Automatic Self Transcending Meditation Versus Treatment as Usual
Condition: Major Depressive Disorder
MeSH terms: Depressive Disorder; Depressive Disorder, Major
Study type: Interventional

Summary: 
      Depression is a leading contributor to global burden of disease. Antidepressants do not
      provide adequate response for many patients. Mind-body therapies are often safe, increasingly
      embraced by patients, however good quality clinical trial data is limited. The PI has shown
      that there is autonomic instability in patients with late life depression (LLD). Through his
      team of across discipline researchers he will investigate benefits of one adjunctive
      mind-body intervention, automatic self transcending meditation on autonomic instability in
      LLD and depressive symptoms compared to treatment as usual. If results are positive, such an
      intervention could be used for management of LLD across all levels of care.

      WHAT IS THE INNOVATION AND MAIN QUESTION/HYPOTHESIS UNDERLYING THIS PROPOSAL? The main study
      objectives are to assess heart rate variability (HRV), other autonomic parameters and
      depression scores in patients with late life depression undergoing an innovative mind-body
      therapy 'automatic self-transcending meditation' (ASTM) not previously evaluated in a
      randomized controlled manner in the treatment of late life depression.

      It is expected that adding ASTM to TAU will be better than TAU in improving HRV, depression
      severity and other autonomic parameters in the treatment of LLD. It is expected that this
      intervention will produce significant anxiolytic and enhanced quality of life outcomes and
      will have no major side effects. If the results of this study are positive, it is possible
      that this intervention could be considered as treatment option for the management of this
      disabling illness in primary, secondary and tertiary care. Such treatment option would be
      more cost and staff effective, and self empowering than the current standard of care. It
      could also provide treatment options for patients who are currently resistant to their
      antidepressants.
    

Detailed description: 
      Late life depression and cardiovascular autonomic function:

      Major depressive disorder in the elderly (in those >60 years of age), also known as late life
      depression (LLD), is common, disabling and associated with a high mortality rate caused by
      suicide as well as cardiovascular events compelling appropriate treatment. Research shows
      that in a naturalistic setting response rate to at least one antidepressant trial of adequate
      dose and duration alone is around 30-40% thereby necessitating usage of additional
      interventions. Such therapies include psychological therapies, and, recently, various forms
      of treatments loosely defined as mind-body therapies such as biofeedback, energy healing,
      meditation, guided imagery, and yoga. Mind-body therapies are being increasingly embraced by
      patients as they have negligible side effects, are easy to administer and display beneficial
      effects on the quality of life as well as comorbid anxiety. There is increasing research on
      the mechanisms and benefits of such therapies, however, good quality trial data is scant. It
      is well established that antidepressants work by mostly modifying neurotransmitter levels in
      the brain. On the other hand, some mind-body therapies target multiple organ systems and
      hence could offer neurobiological advantages as depression is now recognised as a
      multi-system disorder. This is particularly relevant to the LLD population where there is
      increased prevalence of comorbid cardiovascular disorders. Hence, some mind body therapies
      when offered in combination with antidepressants might have a beneficial effect on both
      depression and the cardiovascular system.

      One of the ways of assessing the cardiovascular system is through measurement of various
      autonomic parameters i.e. heart rate, blood pressure and heart rate variability. The most
      commonly reported is heart rate variability (HRV) which is a manifestation of the interplay
      of the central nervous system and the autonomic nervous system on a beat-by-beat basis. One
      of the ways of its estimation is by calculating the elapsed time between two consecutive
      waves, called R waves, on a person's electrocardiogram (ECG). A consistent finding has been
      that there is reduced HRV in people who have suffered a myocardial infarction (MI), and this
      phenomena is a predictor of subsequent cardiac arrhythmia and even death. In addition,
      through previous work the PI has found that in LLD there are significant cardiovascular
      autonomic disturbances compared to age matched controls after controlling for various risk
      factors. Other studies conducted in depression across the human life span have found similar
      results. Hence, if there is a mind-body treatment that specifically targets autonomic
      dysfunction and has a positive benefit on depressive symptoms, it would be valuable to asses.
      The investigators would like to investigate such a therapy which has been selected based on
      previous reports of beneficial effects but has not been evaluated in a randomised controlled
      trial of LLD patients.

