Archives of Psychiatric Nursing 28 (2014) 314318

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Archives of Psychiatric Nursing

journal homepage: www.elsevier.com/locate/apnu

Effectiveness of Mindfulness-Based Cognitive Therapy for Co-Morbid

Depression in Drug-Dependent Males
Navidreza Hosseinzadeh Asl a,, Usha Barahmand b
a
b

Hacettepe University, Ankara, Turkey

University of Mohaghegh Ardabili, Iran

a b s t r a c t
The present study aimed at examining the effect of Mindfulness-Based Cognitive Therapy (MBCT) in
decreasing depression symptoms in dully diagnosed males (drug dependent males with co-morbid
depression).An experimental research design with pre- and post-tests and a control group was used. The
sample of the study comprised 33 drug-dependent men who also endorsed depression symptoms on the Beck
Depression Inventory II (BDI-II). All the selected individuals were assigned randomly to either the
intervention group or control group (16 to the intervention and 17 to the control group). The intervention
group experienced eight 2-h sessions of training in MBCT. At the end of the training, the subjects were once
again evaluated using the BDI-II. Analysis of co-variance was used to analyze the data. The results suggested
that MBCT did contribute to a signicant decrease in the depression symptoms of the dully diagnosed
individuals. It is recommended that the MBCT be used for treating depression in drug-dependent males
undergoing detoxication and treatment for their drug dependence.
2014 Elsevier Inc. All rights reserved.

Substance abuse is a major public health problem that affects

millions of people and imposes substantial nancial and social
burdens on society. According to DSM-5, the essential characteristic
of a substance use disorder is a set of cognitive, behavioral and
psychological symptoms indicating that the individual continues
using the substance despite experiencing signicant problems arising
from the continued consumption (American Psychiatric Association,
2013). Substance use disorders are chronic and recurrent with a
longitudinal recovery. Therefore, despite the documented efcacy of
several psychological and behavioral interventions for substance use
disorders (Anderson, 2004), client compliance is generally poor and
relapse to problematic substance use is a common occurrence
(Rotgers, Keller, and Morgenstern, 1996). There are many risk factors
for relapse. Some of the reasons mentioned by addicts for their
relapses include, apart from social pressure, adverse life events, work
stress, and marital conict, co-existing psychiatric problems like
depression, and anxiety disorders (Billings & Moos, 1983; Cummings,
Gordon, & Marlatt, 1980; Littman, Stapleton, & Oppenheim, 1983).
Mental illness can greatly increase the risk of addiction relapse if left
untreated.
Many patients seeking treatment or patients referred to addiction
therapy centers manifest comorbid depression in addition to the
diagnosis of substance use disorder (Beck, Wright, Newman, & Liese,
Corresponding Author: Navidreza Hosseinzadeh Asl, PhD student, Hacettepe
University, Ankara, Turkey.
E-mail addresses: navidrha@yahoo.com (N. Hosseinzadeh Asl),
usha.barahmand@gmail.com (U. Barahmand).
http://dx.doi.org/10.1016/j.apnu.2014.05.003
0883-9417/ 2014 Elsevier Inc. All rights reserved.

1993).To help these substance-dependent individuals gain relief from

their dependence, one solution is to consider therapy for comorbid
psychological disorders. Depression is one such disorder with a high
frequency of co-morbidity with drug addiction (Crum, Cooper-Patrick,
& Ford, 1994). The co-existence of even a few symptoms of depression
in substance-dependent individuals is sufcient to impair their
functioning and to increase the possibility of their developing
Major Depression. Depression symptoms in substance-dependent
individuals can interfere with or prevent the initiation or the
regular attendance of psychotherapy (Charney, Paraherakis, Negrete,
& Gill, 1998).
An intervention proposed recently for many mental disorders
including depression is Mindfulness-based cognitive therapy (MBCT).
Mindfulness means to consider the present time purposively and with
no judgment (Kabat-zinn, 1990). In other words, mindfulness means
maintaining a moment-by-moment awareness of our thoughts,
feelings, bodily sensations, and surrounding environment, without
judging them. That is, experiencing absolute reality without giving
any explanation (Segal, Williams, & Teasdale, 2002).With roots in
Buddhist meditation, mindfulness is now considered to be an inherent
quality of human consciousness, that is, a capacity of attention and
awareness oriented to the present moment that varies in degree
within and between individuals, and can be assessed empirically and
independent of religious, spiritual, or cultural beliefs (Black, 2011).
Mindfulness is considered not only a dispositional characteristic
(a relatively long-lasting trait), but also an outcome (a state of
awareness resulting from mindfulness training), and a practice
(mindfulness meditation practice itself). Mindfulness has associations

