Mindfulness-Based Cognitive Therapy for Nonremitted Patients with Bipolar Disorder
Thilo Deckersbach, Ph.D., Bipolar Clinic and Research Program, Massachusetts General Hospital, Department of Psychiatry, 50 Staniford Street, 5th Floor, Boston, MA 02114, USA.
Tel.: (617) 724-6300 ext. 1340183;
Fax: (617) 726-4078;
Received 6 August 2010; revision 23 November 2010; accepted 13 December 2010
Introduction: Bipolar disorder is characterized by recurrent episodes of depression and/or mania along with interepisodic mood symptoms that interfere with psychosocial functioning. Despite periods of symptomatic recovery, many individuals with bipolar disorder continue to experience substantial residual mood symptoms that often lead to the recurrence of mood episodes.
Aims: This study explored whether a new mindfulness-based cognitive therapy (MBCT) for bipolar disorder would increase mindfulness, reduce residual mood symptoms, and increase emotion-regulation abilities, psychological well-being, positive affect, and psychosocial functioning. Following a baseline clinical assessment, 12 individuals with DSM-IV bipolar disorder were treated with 12 group sessions of MBCT.
Results: At the end of treatment, as well as at the 3 months follow-up, participants showed increased mindfulness, lower residual depressive mood symptoms, less attentional difficulties, and increased emotion-regulation abilities, psychological well-being, positive affect, and psychosocial functioning.
Conclusions: These findings suggest that treating residual mood symptoms with MBCT may be another avenue to improving mood, emotion regulation, well-being, and functioning in individuals with bipolar disorder.
Bipolar disorder is a chronic, debilitating disorder that is characterized by recurrent depressive and/or manic mood episodes that cause functional impairment . Traditionally, bipolar disorder has been viewed as an episodic illness with periods of recovery in between mood episodes . This view is increasingly challenged by clinical and epidemiological studies that document that, despite pharmacotherapy, patients with bipolar disorder often do not achieve full remission and continue to experience substantial residual mood symptoms in between episodes . These residual mood symptoms, in particular depressive symptoms, are highly predictive for recurrence of mood episodes .
Although the mechanisms leading to recurrence of mood episodes are not yet fully understood, there have been notable advances in our understanding of the cascade of cognitive, affective, and behavioral events that lead to recurrence of mood episodes. For example, in terms of depressive symptoms, patients with bipolar disorder appear to be at risk for the recurrence of negative thoughts (and affect) due to dysfunctional attitudes and pessimistic inferential styles [5, 6]. Negative thoughts and affect can be activated through stressful and/or negative life events [7, 8] and disrupted social rhythms . More broadly, any thoughts and feelings associated with stored memories of depressed mood can serve as an internal context that can reactivate depressed mood and its associated patterns of thinking and feeling . As individuals with major depression, patients with bipolar disorder exhibit a tendency to ruminate in response to negative affect . This appears to create a self-perpetuating cycle of ruminative thinking, decreased motivation and interest, loss of positive affect, coupled with reduced goal-directed behavior leading back into depressive episodes. In terms of mood elevation, there is converging evidence that patients with bipolar disorder exhibit a hypersensitive Behavioral Activation System (BAS) and increased reward responsivity [12–14]. The encounter of BAS-relevant stimuli, goal attainment, or disruptions in social rhythms [15, 16] may trigger initial symptoms of mood elevation (increased motivation, confidence, etc.). Similar to their response to negative affect, patients with bipolar disorder have been shown to ruminate in response to positive affect , which coupled with increases in goal-directed (often pleasurable) activity and decreased sleep, further intensifies symptoms of mood elevation.
Several psychosocial interventions have been developed to treat bipolar disorder adjunctive to medication (for a review, see Miklowitz, 2008) . These include: (1) interpersonal and social rhythm therapy (IPSRT), which focuses on stabilization of social rhythms, and interpersonal problems such as grief, role transitions, role disputes, and interpersonal difficulties , (2) family therapy (e.g., family-focused treatment, or FFT), which includes family psychoeducation and relapse prevention, communication enhancement, and problem-solving training , and (3) cognitive-behavioral approaches [20–22], which include techniques such as psychoeducation, mood monitoring and relapse prevention; cognitive restructuring, problem solving, and activity scheduling. For example, IPSRT for an acute mood episode has been shown to be associated with reduced relapse rates in bipolar patients during a 2-year follow-up period following remission . FFT was more effective in preventing relapse in recently remitted bipolar patients compared to family psychoeducational treatment  and to individually focused psychoeducation, case management, and problem solving . Cognitive behavioral therapies (CBT) for bipolar disorder have been shown to increase medication adherence  and also reduce relapse rates or severity [21, 22, 26]. All three psychosocial treatments (IPSRT, FFT, and CBT) shortened the time to recovery from depressive mood episodes  and improved psychosocial functioning . Unfortunately, despite these advances in treatment, many patients with bipolar disorder remain symptomatic and do not achieve sustained periods of remission [3, 4, 29], and there is also some evidence that patients with a more chronic course of the disorder (i.e., more mood episodes) may not benefit from adjunctive CBT .
