|Year : 2022 | Volume
| Issue : 2 | Page : 126-131
Effectiveness of adjunctive telemode mindfulness-based cognitive therapy on symptom severity and quality of life in patients with depression
Diksha Sachdeva1, Harprit Kaur2, Ajit Avasthi3, Sandeep Grover4
1 Department of Psychiatry, PGIMER, Chandigarh, India
2 Department of Psychology, Punjabi University, Patiala, Punjab, India
3 Department of Mental Health and Behavioural Sciences, Fortis Hospital, Mohali, Punjab, India
4 Department of Psychiatry PGIMER, Chandigarh, India
|Date of Submission||05-Feb-2022|
|Date of Decision||10-Mar-2022|
|Date of Acceptance||12-Mar-2022|
|Date of Web Publication||13-Jan-2023|
Ms. Diksha Sachdeva
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
Background: Mindfulness-based cognitive therapy (MBCT) is reported to improve depression. However, little information is available about the effectiveness of MBCT interventions online. The aim of this study was to evaluate the effect of adjunctive telemode MBCT on the symptom severity and quality of life in patients with depression. Methods: 15 adult patients aged 18–55 years diagnosed with depression received 8-week adjunctive MBCT intervention to the ongoing treatment as usual for all (TAU) delivered through online mode. 12 participants completed the therapy and were reassessed. Patients were assessed at the baseline on Beck Depression Inventory (BDI), Five Facet Mindfulness Questionnaire, and World Health Organization-Quality of life BREF scale. Results: There was statistically significant reduction in the severity of depressive symptoms (P < 0.003) as assessed on the BDI. It led to remission in two-thirds of the patients partially responding to antidepressants. On the World Health Organization Quality of Life, there was statistically significant improvement on the domains of physical (P < 0.002), psychological (P < 0.002), social (P < 0.002), and environment (P < 0.005) domains. There was a significant improvement in the total Five Facet Mindfulness Questionnaire score. Conclusions: Adjunctive online MBCT appears to be a feasible adjunct to TAU in reducing severity of depression, improving mindfulness, and improving quality of life in patients with depression.
Keywords: Cognitive therapy, depression, mindfulness, online
|How to cite this article:|
Sachdeva D, Kaur H, Avasthi A, Grover S. Effectiveness of adjunctive telemode mindfulness-based cognitive therapy on symptom severity and quality of life in patients with depression. J Mental Health Hum Behav 2022;27:126-31
|How to cite this URL:|
Sachdeva D, Kaur H, Avasthi A, Grover S. Effectiveness of adjunctive telemode mindfulness-based cognitive therapy on symptom severity and quality of life in patients with depression. J Mental Health Hum Behav [serial online] 2022 [cited 2023 Jun 2];27:126-31. Available from: https://www.jmhhb.org/text.asp?2022/27/2/126/367740
| Introduction|| |
Mindfulness-based cognitive therapy (MBCT) is a nonpharmacological treatment program that was specifically developed to address latent vulnerability in depression. The rationale of the treatment is based on findings from cognitive research that suggests that mood-related negative thinking patterns,, rumination, thought suppression, and avoidance are responsible for vulnerability for depression. The basic premise underlying mindfulness practice is to focus on the experience of the present moment in a nonjudgemental way, which can effectively counter the effect of negative thoughts about the past and the future, which tend to occur in depression. MBCT emphasizes on changing the individual's relationship with one's thoughts, differing from the emphasis of cognitive behavior therapy on challenging individuals' thought content. MBCT views thoughts as mental events that pass quickly through one's consciousness, which allows depressed individuals to decrease rumination and negative thinking. In other words, rather than avoiding distressing feelings and thoughts or engaging in ruminative thinking, mindfulness encourages people to objectify any dysfunctional thinking and overwhelming emotional states by seeing them as a passing phenomenon.
