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Open Access 01-12-2019 | Affective Disorder | Study protocol

Effectiveness of a brief psychological mindfulness-based intervention for the treatment of depression in primary care: study protocol for a randomized controlled clinical trial

Authors: Alba Lopez-Montoyo, Soledad Quero, Jesus Montero-Marin, Alberto Barcelo-Soler, Maria Beltran, Daniel Campos, Javier Garcia-Campayo

Published in: BMC Psychiatry | Issue 1/2019

Abstract

Background

Depressive symptoms are quite prevalent in Primary Care (PC) settings. The treatment as usual (TAU) in PC is pharmacotherapy, despite the high relapse rates it produces. Many patients would prefer psychotherapy, but specialized services are overloaded. Studies that apply Mindfulness-Based Interventions (MBIs) for the treatment of depression have obtained significant improvements. Brief low-intensity approaches delivered from PC could be a promising approach. This study aims to compare a low-intensity mindfulness intervention for the treatment of depression in PC using different intervention formats – a face-to-face MBI delivered in a group and the same MBI individually applied on the Internet – to a control group that will receive PC medical treatment as usual.

Methods

A randomized controlled clinical trial will be conducted in PC, with about 120 depressed patients allocated (1:1:1) to three groups: “face-to-face MBI + TAU”, “Internet-delivered MBI + TAU”, and “TAU alone”. The MBI programs will be composed of four modules. The primary outcome will be depressive symptoms, measured through the Beck Depression Inventory, assessed at pre- and post-treatment and 6- and 12-month follow-ups. Other outcomes will be mindfulness, happiness, affectivity, quality of life, and the use of healthcare services. Intention-to-treat analysis using linear mixed models adjusted for baseline scores and routine sociodemographic analysis that could show baseline differences will be conducted. Per-protocol secondary outcome analyses will also be performed.

Discussion

This is the first Spanish RCT to apply a low-intensity face-to-face MBI (plus TAU) to treat depression in PC settings compared to TAU (alone). Moreover, this study will also make it possible to evaluate the same MBI program (plus TAU), but Internet-delivered, considering their cost-effectiveness. Positive results from this RCT might have an important impact on mental health settings, helping to decrease the overload of the system and offering treatment alternatives beyond antidepressant medication through high-quality, flexible PC interventions.

Trial registration

Clinical Trials.gov NCT03034343. Trial Registration date 24 January 2017, retrospectively registered.

World Health Organization. WH. The world health report 2001 : mental health : new understanding, new hope. Geneva: World Health Organization; 2001.

Alonso J, Angermeyer MC, Bernert S, Bruffaerts R, Brugha TS, Bryson H, et al. Prevalence of mental disorders in Europe: results from the European study of the epidemiology of mental disorders (ESEMeD) project. Acta Psychiatr Scand. 2004;109(s420):21–7 Available from: http://doi.wiley.com/10.1111/j.1600-0047.2004.00327.x.CrossRef

Mitchell AJ, Vaze A, Rao S. Clinical diagnosis of depression in primary care: a meta-analysis. Lancet. 2009;374(9690):609–19 Available from: https://www.sciencedirect.com/science/article/pii/S0140673609608795.CrossRefPubMed

Roca M, Gili M, Garcia-Garcia M, Salva J, Vives M, Campayo JG, et al. Prevalence and comorbidity of common mental disorders in primary care. J Affect Disord. 2009;119:52–8.CrossRefPubMed

Cuijpers P. Combined pharmacotherapy and psychotherapy in the treatment of mild to moderate major Depression? JAMA Psychiatry. 2014;71(7):747.CrossRefPubMed

Teasdale JD, Segal ZV, Mark J, Williams G, Ridgeway VA, Soulsby JM, et al. Prevention of relapse/recurrence in major Depression by mindfulness-based cognitive therapy. J Consult Clin Psychol. 2000;68(4):615–23.CrossRefPubMed

