Nancy J. Thompson, Ph.D., M.P.H. Elizabeth R. Walker, M.A.T., M.P.H. Rollins School of Public Health...
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Distance Delivery of Mindfulness-based Treatment for Depression: Project UPLIFT Nancy J. Thompson, Ph.D., M.P.H. Elizabeth R. Walker, M.A.T., M.P.H. Rollins School of Public Health of Emory University Ashley Winning, M.P.H. Harvard School of Public Health
Nancy J. Thompson, Ph.D., M.P.H. Elizabeth R. Walker, M.A.T., M.P.H. Rollins School of Public Health of Emory University Ashley Winning, M.P.H. Harvard
Nancy J. Thompson, Ph.D., M.P.H. Elizabeth R. Walker, M.A.T.,
M.P.H. Rollins School of Public Health of Emory University Ashley
Winning, M.P.H. Harvard School of Public Health
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Disclosure We have no actual or potential conflict of interest
in relation to this presentation.
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Ashley Winning, M.P.H. Harvard School of Public Health Harvard
University 1 This work was done at the Rollins School of Public
Health of Emory University
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Using Practice and Learning to Increase Favorable Thoughts
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Project UPLIFT Was designed for delivery of mindfulness-based
cognitive therapy by telephone and Internet The version of Project
UPLIFT presented here was designed for people with epilepsy The
work we are presenting today was funded by the Centers for Disease
Control and Prevention The participants described all resided in
the State of Georgia because of concerns surrounding the state-
level licensing of mental health professionals
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The Content
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About Cognitive-Behavioral Therapy (CBT) Designed by Aaron Beck
to address the unrealistic thinking and outcome expectations
associated with depression. Uses verbal techniques to investigate
the reasoning behind specific attitudes and assumptions. Client is
taught to recognize, monitor, and record negative thoughts on a
daily record. Beck recommends first including behavioral
techniques, like assigning activities to help structure the
depressed individual who may have trouble getting started using
pleasurable activities for reinforcement, breaking tasks into
simple steps, providing assertiveness training, guidance in
role-playing and mental rehearsal.
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A Recent AdditionMindfulness CBT focuses on changing thought
content while mindfulness changes relationship to the thoughts
helps to see them as passing events that do not necessarily
represent a state of reality. Mindfulness is especially important
in preventing relapse, which often occurs with depression. We used
Jon Kabat-Zinns definition of paying attention in a particular way:
on purpose, in the present moment, and non-judgmentally.
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UPLIFT was guided by Mindfulness-based Cognitive Therapy for
Depression Developed by Segal, Williams, and Teasdale MBCT
SessionsUPLIFT Sessions 1. Automatic Pilot1. Monitoring Thoughts 2.
Dealing with Barriers2. Challenging and Changing Thoughts 3.
Mindfulness of the Breath3. Coping and Relaxing 4. Staying
Present4. Attention and Mindfulness 5. Allowing/Letting Be5. The
Present as a Calm Place 6. Thoughts are not Facts6. Thoughts as
Changeable and Impermanent 7. How can I best take care of myself?7.
Pleasure and Reinforcement 8. Using what has been learned in the
future 8. Relapse Action Plans
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Telephone Version TimeActivityDescription 10 minutesCheck-in
The group will report on their experiences with Modifying &
Relaxation and help each other with any problems. 10
minutesTeaching Group will learn about the concepts of Mindfulness
& the importance of paying attention. 10 minutesGroup Exercise
The Pebble Exercise is an activity in mindful attention. The group
will practice what they learned during the teaching portion of the
session. 10 minutesDiscussionDiscussion of the Pebble
Exercise/describe pebble to group. 15 minutesSkill-building w/
discussion Mindfulness of a routine activity: Walking Meditation.
