Eigen onderzoek

MindRest Mindfulness voor studenten

Aanleiding

Studenten in een academische setting staan behoorlijk onder druk. Deadlines, tentamens en financiële zaken vragen constant de aandacht. Dit leidt ertoe dat een groot deel van de studenten stress-gerelateerde klachten ervaren, wat van invloed is op de academische prestaties en de kwaliteit van leven. Een manier die de laatste tijd veel aandacht krijgt om met stress-gerelateerde klachten om te gaan zijn de op mindfulness-gebaseerde interventies. Eerder onderzoek laat zien dat mindfulness kan helpen om angst- en spanningsklachten te voorkomen of te verminderen.

Doel

Het doel van dit onderzoek is om te onderzoeken of de Mindfulness Based Stress Reductie (MBSR) training effectief is in het verminderen van stress bij studenten die in hoge mate last hebben van stress-gerelateerde klachten. Daarnaast willen we beter begrijpen hoe en voor wie de MBSR werkt, om op deze manier stress-gerelateerde klachten bij studenten in de toekomst preventief te kunnen aanpakken en behandelen.

Doelgroep

Aan dit onderzoek zullen 120 studenten van de Radbouduniversiteit, het Radboudumc en de HAN University of Applied Sciences in Arnhem en Nijmegen deelnemen.

Methode

Dit onderzoek is een gerandomiseerde, met wachtlijst gecontroleerde studie. Na een aantal klinische, neurocognitieve en ecologische metingen zullen deelnemers over twee groepen verdeeld worden: een behandelgroep en wachtlijst-controlegroep. In de daaropvolgende twee maanden zullen de deelnemers in de behandelgroep een MBSR training volgen. Deelnemers in de wachtlijst-controlegroep krijgen niets aangeboden, zij zullen twee maanden moeten wachten. Daarna zal er een tweede meetmoment plaatsvinden. Uiteindelijk zal er een derde en laatste meetmoment drie maanden na de MBSR training plaatsvinden.

Periode

Dit onderzoek wordt uitgevoerd door het Radboudumc en vindt tussen juli 2020 en juni 2024 plaats bij het Donders Center for Cognitive Neuroimaging (DCCN) en het Radboudumc Centum voor Mindfulness (CvM).

Onderzoekers

Dit onderzoek wordt uitgevoerd door Nikos Kogias (PhD-student), Dirk Geurts (psychiater en post-doc onderzoeker), Florian Krause (post-doc onderzoeker), Erno Hermans (associate professor), en Anne Speckens (hoogleraar psychiatrie).

Meer informatie en aanmelden

Bekijk hiervoor de website van het MindRest-onderzoek. 

Voor meer informatie kan contact worden opgenomen met Nikos Kogias:

Email: n.kogias@donders.ru.nl

CogMind Werkingsmechanismen van mindfulness

Aanleiding

Depressie is een veel voorkomende en ernstige aandoening die zich kenmerkt door een lang aanhoudende sombere stemming en het verlies van plezier. Dit heeft grote gevolgen voor de patiënt, maar ook voor zijn of haar omgeving, en de maatschappij. Daarnaast is de kans op een terugval groot, en met iedere depressieve episode verslechterd het toekomstperspectief van de patiënt. Mindfulness-gebaseerde cognitieve therapie (MBCT) kan behulpzaam zijn om huidige depressieve klachten te reduceren, en tevens ook de kans op een terugval te verminderen. Echter, de therapie werkt niet even goed voor iedere patiënt. De rede hiervoor is nog onbekend. Hierom is het van belang om het werkingsmechanisme van MBCT te onderzoeken. Op de lange termijn zouden de resultaten bij kunnen dragen aan het verbeteren van de therapie,  en zouden de resultaten het mogelijk kunnen maken om beter te kunnen voorspellen welke groep patiënten het meest gebaat is bij MBCT als behandeling voor depressie.

Doel

Het doel van dit onderzoek is om het werkingsmechanisme van MBCT te verhelderen. In dit onderzoek richten we ons op rumineren (herhaalde negatieve gedachtes, zoals piekeren). Er zal worden onderzocht of MBCT een positief effect heeft op negatieve (piekerende) gedachtes, en of een afname in rumineren vervolgens zorgt voor een afname van depressieve symptomen. Daarnaast zal worden onderzocht of mensen die voor de behandeling meer rumineren/piekeren meer baat hebben bij de therapie. Ook zullen we kijken naar het effect van MBCT op gerelateerde processen, zoals gedragsleren en het werkgeheugen.

Doelgroep

De doelgroep bestaat uit volwassenen met een chronische en/of recidiverende depressie die aangemeld zijn voor een MBCT training. Men spreekt van een chronische depressie indien depressieve symptomen voor ten minste 2 jaar aanhouden.

Methode

Deelnemers worden op basis van startdatum ingedeeld in twee groepen. De eerste groep krijgt meetmomenten voor de start van de MBCT (1), tijdens de MBCT  (2) en na de MBCT (3). Groep twee krijgt twee meetmomenten tijdens de wachtperiode (1 en 2), één voor de start van de MBCT (3), tijdens de MBCT (4) en na de MBCT (5). Met dit studieontwerp kan groep 1 worden vergeleken met groep 2. Meetmomenten bestaan uit cognitieve (computer)taken en vragenlijsten. Daarnaast zullen deelnemers ook direct na iedere MBCT sessie korte vragenlijsten invullen om de effecten van MBCT op verschillende tijdstippen gedurende de therapie te kunnen bestuderen. Deelname aan het onderzoek verandert niets aan de MBCT. Deelnemers in groep 1 en groep 2 zullen dus op normale wijze MBCT ontvangen. Ons doel is om ongeveer 200 mensen deel te laten nemen aan het onderzoek.

Periode

Het onderzoek is gestart in September 2019 en zal doorlopen tot en met 2023. Naast het Radboudumc Centrum voor Mindfulness in Nijmegen is vanaf 2020 het onderzoek ook op andere locaties van start gegaan. In deze periode proberen we zoveel mogelijk patiënten te includeren om ons ambitieuze doel van 200 deelnemers te halen. We zijn hierom erg blij met alle aanmeldingen, en waarderen deelname aan ons onderzoek zeer.

Onderzoekers

Het onderzoek wordt uitgevoerd door het Radboudumc  in samenwerking met Pro Persona. Verantwoordelijke onderzoekers zijn Jelle Lubbers (junior onderzoeker), dr. Dirk Geurts (psychiater en post-doc onderzoeker), dr. Mira Cladder-Micus (psycholoog en post-doc onderzoeker), prof. dr. Anne Speckens (hoogleraar psychiatrie ) en prof. Jan Spijker (hoogleraar chronische depressie).

Meer informatie

Voor meer informatie kunt u contact opnemen met:
Jelle Lubbers (junior onderzoeker)
E: Jelle.lubbers@radboudumc.nl
T: +31 (0)24 36 15445

Mindfulness bij chronische pijn en opiaatverslaving

Aanleiding

Recent zijn we gestart met een pilotstudie bij patiënten met chronische pijn, die verslaafd zijn geraakt aan opiaten (krachtige pijnstillers). Deze patiënten worden opgenomen op de afdeling psychiatrie van het Radboudumc voor afbouw van de opiaten en omzetting naar andere, minder verslavende pijnstillers (suboxonen). Een eerdere pilotstudie, die in het Radboudumc is uitgevoerd, liet zien dat patiënten, na afloop van deze omzetting, minder verslaafd waren aan pijnstillers en minder pijn ervoeren. Ook hadden zij minder psychische klachten zoals angst en depressie. Toch hadden patiënten na de omzetting nog steeds pijnklachten en waren ook de psychische klachten niet volledig verdwenen.

Doel

In de huidige pilotstudie zal worden onderzocht of het volgen van Mindfulness Based Cognitieve Therapie (MBCT), na afloop van de omzetting, de pijn- en psychische klachten verder vermindert en de kwaliteit van leven van deze patiënten verbetert.

De resultaten van deze pilotstudie zullen naar verwachting eind 2021 bekend zijn.

Heeft u vragen of wilt u meer informatie?

Neem contact op met mevr. K. Lathouwers, MSc (karen.lathouwers@radboudumc.nl)

Balansonderzoek Mindfulness bij bipolaire stoornis

Aanleiding

De bipolaire stoornis wordt gekenmerkt door een ernstig en chronisch beloop, waarbij patiënten last hebben van terugkerende depressieve, (hypo)manische en/of gemengde episoden, waarbij zij soms ook last kunnen hebben van psychotische kenmerken. Op dit moment is medicatie de meest voorkomende behandeling bij de bipolaire stoornis. Uit onderzoek blijkt dat medicatie effectief is, maar desondanks hebben nog altijd meer dan 60% van de patiënten last van terugkerende symptomen en episoden. Daarnaast blijkt dat veel patiënten liever geen medicatie slikken, mede doordat er vervelende bijwerkingen kunnen optreden. Er lijkt een behoefte te zijn aan aanvullende, psychologische behandelingen. Een van deze psychologische behandeling is op mindfulness gebaseerde cognitieve therapie (MBCT). Eerdere onderzoeken tonen veelbelovende resultaten van MBCT bij de bipolaire stoornis, waaronder verbeteringen van depressieve en angstklachten en een verbetering in het algeheel functioneren.

Doel

Het doel van het Balans-onderzoek is om te onderzoeken of MBCT een goede aanvulling is op het bestaande behandelaanbod. Hierbij zullen we onder andere kijken naar stemmingsklachten (depressie en manie), angstklachten, terugval en kwaliteit van leven. Ook onderzoeken we de kosteneffectiviteit.

Promotie Imke Hanssen

Op 8 juli 2022 verdedigde Imke Hanssen succesvol haar proefschrift getiteld: ‘In search of balance: Mindfulness-Based Cognitive Therapy for bipolar disorder’. Het volledige proefschrift vind je hier. 

Samenvatting resultaten proefschrift

MBCT is oorspronkelijk ontwikkeld voor mensen met een depressieve stoornis. Bij het ontwikkelen van MBCT voor de bipolaire stoornis, is het van belang om te onderzoeken of er verschillen zijn tussen deze twee populaties.

In hoofdstuk 2 onderzochten wij of mensen met een bipolaire stoornis type I (n = 96) en II (n = 27) anders omgaan met positieve emoties dan mensen met een depressieve stoornis (n = 175). De resultaten laten zien dat dit inderdaad het geval is. Zo zien we dat mensen met een bipolaire stoornis meer positief rumineren (terugkerende gedachten over positieve ervaringen of gevoelens), en mensen met een depressieve stoornis meer dempen (het onderdrukken van positieve emoties). Tijdens MBCT kan het belangrijk zijn om mensen met een bipolaire stoornis te leren zich anders te verhouden tot positieve emoties, zodat zij zich hier niet teveel door laten meenemen.

