Ben Whalley

Efficacy of Mindfulness-Based Cognitive Therapy in Prevention of Depressive Relapse: An Individual Patient Data Meta-analysis From Randomized Trials

IMPORTANCE Relapse prevention in recurrent depression is a significant public health problem, and antidepressants are the current first-line treatment approach. Identifying an equally efficacious nonpharmacological intervention would be an important development. OBJECTIVE To conduct a meta-analysis on individual patient data to examine the efficacy of mindfulness-based cognitive therapy (MBCT) compared with usual care and other active treatments, including antidepressants, in treating those with recurrent depression. DATA SOURCES English-language studies published or accepted for publication in peer-reviewed journals identified from EMBASE, PubMed/Medline, PsycINFO, Web of Science, Scopus, and the Cochrane Controlled Trials Register from the first available year to November 22, 2014. Searches were conducted from November 2010 to November 2014. STUDY SELECTION Randomized trials of manualized MBCT for relapse prevention in recurrent depression in full or partial remission that compared MBCT with at least 1 non-MBCT treatment, including usual care. DATA EXTRACTION AND SYNTHESIS This was an update to a previous meta-analysis. We screened 2555 new records after removing duplicates. Abstracts were screened for full-text extraction (S.S.) and checked by another researcher (T.D.). There were no disagreements. Of the original 2555 studies, 766 were evaluated against full study inclusion criteria, and we acquired full text for 8. Of these, 4 studies were excluded, and the remaining 4 were combined with the 6 studies identified from the previous meta-analysis, yielding 10 studies for qualitative synthesis. Full patient data were not available for 1 of these studies, resulting in 9 studies with individual patient data, which were included in the quantitative synthesis. RESULTS Of the 1258 patients included, the mean (SD) age was 47.1 (11.9) years, and 944 (75.0%) were female. A 2-stage random effects approach showed that patients receiving MBCT had a reduced risk of depressive relapse within a 60-week follow-up period compared with those who did not receive MBCT (hazard ratio, 0.69; 95% CI, 0.58-0.82). Furthermore, comparisons with active treatments suggest a reduced risk of depressive relapse within a 60-week follow-up period (hazard ratio, 0.79; 95% CI, 0.64-0.97). Using a 1-stage approach, sociodemographic (ie, age, sex, education, and relationship status) and psychiatric (ie, age at onset and number of previous episodes of depression) variables showed no statistically significant interaction with MBCT treatment. However, there was some evidence to suggest that a greater severity of depressive symptoms prior to treatment was associated with a larger effect of MBCT compared with other treatments. CONCLUSIONS AND RELEVANCE Mindfulness-based cognitive therapy appears efficacious as a treatment for relapse prevention for those with recurrent depression, particularly those with more pronounced residual symptoms. Recommendations are made concerning how future trials can address remaining uncertainties and improve the rigor of the field.

Consistency of the placebo effect.

OBJECTIVE The existence of reliable personality predictors of the placebo effect is controversial. For prediction to be possible, the response to placebo must be reliable. We tested the consistency of the placebo effect by assessing the response to four trials of placebo analgesic treatment. METHODS Two identical experimental pain stimuli were administered simultaneously to matching fingers on both hands. Pain sensation was compared between one finger, which was treated with a placebo cream and the other which was not treated. Two placebo creams were used, each with a different label. The procedure was repeated between 1 and 8 days later using the same creams and order of presentation. Two personality traits (acquiescence and absorption) and response expectancy were assessed as potential predictors of the placebo effect. RESULTS Placebo effects across trials were highly correlated (r=.60 and .77) when placebos bore the same name but were not significantly correlated when placebos had different names. Placebo effects were significantly associated with response expectancy but not with acquiescence or absorption. CONCLUSIONS Context-specific predictions of placebo response (e.g., expectancy) are possible, but personality predictors will not be consistent across contexts.

Motivational concordance: An important mechanism in self-help therapeutic rituals involving inert (placebo) substances

We tested the contribution of two mechanisms, response expectancy and motivational concordance, to reported psychological benefit from a popular, biologically inactive, self-help, complementary therapy (a placebo). Flower essences were taken by 251 people for self-selected symptoms and were randomized to receive three different kinds of information. When the flower essence was presented as a spiritual therapy, then baseline spirituality (beta=.35, P=.01) and expectancy (beta=.25, P=.03) independently predicted outcome. When flower essences were presented as an affirmation (i.e., nonspiritual) therapy, then spirituality negatively (beta=-.27, P=.03) and expectancy (beta=.33, P=.01) predicted outcome. For both groups, expectancy predicted outcome after controlling for spirituality and compliance, but did not after controlling for ease of task completion. Expectancy failed to predict outcome in the nonenhanced ritual group. The results suggest that motivational concordance is an important therapeutic mechanism for real-life placebos.

