Transcript Mindfulness-based Depression Treatment through Web and

ABSTRACT
Developed for home-based treatment of depression in people with epilepsy,
Project UPLIFT was based upon Mindfulness-based Cognitive Therapy for
depression. It includes 8 modules, group-delivered by either telephone or
Web. Trainees and people with epilepsy co-facilitate the groups, supervised by
a licensed mental health professional. These factors make Project UPLIFT a
relatively low-cost intervention.
Preventing Depression in People with Epilepsy:
An Extension of Project UPLIFT
The goals of this study were to: revise the Project UPLIFT materials for use in
prevention (rather than treatment) of depression and estimate their
effectiveness; and determine whether any effect was maintained.
Participants were recruited through: Emory University, University of Michigan,
University of Texas—Houston, and University of Washington. Those who met
criteria and consented were randomly assigned to one of two conditions:
UPLIFT or a Treatment-as-usual (TAU) waitlist. Within each condition, people
who required a particular delivery mode (Web or telephone) were assigned to
that delivery group and the rest were assigned to equalize the groups.
In the final sample (n=108), the prevention-modified UPLIFT materials were
found effective in significantly: reducing the incidence of depression; reducing
depressive symptoms on three different measures; reducing number of
seizures in the past 4 weeks; increasing knowledge and skills related to
depression and mindfulness; and increasing satisfaction with life. Results
showed a dose-response relationship with number of sessions attended.
Decreased symptoms of depression persisted over the average of 10.5 weeks
of follow-up.
Although developed for people with epilepsy, UPLIFT can easily be adapted to
prevent depression in other disparity populations.
Nancy J. Thompson, Ph.D., M.P.H., Charles E. Begley, Ph.D., Robert T. Fraser, Ph.D.,
Linda M. Selwa, M.D., & Archna Patel, M.P.H.
RESULTS
METHOD
Outcome Phase
Maintenance
 Maintenance over the 8 weeks from interim to posttest was also
assessed. Consistent with the cross-over design, the two
conditions did not differ at baseline, differed at interim, and did not
differ at follow-up.
 Results indicated that the intervention was effective.
Table 2. Differences in Depressive Symptoms by Time
 The incidence of MDD was 0.0% in the intervention group, and
Measure
Participants
Formative Phase
 The Project UPLIFT Preventive Intervention is intended for Englishspeaking people with depressive symptoms, but who do not meet
criteria for major depression.
 The materials were modified and found to be acceptable to the people
with epilepsy.
 The first 42 people from each state who scored between 9-26 on the
Center for Epidemiologic Studies Depression Scale (CES-D) were
asked to provide consent for randomization into the study.
Measures
 Repeated measures ANCOVA found that depressive symptoms
decreased more in the intervention group than the TAU group from
Pretest to Interim for all depression measures except the NDDI-E.
 Beck Depression Inventory (BDI)
 Patient Health Questionnaire-9 (PHQ-9)
colleagues 1
In a review of depression, suicide, and epilepsy, Jones and
reported that the rate of depression in people with epilepsy is between
32% and 48%. Suicide rates among people with epilepsy also are
much higher than in the general population. One study reported that
14% of deaths in people with epilepsy were attributable to suicide. 2
Boylan and colleagues 3 found that depression more strongly predicted
reduced quality of life than did seizure frequency.
Originally funded by the Centers for Disease Control and Prevention
(CDC) as a home-based treatment for depression in people with
epilepsy, Project UPLIFT was developed to provide group delivery of
depression treatment by telephone or Web.
OBJECTIVES
The goals of this multi-site project funded by the
National Center for Minority Health and Health
Disparities were to:
(1) revise the Project UPLIFT materials for use in
prevention (rather than treatment) of depression;
and
(2) estimate their effectiveness in reducing the risk
of depression in people with epilepsy.
Project UPLIFT
Based upon Mindfulness-based Cognitive Therapy for Depression,4 the
UPLIFT materials include modules for eight sessions. Each session
was designed to be one hour in length and was comprised of the
following components:
1. Check-in period
4. Skill-building exercise
2. Teaching on topic of the week 5. Homework assignment
3. Group discussion
Results of the effectiveness of Project UPLIFT for treatment found it
significantly reduced symptoms of depression more than a treatmentas-usual (TAU) waitlist condition.5
References:
1Jones, J. E. et al. (2005). Screening for major depression in epilepsy with common
self-report depression inventories. Epilepsia, 46, 731-735.
2Fukuchi, T. et al. (2002). Death in epilepsy with special attention to suicide cases.
Epilepsy Research, 51, 233-236.
3Boylan, L. S. et al. (2004). Depression but not seizure frequency predicts quality of
life in treatment resistant epilepsy. Neurology, 62, 258-261.
4Segal, Z. V. et al. (2002). Mindfulness-Based Cognitive Therapy for Depression: A
New Approach to Preventing Relapse. New York: Guilford.
5Thompson, N. J. et al. (2010). Distance delivery of mindfulness-based cognitive
therapy for depression: Project UPLIFT. Epilepsy & Behavior, 19, 247-254.
6Thompson, N. J., & McClintock, H. O. (1998). Demonstrating your program’s worth:
a Primer on evaluation for programs to prevent unintentional injury. Atlanta: Centers
for Disease Control and Prevention, National Center for Injury Prevention and
Control.
