Effects of cognitive combined with mindfulness-based stress reduction and sleep in patients with diabetes and endometrial cancer

Abstract

BACKGROUND

Seek highly effective treatment measures for improving mood and sleep.

AIM

To explore the effects of mood and depression in patients with endometrial cancer after cognitive behavioral therapy (CBT) and mindfulness-based stress reduction.

METHODS

In a prospective study, 90 patients with diabetes, endometrial cancer, and depression were selected from January 2023 to January 2024 in our hospital. There were 45 patients in the control group and 45 patients in the observation group. In addition to the conventional treatment, the control group received cognitive behavioral treatment, and the observation group: Control group was given to compare changes in mood state and sleep quality before and after the intervention. Follow-up was performed3 months after treatment completion.

RESULTS

Before treatment, the mood and sleep quality scores between the two groups (P > 0.05); in the observation group, the 5 negative mood scores were lower and lower than the control group; the 2 positive mood scores were higher than in the control group, and the difference was statistically significant (P < 0.05); compared with before treatment, the 7 sleep quality scores and Pittsburgh sleep quality index scale total score in the observation group and lower in the control group (P < 0.05).

CONCLUSION

In patients with diabetes and endometrial cancer, mood state and sleep quality significantly improved after CBT and breathing relaxation. These findings provide new and effective treatment strategies in clinical practice.

Key Words: Cognitive behavioral therapy; Mindfulness and stress reduction intervention; Diabetes; Endometrial cancer; Depression; Mood; Sleep quality

Core Tip: Implementing a scientific and highly efficient cognitive and behavioral therapy program, integrated with a mindfulness-based stress reduction intervention, holds paramount importance for significantly enhancing the mood state and sleep quality of patients diagnosed with both endometrial cancer and depression. This combined approach not only addresses the psychological aspects of their condition but also fosters a holistic well-being, thereby contributing to better overall health outcomes.

INTRODUCTION

Diabetes and endometrial cancer are common clinical chronic diseases, and due to diabetes blood sugar instability, glucose tolerance is abnormal, endocrine in a state of disorder, and may therefore induce endometrial cancer. Diabetes caused by insulin resistance may also affect metabolism and conduction, improve the risk of endometrial cancer, and lead to comorbidity[1,2]. Due to the double blow of the disease, diabetes and endometrial cancer not only aggravate the progression of the disease, but also easily lead to anxiety, irritability, depression, and other negative emotions, further affecting the physical and mental health of patients and forming a vicious circle. Therefore, it is important to select efficient scientific interventions and treatment methods[3,4]. Cognitive behavioral therapy (CBT), a structured psychotherapy method, changes the negative thinking and behavioral patterns of patients and has been widely used in the field of psychotherapy, such as for depression. Mindfulness-based stress reduction (MBSR) intervention helps individuals reduce their stress responses by developing mindfulness awareness to improve their emotional regulation[5,6]. This study aimed to explore the treatment effect of the combined application of CBT and MBSR on such special patient groups.

MATERIALS AND METHODS

General information

Ninety patients with diabetes and endometrial cancer at our hospital were included in the study (January 2023 to January 2024) and were divided into two groups using the lottery method. A comparison of the general data between the two groups (P > 0.05) is presented in Table 1. This trial was approved by the medical ethics committee of our hospital. The inclusion criteria were as follows: (1) Met the diagnostic criteria for diabetes and endometrial cancer was confirmed by pathological biopsy and imaging examination; (2) Diabetes, endometrial cancer, and depression; (3) Complete clinical data; (4) No psychiatric history; and (5) Patients and their families knew the test content and signed a consent form. The exclusion criteria were as follows: (1) Severe cardiopulmonary insufficiency and liver and kidney function impairment; (2) Cognitive and language dysfunction; (3) Other malignant tumors; (4) Previous history of radiotherapy and chemotherapy; and (5) Severe cardiovascular and cerebrovascular diseases.

Table 1 Comparison of the general data between the two groups (mean ± SD).

