Can mindfulness-based interventions improve the quality of life of patients with moderate/severe alopecia areata? A prospective pilot study

Abstract

To the Editor: Mindfulness-based interventions aim to reduce psychological distress by developing nonjudgmental awareness of the present moment and acceptance-based coping strategies. They have been shown to be of help in a wide range of psychiatric and medical conditions, including psoriasis.1Carmody J. Baer R.A. Relationships between mindfulness practice and levels of mindfulness, medical and psychological symptoms and well-being in a mindfulness-based stress reduction program.J Behav Med. 2008; 31: 23-33Crossref PubMed Scopus (1066) Google Scholar, 2Fordham B.A. Nelson P. Griffiths C.E.M. Bundy C. The acceptability and usefulness of mindfulness-based cognitive therapy for people living with psoriasis: a qualitative study.Br J Dermatol. 2015; 172: 823-825Crossref PubMed Scopus (11) Google Scholar Alopecia areata (AA) is an autoimmune disease that may seriously impair quality of life (QoL) especially in the area of mental health.3Liu L.Y. King B.A. Craiglow B.G. Health-related quality of life (HRQoL) among patients with alopecia areata (AA): a systematic review.J Am Acad Dermatol. 2016; 75: 806-812Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar As no dependable treatment is known, psychological support is considered important for these patients. This prospective pilot study aimed to test whether a mindfulness-based stress reduction (MBSR) program1Carmody J. Baer R.A. Relationships between mindfulness practice and levels of mindfulness, medical and psychological symptoms and well-being in a mindfulness-based stress reduction program.J Behav Med. 2008; 31: 23-33Crossref PubMed Scopus (1066) Google Scholar could improve QoL and reduce psychological distress in adults with AA. This is a group program that focuses on the cultivation of mindfulness through meditation practices (ie, sitting meditation, body scan, yoga) and the integration of this capacity into everyday life as a resource for coping with physical symptoms and difficult emotions. Participants attend weekly sessions for 2 months. Regular out-of-class practice is required. Adults with moderate/severe AA attending our outpatient clinic were offered a MBSR program as an adjunct to their usual therapy. Eight patients accepted and were matched by sex and age with control patients who continued their usual therapy alone (Table I). All patients underwent clinical evaluation and completed self-reported measurements of AA-related QoL, psychological symptom status, and perceived stress at baseline, after 2 months (corresponding to the end of the MBSR course for participants) and after 6 months. These measurements were performed by means of 3 validated questionnaires, namely: the AA-QoL,4Fabbrocini G. Panariello L. De Vita V. et al.Quality of life in alopecia areata: a disease-specific questionnaire.J Eur Acad Dermatol Venereol. 2013; 27: 276-281Crossref PubMed Scopus (52) Google Scholar the Brief Symptom Inventory,1Carmody J. Baer R.A. Relationships between mindfulness practice and levels of mindfulness, medical and psychological symptoms and well-being in a mindfulness-based stress reduction program.J Behav Med. 2008; 31: 23-33Crossref PubMed Scopus (1066) Google Scholar and the Perceived Stress Scale.1Carmody J. Baer R.A. Relationships between mindfulness practice and levels of mindfulness, medical and psychological symptoms and well-being in a mindfulness-based stress reduction program.J Behav Med. 2008; 31: 23-33Crossref PubMed Scopus (1066) Google Scholar Significant improvement of QoL and of several psychometric parameters was seen in MBSR participants but not in control patients. The improvement partly persisted at 6-month follow-up (Table II).5Benjamini Y. Hochberg Y. On the adaptive control of the false discovery rate in multiple testing with independent statistics.J Educ Behav Stat. 2000; 25: 60-83Crossref Scopus (1149) Google ScholarTable IClinical characteristics of mindfulness-based stress reduction participants and control patientsClinical characteristicsMBSRControlMean