Applying Mindfulness-Based Cognitive Therapy to Treatment
May 24, 2020This program is a University of California television presentation. Your support makes UV programming possible. Contribute online to UV. tv/ support check out our original uctv prime youtube channel at youtube.com/uctv prime subscribe today to receive new shows every week. I would like to thank you all for coming on a rainy night, so you are all brave souls for doing so. is here so congratulations, I'm a professor here and the director of the UCSF Depression Center and also the principal investigator of several studies that we're going to talk about a little bit, but particularly about practical alternatives to cure the study of depression that we call To abreviate. the study pathway and those are that and another study that also involves depression and meditation and neuroimaging they are actively recruiting and as you learn more about this if you're interested we have some packets of information and if you have questions uh feel free to call the numbers there and we have one of our research assistants, Natalie, who is here so you can also box her in at the end so thanks again for coming.
I'm going to talk about
mindfulness
in general terms and also how we apply it specifically in relation to treating depression and there's been sort of a resurgence of interest in usingmindfulness
meditation as an approach to helping people. with depression in the last five to 10 years and I think it's leading to some very interesting and potentially very useful applications for a large number of people. How many of you have a mindfulness practice? Maybe if they could prove that it's okay, then quite a few mindfulness basically there is. Different definitions, probably the most used is that of John Kabid Zin, which means paying attention in a particular way on purpose in the present moment and without judging, so mindfulness means focusing attention on this present moment and letting go of the future letting go of the past and simply becoming aware of whatever is present in this moment this is another definition of it is a non-evaluative awareness of one's inner and outer environment non-evaluative just like non-judgment is oh I notice that I have uh pain uh from my arm resting against the side of the chair or something, I'm noticing it and not saying this is good or bad, but just being aware and observing it, so mindfulness is bringing that attention without prejudices to something with intention.It has been used for a wide variety of different conditions. John Kev Zen really brought it to the public consciousness with his mindfulness-
based
stress reduction efforts at the University of Massachusetts about 25 to 30 years ago, but it's been applied to other conditions, pain, psoriasis. Eating disorders fibromyalgia pain cancer uh the osher center here is using it for parenting, teaching people how to be more mindful in their parenting or even as an alternative to dealing with labor pains and then on the psychiatric side , has been used to treat anxiety. people with depression with borderline personality disorder who have difficulty regulating emotions due to addictions and even bipolar disorder some of these are more experimental, they have not been widely developed but they are all moving forward and the most developed area is the one I am leaving to focus on tonight and I will give you some examples and that iscognitive
therapy
based
on mindfulness because that is the main intervention of our practice alternatives to heal.Sorry, I guess I hope I'm virus free. uh, uh, mindfulness-based
cognitive
therapy
is our primary intervention to teach people mindfulness approaches to depression over an eight-week course. uh just to say a little bit about depression, you know, people used to try to decide what kind of depression. a person had this is this or maybe that or somewhere on the depression highway what we know now is uh it doesn't really matter that much how the person got there if they have depressive symptoms symptoms that are these if they have these, they deserve to be treated , so it's not appropriate to say "well, of course, this person is depressed because they just got a cancer diagnosis or because they had a breakup or this or that, if someone has these symptoms that last two weeks or more." That's significant evidence of depression and they deserve to be treated, otherwise it would be like someone walking into the emergency room after having a major artery severed in a knife fight and saying, "Well, of course, they're in shock." , But we".We are not going to treat them. If they have depressive symptoms, they need to be treated and these are the hallmarks of what we call DSM 4. If you have five or more of these symptoms for two weeks or more, you're basically talking about someone. have clinical depression or what we call major depression, which is the same terminology, so what do we do with our program? Mindfulness-based cognitive therapy is a mix of some aspects of cognitive therapy and many of you are probably familiar in one way or another with cognitive behavioral therapy or cognitive therapy and it combines some elements of that with a very strong dose of mindfulness meditation and it's primarily mindfulness meditation that is the heart of the program and it's eight sessions a week and it's from two to two and a quarter. hours long and, on the other hand, people during the other six days of the week, when they do not attend class, carry out a daily meditation practice at home and lead groups of six to 14 people and consists of different types of exercises mindfulness, things like formal practice, a sitting meditation, paying attention to the breath, a body scan, paying attention to different sensations in the body, mindful stretching or hatha yoga, and then a variety of other mindfulness approaches to those you attend. to different things and then there are informal practices where people become more familiar with, for example, mindful eating or doing everyday activities, but in a more mindful way, and we also teach very portable techniques, like a breathing space three minutes.
So, at the end of this, The person has become familiar with a variety of techniques and not all will be the same in what they will be carried out. Some people may like body scanning and others may hate it. Some people may like this item or this item and that's perfectly fine. We know that it varies from person to person. We're trying to expose them to a popere of different options so that when they're done they have one practice that they can walk away with and start
applying
for the rest. your life, this is not a technique in which you take the course and finish, what we are doing is offering the course and at the end of eight weeks the person is prepared to continue with their life incorporating a practice in their daily life here I am in the beach doing a formal breathing practice, but here's another one, this is a young man showing the portability of using mindfulness, uh, in a variety of settings, so let's give this a little better flavor, I thought. uh we would do an exercise so that at least we all have a little bit of common ground here for mindfulness, so if you're up for this, sit in your seat and get into a comfortable position with both feet. planted on the ground and if you feel like it you can close your eyes, if you prefer you can just gently look at the seat in front of you and what I would like you to do is focus on the breath coming in and out through the nostrils just paying attention to the breathing, focusing your attention on the breath, breathing in and out if the mind wanders as you do this, gently and kindly bring your attention back to the breath now as you continue to focus on the breath.I would like you to add a second element to this and that is to start counting each breath and start counting it from zero and count up to 10 breaths if your mind wanders like minds do on the way to 10 just go back to zero and start counting again if you get to 10 go back down to zero and start doing it again and when you're ready you can open your eyes and bring your attention back to the room, okay? Would anyone like to say what that is? The experience was for you what you observed, you are breathing more slowly, okay, thanks to everyone else, you relax, you fall asleep, awareness increases, so did you go back to zero and start again?
