Background
Each year, it is estimated up to 3.5 million Canadians will access health services for a primary mood or anxiety disorder [1], and individuals with an anxiety disorder are known to be at an increased risk of developing a comorbid major depressive disorder [2]. These mental health conditions are associated with general medical conditions [3, 4], poor psychosocial functioning [5, 6], and poor occupational functioning [7, 8], leading to significant burden on both affected individuals and society [9]. Canadian clinical practice guidelines list Cognitive Behaviour Therapy (CBT) as a first line treatment for both anxiety and major depressive disorders [2, 10]. CBT is an empirically based psychotherapy with robust evidence for the treatment of adult anxiety and depression [11-13]. CBT is based on identifying and shifting clients’ dysfunctional cognitions and behaviours to reduce maladaptive emotions [14].
CBT is administered in diverse settings by a variety of health care practitioners including general practice physicians, psychiatrists, psychologists, nurses, and occupational therapists. Practitioners traditionally administer CBT to clients individually or in small group sessions, but ensuring equitable and timely access to CBT skills is challenging within this delivery model [15]. Poor access to treatment is a major issue precluding effective public health initiatives in anxiety and depression management, with a substantial proportion of individuals not receiving treatment despite a perceived need [16, 17]. Offering brief, low-intensity CBT within a stepped care model is one strategy aimed at improving CBT access in Canada [18]. Examples include self-help books, website based therapies, and, of particular interest to our study, large psychoeducational groups [19]. Administering CBT in a large-group is a promising solution which enables clinicians to reach a large number of clients.
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Large-group CBT was introduced at a tertiary care clinic in Winnipeg, Canada in 2014 to manage the problem of persistently long wait times. These transdiagnostic 2-session CBT classes were rated useful by clients, led to modest improvements in anxiety symptoms, and reduced wait-times from approximately one year to three months [20]. Given these promising findings and client feedback, the CBT classes were expanded to 4 sessions and introduced mindfulness within the core content. These 4 session transdiagnostic Cognitive Behaviour Therapy with Mindfulness (CBTm) classes were independently developed and administered at the clinic to introduce clients to CBT principles, basic mindfulness strategies, and to provide various self-help resources at a time where they otherwise may not have had access to therapy.
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Mindfulness is the process of being nonjudgmentally aware of the present moment, including one’s thoughts, sensations and environment, while encouraging inquisitiveness, open observation, and acceptance [21, 22].Evidence suggests mindfulness-based interventions, such as mindfulness-based cognitive therapy (MBCT) and mindfulness-based stress reduction (MBSR), are effective in treating anxiety and depression [22, 23]. Mindfulness, as it is taught in these interventions and in the CBTm classes, is intended to reduce identification with thoughts and feelings by cultivating an awareness of the impermanence (arising, passing and changing) of these mind productions. There is accumulating evidence that mindfulness meditation, with the goal of calm attentiveness and acceptance, down-regulates mental activity within the default mode network (DMN). DMN activation is associated with mind wandering, negative affect and rumination as experienced by those with anxiety or depression [24]. Other work shows that mindfulness may improve cognitive flexibility, working memory capacity, goal directed behaviour, and emotional regulation, as one’s attention and cognitive resources are shifted away from dysfunctional thoughts and emotions [25]. Moreover, these complex functions may be modulated by neural networks, whose resources can be constrained by negative emotions and mind wandering; meditation allows for a more flexible allocation of these limited resources, such that they may be available for other, more salutary, cortical functions [24].
To our knowledge, there is no research on brief, low intensity, large group CBT interventions which incorporate mindfulness in the literature. Thus, the current study sought to evaluate the 4-session CBTm class intervention in a Canadian population. We conducted a retrospective chart review of clients who attended classes between 2015 and 2016. The two primary outcomes were: (a) acceptability and retention rates of CBTm classes and (b) clients’ change in anxiety and depressive symptoms as a result of attending CBTm classes. Recent UK studies demonstrated similar large-group CBT interventions are efficient, well tolerated, and effective in treating symptoms of anxiety and depression [26-28]. Thus, we hypothesized the CBTm classes would replicate these findings by being acceptable, both in terms of client feedback and retention rates, and lead to improvements in anxiety and depressive symptoms.
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