The Relationship Between Psychological Stress Response And Perseverative Cognition In Patients With Breast Cancer And The Effect Of A Mindfulness-based Guided Self-help Intervention

The relationship between psychological stress response and perseverative cognition in patients with breast cancer.Objectives1.To describe the level of psychological stress response(negative emotion,sleep problems,memory problems)and perseverative cognition(rumination and worry)in patients with breast cancer.2.To explore the relationship among demographics,disease-related information,stress,perseverative cognition(rumination and worry)and psychological stress response(negative emotion,sleep problems,memory problems).3.To explore the possible mediating effect of perseverative cognition(rumination and worry)in the relationship between stress and psychological stress response(negative emotion,sleep problems,memory problems)in patients with breast cancer.MethodsA cross-sectional study was conducted in the breast ward of a tertiary hospital in Shandong province.Overall stress level was assessed by the Perceived Stress Scale-10 item version(PSS-10).The 9-item Patients Health Questionnaire Depression Module(PHQ-9),General Anxiety Disorder-7(GAD-7),Athens Insomnia Scale(AIS)and Prospective and Retrospective Memory Questionnaire(PRMQ)were used to assess depression symptoms,anxiety symptoms,sleep problems and memory problems in patients with breast cancer.The level of rumination and worry were assessed by the Ruminative Responses Scale(RRS)and Penn State Worry Questionnaire(PSWQ).Descriptive analysis,independent samples t test,ANOVA and Pearson correlation analysis were used to analyze the data.Mediation effect was analyzed by the PROCESS 2.16 plugin for SPSS,using bias-corrected nonparametric bootstrap method.The mediation effect is significant,if the 95%confidence interval for the estimation of indirect effect does not include zero.All statistical analysis was conducted using SPSS 22.0 software.Results1.Totally 400 questionnaires were sent out and 371 valid questionnaires were collected.The effective recovery rate was 92.8%.The average age of the participants was 44.5±9.2 years,range from 18 to 69 years old.2.The mean score of PHQ-9 was 7.90±4.81.The mean score of GAD-7 was 6.10±4.43.Using the cutoff score of 10 points,the prevalence rates of depression and anxiety were 29.2%and 16.7%.The mean score of AIS was 7.10±4.01.Using the cutoff score of 6 points,the incidence of insomnia was 61.9%.The total score PRMQ was 42.85±12.82,with a mean prospective memory score of 21.79±6.57 and a mean retrospective memory score of 21.06±6.67.The average score of PSS-10 was 16.93±5.45.The average score of RRS was 44.63±13.88,and the average score of PSWQ was 45.66±10.92.3.The univariate analysis of the relationships among demographics,disease-related information and psychological stress response showed that participants with the education level of high school or below scored higher in GAD-7 than those with college or above(t=3.066,P=0.002).Participants lived in urban city scored lower in GAD-7 than those lived in non-urban areas(t=-2.066,P=0.039).Participants with no job scored higher in sleep problems(t=-2.015,P=0.045),and participants with no job scored higher in memory problems than those with job(t=-2.454,P=0.015).4.Pearson correlation analysis among stress,perseverative cognition,and psychological stress responses in patients with breast cancer showed that stress,rumination,and worry were positively associated with depressive symptoms,anxiety symptoms,and sleep problems.The higher levels of stress,rumination,and worry were,the more severe the depressive symptoms,anxiety symptoms,and sleep problems were(all P<0.001).The scores of stress were positively related to the scores of memory problems.The higher the stress level was,the more severe the memory problem was(P=0.020).5.The mediating effect of perseverative cognition in the relationship between stress and psychological stress responses suggested that rumination in patients with breast cancer was a mediator in the relationship between stress and depressive symptoms(B=0.109,95%confidence interval(CI):[0.058,0.173]),and the mediating effect was 0.251(95%CI:[0.121,0.461]).Rumination and worry were the mediating factors in the relationship between stress and anxiety symptoms.The mediating effect of rumination was 0.152(95%CI:[0.072,0.247]),and the mediating effect of worry is 0.140(95%CI:[0.051,0.236]).Rumination was the mediator in the relationship between stress and sleep problems(B=0.063,95%CI:[0.024,0.106]),and the mediating effect was 0.210(95%CI:[0.075,0.375]).The overall effect of stress on memory problems was significant,with a 95%confidence interval of[0.045,0.523],but the mediating effects of rumination and worry on the relationship between stress and memory problems were not statistically significant.Conclusion1.The level of psychological stress response(negative emotion,sleep problems,memory problems)and perseverative cognition(rumination and worry)in patients with breast cancer is high,and it is worth for attention.2.Stress not only has a direct effect on depressive symptoms,anxiety symptoms,and sleep problems,but also indirectly leads to increased depression symptoms,anxiety symptoms,and