Excellent, very good, did anyone, did anyone notice that their mind was wandering? It was that surprising. Have you noticed how your mind tends to wander sometimes until you enter a state of stillness? You don't really pay attention to it and that's one of the things that we're interested in in our work of
applying
mindfulness is that people often walk around on autopilot uh not paying attention because they're so preoccupied with the things that come to mind. mind uh Sylvia Boury talks about our minds as popcorn of thoughts that simply appear and if someone has problems with anxiety or depression many of those thoughts that arise are depressogenic or anxiogenic and produce depression, so the thoughts can be of a pending catastrophe or a past catastrophe because anxiety tends to be in many ways future-oriented and depression future-oriented in the sense that some disaster is going to happen, while depression tends to be past-oriented because the person feels as if Some disaster would have already happened to them, so with mindfulness you are helping the person focus on the present moment and give them a release.Focusing on the future or the past and just concentrating on the present moment, but I think as you can see in this exercise, it is very common for these thoughts to appear in our mind without us asking, it is completely normal and it does not matter if you are the most advanced meditator or not. This is what happens, many people have the misconception that meditation means you focus your attention and lack attention on something and then it doesn't change, but actually that is incorrect. What happens with meditation is that you focus your attention and then your mind wanders and meditation catches on.
Ah, my mind just wanders. I wonder what I'm having for dinner tonight or I had this interaction with this person before that irritated me or what I have to do tomorrow or whatever the case may be. be and our minds do it all the time or I feel this sensation that bothers me or I feel itchy, uh, so those thoughts occur in depression, what happens is that they are often biased towards the negative, so the person has thoughts like uh, uh, uh, this. is going to be a disaster or in this case maybe everyone in the audience is going to fall asleep on me or something, so what are we helping people to acquire the skill of focusing on their present moment and being able to let go? go a thought and return attention and that is the heart of what we are talking about with mindfulness.
Now I'm going to say a little bit about these studies, which is the one where we studied path D. We are taking people who have
treatment
-resistant depression and, therefore, people who have not fully recovered with two or more trials of antidepressants and Unfortunately this is not uncommon if someone has major depression and treats it with an antidepressant to the max. dose, only a third of them will fully recover with that initialtreatment
, a second trial with antidepressants must be performed so that 50% of them recover completely, which means that after two trials with antidepressants only 50% recover and our concern was to try to help these other people fully recover, so we are studying people who have had two or more trials of antidepressants and want to try this approach to fully recover and we will divide them into two groups, one receives cognitive therapy based on mindfulness. in addition to your medication management or a health improvement program that consists of physical activity, physical exercise, music therapy and nutritional education from a dietician, so they both receive eight weeks of classes, but they are completely different, one focuses on mindfulness meditation and the other focuses on improving health. focused and we're going to see if there's a difference in the results and what that difference looks like by seeing how if people can recover more effectively using one of these approaches, these are people, just, this is from our current research, we've actually , we've enrolled about a hundred people so far, but if you take a look at this, people's episode length is 91 months and they've suffered from depression for almost 30 years and this is essentially similar, uh, division, uh, in both this is one is blinded so we don't know that one is getting mbct and the other is getting the health improvement that's why it's a condition b or a because they are blinded until the end of the trial but they are both so you see, When people suffer from depression, it tends to be a recurring illness, so it is very important to try to get them to a full recovery, giving them the best chance of not having depression again in the future.We're adding to this and I'm in theIn the second half of today's talk we're going to show you some of the interesting, I think quite exciting, findings about the actual brain changes that occur with depression and with mindfulness meditation to some extent, because we've added a second component to the study. . where we are getting fmri uh before and after mindfulness based cognitive therapy and after health improvement so we are looking at your brain function before and after and fmri is similar to an mri but if you take a mri of a person if you take an mri and look at it, if you had one up here you wouldn't be able to tell if it was on a living or dead individual, it's a It's a structural image, basically, fmri means functional, it actually shows how the brain works second by second, so it shows which areas of the brain light up or don't light up in response to stimuli, so it's a much more dynamic picture of how the brain actually works, we are doing a second study for people who are not taking any medication or psychotherapy.
This is the neuroimaging and meditation study of depression and is mindfulness-based cognitive therapy as a standalone. treatment and again we are looking at people before and after with fmri and comparing them to how much these people and I will show you some of the images of this area to what extent these people return to seeing themselves as healthy control roles and how much their brain abnormalities that are present before treatment they change with mindfulness-based cognitive therapy. Let's talk a little bit about how mindfulness actually works to help people with depression and I think I've alluded to some of the things that are already here.
One is the focus on the here and now in some ways depression and anxiety can be considered time-based illnesses where the person focuses so much on the future and disasters or focuses on the past that they are not in the present moment. I mean, it's kind of like, I think we've all had the experience of going to a conference, maybe a concert or whatever the case may be and then you forget about well, you know I did something that I should have done? Did I mail that letter or, you know, lock that door or something that stays in our mind keeping us out of the present moment and being able to enjoy the present activity that we're attending to, so mindfulness helps? teach people to be able to put aside those orientations and become aware of what is happening right at this moment.
