The Effectiveness of Mindfulness-Based Cognitive Group Therapy on the Quality Of Life and Hope in the Patients with Coronary Heart Disease

Background and objectives: The aim of this study was examining the effectiveness of mindfulness-based cognitive group therapy on the quality of life and hope in the patients with coronary heart disease. Methods: The present study was quasi-experimental with pre-test, posttest and follow-up with control group. To fulfill the study, 30 patients were selected randomly and were assigned into experimental (n = 15) and control groups (n = 15). To collect the data, participants of both groups completed demographic information sheet, MacNew Heart Disease Health-Related Quality of Life Questionnaire and Miller Hope Scale, respectively of coronary heart disease questionnaire at pre-test, post-test and follow-up (2 months after the intervention). Participants of experimental group received eight 90-minute intervention sessions. Results: The results of the multivariate covariance analysis with repeated measures showed that mean score quality of life(P<0.05), hope (P<0.001) in participants of the experimental group had a significant difference compared to the participants of the control group at post-test and followup. Conclusion: results showed that mindfulness based stress reduction treatment can be effective in improving life quality and hope in coronary heart disease. Implication for further research and possible clinical applications are discussed.

World Health Organization defined the quality of life as the perceptions of an individual about their position in life in terms of culture and value systems in which one lives and in relation to the goals, expectations, standards and priorities. Thus, it is quite individual and cannot be viewed by others and is based on individuals' perceptions of various aspects of their lives [9]. Quality of life has been known and used as an indicator to measure the health status in the studies [10].
Examining the quality of life in the health studies on the patients with heart disease help the experts in determining the living conditions and the risks of disease on quality of life and can clarify many unclear points, including undesirable effects of heart disease on the physical, psychological, social performance and in general the quality of life in patients [11]. In recent decades, remarkable progresses have taken place in the development of psychosocial interventions for patients with chronic diseases [12]. Not only because they may increase the success of medical and clinical treatment but also because it can enhance the quality of life in the patients who suffer more than other organic patients [13]. Controlling and reducing the psychological symptoms following the physical ailments not only enhance the skills and raise the fighting spirit in these patients but also boost the immune system and thus reduce and improve the physical symptoms [14]. Teasdale, Segal, & Williams (1995) considered the skills called such as attention control from the mindfulness meditation and believed that they would help the individual to control their mental ruminations that causes restlessness and eventually leads to depression and anxiety [15]. The main learned skills can make the person to put aside the engaging in sustainable patterns of negative thinking. Mindfulness-based cognitive therapy by combining the mindfulness-based stress reduction program and cognitive skills and techniques provide the condition so that the person can see his negative thoughts without judgment [16].
In this treatment, the mindfulness skills to cope with depression and despair and growing awareness of the present moment are taught that include the meditation training, relaxation, yoga and Hatha [17,18]. Mindfulness means paying attention to the present moment in a particular, objective and free from judgment manner [16]. One of the main objectives of the program is to promote health and reduce stress [18]. The meditation practices and mindfulness lead to enhance the ability of self-awareness and self-acceptance in patients [19].Numerous studies have been done on the effectiveness of mindfulness-based therapies to improve the quality of life of patients with chronic diseases. Mindfulness-based treatment model has found some success in improving the quality of life of cancer patients [20]. The meta-analysis study by Bohlmeijeraet al. showed that mindfulness-based therapy was an effective way to reduce stress and improve quality of life for patients with different diagnoses. The groups studied in this meta-analysis included the cancer patients with mental disorders and cardiovascular diseases such as hypertension and chronic pain [21].
The results of the study by Gloria et al. (2008) on the effectiveness of mindfulness-based cognitive therapy in patients with high blood pressure have shown that it was an effective treatment of depression and anxiety in daily life and for reducing the symptoms of chronic illness such as high blood pressure [22]. The results of the study conducted by Parswaniet al. (2013) have shown that mindfulness-based stress intervention program led to the reduction in symptoms of depression and anxiety, blood pressure (BP) and fat mass (BMI) incoronary heart patients and after 3 months follow-up the effects of the treatment remained [23].

