BAGIAN ILMU KEDOKTERAN

FAKULTAS KEDOKTERAN UKRIDA

JAKARTA

JOURNAL READING ON BIPOLAR DISORDER

Mindfulness Based Cognitive Therapy Improves Frontal Control
in Bipolar Disorder

NUR AMIRA BINTI MOHD ROSTAM

112013037

DR PEMBIMBING : DR AGUNG SPKJ

Abstract and Introduction

Although significant advances have been made in understanding the
psychobiology of bipolar disorder, the specific deficit underlying its symptoms
remains unclear. One important possibility is that attentional dysfunction is a
key intermediate phenotype for understanding the pathogenesis of
bipolar disorder (BD).[13] Thus, attentional dysfunction in BD is a consistent
finding in the literature.[1,36]
Electroencephalographic (EEG) studies have made a particular contribution to
this work, reporting asymmetrical activity (at rest) and activation (during task)
in bipolar disorder; however these asymmetrical differences are dependent on
mood state.[4,7,8] In euthymic BD asymmetry can be seen during high task
difficulty and is opposite to that which occurs in controls i.e. completion of
difficult anagrams increased left frontal alpha activation while control
participants showed decreased alpha activation.[9] Similarly EEG Event-related
potential (ERP) studies report a myriad of deficits during attentional tasks
during polar mood states, such as reduced P300 amplitude and latency.[10,11]
However when euthymic, attentional task P300 amplitude and latency are
similar to controls.[10] An earlier ERP auditory attentional component such as
the P50, related to auditory sensory gating, is diminished in schizophrenia and
has also been reported in bipolar disorder if they present with a florid history
of psychosis.[12] At present it still remains unclear which attentional
components are involved euthymic BD during attentional processes.
Attentional dysfunction in BD is suggested to result from interfering neural
processing that is not related to the task at hand, this superfluous or interfering
information processing has been suggested to result from over activity of
emotional brain areas[2] and 'weak' regulation of approach systems.[13] To
overcome the over activity of emotional brain areas individuals with BD show
increased activity of attention related brain areas.[2] This suggests that if we are
able to reduce interfering neural processing and/or improve regulation of
approach systems we would improve attentional processing in BD.
Mindfulness based cognitive therapy (MBCT) combines meditative practices
and aspects of cognitivetherapy, which is based on the mindfulness-based
stress reduction program.[14] The aim of meditative practices is to "reduce or
eliminate irrelevant thought processes through training of internalized
attention."[15] The aim of mindfulness mediation is to "facilitate adaptive coping
2

with life stressors and enhance emotional well-being,"[16] for a recent review
see.[17]
The aim of MBCT is to incorporate the above and include cognitive behavioral
therapy to "teach skills that will enable a greater awareness of thoughts,
without judgment, and viewing negative (positive and neutral) thoughts as
passing mental events rather than as facts."[18] While some research in major
depression has focused on EEG variables relevant to mindfulness,[1921] limited
research has been conducted in BD with these forms of therapy, and no EEG
studies have been conducted to our knowledge.[18,22]

The aims of the present study were therefore to (1) determine brain activity
and activation differences between euthymic BD and controls, at rest (EEG
band frequency analysis) and during an attentional task, a continuous
performance task (EEG ERP wave component analysis). (2) To determine the
effects of MBCT on brain activity and activation differences in euthymic BD, at
rest (EEG band frequency analysis) and during an attentional task, a continuous
performance task (EEG ERP wave component analysis).
Background
Although significant advances have been made in understanding the
psychobiology of bipolar disorder, the specific deficit underlying its symptoms
remains unclear. One important possibility is that attentional dysfunction is a
key intermediate phenotype for understanding the pathogenesis of bipolar
disorder (BD).[13] Thus, attentional dysfunction in BD is a consistent finding in
the literature.[1,36]Electroencephalographic (EEG) studies have made a
particular contribution to this work, reporting asymmetrical activity (at rest)
and activation (during task) in bipolar disorder; however these asymmetrical
differences are dependent on mood state.[4,7,8]
In euthymic BD asymmetry can be seen during high task difficulty and is
opposite to that which occurs in controls i.e. completion of difficult anagrams
increased left frontal alpha activation while control participants showed
decreased alpha activation.[9] Similarly EEG Event-related potential (ERP)
studies report a myriad of deficits during attentional tasks during polar mood
states, such as reduced P300 amplitude and latency.[10,11]
3

