Mindfulness-Based Cognitive Therapy (MBCT)
The term depression describes discouraged or low mood patterns, which occur due to loss (death of a close person) or disappointment. Unlike low moods that have a tendency to resolve with time or improvement in circumstances, depression gets aggravated and triggered by social and environmental factors (Balázs et al., 2013). They are accompanied with self loathing and pervasive worthlessness feelings. Depression is not just restricted to adults. It is a common psychiatric condition that manifests itself in children and gets continued to adulthood. Pediatric depression is quite different from the normal blues and emotional disturbances that a child complains of. If sadness, grief and indifferent nature become persistent in a child, it forces the child to withdraw from school, family life, social activities and play. Up to 8% teenagers had met the criteria for depression in the year 2012 (Kessler & Bromet, 2013). This assignment focuses on using cognitive behavioral therapy as an intervention for pediatric depression.
Mindfulness-Based Cognitive Therapy (MBCT) is a psychological approach developed for people who are at risk for relapse in depression (Gu et al., 2015). This therapy helps them to realize their wellness in the long-term. Mindfulness Based Stress Reduction Program that was developed by Jon Kabat-Zinn, at the University of Massachusetts Medical Center laid the foundation for MBCT. It was initially formulated to assist people who suffered from chronic physical pain. It included meditation techniques and made the participants more aware of their present experiences. To cure depressive relapse, MBCT employs several cognitive therapy exercises and depression focused education (Baer, 2015). The children will be better understand their altering mood patterns, recognize changes in their feelings and thoughts and avoid painful thinking.
This program evaluation will act as an appraisal that will use reliable and valuable methods to examine the outcome of MBCT in treating pediatric depression.
Evidence based practice is defined as integrating clinical expertise with best available research evidence to improve the values and outcomes in patients. The lowest level of evidence is based on the opinion of the practitioner or client, followed by case reports and cross sectional studies. The PICO framework was used to search for clinically relevant evidence (Cooke, Smith & Booth, 2012) (Appendix 1). For this literature review, different databases like MEDLINE, SCOPUS and Cochrane Library were used. The peer reviewed journals, published in English that contained details on the effectiveness of MBCT on children and adolescents suffering from depression were included in the selection criteria. The journals with date of publishing not more than 5 years from the current year were selected. Exclusion criteria contained non-English journals, published abstracts, dissertations and those with publication date prior to 2012.
Literature Review
Research provides evidence that mindfulness training reduces stress and improves self confidence, optimism, self esteem attention and interpersonal relationships. Mindfulness-based cognitive therapy (MBCT) is regarded as evidence based intervention strategy that focuses on psychotherapeutic methods (Crane et al., 2016). These cognitive behavioral methods are integrated for treating patients who suffer from depression. The clinical application of mindfulness involves meditation. (Segal, Williams & Teasdale, 2012). Several clinical guidelines recommend as a type of prophylactic treatment for recurrent depression or MDD (major depressive disorder). Results from several studies suggest that MBCT is a cost-effective intervention strategy. The MBCT manual was first published in 2002 and has shown great implications in clinical effectiveness. Evidence from studies suggests that mindfulness enhances cognitive and academic performances and improves holistic development of a depressed child. According to Segal et al., (2013) MBCT Cognitive vulnerability to relapse and recurrence of depression forms the basis of this intervention method. Research studies state that an increased cognitive vulnerability to depressive recurrence and relapse is seen in patients who experience severe major depression episodes. The increase in cognitive vulnerability is thought to occur as a consequence of greater connectivity between depressogenic cognition and low mood during these episodes. (Kuyken et al., 2015). MBCT targets this cognitive vulnerability. It has successfully reduced the likelihood of any depressive episode configuration in becoming reestablished. Research suggests that apart from meditation, the different mindfulness approaches also include yoga, breathing exercises and body scan. Tai Chi is another approach that focuses on mindfulness and has shown to increase the capacity for alertness and attention in an individual. The therapeutic approaches that utilize yoga and Tai Chi combine movement with focused attention on breathing patterns (Cramer et al., 2013). This gives rise to an outlet for youth energy and may appeal to children and adolescent.