Huijbers MJ, Spinhoven P, Spijker J, Ruhé HG, van Schaik DJF, van Oppen P, et al. Discontinuation of antidepressant medication after mindfulness-based cognitive therapy for recurrent depression: randomised controlled non-inferiority trial. Br J Psychiatry. 2016;208(04):366–73.CrossRefPubMedPubMedCentral

Eaton WW, Shao H, Nestadt G, Lee BH, Bienvenu OJ, Zandi P. Population-based study of first onset and chronicity in major depressive disorder. Arch Gen Psychiatry. 2008;65(5):513.CrossRefPubMedPubMedCentral

Rodgers M, Asaria M, Walker S, McMillan D, Lucock M, Harden M, et al. The clinical effectiveness and cost-effectiveness of low-intensity psychological interventions for the secondary prevention of relapse after depression: a systematic review. Health Technol Assess. 2012;16(28):1–130 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22642789.CrossRefPubMedPubMedCentral

10.

Castro A, García-Palacios A, García-Campayo J, Mayoral F, Botella C, García-Herrera JM, et al. Efficacy of low-intensity psychological intervention applied by ICTs for the treatment of depression in primary care: a controlled trial. BMC Psychiatry. 2015;15(1):106 Available from: http://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-015-0475-0.CrossRefPubMedPubMedCentral

11.

Bennett-Levy J, Richards DA, Farrand P. Low intensity CBT interventions: a revolution in mental health care; 2010.

12.

Cape J, Whittington C, Buszewicz M, Wallace P, Underwood L. Brief psychological therapies for anxiety and depression in primary care: meta-analysis and meta-regression. BMC Med. 2010;8(1):38 Available from: http://bmcmedicine.biomedcentral.com/articles/10.1186/1741-7015-8-38.CrossRefPubMedPubMedCentral

13.

Rimer J, Dwan K, Lawlor DA, Greig CA, McMurdo M, Morley W, et al. Exercise for depression. In: Mead GE, editor. Cochrane database of systematic reviews. Chichester: Wiley; 2012. p. CD004366. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22786489.

14.

Segal ZV, Williams JMG, Teasdale JD, Kabat-Zinn J. Mindfulness-based cognitive therapy for depression; 2018. p. 451.

15.

National Collaborating Centre for Mental Health. Depression in Adults: TheTtreatment and Management of Depression in Adults. 2009. Available from:https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0016605/pdf/PubMedHealth_PMH0016605.pdf

16.

Miloff A, Lindner P, Hamilton W, Reuterskiöld L, Andersson G, Carlbring P. Single-session gamified virtual reality exposure therapy for spider phobia vs. traditional exposure therapy: study protocol for a randomized controlled non-inferiority trial. Trials. 2016;17(1):1–8. https://doi.org/10.1186/s13063-016-1171-1.CrossRef

17.

Tang Y-Y, Tang Y, Tang R, Lewis-Peacock JA. Brief mental training reorganizes large-scale brain networks. Front Syst Neurosci. 2017;11:6 Available from: http://journal.frontiersin.org/article/10.3389/fnsys.2017.00006/full.CrossRefPubMedPubMedCentral

18.

Zeidan F, Johnson SK, Diamond BJ, David Z, Goolkasian P. Mindfulness meditation improves cognition: evidence of brief mental training. Conscious Cogn. 2010;19(2):597–605 Available from: https://www.sciencedirect.com/science/article/pii/S1053810010000681.CrossRefPubMed

19.

Demarzo M, Montero-Marin J, Puebla-Guedea M, Navarro-Gil M, Herrera-Mercadal P, Moreno-González S, et al. Efficacy of 8- and 4-session mindfulness-based interventions in a non-clinical population: A controlled study. Front Psychol. 2017;8:1343.CrossRefPubMedPubMedCentral

20.

Montero-Marín J, Araya R, Pérez-Yus MC, Mayoral F, Gili M, Botella C, et al. An Internet-Based Intervention for Depression in Primary Care in Spain: A Randomized Controlled Trial. J Med Internet Res. 2016;18(8):e231 Available from: http://www.ncbi.nlm.nih.gov/pubmed/27565118.CrossRefPubMedPubMedCentral

21.

