Testing the effectiveness of a mindfulness-based intervention to reduce emotional distress in outpatients with diabetes (DiaMind): design of a randomized controlled trial

Meditation for the primary and secondary prevention of cardiovascular disease

BACKGROUND

Interventions incorporating meditation to address stress, anxiety, and depression, and improve self-management, are becoming popular for many health conditions. Stress is a risk factor for cardiovascular disease (CVD) and clusters with other modifiable behavioural risk factors, such as smoking. Meditation may therefore be a useful CVD prevention strategy.

OBJECTIVES

To determine the effectiveness of meditation, primarily mindfulness-based interventions (MBIs) and transcendental meditation (TM), for the primary and secondary prevention of CVD.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases, and two trials registers on 14 November 2021, together with reference checking, citation searching, and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of 12 weeks or more in adults at high risk of CVD and those with established CVD. We explored four comparisons: MBIs versus active comparators (alternative interventions); MBIs versus non-active comparators (no intervention, wait list, usual care); TM versus active comparators; TM versus non-active comparators.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were CVD clinical events (e.g. cardiovascular mortality), blood pressure, measures of psychological distress and well-being, and adverse events. Secondary outcomes included other CVD risk factors (e.g. blood lipid levels), quality of life, and coping abilities. We used GRADE to assess the certainty of evidence.

MAIN RESULTS

We included 81 RCTs (6971 participants), with most studies at unclear risk of bias. MBIs versus active comparators (29 RCTs, 2883 participants) Systolic (SBP) and diastolic (DBP) blood pressure were reported in six trials (388 participants) where heterogeneity was considerable (SBP: MD -6.08 mmHg, 95% CI -12.79 to 0.63, I2 = 88%; DBP: MD -5.18 mmHg, 95% CI -10.65 to 0.29, I2 = 91%; both outcomes based on low-certainty evidence). There was little or no effect of MBIs on anxiety (SMD -0.06 units, 95% CI -0.25 to 0.13; I2 = 0%; 9 trials, 438 participants; moderate-certainty evidence), or depression (SMD 0.08 units, 95% CI -0.08 to 0.24; I2 = 0%; 11 trials, 595 participants; moderate-certainty evidence). Perceived stress was reduced with MBIs (SMD -0.24 units, 95% CI -0.45 to -0.03; I2 = 0%; P = 0.03; 6 trials, 357 participants; moderate-certainty evidence). There was little to no effect on well-being (SMD -0.18 units, 95% CI -0.67 to 0.32; 1 trial, 63 participants; low-certainty evidence). There was little to no effect on smoking cessation (RR 1.45, 95% CI 0.78 to 2.68; I2 = 79%; 6 trials, 1087 participants; low-certainty evidence). None of the trials reported CVD clinical events or adverse events. MBIs versus non-active comparators (38 RCTs, 2905 participants) Clinical events were reported in one trial (110 participants), providing very low-certainty evidence (RR 0.94, 95% CI 0.37 to 2.42). SBP and DBP were reduced in nine trials (379 participants) but heterogeneity was substantial (SBP: MD -6.62 mmHg, 95% CI -13.15 to -0.1, I2 = 87%; DBP: MD -3.35 mmHg, 95% CI -5.86 to -0.85, I2 = 61%; both outcomes based on low-certainty evidence). There was low-certainty evidence of reductions in anxiety (SMD -0.78 units, 95% CI -1.09 to -0.41; I2 = 61%; 9 trials, 533 participants; low-certainty evidence), depression (SMD -0.66 units, 95% CI -0.91 to -0.41; I2 = 67%; 15 trials, 912 participants; low-certainty evidence) and perceived stress (SMD -0.59 units, 95% CI -0.89 to -0.29; I2 = 70%; 11 trials, 708 participants; low-certainty evidence) but heterogeneity was substantial. Well-being increased (SMD 0.5 units, 95% CI 0.09 to 0.91; I2 = 47%; 2 trials, 198 participants; moderate-certainty evidence). There was little to no effect on smoking cessation (RR 1.36, 95% CI 0.86 to 2.13; I2 = 0%; 2 trials, 453 participants; low-certainty evidence). One small study (18 participants) reported two adverse events in the MBI group, which were not regarded as serious by the study investigators (RR 5.0, 95% CI 0.27 to 91.52; low-certainty evidence). No subgroup effects were seen for SBP, DBP, anxiety, depression, or perceived stress by primary and secondary prevention. TM versus active comparators (8 RCTs, 830 participants) Clinical events were reported in one trial (201 participants) based on low-certainty evidence (RR 0.91, 95% CI 0.56 to 1.49). SBP was reduced (MD -2.33 mmHg, 95% CI -3.99 to -0.68; I2 = 2%; 8 trials, 774 participants; moderate-certainty evidence), with an uncertain effect on DBP (MD -1.15 mmHg, 95% CI -2.85 to 0.55; I2 = 53%; low-certainty evidence). There was little or no effect on anxiety (SMD 0.06 units, 95% CI -0.22 to 0.33; I2 = 0%; 3 trials, 200 participants; low-certainty evidence), depression (SMD -0.12 units, 95% CI -0.31 to 0.07; I2 = 0%; 5 trials, 421 participants; moderate-certainty evidence), or perceived stress (SMD 0.04 units, 95% CI -0.49 to 0.57; I2 = 70%; 3 trials, 194 participants; very low-certainty evidence). None of the trials reported adverse events or smoking rates. No subgroup effects were seen for SBP or DBP by primary and secondary prevention. TM versus non-active comparators (2 RCTs, 186 participants) Two trials (139 participants) reported blood pressure, where reductions were seen in SBP (MD -6.34 mmHg, 95% CI -9.86 to -2.81; I2 = 0%; low-certainty evidence) and DBP (MD -5.13 mmHg, 95% CI -9.07 to -1.19; I2 = 18%; very low-certainty evidence). One trial (112 participants) reported anxiety and depression and found reductions in both (anxiety SMD -0.71 units, 95% CI -1.09 to -0.32; depression SMD -0.48 units, 95% CI -0.86 to -0.11; low-certainty evidence). None of the trials reported CVD clinical events, adverse events, or smoking rates.

