Project UPLIFT

Distance Delivery of Mindfulness-based Treatment for Depression: Project UPLIFTNancy J. Thompson, Ph.D., M.P.H.Elizabeth R. Walker, M.A.T., M.P.H.Rollins School of Public Health of Emory UniversityAshley Winning, M.P.H.Harvard School of Public Health

DisclosureWe have no actual or potential conflict of interest in relation to this presentation.Development of Project UPLIFT1Ashley Winning, M.P.H.Harvard School of Public HealthHarvard University

1This work was done at the Rollins School of Public Health of Emory University

Using Practice and Learning to Increase Favorable Thoughts

Using Practice is a reference to mindfulnessLearning to Increase Favorable Thoughts is a reference to Cognitive-Behavioral Therapy

The hands of the logo are designed to represent a lotus, but also the notion that we do the uplifting with our own hands.4Project UPLIFTWas designed for delivery of mindfulness-based cognitive therapy by telephone and InternetThe version of Project UPLIFT presented here was designed for people with epilepsyThe work we are presenting today was funded by the Centers for Disease Control and PreventionThe participants described all resided in the State of Georgia because of concerns surrounding the state-level licensing of mental health professionals

The Content

About Cognitive-Behavioral Therapy (CBT)Designed by Aaron Beck to address the unrealistic thinking and outcome expectations associated with depression. Uses verbal techniques to investigate the reasoning behind specific attitudes and assumptions. Client is taught to recognize, monitor, and record negative thoughts on a daily record. Beck recommends first including behavioral techniques, like assigning activities to help structure the depressed individual who may have trouble getting startedusing pleasurable activities for reinforcement, breaking tasks into simple steps, providing assertiveness training, guidance in role-playing and mental rehearsal.

A Recent AdditionMindfulnessCBT focuses on changing thought content while mindfulness changes relationship to the thoughtshelps to see them as passing events that do not necessarily represent a state of reality.Mindfulness is especially important in preventing relapse, which often occurs with depression. We used Jon Kabat-Zinns definition of paying attention in a particular way: on purpose, in the present moment, and non-judgmentally.

UPLIFT was guided by Mindfulness-based Cognitive Therapy for DepressionDeveloped by Segal, Williams, and Teasdale

MBCT SessionsUPLIFT Sessions1. Automatic Pilot1. Monitoring Thoughts2. Dealing with Barriers2. Challenging and Changing Thoughts3. Mindfulness of the Breath3. Coping and Relaxing4. Staying Present4. Attention and Mindfulness5. Allowing/Letting Be5. The Present as a Calm Place6. Thoughts are not Facts6. Thoughts as Changeable and Impermanent7. How can I best take care of myself?7. Pleasure and Reinforcement8. Using what has been learned in the future8. Relapse Action Plans

Because we were using UPLIFT to treat people who had limited access to treatment, CBT skills were emphasized in our first three sessions. This is because CBT has been shown to be effective as a depression treatment, while Mindfulness-based Cognitive Therapy had been assessed for relapse prevention.

9Telephone VersionTimeActivityDescription10 minutesCheck-in The group will report on their experiences with Modifying & Relaxation and help each other with any problems.10 minutesTeaching Group will learn about the concepts of Mindfulness & the importance of paying attention.10 minutesGroup Exercise The Pebble Exercise is an activity in mindful attention. The group will practice what they learned during the teaching portion of the session.10 minutesDiscussionDiscussion of the Pebble Exercise/describe pebble to group.15 minutesSkill-buildingw/ discussion Mindfulness of a routine activity: Walking Meditation. The Walking Meditation is meditation in motion; it allows us to practice mindfulness in the most routine of activities.5 minutesReview & Homework Homework: Monitoring with Modification and Practicing Mindfulness of Routine Activities 3 times during the week.Session Four:Attention and Mindfulness

Web Version

Session One:Monitoring Thoughts

Activities were AdaptedUPLIFT ActivityMBCT ActivityThe What-ifs of Epilepsy (S1)---ARMed Against the Blues (S2)---Body Scan and Progressive Muscle Relaxation (S3)Body Scan (S1)Pebble Exercise (4)Raisin Exercise (S1)Guided Meditation on Pleasure (S7) Pleasant Events Calendar (Session 2) For depression treatment For distance delivery For people with epilepsy

As previously mentioned, we emphasized CBT skills in our first three sessions, so there was no equivalent in Mindfulness-based Cognitive Therapy for Depression. Progressive Muscle Relaxation was added to the Body Scan because people with epilepsy have an elevated risk of chronic pain. The pebble exercise was developed to replace the raisin exercise because of the difficulty involved in distributing raisins at a distance.The Guided Meditation on Pleasure replaced the Pleasant Events Calendar because people with epilepsy may be limited in their ability to attend events. 12The Structure

Group Delivery at a DistanceUPLIFT was delivered by Web and telephone to people in groups of 6-7Group Delivery was important for support surrounding EpilepsyThe Web platform used was BlackboardLaptops and Internet access were provided for people assigned to the Web condition who did not have computers or Web access

Group FacilitationGroups were co-facilitatedOne facilitator was a graduate student in Public Health to ensure the integrity of the deliveryThe other facilitator was a person with epilepsy to build capacity in the epilepsy communityA licensed psychologist supervised the facilitators and provided back-upListened to telephone tapesMonitored Web discussions

Potential BenefitsCost-effectiveCan reduce access problems, reducing health disparities mobility limitedruralAllows group delivery even for rare conditionsPotential for anonymity and avoidance of stigmaTeaches skills to prevent relapse

Formative and Process Evaluations of Project UPLIFTElizabeth Walker, M.P.H., M.A.T.Rollins School of Public HealthEmory University

Evaluation Purposes:Determine the acceptability of Project UPLIFT

Assess the complexities anticipated and encountered when participating

Evaluate the overall response to the program components

ParticipantsFormative Evaluationn=9Focus groups (n=3)

Process Evaluationn=38Survey following participation

Tertiary epilepsy clinic

Focus Groupn=9Pilot Participantsn=38Age (years), Mean (SD)33.6 (10.69)35.1 (10.98)Depression score, Mean (SD) Range22.4 (5.59)14-2827.2 (7.25)13-38Gender, n (%)Female7 (77.8)30 (78.9)Race, n (%)White Black7 (77.8)2 (22.2)29 (76.3)9 (23.7)Marital Status, n (%)MarriedSingleSeparated/Divorced/Widowed 15 (39.5)17 (44.7)6 (15.7)Employment Status, n (%)Full-timePart-timeStudentNot working or retired 11 (28.9)5 (13.2)3 (7.9)19 (50.0)Seizures in the past 4 weeks, n (%)Yes24 (63.2)Type of seizure usually experiencedGeneralPartialOtherUnknown26 (63.2)11(29.0)2 (5.3)1 (2.6)Severity of recent seizures (in past 4 weeks)Very MildMildSevereVery Severe5 (20.8)8 (33.3)7 (29.2)4 (16.7)Eligibility criteria: (1) have been diagnosed with epilepsy for at least 1 year; (2) have some depressive symptoms (score >13 on the Center for Epidemiological Studies Depression scale ) but not severe depression (score