In a study (Bakker et al., 2014) conducted on 126 participants who reported recurrent MDD and residual depressive symptoms, the positive effects of the therapy was measured. Correlational analysis and RCT revealed that the genes OPRM1 and CHRM2 played a key role in moderating the positive affect experience in MBCT group. The control group showed an increase in the residual symptoms of depression and that was moderated by variations in the DRD4 and BDNF genes. That deteriorated the effect of therapy. In another study, treatment as usual (TAU) were compare dot that of MBCT on 130 adults suffering from residual depressive symptoms. Worry (PSWQ), mindfulness (KIMS) and momentary negative and positive affect (ESM) were the main measures. Meditation analysis revealed that these measures mediated MBCT efficacy. The effect of worry and anxiety on recurrent depressive symptoms was also mediated by MNPA. 52 individuals were recruited in a study who complained of recurrent MDD. An analysis of MBCT was performed. Following Trier Social Stress test, anxiety regulation showed improvements and the effectiveness of MBCT on depression were partially regulated (Britton et al., 2012). Depressive symptoms were shown to mediate the effects of MBCT interventions on goal attainment likelihood. Goal specificity increase was associated with a parallel increase in specificity of autobiographical memory. Depressed mood showed reductions that were associated with an increase in goal likelihood. When the effectiveness of non-intervention and MBCT were compared on 45 participants, a reduction in attention facilitation for negative information was observed. Attention inhibition for positive information was reduced. There was no change in facilitation of affective information in the control group (De Raedt et al., 2012). MBCT showed a significant increase in positive emotion appraisal and pleasantness activity. Momentary positive emotions received a boost on application of MBCT therapy among 130 MDD patients. They began to engage in pleasant activities (Geschwind et al., 2012).
On combined application of MBCT and TAU on 205 patients with recurrent depression, less depressive symptoms appeared, mindfulness skills increased and rumination and worries showed significant reduction (Van Aalderen et al., 2012). Mindfulness showed an increase in 71 individuals with recurrent MDD. MBCT therapy when compared to waitlist control, proved effective in reducing ruminative thinking and depressive symptoms. However, attention processes like orientation, alerting and executive attention did not show any significant improvement (Van den Hurk et al., 2012). However, in a study conducted by Williams et al., (2014), MBCT failed to show any significant improvements in 255 individuals suffering from depression when compared to the control group. Only participants who had a history of childhood trauma got protection against relapse of depression episodes. In a systematic review based on meta-analysis, the effects of non-pharmacological intervention on preventing relapse of depressive episodes were examined (Clarke et al., 2015). The review concluded that CBT, MBCT and interpersonal psychotherapy were each found to be associated with drastic reduction in relapse condition when compared to inactive and active controls for 12 months. However, it concluded that the efficacy of MBCT may get restricted to respondents who recovered from depression by use of several pharmacological means and by effects of nonspecific treatment. The homogeneity of trials in the review was considered and it was concluded that majority of participants showed better response to pharmacological treatments targeting depression. A meta-analysis of 11 randomized controlled trials was conducted. Patients who reported of a history of 3 or more episodes of MDD were monitored for more than a year. The results showed that MBCT was successful in reducing relapse rates in participants by more than 40% (Galante, Iribarren, & Pearce, 2013).
When the evidences from several studies that illustrated the role of mindfulness based cognitive therapy are taken together, the results suggest that MBCT is an intervention procedure that is empirically supported and it reduces the risk of depression recurrence or relapse among individuals. There must be trained practitioners who efficiently deliver the treatment. The dissemination is often challenged by certain difficulties that arise while implementing the program due to lack of sufficient MBCT practitioners.
