MBCT for Perinatal Women with Mood Disorders

David J. Miklowitz, Ph.D. and Randye Semple, Ph.D. (Department of Psychiatry, UCLA School of Medicine), Monika Hauser, Ph.D. and Sona Dimidjian, Ph.D. (Department of Psychology, University of Colorado, Boulder)

Summary

For women who are vulnerable to depression, the perinatal period is a high-risk time for recurrences. This study examined the effects of an 8-week group program of Mindfulness-Based Cognitive Therapy for 38 women with bipolar disorder or major depression who were pregnant, planning pregnancy, or up to one-year postpartum. Participants reported improvements from baseline to the end of treatment, and up to six months post-treatment with reductions in self-reported depressive symptoms and improvements in mindful awareness scores. If shown to be effective in randomized trials, mindfulness groups may be an important supplement to prenatal and perinatal care for women with a vulnerability to depressive episodes.

See the latest paper on Mindfulness-based cognitive therapy for perinatal women with depression or bipolar spectrum disorder (2015).

Introduction

For women with a vulnerability to mood disorders, the perinatal period – the period in which women are pregnant or in the postpartum period – is a high-risk time for depressive episodes. Left untreated, many women with depression or bipolar disorder remain depressed for as long as one year following childbirth (Goodman et al., 2011). They are also at risk for repeated depressive episodes. Prevention efforts during the preconception, pregnancy, and postpartum periods may be of considerable individual and public health benefit.
The objective of this study was to examine a novel psychosocial treatment for women with bipolar disorder and depression who are pregnant, planning pregnancy, or in the post-partum period. We examined the feasibility of identifying, enrolling, and retaining perinatal women at high risk for mood episodes in an 8-week program of mindfulness-based cognitive therapy (MBCT; Segal, Williams, & Teasdale, 2002). Previously, our group had shown that male and female patients with bipolar disorder who received MBCT showed significant improvement over three months in depression symptoms and suicidality, and to a lesser extent mania symptoms and anxiety (Miklowitz et al., 2009).

The central premise of MBCT is that individuals with histories of depression are vulnerable to recurrence during episodes of sadness, during which negative cognitive patterns are reactivated and can trigger the onset of new depressive or suicidal episodes (Teasdale et al., 2000). Mindfulness aims to interrupt the tendency to respond with strong emotions to particular thoughts or bodily sensations that occur with sad mood, through training individuals to notice and step out of habitual and automatic modes of responding with intentional, non-judgmental, and present-focused awareness. Given its explicit aim to modify core underlying vulnerability factors among recovered individuals with histories of depression, MBCT may have high applicability to the prevention of perinatal depression.

Traditionally, MBCT teaches “nonjudgmental awareness” through breathing practices, yoga, psychoeducation, and cognitive-behavioral skills training in 8 weekly group sessions. We evaluated the acceptability and satisfaction of a modified MBCT protocol (Hauser, Miklowitz, & Dimidjian, 2010) that was sensitive and specific to the physical and emotional needs and limitations of women at high risk of perinatal mood episodes. Feedback regarding the acceptability of and satisfaction with the program was obtained from participants at posttreatment and 6 months following the intervention.

We investigated the pre-post and maintenance effects of MBCT (1-month and 6-months post-treatment) as related to mood symptoms and the ability to acquire mindful ways of thinking. We hypothesized that levels of mood symptoms would decrease over the 8-month study, and that rates of relapse or recurrence at the 6-month follow-up would be lower than expected rates in this population, which are typically as high as 30 to 50% (Di Florio et al., 2013). We also hypothesized that improvements in depression would be correlated with improvements in mindful awareness.

Methods

Participants

The study involved 38 women; 21 of these were treated at UCLA and 17 at the University of Colorado. Women eligible for the study met the following criteria:

  1. pregnant, within one year postpartum, or not pregnant but actively trying to conceive (i.e., undergoing fertility treatments);
  2. meets DSM-IV lifetime criteria for major depressive disorder or bipolar I, II, or bipolar not otherwise specified (NOS) disorder;
  3. not in an acute depressive or manic episode;
  4. available for weekly group intervention meetings;
  5. speaks and reads English, even if it is not their first language; and
  6. age 18 or older.

Women who were abusing drugs or alcohol were excluded. There were no requirements regarding medications or other ancillary treatments.

