Transcript Treatment for Depression

Treatment for Depression
~ Mindfulness Meditation ~
Meditation
Meditation is an old eastern practice dating
back to 2500 years ago, but in the last 40
years, has attracted considerable
professional and popular interest and, with
the growth of holistic medicine and wider
concerns with fitness, health, and emotional
well-being, it continues to be attractive as a
means of natural and healthy development.
About the Intervention
Mindfulness is a particular way of paying attention, in the present moment
and nonjudgmentally (Kabat-Zinn, 1994).
The goal of MM practice is simply to experience what is present from
moment to moment and one eventually learns to face and work with the
full range of human emotions and mind states.
Duration:
Eight-week training program that requires an immediate and significant
lifestyle change most readily seen in the need to devote a minimum of 45
minutes per day, six days per week to practicing the various forms of
meditation and yoga assigned for ‘homework’
About the Intervention
MBCT is based on an integration of aspects of CBT for
depression (Beck et al., 1979) with components of the
mindfulness-based stress reduction program developed by
Kabat-Zinn and colleagues. The Cognitive view of
Depression builds on the basic observation that how
people think can have a profound influence on how they
feel and behave. Unlike CBT, there is little emphasis in
MBCT on changing the content of thoughts; rather, the
emphasis is on changing awareness of and relationship to
thoughts
Movie
~Healing From Within~
Based on Jon Kabat-Zinns approach/procedure to
Mindfulness Meditation
Research Article
Prevention of Relapse/Recurrence in Major Depression by Mindfulness-Based
Cognitive Therapy (Teasdale et al., 2000)
Study evaluated mindfulness-based cognitive therapy (group intervention)
designed to train recovered recurrently depressed patients to disengage from
depressogenic thinking that may mediate relapse/recurrence.
Why is prevention of relapse important?
Patients who recovered from a first depressive episode have about a 50%
chance of developing a new episode, whereas the risk of recurrence is 7080% for those who have a history of two or more depressive episodes. Also,
for about 6- 13%, depression becomes chronic and every new episode just
becomes more and more lethal.
Study Information
Participants:
n= 145 random recovered recurrently major depressed patients
Recruited from community health care facilities and by media announcements at
three different sites: predominantly rural, Welsh speaking area of north Wales,
city of Cambridge, England, and metropolitan area of Toronto, Ontario
Inclusion criteria:
-18-65 years of age
-met DSM III-R criteria for a history of recurrent major depression
-a history of treatment by a recognized antidepressant medication , but off
antidepressant medication for at least 12 weeks
Study Information
Patients who currently practiced yoga more than twice a week were excluded
Relapse/recurrence to major depression was assessed over a 60 week study
period:
8 week treatment phase followed by a 52 week follow up phase
Two baseline variables:
-recency of recovery from last episode of depression (within 0-12 months
prior to randomization vs. within 13-24 months prior to randomization)
and number of previous episodes of MDD ( two vs. more than two)
- both these variables have been found to be related to the risk of
relapse/recurrence in previous studies (Evans et al., 1992)
Study Information
Treatment:
Treatment as usual patients were instructed to seek help from their
family doctor, or other sources, should they encounter symptomatic
deterioration .
MBCT patients were taught skills that allow individuals to disengage
from ‘habitual’ dysfunctional cognitive routines, in particular
depression-related ruminative thought patterns , as a way to reduce
future risk of relapse and recurrence of depression.
Study Information
MBCT program delivered by instructor in eight weekly 2hour
group training sessions, which included daily homework
exercises
Homework: some form of guided (taped) or unguided
awareness exercises, directed at increasing moment by
moment nonjudgmental awareness of bodily sensations,
thoughts, and feelings with exercises designed to integrate
application of awareness skills into daily life
Findings:
For patients with 3 or more previous episodes of depression
(77% of the sample) MBCT significantly reduced (almost halved)
risk of relapse recurrence rates compared with TAU
For patients with only 2 previous episodes, MBCT did not
significantly reduce relapse/recurrence
History= age at admission to study minus age of first onset
yielded a mean for those with three or more episodes
approximately four times as great as that for patients with two
episodes
Limitations:
The key outcome of interest in this study was the prevention of a future
event rather than reduction of symptoms present at baseline assessment
No evidence to show if similar effects would be obtained with different
ethnic or educational backgrounds
Study used only individuals with Major Depressive Disorder, thus not
taking into account those with Bipolar Disorder, who are generally more
likely to try or to commit suicide
Group therapy and not individual
Background