sleep problems by increasing perseverative cognition.The results of this study are consistent with the theory of perseverative cognition,that is,perseverative cognition plays a key mediating effect in the relationship between stress and psychological and physiological responses.3.This study provides new ideas for better understanding of the factors associated with psychological stress response in patients with breast cancer,and the development of the intervention for psychological stress response and perseverative cognition.The effect of a mindfulness-based guided self-help intervention on psychological stress response in patients with breast cancer and the mechanism of perseverative cognitionObjectives1.Combining self-help intervention theory with mindfulness intervention,to explore the effect of a mindfulness-based guided self-help intervention on psychological stress response and perseverative cognition(rumination and worry)in patients with breast cancer through randomized controlled trials.2.To explore the possible mediating effect of perseverative cognition in the effect of a mindfulness-based guided self-help intervention on psychological stress response in patients with breast cancer.MethodsA randomized controlled trial was conducted in the breast ward of a tertiary hospital in Shandong province.One hundred and forty-four patients with breast cancer were randomly assigned to the intervention group(n=72)and wait-list control group(n=72).The intervention group received routine treatment and a 6-week mindfulness-based guided self-help intervention,and the wait-list control group received routine treatment only.At the baseline(T1)and the end of intervention(T2),depression symptoms,anxiety symptoms,sleep problems,memory problems,and the level of rumination and worry were assessed by the 9-item Patients Health Questionnaire(PHQ-9),General Anxiety Disorder-7(GAD-7),Athens Insomnia Scale(AIS),Prospective and Retrospective Memory Questionnaire(PRMQ),Ruminative Responses Scale(RRS),and Penn State Worry Questionnaire(PSWQ).At one month(T3)and three month(T4)after the end of the intervention,participants were followed up for the depressive symptoms,anxiety symptoms,sleep problems,and memory problems.Statistical analysis included descriptive analysis,independent sample t test,and chi-square test.The Generalized Estimated Equation(GEE)was used to analyze the intervention effect of the mindfulness-based guided self-help intervention on depressive symptoms,anxiety symptoms,sleep problems and memory problems at the T2-T4 time points.And the GEE was used to analyze the intervention effect on rumination and worry at T2.The mediating effect was tested based on Baron and Kenny’s sequential test analysis.Based on the outcomes variables(depression symptoms,anxiety symptoms,sleep problems,and memory problems)at T1 and T2,the possible mediating effect of rumination and worry in the effect of a mindfulness-based guided self-help intervention on psychological stress response were explored.Intent-to-treat analysis(ITT)was used for all analyses,with a threshold for significance set at α=0.05.Results1.Of the 144 participants who completed the assessment at T1 and were randomly divided into two groups,115 had completed the assessment at T2,of which 15 were lost from the intervention group(8 lost contact,7 discontinued the study),and 14 lost form the control group(9 lost contact,5 discontinued the study).The loss rate was 20.14%.54 participants in the intervention group and 53 in the control group completed the assessment at T3.At T4,52 participants in the intervention group and 52 in the control group completed the assessment.There was no statistically significant difference in the scores of demographics,disease-related information and psychological stress response between the lost samples and the completed samples.2.The ages of the participants were 21-61 years old,with an average age of 42.4=17.9 years;97.2%of them had partners;75.7%of them had received education in high school or below;and the stages of disease were Ⅰ-Ⅳ.There was no statistical difference between the intervention group and the control group in terms of education level,marital status,place of residence,work status,family monthly income,medical insurance,religious belief,stage of disease,operation method,whether to receive chemotherapy and radiotherapy(all P>0.05),but there was a significant difference in age,in which the average age of participants in the intervention group was younger than those in the control group(t=3.192,P=0.002).3.The days for family exercises in the intervention group ranged from 13 to 31 days,and the average day of practice was 23.48±4.18.2/3 homework days were completed,that is,exercise days were greater than 20 days,which was defined as adherence.The adherence rate of this study was 75.4%.4.GEE was used to analyze the effect of a mindfulness-based guided self-help intervention on depression symptoms.The results indicated that the main effects of time were statistically significant(P<0.001),indicating that the scores of depressive symptoms in both groups changed with time.The interaction effect between group and time was statistically significant(P=0.025),indicating that the scores of depressive symptom in the intervention group