Mindfulness-based cognitive therapy (MBCT) is a treatment that has been developed for preventing relapse in remitted patients with recurrent major depressive episodes . It integrates mindfulness-based meditative practices with elements of cognitive therapy and aims at developing a capacity to be aware of distressing thoughts, feelings, and sensations without taking countermeasures such as trying to change them, replace them with other thoughts, or fix anything about them [10, 31]. From the perspective of MBCT, relapse involves the automatic reactivation of ruminative negative thought patters that were active during people's previous episodes of depression . The thinking focuses on reviewing the unpleasant emotional state, past negative events, and the problems that continue or arise if things do not change (e.g., “why do I always get overwhelmed?”) . Instead of the intended resolution of the undesirable state (i.e., successfully thinking about one's way out), this thinking process tends to increase negative affect, thereby promoting more negative thinking and negative affect, which results in a self-perpetuating cycle of negative, ruminative thinking and downward spiraling mood [10, 31]. According to Segal (2002) , the core skill of MBCT for depression aims to teach patients to recognize and disengage from these mind states of self-perpetuating patterns of negative thought . Participants are guided to gradually adopt a “being mode” that is characterized by a decentered observance and acceptance of thoughts and feelings as passing events in ones’ field of awareness, thereby preventing (or interrupting) ruminative thinking and downward spiraling into depression. This skill is taught through a variety of exercises adapted from the Mindfulness-based Stress Reduction (MBSR) Program developed by Jon Kabat-Zinn . These exercises include  body scans, in which attention is sequentially moved through the body,  different types of sitting meditations (breath awareness, as well as mindful observance of bodily sensations, sounds, feelings, and thoughts,  everyday mindfulness during which observance is brought to everyday activities (e.g., eating), and  exercises geared toward recognizing shifts toward ruminative thinking .
Initially, MBCT was shown to be more effective compared to treatment as usual in preventing relapse in frequently depressed adults with major depressive disorder (MDD) . Subsequent MBCT studies in recurrent MDD replicated this relapse prevention effect [34, 35], and also found that MBCT decreases levels of depression in depressed patients with recurrent major depression in an uncontrolled study  and those with residual depressive symptoms . To our knowledge, to date, two studies have investigated the effects of the MBCT protocol, originally designed by Segal et al. (2002) , in remitted patients with bipolar disorder with mixed results. Williams and colleagues (2008) found decreased depression and anxiety symptoms in remitted patients with bipolar disorder following 8 weeks of MBCT compared to waitlist . Miklowitz et al. (2009)  also used the Segal et al. (2002)  MBCT protocol but included two additional treatment elements specifically designed for patients with bipolar disorder: education about mood changes and its provoking factors (e.g., interpersonal conflict, sleep/wake cycle disruptions) and upon identification of these factors bringing mindfulness to prodromal signs of mood elevation. Using this modified MBCT protocol, Miklowitz et al. (2009) obtained only small-to-medium effect sizes for decreases in depression and anxiety in remitted patients with bipolar disorder [31, 39].
The purpose of this study was to investigate whether MBCT can be used to decrease mood symptoms in nonremitted patients with bipolar disorder with prominent levels of residual mood symptoms in order to decrease the risk for relapse . As in Miklowitz et al. (2009) , we used the Segal et al. (2002) MBCT group treatment protocol  as the basis but added and changed treatment elements after consulting with experts in MBCT and MBSR (Zindel Segal, Zayda Valeyo, Carol Legro; for a detailed description of the intervention see Method). Our program included psychoeducation about mood changes and their triggers, daily mood monitoring to detect increases in mood symptoms early and emergency plans to address worsening in mood symptoms (e.g., prodromal signs of mania) in order to prevent break-through of full depression or mania . Participants were guided toward nonjudgmental observance of bodily sensations, feelings, and thoughts associated with depression and anxiety. They also practiced mindful observance of prodromal signs of mood elevation (sensations, feelings, speeded thoughts, etc.) besides reducing environmental stimulation and activity at that time. This was implemented in order to reduce (or prevent) rumination in response to positive affect  and disengage from cognitive activities (e.g., frequent shifts of attention, multitasking, etc.) that could further increase mood elevation.