In comparison with drop-outs, those who maintain meditation practice
show significantly greater decreases in depression over 1 year (Fehr,
1977).
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A group of long term meditators (with 43 months of TM experience)
showed a significantly lower level of depression than the short-term (6
weeks) meditators. However, in this study, the subjects were not
randomly assigned to meditation and control groups, and so the longterm meditators may already have had relativiely low levels of
depression before learning TM (Ferguson and Gowan, 1976).
Neurobiology of Disorder
Several brain neurotransmitter systems have been implicated
in depression and mania: glutamate, serotonin,
norepinephrine, and dopamine
With the use of neuroimaging studies depressed patients have
shown several abnormalities of regional cerebral blood
flow and glucose metabolism in various brain regions,
including the limbic cortex, the prefrontal cortex, the
hippocampus, the amygdala, and the anterior cingulate
cortex
Neurobiology of Disorder
hippocampus/cingulate gyrus- involved in learning and memory
amygdala- only part of limbic system responsible for emotional responses
-other areas involved with learning and memory of emotions
prefrontal cortex- formulation of plans and strategies
Neurobiology of Disorder
The approach of CBT developed by A.T Beck initially grew out of clinical
observations of depressed patients. Consists of 3 components:
1.
1.Negative automatic thoughts
2.
2. Systematic logical errors
3.
3. Depressogenic schema
4.
Combination of negative expectations about oneself and one’s future
and the rigid thinking that lies behind cognitive errors causes
depressed people to misinterpret events in their lives, which make it
more likely that a sad mood will follow
Neurobiology of Disorder
These reactivated patterns of thinking can act to maintain and intensify the
dysphoric state through escalating and self-perpetuating cycles of
ruminative cognitive-affective processing( Teasdale, 1988, 1997).
Studies have compared patterns of thinking activated by mild dysphoria in
those with and without a history of major depression and can explain
difference through episode sensitization and kindling.
Mindfulness:
Its focus is to teach individuals to become more aware of thoughts and
feelings and relate to them in a wider decentered perspective as
‘mental events’ rather than as aspects of the self or as necessarily
accurate reflections of reality.
Evaluation
Advantages:
-Does not pose serious side effects (ex. Lithium)
-Many antidepressant medications have significant side-effects
-MBCT offers a promising cost-efficient psychological approach to
preventing relapse/recurrence in recovered recurrently depressed
patients
-M-based stress reduction approach is generic and thus can appeal to and
be of significant relevance and benefit for a wide range of people
(patients dealing with heart disease, HIV, anxiety, depression)
Evaluation
Disadvantages:
-Most episodes of depression will improve within a few months even if
untreated, thus effective treatment must show results sooner, therefore great
reliance on many pharmacological treatments
-Since meditation is a self-directed and active process, it may not be readily
dispensed , like medication, to depressed patients if they show little motivation
to practice
-Therefore, the value of meditation is greater for those people who want to be
directly involved in their development than those who want to be ‘cured’
Conclusion
MBCT appropriate because reviewing studies of lifetime course of
depression, a recent commentary concluded that ‘it has been
established that unipolar major depressive disorder is a chronic,
lifelong illness, the risk for repeated episodes exceeds 80%, patients
will experience an average of 4 lifetime major depressive episodes of
20 weeks duration each (Judd, 1997)
 For patients with 3 or more previous episodes of
depression (77% of the sample) MBCT significantly
reduced (almost halved) risk of relapse recurrence rates
compared with TAU
Conclusion


Does CBT need to be combined with antidepressants in
order to be effective with severely depressed outpatients?
-16 weeks of CBT produced a 1 year follow up success
rate that equaled or slightly exceeded that achieved by a
full year of antidepressant treatment , and CBT’s
maintenance effects were clearly superior to short term(16
weeks)
Conclusion
About one third of MDD patients will not respond favorably
to the first psychosocial treatment
We know through crossover studies that many individuals
who fail on one antidepressant will experience treatment
gains when switched to a different medication
No present empirical data to guide clinicians providing
psychotherapy for patients who have failed to improve
following an initial psychosocial intervention
Conclusion

MM based clinical interventions may hold
considerable therapeutic promise, either
alone or in combination with other forms of
intervention