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Jiang X, Jiang H. Mentalising imagery therapy for family dementia caregivers: protocol for a scoping review. BMJ Open 2024; 14:e076727. [PMID: 38754883 PMCID: PMC11097803 DOI: 10.1136/bmjopen-2023-076727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 04/29/2024] [Indexed: 05/18/2024] Open
Abstract
INTRODUCTION Dementia is a growing public health concern, and providing long-term care for individuals affected by this condition is challenging for their family caregivers. While researchers have explored various intervention options to provide psychological support for dementia caregivers, mentalising imagery therapy (MIT) has gained significant recognition as an effective programme. Despite its significance and effectiveness, there is a lack of comprehensive scoping reviews of MIT in dementia caregiving. Thus, conducting such a review can provide valuable insights into the status and outcomes of MIT, identify gaps in existing research and provide recommendations for a more effective clinical practice. METHODS AND ANALYSIS This study proposes a scoping review conducted according to the Joanna Briggs Institute, Arksey and O'Malley's methodological framework, as well as the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Scoping Review Extension. PubMed, Web of Science, Embase, Scopus, CINAHL and PsycINFO databases will be searched while grey literature will be retrieved via Google Scholar. Covidence will be used to manage the literature selection process and remove duplicate publications. Two researchers will independently screen the literature according to the inclusion criteria, with any discrepancies resolved through discussions with a third researcher. Data will be presented in a structured tabular format, with a narrative synthesis providing an overview of the findings on the identified research gaps and the effectiveness of MIT in the field of dementia caregiving. ETHICS AND DISSEMINATION In a scoping review, no ethical approval is necessary. The results will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER The scoping review protocol has been registered with Open Science Framework (https://doi.org/10.17605/OSF.IO/FHRG8).
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Affiliation(s)
- Xue Jiang
- Department of Nursing, Puding County People's Hospital, Anshun, China
| | - Hu Jiang
- Department of Nursing, The Third Affiliated Hospital of Zunyi Medical University (The First People's Hospital of Zunyi), Zunyi, China
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Madarasmi S, Gutierrez-Ramirez P, Barsoum N, Banerjee S, Ramirez Gomez L, Melero-Dominguez M, Gitlin LN, Pederson A, Liu RT, Jain FA. Family dementia caregivers with suicidal ideation improve with mentalizing imagery therapy: Results from a pilot study. JOURNAL OF AFFECTIVE DISORDERS REPORTS 2024; 16:100721. [PMID: 38737194 PMCID: PMC11086673 DOI: 10.1016/j.jadr.2024.100721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024] Open
Abstract
Background Family caregivers of persons living with dementia often experience increased depression and suicidal ideation (SI). However, the feasibility and impact of therapies on caregiver SI has remained largely unexplored. Mentalizing imagery therapy (MIT) helps reduce psychological symptoms through mindfulness and guided imagery. This pilot study examined the feasibility of participation by caregivers with SI in a randomized controlled trial (RCT) of MIT versus a psychosocial support group (SG), and the respective impact of group on SI, depression, and secondary outcomes. Methods A secondary analysis of data from an RCT of 4-week MIT or SG for caregivers (n = 46) was performed, identifying SI (n = 23) and non-SI (n = 23) cohorts. Group attendance and home practice were compared between cohorts. In the SI cohort (total n = 23, MIT n = 11, SG n = 12), group differences in SI, depression, and secondary outcomes were evaluated post-group and at 4-month follow-up. Results Attendance in both groups and home practice in MIT were similar between SI and non-SI cohorts. In the SI cohort, MIT evinced greater improvements relative to SG in SI (p=.02) and depression (p=.02) post-group, and other secondary outcomes at follow-up. Limitations Limitations include small sample size and single-item assessments of SI from validated depression rating scales. Conclusions Participation in an RCT was feasible for caregivers with SI. MIT resulted in important benefits for SI and depression, while SG showed no acute SI benefit. The role of MIT in improving SI should be confirmed with adequately powered trials, as effective therapies to address caregiver SI are critical.
