You are on page 1of 31

Author’s Accepted Manuscript

Detached mindfulness reduced both depression and


anxiety in elderly women with major depressive
disorders

Mohammad Ahmadpanah, Tayebe Akbari, Amineh


Akhondi, Mohammad Haghighi, Leila Jahangard,
Dena Sadeghi Bahmani, Hafez Bajoghli, Edith
Holsboer-Trachsler, Serge Brand www.elsevier.com/locate/psychres

PII: S0165-1781(16)31288-4
DOI: http://dx.doi.org/10.1016/j.psychres.2017.07.030
Reference: PSY10664
To appear in: Psychiatry Research
Received date: 5 August 2016
Revised date: 4 July 2017
Accepted date: 14 July 2017
Cite this article as: Mohammad Ahmadpanah, Tayebe Akbari, Amineh Akhondi,
Mohammad Haghighi, Leila Jahangard, Dena Sadeghi Bahmani, Hafez Bajoghli,
Edith Holsboer-Trachsler and Serge Brand, Detached mindfulness reduced both
depression and anxiety in elderly women with major depressive disorders,
Psychiatry Research, http://dx.doi.org/10.1016/j.psychres.2017.07.030
This is a PDF file of an unedited manuscript that has been accepted for
publication. As a service to our customers we are providing this early version of
the manuscript. The manuscript will undergo copyediting, typesetting, and
review of the resulting galley proof before it is published in its final citable form.
Please note that during the production process errors may be discovered which
could affect the content, and all legal disclaimers that apply to the journal pertain.
Detached mindfulness reduced both depression and anxiety in elderly women with major
depressive disorders

Mohammad Ahmadpanaha, Tayebe Akbarib, Amineh Akhondic, Mohammad Haghighia, Leila


Jahangarda, Dena Sadeghi Bahmanid, Hafez Bajoghlie, Edith Holsboer-Trachslerd, Serge
Brandd,f, g*

a
Behavioral Disorders and Substances Abuse Research Center. Hamadan University of
Medical Sciences, Hamadan, Iran
b
White Jasmine Adult Nursing Home. Hamadan, Iran
c
Hamadan Educational Organization, Ministry of Education. Hamadan, Iran
d
Psychiatric Clinics of the University of Basel, Center for Affective, Stress und Sleep
Disorders, University of Basel, Basel, Switzerland
e
Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical
Sciences, Tehran, Iran
f
Department of Sport, Exercise and Health, Division of Sport and Psychosocial Health,
University of Basel, Basel, Switzerland
g
Sleep Disorders Research Center, Kermanshah University of Medical Sciences (KUMS),
Kermanshah, Iran

*Corresponding address. Serge Brand, PhD, University of Basel, Psychiatric Clinics (UPK),
Center for Affective, Stress and Sleep Disorders (ZASS), Wilhelm Klein-Strasse 27, 4012
Basel – Switzerland, +4161 32 55 114 (voice), +4161 32 55 513 (fax), serge.brand@upkbs.ch

1
Abstract
We investigated the influence of detached mindfulness (DM) in treating symptoms of

depression and anxiety among elderly women. Thirty-four elderly females (mean age: 69.23

years) suffering from moderate major depressive disorders (MDD) and treated with a standard

medication (citalopram) at therapeutic doses were randomly assigned either to an intervention

condition (DM; group treatment, twice weekly) or to a control condition (with leisure

activities, twice weekly). At baseline (BL), four weeks later at study completion (SC), and

four weeks after that at follow-up (FU), participants completed ratings for symptoms of

depression and anxiety; experts blind to patients’ group assignments rated patients’ symptoms

of depression. Symptoms of depression (self and experts’ ratings) and anxiety declined

significantly over time in the DM, but not in the control condition. Effects remained stable at

FU. The pattern of results suggests that, compared to a control condition, a specific

psychotherapeutic intervention such as DM can have a beneficial effect in elderly female

patients with MDD.

Key-words; depression, anxiety, elderly, metacognitive detached mindfulness, healthy


controls

2
1. Introduction
Major depressive disorders (MDD) are unsurprisingly among the most common of

psychiatric disorders. Moreover, Murray and Lopez (1997) have calculated that MDDs are

responsible for the second highest number of years lost due to premature death or disability,

with chronic lifelong risk for recurrent relapse, and high morbidity, co-morbidity and

mortality (Culpepper et al., 2015; Gonda et al., 2015; Lockwood et al., 2015;, Kennedy and

Paykel, 2004; Fava and Ruini, 2002). Accordingly, adequate treatment and care of patients

suffering from MDD is highly desirable for both clinical and economic reasons. However,

several studies indicate that the efficacy of antidepressants is limited; a therapeutic effect is

achieved at most in 60-70% of patients suffering from major depressive disorders (Castren,

2005), with maximum adherence of 50% four weeks after starting treatment (Cassano and

Fava, 2002), probably due to an antidepressant effect time lag of two or more weeks (Castren,

2005), and to various adverse side-effects such as weight gain, dry mouth, and sexual

dysfunction (Reichenpfader et al., 2014).

The first-line options in the treatment of severe MDD are antidepressants. In treating

mild to moderate MDD, psychotherapeutic interventions (e.g. Cuijpers et al., 2011a,b) and

physical activity (Kvam et al., 2016; Josefsson et al., 2014) are valuable options both by

themselves and in combination with antidepressants or ECT (Salehi et al. , 2016). Schuch et al.

(2016) concluded from their meta-analysis that physical activity is a valid treatment option

and should also be considered as a routine component of the management of depression in

older adults.

In the present study, we focused on a psychotherapeutic intervention, and specifically

on detached mindfulness (DM). Briefly, DM is a standardized, time-limited

psychotherapeutic intervention based on metacognitive psychotherapy (see below and Table

2). Metacognitive interventions or detached mindfulness (Solem et al., 2017, 2015) focus on

thinking about one’s own thinking; more specifically, metacognitive interventions ask to what

3
extent one’s own thoughts are helpful in becoming aware (‘mindful’) of mental processes

such as thoughts and feelings, and to increase the capacity to disrupt (or ‘detach’) the relation

between thoughts and reactions to thoughts (Wells, 2006). Specifically, detached mindfulness

aims to strengthen the belief that thoughts are nothing more than inner events separate from

the control of action. Or to put it another way, detached mindfulness helps to achieve

awareness of negative thoughts, to identify and isolate them as mere mental processes, and to

avoid turning these (negative) thoughts into action. Detached mindfulness (DM) has been

used successfully with patients with obsessive-compulsive disorders, generalized anxiety

disorders, and major depressive disorders (Wells et al., 2012; Spada et al., 2010, Wells, 2006;

Matthews and Wells, 2000), and also with patients suffering from hypertension (Ahmadpanah

et al., 2016a).