age, y (SD)46 (15.1)45.9 (11.4)Female/male5/35/3Severity Moderate/severe4/45/3Duration of AA, y 1-543 >545Treatment None30 Squaric acid27 Topical steroids30 Systemic steroids00 Other01AA was considered moderate if patients had ≥3 patches >3 cm or at least 1 patch >10 cm. It was considered severe in case of total/universal alopecia or ophiasis.AA, Alopecia areata; MBSR, mindfulness-based stress reduction. Open table in a new tab Table IILongitudinal scores of the outcome variables of this studyVariableGroupTimeComparison across time∗P values for multiple comparisons were adjusted with the Benjamini-Hochberg (2000) adaptive false discovery rate controlling procedure.5T0T1T2AA QoL index, subjective symptomsControl1.51 (0.32)1.29 (0.32)0.94 (0.32)nsPatient1.86 (0.32)1.21 (0.32)1.29 (0.32)T0 > T1AA QoL index, relationshipControl0.75 (0.26)0.86 (0.26)0.63 (0.26)nsPatient1.65 (0.26)†Significant differences (adjusted P < .05) between groups.1.08 (0.26)0.95 (0.26)T0 > T1, T1 > T2AA QoL index, objective signsControl1.42 (0.33)0.96 (0.33)0.83 (0.33)nsPatient2.13 (0.33)1.58 (0.33)1.75 (0.33)nsPSSControl1.34 (0.19)1.23 (0.19)1.39 (0.19)nsPatient2.15 (0.19)†Significant differences (adjusted P < .05) between groups.1.75 (0.19)1.99 (0.19)†Significant differences (adjusted P < .05) between groups.nsBSI, somatizationControl0.56 (0.20)0.54 (0.21)0.31 (0.20)nsPatient1.15 (0.20)0.75 (0.20)0.77 (0.20)nsBSI, obsessive-compulsiveControl0.73 (0.22)0.70 (0.23)0.73 (0.22)nsPatient1.46 (0.22)†Significant differences (adjusted P < .05) between groups.0.98 (0.22)0.92 (0.22)nsBSI, interpersonal sensitivityControl0.63 (0.30)0.64 (0.32)0.44 (0.30)nsPatient1.41 (0.30)0.69 (0.30)0.84 (0.30)nsBSI, depressionControl0.50 (0.21)†Significant differences (adjusted P < .05) between groups.0.45 (0.22)0.31 (0.21)nsPatient1.15 (0.21)†Significant differences (adjusted P < .05) between groups.0.77 (0.21)0.79 (0.21)nsBSI, anxietyControl0.90 (0.20)0.66 (0.21)0.60 (0.20)nsPatient1.73 (0.20)†Significant differences (adjusted P < .05) between groups.0.90 (0.20)1.04 (0.20)T0 > T1, T0 > T2BSI, hostilityControl0.68 (0.23)0.60 (0.24)0.45 (0.23)nsPatient1.08 (0.23)0.66 (0.23)0.88 (0.23)nsBSI, phobiaControl0.50 (0.22)0.45 (0.23)0.28 (0.22)nsPatient0.95 (0.22)0.33 (0.22)0.33 (0.22)T0 > T1BSI, paranoiaControl0.58 (0.26)0.61 (0.27)0.40 (0.26)nsPatient1.60 (0.26)†Significant differences (adjusted P < .05) between groups.1.08 (0.26)1.20 (0.26)nsBSI, psychoticismControl0.38 (0.19)0.22 (0.21)0.35 (0.19)nsPatient1.00 (0.19)†Significant differences (adjusted P < .05) between groups.0.50 (0.19)0.42 (0.19)nsBSI, global severity indexControl0.58 (0.18)0.52 (0.19)0.43 (0.18)nsPatient1.23 (0.18)†Significant differences (adjusted P < .05) between groups.0.73 (0.18)0.77 (0.18)T0 > T1BSI, positive symptoms totalControl20.00 (4.27)18.61 (4.43)19.13 (4.27)nsPatient32.13 (4.27)†Significant differences (adjusted P < .05) between groups.25.38 (4.27)25.88 (4.27)nsBSI, positive symptoms distress indexControl1.33 (0.14)1.32 (0.14)1.16 (0.14)nsPatient1.85 (0.14)†Significant differences (adjusted P < .05) between groups.1.45 (0.14)1.51 (0.14)T0 > T1AA clinical improvement‡From a clinical point of view, at T1 and T2, patients were classified as improved or not improved (the latter including both stationary and worse clinical outcomes).Patient-2/82/8Control-2/85/8A full factorial linear mixed model was used to evaluate the data.These data show significant baseline differences between the 2 groups of patients in terms of AA QoL index, relationship; AA QoL index, objective signs; BSI, depression; BSI, anxiety; BSI, paranoia; BSI, positive symptoms distress index; and PSS, where the control group had better scores.Although no significant differences across time were observed in control patients, mindfulness-based stress reduction participants showed a significant reduction of scores on AA QoL index, subjective symptoms; AA QoL index, relationship; BSI, anxiety; BSI, phobia; BSI, global severity index; and BSI. Positive symptoms distress index between T0 and T1. The improvement of AA QoL index, relationship and BSI, anxiety scores was still significant at T2.AA, Alopecia areata; BSI, Brief Symptom Inventory; ns, not significant; PSS, Perceived Stress Scale; QoL, quality of life; T1, 2 mo after T0 (corresponding to the end of the mindfulness-based stress reduction course for participants); T2, 6 mo after T0.