Depression, Migraine
Conditions
Keywords
Acceptance and Commitment Therapy (ACT), Depression, Illness Management, Behavioral treatment, Impairment
Brief summary
The purpose of this research study is to examine whether a one-day group workshop, integrating principles from Acceptance and Commitment Therapy with Migraine Education, will result in improvements in depressive symptoms and functioning impairment in patients with comorbid migraine and depression.
Detailed description
Migraine affects approximately 35 million US residents (Bigal & Lipton, 2009) and is associated with excruciating headache and marked functional impairment. Epidemiological and clinical research has shown that people with migraine suffer from psychiatric disorders at a disproportionately higher rate than individuals without. Depression, in particular, is 3-5 times more common in migraine patients than in non-migraineurs. The comorbidity of depression and migraine is a major health concern as it results in poorer prognosis, remission rate, and response to treatment. In addition, an increase in the severity of migraine is associated with a parallel rise in the severity and treatment resistance of comorbid depression. Recent research in behavioral medicine suggests that the pain experience per se does not necessarily lead to depression or impairment. Instead, it is the preoccupation with avoiding aversive stimuli associated with pain (i.e., activities, places, movements) that results in depression and disability (e.g., McCracken et al., 2005). Therefore, given that patients with migraine and/or depression exhibit more avoidance behaviors and lower activity levels than healthy controls (e.g., Stronks et al., 2004), an intervention aimed at optimizing willingness and acceptance and minimizing behavioral avoidance may be beneficial at improving both their depression and migraine and, consequently, their daily functioning. Acceptance and Commitment Therapy (ACT) is an empirically based behavioral therapy that incorporates acceptance and mindfulness strategies with behavioral change strategies. ACT (in group and in individual settings) is effective in treating psychiatric disorders commonly associated with migraine, including depression, anxiety, and stress (e.g., Hayes, 2001) as well as chronic illnesses like pain and diabetes (Dahl et al, 2004; Gregg et al., 2006). Importantly, ACT resulted in positive long-term outcomes even when presented in brief form. For example, a two-day ACT workshop, in a group setting, led to improvements in depression and distress experienced by parents of children diagnosed with autism and these gains were retained 3 months later. Parents also exhibited a reduction in avoidance behaviors (Blackledge & Hayes, 2006).
Interventions
BEHAVIORALACT-IM
1 hour discussion about migraine management (IM) and 5 hours of group therapy based on Acceptance and Commitment Therapy (ACT). IM covers symptoms and triggers for worsening of migraine symptoms, how to use migraine medications, medication overuse headache, etc. The ACT intervention includes: 1) Behavioral Change Training and; 2) Mindfulness and Acceptance Training emphasizing new ways of managing troubling thoughts, feelings, and physical sensations.
Sponsors
Lilian N. Dindo
Study design
Allocation
NON_RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to 75 Years
Healthy volunteers
No
Inclusion criteria
* Age 18-75 * 4 to 12 migraines in the previous month * Major or Minor Depression * English-speaking
Exclusion criteria
* Patients with other major psychiatric disorders such as bipolor disorder, schizophrenia, and current illicit drug use. * Patients with major head injuries. * Patients with serious medical illnesses. * Patients who have started a new medication in previous 4 weeks or plan on starting a new medication in the next 4 weeks. * Patients expressing significant suicidal ideation.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Mean Change in Hamilton Depression Rating Scale (HAM-D) From Baseline to 12 Week Follow-up | 12 week change from baseline | The HAM-D is a structured clinical interview for assessing depression severity. Outcome measure will be change from Baseline in Hamilton Depression Rating Scale at 12 week (3 month) follow-up from baseline. Measure is scored by adding individual items and attaining an overall severity score. Scores range from 0 to 53, with higher values signifying a higher level of depression severity (and thus a worse outcome). A score of 0-7 is generally accepted to be within the normal range (or in clinical remission), while a score of 20 or higher (indicating at least moderate severity) is usually required for entry into a clinical trial. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Mean Change Score in HDI (Headache Disability Inventory) From Baseline to 12 Weeks. | 12 week change from baseline | The HDI is useful in assessing the impact of headache, and its treatment, on daily living. 25 self-report items are rated with answers as Yes (4 points), Sometimes (2 Points), and No (0 points). All items are then added together to create an overall score which can range from 0 (no impact), to 100 (severe impact) of headache on daily life. A 29 point change (95% confidence interval) or greater in the total score from test to retest must occur before the change can be attributed to treatment effects. |
| Mean Change on Short Form Health Survey (SF-36) From Baseline to 12 Week Follow-up. | Change at 12 week follow-up from baseline | The Short Form (36) Health Survey is a 36-item, patient-reported survey of patient health. The SF-36 consists of eight scaled scores, which are the weighted sums of the questions in their section. Each scale is directly transformed into a 0-100 scale on the assumption that each question carries equal weight. The lower the score the more disability. The higher the score the less disability i.e., a score of zero is equivalent to maximum disability and a score of 100 is equivalent to no disability. |
| Mean Change of World Health Organization Disability Assessment (WHO-DAS) From Baseline to 12-week Follow up. | Change at 12 week follow-up from baseline | The WHODAS contains 36 items on functioning and disability with a recall period of 30 days covering 7 domains: Understanding and Communicating (6 items), Getting around (5 items), Self-care (4 items), Getting along with others (5 items), Life activities: household (4 items), Life activities: work/school (4 items), and Participation in society (8 items). Response options go from 1 (no difficulty) to 5 (extreme difficulty or can not do). WHODAS domain scores are computed for each domain by adding the item responses together. A global score is then computed by summing all domains together, and transforming them into a range from 0 to 100, with higher scores indicating higher levels of disability (0= no disability, 100= full disability). |
Countries
United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| ACT-IM The ACT-IM arm is a brief, one-day intervention that includes two components: 1) Illness Management for Migraine and, 2) Acceptance and Commitment Therapy for emotional difficulties that go along with, or are exacerbated by migraine.