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Affiliation(s)
- Saira Madarasmi
- Department of Psychiatry, Depression Clinical and Research Program, Massachusetts General Hospital, Boston, MA, United States
| | - Paulina Gutierrez-Ramirez
- Department of Psychiatry, Depression Clinical and Research Program, Massachusetts General Hospital, Boston, MA, United States
| | - Nader Barsoum
- Department of Psychiatry, Depression Clinical and Research Program, Massachusetts General Hospital, Boston, MA, United States
| | - Sreya Banerjee
- Department of Psychiatry, Depression Clinical and Research Program, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Liliana Ramirez Gomez
- Harvard Medical School, Boston, MA, United States
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Maria Melero-Dominguez
- Department of Psychiatry, Depression Clinical and Research Program, Massachusetts General Hospital, Boston, MA, United States
| | - Laura N. Gitlin
- College of Nursing and Health Professions, Drexel University, Philadelphia, PA, United States
| | - Aderonke Pederson
- Department of Psychiatry, Depression Clinical and Research Program, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Richard T. Liu
- Department of Psychiatry, Depression Clinical and Research Program, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Felipe A. Jain
- Department of Psychiatry, Depression Clinical and Research Program, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
- Harvard-Massachusetts Institute of Technology (MIT) Division of Health Sciences and Technology, Boston, MA, United States
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Ramirez-Gomez L, Johnson JK, Ritchie C, Meyer AK, Tan E, Madarasmi S, Gutierrez-Ramirez P, Aldarondo-Hernández C, Mischoulon D, Banerjee S, Jain FA. Virtual mentalizing imagery therapy for Spanish language Latino family dementia caregivers: A feasibility and acceptability study. Front Psychol 2023; 14:961835. [PMID: 36874854 PMCID: PMC9979537 DOI: 10.3389/fpsyg.2023.961835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 01/11/2023] [Indexed: 02/18/2023] Open
Abstract
Spanish speaking family caregivers of people living with dementia have limited supportive resources in Spanish. There are few validated, culturally acceptable virtual interventions for reducing these caregivers' psychological distress. We investigated the feasibility of a Spanish language adaptation of a virtual Mentalizing Imagery Therapy (MIT) program, which provides guided imagery and mindfulness training to reduce depression, increase mentalizing, and promote well-being. 12 Spanish-speaking family dementia caregivers received a 4-week virtual MIT program. Follow-up was obtained post group and at 4 months post baseline assessment. Feasibility, acceptability, and satisfaction with MIT were assessed. The primary psychological outcome was depressive symptoms; secondary outcomes included caregiver burden, dispositional mindfulness, perceived stress, well-being, interpersonal support, and neurological quality of life. Statistical analysis was performed with mixed linear models. Caregivers were 52 ± 8 (mean ± SD) years of age. 60% had a high school education or less. Participation in weekly group meetings was 100%. Home practice was performed on average 4 ± 1 times per week [range 2-5]. Satisfaction with MIT reached 19 ± 2 of a possible 20 points. Reduction in depression from baseline was observed by week three (p = 0.01) and maintained at 4 month follow-up (p = 0.05). There were significant improvements in mindfulness post-group, and in caregiver burden and well-being at 4 months. MIT was successfully adapted for Latino Spanish language family dementia caregivers within a virtual group environment. MIT is feasible and acceptable and may help reduce depressive symptoms and improve subjective well-being. Larger, randomized controlled trials of MIT should determine durability of effects and validate efficacy in this population.
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Affiliation(s)
- Liliana Ramirez-Gomez
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States.,Department of Neurology, Harvard Medical School, Boston, MA, United States.,Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Julene K Johnson
- Center for Aging in Diverse Communities, University of California, San Francisco, CA, United States
| | - Christine Ritchie
- Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Ashley K Meyer
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - Emily Tan
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - Saira Madarasmi
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - Paulina Gutierrez-Ramirez
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - Cecilianna Aldarondo-Hernández
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - David Mischoulon
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States.,Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Sreya Banerjee
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States.,Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Felipe A Jain
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States.,Department of Psychiatry, Harvard Medical School, Boston, MA, United States
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Yang FC, Zamaria J, Morgan S, Lin E, Leuchter AF, Abrams M, Chang SE, Mischoulon D, Pedrelli P, Fisher L, Nyer M, Yeung A, Jain FA. How family dementia caregivers perceive benefits of a 4-week Mentalizing Imagery Therapy program: a pilot study. PROFESSIONAL PSYCHOLOGY-RESEARCH AND PRACTICE 2022; 53:494-503. [PMID: 36212803 PMCID: PMC9540433 DOI: 10.1037/pro0000388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Background Family caregivers of dementia patients experience high levels of interpersonal stress that often results in elevated anxiety, and depression, and negative impacts on interpersonal relationships. Changes in behaviors and the structure of relationships with the care recipient (CR) and others in the social milieu challenge the caregivers' ability to mentalize, or understand the links between mental states and behaviors. This study investigates the experiences and perceived benefits of family dementia caregivers who underwent Mentalizing Imagery Therapy (MIT), a treatment aiming to improve balanced self-other mentalizing and reduce psychological symptoms. Methods Purposeful sampling was used to select 11 family dementia caregivers who underwent a 4-week pilot trial of MIT. Semi-structured interviews were completed post-intervention to identify subjective benefits, putative psychological mediators and perceived active components. Results Caregivers reported improvements in well-being, mood, anxiety, and sleep, and a majority stated MIT helped with forming and maintaining healthier relationships. Some participants noted benefits extending to how they reacted to their social environment and perceived themselves more objectively from others' perspectives. Specific elements of MIT, including self-compassion, self-care, and the ability to reflect on emotionally arousing challenges, might have mediated these improvements. Conclusion Family dementia caregivers perceived salutary benefits of MIT on multiple domains of well-being. The self reports suggest MIT holds promise for improving well-being, reducing non-mentalizing patterns of thought, and facilitating improvements in balanced mentalization within the caregivers' relationships.