In hoofdstuk 3 onderzochten we of er verschillen zijn in effectiviteit tussen mensen met een bipolaire (n = 30) en depressieve stoornis (n = 501) die MBCT volgden in de klinische praktijk. Vóór en na MBCT werden enkele zelfrapportage vragenlijsten afgenomen, waarmee depressieve klachten, zorgen maken over de toekomst, welzijn, mindfulness en zelfcompassie vaardigheden werden gemeten. Het uitvalpercentage was gelijk in beide groepen. Uit de resultaten bleek dat de mensen met de bipolaire stoornis net zoveel profijt hadden van MBCT als mensen met een depressieve stoornis. MBCT zou dus behulpzaam kunnen zijn bij de behandeling van de bipolaire stoornis. Er is echter meer onderzoek nodig voordat hier definitieve conclusies uit getrokken kunnen worden. Daarnaast onderstreept dit onderzoek het belang om naast positieve effecten ook te kijken naar negatieve effecten van MBCT, omdat er meer negatieve effecten leken te zijn bij de mensen met een bipolaire stoornis die stopte met MBCT (zoals ernstige depressieve klachten en suïcidaliteit).

Hoofdstuk 4 beschrijft het studie protocol van een prospectief, multicenter, gerandomiseerd onderzoek (randomized-controlled trial; RCT) waar MBCT+TAU werd vergeleken met TAU bij mensen met een bipolaire type I en II stoornis tot 15 maanden follow-up. Deelnemers werden driemaandelijks benaderd voor een interview en het invullen van vragenlijsten, waarbij onder anderen klachten van depressie, (hypo)manie, angst, terugval, functioneren en welzijn werden gemeten.   

Hoofdstuk 5 beschrijft de resultaten van de RCT. In totaal werden er 144 deelnemers gerandomiseerd, waarvan 72 naar MBCT+TAU en 72 naar TAU. De resultaten laten zien dat MBCT+TAU niet effectiever is dan TAU in het verminderen van depressieve klachten in alle deelnemers, maar dat het wel behulpzaam is voor deelnemers die voorafgaand aan het onderzoek meer depressieve klachten en problemen in het functioneren ervaarden. Op korte termijn laat de MBCT+TAU groep een verbetering in mindfulness vaardigheden zien ten opzichte van de TAU groep. Ook zijn er verschillen tussen de groepen in angst en welzijn gevonden. Op de andere uitkomstmaten werden geen verschillen tussen de groepen gevonden. Naast het meten van het effect van een interventie met kwantitatieve uitkomstmaten, is het ook belangrijk om kwalitatieve uitkomstmaten te onderzoeken, zoals de persoonlijke ervaringen van deelnemers met behulp van diepte-interviews.

In hoofdstuk 6 worden de resultaten van een kwalitatief onderzoek naar de haalbaarheid van MBCT bij mensen met een bipolaire stoornis beschreven. In totaal werden 16 deelnemers geselecteerd voor deelname aan een interview naar mogelijke belemmerende en bevorderende factoren die ze waren tegen gekomen tijdens het volgen van MBCT. Om deze groep deelnemers zo representatief mogelijk te maken, werden zij geselecteerd op type bipolaire stoornis (type I of II), leeftijd, geslacht en of ze MBCT voltooid hadden of niet. Daarnaast werden ook de mindfulness trainers geïnterviewd. Vier belangrijke thema’s kwamen uit de interviews naar voren, namelijk (1) de interventie, (2) psychosociale factoren, (3) persoonlijke karakteristieken en (4) de bipolaire stoornis. Deze thema’s werden verder onderverdeeld in sub-thema’s. Met betrekking tot het thema ‘bipolaire stoornis’ noemden de deelnemers een aantal belangrijke bevorderende en belemmerende factoren. Depressieve klachten en medicatiegebruik noemden zij als belemmerend bij het volgen van MBCT. Een stabiele stemming en (hypo)manische klachten werden zowel bevorderend als belemmerend bevonden. In het algemeen werd geconstateerd dat MBCT een haalbare interventie is bij de behandeling van een bipolaire stoornis.

In hoofdstuk 7 worden de resultaten van een kwalitatief onderzoek naar het proces van verandering van mensen met een bipolaire stoornis tijdens MBCT beschreven. Hierbij werd gebruik gemaakt van dezelfde methode als beschreven in hoofdstuk 6, alleen werd deze keer gevraagd naar het proces dat de deelnemers tijdens de MBCT hebben doorgemaakt. Drie thema’s kwamen naar voren: (1) bewustzijn van gedachten, emoties, lichamelijke sensaties en inzicht in hoe deze factoren verband met elkaar houden, (2) gedragsmatige veranderingen, en (3) positieve gevolgen. Deze thema’s werden verder onderverdeeld in sub-thema’s. Er werd onderscheid gemaakt naar meer algemene processen en processen die specifiek zijn voor mensen met een bipolaire stoornis. De resultaten bevestigen gevonden resultaten uit eerder onderzoek, waarbij we zien dat er een aantal neuropsychologische processen ten grondslag liggen aan het effect van MBCT bij mensen met een bipolaire stoornis, zoals een toename in bewustzijn en verbeterde emotieregulatie, de mogelijkheid om niet-adaptief gedrag te stoppen en te vervangen door adaptief gedrag en een afname in de hoeveelheid negatieve gedachten. Het is belangrijk dat verder onderzoek wordt gedaan naar andere mogelijke neuropsychologische processen die ten grondslag kunnen liggen aan MBCT bij mensen met een bipolaire stoornis.

In hoofdstuk 8 wordt een mixed-methods studie naar de prevalentie en het beloop van negatieve effecten van MBCT bij mensen met een bipolaire stoornis beschreven. Tijdens MBCT werden 72 deelnemers prospectief gevraagd om structureel een dagboek bij te houden naar eventuele negatieve effecten tijdens MBCT. In totaal rapporteerden 38% van deze deelnemers één of meerdere negatieve effecten. De ervaringen werden onderverdeeld in een aantal domeinen, welke in eerder onderzoek ook naar voren waren gekomen (Lindahl, Fisher, Cooper, Rosen, & Britton, 2017): (1) cognitief, (2) perceptueel, (3) affectief, (4) somatisch, (5) conatief, (6) zelf en (7) sociaal. Aansluitend werden deelnemers benaderd voor deelname aan diepte-interviews, waarin wij onderzochten welke factoren van invloed waren op het ontstaan en het beloop van deze negatieve effecten. Terugkijkend op de negatieve effecten, gaf meer dan de helft van de deelnemers aan dat zij de negatieve effecten eerder als therapeutisch dan als schadelijk hebben ervaren. Dit betekent echter ook dat een substantieel deel van de deelnemers de negatieve effecten alleen als negatief heeft ervaren. 

Organisatie/onderzoekers

Dit onderzoek werd uitgevoerd door Imke Hanssen (psycholoog en junior onderzoeker), Marloes Huijbers (psycholoog en post-doc onderzoeker) en Anne Speckens (hoogleraar psychiatrie). Daarnaast zijn er verschillende externe instellingen bij het onderzoek betrokken, waaronder Altrecht, Dimence, ProPersona (locaties Arnhem en Nijmegen), PsyQ (locaties Rotterdam, Den Haag en Maastricht) en Lentis.

Meer informatie

Voor meer informatie kan contact worden opgenomen met Imke Hanssen:
E: Imke.Hanssen@radboudumc.nl
T: 024 – 361 46 08

Publicaties

• Hanssen, I., Huijbers, M., Lochmann van Bennekom, M., Regeer, E., Stevens, A., Evers, S., Wensing, M., Kupka, R., Speckens, A. (2019). Study protocol of a multicenter randomized controlled trial of mindfulness based cognitieve therapy and treatment as usual in bipolar disorder. 
• Hanssen, I., Boele, M., van der Horst, N., Lochmann van Bennekom, M., Regeer, E., & Speckens, A. (2020). The process of change of mindfulness-based cognitive therapy for people with bipolar disorder: a qualitative study
• Hanssen, I., van der Horst, N., Boele, M., Lochmann van Bennekom, M., Regeer, E., & Speckens, A. (2020). The feasibility of mindfulness-based cognitive therapy for people with bipolar disorder: a qualitative study
• Hanssen, I., Scheepbouwer, V., Huijbers, M., Regeer, E., Lochmann van Bennekom, M., Kupka, R., & Speckens, A. (2021). Adverse or therapeutic? A mixed-methods study investigating adverse effects of Mindfulness-Based Cognitive Therapy in bipolar disorder

Co-Mind Werkingsmechanismen van mindfulness en compassie bij mensen met (terugkerende) depressie

Samenvatting

Binnen het CO-MIND onderzoek worden de werkingsmechanismen van Mindfulness-Based Cognitieve Therapy (MBCT) en Mindfulness-Based Compassionate Living (MBCL) in mensen met (terugkerende) depressie onderzocht. Hierbij wordt onder andere gekeken naar de rol van het maken van huiswerk op depressieve symptomen, alsmede en het samenspel tussen veranderingen in mindfulness/compassie en positief/negatief affect. Daarnaast, wordt onderzocht wie er precies baat heeft bij toewijzing van MBCT.

Resultaat

Mensen met meer depressieve klachten en rumineren (piekeren) en mensen met een lagere kwaliteit van leven bleken meer baat te hebben bij MBCT als toevoeging op gebruikelijke zorg.

Voorlopige resultaten laten verder zien dat mensen met meer depressieve klachten over het algemeen minder huiswerk verrichten, zowel tijdens MBCT als gedurende 1 jaar follow-up. Daarnaast lijkt het erop dat mindfulness en positief affect elkaar versterken gedurende MBCT.
Verwacht wordt dat binnen enkele maanden de overige resultaten beschikbaar zullen zijn.

Aanleiding

MBCT/MBCL is met name voor mensen met (terugkerende) depressie effectief gebleken. Echter, heeft men vaak last van restklachten en blijven terugval percentages relatief hoog. Om trainingen verder te kunnen ontwikkelen is het van belang om meer te weten te komen over die elementen die bijdragen aan de effectiviteit van een training. Daarnaast is het belangrijk om te onderzoeken wie er specifiek baat hebben bij een training, zodat therapie op maat aangeboden kan worden.

