Mindfulness-Based Attention as a Moderator of the Relationship Between Depressive Affect and Negative Cognitions

Here’s another study in the growing body of research suggesting that mindfulness changes how we experience depression.

Researchers at Pacific University collected self-report measures of mindfulness, depression, and negative thinking from a sample of 278 undergraduates. Analyses suggest that there is a weaker relationship between negative thinking and depressive symptom for people higher in mindfulness than for people lower in mindfulness.

What might this mean?

The authors conclude that being more mindful may serve a protective function against becoming depressed when someone experiences negative thoughts. Conversely, less mindful people may be more likely to become depressed when they have negative thoughts.

The results are pretty limited. For one, this was a convenience sample of undergraduate students, not a sample of people with clinical depression. Also, because the results are correlational, we can’t draw any firm conclusions that one thing causes another. We can't tell from these results whether increasing mindfulness actually serves as a prophylactic against becoming depressed.

However, if you're interested in studies that tell us more about how mindfulness may impact how we experience depression, check out some of the past posts from Scientific Mindfulness on Mindfulness-Based Cognitive Therapy and Mindfulness-Based Relapse Prevention. Additionally, a longitudinal study showed that less mindful police officers showed greater increases in depression over time compared to their more mindful counterparts.

For the full citation:

Gilbert, B.D., & Christopher, M.S. (2010). Mindfulness-Based Attention as a Moderator of the Relationship Between Depressive Affect and Negative Cognitions. Cognitive Therapy and Research, 34, 514-521.

You might also be interested in some of these other books about mindfulness and depression: 

I’d like to thank Molly Ellis for her help with this post!

Mindfulness-Based Cognitive Therapy for Bipolar Disorder: A Feasibility Trial

Mindfulness-based cognitive therapy (MBCT) studies generally focus on what’s sometimes called unipolar depression. The term “unipolar” is just a fancy way of distinguishing clinical depression from depression experienced in people with bipolar disorder. People with bipolar disorder may alternate between periods of depression and periods of elation called mania or hypomania (hypomania is less extreme than mania).

In earlier studies of MBCT, people with bipolar depression were screened out. More recently, researchers from Geneva University Hospital in Switzerland set out to determine if MBCT may be helpful for people with bipolar disorder.  They hypothesized that mindfulness may help break the vicious cycles of depression and mania.  This study is the first to pilot the use of MBCT for a sample comprised entirely of people with bipolar disorder.

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The intervention consisted of weekly, 2-hour, MBCT sessions for a total of 8 weeks. Each group met three months after the end of the 8-week program for a 2-hour refresher session. Little was changed to the program except that mania and hypomania were discussed in sessions and mentioned in handouts. Participants were assessed a month before the MBCT class, a month afterward, and at the 3-month follow-up. Of 23 participants, only 15 attended enough sessions to be included in the analyses, and only 9 were assessed at follow-up.

Overall, there were no significant improvements in mindfulness, depression, and hypomania between the beginning and end of the MBCT program. Interestingly, it didn’t look like the researchers included the 3-month follow-up in their analyses. Statistical analyses indicate no significant changes in depressive symptoms, mindfulness, and mania during the study. According to a table in the article, it even looks like depression may have increased at the follow-up! The good news is that 82% of the participants reported having benefited from the program. This point is emphasized by the authors.

A big limitation of this study is sample size: it’s hard to detect changes when working with such a small sample. That said, the study is spun a bit. The authors seem to downplay the nonsignificant changes in symptoms and mindfulness in favor of the participants’ self-report that they found the program beneficial. People says they liked the program, but there's no evidence it impacted depressive symptoms or mania, or that people improved in mindfulness.

In sum, the study suggests that people with bipolar disorder can participate in MBCT, but it provides little evidence that they benefited from it. However, because the sample size was small, it may be worth running another MBCT study for people with bipolar disorder with a larger sample.

The full citation is below:

Weber, B., Jermann, F., Gex-Fabry, M., Nallet, A., Bondolfi, G., & Aubry, J.-M. (2010). Mindfulness-Based Cognitive Therapy for Bipolar Disorder: A Feasibility Trial. European Psychiatry, 25, 334-337.

If you're interested in learning more about MBCT, the original book is one of the more readable therapist manuals out there:

Segal, Z.V., Williams, J.M.G., & Teasdale, J.D. (2001). Mindfulness-Based Cognitive Therapy for Depression: A New Aproach to Preventing Relapse. New York: Guilford.

