Addressing psychosomatic symptom distress with mindfulness-based cognitive therapy in somatic symptom disorder: mediating effects of self-compassion and alexithymia

Objective

This study explored the association between self-compassion, alexithymia, and psychosomatic symptom distress in a clinical sample of somatic symptom disorder (SSD) patients participating in a mindfulness-based cognitive therapy (MBCT) program.

Methods

One hundred sixteen SSD patients who had participated in an MBCT program and completed ≥4 intervention sessions were included in a retrospective study (76.7% women, mean age = 40.0, SD = 9.5). Psychometric measures of psychosomatic symptom distress [Brief Symptom Inventory-18 Global Severity Index (BSI-GSI)], self-compassion [Self-Compassion Scale (SCS)], and alexithymia [Toronto Alexithymia Scale (TAS)] were collected upon admission to the MBCT program and at 6-month follow-up following treatment inclusion.

Results

Serial mediation analysis (MBCT→ΔSCS→ΔTAS→ΔBSI-GSI) suggested that changes in both self-compassion and alexithymia had significant indirect effects on improvement in psychosomatic distress [ΔSCS β = -1.810, 95% bootstrap CI (-2.488, -1.160); ΔTAS β = -1.615, bootstrap 95% CI (-2.413, -0.896); ΔSCS→ΔTAS β = -0.621, bootstrap CI (-1.032, -0.315)]. Furthermore, a post-hoc analysis with a reverse sequence (MBCT→ΔTAS→ΔSCS→ΔBSI-GSI) revealed that reduction in alexithymia improved psychosomatic distress and that an increase in self-compassion was a subsequent outcome of alleviation of alexithymia [ΔTAS β = -2.235, bootstrap 95% CI (-3.305, -1.270); ΔSCS β = 0.013, 95% bootstrap CI (-0.600, 0.682); ΔTAS→ΔSCS β = -1.823, bootstrap CI (-2.770, -1.047)].

Conclusion

Both alleviation of alexithymia and improvement in self-compassion play a mediating role in the reduction of psychosomatic distress in SSD patients following an MBCT program. Improvement in self-compassion might be a subsequent outcome of MBCT-related alleviation of alexithymia.

Differentiating mindfulness-integrated cognitive behavior therapy and mindfulness-based cognitive therapy clinically: the why, how, and what of evidence-based practice

It is important to be able to differentiate mindfulness-based programs in terms of their model, therapeutic elements, and supporting evidence. This article compares mindfulness-based cognitive therapy (MBCT), developed for relapse prevention in depression, and mindfulness-integrated cognitive behavior therapy (MiCBT), developed for transdiagnostic applications, on: (1) origins, context and theoretical rationale (why), (2) program structure, practice and, professional training (how), and (3) evidence (what). While both approaches incorporate behavior change methods, MBCT encourages behavioral activation, whereas MiCBT includes various exposure procedures to reduce avoidance, including a protocol to practice equanimity during problematic interpersonal interactions, and a compassion training to prevent relapse. MBCT has a substantial research base, including multiple systematic reviews and meta-analyses. It is an endorsed preventative treatment for depressive relapse in several clinical guidelines, but its single disorder approach might be regarded as a limitation in many health service settings. MiCBT has a promising evidence base and potential to make a valuable contribution to psychological treatment through its transdiagnostic applicability but has not yet been considered in clinical guidelines. While greater attention to later stage dissemination and implementation research is recommended for MBCT, more high quality RCTs and systematic reviews are needed to develop the evidence base for MiCBT.

Mindfulness-based cognitive therapy v. treatment as usual in people with bipolar disorder: A multicentre, randomised controlled trial

Background

Mindfulness-based cognitive therapy (MBCT) seems a promising intervention for bipolar disorder (BD), but there is a lack of randomised controlled trials (RCT) investigating this. The purpose of this multicentre, evaluator blinded RCT was to investigate the added value of MBCT to treatment as usual (TAU) in BD up to 15 months follow-up (NCT03507647).

Methods

A total of 144 participants with BD type I and II were randomised to MBCT + TAU (n = 72) and TAU (n = 72). Primary outcome was current depressive symptoms. Secondary outcomes were current (hypo)manic and anxiety symptoms, recurrence rates, rumination, dampening of positive affect, functional impairment, mindfulness skills, self-compassion, and positive mental health. Potential moderators of treatment outcome were examined.

Results

MBCT + TAU was not more efficacious than TAU in reducing current depressive symptoms at post-treatment (95% CI [−7.0 to 1.8], p = 0.303, d = 0.24) or follow-up (95% CI [−2.2 to 6.3], p = 0.037, d = 0.13). At post-treatment, MBCT + TAU was more effective than TAU in improving mindfulness skills. At follow-up, TAU was more effective than MBCT + TAU in reducing trait anxiety and improving mindfulness skills and positive mental health. Exploratory analysis revealed that participants with higher depressive symptoms and functional impairment at baseline benefitted more from MBCT + TAU than TAU.

Conclusions

In these participants with highly recurrent BD, MBCT may be a treatment option in addition to TAU for those who suffer from moderate to severe levels of depression and functional impairment.

Trial registration

ClinicalTrials.gov, NCT03507647. Registered the 25 April 2018, https://www.clinicaltrials.gov/ct2/show/NCT01126827 .

Effects of Mindfulness-Based Cognitive Therapy on Major Depressive Disorder with Multiple Episodes: A Systematic Review and Meta-Analysis

This study synthesizes the effect of mindfulness-based cognitive therapy (MBCT) on depression and suicidal ideation among patients with major depressive disorder (MDD). During treatment, patients with MDD may experience repeated episodes, negative counseling, and suicidal ideation, which can lead to further depression and ultimately affect quality of life. Recent studies have shown that MBCT can improve the level of depression and suicidal ideation in patients with MDD. A systematic review and meta-analysis of randomized controlled trials was conducted. The literature search for articles up to December 2021 was performed in the following electronic databases: Airiti Library, PsycINFO, CINAHL, Cochrane Library, PubMed/MEDLINE, ProQuest, and the Index of the Taiwan Periodical Literature System. Records were independently evaluated by two reviewers. Disagreements were resolved through consensus. The quality of study was evaluated using the Modified Jadad Scale score. A meta-analysis was performed using Review Manager Version 5.3.5 software with a random-effects model. Thirteen studies (1159 participants) investigating MBCT for patients with MDD were included. The MBCT sessions lasted 1.5-2.5 h and were delivered by therapists five times per week for 8 weeks. The meta-effects of MBCT among patients with MDD showed significant improvement in depression and suicidal ideation. Future research should evaluate the long-term effects of MBCT. MBCT is relatively convenient and effective for preventing and alleviating depression and suicidal ideation. Further research can provide detailed suggestions for effective MBCT implementation.

Preventing Depression Relapse: A Qualitative Study on the Need for Additional Structured Support Following Mindfulness-Based Cognitive Therapy

Background

Mindfulness-based cognitive therapy (MBCT) is an effective group intervention for reducing rates of depression relapse. However, about one-third of graduates experience relapse within 1 year of completing the course.

Objective

The current study aimed to explore the need and strategies for additional support following the MBCT course.

Methods

We conducted 4 focus groups via videoconferencing, two with MBCT graduates (n = 9 in each group) and two with MBCT teachers (n = 9; n = 7). We explored participants' perceived need for and interest in MBCT programming beyond the core program and ways to optimize the long-term benefits of MBCT. We conducted thematic content analysis to identify patterns in transcribed focus group sessions. Through an iterative process, multiple researchers developed a codebook, independently coded the transcripts, and derived themes.

Results

Participants said the MBCT course is highly valued and was, for some, "life changing." Participants also described challenges with maintaining MBCT practices and sustaining benefits after the course despite using a range of approaches (ie, community and alumni-based meditation groups, mobile applications, taking the MBCT course a second time) to maintain mindfulness and meditative practice. One participant described finishing the MBCT course as feeling like "falling off a cliff." Both MBCT graduates and teachers were enthusiastic about the prospect of additional support following MBCT in the form of a maintenance program.

Conclusion

Some MBCT graduates experienced difficulty maintaining practice of the skills they learned in the course. This is not surprising given that maintained behavior change is challenging and difficulty sustaining mindfulness practice after a mindfulness-based intervention is not specific to MBCT. Participants shared that additional support following the MBCT program is desired. Therefore, creating an MBCT maintenance program may help MBCT graduates maintain practice and sustain benefits longer-term, thereby decreasing risk for depression relapse.

The development and internal evaluation of a predictive model to identify for whom Mindfulness-Based Cognitive Therapy (MBCT) offers superior relapse prevention for recurrent depression versus maintenance antidepressant medication

Depression is highly recurrent, even following successful pharmacological and/or psychological intervention. We aimed to develop clinical prediction models to inform adults with recurrent depression choosing between antidepressant medication (ADM) maintenance or switching to Mindfulness-Based Cognitive Therapy (MBCT). Using data from the PREVENT trial (N=424), we constructed prognostic models using elastic net regression that combined demographic, clinical and psychological factors to predict relapse at 24 months under ADM or MBCT. Only the ADM model (discrimination performance: AUC=.68) predicted relapse better than baseline depression severity (AUC=.54; one-tailed DeLong's test: z=2.8, p=.003). Individuals with the poorest ADM prognoses who switched to MBCT had better outcomes compared to those who maintained ADM (48% vs. 70% relapse, respectively; superior survival times [z=-2.7, p=.008]). For individuals with moderate-to-good ADM prognosis, both treatments resulted in similar likelihood of relapse. If replicated, the results suggest that predictive modeling can inform clinical decision-making around relapse prevention in recurrent depression.