AUTHORS' CONCLUSIONS

Despite the large number of studies included in the review, heterogeneity was substantial for many of the outcomes, which reduced the certainty of our findings. We attempted to address this by presenting four main comparisons of MBIs or TM versus active or inactive comparators, and by subgroup analyses according to primary or secondary prevention, where there were sufficient studies. The majority of studies were small and there was unclear risk of bias for most domains. Overall, we found very little information on the effects of meditation on CVD clinical endpoints, and limited information on blood pressure and psychological outcomes, for people at risk of or with established CVD. This is a very active area of research as shown by the large number of ongoing studies, with some having been completed at the time of writing this review. The status of all ongoing studies will be formally assessed and incorporated in further updates.

The efficacy of theory driven treatment adherence promotion program among type 2 diabetic patients: application of intervention mapping and mHealth

Background

Mobile health interventions (mHealth) may improve health-related lifestyle behaviors and disease management. Successful management of diabetes is patient-centered responsibility. The aim of this research was to determine the efficacy of the theory driven program of promoting treatment adherence in type 2 diabetes (T2DM) patients based on mHealth.

Methods

This quasi-experimental research was conducted on 70 T2DM patients in Tehran, Iran. Participants were randomly divided into intervention (n = 35) or control (n = 35) groups. The data collection tool was a questionnaire based on some of constructs Social Cognitive Theory (SCT) which elicit from formative evaluation. The SCT theory-based intervention program was developed, implemented, and evaluated based on Intervention Mapping (IM) as a framework in 8 sessions using online WhatsApp application. The data was collected through by online interviews before and one month after the implementation of the program and analyzed in SPSS version 16.

Results

After the implementation of the program, a significant increase in self-efficacy (P = 0.009), outcome expectations (P < 0.001), and also diabetes treatment adherence behaviors (P = 0.024) were indicated in the intervention group. The estimated effect sizes for self-efficacy, outcome expectations, social support, and diabetes treatment adherence behaviors were 0.78, 0.06, 0.07, and 0.62, respectively.

Conclusion

Estimated effect size of the implemented intervention was evaluated as "large" effect for diabetes treatment adherence behaviors. Findings indicated the usefulness and efficacy of the mHealth educational program based on SCT constructs and the IM approach in treatment adherence behaviors promotion among T2DM patients in Iran.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-023-01291-5.

Phytofabrication of Silver Nanoparticles and Their Potent Antifungal Activity against Phytopathogenic Fungi

Fungal plant pathogens cause huge losses in agricultural production by decreasing crop yield and quality. To reduce crop loss from fungal damage, various synthetic fungicides are applied indiscriminately in agricultural practice. The majority of synthetic fungicides are non-biodegradable, and several critical human health risks are associated with them. Green synthesis nanotechnology offers an effectual, cost-effective, ecofriendly, and innocuous method for the synthesis of green nanofungicides, an excellent replacement for synthetic chemical fungicides. Origanum majorana is an aromatic herb with immense pharmacological and medicinal properties. In this context, the present study used the leaves of O. majorana to synthesize silver nanoparticles. The biosynthesized particles showed an absorption peak at 441 nm with ultraviolet-visible spectrophotometry (UV-Vis). The spectra obtained from Fourier transform infrared spectroscopy (FT-IR) of O. majorana extract and AgNPs showed a myriad of functional groups corresponding to vital biomolecules that act as capping and reducing agents. The synthesized silver nanoparticles were spheroidal, and their size measured between 8 nm and 42 nm, as depicted by transmission electron microscopy (TEM). The energy-dispersive X-ray spectrum (EDX) showed a silver peak at 3 keV. The phytofabricated silver NPs demonstrated robust inhibitory activity on the mycelial growth of A. alternata f sp. lycopersici (87%), followed by Pestalotiopsis mangiferae (85%), Macrophomina phaseolina (78%), and Colletotrichum musae (75%). The minimum inhibitory concentration value for A. alternata. f sp. lycopersici and Pestalotiopsis mangiferae was 2 μg/mL, while the minimum fungicidal concentrations were 4 and 8 μg/mL, respectively. Additionally, the fabricated AgNPs induced severe damaging and destructive effects to the morphology of hyphae and conidia, as witnessed by scanning electron microscopy studies.