One size does not fit all: Motivational predictors of contextual benefits of therapy

BACKGROUND A common sense view in psychotherapy holds that there are individual differences in response to different treatments. However, despite considerable effort, no clear rationale exists to guide the selection of therapy for individual patients. OBJECTIVES Rather than focusing on specific components of therapy as a basis to predict interactions between patients and treatments, we draw on motivational concordance theory and a contextual model of psychotherapy to test whether, in an analogue study, perceived effectiveness of different therapy vignettes is related to human values. METHOD Two samples (undergraduates and members of the public) read short vignettes, informed by six therapies for depression (cognitive behaviour therapy, client-centred therapy, antidepressant medication, existential psychotherapy, psychodynamic psychotherapy, and a complementary medicine: Bach flower essences), provided ratings of perceived effectiveness, and completed questionnaire measures of dispositional motivations (Schwartz Values Scale and the Spiritual Connection Questionnaire-14). Responses were analysed using multidimensional scaling (MDS). RESULTS In both samples, expectancy for the cognitive behavioural-informed vignette was related to Self-direction and Stimulation, and was opposed to Tradition, Conformity and Security. Expectancies for the Drug vignette were associated with Power and Security. CONCLUSION People perceive therapies as more effective if the therapy is congruent with their values. These preliminary data suggest motivational concordance is a useful framework for predicting client-treatment interactions.

A qualitative study of the impact of severe asthma and its treatment showing that treatment burden is neglected in existing asthma assessment scales.

BackgroundPeople with severe asthma experience significant respiratory symptoms and suffer adverse effects of oral corticosteroids (OCS), including disturbed mood and physical symptoms. OCS impacts on health-related quality of life (HRQoL) have not been quantified. Asthma HRQoL scales are valid as outcome measures for patients requiring OCS only if they assess the deficits imposed by OCS.AimsThe aim of this study was to compare the burden of disease and treatment in patients with severe asthma with items in eight asthma-specific HRQoL scales.MethodsTwenty-three patients with severe asthma recruited from a severe asthma clinic were interviewed about the impact of their respiratory symptoms and the burden of their treatment. The domains from a thematic analysis of these interviews were compared with the items of eight asthma-specific HRQoL scales.ResultsIn addition to the burden caused by symptoms, ten domains of OCS impact on HRQoL were identified: depression, irritability, sleep, hunger, weight, skin, gastric, pain, disease anxiety, and medication anxiety. Some patients experienced substantial HRQoL deficits attributed to OCS. Although all HRQoL scales include some OCS-relevant items, all eight scales fail to adequately assess the several types of burden experienced by some patients while on OCS.ConclusionThe burden of OCS in severe asthma is neglected in policy and practice because it is not assessed in outcome studies. Existing asthma HRQoL scales provide an overly positive estimation of HRQoL in patients with frequent exposure to OCS and underestimate the benefit of interventions that reduce OCS exposure. Changes to existing measurement procedures are needed.

Playing Tetris decreases drug and other cravings in real world settings.

Most research on cognitive processes in craving has been carried out in the laboratory and focuses on food craving. This study extends laboratory findings to real world settings and cravings for drugs or activities as well as food. Previous laboratory research has found that playing Tetris reduces craving strength. The present study used an ecological momentary assessment protocol in which 31 undergraduate participants carried iPods for a week and were prompted 7 times each day, by SMS message, to use their iPod to report craving. Participants reported craving target and strength (0-100), whether they indulged their previous craving (yes/no), and whether they were under the influence of alcohol (yes/no). Those randomly assigned to the intervention condition (n=15) then played Tetris for 3min and reported their craving again. Those in the monitoring-only control condition (n=16) provided baseline craving data to test if Tetris reduced the incidence and strength of spontaneous cravings across the week. Playing Tetris decreased craving strength for drugs (alcohol, nicotine, caffeine), food and drink, and activities (sex, exercise, gaming), with a mean reduction of 13.9 percentage points, effect size f(2)=0.11. This effect was consistent across the week. This is the first demonstration that visual cognitive interference can be used in the field to reduce cravings for substances and activities other than eating.

