The key objectives of this comprehensive literature review are to analyze, evaluate, and discuss rumination as a moderator of post-traumatic stress disorder and comorbid depression, along with the potential of mindfulness and mindfulness-based therapies to combat intrusive thoughts and recurring symptoms. This review addresses the relation mindfulness based practices may have with the treatment of communities of color and during COVID-19. The goal is to better understand the symptomatology and struggles of mental health disorders such as PTSD and major depression in order to provide research-driven mental health care and therapeutic services for suffering individuals. In this review, we emphasize the need for integrating mindfulness-based therapies through exploration of the mechanisms that drive uncontrollable and intrusive thoughts and feelings that accompany diagnoses of PTSD and depression. Our findings serve as an informational tool that fuels the mission of SoundMind Solutions to provide virtual mental health care through cutting edge technology.
Introduction and Methods
In order to assess the effectiveness of mindfulness based therapies and the potential of them to help alleviate symptoms of PTSD and MDD, a thorough literature review was conducted. This review explores the comorbidity of depression and PTSD and the overlapping symptoms of the two disorders. A comprehensive review of the role of rumination as a moderator between PTSD and MDD symptoms demonstrates the need for mindfulness based practices to be considered as supplements to treatment options for individuals suffering from PTSD, depression, and anxiety.
Results and Discussion
Comorbidity of Post-traumatic Stress Disorder and Major Depressive Disorder
Posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) are highly comorbid, as studies have found an estimated 54% of individuals diagnosed with MDD also met the criteria for a diagnosis of PTSD. The comorbidity rates were consistent even after controlling for overlapping symptomatology (Elhai et al., 2008). Despite the coinciding symptoms and high comorbidity rate, previous studies have found that PTSD and MDD are each distinctive diagnostic categories. Analysis of the timeline on which the psychiatric conditions presented in patients revealed that neither PTSD nor MDD invariably presents first. The comorbid relationship of PTSD and MDD introduces the idea of a possible shared disposition that a traumatic event could precipitate (Bleich et al., 1997).
Increases in suicidal ideation have been observed among individuals diagnosed with PTSD. Comorbid major depression could be a catalyst in the association of suicidality in PTSD. The correlation of increased suicidality and PTSD was observed across various population samples from veterans to victims of sexual assault (Panagioti et al., 2012). This finding indicates that suicidality and PTSD along with comorbid MDD are non-discriminatory; because the association is demonstrated through many forms of trauma.
Previous studies have also noted that patients struggling with PTSD have shown impaired executive function when tested against trauma-exposed controls. Significant deficits in executive function across all tested areas were observed among the PTSD patients and comorbid depression is thought to moderate the impairment of function (Olff et al., 2014). Understanding the importance of mental health care is what inspires the efforts of SoundMind Solutions. The impairment of cognitive and executive functions when battling PTSD and comorbid depression can lead to memory loss and can bring hardships in completing everyday tasks. We hope to incorporate exercises that will allow users to improve the overall health of their brains, with a focus on attenuating symptoms that are indicative of executive function impairment.
Mindfulness and Rumination
Rumination is the tendency to have repetitive, persistent, uncontrollable and intrusive thoughts, and has been found to be a significant moderator between PTSD and MDD symptoms. PTSD symptoms predicted greater depressive symptoms in the presence of high levels of repetitive rumination. “Adults who have greater PTSD symptoms and who engage in repetitive rumination or anticipatory rumination are at greater risk for depressive symptoms” (Roley et al., 2015). Researchers have called for more attention to rumination in the assessment of PTSD and MDD as well its maintenance of symptoms (Elwood et al., 2009; Olatunji, Naragon-Gainey, Wolitzkey-Taylor, 2013; Roley et al., 2015).
“The very nature of rumination, which implies an expansive, self-evaluative, ineffective problem-solving orientation, is antithetical to mindfulness” (Hawley et al., 2013). Mindfulness practices have been a significant point of conversation in psychology and therapies for quite some time now. While mindfulness is widely respected in its Western adaptation for clinical use, it is important to acknowledge its historical roots and how an integration may serve useful for communities of color. Mindfulness is derived from ancient Buddhist practices and emphasizes “cultivation of a moment-to-moment, non- judgmental awareness of one’s present experience” (Pirson, Langer, & Zilcha, 2018). The Western concept of mindfulness, while drawing from Eastern practices, has been defined by Dr. Ellen Langer as making deliberate cognitive categories, generating new distinctions, and adapting to changing situations. This conceptualization is often referred to as Langerian mindfulness. The positive effects of Eastern mindfulness and meditation to relieve stress and provide health benefits have been supported by Western scientific research and the two approaches overlap. Clinical practices that utilize mindfulness based interventions employ the Western conceptualization of mindfulness that Langer has developed.
