Tuesday, 23 December 2008

Mindfulness and Stress Reduction

I'm a teacher at a local school in south west London and am fortunate enough to be on holiday at the moment. I've been spending some of my time preparing for a talk I plan to give at an occupational health company. They're not sure what mindfulness is, but are interested in stress reduction and want me and another colleague to present to them. I have read a bit on stress recently and would like to share what I have learnt. Hope that's ok!

If I say the word stress, what does it mean to you? It has become such a common word to throw around, it has almost lost its scientific label. "I'm stressed!", "don't stress me out!", "He looks stressed at the moment - BIG TIME", are comments we hear quite often.

Stress, and what it means to us, actually comes from an engineering term. When a piece of metal is stressed, it's got a force on it. When I feel stressed, I suppose I do have a force on me - deadlines, the internet suddenly decides to shut down or at the moment, the flu, act like a force. Damn flu!

So what? Well, I'm telling a little story about stress and how it was discovered. It all started with a guy called Hans Selye. He started researching stress in 1936, after experimenting on rats. He noticed that the rats kept having the same physiological reactions, no matter what he injected them with. He discovered that they all had a specific response to being 'stressed'. He thought stress was so important that he then went all over the world to tell people from England to Germany to use the word 'stress'. It's the same word used in most countries. Amazing.

So, what is the stress response and why do you need to know about all this anyway? If you know what it is, and what happens to your body in a stress response, you know what's going on. You can then go on to choose coping strategies that would be helpful like mindfulness (finally I got my favourite word in) as apposed to caffeine or cocaine something inbetween.

The stress response is also called the 'fight or flight' response. When someone annoys you, or something for that matter, we feel stressed. Now you know why you feel like shooting your computer or strangling your boss - it's the fight or flight response. Your body produces hormones that make you want to either lash out, or run, run, run. Unfortunately, if you're sitting in an office cubicle, or sitting in traffic, running is not really an option - unless you're quitting your job, or aren't keen on that old banger after all.

What's happening inside to make us want to do this? It all starts at the hypothalamus. This is a small part at the base of the brain. Through the use of nerves and hormones, it releases amongst other things, adrenaline and cortisol into the bloodstream, from the adrenal glands which are at the top of the kidneys.

- Adrenaline increases your heart rate, elevates your blood pressure and boosts energy supplies.
- Cortisol helps to release sugar into the bloodstream, so that the major muscles in the arms and legs are ready for action. It also releases substances to allow tissue to be repaired quickly if it is damaged. Non-essential processes for a dangerous situation, like immune system, reproductive system, digestive system and growth processes are all reduced though the use of cortisol.

OK, so where's the problem with all this? We get stressed, but we get over it, right? Well, yes and no. The body naturally regulates itself after a stressful situation, but if the stress is sustained, long term, day after day, it takes its toll. The intense response is only designed for short periods of time and not continuous. This leads to health problems such as:
- Heart disease
- Obesity
- Sleep problems
- Digestive problems
- Depression
- Memory impairment
- Skin problems such as eczema

That's why it's important to cut down on your stress! Just chill out is easier said than done. That's where mindfulness and the mindfulness based stress reduction (MBSR) program comes in. Eight weeks of hard work on your part, to result in possibly a life time of lower stress and greater well-being. And you don't have to just believe me - go to google, type in MBSR research and look at what the scientists have found out. About 90% of participants in the program continue some sort of meditative practice 3 years later.

Sunday, 21 December 2008

BBC Report on Mindfulness for Depression

Here is the latest report from the BBC on the benefits of mindfulness based cognitive therapy for reducing the relapse of depression.

Group therapy 'beats depression'