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Affiliation(s)
| | - Joseph Zamaria
- Department of Psychiatry, University of California, San Francisco, CA
| | - Stefana Morgan
- Department of Psychiatry, University of California, San Francisco, CA
| | - Eric Lin
- Semel Institute for Neuroscience and Human Behavior, Department of Psychiatry, University of California, Los Angeles, CA
| | - Andrew F. Leuchter
- Semel Institute for Neuroscience and Human Behavior, Department of Psychiatry, University of California, Los Angeles, CA
| | - Michelle Abrams
- Semel Institute for Neuroscience and Human Behavior, Department of Psychiatry, University of California, Los Angeles, CA
| | - Sarah E. Chang
- Semel Institute for Neuroscience and Human Behavior, Department of Psychiatry, University of California, Los Angeles, CA
| | - David Mischoulon
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Paola Pedrelli
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Lauren Fisher
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Maren Nyer
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Albert Yeung
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Felipe A. Jain
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Bersani FS, Accinni T, Carbone GA, Corazza O, Panno A, Prevete E, Bernabei L, Massullo C, Burkauskas J, Tarsitani L, Pasquini M, Biondi M, Farina B, Imperatori C. Problematic Use of the Internet Mediates the Association between Reduced Mentalization and Suicidal Ideation: A Cross-Sectional Study in Young Adults. Healthcare (Basel) 2022; 10:healthcare10050948. [PMID: 35628085 PMCID: PMC9140488 DOI: 10.3390/healthcare10050948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 05/03/2022] [Accepted: 05/09/2022] [Indexed: 12/24/2022] Open
Abstract
Suicide is a major public health problem, and it is urgent to investigate its underlying clinical and psychological concomitants. It has been suggested that low mentalization skills and problematic use of the internet (PUI) are factors that can play a role in suicidal behaviors. It is possible that poor mentalization skills contribute to leading to forms of PUI, which, in turn, can represent triggers for suicidal ideation (SI). We tested this hypothesis through a quantitative and cross-sectional study on a sample (n = 623) of young adults (age range: 18−34). Self-report measures investigating symptoms related to Social Media Addiction (SMA), Internet Gaming Disorder (IGD), mentalization capacity, and SI were used. A single mediation analysis with two mediators was carried out to evaluate the direct and indirect effects of mentalization on SI through the mediating role of SMA- and IGD-related symptoms, controlling for potential confounding factors (e.g., socio-demographic and addiction-related variables). The four explored variables were significantly associated with each other (all p < 0.001) across all subjects; the mediational model showed that the total effect of mentalization on SI was significant (B = −0.821, SE = 0.092 (95% CI: −1.001; −0.641)) and that both SMA- (B = −0.073, SE = 0.034 (95% CI: −0.145; −0.008)) and IGD-related symptoms (B = 0.046, SE = 0.027 (95% CI: −0.107; −0.001)) were significant mediators of such association. Our findings support the possibility that PUI severity plays a relevant role in mediating the association between low mentalization skills and levels of SI.
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Affiliation(s)
- Francesco Saverio Bersani
- Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy; (T.A.); (E.P.); (L.B.); (L.T.); (M.P.); (M.B.)
- Correspondence:
| | - Tommaso Accinni
- Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy; (T.A.); (E.P.); (L.B.); (L.T.); (M.P.); (M.B.)
| | - Giuseppe Alessio Carbone
- Cognitive and Clinical Psychology Laboratory, Department of Human Sciences, European University of Rome, 00163 Rome, Italy; (G.A.C.); (A.P.); (B.F.); (C.I.)
| | - Ornella Corazza
- Department of Clinical, Pharmaceutical and Biological Sciences, University of Hertfordshire, Hatfield AL10 9EU, UK;
| | - Angelo Panno
- Cognitive and Clinical Psychology Laboratory, Department of Human Sciences, European University of Rome, 00163 Rome, Italy; (G.A.C.); (A.P.); (B.F.); (C.I.)
| | - Elisabeth Prevete
- Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy; (T.A.); (E.P.); (L.B.); (L.T.); (M.P.); (M.B.)
| | - Laura Bernabei
- Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy; (T.A.); (E.P.); (L.B.); (L.T.); (M.P.); (M.B.)