However when euthymic, attentional task P300 amplitude and latency are
similar to controls.[10] An earlier ERP auditory attentional component such as
the P50, related to auditory sensory gating, is diminished in schizophrenia and
has also been reported in bipolar disorder if they present with a florid history
of psychosis.[12] At present it still remains unclear which attentional
components are involved euthymic BD during attentional processes.
Attentional dysfunction in BD is suggested to result from interfering neural
processing that is not related to the task at hand, this superfluous or interfering
information processing has been suggested to result from over activity of
emotional brain areas[2] and 'weak' regulation of approach systems.[13] To
overcome the over activity of emotional brain areas individuals with BD show
increased activity of attention related brain areas.[2]
This suggests that if we are able to reduce interfering neural processing and/or
improve regulation of approach systems we would improve attentional
processing in BD. Mindfuness base therapy (MBCT) combines meditative
practices and aspects of cognitive therapy, which is based on the mindfulnessbased stress reduction program.[14] The aim of meditative practices is to
"reduce or eliminate irrelevant thought processes through training of
internalized attention."[15] The aim of mindfulness mediation is to "facilitate
adaptive coping with life stressors and enhance emotional well-being,"[16] for a
recent review see.[17]
The aim of MBCT is to incorporate the above and include cognitive behavioral
therapy to "teach skills that will enable a greater awareness of thoughts,
without judgment, and viewing negative (positive and neutral) thoughts as
passing mental events rather than as facts."[18] While some research in major
depression has focused on EEG variables relevant to mindfulness,[1921] limited
research has been conducted in BD with these forms of therapy, and no EEG
studies have been conducted to our knowledge.[18,22]

The aims of the present study were therefore to (1) determine brain activity
and activation differences between euthymic BD and controls, at rest (EEG
band frequency analysis) and during an attentional task, a continuous
performance task (EEG ERP wave component analysis). (2) To determine the
effects of MBCT on brain activity and activation differences in euthymic BD, at
4

rest (EEG band frequency analysis) and during an attentional task, a continuous
performance task (EEG ERP wave component analysis).

Methods
Participants
Twenty-one participants were recruited for the present study. Twelve
individuals with bipolar I in euthymic state (37 7.3 yrs, 10 females and 2
males, manic episodes 2.8 2.6, depressive episodes 2.8 3.0) and 9 control
individuals (29 6.4 yrs, 7 females and 2 males) with no prior psychiatric
history and no first degree relatives with bipolar diagnoses. The study was
approved by the Faculty of Health Sciences Human Ethics Committee of the
University of Cape Town, and the participants signed informed consent (UCT
HSF HREC 078/2009). The study was conducted in accordance with the
Declaration of Helsinki 2000.[23]

All BD participants were medicated. All BD participants were receiving mood

stabilizers, 8 of which were receiving lithium. Other prescribed medications
included antipsychotics (8 participants), antidepressant (2 participants), and or
anxyolytic (2 participants) medications. Co morbidities present in the BD cohort
included: impulse control disorders (1 participant with trichotillomania and
with compulsive buying, 1 participant with compulsive buying), anxiety
disorders (3 participants with panic disorder and agoraphobia), and substance
abuse disorders (1 participant with a past history of alcohol and cannabis
dependence, 1 participant with a past history of benzodiazepine and diet pill
dependency, 1 participant with current alcohol abuse).

Experimental Design
Each of the participants underwent a structured clinical interview (SCID), to
confirm diagnosis in bipolar group, and exclude mood disorders in the control
group. Each of the participants underwent continuous electroencephalographic
(EEG) record of their brain wave activity, at rest with eyes open for 3 min, with
eyes closed for 3 min, and during a continuous performance task of
5

approximately 10 min long. The bipolar participants completed an 8 week

MBCT intervention. After the MBCT intervention the participants with bipolar
disorder completed the EEG protocol again.