Given these encouraging results, and given the standardized, economic and time-

limited character of DM as an intervention, in the present study we sought to investigate the

influence of DM concomitantly on both depression and anxiety among elderly patients with

MDD. Such a procedure is justified given numerous observations of the high comorbidity of

MDD and anxiety disorders among adolescents, young adults (Melton et al., 2016; Coplan et

al., 2015; Leventhal and Zvolensky, 2015; Quante, 2015), and the elderly (Beattie et al., 2010;

Flood and Buckwalter, 2009; Devanand, 2002; Lenze et al., 2002). Furthermore, Cuijpers et

al. (2011a, b) have shown in a systematic review and meta-analyses that psychological

interventions to treat patients with major depressive disorders are superior to control

conditions, though concomitant effects on anxiety have not been investigated (Hollon and

Ponniah, 2010), nor has the focus of previous studies been on older populations.

Specifically, Laidlaw (2013) also pointed out that findings regarding the

psychotherapeutic treatment of depression and anxiety have often been based on studies of

younger adults or older adults with symptoms of depression and anxiety, though without

diagnosed MDD (see also Klainin-Yobas et al., 2015). To counter this, the first aim of the

4
present study was to compare the influence of DM and a control condition on elderly female

patients diagnosed with MDD. To our knowledge, there has been no research into the longer-

term effects of DM on this category of patients following completion of treatment (Karyotaki

et al., 2016). The second aim of the present study, therefore, was to investigate whether MDM

has an effect four weeks after study completion and if so the scale of such an effect. Third,

given the substantial overlap between symptoms of depression and of anxiety among the

elderly (Beattie et al., 2010; Flood and Buckwalter, 2009; Devanand, 2002; Lenze et al. 2002),

the present study also aimed to investigate the influence of DM on both sets of symptoms

among older patients diagnosed with MDD.

Two hypotheses and two research questions were formulated. First, following Wells

(Wells et al., 2012; Wells, 2006), Ahmadpanah et al. (2016a), Spada et al. (2010), and Hollon

and Ponniah (2010), we expected improvements in symptoms of depression and anxiety, as

rated by patients and experts, in the intervention condition, but not in the control condition. .

Second, following Karyotaki et al. (2016), we anticipated that the influence of DM would

persist for four weeks after intervention completion. We treated as exploratory research

questions whether and under which of the two condition participants would show a response

(first research question) and full remission (second research question).

2. Method
2.1. Procedure

Eligible participants were recruited from the Retirement Home Center of Habib Ibn

Mazaher (Hamadan, Iran). Participants were fully informed about the aims and the procedure

of the study. Furthermore, they were informed about the anonymous data analysis, and that

participation or non-participation would have no influence on their ongoing treatment. All

participants gave written informed consent. Subsequently, participants completed two

5
questionnaires relating respectively to depression and anxiety (see below). Next, they were

randomly assigned either to the intervention or to the control group (see below for details).

The intervention lasted four weeks (study completion [SC]), and assessments were repeated

four weeks later (follow-up [FU]). In parallel, experts blind to participants’ group allocation

rated the latter’s level of depression at baseline, at study completion and at follow-up.

The study was approved by the ethics committee of the University of Hamadan

(Hamadan, Iran) and conducted in accordance with the rules laid down in the Declaration of

Helsinki (World Medical association: http://www.wma.net/en/30publications/10policies/b3/).

2.2. Sample
A total of 34 elderly women (mean age: M = 69.23 years, SD = 4.35) diagnosed with

MDD took part in the study. Inclusion criteria were as follows: 1. Age between 65 and 85

years. 2. Currently suffering from MDD, as diagnosed by a psychiatrist or clinical

psychologist not otherwise involved in the study, and based on a clinical psychiatric interview

with the Structured Clinical Interview for DSM Disorders (SCID; First et al., 1997; Farsi

version: Sharifi et al., 2009). 3. Self-reported symptoms of depression, as rated by the

Geriatric Depression Scale (five or more points; see description below). 4. Symptoms of

depression, as rated by experts (Montgomery-Asberg Depression Rating Scale Ahmadpanah

et al., 2016b; between 7 to 34 points: mild to moderate depression). 5. Suffering from

symptoms of anxiety, as self-reported on the Beck Anxiety Inventory (BAI; Beck et al., 1988;

16 or more points; see description below). 6. Monotherapy with a standard SSRI (citalopram)

at therapeutic levels. 7. Written informed consent. 8. Able and willing to complete self-rating

questionnaires. 9. Mini Mental State Examination (MMSE, Folstein et al., 1975; 26 points or

higher). 10. Life time depressive episodes: three or less.

Exclusion criteria were: 1. Not meeting the inclusion criteria (see above). 2. Suicidal

or psychotic state within the six months prior to study enrollment. 3. Other psychiatric

6
disorders, specifically addiction disorders. 4. Undergoing other treatments such as physical

activity training, relaxation techniques, psychotherapy, or similar. 5. Undergoing treatments

such as rTMS, or ECT.

As shown in Figure 1, 85 eligible participants were approached; of those, 36 (42.4.9%)

were recruited, 19 being allocated to intervention condition, and 17 and to the control

condition. During the study, two participants dropped out of the intervention condition. While

36 participants completed the study, the statistical analysis was performed following the

intent-to-treat algorithm with the last-observation-carried-forward (LOCF) procedure.

Table 1 gives the descriptive and inferential statistics for the socio-demographic and

illness-related variables, separately for patients in the DM group and in the control group. No

significant differences were observed between the two study conditions. Accordingly, socio-

demographic and illness-related variables were not introduced as covariates.

2.3. Randomization

As described elsewhere (Ghaleiha et al., 2016; Haghighi et al., 2014), a psychologist

not otherwise involved in the study prepared an opaque ballot box containing 2 x 20 chips in

two different colors. Each color represented a study condition. The chips were mixed, the

patient drew a chip and was assigned to the corresponding study condition.