      Automatic self-transcending meditation (ASTM):

      ASTM is a class of meditation that helps quiet the mind and induces physiological and mental
      relaxation whilst the eyes are shut. It utilizes a specific sound value (mantra) to draw
      attention inward and permit the mind to experience a restful but alert state of
      consciousness. Research suggests that ASTM is easier to learn and to teach in comparison to
      other meditation techniques including mindfulness. Studies of adult and elderly ASTM
      practitioners have documented reductions in depressive symptoms, as well as improvements in
      cardiovascular function among elderly with and without cardiovascular disease. A study of
      adults with CVD further demonstrated improvements in HRV. Research further suggests ASTM may
      be particularly well suited to elderly populations. In a randomized controlled trial of
      elderly retirement home residents which evaluated ASTM with two other meditative techniques
      and treatment as usual, ASTM produced significantly greater improvements in cognitive
      function, cardiovascular function and quality of life than all other treatment conditions. A
      subsequent meta-analysis of all-cause mortality rates among hypertensive elderly who had
      participated in stress reduction interventions found that ASTM practitioners had a 30% lower
      cardiovascular mortality rate than four other meditative or relaxation interventions.

      The investigators predict that ASTM augmentation is an effective intervention that
      ameliorates the autonomic disturbance associated with LLD, and possibly has beneficial
      effects on depressive symptoms as compared to a control treatment as usual (TAU) group.

      Primary hypothesis: The investigators hypothesise that in patients with LLD, ASTM+TAU will
      lead to a significant increase in HRV from baseline to end of study period as compared to
      TAU.

      Secondary hypotheses: The investigators hypothesise that ASTM+TAU will cause a) significant
      fall in depression scores b) significant improvement in other autonomic parameters including
      heart rate and blood pressure changes in presence of a physiological stress test (hand grip)
      c) significant improvement in depression related symptom pathologies including impaired
      quality of life and anxiety; compared to TAU.

      Study Design:

      This study is a single-centre, single blind longitudinal randomized controlled naturalistic
      trial. Research participants will be 96 men and women (48 in each group), 60-85 years of age,
      who have mild to moderate major depressive disorder (MDD). Participants will be recruited
      from primary, secondary and tertiary care centres in London, Ontario.

      Study recruitment:

      It is expected that the study will recruit from primary secondary and tertiary care practices
      in London identified by the investigators at a rate of at least 2 participants per week over
      a period of 76 weeks allowing attainment of a sample size of n=96. Advertisements about the
      study will be placed at key areas around the city including various community centres and
      libraries.

      Usual standard of care at the trial site:

      The standard of care for patients with late life depression involves starting them on an
      appropriate antidepressant from various classes such as SSRIs, (fluoxetine, fluoxamine,
      paroxetine, citalopram, escitalopram, sertraline, paroxetine), or NaSSA (mirtazapine) or
      Bupropion. Patients are also prescribed additional anxiolytic medications like
      benzodiazepines and trazodone if deemed necessary. Participants will be initiated and
      maintained on appropriate dosages of such medications as part of standard of care. The
      psychiatrist and/or his multidisciplinary team members might offer supportive therapy as part
      of standard of care.

      Screening and initial assessments:

      Potential participants will be screened as per inclusion and exclusion criteria. Upon
      selection, the following scales will be administered: interview for comorbid medical
      conditions (Cumulative illness rating scale- Geriatrics, CIRS-G), a screening cognitive
      examination (Mini Mental State Examination (MMSE)), depression severity assessment (Hamilton
      Rating Scale for Depression score (HRSD 17 items), Clinical Global Impression (CGI), self
      rated Geriatric Depression Scale (GDS)), anxiety (Geriatric Anxiety Inventory (GAI)), side
      effects (Toronto Side Effects Scale, (TSES)), Quality of Life (QOL profile seniors version
      (QOLPS), physical activity assessment (Physical activity scale of the elderly, PASE
      questionnaire).

      Randomization:

      Participants will be randomized to either ASTM+TAU or TAU equally (1:1) using computer
      generated randomisation numbers available at random.org. Concealment of randomisation will be
      ensured by independent staff performing randomisation.

