Preliminary validation of the Cognitive Affective Mindfulness Scale-Revised in cancer populations.

OBJECTIVE: A brief, valid, and comprehensive measure of mindfulness is needed for cancer populations. This study examined the factor structure, internal consistency, construct validity, and measurement invariance of the 10-item Cognitive Affective Mindfulness Scale-Revised (CAMS-R) in patients with cancer. METHODS: Patients with breast, gastrointestinal, lung, or prostate cancer (N = 404, 50% stage IV cancer, 51% women) were recruited from academic and public clinics in Indianapolis, IN. Patients completed the CAMS-R and other psychological measures at one time point. Confirmatory factor analysis (CFA) was used to examine the dimensionality of the CAMS-R. Internal consistency and construct validity were also assessed. Measurement invariance was examined for gender, cancer type, and cancer stage. RESULTS: CFA showed that the original CAMS-R structure with four first-order factors (attention, present focus, awareness, and acceptance) and one second-order factor (mindfulness) had a reasonable fit (RMSEA = 0.09, CFI = 0.95, SRMR = 0.04). Internal consistency was excellent (α = 0.90). The CAMS-R total score showed significant positive associations with several subscales of a widely used mindfulness questionnaire and self-compassion (rs = 0.61-0.66) and significant negative associations with anxiety, depressive symptoms, rumination, psychological inflexibility, and avoidant coping (rs = -0.35-0.58). Measurement invariance testing indicated that the CAMS-R was invariant across populations of varying genders, cancer types, and stages. CONCLUSIONS: Findings provide preliminary support for using the CAMS-R in cancer populations. Future research should assess the responsiveness of the CAMS-R to intervention.

Development and preliminary validation of the Brief Self-Compassion Inventory.

Research and clinical interest in self-compassion has grown due to its associations with physical and mental health benefits. Widely used measures of self-compassion have conceptual and psychometric limitations that warrant attention. The purpose of this project was to develop a new self-compassion measure, the Brief Self-Compassion Inventory (BSCI), and test its psychometric properties. We developed items for the BSCI based on theory, prior research, and expert and cancer patient feedback. The BSCI was then tested with adults diagnosed with breast, gastrointestinal, lung, or prostate cancer (N = 404). Confirmatory factor analysis suggested a unidimensional structure, and internal consistency reliability was excellent. Construct validity of the BSCI was established through its correlations with psychological variables hypothesized to be related to self-compassion, such as mindfulness, acceptance of cancer, and other coping strategies. Furthermore, measurement invariance testing of the BSCI indicated that it could be used across patients of varying genders, cancer types, and stages of illness. In conclusion, the 5-item BSCI was determined to be psychometrically sound and suitable for use with adults of varying genders, cancer types, and stages of disease. The measure warrants testing with other medical and nonclinical populations.

Symptom experiences in post-treatment cancer survivors: associations with acceptance and commitment therapy constructs.

PURPOSE: Acceptance and Commitment Therapy (ACT) has improved symptom and quality-of-life outcomes in pilot research with post-treatment cancer survivors. To further test the ACT model, the present study examined relationships between ACT constructs and subgroups of post-treatment survivors based on the severity of common symptoms. METHODS: Survivors who had completed primary treatment for stage I or II cancer (N = 203) participated in this one-time survey. Latent class analysis (LCA) was used to identify subgroups of survivors based on the severity of fatigue, sleep disturbance, pain, anxiety, and depressive symptoms. Multinomial logistic regressions employing Vermunt's 3-step approach were used to examine ACT constructs (e.g., mindfulness, acceptance, values progress) as correlates of survivor subgroups based on symptoms. RESULTS: The LCA showed three survivor classes: (1) mild-to-moderate levels of all symptoms except for normal pain intensity; (2) mild anxiety, moderate fatigue, and normal levels of all other symptoms; and (3) normal levels of all symptoms. Lower mindfulness, acceptance, and values progress and higher cognitive fusion, psychological inflexibility, and values obstruction were associated with a greater likelihood of being in class 1 or 2 than in class 3. CONCLUSION: Findings are consistent with the ACT model. Survivors with greater symptom burden reported greater withdrawal from personally meaningful activities and less acceptance of their cancer diagnosis and internal experiences (e.g., thoughts, feelings, symptoms). Findings provide strong justification for further testing of ACT to reduce symptom-related suffering in cancer survivors.