Group	Case	Age	Depression disease course	BMI (kg/m2)
Control	45	63.28 ± 6.14	1.09 ± 1.07	23.94 ± 1.23
Observation	45	62.93 ± 5.79	1.16 ± 1.03	23.72 ± 1.21
t		0.278	0.316	0.855
P value		0.782	0.753	0.395

BMI: Body mass index.

Methods

Control group: CBT treatment. (1) Form an intervention team. The team consisted of one professional cognitive behavioral therapist and four physicians with at least 10 years of clinical treatment experience. The therapist led the members to learn the purpose, method, content, and precautions of CBT, focusing on the related measures of depression intervention; (2) Relationship building. The team encouraged, listened to, and provided comfort to patients, and tried other ways to understand patients’ interests, personality characteristics, psychological status, etc. The therapist guided patients to remove unconscious negative thoughts through questioning, imagination, role-playing, and other techniques; and (3) Behavioral therapy. The team guided patients to report their condition, and asked them "why they have this negative idea”, "what evidence is supporting for this idea", and "why they can't sleep well”, and guided the intervention to correct the misconceptions. When a depressed mood occurred, patients were guided to use emotional regulation skills to regulate behaviors such as deep breathing, relaxation training, attention diversion, stimulation control, sleep restriction, and relaxation training. Previous successful cases were introduced to patients to improving their confidence. Training was performed at least once per day. Treatment was continued for 1 month.

The observation group, based on the control group, also underwent MBSR treatment: (1) Establish a trust relationship. Through listening, empathy expression, and professional attitude presentation, the treatment staff established a relationship based on trust, respect, and understanding with patients to provide a safe and non-judgmental environment for them to relax physically and mentally; (2) Mindfulness knowledge education. Through semi-structured interviews, patients were explained the pathogenesis of diabetes, endometrial cancer, and depression, as well as the definition, principle, scientific basis, and function of mindfulness knowledge to stimulate their motivation and interest in practice; (3) Mindfulness practice instruction. Mindful breathing: Patients assume a comfortable sitting posture, close their eyes, adjust breathing, focus on the nose or abdomen, notice the sensation of breathing in and out of the body, slow down the speed of thinking, and reduce any distractions. Mindful eating: Focus on things; focus on the taste, smell, and color of food; slowly taste; fully chew; do not watch TV; and do not play on a mobile phone. Perception of mindfulness. Guide patients to pay attention to the surrounding environment and their own feelings in daily life, such as voices from all directions; judge their timbre, size, and length; and adjust their coping styles; and (4) Regular review. The treatment staff regularly organized review and feedback activities for patients to discuss and share their experiences and insights into personal mindfulness exercises, inspire and encourage each other, and help patients continuously optimize and adjust their practice strategies. The treatment duration in the observation group was consistent with that in the control group.

In CBT, emotional distress may be caused by exposure to therapy. To mitigate this discomfort, the therapist can adjust the speed and intensity of the exposure to ensure that the patient adapts progressively. Regarding the possible increased pain sensation in MBSR, discomfort can be reduced by adjusting the posture and duration of mindfulness meditation.

Observations

(1) Mood state. A concise mood status scale[7] (simplified POMS) was used to evaluate mood before and after treatment. The scale contains 7 evaluation dimensions, including negative dimensions of fatigue, depression, anger, panic, and tension, and energy and self-esteem as positive dimensions, with 40 subdivided items, each item ranging from 0-4 points; a high negative dimension score represents poor mood status and a high positive dimension score indicates good mood; and (2) Sleep quality. Before and after treatment, the Pittsburgh sleep quality index scale[8] was used. The scale contains 7 scoring items, ranging from 0 to 3, with a total score of 21. The higher the score, the worse the patient’s sleep quality.

Statistical analysis

Statistical analysis was performed using SPSS26.0 statistical software. Mood state and sleep quality scores are measurement data and conform to normal distribution by standard deviation (mean ± SD), t test; count data by percentage (n, %), comparison between groups, χ² test. The test value was considered statistically significant at P < 0.05.

RESULTS

State of mind

After treatment, the negative mood score decreased in both the groups, and the score in the observation group was lower than that in the control group; the positive mood score was higher in the observation group than in the control group (P < 0.05) (Table 2).