and the control group showed different trends with time at the four time points.The results of parameter estimation showed that the interactions between group and time were statistical significance(P<0.01)at the T2,T3,and T4.The pairwise comparison of the estimated marginal means showed that the scores of depression symptoms at T2 were lower than T1 in the intervention group(Cohen’s d=0.39);the scores of depression symptoms at T3 were lower than T1(Cohen’s d=0.64)and T2(Cohen’s d=0.22)in the intervention group;and the scores of depression symptoms at T4 were lower than T1(Cohen’s d=0.42)but higher than T3(Cohen’s d=0.26)in the intervention group.The scores of depression symptoms at T3 were lower than T2 in the control group(Cohen’s d=0.19),and the depression scores at T4 were higher than T3(Cohen’s d=0.12).The pairwise comparison of the estimated marginal means suggested that the scores of depression symptoms at T2 were lower than T1 in the intervention group,the depressive symptom scores at T3 were lower than T2,and the depression symptom scores at T2 and T3 in the intervention group has a continued decrease trend.The depressive symptom scores at T4 were slightly higher than T3,but still lower than T1.The depressive symptom scores at T3 were slightly lower than T2,but slightly higher at T4 in the control group,and the effect sizes were small5.GEE was used to analyze the effect of a mindfulness-based guided self-help intervention on anxiety symptoms.The results indicated that there was not statistically significant in the main effects of time,group,and the interaction effects of group and time(all P>0.05).6.GEE was used to analyze the effect of a mindfulness-based guided self-help intervention on sleep problems.The results showed that the main effects of time were statistically significant(P=0.03),indicating that the scores of sleep problems in both groups changed with time.The interaction effect between group and time was statistically significant(P=0.012),indicating that the scores of sleep problems in the intervention group and the control group showed different trends with time at the four time points.The results of parameter estimation suggested that the interactions between group and time were statistically significant(P<0.05)at T2,T3,and T4.The pairwise comparison of the estimated marginal means showed that the scores of sleep problems at T2 were lower than T1 in the intervention group(Cohen’s d=0.52);the scores of sleep problems at T3 were lower than T1(Cohen’s d=0.56);and the scores of sleep problems at T4 were lower than T1(Cohen’s d=0.60)in the intervention group.The scores of sleep problems at T4 were lower than T3 in the control group(Cohen’s d=0.20).The comparison between groups showed that the scores of sleep problems at the T3 and T4 in the intervention group were lower than those in the control group(Cohen’s d=0.50,Cohen’s d=0.34).The pairwise comparison of the estimated marginal means suggested that the scores of sleep problems at T2,T3,and T4 were all lower than T1 in the intervention group,but there was no statistically significant difference between T2,T3,and T4,which indicated that the scores of sleep problems at T2 was lower than T1,and the difference from T1 can be maintained to T3 and T4,but there was no continuous downward trend.The scores of sleep problems at T4 in the control group were slightly lower than T3,and the effect size was small.7.GEE was used to analyze the effect of a mindfulness-based guided self-help intervention on memory problems.The results showed that the main effects of group were statistically significant(P=0.026),indicating that the scores of memory problems between two groups were statistically significant.The interaction effect between group and time was statistically significant(P=0.032),indicating that the scores of memory problems in the intervention group and the control group showed different trends with time at the four time points.The results of parameter estimation showed that the interactions between group and time were statistical significance(P<0.05)at the T3 and T4.The pairwise comparison of the estimated marginal means showed that in the intervention group,the scores of memory problems at T2 were lower than T1(Cohen’s d=0.37),the scores at T3 were lower than T1(Cohen’s d=0.45);and the scores at T4 were lower than T1(Cohen’s d=0.51).In the control group,the scores of memory problems at T3 were higher than T2(Cohen’s d=0.11),and the scores at T4 were lower than T3(Cohen’s d=0.13).The comparison between groups showed that the scores of memory problems at the T3 and T4 in the intervention group were lower than those in the control group(Cohen’s d=0.57,Cohen’s d=0.55).The pairwise comparison of the estimated marginal means suggested that the scores of memory problems at T2,T3,and T4 were all lower than T1 in the intervention group,but there was no statistically significant difference between T2,T3,and T4,which indicated that the score of memory problems at T2 was lower than T1,and the difference from T1 can be maintained to T3 and T4,but there was no continuous downward trend.The scores of memory problems at T3 in the control group were slightly higher than T2,the scores at T4 were slightly lower than T3,and the effect sizes were small.8.GEE was used