On each day of the EEG study, clinical scales were administered; these included
the Young Mania Rating Scale (YMRS) and the Hospital Anxiety and Depression
Scale (HADS) in order to confirm mood state. The EEG record was obtained
within an hour session, between 09 h00 and 13 h30. The EEG session was
completed in a quiet, dimly lit room to reduce distraction. The researcher
conducting the experiments was with the participant at all times during the
testing. All stages of the testing session were programmed in Eprime 1.1, which
sent digital inputs of stimuli to Acqknowledge 4.1 (Biopac Systems Inc.)
software, via an MP150 Biopac acquisition system, that also collected the EEG
data (EEG 100 C amplifier modules).

Sustained Attentional Task

A visual A-X continuous performance task was completed by the participants.
Participants were required to respond with button press on presentation of the
letter X if preceded by the letter A. All non target stimuli were letters of the
alphabet other than A and X and did not include any vowels, to prevent word
formation of randomly presented letters. Inter-stimuli intervals were set to
1000 msec, duration of target and non-target stimuli were for 500 msec. Fifty
target stimuli were presented during the task.

Electroencephalography (EEG)
EEG data was recorded with the use of a bioamplifier system produced by
Biopac Systems Incorporated (MP150 system with 10 EEG100C amplifiers). The
data was stored and processed with Acqknowledge 4.1 software from Biopac
Systems Inc. A standard 10/20 linked ears reference montage EEG system was
used, and individuals were grounded peripherally. Brain frequency activity and
event-related potentials (ERPs) were obtained from: F3, F4, C3, C4, P3, and P4.
The data was sampled at 500 Hz and band pass filtered FIR with a Hamming
window (0.5 - 30 Hz). Electrooculogram (EOG) electrodes were used to assist in

removal of EOG artifact, through an automated independent component

analysis within Acqknowledge 4.1.
To obtain relative frequency power the data underwent Fast Fourier transform
after channel filtering for resting conditions (eyes open and eyes closed) and
the continuous performance task. Absolute power values were obtained and
the relative values for theta (, 47 Hz), alpha (, 714 Hz), and beta (, 1530
Hz) frequency bands were reported.
To obtain the ERP waveforms during the sustained attention task, epochs 200
msec prior to stimulus and 800 msec post target presentation were extracted
to give a 1 sec window. This was also performed for both the target (letter X)
and the cue (letter A). The extraction was set to reject ERPs that were greater
than or less than 100 V. This was followed by visual inspection of the average
ERP for each participant. Each ERP was baseline corrected for 200 msec prior to
stimulus presentation. The prominent wave components extracted during the
target: early positive component (0100 msec window), negative component
(200400 msec window), and late positive component (300500 msec
window). During the cue, P300-like wave component was extracted (200400
msec window).

Mindfulness Based Cognitive Therapy (MBCT)

The MBCT intervention for BD[18] was developed from the 8-week MBCT
program for major depression.[24] Specifically, the 8-week MBCT intervention
for BD included psycho-education with a specific focus on mania and the early
warning signs of mania and depression.[18] During their participation in the
present study, participants were encouraged to continue with all of their
outpatient appointments, medications and other services they were receiving.
None of the participants reported using non-MBCTmeditation or yoga for
therapeutic purpose during their participation in the present study. The MBCT
intervention was led by an experienced therapist with recognized expertise in
the delivery of cognitiv therapy and MBCT.
Statistical Analysis
Statistica 10 was used for the statistical analyses. Independent-sample t-tests
were performed between control participants and individuals with bipolar
7

