001) and mood disturbance (P < .001).
Although MBSR produced a clinically significant change in sleep and psychological outcomes, CBT-I was associated with rapid and durable improvement and remains the best choice for the nonpharmacologic treatment of insomnia.
Journal of Clinical Oncology 01/2014; · 18.04 Impact Factor
[show abstract][hide abstract] ABSTRACT: BACKGROUND: Insomnia symptoms (difficulty falling or staying asleep, early awakenings,
and non-restorative sleep) are common in cardiac patients and are associated with mood
disturbance, impaired concentration, and fatigue. Due to these adverse consequences,
patients with insomnia symptoms may find it difficult to optimally adhere to cardiac rehabilitation
(CR) program requirements. AIM: To determine whether greater severity of
insomnia symptoms is associated with poor CR adherence, as indicated by lower attendance
at supervised exercise sessions and at health education classes. METHODS: Insomnia
symptoms were measured using the Insomnia Severity Index (ISI) in 155 cardiac patients
upon admission to a 12-week phase II CR program at the Cardiac Wellness Institute of
Calgary. Data on attendance, demographics, and disease-related variables were obtained by
chart review following program completion. Ideally, the CR program entails patients attending
24 supervised exercise sessions and �2 health education classes (e.g., nutrition, goalsetting).
Separate, two-stage hierarchical regression analyses were conducted with (1)
supervised exercise attendance as the dependent variable (DV) and (2) health education
attendance as the DV. In the first block, age, gender, risk stratification (based on American
College of Sports Medicine guidelines), and depressive symptoms (Hospital Anxiety and
Depression Scale depression index) were entered as covariates. In the second block, insomnia
symptom severity was entered as the focal independent variable. RESULTS: Forty-seven
percent of patients endorsed at least subthreshold insomnia symptoms (ISI �7) within the
past 2 weeks, indicating mild to severe sleep difficulties. Patients attended an average of
15.85 (SD � 8.04) supervised exercise sessions and 2.40 (SD � 1.63) health education
classes. Without insomnia symptom severity in the regression model, covariates accounted
for 12% of variance in supervised exercise attendance [F (4, 127) � 4.40, SE�7.66, p �.01]
but did not account for significant variance in health education attendance [F (4, 126) � 0.74,
SE � 1.64, P � .568, R2 � .023]. Insomnia symptom severity did not improve prediction of
supervised exercise session attendance [�F (1, 126)˜� 0.50, P �.481, �R2 � .003] or health
education class attendance [�F (1, 125) � 0.41, P � .525, � R2 � .003]. CONCLUSIONS:
Insomnia symptoms are commonly reported by CR patients and warrant appropriate assessment
and treatment, but they do not appear to interfere with CR participation. Future
analyses should examine associations between insomnia symptoms and other indices of CR
engagement (eg, dropout, self-reported exercise, and changes in functional capacity).
[show abstract][hide abstract] ABSTRACT: Background: Depressed mood and anxiety are prevalent among patients with cardiovascular disease (CVD) and are associated with adverse CV outcomes including myocardial infarction and CV mortality. While depressed mood has been associated with autonomic nervous system dysregulation, which represents a potential pathway that may confer increased CV risk, the association between other negative emotions, including anxiety, and autonomic function remains unclear. Heart rate recovery (HRR) following a symptom limited exercise stress test is an indirect measure of cardiac autonomic modulation and lower HRR is prognostic of cardiovascular mortality. Aim: To investigate whether previous reports of associations between depressed mood and autonomic dysregulation, as indexed by low levels of HRR, generalize to symptoms of anxiety. Methods: Anxious and depressive symptoms were measured using the Hospital Anxiety and Depression Scale in 356 cardiac patients entering a 12-week phase II cardiac rehabilitation program at the Cardiac Wellness Institute of Calgary. HRR was measured at 1 minute following a symptom-limited exercise stress test (using the Bruce Protocol) upon admission. A hierarchical multiple regression analysis was conducted with HRR as the dependent variable. In the first block, age, sex, and beta-blocker use were entered as covariates. Depressive and anxious symptoms were entered in the second block. Results: On average, patients fell within the normal range on both anxious (M = 5.58, SD = 3.72) and depressive (M = 3.94, SD = 3.21) symptoms. Anxious symptoms were positively associated with depressive
symptoms (r = .62, p < .01). Correlation analyses indicated that attenuated HRR was associated with depressive symptoms (r = -.13, p < .05) but not with anxiety symptoms (r = .03, p = .63). In the regression model, covariates accounted for 8.7% of variance in HRR, F(3, 355) = 11.11, p < .001. Depressive and anxious symptoms significantly improved prediction of HRR, ΔF (5, 355) = 3.67, p < .05, ΔR2 = .019; however, depressive symptoms, b = -.67, SE = .25, t(355) = -2.71, p < .05, not anxious symptoms, b = .11, SE = .21, t(355) = 1.62, p = .11, emerged as a significant predictor of HRR. Conclusion: Symptoms of depressed mood but not anxiety were associated with attenuated HRR following exercise. The findings suggest specificity for CV risk associated with autonomic function in depressed mood that does not necessarily generalize to other negative emotional states. Future research should investigate other candidate pathways through which anxiety may confer increased CV risk.