Doelgroep

In huidig onderzoeksproject is gebruik gemaakt van data van verschillende onderzoeksprojecten van o.a. van Marloes Huijbers, Joël van Aalderen, Mira Cladder-Micus en Rhoda Schuling. Overall, betreft het data van personen met (terugkerende) depressie welke op verschillende universitaire centra en instellingen voor geestelijke gezondheidszorg in Nederland is verworven.

Methode

Door middel van structurele equation modelling (SEM) technieken worden de werkingsmechanismen van MBCT/MBCL onderzocht. Daarnaast is door middel van de QUalitative INteraction Trees (QUINT) methode onderzocht voor wie MBCT, een toegevoegde waarde heeft naast gebruikelijke zorg.

Periode

Het Co-MinD onderzoek is per 1 september 2017 gestart en zal naar verwachting eind augustus 2020 worden afgerond.

Organisatie/Onderzoekers

Promovenda: Marleen J. ter Avest
Co-promotoren: Marloes J. Huijbers & Corina U. Greven.
Promotoren: Anne E. M. Speckens & Philip Spinhoven.

Meer informatie

Voor meer informatie kunt u contact opnemen met Marleen ter Avest per mail via marleen.teravest@radboudumc.nl of telefonisch via 06-41503925.

Promotie Marleen ter Avest

Op 21 september 2021 verdedigde Marleen haar proefschrift getiteld “Mindfulness-Based Interventions for Depression: How does it work and for whom?”

• ter Avest, M.J., Dusseldorp, E., Huijbers, M.J., van Aalderen, J., Cladder-Micus, M.B., Spinhoven, P., Greven, C.U., Speckens, A.E.M. (2019). Added value of Mindfulness-Based Cognitive Therapy for Depression: A Tree-based Qualitative Interaction Analysis. Behaviour Research and Therapy,
• ter Avest, M. J., Greven, C. U., Huijbers, M. J., Wilderjans, T. F., Speckens, A. E. M., & Spinhoven, P. (2020). Mindfulness and Affect During Mindfulness-Based Cognitive Therapy for Recurrent Depression: an Autoregressive Latent Trajectory Analysis. Mindfulness, 11, 2360-2370.
• ter Avest, M. J., Greven, C. U., Huijbers, M. J., Wilderjans, T. F., Speckens, A. E. M., & Spinhoven, P. (2020). Prospective Associations Between Home Practice and Depressive Symptoms in Mindfulness-Based Cognitive Therapy for Recurrent Depression: A 15 Months Follow-Up Study. Cognitive Therapy and Research.

MOMENT Mindfulness of medicatie en terug­val­preventie

Patients with major depressive disorder have a high risk of relapse/ recurrence. Maintenance antidepressant medication (mADM) is typically recommended to prevent relapse/recurrence. Many individuals, however, are unwilling to continue mADM for a long period, for example because of side effects. Besides, mADM is only effective as long as it is taken. So, a substantial proportion of patients prefer psychosocial interventions. Mindfulness-based cognitive therapy (MBCT) is an eight-week group intervention designed to help patients prevent depressive relapse/recurrence by developing non-judgmental awareness of their automatic patterns of thinking and behaviour. Previous studies have shown that MBCT helps to prevent future depressive episodes in patients with recurrent depression, and that it can be a viable alternative to mADM. However, up till now, no studies have investigated whether the combination of MBCT and mADM is more effective than either of these treatments on its own. The current thesis was designed to assess the effectiveness of MBCT, mADM and its combination in patients with recurrent depression (3 or more previous episodes) in full or partial remission who had been using mADM for at least six months. Chapter 2 describes the design and protocol of the two RCTs that constitute the backbone of this thesis, together referred to as the ‘MOMENT’ study. Originally we intended to conduct a three-armed RCT of MBCT alone, mADM alone or MBCT+mADM, but this turned out not to be feasible since almost all patients who were interested in the study either wanted to participate in MBCT, or hold on to their medication. Therefore we conducted two parallel RCTs. Patients preferring MBCT participated in trial A comparing the combination of MBCT+mADM to MBCT alone, i.e. with discontinuation of mADM. Patients preferring mADM participated in trial B comparing the combination of MBCT+mADM to mADM alone. This enabled us to acknowledge patients’ preferences while maintaining the experimental rigour of randomisation. An advantage of this new approach was that the study was more in line with clinical practice, as particular treatment preferences are very common. In addition, acknowledging patient preference is widely recognized as an important aspect of evidence-based practice (American Psychiatric Association, 2010). The primary finding of the current thesis is that patients who discontinued their mADM after having participated in MBCT had nevertheless an increased risk of relapse/recurrence of depression, even having stated a preference for MBCT rather than mADM (chapter 3). In the intention-to treat sample, relapse rates were 54% for the discontinuation group and 39% for the combination group. In the per-protocol sample these numbers were even higher: 69% and 46%, respectively. Discontinuation seemed much more challenging than we had anticipated, resulting in a large percentage of patients (47%) who did not adhere to the study protocol, i.e. who did not proceed with the process of discontinuing their mADM to zero milligram. Thus, our hypothesis that MBCT followed by discontinuation of mADM would be non-inferior to the combination of MBCT and mADM was rejected. However, the overall course of depression severity during the 15-month follow-up period was similar in both groups, although a small but significant increase of depressive symptoms was observed in the discontinuation group at 3-month follow-up. At that point, patients in the discontinuation group were in the middle of tapering their medication, which may have led to elevated symptom levels. Probably related to this, we observed that besides the fact that almost half of the patients did not complete or even start the discontinuation process, those who did fully discontinue often restarted their mADM within the study period (56%). Other secondary outcomes, including the number, duration and severity of depressive episodes and quality of life during follow-up, did not differ between the groups. Another hypothesis was rejected in chapter 4, where we showed that adding MBCT to mADM did not further decrease the risk of relapse/recurrence compared with mADM alone (36% for MBCT+mADM and 37% for mADM alone). The groups also did not differ on any of the secondary outcomes. The relapse/recurrence rates in the per-protocol analysis (MBCT+mADM 39% and mADM alone 48%) suggested that there may be a small benefit for adding MBCT to mADM in patients adhering to both interventions. However, a sample size of about 500 participants per group would be needed to detect such a difference with 80% power. One of the possible explanations for the absence of an additional effect of MBCT was that in this trial only patients with a preference for mADM were included, whereas those preferring MBCT were included in the previous trial (chapter 3). The possible influence of preference was further explored in chapter 5, where we hypothesized that patients preferring MBCT would benefit more from MBCT than those preferring mADM, in terms of adherence to the combination of treatments (MBCT+mADM) and its outcomes (risk of relapse/recurrence, severity of (residual) depressive symptoms and quality of life). However, neither preference type (MBCT versus mADM) nor preference strength (the score on a questionnaire about expectations of both treatments) affected adherence or outcomes. Again, our findings were in contrast with our expectations. In chapter 6, we tested the hypothesis that higher levels of competence of the mindfulness teacher would be associated with better adherence (number of MBCT sessions attended), reduction of rumination and cognitive reactivity, improvement of mindfulness and self-compassion, and reduction of post treatment depressive symptoms and risk of relapse/recurrence in the year after MBCT. However, the results showed that despite a relatively wide range of competence levels in the sample of teachers in the MOMENT study (n = 15), teacher competence was not related to any of these outcomes. This study also showed that it is fairly difficult to rate teacher competence reliably. The inter-rater reliability was only moderate for most of the subscales of the instrument that we used, the Mindfulness-Based Interventions: Teaching Assessment Criteria (MBI:TAC; Crane et al., 2013). Nevertheless, our findings seemed rather robust as other possible indices of competence, including years of clinical practice, number of MBCT courses taught and amount of personal practice, did not predict patient outcomes either.

Are you interested in reading more?

Click HERE for the online version of the thesis.
For more information you can contact Marloes Huijbers 

Email: marloes.huijbers@radboudumc.nl

Publications

• Huijbers, M.J., Crane, R.S., Kuyken, W., Heijke, L., van den Hout, I., Donders, R.T., Speckens, A.E.M. (2017).  Teacher Competence in Mindfulness-Based Cognitive Therapy for Depression and Its Relation to Treatment Outcome.
• Huijbers, M. J., Spijker, J., Donders, A. R., van Schaik, D. J., van Oppen, P., Ruhe, H. G., . . . Speckens, A. E. (2012). Preventing relapse in recurrent depression using mindfulness-based cognitive therapy, antidepressant medication or the combination: trial design and protocol of the MOMENT study. BMC Psychiatry, 12(1), 125. doi: 10.1186/1471-244x-12-125
• Huijbers, M. J., Spinhoven, P., Spijker, J., Ruhé, H. G., van Schaik, D. J., van Oppen, P., . . . Speckens, A. E. (2016). Discontinuation of antidepressant medication after mindfulness-based cognitive therapy for recurrent depression: randomised controlled non-inferiority trial. The British Journal of Psychiatry , 208(4), 366-373.
• Huijbers, M. J., Spinhoven, P., Spijker, J., Ruhe, H. G., van Schaik, D. J., van Oppen, P., . . . Speckens, A. E. (2015). Adding mindfulness-based cognitive therapy to maintenance antidepressant medication for prevention of relapse/recurrence in major depressive disorder: Randomised controlled trial. Journal of  Affective Disorders, 187, 54-61.
• Huijbers, M. J., Spinhoven, P., van Schaik, D. J., Nolen, W. A., & Speckens, A.E.M. (2016). Patients with a preference for medication do equally well in mindfulness-based cognitive therapy for recurrent depression as those preferring mindfulness. Journal of Affective Disorders, 195, 32-39.
• ter Avest, M.J., Dusseldorp, E.,  Huijbers, M.J., van Aalderen, J., Cladder-Micus, M.B., Spinhoven, P., Greven, C.U., Speckens, A.E.M. (2019). Added value of Mindfulness-Based Cognitive Therapy for Depression: A Tree-based Qualitative Interaction Analysis. Behaviour Research and Therapy, 122.

BeMind 1 Mindfulness bij kanker

Samenvatting

In het BeMind project onderzoeken we de effectiviteit van Mindfulness-Based Cognitive Therapy (MBCT) voor mensen met kanker. We wilden onder andere weten of MBCT ook online aangeboden kan worden. De onderzochte online MBCT was qua inhoud identiek aan de groeps-MBCT, alleen vond er individueel geschreven contact plaats met een trainer via een online programma. De belangrijkste onderzoeksvraag was: zijn zowel groeps- als online MBCT effectiever dan gebruikelijke zorg in het verminderen van psychische klachten? Het vervolgproject, BeMind 2.0, richt zich op de vraag of de vermindering van psychische klachten blijvend is op lange termijn en hoe beide varianten werken.