In fact, mindfulness-based cognitive therapy was originally called selective attention training because it trains people to focus very precisely and this has important ramifications both psychologically and also in terms of some of the brain effects that we will see. A little further down the line, mindfulness also helps people stop ruminating. Ruminating is a condition in which one continues to think about a situation and repeat it over and over again. mind, you can really reflect on ruminating. I mean, when I started reading about ruminating. I mean, you know you could really go crazy. I mean, you know there's rumination, there's rumination, there's melancholy, you know, there's all kinds of things you can get into, uh, meditate on. is the bad one, but it turns out that teaching people mindfulness skills in eight weeks decreases rumination, rumination is a factor in depression, which is why many people with depression ruminate, for example, a young woman who broke up a relationship continues reflecting on what I did. wrong, what should she have said?
That you know? Why did this happened? Why did he leave me and keep repeating it over and over again? That's not solving problems. Problem solving leads to a solution. Ruminating leads to worse depression and that's a way of proving what you're doing. If you ask someone who's reflecting what you think you're doing, what happens when you're reflecting? Well, they think I'm trying to prevent it from happening again or I'm trying to figure out what went wrong, how do you feel afterwards? You could just do a brief study, reflect for a short period of time, and see how you feel.
They generally feel worse, so you are helping the person disengage from rumination. to say, okay, what we do in mindfulness is something like this, okay, focus on the breath and then notice. Ah, I just had this thought about that breakup. I just had that thought, but I can let that thought go and bring attention back, so it's really radical. different to other types of psychotherapy that try to explore and look at things in a more traditional psychotherapeutic way, this does not mean that it focuses more on attention, as you will see, I am going to show you the differences what mindfulness teaches is basically a greater Decentering, we call it when the person begins to distance himself a little from the thoughts and feelings, so when something happens, as if he has the thought that something bad is going to happen, it is typical of the person.
People with a depressed or anxious type of state tend to believe what they say: "Oh, this disaster is really going to happen now." If any of us believe that a disaster is going to happen, why wouldn't he feel anxious or depressed about it? The trick is that the thought is not a fact, it is just one of those popcorn thoughts that occurred in your mind and, in depression for example, you tend to hold on to it and believe it as if it were true and mindful. You learn to be able to say ah. There is a thought, but I can let it go.
I don't have to hold on to it and believe it, and it also helps that mindfulness also helps the individual become more compassionate with others, but very importantly with themselves, so that they become kinder. with themselves, how does this happen? Well, some of that is you get a glimpse of it, you know, when we did that exercise and I said, if you notice your mind wandering or when you notice your mind wandering, you just notice it and you don't say, Oh my gosh. Damn, what the hell is wrong with you? You know you don't get depressed, you say, ah, my mind wanders and I bring the attention back so that you can be kinder and gentler and you can forgive yourself for things through this technique, so it's basically teaching people to see thoughts and feelings as mental events and not as facts.
Here's another example of this, let's do this as a group, so if you imagine this, you're walking down the street and it's a nice day. It's not rainy and you see someone you know across the street and you wave to them and they don't wave back, they just keep walking, what do you think or feel in that situation? busy, right?, they didn't have their glasses on, they didn't see, they didn't see me, okay, what's their problem? so any other feelings, those are some good thoughts, they suck, well, well, what was that shund?, yeah, okay, so there's a variety of things and we actually do this in the group and you'll see, I mean, We only had 10 people who gave different ideas or feelings about the situation, no one really knows what the fact was.
I didn't say whether this guy or this other person. I saw you or I didn't see you or you didn't have glasses or I didn't, we all have our own ideas about it, we don't really know, but if you stick to a certain thing, say well, I know this person rejected me, then it generates certain feelings, but when we did this in a group, for example, a classmate said yes, that happened to me. I never spoke to that person again, you know, because I know he was avoiding me, you know, and so on until the end of eight. weeks, you said boy, that was ridiculous, I didn't know anything about what was going on and it could have been any of these other possibilities, so instead of holding on to this thought like, oh, this is a fact, it's just a thought, is one of these. popcorn thoughts that occur in our minds and one thing that I have seen repeatedly and this could be I don't know what your opinion is on this, but our minds are not always our best friends, you know?
Does that seem strange to you? I know that in many ways, our minds are like bad friends. You know you don't want to go there without a friend by your side, but our minds, especially if you're prone to depression or anxiety, tend to have these popcorn thoughts. that are very negative so they come and say yeah look uh you know this just happened uh you know this bad thing just happened and it's because of your weakness or failure or whatever and these uh uh these thoughts that arise from our mind is really like he was a bad friend, not even necessarily a friend, someone.
I was doing this. This came to mind when I was actually meditating once and my mind wandered and I was thinking about this interaction at work. with someone and I was a little agitated about it and trying to get my mind back and this was happening and then I realized that these thoughts that I was having it sounded like it actually was, it sounded like it was someone I knew and I didn't No I like it and I said why am I listening to this? You know, it's like if someone you don't like says you're ugly, you know, or something else, you take it very differently than if a friend of yours did it.
We don't often think that our mind is not our friend, but in many cases our mind is not our friend and I think that deserves attention in these states of anxiety and depression, and this is what we sometimes use. the term decentering or what's called metacognition because it goes beyond cognitive therapy in a sense, we don't pay attention to the content of the thoughts, we pay attention to the thought processes and that's how it really differs from other therapies and if you can Recognizing this is very liberating because you realize that these thoughts are not actually facts, they are simply something that is arising and if you can let them go, it is much freer for you, it allows you to be in a position to respond skillfully and not just react as my friend Paul Emman described.
Mindfulness tends to give you a bigger gap between the spark and the flame so that you have a chance instead of saying oh, I'm mad at this guy for not waving back and this. either that or I'm depressed by this saying, well wait, there are other possibilities that could have happened like the 10 we just heard, which is a wide variety of things, so this is how mindfulness-based cognitive therapy is difference from the traditional one. Cognitive Behavioral Therapy CBT In cognitive behavioral therapy the person can say something and, by the way, as in depression, all the main negative cognitions have been catalogued.