N. Hosseinzadeh Asl, U. Barahmand / Archives of Psychiatric Nursing 28 (2014) 314318

and inuences on psychological, biological, behavioral and social

variables, and as pointed out by Baer, mindfulness has to do with
particular qualities of attention and awareness that can be cultivated
and developed through meditation. In other words, as mindfulness
involves intentionally bringing one's attention to the internal and
external experiences occurring in the present moment, it is often taught
through a variety of meditation exercises. Mindfulness training
increases the capacity for attention and constant, intellectual awareness
which is beyond thinking. Meditation practices and mindfulness
increase consciousness and self-acceptance. Interventions based on
training in mindfulness skills are becoming increasingly popular as
evidence mounts pointing to the utility of mindfulness-based interventions in the treatment of several disorders (Baer, 2006).
Mindfulness research has found that people with higher natural
levels of mindfulness report feeling less stressed, anxious and
depressed, and more joyful, inspired, grateful, hopeful, content,
vital, and satised with life (Baer, Smith, Hopkins, Krietemeyer, &
Toney, 2006; Brown & Ryan, 2003; Cardaciotto, Herbert, Forman,
Moitra, & Farrow, 2008; Feldman, Hayes, Kumar, Greeson, &
Laurenceau, 2007; Walach, Buchheld, Buttenmuller, Kleinknecht, &
Schmidt, 2006). In addition to these mental health benets of
meditation practice and cultivating mindful awareness, simply being
in a mindful state momentarily is associated with a greater sense of
well-being (Lau et al., 2006).
Research also suggests that people with higher levels of mindfulness are better able to regulate their sense of well-being by virtue of
greater emotional awareness, understanding, acceptance, and the
ability to correct or repair unpleasant mood states (Baer et al., 2008;
cf. Brown, Ryan, & Creswell, 2007; Feldman et al., 2007). The ability to
skillfully regulate ones internal emotional experience in the present
moment may translate into good mental health long-term.
Cultivating greater attention, awareness and acceptance through
meditation practice is associated with lower levels of psychological
distress, including less anxiety, depression, anger, and worry (cf. Baer,
2003; Brown et al., 2007). Mindfulness training reduced distress in
persons with a history of depression by decreasing rumination, a
cognitive process associated with depression and other mood
disorders (Jain et al., 2007; Ramel, Goldin, Carmona, & McQuaid,
2004). Such ndings indicate that the mechanism of mindfulness
appears to involve reshaping ways of thinking that engender
improved emotional well-being.
Teasdale (1988) presented a distinct but related model of
cognitive vulnerability to depressive relapse, the differential activation hypothesis (DAH). The DAH makes three general assumptions.
First, it is hypothesized that depressed mood negatively biases
information processing thereby increasing the accessibility of depressogenic interpretations of experience. Second, as a result of these
mood effects on cognitive processing, increased negative interpretations of events would produce further depression. Third, this theory
assumes individual differences regarding the nature of thinking
patterns activated by depressed mood are related to differences in
the experiences, and their interpretations, which have previously
produced depressed mood. In other words, links between dysphoric
mood and negative thinking patterns will be stronger among
individuals with a history of depression than those who have never
experienced depression (Lau, Segal, & Williams, 2004). Therefore,
Teasdale, Williams, Segal, and Soulsby (2000) assert that skills learned
for controlling attention can be useful in preventing the relapse of
Major Depression episodes. Based on Jon Kabat-Zinn's MindfulnessBased Stress Reduction program, Segal, Williams and Teasdale
designed the Mindfullness Based Cognitive Therapy (MBCT) to
prevent relapse by increasing metacognitive awareness without any
explicit attempt to change negative thinking itself. MBCT combines
the ideas of cognitive therapy with meditative practices and attitudes
based on the cultivation of mindfulness. Individuals are trained to
become acquainted with the modes of mind that often characterize

