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Mindfulnessbased cognitive therapy for prevention of relapse recurrence in depression

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CBT Model Dysfunctional attitudes represent high risk ' ... Priming affected DAS more in pharmacotherapy than CBT patients ' ... – PowerPoint PPT presentation

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Title: Mindfulnessbased cognitive therapy for prevention of relapse recurrence in depression


1
Mindfulness-based cognitive therapy for
prevention of relapse/ recurrence in depression
  • Mark Williams
  • University of Oxford
  • Department of Psychology

Collaborators Zindel Segal, John Teasdale,
Judith Soulsby
Plus Slides from http//obssr.od.nih.gov/BSSRCC/M
indfulness/Zindel20Segal.pdf
2
Mindfulness Based Cognitive Therapy
  • Background
  • Relapse and recurrence in depression
  • Previous approaches to maintenance of treatment
    gains
  • Modelling cognitive risk
  • Development of MBCT
  • Outcome evidence

3
Depression recurrence
  • Lifetime risk estimates 6-17
  • For 5-10, full episode persists 2 years
  • For 20-25, only partially recovery between
    episodes
  • More than 50 who do recover will have at least
    one further episode
  • Those with history of 2 or more episodes have
    70-80 chance of recurrence

4
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5
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6
Previous approaches - 1
  • Continue treatment beyond initial response
  • antidepressant medication
  • continue patients at dosage used to achieve
    remission
  • psychotherapies
  • Interpersonal Psychotherapy (IPT-M)
  • Cognitive Behaviour Therapy (CBT)

7
Previous approaches - 2
  • Use acute treatments that give long-term
    protection
  • best evidence is when CBT has been used in acute
    phase

8
Questions
  • How does CBT reduce risk?
  • What are the psychological factors that make
    someone high risk for relapse and recurrence?
  • Can we teach these skills to patients after they
    have recovered using antidepressants?

9
Cognitive risk factors
  • CBT Model Dysfunctional attitudes represent
    high risk
  • I cannot find happiness without being loved by
    another person
  • I should be happy all the time
  • Turning to someone else for advice or help is an
    admission of weakness
  • BUT Most show Dysfunctional Attitudes get back
    to normal when patient recovered
  • Later research Reactivation of Content and
    Process

10
Differential Activation
Hopelessness
Negative Self-referent Thinking
Memory Bias
Depressed Mood
Dysfunctional Attitude
Fatigue
11
Differential Activation
Hopelessness reduced
Self-referent Thinking normal
Memory Unbiased
Non-Depressed
Attitudes Normal
Fatigue normal
12
Effect of Mood Challenge
Hopelessness
Hopelessness
Negative Self-referent Thinking
Negative Self-referent Thinking
Memory Bias
Memory Bias
Depressed Mood
Depressed Mood
Dysfunctional Attitude
Dysfunctional Attitude
Fatigue
Fatigue
Never depressed
Recovered depressed
13
Priming and recurrence
  • Segal et al (J. Abnormal Psychology, 1999)
  • CBT vs Pharmacotherapy
  • Patients in remission
  • DAS (Time 1) mood priming DAS (Time 2)
  • Results
  • Priming affected DAS more in pharmacotherapy than
    CBT patients
  • primed DAS (Time 2) predicted relapse and
    recurrence
  • How does the mind react when feeling off-track?

14
Cognitive risk mechanism
NO RELAPSE
Negative thinking patterns nipped in the bud
Negative thinking EPISODE
Non-negative thinking REMISSION
POTENTIAL RELAPSE
Negative thinking patterns re-established
LOW MOOD Reactivation of negative thinking
RELAPSE
15
Spiralling Down
This is not what I want Discrepancy between
where I am and where I want to be
Rumination Where did I go wrong? Where will it
end?
16
Outcome Achieved! How?
  • Discrepancy-based processing
  • I had to compare
  • where I was now (current state)
  • with
  • where I wanted to be (my destination or desired
    outcome
  • and
  • where I did not want to be (my non-destination or
    outcome to be avoided)

17
Doing Mode
  • Judging discrepancies
  • Uses thoughts (conceptual)
  • Takes thoughts as real
  • Uses past and future
  • Keeps in mind what to avoid
  • Automatic

18
Applying Doing Mode to mood
  • Where am I?
  • feeling lonely
  • What do I want to be?
  • to be happy
  • What do I want to avoid?
  • another episode of depression
  • feeling dreadful
  • having no friends

Judging discrepancies Uses thought Thoughts as
real Past and future Avoidant Automatic
19
  • Can mindfulness approach help?
  • Jon Kabat-Zinn Full Catastrophe Living
  • Mindfulness-based Stress Reduction (MBSR U-Mass
    Medical Centre)

20
Mindfulness
  • Mindfulness means paying attention in a
    particular way.
  • on purpose
  • in the present moment
  • non-judgmentally.
  • Jon Kabat-Zinn

21
Being mode a different way of seeing
22
Overview of MCBT
  • Eight weekly classes plus all-day session. Each
    2 2.5 hours
  • Pre-class interview
  • To explain, motivate and point out the commitment
    that will be necessary
  • Up to 12 in each class (Kabat-Zinn 30 in each
    class)
  • Homework up to one hour per day, 6 days a week
    mostly audiotapes of mindfulness practice
    generalisation practice
  • Pattern
  • First half concentration/steadying the mind
  • Second half wider awareness relapse prevention

23
Key practices in MBCT
  • Mindfulness of routine activities (e.g eating)
  • Body scan
  • (awareness of sensations in the body learning to
    direct attention to different parts of the body)
  • Mindfulness of the breath
  • (concentration on a single focus), then moving to
    mindfulness of
  • sounds, the whole body, and thoughts
  • Yoga practice and gentle movement exercises
  • Three minute Breathing Space
  • Scheduled regularly in working day, and
    additionally when under stress

24
Homework Overview (Weeks 1-4)
25
Homework Overview (Weeks 5-8)
26
Teasdale et al. (2000)
27
Teasdale et al. (2000)
28
Baseline differences between patients with
patients with 2 vs 3 previous episodes
  • Age
  • 2 episodes 38.9
  • 3 episodes 44.6 (p
  • Age at first onset of depression
  • 2 episodes 33.4
  • 3 episodes 25.0 (p
  • History (years)
  • 2 episode 5.5
  • 3 episode 19.6 (p

29
Outcome trial results
  • No difference in use of Antidepressant medication
    over 12 month follow-up period
  • Risk of relapse in TAU determined by history
  • Number of previous episodes in TAU
  • If 2 p(relapse) 31
  • If 3 p(relapse) 56
  • If 4 p(relapse) 72
  • In MBCT Effect of previous episodes removed

30
Procedural replication (Ma Teasdale, 2004, J.
Consult. Clin. Psychol.)
  • N 75 recovered from MDD
  • 3 or more episodes (75 of sample)
  • TAU -78 relapse
  • MBCT -36 relapse
  • 2 episodes (25 of sample N18)
  • TAU -2/10
  • MBCT -4/8

31
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32
Outcome trials summary
  • First multi-centre RCTs of clinical intervention
    based on mindfulness
  • For more serious patients (history of 3
    episodes), MBCT halves chances of relapse
  • MBCT may be effective for autonomous relapse
    processes
  • Highly cost effective (because class-based
    approach) Clinician time per patient average
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