Andersson G, Cuijpers P. Internet-based and other computerized psychological treatments for adult Depression: a meta-analysis. Cogn Behav Ther. 2009;38(4):196–205.CrossRefPubMed

22.

Cuijpers P, van Straten A, Andersson G. Internet-administered cognitive behavior therapy for health problems: a systematic review. J Behav Med. 2008;31(2):169–77 Available from: http://link.springer.com/10.1007/s10865-007-9144-1.CrossRefPubMed

23.

Spek V, Cuijpers P, Nyklícek I, Riper H, Keyzer J, Pop V. Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: a meta-analysis. Psychol Med. 2007;37(03):319.CrossRefPubMed

24.

Titov N. Internet-delivered psychotherapy for depression in adults. Curr Opin Psychiatry. 2011 Jan;24(1):18–23.CrossRefPubMed

25.

Andrews G, Cuijpers P, Craske MG, McEvoy P, Titov N. Computer Therapy for the Anxiety and Depressive Disorders Is Effective, acceptable and practical health care: a meta-analysis. Baune BT, editor. PLoS One. 2010;5(10):e13196 Available from: https://dx.plos.org/10.1371/journal.pone.0013196.CrossRefPubMedPubMedCentral

26.

Cuijpers P, Berking M, Andersson G, Quigley L, Kleiboer A, Dobson KS. A meta-analysis of cognitive-Behavioural therapy for adult Depression, alone and in comparison with other treatments. Can J Psychiatr. 2013;58(7):376–85 Available from: http://journals.sagepub.com/doi/10.1177/070674371305800702.CrossRef

27.

Spijkerman MPJ, Pots WTM, Bohlmeijer ET. Effectiveness of online mindfulness-based interventions in improving mental health: A review and meta-analysis of randomised controlled trials. Clin Psychol Rev. 2016;45:102–14 Available from: https://www.sciencedirect.com/science/article/pii/S0272735815300623.CrossRefPubMed

28.

Ma Y, She Z, Siu AF-Y, Zeng X, Liu X. Effectiveness of online mindfulness-based interventions on psychological distress and the mediating role of emotion regulation. Front Psychol. 2018;9:2090 Available from: https://www.frontiersin.org/article/10.3389/fpsyg.2018.02090/full.CrossRefPubMedPubMedCentral

29.

Querstret D, Cropley M, Fife-Schaw C. The effects of an online mindfulness intervention on perceived stress, Depression and anxiety in a non-clinical sample: A randomised waitlist control trial. Mindfulness (N Y). 2018;9(6):1825–36 Available from: http://link.springer.com/10.1007/s12671-018-0925-0.CrossRef

30.

Krägeloh CU, Medvedev ON, Taylor T, Wrapson W, Rix G, Sumich A, et al. A pilot randomized controlled trial for a videoconference-delivered mindfulness-based group intervention in a nonclinical setting. Mindfulness (N Y). 2019;10(4):700–11 Available from: http://link.springer.com/10.1007/s12671-018-1024-y.CrossRef

31.

López-Montoyo A, Modrego-Alarcón M, Morillo H, García-Campayo J, Quero S. Programas de ordenador basados en mindfulness. Una revisión de la literatura médica. Mindfulness & Compassion. 2016;1(1):23–30 Available from: https://www.sciencedirect.com/science/article/pii/S2445407916300076.CrossRef

32.

Moher D, Hopewell S, Schulz KF, Montori V, Gøtzsche PC, Devereaux PJ, et al. CONSORT 2010 explanation and elaboration: updated guidelines for reporting parallel group randomised trials. Int J Surg. 2012;10(1):28–55.CrossRefPubMed

33.

Christensen H, Griffiths K, Jorm A. Delivering interventions for Depression by using the internet: randomised controlled trial. BMJ. 2004;328(7434):265. https://doi.org/10.1136/bmj.37945.566632.EE.CrossRefPubMedPubMedCentral

34.