Many individuals with bipolar disorder have cognitive difficulties and are disorganized in their daily lives (e.g., difficulties with attention, memory, and executive functioning) [41–47]. Therefore, we reintroduced mindful movement exercises (an element used in MBSR) into the treatment as a way of providing additional focus for their attention. Body scan and sitting meditations were considerably shortened and at the beginning alternated with movement exercises to accommodate participants’ ability to sustain attention. In addition, we employed cognitive-behavioral and cognitive remediation strategies to increase the frequency and consistency of engaging in mindfulness in daily life (e.g., systematic use of reminder cues for implementing mindfulness). Finally, there is increased recognition that negative affect and positive affect are independent constructs [48, 49]. The decrease or absence of depression (or depression symptoms) does not automatically translate into the presence of positive affect or well-being [50, 51]. Similarly, it has been shown that self-compassion independently from mindfulness predicts depression . Thus, in the second half of this MBCT program, we added mindfulness exercises promoting self-compassion (e.g., Loving-kindness meditations) and systematically added self-soothing experiences and mindfulness toward pleasant experiences in order to increase participants’ well-being.
We explored the effects of this treatment in nonremitted patients with bipolar disorder with residual mood symptoms. We hypothesized that the intervention would increase mindfulness, reduce residual mood symptoms, decrease rumination and anxiety (worry), and increase emotion-regulation abilities, attention, psychological well-being, positive affect, and psychosocial functioning.
Study participants were 12 adults who met DSM-IV criteria for bipolar I disorder (n = 9, 7 females) or bipolar II disorder (n = 3, 2 females) who were recruited through the Bipolar Clinic and Research Program at the Massachusetts General Hospital (MGH). All participants provided written informed consent prior to participation in accordance with approved MGH-IRB consenting procedures. Diagnoses of participants with bipolar disorder were determined using the Mini-International Neuropsychiatric Interview (MINI-Plus) . Participants with bipolar disorder were included in the trial if they: (1) had residual depressive symptoms as defined by feeling depressed or experiencing decreased interest at least 3 days every week during the month preceding the study, but no more than three associated symptoms in the MINI , (2) had no or low residual manic symptoms (YMRS <12) , (3) did not have an episode of a DSM-IV major depression and/or DSM-IV hypomania or mania in the month preceding the screening, and (4) were on a stable dose of medication. Exclusion criteria were: (1) unsafe suicidal ideation, (2) DSM-IV schizophrenia, schizoaffective disorder, delusional disorder, psychotic disorders not otherwise specified, major depressive disorder, mood congruent or mood incongruent psychotic features, (3) current substance dependence disorders, including alcohol, active within the last 12 months, (4) untreated hypothyroidism, (5) receiving electroconvulsive therapy within 6 months preceding enrollment, and (6) current (past 4 weeks) organic mental disorder and/or neurologic conditions as well as any medical conditions affecting the ability to participate in treatment. Following the initial screening visit, participants completed a pretreatment assessment that included measures of mindfulness, depression, mania, rumination and worry, as well as attentional difficulties, positive affect, well-being, and overall psychosocial functioning (see Assessments). Participants then completed 12 sessions of this MBCT for bipolar disorder (see Treatment) followed by a posttreatment assessment at the end of treatment (after session 12) and a 3-month follow-up assessment using the clinical scales and self-report questionnaires administered at the pretreatment assessment.
MBCT for bipolar disorder consisted of twelve, 120-min group treatment sessions conducted weekly over 3 months provided by two doctoral-level psychologists with extensive experience in MBSR (BKH) and CBT (TD). The cognitive-behavioral treatment elements included mood monitoring, problem solving, and emergency plans for managing mood symptoms as well as education about bipolar disorder . We included mindful movement exercises, short mindfulness exercises including short body scans and breath awareness sitting meditations, as well as mindfulness to routine activities, short breathing spaces, mindfulness to difficult emotions and in the second half of the program loving kindness meditations. Problem solving was incorporated so that therapists could assist participants in dealing with daily hassles and obstacles, which may have otherwise caused participants to drop out of treatment. Treatment began with introducing participants to the concept of mindfulness (the raison exercise) and starting to practice mindfulness in routine activities (e.g., eating, brushing teeth); as well daily mood monitoring (session 1–2) (40). As residual mood symptoms often fluctuate, participants learned to identify warning signs for the worsening of mood symptoms and developed emergency plans for worsening mood symptoms (sessions 2–3; ongoing mood monitoring until the end of treatment in session 12). Similarly, starting in session 3, participants were directed to increase their awareness toward triggers for mood symptoms and developed action plans how to best reduce (stimulus control) or bring mindfulness to the sensations, thoughts, and feelings associated with these triggers. As part of the group, the participants received specific education about the vicious cycles of depressed, ruminative, anxious, elevated, and irritable feelings (sessions 3–7).