- Mental Health Department, ASL Roma 5 Hospital, 00184 Rome, Italy
| | - Chiara Massullo
- Experimental Psychology Laboratory, Department of Education, Roma Tre University, 00185 Rome, Italy;
| | - Julius Burkauskas
- Laboratory of Behavioral Medicine, Neuroscience Institute, Lithuanian University of Health Sciences, 00135 Palanga, Lithuania;
| | - Lorenzo Tarsitani
- Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy; (T.A.); (E.P.); (L.B.); (L.T.); (M.P.); (M.B.)
| | - Massimo Pasquini
- Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy; (T.A.); (E.P.); (L.B.); (L.T.); (M.P.); (M.B.)
| | - Massimo Biondi
- Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy; (T.A.); (E.P.); (L.B.); (L.T.); (M.P.); (M.B.)
| | - Benedetto Farina
- Cognitive and Clinical Psychology Laboratory, Department of Human Sciences, European University of Rome, 00163 Rome, Italy; (G.A.C.); (A.P.); (B.F.); (C.I.)
| | - Claudio Imperatori
- Cognitive and Clinical Psychology Laboratory, Department of Human Sciences, European University of Rome, 00163 Rome, Italy; (G.A.C.); (A.P.); (B.F.); (C.I.)
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Török E, Kéri S. The Relationship Among Mentalization, Mindfulness, Working Memory, and Schizotypal Personality Traits in the General Population. Front Psychol 2022; 13:682889. [PMID: 35586232 PMCID: PMC9108540 DOI: 10.3389/fpsyg.2022.682889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 04/12/2022] [Indexed: 11/24/2022] Open
Abstract
Individuals with high schizotypal traits are less able to observe, describe, and monitor inner feelings, thoughts, and experiences, commonly referred to as mindfulness and mentalization. High schizotypy is also associated with impaired working memory (WM). However, the relationship among mindfulness, mentalization, WM, and schizotypal traits is unknown. Three hundred individuals from the community (mean age: 38.0 years, SD = 10.5; 49.3% women) completed questionnaires examining schizotypal traits, mindfulness, and mentalization and performed working memory tasks. Results revealed that mentalization was a general predictor of schizotypal traits, including unusual experiences, cognitive disorganization, introverted anhedonia, and impulsive nonconformity, when the effect of mindfulness and working memory was controlled. We also found a positive correlation between mindfulness and mentalization. Low mindfulness and mentalization performances were associated with high schizotypy. However, poor working memory was only weakly linked to cognitive disorganization and introverted anhedonia. These findings suggest that weak mentalization is a core feature of schizotypy independent of mindfulness and working memory.
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Affiliation(s)
- Edina Török
- Department of Cognitive Science, Budapest University of Technology and Economics, Budapest, Hungary
| | - Szabolcs Kéri
- Department of Cognitive Science, Budapest University of Technology and Economics, Budapest, Hungary
- Nyírő Gyula National Institute of Psychiatry and Addictions, Budapest, Hungary
- Department of Physiology, University of Szeged, Szeged, Hungary
- *Correspondence: Szabolcs Kéri, ;
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Jain FA, Okereke O, Gitlin L, Pedrelli P, Onnela JP, Nyer M, Ramirez Gomez LA, Pittman M, Sikder A, Ursal DJ, Mischoulon D. Mentalizing imagery therapy to augment skills training for dementia caregivers: Protocol for a randomized, controlled trial of a mobile application and digital phenotyping. Contemp Clin Trials 2022; 116:106737. [PMID: 35331943 PMCID: PMC9133149 DOI: 10.1016/j.cct.2022.106737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 03/15/2022] [Accepted: 03/17/2022] [Indexed: 11/23/2022]
Abstract
More than 50 million people worldwide live with a dementia, and most are cared for by family members. Family caregivers often experience chronic stress and insomnia, resulting in decreased mental and physical health. Accessibility of in-person stress reduction therapy is limited due to caregiver time constraints and distance from therapy sites. Mentalizing imagery therapy (MIT) provides mindfulness and guided imagery tools to reduce stress, promote self and other understanding, and increase feelings of interconnectedness. Combining MIT with caregiver skills training might enable caregivers to both reduce stress and better utilize newly learned caregiving skills, but this has never been studied. Delivering MIT through a smartphone application (App) has the potential to overcome difficulties with scalability and dissemination and offers caregivers an easy-to-use format. Harnessing passive smartphone data provides an important opportunity to study behavioral changes continuously and with higher granularity than routine clinical assessments. This protocol describes a randomized, controlled, superiority trial in which 120 family dementia caregivers, aged 60 years or older, will be assigned to smartphone App delivery of caregiver skills with MIT (experimental condition) or without MIT (control condition). The primary objectives of the trial are to assess whether the experimental condition is superior to control on reducing family caregiver stress, insomnia and related outcomes and to demonstrate the feasibility of developing behavioral markers from passive smartphone data that predict health outcomes in older adults. Trial outcomes may inform the suitability of our intervention for caregivers and provide new methods for assessment of older adults.