7
2.4. Tools

2.4.1 Depression (self-report)


The Geriatric Depression Scale (GDS; Sheikh and Yesavage, 1986) was employed.

This self-rating questionnaire consists of 15 items focusing on typical symptoms of

depression such as feeling hopeless, lonely, and sad, social withdrawal, weight loss, or loss of

interest in usual pursuits. Answers are yes (= 1) or no (= 0), with higher scores reflecting a

higher level of depression (Cronbach’s alpha = 0.87). Categorization was made as follows

(Sheikh et al., 1991): 0–4 points: no depression; 5-9 points: mild to moderate depression; 10-

15 points: severe depression.

2.4.2. Depression (experts’ ratings); Montgomery-Asberg Depression Rating Scale


Experts rated patients’ symptoms of depression with the Montgomery-Asberg

Depression Rating Scale (MADRS; original: Montgomery and Asberg, 1979; Farsi validation:

Ahmadpanah et al., 2016). The 10 items forming the scale assess the following symptoms: 1.

apparent sadness; 2. reported sadness; 3. inner tension; 4. reduced sleep; 5. reduced appetite; 6.

concentration difficulties; 7. lassitude; 8. inability to feel; 9. pessimistic thoughts; 10. suicidal

thoughts. Answers are given on a 6-point Likert scale ranging from 0 (= not at all) to 6 (=

definitely), with higher scores reflecting more severe symptoms (Cronbach’s alpha = 0.89).

Categorization was made as follows (Ahmadpanah et al., 2016b; Montgomery and Asberg,

1979): 0-6 points: no depression; 7-19 points: mild depression; 20-34 points: moderate

depression; > 34 points: severe depression.

2.4.3. Anxiety (self-report)

8
Symptoms of anxiety were assessed with the Beck Anxiety Inventory (BAI; Beck et al.

1988). Kaviani and Mosavi (2008) have reported robust and reliable psychometric properties

for the Farsi version of this inventory. The BAI consists of 21 items addressing typical

cognitive, emotional and bodily signs of anxiety such a fear of the worst happening,

numbness and tingling, or sweating not due to heat. Answers are given on 4-point rating

scales with the anchor points 0 (= not at all) and 3 (= severely/it bothered me a lot), and with

higher sum scores reflecting greater symptoms of anxiety (Cronbach’s alpha = 0.88).

Categorization was made as follows (Kaviani and Mousavi, 2008; Beck et al., 1988): 0-9:

minimal anxiety; 10-16: mild anxiety; 17-29: moderate anxiety; 30-63: severe anxiety.

2.5. Interventions

2.5.1. Detached mindfulness (DM) therapy

As described in an earlier intervention study involving patients with hypertension

(Ahmadpanah et al., 2016a), detached mindfulness practice is a form of cognitive

psychotherapeutic intervention aimed at learning how and where to guide one’s attention, and

to focus on thinking about thinking. More specifically, DM aims at becoming aware of one’s

negative thoughts, but recognizing them as mere mental processes without the need to follow

their impulses (see Introduction).

Trained clinical psychologists performed the psychotherapeutic sessions, which lasted

about 60-90min. Sessions took place twice a week as group therapy with 7 to 9 participants

per group, and lasted for four consecutive weeks. Table 2 describes the individual sessions.

Additionally, patients were asked to exercise individually at least three times per week.

9
2.5.2. Control condition

Participants in the control condition met twice a week in small groups to engage in

leisure activities together. These guided and supervised activities included walking through

the park and the woods, painting lessons, museum visits, handcrafts, and similar. The duration,

frequency and intensity of the ‘special program’ for the control condition were identical to the

intervention condition: four consecutive weeks, twice a week for 60-90min per session.

Follow-up (FU) took place four weeks after study completion (SC).

2.5.3. Pharmacologic intervention

All patients were treated with citalopram (an SSRI) at therapeutic dosages. At least

four weeks before being enrolled in the study, patients started pharmacological treatment with

citalopram (40mg/d), which was maintained at this level until the follow-up (2*4 weeks).

With respect to the initial pharmacological intervention, patient-reported side effects included

dry mouth, sweating, nausea and vertigo.

2.6. Response

Response was defined as symptom improvement of 50% or more. Symptoms of depression:

self-rating, Geriatric Depression Scale; experts’ ratings: Montgomery-Asberg Depression

Rating Scale; anxiety scores: Beck Anxiety Inventory.

2.7. Statistical analysis


2.7.1. Preliminary calculations

10
At baseline, there were no statistically or descriptively significant group differences

for age, symptom severity (depression: self- and experts’ ratings; self rated anxiety; see also

Table 2), mental status (Mini Mental Status Examination), number of previous depressive

episodes (see Table 1), or other inclusion and exclusion criteria. Accordingly, no covariates

were entered in the equations.

Data were analyzed as intention-to-treat, with LOCF. Three ANOVAs for repeated

measures were performed with Group (intervention vs. control condition), Time (baseline,

study completion, follow-up), and the Group-by-Time interaction as independent factors and

the depression and anxiety scores as dependent variables. Post-hoc tests were performed with

Bonferroni-Holm corrections for p-values. To allow for deviations from sphericity, statistical

tests were performed using Greenhouse–Geisser corrected degrees of freedom. Throughout

the paper the original degrees of freedom are reported with the relevant Greenhouse-Geisser

epsilon value (ε). To calculate whether the distribution of responders and remitters at SC and

FU differed between the intervention and the control condition, a series of odds-ratio

calculations were performed. The nominal level of significance was set at alpha < 0.05. All

statistics were performed with SPSS® 22.0 (IBM Corporation, Armonk NY, USA) for Apple

Mac®.

3. Results

3.1. Symptoms of depression, self- and experts’ ratings

Tables 3 and 4 give a descriptive and inferential statistical overview for symptoms of

depression as self- (GDS) and expert (MADRS) rated. Statistical indices are only reported in

11
the Tables. Figure 2 displays symptoms of depression over time and separately for the two

groups, as rated by experts.

Symptoms of depression decreased over time, but more so in the treatment than in the

control condition (significant time by group interaction). Compared to the control condition,

symptoms of depression were significantly lower in the treatment condition. Post-hoc

analyses after Bonferroni-Holm corrections for p-values showed that at SC, depression scores

were significantly lower in the treatment than the control condition. Post-hoc analyses after

Bonferroni-Holm corrections for p-values showed that at FU depression scores were still

significantly lower in the treatment than the control condition (see also Figure 2).

