Transcript Project UPLIFT - Emory University

Nancy J. Thompson, Ph.D., M.P.H.
Rollins School of Public Health
Emory University
Project UPLIFT
 Using Practice and Learning to Increase Favorable
Thoughts
 Delivery of mindfulness-based cognitive therapy by
telephone and Internet
 To people with epilepsy
 Most of the work presented here was funded by the
Centers for Disease Control and Prevention
About Mindfulness-based Cognitive
Therapy (MBCT)
• Cognitive Therapy addresses the unrealistic
thinking associated with depression.
• Uses verbal techniques to explore the reasoning
behind specific attitudes and assumptions.
• Client is taught to recognize, monitor, and record
negative thoughts on a daily record.
• CBT focuses on changing thought content while
mindfulness changes relationship to the
thoughts—see them as passing events that do not
necessarily represent a state of reality.
• Mindfulness is important in preventing relapse.
Cognitive Therapy vs. Medications in the
Treatment of Moderate to Severe Depression
Across the 3 treatments ([chi]22 = 10.22, P = .006).
ADM vs. pill placebo ([chi]21 = 10.17, P = .001),
CT vs. pill placebo ([chi]21 = 4.44, P = .04)
ADM vs. CT ([chi]21 = 0.71, P = .40).
Between sites:
Wald [chi]22 = 1.59, P = .45
Follow-up after Mindfulness vs. Treatment
as Usual for the Treatment of Depression
Intent to Treat
4+ Sessions
Project UPLIFT
 Delivery of MBCT by Web and Telephone Groups
 People with epilepsy randomly assigned to groups of 7
 Initially computers and Internet access provided if needed
 Group delivery important for support surrounding epilepsy
 Co-Facilitators
 Graduate Public Health Student
 Person with epilepsy
 Supervised by a licensed psychologist
Potential Benefits
•
•
•
•
•
Cost-effective
Can reach the mobility/transportation limited
Equal reach to urban and rural
Allows peer support, even with rare conditions
Potential for anonymity and avoidance of
stigma
• Can prevent relapse
• Does not require more medication
• Mindfulness may improve attention/cognition
Project UPLIFT
 8 Sessions (1 hour by phone)
Noting
Session #
Challenging/Changing
Impermanent
Topic
1
2
Monitoring Thoughts
3
Coping and Relaxing
4
Attention and Mindfulness
5
The Present as a Calm Place
6
Thoughts as Changeable and Impermanent
7
Pleasure and Reinforcement
8
Relapse Action Plans
Challenging and Changing Thoughts
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
Formative Evaluation Focus Groups
Importance of Group
 “Medical professionals can tell you the what, the why, the
diagnosis, but in a group of people with epilepsy, there’s
camaraderie and you can see what other people go
through.”
 “Being in a group with other people with epilepsy is like
sharing with your close friends. You realize that everyone
has their insecurities and you feel more safe.”
Response to Activities
 “If I could learn to modify my thoughts, that would be
practical.”
 “The good thing about doing mindfulness of sounds and
thoughts is that you can do it anywhere.”
Design—Outcome Evaluation
Stratum 1:
Pretest
6-8 wk phone
Interim
as usual
Follow-up
Stratum 2:
Pretest
6-8 wk Web
Interim
as usual
Follow-up
Stratum 3: Pretest
as usual
Interim
6-8 wk phone
Follow-up
Stratum 4: Pretest
as usual
Interim
6-8 wk Web
Follow-up
Baseline
Week 8
Week 16
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 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
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
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
Summary
 Effective in:
 Reducing depressive symptoms and teaching knowledge
and skills associated with reducing depression
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Intervention group showed significant improvement
compared to the waitlist
Equally effective for those with and without MDD
Reduction in depressive symptoms maintained
 Approaching significance for Satisfaction with Life and
Depression Coping Self-Efficacy
 Delivery
 Both phone and web were significantly more effective in
reducing depression than waitlist condition
Participants’ Comments
 “I told my therapist I think I like this way a lot better…I’ve
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always went and talked to somebody versus learning to
work through things just using my own mindset.”
“The project had great value. I'm thankful that I was able to
participate. I got a lot out of the exercises and coping skills.”
“The program was very helpful and that surprised me. I
printed everything out and recorded the meditations onto
my MP3 player.”
“The program helped me more than the antidepressants I've
been on for years.”
“Thank you for helping me because I have been depressed
and now I can cope.”
Potential Benefits
•
•
•
•
•
Cost-effective
Reaches the mobility limited
Equal reach to urban and rural
Can form groups even with rare conditions
Potential for anonymity and avoidance of
stigma
• Prevent relapse
Project UPLIFT
Next Phase
 ~$1 million Challenge Grant
 UPLIFT for Prevention
 Participants in MEW network states
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Georgia
Michigan
Texas
Washington