Mindfulness meditation along with behavioral activation reduced depressive symptoms in patients with subthreshold depression in a primary care setting, a new study found.
Dr Samuel Wong
Investigators found that the incidence of major depressive disorder in patients who received this combination intervention was less than half that of those who received usual care.
The results may encourage clinicians to consider such group interventions in patients with subthreshold depression, Samuel Y. S. Wong, MD, clinical professor and head, Division of Family Medicine and Primary Healthcare, and associate director of undergraduate education, School of Public Health and Primary Care, Chinese University of Hong Kong, told Medscape Medical News.
“Behavioral activation with mindfulness is a promising intervention that we have shown to be effective in our subthreshold depression population over a short- and long-term period,” Wong said.
The study was published in the March/April issue of Annals of Family Medicine.
Combined Approach
Patients with subthreshold depression have clinically significant symptoms of depression but do not fulfill all diagnostic criteria for major depression. The condition is common in primary care; the estimated lifetime prevalence of subthreshold depression is 10% to 24%.
Research suggests that a significant proportion of patients with subthreshold depression progress to major depression, said Wong. His own research showed that in a primary care setting in Hong Kong, about 27% of patients progress to major depression in the following year.
Behavioral activation is a brief, simple, structured therapy for depression that aims to increase rewarding experiences by encouraging patients to set goals and to engage in social interactions and pleasurable activities.
Mindful meditation emphasizes the acceptance and awareness of present moment emotions, thoughts, and bodily sensations.
Previous research has shown that behavioural activation is effective among people with mild to moderate depression and that mindfulness-based interventions are effective in preventing relapse in patients with recurrent depression.
The new study combined these two approaches.
The study included 231 adult patients from 16 general outpatient clinics who had subthreshold depression, determined on the basis of the patient’s having a score of 5 to 9 on the 9-item Patient Health Questionnaire (PHQ-9) depression scale. The patients had not had a major depressive episode in the past 6 months.
The majority of study patients (93.1%) were women, and most (61.9%) were housewives or retired.
Study participants were not taking medications at baseline.
Investigators randomly assigned these patients to receive either behavioral activation with mindfulness (BAM) (n = 115) or usual care (n = 116).
The BAM intervention consisted of eight weekly 2-hour sessions. The first four sessions included psychoeducation related to well-being, setting short- and long-term goals, self-monitoring of activity and mood, scheduling daily activities, and identifying avoidance and its impact so as to allow patients to be more aware of their decision making.
Sessions five to seven included a half-hour behavioral activation review and a 1.5-hour mindfulness practice that consisted of receiving training in basic mindfulness skills, including body scan (observing bodily sensations in each part of the body) and sitting and walking meditation.
Patients received a compact disc with audio recordings of guided meditation for use at home. They were instructed to practice at home for 10 minutes a day at least 6 days a week after session 5. Home practie sessions were increased to 20 minutes a day after session 6, and to 45 minutes a day after session 7.
Simple, Effective Intervention
Allied healthcare workers, including a nurse, and three social workers served as instructors for the BAM group. These workers received 32 hours of training and 8 hours of supervision.
Patients in the usual-care group continued to receive medical care at general outpatient clinics. They were allowed unrestricted access to medical care for depression or anxiety.
The primary outcome was a reduction of depressive symptoms at 12 months, as measured by the Chinese version of the Beck Depression Inventory–II (BDI-II). That inventory includes 21 items; possible total scores range from 0 to 63.
Compared with the usual-care group, the BAM group demonstrated a significantly greater reduction in depressive symptoms at the end of the intervention (between-group mean difference in BDI-II, -3.57; 95% confidence interval, -5.38 to -1.78; P < .001).
The BAM group also demonstrated greater improvements in quality of life on the mental component summary score of the Chinese version of the Medical Outcomes Study Short Form Health Survey. The difference in scores in the physical component of this survey was not significant, but the authors say these scores may be more difficult to change.
The BAM group had better scores on the Activity and Circumstances Change Questionnaire. In addition, for patients in the BAM group, there was a trend toward a reduction in anxiety, as assessed with the State Trait Anxiety Inventory.
At the 5-month follow-up, there was still a significantly lower level of depressive symptoms in the BAM group compared with the control group (P = .015). At 12 months, there was a persistent but small reduction in depressive symptoms for patients in the BAM group compared to those who received usual care; this reduction was associated with a lower incidence of major depressive disorder (10.8% vs 26.8%; P = .01).
