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Mindfulness and relaxation treatment reduce depressive symptoms in individuals with psychosis
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Original article
Mindfulness and relaxation treatment reduce depressive symptoms in individuals with psychosis S. Moritz a,*,1, B. Cludius a,1, B. Hottenrott a, B.C. Schneider a, K. Saathoff a, A.K. Kuelz b,1, J. Gallinat a,1 a b
Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Martinistr, 52, Hamburg, Germany Department of Psychiatry and Psychotherapy, University Hospital Freiburg, Freiburg, Germany
A R T I C L E I N F O
A B S T R A C T
Article history: Received 31 March 2015 Received in revised form 6 May 2015 Accepted 11 May 2015 Available online xxx
Introduction: Self-help is increasingly accepted for the treatment of mental disorders, including psychosis, as both a provisional first step and a way to bridge the large treatment gap. Though mindfulness-based interventions do not belong to first line treatment strategies in psychosis and randomized controlled trials are lacking, encouraging preliminary findings speak for the usefulness of this approach. For the present study, we examined whether patients with psychosis benefit from mindfulness bibliotherapy. Methods: A sample of 90 patients with psychosis (including a subsample with a verified diagnosis of schizophrenia) took part in the study via the Internet. Following baseline assessment, participants were randomized to either a mindfulness group or a Progressive Muscle Relaxation (PMR) control group and received the respective self-help manual including accompanying audio files. Symptom change was measured six weeks after the baseline assessment with self-rating scales including the Paranoia Checklist. The retention rate was 71%. The quality of the online dataset was confirmed by various strategies (e.g., psychosis lie scale; examination of response biases). The trial was registered at the ISRCTN registry (ISRCTN86762253). Results: No changes across time or between groups were noted for the Paranoia Checklist. Both conditions showed a decline in depressive and obsessive-compulsive symptoms at a medium effect size (per protocol and intention to treat analyses). Discussion/conclusion: The study provided partial support for the effectiveness of self-help mindfulness and PMR for depression in psychosis. Whether mindfulness delivered by a licensed therapist might lead to improved treatment adherence and a superior outcome relative to PMR remains to be established. The results underscore that bibliotherapy is a worthwhile approach to narrow the large treatment gap seen in psychosis. ß 2015 Published by Elsevier Masson SAS.
Keywords: Psychosis Schizophrenia Mindfulness Relaxation Cognitive-behavioral therapy Self-help intervention
1. Introduction Mindfulness-based treatments belong to the ‘‘third-wave’’ of cognitive-behavioral therapy (CBT) [22,25]. The effectiveness of mindfulness-based treatment for mental disorders was first established for depression [13,32,33,52], and recent studies indicate that mindfulness may also be beneficial for other psychopathological syndromes; for example, for obsessive-compulsive disorder (OCD) [20], anxiety [6], and bipolar disorder
* Corresponding author. E-mail address: [email protected] (S. Moritz). 1 The authors have equally contributed to the manuscript and share first authorship. A.K.K. and J.G. also contributed equally.
[43]. However, as of yet, it is not fully established whether mindfulness is equivalent or even superior to established forms of psychotherapy, particularly traditional CBT [15,25]. Factors facilitating or impeding outcome are also not yet fully uncovered [5,54]. Mindfulness encompasses a multitude of techniques. A common denominator is to teach patients through stories as well as practical and mental meditation exercises to contemplate the moment in a non-judgmental and non-reactive way; that is, to contemplate the here and now rather than to dwell on the past or to catastrophize about (negative) future events [15]. These techniques are thought to calm ‘‘hot cognitions’’ and extreme affective fluctuations. Presence of psychosis is commonly an exclusion criterion for relaxation or mindfulness interventions [46]. Cayoun [11], like other authors, considers mindfulness to be
http://dx.doi.org/10.1016/j.eurpsy.2015.05.002 0924-9338/ß 2015 Published by Elsevier Masson SAS.
Please cite this article in press as: Moritz S, et al. Mindfulness and relaxation treatment reduce depressive symptoms in individuals with psychosis. European Psychiatry (2015), http://dx.doi.org/10.1016/j.eurpsy.2015.05.002
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feasible and partially effective in psychosis if certain precautions are met, but views severe states of mania, psychosis, paranoia, and uncontrollable anxiety as contraindications. Indeed, a small but emerging literature suggests that patients with psychosis [12,51], as well as those with only a single psychotic symptom, such as voice-hearing [41], may benefit from mindfulness as well. The dearth of psychotherapy in psychosis is not an issue of evidence [53,57], but rather of dissemination [7,50]. Even in countries that recommend (Germany, DGPPN guidelines) or even impose (UK NICE guidelines) CBT as standard treatment for psychosis, its application is rare [42]. The situation is particularly grave in low- and middle-income countries where 69% of all patients go without any treatment [31]. Although therapistdelivered cognitive-behavioral therapy is regarded the gold standard for the nonpharmacological treatment of psychosis, self-help and online interventions are increasingly successfully adopted in psychosis [4]. It also plays a role as an initial strategy to bridge the large treatment gap, as well as the long waiting periods until face-to-face treatment is finally implemented [35]. Moreover, it is hoped that this type of preliminary treatment will reduce fear of stigma, thus fostering future treatment engagement in currently non-adherent patients. To the best of our knowledge, the present study was the first to examine the effectiveness of a self-help mindfulness intervention (manual with audio files) in patients with psychosis. This study was planned in response to the growing amount of self-help books teaching mindfulness, some of which are written by prominent advocates of mindfulness [24], along with evidence that lowintensity, self-help mindfulness and acceptance-based interventions are partially effective [10]. It is important to assess the effectiveness of self-help tools, even if face-valid and derived from evidence-based techniques, as some approaches that worked in the face-to-face setting have failed as self-help interventions; for example, competitive memory training [49] and the attention training technique [36]. Thus, caution is warranted to assume noninferiority of self-help manuals compared with therapist-delivered therapies. The present study was conducted over the Internet to reach a large group of patients with a mental disorder from the psychosis spectrum. Multiple checks were undertaken to assure validity and diagnostic reliability (i.e. check of retest reliability, application of a psychosis lie scale, invitation to participate in the study via specialized and moderated fora). We expected that mindfulness compared to progressive muscle relaxation (PMR) would reduce depressive and paranoid symptoms in participants with psychosis. While the treatment of psychosis is primarily targeted at positive symptoms, reduction of depression and affective problems represents a critical treatment goal in patients [9]. We also examined if the treatment would also decrease obsessive-compulsive symptoms as many individuals with psychosis present with OCD symptoms [44,48] and mindfulness has shown some benefit to treatment in this psychopathological domain [47]. 2. Methods 2.1. Condition Our investigation was part of a larger study on the effectiveness of a self-help mindfulness intervention on symptom severity across different psychiatric disorders. Participants were randomly allocated (fully automated randomization according to date of participation) to either the experimental condition (manual on mindfulness accompanied by audio files) or the control condition (manual on progressive muscle relaxation accompanied by an audio file). We compared the mindfulness manual against the PMR manual. We chose PMR as