3.2. Anxiety scores (self-rating)

Tables 3 and 4 also give a descriptive and inferential statistical overview for

symptoms of anxiety, as self-rated with the BAI. Statistical indices are reported only in the

Tables. Figure 3 shows the self-rated symptoms of anxiety over time and separately for the

two groups.

Symptoms of anxiety decreased over time, but more so in the treatment than in the

control condition (significant time by group interaction). Anxiety scores did not significantly

differ between the two groups. Post-hoc analyses after Bonferroni-Holm corrections for p-

values showed that at SC, anxiety scores were significantly lower and clinically relevant (cf.

Beck et al. 1988) in the treatment condition than in the control condition. Post-hoc analyses

12
after Bonferroni-Holm corrections for p-values showed that anxiety scores were still

significantly and clinically lower in the treatment condition than in the control condition at

FU (see also Figure 3).

3.3. Response rate at study completion and at follow-up

With the first research question we explored whether and under which of the two

conditions response to treatment would be observed at SC and FU. A decrease of 50% or

more was defined as response to treatment. Response to treatment was observed at SC and FU

in the DM condition but not in the control condition (symptoms of depression [self- and

experts’ ratings] and anxiety).

3.4. Remission rates at study completion and at follow-up

With the second research question we explored whether and if so in which study

condition remissions were observed at SC and FU. The following remission criteria were

applied: Geriatric Depression scale (Sheikh et al., 1991; Sheikh, 1985): 0–4 points = no

depression; Montgomery-Asberg Depression Scale (Ahmadpanah et al., 2016b; Montgomery

and Asberg, 1979): 0-6 points: no depression; Beck Anxiety Inventory (Hossein and Mousavi,

2008; Beck et al., 1988): 0-9: minimal anxiety.

13
As summarized in Table 6, the likelihood of a full remission from depression (self-

and experts’ ratings) was 7.65-15.53-fold higher in the intervention than in control group. No

such pattern of results was found for anxiety scores.

4. Discussion
The key finding of the present study was that, compared to a control condition,

detached mindfulness (DM) psychotherapy led to significant reductions in symptoms of

depression (self- and experts’-rated) and anxiety among elderly women diagnosed with major

depressive disorders and treated with a standard antidepressant. Furthermore, the present

study expanded upon the current literature in showing that the influence of DM persisted even

four weeks after the end of treatment (follow-up).

Two hypotheses and two research questions were formulated and each of these is

considered in turn.

Our first hypothesis was that the MDM intervention would have reduced symptoms of

depression (self- and experts’ rated) and anxiety by completion of the intervention program,

and this was confirmed (see Tables 3 and 4, and Figure 2). In this regard, the present findings

are in line with previous results (Ahmadpanah et al., 2016a; Wells et al., 2012; Spada et al.,

2010; Wells, 2006; Hollon and Ponniah, 2010). However, the present findings also expand

upon previous research in filling a gap in psychotherapeutic research that has largely focused

on younger adults without a diagnosis of major depressive disorders (Laidlaw, 2013).

Moreover, we confirmed that DM had the potential to reduce symptoms of depression and

anxiety among older people (Klainin-Yobas et al., 2015; Cuijpers et al., 2011a, 2011b). Given

the substantial overlap between symptoms of depression and of anxiety that also exists among

the elderly (Beattie et al., 2010; Flood and Buckwalter, 2009; Devanand, 2002; Lenze et al.,

2002), this result was to be expected. It is also noteworthy that symptoms of depression were

14
assessed both by participants and by experts blind to participants’ group allocation; we

believe this further confirms the reliability and validity of the intervention effect and its

clinical relevance.

Our second hypothesis was that, four weeks after the intervention, symptoms of

depression and anxiety would remain stable, and this was confirmed. As shown in Tables 3

and 4 and in Figures 2 and 3, following completion of the DM intervention symptoms of

depression and anxiety remained low, a finding in line with previous research (Karyotaki et

al., 2016). On the other hand, symptoms of depression and anxiety also remained unchanged

in the control condition; that is to say, there were no improvements, but also no deterioration

from baseline to completion of the intervention to follow-up.

Our research questions concerned whether and if so in which group response and

remission would be observed. As reported in the text and in Table 5 and 6, response and

remission in depression (self- and experts’ ratings) were observed in the intervention but not

in the control condition. Notably, the odds of remission with respect to depression were 8 to

15-fold higher in the treatment than in the control condition. We believe this outcome is an

encouraging indication of the efficacy of employing psychotherapeutic interventions

concomitantly with medication treatment with a standard SSRI (citalopram) at therapeutic

levels.

Remitter- and odds-ratio calculations (Table 6) also showed that remission was

generally not achieved as regards anxiety. This result is at odds with the observed

improvements in anxiety (see Tables 3 and 4 and Figure 3), though it is possible that the

remission criterion of nine points or less on a scale from 0 to 63 is too exacting.

The question remains as to why detached mindfulness should have a positive and

enduring impact on patients’ symptoms of depression and anxiety. The data available to us

were insufficient to shed light on the underlying cognitive-emotional processes. However, as

15
elaborated elsewhere (Ahmadpanah et al., 2016a), the following would appear to be possible

explanations.

Detached mindfulness exercises increase awareness of current effects on the cognitive

system and information processing by focusing on breathing and attention to the body and to

the present (“here and now”). Furthermore, the impact of DM on anxiety in a group therapy

setting can be explained as follows: patients are over-sensitized to concerns and anxieties and

are more inclined to misinterpret psychological symptoms and bodily sensations as symptoms

of anxiety. Accordingly, challenging their misinterpretations and reframing their cognitive-

emotional concepts of what might be more or less fearful could have led to a decrease in their

levels of anxiety.

On the other hand, techniques such as DM cause changes in the attitudes and

cognitions of patients such that they accept their current physical and psychological state,

engage with its mental consequences, and learn that emotions and negative thoughts are

nothing more than transient inner processes carrying no requirement that these be translated

into action.

