Mindfulness group therapy in primary care patientswith depression, anxiety or adjustment disorders: randomized controlled trial and follow-up study

Jan Sundquist, MD, PhD, Professor

BACKGROUND

• Depressive disorders, anxiety disorders, and stress and adjustment disorders are common psychiatric disorders in primary health care with a prevalence that vary between 12 and 32%.

BACKGROUND

•Standard treatment of depressive, anxiety, and stress and adjustment disorders in Swedish primary care is cognitive behavioural therapy (CBT) in addition to pharmacological treatment.

•CBT has been recognised as an effective way of treating depressive disorders but it is scarce and expensive.

•A stronger focus on group therapy in primary health care could help to save limited resources.

BACKGROUND

•Mindfulness-based therapies might be suitable for group therapy sessions for psychiatric patients in general practice, such as mindfulness-based stress reduction (MBSR), a clinically based method (Jon Kabat-Zinn)

BACKGROUND

•One important advantage with mindfulness-based group therapy is that certified instructors can give the therapy after a 6-day course.

•The instructors can be nurses, physiotherapists or doctors.

• We performed mindfulness-based group therapy using a modified form of MBSR, including 34 hours of home training, compared with 70 hours in MBSR, and a shorter mindfulness instructor training programme (6 days) + daily own training) adapted for clinicians.

• The patients were taught specific breathing techniques, including learning to be aware and focus and sustain attention.

OUR STUDY

METHODS•215 patients were randomised to 8-week

mindfulness-based group therapy (n=110) and to treatment as usual (TAU), primarily individual-based CBT (n=105).

•Wilcoxon signed-rank test, ordinal mixed models.•The power calculations were based on the

assumption that the mindfulness group therapy would be non inferior to TAU (noninferiority).

•ClinicalTrials.gov ID: NCT01476371.

INTERVENTION• The 8-week RCT, 2 hours sessions, was conducted

during the spring 2012 at 16 primary health care centres in Southern Sweden with two mindfulness instructors per group.

• Eligible patients (aged 20–64 years) scored >10 on the Patient Health Questionnaire-9, >7 on the HAD or 13–34 on the MADRS

INTERVENTION• Bodyscan, sitting meditation and yoga are the

same in mindfulness-based group therapy as in the programme introduced by Ola Schenström, but shorter (only 20 minutes) compared to 40–45 minutes in MBSR. That amounts to 18 hour of home practice and 16 hours of instructor- led training, giving a total of 34 hours of mindfulness training for the patient.

INTERVENTION

•The participants attended, on average, 5.9 group sessions.

•Participants underwent pharmacological treatment, if deemed necessary, and follow-up by the doctor at the primary health care centre.

CONTROL GROUP

• The control group received treatment as usual (TAU), which sometimes included pharmacological treatment.

• Most patients in the control group received individual CBT.

• The average number of individual CBT sessions was 6.

FOLLOW-UP

•Immediately after the intervention, all participants and controls were evaluated for psychiatric symptoms by questionnaires.

•About one year after the completed mindfulness group and CBT therapy, the same questions were posted to all participants including the controls.

RESULTS

A potential mechanism?

• It has been shown that the Epidermal Growth Factor (EGF) family is associated with psychological stress and mental disorders.

• Levels of EGF were significantly decreased in patients treated with both CBT and mindfulness.

• Changes in EGF were significantly associated with response independent of age, sex and pharmacological treatment.

• CBT and mindfulness are associated with treatment response on all scales. These results show that mindfulness and CBT improves depressive and anxiety symptoms and decreases EGF, a stress related marker.

A potential mechanism?• It has been shown that the Epidermal Growth Factor (EGF)

family is associated with psychological stress and mental disorders.

• Levels of EGF were significantly decreased in patients treated with both CBT and mindfulness.

• Changes in EGF were significantly associated with response independent of age, sex and pharmacological treatment.

• CBT and mindfulness are associated with treatment response on all scales. These results show that mindfulness and CBT improves depressive and anxiety symptoms and decreases EGF, a stress related marker.

STRENGTHS OF THE STUDY

• To the best of our knowledge, this is the first RCT performed in a primary health care setting in which the long-standing (1-year) effect of mindfulness-based group therapy has been compared with an active control group (CBT).

• Moreover, our study of 215 randomised patients with a medical diagnosis was performed in a monitored clinical setting of 16 general practices in urban as well as rural areas.

INTERPRETATION

• The present RCT provided evidence that mindfulness group therapy, given by certified instructors, has an equal effect compared to individual-based CBT on depressive and anxiety symptoms one year after completion of the mindfulness therapy as at the 8-week follow-up at the end of the treatment.

CLINICAL IMPLICATIONS

•Mindfulness based group therapy may be used in primary care patients with depressive, anxiety, or stress and adjustment disorders.

•This could help to save limited resources. •However, it is important to note that not all patients are suited to participate in group sessions and it is thus important to offer an individual therapeutic approach to these patients.

PHOTO CREDITS

• Becky Wetherington• John Lord• mindfulness• Grzegorz Łobiński• Kashif Mardani• Daniel Hall

Read more about us:www.cpf.se

Thank you!