it is a widely used and accepted relaxation treatment. The study was approved by the ethics committee of the German Psychological Society (DGPs). The trial was registered at the ISRCTN registry (ISRCTN86762253). 2.2. Participants Participants were recruited via the Internet. We also posted advertisements in online discussion fora for psychosis that are moderated by experts. Most of the patients (see below) were former inpatients in the Psychiatry Department at the University Medical Center Hamburg-Eppendorf (Germany, UKE) with an established diagnosis of schizophrenia, who had given written informed consent to be re-contacted for future studies. The following inclusion criteria applied: age between 18 and 65 years, willingness to participate in two anonymous (internet-based) surveys that were scheduled six weeks apart, and an externally verified diagnosis of schizophrenia/psychosis. Individuals interested in the study were directed to the online baseline survey via a weblink. The anonymous study (no name or address was requested) was created using Questback1, a software for creating online surveys that does not store IP addresses. Participants were informed that they would receive a manual on either PMR or mindfulness (see below) in random fashion subsequent to baseline assessment, and that the respective other manual would be given to them subsequent to post-assessment. A total of 445 individuals completed the baseline survey, of whom 97 reported having an externally verified diagnosis of psychosis and/or bipolar disorder. Blind to results, seven subjects were excluded; all patients (n = 5) who had a diagnosis of bipolar disorder without a concomitant history of schizophrenia or schizoaffective disorder, one participant due to violating age criteria and another due to a comorbid personality disorder. For the remaining 90 participants, a diagnosis of schizophrenia/psychosis had been previously established by a psychiatrist (n = 76), a psychotherapist (n = 5), or by another physician or mental health expert (n = 9). None of the participants violated the cutoff score of the psychosis lie scale [38], which taps into pseudo-psychotic symptoms (see below). We also checked whether subjects made the same responses across all items of the psychopathology scales (see below) suggesting unreliable response behavior; however, no such cases were found. 2.3. Procedure On the first page of the baseline survey, the study rationale was summarized. Participants who did not approve the electronic informed consent were automatically excluded via a ‘‘trap door’’ and kindly reminded that informed consent was a mandatory precondition for participation. Multiple log-ins via the same computer were precluded by means of ‘‘cookies’’. The survey consisted of the following parts: demographic section (e.g., gender, age), medical history (e.g., psychiatric diagnosis), profession of the person who had diagnosed the disorder, assessment of psychopathology (see questionnaires section below), request for an email address (to match baseline and post-survey data), truthfulness of the responses and opportunity to leave comments. Immediately after completion of the baseline assessment, participants were sent a link to download the manual and audio files of the respective intervention (i.e., mindfulness or PMR) via an automated randomization procedure. Six weeks after the baseline assessment, participants were contacted via email for participation in the post-survey. Up to two reminders were sent in case subjects failed to complete/log in to the post-assessment.
Please cite this article in press as: Moritz S, et al. Mindfulness and relaxation treatment reduce depressive symptoms in individuals with psychosis. European Psychiatry (2015), http://dx.doi.org/10.1016/j.eurpsy.2015.05.002
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For the post-survey, individuals were requested to first enter their email address to allow matching of baseline and post data. The post-assessment consisted of the following parts: introduction, questionnaire on psychopathology (see below) and evaluation of the respective manual (in case subjects endorsed that they had read the manual, e.g. comprehensibility). At the end, participants were asked whether they responded honestly and were given the opportunity to leave comments. Then, participants received a link to download all materials. 2.4. Self-help manuals The mindfulness and PMR manuals were accompanied by audio files providing instructions for the relaxation/meditation tasks. The mindfulness manual consisted of 15 pages and included an introduction to the concept of mindfulness and an explanation on how mindfulness can be exercised by means of several classical techniques. For the first four exercises, participants could download audio files. Participants were encouraged to try out all exercises in order to decide which ones they wanted to exercise in the long-term. The exercises are briefly described below: breathing exercise: 3-minute exercise with focus on the perception of one’s own breathing. Can be performed in a lying or sitting position (accompanied by an audio file); body scan: classical 20-minute mindfulness exercise in which focused perception is directed through the whole body while lying in a supine position (accompanied by an audio file); morning exercise: similar to the body scan, but shorter and in a sitting position (accompanied by an audio file); inner smile: instructions for a slight ‘‘inner smile’’ (accompanied by an audio file); mindfulness in everyday activities: patients are encouraged to perform routine activities with mindfulness and awareness (e.g., while taking a shower, drinking coffee, washing hands, walking, eating, brushing teeth, climbing stairs); speed minus 10%: exercise in which the speed of daily activities shall be reduced consciously for some time; STOP – exercise: short pause to become aware of what one is doing at the moment and how it feels. To decide whether one wants to continue in the same way or not; being mindful of needs: short pause for a conscious perception of current physical needs (e.g., hunger, thirst, muscle tension, pinching clothes, uncomfortable posture); bean exercise: exercise for a more conscious perception of positive experiences in everyday life (‘‘counting beans’’); sensory circuit training: exercise to imagine positive experiences with all five senses. Audio files and exercises were prepared and read by BH, a clinical psychologist. Progressive Muscle Relaxation (PMR) according to Jacobson instructs participants to first tense/tighten certain muscle groups for a short time followed by a release of tension. The PMR manual consisted of three pages describing the background/rationale, the exercises and answers to potential questions that might arise while practicing PMR. An audio file providing instructions was also available for download.
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scales (see below) assessing symptoms of paranoia, obsessivecompulsive disorder and depression in a random item order (fixed across participants). We chose to assess those symptoms, as many patients with psychosis also display symptoms of OCD and depression (see introduction). Momentary symptom severity should be rated on a five-point Likert scale ranging from 1 (not at all) to 5 (extremely). The Paranoia Checklist [18] consists of 18 items measuring paranoid beliefs. Factor analysis indicates that the scale is best represented by two dimensions tapping core paranoid beliefs and general suspiciousness [37]. Studies have confirmed good psychometric properties of the Paranoia Checklist [18,29,30]. The shortterm test–retest reliability of the online version is r = .92 [40] and it shows good internal consistency and convergent validity [29]. The Obsessive-Compulsive Inventory-Revised (OCI-R) [16] assesses the frequency of OCD symptoms. Its excellent psychometric properties [1,16,23] also hold true for the German version [19] and it is sensitive to change [2]. Internet administration of the OCI-R [14] has been established to be equivalent to paper-andpencil administration (e.g., relating to means and reliability). The test–retest reliability and validity of the online version of the scale are excellent [34]. We used an abbreviated version of the scale consisting of 10 items. The Center for Epidemiologic Studies-Depression Scale (CES-D) [21,45] is a 20-item questionnaire assessing symptoms of depression. The CES-D has both a good internal consistency and test–retest reliability (r = .81). Speaking to its criterion validity, the CES-D is highly correlated with other depression scales such as the Beck Depression Inventory [8]. The Community Assessment of Psychic Experiences Scale (CAPE) [28] consists of 42 items rated on a four-point Likert scale (‘‘Never’’, ‘‘Sometimes’’, ‘‘Often’’, and ‘‘Nearly always’’) that tap into the psychosis phenotype. The CAPE measures three syndrome scales: positive (item 5 ‘‘Do you ever feel as if things in magazines or on TV were written especially for you?’’), negative (item 8: ‘‘Do you ever feel that you experience few or no emotions at important events?’’), and depressive (item 9: ‘‘Do you ever feel pessimistic about everything?’’). The reliability and (factorial) validity of the scale are good [17,28]. We added a psychosis lie scale consisting of four items [38] mirroring common misconceptions about psychosis (cutoff: 8 points): seeing tiny objects like white mice (indicating delirium rather than psychosis); alien abduction (a rare but highly publicized cliche´ symptom); being a famous historical personality (a rare but highly publicized cliche´ symptom); mental lapses during which one becomes another person (i.e., ‘‘split personality’’; a rare/implausible but highly publicized cliche´ symptom).