Resultaat

Deelnemers die MBCT hebben gehad hebben direct na de training minder psychische klachten dan deelnemers die gebruikelijke zorg hebben gehad. Welke MBCT variant maakte voor het effect niet uit. Daarnaast vielen deelnemers in de online MBCT wel sneller voortijdig uit. Uit gesprekken met deelnemers van de online MBCT komt duidelijk naar voren dat persoonlijke voorkeur erg bepalend is voor de behandelvorm. De individuele aanpak is voor sommigen prettig. Anderen missen de steun van mede-deelnemers. Sommigen vonden de interpersoonlijke afstand prettig, anderen missen de directe interactie met de trainer.

Aanleiding

Ongeveer één derde van de mensen die kanker krijgen, heeft last van aanzienlijke psychische klachten. Uit eerder onderzoek weten we dat MBCT psychische klachten bij kanker kan verminderen, wat het interessant maakte dit verder te onderzoeken. We weten ook dat het voor veel mensen met kanker lastig is om acht keer op locatie te komen om de MBCT te volgen, vanwege onder andere de ziektelast, behandelafspraken, verminderde mobiliteit en vermoeidheid. Daarom wilden wij weten of MBCT ook effectief kan zijn als mensen het thuis op hun eigen tempo in hun eigen omgeving kunnen doen.

Doel

Dit onderzoek vergelijkt de klinische- en kosteneffectiviteit van beide MBCT varianten met gebruikelijke zorg, zowel direct na de training als 3 en 9 maanden erna.

Doelgroep

Mensen met kanker, ongeacht prognose of behandelfase, die bij aanmelding last hadden van (tenminste) milde psychische klachten. Mensen met ernstige acute psychiatrische aandoeningen (bijv. suïcidaliteit) bij aanmelding, werden uitgesloten.

Methode

Deelnemers werden geloot naar één van de drie groepen: groeps-MBCT, online MBCT, of gebruikelijke zorg. Na drie maanden gebruikelijke zorg werd alsnog of groeps- of online MBCT aangeboden. Voor, tijdens, direct na en drie en negen maanden na de MBCT werden deelnemers geïnterviewd over hun psychische klachten en hun zorggebruik. Daarnaast vulden deelnemers diverse vragenlijsten in over psychische klachten, piekeren, angst voor de terugkeer van kanker, positief mentaal welzijn, mindfulness-vaardigheden, kwaliteit van leven.

Organisatie/onderzoekers

Félix Compen en Else Bisseling zijn de hoofdonderzoekers van het BeMind project. Beiden zijn inmiddels gepromoveerd. Op deze pagina kun je het proefschrift van Félix Compen vinden.
Else Bisseling heeft een eigen onderzoekspagina waar je haar proefschrift kunt vinden.

Linda Cillessen zal verder gaan met BeMind 2.0, waarbij zij de vervolgresultaten van BeMind in kaart gaat brengen.

Promotie Félix Compen

Op vrijdag 6 september verdedigde Félix Compen zijn proefschrift getiteld Group- and individual Internet-based Mindfulness-Based Cognitive Therapy for distressed cancer patients. 

Publicaties

• Face-to-Face and Internet-Based Mindfulness-Based Cognitive Therapy Compared With Treatment as Usual in Reducing Psychological Distress in Patients With Cancer: A Multicenter Randomized Controlled Trial
• Consolidation and prediction of long-term treatment effect of group and online mindfulness-based cognitive therapy for distressed cancer patients
• Associations between psychiatric disorder, psychological distress, and healthcare utilization in cancer patients Psycho-Oncology 2018; 27(3): 871-878.
• Study protocol of a multicenter randomized controlled trial comparing the effectiveness of group and individual internet-based Mindfulness-Based Cognitive Therapy with treatment as usual in reducing psychological distress in cancer patients: the BeMind study. Bmc Psychology (2015): 13;3:27 
• Mindfulness-based cognitive therapy for cancer patients delivered via Internet: qualitative study of patient and therapist barriers and facilitators Journal of Medical Internet Research 2017; 19(12): e407. 
• Cost-effectiveness of individual Internet-based and face-to-face MindfulnessBased Cognitive Therapy compared to Treatment As Usual in reducing psychological distress in cancer patients 

BeMind 2 Mindfulness bij kanker

Samenvatting

In het BeMind project onderzoeken we de effectiviteit van Mindfulness-Based Cognitive Therapy (MBCT) voor mensen met kanker. We wilden onder andere weten of MBCT ook online aangeboden kan worden. De onderzochte online MBCT was qua inhoud identiek aan de groeps-MBCT, alleen vond er individueel geschreven contact plaats met een trainer via een online programma. De belangrijkste onderzoeksvraag was: zijn zowel groeps- als online MBCT effectiever dan gebruikelijke zorg in het verminderen van psychische klachten? Het vervolgproject, BeMind 2.0, richt zich op de vraag of de vermindering van psychische klachten blijvend is op lange termijn en hoe beide varianten werken.

Resultaat

Deelnemers die MBCT hebben gehad hebben direct na de training minder psychische klachten dan deelnemers die gebruikelijke zorg hebben gehad. Welke MBCT variant maakte voor het effect niet uit. Daarnaast vielen deelnemers in de online MBCT wel sneller voortijdig uit. Uit gesprekken met deelnemers van de online MBCT komt duidelijk naar voren dat persoonlijke voorkeur erg bepalend is voor de behandelvorm. De individuele aanpak is voor sommigen prettig. Anderen missen de steun van mede-deelnemers. Sommigen vonden de interpersoonlijke afstand prettig, anderen missen de directe interactie met de trainer.

Aanleiding

Ongeveer één derde van de mensen die kanker krijgen, heeft last van aanzienlijke psychische klachten. Uit eerder onderzoek weten we dat MBCT psychische klachten bij kanker kan verminderen, wat het interessant maakte dit verder te onderzoeken. We weten ook dat het voor veel mensen met kanker lastig is om acht keer op locatie te komen om de MBCT te volgen, vanwege onder andere de ziektelast, behandelafspraken, verminderde mobiliteit en vermoeidheid. Daarom wilden wij weten of MBCT ook effectief kan zijn als mensen het thuis op hun eigen tempo in hun eigen omgeving kunnen doen.

Doel

Dit onderzoek vergelijkt de klinische- en kosteneffectiviteit van beide MBCT varianten met gebruikelijke zorg, zowel direct na de training als 3 en 9 maanden erna.

Doelgroep

Mensen met kanker, ongeacht prognose of behandelfase, die bij aanmelding last hadden van (tenminste) milde psychische klachten. Mensen met ernstige acute psychiatrische aandoeningen (bijv. suïcidaliteit) bij aanmelding, werden uitgesloten.

Methode

Deelnemers werden geloot naar één van de drie groepen: groeps-MBCT, online MBCT, of gebruikelijke zorg. Na drie maanden gebruikelijke zorg werd alsnog of groeps- of online MBCT aangeboden. Voor, tijdens, direct na en drie en negen maanden na de MBCT werden deelnemers geïnterviewd over hun psychische klachten en hun zorggebruik. Daarnaast vulden deelnemers diverse vragenlijsten in over psychische klachten, piekeren, angst voor de terugkeer van kanker, positief mentaal welzijn, mindfulness-vaardigheden, kwaliteit van leven.

Organisatie/onderzoekers

Félix Compen en Else Bisseling zijn de hoofdonderzoekers van het BeMind project. Beiden zijn inmiddels gepromoveerd. Op deze pagina kun je het proefschrift van Else Bisseling vinden.

Félix Compen heeft een eigen onderzoekspagina waar je zijn proefschrift kunt vinden.

Linda Cillessen zal verder gaan met BeMind 2.0, waarbij zij de vervolgresultaten van BeMind in kaart gaat brengen.

Promotie Else Bisseling

Op donderdag 21 november verdedigde Else Bisseling haar proefschift getiteld Mindfulness-Based Cognitive Therapy for distressed cancer patients: clinical relevance and therapeutic alliance.

Dit proefschrift richt zich op onderzoek naar de effectiviteit van online mindfulness-based cognitieve therapie (eMBCT) en groeps-MBCT (MBCT) bij het verminderen van psychische problemen (distress), zoals angst- en stemmingsklachten, bij kankerpatiënten. Eveneens werd de relatie tussen behandeluitkomst en therapeutcompetentie, de therapeutische alliantie (werkrelatie tussen patiënt en therapeut), groepscohesie, en de timing van de interventie bestudeerd. Resultaten van onze multicenter RCT toonden aan dat patiënten na zowel eMBCT als MBCT een grotere vermindering van distress meldden dan patiënten na de TAU (Treatment As Usual = gebruikelijke zorg). De sterkte van de therapeutische alliantie droeg hieraan bij. Deze nam in de loop van de tijd in beide behandelvormen toe. De relatie met vermindering van distress verschilde tussen behandelingen: een zwakkere vroege therapeutische alliantie voorspelde grotere mate van distress na behandeling bij MBCT maar niet bij eMBCT. Uit kwalitatieve gegevens bleek dat deelnemers het belangrijk vinden vroeg in het medische traject te worden geïnformeerd over de mogelijkheid tot deelname aan een op mindfulness gebaseerde interventie.

Publicaties

• Face-to-Face and Internet-Based Mindfulness-Based Cognitive Therapy Compared With Treatment as Usual in Reducing Psychological Distress in Patients With Cancer: A Multicenter Randomized Controlled Trial
• Consolidation and prediction of long-term treatment effect of group and online mindfulness-based cognitive therapy for distressed cancer patients
• Associations between psychiatric disorder, psychological distress, and healthcare utilization in cancer patients Psycho-Oncology 2018; 27(3): 871-878.
• Study protocol of a multicenter randomized controlled trial comparing the effectiveness of group and individual internet-based Mindfulness-Based Cognitive Therapy with treatment as usual in reducing psychological distress in cancer patients: the BeMind study. Bmc Psychology (2015): 13;3:27 
• Mindfulness-based cognitive therapy for cancer patients delivered via Internet: qualitative study of patient and therapist barriers and facilitators Journal of Medical Internet Research 2017; 19(12): e407. 
• Cost-effectiveness of individual Internet-based and face-to-face MindfulnessBased Cognitive Therapy compared to Treatment As Usual in reducing psychological distress in cancer patients 

Mindful body Mindfulness bij mensen met onverklaarde lichamelijke klachten

Summary of thesis

Medically unexplained symptoms are symptoms for which no clear biomedical cause has been identified. In general, doctors have great difficulty dealing with patients with persistent medically unexplained symptoms. These patients often feel strongly impaired by their symptoms and they have a relatively high health care use, they receive many medical investigations and interventions. This leads to a high risk for adverse effects. The high healthcare use also leads to considerable healthcare costs. An intervention directed at this specific group of patients has the potential to have large societal and individual impact. In this thesis we have studied ways of identifying patients with persistent medically unexplained symptoms, we have explored the views of these patients upon health care and we have examined the effectiveness of diagnostic tests as a way of reassuring patients. In addition, we have examined a new intervention for patients with medically unexplained symptoms: mindfulness-based cognitive therapy (MBCT). The main aim of this thesis was to study the feasibility, effectiveness and the cost effectiveness of mindfulness training for patients with persistent medically unexplained symptoms. Furthermore, we wanted to gain a deeper understanding of the working mechanisms of MBCT for patients with persistent medically unexplained symptoms (MUS). It is a challenge for physicians to improve their competence in recognizing and managing patients with somatoform disorders, and a screening questionnaire for somatoform disorders might be helpful.