Mindfulness Based Therapies
Mindfulness-Based Stress Reduction (MBSR) focuses on yoga and mindfulness meditations through group intervention and was developed to enhance mindfulness and reduce symptoms of illness or stress and pain. Standing out from other practices of meditation that aspire for ultimate relaxation, MBSR was designed to encourage self understanding and insight (Labelle et al., 2010). Mindfulness-based cognitive therapy (MBCT) is a group-based training program administered by therapists that have undergone MBCT training. It was developed to reduce depressive relapse and rumination among patients who have been diagnosed with depression. One study found that individuals struggling with recurrent depressive episodes face an 80% chance of relapse. MBCT was built on the premise of this finding. It arms patients with mindfulness skills, empathy, and self-compassion, which researchers have found to be the mediators of MBCT’s ability to attenuate recurrence of depressive episodes (Kuyken et al., 2010).
MBCT and MBSR have shown significant clinical efficacy in the treatment of various mood disorders. Preliminary studies have indicated success in reduction of PTSD symptomology through the use of MBCT with approximately 73% of patients demonstrating a reduction of at least 10 points on the Clinically Administered PTSD Scale post mindfulness based treatment intervention (King et al., 2013). Mindfulness based treatments have also been used to reduce depression symptomatology and relapse in civilian populations (Bedard et al., 2014). Additionally, mindfulness based stress reduction treatments were found to decrease the frequency of suicidal ideation by almost half. Among veteran populations, mindfulness was identified as a mediating factor in the relationship between depression, anxiety, and general mental health functionality (Serpa, Taylor, & Tillisch, 2014).
Studies have demonstrated the potential that both MBCT and MBSR have in treating and reducing symptoms of depression, which provides a framework for SoundMind Solutions to develop a mindfulness and meditation aspect of the application that could introduce users to mindfulness-based therapies; hopefully, alleviating and/or preventing recurring episodes of comorbid depression.
Mindfulness and Communities of Color
The potential of mindfulness based therapies opens opportunities for mental health care within communities of color and could be used as a therapeutic services to address the disparity of mental healthcare among minorities. While much has been published about the efficacy of mindfulness meditation with various clinical and non-clinical populations, there has been a significant lack of research on mindfulness in communities of color (Blum, 2014). Psychological stress has been shown to be related to poor health outcomes in Black, Indegenous, and other communities of color (Proulx et al., 2017). According to the 2000 National College Health Assessment Survey, Asian American students were 1.6 times more likely to have seriously considered attempting suicide than their white counterparts. The US Department of Health and Human Services reported that Black individuals are 20% more likely to report experiencing psychological distress (2019). Native Americans have the highest rates of PTSD than any other racial or ethnic group (Bassett et al., 2014). Only 33% of Latinx adults with a mental illness receive treatment in the United States (SAMHSA, 2018). It is startlingly clear that racial disparities exist in the mental health field.
Based on the countless research indicating the benefits of mindfulness in mental health treatment, the integration of cultural competency into mindfulness based practices is paramount to the equitable treatment of BIPoC.
The Intensifying Need for Mental Health Resources During the COVID-19 Pandemic
A review surrounding the COVID-19 pandemic and mental health has shown that increased symptoms of mental health disorders such as MDD and generalized anxiety, as well as psychological distress, have been associated with widespread infections and outbreak (Rajkumar, 2020). Because of the stress, uncertainty, and isolation that the coronavirus pandemic demands, individuals already facing mental health issues are at risk for worsening symptomatology. There is much more research that must be conducted to truly understand what will be the aftermath of the coronavirus in terms of mental health. However, current research is telling us that not only is the world facing a widespread, global pandemic, but we are also in danger of a mental health crisis. Our findings further demonstrate the need for virtual mental health care right now. Through understanding the mental health concerns that the COVID-19 pandemic brings, SoundMind Solutions strives to provide digital and individualized resources for individuals facing mental health struggles. The dangers of attending in person therapy amidst the global pandemic also highlights the need for the development of an application like SoundMind Solutions. It is important to note that we do not intend to provide a replacement, but rather a complement to therapeutic services or telehealth therapy.
The alarming high rates of relapse among individuals struggling with recurrent depressive symptoms calls on health care professionals everywhere to re-evaluate their methods of treatment. Aforementioned studies demonstrate the promise of mindfulness-based therapies such as MBCT and MBSR to attenuate relapse rates and overall symptoms. Understanding the frequency with which MDD occurs comorbidly with PTSD highlights the need for mindfulness programs and their potential to not only alleviate symptoms, but to combat the impairment of executive function that occurs with PTSD. SoundMind Solutions anticipates the continued growth of our current knowledge base and hopes to provide research-guided mindfulness practices alongside the development of our music therapy mobile application.
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