Scores beyond the cutoff speak for simulation of psychosis and/ or unreliable responses (maximum: 16 points). Simulators have been found to show excessive scores on the lie scale and show much higher scores on the CAPE positive syndrome [39]. 3. Results
2.5. Questionnaires 3.1. Baseline characteristics and completion Participants were required to fill out a number of questionnaires. The survey proceeded only if all items had been responded to. The Paranoia-Obsession-Depression Scale (POD) was administered at baseline and six weeks later. The POD incorporates three
Ninety participants with a likely or verified diagnosis of schizophrenia or psychosis participated. As Table 1 shows, groups did not differ on any background or psychopathological index at baseline. Since randomization was automated (not stratified
Please cite this article in press as: Moritz S, et al. Mindfulness and relaxation treatment reduce depressive symptoms in individuals with psychosis. European Psychiatry (2015), http://dx.doi.org/10.1016/j.eurpsy.2015.05.002
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Table 1 Demographic and psychopathological baseline characteristics. Variable
Progressive muscle relaxation (n = 52)
Mindfulness (n = 38)
Statistics (df = 85)
Background Age in years Gender (male/female) Currently in psychological/psychiatric treatment (% yes)
37.46 (10.15) 22/30 81%
38.11 (9.09) 16/22 74%
t = 0.31, P = .757 x2(1) = 0.00, P = .985 x2(1) = 0.64, P = .425
Psychopathology Paranoia Checklist Center for Epidemiological Studies-Depression Scale OCI-R short
35.33 (16.51) 52.02 (18.79) 18.87 (7.13)
36.13 (17.77) 50.53 (17.62) 19.24 (8.16)
t = 0.22, P = .825 t = 0.38, P = .703 t = 0.23, P = .819
CAPE Positive Negative Depression
1.75 (0.46) 2.27 (0.57) 2.28 (0.46)
1.82 (0.30) 2.26 (0.53) 2.25 (0.48)
t = 0.64, P = .519 t = 0.08, P = .933 t = 0.20, P = .843
CAPE: Community Assessment of Psychic Experiences Scale; OCI-R: Obsessive-Compulsive Inventory-revised (abbreviated). Standard deviations in parentheses.
according to diagnoses) and exclusions were made post-hoc (blind to results) the groups were not evenly sized. Results on the CAPE dimensions were in the expected range for patients with verified diagnoses and did not reach the cutoff for people simulating a diagnosis of schizophrenia [39] (M = 2.59 on the positive symptom scale for simulators). Completion (defined as completion at the post-assessment) was 71%; no significant differences emerged between patients in the mindfulness (74% completion) versus PMR (69% completion) condition, x2(1) = 0.21, P = .66. Completers and noncompleters did not differ on any background or psychopathological baseline characteristics (Ps .20). Adherence was satisfactory: 61.5% of the participants in the mindfulness group had fully read the manual (self-report) compared with 51.1% in the PMR group, x2(1) = 0.59, P = .44. 3.2. Per protocol analyses Mixed ANOVAs were computed with Group (Mindfulness, PMR) as the between-subject and Time (pre, post) as the within-subject factors. The POD subscales served as the respective dependent variables. Effect sizes are expressed using h2partial, whereby .01 is equivalent to a small effect, .06 is equivalent to a medium effect and .14 is equivalent to a strong effect [27]. For depression (CES-D), there was a significant effect of Time, which achieved a mediumto-large effect size, F(1, 62) = 6.06, P = .017, hpartial2 = .089
(see Fig. 1). Neither the effect of Group, F(1, 62) = 0.02, P = .89, hpartial2 < .001, nor the interaction of Time Group, F(1, 62) = 0.02, P = .89, hpartial2 < .001, were significant. For paranoia (Paranoia Checklist), neither the effects of Time, F(1, 62) = 0.63, P = .43, hpartial2 = .01, or Group, F(1, 62) = 0.47, P = .50, hpartial2 = .008, nor the interaction, F(1, 62) = 0.14, P = .71, hpartial2 = .002, achieved significance. For OCD symptomatology (OCI-R), the effect of Time bordered significance at a medium effect size, F(1, 62) = 3.91, P = .052, hpartial2 = .059, whereas neither the effect of Group, F(1, 62) = 0.28, P = .60, hpartial2 = .004, nor the interaction, F(1, 62) = 0.23, P = .63, hpartial2 = .004, achieved significance. 3.3. Intention to treat analyses To account for missing values, we calculated linear mixed models. The per protocol results were essentially confirmed. The effect of Time was significant for depression (P = .01) and OCD symptoms (P = .03) but not for paranoia (P = .30). All other effects were nonsignificant (Ps > .4). 3.4. Test–retest reliability The test–retest reliability was satisfactory for all psychopathological scales (Paranoia Checklist: r = .75, P < .001; CES-D: r = .68, P < .001, OCI-R: r = .78, P < .001). 3.5. Subjective effectiveness
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Patients who actively adopted the techniques were asked at post-assessment to assess the manual on a four-point likert scale (fully agree, rather agree, rather disagree, fully disagree). For the following analyses, the response options for fully agree and rather agree were pooled. Most patients found that the programs were suitable for self-administration (mindfulness: 83%; muscle relaxation: 66.6%), found the manuals comprehensible (mindfulness: 100%; muscle relaxation: 83.3%) and useful (mindfulness: 83.3%; muscle relaxation: 50%) and would use the exercises in the future (mindfulness: 83.3%; muscle relaxation: 66.7%); none of the comparisons yielded significance (P > .05).
50
sum score
40
30
20
10
4. Discussion
0
PCL
OCI-R
mindfulness
CES-D
PCL
OCI-R
CES-D
muscle relaxaon
Fig. 1. The entire group showed a moderate decline of depressive and OCD symptoms, while paranoid symptoms remained unchanged from pre (dark grey) to post (light grey) intervention. CES-D: Center for Epidemiologic Studies-Depression Scale; OCI-R: Obsessive-Compulsive Inventory-revised (abbreviated); PCL: Paranoia Checklist.