RESEARCH METHOD
The present study is a quasi-experimental research with pretest and post-test and follow-up design. The research population included all the patients with coronary heart disease referring to the Cardiology Hospital of Tehran province, Iran (of Imam Hossein hospital) from August to October 2015. To calculate the sample size given that the appropriate sample size for each group is 15 people in research experiments, a sample size of 15 participants (n =15) was selected for each group.
Inclusion criteria included diagnosis of coronary heart disease based on the detection of cardiologists, the consent and informant willingness to participate in research, the ability to participate in meetings and collaborate on assignments, to work in completing the instruments, the physical and psychological stability (lack of intervening physical or psychological symptoms during sessions the treatment including fatigue, muscle aches, etc.) Minimum education was the pre-high school degree and the age range of the participants was 20 to 45 years. Also, the patient was excluded if she or he was treated because of a physical or psychological illness or in the presence of cognitive impairment or impaired cognitive function, acute and severe symptoms so that the patients' participation in the present was difficult or almost impossible. Accordingly, a number of patients were selected from among the patients with coronary heart disease referring to the Cardiology Hospital of Tehran province, Iran (Imam Hossein hospital) from August to October 2015 and in case of having consent and inclusion criteria were randomly selected and divided into two groups of mindfulness-based cognitive therapy (experiment) and control group.

Research Instruments
The instruments used in this study included the demographic information sheet, MacNew Heart Disease Health-Related Quality of Life Questionnaire and Miller Hope Scale, respectively.
• The sheet of the demographic information This sheet included the information on age, education level and marital status which was developed and evaluated by the researcher of the present study.
• MacNew Heart Disease Health-Related Quality of Life Questionnaire: This is a self-report questionnaire developed in English by Neil Aldrich and Lynette Lim (1994) in America and was revised by Valenti (1996); it contains 27 questions and measures the quality of life in 3 emotional, physical and social domains. Any questions is rated based on the 7-point Likert scale (from always to never) and average response time was 10 minutes. The way of dividing the questions in the scale is in such a way that any questions can be set in one, two or three areas [24]. This instrument has the reliability, validity and responsive to clinical changes. As such, in the study of AsadiLary, Javadi, Malawi and Aldrich (2003), the Cronbach's alpha reliability of the MacNew questionnaire in Iran's population was as the following: the emotional dimension 0.92 ,physical dimension 0.92, the social dimension 0.95 and total score of 0.95, respectively. The correlation coefficient of it included: the emotional dimension 0.42, physical dimension 0.38,the social dimension, 031 and total score of 0.50, respectively. Intergroup correlation on the emotional dimension was 0.92, physical dimension, 0.92, the social dimension 0.93 and total score of 0.95, respectively. The validity of the questionnaire through construct validity for the emotional, physical and social dimensions was in the whole range of 0.63 to 0.66.5.
• The Miller Hope Scale The Miller Hope Scale (1988) is a diagnostic test that was first used to measure hope in heart disease patients in America. The questionnaire consisted of forty-eight aspect of the modes of the hope and desperation, the items of which are selected based on the covert and overt behavior of the individuals in hopeful and desperate people. Every aspect that represents a behavioral signs is rated based on the 5-point Likert scale ranging from strongly disagree (score 1) to strongly agree (score 5) and everyone should select the one option which is mostly true about him. The total score ranging from 48 (least hope) to 240 (most optimistic) will be acquired in this way. Finally, the total score obtained can indicate the hope and despair. 15 statements of the Miller scale are composed of a negative items and the scores are reversed including the statements of 11,13,16,18,25,27,28,31,33,34,38,39,44,47 and 48 [25]. The reliability and validity of the questionnaire have been confirmed in several studies. Abdi and Assadi Larry (2011) in Iran have approved the validity and reliability of the questionnaire and stated that the Miller Hope Scale is the best test to predict hope in the patients with low selfesteem and damaged social support and academic support. In the study of Darvishi the reliability of the questionnaire was obtained (0.89) using Cronbach's alpha and (0.79) using split-half and its validity was evaluated as 0.79. In the present study reliability of this questionnaire was 0.929 using Cronbach's alpha.

Research Procedure
In order to conduct the study, first, 30 patients who have inclusion criteria were selected from among the patients referring to the specialized heart hospital in Tehran province (Imam Hossein hospital) which had records and referred for the regular visits to the heart specialist in certain dates. All the patients were randomly assigned to two groups of A and B and then they were randomly divided into the experimental group and the control group. Mindfulness-based cognitive therapy patients in heart clinic were trained for by two clinical therapists, who passed the course of treatment and had the necessary expertise and experience in this context, each week for 1 session of2 and half hours. The protocol of the mindfulness-based cognitive therapy sessions for patients is presented in Table 1 [26].