[show abstract][hide abstract] ABSTRACT: A review of the literature was conducted to assess the association between oxytocin (OT) and pain.
PsychInfo, PubMed, and Medline (EBSCO) research databases were searched for peer-reviewed articles written between 1950 and 2012. Of a total of 1166 articles returned, 50 (9 human, 33 animal, and 8 spinal cord samples) met full inclusion criteria and were included in the review.
OT had a reliable effect as defined by increasing pain tolerance in 29 of 33 animal studies reviewed. This effect persisted across central and peripheral modes of administration and type of noxious stimulus used (eg, heat, electric). The results suggest that OT acts as an analgesic for acute pain in animals. Preliminary research with humans offers consistent evidence to suggest that OT decreases pain sensitivity, though the reliability and stability of such effects cannot yet be determined. Although the findings are encouraging, there is a need for methodologically rigorous work in humans where OT is administered centrally.
Further research seems to be warranted as the existence of biologically and psychologically plausible mechanisms linking OT and pain have been well supported using animal models with limited but encouraging human research. Implications and recommendations are discussed. Findings from this research may inform therapeutic methods for the management of pain.
The Clinical journal of pain 07/2013; · 3.01 Impact Factor
[show abstract][hide abstract] ABSTRACT: BACKGROUND: The experience of low socioeconomic position in childhood may increase risk for adult cardiovascular disease above and beyond the effects of current socioeconomic position. One limitation of most previous research is that childhood socioeconomic position was assessed retrospectively. METHODS: Measures of ambulatory blood pressure, heart rate, and heart rate variability were obtained from 110 young men (22 years) who were enrolled in a long-term study of child development at age 6. RESULTS: Men who had lower childhood socioeconomic position had smaller decreases in systolic blood pressure (SBP) during sleep independent of current education, daytime SBP, and body mass index (BMI). They also displayed smaller decreases in low-frequency heart rate variability during sleep. Twenty-four-hour SBP was negatively associated with childhood socioeconomic position independent of current education and BMI. CONCLUSIONS: While the mechanisms are unclear, childhood socioeconomic position may influence blood pressure in early adulthood independent of current life circumstances.
Annals of Behavioral Medicine 04/2013; · 4.20 Impact Factor
[show abstract][hide abstract] ABSTRACT: Objective
This study examined the dose-dependent effects of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) supplementation on heart rate variability (HRV) at rest and during standard laboratory stress tasks. We also investigated whether EPA + DHA supplementation was associated with changes in mood state.Methods
This placebo-controlled, double-blind, randomized, three-period crossover trial (8-week treatment, 6-week washout) compared two doses of EPA + DHA supplementation (0.85 and 3.4 g/d) in 26 adults with elevated triglycerides. After each treatment period, HRV was assessed during an acute stress protocol that included a resting baseline, standard laboratory stress tasks (speech task and cold pressor), and recovery periods. In addition, mood state was assessed.ResultsRoot mean square of successive differences in interbeat interval and total power increased 9.9% and 20.6%, respectively, after the high dose relative to placebo (Tukey p = .016 and .012, respectively). The low dose was not significantly different from the high dose or placebo dose. There was a trend for a treatment effect on high-frequency HRV (p = .058), with 21.0% greater power observed after the high dose compared with placebo (Tukey p = .052). Mood did not differ between treatments, and there was no association between mood state and HRV.Conclusions
In healthy adults with elevated triglycerides, supplementation of 3.4 g/d EPA + DHA resulted in greater HRV, whereas 0.85 g/d EPA + DHA had no effect. These results indicate that EPA + DHA supplementation may improve autonomic tone in adults at increased risk for cardiovascular disease within 8 weeks.Trial RegistrationNCT00504309 (SClinicalTrials.gov).