Gradually, along with educational instruction about depressed, anxious, irritable, or elevated mood, participants were instructed to bring mindfulness to difficult situations, thoughts and feelings (starting in session 4 going until 12). Formal mindfulness exercises were initially practiced by mindful movement exercises that provided an attentional focus (sessions 1–4) followed by short body scans (sessions 1 and 2) and/or short sitting meditations (breath awareness, sessions 3–4). Traditional MBCT uses mindful meditation exercises to teach the skill of mindfulness. Patients are given approximately 40-min guided recordings in session and to practice with at home daily. The recordings lead them through body scans and sitting meditations in which attention is sequentially moved through the body. Given bipolar patients’ difficulty with sustaining attention and their often disorganized schedules and difficulties adhering to regimens, we felt the in-session exercises and corresponding homework assignments prescribed by MBCT would have been too difficult for many patients. Furthermore, we decided to add/reinstate the gentle yoga exercises used in MBSR treatment , as many individuals find it is easier to keep attention focused during yoga exercises. In sessions 1–3, short body scans and sitting meditation exercises were alternated with mindful yoga or movement exercises. Body scans and sitting meditation exercises were then gradually increased in length depending on each participant's ability to sustain attention. Starting in session 5, participants also practiced sitting meditations that focused on the mindful observance of difficult feelings and thoughts. Early on (sessions 2–12), participants brought mindfulness to routine activities in daily life (e.g., brushing teeth, eating) and also started to implement breathing spaces (a short mindfulness exercise) in daily life. As bipolar patients often have difficulties organizing and planning daily activities, standard problem-solving techniques  were employed to remove obstacles against practicing mindfulness and to help participants cope with daily “hassles.” Similarly, cueing and contingency techniques were employed to systematically increase mindfulness in participants’ daily lives . For example, cell phones alarms were used to remind participants to implement mindfulness exercises in the subway on their way to work, or during lunch breaks in their offices and participants rewarded themselves for following through. As in MBSR and MBCT, all mindfulness instructions emphasized an accepting, observational stance to whatever was the object of observation.
While participants continued to practice the skills learned in sessions 1–6, the second half of the program emphasized self-compassion, pleasurable activities, and mindfulness toward those activities (sessions 7–12). Participants were introduced to the concept of compassionate self-coaching (session 7). This was complemented by loving-kindness meditation, a form of meditation during which participants extend compassion, empathy, and whishes of well-being to others as well as to themselves (sessions 7–12). Participants gradually included more self-soothing activities into their days and brought mindfulness to these activities (sessions 7–12). The program concluded with a review of the skills that were learned and education about relapse prevention (session 12).
Clinician-rated scales (HAM-D; YMRS; and LIFE-RIFT) were administered by a research coordinator (JPS) who did not have access to treatment-related information. He had received extensive training in these scales and had 2 years of experience in the administration of these scales. Medication adherence throughout the study was monitored using mood diaries in which participants noted whether they had taken their daily medications.
- 1Five-Factor Mindfulness Questionnaire (FFMQ). The FFMQ  is a 39-item instrument to measure five aspects of mindfulness: Observing (attending to or noticing internal and external stimuli, such as sensations, emotions, cognitions, sights, sounds, and smells; scale “Observe”; pretreatment Cronbach α= 0.75), describing (noting or mentally labeling these stimuli with words; scale “Describe”; pretreatment Cronbach α= 0.86), acting with awareness (attending to one's current actions, as opposed to behaving automatically or absent-mindedly; scale “Act with Awareness”; pretreatment Cronbach α= 0.53), nonjudging of inner experience (refraining from evaluation of one's sensations, cognitions, and emotions; scale “Nonjudge”; pretreatment Cronbach α= 0.93) and nonreactivity to inner experience (allowing thoughts and feeling to come and go, without attention getting caught up in them; scale “Nonreact”; pretreatment Cronbach α= 0.73).
- 2Hamilton Depression Scale (HAM-D). The severity of depressive symptoms was assessed with the Hamilton Depression Scale, 17-item version (54). Scores range from 0 to 54, with higher scores indicating greater depressive symptoms.
- 3Young Mania Rating Scale (YMRS). The severity of residual manic symptoms was assessed with the YMRS . Scores range from 0 to 56, with higher scores indicating greater symptoms of mania/hypomania.
- 4Penn State Worry Questionnaire (PSWQ). The PSWQ  is a 16-item self-report inventory of the extent to which individuals worry habitually. Scores range from 16 to 80, with higher scores indicating greater levels of worry (pretreatment Cronbach α= 0.94).