to analyze the effect of a mindfulness-based guided self-help intervention on perseverative cognition(rumination and worry).The results showed that the interactions between group and time were statistically significant(P<0.05).The results of parameter estimation indicated that the intervention could significantly reduce the scores of rumination(B=-5.121,95%CI=[-9.995,-0.248])and worry(B=-5.808,95%CI=[-10.954,-0.663])in patients with breast cancer.9.The test of the mediating effect is based on Baron and Kenny’s sequential test analysis.Firstly,we test whether the effect of the intervention on the outcome variables is significant,and then test whether the effect of the intervention on the mediation variables is significant.Finally,the effect of the intervention and mediating variables on the outcome variables are considered in the model at the same time,and we test whether the effect of mediating variables on the outcome variables is significant.Results 4,6,and 7 indicated that mindfulness-based guided self-help intervention can improve depression symptoms,sleep problems,and memory problems in patients with breast cancer.Results 8 indicated that mindfulness-based guided self-help intervention can improve the rumination and worry of breast cancer patients.Therefore,this study will add the time,group,the interaction of time and group,as well as the mediator variables(rumination and worry)to the model,and examine the effect of the mediator variables on the outcome variables(depressive symptoms,sleep problems,memory problems).If the mediator variables have a significant effect on the outcome variable,it indicates that the mediating effect is significant.The results showed that when the effects of time,group,the interaction of time and group,as well as the mediator variables(rumination and worry)on depressive symptoms were taken into account,the effects of rumination and worry on depressive symptoms were still significant(all P<0.001),which indicated that rumination and worry played an intermediary role in the effect of the mindfulness-based guided self-help intervention on depressive symptoms.When considering the effects of time,group,the interaction of time and group,as well as the mediator variables(rumination and worry)on sleep problems at the same time,the effects of rumination and worry on sleep problems were still significant(P=0.001,P<0.001),indicating that rumination and worry played an intermediary role in the effect of the mindfulness-based guided self-help intervention on sleep problems.When considering the effects of time,group,the interaction of time and group,as well as the mediator variables(rumination and worry)on memory problems at the same time,the effect of rumination on memory problems was still significant(P=0.009),and the effect of worry on memory problems was not statistically significant(P=0.536).It showed that rumination plays an intermediary role in the effect of the mindfulness-based guided self-help intervention on memory problems.Conclusion1.The loss rate in this study was 20.01%.The adherence rate of home practice in the intervention group was 75.40%.The loss rate and the adherence rate are consistent with previous studies.2.This study examined the effect of the mindfulness-based guided self-help intervention on psychological stress response in patients with breast cancer at baseline,end of intervention,1 month after the end of intervention,and 3 months after the end of intervention by randomized controlled trials.The study found that the mindfulness-based guided self-help intervention can alleviate patients’ depressive symptoms,sleep problems,and memory problems.3.This study examined the effect of the mindfulness-based guided self-help intervention on perseverative cognition(rumination and worry)in patients with breast cancer at baseline and end of intervention by randomized controlled trials.The study found that the mindfulness-based guided self-help intervention can reduce patients’level of rumination and worry.4.The results of mediation analysis shows that rumination and worry play a significant mediating role in the effect of the mindfulness-based guided self-help intervention on depressive symptoms and sleep problems,that is,the intervention improves depression symptoms and sleep problems by reducing the level of rumination and worry.Rumination play a significant mediating role in the effect of the mindfulness-based guided self-help intervention on memory problems,that is,the intervention alleviates memory problems by reducing the level of rumination.5.This study combines self-help intervention theory with mindfulness-based intervention and develops a mindfulness-based guided self-help intervention that is suitable for application and generalization in cancer patients in China.Besides,this study tests the effect of the mindfulness-based guided self-help intervention on psychological stress response in patients with breast cancer through empirical research.And the study further explores the mechanism of the mindfulness-based guided self-help intervention and lays the foundation for the better application of the mindfulness-based guided self-help intervention in breast cancer patients,other cancer patients,and even more patients with other disease and health-related problems.