Does self-esteem mediate the association between perfectionism and mindfulness among Lebanese university students?

Objectives

To evaluate the associations between mindfulness, self-esteem and perfectionism in a Lebanese sample of university students, as well as the indirect effect of self-esteem between mindfulness and perfectionism was investigated.

Methods

This cross-sectional study was carried out between July and September 2021. A total of 363 university students were recruited through convenience sampling through several universities in Lebanon’s governorates. An online survey that included a part that collected sociodemographic information, the Freiburg Mindfulness Inventory to assess mindfulness, the Rosenberg Self‐Esteem Scale to assess self-esteem and the Big Three Perfectionism Scale to assess perfectionism was completed by participants.

Results

Higher self-esteem (Beta = 1.30) was significantly associated with more mindfulness, whereas higher self-critical perfectionism (Beta = − 0.61) was significantly associated with less mindfulness. Self-esteem mediated the association between self-critical and narcissistic perfectionism and mindfulness. More perfectionism was significantly and directly associated with less mindfulness and lower self-esteem, whereas higher self-esteem was significantly associated with more mindfulness.

Conclusion

This study provides valuable findings that enable practitioners to effectively identify people needing interventions to improve psychological health through mindfulness, self-esteem and perfectionism. The conclusions that can be deduced from this study can help educational psychologists and counselors guide university students towards effective mindfulness practices that can increase self-esteem levels and balance maladaptive perfectionism that can cause distress and impairment in the social and academic settings.

Origanum majorana L.: A Nutritional Supplement With Immunomodulatory Effects

Origanum majorana L. is an aromatic herb that has been grown in several Mediterranean countries since ancient times, but became popular during the Middle Ages as a medicinal plant and seasoning ingredient. O. majorana has many pharmacological effects, but its immunoreactive components and mechanisms are still unclear. In this study, four compounds were isolated and identified from O. majorana by a spectral analysis, including ¹H and ¹³C-NMR. They were 1H-indole-2-carboxylic acid (1), (+)-laricresol (2), (+)-isolaricresol (3), and procumboside B (4, pB), which were isolated for the first time in O. majorana. The immunomodulatory effects of the four compounds were screened, and pB had good immunomodulatory activity on RAW 264.7 cells. The immunomodulatory mechanism of pB was proved, in which pB could increase the secretion of nitric oxide (NO), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and reactive oxygen species (ROS) and simultaneously upregulate the expression of CD80 and CD86 on the cell surface. These results suggested that the mechanism of pB may be related to the activation of nuclear factor-kappaB (NF-κB) and mitogen-activated protein kinases (MAPKs)-signaling pathways. O. majorana is rich in nutrients and is commonly used in diets, so it can be used as a nutritional supplement with immunomodulatory effects.

Traditional use, phytochemistry, toxicology, and pharmacology of Origanum majorana L

ETHNOPHARMACOLOGICAL RELEVANCE

Origanum majorana L., is an aromatic and medicinal plant distributed in different parts of Mediterranean countries. This species is widely used in traditional medicine for the treatment of many diseases such as allergies, hypertension, respiratory infections, diabetes, stomach pain, and intestinal antispasmodic.

AIM OF THE REVIEW

This work reports previous studies on O. majorana concerning its taxonomy, botanical description, geographical distribution, traditional use, bioactive compounds, toxicology, and biological effects.

MATERIALS AND METHODS

Different scientific data bases such as Web of Science, Scopus, Wiley Online, SciFinder, Google Scholar, PubMed, ScienceDirect, and SpringerLink were consulted to collect data about O. majorana. The presented data emphasis bioactive compounds, traditional uses, toxicological investigations, and biological activities of O. majorana.

RESULTS

The findings of this work marked an important correlation between the traditional use of O. majorana as an anti-allergic, antihypertensive, anti-diabetic agent, and its biological effects. Indeed, pharmacological investigations showed that essential oils and extracts from O. majorana exhibit different biological properties, particularly; antibacterial, antifungal, antioxidant, antiparasitic, antidiabetic, anticancer, nephrotoxicity protective, anti-inflammatory, analgesic and anti-pyretic, hepatoprotective, and antimutagenic effects. Toxicological evaluation confirmed the safety and innocuity of this species and supported its medicinal uses. Several bioactive compounds belonging to different chemical family such as terpenoids, flavonoids, and phenolic acids were also identified in O. majorana.

CONCLUSIONS

The results suggest that the pharmacological properties of O. majorana confirm its traditional uses. Indeed, O. majorana essential oils showed remarkable antimicrobial, antioxidant, anticancer, anti-inflammatory, antimutagenic, nephroprotective, and hepatoprotective activities. However, further investigations regarding the evaluation of molecular mechanisms of identified compounds against human cancer cell lines, inflammatory process, and microbial infections are needed to validate pharmacodynamic targets. The toxicological investigation of O. Majorana confirmed its safety and therefore encouraged pharmacokinetic evaluation tests to validate its bioavailability.