- 5Response Style Questionnaire (RSQ). The RSQ [60, 61] evaluates responses to depressive mood and contains three response style subscales: rumination, distraction, and problem solving. This study used the 22-item rumination subscale. Scores range from 22 to 88, with higher scores indicating greater tendency to ruminate in response to depressed mood (pretreatment Cronbach α= 0.90).
- 6Emotion Reactivity Scale (ERS). The ERS  is a 21-item self-report instrument designed to measure emotional sensitivity, intensity, and persistence. Scores range from 0 to 84, with higher scores indicating greater emotional reactivity (pretreatment Cronbach α= 0.97).
- 7Adult ADHD Self-Report Scale (ASRS1.1). The ASRS1.1  is an 18-item questionnaire that assesses the 18 DSM-IV-TR criteria for ADHD in adults. Individuals indicate how often each question is true of their lives on a 5-point scale from “never” to “very often.” The scale permits to compute two sub-subscales, “Inattention” (pretreatment Cronbach α= 0.81) and “Hyperactivity” (pretreatment Cronbach α= 0.83), each composed of nine items. Scores on each subscale range from 0 to 36, with higher scores on either subscale indicating greater endorsement of symptoms consistent with adult ADHD.
- 8Clinical Positive Affective Scale (CPAS). The CAPS  is a 16-item instrument that evaluates positive feelings that individuals may experience. Scores range from 0 to 64, with higher scores indicating greater positive affect (pretreatment Cronbach α= 0.97).
- 9Psychological Well-Being Scale (PWBS). The PWBS [65, 66] is an 84-item self-report questionnaire that examines six dimensions of psychological well-being: Autonomy (pretreatment Cronbach α= 0.86), Environmental Mastery (pretreatment Cronbach α= 0.91), Personal Growth (pretreatment Cronbach α= 0.83), Positive Relations with Others (pretreatment Cronbach α= 0.89), Purpose in Life (pretreatment Cronbach α= 0.87), and Self-Acceptance (pretreatment Cronbach α= 0.95). Participants indicate on a 6-point Likert scale (from “strongly agree” to “strongly disagree”) the extent to which statements are true of them. Higher scores on each subscale indicate greater well-being in that dimension.
- 10The Longitudinal Interval Follow-up Evaluation – Range of Impaired Functioning Tool (LIFE-RIFT). The LIFE-RIFT  was used as a broader measure of overall psychosocial functioning. It includes four domains: work (employment, household, and student), relationships, recreation, and global satisfaction. The scores in each domain are summed to a total score ranging between 0 and 20.
The impact of MBCT for bipolar disorder on these measures was analyzed using repeated measures analysis of variance (ANOVA) with time (pretreatment, posttreatment, and follow-up) as the within-subjects factor. This was followed up with simple f-tests or trend tests. We conducted an “intent-to-treat” (ITT) analysis of all participants enrolled in the trial with their last visit carried forward as long as they had at least one treatment visit following the pretreatment assessment. We then also performed a “completer” analysis of all participants finishing the trial. Because of the risk of Type-I error due to multiple comparisons, we also provide Cohen's d effect sizes for the magnitude of changes in mindfulness, mood symptoms, rumination and worry, attention difficulties, emotion regulation, well-being, positive affect, and psychosocial functioning. Following the convention by Cohen  effect sizes of 0.2 were considered small, effect sizes of 0.5 were considered medium, and effect sizes of 0.8 were considered large.
Ten of the 12 enrolled participants with bipolar disorder met criteria for the ITT analysis (8 females). Two participants dropped out after the screening visit for unknown reasons with no further visits. Nine participants completed the study (7 females). One participant who completed the treatment could not be reached for the follow-up. The ITT sample had a mean age of 38.7 (SD = 9.5) and 16 years of education (M = 16.2, SD = 2.9). All but four participants were medically healthy by self-report. One participant had Lupus that was well controlled with medication. One participant reported hypothyroidism, treated with levothyroxine sodium. One participant had asthma treated with albuterol; one participant reported suffering from tension headaches. All but one participant (who was closely monitored by the treating psychiatrist) took mood-stabilizing medications including lithium (n = 4), lamotrigine (n = 4), tiagabine (n = 1), topiramate (n = 1), carbamazepine (n = 1), antipsychotics (quetiapine, aripiprazole, perphenazine, n = 7), selective serotonin reuptake inhibitors (sertraline, escitalopram, n = 2), and anxiolytics (buspirone, clonazepam, n = 2). Seven participants had comorbid DSM-IV anxiety disorders including generalized anxiety disorder, n = 4, panic disorder, n = 2, obsessive-compulsive disorder, n = 2, and posttraumatic stress disorder, n = 1. Two participants had a history of DSM-IV alcohol abuse. One participant had a history of both alcohol and amphetamine abuse. One participant reported a history of childhood ADHD and one participant had a history of DSM-IV binge eating disorder. The average onset of bipolar disorder in this sample was 21.9 years (SD = 12.2). All but two participants had more than a total of 12 mood episodes. Four participants were employed. Two participants were attending graduate school. Two participants were homemakers and two patients were disabled. Pretreatment, three participants experienced both depressive and manic residual symptoms whereas all other participants had low or no residual manic symptoms but ongoing residual depressive symptoms. During the treatment phase, one of the participants with residual depressive and manic symptoms experienced hypomania and temporarily increased quetiapine (<1 week). Another participant experienced a depressive episode during the treatment phase, which lasted for 3 weeks and during this phase increased lamotrigine. Two participants experienced a 1-week phase of temporarily increased depressive mood during the treatment phase that met criteria for a major depressive episode except of the duration criterion. Medication was kept stable for these two patients. During the follow-up phase, one participant gradually lowered lithium to a lower-dose maintenance level without experiencing any mood episode. During the follow-up period, two participants experienced a major depressive episode that had resolved at the time of the follow-up assessment. One participant who became hypomanic in the week before the follow-up assessment started quetiapine in the week before the follow-up assessment. All medication changes were supervised by the treating psychiatrist.