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Affiliation(s)
- Felipe A Jain
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Olivia Okereke
- Harvard Medical School, Boston, MA, USA; Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Massachusetts Alzheimer's Disease Research Center, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Laura Gitlin
- College of Nursing and Health Professions, Drexel University, Philadelphia, PA, USA
| | - Paola Pedrelli
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Jukka-Pekka Onnela
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Maren Nyer
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Liliana A Ramirez Gomez
- Harvard Medical School, Boston, MA, USA; Massachusetts Alzheimer's Disease Research Center, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Multicultural Alzheimer's Prevention Program, Massachusetts General Hospital, Boston, MA, USA
| | - Michael Pittman
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Abu Sikder
- Innovation Studio, Children's Hospital, Los Angeles, CA, USA
| | - D J Ursal
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - David Mischoulon
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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Kraemer KM, Jain FA, Mehta DH, Fricchione GL. Meditative and Mindfulness-Focused Interventions in Neurology: Principles, Science, and Patient Selection. Semin Neurol 2022; 42:123-135. [PMID: 35139550 PMCID: PMC9177528 DOI: 10.1055/s-0042-1742287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
A growing body of research suggests that meditative- and mindfulness-focused interventions may improve neuropsychiatric symptoms that commonly occur in a range of neurological disorders. In this article, the principles of meditation and mindfulness are first defined, as well as briefly describing the neurobiological mechanisms implicated in these interventions. Thereafter, a range of meditative- and mindfulness-focused interventions are detailed, along with their supporting evidence to treat neuropsychiatric symptoms in neurological conditions (e.g., headache, movement disorders, chronic pain, etc.). Overall, these interventions warrant further investigation among individuals with neurological conditions. When recommending these interventions, health care professionals must consider a combination of structural (e.g., insurance reimbursement) and patient factors (e.g., ability to tolerate a group setting).
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Affiliation(s)
- Kristen M. Kraemer
- Division of General Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, CO-1309, 2nd Floor, Boston, MA 02215
| | - Felipe A. Jain
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, One Bowdoin Square, 6th Floor, Boston MA 02114
| | - Darshan H. Mehta
- Benson-Henry Institute for Mind Body Medicine, Massachusetts General Hospital, 151 Merrimac Street, 4th Floor, Boston, MA 02114
- Osher Center for Integrative Medicine, Brigham & Women’s Hospital, 900 Commonwealth Avenue East, 3rd Floor, Boston, MA 02215
| | - Gregory L. Fricchione
- Benson-Henry Institute for Mind Body Medicine, Massachusetts General Hospital, 151 Merrimac Street, 4th Floor, Boston, MA 02114
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Jain FA, Chernyak SV, Nickerson LD, Morgan S, Schafer R, Mischoulon D, Bernard-Negron R, Nyer M, Cusin C, Ramirez Gomez L, Yeung A. Four-Week Mentalizing Imagery Therapy for Family Dementia Caregivers: A Randomized Controlled Trial with Neural Circuit Changes. PSYCHOTHERAPY AND PSYCHOSOMATICS 2022; 91:180-189. [PMID: 35287133 PMCID: PMC9064903 DOI: 10.1159/000521950] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 01/03/2022] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Family caregivers of patients with dementia suffer a high burden of depression and reduced positive emotions. Mentalizing imagery therapy (MIT) provides mindfulness and guided imagery skills training to improve balanced mentalizing and emotion regulation. OBJECTIVE Our aims were to test the hypotheses that MIT for family caregivers would reduce depression symptoms and improve positive psychological traits more than a support group (SG), and would increase dorsolateral prefrontal cortex (DLPFC) connectivity and reduce subgenual anterior cingulate cortex (sgACC) connectivity. METHODS Forty-six caregivers participated in a randomized controlled trial comparing a 4-week MIT group (n = 24) versus an SG (n = 22). Resting state neuroimaging was obtained at baseline and post-group in 28 caregivers, and questionnaires completed by all participants. The primary outcome was change in depression; secondary measures included anxiety, mindfulness, self-compassion, and well-being. Brain networks with participation of DLPFC and sgACC were identified. Connectivity strengths of DLPFC and sgACC with respective networks were determined with dual regression. DLPFC connectivity was correlated with mindfulness and depression outcomes. RESULTS MIT significantly outperformed SG in improving depression, anxiety, mindfulness, self-compassion, and well-being, with moderate to large effect sizes. Relative to SG, participants in MIT showed significant increases in DLPFC connectivity - exactly replicating pilot study results - but no change in sgACC. DLPFC connectivity change correlated positively with mindfulness and negatively with depression change. CONCLUSIONS In this trial, MIT was superior to SG for reducing depression and anxiety symptoms and improving positive psychological traits. Neuroimaging results suggested that strengthening DLPFC connectivity with an emotion regulation network might be mechanistically related to MIT effects.
