Comparison of Effectiveness of the Mindfulness-Based Cognitive Therapy and the Metacognition Treatment on Anxiety , Depression and Stress Among Breast Cancer Patients

Background: The present study aimed to compare the effectiveness the metacognition treatment (MCT) and mindfulness-based cognitive therapy (MBCT) on anxiety, depression, and stress in the females with breast cancer. Methods: The planning of this study is through a quasi-experimental method of pretest and posttest type with control group. The target society of the research included every cancer patient who admitted to Tehran hospitals for breast cancer. Through assigned randomly, 12 patients were selected for the MCT group and 12 patients for the MBCT group, and the other were assigned control group. The data collection tools included depression, anxiety and stress scale 21 items (DASS-21) questionnaire. For statistical analysis, descriptive tests and repeated measures analysis of variance were performed. Results: Data analysis with repeated multivariate measurements illustrated that there is a significant difference in the rate of depression, anxiety and stress, in three groups. Conclusion: According to our results, MBCT was more effective compared to metacognitive therapy.


Introduction
The prevalence of breast cancer has been reported to be more than 23% in 40 to 55 years old women around the world. 1,2Due to medical progresses; many people are living with cancer nowadays compared to before.Despite the progressive treatments, expectations and needs of patients had often been attend. 3Emotional health is one of the important aspects of health that is of psychologists' interest.Breast cancer can develop a lot of deep emotions such as depression, anxiety and emotions accompanying anxiety and depression such as feelings of worthlessness or hopelessness.Also, reactions such as denial, anger and feeling of guilt can be seen and they affect patients' general health negatively.Some patients, at the end of medical therapy, find out that the cancer has brought about negative stable psychological consequences for them. 4,5e of the treatments that their impact is clearly shown in this symptom, is metacognition therapy 6 not only this treatment method pay attention on changing and acceptance but also this method has short sessions. 7,8etacognition includes understanding of inner states and coping strategies 9 also discussing about positive and negative beliefs are emphasized. 10ccording to some studies, the other treatment that has been shown to have clinical benefits in the treatment of anxiety and depression is mindfulnessbased cognitive therapy (MBCT) is presented by Kabat-Zinn. 11,120][21] Also studies about metacognition has been illustrated about impact of this treatment in depression patients, 22,23 post-traumatic stress disorder 24 and anxiety disorders. 25herefore, in order to address this research gap and the need to improve and reduce anxiety, depression and stress in these patients, it is necessary to conduct such a study.Consequently, the theoretical and research principles and information on the impact of metacognition treatment (MCT) and MBSR in females with breast cancer are sparse.

Materials and Methods
The planning of this study is through a quasi-experimental method of pre-test and post-test type with control group.The target society of the research included all women who referred to the Division of Oncology and Radiotherapy of Imam Hossein hospital during March 2016 to May 2017.Among patients diagnosed of breast cancer, of which a sample of 36 patients was selected with convenient method.Through assigned randomly, 12 patients were selected for the MCT group and 12 patients for the MBCT group, and the other were assigned control group.
Inclusion criteria for this study included: Informed consent and desire to participate in the study, ability to participate in meetings and collaborate on homework, diagnosis of breast cancer and age range of 30-55 years, minimum education level of high school and a month history of cancer (minimum).
Exclusion criteria for experimental group included: absence, unwillingness or inability to participate in meetings; receiving other treatment.
The target society of the research included every cancer patient who admitted Oncology of Imam Hossein hospital in Tehran.Two clinical psychologists did interventions also they knew about MBCT and MCT.Thirty-six patients were selected with convenient method.MBCT intervention included 8 sessions (1 session per week about 2 hours). 26The MBCT protocol is presented in Table 1.The MCT protocol is presented in Table 2.The data collection tools included depression, anxiety and stress scale -21 items (DASS-21) questionnaire.

Sample Demographic Sheet
The sample sheet included age, sex, educational level, and marital status of the patients.It was prepared and evaluated by the researchers.

DASS-21
The short form of this questionnaire with 42 questions has been examined by Leviband (1995) to assess depression, anxiety, and stress. 27Confirmatory factor analysis results has confirmed the existence of the 3 factors of depression, anxiety and stress.Retest coefficient of 3 subscales of this questionnaire was mentioned with sample consisted of 20 patients between 71%-81% at an interval of 2 weeks. 28eliability and validity of this questionnaire were studied on a number of subjects in England. 29Retest reliability for depression, anxiety and stress are reported respectively 80%, 76% and 77% and Cronbach's alpha for them are reported respectively 81%, 79% and 78%.Validity of this scale was examined by confirmatory factor analysis and in main components method.Kaiser-Meyer-Olkin (KMO) index value was equal to 90% and in Bartlett's test, χ2 index was equal to 3092.93 that was significant in the level of 0.0007 and it suggested adequacy of sample and selected variables for factor analysis.