Mindfulness Treatment

The women participated in one of three 8-week groups conducted by Randye J. Semple, Ph.D. (UCLA) or one of two 8-week groups conducted by Monika Hauser, Ph.D. (Colorado). All participants received the book “The Mindful Way through Depression” (Williams, Teasdale, Segal, & Kabat-Zinn, 2007).

MBCT is an 8-session group intervention that aims to help individuals change their relationship to the thoughts, feelings, and bodily sensations that can contribute to a mood relapse. The core skill that MBCT aims to teach is the ability, at times of potential relapse, to recognize and disengage from unhelpful mind states characterized by self-perpetuating patterns of ruminative thought. Such patterns, if left unchecked, are likely to produce a downward spiraling of mood, and, eventually, the onset of relapse. This process is known as decentering.

The focus of sessions 1 through 4 is to bring greater awareness to the present moment, on purpose and nonjudgmentally. By returning attention to thoughts, feelings and body sensations, participants become aware of how little attention is usually given to daily life. They learn to become aware of how quickly the mind shifts from one topic to another, often wandering into unhelpful past- or future-oriented ruminations. Second, having noticed that the mind is wandering, they learn to bring it back to a single focus. This is taught with simple practices that repeatedly return awareness to the breath, body sensations, or body movements. Third, the participant learns how to become aware of how this mind-wandering can exacerbate negative thoughts and feelings. She can then use this enhanced awareness to be vigilant for mood shifts, and respond by handling them (at the time) or dealing with them later.

Appropriate responding is the focus of sessions 5 through 8. Whenever negative thoughts or feelings arise, the MBCT training emphasizes simply allowing them to be there, before taking steps to respond skillfully by using specific strategies. Participants learn to become fully aware of the thoughts or feelings, and then, having acknowledged them, shift attention to their breathing for a minute, and then expand attention to the body as a whole. Taking this “breathing space” may alone be sufficient to handle difficult mood states by reducing the intensity or duration of the unpleasant thoughts or feelings. The participant may choose to deal with the thoughts or feelings directly (then, or later), by experiencing them simply as thoughts or feelings, or she may choose to note how the thoughts affect the body. Alternatively, she may choose a proactive behavior that can increase pleasure, de-escalate a challenging situation, or bolster her sense of self-efficacy.

Procedures

Participants signed a University-approved informed consent form after receiving a full explanation of the study procedures. They were interviewed by trained diagnosticians before being offered a place in the groups.

Measures

Each participant was paid $20 in cash for completing research interviews and questionnaire batteries before the MBCT intervention, after MBCT, at the 1-month follow-up, and at the 6-month follow-up. The interviews and questionnaires asked about symptoms, mindful awareness, and overall functioning. We examined diagnoses, changes in mood, and self-ratings of mindfulness (greater awareness and openness to experience) over time using the following instruments:

  • Structured Clinical Interview for DSM-IV-TR, Axis I disorders, Research Version, Patient edition (SCID-I/P; First, Spitzer, Miriam, & Williams, 2002) was used to ascertain clinical diagnoses. Only those modules were included that assess mood, psychotic, substance, anxiety, and eating disorders.
  • Hamilton Rating Scale for Depression (HAM-D; Hamilton, 1960) is a 17-item clinician-administered rating scale for depression that assesses the frequency of each symptom, its duration, and its severity.
  • Young Mania Rating Scale (YMRS; Young, Biggs, Ziegler, & Meyer, 1978) is an 11-item clinician-administered rating scale that assesses the frequency of each mania or hypomania symptom, its duration, and its severity.
  • Beck Depression Inventory, 2nd Ed. (BDI-II; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) is a 21-item self-report questionnaire designed to measure the presence and severity of symptoms of depression over the past two weeks.
  • Five Facet Mindfulness Questionnaire (FFMQ; Baer et al., 2008) is a 39-item self-report measure designed to assess five domains of mindfulness. These include observing, describing, acting with awareness, and accepting without judgment. The FFMQ measures key skills taught in the MBCT program.
  • Client Satisfaction Questionnaire, 8-item version (CSQ-8; Larsen, Attkisson, Hargreaves, & Nguyen, 1979) is a self-report questionnaire that measures participant satisfaction with clinical services.