Although MBCT was originally designed with the aim of relapse prevention in depression, recent research has shown that the use of MBCT may extend to a broader range of clinical population. Literature has shown the effectiveness of MBCT in patients with depression. A meta-analysis of 12 randomized controlled trials evaluating mindfulness-based interventions for individuals with current anxiety or major depression demonstrated significant beneficial effect with MBCT, compared to control conditions and mindfulness-based stress reduction (MBSR) to be beneficial in reduction in primary symptom severity among patients with current depression.
An exploratory mixed methods study suggested that MBCT has a role to play in treating active depression and anxiety in primary care. The majority of the patients showed improvement in depressive symptoms (72%; 8 out of 11) and anxiety symptoms (63%; 7 out of 11).
A study from NIMHANS, India, examined the effectiveness of MBCT in 15 patients with depression showed significant improvement in depression, work and social adjustment, and quality of life. Another study examined the effects of MBCT on mindfulness skills, acceptance, and spiritual intelligence in patients with depression. The sample consisted of five patients with a diagnosis of recurrent depressive disorder as per the International Classification of Disease, 10th Revision (ICD-10). This study revealed clinically significant reduction in the severity of depression and considerable to significant improvements in acceptance, improvement in mindfulness skills, and spiritual intelligence.
Psychotherapy delivered by telemode has been shown to be effective in various psychiatric conditions. Although different kinds of psychotherapies have been used by the telemode, there is limited data on the utilization of MBCT by telemode. Only one randomized controlled evaluated the utility of online MBCT as an adjunctive intervention for the management of residual depressive symptoms. However, there is a scarcity of research on MBCT in the Asian population. In this background, the current study aimed to evaluate the effectiveness of online MBCT in patients with depression.
| Methods|| |
Study design and participants
This was an open-label study, conducted in a tertiary care hospital, conducted after obtaining Institutional Ethics Committee approval. All the participants were included after obtaining written informed consent. Fifteen patients diagnosed with depressive disorder (first episode or recurrent depressive disorder) as per the ICD-10 by a qualified psychiatrist were recruited from March 2021 to June 2021 from outpatient telepsychiatry services of the Department of Psychiatry of tertiary care hospital. To be included in the study, the participants were required to be aged between 18 and 55 years (both years inclusive) and must have been educated up to the 10th standard.
The following measures were used administered.
This obtained information about age, gender, education, and occupation.
Clinical assessment Proforma
This included provision to record the data for the duration of illness and age of onset and treatment history.
Beck Depression Inventory (Beck et al., 1988)
The Beck Depression Inventory-Second Edition (BDI-II) is a 21-item self-report instrument intended to assess the severity of symptoms of depression. Each item is rated on 4 points (0–3), with total scores ranging from 0 to 63. The internal consistency of the scale is 0.9 and the test-retest reliability ranges from 0.73 to 0.96, and the concurrent validity for the scale ranges from 0.62 to 0.66.
Five Facet Mindfulness Questionnaire
Five Facet mindfulness questionnaire is the 39-item, self-report questionnaire, that measures five facets of mindfulness skills in daily life, i.e., observing, describing, acting with awareness, nonjudging of inner experience, and nonreactivity to inner experience. Each item is rated on a 5-point Likert-type scale ranging from 1 (never or very rarely true) to 5 (very often oral ways true).
The World Health Organization Quality of Life-BREF, Hindi Version
It is a self-administered generic quality of life questionnaire available in Hindi. It is a 26 item shorter version of the World Health Organization Quality of Life-100 (WHOQOL) scale which was developed as a measure that would be applicable cross-culturally. It lays emphasis on subjective evaluation of the respondent's health, living condition and functioning, and quality of life on the dimensions of physical, psychological, environmental, and social domains. Each of these domains is treated as a separate numeric variable, with higher scores indicating better quality of life.
Clinical psychologist initially approached the patients diagnosed with depressive disorder by a qualified psychiatrist through the voice call and was explained about the study. Those who provided verbal consent were evaluated on the selection criteria and all the patients fulfilling the selection criteria were sent the Google form link to complete the written informed consent. Clinical details were obtained from patients, their caregivers, and the treatment records. Self-administer tools (both in English/Hindi language) were provided to the participants through Google forms.