We give people in our class a top 30 list, it's like Letterman's top 30, and then we ask people to check it out. which ones apply to them because it's different for every person, but everyone is really known like it's a rotten person. I feel like a failure. I'm a failure. I will never be successful, blah, blah, blah, blah, blah, and so on. The person says I'm a bad person. Well, based on mindfulness. Well, let's go with this for a moment. They say I'm a bad person. So in cognitive therapy, what happens is you attend to that and try to help the person see it. a little bit different you can have them challenge you and say well I'm a bad person, well what's the evidence in that stew that you're a bad person?
Well, you know, I stepped on an ant before I came in here, uh and or I didn't I pushed clothes in the elevator when someone was trying to uh I was running uh you know well, is there any evidence that you're a good person? Well, I helped this person cross the street or this, so it's a more balanced thought. I would be bad in many ways in terms of the elevator, but in some ways I am a good person, so you are helping the person to respond and change the content of the thought, that is what cognitive behavioral therapy in mindfulness does when the person says.
I am a bad person what you are doing is saying that you are thinking that you are a bad person now that we have lost focus I am having the thought that I am a bad person now what do you want to do with that? We're not saying to change that because one of the challenges in doing cognitive therapy and I did cognitive therapy for a long time and ran cognitive therapy groups, you find someone who's been depressed for a long time and they remember those numbers from previous people. with depression you can be depressed for a long time if you say what is the evidence that you are not a bad person or that you are a bad person and you say you want evidence.
I have a social basket of books full of evidence for you because I've been depressed for so many years they've been accumulating all this negative evidence, so this doesn't get into the fact that sometimes in those groups I feel like I'm a lawyer, you know, Like I was trying to prove a case or something with him and I was, you know, saying that they're not that bad people or something because they were rigorously sticking to it in this, uh, don't do that, you're like, okay, I'm thinking that I am a bad person and what do you want to do with that thought and you are concentrating on the thought process and you say well, if you want you can let it go.
I'm not going to challenge thought and try to prove it one way or another. another, this is a different approach, okay, you have the thought, but now you are in a positionto say: let it go, just as you let go of other thoughts and returned your attention to something. Also identify those thoughts as if they were not a fact. I'm thinking I'm a bad person, that's not a fact, it's just a thought and it allows the person to have a different way of being in the world, whereas this CBT focuses more on looking at those negative things and trying to challenge them. those beliefs and finding new ways and new contents of thinking, which is good for many people, but sometimes it is quite challenging for people who do cognitive therapy and this is a different approach, so what do we do with cognitive therapy based in mindfulness?
It was originally developed as a relapse prevention program to help people stay free of depression once they had fully recovered from an episode, so the first study conducted in 2000 looked at people , half of the people received mindfulness-based cognitive therapy and half of them received the usual treatment and it was shown that Basically, many more people remained free of depression if they had received the mindfulness training about twice as much, so which was a very good sign, especially for people who had three or more episodes of depression, for people who had only one or two episodes. There wasn't much difference, but these are for people who had chronic recurrent depression.
Another replication of that study showed even somewhat better results in that more people remained free of depression. The creators of mindfulness-based cognitive therapy. study carried out and that was that the previous study was carried out in Canada and England. This study was done in Belgium in 2010 and it actually basically showed the same thing, it was done by people other than the author, so can other people get the same kind of results? and this again showed that people with mindfulness training tended to stay in remission compared to people who relapsed here. This is a limit of survival, so many more people who remained free of depression were now people receiving the usual treatment, so in some ways they were good preliminaries. studies, but they weren't as powerful because in physical education some people were getting mindfulness training and the eight weeks group and the others weren't getting anything, so you could say well, it's not that surprising that others in the group experimental they did so well.
This was a more demanding study, it was done at Exer University in England and people at high risk of depression were required to have multiple episodes of depression and as many of you will know, one of the gold standards is for people like i.e. , keep them on antidepressant medication, if someone has had three or more episodes of depression, you would say that this person should probably be put on medication rather than put on medication and then taken off and on, they should probably be stabilized on medication is conventional wisdom and kind of if someone has high blood pressure, you don't just take it off and put it on, if they have it recurrently you would probably treat them on an ongoing basis, so they took these people who had recovered from depression and then randomized them into two groups, one got mindfulness-based cognitive therapy and they were tapered off the antidepressant and the other group stayed on an antidepressant, so it was a much more active comparison for mindfulness-based cognitive therapy, actually essentially the standard treatment for gold of yes, yes, they tapered off in the first three months, it was a one-year study and they tapered off in the first three months, so if they were to relapse, there would be an opportunity for them to relapse during the study, well, I mean, because if they cut them down at the end of the study, you know it wouldn't have been meaningless, so they tried to get them out of and there was a certain schedule that they used to do it and then they would shelve them for a year.
How many people think mbct was better? Well, how many people think that maintenance antidepressants were better? Not many, well they are both wrong, they were. equivalent, they were equivalent, so they were the same whether people were taken off the antidepressant and tapered or kept on maintenance, both showed the same relapse rates as people who were, however, there was a significant The difference between people who received mindfulness training had less residual depression and better quality of life, so it was an interesting study. Pharmaceutical manufacturers did not sponsor this one. This is another interesting study. It was a powerful and unique study that showed a Basically, people who were randomly assigned to three groups after achieving remission, they stayed on antidepressants, they received mbct training or they received a placebo, so it was a unique and really challenging study and basically what he showed for people. who were unstable remitters, that means that people who had ups and downs, that mindfulness-based cognitive therapy or antidepressant maintenance were much more effective than placebo in preventing relapse, but here's an interesting feature for people who are stable remitters and it means people who improved with their initial treatment and it didn't change when we say stable remitters, what they mean is we use a scale called Hamilton most commonly in these studies, so below this level is remission, you want to have the fewest symptoms possible so that the people who remitted and had seven or less what are in remission and stayed there throughout the treatment they were receiving those people who were called stable versus the unstable the remitters were people who People who are stable remitters were bouncing up and down toward remission, actually all three conditions had this equivalent effect on relapse prevention, which was an interesting finding and again goes against the conventional wisdom of saying that people had to stay on medication, although this is the first study that had shown this effect and it was a unique finding.