The core MBCT originators also created a self-help book called The Mindful Way Through Depression.

I'd like to thank Molly Ellis for her help with this post.

Therapist and Client Perceptions of Therapeutic Presence: The Development of a Measure

This post isn't directly related to mindfulness, but the topic overlaps. Most psychotherapists would agree that the therapeutic relationship with clients is very important. There is less agreement, however, in a definition of what makes up a good therapeutic relationship and how it can be measured.

The lab of Dr. Les Greenberg, the core originator of Emotion Focused Therapy, has taken some initial steps to address this issue more empirically. The first author is Dr. Shari Geller.

These researchers from York University in Toronto have developed two measures of what the call therapeutic presence. Therapeutic presence, according to their definition, involves "bringing one’s whole self into the encounter with clients, by being completely in the moment on multiple levels:  physically, emotionally, cognitively, and spiritually."

Therapeutic presence differs from mindfulness, according to the authors, in two ways. The authors consider mindfulness a technique used to cultivate presence rather than presence itself. They also suggest that mindfulness--at least how it's presented in the research literature--is a way of engaging the internal world of one's self and another person, whereas "therapeutic presence is an internal and relational therapeutic stance that includes the therapist's present-centered sensory attention in direct relation to the client's in-the-moment experience.

I found the authors terminology a little imprecise for my tastes. There seemed to be a blurring of technical terms with vaguely defined descriptions; however, it could be that they're drawing from a research literature I'm not all that familiar with. Regardless, I believe it's clinically useful to define therapuetic presence as something separate from mindfulness.

The study went through a series of stages, beginning with creating items and, eventually, using them in an actual clinical setting with clients who met criteria for depression. The researchers developed two versions of a measure they call Therapeutic Presence Inventory. In one version (TPI-C), clients rate the presence of their therapist; in the other (TPI-T), therapists rate themselves.

The client measure predicted the therapeutic relationship and improved outcomes. The therapist version wasn't predictive of either. This supports a long line of research showing that psychotherapists aren't a very good judge of how well therapy is going. Psychotherapists tend to overestimate how much their clients like them! Consequently, the findings for the therapist measure are not too surprising.

The client version, though, is potentially really useful. It's short (only 3 items), and it can give therapists feedback about how clients perceive their relationship. Moreover, this feedback appears to be related to how clients change and improve.

In my own practice, I often give clients the option of filling out a feedback form about how well the session went. When I get the chance, I intend to revise my form to incorporate these three items.

To download the article, click on the full citation below:

Geller, S.M., Greenberg, L.S., & Watson, J.C. (2010). Therapist and Client Perceptions of Therapeutic Presence: The Development of a Measure. Psychotherapy Research, 20(5), 599-610.

How Does Mindfulness-Based Cognitive Therapy Work?

Mindfulness-Based Cognitive Therapy (MBCT) has demonstrated it reduces depressive relapse in those with three or more depressive episodes across several studies now. But why--what changes occur in MBCT that reduce relapse? The theory behind MBCT suggests increased mindfulness leads to reduced chance of relapse; however, treatments may be effective for reasons having little to do with why we think they're effective.

A recent article by Kuyken and colleagues examines processes of change in MBCT in order to assess the theory behind underlying it. The researchers used what are called mediational analyses. Mediational analyses look at whether changes in one factor (e.g., mindfulness) lead to changes in another (e.g. lower depression).

The authors used data from a previous study (Kuyken et al., 2008) in which 123 people with 3 or more depressive episodes who were currently prescribed antidepressant medication were randomly assigned to either 8-weeks of MBCT or were placed on a wait list. Those in the MBCT condition were weaned off their medication while those not assigned to MBCT remained on their meds. Participants were assessed every 3 months up to a 15 month follow-up. (In the original study, there was no difference in rate of relapse between MBCT and antidepressant meds; however, people in MBCT exhibited fewer depressive symptoms by the 15-month follow-up.)

Results of this study suggest increases in mindfulness and self-compassion mediated the effect of MBCT on depressive symptoms at follow-up. Researchers also looked at what they called cognitive reactivity. Cognitive reactivity was defined as changes in depressive thinking before and after a short piece of "sad" music (i.e., Prokofiev).