The present study assessed the effectiveness of relaxation and mindfulness self-help interventions in psychosis. Cognitive and psychotherapeutic approaches are still rarely applied in psychosis, and years ago were even considered potentially harmful. As such, a study on bibliotherapy may be considered by some to be ‘‘doomed.’’ However, in light of the feasibility of other self-help
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approaches for psychosis [3,4], and significant benefits of self-help mindfulness techniques for psychosis as well as other disorders [10,12,51], in our view, our study represents a reasonable and even important endeavor. Some pilot studies were able to detect significant effects of self-help interventions in psychosis, including mindfulness-based techniques [12,51]. Finally, as psychotherapeutic self-help techniques are easily available via (online) bookstores or websites, the efficacy of these forms of intervention needs to be tested, particularly to confirm the sometimes bold claims of the authors. Our retention rate was relatively high (71%). This together with the good test–retest reliability speaks for the practicability and usefulness of the online approach. For both interventions, substantial change occurred for depression and OCD symptoms (medium effect size), while for paranoia, no change was observed. The study thus confirms that relaxation and mindfulness positively impacts affective states (future trials may however also set a waitlist control condition to account for the effects of natural course/passage of time). Somewhat unexpectedly, however, the trial did not detect evidence for the superiority of mindfulness treatment for psychosis relative to PMR when applied as a self-help resource. In view of the rather large sample and the very small effect sizes, insufficient power can be ruled out in explaining the absence of interaction effects. Though the high test–retest reliability and good retention rates, paired with a sizable subsample of patients with a verified diagnosis of schizophrenia, assert the quality of the data, it is hard to draw firm conclusions from the results other than that mindfulness and relaxation are partially effective in reducing depression symptoms in psychosis when applied as a self-help tool. In line with recent results on mindfulness-based therapy for psychosis [55], no adverse effects of mindfulness and relaxation on psychotic symptoms were found. As we did not employ a follow-up measurement, we cannot discern whether a potential superiority of mindfulness over PMR may have evolved at a later point in time (i.e., ‘‘sleeper effect’’). Of note, only a subgroup of patients really read the entire manual. This rate is likely higher if the exercises are performed/introduced in a group and patients are externally prompted to do the exercises (e.g., by therapists or calendar alerts). Importantly, we used classical techniques of mindfulness (such as the body scan) assisted by audio files. While this intervention was clearly unguided in the sense that no therapist presented the exercises and experiences were not subsequently shared with others, the audio files (which were narrated by a psychologist) at least mimicked the presence of a therapist. To raise compliance future trials should use less exercises and describe them more briefly. The mindfulness manual was rather long and presenting individuals with exercises in successive fashion (e.g. weekly emails or electronic (e.g. app) messages with single exercises) may be advisable. Interim reminders may prove helpful in view of often severe memory dysfunction in the disorder [26]. Fifteen pages of text may have overwhelmed some patients in the mindfulness group who are less skilled with reading or suffer from poor attention span (however, self-help books on mindfulness are usually much longer). However, adherence was similar in the control condition, which only consisted of a 3-page manual. For some of the mindfulness techniques, presentation of video clips could have facilitated comprehension. As another suggestion for future trials, the range of symptoms assessed should be expanded. For example, we did not examine whether the treatment ameliorated hallucinations or negative symptoms, which are characteristic of psychosis. Clearly, the possibility that mindfulness therapy is not superior to relaxation techniques cannot be dismissed. For example, a recent sizable study of MBCT against an active control showed no differences in relapse rates in patients with recurrent depression
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[56]. Similar to other forms of intervention, dismantling studies are needed to identify which of the many elements of mindfulness interventions and relaxation procedures are effective or ineffective, and how therapeutic techniques are best delivered. Here, the skills, education and academic background of the therapist deserve special attention. We encourage researchers to evaluate whether other initially therapist-delivered approaches that have proven feasible and partially effective may also be applied as self-help in view of the large treatment gap in psychosis. As mentioned before, it has been estimated that 69% of patients with psychosis in low- and middleincome countries [31] receive no treatment and even in Western countries with an advanced care system, many patients are refused care or do not seek treatment because of resentment of the medical system or are non-adherent to treatment. Even those who get treatment do oftentimes not get the full range of efficacious treatment options – psychotherapeutic techniques are still only rarely adopted in psychosis. These patients may benefit from lowthreshold online or bibliotherapeutic intervention, as even patients with lack of insight into psychosis are often willing to acknowledge that they have a psychological problem (e.g., memory problems, sleeping disorder). Generic approaches may prove particularly valuable here. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Abramowitz JS, Deacon BJ. Psychometric properties and construct validity of the Obsessive-Compulsive Inventory – Revised: replication and extension with a clinical sample. J Anxiety Disord 2006;20:1016–35. [2] Abramowitz JS, Tolin D, Diefenbach G. Measuring change in OCD: sensitivity of the Obsessive-Compulsive Inventory-Revised. J Psychopathol Behav Assess 2005;27:317–24. [3] Alvarez-Jimenez M, Alcazar-Corcoles MA, Gonzalez-Blanch C, et al. Online, social media and mobile technologies for psychosis treatment: a systematic review on novel user-led interventions. Schizophr Res 2014;156:96–106. [4] A´lvarez-Jime´nez M, Gleeson JF, Bendall S, et al. Internet-based interventions for psychosis: a sneak-peek into the future. Psychiatr Clin North Am 2012;35:735–47. [5] Arch JJ, Ayers CR. Which treatment worked better for whom? Moderators of group cognitive behavioral therapy versus adapted mindfulness based stress reduction for anxiety disorders. Behav Res Ther 2013;51:434–42. [6] Arch JJ, Ayers CR, Baker A, et al. Randomized clinical trial of adapted mindfulness-based stress reduction versus group cognitive behavioral therapy for heterogeneous anxiety disorders. Behav Res Ther 2013;51:185–96. [7] Bechdolf A, Klingberg S. Psychotherapy of schizophrenia: not a problem of evidence, but a problem of implementation [Psychotherapie bei schizophrenen Sto¨rungen: Kein Evidenz-, sondern ein Implementierungsproblem]. Psychiatr Prax 2014;41:8–10. [8] Beck AT, Steer RA. Beck Depression Inventory Manual. San Antonio: Psychological Corporation; 1993. [9] Byrne R, Davies L, Morrison AP. Priorities and preferences for the outcomes of treatment of psychosis: a service user perspective. Psychosis 2010;2: 210–7. [10] Cavanagh K, Strauss C, Forder L, Jones F. Can mindfulness and acceptance be learnt by self-help? A systematic review and meta-analysis of mindfulness and acceptance-based self-help interventions. Clin Psychol Rev 2014;34:118–29. [11] Cayoun BA. Mindfulness-integrated CBT: principles and practice. Chichester, U.K.: Wiley & Sons; 2011. [12] Chadwick P. Mindfulness for psychosis. Br J Psychiatry 2014;204:333–4. [13] Coelho HF, Canter PH, Ernst E. Mindfulness-based cognitive therapy: evaluating current evidence and informing future research. Psychol Conscious 2013;1:97–107. [14] Coles ME, Cook LM, Blake TR. Assessing obsessive compulsive symptoms and cognitions on the Internet: evidence for the comparability of paper and Internet administration. Behav Res Ther 2007;45:2232–40. [15] Fjorback LO, Arendt M, Ørnbøl E, et al. Mindfulness-based stress reduction and mindfulness-based cognitive therapy – a systematic review of randomized controlled trials. Acta Psychiatr Scand 2011;124:102–19. [16] Foa EB, Huppert JD, Leiberg S, et al. The Obsessive-Compulsive Inventory: development and validation of a short version. Psychol Assess 2002;14: 485–96.