Let me say a little bit about treatment-resistant depression, which, as we've said, is people who don't respond to two or more trials of antidepressants and basically if you take people and follow them over the course of the year, really you end up with a very limited number of people who have remitted 43% in this study, at the end of a year of treatment, so it is a very difficult condition to treat. and it's important for people to know this because that's why mindfulness-based cognitive therapy was initially developed. We need to find better ways to prevent relapses. It tends to be a recurring disease and people must be given tools to deal with the disease in the long term. term not just deal with this for one episode uh this is our study uh a pilot study that we did here uh I won't say much about it, but again we compared 24 people who received mpct with 24 who received only medications and the actually, the group nbct was somewhat more chronic and had had three or more episodes and this shows that the results of the medication alone people had only a slight decrease compared to the decrease in depression and anxiety that people who received cognitive based cognitive therapy received. mindfulness and 30% remitted with mindfulness-based cognitive therapy, while only 10% remitted with usual treatment again.
This is a serious population, which is why several studies have been done around the world. This was in England and this was in Australia. This is an interesting study. side light only uh This was done at the black dog clinic in Australia it's named after Winston Churchill because Churchill called his depression the black dog the black dog is back today uh say a little bit about the passion for self-pity, it's basically accepting yourself oneself again without the critical qualities, then, it is different from self-esteem. I mean, even a person who doesn't have that much self-esteem can't be compassionate towards them and they don't have to be judgmental or judgmental, and that's a big problem in depression, you know, you can call it with various terminologies, like severe super ego or self. critical or whatever, but people with depression are very critical of themselves and mindfulness really teaches them a way to be kinder to themselves and less critical.
These are some comments taken from some patients who finished the group I am kinder to myself I am less critical I can talk to myself more when those thoughts arise I can say Oh, that's that person I didn't like now We'll talk a little about the biological aspects of this. This was an intriguing study that was done with mindfulness-based stress reduction at the University of Wisconsin by Richie Davidson and John Cabin Zin a few years ago and it was basically an intervention where they took people and taught them that Mindfulness-based stress reduction is very similar to mindfulness-based cognitive therapy, only it doesn't focus on anxiety and depression, it focuses on stress reduction and coping with a wide variety of things, from chronic pain to heart disease or cancer, you name it. the case may be that it's some kind of generic stress reduction approach and they took people from a corporation in central Wisconsin and they taught them mindfulness-based stress reduction and they showed quite remarkably that at the end of eight weeks people who had received the training Compared to a weightless control, had activation of this left frontal region that is associated with positive moods detectable in EEG, so eight weeks of training affected the brain and also showed that there was a greater antibody response.
They gave them the flu vaccine and showed them. that influenza antibodies increased significantly in the mindfulness group, suggesting that there were some neurohumoral effects with mindfulness training, so it was an intriguing study, it was kind of striking because it showed these dramatic effects after eight weeks, However, it was a little biased in the sense that John Caben, if any of you have seen him, was a charismatic figure who flew in from Massachusetts every week to give the group the mindfulness-based training, so a group received John Cabat came flying in and the other group got nothing and they actually got a little worse, you know, because their friends were getting the good stuff, but it was an intriguing study and it highlighted something that I think probably leads to one.
One of the most important points for us to learn tonight is that we now know that there are significant abnormalities in the brains of people who suffer from depression due to other psychiatric disorders as well, but tonight I will focus on depression because we now know much more specifically about the abnormalities that are occurring and in summary you can think of the brain as being regulated by different control systems, there is a dorsal executive control system and dorsal means the upper half of the brain and a vental or lower one. the half of the brain in yellow affective processing affect is another terminology for mood or the appearance of mood, so this is involved with decision making, reason, etc., a function of memory and this is with the processing of emotions and basically this system has a tendency to regulate.
What's going on down here in a broad sense, you see what it's like, I mean, it's not all, it's certainly not one way, there's a lot of back and forth between these different parts of the system, but in the depression, what What I usually see is this area, for example, I'm going to focus on this because you'll see more in a moment. This is the dorsal lateral prefrontal cortex which is right in this area of the forehead and which is associated with executive functioning. with decision making with reason and judgment memory, while this area is with emotion processing and particularly the amydala is probably the best known, although it is also these other areas, but let's take the amydala for example, since it is very active in depression, so The person is acting when you look at this and you will see it a little bit in depression.
This has a higher Activation and a lower Activation, so just break it down to simplify it a bit. This decreases emotional processing. down here is hyperactive and this is hypoactive so the person is being driven by emotions and not thinking very clearly about the processes and I don't think we can all relate to that when you're upset about something you're not thinking things through very much. clarity and if we took a snapshot of your brain with an MRI machine, chances are we would see some of these alterations in these systems, that's right, and that's why we developed that study looking at MRI with the hypothesis that we would seechanges.
In treatment-resistant depression there would be a decrease in the dorsal lateral prefrontal cortex, but with mindfulness training we see an increase. We believe that mindfulness training energizes that area of the brain and restores attentional control in the dorsal lateral prefrontal cortex. There are several studies that have shown that It is as demonstrated by Richie uh Davidson's study with an EEG in uh fmri studies. Mindfulness is associated with enhancement of the dorsal lateral prefrontal cortex and we also see in depression increased amydala activations and we expect to see decreased amydala activations. along with an increase in the dorsal lateral prefrontal cortex, in other words, we are seeing this area get exercised again.