Despite the positive findings of this study, several limitations warrant against

overgeneralization. First, in Iran, wards and health care units are gender-segregated;

consequently psychotherapeutic interventions are also gender-segregated, and in the present

study only females were assessed. Thus, it remains unclear to what extent the present findings

would generalize to male patients. Second, sleep was not assessed, though several studies

have shown poor sleep to be causally related to poor mental health (Lovato and Gradisar,

2014), and that, compared to males, females complain more about insomnia (Zhang and Wing,

2006). Third, the present pattern of results might have emerged due to further latent but

unassessed dimensions (such as motivation, attachment styles, expectations, subjectively

perceived peer acceptance and rejection), which might have biased two or more variables in

the same or opposite directions. Fourth, we applied statistical procedures, which by definition

16
assumed linear associations. However, a more fine-grained day-by-day analysis would have

allowed for the exploration of non-linear processes, with possible accelerated improvements

at the beginning of the treatment and continuous deceleration. Such a microanalysis would

allow for the fine-tuning of interventions in terms of frequency, duration and intensity.

Further, it would also have permitted a clearer understanding as to why for patients in the

control condition the impact of the social setting was apparently zero, or at least not aversive.

However, this observation does not support the so-called social deprivation hypothesis, which

explains the emergence and maintenance of symptoms of depression in terms of low social

interaction rates (Lewinsohn, 1974). Rather, as regards the control group, the pattern of

results suggested that the cognitive-emotional content of social contacts rather than the mere

fact of social contact seems to be of particular importance. Fifth, as regards the control

condition, we observed that the psychopharmacologic treatment with SSRIs had no beneficial

(and no detrimental) effects. We believe this pattern of results is consistent with that from a

recent study among primiparae with postpartum depression (Ahmadpanah et al., in press):

While both Detached Mindfulness and Stress Management Training reduced symptoms of

depression after eight to sixteen weeks, no substantive changes were observed in the control

group treated with a standard SSRI (citalopram). Sixth, a major limitation of the study is the

absence of any direct evidence concerning patients’ cognitive-emotional processes: what

cognitive-emotional concepts if any were modified, and why? Furthermore, while the DM

intervention had effects that persisted for at least four weeks beyond completion of the

program, we do not know what cognitive-emotional processes might have been responsible

for this effect. Accordingly, we believe that future studies should focus more directly on the

effect of psychotherapeutic interventions on patients’ cognitive-emotional concepts. This is

especially important as Driessen et al. (2015) have shown that a publication bias might inflate

the apparent efficacy of psychological treatments for MDDs (as is also the case for

pharmacotherapy).

17
5. Conclusion
Compared to a control condition reproducing very similar social conditions, detached

mindfulness (DM) reduced symptoms of depression and anxiety in elderly female patients

with major depressive disorders (MDD), both over the course of a four week intervention and

four weeks after completion of this program.

Conflict of interests and financial disclosure


All authors declare no conflicts of interest. The entire study was performed without

external funding.

Acknowledgements
We thank Nick Emler (University of Surrey, Surrey UK) for proofreading the

manuscript.

18
References

Abbott, R.A., Whear, R., Rodgers, L.R., Bethel, A., Thompson Coon, J., Kuyken, W., et al.,
2014. Effectiveness of mindfulness-based stress reduction and mindfulness
based cognitive therapy in vascular disease: A systematic review and meta-
analysis of randomised controlled trials. J. Psychosom. Res. 76, 341-351.
Ahmadpanah, M., Paghale, S.J., Bakhtyari, A., Kaikhavani, S., Aghaei, E., Nazaribadie, M., et
al., 2016a. Effects of psychotherapy in combination with pharmacotherapy,
when compared to pharmacotherapy only on blood pressure, depression, and
anxiety in female patients with hypertension. J. Health Psychol. 21, 1216-1227.
Ahmadpanah, M., Sheikhbabaei, M., Haghighi, M., Roham, F., Jahangard, L., Akhondi, A., et
al., 2016b. Validity and test-retest reliability of the Persian version of the
Montgomery-Asberg Depression Rating Scale. Neuropsych. Dis. Treat. 12, 603-
607.
Ahmadpanah, M., Nazaribadie, M., Aghaei, E., Ghaleiha, A., Bakhtiari, A., Haghighi, M., et
al., in press. Influence of adjuvant detached mindfulness and stress management
training compared to pharmacologic treatment in primiparae with postpartum
depression. Archives of Women's Mental Health.
Archer, T., Josefsson, T., Lindwall, M., 2014. Effects of physical exercise on depressive
symptoms and biomarkers in depression. CNS Neurol. Disord. Drug Targets. 13,
1640-1653.
Beattie, E., Pachana, N.A., Franklin, S.J., 2010. Double jeopardy: Comorbid anxiety and
depression in late life. Res. Geront. Nur. 3, 209-220.
Beck, A.T., Epstein, N., Brown, G., Steer, R.A., 1988. An inventory for measuring clinical
anxiety: psychometric properties. J Consult Clin Psychol. 56, 893-897.
Brand, S., Holsboer-Trachsler, E., Naranjo, J.R., Schmidt, S., 2012. Influence of
mindfulness practice on cortisol and sleep in long-term and short-term
meditators. Neuropsychobiol. 65, 109-118.
Brüne, M., 2015. Textbook of Evolutionary Psychiatry and Psychosomatic Medicine. The
Origins of Psychopathology. Oxford University Press, Oxford, UK.
Buss, D.M., 2015. Evolutionary Psychology. The New Science of the Mind, 5th ed.
Routledge, Taylor & Francis, London-New York.
Cassano, P., Fava, M., 2002. Depression and public health: an overview. J. Psychosom Res.
53, 849-857.
Castren, E., 2005. Is mood chemistry? Nat Rev Neurosci. 6, 241-246.
Chambers, R., Gullone, E., Allen, N.B., 2009. Mindful emotion regulation: an integrative
review. Clin. Psychol. Rev. 29, 560-572.
Coplan, J.D., Aaronson, C,J,, Panthangi, V., Kim, Y., 2015. Treating comorbid anxiety and
depression: Psychosocial and pharmacological approaches. W. J Psychiatr. 5,
366-378.
Cuijpers, P., Andersson, G., Donker, T., van Straten, A., 2011a. Psychological treatment of
depression: results of a series of meta-analyses. Nord J Psychiatry. 65, 354-364.
Cuijpers, P., Clignet, F., van Meijel, B., van Straten, A., Li, J., Andersson, G.. 2011b.
Psychological treatment of depression in inpatients: a systematic review and
meta-analysis. Clin Psychol Rev. 31, 353-360.
Culpepper, L., Muskin, P.R., Stahl, S.M., 2015. Major Depressive Disorder: Understanding
the Significance of Residual Symptoms and Balancing Efficacy with Tolerability.
Am J Med. 128, S1-s15.