Curiously, people who participated in MBCT exhibited greater cognitive reactivity than those who remained on antidepressant medication. Here's the interesting part, though: whereas cognitive reactivity was associated with poorer outcome for people taking antidepressants, participation in MBCT appears to erase this relationship. Said another way, for people who participated in MBCT, cognitive reactivity no longer appeared to impact depressive symptoms. This reminds me of the Mindfulness-Based Relapse Prevention study in which the researchers found the relationship between depression and relapse appeared to disappear for those who participated in the program.

These results of the current study offer further evidence that mindfulness doesn't change patterns of thinking so much as it changes how people relate to thinking. Additionally, this is another study showing the useful in self-compassion in understanding mechanisms of change in mindfulness based treatments. (For another study indicating the importance of self-compassion, click here.)

As with any study, there are limitations. Mediational analyses don't definitively tell us that particular variables lead to change. However, the results largely supported the hypotheses of the researchers, offering additional evidence in support of the theory.

To download a copy of the article, click on the full citation below:

Kuyken, W., Watkins, E., Holden, E., White, K., Taylor, R.S. et al. (2010). How Does Mindfulness-Based Cognitive Therapy Work? Behaviour Research and Therapy, 48, 1105-1113.

Mindfulness-Based Treatments for Co-Occurring Depression and Substance Use Disorders: What Can We Learn from the Brain?

In a previous post, I wrote about the implications if a pilot study that Mindfulness-Based Relapse Prevention (MBRP) may help people in recovery avoid relapse during depressed moods (Witkiewitz & Bowen, 2010). A recent article in Addiction by Brewer and colleagues explores how mindfulness-based treatments may be useful in treating people with both substance use problems and depression. (The authors of the article include a few of the developers of MBRP--Drs. Alan Marlatt and Sarah Bowen.)

The article is largely theoretical and includes explorations of potential neurobiological processes that may change through mindfulness training. It's relatively brief, so feel free to check it yourself!

To download a copy of the article, click on the citation below:

Brewer, J.A., Bowen, S., Smith, J.T., Marlatt, G.A., & Potenza, M.N. (2010). Mindfulness-Based Treatments for Co-Occurring Depression and Substance Use Disorders: What Can We Learn from the Brain? Addiction, 105(10), 1698-1706.

A Novel Application of Acceptance and Commitment Therapy for Psychosocial Problems Associated with Multiple Sclerosis

In a previous post, I wrote about an 8-week mindfulness-based intervention for multiple sclerosis. Here's one that's even shorter: it's a one-shot 5-hour workshop.

This study is from Dr. John Forsyth's lab at the University of Albany - SUNY. His lab is also currently investigating the effectiveness of Dr. Forsyth's self-help book, from which some preliminary data looking at mindfulness and self-compassion was recently published.

Dr. Forsyth and another psychologist led a 5-hour Acceptance and Commitment Therapy (ACT) workshop for people with multiple sclerosis (MS). At the end of the workshop, participants were given a CD of various mindfulness exercises and a bunch of worksheets and exercises from the workshop. They also received daily practice logs to track what they did following the workshop. Fifteen people with MS completed a battery as part of the workshop, and 11 completed the battery again 12 weeks later.

According to the authors, MS is the most common cause of neurologic disability in the US. MS is incurable and associated with pain, fatigue, depression, and anxiety.

For a one-short 5-hour workshop, the results are very promising. Depression decreased over time, showing a large effect. (Depression went from the moderate-severe range down to the mild-moderate range.) Although the effect of pain itself did not change, the impact of pain on behavior and mood decreased at follow-up. Mindfulness did not improve, but people reported a reduced tendency to suppress thoughts, which suggests increased mindful acceptance. Lastly, overall quality of life improved at the follow-up. Participants reported practicing exercises from the workshop or listening to the mindfulness CD nearly 3 hours per week, which is pretty good.

Because of the design of the study, the findings are preliminary. With only 15 people, 4 of whom dropped out, it's difficult to know how representative the sample is; however, with such a small sample size, it's impressive the researchers found significant results at all, as the results had to be very strong to be detected. Also, without a comparison group, it's impossible to know if ACT was the active ingredient. The authors acknowledged these weaknesses and others in the paper.

Limitations aside, the results are extremely promising. If a 5-hour group could lead to some pretty strong improvements for people with a painful, incurable disease, this is well worth exploring further. According to the authors, traditional cognitive behavioral treatments have shown mixed results for people with MS, and even the positive results weren't all that impressive. By contrast, this is a short, inexpensive group intervention that may have made a real different in the lives of people with MS.