This is an example of this that was done with mindfulness-based stress reduction for eight weeks and the key finding here is to show that These are pre and post workouts to show if you can see how this is active here and down here is more lateral. It's an example of how mindfulness training changes brain function to focus more on the present moment, in this case. Sensations in the body that existed before the training took place, so we are using a couple of different tasks on the fmri machine to observe how people function while they are on the Mr fmri machine to see what happens in their brain. and we basically have them look at a scrambled color shape and then look at some objects and then some more pictures and then show them objects and ask them to remember which one of these you saw and they press a uh they have a button in each hand, they can press right or To the left, which one did you see before?
This way you are checking how much they keep things in their memory, and you also give them different types of stimuli, neutral stimuli or emotionally unpleasant stimuli. evocative stimuli or Pleasant this is a baby and a baby seal uh so you show them different things to see how much they are affected and the idea with uh as you will see is that depression can affectThis is quite a lot so this is how much the person keeps their working memory function and basically this top row are treatment resistant patients from our study and these are healthy controls from another study, they don't match perfectly but they are similar and what you see is that people with treatment resistant depression, if you subtract this from that and this from that, this shows you how different TRD patients really are and you see that there is great activation from both emotional distractors and emotionally evocative images. as well as neutral distractors like the baby seal uh uh and or or The scrambled image rather uh and the amydala is very active in these patients, so the amydala triggers neutral and emotionally evocative stimuli, which means that people with depression are people who come into the study with depression have a highly charged ventral affective processing system, so they respond to neutral or emotionally evocative stimuli by getting very high hyperactivation in the amydala, which is kind of like, in a way, you know, stimulates other areas. of the brain to react here is another image that shows something quite similar uh people with depression had here is the dorsal lateral prefrontal cortex and here is the vental lateral prefrontal cortex which is an area like the amydala that is deeper here but in this image focused on this, it shows that these individuals have a decrease in activation, the depressed individuals, it is colder than the people down here in the ventral effective processing system, so these people again have highly charged emotional systems and are This is mainly related to why people with depression sometimes say they can't remember anything.
I mean, it's not just or uh or sometimes they mistake them for insane, so they called it, you know, pseudo depressive, pseudo. Dementia is actually not so pseudo in the sense that your brain function is actually diminished, it is not dementia in terms of irreversible because if you treat the depression properly it is completely reversible, but you can see how this area that is tasked with maintaining memory and executive function is disabled in a sense in this state uh and well, this is another example to show that when I think this one shows it, it's probably best with the emotional probes that you see in these individuals when they try to recall the memory , they have to illuminate much larger areas of the brain than the individual here because they have trouble concentrating, the person who has depression, if any of you know, people like that, they say, "I don't remember anything or I can't." decide anything I don't know what to wear I don't know what I should do I don't know what I should do in this situation I can't solve the problem well, part of that is because they actually lack the ability in their executive function areas of their brain to work to make those decisions and remember as they would if their brains returned to normal.
This is shown in our population of people with treatment-resistant depression. What you see here is the activation of the subgenual. area in the rostal anterior singular cortex AC this area Broadman area 25 is a hallmark of particularly difficult to treat depression and you have all heard of deep brain stimulation for depression. I don't know if yes, no, this is it. It's not the Las Vegas nerve that deep brain stimulation is. It's an experimental approach and it actually involves a neurosurgical procedure where they drill a hole in the brain in the skull and insert an electrode into the brain and it connects to a pacemaker and Helen.
Mayberg, who was at Emory, developed this and it's been done on probably about 60 people in the world so far, so it's not a very widespread method, you know, it's still pretty experimental, but where you put it is here where you put it. the electrode. this region and when you turn on the stimulator before the stimulator, the person says how you feel terrible, the weight of the world is on me, they flip the switch, the person doesn't know they are blind, this is while they are in the operating room. room by the way to make sure they are in the right area.
I flip the switch, how do you feel now? Without light, just like that and the stimulation goes off. This is not to stimulate it, it is to turn it off. This area needs to be disabled and we may start to see that there are different ways to disable this area. Stanford is doing some research, Ian Golb, on using fmri feedback to visually train people to turn this off and we're hoping to see some. There are also changes with mindfulness training on this, so we don't have the results of that yet, but let me save the questions for last.
That's right, but it's certainly intriguing and will be much more. I think it's more enjoyable for people than having a whore drilled in your head. I don't think I know, but it's dramatic. He shows videotapes of people and these are people who have been very depressed. They have received electrical convulsive treatment. you know 20 different medications and nothing has helped them and they can respond instantly this is another condition that we use while people are in the scanner we asked them to look at these different images one is label effect to label that mood state if this person is angry or scared and then, as a control, we ask her what this person's name is, Sylvia or Allen, these coincide to have the same number of letters and the same length, and this only observes the affection of the face. and this is a control to simply see pair this with this to make a match without any affective component, so this is a way to see how people process emotions and our idea is that people with depression do not process them very well, so here is an example of that, this state just observes, so look at this face, they are in the scanner and then we see what happens in their brain.
This is the region of the amidala. Now look at what happens in that same region when we ask them to label. So they see the face and say, let's say angry, let's say okay, now label it, look at this area so that the same thing through the labeling process can be seen in a sense based on the executive functioning areas of the brain rewetting that. . Amydala's response, then the person instead of saying oh, it's a nasty face. I'm exaggerating a little bit and you can't move your head in the scanner anyway, but, um, you know, instead of having this reaction of saying ah. angry face and this is essentially what we're doing in mindfulness training, so you focus on your breathing and you start to feel oh, I'm really angry about this interaction with my boss or this or I'm really depressed about this breakup or whatever, let's say sadness, what we teach people is to frame their emotions, so say, "okay, uh, when your mind wanders, notice what it's wandering to, then, uh, okay, I have a planning thought, what am I going to do tomorrow?
