Editor's Note: The investigators from the Osher Center chose this issue to explore mind–body research focused on women and pregnancy. Unlike our experience with the focus on children and youth for the March 2017 JACM that revealed a relative dearth of mind–body studies, initial searches in this area reaped a significant yield of intriguing studies from which the team members made their choices. The studies selected include one on alleviating pain in breast cancer survivors, a second that casts light on gender-related differences in emotional regulation, and a third on a novel single-session program with an underserved population of pregnant women focused on fetal outcomes. A rich mix! —John Weeks, Editor-in-Chief, JACM
Easing Persistent Pain in Breast Cancer Survivors with Mindfulness-Based Cognitive Therapy
Improvements in the detection and treatment of breast cancer have resulted in an increasing number of women living long lives after treatment. Unfortunately, many are left with long-term physical and psychosocial morbidities. Persistent post-treatment pain is of considerable concern, affecting one of five breast cancer survivors and with moderate to severe pain lasting, on average, 5–9 years. This form of chronic cancer pain typically leads to complex combinations of physical, psychological, and social distress. Thus, there is growing interest in the use of holistic mind–body therapeutic approaches that therapeutically target multiple physical and psychosocial symptoms.
Johannsen et al. based at Aarhus University Hospital in Denmark recently published a series of articles evaluating the effectiveness and cost-effectiveness of mindfulness-based cognitive therapy (MBCT) for post-treatment breast cancer pain.1,2 They conducted a randomized wait-list-controlled trial with 129 breast cancer survivors reporting post-treatment pain (score ≥3 out of 10 on pain intensity or pain burden). Participants were randomly assigned to a manualized 8-week MBCT program or a wait-list control group. Of note, and differing from prior mind–body cancer studies, pain was the primary outcome of interest and was assessed with the Short Form McGill Pain Questionnaire 2 (SF-MPQ-2), the McGill Present Pain Intensity (PPI) subscale, and perceived pain intensity and pain burden (numeric rating scales). Secondary outcomes were quality of life, psychological distress, and self-reported use of pain medication.
Results based on linear models indicated statistically significant and clinically meaningful improvements in the MBCT versus control group for pain intensity (d = 0.61; p = 0.002). Statistically significant effects were also observed for PPI (d = 0.26; p = 0.026), neuropathic pain (d = 0.24; p = 0.036), quality of life (d = 0.42; p = 0.028), and nonprescription pain medication use (d = 0.40; p = 0.038). Of note, benefits to pain reduction and quality of life persisted at the 6-month follow-up. Formal economic analyses centered on healthcare utilization concluded that MBCT is cost-effective for reducing pain in breast care survivors treated for persistent pain.3
Although multiple prior studies of mind–body therapies in cancer have reported benefits to cancer-related quality of life and emotional well-being, few large scale randomized trials have been designed specifically to evaluate pain. This study suggests that MBCT is effective for managing chronic cancer pain and offers an approach that negates or minimizes the need for pharmacological pain management, which adds additional risks and side-effect. Of note, this study reported modest, yet statistically significant reductions in neuropathic pain, which is especially resistant to treatment, thus warranting further investigation.
Another strength of this study is exploratory analyses of effect moderators, which identified larger effects in patients with attachment avoidance behaviors, but dampened responses in patients exposed to radiotherapy.3 Further analyses identified the constructs of mindfulness nonreactivity and pain catastrophizing as important mediators of response.4 Collectively, this study illustrates how a well-designed and adequately powered study can address questions of clinical efficacy and cost-effectiveness, and also contribute insights into moderators and mediators that can inform optimization of clinical delivery.
Citations: 1. Johannsen M, O'Connor M, O'Toole MS, et al. Efficacy of mindfulness-based cognitive therapy on late post-treatment pain in women treated for primary breast cancer: A randomized controlled trial. J Clin Oncol 2016;34:3390–3399.
2. Johannsen M, Sørensen J, O'Connor M, et al. Mindfulness-based cognitive therapy (MBCT) is cost-effective compared to a wait-list control for persistent pain in women treated for primary breast cancer—Results from a randomized controlled trial. Psychooncology 2017. [Epub ahead of print]; DOI: 10.1002/pon.4450.
3. Johannsen M, O'Toole MS, O'Connor M, et al. Clinical and psychological moderators of the effect of mindfulness-based cognitive therapy on persistent pain in women treated for primary breast cancer—Explorative analyses from a randomized controlled trial. Acta Oncol 2017;56:321–328.
4. Johannsen M, O'Connor M, O'Toole MS, et al. Mindfulness-based cognitive therapy and persistent pain in women treated for primary breast cancer: Exploring possible statistical mediators—Results from a randomized controlled trial. Clin J Pain 2017. [Epub ahead of print]; DOI: 10.1097/AJP.0000000000000510.
Meditation for Psychological Distress: Do Women Really Benefit More Than Men?
Studies on psychological distress over the past 30+ years has suggested that men and women are different in the experience of psychological symptoms and distress. Historically, women have been shown to experience more distress than men and to respond to that stress in gender-specific ways. Multiple theories have been posited to explain this gender–distress relationship from methodological, cognitive-behavioral, and gender role perspectives. As a whole, research suggests that in response to distress, men tend to utilize more externalizing techniques (e.g., distraction and instrumental coping), whereas women tend to utilize more internalizing techniques (e.g., rumination and emotion-focused coping). Since meditation may improve psychological health through improving coping strategies, understanding gender differences in coping styles may have important implications. To date, however, little is known about gender-specific response mechanisms in the context of mind–body training.