Licensed clinical psychologist conducted MBCT intervention through telemode by using Google meet online platform. The 8 weekly sessions of MBCT were conducted individually for each patient according to a time that was suitable and convenient to the patient and therapist. All the participants were continued on the treatment a usual (TAU) during the process of MBCT. Following the termination of the therapy, participants were again assessed on the same instruments through google form.
MBCT used in this study was adapted from the manual of MBCT for depression developed by Segal et al., 2013. It consisted of 7–12 weekly sessions, each of 60–90 min taken individually for each participant. The sessions focused to enhance the nonjudgemental awareness toward the thoughts, sensations, and feelings and learn to regulate the emotions, without immediately reacting to them. Initially, rapport building and psychoeducation session were taken. The participants were trained to bring mindfulness in their everyday life by bringing awareness to routine tasks such as eating and walking. Activity scheduling and monitoring on mastery and pleasure principle were added to the therapeutic process. The concept of the automatic pilot with rasin exercise was introduced. Body scan was taught in the next session. In the middle phase of therapy, the cognitive model of depression was explained. Thought record assignment was given to enhance awareness toward thoughts and feelings. The 3-min breathing exercise and silent meditation were taught in successive sessions to practice the skills to get detach from thoughts and feelings and view them as mental events and experiencing that thoughts are not facts. Body scan and sitting meditations were translated into the Hindi language and recorded. Both recordings were provided to participants through WhatsApp or E-mail. Some of the longer meditations were made short due to difficulty in concentration for long in patients with depressive symptoms. Body scan was reduced to 30 min and silent sitting was reduced to 15 min. Finally, a relapse prevention session including the plan for further mindfulness practices at home was included. After termination of therapy, tools were given through Google form for postassessment.
Analysis was conducted using the Statistical Package for the Social Sciences, 22 version (SPSS) (IBM Corp. Released 2018. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.). Frequency and percentages were computed for the categorical variables, whereas mean and standard deviation were computed for the continuous variables. The pre and postassessment data were compared by using Wilcoxon signed-rank test.
| Results|| |
In total 15 participants consented for the study, out of which 12 participants attended all sessions and completed postassessment. The mean age of the study completers was 37 years (range: 25–55 years). The majority of the study participants were females (83%), were graduates (50%) or postgraduate (25%), and were married (75%). An equal proportion of patients belonged to nuclear (50%) and joint (50%) families [Table 1].
The majority of the study participants were going through the first episode of depression (75%), and one-fourth of them were diagnosed with recurrent depressive disorder, currently in an episode of depression. Majority (58%) of the patients had depressive disorder of 1–2 years duration, and one-fourth (25%) had duration of illness of 3–5 years. A small proportion (17%) of them had duration of illness of <1 year [Table 1]. All the patients were receiving antidepressant medications in adequate therapeutic doses for at least 1 month before start of the MBCT program. Escitalopram was the commonly prescribed antidepressants (n = 6; mean dose 15 mg/day), followed by sertraline (n = 3; mean dose 133.33 mg/day), and one patient each was receiving venlafaxine (112.5 mg/day) and paroxetine (25 mg/day and mirtazapine (45 mg/day). The mean duration of antidepressant use before start of MBCT was 2.75 months with a median of 2 months.
The mean BDI score at the baseline assessment was 27.92 (standard deviation [SD]: 9.12), which reduced to 10.08 (SD: 7.03) at the end of the therapy and this improvement in the symptoms was statistically significant (P < 0.003). When the improvement in individual depressive symptoms was evaluated, there was a significant reduction in the severity of 15 out of 21 symptoms as noted on BDI, with 8 out of 12 patients achieving remission, i.e., BDI score of <10 [Table 2].
|Table 2: Effectiveness of mindfulness-based cognitive therapy on depression|
Click here to view
On the Five Facets Mindfulness Questionnaire (FFMQ), there was a significant improvement in the total score from baseline total score of 112.67 (SD: 13.7) to 129.5 (20.3). When the scores on individual domains were evaluated, significant improvement was noted for the items of describing and nonreactivity to the inner experience [Table 2]. On the WHO quality of life scale, there was statistically significant improvement in the quality of life in all the domains and the total WHOQOL-BREF score [Table 2].
