Nancy J. Thompson, Ph.D., M.P.H. Rollins School of Public Health Emory University

Project UPLIFT Using Practice and Learning to Increase Favorable Thoughts Delivery of mindfulness-based cognitive therapy by telephone and Internet To people with epilepsy Most of the work presented here was funded by the Centers for Disease Control and Prevention

About Mindfulness-based Cognitive Therapy (MBCT) Cognitive Therapy addresses the unrealistic thinking associated with depression. Uses verbal techniques to explore the reasoning behind specific attitudes and assumptions. Client is taught to recognize, monitor, and record negative thoughts on a daily record. CBT focuses on changing thought content while mindfulness changes relationship to the thoughts—see them as passing events that do not necessarily represent a state of reality. Mindfulness is important in preventing relapse.

Cognitive Therapy vs. Medications in the Treatment of Moderate to Severe Depression Across the 3 treatments ([chi]22 = 10.22, P =.006). ADM vs. pill placebo ([chi]21 = 10.17, P =.001), CT vs. pill placebo ([chi]21 = 4.44, P =.04) ADM vs. CT ([chi]21 = 0.71, P =.40). Between sites: Wald [chi]22 = 1.59, P =.45

Intent to Treat 4+ Sessions Follow-up after Mindfulness vs. Treatment as Usual for the Treatment of Depression

Project UPLIFT Delivery of MBCT by Web and Telephone Groups People with epilepsy randomly assigned to groups of 7 Initially computers and Internet access provided if needed Group delivery important for support surrounding epilepsy Co-Facilitators Graduate Public Health Student Person with epilepsy Supervised by a licensed psychologist

Potential Benefits Cost-effective Can reach the mobility/transportation limited Equal reach to urban and rural Allows peer support, even with rare conditions Potential for anonymity and avoidance of stigma Can prevent relapse Does not require more medication Mindfulness may improve attention/cognition

Session #Topic 1 Monitoring Thoughts 2 Challenging and Changing Thoughts 3Coping and Relaxing 4Attention and Mindfulness 5The Present as a Calm Place 6Thoughts as Changeable and Impermanent 7Pleasure and Reinforcement 8Relapse Action Plans Project UPLIFT 8 Sessions (1 hour by phone) Noting Challenging/Changing Impermanent

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

Web Version Session One: Monitoring Thoughts

Formative Evaluation Focus Groups Importance of Group “Medical professionals can tell you the what, the why, the diagnosis, but in a group of people with epilepsy, there’s camaraderie and you can see what other people go through.” “Being in a group with other people with epilepsy is like sharing with your close friends. You realize that everyone has their insecurities and you feel more safe.” Response to Activities “If I could learn to modify my thoughts, that would be practical.” “The good thing about doing mindfulness of sounds and thoughts is that you can do it anywhere.”

Design—Outcome Evaluation Stratum 1: Pretest 6-8 wk phone Interim as usual Follow-up Stratum 2: Pretest 6-8 wk Web Interim as usual Follow-up Stratum 3: Pretest as usual Interim 6-8 wk phone Follow-up Stratum 4: Pretest as usual Interim 6-8 wk Web Follow-up Baseline Week 8 Week 16

Depression: BDI UPLIFT vs. Waitlist (treatment as usual) F overall = 42.22, p=.0001 F interaction = 11.99, p=.001*

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*

No difference with Major Depressive Disorder or not (F 1,35 = 1.21, p = 0.279) Maintenance MeasureTimeIntervention Treatment -as-Usual Waitlist Fdfp-value BDIPretest Interim Posttest , * 0.297

Knowledge/Skills & Self-Efficacy MeasureTimeInterventionTAU WaitlistF interaction df 1,37 P-value Knowledge/ Skills Pretest Interim * Depression Coping Self-Efficacy Pretest Interim

Quality of Life MeasureTimeIntervention Tx As Usual Waitlist F interaction df 1,37 P-value Satisfaction with Life Pretest Interim Mental Health QOL Pretest Interim Physical Health QOL Pretest Interim <p<.10

Summary Effective in: Reducing depressive symptoms and 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 Approaching significance for Satisfaction with Life and Depression Coping Self-Efficacy Delivery Both phone and web were significantly more effective in reducing depression than waitlist condition

Participants’ Comments “I told my therapist I think I like this way a lot better…I’ve always went and talked to somebody versus learning to work through things just using my own mindset.” “The project had great value. I'm thankful that I was able to participate. I got a lot out of the exercises and coping skills.” “The program was very helpful and that surprised me. I printed everything out and recorded the meditations onto my MP3 player.” “The program helped me more than the antidepressants I've been on for years.” “Thank you for helping me because I have been depressed and now I can cope.”

Potential Benefits Cost-effective Reaches the mobility limited Equal reach to urban and rural Can form groups even with rare conditions Potential for anonymity and avoidance of stigma Prevent relapse

Project UPLIFT Next Phase ~$1 million Challenge Grant ~$1 million Challenge Grant UPLIFT for Prevention UPLIFT for Prevention Participants in MEW network states Participants in MEW network states  Georgia  Michigan  Texas  Washington