"Perceived stress" and its associated factors among diabetic patients receiving care from a rural tertiary health care center in South India

BACKGROUND

"Stress" acts as both etiological link and also as an outcome in the case of diabetes mellitus. There is a paucity of literature regarding stress levels and also factors associated with it among diabetic patients in India.

OBJECTIVE

To assess the perceived stress levels and their associated factors among diabetic inpatients in a rural tertiary health care center, South India.

MATERIALS AND METHODS

A facility-based cross-sectional analytical study was conducted among inpatient diabetics seeking care at a rural tertiary care center in Kolar district of Karnataka. A pre-tested semi-structured questionnaire was used to capture the sociodemographic, disease-related, treatment-related and behavior-related characteristics of the inpatients. The outcome of "perceived stress" was captured using a standard questionnaire of Cohen Perceived Stress Scale-10. Poisson regression was used for multivariable analysis, and the association was expressed as prevalence ratio with 95% confidence intervals (CI).

RESULTS

Out of the 247 study participants analysed, "perceived stress" was seen among 97 (39.3%) of the participants (95% CI: 33.3%-45.5%). Multivariable analysis showed that factors like younger age, lesser duration of diabetes, presence of any comorbidity, being underweight, having conflicts at work place/home in the last 1 month, and not having enough money for treatment had shown higher levels of "perceived stress."

CONCLUSION

About two out of five inpatient diabetics seeking care from rural tertiary health centres had shown to have "perceived stress." There is a need for the inclusion of stress management techniques in the diabetes education program at all levels of health-care systems.

Study protocol for a randomized control trial to investigate the effectiveness of an 8-week mindfulness-integrated cognitive behavior therapy (MiCBT) transdiagnostic group intervention for primary care patients

BACKGROUND

Effective transdiagnostic treatments for patients presenting with principal or comorbid symptoms of anxiety and depression enable more efficient provision of mental health care and may be particularly suitable for the varied population seen in primary healthcare settings. Mindfulness-integrated cognitive behavior therapy (MiCBT) is a transdiagnostic intervention that integrates aspects of CBT, including exposure skills targeting avoidance, with training in mindfulness meditation skills adopted from the Vipassana or insight tradition taught by the Burmese teachers U Ba Khin and Goenka. MiCBT is distinguished from both cognitive therapy and mindfulness-based cognitive therapy by the use of a theoretical framework which proposes that the locus of reinforcement of behavior is the interoceptive experience (body sensations) that co-arises with self-referential thinking. Consequently, MiCBT has a strong focus on body scanning to develop interoceptive awareness and equanimity. Designed for clinical purposes, the four-stage systemic approach of MiCBT, comprising intra-personal (Stage 1) exposure (Stage 2), interpersonal (Stage 3), and empathic (Stage 4) skillsets, is a distinguishing feature among other mindfulness-based interventions (MBIs). The aim of this study is to investigate whether and how group MiCBT decreases depression and anxiety symptoms for patients with a range of common mental health conditions.

METHODS

Participants (n = 120) recruited via medical practitioner referral will be randomized to MiCBT or a wait-list control. Inclusion criteria are age 18-75; fluent in English and having a Kessler Psychological Distress Scale (K10) score of 20 or more. The MiCBT treatment group receive an 8-week MiCBT intervention delivered in a private psychology practice. Participants complete a suite of online self-report measures and record the amount of meditation practice undertaken each week. The control group receive usual treatment and complete the measures at the same time points. Primary outcome measures are the Depression Anxiety Stress Scale-21 (DASS-21) and K10. Analysis will use mixed-model repeated measures.

DISCUSSION

The potential ability of MiCBT to provide a comprehensive therapeutic system that is applicable across diagnostic groups would make it an attractive addition to the available MBIs.

TRIAL REGISTRATION

This trial is registered with the Australia and New Zealand Clinical Trials Registry: ACTRN12617000061336; Date of registration: 11th January 2017.

Self-care behaviors in patients with type 2 diabetes: Education intervention base on social cognitive theory

AIM

This study aimed to determine the effect of education intervention, based on social cognitive theory, on self-care behaviors in patients with type 2 diabetes.

METHODS

This study was conducted in descriptive and interventional stages. The effective factors and constructs of social cognitive theory were identified in a descriptive study (n = 320). After that, a quasi-experimental study was conducted to determine the effect of intervention on 120 diabetic patients whom were randomly assigned to experimental and control groups. The educational intervention was implemented in six 40 -minute sessions for the experimental group. The questionnaires were completed before, immediately after and three months after the intervention.

RESULTS

The results of regression showed that emotional adaptation (P < 0.05), self-efficacy to overcome barriers (P < 0.05) and self-regulation (P < 0.05) could predict self-care. There was no significant difference between the experimental and control groups before the educational intervention, however, after the intervention, there was a significant difference in self-care (p < 0.001), knowledge (p < 0.001), outcome expectations (p < 0.001), outcome value (p < 0.001), self-efficacy (p < 0.001), self-efficacy to overcome barriers(P < 0.001) p), environment (p < 0.001), observational learning (P < 0.05), situational perception (p < 0.001), self-regulation (p < 0.001) and emotional adaptation (p < 0.001)) in the intervention group.

