A parallel-group, randomized controlled trial into the effectiveness of Mindfulness-Based Compassionate Living (MBCL) compared to treatment-as-usual in recurrent depression: Trial design and protocol

Interplay between self-compassion and affect during Mindfulness-Based Compassionate Living for recurrent depression: An Autoregressive Latent Trajectory analysis

BACKGROUND

The current study aimed to investigate the possible interplay between self-compassion and affect during Mindfulness-Based Compassionate Living (MBCL) in recurrently depressed individuals.

METHODS

Data was used from a subsample of a parallel-group randomized controlled trial investigating the efficacy of MBCL in recurrently depressed adults (n = 104). Self-reports of self-compassion and positive/negative affect were obtained at the start of each of the eight MBCL sessions.

RESULTS

Bivariate Autoregressive Latent Trajectory (ALT) modeling showed that, when looking at the interplay between self-compassion and positive/negative affect on a session-to-session basis, no significant reciprocal cross-lagged effects between self-compassion and positive affect were found. Although there were no cross-lagged effects from negative affect to self-compassion, higher levels of self-compassion at each session did predict lower levels of negative affect at the subsequent session (b_{SC(t-1),NA(t)} = -0.182, s.e. = 0.076, p = .017).

CONCLUSIONS

The current study shows that increases in self-compassion are followed by decreases in negative affect in MBCL for depression.

Recovery from recurrent depression: Randomized controlled trial of the efficacy of mindfulness-based compassionate living compared with treatment-as-usual on depressive symptoms and its consolidation at longer term follow-up

INTRODUCTION

Mindfulness-Based Cognitive Therapy (MBCT) has been shown to reduce depressive symptoms in patients with recurrent or chronic depression. However, sequential, follow-up interventions are needed to further improve outcome for this group of patients. One possibility is to cultivate mechanisms thought to support recovery from depression, such as (self-)compassion. The current study examined the efficacy of mindfulness-based compassionate living (MBCL) in recurrently depressed patients who previously received MBCT, and consolidation effects of MBCL at follow-up.

METHODS

Part one is a randomized controlled trial (RCT) comparing MBCL in addition to treatment as usual (TAU) with TAU alone. The primary outcome measure was severity of depressive symptoms. Possible mediators and moderators of treatment outcome were examined. Part two is an uncontrolled study of both intervention- and control group on the consolidation of treatment effect of MBCL over the course of a 6-months follow-up period.

RESULTS

Patients were recruited between July 2013 and December 2014 (N = 122). MBCL participants (n = 61) showed significant improvements in depressive symptoms (Cohen's d = 0.35), compared to those who only received TAU (n = 61). The results at 6-months follow-up showed a continued improvement of depressive symptoms.

LIMITATIONS

As MBCL was not compared with an active control condition, we have little information about the possible effectiveness of non-specific factors.

CONCLUSION

MBCL appears to be effective in reducing depressive symptoms in a population suffering from severe, prolonged, recurrent depressive symptoms. To optimise the (sequential) treatment trajectory, replication of the study in a prospective sequential trial is needed. Registered at ClinicalTrials.gov:NCT02059200.

The Role of Compassion and Mindfulness in Building Parental Resilience When Caring for Children With Chronic Conditions: A Conceptual Model

Compassion- and mindfulness-based interventions (CMBIs) and therapies hold promise to support parent resilience by enabling adaptive stress appraisal and coping, mindful parenting, and perhaps crucially, self-compassion. These contemplative modalities have recently been expanded to parents of children with chronic illness, building on successful applications for adults facing stress, chronic pain, or mental illness, and for healthcare professionals in response to caregiver burnout resulting from their work. The design and adaptation of interventions and therapies require a conceptual model of parent resilience in the context of childhood chronic illness that integrates mindfulness and compassion. The objective of this paper is to propose and describe such a model. First, we review the need for parent support interventions for this population. Second, we introduce a Model of Compassion, Mindfulness, and Resilience in Parental Caregiving. We highlight the mindful parenting approaches, guiding theories for adaptive coping, and family resilience frameworks that informed our model. Third, we describe a case of a parent to illustrate a practical application model. Finally, we outline future directions for intervention development and research to examine the impact of CMBIs on parent resilience.