Session Topic First session: Automatic Pilot
The introduction of automatic guidance system/knowing how to use present moment awareness of bodily sensation, thoughts and emotions in reducing stress/practicing eating raisins 6 ,giving feedback and discussion about the practice/three -minute breathing, giving assignment for next week and distributing leaflets of the first session and CDs of meditation Second session: facing obstacles Re-examining body workout/ giving feedback and discussion about examining body workout/ practicing breathing mindfulness meditation/ /distributing leaflets of the second session and CDs of meditation Third session: Kindness with breathing, body and awareness about breathing and body movement Having conscious sitting with awareness of breathing(the sitting meditation)/ practicing three -minute breathing /distributing leaflets of the third session and video tape of yoga practices

Fourth session: learning how to answer
Re-examining body workout / (in the hospital chapel)/5-minute practicing of "seeing or hearing"/ re-practicing conscious session with awareness of breathing and body/ distributing leaflets of fourth session and CDs of meditation Fifth session: slowly cope with difficulty (attendance) Practicing breathing /re-practicing conscious session(awareness of breathing ,body, sounds and thoughts)/explaining the stress and identifying participants' reactions to stress/examining awareness of pleasant and unpleasant events on feeling ,thoughts and bodily sensations/ practicing 3-minute breathing /distributing leaflets Sixth session: thoughts are not facts practicing sitting meditation (mindfulness of sounds and thoughts)/distributing leaflets of the sixth session and number4 video tape to participants Seventh session: self-care Practicing mountain meditation/sleep hygiene/ repeating exercises of the previous session/making a list of enjoyable activities/distributing leaflets of the seventh session Eighth session: going beyond fear Examining body workout /overview of program/examining and discussing programs /practicing stone, beads and marbles meditation 6 Object attention training

RESULTS
The demographic characteristics of the sample in this study are presented in Table 2. In the following, the mean and standard deviation of the variable of the quality of life and hope in the pretest, posttest, and follow-up in terms of experimental and control groups is reported in Table 3. As can be seen in Table 3, not only all aspects of quality of life scores in the experimental group (emotional, physical and social)has increased from pre-test to post-test. It is in the pursuit of relative stability and the largest increase in score reduction is observed in social and emotional dimension. Total score for the quality of life in patients with coronary heart disease also increased from pre-test to post-test which is the sign of improvement in quality of life.The mean and standard deviation of hope increased from pre-test to post-test and in follow up period had a relative stability.

Table 3: Mean and standard deviation of hope the quality of life in patients with coronary heart disease over time (pre-test, post-test, follow-up)
In this study, the statistical analysis of quality of life and hope scores in both experimental and control groups was performed with multivariate analysis of covariance with repeated measures .In this analysis, the pre-test scores as a covariate and post-test and follow-up scores were considered as the dependent variable and time was considered as a moderating variable.Prior to the analysis, first the assumptions of the model were investigated. Given that the difference between the experimental and control groups was significant and according to the results presented in Table 3, the mean score of post-test and follow-up in the experimental group was higher than the control group. It can be concluded that the independent variable (mindfulness-based cognitive therapy) has been effective on in creased hope. In addition, the effect of (mutual) interaction between group × time was significant (Partial Eta Square= 0/865،P < 0.001، F= 86.209 Pillai's Trace = 0.865). Given that the difference between the experimental and control groups was significant and according to the results presented in Table 3, the mean score of post-test and follow-up in the experimental group was higher than the control group. It can be concluded that the independent variable (mindfulness-based cognitive therapy) has been effective on increased hope.
The results of the Mauchly's Test showed that the assumption of the equal covariance matrix does not hold (P=0/672 Mauchly's W= 0/971, DF=2). Thus, the Sphericity Assumed test was used because of the lack of equality of variance -covariance. The value of the test of the main effect of time was not significant within groups ((P<0.001, Partial Eta Squared= 0.726،F=74/182). However, the test of interaction between time and group was significant (P<0.001, Partial Eta Squared= 0/701, F=65/542). The results of multivariate tests showed that the effect of time (pre-test, posttest and follow-up) was significant for hope variable ((Partial Eta Square= 0/784،P < 0.001،F= 75/152, Pillai's Trace =0.848). In addition, the effect of (mutual) interaction between group × time was significant (Partial Eta Square= 0.845،P < 0.001،F= 73/442, Pillai's Trace = 0.845). Given that the difference between the experimental and control groups was significant and according to the results presented in Table 3, the mean score of posttest and follow-up in the experimental group was higher than the control group. It can be concluded that the independent variable (mindfulness-based cognitive therapy)has been effective on increased emotional aspect of the patients.
The results of the Mauchly's Test showed that the assumption of the equal covariance matrix does not hold (P=0.759 Mauchly's W= 0/682, DF=2). Thus, the Sphericity Assumed test was used because of the lack of equality of variance -covariance. The value of the test of the main effect of time was not significant within groups (P<0.001, Partial Eta Squared= 0/384،F=17.472). However, the test of interaction between time and group was significant (P<0.001, Partial Eta Squared= 0.739, F=79/148). The results of multivariate tests showed that the effect of time (pretest, posttest and follow-up) was significant for hope variable ((Partial Eta Square= 0/784،P < 0.001،F= 75/152, Pillai's Trace=0.848). In addition, the effect of (mutual) interaction between group × time was significant (Partial Eta Square= 0.789،P < 0.001،F= 50/363, Pillai's Trace = 0.789). Given that the difference between the experimental and control groups was significant and according to the results presented in Table 3, the mean score of post-test and follow-up in the experimental group was higher than the control group. It can be concluded that the independent variable (mindfulness-based cognitive therapy) has been effective on increased physical aspect of the patients. ). In addition, the effect of (mutual) interaction between group × time was significant (Partial Eta Square= 0/626،P < 0.001،F= 22/580, Pillai's Trace = 0.626). Given that the difference between the experimental and control groups was significant and according to the results presented in Table 3, the mean score of posttest and follow-up in the experimental group was higher than the control group. It can be concluded that the independent variable (mindfulness-based cognitive therapy) has been effective on increased physical aspect of the patients.