CONCLUSION

The results of this study showed that intervention, based on social cognitive model, has a positive effect on diabetes self-care in the patients. Emotional adaptation, self-efficacy to overcome barriers and self-regulation have the biggest impact on diabetes self-care.

The effectiveness of stress management training on blood glucose control in patients with type 2 diabetes

BACKGROUND

Type 2 diabetes is a chronic disease that is expanding at an alarming rate in the world. Research on individuals with type 2 diabetes showed that stressful life events cause problems in the effective management and control of diabetes. This study aimed at investigating the effect of a stress management intervention on blood glucose control in individuals with type 2 diabetes referred to Zarandeh clinic, Iran.

METHODS

In this experimental study, 230 individuals with type 2 diabetes (179 female and 51 male) were enrolled and assigned to experimental (n = 115) and control (n = 115) groups. A valid and reliable multi-part questionnaire including demographics, Perceived Stress Scale, Coping Inventory for Stressful Situations, Coping Self-Efficacy Scale, and multidimensional scale of perceived social support was used to for data collection. The experimental group received a training program, developed based on the social cognitive theory and with an emphasis on improving self-efficacy and perceived social support, during eight sessions of one and a half hours. Control group received only standard care. Data were analyzed using SPSS 15 applying the t test, paired t-tests, Pearson correlation coefficient, and Chi square analysis. The significance level was considered at 0.05.

RESULTS

Before the intervention, the mean perceived stress scores of the experimental and control groups were 33.9 ± 4.6 and 35 ± 6.5, respectively, and no significant difference was observed (p > 0.05). However, after the intervention, the mean perceived stress score of the experimental group (26.7 ± 4.7) was significantly less than that of the control group (34.5 ± 7) (p = 0.001). Before the intervention, the mean scores of HbA1c in the experimental and control groups were 8.52 ± 1 and 8.42 ± 1.2, respectively, and there was no significant difference between the two groups. However, after the intervention, the results showed a significant decrease in glycosylated hemoglobin levels in the experimental group (p ≤ 0.05). Moreover, after the intervention, the result showed a significant difference between the mean scores of all aspects of Coping Inventory for Stressful Situations, coping self-efficacy, and perceived social support in the two groups (p < 0.05).

CONCLUSION

Our results suggested that the theory-based stress management intervention based on social cognitive theory may help to decrease stress and increase coping self-efficacy, stress management, perceived social support, and lead to a reduction in the glycosylated hemoglobin levels among patients with diabetes.

Does Mindfulness-Based Cognitive Therapy benefit all people with diabetes and comorbid emotional complaints equally? Moderators in the DiaMind trial

OBJECTIVES

Research has shown the effectiveness of mindfulness-based interventions for a variety of emotional problems in different samples, but it is unknown which factors influence this effectiveness. Therefore, the aim of the current study was: which factors (demographic, personality, and baseline levels of mindfulness skills) moderate the effectiveness of Mindfulness-Based Cognitive Therapy (MBCT)?

METHODS

Outpatients with diabetes (type 1 or type 2; N=139) and an elevated level of emotional distress participated in the Diabetes and Mindfulness (DiaMind) trial. They were randomized into MBCT (N=70) or a control group (N=69) that received treatment as usual and that was offered the intervention 6months later. Primary outcomes were anxiety, depressive symptoms, and perceived stress at post-intervention and at 6-month follow-up.

RESULTS

Mixed models analyses showed that sex, extraversion, and baseline acting with awareness were significant moderators of effectiveness. In the MBCT group, women showed larger decreases in anxiety and depression across time (large effects) compared to men (medium to small effects). For extraversion divided into quartiles, the three lowest quartiles generally exhibited large decreases in symptoms, whereas the high extraversion group showed medium (perceived stress) to small (depression) decreases.

CONCLUSION

MBCT seems to be effective to decrease symptoms of anxiety, depression, and perceived stress for a broad range of person characteristics in patients with diabetes. However, men and those high in extraversion showed considerably lower effectiveness compared to the other groups. The small effect in high extraverts may be due to the large dropout in this subgroup.

Mindfulness facets as differential mediators of short and long-term effects of Mindfulness-Based Cognitive Therapy in diabetes outpatients: Findings from the DiaMind randomized trial

BACKGROUND

There is increasing evidence that mindfulness-based interventions reduce psychological distress in various medical populations. However, it has hardly been studied if these effects are mediated by an increase in mindfulness. The aim of this study was to examine mediating effects of various mindfulness facets on effects of a Mindfulness Based Cognitive Therapy (MBCT) on perceived stress and mood.

METHODS

Outpatients with diabetes types 1 and 2 and low levels of emotional wellbeing were randomized into a group receiving MBCT (n=70) or a waiting-list control group (n=69). Primary outcomes were mood and perceived stress. Before, after and at follow-up (6months post intervention) relevant questionnaires were completed.

RESULTS

Mediation analysis using bootstrap resampling indicated that increases in total mindfulness and the facets observing and nonreactivity mediated the effects of the intervention on depressed and angry mood, anxiety (only observing), and perceived stress (only nonreactivity) from pre- to post-intervention. In contrast, from post-intervention to follow-up, besides total mindfulness the facets of acting with awareness and nonjudging mediated the effects on depressed, anxious, and angry mood, while only nonjudging mediated the effects on perceived stress.