Table 2 Comparison of pre-and post-treatment mood status scores between the two groups (mean ± SD).

Dimension	Control (n = 45)		Observation (n = 45)
	Before	After	Before	After
Tired	15.17 ± 2.45	12.43 ± 1.35a	15.25 ± 2.16	10.07 ± 1.08a,b
Constrain	15.34 ± 2.18	12.11 ± 1.23a	15.37 ± 2.44	9.55 ± 1.06a,b
Designation	18.56 ± 2.43	15.07 ± 1.29a	18.36 ± 2.35	13.36 ± 1.13a,b
Nervous	19.36 ± 2.06	16.10 ± 1.17a	19.22 ± 2.08	12.36 ± 1.04a,b
Flustered	15.22 ± 2.16	12.36 ± 1.34a	15.36 ± 2.36	10.38 ± 1.23a,b
Vigor	15.36 ± 1.36	17.36 ± 2.03a	15.08 ± 2.36	21.40 ± 2.77a,b
Sense of self-importance	12.36 ± 1.34	15.57 ± 2.82a	12.37 ± 2.33	19.24 ± 2.33a,b

^aP < 0.05 vs before treatment.

^bP < 0.05 vs control group.

Sleep quality

Without treatment (P > 0.05); after treatment, the sleep quality and Pittsburgh sleep quality index scale total scores decreased in the observation group compared with those before treatment; the observation group had lower scores than the control group (P < 0.05) (Table 3).

Table 3 Comparison of pre-and post-treatment Pittsburgh sleep quality index sleep scores between the two groups (mean ± SD, score).

Group	Sleep quality		Sleep time		Hypnotic drugs		Insomnia		Hour of sleep		Sleep efficiency		Day dysfunction		PSQI
	Before	After	Before	After	Before	After	Before	After	Before	After	Before	After	Before	After	Before	After
Control (n = 45)	2.16 ± 0.48	1.48 ± 0.30a	2.18 ± 0.35	1.99 ± 0.48a	1.65 ± 0.34	0.54 ± 0.24a	1.89 ± 0.27	1.52 ± 0.14a	2.21 ± 0.39	1.68 ± 0.30a	2.18 ± 0.35	1.79 ± 0.28a	2.39 ± 0.49	1.89 ± 0.28a	14.56 ± 2.64	10.89 ± 2.02a
Observation (n = 45)	2.08 ± 0.41	1.35 ± 0.26a	2.13 ± 0.35	1.71 ± 0.43a	1.58 ± 0.31	0.43 ± 0.19a	1.72 ± 0.24	1.44 ± 0.13a	2.19 ± 0.38	1.25 ± 0.26a	2.13 ± 0.35	1.50 ± 0.34a	2.34 ± 0.52	1.53 ± 0.24a	14.17 ± 2.50	9.21 ± 1.85a
t	0.760	2.197	0.678	2.607	1.021	2.411	3.157	2.809	0.246	5.576	0.678	3.950	0.469	2.910	0.644	3.680
P value	0.450	0.031	0.500	0.011	0.310	0.018	0.002	0.006	0.806	< 0.001	0.500	< 0.001	0.640	0.005	0.522	< 0.001

^aP < 0.05 vs before treatment.

PSQI: Pittsburgh sleep quality index.

DISCUSSION

The pathogenesis of diabetes combined with endometrial cancer and depression is complex. Physiologically, diabetes can cause[9] symptoms such as polydipsia, polyuria, hyperfeagsia, and weight loss. In the treatment of endometrial cancer, the impact of chemotherapy drugs on the body cannot be ignored. Chemotherapy drugs may inhibit the secretion of insulin, further aggravate the symptoms of diabetes, cause other adverse reactions such as gastrointestinal discomfort, and aggravate the physical and mental burden of patients[10]. At a psychological level, patients' cognition of diabetes and endometrial cancer may be biased that these diseases cannot be cured or the treatment cost is high, resulting in fear, anxiety, pessimism, and other emotions, eventually leading to depression[11]. Therefore, patients with multiple comorbidities require scientific and effective treatment measures to help them establish correct disease cognition, promote disease recovery, and return to normal life as soon as possible.