In chapter 2 we present our study examining whether the PHQ-15 is a suitable questionnaire for the detection of somatoform disorders in a high-risk primary care population. The study shows that the PHQ-15 is a valid and moderately reliable questionnaire for the screening of patients in a primary care setting at risk for somatoform disorders. The positive predictive value of the PHQ-15 for a somatoform disorder was 21%. With little evidence available on the experiences of patients with persistent MUS, we interviewed 17 patients with a long history of presenting MUS in chapter 3. The patients wanted to be taken seriously by their GP, they wanted to be partners in decision making and expected ongoing guidance from their GP. In addition, they wanted prevention of further suffering and a clear explanation for what was going on. The participants showed a relatively high level of health anxiety. They expected their GP to react quickly to their symptoms and, if necessary, to use diagnostic tests. These patients seem to have a high level of distress intolerance. New interventions for persistent MUS might focus on improving the doctor-patient relationship and on increasing the patient’s acceptance of symptoms.

In chapter 4, we examined whether diagnostic tests lead to increased reassurance of patients by performing a systematic review. In total, five randomized controlled trials examined the reassuring value of a diagnostic test. The trials used different diagnostic tests for different frequently presented physical symptoms. Four out of five trials did not find a significant reassuring value of the diagnostic tests. One study reported a reassuring effect at three months, but this had disappeared after one year. The results point in the direction of diagnostic tests making hardly any contribution to the level of reassurance of patients. Diagnostic tests are easily available and might seem to be a good instrument to reassure patients, but the reassuring effect of diagnostic tests is limited. Patients with persistent MUS make heavy demands on the health care system. Cognitive behavioral therapy (CBT) has been proven to be effective, but an off er for psychological treatment is often declined because these patients do not expect an improvement from psychological treatment. Thus, there is a need for acceptable and effective treatments for persistent MUS. Mindfulness-based cognitive therapy (MBCT) is a relatively new development within the fi eld of medicine. It consists of meditation, yoga exercises and psycho-education during eight weekly group sessions and daily homework exercises. MBCT facilitates participants in developing the ability to tolerate symptoms while at the same time not letting the symptoms dictate behavior. MBCT is a group based skills training program intended to enable participants to become more aware of their bodily sensations, thoughts, and feelings. It has a body focused and experiential approach, which is diff erent from CBT. MBCT might be acceptable to patients with MUS because it is off ered as a group training that is directed towards the body to enhance self-care rather than as a psychological treatment. Previous studies have demonstrated the eff ectiveness of MBCT for patients with depressive and anxiety disorders, fi bromyalgia, chronic pain and chronic fatigue syndrome. MBCT might also be eff ective for patients with persistent medically unexplained symptoms.

Chapter 5 describes the primary results of our randomized controlled trial (RCT). We performed a randomized controlled trial investigating the feasibility and effectiveness of mindfulness-based cognitive therapy (MBCT) on patients with persistent MUS. Nineteen gPs in the area of Nijmegen participated. They selected patients with MUS from their 10% most frequent attenders. These patients were invited to participate in the trial. Patients who were interested, were seen for a research interview. 125 Patients were randomized over two conditions: receiving MBCT or receiving enhanced usual care (EUC). Participants receiving MBCT had a significant greater improvement in mental functioning at the end of the training, specifically vitality and social functioning improved. Physical functioning and general health status did not diff er between groups. We conclude that MBCT was feasible for these frequently attending patients with persistent MUS. MBCT led to clinically relevant improvements in mental functioning.

In chapter 6, we present the results of the economic analysis performed alongside the RCT. We performed a cost-effectiveness analysis with a time horizon of one year from a societal perspective. MBCT led to a small increase in quality adjusted life years (QALy) and slightly higher societal costs. Participants in the MBCT condition used re[1]latively more mental health care and less hospital care than participants in the control condition. The shift in health care use might lead to more effective care for patients with persistent MUS. At a willingness to pay of € 80,000 per QALy, the probability that MBCT was cost-effective is 57%. MBCT is a relatively cheap intervention, in our study MBCT was more cost-effective than usual care within one year. To reach a deeper understanding of the findings of the RCT we performed a qualitative study examining how mindfulness training works in patients with persistent MUS. In chapter 7 we present a theoretical model which was derived from the analysis of different sources: longitudinal interviews with participants and observational reports of two researchers who attended a full MBCT course. In total, 35 qualitative interviews were carried out. MBCT initiated a process of change, starting with awareness of the present moment, the associated sensory experiences, thoughts and emotions, and accepting rather than resisting these. Participants started to recognize their own behavioral patterns and change them, thus improving self care. In some participants we noticed an increase in self[1]compassion. Main barriers were concurrent social problems and the inability or unwillingness to accept symptoms. Whereas before MBCT patients with MUS focused on short term symptom relief, MBCT created an opportunity for many of them to accept symptoms as a part of life. At the same time these patients took better care of themselves.

Defense

The defense was in 2013.

More information?

Do you want to read more of this thesis? Please click HERE. 

Publicaties

Proefschrift: ‘Minding the Body – Mindfulness Based Cognitive Therapy for patients with medically unexplained symptoms’ – Van Ravesteijn, H.J.

• Van Ravesteijn, H. J., Suijkerbuijk, Y. B., Langbroek, J. A., Muskens, E., Lucassen, P. L., van Weel, C., … & Speckens, A. E. (2014). Mindfulness-based cognitive therapy (MBCT) for patients with medically unexplained symptoms: Process of change. Journal of psychosomatic research, 77(1), 27-33
• Van Ravesteijn, H., Lucassen P., Bor H., van Weel C., Speckens A. (2013). Mindfulness-based cognitive therapy for patients with medically unexplained symptoms: A randomized controlled trial. Psychother Psychosom. 82, 299-310. doi: 10.1159/000348588
• Van Ravesteijn, H., Grutters, J., Olde Hartman, T., Lucassen, P., Bor, H., van Weel, C., . . . Speckens, A. (2013). Mindfulness-based cognitive therapy for patients with medically unexplained symptoms: A cost-effectiveness study. J Psychosom Res, 74(3), 197-205. doi: 10.1016/j.jpsychores.2013.01.001

Mindfulness en het afbouwen van anti­depressiva

Background

Antidepressant use continues to rise, mainly explained by an increase in the proportion of patients receiving long term treatment. Although treatment guidelines recommend discontinuation after sustained remission, discontinuing antidepressants appears to be challenging for both patients and general practitioners (GPs). Mindfulness- Based Cognitive Therapy (MBCT) is an effective intervention that reduces the risk of relapse in recurrent depression and might facilitate discontinuation by teaching patients to cope with withdrawal symptoms and fear of relapse.

Aim

This study aimed to investigate the effectiveness of the combination of Supported Protocolized Discontinuation (SPD) and MBCT in comparison with SPD alone in successful discontinuation of long-term use of antidepressants in primary care.

Population

Patients were recruited from 34 GPs with a mental health assistant in the north, middle and east part of the Netherlands. They had received prescriptions for antidepressants in primary care for at least the past 9 months and were 18 years or older.

Methods

This study involved a cluster-randomized controlled trial conducted in primary care patients with long-term use antidepressants with baseline and 6, 9 and 12 months follow-up assessments. Patients choosing to discontinue their medication were offered a combination of SPD and MBCT or SPD alone. Our primary outcome will be full discontinuation of antidepressant medication (= 0 mg) within 6 months after baseline assessment. Secondary outcome measures will be the severity of withdrawal symptoms, symptoms of depression and anxiety, psychological well-being, quality of life and medical and societal costs.

Time period

This study was conducted between 2016 and 2019 and recruitment is now closed. Data are currently analyzed and reported.

More information (in Dutch)

• Patiëntfolder Afbouw van antidepressiva
• Keuzehulp Afbouw van antidepressiva
• Antidepressiva Afbouwprotocol (suggesties voor afbouwschema’s)
• Globale leidraad bij de afbouw van antidepressiva door de POH-GGZ

For questions related to this study, contact Marloes.Huijbers@radboudumc.nl 

Publications

• Enhancing shared decision making about discontinuation of antidepressant medication: a conceptmapping study in primary and secondary mental health care

MiLon Mindfulness bij longkanker

Summary of thesis

Lung cancer is the leading cause of death by cancer worldwide, accounting for approximately 20% of cancer deaths. Besides a poor prognosis, lung cancer patients suffer from severe physical symptoms and undergo intensive treatment. Also partners are emotionally affected by lung cancer as they often take on the role of caregiver and face the fear of losing their partner. The burden lung cancer poses on patients and their partners makes them vulnerable to developing psychological distress and psychiatric disorders. Lung cancer patients report among the highest psychological distress rates of all cancer patients. Despite these high distress rates, lung cancer patients are less likely to receive psychosocial care than patients with other cancer types. Moreover, limited research has been conducted on the effectiveness of psychosocial interventions in lung cancer patients and their partners. Recently, mindfulness-based interventions (MBIs), such as MBSR, have proven to be effective in reducing psychological distress in cancer patients. However, hardly any evidence is available on the effectiveness of MBSR in lung cancer patients and their partners.

1.       How suitable are commonly used self-report questionnaires to differentiate between lung cancer patients and partners with and without a psychiatric disorder?

In a systematic screening study (Chapter 2), we examined to what extent the Hospital Anxiety and Depression Scale (HADS), Distress Thermometer, Beck Depression Inventory and State subscale of State Trait Anxiety Inventory were suitable to screen for psychiatric disorders in lung cancer patients and partners. A consecutive sample of 144 patients and 99 partners completed the screening instruments and were interviewed with the Structured Clinical Interview DSM-IV (SCID-I) to diagnose psychiatric axis I disorders. Overall, 18% of patients and 20% of partners were diagnosed with a psychiatric disorder (i.e. anxiety disorders, depressive disorders and adjustment disorder). In patients and partners, the HADS total score outperformed the other questionnaires in terms of both ruling out those without a psychiatric disorder and identifying those with a psychiatric disorder, using a cut-off level of ≥15. 8 153 The findings of this screening study implied that the HADS seems the most suitable screening measure to differentiate between those with and without a psychiatric disorder. Patients and partners scoring above the cut-off should be referred to a psychologist or psychiatrist for further diagnostics and treatment.

