Transcript Project UPLIFT

Nancy J. Thompson, Ph.D., M.P.H.
Elizabeth R. Walker, M.A.T., M.P.H.
Rollins School of Public Health of Emory University
Ashley Winning, M.P.H.
Harvard School of Public Health
Disclosure
We have no actual or potential
conflict of interest in relation to
this presentation.
Ashley Winning, M.P.H.
Harvard School of Public Health
Harvard University
1This work was done at the Rollins School of Public Health
of Emory University
Using Practice and
Learning to Increase Favorable Thoughts
Project UPLIFT
 Was designed for delivery of mindfulness-based
cognitive therapy by telephone and Internet
 The version of Project UPLIFT presented here was
designed for people with epilepsy
 The work we are presenting today was funded by the
Centers for Disease Control and Prevention
 The participants described all resided in the State of
Georgia because of concerns surrounding the statelevel licensing of mental health professionals
The Content
About Cognitive-Behavioral
Therapy (CBT)
• Designed by Aaron Beck to address the unrealistic
thinking and outcome expectations associated with
depression.
• Uses verbal techniques to investigate the reasoning
behind specific attitudes and assumptions.
• Client is taught to recognize, monitor, and record negative
thoughts on a daily record.
• Beck recommends first including behavioral techniques,
like assigning activities to help structure the depressed
individual who may have trouble getting started
– using pleasurable activities for reinforcement,
– breaking tasks into simple steps,
– providing assertiveness training,
– guidance in role-playing and mental rehearsal.
A Recent Addition—Mindfulness
 CBT focuses on changing thought content while
mindfulness changes relationship to the thoughts—
helps to see them as passing events that do not
necessarily represent a state of reality.
 Mindfulness is especially important in preventing
relapse, which often occurs with depression.
 We used Jon Kabat-Zinn’s definition of “paying
attention in a particular way: on purpose, in the
present moment, and non-judgmentally.”
UPLIFT was guided by Mindfulness-based
Cognitive Therapy for Depression
 Developed by Segal, Williams, and Teasdale
MBCT Sessions
UPLIFT Sessions
1. Automatic Pilot
1. Monitoring Thoughts
2. Dealing with Barriers
2. Challenging and Changing Thoughts
3. Mindfulness of the Breath
3. Coping and Relaxing
4. Staying Present
4. Attention and Mindfulness
5. Allowing/Letting Be
5. The Present as a Calm Place
6. Thoughts are not Facts
6. Thoughts as Changeable and
Impermanent
7. How can I best take care of myself?
7. Pleasure and Reinforcement
8. Using what has been learned in the
future
8. Relapse Action Plans
Telephone Version
Session Four:
Attention and Mindfulness
Time
Activity
Description
10 minutes
Check-in
 The group will report on their experiences with Modifying &
Relaxation and help each other with any problems.
10 minutes
Teaching
 Group will learn about the concepts of Mindfulness & the
importance of paying attention.
10 minutes
Group Exercise
 The Pebble Exercise is an activity in mindful attention. The
group will practice what they learned during the teaching
portion of the session.
10 minutes
Discussion
Discussion of the Pebble Exercise/describe pebble to group.
15 minutes
Skill-building
w/ discussion
 Mindfulness of a routine activity: Walking Meditation. The
Walking Meditation is meditation in motion; it allows us to
practice mindfulness in the most routine of activities.
5 minutes
Review &
Homework
 Homework: Monitoring with Modification and Practicing
Mindfulness of Routine Activities 3 times during the week.
Web Version
Session One:
Monitoring Thoughts
Activities were Adapted
• For depression treatment
• For distance delivery
• For people with epilepsy
UPLIFT Activity
MBCT Activity
The “What-ifs” of Epilepsy (S1)
---
ARMed Against the Blues (S2)
---
Body Scan and Progressive Muscle
Relaxation (S3)
Body Scan (S1)
Pebble Exercise (4)
Raisin Exercise (S1)
Guided Meditation on Pleasure (S7)
Pleasant Events Calendar (Session 2)
The Structure
Group Delivery at a Distance
 UPLIFT was delivered by Web and
telephone to people in groups of 6-7
 Group Delivery was important for support
surrounding Epilepsy
 The Web platform used was Blackboard
 Laptops and Internet access were provided
for people assigned to the Web condition
who did not have computers or Web access
Group Facilitation
 Groups were co-facilitated
 One facilitator was a graduate student in Public
Health to ensure the integrity of the delivery
 The other facilitator was a person with epilepsy
to build capacity in the epilepsy community
 A licensed psychologist supervised the
facilitators and provided back-up
 Listened to telephone tapes
 Monitored Web discussions
Potential Benefits
• Cost-effective
• Can reduce access problems, reducing health
disparities
• mobility limited
• rural
• Allows group delivery even for rare conditions
• Potential for anonymity and avoidance of
stigma
• Teaches skills to prevent relapse
Elizabeth Walker, M.P.H., M.A.T.
Rollins School of Public Health
Emory University
Evaluation Purposes:
 Determine the acceptability of Project UPLIFT
 Assess the complexities anticipated and encountered
when participating
 Evaluate the overall response to the program
components
Participants
 Formative Evaluation
 n=9
 Focus groups (n=3)
 Process Evaluation
 n=38
 Survey following
participation
 Tertiary epilepsy clinic
Focus Group
n=9
Pilot
Participants
n=38
Age (years), Mean (SD)
Depression score, Mean (SD)
Range
Gender, n (%)
Female
Race, n (%)
White
Black
Marital Status, n (%)
Married
Single
Separated/Divorced/Widowed
Employment Status, n (%)
Full-time
Part-time
Student
Not working or retired
Seizures in the past 4 weeks, n (%)
Yes
Type of seizure usually experienced
General
Partial
Other
Unknown
Severity of recent seizures (in past 4
weeks)
Very Mild
Mild
Severe
Very Severe
33.6 (10.69)
35.1 (10.98)
22.4 (5.59)
14-28
27.2 (7.25)
13-38
7 (77.8)
30 (78.9)
7 (77.8)
2 (22.2)
29 (76.3)
9 (23.7)
15 (39.5)
17 (44.7)
6 (15.7)
11 (28.9)
5 (13.2)
3 (7.9)
19 (50.0)
24 (63.2)
26 (63.2)
11(29.0)
2 (5.3)
1 (2.6)
5 (20.8)
8 (33.3)
7 (29.2)
4 (16.7)
Procedures
Formative Evaluation
Process Evaluation
 Focus groups
 Survey
 Co-facilitated by a PWE
 Client Satisfaction Scale
 Participants received
 Open-ended questions:
 what facilitated participation
in the sessions,
 what they liked,
 what they did not like,
 what they would change
materials in advance
 Discussed proposed materials
and exercises
Data Analysis
Qualitative
Quantitative
 Focus groups (formative)
 A priori codes: acceptability,
complexity, program
components
 Emerging themes
 Client Satisfaction Scale
 Open-ended survey questions
(process)
 Focus group codebook
 Emerging themes
(process)
 Descriptive statistics
 Independent t-tests used to
examine differences in
satisfaction between:


