Mindfulness-based interventions (MBIs) are at a pivotal point in their future development. Spurred on by an ever-increasing number of studies and breadth of clinical application, the value of such ...approaches may appear self-evident. We contend, however, that the public health impact of MBIs can be enhanced significantly by situating this work in a broader framework of clinical psychological science. Utilizing the National Institutes of Health stage model (Onken, Carroll, Shoham, Cuthbert, & Riddle, 2014), we map the evidence base for mindfulness-based cognitive therapy and mindfulness-based stress reduction as exemplars of MBIs. From this perspective, we suggest that important gaps in the current evidence base become apparent and, furthermore, that generating more of the same types of studies without addressing such gaps will limit the relevance and reach of these interventions. We offer a set of 7 recommendations that promote an integrated approach to core research questions, enhanced methodological quality of individual studies, and increased logical links among stages of clinical translation in order to increase the potential of MBIs to impact positively the mental health needs of individuals and communities.
Although the psychological benefits of mindfulness training on emotion regulation are well-documented, the precise mechanisms underlying these effects remain unclear. In the present account, we ...propose a new linkage between mindfulness and improved emotion regulation—one that highlights the role played by executive control. Specifically, we suggest that the present-moment awareness and nonjudgmental acceptance that is cultivated by mindfulness training is crucial in promoting executive control because it increases sensitivity to affective cues in the experiential field. This refined attunement and openness to subtle changes in affective states fosters executive control because it improves response to incipient affective cues that help signal the need for control. This, in turn, enhances emotion regulation. In presenting our model, we discuss how new findings in executive control can improve our understanding of how mindfulness increases the capacity for effective emotion regulation.
One component of mindfulness training (MT) is the development of interoceptive attention (IA) to visceral bodily sensations, facilitated through daily practices such as breath monitoring. Using ...functional magnetic resonance imaging (fMRI), we examined experience-dependent functional plasticity in accessing interoceptive representations by comparing graduates of a Mindfulness-Based Stress Reduction course to a waitlisted control group. IA to respiratory sensations was contrasted against two visual tasks, controlling for attentional requirements non-specific to IA such as maintaining sensation and suppressing distraction. In anatomically partitioned analyses of insula activity, MT predicted greater IA-related activity in anterior dysgranular insula regions, consistent with greater integration of interoceptive sensation with external context. MT also predicted decreased recruitment of the dorsomedial prefrontal cortex (DMPFC) during IA, and altered functional connectivity between the DMPFC and the posterior insula, putative primary interoceptive cortex. Furthermore, meditation practice compliance predicted greater posterior insula and reduced visual pathway recruitment during IA. These findings suggest that interoceptive training modulates task-specific cortical recruitment, analogous to training-related plasticity observed in the external senses. Further, DMPFC modulation of IA networks may be an important mechanism by which MT alters information processing in the brain, increasing the contribution of interoception to perceptual experience.
Patients with residual depressive symptoms face a gap in care because few resources, to date, are available to manage the lingering effects of their illness.
To evaluate the effectiveness for ...treating residual depressive symptoms with Mindful Mood Balance (MMB), a web-based application that delivers mindfulness-based cognitive therapy, plus usual depression care compared with usual depression care only.
This randomized clinical trial was conducted in primary care and behavioral health clinics at Kaiser Permanente Colorado, Denver. Adults identified with residual depressive symptoms were recruited between March 2, 2015, and November 30, 2018. Outcomes were assessed for a 15-month period, comprising a 3-month intervention interval and a 12-month follow-up period.
Patients were randomized to receive usual depression care (UDC; n = 230) or MMB plus UDC (n = 230), which included 8 sessions delivered online for a 3-month interval plus minimal phone or email coaching support.
Primary outcomes were reduction in residual depressive symptom severity, assessed using the Patient Health Questionaire-9 (PHQ-9); rates of depressive relapse (PHQ-9 scores ≥15); and rates of remission (PHQ-9 scores <5). Secondary outcomes included depression-free days, anxiety symptoms (General Anxiety Disorder-7 Item Scale), and functional status (12-Item Short Form Survey).