Results
People were ranged from 38 to 49 years.Table 3 shows the mean and standard deviation in for age of patients.
Mean and standard deviation of anxiety, depression and stress in 3 groups are reported in Table 4.
Results of Table 4 show that the components of depression, anxiety and stress are almost similar between 2 groups.Comparison of the 2 experimental groups in post-test and follow-up indicates that mindfulness therapy shows more decrease in the mean score of participants in depression, anxiety and stress components compared to metacognitive therapy.Multivariate repeated measures model was used to compare 2 therapeutic approaches in control group to decrease depression, anxiety and stress.Therefore, firstly the assumptions of using the model were examined.The results of Mauchly's sphericity test show that the Mauchly's sphericity assumption is rejected in all dimensions but anxiety dimension.Thus, Hevin-Felt corrected values were used for comparison.The assumption of homogeneity of variances was assessed using Levene's test.The results indicate that this assumption is established.
Results of paired comparison in Table 5 show that there  2. Comparison of 2 experimental groups in terms of the amount of stress indicated that there is a significant difference between mindfulness-based therapy and metacognitive therapy and the comparison of these 2 groups to control group also indicated there is a significant difference between experimental groups and control group.

Discussion
Studies have shown that we will have 15 million cancer patients worldwide by 2020. 30Considering problems of breast cancer and its interventions, it seems that it is an important factor that we should focus on quality of patient's life. 31s the results show, anxiety, depression and stress scores decrease in experimental groups in variables and then people showed stability in follow-up.MBCT have shown effectiveness on variables in participates than MCT.This finding is consistent with results of studies conducted in Iran and the world. 32tudies showed reductions in research variables after treatments and our results show consistent with these studies. 21,27In addition, MBCT intervention showed more impact in experimental group.However, positive impact of treatment was not continued in follow-up.In this regard findings have been similar with previous studies. 18,33hile application of MBCT intervention has reduced side effect significantly and increased quality of life and well-being in the control group and MCT group.Therefore, several studies have supported the impact of MBCT on anxiety. 18,21 arlson and Spaca have investigated not only impact of MBCT in declining anxiety, pressure and physical stress, but also enchanting mental health, quality of life and well-being. 21Research investigated conscious practices and levels, medical and psychological symptoms have an important roles and effect in MBCT intervention. 34rthermore, knowledge and understanding of mindfulness by meditation practices through MBCT can help increase in self-awareness and self-acceptance ability in patients.Therefore, MBCT is an accessible pattern to decrease pain and growth of positive quality of life; consequently, this dynamic growth improves the management of depression, anxiety and stress. 17onsistent with the present findings, MBCT by using selfregulation has a valuable impact on experience patients and this treatment help cancer people to become relax and awareness. 34ased on the results of the present study, the MCT program has a role in identifying rumination periods, core belief and intermediate beliefs.In addition, this intervention uses practical techniques in order to increase attention.MCT program try to identify the rumination belief and uncontrollable thoughts, in addition to modify uncontrollable beliefs and preventing harmful coping behavior.MCT follows cognitive method.
There were some limitations for the study including small sample size per group and also since some patient were not willing to participate in the study affects the generalization of the findings to the population of the study.Therefore, it is suggested to promote the patients to participate in training and psychotherapy sessions by emphasizing the importance of mental health along with medical treatments.This study was done on patients of Imam Hossein hospital in Tehran.Therefore, researchers recommend that similar studies should be performed on specific types of cancer in samples selected from different cities.

Table 2 .
Protocol of MCT Training Sessions 7thExamining negative beliefs and useless strategies/writing new designs of recurrent fears 8th Reviewing about all sessions, examining the other cognitive beliefs/discussing about using new program.

Table 3 .
Mean and Standard Deviation of Patients

Table 4 .
Mean and Standard Deviation of Anxiety, Depression, Stress in Patients

Table 5 .
Paired Comparison of Depression, Anxiety and Stress Between 2 Groups Mindfulness-Based Cognitive Therapy and the Metacognition in Breast Cancer journals.sbmu.ac.ir/Neuroscience