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Original article
Mindfulness and relaxation treatment reduce depressive symptoms in individuals with psychosis S. Moritz a,*,1, B. Cludius a,1, B. Hottenrott a, B.C. Schneider a, K. Saathoff a, A.K. Kuelz b,1, J. Gallinat a,1 a b
Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Martinistr, 52, Hamburg, Germany Department of Psychiatry and Psychotherapy, University Hospital Freiburg, Freiburg, Germany
A R T I C L E I N F O
A B S T R A C T
Article history: Received 31 March 2015 Received in revised form 6 May 2015 Accepted 11 May 2015 Available online xxx
Introduction: Self-help is increasingly accepted for the treatment of mental disorders, including psychosis, as both a provisional first step and a way to bridge the large treatment gap. Though mindfulness-based interventions do not belong to first line treatment strategies in psychosis and randomized controlled trials are lacking, encouraging preliminary findings speak for the usefulness of this approach. For the present study, we examined whether patients with psychosis benefit from mindfulness bibliotherapy. Methods: A sample of 90 patients with psychosis (including a subsample with a verified diagnosis of schizophrenia) took part in the study via the Internet. Following baseline assessment, participants were randomized to either a mindfulness group or a Progressive Muscle Relaxation (PMR) control group and received the respective self-help manual including accompanying audio files. Symptom change was measured six weeks after the baseline assessment with self-rating scales including the Paranoia Checklist. The retention rate was 71%. The quality of the online dataset was confirmed by various strategies (e.g., psychosis lie scale; examination of response biases). The trial was registered at the ISRCTN registry (ISRCTN86762253). Results: No changes across time or between groups were noted for the Paranoia Checklist. Both conditions showed a decline in depressive and obsessive-compulsive symptoms at a medium effect size (per protocol and intention to treat analyses). Discussion/conclusion: The study provided partial support for the effectiveness of self-help mindfulness and PMR for depression in psychosis. Whether mindfulness delivered by a licensed therapist might lead to improved treatment adherence and a superior outcome relative to PMR remains to be established. The results underscore that bibliotherapy is a worthwhile approach to narrow the large treatment gap seen in psychosis. ß 2015 Published by Elsevier Masson SAS.
Keywords: Psychosis Schizophrenia Mindfulness Relaxation Cognitive-behavioral therapy Self-help intervention
1. Introduction Mindfulness-based treatments belong to the ‘‘third-wave’’ of cognitive-behavioral therapy (CBT) [22,25]. The effectiveness of mindfulness-based treatment for mental disorders was first established for depression [13,32,33,52], and recent studies indicate that mindfulness may also be beneficial for other psychopathological syndromes; for example, for obsessive-compulsive disorder (OCD) [20], anxiety [6], and bipolar disorder
* Corresponding author. E-mail address: [email protected] (S. Moritz). 1 The authors have equally contributed to the manuscript and share first authorship. A.K.K. and J.G. also contributed equally.
[43]. However, as of yet, it is not fully established whether mindfulness is equivalent or even superior to established forms of psychotherapy, particularly traditional CBT [15,25]. Factors facilitating or impeding outcome are also not yet fully uncovered [5,54]. Mindfulness encompasses a multitude of techniques. A common denominator is to teach patients through stories as well as practical and mental meditation exercises to contemplate the moment in a non-judgmental and non-reactive way; that is, to contemplate the here and now rather than to dwell on the past or to catastrophize about (negative) future events [15]. These techniques are thought to calm ‘‘hot cognitions’’ and extreme affective fluctuations. Presence of psychosis is commonly an exclusion criterion for relaxation or mindfulness interventions [46]. Cayoun [11], like other authors, considers mindfulness to be
http://dx.doi.org/10.1016/j.eurpsy.2015.05.002 0924-9338/ß 2015 Published by Elsevier Masson SAS.
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feasible and partially effective in psychosis if certain precautions are met, but views severe states of mania, psychosis, paranoia, and uncontrollable anxiety as contraindications. Indeed, a small but emerging literature suggests that patients with psychosis [12,51], as well as those with only a single psychotic symptom, such as voice-hearing [41], may benefit from mindfulness as well. The dearth of psychotherapy in psychosis is not an issue of evidence [53,57], but rather of dissemination [7,50]. Even in countries that recommend (Germany, DGPPN guidelines) or even impose (UK NICE guidelines) CBT as standard treatment for psychosis, its application is rare [42]. The situation is particularly grave in low- and middle-income countries where 69% of all patients go without any treatment [31]. Although therapistdelivered cognitive-behavioral therapy is regarded the gold standard for the nonpharmacological treatment of psychosis, self-help and online interventions are increasingly successfully adopted in psychosis [4]. It also plays a role as an initial strategy to bridge the large treatment gap, as well as the long waiting periods until face-to-face treatment is finally implemented [35]. Moreover, it is hoped that this type of preliminary treatment will reduce fear of stigma, thus fostering future treatment engagement in currently non-adherent patients. To the best of our knowledge, the present study was the first to examine the effectiveness of a self-help mindfulness intervention (manual with audio files) in patients with psychosis. This study was planned in response to the growing amount of self-help books teaching mindfulness, some of which are written by prominent advocates of mindfulness [24], along with evidence that lowintensity, self-help mindfulness and acceptance-based interventions are partially effective [10]. It is important to assess the effectiveness of self-help tools, even if face-valid and derived from evidence-based techniques, as some approaches that worked in the face-to-face setting have failed as self-help interventions; for example, competitive memory training [49] and the attention training technique [36]. Thus, caution is warranted to assume noninferiority of self-help manuals compared with therapist-delivered therapies. The present study was conducted over the Internet to reach a large group of patients with a mental disorder from the psychosis spectrum. Multiple checks were undertaken to assure validity and diagnostic reliability (i.e. check of retest reliability, application of a psychosis lie scale, invitation to participate in the study via specialized and moderated fora). We expected that mindfulness compared to progressive muscle relaxation (PMR) would reduce depressive and paranoid symptoms in participants with psychosis. While the treatment of psychosis is primarily targeted at positive symptoms, reduction of depression and affective problems represents a critical treatment goal in patients [9]. We also examined if the treatment would also decrease obsessive-compulsive symptoms as many individuals with psychosis present with OCD symptoms [44,48] and mindfulness has shown some benefit to treatment in this psychopathological domain [47]. 2. Methods 2.1. Condition Our investigation was part of a larger study on the effectiveness of a self-help mindfulness intervention on symptom severity across different psychiatric disorders. Participants were randomly allocated (fully automated randomization according to date of participation) to either the experimental condition (manual on mindfulness accompanied by audio files) or the control condition (manual on progressive muscle relaxation accompanied by an audio file). We compared the mindfulness manual against the PMR manual. We chose PMR as