Participants attended on average 8.5 sessions (SD = 1.6). Scores of clinician-rated scales and self-rated questionnaires pretreatment and effect sizes (Cohen's d), at the end of treatment and follow-up are shown in Table 1.
Table 1. Pretreatment, posttreatment, and follow-up assessment data of patients with bipolar disorder (intent-to-treat [ITT] sample)
| Act with awareness||23.00||3.68||24.20||5.27||25.20||5.83||0.43||0.45||0.55|
|Emotion regulation (ERS)||41.80||24.90||35.40||25.51||32.90||24.59||0.68||0.23||0.93|
|Positive affect (CPAS)||44.50||17.06||55.80||11.10||51.90||13.98||0.88||0.33||0.41|
| Environmental mastery||43.80||13.81||53.40||14.95||53.90||13.07||1.06||0.11||0.98|
| Personal growth||71.60||8.97||73.70||6.82||72.50||8.26||0.29||0.29||0.12|
| Positive relations||64.40||14.38||67.80||13.51||69.50||12.52||0.59||0.41||0.73|
| Purpose in life||53.20||14.20||61.90||14.72||60.20||16.10||1.32||0.30||0.78|
Mindfulness (FFMQ). For the ITT analysis, the repeated measures ANOVA indicated significant changes in the FFMQ subscales “Observe” (F(2,18) = 14.06, P < 0.001), “Nonjudge” (F(2,18) = 5.51, P= 0.014) and “Nonreact” (F(2,18) = 5.88, P= 0.011), but not for the subscales “Describe” (F(2,18) = 2.51, P= 0.11) and “Act with Awareness” (F(2,18) = 2.51, P= 0.11). There was an increase in attending to or noticing internal and external stimuli (scale “Observe”) from pre- to posttreatment (F(1,9) = 24.44, P < 0.001) with no significant change from posttreatment to the follow-up (F(1,9) = 1.79, P= 0.21). From pre- to posttreatment, participants increasingly refrained from evaluating feelings and thoughts (scale “Nonjudge”; F(1,9) = 21.62, P < 0.001) with no significant change from posttreatment to follow-up (F(1,9) = 1.47, P= 0.26). They also reported an increase in nonreactivity to inner experiences from pre- to posttreatment (scale “Nonreact”; (F(1,9) = 13.63, P= 0.005) with a nonsignificant decrease from posttreatment to follow-up (F(1,9) = 1.87, P= 0.20).
Depression and Mania Symptoms (HAM-D and YMRS). The repeated measures ANOVA (ITT analysis) indicated a significant change in residual depressive symptoms (HAM-D; F(2,18) = 6.84, P= 0.006) but not in residual manic symptoms over time (YMRS; (F(3,18) = 1.94, P= 0.17). At the pretreatment assessment, participants exhibited mild-to-moderate depressive symptoms and low residual manic symptoms (see Table 1). HAM-D scores decreased from pretreatment to posttreatment (F(1,9) = 10.45, P= 0.01). The reincrease from posttreatment to follow-up (F(1,9) = 1.41, P= 0.27) was nonsignificant. Overall, the change in HAM-D scores corresponded to a large effect size both from pre- to posttreatment as well from pretreatment to follow-up (see Table 1). With respect to manic symptoms, there was no change in scores from pretreatment to posttreatment (see Table 1). There was a numeric increase in YMRS scores at the follow-up visit that corresponded to a medium effect size (see Table 1). This effect was driven by one participant, who experienced increased mood elevation at the follow-up visit.