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Affiliation(s)
- Felipe A. Jain
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sergey V. Chernyak
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lisa D. Nickerson
- Applied Neuroimaging Statistics Laboratory, McLean Hospital, Harvard Medical School, Belmont, MA, USA
| | - Stefana Morgan
- Weill Institute for Neurosciences and Langley Porter Psychiatric Hospital and Clinics, University of California, San Francisco, CA, USA
| | - Rhiana Schafer
- Department of Neurology, Northwestern University, Chicago, IL, USA
| | - David Mischoulon
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard Bernard-Negron
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Maren Nyer
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Cristina Cusin
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Liliana Ramirez Gomez
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Albert Yeung
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Jain FA, Chernyak S, Nickerson L, Abrams M, Iacoboni M, Christov-Moore L, Connolly CG, Fisher LB, Sakurai H, Bentley K, Tan E, Pittman M, Lavretsky H, Leuchter AF. Mentalizing imagery therapy for depressed family dementia caregivers: Feasibility, clinical outcomes and brain connectivity changes. JOURNAL OF AFFECTIVE DISORDERS REPORTS 2021; 5. [PMID: 34498016 PMCID: PMC8423372 DOI: 10.1016/j.jadr.2021.100155] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Background Family dementia caregivers experience high rates of depression and anxiety that often go untreated due to time demands. We aimed to determine the feasibility of a brief, 4-week Mentalizing Imagery Therapy intervention, which couples mindfulness with guided imagery practices aimed at bolstering mentalizing capacity, to reduce caregiver psychological symptoms and to explore potential impact on dorsolateral prefrontal cortex connectivity. Methods Twenty-four family dementia caregivers with moderate depression symptoms (a score of 10 in Patient Health Questionnaire-9) were assigned to either group Mentalizing Imagery Therapy (MIT, n = 12) or a waitlist augmented by optional relaxation exercises (n = 12). Participants completed questionnaires to measure depression and anxiety at baseline and followup, and those eligible also underwent resting state functional magnetic resonance (fMRI) brain imaging at these time points. Results Eleven of 12 caregivers assigned to MIT completed the intervention and attended weekly groups 98% of the time. MIT home practice logs indicated average practice of 5 ± 2 sessions per week for 23 ± 8 min per session. All participants in waitlist completed the post-assessment. MIT participants exhibited significantly greater improvement than waitlist on self-reported depression and anxiety symptoms (p<.05) after 4 weeks. Neuroimaging results revealed increased dorsolateral prefrontal cortex connectivity with a putative emotion regulation network in the MIT group (p = .05) but not in waitlist (p = 1.0). Limitations Sample size limitations necessitate validation of findings in larger, randomized controlled trials. Conclusions A 4-week group MIT program was feasible for caregivers, with high levels of participation in weekly group meetings and home practice exercises.
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Affiliation(s)
- Felipe A Jain
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Sergey Chernyak
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Lisa Nickerson
- Applied Neuroimaging Statistics Laboratory, McLean Hospital, Harvard Medical School, Belmont, MA, United States
| | - Michelle Abrams
- Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, United States
| | - Marco Iacoboni
- Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, United States
| | - Leonardo Christov-Moore
- Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, United States
| | - Colm G Connolly
- Department of Biomedical Sciences, College of Medicine, Florida State University, Tallahassee, FL, United States
| | - Lauren B Fisher
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Hitoshi Sakurai
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Kate Bentley
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Emily Tan
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Michael Pittman
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Helen Lavretsky
- Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, United States
| | - Andrew F Leuchter
- Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, United States
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11
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Imperatori C, Corazza O, Panno A, Rinaldi R, Pasquini M, Farina B, Biondi M, Bersani FS. Mentalization Impairment Is Associated with Problematic Alcohol Use in a Sample of Young Adults: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17228664. [PMID: 33266367 PMCID: PMC7700465 DOI: 10.3390/ijerph17228664] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/18/2020] [Accepted: 11/20/2020] [Indexed: 12/13/2022]
Abstract
Background: Alcohol is one of the most widely used drugs among adolescents and young people, and problematic alcohol use (PAU) is related to significant long-term biological, clinical, and psychosocial sequelae. Although preliminary reports have linked deficits in mentalization to increased vulnerability to addiction, no studies have specifically explored this phenomenon in relation to PAU. Methods: The association between mentalization impairment and PAU severity was investigated in a sample of 271 young adults (183 females, 65.9%; mean age: 23.20 ± 3.55 years; range: 18–34). Self-report measures investigating PAU and mentalization were administered to all participants. Results: Individuals with PAU reported a more frequent use of tobacco and illicit drugs in the last 12 months. PAU severity was negatively associated with mentalization capacity (rho = −0.21; p < 0.001), and also, when possible, confounding variables (i.e., gender, age, occupation, education, tobacco and illegal drugs use) were controlled for (rho = −0.17; p = 0.004). Conclusion: The present data showed that mentalization impairment is significantly associated with PAU among young adults, suggesting that it may have a role in the development and/or maintenance of alcohol use.