Brief adjunctive mindfulness-based cognitive therapy via Telehealth for anxiety during the COVID-19 pandemic

BACKGROUND AND OBJECTIVES

While cognitive-behavioral therapy is a highly efficacious treatment for anxiety, additional research is needed to identify adjunctive interventions that may augment treatment outcome.

DESIGN

In response to the COVID-19 pandemic, we conducted an open feasibility trial of brief (i.e., four 75- to 90-minute sessions) mindfulness-based cognitive therapy (MBCT) for anxiety via telehealth for patients (N = 23) receiving individual CBT at an outpatient specialty clinic.

METHODS

Self-report measures of home practice compliance (weekly), intervention acceptability (post-intervention), mindfulness and self-compassion, anxiety and depressive symptoms, and transdiagnostic processes (pre- and post-intervention) were administered as part of routine clinical practice.

RESULTS

Results indicated good retention and attendance rates, few technical difficulties, good home practice compliance, and high levels of perceived importance. Participants indicated that they would highly recommend the group to others and also recommended extending the group beyond four sessions. There were significant improvements in mindfulness and self-compassion and reductions in intolerance of uncertainty, anxiety sensitivity, distress intolerance, emotion dysregulation, and anxiety symptoms from pre- to post-intervention.

CONCLUSIONS

Brief MBCT as an adjunctive treatment for anxiety via telehealth is feasible and acceptable, and shows promise in terms of engaging treatment targets and transdiagnostic processes and reducing anxiety symptoms.

Intervention Fidelity in Mindfulness-Based Research and Practice: Developing Criteria to Acknowledge New Training Programs

The field of mindfulness-based research and practice is expanding fast. This development calls for a careful evaluation of the merits and scientific underpinnings of newly developed mindfulness-based programs (MBP's). In this viewpoint, we describe a process initiated by two professional mindfulness teacher training organisations (the Dutch Vereniging Mindfulness-based Trainers Nederland, VMBN, and the British Association of Mindfulness-based Approaches, BAMBA) to develop a framework for evaluating the integrity of newly developed MBP's. The framework aims to articulate criteria describing the elements and processes required to ensure that a new MBP meets good practice, adheres to evidenced-based practice, and is attending to the challenge of implementation and scalability. The development and implementation of the criteria are still a 'work in progress'. We hope that this initiative offers a foundation for supporting the MBP field to balance innovation and grassroot community development with aligning to the principles of evidence-based practice.

Effects of mindfulness-based interventions on fatigue and psychological wellbeing in women with cancer: A systematic review and meta-analysis of randomised control trials

BACKGROUND

Cancer diagnosis and treatment can cause fatigue, stress and anxiety which can have a detrimental effect on patients, families and the wider community. Mindfulness-based interventions appear to have positive effects on managing these cancer-related symptoms.

OBJECTIVE

To investigate the efficacy of mindfulness on cancer related fatigue (CRF) and psychological well-being in female cancer patients.

METHODS

Five databases (CINHAL, Ovid Medline, Ovid Psych Info, Scopus, and Cochrane), and two trial registers (WHO and Clinicaltrials.gov) were searched for randomised control trials from inception to April 2021 and updated in August 2022. Meta-analysis was performed using Review Manager 5.4. The standardised mean difference (SMD) and 95% confidence intervals (CI) were used to determine the intervention effect. Subgroup analysis was performed for adaptation to types of mindfulness, length of intervention and types of comparator used.

RESULTS

Twenty-one studies with a total of 2326 participants were identified. Mindfulness significantly improved CRF (SMD -0.81, 95% CI -1.17 to -0.44), depression (SMD-0.74, 95% CI -1.08 to -0.39) and anxiety (SMD -0.92, 95% CI -1.50 to -0.33). No effect was observed for quality of life (SMD 0.32, 95% CI -0.13-0.87) and sleep (SMD -0.65, 95% CI -1.34-0.04). Subgroup analysis revealed that there was little difference in SMD for adapted type of mindfulness (p = 0.42), wait list control compared to active comparator (p = 0.05) or length of intervention (p = 0.29).

CONCLUSION

Mindfulness appears to be effective in reducing CRF and other cancer related symptoms in women. Adaptations to mindfulness delivery did not have negative impact on results which may aid delivery in the clinical settings.

A mindfulness-based cognitive therapy informed virtual psychiatry trainee wellbeing programme: Development and preliminary feedback

OBJECTIVE

To report the development and feedback on a newly created mindfulness-based cognitive therapy (MBCT) informed virtual wellbeing programme for psychiatry trainees.

METHODS

Thirteen of the 14 trainees participated in the programme provided feedback via an online questionnaire. Qualitative data was analysed using thematic analysis.

RESULTS

Thematic analysis revealed three main themes: timing of the intervention in relation to the COVID-19 pandemic; trainees were connected to the facilitator, their peers and within oneself; and trainees were going through a transformative experience.

DISCUSSION

Our findings support including an optional MBCT informed wellbeing programme in psychiatry training programmes. Future research could measure efficacy of this online programme by utilising pre- and post-outcome measures of dispositional mindfulness and stress.

Self-compassion and related factors in severe mental illness: A scoping review

PURPOSE

To clarify what is known and identify research gaps on the role of self-compassion (SC) and potential interventions for individuals with severe mental illness (SMI).

DESIGN AND METHODS

We analyzed 24 studies of SC in schizophrenia spectrum disorder, bipolar disorder (BD), and major depressive disorder (MDD).

FINDINGS

Mindfulness-based cognitive therapy (MBCT) was the most common intervention. Predicting depression by SC was common in MDD and BD; however, relationships between demographics/clinical variables and SC in BD and schizophrenia spectrum disorder remain unclear.

PRACTICE IMPLICATIONS

MBCT increases SC in SMI. Data regarding predictors of SC are limited, especially in schizophrenia.

Effectiveness and Cost-effectiveness of Online Brief Mindfulness-based Cognitive Therapy for the Improvement of Productivity in the Workplace: Study Protocol for a Randomized Controlled Trial

Background

Numerous studies have demonstrated the effectiveness of mindfulness-based programs (MBPs) among both clinical and nonclinical populations. These data document positive impacts in the workplace, including reducing perceived stress and burnout and increasing well-being. However, the effectiveness for productivity, which is of most interest to managers and administrators, is still unclear. In addition, MBPs in the workplace tend to be modified by reducing the number of the program sessions or delivering content online to improve accessibility. To date, however, the impact of MBPs that feature these modifications on productivity in the workplace has not been investigated.

Objective

The study aims to investigate the effectiveness and cost-effectiveness of online-delivered brief mindfulness-based cognitive therapy (bMBCT) for improving productivity and other work-related outcomes among healthy workers compared to the waitlist control.

Methods

We will conduct a 4-week randomized controlled trial (RCT) with a 6-month follow-up. Employees are included in the study if they (1) are between the ages of 20 and 65 years and (2) work longer than 30 hours weekly. Employees are randomly allocated to either the bMBCT group or the waitlist control group. The primary outcome of the study is the mean difference of productivity measured by the World Health Organization Health and Work Performance Questionnaire (WHO-HPQ) between the groups at 4, 16, and 28 weeks. Secondary outcomes include several clinical outcomes and health economics evaluation.

Results

We started recruiting participants in August 2021, and the intervention began in October 2021. A total of 104 participants have been enrolled in the study as of October 2021. The intervention is scheduled to be completed in December 2023. Data collection will be completed by the end of January 2024.

Conclusions

The novelty of the study is that (1) it will investigate bMBCT’s effectiveness on productivity, which is still unclear, and (2) samples are recruited from 3 companies in different industries. The limitations of the study are that (1) all measures assessed are in self-report format and (2) we lack an active control group. This study has the potential to provide new data on the relationship between MBPs and occupational health and productivity.

Trial Registration

University Hospital Medical Information Network Clinical Trials Registry UMIN000044721; https://tinyurl.com/4e2fh873

International Registered Report Identifier (IRRID)

DERR1-10.2196/36012

An ongoing process of reconnection: A qualitative exploration of mindfulness-based cognitive therapy for adults in remission from depression

OBJECTIVES

Mindfulness-based cognitive therapy (MBCT) is an 8-week relapse-prevention intervention designed for people who have experienced multiple episodes of depression and remain vulnerable to relapse. Previous qualitative explorations of the effects of MBCT for people in remission from depression have suggested a number of themes regarding changes arising from participating in MBCT ranging from awareness, agency, perspective, group processes, self-related change, and new ways of understanding depression. We aimed to qualitatively explore how participants in remission from depression experienced MBCT both post-MBCT and during a follow-up period.

METHODS

In a preference-choice trial design, 35 participants took part in qualitative interviews and assessments post-MBCT and at three time points during a 12-month follow-up. Data were analysed using reflexive thematic analysis.