To download a pdf of the article, click on the citation below:

Sheppard, S.C., Forsyth, J.P., Hickling, E.J., & Bianchi, J.M. (2010). A Novel Application of Acceptance and Commitment Therapy for Psychosocial Problems Associated with Multiple Sclerosis: Results from a Half-Day Workshop Intervention. International Journal of MS Care, 12, 200-206.

On Being Mindful, Emotionally Aware, and More Resilient: Longitudinal Pilot Study of Police Recruits

I don't tend to read much research about the study of law enforcement. Consequently, it was with great curiosity that I came across a recent study by a group of researchers at the University of Wollongong in New South Wales, Australia.

Dr. Williams--along with Dr. Ciarrochi, who authored another study I recently wrote about on adolescent well-being--examined changes in police recruits between becoming trainees to being "probationary constables." Of the 592 recruits who completed the initial assessment through a Bachelor of Policing course, 60 completed the follow-up measures.

According to the authors, police are encouraged to not show emotions within the law enforcement culture. Research has shown that police become more emotionally detached within 18 months of service. As there's a large body of research suggesting that detachment from emotions can have detrimental consequences to emotional health, the researchers were interested in the interaction of these variables over time.

Perhaps the most striking finding of this study was that police recruits showed an increase in depression and other mental health problems after starting the job. What's really interesting, though, is that officers who were more mindful, less likely to suppress thoughts, and more able to identify feelings, showed smaller increases in depression. Moreover, of the variables measured by the researchers, low mindfulness was the strongest predictor of depression. (This indirectly supports the Mindfulness-Based Cognitive Therapy research.) Results suggest that mindfulness and the ability to identify one's feelings may have a protective factor for police recruits.

This study measured dispositional mindfulness. As the authors suggest, it would be really interesting to see if a mindfulness-based intervention may help to foster these abilities in police recruits. There could be significant long-term benefits for law enforcement agencies.

To download a copy of the study, click on the citation below:

Williams, V., Ciarrochi, J., & Deane, F.P. (2010). On Being Mindful, Emotionally Aware, and More Resilient: Longitudinal Pilot Study of Police Recruits. Australian Psychologist, 45(4), 274-282.

Self-Compassion is a Better Predictor Than Mindfulness of Symptom Severity and Quality of Life in Mixed Anxiety and Depression

Way back in June, I wrote about some data Dr. John Forsyth had collected about his self-help book, The Mindfulness and Acceptance Workbook for Anxiety. Dr. Forsyth's lab is still collecting data for the second part of the study; in the meantime, they've used some of it to look at the relationship between mindfulness and self-compassion to anxiety and depression. Self-compassion, which SM has posted about before, was developed by Dr. Kristin Neff and is based on Buddhist notions of compassion. The three components of self-compassion are mindfulness, kindness to one's self (as opposed to self-judgment), and feeling part of a common humanity (as opposed to isolation).

Dr. Forsyth's lab analyzed some of the data they've been collecting from 504 people to look at what processes may be most important to anxiety and depression. They used Dr. Neff's Self-Compassion Scale (SCS; Neff, 2003) and--for their measure of mindfulness--the Mindful Attention Awareness Scale (MAAS; Brown & Ryan, 2003). The articles uses some very precise statistical terms that I'll try to translate for a more general audience, but please bear in mind that my descriptions below lose some of the nuance of the original.

Interestingly, self-compassion was a much better measure than mindfulness in accounting for problems with anxiety, depression, and overall quality of life. The SCS has several subscales: the most important one for anxiety and depression was the self-judgment subscale. Greater self-judgment showed a comparatively larger relationship with greater anxiety and depression. What this means is that the SCS appears to be a better than the MAAS in measuring treatment outcomes for people with anxiety and depression. It also suggests that awareness of thoughts and emotions may be less important than how one relates to them. What this means is that self-compassion may be a particularly important component in mindfulness-based treatments, and that it is a useful predictor of psychological health.

A caveat to these findings is that the MAAS is only one of several mindfulness measures. Some of the other mindfulness measures such as the Kentucky Inventory of Mindfulness Skills (KIMS) and the Five Facet Mindfulness Questionnaire (FFMQ) measure 4-5 aspects of mindfulness whereas the MAAS measures one. What is does suggest, though, is that self-compassion, as it is measured by the SCS, may be an extremely important construct in measuring treatment outcome for mindfulness-based therapies. This study contributes to a growing body of literature suggesting the importance of self-compassion as a construct.