disorder. Dependent-sample t-tests were performed between the individuals

with bipolar prior and post their mindfulness based intervention. No further
analyses were performed due to the pilot nature of these data. Data were
reported as mean STDEV, significant values p < 0.05 and when refer to
tendencies p < 0.1.
Results
The individuals with bipolar disorder reported had higher mean YMRS (3.41
3.02) than control individuals (0.00). There was no difference in the Hospital
Anxiety (bipolaranxiety = 8.41 4.48, controlanxiety = 7.33 4.58) and Depression
(bipolardepression = 5.08 2.93, controldepression = 3.33 2.59) rating scores
between the groups. There was no significant change in Hospital Anxiety
(bipolaranxiety = 7.83 3.51) or Depression (bipolardepression = 5.83 4.76) rating
scores post MBCT.
Brain Activity (Resting States)
Individuals with BD showed decreased theta band power during the resting
condition with eyes closed, over the frontal cortex (F3 t = 2.29; F4 t = 2.75, p <
0.05) and cingulate cortex (C3 t = 2.19; C4 t = 2.36, p < 0.05) (Table 1).
Individuals with bipolar disorder showed increased beta band power during the
resting condition with eyes closed, over the frontal cortex (F3 t = 2.43; F4 t =
2.76, p < 0.05) and cingulate cortex (C3 t = 2.25; C4 t = 2.51, p < 0.05) (Table
1). No significant difference was seen over the parietal cortex (Table 1). These
differences in theta and beta band power over the frontal and cingulate cortex
can be expressed as differences in the theta/beta ratios during the resting
condition with eyes closed over the frontal (F3 t = 2.68; F4 t = 3.42, p < 0.05) and
cingulate cortex (C3 t = 2.29; C4 t = 2.64, p < 0.05) (Table 1). No differences were
seen over the parietal cortex (Table 1).
Post MBCT individuals with bipolar disorder showed decreased beta band
power over the right frontal cortex during the resting condition with eyes
closed (F4 t = 2.23, diff = 0.05, Std.Dv.Diff = 0.087, p < 0.05) (Table 1). Theta
band power (F4 t = 1.96, diff = 0.05, Std.Dv.Diff = 0.089, p = 0.075) and
theta/beta ratio (F4 t = 2.1, diff = 0.23, Std.Dv.Diff = 0.388, p = 0.059) for the
left frontal cortex showed a trend towards significance. No other changes in
relative band power were found (Table 1).

Table 1. Relative EEG band power and theta/beta ratios during resting conditions (eyes
open, eyes closed) and during a continuous performance task
Control

Bipolar

Bipolar MBCT

Control

Bipolar

Bipolar MBCT

MEAN STDEV MEAN STDEV MEAN STDEV MEAN STDEV MEAN STDEV MEAN STDEV
Left Frontal (F3)

Right Frontal (F4)

Resting Eyes Open

relative
theta band
power (4

0.29

0.10

0.23

0.07

0.27

0.09

0.30

0.09

0.24

0.06

0.27

0.09

0.35

0.03

0.38

0.11

0.33

0.06

0.35

0.03

0.35

0.05

0.34

0.06

0.37

0.10

0.39

0.10

0.40

0.09

0.35

0.08

0.41

0.08

0.39

0.08

0.94

0.72

0.63

0.24

0.74

0.38

0.92

0.48

0.63

0.23

0.74

0.39

7 Hz)
relative
alpha
band
power (7
14 Hz)
relative
beta band
power
(1530
Hz)
theta/beta
ratio

Resting Eyes Closed

relative
theta band
power (4

0.24

0.05*

0.19

0.05

0.22

0.07

0.25

0.06*

0.19

0.04 t

0.24

0.08

0.41

0.05

0.39

0.07

0.40

0.07

0.41

0.05

0.39

0.08

0.39

0.07

0.36

0.04*

0.43

0.08

0.38

0.08

0.34

0.03*

0.42

0.08 #

0.37

0.08

7 Hz)
relative
alpha
band
power (7
14 Hz)
relative
beta band
power
(1530

Hz)
theta/beta
ratio

0.68

0.16*

0.46

0.20

0.62

0.34

0.75

0.21*

0.47

0.16 t

0.69

0.36

Continuous Performance Task

relative
theta band
power (4

0.28

0.06

0.27

0.07

0.24

0.07

0.29

0.06

0.27

0.06

0.24

0.07

0.34

0.02

0.34

0.04

0.34

0.04

0.35

0.03

0.34

0.05

0.33

0.05

0.37

0.06

0.39

0.07

0.41

0.09

0.36

0.05

0.39

0.07

0.42

0.11

0.81

0.28

0.72

0.28

0.64

0.25

0.84

0.29

0.71

0.25

0.64

0.30

7 Hz)
relative
alpha
band
power (7
14 Hz)
relative
beta band
power
(1530
Hz)
theta/beta
ratio

Left Cingulate (C3)

Right Cingulate (C4)