Delivery groups (phone vs
Internet)
Treatment groups (initial
treatment vs waitlist control)
Results: Qualitative
Theme
Acceptability
Complexity
•
•
•
•
•
•
•
•
Comments
Exercises were “functional” and “practical”
Program had great value
Learned useful skills
Program helped more than antidepressants
Difficulties participating due to:
• physical limitations
• time commitments
• feelings of guilt for taking time
Scheduling
Not connected with group
Felt embarrassed or nervous
Results: Qualitative
Theme
CBT exercises
Relaxation exercises
Mindfulness exercises
Comments
Benefits:
 Useful to write down thoughts
Issues:
 Difficult to identify one thought and one feeling
 Not enough variety in CBT homework activities
Benefits:
 Facilitates relaxation
 Helpful in relieving stress
 Can become aware of tension in the body
Issues:
 Feel more tense
Benefits:
 Allows for time to quiet thoughts
 Can do it anywhere
Issues
 Prefer a more direct link between epilepsy and mindfulness
 Mindful attention is hard to do
Results: Qualitative
Theme
Delivery
Comments
• Include in-person meeting at the end
• Incorporate phone and web aspects together
• More intimate than web
Phone
• People talked over each other
• Smaller groups or longer session
• Anonymous
Web
• Someone will always be on
• Low participation, lack of connection
• Difficulties navigating the site and using the discussion board
• Connect with group members because everybody had epilepsy
Group setting
• Liked sharing with group members
• Learn from each other, see different perspectives
• When group ended, support taken away
Living with Epilepsy • Impact of epilepsy on lives and relationships
• Stigma
Results: Quantitative
 Mean CSQ score = 28.66 (SD=3.411)
 Delivery Method: Web vs. Phone
 Phone group reported higher satisfaction (p=.08)
 Treatment Group: Initial group vs. Waitlist control
 No significant difference in satisfaction
Limitations
 Formative evaluation – small sample
 Process evaluation – attrition
 Recruited from tertiary epilepsy clinic
 Social desirability – evaluations conducted by study
staff
Discussion
 Project UPLIFT materials and exercises viewed as:
 Beneficial
 Acceptable
 Taught needed skills
 Phone group more satisfied than Web group
 Barriers to participation: health problems, time
restrictions, scheduling difficulties, and lack of connection
 Group design was a key component
Implications
 Mindfulness-based CBT program delivered over phone
or Web perceived to be beneficial
 Building skills to reduce depressive symptoms
 Creating connections between PWE
 Provide hard-to-reach populations with an acceptable
method of treatment for depression
Nancy J. Thompson, Ph.D., M.P.H.
Rollins School of Public Health
Emory University
Design—Outcome Evaluation
• Comparison Group: treatment-as-usual
Stratum 1:
Pretest
8 wk phone
Interim
as usual
Follow-up
Stratum 2: Pretest
8 wk Web
Interim
as usual
Follow-up
Stratum 3: Pretest
as usual
Interim
8 wk phone
Follow-up
Stratum 4: Pretest
as usual
Interim
8 wk Web
Follow-up
Baseline
Week 8
Week 16
Participation
 Screened Eligible (n=53)
 Assessments
 Completed Baseline (n=48)
 Completed Interim Survey (n=40)
 Completed Third Survey (n=35)
 Participated in at least one session