315

mood disorders while simultaneously learning to develop a new

relationship to them. In this method, depressed individuals are
trained to observe their thoughts and feelings without judging them.
Instead of viewing them as a part of themselves or as a reection of
reality, they view their thoughts and feelings as simple mental events
which pass. This kind of attitude prevents negative thoughts and
intellectual rumination from being intensied (Teasdale et al., 2000).
In this paper, evidence regarding the effectiveness of MBCT in
decreasing depression in dually diagnosed individuals is presented.
Various studies have suggested that short term therapy has a positive
inuence on reducing depression disorders in substance-dependent
individuals (Levkovitz et al., 2000; Shwartz et al., 2004). However, few
studies have focused on the inuence of MBCT on dually diagnosed
individuals who are simultaneously undergoing detoxication and
treatment for their substance-dependence. Most studies in Iran have
considered the inuence of MBCT on the relapse of substance use and
dependence after aficted individuals have undergone detoxication
and treatment (Kaldavi, Barjaali, Falsanejad, & Sohrabi, 2012). The
intent of the present paper is to present ndings regarding the
inuence of mindfulness-based cognitive therapy in alleviating
symptoms of depression in drug-dependent males. It is hoped that
ndings of the present study indicating the inuence of MBCT on
symptoms of depression in drug-dependent individuals will facilitate
the treatment of dually diagnosed individuals and eliminate some of
the existing barriers to their recovery, thereby preventing relapse.
METHOD
Participants
The study was experimental and used a pretestposttest control
group approach (Kazdin, 1999). The study sample comprised male
drug-dependent individuals who also suffered from symptoms of
depression. The study was conducted in the following way. After
receiving permission from one of the addiction treatment centers
afliated to the ministry of health and treatment, the Beck Depression
Inventory II-2 (BDI-II) was administered to 62 drug-dependent males.
Those scoring 14 or higher on the BDI-II were recruited for the study.
Using this inclusion criterion, 35 individuals were chosen and
randomly assigned to the intervention (18 individuals) and control
groups (17 individuals). In this study, two sessions of absence were
permissible and absence on more than two sessions was considered as
a criterion of failure. As 2 individuals failed to attend therapy sessions
on 2 occasions, they were excluded from the study. Therefore, the
intervention group consisted of 16 individuals, with a total sample of
33 drug-dependent males. All subjects were dependent either on
opium or heroin, and were being treated with methadone during the
study. The subjects ranged in age from 17 to 43 years, with mean age
being 29.5 years. The intervention group received 8 sessions of
mindfulness-based cognitive therapy while the control group received no therapy. After the 8 sessions, the BDI-II was administered to
both the intervention and control groups.
Measures
The Beck Depression Inventory (BDI-II)
The Beck Depression Inventory (BDI-II) is a widely used tool in line
with the depression criteria of DSM-IV. The BDI-II consists of 21 items
to assess the intensity of depression in clinical and normal patients.
Each item is a list of four statements arranged in increasing severity
about a particular symptom of depression. Items on this scale explore
agitation, worthlessness, concentration difculty, loss of energy and
increases and decreases in sleep and appetite (Beck, Steer, & Brown,
1996). The administration of the BDI-II on an Iranian sample of 94
subjects revealed the internal consistency of the instrument to be 0.91
and a testretest correlation coefcient of 0.89 (Fati, 2003).