Relations of Mindfulness and Illness Acceptance With Psychosocial Functioning in Patients With Metastatic Breast Cancer and Caregivers.

OBJECTIVES: To examine relationships in mindfulness and illness acceptance and psychosocial functioning in patients with metastatic breast cancer and their family caregivers. SAMPLE & SETTING: 33 dyads from an academic cancer center in the United States. METHODS & VARIABLES: Participants completed questionnaires on mindfulness, illness acceptance, relationship quality, anxiety, and depressive symptoms. Dyadic, cross-sectional data were analyzed using actor-partner interdependence models. RESULTS: Greater nonjudging, acting with awareness, and illness acceptance among caregivers were associated with patients' and caregivers' perceptions of better relationship quality. Higher levels of these processes were associated with reduced anxiety and depressive symptoms in patients and caregivers. IMPLICATIONS FOR NURSING: Aspects of mindfulness and illness acceptance in dyads confer benefits that are primarily intrapersonal in nature. Nurses may consider introducing mindfulness and acceptance-based interventions to patients and caregivers with adjustment difficulties.

Psychological Processes and Symptom Outcomes in Mindfulness-Based Stress Reduction for Cancer Survivors: A Pilot Study.

OBJECTIVES: Growing evidence supports the efficacy of mindfulness-based interventions for symptoms in cancer survivors. Identifying theory-based psychological processes underlying their effects on symptoms would inform research to enhance their efficacy and cost-effectiveness. We conducted secondary analyses examining the effect of mindfulness-based stress reduction (MBSR) for cancer-related fatigue on mindfulness facets, self-compassion, and psychological inflexibility. We also examined whether changes in these processes were associated with the symptom outcomes of fatigue interference, sleep disturbance, and emotional distress. METHODS: Thirty-five persistently fatigued cancer survivors (94% female, 77% breast cancer survivors) were randomized to either MBSR for cancer-related fatigue or a waitlist control (WC) condition. Self-report measures were administered at pre-intervention, post-intervention, and 1-month follow-up. Then the WC group received MBSR and completed a post-intervention follow-up. RESULTS: Linear mixed modeling analyses of the first three time points showed steady increases over time for certain mindfulness facets (observing, acting with awareness, and nonjudging) and self-compassion in favor of the MBSR group. When analyzing pre- and post-intervention data across study conditions, none of the psychological processes predicted change in fatigue interference. However, increased nonjudging was associated with decreased sleep disturbance (ß = -.39, p = .003), and increased acting with awareness was associated with decreased emotional distress (ß = -.36, p = .003). Self-compassion did not predict change in symptom outcomes. CONCLUSIONS: Results point to specific psychological processes that may be targeted to maximize the efficacy of future MBSR interventions for cancer survivors.

Mindfulness Training Supports Quality of Life and Advance Care Planning in Adults With Metastatic Cancer and Their Caregivers: Results of a Pilot Study.

BACKGROUND: Emotional distress often causes patients with cancer and their family caregivers (FCGs) to avoid end-of-life discussions and advance care planning (ACP), which may undermine quality of life (QoL). Most ACP interventions fail to address emotional barriers that impede timely ACP. AIM: We assessed feasibility, acceptability, and preliminary effects of a mindfulness-based intervention to facilitate ACP for adults with advanced-stage cancer and their FCGs. DESIGN: A single-arm pilot was conducted to assess the impact of a 6-week group mindfulness intervention on ACP behaviors (patients only), QoL, family communication, avoidant coping, distress, and other outcomes from baseline (T1) to post-intervention (T2) and 1 month later (T3). PARTICIPANTS: Eligible patients had advanced-stage solid malignancies, limited ACP engagement, and an FCG willing to participate. Thirteen dyads (N = 26 participants) enrolled at an academic cancer center in the United States. RESULTS: Of eligible patients, 59.1% enrolled. Attendance (70.8% across 6 sessions) and retention (84.6% for patients; 92.3% for FCGs) through T3 were acceptable. Over 90% of completers reported high intervention satisfaction. From T1 to T3, patient engagement more than doubled in each of 3 ACP behaviors assessed. Patients reported large significant decreases in distress at T2 and T3. Family caregivers reported large significant improvements in QoL and family communication at T2 and T3. Both patients and FCGs reported notable reductions in sleep disturbance and avoidant coping at T3. CONCLUSIONS: The mindfulness intervention was feasible and acceptable and supported improvements in ACP and associated outcomes for patients and FCGs. A randomized trial of mindfulness training for ACP is warranted. The study is registered at ClinicalTrials.gov with identifier NCT02367508 ( https://clinicaltrials.gov/ct2/show/NCT02367508 ).

