Cases That Test Your Skills
A life of drugs and ‘downtime’
Unrelenting depression and opioid addiction have destroyed Mr. B’s career and marriage. Numerous medications have not improved either condition....
What could be perpetuating Mr. B’s depression?
a) psychosocial stressors
b) over-expression of CRF gene due to psychosocial stressors
c) a and b
Treatment Mindfulness practice
Mr. B was started on CBT to manage anxiety symptoms and cognitive distortions. After 2 months, he reports no improvements in anxiety, depression, or cognitive distortions.
We consider MBI for Mr. B, which was developed by Segal et al7 to help prevent relapse of depression and gain the benefits of MM. There is evidence that MBI can prevent relapse of SUDs.12 Mr. B’s MBI practice is based on MBCT, as outlined by Segal et al.7 He attends biweekly, 45-minute therapy sessions at our outpatient clinic. During these sessions, MM is practiced for 10 minutes under a psychiatrist’s supervision. The MBCT manual calls for 45 minutes of MM practice but, during the 10-minute session, we instruct Mr. B to independently practice MM at home. Mr. B is assessed for relapses, and drug cravings; a urine toxicology screen is performed every 6 months.
We score Mr. B’s day-to-day level of mindfulness experience, depression, and anxiety symptoms before starting MBI and after 8 weeks of practicing MBI (Figure 1). Mindfulness is scored with the Mindful Attention Awareness Scale (MAAS), a valid, reliable scale.13 The MAAS comprises 15 items designed to reflect mindfulness in everyday experiences, including awareness and attention to thoughts, emotions, actions, and physical states. Items are rated on a 6-point Likert-type scale of 1 (“almost never”) to 6 (“almost always”). A typical item on MAAS is “I find myself doing things without paying attention.”
Depression and anxiety symptoms are measured using the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder Scale-7 (GAD-7) Item Scale. Mr. B scores a 23 on PHQ-9, indicating severe depression (he reports that he finds it ‘‘extremely difficult” to function) (Figure 2).
There is evidence to support the use of PHQ-9 for measurement-based care in the psychiatric population.14 PHQ-9 does not capture anxiety, which is a strong predicator of suicidal behavior; therefore, we use GAD-7 to measure the severity of Mr. B’s subjective anxiety.15 He scores a 14 on GAD-7 and reports that it is “very difficult” for him to function.
Mr. B is retested after 8 weeks. During those 8 weeks, he was instructed by audio guidance in body scan technique. He practices MBI techniques for 45 minutes every morning between 5 AM and 6 AM.6
After 3 months of MBI, Mr. B is promoted at work and reports that he is handling more responsibilities. He is stressed at his new job and, subsequently, experiences a relapse of anxiety symptoms and insomnia. Partly, this is because Mr. B is not able to consistently practice MBI and misses a few outpatient appointments. In the meantime, he has difficulties with sleep and concentration and anxiety symptoms.
The treating psychiatrist reassures Mr. B and provides support to restart MBI. He manages to attend outpatient clinic appointments consistently and shows interest in practicing MBI daily. Later, he reports practicing MBI consistently along with his routine treatment at our clinic. The timeline of Mr. B’s history and treatment are summarized in Figure 3.
The authors’ observations
Mr. B’s CRF may have been down-regulated by MBI. This, in turn, decreased his depressive and anxiety symptoms, thereby helping to prevent relapse of depression and substance abuse. He benefited from MBI practices in several areas of his life, which can be described with the acronym FACES.10
Flexible. Mr. B became more cognitively flexible. He started to realize that “thoughts are not facts.”7 This change was reflected in his relationship with his wife. His wife came to one of our sessions because she noticed significant change in his attitude toward her. Their marriage of 15 years was riddled with conflict and his wife was excited to see the improvement he achieved within the short time of practicing MBI.
Adaptive. He became more adaptive to changes at the work place and reported that he is enjoying his work. This is a change from his feeling that his job was a burden, as he observed in our earlier sessions.
Coherent. He became more cognitively rational. He reported improvement in his memory and concentration. Five months after initiation of MBI and MM training, he was promoted and could cope with the stress at work.
Energized. Initially, he had said that he never wanted to be part of his extended family. During a session toward the end of the treatment, he mentioned that he made an effort to contact his extended family and reported that he found it more meaningful now to be reconnected with them.