      Medication adherence follow-up:

      All medication types will be permitted in this study. Any dosage modifications will be
      recorded.

      Measurement of outcomes:

      PRIMARY (HEART RATE VARIABILITY): Participants from both arms will be asked to report to the
      Laboratory for Brain and Heart Health at Western University Campus. Participants in both
      study arms will be requested to attend appointments at weeks 0 and 12 while participants in
      the ASTM arm will be requested to attend an additional assessment at 24 weeks.

        1. Heart rate will be monitored using an electrocardiogram (ECG) with three adhesive leads.

        2. Blood pressure will be measured using a small cuff placed on a finger (Finometer) or
           using a wrist cuff device (Colin Pilot). These continuous measures of blood pressure
           will be confirmed against values obtained periodically by an automated sphygmomanometer
           (Dinamap).

        3. Electrocardiogram: A standard electrocardiogram will be collected via small surface
           electrodes on the chest to determine heart rate.

        4. A bellows placed around the chest will provide information on respiratory excursions.

      SECONDARY OUTCOME MEASURES:

      Depression and comorbid symptoms will be assessed by a blinded rater on various scales at
      study visit days (week 0, 4, 8, and 12 for all participants and ASTM participants will attend
      an additional assessment at week 24). These scales are the rater assessed (Hamilton Rating
      Scale for Depression score (HRSD 17 items)) and Clinical Global Impression (CGI). Self rated
      scales include the Geriatric Depression Scale (GDS)), anxiety (Geriatric Anxiety Inventory
      (GAI)), Physical activity (PASE), adverse events (TSES) and quality of life (QOLPS).

      Statistical analysis plan:

      The main outcome of interest, HRV, will be calculated by standard deviation of all R-R
      intervals (SDNN) on ECG, root-mean square of successive differences (RMSSD), and number of
      R-R intervals differing by >50 m sec from adjacent intervals (NN50) in time domain analysis.

      Analyses will be conducted on a PC running SAS v9.4 (SAS Institute Inc. Cary, USA) on a
      Windows 7 Platform. Demographic and clinical characteristics of the intervention (SSM) and
      control (TAU) condition will be compared by independent samples t-tests and χ2 or Fisher's
      exact test for continuous and categorical data, respectively. Linear mixed models (described
      below), controlling for baseline score, will be used to compare the SSM and TAU groups'
      change score from baseline to 12-week follow-up on SDNN and LF HRV (primary outcome) and
      depression severity (HRSD-17) (secondary outcome). Other exploratory outcomes will be
      evaluated in a similar way. Linear mixed models will also be used to compare the percent
      change in HRSD-17 scores, whereas generalised linear models will be used to compare the
      proportion of patients who responded to the intervention (≥50% decrease from baseline on the
      HRSD, defined a priori) and the proportion of patients who achieved remission (scores ≤7 on
      the HRSD-17, defined a priori) at the end of intervention (week 12). Linear mixed models with
      variance components covariance structure will be used in comparing HRSD-17 scores between
      groups (SSM and TAU), time (week 0, 4, 8 and 12) and group × time interaction. All
      HRV-related measures will be natural log-transformed. Cohen's d will be calculated by
      dividing the mean difference in change scores between the two groups by the s.d. of the
      control groups' change score. Following established guidelines, the linear mixed models will
      account for the partially nested design, which allows clustering in the intervention group
      (because of participants experiencing a group-based intervention, added as a random effect)
      and no clustering in the control group. Using this method, different hierarchical structures
      can be fit for the two groups. PROC MIXED will be used for continuous outcome variables, and
      PROC GLIMMIX will be used for binary outcome variables. Restricted maximum likelihood
      estimates will be used and the d.f. adjusted with the Satterthwaite method. Residual and
      influence diagnostics will be checked to confirm if the models fit the data well. The level
      of statistical significance will be set at α = 0.05. Complete-case analysis will be used.

      Interim analysis may be completed in order to meet one or more of these conditions a) funder
      reporting requirements and/or b) research training requirements of students and/or c) data
      safety monitoring for stop or continue decisions.
    

Intervention name(s): Automatic Self Transcending Meditation
Intervention type(s): Behavioral
Intervention description(s): as above
Other intervention name(s): ASTM
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: MDD