RESULTS

Two overarching themes were developed as follows: (1) 'reconnection with experience, self, and others' and (2) 'acknowledging an ongoing process of change'. In theme one, sub-themes captured participants' experiences of increasing levels of awareness of their experience (e.g., thoughts, emotions, sensations, and present moment) from which they described changes in their relationship with experience describing increases in control, choice, acceptance, and calm. Participants described shifts towards reconnection with aspects of the self and relationships with others. In theme two, sub-themes reflected participants' conflict between avoidance and engagement in mindfulness practices, and the recognition of the gradual change following MBCT and long-term investment needed in mindfulness practices.

CONCLUSIONS

Our findings have clinical implications in terms of facilitating MBCT and point to important themes around recognizing the ongoing process of reconnection with experiences, self, and others.

PRACTITIONER POINTS

Participants with histories of depression may have experienced disconnection and isolation from internal experiences (e.g., thoughts and emotions), self, and others; MBCT encourages a deliberate shift towards reconnection with these experiences. Practitioners could encourage more psychoeducation and discussions around depression during MBCT to encourage reflections on the process of reconnection. Practitioners should maintain an awareness of the ongoing, gradual processes of change and potential for conflict experienced during MBCT Practitioners could provide a stronger emphasis on building awareness of body sensations during MBCT, with suggestions provided in the discussion section.

Mindfulness-Based Interventions and Body Awareness

Body awareness (BA) has long been proposed as a working mechanism of mindfulness-based interventions (MBIs), yet research on the mediating role of BA is scarce. Hence, the present study assesses the impact of an 8-week MBI on self-reported and indirect measures of BA, investigates the potential mediating role of BA in the relationship between an MBI and symptomatology, evaluates the impact of an MBI on important psychological processes (i.e., experiential avoidance, rumination, self-efficacy, and self-discrepancy), and explores whether these variables act alongside BA in mediating the relationship between an MBI and symptomatology. A non-randomized controlled trial was conducted with 148 participants (n = 89 in the MBI group; n = 59 in the control group) who completed questionnaires assessing BA and the above-mentioned psychological processes before and after an MBI. A sub-sample of participants (n = 86) completed a task that evaluates BA indirectly. Results showed a significant effect of MBI on the self-reported BA but not on the indirect measure of BA. The MBI significantly reduced symptomatology, and this effect was mediated by regulatory and belief-related dimensions of BA. Multiple mediator models showed a significant mediation via various pathways involving improved BA and various transdiagnostic psychological processes.

A systematic review and meta-ethnographic synthesis of Mindfulness-based Cognitive Therapy for people with major depression

BACKGROUND

Mindfulness-based Cognitive Therapy (MBCT) is a relapse-prevention intervention for people experiencing major depression. Three qualitative meta-syntheses investigating experiences of taking part in MBCT and/or Mindfulness-based Stress Reduction (MBSR) across different diagnostic populations reported themes including control, choice, group processes, relationships and struggles. As multiple studies have been published since, we aimed to update, systematically review and synthesize the experiences of participants with depression taking part in MBCT.

METHODS

Four databases were searched systematically (PsycInfo, Web of Science, Medline and CINAHL) up to and including 12 November 2021. Twenty-one qualitative studies met the review criteria. All papers were rated as fair using a quality appraisal tool. Meta-ethnography was applied.

RESULTS

Across 21 studies of participants with current or previous depression who had participated in MBCT, three overarching themes were developed: 'Becoming skilled and taking action', 'Acceptance' and 'Ambivalence and Variability'. Participants became skilled through engagement in mindfulness practices, reporting increased awareness, perspective and agency over their experiences. Participants developed acceptance towards their experiences, self and others. There was variability and ambivalence regarding participants' expectations and difficulties within mindfulness practices.

LIMITATIONS

Many studies were conducted in MBCT-research centres that may hold conflicts of interest. Many studies did not address the impact of the participant-researcher relationship thus potentially affecting their interpretations. Studies were skewed towards the experiences of female participants.

CONCLUSIONS

Our findings help to enhance participant confidence in MBCT, alongside understanding the processes of change and the potential for difficulties. MBCT is beneficial and provides meaningful change for many but remains challenging for some.

Mindfulness-Based Cognitive Therapy in Recurrent MDD Patients With Residual Symptoms: Alterations in Resting-State Theta Oscillation Dynamics Associated With Changes in Depression and Rumination

Many patients with major depressive disorder (MDD) suffer from residual symptoms. Rumination is a specific known risk factor for the onset, severity, prolongation, and relapse of MDD. This study aimed to examine the efficacy and EEG substrates of mindfulness-based cognitive therapy (MBCT) in alleviating depression and rumination in an MDD population with residual symptoms. We recruited 26 recurrent MDD individuals who had residual symptoms with their current antidepressants to participate in the 8-week MBCT intervention. We evaluated the efficacy and changes in the dynamics of resting-state theta rhythm after the intervention, as well as the associations between theta alterations and improvements in depression and rumination. The participants showed reduced depression, enhanced adaptive reflective rumination, and increased theta power and phase synchronization after MBCT. The increased theta-band phase synchronizations between the right occipital regions and the right prefrontal, central, and parietal regions were associated with reduced depression, while the increase in theta power in the left parietal region was associated with improvements in reflective rumination. MBCT could alleviate depression and enhance adaptive, reflective rumination in recurrent MDD individuals with residual symptoms through the modulation of theta dynamics in specific brain regions.

Mindfulness-Based Cognitive Therapy Regulates Brain Connectivity in Patients With Late-Life Depression

Late-life depression (LLD) is an important public health problem among the aging population. Recent studies found that mindfulness-based cognitive therapy (MBCT) can effectively alleviate depressive symptoms in major depressive disorder. The present study explored the clinical effect and potential neuroimaging mechanism of MBCT in the treatment of LLD. We enrolled 60 participants with LLD in an 8-week, randomized, controlled trial (ChiCTR1800017725). Patients were randomized to the treatment-as-usual (TAU) group or a MBCT+TAU group. The Hamilton Depression Scale (HAMD) and Hamilton Anxiety Scale (HAMA) were used to evaluate symptoms. Magnetic resonance imaging (MRI) was used to measure changes in resting-state functional connectivity and structural connectivity. We also measured the relationship between changes in brain connectivity and improvements in clinical symptoms. HAMD total scores in the MBCT+TAU group were significantly lower than in the TAU group after 8 weeks of treatment (p < 0.001) and at the end of the 3-month follow-up (p < 0.001). The increase in functional connections between the amygdala and middle frontal gyrus (MFG) correlated with decreases in HAMA and HAMD scores in the MBCT+TAU group. Diffusion tensor imaging analyses showed that fractional anisotropy of the MFG-amygdala significantly increased in the MBCT+TAU group after 8-week treatment compared with the TAU group. Our study suggested that MBCT improves depression and anxiety symptoms that are associated with LLD. MBCT strengthened functional and structural connections between the amygdala and MFG, and this increase in communication correlated with improvements in clinical symptoms. Randomized Controlled Trial; Follow-Up Study; fMRI; Brain Connectivity.

Mindfulness-based cognitive therapy added to usual care improves eating behaviors in patients with bulimia nervosa and binge eating disorder by decreasing the cognitive load of words related to body shape, weight, and food

BACKGROUND

This study aimed to investigate the effectiveness of mindfulness-based cognitive therapy (MBCT) as a complementary approach in patients with bulimia nervosa (BN) or binge eating disorder (BED), and to assess how the reduction of the cognitive load of words related to eating disorders (ED) could constitute an intermediate factor explaining its global efficacy.

METHODS

Eighty-eight women and men participated in clinical assessments upon inscription, prior to and following 8-week group MBCT. Mindfulness skills were assessed using the five facet mindfulness questionnaire; eating behaviors were assessed using the Three Factor Eating Questionnaire (TFEQ); comorbid pathologies were assessed using the beck depression index and the state-trait anxiety inventory. The cognitive load of words associated with ED was assessed through a modified version of the Stroop color naming task.

RESULTS

Mindfulness skills improved significantly (p < .05) after group MBCT. The improvement of TFEQ scores was accompanied by reduced levels of depressive mood and trait anxiety. The positive impact of MBCT on TFEQ score was directly related to an improvement of the performance in the Stroop task.

CONCLUSIONS

MBCT represents an interesting complementary therapy for patients with either BN or BED, at least when cognitive and behavioral domains are concerned. Such efficacy seems to be mediated by the reduction of the cognitive load associated with ED stimuli, which offers a possible explanation of how MBCT could reduce binge-eating behaviors. Other studies are needed, in independent centers, to focus more directly on core symptoms and long-term outcome.

A Long-Term Pilot Study of Mindfulness-Based Cognitive Therapy for Subjective Well-Being Among Healthy Individuals in Comparison with Clinical Samples

Purpose

Mindfulness-based cognitive therapy (MBCT) could be an intervention for improving subjective well-being among healthy individuals (HIs). However, MBCT studies for HIs to improve their subjective well-being are rare. The aim of this study was to report the feasibility, safety and effectiveness of MBCT for HIs in comparison with clinical samples.