The research proposal aims to conduct a randomized clinical trial of MBCT in children. It plans to train more than 4 experienced clinicians to conduct MBCT in the group following proper protocol. Evidence based methods will be used to separate children who suffer from anxiety and depression. The acceptability and feasibility of mindfulness based cognitive therapy will be measured. Threats to internal validity like selection bias, confounding and regression towards mean will be avoided by recruiting alike subjects in both the groups, negating the existence of any third variable that affects our outcome and measuring the mean twice before the intervention begins to remove effect of any extreme scores respectively.
English speaking children between ages 9-12, who are enrolled in some remedial programs for depression in local community clinics will be invited for participation. Children who meet the DSM-IV-TR diagnostic criteria will be enlisted (American Psychiatric Association, 2013). Recruitment efforts will involve an initial mailing and phone calls to the respective parents of all children who are eligible. Sample size should not be less than 40. Parents will be instructed to sign the informed consent form showing their approval for the research study. Questionnaires specific for the children and their parents were designed.
The enlisted children will be randomized into eight groups. Each of these groups will consist of at least 5 children and 2 therapists. The interventions will be conducted at the schools they attend. The intervention will be carried out for 12 weeks. Before the program is initiated, all children will be evaluated. Reevaluation will be carried out at the end of 6 months, following completion of the intervention (Crane, 2017). If any children is undergoing medication management, that will continue at the discretion of the concerned psychiatrist. Assessments will be conducted in 3 waves. Time 1 will provide baseline measures for participants who enrolled in immediate arm of the therapy. Time 2 will assess treatment effects in immediate arm and baseline measures for delayed arm of the therapy. Time 3 will assess effects on delayed arm.
Data from these 3 assessment phases will be combined and then analyzed in the form of a single open clinical trial. Pre-test measures for all participants, that were taken before participation in the therapeutic program will be compiled. The participant questionnaire will evaluate the overall experience of the child regarding the program. The parent questionnaire will be used to analyze their experience and perception of behavioral changes of their child. The post-test measures will be similarly compiled. Sample t tests that are one-tailed dependent will be conducted. This will help in evaluating the differences between the outcome variables of pre-test and post-test results by using an alpha level of .10. The effect sizes will be calculated for correlated samples.
It is hypothesized that MBCT will act as a feasible implementation in clinically diagnosed children aged 9-12, with depression. It will create high level of satisfaction and compliance to treatment (Khoury et al., 2013). The clinical outcome measures are expected to display larger reductions in MDD and will improve social-emotional functioning. MBCT will also lead to larger scores on measures of attention in the participants.
Conclusion
Nearly one in five children experience depressive symptoms that impair their life. Majority of these children do not receive any treatment and their symptoms worsen over time. It leads to chronic behavior problems and with increase in age the affected people become isolated and develop suicidal thoughts. A time limited intervention therapy is required that will be conducted in their schools and will have the potential to reach a greater number of children suffering from MDD. Thus, this proposal seeks to investigate the effectiveness of MBCT on treating children with depressive disorders.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub. Baer, R. A. (Ed.). (2015). Mindfulness-based treatment approaches: Clinician’s guide to evidence base and applications. Academic Press.
Bakker, J. M., Lieverse, R., Menne-Lothmann, C., Viechtbauer, W., Pishva, E., Kenis, G., … & Wichers, M. (2014). Therapygenetics in mindfulness-based cognitive therapy: do genes have an impact on therapy-induced change in real-life positive affective experiences?. Translational psychiatry, 4(4), e384.
Balázs, J., Miklósi, M., Keresztény, Á., Hoven, C. W., Carli, V., Wasserman, C., … & Cotter, P. (2013). Adolescent subthreshold?depression and anxiety: Psychopathology, functional impairment and increased suicide risk. Journal of child psychology and psychiatry, 54(6), 670-677.
