Mindfulness-Based Cognitive Therapy for TBI
Transforming Depression & Lives
RESULTS OF A MULTI-CENTER
RANDOMIZED CONTROL TRIAL
Melissa Felteau MAdEd, Lakehead University
Mary Donaghy PhD, St. Joseph’s Care Group
Nancy McCormick MSW, RSW, The Ottawa Hospital
Sucheta Heble
MA, MS, Toronto Rehab –
UHN
Toronto ABI Network Conference 2012
Research Team
Deep gratitude is extended to the study participants who devoted themselves to the
practice of MBCT-TBI
Investigators
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Michel Bedard, PhD, Lakehead University
Melissa Felteau, MAdEd, Lakehead University
Shawn Marshall, MD, The Ottawa Hospital
Nora Cullen, MD, Toronto Rehab - UHN
Sacha Dubois, MPH, St Joseph’s Care Group
Carrie Gibbons, MPH, SJCG
Hilary Maxwell, MPH, SJCG
Bruce Weaver, MSc, Northern Ontario School of
Medicine
Rolf Gainer, PhD, CEO, Neurologic Institute of
Ontario & Brookhaven Hospital
Dwight Mazmanian, PhD, Lakehead University
Rupert Klein, PhD, Lakehead University
Amy Moustgaard, PhD, University of Ottawa
Laura Rees, PhD, The Ottawa Hospital
Facilitators
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St. Joseph’s Care Group, Thunder Bay:
Mary Donaghy, PhD, Psychologist
John Clack, MSc OT, Occupational
Therapist
Toronto Rehab - UHN:
Sucheta Heble, MS, Speech Pathologist
Martin Vera, MClSc, Speech Pathologist
The Ottawa Hospital:
Elly Endorp, MSW, Social Worker
Jennifer Heron, BA, Rehabilitation
Therapist
Nancy McCormick, MSW, Social Worker
Evelyn Tan, MA, Speech Pathologist
Mindfulness-Based Cognitive
Therapy
Mindfulness-Based Cognitive Therapy-TBI:
10 week psychoeducational group
Intensive training in
Mindfulness meditation
To apply to challenges
of their daily lives
Based on Segal, Williams, Teasdale, 2002
TBI Adaptation Felteau, 2010
Participants learn to:
Reduce reactivity
Decenter from
ruminative thinking
‘Sit with’ + - +/thoughts,
emotions,
physical sensations
Prevent further
depressive relapse
Practices include: body scans, sitting meditation,
walking meditation, mindful movement,
process of inquiry & dialogue
MBCT – TBI Results
(Previous Studies)
• MBCT – TBI
consistently
showed a
59%
reduction in
depression
symptoms
Bedard, Felteau et al., 2012;
2005; 2003
Brains on Meditation
Hippocampus learning &
memory
Cingulate self-awareness,
compassion & introspection
Amygdala anxiety & stress
Hoelzel et al., (2011). Mindfulness practice leads to increases in regional brain gray matter
density. Psychiatry Research: Neuroimaging. 191;1:36-43. See also Davidson et al., 2003-2012
Areas of Brain Activation during Meditation
Hippocampus
Anterior Cingulate
(Hoelzel et al., 2011)
Amygdala
Multi-site RCT of MBCT-TBI
3 centers: Toronto, Ottawa, Thunder Bay Canada
Blinded, block randomization, of 120 participants
Controls were crossed-over
5 treatment waves Sept 2010 – June 2012
RCT of MBCT-TBI
Inclusions: 18+, 1>10 yrs post TBI, any severity level
with insight
Exclusions: concurrent interventions, anti-depressants
allowed, unusual psychological processes, suicidal
ideation, substance abuse, lack of insight
(BDI-II, SCL-90-R, Alcohol, Substance & Drug Abuse Scales)
RCT Measurements for
Depression, Memory, Health Status
Mindfulness & Satisfaction
Instrument
• Demographics (S)
• BDI-II (S) & PHQ-9
• CVLT (S)
• COWAT
• WAIS: Digit Span (S)
• WAIS: Similarities (S)
S = Screening
Outcome Measured
& medication use/pain VAS
Depression symptoms
Auditory attention/ST
memory/ learning strategies
Speeded verbal fluency/ exec
functioning
Auditory att./working mem
Verbal abstract reasoning
RCT Measures Con’t
Instrument
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Trail Making Test
RAND-36
SCL-90-R (S)
PHLMS & TMS
SWLS
Outcome Measured
Executive functioning
Health status
Psychological symptom pattern
Mindfulness
Satisfaction with life
MBCT – TBI RCT Results
• Total of 119 patients recruited
– 14 did not meet inclusion criteria
– 105 eligible cases
• 100 randomized to either treatment or control
• 5 assigned to treatment (given site recruitment
limitation)
– 17 did not start; 8 discontinued intervention; 2 withdrew
post-intervention; 2 excluded from analysis
– 76 cases analyzed (38 each group)
30%
drop-out
typical in
TBI
RCT of MBCT – TBI Results
Our RCT
found a
statistically significant
26%
reduction
in
overall depression
symptoms (BDI II)