DISCUSSION

The findings indicate that increases in levels of mindfulness mediate the effects of the Mindfulness-Based Cognitive Therapy in patients with diabetes. It is notable that different facets may be important for immediate change versus long-term outcome. These findings might be relevant for post-intervention care.

[Effects of Self-management Program applying Dongsasub Training on Self-efficacy, Self-esteem, Self-management Behavior and Blood Pressure in Older Adults with Hypertension]

PURPOSE

The purpose of this study was to develop a self-management program applying Dongsasub training based on self-efficacy theory, and to verify the program effectiveness on self-esteem as well as self-efficacy, self-management behaviors, and blood pressure.

METHODS

The study design was a non-equivalent, pre-post controlled quasi-experiment study. Thirty-eight patients aged 65 and older from a senior welfare center in Seoul participated in this study (20 patients in the experimental group and 18 patients in the control group). The self-management program applying Dongsasub training consisted of eight sessions. After development was complete the program was used with the experimental group. Outcome variables included self-efficacy, self-esteem, self-management behaviors measured by questionnaires, and blood pressure measured by electronic manometer.

RESULTS

Self-efficacy (t=2.42, p=.021), self-esteem (t=2.57, p=.014) and self-management behaviors (t=2.21, p=.034) were significantly higher and systolic blood pressure (t=-2.14, p=.040) was significantly lower in the experimental group compared to the control group. However, diastolic blood pressure (t=-.85, p=.400) was not significantly different between the two groups.

CONCLUSION

The results indicate that the self-management program applying Dongsasub training can be used as a nursing intervention in community settings for improving self-management behaviors for older adults with hypertension.

Mindfulness-based cognitive therapy for people with diabetes and emotional problems: long-term follow-up findings from the DiaMind randomized controlled trial

OBJECTIVE

The DiaMind trial showed beneficial immediate effects of mindfulness-based cognitive therapy (MBCT) on emotional distress, but not on diabetes distress and HbA1c. The aim of the present report was to examine if the effects would be sustained after six month follow-up.

METHODS

In the DiaMind trial, 139 outpatients with diabetes (type-I or type-II) and a lowered level of emotional well-being were randomized into MBCT (n=70) or a waiting list with treatment as usual (TAU: n=69). Primary outcomes were perceived stress, anxiety and depressive symptoms, and diabetes distress. Secondary outcomes were, among others, health status, and glycemic control (HbA1c).

RESULTS

Compared to TAU, MBCT showed sustained reductions at follow-up in perceived stress (p<.001, d=.76), anxiety (p<.001, assessed by HADS d=.83; assessed by POMS d=.92), and HADS depressive symptoms (p=.004, d=.51), but not POMS depressive symptoms when using Bonferroni correction for multiple testing (p=.016, d=.48). No significant between-group effect was found on diabetes distress and HbA1c.

CONCLUSION

This study showed sustained benefits of MBCT six months after the intervention on emotional distress in people with diabetes and a lowered level of emotional well-being.

TRIAL REGISTRATION

Dutch Trial Register NTR2145, http://www.trialregister.nl.

REDEEM: a pragmatic trial to reduce diabetes distress

OBJECTIVE

To compare three interventions to reduce diabetes distress (DD) and improve self-management among non-clinically depressed adults with type 2 diabetes mellitus (T2DM).

RESEARCH DESIGN AND METHODS

In REDEEM, 392 adults with T2DM and DD were randomized to computer-assisted self-management (CASM), CASM plus DD-specific problem solving (CAPS), or a computer-administered minimal supportive intervention. Primary outcomes were Diabetes Distress Scale (DDS) total, the Emotional Burden (EB) and Regimen Distress (RD) DDS subscales, and diet, exercise, and medication adherence.

RESULTS

Significant and clinically meaningful reductions in DD (DDS, EB, and RD) and self-management behaviors occurred in all three conditions (P < 0.001), with no significant between-group differences. There was, however, a significant group × baseline distress interaction (P < 0.02), in which patients with high baseline RD in the CAPS condition displayed significantly larger RD reductions than those in the other two conditions. RD generated the most distress and displayed the greatest distress reduction as a result of intervention. The pace of DD reduction varied by patient age: older patients demonstrated significant reductions in DD early in the intervention, whereas younger adults displayed similar reductions later. Reductions in DD were accompanied by significant improvements in healthy eating, physical activity, and medication adherence, although not by change in HbA1c.

CONCLUSIONS

DD is malleable and highly responsive to intervention. Interventions that enhance self-management also reduce DD significantly, but DD-specific interventions may be necessary for patients with high initial levels of DD. Future research should identify the minimal, most cost-effective interventions to reduce DD and improve self-management.

Adverse effects of depression on glycemic control and health outcomes in people with diabetes: a review

In the past decades, important advances have been achieved in the psychological aspects of diabetes. This article reviews the associations between diabetes, depression, and adverse health outcomes. The article provides an update on the literature regarding the prevalence of depression in diabetes, discusses the impact of depression on diabetes self-care and glycemic control in people with diabetes, and summarizes the results of longitudinal studies that have investigated depression as a risk factor for adverse health outcomes.