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Affiliation(s)
- Claudio Imperatori
- Cognitive and Clinical Psychology Laboratory, Department of Human Science, European University of Rome, 00163 Rome, Italy; (C.I.); (A.P.); (B.F.)
| | - Ornella Corazza
- Department of Clinical, Pharmaceutical and Biological Sciences, University of Hertfordshire, Hatfield AL109AB, UK;
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, 04100 Latina, Italy
| | - Angelo Panno
- Cognitive and Clinical Psychology Laboratory, Department of Human Science, European University of Rome, 00163 Rome, Italy; (C.I.); (A.P.); (B.F.)
| | - Raffaella Rinaldi
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, 00185 Rome, Italy;
| | - Massimo Pasquini
- Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy; (M.P.); (M.B.)
| | - Benedetto Farina
- Cognitive and Clinical Psychology Laboratory, Department of Human Science, European University of Rome, 00163 Rome, Italy; (C.I.); (A.P.); (B.F.)
| | - Massimo Biondi
- Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy; (M.P.); (M.B.)
| | - Francesco Saverio Bersani
- Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy; (M.P.); (M.B.)
- Correspondence:
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12
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Kim JJ, Kent KM, Cunnington R, Gilbert P, Kirby JN. Attachment styles modulate neural markers of threat and imagery when engaging in self-criticism. Sci Rep 2020; 10:13776. [PMID: 32792601 PMCID: PMC7426808 DOI: 10.1038/s41598-020-70772-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/04/2020] [Indexed: 11/09/2022] Open
Abstract
Attachment styles hold important downstream consequences for mental health through their contribution to the emergence of self-criticism. To date, no work has extended our understanding of the influence of attachment styles on self-criticism at a neurobiological level. Herein we investigate the relationship between self-reported attachment styles and neural markers of self-criticism using fMRI. A correlation network analysis revealed lingual gyrus activation during self-criticism, a marker of visual mental imagery, correlated with amygdala activity (threat response). It also identified that secure attachment positively correlated with lingual gyrus activation, whilst avoidant attachment was negatively correlated with lingual gyrus activation. Further, at greater levels of amygdala response, more securely attached individuals showed greater lingual gyrus activation, and more avoidantly attached individuals showed less lingual gyrus activation. Our data provide the first evidence that attachment mechanisms may modulate threat responses and mental imagery when engaging in self-criticism, which have important clinical and broader social implications.
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Affiliation(s)
- Jeffrey J Kim
- Compassionate Mind Research Group, School of Psychology, The University of Queensland, Level 3 Building 24a, St Lucia, Brisbane, QLD, 4072, Australia. .,The Centre for Advanced Imaging, The University of Queensland, Brisbane, QLD, Australia.