Patients and Methods

We conducted a single-arm, pre-post comparison pilot study offering MBCT to both HIs and people with common mental disorders. Twenty-four participants in total were included in the study. Eight weekly two-hour sessions with six monthly boosters were offered to all participants. Assessment was carried out at baseline, week 4, 8, and during follow-up. The 5-item World Health Organization Well-Being Index (WHO-5) was the primary clinical outcome measure.

Results

The results showed the MBCT is sufficiently safe and would be more feasible in HIs compared to in clinical samples (attendance rate: 81.5% vs 61.3%, p=0.06). Although Satisfaction with Life Scale, the other scale of subjective well-being used, improved significantly at week 20 (p=0.01), no significant improvement was seen in WHO-5. The results of the sub-group analysis revealed WHO-5 improved significantly at week 8 and 32 among the subjects whose baseline scores began in the lower half.

Conclusion

MBCT is sufficiently safe and would be more feasible with HIs compared to the clinical samples. In designing randomized controlled trials, selecting HIs with lower subjective well-being would be reasonable to minimize the “ceiling effect” on outcomes.

Mindfulness-based cognitive therapy for depression in people with dementia: A qualitative study on participant, carer and facilitator experiences

Background

Depression in dementia is common and associated with negative health outcomes. Mindfulness-based cognitive therapy is a recommended treatment of choice for recurrent depression, but its use for depression in dementia is yet to be assessed.

Objective

This study aimed to investigate the experiences of people with depression and dementia who participated in the mindfulness-based cognitive therapy intervention and those of their carers and facilitators.

Methods

This qualitative study was nested within a randomised controlled feasibility study. Semi-structured interviews were conducted with 18 people (eight people with dementia and depression, six carers and four course facilitators). Thematic analysis was used to analyse the data.

Findings

Several beneficial effects of mindfulness-based cognitive therapy were described. These were a sense of shared suffering among the group, greater present moment focus and awareness, various positive emotional changes, including greater self-compassion, and benefits for carers, such as the reduction of anxiety. Specific aspects of the programme were identified as particularly useful, including facilitator characteristics and certain mindfulness practices. Carer involvement, cognitive difficulties and barriers to home practice influenced engagement with the course. Facilitators described adaptations made to mindfulness-based cognitive therapy and suggested additional modifications for future groups.

Conclusion

Results of this process evaluation suggest that mindfulness-based cognitive therapy is a potentially useful intervention for people with depression in dementia, but that further adaptation of the intervention is required to make the programme suitable for this clinical population.

Improvement of Tardive Dyskinesia during Mindfulness Meditation

Background: We report the case of a patient presenting with orofacial tardive dyskinesia (TD), following administration of a first-generation antipsychotic (Loxapine). Intervention: Four weeks of repeated sessions of mindfulness-based cognitive therapy (MBCT) and mindfulness-based stress reduction (MBSR) protocols were administered, with TD hetero-quantified before and during each session via the Abnormal Involuntary Movement Scale (AIMS). Results: The dyskinesia ameliorated quantitatively and qualitatively (1) during each session, and (2) at resting conditions in the long term. During some sessions, after which patients’ compliance was auto-evaluated as maximal, complete arrest of the TD was observed. Hypothesis and Conclusion: We suggest mindfulness meditation as a novel adjunctive therapeutic approach for tardive dyskinesia, and invite for further clinical and neurological investigations.

The Contribution of Common and Specific Therapeutic Factors to Mindfulness-Based Intervention Outcomes

While Mindfulness-Based Interventions (MBIs) have been shown to be effective for a range of patient populations and outcomes, a question remains as to the role of common therapeutic factors, as opposed to the specific effects of mindfulness practice, in contributing to patient improvements. This project used a mixed-method design to investigate the contribution of specific (mindfulness practice-related) and common (instructor and group related) therapeutic factors to client improvements within an MBI. Participants with mild-severe depression (N = 104; 73% female, M age = 40.28) participated in an 8-week MBI. Specific therapeutic factors (formal out-of-class meditation minutes and informal mindfulness practice frequency) and social common factors (instructor and group ratings) were entered into multilevel growth curve models to predict changes in depression, anxiety, stress, and mindfulness at six timepoints from baseline to 3-month follow-up. Qualitative interviews with participants provided rich descriptions of how instructor and group related factors played a role in therapeutic trajectories. Findings indicated that instructor ratings predicted changes in depression and stress, group ratings predicted changes in stress and self-reported mindfulness, and formal meditation predicted changes in anxiety and stress, while informal mindfulness practice did not predict client improvements. Social common factors were stronger predictors of improvements in depression, stress, and self-reported mindfulness than specific mindfulness practice-related factors. Qualitative data supported the importance of relationships with instructor and group members, involving bonding, expressing feelings, and instilling hope. Our findings dispel the myth that MBI outcomes are exclusively the result of mindfulness meditation practice, and suggest that social common factors may account for much of the effects of these interventions. Further research on meditation should take into consideration the effects of social context and other common therapeutic factors.

Therapist behaviours in a web-based mindfulness-based cognitive therapy (eMBCT) for chronic cancer-related fatigue - Analyses of e-mail correspondence

Web-based mindfulness-based cognitive therapy (eMBCT) has been found effective in decreasing fatigue severity in patients suffering from Chronic Cancer-Related Fatigue (CCRF). In web-based therapy, guidance from a therapist positively affects treatment outcome. So far, less is known about what kind of therapist behaviours contribute to treatment outcome. The present study aimed at 1) identifying therapist behaviours during eMBCT and 2) exploring whether these behaviours were correlated to a decrease in fatigue severity among patients. Qualitative content analyses were performed on 537 feedback e-mails from five therapists sent to 31 patients within a secured portal. Through content analyses, nine therapist behaviours were identified: emphatic utterances, probing self-reflection, informing, psychoeducation, task prompting, paraphrasing, task reinforcement, providing group context and alliance bolstering. Among these behaviours task prompting (19%), paraphrasing (16%) and task reinforcement (15%) were the most common. Linear regression analyses showed a significant association between informing and task prompting on the one hand and a decrease in fatigue severity on the other. Multivariate analysis indicated that informing and task prompting jointly explain the decrease in fatigue. These findings underline the importance for therapists to provide patients with sufficient information and to encourage them to do the exercises.

Mindfulness-Based Cognitive Therapy for Treating Chronic Pain A Systematic Review and Meta-analysis

Chronic pain is a significant public health problem with emotional and disabling factors, which may not completely respond to current medical treatments such as opioids. The systematic review and meta-analysis aimed to examine the effectiveness and safety of MBCT for patients with chronic pain. Database searches of PubMed, Medline, EMBASE, the Cochrane Library, PsycINFO, Web of Science, Scopus and CINAHL up to 15 October 2019. Included studies assessed with the Cochrane risk-of-bias tool. Eight RCTs involved 433 patients, including chronic low back pain, fibromyalgia, migraine, rheumatoid arthritis and mix etiology. MBCT intervention demonstrated a short-term improvement on depression mood [standardized mean difference -0.72; 95% confidence interval = -1.22 to -0.22, p = 0.005] compared with usual care and was associated with short-term improvement in mindfulness compared with non-MBCT [SMD 0.51; 95% CI = 0.01 to 1.01, p = 0.04]. Between-group differences in pain intensity, pain inference and pain acceptance were not significant at short- or long-term follow-up. Compared to active treatments, MBCT intervention not found significant differences in either short- or long-term outcomes. MBCT showed short-term efficacious on depressed mood and mindfulness of chronic pain patients. Longer follow-ups, large sample and rigorous RCTs that can be best understand remaining uncertainties needed.

Discontinuing antidepressant medication after mindfulness-based cognitive therapy: a mixed-methods study exploring predictors and outcomes of different discontinuation trajectories, and its facilitators and barriers

OBJECTIVES

This study aimed to explore predictors and outcomes associated with different trajectories of discontinuing antidepressant medication (ADM), in recurrently depressed individuals after participation in mindfulness-based cognitive therapy (MBCT). Facilitators and barriers of discontinuation were explored qualitatively.

DESIGN

Mixed-methods study combining quantitative and qualitative data, drawn from a randomised controlled trial.

SETTING

Twelve secondary and tertiary psychiatric outpatient clinics in the Netherlands.

PARTICIPANTS

Recurrently depressed individuals (N=226) who had been using ADM for at least 6 months and in partial or full remission. Regardless of trial condition, we made post-hoc classifications of patients' actual discontinuation trajectories: full discontinuation (n=82), partial discontinuation (n=34) and no discontinuation (n=110) of ADM within 6 months after baseline. A subset of patients (n=15) and physicians (n=7) were interviewed to examine facilitators and barriers of discontinuation.

INTERVENTIONS

All participants were offered MBCT, which consisted of eight weekly sessions in a group.

PRIMARY AND SECONDARY OUTCOME MEASURES

Demographic and clinical predictors of successful discontinuation within 6 months, relapse risk within 15 months associated with different discontinuation trajectories, and barriers and facilitators of discontinuation.

RESULTS

Of the 128 patients assigned to MBCT with discontinuation, only 68 (53%) fully discontinued ADM within 6 months, and 17 (13%) discontinued partially. Predictors of full discontinuation were female sex, being employed and lower levels of depression. Relapse risk was lower after no discontinuation (45%) or partial discontinuation (38%), compared with full discontinuation (66%) (p=0.02). Facilitators and barriers of discontinuation were clustered within five themes: (1) pre-existing beliefs about depression, medication and tapering; (2) current experience with ADM; (3) life circumstances; (4) clinical support and (5) mindfulness.