| Discussion|| |
The present study aimed to assess the effectiveness of the MBCT program delivered by telemode for patients suffering from depression. The present study showed that adjunctive MBCT program can be successfully delivered by the telemode and is useful in the reduction of depressive symptoms, improvement in mindfulness, and improvement in quality of life. Further, the present study suggests that when used as an augmentation treatment, MBCT can lead to remission in two-thirds of the patients partially responding to antidepressants.
Our findings align with prior evidence for the available data on the effectiveness of MBCT in patients with depression., This study also showed that online MBCT can be effectively delivered and has been reported as effective as in-person MBCT. Our findings are supported by another study that reported significant improvement in depression with therapies delivered by mental health-based apps. In terms of individual items of BDI, there was a significant improvement in 15 out of 21 items, suggestive that telemode-based MBCT leads to significant improvement across various depressive symptoms. The findings of the present study are in similar lines with a recent study that used web-based MBCT intervention and compared it with usual depression care (UDC) and showed significant improvement in depression and psychological well-being compared with UDC only. Accordingly, it can be said that MBCT can be offered to all the patients willing to receive the same, along with the ongoing antidepressants.
The present study revealed that telemode-based MBCT is beneficial in improving mindfulness. This finding of the present study is supported by one of the existing studies, which showed significant reduction in depressive symptoms by 4 weeks of intervention. The domain of FFMQ, i.e., describing and nonreactivity to inner experience showed statistically significant improvement. Describing refers to the ability to express their experience in words. An improvement in this domain by MBCT suggests that patients were able to learn to describe their thoughts and feelings with the therapy. Nonreactivity to inner experience means the ability to detach from thoughts and emotions, allowing them to come and go without getting tangled or reacting to them. This is the central capacity to be cultivated in MBCT. This helps to enhance the ability to act with awareness and be in the present moment. A significant improvement in this domain by MBCT delivered by the telemode suggests that therapy can address the basic tenet, for which it has been developed. Our findings are in concordance with a randomized wait-list controlled trial that revealed significant increase in facets of observing, nonreactivity, and nonjudgment enhancing mindfulness ability with MBCT. The lack of improvement in other domains of FFMQ should be considered preliminary and could have been affected by the small sample size of the study. Hence, these findings should be replicated in studies involving larger number of patients. The present study also supports the existing literature which suggests significant improvement in quality of life in patients with depression with mindfulness-based interventions.
The present study is limited by the small sample size and lack of an active control group. Moreover, the present study was an open-label study and MBCT was administered as an adjunctive treatment to the ongoing treatment. The rater was not blind to the intervention being carried out and this could have affected the outcome of the study. However, patients were able to participate in the weekly session from distance places through online mode. Future studies must attempt to overcome the limitations of the present study. Future studies may evaluate the acceptability of the MBCT interventions and the completion rates of the patients.
| Conclusion|| |
To conclude, the present study shows that adjunctive tele MBCT appears to be a feasible adjunct to TAU in reducing severity of depression, improving mindfulness, and improving quality of life in patients with depression. When used as an augmentation treatment, it can lead to remission in two-thirds of the patients partially responding to antidepressants. Accordingly, telemode MBCT can be offered as an adjunctive treatment to patients with depression.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Lau MA, Segal ZV, Williams JM. Teasdale's differential activation hypothesis: Implications for mechanisms of depressive relapse and suicidal behaviour. Behav Res Ther 2004;42:1001-17.
Scher CD, Ingram RE, Segal ZV. Cognitive reactivity and vulnerability: Empirical evaluation of construct activation and cognitive diatheses in unipolar depression. Clin Psychol Rev 2005;25:487-510.
Watkins ER. Constructive and unconstructive repetitive thought. Psychol Bull 2008;134:163-206.