A Randomized Study Examining the Effects of Mild-to-Moderate Group Exercises on Cardiovascular, Physical, and Psychological Well-being in Patients With Heart Failure.

PURPOSE: To compare 2 mild-to-moderate group exercises and treatment as usual (TAU) for improvements in physical function and depressive symptoms. METHODS: Patients with heart failure (n = 70, mean age = 66 yr, range = 45-89 yr) were randomized to 16 wk of tai chi (TC), resistance band (RB) exercise, or TAU. RESULTS: Physical function differed by group from baseline to follow-up, measured by distance walked in the 6-min walk test (F = 3.19, P = .03). Tai chi participants demonstrated a nonsignificant decrease of 162 ft (95% confidence interval [CI], 21 to -345, P = .08) while distance walked by RB participants remained stable with a nonsignificant increase of 70 ft (95% CI, 267 to -127, P = .48). Treatment as usual group significantly decreased by 205 ft (95% CI, -35 to -374, P = .02) and no group differences occurred over time in end-systolic volume (P = .43) and left ventricular function (LVEF) (P = .67). However, groups differed over time in the Beck Depression Inventory (F = 9.2, P < .01). Both TC and RB groups improved (decreased) by 3.5 points (95% CI, 2-5, P < .01). Treatment as usual group decreased insignificantly 1 point (95% CI, -1 to 3, P = .27). CONCLUSIONS: Tai chi and RB participants avoided a decrease in physical function decrements as seen with TAU. No groups changed in cardiac function. Both TC and RB groups saw reduced depression symptoms compared with TAU. Thus, both TC and RB groups avoided a decrease in physical function and improved their psychological function when compared with TAU.

Differential Peripheral Inflammatory Factors Associated with Cognitive Function in Patients with Heart Failure.

OBJECTIVE: Cognitive deficits are common in patients with heart failure (HF), and can negatively affect self-care, predict rehospitalizations, and increase mortality rates 5-fold. Inflammation can produce vascular pathology, reducing cerebral blood flow to brain regions necessary for optimal cognitive function. The purpose of the investigation was to identify a pattern of peripheral blood inflammation-related biomarkers associated with cognitive impairment in patients with HF. METHODS: Forty-five outpatients (median age = 67 years, SD = 9.9) were recruited from University of California, San Diego (UCSD) and Veterans Affairs San Diego Healthcare Systems (VASDHS), diagnosed with New York Heart Association Stages I-III HF. Participants were administered the Montreal Cognitive Assessment (MoCA) as a measure of global cognitive impairment, and blood was analyzed for plasma biomarkers, interferon-γ, tumor necrosis factor-α (TNFα), soluble intercellular adhesion molecule-1 (sICAM-1), soluble vascular cell adhesion molecule-1 (sVCAM-1), brain-derived neurotrophic factor (BDNF), interleukin-8 (IL-8), matrix metallopeptidase-9 (MMP-9), IL-6, C-reactive protein (CRP), and serum amyloid-A (SAA). RESULTS: Almost half the patients scored below the threshold on the MoCA, indicating at least mild cognitive impairment. A factor analysis produced three biomarker factors: vascular inflammatory factor-1: TNFα, sICAM1, sVCAM1; neuroinflammatory factor-2: BDNF, MMP-9, IL-8; peripheral inflammatory factor-3: IL-6, CRP, SAA. Only vascular inflammatory factor-1 was significantly associated with cognitive function (MoCA) (ΔR2 = 0.214, beta = -0.468, p = 0.008). CONCLUSIONS: In this cohort with HF, vascular inflammation appears related to poorer cognitive function. This could indicate targets for treatment to reduce cognitive deficits in HF. However, this is a preliminary study, and further research is needed.