The Walking Meditation is meditation in motion; it allows us to
practice mindfulness in the most routine of activities. 5
minutesReview & Homework Homework: Monitoring with Modification
and Practicing Mindfulness of Routine Activities 3 times during the
week. Session Four: Attention and Mindfulness
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Web Version Session One: Monitoring Thoughts
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Activities were Adapted UPLIFT ActivityMBCT Activity The
What-ifs of Epilepsy (S1)--- ARMed Against the Blues (S2)--- Body
Scan and Progressive Muscle Relaxation (S3) Body Scan (S1) Pebble
Exercise (4)Raisin Exercise (S1) Guided Meditation on Pleasure
(S7)Pleasant Events Calendar (Session 2) For depression treatment
For distance delivery For people with epilepsy
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The Structure
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Group Delivery at a Distance UPLIFT was delivered by Web and
telephone to people in groups of 6-7 Group Delivery was important
for support surrounding Epilepsy The Web platform used was
Blackboard Laptops and Internet access were provided for people
assigned to the Web condition who did not have computers or Web
access
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Group Facilitation Groups were co-facilitated One facilitator
was a graduate student in Public Health to ensure the integrity of
the delivery The other facilitator was a person with epilepsy to
build capacity in the epilepsy community A licensed psychologist
supervised the facilitators and provided back-up Listened to
telephone tapes Monitored Web discussions
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Potential Benefits Cost-effective Can reduce access problems,
reducing health disparities mobility limited rural Allows group
delivery even for rare conditions Potential for anonymity and
avoidance of stigma Teaches skills to prevent relapse
Slide 17
Elizabeth Walker, M.P.H., M.A.T. Rollins School of Public
Health Emory University
Slide 18
Evaluation Purposes: Determine the acceptability of Project
UPLIFT Assess the complexities anticipated and encountered when
participating Evaluate the overall response to the program
components
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Participants Formative Evaluation n=9 Focus groups (n=3)
Process Evaluation n=38 Survey following participation Tertiary
epilepsy clinic Focus Group n=9 Pilot Participants n=38 Age
(years), Mean (SD) 33.6 (10.69)35.1 (10.98) Depression score, Mean
(SD) Range 22.4 (5.59) 14-28 27.2 (7.25) 13-38 Gender, n (%) Female
7 (77.8)30 (78.9) Race, n (%) White Black 7 (77.8) 2 (22.2) 29
(76.3) 9 (23.7) Marital Status, n (%) Married Single
Separated/Divorced/Widowed 15 (39.5) 17 (44.7) 6 (15.7) Employment
Status, n (%) Full-time Part-time Student Not working or retired 11
(28.9) 5 (13.2) 3 (7.9) 19 (50.0) Seizures in the past 4 weeks, n
(%) Yes 24 (63.2) Type of seizure usually experienced General
Partial Other Unknown 26 (63.2) 11(29.0) 2 (5.3) 1 (2.6) Severity
of recent seizures (in past 4 weeks) Very Mild Mild Severe Very
Severe 5 (20.8) 8 (33.3) 7 (29.2) 4 (16.7)
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Procedures Formative Evaluation Process Evaluation Focus groups
Co-facilitated by a PWE Participants received materials in advance
Discussed proposed materials and exercises Survey Client
Satisfaction Scale Open-ended questions: what facilitated
participation in the sessions, what they liked, what they did not
like, what they would change
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Data Analysis Qualitative Quantitative Focus groups (formative)
A priori codes: acceptability, complexity, program components
Emerging themes Open-ended survey questions (process) Focus group
codebook Emerging themes Client Satisfaction Scale (process)
Descriptive statistics Independent t-tests used to examine
differences in satisfaction between: Delivery groups (phone vs
Internet) Treatment groups (initial treatment vs waitlist
control)
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Results: Qualitative ThemeComments Acceptability Exercises were
functional and practical Program had great value Learned useful
skills Program helped more than antidepressants Complexity
Difficulties participating due to: physical limitations time
commitments feelings of guilt for taking time Scheduling Not
connected with group Felt embarrassed or nervous
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Results: Qualitative ThemeComments CBT exercises Benefits:
Useful to write down thoughts Issues: Difficult to identify one
thought and one feeling Not enough variety in CBT homework
activities Relaxation exercises Benefits: Facilitates relaxation