Resting Eyes Open

relative
theta band
power (4

0.27

0.09

0.22

0.05

0.24

0.10

0.27

0.09

0.22

0.05

0.25

0.10

0.36

0.02

0.37

0.04

0.34

0.06

0.35

0.03

0.37

0.04

0.35

0.05

0.38

0.10

0.41

0.05

0.42

0.10

0.37

0.09

0.41

0.06

0.40

0.09

7 Hz)
relative
alpha
band
power (7
14 Hz)
relative
beta band
power

10

(1530
Hz)
theta/beta
ratio

0.87

0.72

0.55

0.19

0.69

0.49

0.85

0.57

0.57

0.20

0.72

0.50

Resting Eyes Closed

relative
theta band
power (4

0.23

0.04*

0.19

0.05

0.20

0.07

0.24

0.03*

0.19

0.05

0.21

0.07

0.40

0.04

0.39

0.06

0.38

0.06

0.41

0.04

0.39

0.06

0.39

0.05

0.37

0.03*

0.43

0.07

0.42

0.09

0.36

0.03*

0.42

0.07

0.40

0.07

0.64

0.13*

0.46

0.20

0.53

0.32

0.66

0.11*

0.47

0.20

0.58

0.33

7 Hz)
relative
alpha
band
power (7
14 Hz)
relative
beta band
power
(1530
Hz)
theta/beta
ratio

Continuous Performance Task

relative
theta band
power (4

0.27

0.04

0.23

0.05

0.20

0.05

0.27

0.04

0.23

0.05

0.20

0.05

0.36

0.03

0.35

0.04

0.36

0.04

0.36

0.04

0.35

0.04

0.36

0.04

0.37

0.04

0.42

0.07

0.45

0.07

0.38

0.05

0.42

0.07

0.44

0.08

7 Hz)
relative
alpha
band
power (7
14 Hz)
relative
beta band
power
(1530

11

Hz)
theta/beta
ratio

0.73

0.19

0.56

0.20

0.46

0.17

0.73

0.18

Left Parietal (P3)

0.56

0.17

0.48

0.20

RightParietal (P4)

Resting Eyes Open

relative
theta band
power (4

0.26

0.09

0.22

0.05

0.25

0.09

0.26

0.10

0.22

0.05

0.26

0.10

0.39

0.03

0.41

0.05

0.39

0.06

0.38

0.02

0.41

0.05

0.39

0.06

0.35

0.08

0.38

0.05

0.36

0.06

0.36

0.08

0.37

0.05

0.35

0.07

0.89

0.76

0.59

0.19

0.78

0.45

0.89

0.81

0.61

0.20

0.85

0.60

7 Hz)
relative
alpha
band
power (7
14 Hz)
relative
beta band
power
(1530
Hz)
theta/beta
ratio

Resting Eyes Closed

relative
theta band
power (4

0.19

0.08

0.18

0.05

0.20

0.06

0.21

0.04

0.17

0.05

0.21

0.06

0.46

0.07

0.44

0.07

0.45

0.06

0.46

0.07

0.44

0.08

0.44

0.06

0.34

0.04

0.38

0.08

0.35

0.06

0.34

0.04

0.39

0.07

0.35

0.06

7 Hz)
relative
alpha
band
power (7
14 Hz)
relative
beta band
power

12

(1530
Hz)
theta/beta
ratio

0.58

0.22

0.48

0.21

0.60

0.27

0.61

0.10

0.47

0.19

0.62

0.30

Continuous Performance Task

relative
theta band
power (4

0.26

0.05

0.23

0.05

0.21

0.04

0.25

0.05

0.23

0.05

0.21

0.04

0.40

0.04

0.39

0.05

0.40

0.05

0.40

0.05

0.39

0.05

0.40

0.04

0.34

0.03

0.38

0.06

0.39

0.05

0.35

0.03

0.38

0.06

0.39

0.05

0.77

0.22

0.63

0.19

0.55

0.15

0.73

0.18

0.64

0.20

0.55

0.16

7 Hz)
relative
alpha
band
power (7
14 Hz)
relative
beta band
power
(1530
Hz)
theta/beta
ratio

*Significant differences between control participants and participants with bipolar disorder. #Significant differences in participants with
bipolarl disorder as a result of mindfulness based cognitive therapy (p < 0.05). t tendencies toward significant differences (p < 0.1).
nControl = 10, nBipolar = 12, nBipolar MBCT = 12, MEAN STDEV.