Rumination (RSQ) and Worry (PSWQ). In the ITT sample, the repeated-measures ANOVA indicated significant changes in ruminative response styles (F(2,18) = 4.57, P= 0.025) with a decrease from pre- to posttreatment (F(1,9) = 10.34, P= 0.01) that did not reincrease significantly from posttreatment to follow-up (F(1,9) = 1.22, P= 0.30). Similarly, there was an overall change in the tendency to worry (F(2,14) = 14.88, P < 0.001), reflecting a decrease from pre- to posttreatment (F(1,8) = 15.97, P= 0.004) without a significant increase from posttreatment to follow-up (F(1,7) = 2.25, P= 0.18).
Emotion Regulation (ERS). There was an overall change in emotion-regulation abilities (F(2,18) = 4.30, P= 0.03; ITT analysis) corresponding to a linear increase in emotion-regulation abilities from pre to post to follow-up (F(1,9) = 8.62, P= 0.02).
Attention (ASRS). There was an overall change in attentional difficulties (F(2,16) = 4.69, P= 0.025; ITT analysis). Attentional difficulties (Attention subscale) decreased from pre- to posttreatment (F(1,8) = 20.27, P= 0.002) and did not significantly increase from posttreatment to follow-up (F(1,9) = 0.41, P= 0.54). There were no changes in symptoms of hyperactivity (Hyperactivity subscale: F(2,16) = 0.16, P= 0.86).
Psychological Well-being (PWBS), Positive Affect (CPAS), and Psychosocial Functioning (LIFE-RIFT). For the PWBS, there were significant changes in Environmental Mastery (F(2,18) = 9.26, P= 0.002), Positive Relations (F(2,18) = 4.06, P= 0.035), Purpose in Life (F(2,18) = 8.18, P= 0.003), and Self-acceptance (F(2,18) = 5.31, P= 0.015) but not for Personal Growth (F(2,18) = 0.54, P= 0.59) or Autonomy (F(2,18) = 0.29, P= 0.75). For Environmental Mastery, there was an increase from pre- to posttreatment (F(1,9) = 11.29, P= 0.008) but no change between posttreatment and follow-up (see Table 1; F(1,9) = 0.12; P= 0.74). Positive Relations linearly increased from pre- to posttreatment to follow-up (F(1,9) = 5.26, P= 0.047). There was an increase in Purpose in Life from pre- to posttreatment (F(1,9) = 17.55, P= 0.002) with no change from posttreatment to follow-up (see Table 1; F(1,9) = 0.92, P= 0.36). Self-acceptance increased from pre- to posttreatment (F(1,9) = 7.24, P= 0.025) with a nonsignificant decrease from posttreatment to follow-up (F(1,9) = 3.15, P= 0.11). For the CPAS, there was a trend toward a significant change in positive affect from pretreatment to posttreatment (F(2,18) = 3.09, P= 0.07). Self-reported positive affect increased from pre- to posttreatment (F(1,9) = 7.76, P= 0.02) and did not significantly decrease from posttreatment to follow-up (F(1,9) = 1.08, P= 0.33). For the LIFE-RIFT, there was a significant quadratic trend (F(1,9) = 12,20, P= 0.007) such that overall functioning improved from pre- to posttreatment (F(1,9) = 7.67, P= 0.02 and then decreased (nonsignificantly) from posttreatment to follow-up (F(1,9) = 0.80, P= 0.39; see Table 1).
Completer Analysis. The pattern of results obtained in the completer analysis resembled the results obtained in the ITT analysis. All P values remained significant (P < 0.05). Effect sizes resembled those obtained in the ITT analysis. Effect sizes remained largely unchanged if the analyses were repeated excluding participants with BP-II (n = 2), or excluding participants without anxiety disorders (n = 3), excluding participants with medical issues (n = 4), or excluding the two participants who changed medication dosages during the treatment phase of the study (n = 2).
