Posted 04.15.2019 | by AMRA
Most patients with mild-to-moderate psychological problems are diagnosed and treated in primary care rather than mental health settings. Many of these patients also suffer from physical disorders, or from physical symptoms caused or made worse by psychological factors. Mindfulness-based programs that reduce anxiety and depression and promote self-care are useful supplements to primary care treatments; however, existing barriers hinder their successful implementation. These barriers include limitations on staff time and training, staff unfamiliarity with mindfulness, and problems with insurance reimbursement.
Gawande et al [Mindfulness] studied the feasibility, acceptability, and effectiveness of a mindfulness-based primary care program in reducing symptoms and improving self-care for patients with mild-to-moderate psychological problems.
The researchers randomly assigned 81 primary care patients (69% female; average age = 44; 78% Caucasian; 44% meditation naive) with anxiety, depressive, stress- or trauma-related disorders to either a Mindfulness Training for Primary Care (MTPC) program or a low-dose comparison group. If participants were already receiving psychological help in the primary care setting, they continued to receive it as usual.
MTPC is an 8-week group program based on Mindfulness-Based Cognitive Therapy that incorporates elements of self-compassion training, values clarification, and relapse prevention. MTPC and low dose comparison group participants were asked to develop a self-care plan together with their primary care providers during the sixth week of the program. MTPC group leaders were either appropriately trained mental health clinicians or primary care physicians, with the groups being tailored to meet the insurance requirements of each discipline.
The low dose comparison control consisted of a one-hour didactic/experiential introduction to mindfulness with information on how to access community and digital mindfulness resources. Low dose comparison participants were also placed on a 6-month MTPC waiting list. All participants were assessed at baseline and again at 8-weeks on self-report measures of anxiety, depression, perceived stress, self-efficacy, self-control, mindfulness (Five Facet Mindfulness Questionnaire), and self-compassion.
MTPC participants showed significant pre-post decreases in anxiety (d = -0.72), stress (d = – 0.81), and depression (d = -0.40), as well as significant pre-post increases in self-efficacy (d = 0.43), self-compassion (d = 1.01), and mindfulness (d = 0.93). The low dose comparison participants showed a significant decrease in stress (d = -0.50). Three between-group differences reached statistical significance, with the MTPC group showing a greater decrease in anxiety and a greater increase in self-compassion and mindfulness than the controls.
Based on self-ratings, MTPC participants were significantly more likely to have taken steps towards implementing their six-week self-care plan than low dose comparison participants (35% compared to 11%).
Over the course of 14 months, primary care physicians made 344 referrals to the program, with about a quarter of referred individuals actually enrolling. Most visits were paid for by insurance, although some patients were upset at unexpected out-of-pocket costs and copays. 65% of MTPC participants attended at least 6 of the 9 group sessions with 67% of MTPC participants and 70% of low dose comparison participants completing post-intervention assessments.
The majority of MTPC participants (92%) who completed the final assessments said they would recommend the program to a friend. The only adverse event attributable to MTPC was a panic attack experienced by one participant during the 7-hour retreat.
This study provides evidence for the initial efficacy of delivering an insurance-reimbursable mindfulness program within a primary care setting. MTPC patients demonstrated a greater decrease in anxiety and larger increases in mindfulness and self-compassion than controls. The study is limited by its reliance on self-report measures, its lack of an attention-matched control, and its relatively high final questionnaire non-completion rate.
Gawande, R., Pine, E., Griswold, T., Creedon, T., Vallejo, Z., Rosenbaum, E., . . . Schuman-Olivier, Z. (2019). Insurance-Reimbursable mindfulness for safety-net primary care patients: A pilot randomized controlled trial. Mindfulness.