Vijayananthan A, Nawawi O. The importance of Good Clinical Practice guidelines and its role in clinical trials. Biomed Imaging Interv J. 2008;4(1):e5 Available from: http://www.ncbi.nlm.nih.gov/pubmed/21614316.CrossRefPubMedPubMedCentral

35.

Diez-Quevedo C, Rangil T, Sanchez-Planell L, Kroenke K, Spitzer RL. Validation and utility of the patient health questionnaire in diagnosing mental disorders in 1003 general hospital Spanish inpatients. Psychosom Med. 2001;63(4):679–86.CrossRefPubMed

36.

Wielgosz J, Goldberg SB, Kral TRA, Dunne JD, Davidson RJ. Mindfulness Meditation and Psychopathology. Annu Rev Clin Psychol. 2019;15(1):annurev-clinpsy):021815–93423.CrossRef

37.

Cavanagh K, Shapiro DA, Berg S, Swain S, Barkham M, Proudfoot J. The effectiveness of computerized cognitive behavioural therapy in routine care. Br J Clin Psychol. 2006;45(4):499–514. https://doi.org/10.1348/014466505X84782.CrossRefPubMed

38.

Purves DG, Bennett M, Wellman N. An open trial in the NHS of blues Begone®: A new home based computerized CBT program. Behav Cogn Psychother. 2009;37(05):541.CrossRefPubMed

39.

Abdi H. The Greenhouse-Geisser Correction. In: Encyclopedia of research design. Thousand Oaks: Sage; 2010.

40.

Strauss C, Cavanagh K, Oliver A, Pettman D. Mindfulness-based interventions for people diagnosed with a current episode of an anxiety or depressive disorder: a meta-analysis of randomised controlled trials. Laks J, editor. PLoS One. 2014;9(4):e96110 Available from: http://dx.plos.org/10.1371/journal.pone.0096110.CrossRefPubMedPubMedCentral

41.

Guo Y, Logan HL, Glueck DH, Muller KE. Selecting a sample size for studies with repeated measures. BMC Med Res Methodol. 2013;13(1):100 Available from: https://bmcmedresmethodol.biomedcentral.com/articles/10.1186/1471-2288-13-100.CrossRefPubMedPubMedCentral

42.

Richards D, Richardson T. Computer-based psychological treatments for depression: A systematic review and meta-analysis. Clin Psychol Rev. 2012;32:329–42.CrossRefPubMed

43.

Sheehan D, Lecrubier Y, Sheehan K, Amorim P, Janavs J, Weiller E, et al. The Mini-international neuropsychiatric interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry. 1998;59(Suppl 2):22–33.PubMed

44.

Ferrando L, Franco L, Soto M, Bobes J, Soto O, Gibert J. MINI International Neuropsychiatric Interview. Versión en Español 5.0.0. Madrid: IAP; 1998.

45.

Beck AT, Steer RA, Brown GK. Beck depression inventory -II. Psychol Corporation. 1990;78(2):490–8.

46.

Araya R, Montero-Marin J, Barroilhet S, Fritsch R, Montgomery A. Detecting depression among adolescents in Santiago, Chile: sex differences. BMC Psychiatry. 2013;13(1):122 Available from: http://bmcpsychiatry.biomedcentral.com/articles/10.1186/1471-244X-13-122.CrossRefPubMedPubMedCentral

47.

Sanz J, Perdigón A, Vázquez C. Adaptación española del Inventario para la Depresión de Beck-II (BDI-II): 2. Propiedades psicométricas en población general. Clínica y Salud. 2003;14(3):249–80.

48.

Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;1(9):606–13 Available from: http://www.ncbi.nlm.nih.gov/pubmed/11556941.CrossRef

49.

Watson D, Clark LA, Tellegen A. Development and validation of brief measures of positive and negative affect: The PANAS scales. J Pers Soc Psychol. 1988;54(6):1063–70. https://doi.org/10.1037/0022-3514.54.6.1063.CrossRefPubMed

50.