Psychosomatic Medicine 04/2013; · 4.08 Impact Factor
[show abstract][hide abstract] ABSTRACT: Dispositional mindfulness, or the tendency to be more mindful in daily life, has been associated with better psychological functioning and reduced overall distress. This study investigated the degree to which dispositional mindfulness was associated with sleep disturbances in cancer patients with insomnia. Further, we examined whether levels of mindfulness moderated the relationship between stress levels, mood disturbance, insomnia severity, sleep quality and dysfunctional sleep beliefs. Participants (N = 111) were adults who had been previously treated for cancer and currently met diagnostic criteria for insomnia. Higher levels of acting with awareness, non-judging and non-reacting were associated with better sleep and psychological outcomes. Despite these significant associations, mindfulness facets did not significantly moderate the relationship between stress, mood and sleep outcomes. This negative finding raises the possibility that increased mindfulness may not act directly to improve psychological outcomes, but rather through a series of other cognitive and affective changes. Our results emphasize the importance of addressing mood symptoms and stress appraisals as predictors of sleep disturbance in cancer patients.
Personality and Individual Differences 04/2013; · 1.88 Impact Factor
[show abstract][hide abstract] ABSTRACT: We updated the evidence-based recommendations for the diagnosis, assessment, prevention, and treatment of hypertension in adults for 2013. This year's update includes 2 new recommendations. First, among nonhypertensive or stage 1 hypertensive individuals, the use of resistance or weight training exercise does not adversely influence blood pressure (BP) (Grade D). Thus, such patients need not avoid this type of exercise for fear of increasing BP. Second, and separately, for very elderly patients with isolated systolic hypertension (age 80 years or older), the target for systolic BP should be < 150 mm Hg (Grade C) rather than < 140 mm Hg as recommended for younger patients. We also discuss 2 additional topics at length (the pharmacological treatment of mild hypertension and the possibility of a diastolic J curve in hypertensive patients with coronary artery disease). In light of several methodological limitations, a recent systematic review of 4 trials in patients with stage 1 uncomplicated hypertension did not lead to changes in management recommendations. In addition, because of a lack of prospective randomized data assessing diastolic BP thresholds in patients with coronary artery disease and hypertension, no recommendation to set a selective diastolic cut point for such patients could be affirmed. However, both of these issues will be examined on an ongoing basis, in particular as new evidence emerges.
The Canadian journal of cardiology 03/2013; · 3.12 Impact Factor
[show abstract][hide abstract] ABSTRACT: BACKGROUND: Despite little evidence to suggest that HPA axis responses to psychological provocation are attenuated during pregnancy, it is widely held that dampening of the HPA axis response to psychological distress serves a protective function for the mother and fetus. The current study was designed to assess changes in biobehavioral coherence between psychological distress and cortisol over the course of pregnancy. METHODS: Ambulatory assessment of ecologically relevant psychological distress and salivary cortisol were repeated in all three trimesters for 82 pregnant women. Samples were collected 5 times per day over the course of 2days in each trimester. RESULTS: Psychological distress and cortisol were positively associated, β=.024, p<.01, indicating that increases in psychological distress were associated with increases in cortisol. Gestational age did not moderate this association, β=.0009, p=.13, suggesting that negative psychological experiences remain potent stimuli for the HPA axis during pregnancy. CONCLUSION: Biobehavioral coherence between ecologically relevant experiences of psychological distress and cortisol is not attenuated with advancing gestation.
[show abstract][hide abstract] ABSTRACT: Elevated stress can exacerbate cancer symptom severity, and after completion of primary cancer treatments, many individuals continue to have significant distress. Mindfulness-Based Cancer Recovery (MBCR) is an 8-week group psychosocial intervention consisting of training in mindfulness meditation and yoga designed to mitigate stress, pain, and chronic illness. Efficacy research shows face-to-face (F2F) MBCR programs have positive benefits for cancer patients; however barriers exist that impede participation in F2F groups. While online MBCR groups are available to the public, none have been evaluated. Primary objective: determine whether underserved patients are willing to participate in and complete an online MBCR program. Secondary objectives: determine whether online MBCR will mirror previous efficacy findings from F2F MBCR groups on patient-reported outcomes.
The study includes cancer patients in Alberta, exhibiting moderate distress, who do not have access to F2F MBCR. Participants will be randomized to either online MBCR, or waiting for the next available group. An anticipated sample size of 64 participants will complete measures online pre and post treatment or waiting period. Feasibility will be tracked through monitoring numbers eligible and participating through each stage of the protocol.
47 have completed/completing the intervention. Data suggest it is possible to conduct a randomized waitlist controlled trial of online MBCR to reach underserved cancer survivors.
Clinical Trials.gov Identifier: NCT01476891.
