Improve Caregiver and Cirrhosis Patient Psychological Health with Mindfulness
By John M. de Castro, Ph.D.
“Mindfulness practices also help people observe their thoughts and behaviors with less reactivity and judgment, which could enable caregivers to better respond to the emotional and physical difficulties they encounter.” – Emily Nauman
There is a tremendous demand for caregiving in the US. It is estimated that over 65 million (29% of the adult population) provides care to someone who is mentally or physically ill, disabled or aged, averaging 20 hours per week spent caring for their loved ones. This caregiving comes at a cost to the caregiver. It exacts a tremendous toll on caregivers’ health and well-being. Caregiving has been associated with increased levels of depression and anxiety as well as higher use of psychoactive medications, poorer self-reported physical health, compromised immune function, and increased mortality.
Liver disease affects about 3.9 million people and Cirrhosis kills nearly 40,000 people each year. Providing care for an individual with end stage liver disease has not been seriously studied. The challenges of caring for an individual with cirrhosis require that the individual be able to deal with stress, to regulate their own emotions, and to be sensitive and attentive. These skills are exactly those that are developed in mindfulness training. It improves the psychological and physiological responses to stress. It improves emotion regulation. And it improves the ability to maintain attention and focus in the face of high levels of distraction. So, it is not surprising that mindfulness improves caregiving and assists the caregiver in coping with the stress.
In today’s Research News article “Mindfulness-Based Stress Reduction Therapy Improves Patient and Caregiver-Reported Outcomes in Cirrhosis.” See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5539344/, Bajaj and colleagues recruited patients with cirrhosis and their caregivers. The majority of the caregivers were women and spouses. They measured the patients before and after treatment for depression, anxiety, sleep quality, sleepiness, health related quality of life, and sickness impact. Caregivers were also measured for depression, anxiety, sleep quality, caregiving burden and perceived caregiver burden. Both patients and their caregivers received a 4-week program of modified structured Mindfulness-Based Stress Reduction (MBSR) along with discussions of barriers and strategies to deal with stress. The program included training in Qigong (gentle movements), body scan, progressive relaxation, and loving kindness meditation. Patients and caregivers were encouraged to practice these skills at home.
They found that following treatment the patients showed significant improvements in depression, sleep quality, and health related quality of life. In addition, they found that after treatment the caregivers had significant improvements in depression, sleep quality, caregiving burden and perceived caregiver burden. Mindfulness training has been shown to reduce depression, improve sleep and health related quality of life, and caregiving in a wide variety of healthy and ill individuals. So, it is not surprising that the modified MBSR program produced similar significant benefits for both the cirrhosis patients and their caregivers. It is encouraging that a relatively brief (4 week) program can have such positive benefits.
The study did not have a control condition. So, unequivocal conclusions cannot be reached. But, the results are sufficiently encouraging to justify the implementation of a large scale randomized controlled clinical trial including an active control condition of the effectiveness of MBSR training for cirrhosis patients and their caregivers.
So, improve caregiver and cirrhosis patient psychological health with mindfulness.
“When it comes to embracing mindfulness as a caregiver, start with asking yourself questions. How can you look at ways to reduce stress so you don’t take on the entire thing as your job and you have to do everything? When you’re more intentional, you can look at what is truly needed in this picture to help the care recipient and ask who might be supportive besides yourself and how can you involve other resources?” – Nancy Kriseman
CMCS – Center for Mindfulness and Contemplative Studies
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Bajaj, J. S., Ellwood, M., Ainger, T., Burroughs, T., Fagan, A., Gavis, E. A., … Wade, J. B. (2017). Mindfulness-Based Stress Reduction Therapy Improves Patient and Caregiver-Reported Outcomes in Cirrhosis. Clinical and Translational Gastroenterology, 8(7), e108–. http://doi.org/10.1038/ctg.2017.38
Patient-reported outcomes such as health-related quality of life (HRQOL) are impaired in cirrhosis due to under-treated mood and sleep disorders, which can adversely impact their caregivers. Mindfulness-based stress reduction (MBSR) can improve patient-reported outcomes (PRO) in non-cirrhotic patients but their impact in cirrhosis is unclear. To evaluate the effect of MBSR and supportive group therapy on mood, sleep and HRQOL in cirrhotic patients and their caregivers.
Cirrhotic outpatients with mild depression (Beck Depression Inventory (BDI)>14) on screening with an adult caregiver were enrolled. At baseline, BDI, sleep (Pittsburgh sleep quality index PSQI, Epworth Sleepiness Scale, ESS), anxiety (Beck Anxiety inventory) and HRQOL (Sickness Impact Profile, SIP) for both patients/caregivers and caregiver burden (Zarit Burden Interview Short-form, ZBI-SF and perceived caregiver burden, PCB) and patient covert HE(CHE) status were measured. Patients who had BDI>14 at baseline, along with their caregivers then underwent a structured MBSR program with four weekly hour-long group sessions interspersed with home practice using CDs. After the last group, all questionnaires were repeated.
20 patient/caregiver dyads were included. All patients were men (60±8 years MELD 12.9±5.7, 14 prior hepatic encephalopathy (HE)) while most caregivers (n=15) were women (55±12 years, 23±14 years of relationship, 65% spouses). There was no change in patient BDI between screening and baseline (20.1±11.2 vs. 19.0±10.6, P=0.81). All dyads were able to complete the four MBSR+supportive group therapy sessions. There was a significant improvement in BDI (19.0±10.6 vs.15.6±8.2 P=0.01), PSQI (7.2±3.7 vs. 5.5±3.7, P<0.001) and overall HRQOL (25.0±13.2 vs. 17.7±14.0,P=0.01) but not in anxiety or CHE rates in patients. Similarly caregiver burden (ZBI-SF13.0±9.0 vs. 9.8±6.9,P=0.04, Perceived burden 72.1±29.9 vs. 63.0±14.5,P=0.05) and depression reduced (BDI 9.1±7.8 vs. 5.9±6.0,P=0.03) while caregiver sleep quality (7.2±3.7 vs. 5.5±3.7,P<0.001) improved. Prior HE did not affect PRO change after MBSR+supportive groups but the ZBI-SF of caregivers taking care of HE patients improved to a greater extent (delta −1.1±6.5 vs. 7.4±5.3 HE, P=0.04).
A short program of mindfulness and supportive group therapy significantly improves PRO and caregiver burden in cirrhotic patients with depression. This non-pharmacological method could be a promising approach to alleviate psychosocial stress in patients with end-stage liver disease and their caregivers.