Pilot Randomized Study of a Gratitude Journaling Intervention on Heart Rate Variability and Inflammatory Biomarkers in Patients With Stage B Heart Failure.

OBJECTIVE: Stage B, asymptomatic heart failure (HF) presents a therapeutic window for attenuating disease progression and development of HF symptoms, and improving quality of life. Gratitude, the practice of appreciating positive life features, is highly related to quality of life, leading to development of promising clinical interventions. However, few gratitude studies have investigated objective measures of physical health; most relied on self-report measures. We conducted a pilot study in Stage B HF patients to examine whether gratitude journaling improved biomarkers related to HF prognosis. METHODS: Patients (n = 70; mean [standard deviation] age = 66.2 [7.6] years) were randomized to an 8-week gratitude journaling intervention or treatment as usual. Baseline (T1) assessments included the six-item Gratitude Questionnaire, resting heart rate variability (HRV), and an inflammatory biomarker index. At T2 (midintervention), the six-item Gratitude Questionnaire was measured. At T3 (postintervention), T1 measures were repeated but also included a gratitude journaling task. RESULTS: The gratitude intervention was associated with improved trait gratitude scores (F = 6.0, p = .017, η = 0.10), reduced inflammatory biomarker index score over time (F = 9.7, p = .004, η = 0.21), and increased parasympathetic HRV responses during the gratitude journaling task (F = 4.2, p = .036, η = 0.15), compared with treatment as usual. However, there were no resting preintervention to postintervention group differences in HRV (p values > .10). CONCLUSIONS: Gratitude journaling may improve biomarkers related to HF morbidity, such as reduced inflammation; large-scale studies with active control conditions are needed to confirm these findings. TRIAL REGISTRATION: Clinicaltrials.govidentifier:NCT01615094.

The Role of Gratitude in Spiritual Well-being in Asymptomatic Heart Failure Patients.

Spirituality and gratitude are associated with wellbeing. Few if any studies have examined the role of gratitude in heart failure (HF) patients or whether it is a mechanism through which spirituality may exert its beneficial effects on physical and mental health in this clinical population. This study examined associations bet ween gratitude, spiritual wellbeing, sleep, mood, fatigue, cardiac-specific self-efficacy, and inflammation in 186 men and women with Stage B asymptomatic HF (age 66.5 years ±10). In correlational analysis, gratitude was associated with better sleep (r=-.25, p<0.01), less depressed mood (r=-.41, p<0.01), less fatigue (r=-.46, p<0.01), and better self-efficacy to maintain cardiac function (r=.42, p<0.01). Patients expressing more gratitude also had lower levels of inflammatory biomarkers (r=-.17, p<0.05). We further explored relationships among these variables by examining a putative pathway to determine whether spirituality exerts its beneficial effects through gratitude. We found that gratitude fully mediated the relationship between spiritual wellbeing and sleep quality (z=-2.35, SE=.03, p=.02) and also the relationship between spiritual wellbeing and depressed mood (z=-4.00, SE=.075, p<.001). Gratitude also partially mediated the relationships between spiritual wellbeing and fatigue (z=-3.85, SE=.18, p<.001), and between spiritual wellbeing and self-efficacy (z=2.91, SE=.04, p=.003). In sum, we report that gratitude and spiritual wellbeing are related to better mood and sleep, less fatigue, and more self-efficacy, and that gratitude fully or partially mediates the beneficial effects of spiritual wellbeing on these endpoints. Efforts to increase gratitude may be a treatment for improving wellbeing in HF patients' lives and be of potential clinical value.

Effects of COMT genotype on cognitive ability and functional capacity in individuals with schizophrenia.

Cognitive and functional impairments are core features of schizophrenia. This study examined the catechol-O-methyltransferase (COMT) genotype and its relationship to cognition and functional capacity in 188 individuals with schizophrenia or schizoaffective disorder. We found that in a dose-response fashion, individuals with more Met alleles performed significantly better on tests of learning/memory and abstraction. The effects of COMT genotype on cognition were modest, explaining about 3% of the variance in learning/memory and abstraction. Larger studies will be needed to examine the relationships between COMT and other genes and cognitive performance and everyday functioning.