Chi congres 2011 psychosocial research and practice Effect of Mindfulness-based cognitive therapy on Chronic cancer-related fatigue: faceto-face and online treatment
Fatigue Mindfulness Online therapy Marije van der Lee, Anette Pet, Eltica de Jager Meezenbroek Fieke Everts, Toesja Klein, Tanja van Dijk
Programme:
Problem:
-The problem: Chronic Cancer-related Fatigue CCRF -What helps? CBT and MBCT -What is MBCT? -MBCT face-to-face study -Implementation: development online MBCT -Online therapy www.Mindermoebijkanker.nl: -What does it look like? -First experiences and first results -New study: online MBCT and physical activity intervention
16% – 38% severly fatigued after cancer (versus 11%) (Gielissen, 2008) Characteristics 1. Sudden onset 2. Experienced as extreme 3. Takes longer time to recover 4. Often together with other somatic symptoms
Chi congres nov 2011 dr. Marije van der Lee
50 40
Percentage severly fatigued patients after different types of cancer 38
Functional Impariment 35 disease-free pts severely fatigued
180
28
30
disease-free pts not fatigued
% 20
120
10
60
0 rec r
wo rk
ale rt
wa lki ng
0 so c.i nt
Hodgkin 1 - 22 years after stem cell transplantation
mo b
Bone tumours 1 -15 years after end of treatment
sle ep ho us eh old
breastcancer 6 month-5 years after end of treatment
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Relation fatigue with earlier treatment
Evidence-based interventions
gem. vermoeidheidsscore
30
26 20
20
What helps?
25
26 no adjuvante therapy radiotherapy chemotherapy
10 radio- and chemotherapy
1. Cognitive Behavioural Therapy– (Prof. Bleyenberg, Dr. Gielissen, NKCVNijmegen) 2. Mindfulness Based Cognitieve Therapie (MBCT) – (van der Lee, Garssen)
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Mindfulness Based Cognitive Therapy MBCT • • •
MBCT changes automatic pilot
Paying attention in the present moment, non-judgementally Less experiental avoidance, less automatic behaviour Insight into thoughts, feelings and behaviour that increases fatigue and stress
Relational Frame theory: Hayes
Acceptance based therapy assumptions:
Cognitive control strategies to avoid unwanted states Thought suppression Worried rumination Distraction Internal and external control maintains distress/fatigue or causes rebound
Emotions are just emotions; thoughts are just thoughts; memories are just memories Emotions are information; not good or bad Control of internal events is not an option Control is the problem, not the solution
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Difference with CBT:
Difference with CBT:
Attention
Cognition – radically different understanding of the role of cognition in development and treatment of disorders
CBT emphasizes directing attention toward stimuli associated with disorder (or distract from) ABT emphasizes directing attention broadly toward flow of experience
Cognitions are causal vs. cognitions are responses Importance of content vs. importance of function Goal to change content vs. goal to change relationship to one’s own thoughts and feelings
Mechanisms in Mindfulness:
Steps in Mindfulness training:
Exposure to avoided emotional experience, leading to decreased distress via extinction Self-monitoring associated with improved appraisal of actual contingencies, leading to increased flexibility in responding State of relaxation (Baer, 2003; Teasdale et al. 2002; Segal et al. 2002)
Practice attention to a single sense Practice attention to the flow of experience Practice attention to thoughts, feelings, images as part of the flow of experience Practice attention to the flow of experience during activities
Assessing Fatigue Checklist Individual Strength (CIS) Ik voel me moe Ik ben gauw moe Ik voel me fit Lichamelijk voel ik me uitgeput
Mindfulness Based Cognitieve therapie 1. 2. 3. 4. 5.
Ik moet ook altijd alles doen Ik wil dat ze mijn moeheid begrijpen Ik moet alles perfect doen Ik kan weer niks Ik moet weer zijn zoals ik was voor ik ziek was
.
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Face-to-face MBCT study 83 curative patients (> 1 year after treatment) randomly allocated to waitinglist or MBCT ‘Minder Moe door minder stress’ (9 weeks, groups of 12) Van der Lee, M.L., Garssen, B. Psycho-oncology, 2010
MBCT consists of •9 session 2,5 hours •One session of 6 hours •Practicing awareness exercises at home each dag 45 min. •Accent during sessions is on experiencing
Treatment effect on CCRF 3.8 – 12.6 (95%CI)
50 48 46 44 42 40 38 36 34 32 30
Ernst ervaren vermoeidheid
Controle (n=23) Interventie (n=59) Partners
voor
na
follow-up
Implementation MBCT Minder Moe How can we reach all those patients living far from our institute, those who do not want to join a group, or for other reasons not want to come to an insitute for help? Training other psychologists and development of online therapy: www.mindermoebijkanker.nl
Intervention group 31% clinically relevant improvement versus 4% in the waiting list control group Van der Lee, M.L., Garssen, B. Psycho-oncology, 2010
Online therapy Minder Moe Bij Kanker Inclusion 1. Has or has had cancer, suffers severe chronic fatigue > half a year 2. No somatic cause that is treatable 3. Motivated to practice at home for about 45 min/day 4. >18 years or older
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Online therapy Minder Moe Bij Kanker Exclusion 1. Severe Major Depressive Episode 2. Psychotic delusions 3. Major life stressor at this moment (divorce or current intensive treatment with chemotherapy or radiotherapy).