Psychological therapies for treatment-resistant depression in adults

BACKGROUND

Antidepressants are a first-line treatment for adults with moderate to severe major depression. However, many people prescribed antidepressants for depression don't respond fully to such medication, and little evidence is available to inform the most appropriate 'next step' treatment for such patients, who may be referred to as having treatment-resistant depression (TRD). National Institute for Health and Care Excellence (NICE) guidance suggests that the 'next step' for those who do not respond to antidepressants may include a change in the dose or type of antidepressant medication, the addition of another medication, or the start of psychotherapy. Different types of psychotherapies may be used for TRD; evidence on these treatments is available but has not been collated to date.Along with the sister review of pharmacological therapies for TRD, this review summarises available evidence for the effectiveness of psychotherapies for adults (18 to 74 years) with TRD with the goal of establishing the best 'next step' for this group.

OBJECTIVES

To assess the effectiveness of psychotherapies for adults with TRD.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (until May 2016), along with CENTRAL, MEDLINE, Embase, and PsycINFO via OVID (until 16 May 2017). We also searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov to identify unpublished and ongoing studies. There were no date or language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with participants aged 18 to 74 years diagnosed with unipolar depression that had not responded to minimum four weeks of antidepressant treatment at a recommended dose. We excluded studies of drug intolerance. Acceptable diagnoses of unipolar depression were based onthe Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) or earlier versions, International Classification of Diseases (ICD)-10, Feighner criteria, or Research Diagnostic Criteria. We included the following comparisons.1. Any psychological therapy versus antidepressant treatment alone, or another psychological therapy.2. Any psychological therapy given in addition to antidepressant medication versus antidepressant treatment alone, or a psychological therapy alone.Primary outcomes required were change in depressive symptoms and number of dropouts from study or treatment (as a measure of acceptability).

DATA COLLECTION AND ANALYSIS

We extracted data, assessed risk of bias in duplicate, and resolved disagreements through discussion or consultation with a third person. We conducted random-effects meta-analyses when appropriate. We summarised continuous outcomes using mean differences (MDs) or standardised mean differences (SMDs), and dichotomous outcomes using risk ratios (RRs).

MAIN RESULTS

We included six trials (n = 698; most participants were women approximately 40 years of age). All studies evaluated psychotherapy plus usual care (with antidepressants) versus usual care (with antidepressants). Three studies addressed the addition of cognitive-behavioural therapy (CBT) to usual care (n = 522), and one each evaluated intensive short-term dynamic psychotherapy (ISTDP) (n = 60), interpersonal therapy (IPT) (n = 34), or group dialectical behavioural therapy (DBT) (n = 19) as the intervention. Most studies were small (except one trial of CBT was large), and all studies were at high risk of detection bias for the main outcome of self-reported depressive symptoms.A random-effects meta-analysis of five trials (n = 575) showed that psychotherapy given in addition to usual care (vs usual care alone) produced improvement in self-reported depressive symptoms (MD -4.07 points, 95% confidence interval (CI) -7.07 to -1.07 on the Beck Depression Inventory (BDI) scale) over the short term (up to six months). Effects were similar when data from all six studies were combined for self-reported depressive symptoms (SMD -0.40, 95% CI -0.65 to -0.14; n = 635). The quality of this evidence was moderate. Similar moderate-quality evidence of benefit was seen on the Patient Health Questionnaire-9 Scale (PHQ-9) from two studies (MD -4.66, 95% CI 8.72 to -0.59; n = 482) and on the Hamilton Depression Rating Scale (HAMD) from four studies (MD -3.28, 95% CI -5.71 to -0.85; n = 193).High-quality evidence shows no differential dropout (a measure of acceptability) between intervention and comparator groups over the short term (RR 0.85, 95% CI 0.58 to 1.24; six studies; n = 698).Moderate-quality evidence for remission from six studies (RR 1.92, 95% CI 1.46 to 2.52; n = 635) and low-quality evidence for response from four studies (RR 1.80, 95% CI 1.2 to 2.7; n = 556) indicate that psychotherapy was beneficial as an adjunct to usual care over the short term.With the addition of CBT, low-quality evidence suggests lower depression scores on the BDI scale over the medium term (12 months) (RR -3.40, 95% CI -7.21 to 0.40; two studies; n = 475) and over the long term (46 months) (RR -1.90, 95% CI -3.22 to -0.58; one study; n = 248). Moderate-quality evidence for adjunctive CBT suggests no difference in acceptability (dropout) over the medium term (RR 0.98, 95% CI 0.66 to 1.47; two studies; n = 549) and lower dropout over long term (RR 0.80, 95% CI 0.66 to 0.97; one study; n = 248).Two studies reported serious adverse events (one suicide, two hospitalisations, and two exacerbations of depression) in 4.2% of the total sample, which occurred only in the usual care group (no events in the intervention group).An economic analysis (conducted as part of an included study) from the UK healthcare perspective (National Health Service (NHS)) revealed that adjunctive CBT was cost-effective over nearly four years.