Bedard, Felteau, Marshall, Cullen, Dubois et al., 2012 unpublished data
Pre Post
Depression
Group
Measures
Means
RCT Results - Depression
Parallel Analyses
All Sites
Comparison (UNIANOVA) Effect Size
F (p-value)
Cohen's d
N Pre
Post
Group
Group*Site
38 25.47 (8.12) 18.84 (10.26) 4.99 (0.029)
1.39 (0.256)
0.56
38 27.13 (10.61) 25.00 (13.12)
BDI: Overall
Treatment
Control
BDI: Cognitive
Treatment
Control
38 7.95 (4.36)
38 7.61 (4.46)
5.42 (4.06)
6.66 (5.30)
3.66 (0.060)
1.17 (0.315)
0.52
BDI: Somatic
Treatment
Control
38 17.53 (4.99)
38 19.53 (7.24)
13.42 (7.34)
18.34 (8.72)
4.42 (0.039)
1.22 (0.301)
0.49
PHQ: Overall
Treatment
Control
36 11.53 (5.03)
38 14.08 (6.52)
10.19 (5.88)
12.84 (6.74)
0.55 (0.461)
0.72 (0.489)
0.02
SCL-90R:
Depression Subscale
Treatment
Control
38 1.62 (0.80)
37 1.74 (0.94)
1.36 (0.90)
1.49 (1.04)
0.13 (0.715)
1.79 (0.174)
0.02
F-Test of
F-Test of site
Effect
pre-post
Size
effect
difference
RCT Results - Depression
Statistically significant
decreases for BDI:
Overall and Somatic
Subscale
Parallel Analyses
All Sites
Comparison (UNIANOVA) Effect Size
F (p-value)
Cohen's d
N Pre
Post
Group
Group*Site
38 25.47 (8.12) 18.84 (10.26) 4.99 (0.029)
1.39 (0.256)
0.56
38 27.13 (10.61) 25.00 (13.12)
BDI: Overall
Treatment
Control
BDI: Cognitive
Treatment
Control
38 7.95 (4.36)
38 7.61 (4.46)
5.42 (4.06)
6.66 (5.30)
3.66 (0.060)
1.17 (0.315)
0.52
BDI: Somatic
Treatment
Control
38 17.53 (4.99)
38 19.53 (7.24)
13.42 (7.34)
18.34 (8.72)
4.42 (0.039)
1.22 (0.301)
0.49
PHQ: Overall
Treatment
Control
36 11.53 (5.03)
38 14.08 (6.52)
10.19 (5.88)
12.84 (6.74)
0.55 (0.461)
0.72 (0.489)
0.02
SCL-90R:
Depression Subscale
Treatment
Control
38 1.62 (0.80)
37 1.74 (0.94)
1.36 (0.90)
1.49 (1.04)
0.13 (0.715)
1.79 (0.174)
0.02
Medium
No
effect size
difference
observed for
by site
BDI
RCT Results - Mindfulness
All Sites
Mean (SD)
N Pre
Philadelphia Mindfulness Scale
Awareness Treatment 31 33.84 (6.62)
Control
36 33.97 (6.02)
Acceptance
Treatment
Control
31 28.35 (7.42)
36 28.14 (7.45)
Post
Parallel Analyses
Comparison (UNIANOVA) Effect Size
F (p-value)
Cohen's d
Group
Group*Site
35.10 (6.01)
34.42 (5.17)
0.89 (0.348)
0.71 (0.497)
0.16
31.16 (7.35)
29.39 (7.55)
0.61 (0.439)
0.93 (0.401)
0.27
-0.08
0.26
Toronto Mindfulness Scale
Curiosity
Treatment
15 14.13 (6.16)
13.60 (6.86)
Paired Analyses
Comparison (GLM)
F (p-value)
Time
Time*Site
0.44 (0.521) 1.23 (0.327)
Decentering Treatment
15 12.87 (5.50)
14.53 (7.00)
0.16 (0.692)
0.55 (0.589)
Mindfulness
remained
stable in
both
treatment
and control
groups
Small effect
size
observed for
PHLMS and
TMSDecentering
Mind as Mechanism
• Treatment group saw some reduction across
certain depression measures
• Mindfulness remained stable
Mind as Mechanism
• However, these are group scores
• We know certain individuals saw greater
changes in mindfulness than others
• Let’s examine change in depression by change
in mindfulness
Y-axis:
Pre-Post change
in depression
Mind as Mechanism
Moderate
correlation
between increase
in mindfulness
and reduced
depression
symptoms
(r(29) = -.401, p =.025)
Increase in
depression
symptoms post
test
Decrease in
X-axis:
depression
Pre-Post change
symptoms post
in mindfulness
test
Mindfulness
Reduced PostTest:
About 50/50
increase/decrease
in depression
symptoms
Mind as Mechanism
Mindfulness
Increased PostTest:
Most saw
decrease in
depression
symptoms
Mind as Mechanism
• Similar patterns were seen in the SCL90-R Depression scale
RCT Results - Mindfulness
An improvement
in
depression scores
showed a
correlation
to
increases in
mindfulness scores
Bedard, Felteau, Marshall, Cullen, Dubois et al., 2012 unpublished data
Don’t Get Trapped
The delivery of
successful
outcomes is
associated with a
longitudinal
training program
Crane et al., 2010
Embodiment, not Methodology
• The teacher embodies
the heart of inquiry; the
possibility of
encountering, being
with and befriending
experiences with
• Loving kindness
• Compassion
• Sympathetic joy
• Equanimity
Woods SL, 2011
Longitudinal Multidimensional
MBCT Clinician Training Plan
Initial Retreat
Biweekly
Learning
Conferences
RCT
5 Waves of
MBCT
Ongoing
Consultation
Supervision
Support
MBCT
Adherence
& Website
MBCT 5-Day
Training
Scale
Practice
Teaching
Felteau & Segal, 2008
In theory there is no
difference between
theory and practice;
in practice, there is.”