The effects of a mindfulness-based intervention on emotional distress, quality of life, and HbA(1c) in outpatients with diabetes (DiaMind): a randomized controlled trial

OBJECTIVE

Emotional distress is common in outpatients with diabetes, affecting ∼20-40% of the patients. The aim of this study was to determine the effectiveness of group therapy with Mindfulness-Based Cognitive Therapy (MBCT), relative to usual care, for patients with diabetes with regard to reducing emotional distress and improving health-related quality of life and glycemic control.

RESEARCH DESIGN AND METHODS

In the present randomized controlled trial, 139 outpatients with diabetes (type 1 or type 2) and low levels of emotional well-being were randomized to MBCT (n = 70) or a waiting list group (n = 69). Primary outcomes were perceived stress (Perceived Stress Scale), anxiety and depressive symptoms (Hospital Anxiety and Depression Scale), mood (Profiles of Mood States), and diabetes-specific distress (Problem Areas In Diabetes). Secondary outcomes were health-related quality of life (12-Item Short-Form Health Survey), and glycemic control (HbA(1c)). Assessments were conducted at baseline and at 4 and 8 weeks of follow-up.

RESULTS

Compared with control, MBCT was more effective in reducing stress (P < 0.001, Cohen d = 0.70), depressive symptoms (P = 0.006, d = 0.59), and anxiety (P = 0.019, d = 0.44). In addition, MBCT was more effective in improving quality of life (mental: P = 0.003, d = 0.55; physical: P = 0.032, d = 0.40). We found no significant effect on HbA(1c) or diabetes-specific distress, although patients with elevated diabetes distress in the MBCT group tended to show a decrease in diabetes distress (P = 0.07, d = 0.70) compared with the control group.

CONCLUSIONS

Compared with usual care, MBCT resulted in a reduction of emotional distress and an increase in health-related quality of life in diabetic patients who had lower levels of emotional well-being.

Psychological and pharmacological interventions for depression in patients with diabetes mellitus and depression

BACKGROUND

Depression occurs frequently in patients with diabetes mellitus and is associated with a poor prognosis.

OBJECTIVES

To determine the effects of psychological and pharmacological interventions for depression in patients with diabetes and depression.

SEARCH METHODS

Electronic databases were searched for records to December 2011. We searched CENTRAL in The Cochrane Library, MEDLINE, EMBASE, PsycINFO, ISRCTN Register and clinicaltrials.gov. We examined reference lists of included RCTs and contacted authors.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) investigating psychological and pharmacological interventions for depression in adults with diabetes and depression. Primary outcomes were depression and glycaemic control. Secondary outcomes were adherence to diabetic treatment regimens, diabetes complications, death from any cause, healthcare costs and health-related quality of life (HRQoL).

DATA COLLECTION AND ANALYSIS

Two review authors independently examined the identified publications for inclusion and extracted data from included studies. Random-effects model meta-analyses were performed to compute overall estimates of treatment outcomes.

MAIN RESULTS

The database search identified 3963 references. Nineteen trials with 1592 participants were included. Psychological intervention studies (eight trials, 1122 participants, duration of therapy three weeks to 12 months, follow-up after treatment zero to six months) showed beneficial effects on short (i.e. end of treatment), medium (i.e. one to six months after treatment) and long-term (i.e. more than six months after treatment) depression severity (range of standardised mean differences (SMD) -1.47 to -0.14; eight trials). However, between-study heterogeneity was substantial and meta-analyses were not conducted. Short-term depression remission rates (OR 2.88; 95% confidence intervals (CI) 1.58 to 5.25; P = 0.0006; 647 participants; four trials) and medium-term depression remission rates (OR 2.49; 95% CI 1.44 to 4.32; P = 0.001; 296 participants; two trials) were increased in psychological interventions compared to usual care. Evidence regarding glycaemic control in psychological intervention trials was heterogeneous and inconclusive. QoL did not improve significantly based on the results of three psychological intervention trials compared to usual care. Healthcare costs and adherence to diabetes and depression medication were examined in only one study and reliable conclusions cannot be drawn. Diabetes complications and death from any cause have not been investigated in the included psychological intervention trials.With regards to the comparison of pharmacological interventions versus placebo (eight trials; 377 participants; duration of intervention three weeks to six months, no follow-up after treatment) there was a moderate beneficial effect of antidepressant medication on short-term depression severity (all studies: SMD -0.61; 95% CI -0.94 to -0.27; P = 0.0004; 306 participants; seven trials; selective serotonin reuptake inhibitors (SSRI): SMD -0.39; 95% CI -0.64 to -0.13; P = 0.003; 241 participants; five trials). Short-term depression remission was increased in antidepressant trials (OR 2.50; 95% CI 1.21 to 5.15; P = 0.01; 136 participants; three trials). Glycaemic control improved in the short term (mean difference (MD) for glycosylated haemoglobin A1c (HbA1c) -0.4%; 95% CI -0.6 to -0.1; P = 0.002; 238 participants; five trials). HRQoL and adherence were investigated in only one trial each showing no statistically significant differences. Medium- and long-term depression and glycaemic control outcomes as well as healthcare costs, diabetes complications and mortality have not been examined in pharmacological intervention trials. The comparison of pharmacological interventions versus other pharmacological interventions (three trials, 93 participants, duration of intervention 12 weeks, no follow-up after treatment) did not result in significant differences between the examined pharmacological agents, except for a significantly ameliorated glycaemic control in fluoxetine-treated patients (MD for HbA1c -1.0%; 95% CI -1.9 to -0.2; 40 participants) compared to citalopram in one trial.