Sandín B, Chorot P, Lostao L, Joiner T, Santed MA, Valiente R. Escalas PANAS de afecto positivo y negativo: validación factorial y convergencia transcultural. Psichothema. 1999;11(1):37–51.

51.

Hervás G, Vázquez C. Construction and validation of a measure of integrative well-being in seven languages: The Pemberton happiness index. Health Qual Life Outcomes. 2013;11(1):66.CrossRefPubMedPubMedCentral

52.

Ware J Jr, Kosinski M, Keller S. A 12-item short-form health survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996;34(3):220–33.CrossRefPubMed

53.

Gandek B, Ware JE, Aaronson NK, Apolone G, Bjorner JB, Brazier JE, et al. Cross-validation of item selection and scoring for the SF-12 Health Survey in nine countries: results from the IQOLA project. international quality of life assessment. J Clin Epidemiol. 1998;51(11):1171–8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/9817135.CrossRefPubMed

54.

Vilagut G, Ferrer M, Rajmil L, Rebollo P, Permanyer-Miralda G, Quintana JM, et al. The Spanish version of the short form 36 health survey: a decade of experience and new developments. Gac Sanit. 2005;19(2):135–50 Available from: http://www.ncbi.nlm.nih.gov/pubmed/15860162.CrossRefPubMed

55.

Badia X, De Charro F. EuroQol; un instrumento para valorar la salud EQ-5D guía del usuario, version española. Med Clin (Barc). 1999;114:6–14.

56.

Badia X, Roset M, Herdman M, Kind P. A comparison of United Kingdom and Spanish general population time trade-off values for EQ-5D health states. Med Decis Mak. 2001;21(1):7–16.CrossRef

57.

Beecham J, Knapp M, Hallam A, Baines B. Costing psychiatric interventions. Measuring Mental Health Needs. 2001;2:200–24.

58.

Vázquez-Barquero JL, Gaite L, Cuesta MJ, Gacría Usieto E, Knapp M, Beecham J. Spanish version of the CSRI: a mental health cost evaluation interview. Arch Neurobiol. 1991;60:1717–184.

59.

Baer RA, Smith GT, Hopkins J, Krietemeyer J, Toney L. Using self-report assessment methods to explore facets of mindfulness. Assessment. 2006;13(1):27–45. https://doi.org/10.1177/1073191105283504.CrossRefPubMed

60.

Cebolla A, García-Palacios A, Soler J, Guillen V, Baños R, Botella C. Psychometric properties of the Spanish validation of the five facets of mindfulness questionnaire (FFMQ). Eur J Psychiatry. 2012;26(2):118–26.CrossRef

61.

Borkovec TD, Nau SD. Credibility of analogue therapy rationales. J Behav Ther Exp Psychiatry. 1972;3(4):257–60 Available from: https://www.sciencedirect.com/science/article/pii/0005791672900456.CrossRef

62.

Moher D, Hopewell S, Schulz KF, Montori V, Gøtzsche PC, Elbourne D, et al. CONSORT 2010 Explanation and Elaboration: updated guidelines for reporting parallel group randomised trials. BMJ. 2011;343(sep29 2):d6131 Available from: http://www.bmj.com/cgi/doi/10.1136/bmj.d6131.CrossRef

63.

Moher D, Schulz KF, Altman DG. The CONSORT statement: revised recommendations for improving the quality of reports of parallel group randomized trials. BMC Med Res Methodol. 2001;1(1):2 Available from: http://bmcmedresmethodol.biomedcentral.com/articles/10.1186/1471-2288-1-2.CrossRefPubMedPubMedCentral

64.

Morris SB. Estimating effect sizes from pretest-posttest-control group designs. Organ Res Methods. 2008;11(2):364–86 Available from: http://journals.sagepub.com/doi/10.1177/1094428106291059.CrossRef

65.

