Predicting which intervention works better for whom: Moderators of treatment effect of Mindfulness-Based Cognitive Therapy and Positive Psychology Intervention in patients with bipolar disorder.

BACKGROUND: This study aimed to identify moderators of treatment effect (i.e. depressive symptoms and well-being) of Mindfulness-Based Cognitive Therapy (MBCT) and Positive Psychology Intervention (PPI) in patients with bipolar disorder. METHODS: Data were drawn from two multicenter randomized controlled trials investigating effectiveness of MBCT vs treatment as usual (TAU; n = 144) and PPI vs TAU (n = 97) in bipolar disorder. Outcomes were assessed at baseline, posttreatment, and 12 months after baseline. Data were analyzed using separate linear regression models, comparing the pooled MBCT or PPI outcomes to TAU, and comparing MBCT to PPI. RESULTS: The exploratory analyses not corrected for multiple comparisons showed a number of variables that were associated with stronger response to the interventions, including higher baseline anxiety, lower well-being, and lower levels of self-focused positive rumination, well-being, and self-compassion, and variables associated with a stronger response to either MBCT (higher levels of depression and anxiety and being married) or PPI (being male). After correcting for multiple testing, depressive symptoms appeared to be the most robust variable associated with better response to MBCT than PPI. LIMITATIONS: The RCTs handled slightly different enrollment criteria and outcome measures. CONCLUSIONS: The most robust finding is that patients with more severe symptomatology seem to benefit more from MBCT than PPI. CLINICAL IMPLICATIONS: This is a first step to improve personalized assignment of third-wave CBT interventions for patients with bipolar disorder. However, before definite treatment assignment criteria can be formulated and implemented in clinical practice, these findings should be replicated.

Trial-based economic evaluation of mindfulness-based cognitive therapy compared to treatment as usual for bipolar disorder.

OBJECTIVE: Aim of this study was to assess the cost-effectiveness and cost-utility of mindfulness-based cognitive therapy (MBCT) and treatment as usual (TAU) compared to TAU alone in adults with Bipolar disorder (BD). METHODS: An economic evaluation with a time horizon of 15 months was conducted from a societal perspective. Outcomes were expressed in costs per quality adjusted life years (QALYs) and costs per responder using the inventory of depressive symptomatology clinician rating score. RESULTS: People with BD (N = 144) were included in this study. From a societal perspective, the difference of total costs between MBCT + TAU and TAU was €615, with lower costs in the MBCT + TAU group. Only healthcare costs differed significantly between the two groups. A small difference in QALYs in favor of MBCT + TAU was found combined with lower costs (-€836; baseline adjusted) for MBCT + TAU compared to TAU, resulting in a dominant incremental cost-utility ratio. The probability that the MBCT + TAU was cost-effective was 65%. All sensitivity analyses attested to the robustness of the base case analyses. CONCLUSION: Concludingly, MBCT + TAU seems to be cost-effective compared to TAU alone, indicated by a small or neglectable difference in effect, in favor of MBCT + TAU, while resulting in lower costs.

Mindfulness-based cognitive therapy for chronic noncancer pain and prescription opioid use disorder: A qualitative pilot study of its feasibility and the perceived process of change.

BACKGROUND: Mindfulness-based interventions have a positive impact on pain, craving, and well-being in both patients with chronic pain and those with opioid use disorder (OUD). Although data are limited, mindfulness-based cognitive therapy (MBCT) might be a promising treatment for patients with chronic noncancer pain combined with OUD. The aim of this qualitative study was to explore the feasibility and process of change during MBCT in this particular population. METHODS: In this qualitative pilot study, 21 patients who were hospitalized for rotation to buprenorphine/naloxone as agonist treatment for chronic pain and OUD were offered MBCT. Semistructured interviews were conducted to explore experienced barriers and facilitators to MBCT. Patients who participated in MBCT were also interviewed on their perceived process of change. RESULTS: Of 21 patients invited to participate in MBCT, 12 initially expressed interest but only four eventually participated in MBCT. The timing of the intervention, group format, somatic complaints, and practical difficulties were identified as the main barriers to participation. Facilitating factors included having a positive attribution toward MBCT, an intrinsic motivation to change, and practical support. The four MBCT participants mentioned several important mechanisms of change, including reduction of opioid craving and improved coping with pain. CONCLUSIONS: MBCT offered in the current study was not feasible for the majority of patients with pain and OUD. Changing the timing of MBCT by providing it at an earlier stage of the treatment and offering MBCT in an online format may facilitate participation.