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N. Hosseinzadeh Asl, U. Barahmand / Archives of Psychiatric Nursing 28 (2014) 314318

Summary of Training Sessions:

Manual for the Use of Mindfulness-based Cognitive Therapy for the
Treatment of Depression
The training sessions were arranged as prescribed in the book
titled MBCT for depression (Segal et al., 2002). The treatment period
included 8 sessions of group training, held as 2-h sessions weekly.
During these sessions, subjects in the intervention group were trained
to gain an ability to realign themselves away from their thoughts and
feelings and focus instead on the changes occurring in their body and
mind. Clients were encouraged to adopt a new way of being and
relating to their thoughts and feelings, while placing little emphasis
on altering or challenging specic cognitions. Participants learned to
detect and recognize depression relapse-related patterns of negative
thinking, feelings, and bodily sensations and to relate to them
constructively by assuming a more detached response (i.e., viewing
them as passing events in the mind). Participants also learned to
purposefully shift their mental focus away from the ruminative
thought patterns that would otherwise lead the relapse process into
an episode of major depression. Later sessions included the
formulation of individually customized strategies that the participant
could use outside of the program to prevent depression relapse or
recurrence (e.g., involving family members in an early warning
system, keeping written suggestions to engage in activities that are
helpful in interrupting relapse processes, looking out for habitual
negative thoughts).
In keeping with suggestions provided in the original edition of the
book by Segal et al. (2002), in some sessions, poems with mindfulness
content were used for clients to focus on. Poems by Iranian poets
(Sohrab Sepehri, Nader Naderpour, and Shaee Kadkani) were used.
In addition, audio tapes and books of deep relaxation were used to
guide clients in performing mindfulness exercises at home (Bahadoran
and Pournaseh, 2003).
The purpose of the sessions was to:
Enhance awareness of feelings, thoughts and events occurring in
the body, being in the present moment, being here and now.
Increase attention to feelings and thoughts and develop an
acceptance of undesirable feelings and thoughts.
Develop skills to respond to undesirable feelings or thoughts.
Prevent the stabilization of negative thoughts.
Change old habits of thinking.
Increase awareness of alarming symptoms of depression.
Increase awareness of detailed changes of attitudes.
Sessions one to four
The concept of mindfulness was explained through emphasizing
the importance of being in the present moment, of being here
and now.
Training was provided to notice how the mind wanders and
practice was provided in paying attention to the body, physical
feelings and breathing.
Meditation was taught and practiced to maintain attention to the
present moment.
Clients learned to remain in the moment of the present without
escaping and avoiding people and without experiencing the
turbulence of thoughts.
Sessions Five to Eight
Participants were trained to be completely aware of their thoughts and
feelings and to accept them without direct judgment and interference.
Participants learned to change their attitudes to their thoughts by
considering them as just thoughts and not as reality.
Participants were trained to be observant about depression symptoms
and to schedule a program to deal with possible depression symptoms.