CONCLUSIONS

Discontinuing antidepressants appears to be difficult, stressing the need to support patients and physicians in this process. MBCT may offer one of these forms of support.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT00928980); post-results.

Effectiveness of a healthy lifestyle promotion program as adjunctive teletherapy for treatment-resistant major depression during COVID 19 pandemic: A randomized clinical trial protocol

INTRODUCTION

Treatment-resistant depression (TRD) has a high prevalence and can be exacerbated by poor physical health and economic hardships, which have become common stressors during the current COVID-19 pandemic. The therapeutic approaches used to treat these patients are not always available, may be not be accepted by some patients, and often require face-to-face interactions.

OBJECTIVE

The main aim of this study will be to evaluate the effectiveness of an Internet-based adjuvant lifestyle-based intervention for patients with TRD.

METHODS

This will be a parallel, randomized, and controlled clinical trial. A total of 180 patients with TRD will be randomly allocated (1:1:1) to 1 of 3 groups: treatment prescribed by the mental health team and written suggestions for lifestyle changes (placebo control group); treatment prescribed by the mental health team, written suggestions for lifestyle changes, and an 8-week mindfulness-based cognitive therapy program (active control group); or treatment prescribed by the mental health team, written suggestions for lifestyle changes, and an 8-week lifestyle change promotion program (intervention group). We will perform this study during the COVID-19 pandemic, and will administer interventions by teletherapy, and contact participants by telephone calls, text messages, and/or teleconferences. We will collect patient data using questionnaires administered at baseline, immediately after the intervention, and after 6 and 12 months. The primary outcome will be score on the Beck Depression Inventory-II. The secondary outcomes will be score on the Clinical Global Impressions Scale (used to quantify and track patient progress and treatment response over time) and health-related quality of life measured using the European Quality of Life-5 Dimensions Questionnaire.

DISCUSSION

Patients with TRD are especially vulnerable when face-to-face psychotherapy is unavailable. The main strength of the proposed study is the novelty of the intervention to be used as an adjuvant therapy. Our results may provide guidance for treatment of patients with TRD in future situations that require lockdown measures.

CLINICALTRIALS REGISTRATION NUMBER

NCT04428099.

Mindfulness-based cognitive therapy on bereavement grief: Alterations of resting-state network connectivity associate with changes of anxiety and mindfulness

Bereavement, the experience of losing a loved one, is one of the most catastrophic but inevitable events in life. It causes grief and intense depression‐like sadness. Recent studies have revealed the effectiveness and proficiency of mindfulness‐based cognitive therapy (MBCT) in emotional regulation among bereavement populations. MBCT improves the well‐being of the bereaved by enhancing cognitive performances. Regarding the neural correlates of bereavement grief, previous studies focused on the alleviation of emotion–cognition interferences at specific brain regions. Here, we hypothesized that the bereavement grief fundamentally triggers global alterations in the resting‐state brain networks and part of the internetwork connectivity could be reformed after MBCT intervention. We recruited 19 bereaved individuals who participated the 8‐week MBCT program. We evaluated (a) the large‐scale changes in brain connectivity affected by the MBCT program; as well as (b) the association between connectivity changes and self‐rated questionnaire. First, after MBCT, the bereaved individuals showed the reduction of the internetwork connectivity in the salience, default‐mode and fronto‐parietal networks in the resting state but not under emotional arousal, implying the alleviated attention to spontaneous mind wandering after MBCT. Second, the alterations of functional connectivity between subcortical (e.g., caudate) and cortical networks (e.g., cingulo‐opercular/sensorimotor) were associated with the changes of the mindfulness scale, the anxiety and the emotion regulation ability. In summary, MBCT could enhance spontaneous emotion regulation among the bereaved individuals through the internetwork reorganizations in the resting state.

Can mindfulness-based interventions benefit people with dementia? Drawing on the evidence from a systematic review in populations with cognitive impairments

INTRODUCTION

Non-pharmacological interventions that promote quality of life in people with dementia are urgently needed. To accelerate development, evidence-based psychotherapies used in other populations can be considered. Mindfulness-based interventions with standardized protocols, namely mindfulness-based cognitive therapy (MBCT) and mindfulness-based stress reduction (MBSR), may be effective in people with dementia, although tailoring for cognitive impairment may be needed. Evidence from other cognitive disorders can inform research.

AREAS COVERED

The authors reviewed 12 studies of MBCT/MBSR conducted in people with cognitive impairments, including 10 in stroke, traumatic brain injury, and mild cognitive impairment; and two in dementia. Protocol modifications, outcomes, and evidence quality were analyzed. Common themes to address cognitive difficulties included: shortened session duration, use of memory aids, increase in repetition, simplified language, and omitted retreat sessions.

EXPERT OPINION

MBCT and MBSR can be applied without drastic modifications in people with cognitive impairment. Their effectiveness in people with dementia remains unknown: empirical studies using/adapting evidence-based MBCT/MBSR protocols in this population is seriously lacking. Studies used a diverse range of outcome measures, which made direct comparison difficult. Further research with high methodological quality, sufficient power, and longer follow-up is urgently needed. Development of manuals would enhance the replicability of future studies.

Predictors and Effects of Usage of an Online Mindfulness Intervention for Distressed Cancer Patients: Usability Study

Background

One in three cancer patients experience high psychological distress. Mindfulness-based interventions are effective in reducing psychological distress in this patient group. However, these interventions lack availability and flexibility, which may compromise participation in the intervention for cancer patients experiencing late symptoms like fatigue or pain. Therefore, mindfulness-based interventions are increasingly offered via the internet. However, little is known about the usage of these online mindfulness-based interventions.

Objective

The aim of this study was to (1) predict uptake of and adherence to online mindfulness-based cognitive therapy (eMBCT) using baseline patient characteristics (demographic, cancer-related, personality, and psychological variables) and (2) examine the relations between adherence and treatment outcomes in eMBCT for cancer patients.

Methods

A total of 125 cancer patients were assigned to eMBCT in a parent randomized controlled trial comparing MBCT and eMBCT with treatment as usual in distressed cancer patients. Various usage measures of eMBCT were automatically tracked within the online program. Based on activity of use, participants were classified as nonusers, minimal users, low users, and intended users. Questionnaires were used to assess baseline characteristics (preintervention) and outcomes (pre- and postintervention). To answer the research questions, data were analyzed with t tests, χ² tests, and linear regression models.

Results

Based on weekly activity, participants were classified as nonusers (n=17, 13.6%), who completed no exercises in MBCT; minimal users (n=31, 24.8%), who completed at least one exercise of one to three sessions; low users (n=12, 9.6%), who completed at least one exercise of four to seven sessions; and intended users (n=65, 52.0%), who completed at least one exercise of eight to nine sessions. Nonusers had more fear of cancer recurrence at baseline than users (uptake), and intended users were more conscientious than minimal and low users (adherence). Intended users reported a larger reduction in psychological distress and more improvement of positive mental health (ie, emotional, psychological, and social well-being) after the intervention than other participants.

Conclusions

This study showed that adherence was related to improved patient outcomes. Patients with strong fear of recurrence or low levels of conscientiousness should receive extra attention, as they are less likely to respectively start or complete eMBCT. Future research may focus on the development of flexible and adaptive eMBCT programs to fit individual needs.

Treatment as Usual in Late-Life Depression and Anxiety: An Open-Label Extension Study

OBJECTIVES

Mindfulness-based cognitive therapy (MBCT) is a novel treatment for depression. Our published randomized controlled trial shows that MBCT improves symptoms of late-life depression (LLD) and anxiety (LLA). We now examine whether continuation sessions of MBCT (MBCT-C) can prevent LLD/LLA symptom recurrence.

METHODS/DESIGN

Following an 8-week MBCT intervention, we compared patients who attended open-label weekly 1-hour MBCT-C for another 26 weeks (n = 10) vs those who did not (n = 17) for change in depressive and anxiety symptoms.

RESULTS

While there were no significant differences between groups on depressive or anxiety symptom severities between 8- and 34- weeks (Cohen's d = 0.045), we observed a small clinical effect of MBCT-C on symptoms of anxiety (d = 0.29).

CONCLUSIONS

These preliminary results suggest that MBCT-C may be somewhat beneficial for symptoms of LLA, but not for LLD. Healthcare providers should consider what is clinically feasible before investing time and resources into MBCT-C in older adults with depression and/or anxiety.

Cost-Utility Analysis of Mindfulness-Based Cognitive Therapy Versus Antidepressant Pharmacotherapy for Prevention of Depressive Relapse in a Canadian Context: Analyse coût-utilité de la thérapie cognitive basée sur la pleine conscience contre la pharmacothérapie antidépressive pour prévenir la rechute de la dépression en contexte canadien

OBJECTIVE

Patients suffering from major depressive disorder (MDD) experience impaired functioning and reduced quality of life, including an elevated risk of episode return. MDD is associated with high societal burden due to increased healthcare utilization, productivity losses, and suicide-related costs, making the long-term management of this illness a priority. The purpose of this study is to evaluate the cost-effectiveness of mindfulness-based cognitive therapy (MBCT), a first-line preventative psychological treatment, compared to maintenance antidepressant medication (ADM), the current standard of care.