BMC Complementary and Alternative Medicine 01/2013; 13:34. · 2.08 Impact Factor
[show abstract][hide abstract] ABSTRACT: OBJECTIVE:: To determine the risk of injury associated with athletic identity, attitudes toward body checking, competitive state anxiety, and reinjury fear in elite youth ice hockey. Also, to determine if there is an elevated risk of subsequent injury associated with return to play before medical clearance. DESIGN:: Cohort study. SETTING:: Hockey arenas, Calgary, Alberta. PARTICIPANTS:: A total of 316 male participants from 18 elite (A, AA, AAA) Bantam (age, 13-14 years) and Midget (age, 15-17 years) teams. ASSESSMENT OF RISK FACTORS:: At season commencement and postinjury, participants completed the Athletic Identity Measurement Scale, Competitive State Anxiety Inventory-2R, Body Checking Questionnaire, and fear of reinjury questions. MAIN OUTCOME MEASURES:: Hockey injury resulting in medical attention, the inability to complete a hockey session, and/or missing a subsequent hockey session. RESULTS:: Players scoring below the 25th percentile in athletic identity were at increased risk of a first injury [incidence rate ratios (IRR): 1.53, 95% confidence interval (CI): 1.05-2.22], but scoring above the 25th percentile was associated with subsequent injury (IRR = 2.28, 95% CI: 1.01-6.04). There was no increase in risk associated with return to play before clearance (IRR: 1.58; 95% CI: 0.30-5.42). CONCLUSIONS:: Athletic identity was implicated as an injury risk factor in this population. Return to play before medical clearance was not a risk factor in this study, but the point estimate warrants additional investigation.
Clinical journal of sport medicine: official journal of the Canadian Academy of Sport Medicine 09/2012; · 1.50 Impact Factor
[show abstract][hide abstract] ABSTRACT: Research describing whether stress management can improve clinical outcomes for patients in cardiac rehabilitation (CR) has yielded equivocal findings.
The present investigation retrospectively examined the incremental impact of exercise and stress management (n = 188), relative to exercise only (n = 1389), on psychosocial and physical health outcomes following a 12-week CR program.
Participation in stress management and exercise was associated with greater reductions in waist circumference and systolic blood pressure, relative to exercise alone, for patients with baseline clinical elevations on these measures. The stress management group had more depressive symptoms (as measured by the Hospital Anxiety and Depression Scale; t = 3.81, P < .001) and lower physical quality of life (as measured by the 12-Item Short Form Health Survey Physical Component; t = 3.00, P = .003) than the exercise-only group at baseline, but there were no differences between the groups at 12 weeks in terms of depressive symptoms (t = 1.74, P = .082) or physical quality of life (t = 1.56, P = .120).
These findings suggest that stress management may offer additional benefits in selected patients over and above exercise in CR.
Journal of cardiopulmonary rehabilitation and prevention 09/2012; 32(5):296-304. · 1.59 Impact Factor
[show abstract][hide abstract] ABSTRACT: Pregnancy is thought to diminish a woman's appraisal of and affective response to stressors. To examine this assumption, we used an electronic diary and an ecological momentary assessment strategy to record women's (n = 85) experiences of positive and negative affect five times each day over 2 days within each trimester of pregnancy. The women also completed the Edinburgh Postnatal Depression Scale in each trimester. Multilevel modeling indicated nonlinear patterns for both positive and negative affect that differed by the level of depressive symptoms. The findings suggest that changes in the psychological experience over the course of pregnancy are dynamic and not progressively attenuated.
Archives of Women s Mental Health 08/2012; · 2.01 Impact Factor
[show abstract][hide abstract] ABSTRACT: Adherence to inhaled corticosteroids (ICS) remains poor among asthmatics, yet little is known about the efficacy of interventions to improve adherence. Implementing the Chronic Care Model (CCM) components among patients with respiratory disorders has been associated with an improvement in outcomes, yet little is known about its effects on ICS adherence in asthmatics.
We conducted a systematic review to assess the efficacy of interventions to improve ICS adherence among adult-asthmatics, and whether the use of CCM components (i.e., teaching self-management skills, providing decision support, delivery system design, and clinical information systems) resulted in greater ICS adherence.
All English language articles testing the efficacy of an intervention including ICS medication on outcome from MEDLINE and PsychINFO databases through Aug-2010 were reviewed. Interventions were categorized based on the inclusion of CCM components. We standardized treatment effects to obtain effect-size's (ES's) and we combined the ES's of studies according to the number of CCM components included in their interventions.