2. What is the currently available evidence for the effectiveness of MBIs in reducing psychological distress in cancer patients?

A systematic review (Chapter 3) was conducted on randomized controlled trials (RCT) that examined the effectiveness of MBIs in cancer patients and have been published since an earlier meta-analysis in 2012. We included 5 RCTs (n = 690), which confirmed the effectiveness of MBIs in decreasing psychological distress and improving quality of life. The methodological quality of the studies was good. Three RCTs reported on a comparison with an active control group, demonstrating that the MBI was superior to Supportive Expressive Group Therapy (SET) and a nutrition education programme in reducing distress, but inferior to Cognitive Behavioural Therapy in reducing insomnia. The external validity of the RCTs was low once again. The majority of participants were women and diagnosed with curable breast cancer. Fortunately, ongoing trials are examining other cancer populations, such as lung and prostate cancer, in palliative stages as well.

Interestingly, since the publication of this systematic review in 2015, four new RCTs have been published, of which three demonstrated the effectiveness of MBIs on a range of outcomes in breast cancer patients, such as pain, fatigue and post-traumatic growth (Johannsen et al. 2016; Lengacher et al. 2016; Zhang, Zhou et al. 2016). Importantly, the RCT in advanced prostate cancer patients has also been published (Chambers et al. 2016), revealing that the men did not benefit from the six 45-min MBCT sessions delivered by telephone in comparison to minimally enhanced usual care.

3.       What is the effectiveness of MBSR added to CAU compared to solely CAU in reducing psychological distress in lung cancer patients and their partners?

In the MILON study, a multicentre, parallel-group RCT (Chapter 4), patients with lung cancer and their partners were randomised to either MBSR in addition to care as usual (CAU+MBSR) or solely CAU. MBSR is an 8-week group-based intervention, including mindfulness practices and teachings on stress. CAU included anti-cancer treatment, medical consultations and supportive care. The primary outcome was psychological distress (HADS). Secondary outcomes included quality of life, caregiver Chapter 8. Summary and General Discussion 154 burden, relationship satisfaction, mindfulness skills, self-compassion, rumination and post-traumatic stress symptoms. Outcomes were assessed at baseline, post-intervention and at 3-month follow-up. Linear mixed modeling was conducted on an intention-to[1]treat and per-protocol sample. Results of the MILON study (Chapter 5) demonstrated that 63 patients and 44 partners were included in the trial; 31 patients and 21 partners were randomized to MBSR and 32 patients and 23 partners to CAU. As hypothesized, patients in the CAU+MBSR group reported significantly less psychological distress than those in the CAU group. Additionally, patients showed more improvements in quality of life, mindfulness skills, self-compassion and rumination after CAU+MBSR versus CAU. Baseline distress levels appeared to predict treatment outcome: those with more distress benefitted most from MBSR. In partners, no differences were found between the two groups. To conclude, this RCT suggested that MBSR can reduce psychological distress and improve quality of life in patients, especially in distressed patients. However, partners did not seem to benefit from MBSR, possibly because they were more focused on patients’ wellbeing rather than their own.

4.       How do lung cancer patients and their partners who refuse participation in a trial on MBSR differ from those who do participate?

And what are the reasons of patients and partners to refuse or to participate? In a mixed methods study (Chapter 6) we examined the characteristics of lung cancer patients and partners who participated and refused participation in the RCT on MBSR, and their underlying reasons for refusing or participating. After participation in the screening study (Chapter 2), a subsample of 137 lung cancer patients and 99 partners were invited for the RCT, of which 21 patients and 13 partners eventually participated. Patients who were retired, who received no current anti-cancer treatment and who reported higher levels of self-compassion were more likely to refuse than to participate. Partners who reported lower psychological distress levels were more likely to refuse participation. Qualitative analysis showed that participants wanted to participate because they or their partner were distressed and in need of help. Some refusers, however, reported distress but did not want help because they did not want to face the fact they (or their partner) had lung cancer. By integrating psychosocial interventions into regular cancer care, we might be able to better reach those patients and partners in need of psychosocial care.

5.       What kind of role do mindfulness and self-compassion play in the relationship between patients and partners with respect to psychological distress and communication about cancer?

More specifically, to what extent are mindfulness and self-compassion of oneself and mindfulness and self-compassion of one’s partner related to one’s psychological distress and communication about cancer? In a cross-sectional sample (Chapter 7) of 88 couples facing lung cancer, the actor[1]partner interdependence model was used to examine how mindfulness and self[1]compassion are related to psychological distress and communication about cancer within and between partners. Within partners, levels of mindfulness and self-compassion were inversely related to levels of psychological distress. At a dyadic level we found that the association between self-compassion and distress in one partner was less strong if the other partner reported higher levels of self-compassion. In addition, within partners levels of self-compassion were positively associated with communication about cancer, while levels of mindfulness were not. At a dyadic level, mindfulness of one partner tended to be related to more open communication in the other partner. These findings point to the possibility that mindfulness and self-compassion skills go beyond the individual, and may impact couple functioning.

More information?

Please click HERE if you would like access to the whole thesis.

DEMETER Depressie, mindfulness en therapie­resistentie

Summary thesis

The overall goals of the studies included in this dissertation were a) to investigate the effectiveness of MBCT for chronic, treatment resistant depression, b) to explore cognitive reactivity and rumination as potential working mechanisms of MBCT and c) to investigate the psychometric properties of the Dutch translation of a novel, comprehensive questionnaire to assess mindfulness skills. This chapter summarizes and discusses the studies in relation to the existing literature. In addition, strengths and limitations are identified and directions for future research and clinical implications are given. 

Chapter 2 describes the rationale, design and methods of the RCT comparing MBCT with treatment-as-usual (TAU) for chronically, treatment-resistant depressed patients. All participants were depressed for at least 12 months, despite of at least 10 sessions of evidence-based psychological treatment, such as CBT or IPT and treatment with at least one antidepressant (> 4 weeks) during the current episode. At the beginning of the study all participants were moderately to severely depressed. Before and after the MBCT or treatment-as-usual (TAU), depressive symptoms, rumination, quality of life, mindfulness skills and self-compassion were assessed. In addition, remission rates were investigated with a psychiatric interview according to DSM-IV criteria. 

Chapter 3 presents the findings of this RCT. In total, 106 participants were included in the study. Results of the intention-to-treat analyses including all available data show that there was no significant difference in reduction of depressive symptoms between the conditions. However, at post-treatment more participants of the MBCT condition compared with TAU reached (partial) remission from their depressive disorder. In addition, participants of the MBCT group showed significant less rumination, a higher quality of life, more mindfulness skills, and more self-compassion compared with TAU. The percentage of participants who dropped out of the MBCT was higher than expected, i.e. 24.5%. When only including completers of the MBCT in the analysis (‘per-protocol analysis’), the MBCT condition did show a significant reduction in depressive symptoms compared with TAU. Severity of symptoms, treatment-resistancy and childhood trauma did not moderate the effect of MBCT or TAU on depressive symptoms. However, baseline levels of rumination did moderate the effect of MBCT on depressive symptoms. Participants with high levels of rumination on baseline showed significantly lower depressive symptoms post-treatment when allocated to MBCT compared with TAU. This implies that chronically, treatment-resistant depressed patients who experienced high levels of rumination seemed to benefit most of MBCT. 

Chapter 4 and 5 both investigated dysfunctional cognitive processes as potential working mechanisms of MBCT. In data of another RCT in remitted depressed patients (N=115) were analyzed to test whether MBCT compared with a waitlist-group affects cognitive reactivity. As previous analyses showed that MBCT reduces depressive symptoms in this sample, we also investigated whether cognitive reactivity mediated the effect of MBCT on depressive symptoms. Results showed that after MBCT, cognitive reactivity was indeed significantly diminished in the MBCT group and that cognitive reactivity mediated the effect of MBCT on depressive symptoms. This provides preliminary evidence for cognitive reactivity as a potential working mechanism of MBCT. Chapter 5 investigated the effects of MBCT on rumination in a sub-sample (n=62) of the RCT described in chapter 2 and 3. Rumination is typically assessed with self-report questionnaires. Although easy to administer, questionnaires might be influenced by memory and response bias. In chapter 5, we therefore utilized a new, on-line behavioral measure of rumination, called the ‘breathing focus task’ (BFT). Because the BFT has never been used in a clinically depressed sample, we first compared the chronically, treatment-resistant depressed sample (n=62) with a never-depressed sample (n=106) matched on age and gender. Results show that chronically, treatment-resistant depressed patients have significantly more negative -but not more neutral or positive- thought intrusions on the BFT compared with the never-depressed controls. Higher levels of negative thought intrusions were associated with a self-report measure of rumination and patients showed an increase in sad mood. Secondly, the scores on the BFT of the chronically, treatment-resistant depressed sample were compared before and after MBCT and TAU. As expected, the MBCT group showed a significantly larger decrease in negative thought intrusions after treatment than the TAU group. This study supports the hypothesis that MBCT reduces state rumination. 

In chapter 6, the validity of the Dutch translation of a new questionnaire to assess mindfulness skills is presented. Recent studies have questioned whether the factor structure of one of the most frequently used questionnaires to assess mindfulness skills (FFMQ) is independent of meditation experience. Bergomi et al. (2014) developed a new questionnaire (Comprehensive Inventory of Mindfulness Experiences; CHIME) based on all available mindfulness questionnaires and reformulated items to make sure that the understanding of items is independent of mindfulness experiences. However, the CHIME was not yet available in Dutch. We translated the CHIME to Dutch and tested its factor structure, internal consistency, and its discriminant and convergent validity in a sample (N=481) consisting of clinical and non-clinical subsamples. Furthermore, a short version of the CHIME (CHIME-SF) was developed and the CHIME and CHIMESF were administered before and after MBCT or MBSR training. Results show that the psychometric properties of the CHIME were acceptable and that the CHIME and CHIMESF were both sensitive to change.

