John M. Talmadge, M.D.

A Blog Covering Many Topics

Mindfulness Therapy: Alternative to Antidepressants

Many psychiatrists like me recommend mindfulness and cognitive therapy to our patients. These two approaches work well together because psychotherapy ("talk therapy" is best when individualized rather than using a "cookbook" approach. One size does not fit all. The legendary British medical journal The Lancet (April 2015 includes a recent scientific paper showing that mindfulness-based cognitive therapy (MBCT) could provide an alternative non-drug treatment for people who do not wish to continue long-term antidepressant treatment. This is one example of brain science at its best.

Mindfulness-based cognitive therapy aims to change the way people think and feel about their experiences. How we think affects how we feel. And the use of mindfulness practice is relatively easy for most people. Just 10-15 minutes two or three times daily makes a difference. The current study compares MBCT with maintenance antidepressant medication for reducing the risk of relapse in depression. The results are encouraging.

The study aimed to establish whether MBCT is superior to maintenance antidepressant treatment in terms of preventing relapse of depression. Although the findings show that MBCT isn't always more effective than maintenance antidepressant treatment in preventing relapse of depression, the results, combined with those of previous trials, suggest that MCBT may offer similar protection against relapse or recurrence for people who have experienced multiple episodes of depression, with no significant difference in cost.

"Mindfulness gives me a set of skills which I use to keep well in the long term. Rather than relying on the continuing use of antidepressants mindfulness puts me in charge, allowing me to take control of my own future, to spot when I am at risk and to make the changes I need to stay well." — Study Participant

MBCT builds on the insight that when people with a history of depression experience even a brief period of feeling low they tend to be especially vulnerable to negative thinking. That negative thinking is often accompanied by what’s known as “processing biases”: worrying about past problems, for example, or returning to unpleasant memories. Thinking like this raises the risk of a full-blown depressive episode.

MBCT focuses on helping people to become more aware of these thoughts and feelings, and thus better able to gain distance from them. As its founders put it: “We discover that difficult and unwanted thoughts and feelings can be held in awareness, and seen from an altogether different perspective – a perspective that brings with it a sense of warmth and compassion to the suffering we are experiencing.”

Female Veteran Suicides

My first experience working with our veterans was during the Vietnam era, when I trained at Duke University Medical Center and The University of Wisconsin Medical Center. Fifteen years ago I was the first director of our UT Southwestern Addiction Psychiatry Fellowship Program, and our primary clinical service was at The North Texas VA Healthcare System ("the VA Hospital") in Dallas. Compared to the 1970's, the military today is increasingly diverse, and for the first time we are treating many women who have served in our armed forces. The latest studies on suicide in the military are alarming. The 2012 VA Report on Suicide can be found here, and the main findings are cited below.

Women are generally a lot less likely to kill themselves than men, but female veterans are an exception with shockingly high suicide rates, according to new Veterans Affairs Department research. Among women of all ages who have served in the military, the suicide rate is 28.7 per 100,000—higher than the rate among male civilians, nearly six times the rate of civilian women, and approaching the 32.1 rate among male veterans. "It's staggering," a Northeastern University epidemiologist said to the Los Angeles Times. "We have to come to grips with why the rates are so obscenely high." Women vets ages 18 to 29 kill themselves at nearly 12 times the rate of civilian women the same age, but the rate was up to eight times higher even among women who served in the 1950s. It is not clear what is driving the rates. VA researchers and experts who reviewed the data for The Times said there were myriad possibilities, including whether the military had disproportionately drawn women at higher suicide risk and whether sexual assault and other traumatic experiences while serving played a role.

The VA suicide study involved data on 173,969 adult suicides in 23 states over 11 years, which included the deaths of 40,571 male vets and 2,637 female vets. The article in Psychiatric Services also says that that people who join the military are more likely to have had troubled childhoods; and it could be the case that women who signed up were at higher risk of suicide in the first place.

• While the percentage of all suicides reported as Veterans has decreased, the number of suicides has increased.
• A majority of Veteran suicides are among those age 50 years and older.
• Male Veterans who die by suicide are older than non-Veteran males who die by suicide.
• The age distribution of Veteran and non-Veteran women who have died from suicide is similar.
• The demographic characteristics of Veterans who have died from suicide are similar among those with and without a history of VHA service use.
• Among those at risk, the first 4 weeks following service require intensive monitoring and case management. • There is preliminary evidence in 2012 indicating a decrease in the rate of non-fatal suicide events for VHA utilizing Veterans.
• Decreasing rates of non-fatal suicide events are associated with increasing age.
• The data show a decrease in the 12 month re-event prevalence in fiscal year (FY) 2012.
• The majority of Veterans who have a suicide event were last seen in an outpatient setting.
• A high prevalence of non-fatal suicide events result from overdose or other intentional poisoning.
• Continued increases in calls to the Veterans Crisis Line may be associated with efforts to enhance awareness of VHA services through public education campaigns.
• The majority of callers to the Veterans Crisis Line are male and between the ages of 50- 59.
• Differences in the age composition of callers to the Veterans Crisis Line are associated with gender.
• A large percentage of callers to the Veterans Crisis Line are identified as Veterans.
• Approximately 19 percent of callers to the Veterans Crisis Line call more than once each month.
• The percentage of callers to the Veterans Crisis Line who are currently thinking of suicide has decreased.
• The percentage of all calls resulting in a rescue has decreased, indicating that the calls are less emergent and callers are using the Crisis Line earlier.
• The percentage of callers receiving a referral for follow-up care is increasing.
• Approximately 93 percent of all Veterans Crisis Line referrals are made to callers with a history of VHA service use in the past 12 months.
• Service use continues to increase following a referral for care.
• Between FY 2009 – FY 2011, use of inpatient and outpatient services increased following a rescue.
• The 12 month re-event prevalence has decreased among those who have been rescued or received a referral for follow-up care.