The group therapy is based on some techniques found in Buddhism
Group-taught meditation is as effective as staying on drug treatments for stopping people slipping back into depression, say UK scientists.
Compared to one-to-one sessions, or medication, "mindfulness-based cognitive therapy" (MBCT) is cheaper for the NHS, they say.
The trial of 123 people found similar relapse rates in those having group therapy and those taking drugs.
The study was published in the Journal of Consulting and Clinical Psychology.
It's given me the ability to come up against something that would have previously thrown me, think it through, come up with a solution and then move on.
Di CowanPatient
Recent years have seen much more evidence that so-called "talking therapies" can be as effective as drugs in alleviating mild to moderate depression, and health secretary Alan Johnson recently announced millions in new funding for the treatments.
However, this is the first time, according to its authors, that a group therapy has been shown as an alternative to a prescription.
The study, funded by the Medical Research Council, found MBCT, developed in 2002 by a team of psychologists from Canada, Oxford, and Cambridge, was actually more effective than medication in improving patients' quality of life.
The sessions involve the teaching of meditation techniques based on some found in Buddhism.
The aim is to teach skills which help patients recognise and cope with their tendency towards depression.
GP alternative
Di Cowan, from East Devon, had suffered from depression since his late teens.
The 53-year-old said: "It's helped me immensely - it's given me the ability to come up against something that would have previously thrown me, think it through, come up with a solution and then move on.
"My view of the world has changed and I look at life in a new light."
One of those championing the technique is Professor Willem Kuyken, of the Mood Disorders Centre at the University of Exeter.
He said: "Our results suggest MBCT may be a viable alternative for some of the 3.5 million people in the UK known to be suffering from this debilitating condition.
"I think we have the basis for offering patients and GPs an alternative to long-term antidepressant medication."
Marjorie Wallace, the chief executive of mental health charity SANE, said the charity would be helping to fund future research into how "ancient meditative techniques" could work together with modern psychotherapy in people with long-term depression.
She said: "We are delighted that this study shows the potential of Mindfulness-Based Cognitive Therapy as an alternative for the treatment of severe and recurring depression.
"Just one in five depressed callers to our helpline report that they are receiving any kind of talking therapy, which is recommended as a first line of treatment."

The NHS responded to the above article with the following:

Meditation and depression

MBCT involves group sessions
“Buddhist meditation techniques can be just as effective at combating depression as medication,” the Daily Mail reported. It said a study has found that “mindfulness-based cognitive therapy (MBCT)” helps people to focus on the present rather than looking to past or future events. The newspaper continued that 15 months after an eight-week trial in people with long-term depression, 47% of those who had the therapy relapsed compared to 60% of those taking antidepressants.
This well-designed trial has been oversimplified by the news reports. The trial did not compare MBCT alone with antidepressants alone, but examined how relapse rates compared between combined MBCT and antidepressants and simply continuing with antidepressants. Therefore, MBCT cannot be said to be “as effective as medication”. It did, however, significantly reduce the amount of time the participants spent on antidepressants with the same relapse rates.
How comparable Buddhist meditation is to MBCT is also questionable, as the therapy involves a schedule of group education by a trained therapist, of which meditation is only a part.Where did the story come from?
This research was carried out by Willem Kuyken and colleagues from the University of Exeter, the Peninsula Medical School, Kings College London, and Devon Primary Care Trust. The work was funded by the UK Medical Research Council. The study was published in the peer-reviewed, Journal of Consulting and Clinical Psychology.What kind of scientific study was this?
In this randomised controlled trial, the researchers compared the effectiveness of cognitive therapy and ‘maintenance antidepressant’ medication with maintenance antidepressants alone for preventing relapse in people with recurrent depression. Maintenance antidepressants, means the continued use of antidepressants by people who have recovered following treatment for an episode of depression, but the drug is continued at a lower dose with the aim of preventing recurrence.
The therapy that the researchers were interested in was Mindfulness Based Cognitive Therapy (MBCT). It consists of classes involving group-based education in skills for easing distress and preventing the recurrence of depression. It aims to make people more aware of the thoughts and feelings that are counterproductive and contribute to depression and self-criticism. In this study, sessions included mindfulness practises (including yoga and meditation), teaching and discussion, weekly homework and a review of the participants’ experiences.
The researchers recruited 123 people over 18 years of age with recurrent depression who had been diagnosed using recognised criteria. All the participants had a history of at least three previous episodes of depression. They had received MBCT treatment for the previous six months and were now in either full or partial remission and taking antidepressant medication. The researchers excluded those with other psychiatric disorders or substance abuse.
The participants were randomly allocated to either continue on antidepressants alone or have an additional eight-week MBCT course. The course was made up of eight, once weekly two-hour sessions, and four follow-up sessions the next year.
The MBCT included support in decreasing or discontinuing antidepressants. This subject was initially raised with participants during weeks four to five of the regime. Participants were asked to consider decreasing or discontinuing their medication as soon as they and their physician deemed appropriate following MBCT and within six months of the course ending. An ‘adequate dose’ of MBCT was considered to be participation in four of the eight sessions. Medication adherence was monitored by the participants’ self-report at each three-month follow-up and scored on an adherence scale.
The participants were followed up at three-monthly intervals for 15 months. The main outcome that was examined was the relapse or recurrence of depression. Secondary outcomes including cost effectiveness and quality of life measures were also examined, but are not discussed here.What were the results of the study?
Of the 123 participants, 85% completed the study, with exclusions/drop-outs balanced between the two treatment groups. There was generally good adherence to study protocol. The average number of days that antidepressants were taken was significantly shorter in the MBCT group (266 days) compared to those taking antidepressants alone (411 days). At the end of six months, 75% of the MBCT group had stopped taking antidepressants.
There was a general trend towards reduction in the risk of relapse/recurrence among those treated with MBCT and antidepressants compared to antidepressants alone. Over the total 15-month follow-up, 47% of the MBCT patients relapsed compared to 60% of those on antidepressants alone; however, this difference was not statistically significant.What interpretations did the researchers draw from these results?
The authors conclude that in people with recurrent depression, MBCT in addition to antidepressants produces comparable outcomes to antidepressants alone in terms of relapse and recurrence rates, and therefore significantly reduces antidepressant use.
What does the NHS Knowledge Service make of this study?This was a well-designed randomised controlled trial. It demonstrated that MBCT with antidepressants produces comparable outcomes to antidepressants alone in terms of relapse and recurrence rates. MBCT also has significant benefit in terms of helping to reduce antidepressant use.
However, this trial has been over simplified by the news report:
This study was in a very select group of people. All had recurrent episodes of depression, for which they had recently received antidepressant treatment, and were currently receiving lower dose antidepressants. The results cannot therefore be generalised to people with depression who do not fulfil these specific criteria.
Although there was a trend towards reduced relapse and recurrence rates with MBCT, this difference was not statistically significant when compared to taking antidepressants alone.
The news incorrectly refers to the treatment as meditation. Although meditation was involved, this was only a part of the sessions, which involved a complex schedule of group education by a trained clinical psychologist or occupational therapist. This cannot be considered comparable to unsupervised meditation alone at home.
As the researchers state, it is likely the participants had a greater adherence to their medication compared to what would be found in general practise due to the measures that the researchers took to enhance adherence.
The trial could not be blinded and so the participants knew the nature of the trial when they chose to take part. This could have led to some people with an interest in psychological interventions to take part and therefore introduce some possible bias in the results (i.e. believing that MBCT was helping them).
This is the first trial to investigate what is a relatively new therapy (MBCT) and compare it to another active treatment (antidepressant medication). It should be noted, however, that the study only examined whether combined MBCT and antidepressants had a different outcome to taking antidepressants alone. It did not make a direct comparison between MBCT and antidepressants and so it cannot be concluded that one is more effective than the other. Further research into MBCT is required for a clearer picture.
Sir Muir Gray adds...Good study and worth trying. Combine it with an extra 3,000 steps a day as walking is also effective for depression.
Links to the headlines
Meditation 'as effective as medication' in treating depression. Daily Mail, December 01 2008
Group therapy 'beats depression'. BBC News, December 01 2008
Links to the science
Kuyken W, Taylor RS, Barrett B, et al. Mindfulness based cognitive therapy to prevent relapse in recurrent depression. Journal of Consulting and Clinical Psychology 2008
Further readingThere are several reviews in the Cochrane Library that deal with treatments (including psychological) for depression, including the examples below. None specifically considers MBCT.
Lane DA, Chong AY, Lip GYH. Psychological interventions for depression in heart failure. Cochrane Database Syst Rev 2005, Issue 1
Dennis CL, Ross LE, Grigoriadis S. Psychosocial and psychological interventions for treating antenatal depression. Cochrane Database Syst Rev 2007, Issue 3
Jorm AF, Morgan AJ, Hetrick SE. Relaxation for depression. Cochrane Database Syst Rev 2008, Issue 4
Analysis by
Edited by NHS Choices