You have anger, anger and you bring your attention back and you can start to see how some of these things are connected because they're not just, you know, kind of exhaling smoke. , but they are actually affecting and improving the ability of the brain to function in certain things respects and restore the dorsal executive control system uh to re-exercise the component of the brain here you see it to treat uh the first two patients that we've had , you see how in healthy individuals you see the amydala tend to see here how there is no emotional response to those shapes, there were just those black dots, there is very little reactivity here, you see if it is neutral, if any of the other conditions just by looking at those faces labeling gender or labeling affect didn't really change much under normal conditions.
In people, this would decrease significantly, but in depressed people they lack that ability to process emotions. And this other area, the ventrolateral preprefrontal cortex of the VL, was another part of the same vental system that I showed you on that slide as the Amydala, the same effect takes place here, the vental prefrontal cortex has increased activations in all of these conditions except just by control accordingly. I'm going to do it. I think I would like to thank several people who have helped me. You know Natalie. Here, but Dan Mathon is the neuroimaging specialist that I collaborate with, from the VA, and I'm sure I'm leaving out other people, but I have a wonderful team that makes this research possible and, oh, I wanted to. to highlight a couple more things, this is the book that really started it, it's called mindfulness-based cognitive therapy, I think it's around 2002, it's actually in revision, they're doing a new edition, but it's not out yet . uh but since this is really focused on doctors, I would say for most people this would be the book to get and this is like 2007 or eight and the conscious path through depression, this is a fabulous book. , is written by all the Originators of this approach and has a CD in the back with meditations by John Cabitt Z and so it is, it is very clear and very easy to read and very useful.
They warn against using it for people who are actively depressed, which is different because these people, Zindel Seagull and Mark Williams, have used it primarily for relapse prevention, but as you may have heard, we're using it to treat active depression and There is a growing movement to do so. around the world, so keep that in mind when you read that warning in the book. If you understand it, but it's wonderful, it's a beautifully written book and I think everyone will enjoy it, this is our study. uh there's a couple of these handouts here if you're interested in participating or you know someone who might be people who haven't fully recovered and are on two antidepressants uh have had two trials of antidepressants or for people. who aren't on any antidepressants or aren't in any kind of therapy and want to do this, they're both free and we actually pay you to do the assessments and have your brain scanned before, before and after, so it's pretty cool. , they give you your brain scan on a disk and you can use it as a screen saver.
I should have brought mine. I know I love mine. They because they have this. They make this 3D image of your head. except they cut your face off, it's pretty disturbing but kind of surprising because it's the perfect reconstruction of your brain and this is the website you can go to if you go to the Department of Psychiatry at UCSF and look for me, you'll get, you can get it's that one way, but this is also there and, at this point, why don't we open ourselves to questions? Yes, okay, the question is what about OCD and the dorsal lateral prefrontal cortex or how are they related and how can mindfulness be trained? help with that.
I think there haven't been many good studies on this, but in OCD it's largely deeper structures of the basil ganglia that are hyperfunctioning, so you can see the catato and the paman. and some of these other regions that have more activity along with some of these other areas of thebrain that may be involved, especially the midline structure, like the vental medial prefrontal cortex and the orbital frontal cortex, where you see some of those, also have greater activation, what tends to happen in depressive disorders is that midline structures are focused and greater activation is seen in depression and rumination.
Ruminative states tend to decrease as the person receives mindfulness training, which is why I showed you that. a slide where that changed from midline to focus more laterally after mindfulness training, but there hasn't been a really good randomized control. OB trials of mindfulness training that I know of for obsessive compulsive disorder, you'd think it would be helpful but I don't think it's been tried yet, yeah well the question is can depression affect memory and does it have any relation to depression and Alzheimer's. That is a good question. I don't think the answer is completely. Of course, depression is a risk factor for Alzheimer's, that's definitely true, why that can't necessarily be related to what we were seeing here, because Alzheimer's is a more diffuse brain disease and this is really, this is talking of specific areas and on reversible changes, so if you treat people successfully for depression, you will see that the dorsal lateral prefrontal cortex that had decreased activation is restored to normal and obviously that is not the case with Alzheimer's Now, on the other hand, whatever it is. predispose, let's say vascular changes that can predispose to depression or Alzheimer's may be a common link there, so there is some connection, but I don't think it's well resolved yet.
Yes, okay, the question is, yoga has some of the same characteristics and and meditation and meditation Yes, in fact, I think they could make the same claims. It hasn't been studied as well, but there are studies, particularly in India, on the use of yoga as a treatment for major depression and one of our colleagues here at the Osher Center. he has been using Sky yoga as a treatment. I can't pronounce what it means, but it involves breathing techniques and other elements to focus attention, so there is a lot of overlap. You are absolutely right that there is a lot.
There's some overlap between some of the terminology and some of the features of yoga and we use yoga in mindfulness-based cognitive therapy and some people that's what they want to focus on the most, so there's actually a lot of overlap if someone practices yoga. twice a week or more. They are not eligible for our study because they are already doing many of the same things, well, some of that is a good question, a complicated question, but there is something that happens to people who have been traumatized, it can be difficult to treat because It is because it is so traumatic for them that there are efforts to apply this technique to trauma.
There is a study underway at the University of Michigan on the use of mindfulness-based cognitive therapy for post-traumatic stress disorder, for example. It has to be significantly modified from the approach I told you, like for example you could see if you have someone who has been sexually abused or raped or something and have them lie down in class and do a body scan. It may get out of their skin, it may not be an easy thing for them or even just sitting still for 45 minutes breathing or something, so there has to be significant modifications, but on the other hand, mindfulness can help. they distance themselves a little bit from the situation, a lot of what's going on in a lot of different states.