19
Devanand, D.P., 2002. Comorbid psychiatric disorders in late life depression. Biol.
Psychiatry. 52, 236-242.
Driessen, E., Hollon, S.D., Bockting, C.L., Cuijpers, P., Turner, E.H., 2015. Does publication
bias inflate the apparent efficacy of psychological treatment for major depressive
disorder? A systematic review and meta-analysis of US National Institutes of Health-
funded trials. PLoS One. 10, e0137864.
Fava, G.A., Ruini, C., 2002. The sequential approach to relapse prevention in unipolar
depression. World Psychiatry. 1, 10-15.
First, M.B.G.M., Spitzer, R,L., Williams, J.B.W., Benjamin, L.S., 1997. Structured Clinical
Interview for DSM-IV Axis II Personality Disorders, (SCID-II). American
Psychiatric Press, Washington, DC.
Flood, M., Buckwalter, K.C., 2009. Recommendations for mental health care of older
adults: Part 1--an overview of depression and anxiety. J Geront. Nurs. 35, 26-34.
Folstein, M.F., Folstein, S.E., McHugh, P.R., 1975. "Mini-mental state". A practical method
for grading the cognitive state of patients for the clinician. J. Psychiatr. Res. 12,
189-198.
Ghaleiha, A,, Davari, H,, Jahangard, L,, Haghighi, M,, Ahmadpanah, M,, Seifrabie, M,A., et al.,
2016. Adjuvant thiamine improved standard treatment in patients with major
depressive disorder: results from a randomized, double-blind, and placebo-
controlled clinical trial. Eur. Arch. Psychiatry Clin. Neurosci. 266, 695-702.
Gonda, X., Pompili, M., Serafini, G., Carvalho, A.F,, Rihmer, Z., Dome, P., 2015. The role of
cognitive dysfunction in the symptoms and remission from depression. Ann.
Gen. Psychiatry. 14, 27.
Haghighi, M., Khodakarami, S., Jahangard, L., Ahmadpanah, M., Bajoghli, H., Holsboer-
Trachsler, E., et al., 2014. In a randomized, double-blind clinical trial, adjuvant
atorvastatin improved symptoms of depression and blood lipid values in
patients suffering from severe major depressive disorder. J. Psychiatr. Res. 58,
109-114.
Hollon, S.D., Ponniah, K., 2010. A review of empirically supported psychological
therapies for mood disorders in adults. Depress. Anxiety. 27, 891-932.
Hossein Kaviani, H., Mousavi, A.S., 2008. Psychometric properties of the Persian version
of Beck Anxiety Inventory (BAI). Tehran University Medical Journal. 66, 136-
140.
Jahangard, L., Soroush, S., Haghighi, M., Ghaleiha, A., Bajoghli, H., Holsboer-Trachsler, E.,
et al., 2014. In a double-blind, randomized and placebo-controlled trial,
adjuvant allopurinol improved symptoms of mania in in-patients suffering from
bipolar disorder. Eur. Neuropsychopharmacol. 24, 1210-1221.
Josefsson, T., Lindwall, M., Archer, T., 2014. Physical exercise intervention in depressive
disorders: meta-analysis and systematic review. Scand. J. Med. Sci. Sports. 24,
259-272.
Kang YG, J, Grey J.R. Mindfulness and de-automatization. Emotion Review. 2013;5:191-
201.
Karyotaki, E., Smit, Y., de Beurs, D.P., Henningsen, K.H., Robays, J., Huibers, M.J., et al.
2016. The long-term efficacy of acute-phase psychotherapy for depression: a
meta-analysis of randomized trials. Depress. Anxiety, 33, 370-383.
Kennedy, N., Paykel, E.S., 2004. Residual symptoms at remission from depression:
impact on long-term outcome. J. Affect. Dis. 80, 135-144.
Klainin-Yobas, P., Oo, W.N., Suzanne Yew, P.Y., Lau, Y., 2015. Effects of relaxation
interventions on depression and anxiety among older adults: a systematic
review. Aging Ment. Health. 19, 1043-1055.

20
Kvam, S., Kleppe, C.L., Nordhus, I.H., Hovland, A., 2013. Exercise as a treatment for
depression: A meta-analysis. J. Affect. Dis. 2016;202:67-86.
Laidlaw, K., 2013. A deficit in psychotherapeutic care for older people with depression
and anxiety. Gerontology. 59, 549-556.
Lenze, E.J., Mulsant, B.H., Shear, M.K., Houck, P., Reynolds, I.C., 2002. Anxiety symptoms
in elderly patients with depression: what is the best approach to treatment?
Drugs & Aging. 19, 753-760.
Leventhal, A.M., Zvolensky, M.J., 2015. Anxiety, depression, and cigarette smoking: a
transdiagnostic vulnerability framework to understanding emotion-smoking
comorbidity. Psychol. Bull. 141, 176-212.
Lewinsohn, P.M., 1974. A behavioral approach to depression, in: Friedman, R., Katz, M.
(Eds.), Psychology of Depression: Contemporary Theory and Research. Winston-
Wiley, Washington, DC., pp. 157-185.
Lockwood, L.E., Su, S., Youssef, N.A., 2015. The role of epigenetics in depression and
suicide: A platform for gene-environment interactions. Psychiatr. Res. 28, 235-
242.
Lovato, N., Gradisar, M., 2014. A meta-analysis and model of the relationship between
sleep and depression in adolescents: recommendations for future research and
clinical practice. Sleep Med. Revs. 18, 521-529.
Matthews, G., Wells, A., 2000. Attention, automaticity, and affective disorder. Behavior
Modification. 24, 69-93.
Melton, T.H., Croarkin, P.E., Strawn, J.R., McClintock, S.M., 2016. Comorbid anxiety and
depressive symptoms in children and adolescents: A systematic review and
analysis. J. Psych. Practice, 22. 84-98.
Montgomery, S.A., Asberg, M., 1979. A new depression scale designed to be sensitive to
change. Br. J. Psychiatry 134, 382-389.
Murray, C.J., Lopez, A.D., 1997. Global mortality, disability, and the contribution of risk
factors: Global Burden of Disease Study. Lancet. 349, 1436-1442.
Norton, A.R., Abbott, M.J., Norberg, M.M., Hunt, C., 2015. A systematic review of
mindfulness and acceptance-based treatments for social anxiety disorder. J Clin.
Psychol. 71. 283-301.
Quante ,A., 2015. [Acute pharmacotherapy for anxiety symptoms in patients with
depression]. Fortschritte der Neurologie-Psychiatrie. 83, 142-148.
Reichenpfader, U., Gartlehner, G., Morgan, L.C., Greenblatt, A., Nussbaumer, B., Hansen,
R.A., et al., 2014. Sexual dysfunction associated with second-generation
antidepressants in patients with major depressive disorder: results from a
systematic review with network meta-analysis. Drug Safety. 37, 19-31.
Salehi, I., Hosseini, S.M., Haghighi, M., Jahangard, L., Bajoghli, H., Gerber, M., et al., 2016.
Electroconvulsive therapy (ECT) and aerobic exercise training (AET) increased
plasma BDNF and ameliorated depressive symptoms in patients suffering from
major depressive disorder. J. Psychiatr. Res. 76, 1-8.
Schuch, F.B., Vancampfort, D., Rosenbaum, S., Richards, J., Ward, P.B., Veronese N, et al.
2016. Exercise for depression in older adults: a meta-analysis of randomized
controlled trials adjusting for publication bias. Rev. Bras. Psiquiatr. 38, 247-254.
Sharifi, V., Assadi, S.M., Mohammadi, M.R., Amini, H., Kaviani, H., Semnani, Y., et al., 2009.
A Persian translation of the Structured Clinical Interview for Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition: psychometric properties.
Compr. Psychiatry. 50, 86-91.