Helpful in relieving stress Can become aware of tension in the body
Issues: Feel more tense Mindfulness exercises Benefits: Allows for
time to quiet thoughts Can do it anywhere Issues Prefer a more
direct link between epilepsy and mindfulness Mindful attention is
hard to do
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Results: Qualitative ThemeComments Delivery Include in-person
meeting at the end Incorporate phone and web aspects together Phone
More intimate than web People talked over each other Smaller groups
or longer session Web Anonymous Someone will always be on Low
participation, lack of connection Difficulties navigating the site
and using the discussion board Group setting Connect with group
members because everybody had epilepsy Liked sharing with group
members Learn from each other, see different perspectives When
group ended, support taken away Living with Epilepsy Impact of
epilepsy on lives and relationships Stigma
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Results: Quantitative Mean CSQ score = 28.66 (SD=3.411)
Delivery Method: Web vs. Phone Phone group reported higher
satisfaction (p=.08) Treatment Group: Initial group vs. Waitlist
control No significant difference in satisfaction
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Limitations Formative evaluation small sample Process
evaluation attrition Recruited from tertiary epilepsy clinic Social
desirability evaluations conducted by study staff
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Discussion Project UPLIFT materials and exercises viewed as:
Beneficial Acceptable Taught needed skills Phone group more
satisfied than Web group Barriers to participation: health
problems, time restrictions, scheduling difficulties, and lack of
connection Group design was a key component
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Implications Mindfulness-based CBT program delivered over phone
or Web perceived to be beneficial Building skills to reduce
depressive symptoms Creating connections between PWE Provide
hard-to-reach populations with an acceptable method of treatment
for depression
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Nancy J. Thompson, Ph.D., M.P.H. Rollins School of Public
Health Emory University
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DesignOutcome Evaluation Stratum 1: Pretest 8 wk phone Interim
as usual Follow-up Stratum 2: Pretest 8 wk Web Interim as usual
Follow-up Stratum 3: Pretest as usual Interim 8 wk phone Follow-up
Stratum 4: Pretest as usual Interim 8 wk Web Follow-up Baseline
Week 8 Week 16 Comparison Group: treatment-as-usual
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Participation Screened Eligible (n=53) Assessments Completed
Baseline (n=48) Completed Interim Survey (n=40) Completed Third
Survey (n=35) Participated in at least one session Phone
Intervention Group (n=12) Web Intervention Group (n=10) Phone
Waitlist Group (n=10) Web Waitlist Group (n=10) 40 (75.5%)
participated and completed the assessment following their
participation
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Mediators Knowledge & Skillsdeveloped with UPLIFT
Depression Coping Self-efficacy Self Compassion Outcomes Depression
mBDI Patient Health Questionnaire (PHQ-9) Neurological Disorders
Depression Inventory for Epilepsy (NDDI-E) Quality of Life SF-36
Physical and Mental Health QOL Satisfaction with Life Measures
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Data Analysis Baseline Differences Only mean Self Compassion
was statistically significant (t = 3.00, df = 38, p = 0.005)
Intervention group (mean = 19.7) Waitlist group (mean = 16.0)
Repeated Measures ANCOVA Assessed the change in scores over time in
the intervention and the waitlist groups Controlled all analyses
for Self Compassion
Depression: BDI UPLIFT vs. Waitlist (treatment as usual) F
overall = 42.22, p=.0001 F interaction = 11.99, p=.001*
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Depression: BDI By Intervention Type Phone vs. Web vs. Waitlist
(treatment as usual) F overall = 41.65, p=.0001 F interaction =
5.93, p=.006*
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No difference with Major Depressive Disorder at baseline or not
(F 1,35 = 1.21, p = 0.279) Maintenance MeasureTimeIntervention
Treatment -as-Usual Waitlist Fdfp-value BDIPretest Interim Posttest
14.5 4.6 5.7 13.4 10.8 8.3 0.121 7.541 1.124 1,30 0.730 0.010*
0.297
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Quality of Life MeasureTimeIntervention Tx As Usual Waitlist F
interaction df 1,37 P-value Satisfaction with Life Pretest Interim
18.2 21.0 18.3 18.0 3.0290.090 1 Mental Health QOL Pretest Interim
59.3 80.9 65.4 83.6 0.1230.727 Physical Health QOL Pretest Interim
68.9 78.9 76.2 80.8 0.4960.486 1.05