| | - Kirsty M Kent
- Compassionate Mind Research Group, School of Psychology, The University of Queensland, Level 3 Building 24a, St Lucia, Brisbane, QLD, 4072, Australia
| | - Ross Cunnington
- Compassionate Mind Research Group, School of Psychology, The University of Queensland, Level 3 Building 24a, St Lucia, Brisbane, QLD, 4072, Australia
| | - Paul Gilbert
- Compassionate Mind Research Group, School of Psychology, The University of Queensland, Level 3 Building 24a, St Lucia, Brisbane, QLD, 4072, Australia.,School of Allied Health and Social Care, University of Derby, Derby, DE22 1GB, UK
| | - James N Kirby
- Compassionate Mind Research Group, School of Psychology, The University of Queensland, Level 3 Building 24a, St Lucia, Brisbane, QLD, 4072, Australia
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13
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Jain FA, Connolly CG, Moore LC, Leuchter AF, Abrams M, Ben-Yelles RW, Chang SE, Ramirez Gomez LA, Huey N, Lavretsky H, Iacoboni M. Grief, Mindfulness and Neural Predictors of Improvement in Family Dementia Caregivers. Front Hum Neurosci 2019; 13:155. [PMID: 31156412 PMCID: PMC6530345 DOI: 10.3389/fnhum.2019.00155] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 04/24/2019] [Indexed: 01/09/2023] Open
Abstract
Background: Family dementia caregivers often suffer from an immense toll of grief while caring for their loved ones. We sought to identify the clinical relationship between grief, depression and mindfulness and identify neural predictors of symptomatology and improvement. Methods: Twenty three family dementia caregivers were assessed at baseline for grief, mindfulness and depression, of which 17 underwent functional magnetic resonance imaging (fMRI). During fMRI, caregivers were shown faces of either their dementia-stricken relative or that of a stranger, paired with grief-related or neutral words. In nine subjects, post fMRI scans were also obtained after 4 weeks of either guided imagery or relaxation. Robust regression was used to predict changes in symptoms with longitudinal brain activation (BA) changes as the dependent variable. Results: Grief and depression symptoms were correlated (r = 0.50, p = 0.01), and both were negatively correlated with mindfulness (r = -0.70, p = 0.0002; r = -0.52, p = 0.01). Relative to viewing strangers, caregivers showed pictures of their loved ones (picture factor) exhibited increased activation in the dorsal anterior cingulate gyrus and precuneus. Improvement in grief but not mindfulness or depression was predicted by increased relative BA in the precuneus and anterior cingulate (different subregions from baseline). Viewing grief-related vs. neutral words elicited activity in the medial prefrontal cortex and precuneus. Conclusions: Caregiver grief, depression and mindfulness are interrelated but have at least partially nonoverlapping neural mechanisms. Picture and word stimuli related to caregiver grief evoked brain activity in regions previously identified with bereavement grief. These activation foci might be useful as biomarkers of treatment response.
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Affiliation(s)
- Felipe A. Jain
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Colm G. Connolly
- Department of Biomedical Sciences, College of Medicine, Florida State University, Tallahassee, FL, United States
| | - Leonardo C. Moore
- Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
- Institute for Simulation and Training, University of Central Florida, Orlando, FL, United States
| | - Andrew F. Leuchter
- Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Michelle Abrams
- Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Ramzi W. Ben-Yelles
- Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Sarah E. Chang
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA, United States
| | - Liliana A. Ramirez Gomez
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Nora Huey
- Department of Psychiatry, University of California, San Francisco, San Francisco, CA, United States
| | - Helen Lavretsky
- Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Marco Iacoboni
- Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
- Ahmanson-Lovelace Brain Mapping Center, Brain Research Institute, University of California, Los Angeles, Los Angeles, CA, United States
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Sikder AT, Yang FC, Schafer R, Dowling GA, Traeger L, Jain FA. Mentalizing Imagery Therapy Mobile App to Enhance the Mood of Family Dementia Caregivers: Feasibility and Limited Efficacy Testing. JMIR Aging 2019; 2:e12850. [PMID: 31518275 PMCID: PMC6715046 DOI: 10.2196/12850] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Revised: 12/26/2018] [Accepted: 12/27/2018] [Indexed: 01/19/2023] Open
Abstract
Background Family caregivers of patients with Alzheimer disease and related dementias (AD and ADRD) often experience high stress and are at high risk for depression. Technologically delivered therapy is attractive for AD and ADRD caregivers because of the time demands associated with in-person participation. Objective We aimed to study the feasibility and conduct limited efficacy testing of a mobile app intervention delivering mentalizing imagery therapy (MIT) for family caregivers. Methods A 4-week trial of the MIT app for family AD and ADRD caregivers was conducted to assess the feasibility of use and investigate changes in depression symptoms, mood, and caregiving experience. Semistructured interviews were conducted to characterize participants’ perceived feasibility and benefits. Results A total of 17 of the 21 (80%) consented participants (mean age 67 years, range 54-79) utilized the app at least once and were further analyzed. Average usage of audio recordings was on 14 (SD 10) days out of 28 possible and comprised 29 (SD 28) individual sessions. There were improvements in depression with a large effect size for those who used the app at least moderately (P=.008), increases in positive mood postintervention (P<.05), and acute increases in mood following daily guided imagery practice (Stretching and Breathing, P<.001; Eye in the Center, P<.001; Nesting Doll, P=.002; Situation Solver, P=.003; and Life Globe, P=.006). Semistructured interviews revealed perceived benefits such as greater ability to remain “centered” despite caregiving challenges and positive reframing of the caregiver experience. Conclusions App delivery of MIT is feasible for family AD and ADRD caregivers, including aging seniors. Results showed moderate to high usage of the app for a majority of users. Limited efficacy testing provides justification for studying the MIT app for AD and ADRD caregivers to improve mood and reduce depression in larger, controlled trials.
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Affiliation(s)
| | | | - Rhiana Schafer
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Evanston, IL, United States
| | - Glenna A Dowling
- Department of Physiological Nursing, University of California, San Francisco, San Francisco, CA, United States
| | - Lara Traeger
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Felipe Ananda Jain
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
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