Among 460 randomized participants (mean SD age, 48.30 14.89 years; 346 women 75.6%), data were analyzed for the intent-to-treat sample, which included 362 participants (78.7%) at 3 months and 330 (71.7%) at 15 months. Participants who received MMB plus UDC had significantly greater reductions in residual depressive symptoms than did those receiving UDC only (mean SE PHQ-9 score, 0.95 0.39, P < .02). A significantly greater proportion of patients achieved remission in the MMB plus UDC group compared with the UDC only group (PHQ-9 score, <5: β SE, 0.38 0.14, P = .008), and rates of depressive relapse were significantly lower in the MMB plus UDC group compared with the UDC only group (hazard ratio, 0.61; 95% CI, 0.39-0.95; P < .03). Compared with the UDC only group, the MMB plus UDC group had decreased depression-free days (mean SD, 281.14 164.99 days vs 247.54 158.32 days; difference, -33.60 154.14 days; t = -2.33; P = .02), decreased anxiety (mean SE General Anxiety Disorder-7 Item Scale score, 1.21 0.42, P = .004), and improved mental functioning (mean SE 12-Item Short Form Survey score, -5.10 1.37, P < .001), but there was no statistically significant difference in physical functioning.
Use of MMB plus UDC resulted in significant improvement in depression and functional outcomes compared with UDC only. The MMB web-based treatment may offer a scalable approach for the management of residual depressive symptoms.
ClinicalTrials.gov identifier: NCT02190968.
How exteroceptive attention (EA) alters neural representations of the external world is well characterized, yet little is known about how interoceptive attention (IA) alters neural representations of ...the body's internal state. We contrasted visual EA against IA toward respiration. Visual EA modulated striate and extrastriate cortices and a lateral frontoparietal "executive" network. By contrast, respiratory IA modulated a posterior insula region sensitive to respiratory frequency, consistent with primary interoceptive cortex, and a posterior limbic and medial parietal network, including the hippocampus, precuneus, and midcingulate cortex. Further distinguishing between EA and IA networks, attention-dependent connectivity analyses revealed that EA enhanced visual cortex connectivity with the inferior parietal lobule and pulvinar of the thalamus, while IA enhanced insula connectivity with the posterior ventromedial thalamus, a relay of the laminar I spinothalamocortical pathway supporting interoceptive afference. Despite strong connectivity between the posterior and the anterior insula, anatomical parcellation of the insula revealed a gradient of IA to EA recruitment along its posterior-anterior axis. These results suggest that distinct networks may support EA and IA. Furthermore, the anterior insula is not an area of pure body awareness but may link representations of the outside world with the body's internal state--a potential basis for emotional experience.
Objective: Digital delivery of mindfulness-based cognitive therapy through the Mindful Mood Balance (MMB) program is clinically effective (Segal et al., 2020); however, the mechanisms through which ...this program delivers its benefits have not been established. Method: This study investigates the differential impact of the MMB program paired with usual depression care (UDC) compared to UDC alone on the putative targets of self-reported mindfulness, decentering, and rumination and the extent to which change in these targets mediates subsequent depressive relapse among a sample of predominantly White, female participants, with residual depressive symptoms. Results: The MMB program relative to UDC was associated with a significantly greater rate of change in decentering (t = 4.94, p < .0001, d = 0.46), mindfulness (t = 6.04, p < .0001, d = 0.56), and rumination (t = 3.82, p < .0001, d = 0.36). Subsequent depressive relapse also was mediated by prior change in these putative targets, with a significant natural indirect effect for decentering, χ2(1) = 7.25, p < .008, OR = 0.57; mindfulness, χ2(1) = 9.99, p < .002, OR = 0.50; and rumination, χ2(1) = 12.95, p < .001, OR = 0.35. Conclusions: These findings suggest the mechanisms of MMB are consistent with the conceptual model for mindfulness-based cognitive therapy and depressive relapse risk and that such processes can be modified through digital delivery.
What is the public health significance of this article?
Evidence for putative target engagement and mediation is critical to identifying proximal markers of long-term benefit and guidance for the measurement and design of digital interventions for depression.
•Suicidal ideation and depression relapse are prevalent among people with recurrent depression.•Access to effective preventive approaches is critical for suicidal ideation and residual depression ...symptoms.•The MMB online program may be a promising approach to reducing suicidal ideation.•The MMB online program may be a promising approach to improving residual depression symptoms.
To address the elevated prevalence of depression, suicide, and suicidal ideation, patients require increased access to effective interventions. Mindfulness-Based Cognitive Therapy has a strong evidence base in relapse prophylaxis and can be delivered digitally through Mindful Mood Balance (MMB).