it is a widely used and accepted relaxation treatment. The study was approved by the ethics committee of the German Psychological Society (DGPs). The trial was registered at the ISRCTN registry (ISRCTN86762253). 2.2. Participants Participants were recruited via the Internet. We also posted advertisements in online discussion fora for psychosis that are moderated by experts. Most of the patients (see below) were former inpatients in the Psychiatry Department at the University Medical Center Hamburg-Eppendorf (Germany, UKE) with an established diagnosis of schizophrenia, who had given written informed consent to be re-contacted for future studies. The following inclusion criteria applied: age between 18 and 65 years, willingness to participate in two anonymous (internet-based) surveys that were scheduled six weeks apart, and an externally verified diagnosis of schizophrenia/psychosis. Individuals interested in the study were directed to the online baseline survey via a weblink. The anonymous study (no name or address was requested) was created using Questback1, a software for creating online surveys that does not store IP addresses. Participants were informed that they would receive a manual on either PMR or mindfulness (see below) in random fashion subsequent to baseline assessment, and that the respective other manual would be given to them subsequent to post-assessment. A total of 445 individuals completed the baseline survey, of whom 97 reported having an externally verified diagnosis of psychosis and/or bipolar disorder. Blind to results, seven subjects were excluded; all patients (n = 5) who had a diagnosis of bipolar disorder without a concomitant history of schizophrenia or schizoaffective disorder, one participant due to violating age criteria and another due to a comorbid personality disorder. For the remaining 90 participants, a diagnosis of schizophrenia/psychosis had been previously established by a psychiatrist (n = 76), a psychotherapist (n = 5), or by another physician or mental health expert (n = 9). None of the participants violated the cutoff score of the psychosis lie scale [38], which taps into pseudo-psychotic symptoms (see below). We also checked whether subjects made the same responses across all items of the psychopathology scales (see below) suggesting unreliable response behavior; however, no such cases were found. 2.3. Procedure On the first page of the baseline survey, the study rationale was summarized. Participants who did not approve the electronic informed consent were automatically excluded via a ‘‘trap door’’ and kindly reminded that informed consent was a mandatory precondition for participation. Multiple log-ins via the same computer were precluded by means of ‘‘cookies’’. The survey consisted of the following parts: demographic section (e.g., gender, age), medical history (e.g., psychiatric diagnosis), profession of the person who had diagnosed the disorder, assessment of psychopathology (see questionnaires section below), request for an email address (to match baseline and post-survey data), truthfulness of the responses and opportunity to leave comments. Immediately after completion of the baseline assessment, participants were sent a link to download the manual and audio files of the respective intervention (i.e., mindfulness or PMR) via an automated randomization procedure. Six weeks after the baseline assessment, participants were contacted via email for participation in the post-survey. Up to two reminders were sent in case subjects failed to complete/log in to the post-assessment.
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For the post-survey, individuals were requested to first enter their email address to allow matching of baseline and post data. The post-assessment consisted of the following parts: introduction, questionnaire on psychopathology (see below) and evaluation of the respective manual (in case subjects endorsed that they had read the manual, e.g. comprehensibility). At the end, participants were asked whether they responded honestly and were given the opportunity to leave comments. Then, participants received a link to download all materials. 2.4. Self-help manuals The mindfulness and PMR manuals were accompanied by audio files providing instructions for the relaxation/meditation tasks. The mindfulness manual consisted of 15 pages and included an introduction to the concept of mindfulness and an explanation on how mindfulness can be exercised by means of several classical techniques. For the first four exercises, participants could download audio files. Participants were encouraged to try out all exercises in order to decide which ones they wanted to exercise in the long-term. The exercises are briefly described below: breathing exercise: 3-minute exercise with focus on the perception of one’s own breathing. Can be performed in a lying or sitting position (accompanied by an audio file); body scan: classical 20-minute mindfulness exercise in which focused perception is directed through the whole body while lying in a supine position (accompanied by an audio file); morning exercise: similar to the body scan, but shorter and in a sitting position (accompanied by an audio file); inner smile: instructions for a slight ‘‘inner smile’’ (accompanied by an audio file); mindfulness in everyday activities: patients are encouraged to perform routine activities with mindfulness and awareness (e.g., while taking a shower, drinking coffee, washing hands, walking, eating, brushing teeth, climbing stairs); speed minus 10%: exercise in which the speed of daily activities shall be reduced consciously for some time; STOP – exercise: short pause to become aware of what one is doing at the moment and how it feels. To decide whether one wants to continue in the same way or not; being mindful of needs: short pause for a conscious perception of current physical needs (e.g., hunger, thirst, muscle tension, pinching clothes, uncomfortable posture); bean exercise: exercise for a more conscious perception of positive experiences in everyday life (‘‘counting beans’’); sensory circuit training: exercise to imagine positive experiences with all five senses. Audio files and exercises were prepared and read by BH, a clinical psychologist. Progressive Muscle Relaxation (PMR) according to Jacobson instructs participants to first tense/tighten certain muscle groups for a short time followed by a release of tension. The PMR manual consisted of three pages describing the background/rationale, the exercises and answers to potential questions that might arise while practicing PMR. An audio file providing instructions was also available for download.
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scales (see below) assessing symptoms of paranoia, obsessivecompulsive disorder and depression in a random item order (fixed across participants). We chose to assess those symptoms, as many patients with psychosis also display symptoms of OCD and depression (see introduction). Momentary symptom severity should be rated on a five-point Likert scale ranging from 1 (not at all) to 5 (extremely). The Paranoia Checklist [18] consists of 18 items measuring paranoid beliefs. Factor analysis indicates that the scale is best represented by two dimensions tapping core paranoid beliefs and general suspiciousness [37]. Studies have confirmed good psychometric properties of the Paranoia Checklist [18,29,30]. The shortterm test–retest reliability of the online version is r = .92 [40] and it shows good internal consistency and convergent validity [29]. The Obsessive-Compulsive Inventory-Revised (OCI-R) [16] assesses the frequency of OCD symptoms. Its excellent psychometric properties [1,16,23] also hold true for the German version [19] and it is sensitive to change [2]. Internet administration of the OCI-R [14] has been established to be equivalent to paper-andpencil administration (e.g., relating to means and reliability). The test–retest reliability and validity of the online version of the scale are excellent [34]. We used an abbreviated version of the scale consisting of 10 items. The Center for Epidemiologic Studies-Depression Scale (CES-D) [21,45] is a 20-item questionnaire assessing symptoms of depression. The CES-D has both a good internal consistency and test–retest reliability (r = .81). Speaking to its criterion validity, the CES-D is highly correlated with other depression scales such as the Beck Depression Inventory [8]. The Community Assessment of Psychic Experiences Scale (CAPE) [28] consists of 42 items rated on a four-point Likert scale (‘‘Never’’, ‘‘Sometimes’’, ‘‘Often’’, and ‘‘Nearly always’’) that tap into the psychosis phenotype. The CAPE measures three syndrome scales: positive (item 5 ‘‘Do you ever feel as if things in magazines or on TV were written especially for you?’’), negative (item 8: ‘‘Do you ever feel that you experience few or no emotions at important events?’’), and depressive (item 9: ‘‘Do you ever feel pessimistic about everything?’’). The reliability and (factorial) validity of the scale are good [17,28]. We added a psychosis lie scale consisting of four items [38] mirroring common misconceptions about psychosis (cutoff: 8 points): seeing tiny objects like white mice (indicating delirium rather than psychosis); alien abduction (a rare but highly publicized cliche´ symptom); being a famous historical personality (a rare but highly publicized cliche´ symptom); mental lapses during which one becomes another person (i.e., ‘‘split personality’’; a rare/implausible but highly publicized cliche´ symptom).