ACT-IM: 1 hour discussion about migraine management (IM) and 5 hours of group therapy based on Acceptance and Commitment Therapy (ACT). IM covers symptoms and triggers for worsening of migraine symptoms, how to use migraine medications, medication overuse headache, etc. The ACT intervention includes: 1) Behavioral Change Training and; 2) Mindfulness and Acceptance Training emphasizing new ways of managing troubling thoughts, feelings, and physical sensations. | 31 |
| Waitlist/Treatment as Usual The Waitlist/Treatment as Usual (WL/TAU)condition completes the same assessments as the active treatment group but does not undergo the active treatment (workshop) until after the 12-week follow-up visit. At that point, the WL/TAU participants are given the opportunity to join a treatment workshop. | 14 |
| Total | 45 |
Baseline characteristics
| Characteristic | ACT-IM | Waitlist/Treatment as Usual | Total |
|---|---|---|---|
| Age, Continuous | 32.5 years STANDARD_DEVIATION 13.3 | 33.5 years STANDARD_DEVIATION 12.9 | 33 years STANDARD_DEVIATION 13.1 |
| Sex: Female, Male Female | 30 Participants | 12 Participants | 42 Participants |
| Sex: Female, Male Male | 1 Participants | 2 Participants | 3 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | — / — | — / — |
| other Total, other adverse events | 0 / 31 | 0 / 14 |
| serious Total, serious adverse events | 0 / 31 | 0 / 14 |
Outcome results
Primary
Mean Change in Hamilton Depression Rating Scale (HAM-D) From Baseline to 12 Week Follow-up
The HAM-D is a structured clinical interview for assessing depression severity. Outcome measure will be change from Baseline in Hamilton Depression Rating Scale at 12 week (3 month) follow-up from baseline. Measure is scored by adding individual items and attaining an overall severity score. Scores range from 0 to 53, with higher values signifying a higher level of depression severity (and thus a worse outcome). A score of 0-7 is generally accepted to be within the normal range (or in clinical remission), while a score of 20 or higher (indicating at least moderate severity) is usually required for entry into a clinical trial.
Time frame: 12 week change from baseline
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| ACT-IM | Mean Change in Hamilton Depression Rating Scale (HAM-D) From Baseline to 12 Week Follow-up | -15.1 units on a scale | Standard Error 1.6 |
| Waitlist/Treatment as Usual | Mean Change in Hamilton Depression Rating Scale (HAM-D) From Baseline to 12 Week Follow-up | -4.3 units on a scale | Standard Error 2.5 |
Secondary
Mean Change of World Health Organization Disability Assessment (WHO-DAS) From Baseline to 12-week Follow up.
The WHODAS contains 36 items on functioning and disability with a recall period of 30 days covering 7 domains: Understanding and Communicating (6 items), Getting around (5 items), Self-care (4 items), Getting along with others (5 items), Life activities: household (4 items), Life activities: work/school (4 items), and Participation in society (8 items). Response options go from 1 (no difficulty) to 5 (extreme difficulty or can not do). WHODAS domain scores are computed for each domain by adding the item responses together. A global score is then computed by summing all domains together, and transforming them into a range from 0 to 100, with higher scores indicating higher levels of disability (0= no disability, 100= full disability).
Time frame: Change at 12 week follow-up from baseline
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| ACT-IM | Mean Change of World Health Organization Disability Assessment (WHO-DAS) From Baseline to 12-week Follow up. | -9.1 units on a scale | Standard Error 2 |
| Waitlist/Treatment as Usual | Mean Change of World Health Organization Disability Assessment (WHO-DAS) From Baseline to 12-week Follow up. | -.3 units on a scale | Standard Error 2.9 |
Secondary
Mean Change on Short Form Health Survey (SF-36) From Baseline to 12 Week Follow-up.
The Short Form (36) Health Survey is a 36-item, patient-reported survey of patient health. The SF-36 consists of eight scaled scores, which are the weighted sums of the questions in their section. Each scale is directly transformed into a 0-100 scale on the assumption that each question carries equal weight. The lower the score the more disability. The higher the score the less disability i.e., a score of zero is equivalent to maximum disability and a score of 100 is equivalent to no disability.
Time frame: Change at 12 week follow-up from baseline
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| ACT-IM | Mean Change on Short Form Health Survey (SF-36) From Baseline to 12 Week Follow-up. | 17.0 units on a scale | Standard Error 2.5 |
| Waitlist/Treatment as Usual | Mean Change on Short Form Health Survey (SF-36) From Baseline to 12 Week Follow-up. | 7.7 units on a scale | Standard Error 3.8 |
Secondary
Mean Change Score in HDI (Headache Disability Inventory) From Baseline to 12 Weeks.
The HDI is useful in assessing the impact of headache, and its treatment, on daily living. 25 self-report items are rated with answers as Yes (4 points), Sometimes (2 Points), and No (0 points). All items are then added together to create an overall score which can range from 0 (no impact), to 100 (severe impact) of headache on daily life. A 29 point change (95% confidence interval) or greater in the total score from test to retest must occur before the change can be attributed to treatment effects.
Time frame: 12 week change from baseline
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| ACT-IM | Mean Change Score in HDI (Headache Disability Inventory) From Baseline to 12 Weeks. | -27.9 units on a scale | Standard Error 3.4 |
| Waitlist/Treatment as Usual | Mean Change Score in HDI (Headache Disability Inventory) From Baseline to 12 Weeks. | -10.7 units on a scale | Standard Error 5.2 |