Development and validation of a Manic Thought Inventory.

OBJECTIVE: This article describes the development and psychometric evaluation of the Manic Thought Inventory (MTI), a patient-driven self-report inventory to assess the presence of typical (hypo)manic cognitions. METHODS: The initial item pool was generated by patients with bipolar disorder (BD) type I and assessed for suitability by five psychiatrists specialized in treating BD. Study 1 describes the item analysis and exploratory factor structure of the MTI in a sample of 251 patients with BD type I. In study 2, the factor structure was validated with confirmatory factor analysis, and convergent and divergent validity were assessed in an independent sample of 201 patients with BD type I. RESULTS: Study 1 resulted in a 50-item version of the MTI measuring one underlying factor. Study 2 confirmed the essentially unidimensional underlying construct in a 47-item version of the MTI. Internal consistency of the 47-item version of the MTI was excellent (α = 0.97). The MTI showed moderate to large positive correlations with other measures related to mania. It was not correlated with measures of depression. CONCLUSION: The MTI showed good psychometric properties and can be useful in research and clinical practice. Patients could use the MTI to select items that they recognize as being characteristic of their (hypo)manic episodes. By monitoring and challenging these items, the MTI could augment current psychological interventions for BD.

Mindfulness based cognitive therapy (MBCT) reduces depression-related self-referential processing in patients with bipolar disorder: an exploratory task-based study.

Negative self-referential processing has fruitfully been studied in unipolar depressed patients, but remarkably less in patients with bipolar disorder (BD). This exploratory study examines the relation between task-based self-referential processing and depressive symptoms in BD and their possible importance to the working mechanism of mindfulness-based cognitive therapy (MBCT) for BD. The study population consisted of a subsample of patients with BD (n = 49) participating in an RCT of MBCT for BD, who were assigned to MBCT + TAU (n = 23) or treatment as usual (TAU) (n = 26). Patients performed the self-referential encoding task (SRET), which measures (1) positive and (2) negative attributions to oneself as well as (3) negative self-referential memory bias, before and after MBCT + TAU or TAU. At baseline, all three SRET measures were significantly related to depressive symptoms in patients with BD. Moreover, repeated measures analyses of variance revealed that negative self-referential memory bias diminished over time in the MBCT + TAU group, compared with the TAU group. Given the preliminary nature of our findings, future research should explore the possibly mediating role of reducing negative self-referential memory bias in preventing and treating depressive symptoms in BD through MBCT.

The effect of mindfulness-based cognitive therapy on rumination and a task-based measure of intrusive thoughts in patients with bipolar disorder.

BACKGROUND: Preliminary evidence suggests that Mindfulness-Based Cognitive Therapy (MBCT) is a promising treatment for bipolar disorder (BD). A proposed working mechanism of MBCT in attenuating depressive symptoms is reducing depressive rumination. The primary aim of this study was to investigate the effect of MBCT on self-reported trait depressive rumination and an experimental state measure of negative intrusive thoughts in BD patients. Exploratively, we investigated the effect of MBCT on positive rumination and positive intrusive thoughts. METHODS: The study population consisted of a subsample of bipolar type I or II patients participating in a multicenter randomized controlled trial comparing MBCT + treatment as usual (TAU) (N = 25) to TAU alone (N = 24). Trait depressive rumination (RRS brooding subscale) and intrusive thoughts (breathing focus task (BFT)) were assessed at baseline (full subsample) and post-treatment (MBCT + TAU; n = 15, TAU; n = 15). During the BFT, participants were asked to report negative, positive and neutral intrusive thoughts while focusing on their breathing. RESULTS: Compared to TAU alone, MBCT + TAU resulted in a significant pre- to post-treatment reduction of trait depressive rumination (R2 = .16, F(1, 27) = 5.15, p = 0.031; medium effect size (f2 = 0.19)) and negative intrusive thoughts on the BFT (R2 = .15, F(1, 28) = 4.88, p = 0.036; medium effect size (f2 = 0.17)). MBCT did not significantly change positive rumination or positive intrusive thoughts. CONCLUSIONS: MBCT might be a helpful additional intervention to reduce depressive rumination in BD which might reduce risk of depressive relapse or recurrence. Considering the preliminary nature of our findings, future research should replicate our findings and explore whether this reduction in rumination following MBCT indeed mediates a reduction in depressive symptoms and relapse or recurrence in BD.