Scores beyond the cutoff speak for simulation of psychosis and/ or unreliable responses (maximum: 16 points). Simulators have been found to show excessive scores on the lie scale and show much higher scores on the CAPE positive syndrome [39]. 3. Results
2.5. Questionnaires 3.1. Baseline characteristics and completion Participants were required to fill out a number of questionnaires. The survey proceeded only if all items had been responded to. The Paranoia-Obsession-Depression Scale (POD) was administered at baseline and six weeks later. The POD incorporates three
Ninety participants with a likely or verified diagnosis of schizophrenia or psychosis participated. As Table 1 shows, groups did not differ on any background or psychopathological index at baseline. Since randomization was automated (not stratified
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Table 1 Demographic and psychopathological baseline characteristics. Variable
Progressive muscle relaxation (n = 52)
Mindfulness (n = 38)
Statistics (df = 85)
Background Age in years Gender (male/female) Currently in psychological/psychiatric treatment (% yes)
37.46 (10.15) 22/30 81%
38.11 (9.09) 16/22 74%
t = 0.31, P = .757 x2(1) = 0.00, P = .985 x2(1) = 0.64, P = .425
Psychopathology Paranoia Checklist Center for Epidemiological Studies-Depression Scale OCI-R short
35.33 (16.51) 52.02 (18.79) 18.87 (7.13)
36.13 (17.77) 50.53 (17.62) 19.24 (8.16)
t = 0.22, P = .825 t = 0.38, P = .703 t = 0.23, P = .819
CAPE Positive Negative Depression
1.75 (0.46) 2.27 (0.57) 2.28 (0.46)
1.82 (0.30) 2.26 (0.53) 2.25 (0.48)
t = 0.64, P = .519 t = 0.08, P = .933 t = 0.20, P = .843
CAPE: Community Assessment of Psychic Experiences Scale; OCI-R: Obsessive-Compulsive Inventory-revised (abbreviated). Standard deviations in parentheses.
according to diagnoses) and exclusions were made post-hoc (blind to results) the groups were not evenly sized. Results on the CAPE dimensions were in the expected range for patients with verified diagnoses and did not reach the cutoff for people simulating a diagnosis of schizophrenia [39] (M = 2.59 on the positive symptom scale for simulators). Completion (defined as completion at the post-assessment) was 71%; no significant differences emerged between patients in the mindfulness (74% completion) versus PMR (69% completion) condition, x2(1) = 0.21, P = .66. Completers and noncompleters did not differ on any background or psychopathological baseline characteristics (Ps .20). Adherence was satisfactory: 61.5% of the participants in the mindfulness group had fully read the manual (self-report) compared with 51.1% in the PMR group, x2(1) = 0.59, P = .44. 3.2. Per protocol analyses Mixed ANOVAs were computed with Group (Mindfulness, PMR) as the between-subject and Time (pre, post) as the within-subject factors. The POD subscales served as the respective dependent variables. Effect sizes are expressed using h2partial, whereby .01 is equivalent to a small effect, .06 is equivalent to a medium effect and .14 is equivalent to a strong effect [27]. For depression (CES-D), there was a significant effect of Time, which achieved a mediumto-large effect size, F(1, 62) = 6.06, P = .017, hpartial2 = .089
(see Fig. 1). Neither the effect of Group, F(1, 62) = 0.02, P = .89, hpartial2 < .001, nor the interaction of Time Group, F(1, 62) = 0.02, P = .89, hpartial2 < .001, were significant. For paranoia (Paranoia Checklist), neither the effects of Time, F(1, 62) = 0.63, P = .43, hpartial2 = .01, or Group, F(1, 62) = 0.47, P = .50, hpartial2 = .008, nor the interaction, F(1, 62) = 0.14, P = .71, hpartial2 = .002, achieved significance. For OCD symptomatology (OCI-R), the effect of Time bordered significance at a medium effect size, F(1, 62) = 3.91, P = .052, hpartial2 = .059, whereas neither the effect of Group, F(1, 62) = 0.28, P = .60, hpartial2 = .004, nor the interaction, F(1, 62) = 0.23, P = .63, hpartial2 = .004, achieved significance. 3.3. Intention to treat analyses To account for missing values, we calculated linear mixed models. The per protocol results were essentially confirmed. The effect of Time was significant for depression (P = .01) and OCD symptoms (P = .03) but not for paranoia (P = .30). All other effects were nonsignificant (Ps > .4). 3.4. Test–retest reliability The test–retest reliability was satisfactory for all psychopathological scales (Paranoia Checklist: r = .75, P < .001; CES-D: r = .68, P < .001, OCI-R: r = .78, P < .001). 3.5. Subjective effectiveness
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Patients who actively adopted the techniques were asked at post-assessment to assess the manual on a four-point likert scale (fully agree, rather agree, rather disagree, fully disagree). For the following analyses, the response options for fully agree and rather agree were pooled. Most patients found that the programs were suitable for self-administration (mindfulness: 83%; muscle relaxation: 66.6%), found the manuals comprehensible (mindfulness: 100%; muscle relaxation: 83.3%) and useful (mindfulness: 83.3%; muscle relaxation: 50%) and would use the exercises in the future (mindfulness: 83.3%; muscle relaxation: 66.7%); none of the comparisons yielded significance (P > .05).
50
sum score
40
30
20
10
4. Discussion
0
PCL
OCI-R
mindfulness
CES-D
PCL
OCI-R
CES-D
muscle relaxaon
Fig. 1. The entire group showed a moderate decline of depressive and OCD symptoms, while paranoid symptoms remained unchanged from pre (dark grey) to post (light grey) intervention. CES-D: Center for Epidemiologic Studies-Depression Scale; OCI-R: Obsessive-Compulsive Inventory-revised (abbreviated); PCL: Paranoia Checklist.