21
Sheikh, J.I., Yesavage, J.A., Brooks, J.O., 3rd, Friedman, L., Gratzinger, P., Hill, R.D., et al.,
1991. Proposed factor structure of the Geriatric Depression Scale. Int.
Psychogeriatr. 3, 23-28.
Sheikh, J.I.Y., 1985. Geriatric Depression Scale (GDS): Recent evidence and development
of a shorter version. Clinical Gerontologist. 5, 165-173.
Solem, S., Hagen, R., Wang, C.E., Hjemdal, O., Waterloo, K., Eisemann, M., et al., 2017.
Metacognitions and mindful attention awareness in depression: A comparison
of currently depressed, previously depressed and never depressed individuals.
Clinical Psychology & Psychotherapy. 24, 94-102.
Solem, S., Thunes, S.S., Hjemdal, O., Hagen, R., Wells, A., 2015. A metacognitive
perspective on mindfulness: An empirical investigation. BMC Psychol. 3:24.
Spada, M.M., Georgiou, G.A., Wells, A., 2010. The relationship among metacognitions,
attentional control, and state anxiety. Cogn. Behav. Ther. 39, 64-71.
Stevens, A., Price, J. 2000. Evolutionary Psychiatry. A New Beginning. Routledge, Taylor
& Francis Group, London-New York.
Wells, A., 2006. Detached mindfulness in cognitive therapy: A metacognitive analysis
and ten techniques. Journal of Rationale-Emotive & Cognitive-Behavior Therapy.
23, 337-355.
Wells, A., Fisher, P., Myers, S., Wheatley, J., Patel, T., Brewin, C.R., 2012. Metacognitive
therapy in treatment-resistant depression: a platform trial. Behav. Res. Ther. 50,
367-373.
Wiles, N., Thomas, L., Abel, A., Barnes, M., Carroll, F., Ridgway, N., et al., 2104. Clinical
effectiveness and cost-effectiveness of cognitive behavioural therapy as an
adjunct to pharmacotherapy for treatment-resistant depression in primary
care: the CoBalT randomised controlled trial. Health. Technol. Assess. 18. 1-167,
vii-viii.
Zhang, B., Wing, Y.K., 2006. Sex differences in insomnia: a meta-analysis. Sleep. 29, 85-93.

Table 1 Descriptive and inferential statistical indices of socio-demographic and illness-


related information of patients in the Detached Mindfulness group and Control group.

Groups Statistics
Detached Control
Mindfulness condition
condition
N 17 17
Age (years) 68.28 (5.28) 70.18 (6.56) t(32) = 0.98, p = 0.33
Mini Mental Status 27.83 (1.07) 28.18 (0.89) t(32) = 1.05, p = 0.30

22
Examination
Civil status (single- 11/6 9/8 X2(N = 34; df = 1) =
widowed/married) 0.49, p = 0.49)

Duration of current 3.65 (2.03) 3.47 (1.77) t(32) = 0.27, p = 0.79


episode (months)
Number of previous 1.11 (0.53) 1.29 (0.89) t(32)= 0.56, p = 0.67
episodes

Table 2. Metacognitive detached mindfulness therapy; sessions and description.

Sessions Session description


1. Orientation, motivation, goal of sessions; BDI
2. Explanation of treatment plan, metacognitive detached mindfulness
therapy, Attention Training Techniques (ATT)
3. Discussion of home assessment, training and exercise of
metacognitive leading, assessment against prevented inhibition
4. Discussion of home assessment, training and exercise of association
techniques
5. Discussion of home assessment, training and exercise of wandering
mind and task orientation
6. Discussion of home assessment, training and exercise of circle words
and unruly child management
7. Discussion of home assessment, training and exercise of imagery
clouds and train station tasks
8. Review of techniques and completion of BDI

Notes: BDI = Beck Depression Inventory

23
Table 3 Descriptive overview of symptoms of depression (self- and experts’ ratings) and anxiety
(self-rating), separately for Time (baseline, on study completion, and 4 weeks later at follow-up),
and separately for the two groups (detached mindfulness DM; controls CG)

Groups

Detached Mindfulness Control group

Baseline Study Follow- Baseline Study Follow-

completion up completion up
(BL) (BL)

(SC) (FU) (SC) (FU)

N 19 17

M (SD) M (SD) M (SD) M (SD) M (SD) M (SD)

Geriatric Depression 8.12 4.00 (2.69) 4.30 8.53 8.65 (2.69) 9.06

Scale (GDS; self-rating) (2.67) (2.46) (3.43) (2.46)

Beck Anxiety Inventory 34.29 21.24 20.88 36.71 40.65 40.00

(BAI; self-rating) (7.10) (9.25) (7.22) (8.84) (8.32) (9.08)

Depression (MADSR; 30.06 12.19 13.60 29.43 30.83 29.88

experts’ ratings) (2.52) (6.78) (6.00) (4.21) (5.40) (4.56)

Notes: MADRS = Montgomery-Asberg Depression Rating Scale.