Eighteen studies met inclusion criteria. Inclusion of a greater number of CCM components within interventions was associated with stronger effects on ICS adherence outcomes, with interventions featuring one, two, and four CCM components having medium (ES = 0.29; 95%CI, 0.16-0.42), large (0.53; 0.40-0.66), and very-large (0.83; 0.69-0.98) effects respectively.
Findings provide support for using the CCM as a framework for the design and implementation of interventions to improve adherence among adult-asthmatics.
Respiratory medicine 07/2012; 106(9):1211-25. · 2.33 Impact Factor
[show abstract][hide abstract] ABSTRACT: BACKGROUND: Irritable bowel syndrome (IBS) is a functional disorder of the lower gastrointestinal (GI) tract affected by stress, which may benefit from a biopsychosocial treatment approach such as mindfulness-based stress reduction (MBSR). PURPOSE: A treatment as usual (TAU) wait-list controlled trial was conducted in Calgary, Canada to investigate the impact of MBSR on IBS symptoms. It was hypothesized that MBSR patients would experience greater reduction in overall IBS symptom severity and self-reported symptoms of stress relative to control patients. METHOD: Ninety patients diagnosed with IBS using the Rome III criteria were randomized to either an immediate MBSR program (n = 43) or to wait for the next available program (n = 47). Patients completed IBS symptom severity, stress, mood, quality of life (QOL), and spirituality scales pre- and post-intervention or waiting period and at 6-month follow-up. Intent-to-treat linear mixed model analyses for repeated measures were conducted, followed by completers analyses. RESULTS: While both groups exhibited a decrease in IBS symptom severity scores over time, the improvement in the MBSR group was greater than the controls and was clinically meaningful, with symptom severity decreasing from constantly to occasionally present. Pre- to post-intervention dropout rates of 44 and 23 % for the MBSR and control groups, respectively, were observed. At 6-month follow-up, the MBSR group maintained a clinically meaningful improvement in overall IBS symptoms compared to the wait-list group, who also improved marginally, resulting in no statistically significant differences between groups at follow-up. Improvements in overall mood, QOL, and spirituality were observed for both groups over time. CONCLUSIONS: The results of this trial provide preliminary evidence for the feasibility and efficacy of a mindfulness intervention for the reduction of IBS symptom severity and symptoms of stress and the maintenance of these improvements at 6 months post-intervention. Attention and self-monitoring and/or anticipation of MBSR participation may account for smaller improvements observed in TAU patients.
International Journal of Behavioral Medicine 05/2012; · 2.63 Impact Factor
[show abstract][hide abstract] ABSTRACT: We updated the evidence-based recommendations for the diagnosis, assessment, prevention, and treatment of hypertension in adults for 2012. The new recommendations are: (1) use of home blood pressure monitoring to confirm a diagnosis of white coat syndrome; (2) mineralocorticoid receptor antagonists may be used in selected patients with hypertension and systolic heart failure; (3) a history of atrial fibrillation in patients with hypertension should not be a factor in deciding to prescribe an angiotensin-receptor blocker for the treatment of hypertension; and (4) the blood pressure target for patients with nondiabetic chronic kidney disease has now been changed to < 140/90 mm Hg from < 130/80 mm Hg. We also reviewed the recent evidence on blood pressure targets for patients with hypertension and diabetes and continue to recommend a blood pressure target of less than 130/80 mm Hg.
The Canadian journal of cardiology 05/2012; 28(3):270-87. · 3.12 Impact Factor
[show abstract][hide abstract] ABSTRACT: Exaggerated and prolonged cardiovascular responses to mental stress have been implicated in the etiology of hypertension. Rumination may play a role in the maintenance or reactivation of cardiovascular responses to mental stress and prevent cardiovascular adaptation or create sensitization on reexposure. The purpose of this study was to evaluate the influence of trait rumination on patterns of cardiovascular response adaptation after repeated exposure to a mental stressor.
Cardiovascular data were collected from 82 undergraduate women during a baseline period and during a 5-minute emotional recall task on two separate occasions. Trait rumination was assessed using the Stress-Reactive Rumination Scale.
A series of session (Sessions 1 and 2)-by-trait rumination general linear model repeated-measures analyses of covariance revealed several session-by-trait rumination interactions, such that participants who displayed higher levels of trait rumination showed less SBP (partial η(2) = 0.83, p = .01), diastolic blood pressure (partial η(2) = 0.84, p = .01), and heart rate (partial η(2) = 0.82, p = .02) adaptation to the laboratory mental stress task at the second exposure relative to those with lower levels of trait rumination.
These findings suggest that trait rumination may contribute to sustained increases in blood pressure by influencing adaptation to mental stress.
Psychosomatic Medicine 03/2012; 74(3):258-62. · 4.08 Impact Factor