Phone Intervention Group (n=12)
Web Intervention Group (n=10)
Phone Waitlist Group (n=10)
Web Waitlist Group (n=10)
 40 (75.5%) participated and completed the
assessment following their participation
Measures
• Mediators
– Knowledge & Skills—developed with UPLIFT
– Depression Coping Self-efficacy
– Self Compassion
• Outcomes
– Depression
– mBDI
– Patient Health Questionnaire (PHQ-9)
– Neurological Disorders Depression Inventory for
Epilepsy (NDDI-E)
– Quality of Life
– SF-36 Physical and Mental Health QOL
– Satisfaction with Life
Data Analysis
 Baseline Differences
 Only mean Self Compassion was statistically significant
(t = 3.00, df = 38, p = 0.005)


Intervention group (mean = 19.7)
Waitlist group (mean = 16.0)
 Repeated Measures ANCOVA
 Assessed the change in scores over time in the
intervention and the waitlist groups
 Controlled all analyses for Self Compassion
Knowledge/Skills
& Self-Efficacy
Measure
Time
Intervention
TAU Waitlist
Finteraction
P-value
df 1,37
Knowledge/Skills
Pretest
Interim
122.5
136.3
123.5
126.0
4.75
0.036*
Depression
Coping
Self-Efficacy
Pretest
Interim
67.7
75.5
72.4
72.9
3.59
0.066
Depression: BDI
40.0
 UPLIFT vs. Waitlist
(treatment as usual)
 Foverall = 42.22, p=.0001
 Finteraction = 11.99, p=.001*
35.0
30.0
25.0
Intervention
20.0
Waitlist
15.0
10.0
5.0
0.0
Pretest
Interim
Depression: BDI
By Intervention Type
BDI
40
35
• Phone vs. Web vs. Waitlist
(treatment as usual)
 Foverall = 41.65, p=.0001
 Finteraction = 5.93, p=.006*
30
25
Phone Tx
20
Web Tx
15
Waitlist
10
5
0
Pretest
Interim
 No difference with Major Depressive Disorder
at baseline or not
(F1,35= 1.21, p = 0.279)
 Maintenance
Measure
Time
Intervention Treatment
-as-Usual
F
df
p-value
Waitlist
BDI
Pretest
14.5
13.4
0.121
1,30
0.730
Interim
4.6
10.8
7.541
1,30
0.010*
Posttest
5.7
8.3
1.124
1,30
0.297
Quality of Life
Measure
Time
Intervention
Tx As Usual
Waitlist
Finteraction
P-value
df 1,37
Satisfaction
with Life
Pretest
Interim
18.2
21.0
18.3
18.0
3.029
0.0901
Mental
Health QOL
Pretest
Interim
59.3
80.9
65.4
83.6
0.123
0.727
Physical
Health QOL
Pretest
Interim
68.9
78.9
76.2
80.8
0.496
0.486
1.05<p<.10
QOL Results
 Consistent with the premises of mindfulness
 that suffering is not something to turn away from or
something in need of fixing,
 that it is worthy of attention,
 that through attention we can see the ways in which we
attach thoughts to the suffering that exacerbate it, and
 that letting go of these thoughts reduces suffering (Segal
et al.)
Summary
 UPLIFT was effective in:
 Reducing Depressive Symptoms and teaching Knowledge
and Skills associated with reducing depression



Intervention group showed significant improvement
compared to the waitlist
Equally effective for those with and without MDD
Reduction in depressive symptoms maintained
 Approached significance for Depression Coping Self-
Efficacy and Satisfaction with Life
 Delivery
 Both phone and Web were significantly more effective in
reducing depression than treatment-as-usual condition
Going Forward
 ~$1 million Challenge Grant--UPLIFT for
Prevention
 Managing Epilepsy Well Network
 Participants in 4 states
 Georgia
 Michigan
 Texas
 Washington
 Application to other populations
(MS, caregivers, workplace)