To download a copy of the article, click on the full citation below:

Van Dam, N.T., Sheppard, S.C., Forsyth, J.P., & Earlywine, M. (2011). Self-Compassion is a Better Predictor Than Mindfulness of Symptom Severity and Quality of Life in Mixed Anxiety and Depression. Journal of Anxiety Disorders, 25, 123-130.

Science Daily: Mindfulness-Based Cognitive Therapy vs. AntiDepressant in Preventing Depressive Relapse

Science Daily has an article about a recent study of Mindfulness-Based Cognitive Therapy (MBCT). In a group of people who had experienced at least two depressive episodes, study participants were randomly assigned to one of three groups. People who were tapered off an antidepressant and completed an 8-week MBCT course showed a 38% relapse rate, compared to 46% who remained on an antidepressant, and 60% whose antidepressant was replaced by a placebo. Quoted from the article:

"Our data highlight the importance of maintaining at least one active long-term treatment in recurrently depressed patients whose remission is unstable," the authors write. "For those unwilling or unable to tolerate maintenance antidepressant treatment, mindfulness-based cognitive therapy offers equal protection from relapse during an 18-month period."

 I intend to track down the original article. In the meantime, you can read the Science Daily article here.

For the full citation:

Segal, Z.V., Bieling, P., Young, T., MacQueen, G. Cooke, R. et al. (2010). Antidepressant Monotherapy vs Sequential Pharmacotherapy and Mindfulness-Based Cognitive Therapy, or Placebo, for Relapse Prophylaxis in Recurrent Depression. Archives of General Psychiatry, 67(12), 1256-1264.

Interview with Rob Zettle, PhD, on Acceptance and Commitment Therapy for Depression

BehaviorTherapist.com has an interview with Rob Zettle, PhD, who, as the first graduate student of Steven Hayes, PhD, was involved in the development of what would eventually become Acceptance and Commitment Therapy (ACT). Dr. Zettle is also the author of the book, ACT for Depression.

Dr. Trent Codd interviews Dr. Zettle about his early work in developing ACT and his work on using ACT to treat depression. (The American Psychological Association Division 12 officially recognized ACT as a research-supported treatment for depression.) The interview may a little technical for people unfamiliar ACT but provides a fascinating window into its early development.

The interview can be found on BehaviorTherapist.com here.

If you're interested in Dr. Zettle's book, the citation is below:

Zettle, R. D. (2007). ACT for Depression: A Clinician's Guide to Using Acceptance and Commitment Therapy in Treating Depression. Oakland, CA: New Harbinger.

The Effects of Mindfulness-Based Therapy on Anxiety and Depression: A Meta-Analytic Review

The Journal of Consulting and Clinical Psychology recently published a meta-analysis by Dr. Stefan Hoffman and colleagues at Boston University on mindfulness-based therapies for anxiety and depression.

For those of you who don’t know, a meta-analysis is an analysis of a collection of research studies. Researchers calculate what are called effect sizes for the studies. This allows researchers to amalgamate several studies in order to test research hypotheses.

After conducting a thorough literature review, the researchers found 39 studies that met their criteria. The vast majority of these were studies of Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT).

From the results, the researchers conclude that mindfulness-based treatments appear to be effective in treating anxiety and depression. Additionally, the researchers note that mindfulness-based treatment may have a general applicability in addressing different processes across a wide range of conditions, severity, and in association with other problems such as medical conditions (e.g., cancer).

At the end of the study, the authors state their personal biases about the outcomes they expected. They admit that they were skeptical of mindfulness-based therapies and expected to find very small, if not nonsignificant effects. In fact, Dr. Hofmann co-authored a paper a few years ago that was critical of mindfulness-based treatment, titled, “Acceptance and Mindfulness-Based Therapy: New Wave or Old Hat?” For these reasons, I think this article is an inspiring example of the integrity of the scientific method and the researchers who adhere to it. Despite their biases, Hofmann and colleagues were willing to move where the data led them. They did not try to explain away results that contradicted their expectations; instead, they conclude in the abstract that mindfulness-based therapy is a “promising intervention” for treating anxiety and depression.

For ACBS members, you can download the paper at their website. (UPDATE: Download an NIH copy of the article for free here.)

The full citation:

Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness-based therapy on anxiety and depression: A meta-analytic review. Journal of Consulting and Clinical Psychology, 78(2), 169-183.