AUTHORS' CONCLUSIONS

Moderate-quality evidence shows that psychotherapy added to usual care (with antidepressants) is beneficial for depressive symptoms and for response and remission rates over the short term for patients with TRD. Medium- and long-term effects seem similarly beneficial, although most evidence was derived from a single large trial. Psychotherapy added to usual care seems as acceptable as usual care alone.Further evidence is needed on the effectiveness of different types of psychotherapies for patients with TRD. No evidence currently shows whether switching to a psychotherapy is more beneficial for this patient group than continuing an antidepressant medication regimen. Addressing this evidence gap is an important goal for researchers.

The relationship between self-compassion and the risk for substance use disorder

OBJECTIVE

This study explored the relationship between substance use disorder risk and self-compassion and posits a model for how the two are related through the mitigation of suffering.

METHOD

Study participants were recruited using social media to complete an online survey that included a basic socio-demographic survey and two validated instruments, the Self-Compassion Survey and the National Institute on Drug Abuse (NIDA) Alcohol Smoking and Substance Involvement Screening Test (ASSIST), which screens for substance use disorder (SUD) risk. Established cut scores for ASSIST were used to divide participants into low, moderate and high-risk groups.

RESULTS

Participants (n=477) were 31 years old on average, almost evenly split by gender, mostly non-Hispanic white, slightly more likely to be single and to hold an Associate's degree or higher. Overall, 89% of participants reported using drugs and/or alcohol in their lifetime. SUD risk was distributed between low risk (52%), moderate risk (37%) and a smaller percentage of high risk (11%). Self-compassion was inversely related to SUD risk. The low risk group had a higher mean self-compassion score (M=2.86, SD=0.75) than the people who were high risk (M=2.25, SD=0.61) (t(298)=5.58 p<0.0001). Bivariate Pearson correlations showed strong associations between high risk and all self-compassion subscales, as well as low risk and five of the subscales.

CONCLUSIONS

This study suggests SUD risk has an inverse relationship to self-compassion. Raising self-compassion may be a useful addition to substance use disorder prevention and treatment interventions.

Working on self-compassion online: A proof of concept and feasibility study

OBJECTIVES

Low self-compassion has repeatedly been associated with psychopathology. There are many promising face-to-face group format interventions focusing on self-compassion. We investigated the feasibility of an online self-compassion program.

DESIGN

A feasibility and proof-of-concept study of an online adapted Mindfulness-based Compassionate Living (MBCL) program.

PARTICIPANTS

Self-referred participants suffering from harsh self-criticism (N = 39) were offered an online program and were asked to complete outcome measures at baseline, after 8 weeks (post-intervention) and after 14 weeks (follow-up).

INTERVENTION

The online program consisted of seven sessions, including a first session introducing mindfulness and mindfulness meditation followed by a six-session adaptation of the MBCL program.

PRIMARY AND SECONDARY OUTCOME MEASURES

The Self-Compassion Scale (SCS) was the primary outcome measure. Secondary outcome measures were the Forms of Self-criticizing/Attacking and Self-reassuring Scale (FSCRS), the Satisfaction with Life Scale (SWLS), the Comprehensive Inventory of Mindfulness Experience (CHIME), the Fear of Self-compassion (FSC), and the Perceived Stress Questionnaire (PSQ). Additionally, we assessed satisfaction with the program and negative effects related to the program. Furthermore, we used several measures of program usage (number of processed modules, number of logins, time spent in the program, number of diary entries, number of entries in completed exercises).

RESULTS

Self-compassion, mindfulness, reassuring-self and satisfaction with life significantly increased whereas inadequate self, hated self, perceived stress and fear of self-compassion significantly decreased from pre- to the 8-week assessment. Results remained stable from post- to the 6-week follow-up. Pre-to-post within-effect sizes were medium to large (ds = 0.50-1.50) and comparable to those found within a face-to-face group format in a similar sample. Time spent in the program significantly predicted self-compassion at post.

CONCLUSIONS

The results of this pilot study are promising. However, they must be seen as preliminary since replication in a randomized controlled trial, with clinical measures/diagnoses and a longer follow-up period, is necessary.