Please click HERE to access the thesis

Publications

• Cladder-Micus, M. B., Vrijsen, J. N., Becker, E. S., Donders, R., Spijker, J., & Speckens, A. E. (2015). A randomized controlled trial of Mindfulness-Based Cognitive Therapy (MBCT) versus treatment-as-usual (TAU) for chronic, treatment-resistant depression: study protocol. BMC psychiatry, 15(1), 1-8.
• Cladder‐Micus, M. B., Speckens, A. E., Vrijsen, J. N., T. Donders, A. R., Becker, E. S., & Spijker, J. (2018). Mindfulness‐based cognitive therapy for patients with chronic, treatment‐resistant depression: A pragmatic randomized controlled trial. Depression and anxiety.
• Cladder-Micus, M. B., van Aalderen, J., Donders, A. R. T., Spijker, J., Vrijsen, J. N., & Speckens, A. E. M. (2017). Cognitive reactivity as outcome and working mechanism of mindfulness-based cognitive therapy for recurrently depressed patients in remission. Cognition and Emotion, 1-8. doi: 10.1080/02699931.2017.1285753.
• Cladder-Micus, M. B., Becker, E. S., Spijker, J., Speckens, A. E., & Vrijsen, J. N. (2019). Effects of Mindfulness-Based Cognitive Therapy on a Behavioural Measure of Rumination in Patients with Chronic, Treatment-Resistant Depression. Cognitive Therapy and Research, 1-13.

Proefschrift

Mindfulness Based Cognitive Therapy for chronic, treatment-resistant depression

Artsen met aandacht Mindfulness voor artsen in opleiding

Summary thesis

Medical residency is a demanding and challenging period, and burnout is highly prevalent in medical residents. In the Netherlands, approximately one fifth of medical residents have moderate to severe burnout symptoms. Although burnout has significant effects on the health of the individual and on his or her job performance, research on interventions to prevent or reduce burnout in medical residents is limited. Over the last few years, mindfulness-based interventions (MBIs), such as Mindfulness-Based Stress Reduction (MBSR) have been reported to be helpful in decreasing burnout and promoting wellbeing in healthcare professionals. However, hardly any evidence is available on the effectiveness of MBSR in medical residents. The primary aim of this thesis was to examine the effectiveness of MBSR in reducing burnout in medical residents. The following four research questions were addressed:

1)      What are potential contributing factors of burnout and work engagement in medical residents?

In chapter 2 we focused on the potential predictors of burnout in medical residents. We examined the associations of job demands and resources, home demands and resources, and work–home interferences with burnout in male and female medical residents. The study population consisted of a nation-wide sample of medical residents. Path analysis was used to examine the associations between job and home characteristics and work–home interference and burnout in both males and females. In total, 2115 (41.1%) residents completed the questionnaire. In both sexes emotional demands at work and the interference between work and home were important contributing factors of burnout. Opportunities for job development appeared to be an important protective factor. Other contributing and protective factors were different for male and female residents. In females, social support from family or partner seemed protective against burnout. In males, social support from colleagues and participation in decision-making at work seemed important. This study implied that effectively handling emotional demands at work, dealing with the interference between work and home, and having opportunities for job development are essential factors that should be addressed when developing interventions to prevent or reduce burnout in medical residents. However, it is important to take gender differences into consideration when implementing preventive or therapeutic interventions for burnout in medical residents.

While chapter 2 focused on burnout, chapter 3 focused on work engagement in medical residents. In this chapter, the results of a study on the potential predictors of work engagement in the same cross-sectional sample are described. Path analysis was used to examine the associations between the potential predictors and work engagement. Important positive contributing factors of work engagement were opportunities for job development, mental demands at work, positive work[1]home interference and positive home-work interference. Emotional demands at work and negative home-work interference were negatively associated with work engagement and seem to hinder work engagement. The influence of these factors on work engagement was similar in male and female residents. This study implied that opportunities for job development, having challenging work, dealing effectively with emotional demands and home-work interference are of high relevance in enhancing work engagement.

2)      What is the feasibility and effectiveness of MBSR in physicians?

Chapter 4 described the results of a mixed methods pilot study of MBSR in general practitioners (GPs). MBSR is an 8-week group-based intervention, including mindfulness practices and teachings on stress. This study was conducted in order to gain insight into the feasibility and effects of MBSR on burnout, empathy, and (work-related) wellbeing in GPs. A waiting list-controlled pre-/post-study and a qualitative study were conducted. Fifty Dutch GPs participated in this study. The MBSR group reported greater improvements in depersonalization (burnout), dedication (work engagement) and mindfulness skills compared with the control group. There was no change in empathy. The qualitative data indicated that the MBSR course increased their wellbeing and compassion towards themselves and others, including their patients. The study indicated that MBSR for GPs is feasible and might result in fewer burnout symptoms and increased work engagement and wellbeing. However, an adequately powered randomized controlled trial is needed to confirm these findings. 128

3)      What is the effectiveness of MBSR in reducing burnout in medical residents?

In Chapter 5 the outcomes of the randomized controlled trial (RCT) of Mindfulness-Based Stress Reduction (MBSR) in medical residents are reported. In total, 148 medical residents participated in the RCT comparing MBSR with a waitlist-control group. In contrast to our expectations, no significant difference was found between the two groups on the primary outcome, emotional exhaustion (burnout). However, exploratory moderation analysis showed that the intervention outcome was moderated by baseline severity of emotional exhaustion; those with more emotional exhaustion at baseline did seem to benefit. Furthermore, the MBSR group did report significantly greater improvements compared to the control group in reduced personal accomplishment, worry, mindfulness skills, self-compassion and perspective taking (empathy). To conclude, this RCT suggested that although MBSR did not result in a significant reduction of emotional exhaustion in the whole group, residents with high baseline levels of emotional exhaustion seemed to benefit from the intervention. This indicates the potential of MBSR as a burnout intervention for residents. Our findings also indicate that MBSR might be beneficial for medical residents in terms of wellbeing more generally and therefore could have a valuable place in medical residency programs. However, our findings are preliminary and should be interpreted with care. More research is needed in order to confirm these findings. 4) How does MBSR influence the professional development of medical residents?

Chapter 6 described the results of a qualitative study in which we explored how MBSR influences medical residents’ professional development. In-depth, face-to-face interviews were conducted with 19 medical residents. The constant comparison method was used to analyze the data. The analysis of the data resulted in five themes: (1) awareness of thoughts, emotions, bodily sensations and behavior; (2) increased self-reflection; (3) acceptance and non-judgment; (4) increased resilience; and (5) relating to others. Medical residents indicated that the MBSR training increased their awareness and self-reflection at work and that they were more accepting towards themselves and towards their limitations. Furthermore, they mentioned that they were more resilient (the competence to cope and adapt in the face of adversity and to bounce back when stressors become overwhelming) and better at setting priorities and limits. They improved their self-care and work-life balance. In addition, residents indicated that the training made them more aware of how they communicated. They asked for help more often and they seemed to be more open towards feedback. Finally, they indicated an increased sense of compassion for others. This study indicated that mindfulness training can serve as a tool to cultivate important professional competencies for medical residents.

More information?

Click on this link to access the thesis.

Publications

• Verweij, H., van der Heijden, F., van Hooff, M., Prins, J., Lagro-Janssen, A., van Ravesteijn, H., & Speckens, A. (2017). The contribution of work characteristics, home characteristics and gender to burnout in medical residents.
• Verweij, H., van Hooff, M., van der Heijden, F., Prins, J., Largo-Janssen, A., van Ravesteijn, H., & Speckens, A. (2017). The relationship between work and home characteristics and work engagement in medical residents. 
• Verweij, H., Waumans, R., Smeijers, D., Lucassen, P., Donders, R., van der Horst, H., & Speckens, A. (2016). Mindfulness-based stress reduction for GPs: results of a controlled mixed methods pilot study in Dutch primary care.
• Verweij, H., van Ravesteijn, H., van Hooff, M., Largo-Janssen, A., & Speckens, A. (2018). Mindfulness-based stress reduction for residents: A randomized controlled trial. 
• Verweij, H., van Ravesteijn, H., van Hooff, M., Largo-Janssen, A., & Speckens, A. (2018). Does mindfulness training enhance the professional development of residents? A qualitative study

ReMind MS Mindfulness bij MS

Aanleiding

Cognitieve klachten zijn een veelvoorkomend probleem bij mensen met multiple sclerose (MS). Met cognitieve klachten bedoelen we problemen met het denken, zoals concentratieproblemen, vergeetachtigheid en moeite om meerdere dingen tegelijk te doen. Tijdens dagelijkse bezigheden, zoals het werk, een studie of het gezinsleven, wordt een beroep gedaan op deze cognitieve vaardigheden. De impact van cognitieve problemen kan hierdoor groot zijn. Op dit moment is het niet duidelijk welke behandelingen de  cognitieve problemen bij MS kunnen verminderen. Met het REMIND-MS onderzoek willen we beter inzicht te krijgen in de oorzaak en behandeling van cognitieve problemen bij MS.

Resultaat

De training zorgde niet voor een afname in burnoutklachten voor de hele groep, maar wel voor de groep deelnemers met veel burnoutklachten aan het begin van de studie. Daarnaast resulteerde de mindfulnesstraining in verbeteringen op meer algemene aspecten van welbevinden (persoonlijke bekwaamheid ,minder piekeren, ontwikkelen van mindfulnessvaardigheden, meer zelfcompassie en aspecten van empathie).  Tijdens interviews met deelnemers gaven zij ook op professioneel gebied baat te hebben bij de training. Deze studie laat zien dat mindfulness mogelijk een effectieve training is voor jonge artsen met een burnout en kan bijdragen aan zowel de persoonlijke als professionele ontwikkeling van artsen in opleiding.

Doel

Met dit onderzoek willen we beter inzicht te krijgen in de oorzaak en behandeling van cognitieve problemen bij MS. Zo gaan we uitzoeken of drie soorten behandelingen (mindfulness, cognitieve revalidatietherapie en informatievoorziening door een MS-verpleegkundige) de cognitieve problemen verminderen. Ook onderzoeken we het effect van de behandelingen op de stemming, het dagelijks functioneren, het welbevinden en de hersenen. Daarnaast bekijken we of veranderingen in de hersenen de cognitieve problemen bij MS kunnen verklaren.

Doelgroep

Mensen met MS tussen de 18 en 65 jaar met cognitieve klachten (zoals geheugen-, concentratie-, of aandachtsproblemen), in staat om Nederlands te schrijven en lezen en geen ervaring met een meerdaagse mindfulness cursus.