METHOD

A cost-utility analysis was conducted over a 24-month time horizon to model differences between MBCT and ADM in cost and quality-adjusted life years (QALY). The analysis was conducted using a decision tree analytic model. Intervention efficacy, utility, and costing data estimates were derived from published sources and expert consultation.

RESULTS

MBCT was found to be cost-effective compared to maintenance ADM over a 24-month time horizon. Antidepressant pharmacotherapy resulted in 1.10 QALY and $17,255.37 per patient on average, whereas MBCT resulted in 1.18 QALY and $15,030.70 per patient on average. This resulted in a cost difference of $2,224.67 and a QALY difference of 0.08, in favor of MBCT. Multiple sensitivity analyses supported these findings.

CONCLUSIONS

From both a societal and health system perspective, utilizing MBCT as a first-line relapse prevention treatment is potentially cost-effective in a Canadian setting. Future economic evaluations should consider combined treatment (e.g., ADM and psychotherapy) as a comparator and longer time horizons as the literature advances.

Patients' interpersonal problems as moderators of depression outcomes in a randomized controlled trial comparing mindfulness-based cognitive therapy and a group version of the cognitive-behavioral analysis system of psychotherapy in chronic depression

OBJECTIVES

Interpersonal problems were examined as moderators of depression outcomes between mindfulness-based cognitive therapy (MBCT) and cognitive behavioral analysis system of psychotherapy (CBASP) in patients with chronic depression.

METHODS

Patients received treatment-as-usual and, in addition, were randomized to 8-weeks of MBCT (n = 34) or 8-weeks of CBASP (n = 34). MBCT and CBASP were given in a group format. The Hamilton depression rating scale (HAM-D) was the primary and the Beck Depression Inventory (BDI-II) the secondary outcome. The subscales of the Inventory of interpersonal problems (IIP-32) were moderators. Multilevel models were performed.

RESULTS

Higher scores on the "vindictive/self-centered" subscale were associated with a better outcome in MBCT than in CBASP (HAM-D: p < .01; BDI-II: p < .01). Higher scores on the "nonassertive" subscale were associated with a better outcome in CBASP than in MBCT (HAM-D: p < .01; BDI-II: p < .01).

CONCLUSIONS

If these results can be replicated in larger trials, MBCT should be preferred to CBASP in chronically depressed patients being vindictive/self-centered, whereas CBASP should be preferred to MBCT in chronically depressed patients being nonassertive.

Mindfulness-Based Cognitive Therapy for Improving Subjective Well-Being Among Healthy Individuals: Protocol for a Randomized Controlled Trial

Background

Previous studies have indicated that higher subjective well-being works as a protective factor for health. Some studies have already shown the effects of mindfulness-based interventions on improving subjective well-being. However, these studies targeted specific populations rather than the general public. Furthermore, they assessed either life evaluation or affective aspects of subjective well-being rather than the concept as a whole, including the eudemonic aspect of well-being.

Objective

This study aims to investigate the effectiveness and cost-effectiveness of mindfulness-based cognitive therapy (MBCT) for improving the wholistic aspects of subjective well-being in healthy individuals.

Methods

This study was an 8-week, randomized, parallel-group, superiority trial with a 2-month follow-up. Healthy individuals aged 20-65 years with scores lower than 25 on the Satisfaction With Life Scale (SWLS) were eligible to participate and randomly allocated to the MBCT group or the wait-list control group. The intervention program was developed by modifying an MBCT program to improve the well-being of a nonclinical population. The primary outcome was the difference between the two groups in mean change scores from the baseline on the SWLS. The secondary outcomes included scores on the Flourishing Scale and the Scale of Positive and Negative Experience as well as the incremental cost-effectiveness ratio.

Results

This study began recruiting participants in July 2018 and recruitment was completed at the end of September 2019. Data collection and dataset construction was completed by the end of March 2020.

Conclusions

This study is unique in that it investigates MBCT’s effects on the three different aspects of subjective well-being: life evaluation, affect, and eudemonia. It is limited, as the specific effect attributable to MBCT cannot be detected because of the lack of an active control group.

Trial Registration

University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR) UMIN000031885; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000036376

International Registered Report Identifier (IRRID)

DERR1-10.2196/15892

Mindfulness in migraine: A narrative review

Introduction: Migraine is the second leading cause of disability worldwide, yet many patients are unable to tolerate, benefit from, or afford pharmacological treatment options. Non-pharmacological migraine therapies exist, especially to reduce opioid use, which represents a significant unmet need. Mindfulness-based interventions (MBI) have potential as a non-pharmacological treatment for migraine, primarily through the development of flexible attentional capacity across sensory, cognitive, and emotional experiences.Areas covered: The authors review efficacy and potential mechanisms of MBIs for migraine, including mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT).Expert opinion: While most mindfulness research studies for migraine to date have been pilot trials, which are small and/or lacked rigor, initial evidence suggests there may be improvements in overall headache-related disability and psychological well-being. Many research questions remain to help target the treatment to patients most likely to benefit, including the ideal dosage, duration, delivery method, responder characteristics, and potential mechanisms and biomarkers. A realistic understanding of these factors is important for patients, providers, and the media. Mindfulness will not 'cure' migraine; however, mindfulness may be an important tool as part of a comprehensive treatment approach to help patients 'mindfully' engage in valued life activities.

The pursuit of euthymia

Psychiatrists often consider the positive characteristics displayed by a patient in their clinical judgment, yet current assessment and treatment strategies are shifted on the side of psychological dysfunction. Euthymia is a transdiagnostic construct referring to the presence of positive affects and psychological well-being, i.e., balance and integration of psychic forces (flexibility), a unifying outlook on life which guides actions and feelings for shaping future accordingly (consistency), and resistance to stress (resilience and tolerance to anxiety or frustration). There is increasing evidence that the evaluation of euthymia and its components has major clinical implications. Specific instruments (clinical interviews and questionnaires) may be included in a clinimetric assessment strategy encompassing macro-analysis and staging. The pursuit of euthymia cannot be conceived as a therapeutic intervention for specific mental disorders, but as a transdiagnostic strategy to be incorporated in an individualized therapeutic plan. A number of psychotherapeutic techniques aiming to enhance positive affects and psychological well-being (such as well-being therapy, mindfulness-based cognitive therapy, and acceptance and commitment therapy) have been developed and validated in randomized controlled clinical trials. The findings indicate that flourishing and resilience can be promoted by specific interventions leading to a positive evaluation of one's self, a sense of continuing growth and development, the belief that life is purposeful and meaningful, satisfaction with one's relations with others, the capacity to manage effectively one's life, and a sense of self-determination.

Treatment of Resistant Depression: A Pilot Study Assessing the Efficacy of a tDCS-Mindfulness Program Compared With a tDCS-Relaxation Program

Background: This pilot study explores a therapeutic setting combining transcranial direct current stimulation (tDCS) and mindfulness-based cognitive therapy (MBCT) for patients with drug-resistant depression. tDCS has shown efficacy for depression treatment and improvement could be maintained with the combination with mindfulness, which has shown depression relapse-prevention properties. Methods: Thirty-one treatment-resistant depressed patients have been assigned to our experimental treatment condition [tDCS combined with MBCT (n = 15)] or to a control condition [tDCS combined with relaxation (n = 16)]. Patients have completed both an intensive treatment block (eight consecutive days) and a single remind session 2 weeks after the intensive treatment. Clinical (depression, anxiety, and rumination) and cognitive (general cognitive functioning, mental flexibility, and working memory) symptoms of depression have been assessed through different questionnaires at baseline (t0), after the first block of treatment (t1), and after the remind session (t2). Results: Results seem to indicate a positive impact of both treatment conditions on clinical and cognitive symptoms of depression at t1. However, the treatment condition combining tDCS with mindfulness has been found to better maintain clinical improvements at t2 regarding some clinical [Montgomery-Åsberg Depression Rating Scale (MADRS) and Sadness and Anger Ruminative Inventory (SARI)] and cognitive variables (Digit Span-F and Digit Span-B). Conclusion: Based on the current observations, a multi-disciplinary treatment approach combining tDCS and MBCT might be effective in resistant depressed patients in the long run, even though further clinical research is necessary.

Mindfulness-based interventions for psychological and physical health outcomes in cancer patients and survivors: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Mindfulness-based interventions (MBIs) are increasingly used within psycho-oncology. Since the publication of the most recent comprehensive meta-analysis on MBIs in cancer in 2012, the number of published trials has more than doubled. We therefore conducted a systematic review and meta-analysis of randomized controlled trials (RCTs), testing the efficacy of MBIs on measures of psychological distress (primary outcome) and other health outcomes in cancer patients and survivors.

METHODS

Two authors conducted independent literature searches in electronic databases from first available date to 10 October 2018, selected eligible studies, extracted data for meta-analysis, and evaluated risk of bias.