Results

We achieved a high rate of success in conducting follow-up assessments by collecting post-treatment or follow-up data on 34 of the 38 women. The following conclusions could be drawn from analyses of pre- and post-treatment and follow-up scores:

  1. MBCT groups are feasible to offer to perinatal women with bipolar disorder and depression, with high ratings of satisfaction and user acceptability. The Client Satisfaction Questionnaire had a mean score of 29.2 (range 19–32) after the groups, indicating a high level of satisfaction. These scores remained stable at 1 and 6 months, meaning that the women continued to have positive views of the program well after it was over.
  2. Perinatal women with mood disorders showed statistically significant increases in mindful awareness from before to after the groups, and at 1 and 6 months, without showing any evidence of mood relapse (Figure 1).
  3. We observed significant improvements in depression ratings, measured at baseline, post-treatment, 1 month, and 6 months. These scores on the Beck Depression Inventory are pictured in Figure 1. There were no changes in interview based Hamilton depression or Young Mania scores, but it should be noted that these scores were very low at the beginning.
  4. No recurrences of depression, mania, or hypomania were observed in any participant during the study.
  5. The decreases in depression scores and increases in mindful awareness scores were highly correlated over time, (p < .0001).
Figure 1.



21 participants at UCLA, 17 at Colorado.


Conclusion

Together with our earlier results on MBCT for bipolar adults in the U.K. and the U.S., we conclude that MBCT is a cost-effective treatment for persons with depression or bipolar disorder, across countries (U.K. and U.S.), across study centers in the U.S. (Colorado and UCLA), and including those who are pregnant or have given birth recently. Perinatal women showed significant decreases in self-reported depressive symptoms on the Beck Depression Inventory-II, suggesting that their mood had improved during the course of treatment, and remained stable after treatment for up to six months. No recurrences of mood disorder were observed in this cohort. In naturalistic studies, women with depression or bipolar disorder have been found to have recurrence rates of up to 50% following childbirth (Di Florio et al., 2013).

Improvements in depression were correlated with increases in mindful awareness. Because these variables were measured at the same time, we do not know whether improvements in mindfulness lead to improvements in mood; whether improvements in mood lead to improvements in mindful awareness; or whether changes in both are simply the result of time or the natural progression of bipolar and depressive disorders. This study did not have a randomly assigned control group, so we cannot attribute these changes to MBCT, as opposed to changes in other variables (e.g., medication usage). Randomized trials of MBCT for women with depression are currently underway (Dimidjian & Goodman, in preparation).

This study also does not address whether some women can remain off antidepressants during pregnancy and instead substitute MBCT and a self-guided meditation practice. Indeed, some of the participants told us that they had been able to remain off antidepressants while pregnant, without having a relapse. However, we did not study this question systematically by randomly assigning participants to different medication or psychosocial treatments.

In summary, MBCT is a promising treatment for perinatal women. Future studies should recruit larger samples of bipolar and major depressive patients to determine whether the treatment is equally effective for both. We also see value in studies that systematically compare the responses to mindfulness treatment of women who are pregnant, post-partum, or planning pregnancy.

Comments by Participants

Perhaps even more significant than the early data analyses are the written reactions to the groups given by women who took part in the groups. Here is a representative sampling of comments from Exit Interview:

“I feel like my overall quality of life has dramatically improved; my relationship with myself, my husband, my dog, my family has become less of a struggle, and I’ve been able to enjoy life fully for the first time in what seems like forever.”

“I’ve become able to recognize patterns in thoughts and behaviors as patterns in and of themselves instead of what I previously thought were facts. The ability to react mindfully before I am emotionally hijacked is such an amazing experience.”

“I’ve noticed my general outlook on life is remarkably better since starting this program and I know that continued practice will help keep me in emotional balance and allow me to enjoy my life despite the inevitable ups and downs that come with manic-depression.”

“I feel as if it’s been life changing. I have found myself proselytizing to anyone who will listen about the real benefits of this practice.”

“This has truly changed my life and I am incredibly grateful to have had the opportunity to learn MBCT. I can live in less fear of depression now, knowing that I have a powerful tool to help me.”

“It has introduced me to skills and processes that I otherwise would never have learned… I’ve become more aware of my thought processes and how they lead to negative moods.”

“I’ve recommended the course to my sister and talk about it with everyone I know.”

“I see this course as a lifeboat…I will place (mindful meditation) as a high priority in my daily routine.”

This course has taught me that I am more than my label - “depressed”… My thoughts are just thoughts! ...This class gave me the tools to figure out what self-care activities (are helpful) and when I need to do them.”

“I would also like to say that I got off my antidepressant medication… I now have meditation to fall back on… I feel better than ever.”

References

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