7Gillham, J. et al. Preventing depression: A review of cognitive-behavioral and family
interventions. Appl & Prev Psychol, 2006 (9): p. 63-88.
 Number of Seizures
Measure Condition
 Satisfaction with Life
n
Mean
Baseline
Mean
Interim
Interaction
F
df
pvalue
mBDI
UPLIFT
Procedure: Formative Phase
52
20.090
 Two focus groups of people with epilepsy who participated in Project
UPLIFT for treatment assisted in re-evaluating the appropriateness of
the revised intervention. One of the two facilitators of the focus groups
was a person with epilepsy.
BDI
PHQ-9
TAU
56
20.113
19.735
UPLIFT
52
7.143
5.129
TAU
54
6.344
6.672
UPLIFT
52
6.222
6.005
TAU
56
5.704
6.871
6.588
1, 105 .012*
8.254
1, 103 .005**
3.951
1, 105 .049*
Procedure: Outcome Phase
Randomization
 Supervised by a licensed clinical psychologist at Emory University,
each intervention group was lead by two co-facilitators: a graduate
student in public health and a person with epilepsy.
 There was no difference in change in depressive symptoms between
delivery method of telephone vs. Web (see graph below).
 Additional analyses found significant differences between UPLIFT
 The impact and outcome of the prevention intervention were assessed
using a cross-over design.6
and TAU for change in the following:
 Self-reported number of seizures in the past 4 weeks
 A maximum of 168 participants were randomly assigned to intervention
or waitlist.
 Increase in knowledge and skills related to depression and
mindfulness
 Those with a preference for a particular mode of delivery were
assigned to that mode, and the remainder were assigned to
equalize the groups.
 Each stratum was comprised of six 7-person groups. After the first
28 people were recruited from a state, they were randomly
assigned to a group in one of four strata, and the groups
commenced.
 Increased satisfaction with life
mBDI by Intervention Type
Self-reported Number of
Seizures
40
30
25
 When the final 14 participants from a state were recruited, they were
assigned to either telephone and waitlist or Web and waitlist,
depending on the availability of Web access for the participants;
thereafter they followed the same schedule. A schematic
representation of the cross-over design follows:
Stratum
1
20
Pretest
7.6
6.9
0.415
1, 116 .521
Interim
5.1
7.2
4.453
1, 105 .037*
Posttest
6.3
5.5
0.356
1, 85
Pretest
20.8
19.7
0.440
1, 116 .508
Interim
16.3
19.7
4.224
1, 105 .042*
Posttest
18.5
17.2
0.419
1, 85
.553
.519
DISCUSSION
A number of features of Project UPLIFT make it particularly attractive
for use in preventing depression, especially among disparity
populations with regard to access to care.
Low cost
 Led by trained facilitators supervised by a licensed clinical
psychologist, this intervention was relatively low cost.
Accessible
 In addition, delivery by Web and telephone reduced access
problems, thereby reducing health disparities for those who were
mobility-limited or located in rural areas.
Supportive
 The formative and process evaluations indicated that group
delivery was very important for these people with epilepsy, many
of whom had never spoken to anyone else with the condition.
Effective
Web
TAU
CONCLUSIONS
10
5
0
Pretest
Interim
Phone vs. Web vs. Waitlist
Finteraction = 3.46, p=.035
Knowledge & Skills
Treatment vs. TAU Waitlist
Finteraction = 5.178, p = 0.025
Satisfaction with Life
8 weeks
follow-up
Stratum
8-week Web
Interim
2
intervention
Posttest
Pretest
Test
Stratum
8-week phone
3
intervention
8 weeks
TAU
Stratum
8-week Web
4
intervention
pvalue
Phone
15
 When the 8-week intervention was complete in these groups, there
were 3 weeks to complete the interim assessment before the groups
assigned to the other two strata received the intervention; one each by
telephone and Web.
df
 The outcome evaluation found that it was effective in reducing the
incidence of Major Depressive Disorder (MDD) among those who
had symptoms of depression but did not yet meet criteria for MDD.
35
Intervention Delivery and Assessment
 First, two of the groups received the prevention intervention: one by
telephone conference call, and one by Web.
UPLIFT
TAU Interaction
Intervention Waitlist
F
16.266
mBDI
 The modules were reviewed for language and/or activities that were
specific to treatment, and modified for prevention.
8-week
phone
intervention
BDI
Table 1. ANCOVA Results for Depressive Symptom Measures
 Knowledge and Skills
Statement of the Problem
Time
10.7% in the TAU group (Fisher’s Exact 2-tailed probability = .028).
 Modified Beck Depression Inventory (mBDI)
INTRODUCTION AND BACKGROUND
RESULTS (continued)
This study found that Project UPLIFT can also be
effective for prevention, adding the benefits of:
(1) avoiding disability and lost productivity associated
with depression;7
(2) eliminating tangible and intangible costs
associated with treating depression after it has
occurred;
(3) providing people with the skills to manage future
stress and difficult life circumstances.
For additional information please contact:
Treatment vs. TAU Waitlist
Finteraction = 4.184, p = 0.043
Treatment vs. TAU Waitlist
Finteraction = 7.898, p = 0.006
Nancy J. Thompson, Ph.D., M.P.H.
Behavioral Sciences and Health Education
Rollins School of Public Health, Emory University
[email protected]