Distance Delivery of Mindfulness-based Treatment for Depression: Project UPLIFT

1. 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

2. Disclosure We have no actual or potential conflict of interest in relation to this presentation.

3. Development of Project UPLIFT1 Ashley Winning, M.P.H. Harvard School of Public Health Harvard University 1This work was done at the Rollins School of Public Health of Emory University

4. Using Practice and Learning to Increase FavorableThoughts

5. 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

6. The Content

7. 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.

8. A Recent Addition—Mindfulness • 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-Zinn’s definition of “paying attention in a particular way: on purpose, in the present moment, and non-judgmentally.”

9. UPLIFT was guided by Mindfulness-based Cognitive Therapy for Depression • Developed by Segal, Williams, and Teasdale

10. Telephone Version Session Four: Attention and Mindfulness

11. Web Version Session One: Monitoring Thoughts

12. Activities were Adapted • For depression treatment • For distance delivery • For people with epilepsy

13. The Structure

14. 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

15. 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

16. 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

17. Formative and Process Evaluations of Project UPLIFT Elizabeth Walker, M.P.H., M.A.T. Rollins School of Public Health Emory University

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

19. Participants • Formative Evaluation • n=9 • Focus groups (n=3) • Process Evaluation • n=38 • Survey following participation • Tertiary epilepsy clinic

20. 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

21. 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)

22. Results: Qualitative

23. Results: Qualitative

24. Results: Qualitative

25. 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

26. Limitations • Formative evaluation – small sample • Process evaluation – attrition • Recruited from tertiary epilepsy clinic • Social desirability – evaluations conducted by study staff

27. 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

28. 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

29. Outcome Evaluation of Project UPLIFT Nancy J. Thompson, Ph.D.,M.P.H. Rollins School of Public Health Emory University

30. Design—Outcome Evaluation • Comparison Group: treatment-as-usual Stratum 1:Pretest8 wk phoneInterimas usualFollow-up Stratum 2:Pretest8 wk WebInterimas usualFollow-up Stratum 3: Pretestas usual Interim8 wk phoneFollow-up Stratum 4: Pretestas usualInterim8 wk Web Follow-up Baseline Week 8 Week 16

31. 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

32. Measures • Mediators • Knowledge & Skills—developed 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

33. 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

34. Knowledge/Skills & Self-Efficacy

35. Depression: BDI • UPLIFT vs.Waitlist (treatment as usual) • Foverall = 42.22, p=.0001 • Finteraction= 11.99, p=.001*

36. Depression: BDI By Intervention Type • Phone vs. Web vs. Waitlist (treatment as usual) • Foverall = 41.65, p=.0001 • Finteraction= 5.93, p=.006*

37. No difference with Major Depressive Disorder • at baseline or not (F1,35= 1.21, p = 0.279) • Maintenance

38. Quality of Life 1.05<p<.10

39. QOL Results • Consistent with the premises of mindfulness • that suffering is not something to turn away from or something in need of fixing, • that it is worthy of attention, • that through attention we can see the ways in which we attach thoughts to the suffering that exacerbate it, and • that letting go of these thoughts reduces suffering (Segal et al.)

40. Summary • UPLIFT was effective in: • Reducing Depressive Symptomsand teaching Knowledge and Skills associated with reducing depression • Intervention group showed significant improvement compared to the waitlist • Equally effective for those with and without MDD • Reduction in depressive symptoms maintained • Approached significance for Depression Coping Self-Efficacy and Satisfaction with Life • Delivery • Both phone and Web were significantly more effective in reducing depression than treatment-as-usual condition

41. Going Forward • ~$1 million Challenge Grant--UPLIFT for Prevention • Managing Epilepsy Well Network • Participants in 4 states • Georgia • Michigan • Texas • Washington • Application to other populations • (MS, caregivers, workplace)