Distance delivery of mindfulness-based cognitive therapy for depression: Project UPLIFT

Abstract

This study evaluated the efficacy of a newly developed, home-based depression intervention for people with epilepsy. Based on mindfulness-based cognitive therapy (MBCT), the eight-session, weekly intervention was designed for group delivery via the Internet or telephone. Forty participants were randomly assigned to intervention or waitlist. Depressive symptoms and other outcomes were measured at baseline, after intervening in the intervention group (~ 8 weeks), and after intervening in the waitlist group (~ 16 weeks). Depressive symptoms decreased significantly more in the intervention group than the waitlist group; Internet and telephone did not differ. This effect persisted over the 8 weeks when those waitlisted received the intervention. Knowledge/skills increased significantly more in the intervention than the waitlist group. All other changes, though not significant, were in the expected direction. Findings indicate that distance delivery of group MBCT can be effective in reducing symptoms of depression in people with epilepsy. Directions for future research are proposed.

Introduction

Thirteen [1] to seventeen [2] percent of the U.S. population are at risk for having major depressive disorder (MDD) during their lifetime. Persons with chronic illnesses like epilepsy have even higher rates of MDD and depressive symptoms [3], [4], [5]. A review of articles on depression, suicide, and epilepsy reported that the rate of depression in people with epilepsy is between 32 and 48% [6].

Although it is the most frequent psychiatric disorder among people with epilepsy [7], [8], [9], depression often goes unrecognized and undertreated [10], [11] for reasons including concern about adding medications to the epilepsy treatment regimen and lack of access to mental health providers. People with epilepsy experience high rates of unemployment and may need to be accommodated within the workplace [12], [13]. In addition, all states have laws restricting drivers’ licenses for persons with active, uncontrolled seizures—about 25% of people with seizures [11], [14]. This further complicates their employment and access to medical care.

Research suggests that causes of depression are biological, requiring chemical intervention, and cognitive, associated with the way an individual thinks [15]. People with a sense of personal control tend to show fewer depressive symptoms [16], and a study found that people with high levels of self-efficacy for managing their epilepsy were less likely to report depressive symptoms [17]. Therefore, interventions to improve patients’ thoughts about their illness and their situation can decrease their depression [18], [19].

In general populations, cognitive and behavioral interventions have been found efficacious in addressing depression [20], [21]. Several studies have demonstrated that cognitive-behavioral therapy (CBT) and treatment with antidepressant medications do not statistically differ in effectiveness for reducing depressive symptoms [22], [23], [24], [25]. Despite the efficacy of CBT-based interventions [26], however, research on their use to manage depression among people with epilepsy is limited; most CBT interventions for this population focus on general well-being and symptom management. Ramaratnam and colleagues [27] called for more trials to understand the effects of psychological interventions, including CBT, for people with epilepsy.

Recent work has demonstrated the value of adding mindfulness training to cognitive therapy [28]. CBT has focused on changing the content of thoughts; mindfulness, defined as paying attention “on purpose, in the present moment, and nonjudgmentally” [29], allows one to start viewing thoughts as passing events that may not represent reality. Mindfulness views suffering as worthy of attention, not something to be blocked out or fixed. Through attention to suffering, one can learn that one attaches thoughts to suffering that exacerbate it; letting go of these thoughts reduces suffering. A recent review noted the increase in interventions incorporating mindfulness [30].

Segal and colleagues [28] developed mindfulness-based cognitive therapy (MBCT), a program shown to promote recovery from depression and prevent relapse. MBCT is particularly effective for people with current and treatment-resistant depression [31], [32]. In a study among people with recurrent MDD, those receiving MBCT reported significantly fewer residual depressive symptoms than those receiving treatment as usual [33].

Although CBT has been delivered by telephone, conference call, and Internet [34], [35], to date, mindfulness has not been included in distance delivery. In two studies, an intervention composed of weekly 50-minute telephone group sessions was significantly better than the comparison in reducing depressive symptoms [36], [37]. With respect to computerized CBT, a review of 16 studies supported its effectiveness when compared with therapist-delivered therapy [38]. One study compared it with therapist-delivered CBT and a waitlist control [39]. Both the computerized and therapist-delivered CBT groups reduced their Beck Depression Inventory (BDI) scores compared with the waitlist control group, and the computer-based program was comparable to therapist treatment for relieving mild to moderate depression. At present, however, CBT has not been delivered to groups via the Internet. Offering interventions to a group is particularly helpful for those with transportation limitations, among whom social support is often lacking. Groups allow people to learn from each other [30] and provide modeling and social support from others.

Project UPLIFT was funded by the Centers for Disease Control and Prevention (CDC) as a home-based depression treatment for people with epilepsy. The UPLIFT acronym refers to both mindfulness (Using Practice) and CBT (Learning to Increase Favorable Thoughts), which formed the basis of the intervention materials. The UPLIFT materials were designed for group delivery by either the Internet or telephone.

Project UPLIFT had two stages: intervention development and pilot testing. During intervention development, we created eight cognitive therapy and mindfulness sessions targeting people with epilepsy for delivery by Internet or telephone, and then held focus groups to elicit feedback about them from people with epilepsy. During pilot testing, we delivered the eight sessions to people with epilepsy and depression to assess acceptability and explore efficacy in: reducing depression, increasing knowledge/skills and self-efficacy, and improving quality of life. This article describes the efficacy results of the pilot study. Our main hypothesis was that the change in symptoms of depression at the interim test would be greater in the intervention group than in the treatment-as-usual control group.