Contrary to the traditional view of interepisode recovery, many individuals with bipolar disorder experience fluctuating mood symptoms, lack of well-being, and difficulties in daily functioning when they are not depressed or hypomanic/manic. This study explored whether a new version of adjunctive MBCT for bipolar disorder can increase mindfulness, lower residual mood symptoms, and increase attention, emotion-regulation abilities, positive affect, well-being, and functioning. Participants included in this study exhibited moderate residual depressive and varying degrees of residual manic symptoms. All of these participants had experienced a chronic course of bipolar disorder and exhibited common comorbid conditions including anxiety disorders (GAD, panic disorder, OCD, and PTSD) and history of substance abuse. Overall, the treatment was well tolerated. Although two participants dropped out before the start of treatment, the remaining participants attended a mean of 8.5 out of 12 sessions (72%) of all treatment sessions and 9 out of 10 participants were reached for follow-up. This is encouraging given the rather low attendance rates reported for some previous psychosocial treatment trials . Consistent with our hypothesis, we observed changes in central aspects of mindfulness including the ability to observe, being nonjudgmental, and less reactive to thoughts and feelings. Conversely, at posttreatment, participants exhibited reduced depressive and hypomanic/manic mood symptoms. The small reincrease in mood elevation at the follow-up assessment was driven by one participant who experienced hypomania at the time of the follow-up (and was treated for this). Participants also showed medium-to-large effect sizes in terms of decreased rumination, worry and reduced attentional difficulties, and increased emotion-regulation abilities, well-being and positive affect at the end of treatment. For the most part, however, these gains were not fully maintained. This suggests that booster sessions (either in group or individual-session format) revitalizing skills acquired in this MBCT treatment or continued MBCT maintenance treatment is warranted. Notably, emotion-regulation abilities and positive interpersonal relationships showed a linear improvement from pretreatment to follow-up, which may suggest that improved abilities to regulate emotions had a positive impact on participants’ interpersonal relationships.
Findings of decreased depression and anxiety are consistent with both previous trials of MBCT for remitted patients with bipolar disorder [38, 39]. Our study extends these findings that MBCT can be successfully implemented in nonremitted patients with bipolar disorder. Improved attention and well-being are also consistent with the findings of studies employing MBSR treatment (a treatment on which MBCT is largely based and from which it was developed) in various populations including patients suffering from anxiety [69, 70], substance abuse , eating disorders , chronic pain conditions [73, 74], or cancer . Consistent with our findings, studies on the effects of mindfulness-based interventions show increased mindfulness and psychological well-being , improved attention , improved emotion regulation , decreased rumination , and increased positive affect .
Overall, appropriate caution is warranted when interpreting results of open trials. In the absence of a randomized control group, it is unclear whether this treatment yielded any effects above and beyond those that could have been observed with either no treatment, generic supportive psychotherapy, or existing manualized adjunctive psychosocial protocols that have already been tested for bipolar disorder (e.g., IPSRT, family therapy, cognitive behavior therapy for medication adherence, depression or relapse prevention). Similarly, given this very small sample, it is not possible to generalize these findings to bipolar disorder as a larger cohort, and the ability to find meaningful differences is necessarily limited. For example, participants in this study were generally interested in participating in a study exploring the effects of mindfulness, which likely improved the attendance rates and effects in our study. Similarly, changes in questionnaire scores or clinical scales in the absence of a control condition may simply reflect that participants are aware of and respond to the expectations or demand characteristics of the treatment. Overall, the findings from this study warrant a replication and extension in a randomized controlled trial with a larger sample.
Conceptually, this treatment blends interventions already included in existing psychosocial treatments for bipolar disorder (e.g., mood monitoring; relapse prevention plans; problem solving) with a modified mindfulness-based approach. We included previously established treatment components because we consider them essential elements in the psychosocial treatment of bipolar disorder. The unique contribution of mindfulness skills may lie in its effects on rumination and emotion regulation. They may boost the effect of behavioral antimania strategies (e.g., reducing stimulation/activities) similar to the effects of applied relaxation (see Johnson & Fulford, 2009) . Additional benefits may lie in the improvement of attentional and cognitive functioning with continued practice. Finally, the emphasis on self-compassion and mindfulness toward pleasurable activities may provide an additional buffer against the recurrence of depressive symptoms (i.e., rumination, low motivation).
Clinically, it is our impression that combining mindful movement exercises with short mindfulness exercises was helpful for patients to gradually adopt a more mindful approach. Integrating problem solving into MBCT was also reportedly found helpful, such that therapists could assist patients in dealing with daily hassles and obstacles, which may have otherwise caused patients to drop out of treatment. Similarly, compared to existing MBCT or MBSR treatments, our treatment addressed more systematically how participants could implement mindfulness into their days, which may have been particularly helpful for patients with organizational difficulties. Finally, for modifications for future versions of this MBCT treatment one may consider to capitalize on the gradual increase in interpersonal functioning (Psychological Well-Being subscale Positive Relations) and involve spouses, caregivers, and family members as coaches.
In summary, results of this clinical trial suggest that it may be worthwhile to further investigate whether this version of MBCT for bipolar disorder may become a treatment option for patients with residual mood symptoms in the menu of already empirically supported approaches (e.g., family therapy, IPSRT, and CBT), especially for patients with a more chronic course of the illness.
This work was supported by a K-23 NIMH Career Award 1K23MH074895 to Thilo Deckersbach. Part of this research has been presented at the annual meeting of the World Congress for Cognitive and Behavior Therapies, Boston, 2010.
Conflict of Interest
The authors have no conflict of interest.