The present study assessed the effectiveness of relaxation and mindfulness self-help interventions in psychosis. Cognitive and psychotherapeutic approaches are still rarely applied in psychosis, and years ago were even considered potentially harmful. As such, a study on bibliotherapy may be considered by some to be ‘‘doomed.’’ However, in light of the feasibility of other self-help
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approaches for psychosis [3,4], and significant benefits of self-help mindfulness techniques for psychosis as well as other disorders [10,12,51], in our view, our study represents a reasonable and even important endeavor. Some pilot studies were able to detect significant effects of self-help interventions in psychosis, including mindfulness-based techniques [12,51]. Finally, as psychotherapeutic self-help techniques are easily available via (online) bookstores or websites, the efficacy of these forms of intervention needs to be tested, particularly to confirm the sometimes bold claims of the authors. Our retention rate was relatively high (71%). This together with the good test–retest reliability speaks for the practicability and usefulness of the online approach. For both interventions, substantial change occurred for depression and OCD symptoms (medium effect size), while for paranoia, no change was observed. The study thus confirms that relaxation and mindfulness positively impacts affective states (future trials may however also set a waitlist control condition to account for the effects of natural course/passage of time). Somewhat unexpectedly, however, the trial did not detect evidence for the superiority of mindfulness treatment for psychosis relative to PMR when applied as a self-help resource. In view of the rather large sample and the very small effect sizes, insufficient power can be ruled out in explaining the absence of interaction effects. Though the high test–retest reliability and good retention rates, paired with a sizable subsample of patients with a verified diagnosis of schizophrenia, assert the quality of the data, it is hard to draw firm conclusions from the results other than that mindfulness and relaxation are partially effective in reducing depression symptoms in psychosis when applied as a self-help tool. In line with recent results on mindfulness-based therapy for psychosis [55], no adverse effects of mindfulness and relaxation on psychotic symptoms were found. As we did not employ a follow-up measurement, we cannot discern whether a potential superiority of mindfulness over PMR may have evolved at a later point in time (i.e., ‘‘sleeper effect’’). Of note, only a subgroup of patients really read the entire manual. This rate is likely higher if the exercises are performed/introduced in a group and patients are externally prompted to do the exercises (e.g., by therapists or calendar alerts). Importantly, we used classical techniques of mindfulness (such as the body scan) assisted by audio files. While this intervention was clearly unguided in the sense that no therapist presented the exercises and experiences were not subsequently shared with others, the audio files (which were narrated by a psychologist) at least mimicked the presence of a therapist. To raise compliance future trials should use less exercises and describe them more briefly. The mindfulness manual was rather long and presenting individuals with exercises in successive fashion (e.g. weekly emails or electronic (e.g. app) messages with single exercises) may be advisable. Interim reminders may prove helpful in view of often severe memory dysfunction in the disorder [26]. Fifteen pages of text may have overwhelmed some patients in the mindfulness group who are less skilled with reading or suffer from poor attention span (however, self-help books on mindfulness are usually much longer). However, adherence was similar in the control condition, which only consisted of a 3-page manual. For some of the mindfulness techniques, presentation of video clips could have facilitated comprehension. As another suggestion for future trials, the range of symptoms assessed should be expanded. For example, we did not examine whether the treatment ameliorated hallucinations or negative symptoms, which are characteristic of psychosis. Clearly, the possibility that mindfulness therapy is not superior to relaxation techniques cannot be dismissed. For example, a recent sizable study of MBCT against an active control showed no differences in relapse rates in patients with recurrent depression
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[56]. Similar to other forms of intervention, dismantling studies are needed to identify which of the many elements of mindfulness interventions and relaxation procedures are effective or ineffective, and how therapeutic techniques are best delivered. Here, the skills, education and academic background of the therapist deserve special attention. We encourage researchers to evaluate whether other initially therapist-delivered approaches that have proven feasible and partially effective may also be applied as self-help in view of the large treatment gap in psychosis. As mentioned before, it has been estimated that 69% of patients with psychosis in low- and middleincome countries [31] receive no treatment and even in Western countries with an advanced care system, many patients are refused care or do not seek treatment because of resentment of the medical system or are non-adherent to treatment. Even those who get treatment do oftentimes not get the full range of efficacious treatment options – psychotherapeutic techniques are still only rarely adopted in psychosis. These patients may benefit from lowthreshold online or bibliotherapeutic intervention, as even patients with lack of insight into psychosis are often willing to acknowledge that they have a psychological problem (e.g., memory problems, sleeping disorder). Generic approaches may prove particularly valuable here. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Abramowitz JS, Deacon BJ. Psychometric properties and construct validity of the Obsessive-Compulsive Inventory – Revised: replication and extension with a clinical sample. J Anxiety Disord 2006;20:1016–35. [2] Abramowitz JS, Tolin D, Diefenbach G. Measuring change in OCD: sensitivity of the Obsessive-Compulsive Inventory-Revised. J Psychopathol Behav Assess 2005;27:317–24. [3] Alvarez-Jimenez M, Alcazar-Corcoles MA, Gonzalez-Blanch C, et al. Online, social media and mobile technologies for psychosis treatment: a systematic review on novel user-led interventions. Schizophr Res 2014;156:96–106. [4] A´lvarez-Jime´nez M, Gleeson JF, Bendall S, et al. Internet-based interventions for psychosis: a sneak-peek into the future. Psychiatr Clin North Am 2012;35:735–47. [5] Arch JJ, Ayers CR. Which treatment worked better for whom? Moderators of group cognitive behavioral therapy versus adapted mindfulness based stress reduction for anxiety disorders. Behav Res Ther 2013;51:434–42. [6] Arch JJ, Ayers CR, Baker A, et al. Randomized clinical trial of adapted mindfulness-based stress reduction versus group cognitive behavioral therapy for heterogeneous anxiety disorders. Behav Res Ther 2013;51:185–96. [7] Bechdolf A, Klingberg S. Psychotherapy of schizophrenia: not a problem of evidence, but a problem of implementation [Psychotherapie bei schizophrenen Sto¨rungen: Kein Evidenz-, sondern ein Implementierungsproblem]. Psychiatr Prax 2014;41:8–10. [8] Beck AT, Steer RA. Beck Depression Inventory Manual. San Antonio: Psychological Corporation; 1993. [9] Byrne R, Davies L, Morrison AP. Priorities and preferences for the outcomes of treatment of psychosis: a service user perspective. Psychosis 2010;2: 210–7. [10] Cavanagh K, Strauss C, Forder L, Jones F. Can mindfulness and acceptance be learnt by self-help? A systematic review and meta-analysis of mindfulness and acceptance-based self-help interventions. Clin Psychol Rev 2014;34:118–29. [11] Cayoun BA. Mindfulness-integrated CBT: principles and practice. Chichester, U.K.: Wiley & Sons; 2011. [12] Chadwick P. Mindfulness for psychosis. Br J Psychiatry 2014;204:333–4. [13] Coelho HF, Canter PH, Ernst E. Mindfulness-based cognitive therapy: evaluating current evidence and informing future research. Psychol Conscious 2013;1:97–107. [14] Coles ME, Cook LM, Blake TR. Assessing obsessive compulsive symptoms and cognitions on the Internet: evidence for the comparability of paper and Internet administration. Behav Res Ther 2007;45:2232–40. [15] Fjorback LO, Arendt M, Ørnbøl E, et al. Mindfulness-based stress reduction and mindfulness-based cognitive therapy – a systematic review of randomized controlled trials. Acta Psychiatr Scand 2011;124:102–19. [16] Foa EB, Huppert JD, Leiberg S, et al. The Obsessive-Compulsive Inventory: development and validation of a short version. Psychol Assess 2002;14: 485–96.
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Please cite this article in press as: Moritz S, et al. Mindfulness and relaxation treatment reduce depressive symptoms in individuals with psychosis. European Psychiatry (2015), http://dx.doi.org/10.1016/j.eurpsy.2015.05.002