Methode

Meedoen aan het onderzoek betekent deelname aan een van de volgende drie behandelingen: (1) mindfulness, (2) cognitieve revalidatietherapie, (3) informatievoorziening MS-verpleegkundige. Loting bepaalt welke behandeling de deelnemer krijgt. De behandelingen duren negen weken en bestaan uit bijeenkomsten in het VUmc te Amsterdam of Klimmendaal Revalidatiespecialisten te Arnhem. Deelnemers hebben zelf de keuze of zij de behandeling in Amsterdam of Arnhem volgen. Naast deze behandeling vindt er drie keer een meting plaats in het VUmc in Amsterdam. De metingen bestaan uit een neuropsychologisch onderzoek, een MEG-scan (hersenscan) en vragenlijsten.

Periode

In het begin van 2018 zijn de eerste behandelingen van het onderzoek gestart. Deze duurden tot en met 2019.  

Promotie

Op 5 september 2023 is Ilse Nauta gepromoveerd. Meer informatie hierover kun je vinden in dit nieuwsbericht.

Haar digitale proefschrift kun je lezen via: Towards a better management of cognitive decline in multiple sclerosis: Linking neuropsychology to neurophysiology — Vrije Universiteit Amsterdam (vu.nl)

Organisatie/onderzoekers

Het onderzoek is een samenwerking tussen de volgende organisaties: het VUmc MS Centrum in Amsterdam, Klimmendaal Revalidatiespecialisten in Arnhem, het Centrum voor Mindfulness van het Radboudumc in Nijmegen en de Radboud Universiteit in Nijmegen.
De hoofdonderzoeker van het project is dr. Brigit de Jong, neuroloog van het VUmc MS Centrum in Amsterdam. De coördinator van het onderzoek is Ilse Nauta, onderzoeker van het VUmc MS Centrum in Amsterdam.

Medical Clerkship Mindfulness voor co-assistenten

Summary of thesis

Complete mental health exists of the absence of psychological distress and the presence of positive feelings and positive functioning (‘positive mental health’). Psychological distress is prevalent in medical students, but there is little knowledge about positive mental health. High levels of psychological distress and languishing positive mental health are related to worse self-reported functioning and lower self-reported empathy of medical clerkship students. Previous studies showed that mindfulness-based stress reduction (MBSR) decreased distress in medical students, but response rates were modest, follow-up was short and studies in medical clerkship students were underrepresented.

The current thesis examined three main topics:

1. Mental health of medical clerkship students; We assessed prevalence rates and predictors of both psychological distress and positive mental health.

2. Effects of MBSR on mental health of medical clerkship students; We used quantitative and qualitative methods to examine the long-term effects of an MBSR training integrated in the core curriculum.

3. Effects of MBSR on medical clerkship student empathy. We explored the feasibility of using a simulated patient-reported instrument to assess physician empathy and used it to examine effectiveness of MBSR in enhancing student empathy.

1. Mental health of medical clerkship students

In chapter 2 we examined the prevalence of psychological distress and positive mental health and their possible predictors in all 454 fourth-year medical students of the Radboud University Medical Center in their first year of clinical clerkships. Of those eligible, 406 (89%) students completed the assessment, 86 (21%) of whom reported clinical levels of distress. We found a flourishing mental health in 159 (41%) students, meaning that they experienced feelings such as happiness and interest in life and reported positive psychological and social functioning such as self[1]acceptance and rewarding relationships. As hypothesized, psychological distress and positive mental health did not appear to be two ends of the same continuum: Students without psychological distress did not necessarily have a flourishing positive mental health and vice versa. Out of a number of possible contributing factors, psychological distress appeared to be most related to less ‘acting with awareness’ and more ‘worrying’. Positive mental health, on the other hand, was strongly related to a lack of ‘problem avoidance’ and ‘emotional irresponsibility’ (the feeling that human suffering including your own is beyond your control). Although Summary and general discussion | 139 8 no conclusion on causality can be drawn, this study supports the idea that self[1]awareness and active, nonavoidant coping strategies are related to lower distress and higher positive mental health. Supporting the development of these skills might contribute to student well-being.

2. Effects of MBSR on mental health of medical clerkship students

As previous studies on MBSR in medical students suffered from a low response rate and offered MBSR as elective, their results could have been distorted by selection bias. Students refusing participation in a study assessing the effect of MBSR could either be those less distressed and more mindful or those more distressed and less mindful. We performed a preliminary study (chapter 3) to examine the characteristics of students willing to participate in a training in terms of demographic information, levels of psychological distress, personality traits and mindfulness skills. Of 179 students included in the study, 97 (53%) indicated they would be interested in participating in a training. Interested students reported significantly higher levels of psychological distress and neuroticism than non-interested students. Subsequently, we compared the 167 (72%) participants in our randomized-controlled trial with 41 non-participants. Again, the participants reported significantly higher levels of psychological distress, worrying and problem avoidance and lower levels of mindfulness skills. Taken together, these results showed that by offering an MBSR training we probably do reach students who can benefit most of it, namely those with the highest distress levels and the lowest mindfulness skills.

In chapter 4 we discussed the results of a cluster-randomized controlled trial investigating the effects of MBSR training on psychological distress and positive mental health of medical clerkship students over the entire duration of their core clerkships. Of the 232 eligible fourth-year students at the beginning of their clerkships, 167 (72%) were randomized in their clerkship cohort to either clerkships as usual (n=83) or clerkships with addition of MBSR training (n=84). The students in the MBSR group reported a small statistically significant reduction of psychological distress (Cohen’s d=0.20) and a moderate statistically significant improvement of positive mental health (Cohen’s d=0.44) throughout the 20 months of clerkships. They reported a reduction in dysfunctional cognitions (Cohen’s d=0.18) and an increase of mindfulness skills (Cohen’s d=0.35) and life satisfaction (Cohen’s d=0.51).

In addition to the randomized controlled trial, we conducted a qualitative study by interviewing 16 students two years after the training about the nature and effects of their current mindfulness practice (if present). We applied purposive sampling based on gender, clerkship group and satisfaction with the course, attempting to maximize diversity of the reported experiences. Chapter 5 summarizes the results of 140 | Chapter 8 8 the constant comparative analysis of the transcribed interviews. The 16 interviews resulted in six main themes related to the nature and effects of students long[1]term mindfulness practice; (1) the ‘unchanged lifestyle’ reported by the students that discontinued practice; (2) understanding and intention as ‘pre-conditions’ for developing long-term practice; (3) ‘attention regulation and awareness’ during daily activities as core elements of students’ long-term mindfulness practice; (4) practice sometimes resulted in ‘changed ways of coping’ such as taking a pause, reflecting and recognizing automatic behavioral patterns, making room for a conscious response. Students described both conscious internal responses such as taking distance (decentering) from negative thoughts, as well as external responses such as changing behavior towards a clerkship supervisor or patient; (5) ‘quality of life increased’ by enhanced enjoyment of daily activities, improved work-life balance and sometimes even different career choices and; (6) students reported practical, personal and professional ‘barriers and facilitators’ of maintaining mindfulness practice. Overall, changes in attitude (e.g. non-judgment, compassion) seemed less present than changes in attention regulation.

3. Effects of MBSR on medical clerkship student empathy

In addition to using self-report empathy measures, we wanted to explore the effects of MBSR on medical clerkship student empathy as reported by patients after a simulated consultation. As the only patient-rated measure with evidence of reliability and validity was not available in Dutch, we translated it and conducted a preliminary investigation of its psychometric properties (chapter 6). We distributed this 10-item patient-rated Consultation and Relational Empathy Measure (CARE Measure) among patients of 19 general practitioners in 5 primary care centers and compared it to seven items of the QUality trOugh The patient’s Eyes (QUOTE) questionnaire assessing ‘affective performance’ of the physician. Analyses of the 655 questionnaires that were returned showed high internal reliability of the CARE Measure (Cronbach’s alpha 0.974) and a modest positive correlation (r=0.34) with the QUOTE confirming convergent validity.

Chapter 7 describes the exploratory secondary outcome measure of our randomized controlled trial comparing the effects of clerkships as usual (CAU) to clerkships with additional MBSR on simulated patient-rated empathy of medical clerkships students. Of 167 participating students, at least one valid CARE Measure score could be obtained from 75 CAU students and 71 MBSR students. Empathy increase in the MBSR group did not significantly differ from the increase in the CAU group (Cohen’s d=0.19). However, baseline psychological distress moderated the effect of MBSR on student empathy. In students with pathological levels of psychological distress at baseline, simulated patient-reported empathy increased significantly in the MBSR group compared to a decrease in the control group (Cohen’s d=0.71).

More information?

Click here to access the thesis

Publications

• van Dijk, I., Lucassen, P., van Weel, C., & Speckens, A. (2017). A cross-sectional examination of psychological distress, positive mental health and their predictors in medical students in their clinical clerkships. 
• van Dijk, I., Lucassen, P., & Speckens, A. (2015). Mindfulness training for medical students in their clinical clerkships: two cross-sectional studies exploring interest and participation. 
• van Dijk, I., Lucassen, P., Akkermans, R., van Engelen, B., van Weel, C., & Speckens, A. (2017). Effects of Mindfulness-Based Stress Reduction on the mental health of clinical clerkship students: A cluster randomized controlled trial.
• van Dijk, I., Scholten, N.,  Lenferink, M., Lucassen, P., Mercer, S., van Weel, C., Hartman, T., & Speckens, A. (2017). Reliability and validity of the Dutch version of the consultation and relational empathy measure in primary care.

Aandacht voor ADHD Mindfulness voor volwassenen met ADHD

Click here to access the thesis Attention for ADHD.

Publications

• Hepark, S., Janssen, L., de Vries, A., Schoenberg, P., Donders, R., Kan, C., & Speckens. (2019). The efficacy of adapted MBCT on core symptomsand executive functioning in adults with ADHD: a preliminary randomized controlled trial. 
• Janssen, L., Kan, C., Carpentier, P., Sizoo, B., Hepark, S., Grutters, J., Donders, R., Buitelaar, J., & Speckens. (2015). Mindfulness Based Cognitive Therapy versus treatment as usual in adult with attention deficit hyperactivity disorder (ADHD).
• Janssen, L., de Vries, A., Hepark, S., & Speckens, A. (2017). The feasibility, effectiveness, and process of change of mindfulness based cognitive therapy for adults with ADHD: a mixed-method pilot study.
• Janssen, L., Kan, C., Carpentier, P., Sizoo, B., Hepark, S., Schellekens, M., Donders, R., Buitelaar, J., & Speckens, A. (2018). Mindfulness based cognitive therapy v. treatment as usual in adult with ADHD: a multicentre, single-blind, randomized controlled trial.

Compassie-onderzoek Mindfulness-gebaseerde compassie­training voor volwassenen met (terug­kerende) depressie

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