I would say that in many psychiatric disorders it is that people get upset about them and the upset about the disorder is almost worse than the disorder, so people People with PTSD are afraid of having a flashback and for example , there's a technique called metacognitive therapy for PTSD that actually says okay, you're going to have flashbacks, but instead of saying, oh, that's terrible or that's abnormal or scary you say okay, there's a flashback, that's what happened, I'm going to have it and accepting it as if it were paradoxical, that tends to diminish it, tends to resist it, has a tendency to increase the prevalence of those things. so it's a specific technique that can be very useful in helping people accept.
Well, this is what is happening and the same goes for depression. Many people get depressed because they are depressed. Know? and I do not. Say oh, because that part of what we teach in mindfulness-based cognitive therapy is okay, here's depression, what does it feel like? Well, it doesn't feel good or I feel tense or you know whatever or I have a headache with this or a stomach ache or whatever, but it's only going to get worse, this is going to be a disaster and the depressive thoughts start to occur about depression and if you can get the person to tune out and say "okay, here's depression, this is what it feels like, but let's just let go of those other thoughts like it's terrible.
I have depression. I'm weak because I have depression. It's morally wrong that I have depression. I must have sinned because I have depression. All that crap and just having direct depression actually decreases suffering. It's like saying okay and we use this example in our course okay, here's Winston Churchill's black dog. entered the room here is the black dog now you could say I am afraid of black dogs, you know they are terrible, it is a big black dog, this one is terrible, it is here, you know, this is what it is going to do, what is it The next thing that's going to happen, it's going to bite me or what you say, okay, here's the black dog, but we teach less resistance and say okay, instead of panicking, let's go. just take a look at this observation, become aware of this, what is the black back dog?
It may not be an attractive black dog, but when you stop letting go of the fear, it changes the relationship and you say that's not really it. bad look, you know or you know, maybe I can learn something from it, you know, like one woman said when her depression came back, she used to be terrified, but after the course, when the depression came, she says you know when the depression. now I know it's a sign that I'm not asserting myself in a relationship and so she started using depressive awareness in a very different way than being terrified.
Oh no, here comes the depression again, so I think that's the best answer I can. talk to you about post-traumatic stress, you're up there, okay, is depression contagious? There are also many ways to deal with depression, let's not forget, I hope not, the other speakers have been addressing that as well, but, I think it's generally not contagious, you know exactly like an infectious disease, but I think you raise a good point: you know there are these things called memes of ideas that can be transmitted from one person to another or to entire groups of people and if you know if if I say uh oh yeah, the world is a terrible place and everyone leaves here believing what I'm sure that's not going to happen and I, but uh, but I mean, if that were the case, yeah, you, you.
I could have a contagion of ideas. I think the most resilient people are usually able to tell the difference if this person is saying that because you know how depressed they are or whatever, so it's usually not contagious in that sense, but it's not pleasant to be around someone. someone who's depressed and if you're in that situation it could be a stressor in itself, yes it could be, but it's not exactly contagious in itself and hopefully you can keep your distance enough, you know? You know, I don't even know why you come here because there's nothing to do about it.
You know, this is all rubbish, you know, you know, you'd say well, this guy's a terrible lecturer or something, you know what you'd say. I don't accept it and would have enough powers of observation to distance myself, so it usually doesn't lead directly to depression, but it could have a loved one depressed. He has the potential to be a significant stressor. Not anyone has done it. the question is what would qualify, what professional training would qualify a person to do mbct training. Well, I think being in the mental health field of some kind and there are a variety of different attractions that one can have, so they are.
I'm very familiar with depression and its variations and then I think the other requirement is to have your own personal mindfulness practice because you can't read the book and say, "Okay, I'm going to do this and not practice mindfulness." It doesn't work, uh, because in order to be able to say well, I can see these thoughts emerge, you must have seen your own thoughts emerge in Consciousness, so you must have a mindfulness practice to know instead of being like me. G, go teach swimming because I've read about it and you do one like this and one like this and it's easy because you know unless you've swum you can't teach it so that's probably the most important way so I think there could be a variety of disciplines, well the question is how does this relate to Buddhism and I think some Buddhist practitioners I think a lot of them who enter the mental health field have degrees or decoys. in Psychology or counseling or something like that.
I think the difference I would say in teaching this is that the structure and the terminology are rooted in psychological concepts built on mindfulness meditation which of course is related to Buddhist meditation in its beginnings. Roots, uh, so there is overlap, but it's not like that, it's rather secular and people sometimes have problems with that, you know, can you teach a meditation in a secular way, etc., but our experience is that yes, you can and we don't use you? I know that if you go to a Buddhist retreat you will get a completely different perspective on these things than what we are teaching.
Well, one more question. The question is: why can't this be taught in schools to prevent depression? That's a great point. and there is a movement to do exactly that, there is a growing trend to have mindfulness meditation in schools, and Stanford has a project that teaches elementary school children that and, to try to make it part of the educational system, There was a study. that was done here to teach teachers how to be more aware, it was called the emotional balance cultivation study that was partially funded by the do Lama actually and it shows that you can help teachers to be more aware, he passed it on to the next generation, so I think there's a lot of effort going on to try to translate it into preventive techniques, in fact, some of us were talking about trying to do that, provide mindfulness-based prevention to high school seniors who are going to university as a way to prevent. this, but it's moving there, but there's a lot of work to prove that it's effective and testing it and the challenges in developing an effort like that, but it's definitely moving in that direction, so thanks for that question, okay. , thank you all for coming.
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