RESULTS

Twenty-nine independent RCTs (reported in 38 papers) with 3274 participants were included. Small and statistically significant pooled effects of MBIs on combined measures of psychological distress were found at post-intervention (Hedges's g = 0.32; 95%CI: 0.22-0.41; P < .001) and follow-up (g = 0.19; 95%CI: 0.07-0.30; P < .002). Statistically significant effects were also found at either post-intervention or follow-up for a range of self-reported secondary outcomes, including anxiety, depression, fear of cancer recurrence, fatigue, sleep disturbances, and pain (g: 0.20 to 0.51; p: <.001 to.047). Larger effects of MBIs on psychological distress were found in studies (a) adhering to the original MBI manuals, (b) with younger patients, (c) with passive control conditions, and (d) shorter time to follow-up. Improvements in mindfulness skills were associated with greater reductions in psychological distress at post-intervention.

CONCLUSIONS

MBIs appear efficacious in reducing psychological distress and other symptoms in cancer patients and survivors. However, many of the effects were of small magnitude, suggesting a need for intervention optimization research.

'Mind the gaps': the accessibility and implementation of an effective depression relapse prevention programme in UK NHS services: learning from mindfulness-based cognitive therapy through a mixed-methods study

OBJECTIVES

Mindfulness-based cognitive therapy (MBCT) is an evidence-based approach for people at risk of depressive relapse to support their long-term recovery. However, despite its inclusion in guidelines, there is an 'implementation cliff'. The study objective was to develop a better explanation of what facilitates MBCT implementation.

SETTING

UK primary and secondary care mental health services.

DESIGN, PARTICIPANTS AND METHODS

A national two-phase, multi-method qualitative study was conducted, which was conceptually underpinned by the Promoting Action on Research Implementation in Health Services framework. Phase I involved interviews with stakeholders from 40 service providers about current provision of MBCT. Phase II involved 10 purposively sampled case studies to obtain a more detailed understanding of MBCT implementation. Data were analysed using adapted framework analysis, refined through stakeholder consultation.

RESULTS

Access to MBCT is variable across the UK services. Where available, services have adapted MBCT to fit their context by integrating it into their care pathways. Evidence was often important to implementation but took different forms: the NICE depression guideline, audits, evaluations, first person accounts, experiential taster sessions and pilots. These were used to build a platform from which to develop MBCT services. The most important aspect of facilitation was the central role of the MBCT implementers. These were generally self-designated individuals who 'championed' grass-roots implementation. Our explanatory framework mapped out a prototypical implementation journey, often over many years with a balance of bottom-up and top-down factors influencing the fit of MBCT into service pathways. 'Pivot points' in the implementation journey provided windows of either challenge or opportunity.

CONCLUSIONS

This is one of the largest systematic studies of the implementation of a psychological therapy. While access to MBCT across the UK is improving, it remains patchy. The resultant explanatory framework about MBCT implementation provides a heuristic that informed an implementation resource.

Functional Brain Changes During Mindfulness-Based Cognitive Therapy Associated With Tinnitus Severity

Mindfulness-based therapies have been introduced as a treatment option to reduce the psychological severity of tinnitus, a currently incurable chronic condition. This pilot study of twelve subjects with chronic tinnitus investigates the relationship between measures of both task-based and resting state functional magnetic resonance imaging (fMRI) and measures of tinnitus severity, assessed with the Tinnitus Functional Index (TFI). MRI was measured at three time points: before, after, and at follow-up of an 8-week long mindfulness-based cognitive therapy intervention. During the task-based fMRI with affective sounds, no significant changes were observed between sessions, nor was the activation to emotionally salient compared to neutral stimuli significantly predictive of TFI. Significant results were found using resting state fMRI. There were significant decreases in functional connectivity among the default mode network, cingulo-opercular network, and amygdala across the intervention, but no differences were seen in connectivity with seeds in the dorsal attention network (DAN) or fronto-parietal network and the rest of the brain. Further, only resting state connectivity between the brain and the amygdala, DAN, and fronto-parietal network significantly predicted TFI. These results point to a mostly differentiated landscape of functional brain measures related to tinnitus severity on one hand and mindfulness-based therapy on the other. However, overlapping results of decreased amygdala connectivity with parietal areas and the negative correlation between amygdala-parietal connectivity and TFI is suggestive of a brain imaging marker of successful treatment.

Treatment Engagement and Outcomes of Mindfulness-Based Cognitive Therapy for Veterans with Psychiatric Disorders

Objectives: The aim of this study was to evaluate utilization and outcomes of mindfulness-based cognitive therapy (MBCT) provided to veterans with psychiatric disorders.

Design: Retrospective chart review.

Settings: Veterans Administration Medical Center (VAMC).

Subjects: Ninety-eight veterans with psychiatric illness who were enrolled in an MBCT class between May of 2012 and January of 2016. Subjects were predominately white (95%), male (81%), and >50 years old (74%). The most common psychiatric conditions were any mood disorder (82%) and post-traumatic stress disorder (54%).

Intervention: Eight-week MBCT class.

Outcome measures: Session attendance and pre- to postintervention changes in numbers of emergency department (ED) visits and psychiatric hospitalizations.

Results: The average number of sessions attended was 4.87 of 8 and only 16% were present for all sessions. Veteran demographic variables did not predict the number of MBCT sessions attended. However, both greater numbers of pre-MBCT ED visits (p = 0.004) and psychiatric admissions (p = 0.031) were associated with attending fewer sessions. Among patients who experienced at least one pre- or post-treatment psychiatric admission in the 2 years pre- or postintervention (N = 26, 27%), there was a significant reduction in psychiatric admissions from pre to post (p = 0.002). There was no significant change in ED visits (p = 0.535).

Conclusions: MBCT may be challenging to implement for veterans with psychiatric illness in, at least some, outpatient VAMC settings due to a high attrition rate. Possible mediation approaches include development of methods to screen for high dropout risk and/or development of shorter mindfulness-based interventions (MBIs) and/or coupling MBIs with pleasurable activities. The finding of a significant decrease in psychiatric hospitalizations from pre- to post-MBCT suggests that prospective studies are warranted utilizing MBCT for veterans at high risk for psychiatric hospitalization.

The Efficacy of Adapted MBCT on Core Symptoms and Executive Functioning in Adults With ADHD: A Preliminary Randomized Controlled Trial

OBJECTIVE

The aim of this study was to examine the effectiveness of mindfulness as a treatment for adults diagnosed with ADHD. A 12-week-adapted mindfulness-based cognitive therapy (MBCT) program is compared with a waiting list (WL) group.

METHOD

Adults with ADHD were randomly allocated to MBCT ( n = 55) or waitlist ( n = 48). Outcome measures included investigator-rated ADHD symptoms (primary), self-reported ADHD symptoms, executive functioning, depressive and anxiety symptoms, patient functioning, and mindfulness skills.

RESULTS

MBCT resulted in a significant reduction of ADHD symptoms, both investigator-rated and self-reported, based on per-protocol and intention-to-treat analyses. Significant improvements in executive functioning and mindfulness skills were found. Additional analyses suggested that the efficacy of MBCT in reducing ADHD symptoms and improving executive functioning is partially mediated by an increase in the mindfulness skill "Act With Awareness." No improvements were observed for depressive and anxiety symptoms, and patient functioning.

CONCLUSION

This study provides preliminary support for the effectiveness of MBCT for adults with ADHD.

treatment as usual in adults with ADHD: a multicentre, single-blind, randomised controlled trial

BACKGROUND

There is a high need for evidence-based psychosocial treatments for adult attention-deficit hyperactivity disorder (ADHD) to offer alongside treatment as usual (TAU). Mindfulness-based cognitive therapy (MBCT) is a promising psychosocial treatment. This trial investigated the efficacy of MBCT + TAU v. TAU in reducing core symptoms in adults with ADHD.

METHODS

A multicentre, single-blind, randomised controlled trial (ClinicalTrials.gov: NCT02463396). Participants were randomly assigned to MBCT + TAU (n = 60), an 8-weekly group therapy including meditation exercises, psychoeducation and group discussions, or TAU only (n = 60), which reflected usual treatment in the Netherlands and included pharmacotherapy and/or psychoeducation. Primary outcome was ADHD symptoms rated by blinded clinicians. Secondary outcomes included self-reported ADHD symptoms, executive functioning, mindfulness skills, self-compassion, positive mental health and general functioning. Outcomes were assessed at baseline, post-treatment, 3- and 6-month follow-up. Post-treatment effects at group and individual level, and follow-up effects were examined.

RESULTS

In MBCT + TAU patients, a significant reduction of clinician-rated ADHD symptoms was found at post-treatment [M difference = -3.44 (-5.75, -1.11), p = 0.004, d = 0.41]. This effect was maintained until 6-month follow-up. More MBCT + TAU (27%) than TAU participants (4%) showed a ⩾30% reduction of ADHD symptoms (p = 0.001). MBCT + TAU patients compared with TAU patients also reported significant improvements in ADHD symptoms, mindfulness skills, self-compassion and positive mental health at post-treatment, which were maintained until 6-month follow-up. Although patients in MBCT + TAU compared with TAU reported no improvement in executive functioning at post-treatment, they did report improvement at 6-month follow-up.

CONCLUSIONS

MBCT might be a valuable treatment option alongside TAU for adult ADHD aimed at alleviating symptoms.

What if Life Is Not Worth Living?