∗ P values for multiple comparisons were adjusted with the Benjamini-Hochberg (2000) adaptive false discovery rate controlling procedure.5Benjamini Y. Hochberg Y. On the adaptive control of the false discovery rate in multiple testing with independent statistics.J Educ Behav Stat. 2000; 25: 60-83Crossref Scopus (1149) Google Scholar† Significant differences (adjusted P < .05) between groups.‡ From a clinical point of view, at T1 and T2, patients were classified as improved or not improved (the latter including both stationary and worse clinical outcomes). Open table in a new tab AA was considered moderate if patients had ≥3 patches >3 cm or at least 1 patch >10 cm. It was considered severe in case of total/universal alopecia or ophiasis. AA, Alopecia areata; MBSR, mindfulness-based stress reduction. A full factorial linear mixed model was used to evaluate the data. These data show significant baseline differences between the 2 groups of patients in terms of AA QoL index, relationship; AA QoL index, objective signs; BSI, depression; BSI, anxiety; BSI, paranoia; BSI, positive symptoms distress index; and PSS, where the control group had better scores. Although no significant differences across time were observed in control patients, mindfulness-based stress reduction participants showed a significant reduction of scores on AA QoL index, subjective symptoms; AA QoL index, relationship; BSI, anxiety; BSI, phobia; BSI, global severity index; and BSI. Positive symptoms distress index between T0 and T1. The improvement of AA QoL index, relationship and BSI, anxiety scores was still significant at T2. AA, Alopecia areata; BSI, Brief Symptom Inventory; ns, not significant; PSS, Perceived Stress Scale; QoL, quality of life; T1, 2 mo after T0 (corresponding to the end of the mindfulness-based stress reduction course for participants); T2, 6 mo after T0. At the end of the MBSR course, participants completed a semistructured questionnaire regarding their views on the intervention and their difficulties in practicing what they learned. Overall, they enjoyed the course and considered it very useful but reported that it was difficult to keep practicing mindfulness on their own and requested support in the form of reminders. Unfortunately, our sample size was small and MBSR participants turned out to have worse baseline scores than control patients (Table II), which implies higher room for improvement and may suggest a stronger motivation to attend the course. Despite these limitations, the significant improvement of QoL and of several psychometric parameters in MBSR participants, but not in control patients, suggest that mindfulness-based interventions may truly improve the QoL of patients with AA and help them cope with their disease. Noteworthy, the psychological status and QoL improved in the absence of significant clinical improvement (Table II). Similar results have been reported with hypnotherapy, the only psychological intervention for which the effect on health-related QoL has been evaluated to date in patients with AA.6Willemsen R. Haentjens P. Roseeuw D. et al.Hypnosis in refractory alopecia areata significantly improves depression, anxiety, and life quality but not hair regrowth.J Am Acad Dermatol. 2010; 62: 517-518Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar Conversely, a significant improvement in both psoriasis severity and QoL has been reported in patients with psoriasis who underwent mindfulness training.2Fordham B.A. Nelson P. Griffiths C.E.M. Bundy C. The acceptability and usefulness of mindfulness-based cognitive therapy for people living with psoriasis: a qualitative study.Br J Dermatol. 2015; 172: 823-825Crossref PubMed Scopus (11) Google Scholar Further research seems worthwhile. Thanks are due to Niccolò Gorgoni, junior mindfulness trainer, for co-conducting the classes, and to Nicoletta Cinotti, senior mindfulness trainer, for supervision.