That the incidence of major depressive disorder in the BAM group was less than half that of the usual-care group suggests that the intervention can be viewed as a “preventive intervention” among patients with subthreshold depression who have not had a major depressive episode within the past 6 months, say the authors.
On average, BAM patients attended six of the eight sessions.
In a per protocol analysis, 67.3% of patients in the BAM group and 84.5% of those in the usual-care group were evaluated. In this analysis, the BAM group demonstrated significantly lower levels of depressive symptoms compared with the usual-care group at the end of the intervention (P = .001), as well as at 5 months (P = .012) and 12 months (P = .003). These findings were consistent with the primary analysis.
The researchers found that the intervention was delivered according to protocol, suggesting that trained allied healthcare workers can deliver it effectively.
“In my opinion, any certified healthcare professional with prior training can deliver this BAM intervention,” said Wong. “Compared with other psychological interventions, BAM is relatively simple.”
Complementary Therapies
From the study results, it was difficult to differentiate the effectiveness of behavioral activation from that of mindfulness, because the two treatments were combined. But it appears that the two components complement each other, said Wong.
“The reason for not distinguishing the two is that we hope to make the treatment a cohesive whole for the future application in clinical practice,” he said.
Wong noted that patients regarded the two approaches as complementary.
“They felt that when they encountered a sense of failure when doing homework assignments as part of the behavioral activation activities, they could later use mindfulness skills to bring them back to the present moment, and they cultivated more accepting attitudes towards themselves,” he said.
Results of an evaluation by the patients of the BAM course showed that the mean overall satisfaction level was 4.16 on a scale of 1 to 5, with 5 being “very satisfied.” Study patients expressed satisfaction with the course content, the course philosophy, the class format, the class atmosphere, the relationships between class members, and the class location and environment.
About 80% of patients thought the practice sessions and homework helped reduce their depressive symptoms. Most patients indicated that they would keep practicing the learned skills in the future (74.5%) and would recommend this intervention to others (85.9%).
It is possible that the BAM intervention might also be beneficial in patients with dysthymia, although further research is needed, say the authors. Patients with dysthymia experience persistent depressive symptoms most days for at least 2 years.
Wong and his colleagues are launching a pilot study to examine the use of BAM in primary care for patients with major depression.
“If the pilot results are encouraging, we plan to conduct a larger randomized controlled trial,” Wong said.
More than a third of patients in the current study were housewives. Wong explained that many patients find it difficult to participate in a program for 8 consecutive weeks.
“Future studies can take this into account and adjust the location and time to better suit those who work, or consider adjusting the format to online teaching or apps,” he said.
Wong believes that the intervention would likely work well for other groups, including men. He pointed out that previous research showed no sex differences in the effectiveness for depression of either mindfulness or behavioral activation.
A limitation of the study was that it was not possible to conceal group assignments.
“Frontline” Therapy
Commenting on the study for Medscape Medical News, Simon Goldberg, PhD, postdoctoral fellow, Department of Health Sciences, University of Washington, Seattle, said the study includedseveral “nice methodological features.
“It included a reasonably large sample size and involved a robust intervention based on psychological principles and a novel combination of behavioral activation with mindfulness.”
Behavioral activation, said Goldberg, is a “frontline” cognitive-behavioral therapy for depression.
He also noted that the authors used conservative analytical methods, for example, per protocol analyses that accounted for missing data, and that the study had a lengthy follow-up period.
As well, the intervention seemed well-tolerated by patients, he said.
A “vital” future direction for establishing the evidence base for BAM and other mindfulness-based interventions will be to use active comparisons rather than the treatment-as-usual comparison employed in the current study, said Goldberg.
“Trials of this kind can establish the relative efficacy of BAM and other therapies, allowing providers to choose interventions that are the most likely to be acceptable and effective,” he said.
Clinically, the combination of behavioral activation and mindfulness “seems promising,” although it may be important for providers to have some supervision or background in these kinds of interventions, as was the case in the current study, said Goldberg.
The study was supported by the Health and Medical Research Fund. The authors have disclosed no relevant financial relationships.
Ann Fam Med. 2018;16:111-119. Abstract
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