In this study, the observation group had lower scores than the control group, and the score of the positive dimension was significantly improved (P < 0.05), suggesting that CBT and MBSR could significantly improve the mood state of patients with concurrent depression. The mechanism by which CBT combined with MBSR improves the mood state of patients is multifaceted and involves psychological, physiological, and behavioral factors[12]. First, by identifying and correcting patients with unreasonable or wrong cognition, CBT helps patients establish a more positive, healthy, and upward way of thinking, such as through face-to-face conversation and asking questions to break negative thinking, guiding patients to recognize and replace negative self-evaluation, teaching skills to deal with negative emotions, and assisting patients to re-examine negative emotions in the heart and improve behavior[13,14]. On the other hand, MBSR emphasizes mindfulness practice to improve awareness and feelings about current moments and reduce excessive thinking and emotional reactions. For diabetes patients with endometrial cancer, mindful breathing, eating, and perception will help patients focus on themselves, focus on the moment, reduce fear of the future and the remorse of the past interference mood, gradually relax, and reduce tension and anxiety[15]. CBT focuses on cognitive and behavioral levels of intervention by changing the patient's thinking and behavior patterns to reduce depression symptoms. MBSR is more focused on emotional and psychological adjustment by cultivating mindfulness to enhance the patient's psychological toughness, which can provide complementary advantages to improve the patient's mood state[16].

Because the patient has depressive symptoms, the mood is easily low, unconscious negative thoughts frequently arise, and it is easy to fall into a vicious cycle of insomnia and anxiety, thereby greatly affecting the sleep condition. CBT helps patients to identify and correct related negative cognition affect sleep quality, through logical analysis, evidence support way to help patients gradually replace negative thinking with more realistic positive ideas, help patients to break the vicious cycle of depression, enhance self-confidence, at the same time make it gradually open, accept, relax yourself, relax, is easier to sleep[17] at night. In addition, CBT can also intervene in patients' behavior to assist them in establishing a good sleep environment, such as supervising patients to reduce stimulating activities unrelated to sleep, with deep breathing, progressive muscle relaxation, relaxation training, and other ways to help patients relax their bodies and minds before going to bed to improve sleep quality[18]. The core of mindfulness practice in MBSR is to help patients clearly perceive their bedtime state, bedtime mood, self-awareness, etc., and then focus their attention on breathing and physical feelings as much as possible, so that they can face their emotions with a more peaceful and objective attitude. Adjusting the breathing rhythm and massage and relaxation of the tense parts of the body relieves mood fluctuations caused by diseases and sleep problems and gradually releases fatigue and nervous nerves, making it easier to fall asleep[19]. In addition, mindfulness practice can also improve patients’ self-management ability, making it easier to be aware of bad behaviors or thinking patterns that affect sleep and consciously correct them, thus reducing the impact on sleep quality[20].

These two treatment methods promote each other during the intervention process, forming a virtuous cycle; thus, sleep quality improves to a certain extent. Studies have noted that CBT and MBSR overlap in measures to reduce catastrophic thinking and increase self-efficacy, pain acceptance, and mindfulness, suggesting that both treatments may improve pain, function, and other outcomes by influencing the same treatment mechanisms. Although CBT and MBSR differ in content, both include relaxation techniques and strategies to reduce pain threat values. The results of this study showed that the sleep quality score and total score of the observation group were lower than those of the control group (P < 0.05), suggesting that the combination of CBT and MBSR could significantly improve the sleep quality of patients with diabetes, endometrial cancer, and depression.

This study had some limitations, such as a relatively small sample size and short follow-up time. Future studies should consider increasing the sample size and extending the follow-up period to enhance the generalizability and long-term validity of our findings. Furthermore, future studies could explore the applicability and efficacy of CBT and MBSR in different patient populations and how these interventions can be better integrated into daily clinical practice.

CONCLUSION

In summary, CBT and MBSR comprehensive therapy can significantly alleviate diabetes with endometrial cancer depression, improve the ability to actively cope with the disease, and simultaneously optimize the quality of sleep, reduce awakening at night and sleep difficulty, thereby not only help patients recover but also provide new treatment for clinical application.