DISCUSSION
According to the statistical findings, it can be concluded that mindfulness-based cognitive group therapy (control group) compared to the control group in both post-test and follow up had a significant impact on the improvement of quality of life and hope for patients with coronary heart disease. The results of the present study showed that healthy lifestyle behaviors through Mindfulness-based training has led to enhance the quality of life of patients and this change was statistically significant (Table 3).
This study has shown that mindfulness-based cognitive therapy training lifestyle reduces psychological symptoms of frustration and depression, thus leading to improved quality of life for patients. In the present study, we can conclude explain behavior training related to healthy lifestyle factors such as: stress management, interpersonal support, nutrition, exercise and so on MBCT group therapy techniques such as focus techniques, the emotion regulation, breathe and eat consciously and practice yoga to reduce psychological symptoms (depression, anxiety, etc.) and thus to improve the quality of life in patients with coronary heart.
It can be said that on the one hand, judgments and prejudices have caused despair and depression in many patients with chronic conditions, and it would increase the use of cognitive errors. This vicious cycle can lead to the increase in the diseases and disorders. In order to reduce the use of these errors is necessary that the patients should avoid any kind of judgment (emotions and events) and accept them as they are [27].
On the other hand, this understanding without the judgment and practicing the mindfulness techniques (meditation, yoga, body scan, stress management, etc.), increase the ability of clients to tolerate negative emotional states and makes them ready to deal effectively, will be followed enabling reduced use of maladaptive coping strategies [28].
Using the techniques of mindfulness (auto practice, focus) and relaxation training (body checking, relaxation, Hatha, Yoga, etc.) largely as a stress management skills must be used regularly and patient (22) and studies have shown that mindfulness on improving the mental and physical well-being and reduce physical symptoms is effective (16). This finding can be said to justify because mindfulness is the feelings without judgment and balance of consciousness that helps clearly seeing and accepting emotions and physical phenomena, (20).
Therefore, teaching it to patients with coronary heart disease who suffer from the physical and psychological problems encourages them to accept their physical feelings and symptoms and accepting the feelings reduces the excessive attention and sensitivity to the problems.In this regard, the studies suggest that the emotional inhibition as a negative emotion regulation strategies lead to cardiovascular disease and blood pressure and emotional and cognitive appraisal as a positive strategyis followed by the emotion regulation and reducing blood pressure [29].
In explaining the other results, it can be said that depression, anxiety and stress are among the important contributing factor on the decline in the quality of life (8,10). In order to justify the finding, it can be said that the techniques stress reduction program of mindfulness-based and conscious yoga, on the one hand, increase the attention and awareness of thoughts, emotions and practical desires and lead to the individual and social improvement and so the psychological factors such as depression are thus reduced [30].
Furthermore, it leads to reducing the physical stress and epinephrine and norepinephrinehormones and in parallel reducing the stress and anxiety and thus improving the quality of life in patients.According to Benson, the relaxation exercises (relaxation, body scanning, meditation and yoga) lead to the physiological changes and these changes are coordinated by reducing sympathetic nervous system activity and thus lead to a decrease in blood pressure [31].The effects of the treatment group therapy is to increase coping ability to adapt, create a sense of hope, more responsive to treatment and therefore fall under the influence therapeutic outcomes [32]. But it should be noted that the persistence of this effect requires continuous training and extends throughout life is mindfulness techniques so that this method will become a way of life. . Lack of follow up longer than three months and the lack of comprehensive sampling of all urban areas and limiting it to just one hospital were among the limitation of this study. It is recommended that this type of treatment to be used as a way of psychotherapy and complementary medical therapies to reduce blood pressure in patients with hypertension. It is finally included that mindfulness-based cognitive group therapy has the potential to improve the quality of life and in increasing the hope in patients with coronary heart disease.