Cohen J. In: Lawrence E, editor. Statistical power analysis for the behavioral sciences. Hillsdale: NJ: L; 1988.

66.

Jacobson NS, Truax P. Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. J Consult Clin Psychol. 1991;59(1):12–9 Available from: http://doi.apa.org/getdoi.cfm?doi=10.1037/0022-006X.59.1.12.CrossRefPubMed

67.

Eveleigh R, Muskens E, Lucassen P, Verhaak P, Spijker J, van Weel C, et al. Withdrawal of unnecessary antidepressant medication: a randomised controlled trial in primary care. BJGP Open. 2018;1(4):bjgpopen17X101265 Available from: http://bjgpopen.org/lookup/doi/10.3399/bjgpopen17X101265.CrossRefPubMed

68.

Moré Herrero MA, Jiménez Arriero MA, Muñoz Rodríguez PE. Muñoz de Morales A, Zufía García J. preliminary study aimed at the construction of a questionnaire for referral from primary care to mental health services. Actas Esp Psiquiatr. 2008;36(4):210–7.

69.

Demarzo MMP, Montero-Marin J, Cuijpers P, Zabaleta-del-Olmo E, Mahtani KR, Vellinga A, et al. The efficacy of mindfulness-based interventions in primary care: a meta-analytic review. Ann Fam Med. 2015;13(6):573–82 Available from: http://www.ncbi.nlm.nih.gov/pubmed/26553897.CrossRefPubMedPubMedCentral

70.

Andrews G, Cuijpers P, Craske MG, McEvoy P, Titov N. Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: a meta-analysis. Baune BT, editor. PLoS One. 2010;5(10):e13196 Available from: http://dx.plos.org/10.1371/journal.pone.0013196.CrossRefPubMedPubMedCentral

71.

Arroll B, Moir F, Kendrick T. Effective management of depression in primary care: a review of the literature. BJGP Open. 2017;1(2):BJGP-2016-0641 Available from: http://bjgpopen.org/lookup/doi/10.3399/bjgpopen17X101025.CrossRef

72.

Kuyken W, Hayes R, Barrett B, Byng R, Dalgleish T, Kessler D, et al. Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): a randomised controlled trial. Lancet. 2015;386(9988):63–73 Available from: https://www.sciencedirect.com/science/article/pii/S0140673614622224.CrossRefPubMed

73.

Lester H, Howe A. Depression in primary care: three key challenges. Postgrad Med J. 2008;84(996):545–8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/19017840.CrossRefPubMed

74.

Hofmann SG, Sawyer AT, Witt AA, Oh D. The effect of mindfulness-based therapy on anxiety and depression: A meta-analytic review. J Consult Clin Psychol. 2010;78(2):169–83 Available from: http://doi.apa.org/getdoi.cfm?doi=10.1037/a0018555.CrossRefPubMedPubMedCentral

75.

Goyal M, Singh S, Sibinga EMS, Gould NF, Rowland-Seymour A, Sharma R, et al. Meditation programs for psychological stress and well-being: a systematic review and meta-analysis. JAMA Intern Med. 2014;174(3):357–68 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24395196.CrossRefPubMedPubMedCentral

Title: Effectiveness of a brief psychological mindfulness-based intervention for the treatment of depression in primary care: study protocol for a randomized controlled clinical trial
Authors: Alba Lopez-Montoyo
Soledad Quero
Jesus Montero-Marin
Alberto Barcelo-Soler
Maria Beltran
Daniel Campos
Javier Garcia-Campayo
Publication date: 01-12-2019
Publisher: BioMed Central
Keywords: Affective Disorder
Care
Affective Disorder
Published in: BMC Psychiatry / Issue 1/2019
Electronic ISSN: 1471-244X
DOI: https://doi.org/10.1186/s12888-019-2298-x

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Effectiveness of a brief psychological mindfulness-based intervention for the treatment of depression in primary care: study protocol for a randomized controlled clinical trial

Abstract

Background

Methods

Discussion

Trial registration

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Background

Methods

Discussion

Trial registration

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