In a provocative investigation by Rojiani et al.,1 the gender effects of meditation on affect and coping strategies were examined in a prospective, observational study in college students. One hundred and fourteen undergraduate students (N = 54 women) self-selected into 12-week courses that included didactic seminars and experiential “meditation labs.” Meditation labs were scheduled three times per week and included 30 min of a specific contemplative practice from Buddhist or Taoist traditions followed by 5–10 min of written reflection. Sessions primarily involved focused attention and open monitoring forms of practice. Participants completed questionnaires at baseline and 12 weeks including measures of affect, mindfulness, and self-compassion.
In the 77 participants (N = 36 women) who attended at least 50% of sessions and had complete data, investigators found that women showed a significant reduction in negative affect, whereas men showed a small, nonsignificant increase. The change in negative affect was correlated with change in mindfulness skills, awareness, nonreactivity, and self-compassion skills in women, but not in men. There were no baseline differences in positive or negative affect, nor differences in intervention adherence, to account for their results. Investigators posited that these data support prior theories of gender-based mechanistic differences in emotion regulation techniques. Mindfulness may decrease negative affect in women by decreasing ruminating tendencies (congruent with their emotional response), whereas increased attention toward thoughts and emotions in men (incongruent with their coping style) may result in increased negative affect.
Despite a large attrition rate and self-selected, age-limited sample, this work raises interesting questions and clinical implications. How can this information be used to better target the population that is most likely to benefit from mind–body interventions? Perhaps current mindfulness programs may be particularly suited to address emotional issues in women with certain coping styles. Perhaps we need to adapt mind–body interventions to better match individual male coping styles. How are these study results to be interpreted and applied in the context of a growing body of literature of mindfulness techniques being successfully used in male-dominated military and sports arenas?
A broader question also emerges. To what extent are these gender-specific responses even a result of physiology versus society-imposed gender norms? Although neuroimaging research using functional magnetic resonance imaging (fMRI) has shown that women demonstrate more activation of brain regions involved in emotional regulation, the mind–body literature in this area is still sparse. This line of inquiry is timely and will undoubtedly be important in our quest toward more individualized, targeted, and holistic mental healthcare.
Citation: 1. Rojiani R, Santoyo JF, Rahrig H, et al. Women benefit more than men in response to college-based meditation training. Front Psychol 2017;8:551.
Prenatal Yoga—The Effect of One Class on Fetal Well-Being
Per the American Congress of Obstetricians and Gynecologists (ACOG), pregnant women are encouraged to perform 30 min daily exercise (moderate intensity) on most days throughout the course of the pregnancy. Yoga can be considered a form of exercise that would meet these recommendations. As is well known, yoga has been shown to decrease stress and inflammatory markers in nonpregnant individuals. In pregnant individuals, it has been shown to have reduction in anxiety and depression parameters. However, very little is known about the effect of yoga on fetal parameters—especially if there are any adverse effects.
In this clever study by Babbar et al.,1 the authors conducted a single-blinded randomized prospective trial comparing a yoga sequence with the control intervention. A total of 46 patients (mean age, 25 years; 31 weeks gestational age) were randomized. The yoga intervention was delivered by a certified yoga instructor who had specialized training in prenatal yoga. It consisted of a one-time class involving 23 postures, 1 breathing technique, and an 8 to 10-min final resting pose. This was accompanied with educational materials to perform this at home. The control intervention received education based upon ACOG guidelines.
Outcomes were reported at baseline and immediately after the intervention. The primary outcome was fetal well-being, as assessed by umbilical artery Doppler indices (systolic to diastolic ratio, resistance index, and pulsatility index), fetal heart rate, and biophysical profiles. These findings were interpreted by a maternal–fetal medicine specialist who was blinded to the treatment assignment, as well as whether they were before or after the intervention.
No significant change in metrics of fetal well-being was found in the intervention group, as compared with the control, including findings in fetal blood flow or fetal behavior. Maternal parameters, including maternal heart rate and maternal blood pressure, also remained unchanged. Of note, the study found that both groups had increases in their report of exercising by participating in this study. This suggests that simple reiteration of recommendations can result in improved compliance with ACOG recommendations.
This study is unique in that it utilized a fetal outcome as the primary outcome. In addition, most patients studied were either uninsured or covered by Medicaid—suggesting that the simple intervention can be applicable in an underserved population. And although the study was limited by this being a one-time intervention, this is consistent with other prenatal studies. If yoga caused any type of fetal hypoxia or distress, it would have persisted in the time frame of the postintervention Doppler studies. As such, this study paves the way for future studies in pregnant women in diverse populations using a standardized prenatal yoga intervention.
Citation: 1. Babbar S, Hill JB, Williams KB, et al. Acute fetal behavioral response to prenatal yoga: A single, blinded, randomized controlled trial (TRY yoga). Am J Obstet Gynecol 2016;214:399.e1–e8.