I tend to become reflective as the end of each year approaches. Thinking about what I managed to achieve during the past 12 months, what I have left undone, and how to try to make the next 12 months better occupies my mind as I drive to and from work or while on my treadmill. The year that is almost over has been a particularly turbulent one in part because of the news about celebrities ending their lives. I certainly enjoyed Anthony Bourdain's books and TV shows and admired his apparent love of the good things in life. Of course, we can never know the truest parts of another's heart, and his suicide in a hotel in France left many shaken.

Relapse/Recurrence Prevention in Major Depressive Disorder: 26-Month Follow-Up of Mindfulness-Based Cognitive Therapy Versus an Active Control

We conducted a 26-month follow-up of a previously reported 12-month study that compared mindfulness-based cognitive therapy (MBCT) to a rigorous active control condition (ACC) for depressive relapse/recurrence prevention and improvements in depressive symptoms and life satisfaction. Participants in remission from major depression were randomized to an 8-week MBCT group (n = 46) or the ACC (n = 46). Outcomes were assessed at baseline; postintervention; and 6, 12, and 26 months. Intention-to-treat analyses indicated no differences between groups for any outcome over the 26-month follow-up. Time to relapse results (MBCT vs. ACC) indicated a hazard ratio = .82, 95% CI [.34, 1.99]. Relapse rates were 47.8% for MBCT and 50.0% for ACC. Piecewise analyses indicated that steeper declines in depressive symptoms in the MBCT vs. the ACC group from postintervention to 12 months were not maintained after 12 months. Both groups experienced a marginally significant rebound of depressive symptoms after 12 months but were still improved at 26 months compared to baseline (b = -4.12, p <= .008). Results for life satisfaction were similar. In sum, over a 26-month follow-up, MBCT was no more effective for preventing depression relapse/recurrence, reducing depressive symptoms, or improving life satisfaction than a rigorous ACC. Based on epidemiological data and evidence from prior depression prevention trials, we discuss the possibility that both MBCT and ACC confer equal therapeutic benefit. Future studies that include treatment as usual (TAU) control conditions are needed to confirm this possibility and to rule out the potential role of time-related effects. Overall findings underscore the importance of comparing MBCT to TAU as well as to ACCs.

Mindfulness-based cognitive therapy for obsessive-compulsive disorder: Study protocol for a randomized controlled trial with functional magnetic resonance imaging and a 6-month follow-up

This article presents a study protocol for a single-blind randomized controlled trial to test the efficacy and feasibility of mindfulness-based cognitive therapy. A total of 120 un-medicated Chinese obsessive-compulsive disorder patients will be randomized to the mindfulness-based cognitive therapy group, the selective serotonin reuptake inhibitor group or the psycho-education group for 11 sessions in 10 weeks. A range of scales for clinical symptoms and functional magnetic resonance imaging will be completed at baseline (week 0), mid-intervention (week 4), post-intervention (week 10) and the 6-month follow-up (weeks 14, 22 and 34). The study will have relevance to decisions about treatment options for un-medicated obsessive-compulsive disorder patients.

Measuring Mindfulness: A Psychophysiological Approach

Mindfulness-based interventions have proved effective in reducing various clinical symptoms and in improving general mental health and well-being. The investigation of the mechanisms of therapeutic change needs methods for assessment of mindfulness. Existing self-report measures have, however, been strongly criticized on various grounds, including distortion of the original concept, response bias, and other. We propose a psychophysiological method for the assessment of the mindfulness learned through time-limited mindfulness-based therapy by people who undergo meditation training for the first time. We use the individual pre-post-therapy changes (dERPi) in the event-related brain potentials (ERPs) recorded in a passive meditation task as a measure of increased mindfulness. dERPi is computed through multivariate assessment of individual participant's ERPs. We tested the proposed method in a group of about 70 recurrently depressed participants, randomly assigned in 1.7:1 ratio to mindfulness-based cognitive therapy (MBCT) or cognitive therapy (CT). The therapy outcome was measured by the long-term change (dDS) relative to baseline in the depression symptoms (DS) assessed weekly, for 60 weeks, by an online self-report questionnaire. We found a strong, highly significant, negative correlation (r = -0.55) between dERPi (mean = 0.4) and dDS (mean = -0.7) in the MBCT group. Compared to this result, the relationship between dDS and the other (self-report) measures of mindfulness we used was substantially weaker and not significant. So was also the relationship between dERPi and dDS in the CT group. The interpretation of dERPi as a measure of increased mindfulness was further supported by positive correlations between dERPi and the other measures of mindfulness. In this study, we also replicated a previous result, namely, the increase (dLCNV) of the late contingent negative variation (LCNV) of the ERP in the MBCT group, but not in the control group (in this case, CT). We interpreted dLCNV as a measure of increased meditative concentration. The relationship between dLCNV and dDS was, however, very week, which suggests that concentration might be relatively unimportant for the therapeutic effect of mindfulness. The proposed psychophysiological method could become an important component of a "mindfulness test battery" together with self-report questionnaires and other newly developed instruments.

Mindfulness-based cognitive therapy in patients with depression: current perspectives

Mindfulness-based cognitive therapy (MBCT) was developed to prevent relapse in individuals with depressive disorders. This widely used intervention has garnered considerable attention and a comprehensive review of current trends is warranted. As such, this review provides an overview of efficacy, mechanisms of action, and concludes with a discussion of dissemination. Results provided strong support for the efficacy of MBCT despite some methodological shortcomings in the reviewed literature. With respect to mechanisms of action, specific elements, such as mindfulness, repetitive negative thinking, self-compassion and affect, and cognitive reactivity have emerged as important mechanisms of change. Finally, despite a lack of widespread MBCT availability outside urban areas, research has shown that self-help variations are promising. Combined with findings that teacher competence may not be a significant predictor of treatment outcome, there are important implications for dissemination. Taken together, this review shows that while MBCT is an effective treatment for depression, continued research in the areas of efficacy, mechanisms of action, and dissemination are recommended.

Understandings of psychological difficulties in people with the Huntington's disease gene and their expectations of psychological therapy

OBJECTIVES

This study sought to investigate how people who had tested positive for the Huntington's disease (HD) gene mutation understood and experienced psychological distress and their expectations of psychological therapy.

DESIGN

A qualitative methodology was adopted involving semi-structured interviews and interpretative phenomenological analysis (IPA).

METHOD

A total of nine participants (five women and four men) who had opted to engage in psychological therapy were recruited and interviewed prior to the start of this particular psychological therapeutic intervention. Interviews were transcribed verbatim and analysed using IPA whereby themes were analysed within and across transcripts and classified into superordinate themes.

RESULTS

Three superordinate themes were developed: Attributing psychological distress to HD: 'you're blaming everything on that now'; Changes in attributions of distress over time: 'in the past you'd just get on with it'; and Approaching therapy with an open mind, commitment, and hope: 'a light at the end of the tunnel'.

CONCLUSION

Understandings of psychological distress in HD included biological and psychological explanations, with both often being accepted simultaneously by the same individual but with biomedical accounts generally dominating. Individual experience seemed to reflect a dynamic process whereby people's understanding and experience of their distress changed over time. Psychological therapy was accepted as a positive alternative to medication, providing people with HD with hope that their psychological well-being could be enhanced.

PRACTITIONER POINTS

People with the Huntington's disease gene mutation have largely biomedical understandings of their psychological distress. This largely biomedical understanding does not, however, preclude them for being interested in the potential gains resulting from psychological therapy. The mechanisms of psychological therapy should be explained in detail before therapy and explored along with current attributions of distress.

Long-Term Efficacy of Psychosocial Treatments for Adults With Attention-Deficit/Hyperactivity Disorder: A Meta-Analytic Review

Background: Recent evidence suggests that psychosocial treatments, particularly cognitive-behavioral therapy (CBT), are effective interventions for adult attention deficit hyperactivity disorder (ADHD). The objective of this review was to determine the long-term efficacy of psychosocial interventions in improving clinically relevant variables, including ADHD core symptoms, clinical global impression (CGI), and global functioning. Methods: In total, nine randomized controlled trials and three uncontrolled single-group pretest-posttest studies were included. The data from these studies were combined using the inverse variance method. Heterogeneity and risk of bias were assessed. Subgroup analyses and meta-regressions were performed, to determine the influence of different potential moderator variables (risk of bias, medication status, follow-up length, therapy type and setting, and control group type) on effect size (ES) estimates. Results: Up to 680 of a total of 1,073 participants assessed pre-treatment were retained at follow-up. Treatment groups showed greater improvement than control groups in self-reported total ADHD symptoms, inattention, and hyperactivity/impulsivity, in addition to CGI and global functioning. Blind assessors also reported a large ES in within-subject outcomes. Studies using dialectical behavioral therapy (DBT) in a group setting, with active control matching, and that were rated as having an unclear risk of bias, achieved significantly lower ES estimates for most outcomes. Treatment effectiveness, according to the CGI measure, and global functioning were significantly increased when the percentage of medicated participants was greater. Conclusions: Our results indicate that the post-treatment gains reported in previous reviews are sustained for at least 12 months. Nevertheless, these results must be interpreted with caution, because of a high level of heterogeneity among studies and the risk of bias observed in the majority of outcomes. Thus, these findings indicate that psychological interventions are a highly valuable and stable clinical tool for the treatment of core symptoms and global functioning in adults with ADHD.