24
Table 4 Inferential statistical overview of symptoms of depression (self- and experts’ ratings)
and anxiety (self-rating), separately for Time (pre-test, on completion of the study (post-test),
and 4 weeks later at follow-up), Group (metacognitive detached mindfulness MDM; controls CG),
and the Time by Group interaction

Factors

Time Group Time * Group Post-hoc tests

interaction

F partial F partial F partial eta2 Greenhouse- Study Follow-

eta2 eta2 Geisser completion up

epsilon

Geriatric 9.34*** 82.26*** 52.05*** 0.927 MDM < CG MDM <

Depression 0.23 [L] 0.73 [L] 0.63 [L] CG

Scale (GDS;

self-rating)

Beck Anxiety 0.12 75.70*** 41.67*** 0.895 MDM < CG MDM <

Inventory (BAI; 0.004 [S] 0.71 [L] 0.57 [L] CG

self-rating)

Depression 5.45*** 54.99*** 36.23*** 0.901 MDM < CG MDM <

(experts’ 0.20 [L] 0.64 [L] 0.45 [L] CG

ratings;

MADSR)

Notes: MADRS = Montgomery-Asberg Depression Rating Scale; MDM = metacognitive detached


mindfulness; CG = control group. Degrees of freedom for Group: (1, 31); degrees of freedom for
Time: (2, 62); degrees of freedom for Time * Group interaction: (2, 62). *** = p < 0.001. All
variables are controlled for baseline. [S] = small effect size; [L] = large effect size.

25
Table 5 Response rates at study completion four weeks later, and at follow-up four weeks
after study completion.

Time points

Study completion Follow-up


DM CG Statistics DM CG Statistics
R/NR R/NR R/NR R/NR
Geriatric Depression Scale 9/8 3/14 X2(1, 36) 10/9 4/13 X2(1, 36)
(GDS; self-rating) = 8.45** = 5.34*

Montgomery-Asberg 8/9 1/16 X2(1, 36) 9/10 2/15 X2(1, 36)


Depression Rating Scale = 8.41** = 7.15*
(MADRS; experts’ rating)

Beck Anxiety Inventory 3/16 1/16 X2(1, 36) 4/15 5/12 X2(1, 36)
(BAI; self-rating) = 3.29 = 4.53*

DM = detached mindfulness; CG = control group; R/NR = response/non-response. * = p <


0.05, ** = p <0.01, *** = p < 0.001.

Table 6 Remission rates at baseline, at study completion four weeks later, and at follow-
up four weeks after study completion.

Time points

Baseline Study completion Follow-up


DM CG Statisti DM CG Statisti DM CG Statistic
cs cs s
R/N R/N R/N R/N R/N R/N
R R R R R R
Geriatric 0/1 0/1 - 7/1 0/1 X2(1, 10/ 0/1 X2(1,
Depression 9 7 2 7 36) = 9 7 36) =
Scale (GDS; 18.55** 14.17**
self-rating) * *

OR = OR =
15.53, 11.34,
CI = CI =
0.14- 0.35-
0.64 0.83
Montgomer 0/1 0/1 - 10/ 0/1 X2(1, 9/1 0/1 X2(1,
y-Asberg 9 7 9 7 36) = 0 7 36) =
Depression 10.46** 8.82**

26
Rating *
Scale OR =
(MADRS; OR = 8.43, CI
experts’ 7.65, CI = 0.41-
rating) = 0.34- 0.88
0.83
Beck 0/1 0/1 - 2/1 1/1 X2(1, 4/1 2/1 X2(1,
Anxiety 9 7 7 6 36) = 5 5 36) =
Inventory 1.12 3.65
(BAI; self-
rating) OR = OR =
1.4, CI 2.54 CI
= 0.48- = 0.82-
5.65 7.65

DM = detached mindfulness; CG = control group; R/NR = remission/non-remission. *** =


p < 0.001.

Highlights

· Detached mindfulness (DM) was employed to treat symptoms of depression and anxiety

· Participants were elderly women (mean age: 69 years) with major depressive disorders

· Compared to the control condition, in he DM condition, but not in the control condition

· Effects of DM remained stable even four weeks after study completion.

27
Enrollment Assessed for eligibility (n= 85)

Excluded (n= 49)


¨ Did not meet inclusion criteria (n= 30)
¨ Declined to participate (n= 14)
¨ Other reasons (n= 5)

Randomized (n= 36)

Allocation
Allocated to active intervention (n= 19) Allocated to control condition (n= 17)
¨ Received allocated intervention (n= 19) ¨ Received allocated intervention (n= 17)
¨ Did not receive allocated intervention (n= 0) ¨ Did not receive allocated intervention (give
reasons) (n= 0)

Follow-Up
Lost to follow-up (n= 2) Lost to follow-up (n= 0)

Discontinued intervention (give reasons) (n= 0)

Analysis
Analysed (n= 19) = intention-to-treat-analysis Analysed (n= 17)
Figure 2

Montgomery-Asberg Depression scores (MADRS; experts’ ratings) decreased over time (F =


5.45, p < 0.001), but more so in the Detached Mindfulness group (DM), compared to the control
condition (CC) (F = 36.23, p < 0.001). Mean scores were significantly lower in the Detached
Mindfulness group than in the the control group. (F = 54.99, p < 0.001). After study completion,
scores remained unaltered in both groups. Points are means and bars are standard deviations. For
visual clarity, standard deviations are represented only in one direction.
Figure 3

Beck Anxiety scores (self-rating) did not decrease over time (F = 0.12), though anxiety scores decreased
over time in the Detached Mindfulness group (DM), compared to the control condition (CC) (F = 41.67,
p < 0.001). Compared to the control condition, anxiety scores were significantly lower in the Detached
Mindfulness group (F = 75.70, p < 0.001). After study completion, scores remained unaltered in both
groups. Points are means and bars are standard deviations. For visual clarity, standard deviations are
represented only in one direction.