Overall characteristics participants Between november 2009november 2011 315 online intakes, 14% in palliative / chronic phase, 75% female, mean age 50 years. End evaluation n =124 mensen, incl drop outs. 41,8% normalized fatigue.
What does it look like? - all online from admission to evaluation - individually - 9 sessions - Weekly new reader, exercises (mp3), logs to register experience with exercises - Personal feedback by therapist each week
Flow chart curatief online 98 gestart met online therapie; 57 eligible • N = 8 took longer than 3 months, could not be included • N= 13 no evaluation, • N =13 stopped, 2 on advice therapist
Exclusie • N = 10; 3 psychiatric comorbidity; 7 cancer recurrence • Complete data N = 26 curatively treated pts
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Results
Results
Online MBCT n= 26
Face-to-face MBCT n= 54
Wait-list n= 23
Online MBCT n= 26
Face-to-face MBCT n= 54
Wait-list n= 23
Treatment
Type of cancer Breast 30,8 Hodgkin 23,1 Prostate 0 GastroIntestinal 3,8
55,6 1,9 5,6 3,7
52,2 13 8,7 4,3
Surgery Chemoth. Radioth. Hormone th. Medication Sleep Pain Antidepr.
61,5 84,6 57,7 26,9
94,4 51,9 68,5 29,6
87 52,2 78,3 43,5
3,8 7,7 3,8
25,9 37 18,5
30,4 30,4 8,7
Resultaten Online vs face-to-face MBCT
Results Clinically relevant improvement Online 46% Face-to-face 31% Waiting list control 4%
(ANCOVA)
MBCT Minder Moe is effectief! Hoe bereiken we al die mensen die ver weg wonen, niet in een groep willen of om andere redenen niet naar het HDI willen of kunnen komen? Ontwikkeling internet variant:
www.mindermoebijkanker.nl online sinds november 2009
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Reasons to choose for online treatment •prettig om aan problemen te kunnen werken op elk moment van de dag of nacht, in plaats van te moeten wachten op een afspraak waar ik mijn therapeut zie 55 % • ik woon ver weg van een instelling die hulp aan kankerpatiënten biedt 29 % •ik ben niet of nauwelijks in staat om te reizen 23 %
New research projects
Questions?
Conclusion • First results are good • Patients value the possibility to work on their problem in their own time • Patients value their personal contact with their therapist • More people drop out than face-to-face • Obviously more research needs to be done:
•KWF/Alped’Huzes finance our new research project: a randomized controlled trial where we compare online MBCT with ambulant activity and with a control group. •We will also study the role of patient’s expectations and working mechanisms of both interventions.
‘Ik ben minder vaak moe en als ik last heb van vermoeidheid is dit niet meer zo'n allesoverheersende, uitputtende vermoeidheid. Ik doe veel meer, zowel qua werk als in mijn vrije tijd.’ ‘Ik ben rustiger en meer tevreden. Ik stel minder hoge eisen aan mezelf en probeer meer te genieten van hoe het loopt en heb niet meer torenhoge verwachtingen.’ ‘De training heeft me opgeleverd dat ik minder moe ben. Dat ik bewuster met de vermoeidheid en de daarbij behorende emoties omga. Meer aandacht aan mezelf schenk.’
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Helen Dowling Instituut ‘Dat ik soms wat negatief over mezelf denk, wist ik wel, maar dat ik zoveel negatieve gedachten heb, daarvan was ik me nou ook weer niet bewust.’ ‘De training heeft mij een groot cadeau gegeven namelijk rust in mijn hoofd. Anderen merken dat ook, zo hoor ik vaak. Ik ben nu tevreden met mijn leven met beperkingen. Heel belangrijk is ook dat ik me niet meer laat meeslepen door gedachten en gevoelens. Ontdekken hoe boos ik eigenlijk voortdurend was, was een moeilijk moment in de training.’
Begeleiding bij kanker Rubenslaan 190 3582 JJ Utrecht T 030 252 40 20 W www.hdi.nl W www.mindermoebijkanker.nl E
[email protected]
Met dank aan: Innovatiefonds Zorgverzekeraars & St. Willemien Cohen
Pilot resultaten
Resultaten
Verloop van de mate van mindfulness en subjectief gevoel van fit zijn
Online MBCT n= 26
Mindfulness & Fitheid 6,5
Wait-list n= 23
mindfulness fit
6
score
Face-to-face MBCT n= 54
5,5 5
gem= 5,66 st.dev= 0,41 gem= 5,68 st.dev= 0,56
4,5 4 1
2
3
4
5
6
7
8
9
sessions
Leeftijd Vrouw Met partner Opleiding
47,5 (11) 52,83 (9) 76,9 % 87 65,4 % 61,1 5,4 (1,5) 5,2 (1,6)
50,09 (11) 78,3 73,9 4,7 (1,8)
range 0- 7 Betaald werk 65,4 %
44,4
43,5
Resultaten Online MBCT n= 26
Face-to-face MBCT n= 54
Wait-list n= 23
Maanden sinds afronden behandeling 30,8(21,4)
35,4 (28,0)
38,8 (30,3)
Ernst van de vermoeidheid CIS bij aanvang 45,1 (6,7) 47,4 (6,3) 47,4 (6,7)
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