Correlation of psychological and physical symptoms with chronically elevated cytokine levels associated with a common immune dysregulation

BACKGROUND Chronically elevated levels of proinflammatory cytokines are associated with inflammatory diseases and psychological symptoms of depression and tiredness. OBJECTIVE To test the prediction that, in a healthy population without medically diagnosed diseases, psychological symptoms (depression and tiredness) associated with proinflammatory cytokines correlate with physical symptoms associated with inflammatory disease. METHODS A total of 1,143 women between 45 and 65 years old completed a health complaint checklist containing 11 target symptoms (5 related to allergy, 4 to gastrointestinal symptoms, and 2 to pain), 7 control symptoms or health complaints, and 2 psychological symptoms (depression and tiredness). They also completed a menopausal quality-of-life questionnaire; to compensate for response bias, we removed variance attributable to quality of life. RESULTS The partial correlations show that tiredness (but not depression) correlated with 9 of the 11 target symptoms (P < .001) but with 0 of the 7 control symptoms or complaints. Symptoms of both the specific and the systemic components of inflammatory disease are correlated in a healthy population. CONCLUSION Immune dysregulation may explain the existence and covariation of psychological and physical symptoms in the healthy population, including people with medically unexplained symptoms.

Frequency of non-asthma GP visits predicts asthma exacerbations: an observational study in general practice

BACKGROUND Being able to identify patients at risk of exacerbations is useful as it enables resources to be targeted at these patients. AIMS To test the theoretically-derived prediction that the frequency of non-asthma related visits to the general practitioner (GP) predicts exacerbations. METHODS Clinical and demographic data and both self-report and prescription-based adherence data were obtained from 166 patients diagnosed with asthma attending a GP clinic, all of whom were prescribed inhaled corticosteroids (ICS). Asthma exacerbations (treated by the GP or in hospital) and non-asthma visits and symptoms were assessed from notes for the subsequent 5 years. RESULTS Exacerbations correlated with non-asthma visits (0.35), severity as measured by BTS step (0.28), and with prescription-based adherence (0.28). Asthma severity correlated with non-asthma visits (0.35). Receiver operating curves showed that ≥2 non-asthma visits per year provided 79% sensitivity and 58% specificity for detecting ≥3 exacerbations over 5 years. Poor adherence predicted outcomes only for patients with high levels of non-asthma visits (≥3) and only for those reporting regular-but-less ICS use but not symptom-directed ICS use. CONCLUSIONS Non-asthma visits are a good predictor of asthma exacerbations, particular in non-adherent patients. These results are consistent with a mechanism where exacerbations result from a combination of random oscillating specific and non-specific inflammatory processes. It is important to consider the total patient rather than just the lung when managing patients with asthma.

Refractory depression: mechanisms and evaluation of radically open dialectical behaviour therapy (RO-DBT) [REFRAMED]: protocol for randomised trial

Introduction Only 30–40% of depressed patients treated with medication achieve full remission. Studies that change medication or augment it by psychotherapy achieve only limited benefits, in part because current treatments are not designed for chronic and complex patients. Previous trials have excluded high-risk patients and those with comorbid personality disorder. Radically Open Dialectical Behaviour Therapy (RO-DBT) is a novel, transdiagnostic treatment for disorders of emotional over-control. The REFRAMED trial aims to evaluate the effectiveness and cost-effectiveness of RO-DBT for patients with treatment-resistant depression. Methods and analysis REFRAMED is a multicentre randomised controlled trial, comparing 7 months of individual and group RO-DBT treatment with treatment as usual (TAU). Our primary outcome measure is depressive symptoms 12 months after randomisation. We shall estimate the cost-effectiveness of RO-DBT by cost per quality-adjusted life year. Causal analyses will explore the mechanisms by which RO-DBT is effective. Ethics and dissemination The National Research Ethics Service (NRES) Committee South Central – Southampton A first granted ethical approval on 20 June 2011, reference number 11/SC/0146. Trial registration number ISRCTN85784627.

Understanding fear and anxiety in patients at the time of an exacerbation of chronic obstructive pulmonary disease: a qualitative study

Objectives To determine the importance of fear and anxiety at the time of an exacerbation of chronic obstructive pulmonary disease. To assess the influence of carers and health professionals on this fear and anxiety. Design A qualitative study to elicit the views of patients and their carers during a hospital admission for exacerbations of chronic obstructive pulmonary disease. Setting Interviews were conducted in a District General Hospital. Participants Twenty patients were interviewed shortly after admission to hospital with an exacerbation. Main outcome measures Key themes were identified using cross-sectional thematic analysis of transcripts where commonalities and differences were identified. Results Four themes emerged: panic and fear; anxiety management techniques used during an exacerbation; intervention from family members and carers; response to medical services. Conclusion Panic and fear are important emotions prior to admission. Many patients recognised the link between panic-fear and a worsening of symptoms, and some were able to use self-management techniques to reduce their panic-fear. Some relatives were seen as helping and others exacerbating the symptoms of panic-fear. The emergency services were seen as positive: providing reassurance and a sense of safety. How best to help patients with chronic obstructive pulmonary disease manage panic and fear remains a challenge.