Britton, W. B., Shahar, B., Szepsenwol, O., & Jacobs, W. J. (2012). Mindfulness-based cognitive therapy improves emotional reactivity to social stress: results from a randomized controlled trial. Behavior therapy, 43(2), 365-380.
Clarke, K., Mayo-Wilson, E., Kenny, J., & Pilling, S. (2015). Can non-pharmacological interventions prevent relapse in adults who have recovered from depression? A systematic review and meta-analysis of randomised controlled trials. Clinical psychology review, 39, 58-70.
Cooke, A., Smith, D., & Booth, A. (2012). Beyond PICO: the SPIDER tool for qualitative evidence synthesis. Qualitative Health Research, 22(10), 1435-1443.
Cramer, H., Lauche, R., Langhorst, J., & Dobos, G. (2013). Yoga for depression: A systematic review and meta?analysis. Depression and anxiety, 30(11), 1068-1083.
Crane, C., Byford, S., Kuyken, W., Schweizer, S., Speckens, A., Hayes, R., … & Williams, M. (2016). Efficacy of Mindfulness-Based Cognitive Therapy in Prevention of Depressive Relapse.
Crane, R. (2017). Mindfulness-based cognitive therapy: Distinctive features. Taylor & Francis.
De Raedt, R., Baert, S., Demeyer, I., Goeleven, E., Raes, A., Visser, A., … & Speckens, A. (2012). Changes in attentional processing of emotional information following mindfulness-based cognitive therapy in people with a history of depression: Towards an open attention for all emotional experiences. Cognitive therapy and research, 36(6), 612-620.
Galante, J., Iribarren, S. J., & Pearce, P. F. (2013). Effects of mindfulness-based cognitive therapy on mental disorders: a systematic review and meta-analysis of randomised controlled trials. Journal of Research in Nursing, 18(2), 133-155.
Geschwind, N., Peeters, F., Huibers, M., van Os, J., & Wichers, M. (2012). Efficacy of mindfulness-based cognitive therapy in relation to prior history of depression: randomised controlled trial. The British Journal of Psychiatry, 201(4), 320-325.
Gu, J., Strauss, C., Bond, R., & Cavanagh, K. (2015). How do mindfulness-based cognitive therapy and mindfulness-based stress reduction improve mental health and wellbeing? A systematic review and meta-analysis of mediation studies. Clinical psychology review, 37, 1-12.
Kessler, R. C., & Bromet, E. J. (2013). The epidemiology of depression across cultures. Annual review of public health, 34, 119-138.
Khoury, B., Lecomte, T., Fortin, G., Masse, M., Therien, P., Bouchard, V., … & Hofmann, S. G. (2013). Mindfulness-based therapy: a comprehensive meta-analysis. Clinical psychology review, 33(6), 763-771.
Kuyken, W., Hayes, R., Barrett, B., Byng, R., Dalgleish, T., Kessler, D., … & Causley, A. (2015). Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): a randomised controlled trial. The Lancet, 386(9988), 63-73.
Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2012). Mindfulness-based cognitive therapy for depression. Guilford Press.
Van Aalderen, J. R., Donders, A. R. T., Giommi, F., Spinhoven, P., Barendregt, H. P., & Speckens, A. E. M. (2012). The efficacy of mindfulness-based cognitive therapy in recurrent depressed patients with and without a current depressive episode: a randomized controlled trial. Psychological medicine, 42(5), 989-1001.
Van den Hurk, P. A. M., Van Aalderen, J. R., Giommi, F., Donders, R., Barendregt, H. P., & Speckens, A. E. M. (2012). An investigation of the role of attention in mindfulness-bases cognitive therapy for recurrently depressed patients.
Williams, J. M. G., Crane, C., Barnhofer, T., Brennan, K., Duggan, D. S., Fennell, M. J., … & Shah, D. (2014). Mindfulness-based cognitive therapy for preventing relapse in recurrent depression: a randomized dismantling trial. Journal of consulting and clinical psychology, 82(2), 275.
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