Participants received instruction and guidance in planning for the

future. They received instruction regarding the continued use of the
techniques of being in the present time in life.
Data Analysis
The depression scores obtained at pre- and post-test were
analyzed using repeated measures analysis of variance with pre-test
scores used as a covariate.
It should be noted that once the study was terminated, for ethical
reasons, the individuals assigned to the control group also received
the MBCT.
RESULTS
The mean scores obtained by the intervention and control groups
on the BDI-II at pre- and post-test are displayed in Table 1 along with
results of their comparison.
There was no signicant difference in the mean scores of the
intervention and control groups on the BDI-II at pre-test (t = 0.61,
p b .05), implying that the two groups were comparable in terms of
depression at the start of the study.
As obvious from Table 1, the mean BDI-II post-test scores for the
intervention group are much lower than those of the control group
which suggest that MBCT was effective in reducing depression
symptoms in the intervention group.
The obtained data were analyzed using an analysis of covariance
with pre-test scores as the covariate. As shown in Table 1, the
difference in the mean post-test scores was found to be signicant.
Fig. 1 illustrates the means of pre-test and post-test scores for the
groups and their differences are easily visible.
Findings reveal a signicant decrease in depressive symptoms
associated with MBCT therapy for the intervention group. Therefore, the
research hypothesis that Mindfulness-based cognitive therapy is effective
in reducing depression symptoms in dually diagnosed males is retained.
DISCUSSION AND CONCLUSION
As observed from the results, mindfulness-based cognitive therapy
is a useful method for decreasing the depression symptoms of male
drug-dependent individuals. This nding is congruent with those of
previous studies that also reported the effectiveness of MBCT on
depression (Britton, Shahar, Szepsenwol, & Jacobs, 2012; Chiesa &
Serretti, 2011; Kuyken et al., 2010). In Iran, Kaviani, Javaheri, and
Bahirayi (2005) conducted a follow-up study 60 days after MBCT.
They found signicant decreases in the depression and anxiety
reported by the group that received MBCT in comparison with the
control group that did not receive any training. However, it should be
noted that this study was carried out on non-clinical samples while
the present study focused on drug-dependent males.
It is likely that MBCT increases the awareness of the individual
toward the present and by using techniques like attention to
breathing and the body, and shifting consciousness to here and
now, MBCT affects both the cognitive system and data processing,
thereby leading to a coordination of adaptive behaviors and
psychological states (Chambers, Gullone, & Allen, 2009). Findings of
Table 1
Comparison of Mean Pre-Test and Post-Test BDI-II Scores of the Intervention and
Control Groups.

pre-test
post-test

Groups

Mean

Std. Deviation

control group
intervention group
control group
intervention group

17
16
17
16

24.52
26.75
23.65
16.94

8.46
12.26
8.05
7.64

sig

71.31

.000

N. Hosseinzadeh Asl, U. Barahmand / Archives of Psychiatric Nursing 28 (2014) 314318

30
25
20
Control group

15

Intervention group

10
5
0
Pre-test

Post-test

Fig. 1. Mean BDI-II pre-test and post-test scores of the groups.

the present study conrm that cultivating a more mindful way of

being is associated with less depression, which may imply less
emotional distress and more positive states of mind. Increased
attention to and awareness of thoughts and emotions, acceptance,
and compassion appear to promote optimal mental health. The
awareness of drug-dependent individuals of their negative and
positive emotions appears to play an important role in their recovery
and adjustment to their emotional states. Although additional welldesigned studies using larger samples of dually diagnosed individuals
and active control groups are needed to replicate and verify the
mental health benets of mindfulness meditation training (Toneatto
& Nguyen, 2007), the ndings of this study support a relationship
between cultivating a more mindful way of being on the one hand,
and a tendency to experience less emotional distress and more
positive states of mind on the other. This study conrms that one
salutary mechanism of mindfulness appears to involve reshaping
ways of thinking that engender improved emotional well-being.
Findings imply that advance practice psychiatric nurses can integrate
mindfulness-based psychotherapeutic approaches into their treatment. Finding effective nursing interventions for the treatment of comorbid mental illness in dually diagnosed patients is a major concern
for advanced practice psychiatric nurses, and MBCT appears to be an
effective innovative technique.
Considering the high rate of co-morbid depression in drugdependent individuals (Crum et al., 1994) as well as the importance
of its treatment, the development of efcient, short term therapeutic
techniques such as MBCT is crucial. The effectiveness of MBCT justies
the use of this method for treating depression in drug-dependent
males while they undergo the detoxication process and treatment.
Certain limitations of the study should be taken into account while
generalizing the results. Treatment expectancies or patients initial
beliefs about the success of the intervention could have inuenced
treatment outcomes. Patients assigned to the intervention group did
not choose to undergo the MBCT intervention and preference could
have played a predictive role in affecting clinical outcomes. The
generalization of the results of the present study is also limited by the
small sample, it is suggested that future research focus on larger more
heterogeneous samples of individuals with substance use disorder.
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