Adverse or therapeutic? A mixed-methods study investigating adverse effects of Mindfulness-Based Cognitive Therapy in bipolar disorder.

BACKGROUND: Mindfulness-Based Interventions (MBIs) are widely used in clinical and non-clinical populations, but little attention has been given to potential adverse effects (AEs). AIMS: This study aimed to gain insight in the prevalence and course of AEs during Mindfulness-Based Cognitive Therapy (MBCT) for patients with bipolar disorder (BD). METHOD: The current mixed-methods study was conducted as part of a RCT on (cost-) effectiveness of MBCT in 144 patients with BD (Trial registered on 25th of April 2018, ClinicalTrials.gov, NCT03507647). During MBCT, occurrence of AEs was monitored prospectively, systematically, and actively (n = 72). Patients who reported AEs were invited for semi-structured interviews after completing MBCT (n = 29). Interviews were analysed with directed content analysis, using an existing framework by Lindahl et al. RESULTS: AEs were reported by 29 patients, in seven of whom the experiences could not be attributed to MBCT during the interview. AEs were reported most frequently up to week 3 and declined afterwards. Baseline anxiety appeared to be a risk factor for developing AEs. Seven existing domains of AEs were observed: cognitive, perceptual, affective, somatic, conative, sense of self, and social. Influencing factors were subdivided into predisposing, precipitating, perpetuating, and mitigating factors. With hindsight, more than half of patients considered the reported AEs as therapeutic rather than harmful. CONCLUSIONS: Although the occurrence of AEs in MBCT for patients with BD is not rare, even in this population with severe mental illness they were not serious or had lasting bad effects. In fact, most of them were seen by the patients as being part of a therapeutic process, although some patients only experienced AEs as negative.

The feasibility of mindfulness-based cognitive therapy for people with bipolar disorder: a qualitative study.

BACKGROUND: Mindfulness- Based Cognitive Therapy (MBCT) could be a promising psychosocial intervention for people with bipolar disorder (BD). However, little is known about the feasibility of MBCT for people with BD. In this study we explore the facilitators and barriers people with BD experience of an adapted MBCT program. METHOD: This qualitative study is part of a large, multicenter randomized controlled trial on MBCT for BD (trial registration number: NCT03507647). The present study included 16 participants with BD who participated in an 8-week adapted MBCT program. Semi- structured interviews exploring the feasibility, with a particular focus on the bipolar symptoms, were recorded verbatim, transcribed and analyzed. For reasons of triangulation, teachers were interviewed as well. RESULTS: Participants reported different barriers and facilitators of MBCT, both generally as well as with regard to their bipolar disorder. Four key themes arose: the training itself, psychosocial factors, personal characteristics and the bipolar disorder. Themes were further divided in subthemes. CONCLUSION: The adapted MBCT program seemed to be feasible for people with BD. Depressive symptoms often acted as a barrier for participating in MBCT, suggesting that participants might need additional support when depressed. Manic symptoms could act both as a barrier and facilitator, suggesting that the occurrence of (hypo)mania does not necessarily have to be an exclusion criterion for participation. Further clinical and research implications are suggested. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03507647. Registered 25th of April 2018, https://clinicaltrials.gov/ct2/show/NCT03507647 .

Validation of prospective portion size and latency to eat as measures of reactivity to snack foods.

In experimental studies that investigate reactivity to the sight and smell of highly palatable snack foods, ad libitum food intake is commonly used as a behavioural outcome measure. However, this measure has several drawbacks. The current study investigated two intake-related measures not yet validated for food cue exposure research involving common snack foods: prospective portion size and latency to eat. We aimed to validate these measures by assessing prospective portion size and eating latencies in female undergraduate students who either underwent snack food exposure or a control exposure. Furthermore, we correlated prospective portion size and latency to eat with commonly used measures of food cue reactivity, i.e., self-reported desire to eat, salivation, and ad libitum food intake. Results showed increases in prospective portion size after food cue exposure but not after control exposure. Latency to eat did not differ between the two conditions. Prospective portion size correlated positively with desire to eat and food intake, and negatively with latency to eat. Latency to eat was also negatively correlated with desire to eat and food intake. It is concluded that the current study provides initial evidence for the prospective portion size task as a valid measure of reactivity to snack foods in a Dutch female and mostly healthy weight student population.