This study was a secondary analysis of the impact of MMB paired with usual depression care (UDC) compared to UDC alone on patients in a randomized clinical trial for residual depression (Segal et al., 2020) who had a history of attempted suicide or reported current suicidal ideation (N = 109).
MMB relative to UDC was associated with a greater rate of reduction in suicidal ideation (SI; t(103) = 2.50, p = 0.014, d = 0.49, 95% CI 0.09–0.88) and a greater likelihood of being in a lower severity category of SI (t(103) = 2.02, p = 0.046, odds ratio = 3.43, 95% CI 1.02–11.53). There was also evidence that MMB reduces depression severity outcomes among this at risk group (t(105) = 2.38, p < 0.02, d = 0.46, 95% CI 0.07–0.85).
Reported findings are based on a subgroup of patients in a clinical trial originally designed to treat residual depressive symptoms.
Online interventions, such as MMB, may offer one solution to the challenge of expanding the reach of services for patients with residual depression who are at risk of suicidal ideation and behavior.
Objective: Both Mindfulness Based Cognitive Therapy (MBCT) and Cognitive Therapy (CT) enhance self-management of prodromal symptoms associated with depressive relapse, albeit through divergent ...therapeutic procedures. We evaluated rates of relapse in remitted depressed patients receiving MBCT and CT. Decentering and dysfunctional attitudes were assessed as treatment-specific process markers. Method: Participants in remission from Major Depressive Disorder (MDD; N = 166) were randomized to 8 weeks of either MBCT (N = 82) or CT (N = 84) and were followed for 24 months, with process markers measured every 3 months. Attendance in both treatments was high (6.3/8 session) and treatment fidelity and competence were evaluated. Relapse was defined as a return of symptoms meeting the criteria for major depression on Module A of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (SCID). Results: Intention-to-treat analyses indicated no differences between MBCT and CT in either rates of relapse to MDD or time to relapse across 24 months of follow up. Both groups experienced significant increases in decentering and participants in CT reported greater reductions in dysfunctional attitudes. Within both treatments, participants who relapsed evidenced lower decentering scores than those who stayed well over the follow up. Conclusions: This is the first study to directly compare relapse prophylaxis following MBCT and CT directly. The lack of group differences in time to relapse supports the view that both interventions are equally effective and that increases in decentering achieved via either treatment are associated with greater protection. These findings lend credence to Teasdale et al.'s (2002) contention that, even though they may be taught through dissimilar methods, CT and MBCT help participants develop similar metacognitive skills for the regulation of distressing thoughts and emotions.
What is the public health significance of this article?
In this randomized clinical trial, Cognitive Therapy and Mindfulness Based Cognitive Therapy provided equal protection against relapse for individuals in recovery from Major Depressive Disorder. Participants in both treatments acquired metacognitive skills and greater use of these skills in regulating negative affect was associated with longer periods of wellness over 2 years of follow up.
Background: Due to the clinical challenges of treatment-resistant depression (TRD), we evaluated the efficacy of mindfulness-based cognitive therapy (MBCT) relative to a structurally equivalent ...active comparison condition as adjuncts to treatment-as-usual (TAU) pharmacotherapy in TRD. Methods: This single-site, randomized controlled trial compared 8-week courses of MBCT and the Health Enhancement Program (HEP), comprising physical fitness, music therapy and nutritional education, as adjuncts to TAU pharmacotherapy for outpatient adults with TRD. The primary outcome was change in depression severity, measured by percent reduction in the total score on the 17-item Hamilton Depression Rating Scale (HAM-D 17 ), with secondary depression indicators of treatment response and remission. Results: We enrolled 173 adults; mean length of a current depressive episode was 6.8 years (SD = 8.9). At the end of 8 weeks of treatment, a multivariate analysis showed that relative to the HEP condition, the MBCT condition was associated with a significantly greater mean percent reduction in the HAM-D 17 (36.6 vs. 25.3%; p = 0.01) and a significantly higher rate of treatment responders (30.3 vs. 15.3%; p = 0.03). Although numerically superior for MBCT than for HEP, the rates of remission did not significantly differ between treatments (22.4 vs. 13.9%; p = 0.15). In these models, state anxiety, perceived stress and the presence of personality disorder had adverse effects on outcomes. Conclusions: MBCT significantly decreased depression severity and improved treatment response rates at 8 weeks but not remission rates. MBCT appears to be a viable adjunct in the management of TRD.
PDF