AUTHORS' CONCLUSIONS

Psychological and pharmacological interventions have a moderate and clinically significant effect on depression outcomes in diabetes patients. Glycaemic control improved moderately in pharmacological trials, while the evidence is inconclusive for psychological interventions. Adherence to diabetic treatment regimens, diabetes complications, death from any cause, health economics and QoL have not been investigated sufficiently. Overall, the evidence is sparse and inconclusive due to several low-quality trials with substantial risk of bias and the heterogeneity of examined populations and interventions.

Mindfulness-based interventions for physical conditions: a narrative review evaluating levels of evidence

Research on mindfulness-based interventions (MBIs) for treating symptoms of a wide range of medical conditions has proliferated in recent decades. Mindfulness is the cultivation of nonjudgmental awareness in the present moment. It is both a practice and a way of being in the world. Mindfulness is purposefully cultivated in a range of structured interventions, the most popular of which is mindfulness-based stress reduction (MBSR), followed by mindfulness-based cognitive therapy (MBCT). This paper begins with a discussion of the phenomenological experience of coping with a chronic and potentially life-threatening illness, followed by a theoretical discussion of the application of mindfulness in these situations. The literature evaluating MBIs within medical conditions is then comprehensively reviewed, applying a levels of evidence rating framework within each major condition. The bulk of the research looked at diagnoses of cancer, pain conditions (chronic pain, low back pain, fibromyalgia, and rheumatoid arthritis), cardiovascular disease, diabetes, human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS), and irritable bowel syndrome. Most outcomes assessed are psychological in nature and show substantial benefit, although some physical and disease-related parameters have also been evaluated. The field would benefit from more adequately powered randomized controlled trials utilizing active comparison groups and assessing the moderating role of patient characteristics and program "dose" in determining outcomes.

The broad reach of the wellbeing debate: Emotional wellbeing and vision loss

What is meant by the term ‘wellbeing’? Much has been written on the relationship between chronic illness and mental health outcomes, particularly in terms of ‘happiness’, and the reciprocal relationship between physical and emotional health. Visual impairment research into wellbeing has tended to focus specifically on the concept of e motional wellbeing, and how functional disability may impact negatively on mental health. As a consequence of such research, there is an increasing awareness of the importance of ‘preventing’ negative mental health outcomes in the visually impaired population and ‘promoting’ emotional wellbeing. However, despite the many wellbeing interventions and initiatives, the actual meaning of the term remains rather nebulous. Depending on one’s standpoint, ‘wellbeing’ may translate as a physical, social, emotional or even spiritual construct and follow different models which all have their own agendas, aims, methodologies and discourse. Furthermore, a shift is evident towards a two-dimensional framework of wellbeing which considers not just what makes chronically ill individuals happy in terms of goals and aspirations, but what makes them ‘flourish’ and find meaning in life. It is specifically this second dimension of wellbeing which remains to be investigated in visual impairment research. The purpose of this article is therefore to present the theoretical underpinnings of the wellbeing agenda, the methodological implications, and the impact on future research into wellbeing and visual impairment.

Mindfulness training reduces the severity of irritable bowel syndrome in women: results of a randomized controlled trial

OBJECTIVES

This prospective, randomized controlled trial explored the feasibility and efficacy of a group program of mindfulness training, a cognitive-behavioral technique, for women with irritable bowel syndrome (IBS). The technique involves training in intentionally attending to present-moment experience and non-judgmental awareness of body sensations and emotions.

METHODS

Seventy-five female IBS patients were randomly assigned to eight weekly and one half-day intensive sessions of either mindfulness group (MG) training or a support group (SG). Participants completed the IBS severity scale (primary outcome), IBS-quality of life, brief symptom inventory-18, visceral sensitivity index, treatment credibility scale, and five-facet mindfulness questionnaire before and after treatment and at 3-month follow-up.

RESULTS

Women in the MG showed greater reductions in IBS symptom severity immediately after training (26.4% vs. 6.2% reduction; P=0.006) and at 3-month follow-up (38.2% vs. 11.8%; P=0.001) relative to SG. Changes in quality of life, psychological distress, and visceral anxiety were not significantly different between groups immediately after treatment, but evidenced significantly greater improvements in the MG than in the SG at the 3-month follow-up. Mindfulness scores increased significantly more in the MG after treatment, confirming effective learning of mindfulness skills. Participants' ratings of the credibility of their assigned interventions, measured after the first group session, were not different between groups.

CONCLUSIONS

This randomized controlled trial demonstrated that mindfulness training has a substantial therapeutic effect on bowel symptom severity, improves health-related quality of life, and reduces distress. The beneficial effects persist for at least 3 months after group training.