Wenzlaff RM, Bates DE. Unmasking a cognitive vulnerability to depression: How lapses in mental control reveal depressive thinking. J Pers Soc Psychol 1998;75:1559-71.
Hayes SC, Strosahl K, Wilson KG, Bissett RT, Pistorello J, Toarmino D, et al.
Measuring experiential avoidance: A preliminary test of a working model. Psychol Rec 2004;54:553-78.
Hofmann SG, Sawyer AT, Witt AA, Oh D. The effect of mindfulness-based therapy on anxiety and depression: A meta-analytic review. J Consult Clin Psychol 2010;78:169-83.
Segal ZV, Williams JM, Teasdale J. Mindfulness-Based Cognitive Therapy for Depression. New York: Guilford Press; 2002.
Teasdale JD, Segal Z, Williams JM. How does cognitive therapy prevent depressive relapse and why should attentional control (mindfulness) training help? Behav Res Ther 1995;33:25-39.
Segal ZV, Williams JM, Teasdale JD. Mindfulness-Based Cognitive Therapy for Depression. 2nd
ed. New York: Guilford Press; 2013.
Strauss C, Cavanagh K, Oliver A, Pettman D. Mindfulness-based interventions for people diagnosed with a current episode of an anxiety or depressive disorder: A meta-analysis of randomised controlled trials. PLoS One 2014;9:e96110.
Finucane A, Mercer SW. An exploratory mixed methods study of the acceptability and effectiveness of Mindfulness-Based Cognitive Therapy for patients with active depression and anxiety in primary care. BMC Psychiatry 2006;6:14.
Sharma MP, Sudhir PM, Narayan R. Effectiveness of mindfulness-based cognitive therapy in persons with depression: A preliminary investigation. J Indian Acad Appl Psychol 2013;39:43-50.
Nangia D, Sharma MP, Nimhans B. Effects of mindfulness based cognitive therapy on mindfulness skills, acceptance and spiritual Intelligence in patients with Depression. Amity J Appl Psychol [Internet] 2012;3:152244115. Available from https://www.semanticscholar.org
Segal ZV, Dimidjian S, Beck A, Boggs JM, Vanderkruik R, Metcalf CA, et al.
Outcomes of online mindfulness-based cognitive therapy for patients with residual depressive symptoms: A randomized clinical trial. JAMA Psychiatry 2020;77:563-73.
Wang YP, Gorenstein C. Assessment of depression in medical patients: A systematic review of the utility of the Beck Depression Inventory-II. Clinics (Sao Paulo) 2013;68:1274-87.
Baer RA, Smith GT, Hopkins J, Krietemeyer J, Toney L. Using self-report assessment methods to explore facets of mindfulness. Assessment 2006;13:27-45.
Saxena S, Chandiramani K, Bhargava R. WHOQOL-Hindi: A questionnaire for assessing quality of life in health care settings in India. World Health Organization Quality of Life. Natl Med J India 1998;11:160-5.
Eisendrath SJ, Gillung E, Delucchi KL, Segal ZV, Nelson JC, McInnes LA, et al.
A Randomized controlled trial of mindfulness-based cognitive therapy for treatment-resistant depression. Psychother Psychosom 2016;85:99-110.
Weisel KK, Fuhrmann LM, Berking M, Baumeister H, Cuijpers P, Ebert DD. Standalone smartphone apps for mental health: A systematic review and meta-analysis. NPJ Digit Med 2019;2:118.
Al-Refae M, Al-Refae A, Munroe M, Sardella NA, Ferrari M. A Self-compassion and mindfulness-based cognitive mobile intervention (serene) for depression, anxiety, and stress: Promoting adaptive emotional regulation and wisdom. Front Psychol 2021;12:648087.
Schanche E, Vøllestad J, Visted E, Svendsen JL, Osnes B, Binder PE, et al.
The effects of mindfulness-based cognitive therapy on risk and protective factors of depressive relapse –
A randomized wait-list controlled trial. BMC Psychol 2020;8:57.
[Table 1], [Table 2]