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Chi congres 2011 psychosocial research and practice

Effect of Mindfulness-based cognitive therapy on Chronic cancer-related fatigue: face-to-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:

-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

Chi congres nov 2011 dr. Marije van der Lee

Problem: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

38

28

35

0

10

20

30

40

50

%

Bone tumours

1 -15 years after

end of treatment

breastcancer

6 month-5 years

after end of

treatment

Hodgkin 1 - 22 years

after stem cell

transplantation

Percentage severly fatigued patients after different types

of cancerFunctional Impariment

0

60

120

180

sle

ep

household

mob

soc.in

t

walk

ing

ale

rt

work

recr

disease-free pts severely

fatigued

disease-free pts not fatigued

2

Relation fatigue with earlier treatment

20

26 25 26

0

10

20

30

gem

. verm

oeid

heid

sscore no adjuvante

therapy

radiotherapy

chemotherapy

radio- andchemotherapy

What helps?Evidence-based interventions

1. Cognitive Behavioural Therapy– (Prof. Bleyenberg, Dr. Gielissen, NKCV-Nijmegen)

2. Mindfulness Based Cognitieve Therapie (MBCT) – (van der Lee, Garssen)

Mindfulness Based Cognitive Therapy MBCT

• 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

MBCT changes automatic pilot

Relational Frame theory: HayesCognitive control strategies to avoid unwanted states

Thought suppressionWorried rumination Distraction

Internal and external control maintains distress/fatigue or causes rebound

Acceptance based therapy assumptions:Emotions are just emotions; thoughts are just thoughts; memories are just memoriesEmotions are information; not good or

badControl of internal events is not an optionControl is the problem, not the solution

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Difference with CBT:Attention

CBT emphasizes directing attention toward stimuli associated with disorder (or distract from)ABT emphasizes directing attention broadly toward flow of experience

Difference with CBT:Cognition – radically different

understanding of the role of cognition in development and treatment of disorders

Cognitions are causal vs. cognitions are responsesImportance of content vs. importance of functionGoal to change content vs. goal to change relationship to one’s own thoughts and feelings

Steps in Mindfulness training:Practice attention to a single sensePractice attention to the flow of experiencePractice attention to thoughts, feelings,

images as part of the flow of experiencePractice attention to the flow of experience during activities

Mechanisms in Mindfulness:Exposure to avoided emotional experience, leading to decreased distress via extinctionSelf-monitoring associated with improved appraisal of actual contingencies, leading to increased flexibility in respondingState of relaxation(Baer, 2003; Teasdale et al. 2002; Segal et al. 2002)

Assessing Fatigue

Checklist Individual Strength (CIS)

Ik voel me moeIk ben gauw moeIk voel me fit

Lichamelijk voel ik me uitgeput

Mindfulness BasedCognitieve therapie

1. Ik moet ook altijd alles doen2. Ik wil dat ze mijn moeheid begrijpen3. Ik moet alles perfect doen4. Ik kan weer niks5. 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

Ernst ervaren vermoeidheid

30

32

34

36

38

40

42

44

46

48

50

voor na follow-up

Controle (n=23)

Interventie (n=59)

Partners

Treatment effect on CCRF3.8 – 12.6 (95%CI)

Intervention group 31% clinicallyrelevant improvement versus 4% in the waiting list control group

Van der Lee, M.L., Garssen, B. Psycho-oncology, 2010

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

Online therapy Minder Moe Bij Kanker

Inclusion1. Has or has had cancer, suffers severe chronic fatigue > half a

year2. No somatic cause that is treatable 3. Motivated to practice at home for about 45 min/day4. >18 years or older

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Online therapy Minder Moe Bij Kanker

Exclusion

1. Severe Major Depressive Episode 2. Psychotic delusions3. Major life stressor at this moment (divorce or current intensive

treatment with chemotherapy or radiotherapy).

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

Overall characteristics participants

Between november 2009-november 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.

Flow chart curatief online98 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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ResultsOnline MBCT Face-to-face Wait-list

n= 26 MBCT n= 54 n= 23Type of cancerBreast 30,8 55,6 52,2Hodgkin 23,1 1,9 13

Prostate 0 5,6 8,7GastroIntestinal 3,8 3,7 4,3

ResultsOnline MBCT Face-to-face Wait-list

n= 26 MBCT n= 54 n= 23TreatmentSurgery 61,5 94,4 87Chemoth. 84,6 51,9 52,2

Radioth. 57,7 68,5 78,3Hormone th. 26,9 29,6 43,5

MedicationSleep 3,8 25,9 30,4Pain 7,7 37 30,4

Antidepr. 3,8 18,5 8,7

ResultatenOnline vs face-to-face MBCT (ANCOVA)

ResultsClinically relevant improvement

Online 46% Face-to-face 31% Waiting list control 4%

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 %

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:

New research projects

•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.

Questions?

‘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 behorendeemoties omga. Meer aandacht aan mezelf schenk.’

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‘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.’

Helen Dowling InstituutBegeleiding bij kankerRubenslaan 1903582 JJ Utrecht

T 030 252 40 20W www.hdi.nlW www.mindermoebijkanker.nlE mvanderlee@hdi.nl

Met dank aan: Innovatiefonds Zorgverzekeraars & St. Willemien Cohen

Pilot resultatenVerloop van de mate van mindfulness en subjectief gevoel van fit zijn

Mindfulness & Fitheid

4

4,5

5

5,5

6

6,5

1 2 3 4 5 6 7 8 9

sessions

sc

ore

mindfulness

fit

gem= 5,66

st.dev= 0,41

gem= 5,68

st.dev= 0,56

ResultatenOnline MBCT Face-to-face Wait-list

n= 26 MBCT n= 54 n= 23

Leeftijd 47,5 (11) 52,83 (9) 50,09 (11)Vrouw 76,9 % 87 78,3Met partner 65,4 % 61,1 73,9Opleiding 5,4 (1,5) 5,2 (1,6) 4,7 (1,8)range 0- 7Betaald werk 65,4 % 44,4 43,5

ResultatenOnline MBCT Face-to-face Wait-list

n= 26 MBCT n= 54 n= 23

Maanden sinds afronden behandeling30,8(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)