Yogi Berra
Observed Participant Benefits
• Increased present moment
awareness
• Lessened reactivity
• Decentering from
thoughts/rumination
• Noticing impermanence of
pain
• Increased affiliation
• Increased self-compassion,
• Non-judgment &
acceptance
• Improved relationships
(Results from RCT of MBCT-TBI, 2012)
The Skills of Co-Facilitation
• Honest, reflective
dialogue
• Reflecting mindfulness
through transparency
• “Taking a seat” in the
group
Ongoing Training as Personal Practice
• Experiential process
• Focus is on embodiment
of the 7 Attitudes of
Mindfulness (e.g. non-judging,
non-striving)
• Modeling is essential
• Understanding of
venerable Buddhist roots
Incorporating into Private Practice?
• Mind training vs.
informal mindfulness
• Undesirable
simplification
• Training & supervision
issues
The Road Forward
• Diffusion &
Dissemination
• Publication of manual
• Global Implementation
• Online training program
• Interested?
• Contact us
Bibliography
1. Gibbons C, Felteau M, Cullen N, Marshall S, Dubois S, Maxwell H, Mazmanian D,
Weaver B, Rees L, Gainer R, Klein R, Moustgaard A, Bedard M. Training Clinicians
to Deliver a Mindfulness Intervention. Mindfulness, 2012;3(4).
2. Bedard M, Felteau M, Marshall S, Weaver B, Dubois S, Gibbons C, Maxwell H, Klein
R. Mindfulness-Based Cognitive Therapy: Benefits in reducing depression
following a traumatic brain injury. Advances in Mind-Body Medicine, 2012;
26(1):14-20.
3. Felteau M, Marshall S, Gainer R. The Role of Clinician Training in MindfulnessBased Cognitive Therapy for TBI. Brain Injury, 2012(26)4-5.
4. Felteau M, Bedard M, Marshall S, Dubois S, Weaver B, Gibbons C, et al.,
Mindfulness-based cognitive therapy reduces depression symptoms in people
with traumatic brain injury: Results from a pilot study. Brain Injury, 2008;22(1)67.
5. Moustgaard A, Bedard M, Felteau M. Mindfulness-Based Cognitive Therapy for
Individuals who had a stroke: Application of a novel intervention. Journal of
Cognitive Rehabilitation, 2007;3:4-10.
6. Bedard M, Felteau M, Gibbons C, Klein R, Mazmanian D, Fedyk K, Mack G. A
Mindfulness-based intervention to improve quality of life among individuals who
sustained traumatic brain injuries: One-year follow-up. Journal of Cognitive
Rehabilitation, 2005.
Bibliography Con’t
7. Bedard M, Felteau M, Mazmanian D, Fedyk K, Klein R, et al. Pilot evaluation of a
mindfulness-based intervention to improve quality of life among individuals who
sustained traumatic brain injuries. Disability Rehabilitation, 2003;25(13):722-31.
8. Felteau M. (2002). Know thyself, heal thyself: Novel research using holistic
techniques. In S. Abbey (Ed.), Ways of knowing in and through the body: Diverse
perspectives on embodiment (pp. 121-125). Welland: Soleil Publishing Inc.
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Other Publications:
Tilney McDonough, V. (2009). The Role of Mindfulness, Meditation, and Prayer
after Brain Injury. Retrieved from Brainline.org website
http://brainline.org.content.2009/12/the-role-of-mindfulness-meditation-andprayer-after-brain-injury.html
Mason , M. (2008). In All Earnestness in Head Cases: Stories of Brain Injury and its
Aftermath. New York: Farrar, Straus and Giroux.
Slides are hosted at www.traumaticbraininjury.net
under Resources
For further information, please
contact:
Melissa Felteau, MAdEd
Melissa
Lead
ClinicalFelteau,
Educator MAdEd
Lead Clinical
Educator,
Lakehead
University
MBCT-TBI Study
/University
of Toronto
University of Ottawa
Rehab Research Group
[email protected]
Rehab Research Group
Lakehead University, University of Toronto, University of Ottawa
[email protected]