Brain Activation (Attentional Task)

Individuals with BD showed no significant differences in the target (letter X)
ERP components extracted when compared with controls, although there were
trends towards significance (F3(0100 msec) t = 1.91, p= 0.07; F3(300500 msec) t =
1.87, p = 0.07; F4(300500 msec) t = 1.73, p = 0.099) (Figure 1). Individual with BD
showed significant differences in the cue (letter A) ERP P300-like component
when compared with controls over the frontal cortex (F3 t = 2.11; F4 t =
2.00, p < 0.05) (Figure 1).
13

14

Figure 1.
Grand mean event-related potentials (ERPs) for frontal (F3 & F4), cingulate (C3 & C4), and
parietal (P3 & P4) cortices, for the target (letter X) and the cue (letter A) of the continuous
performance task. The target ERP yielded no significant differences between controls and
bipolar disorder (BD), however tendencies were found over the left frontal cortex (t control vs. bipolar (0100
ms) = 0.07; t control vs. bipolar (300400 ms) = 0.07) and right frontal cortex (t control vs. bipolar (300400 ms) = 0.09). The cue
yielded *significant differences between controls and bipolar disorder (BD) over the frontal cortex,
as individuals with BD showed a P300-like wave component frontally and Mindfulness based
cognitive therapy (MBCT) attenuated the P300-like wave component over the frontal cortices in
the bipolar cohort (p < 0.05, t < 0.1, Controlsn = 9, Bipolarn = 12).

-----------------------------------------------------------------------------------------------------------

Post MBCT BD individuals showed no significant differences in the target (letter

X) ERP components. Post MBCT BD individuals showed a change in the P300like waveform to one which is comparable to that seen in normal subjects
during the cue (letter A) ERP over the frontal cortex (F3 t = 2.82, diff = 8.38,
Std.Dv.Diff = 10.26; F4 t = 2.51, diff = 6.59, Std.Dv.Diff = 9.081, p < 0.05) (Figure
1).
Discussion
Several findings emerge from this study. First, prior to MBCT brain activity in BD
was greater over the frontal and cingulate cortex during resting eyes closed,
which suggests decreased attentional readiness, MBCT improved attentional
readiness slightly. Second, prior to MBCT brain activation in BD showed
activation of non-relevant information processing over the frontal cortex,
MBCT attenuated activation of this non-relevant information processing.
Brain activity prior to MBCT, individuals with BD showed decreased attentional
readiness, as theta activity was decreased, beta activity was increased, and
theta/beta ratios was decreased over the frontal (F3 & F4) and cingulate (C3 &
C4) cortices during resting eyes closed. Increased anterior and frontal midline
theta has been positively correlated with internalized attention and positive
emotional state, in experienced mediators during rest.[25] During attentional
processes frontal theta activity is suggested to originate from the functional
connectivity between the frontal cortex and anterior cingulate cortex[26] and
serves to maintain attentional processes,[27] which is lacking in
15

BD.[2,13] Furthermore increased beta activity during eyes closed has been
referred to as an index of spontaneous cognitive operations of these similar
brain areas, and several others areas.[28] In hand, a recent study related
increased theta/beta ratios to mechanisms of approach.[29] The present data
suggests that individuals with BD have deficits in resting brain activity, which
may decrease their abilities to attend to relevant information, and therefore
lack attentional readiness. Post MBCT intervention individuals with BD showed
a slight improvement in attentional readiness, as right frontal EEG activity
improved, beta activity was decreased and there was a tendency for theta and
theta/beta ratios to increase. The present resting data supports the literature,
that BD has 'weak' regulation of behavioral systems that are required for
attentional processes.[13] MBCT intervention in BD may serve to improve
attentional readiness.
Brain activation prior to MBCT individuals with BD showed activation of nonrelevant information processing over the frontal cortex, as controls did not
require this information processing. During the cueing process of the
continuous performance task (letter A) individuals with BD showed a
prominent P300-like wave form over the frontal (F3 & F4) cortices. This P300like wave form persisted during the target but did not reach significance.
Source analysis of frontal P300 wave forms has been attributed to extended
cortical networks, unlike the parietal P300 wave form, at the temporal parietal
junction.[30] The cueing process may assist BD by permitting activation of
compensatory mechanisms, being the activation of working memory in the
present attentional task.[2,6,31] Post MBCT intervention individuals with BD
showed attenuated P300-like wave form over the frontal cortices. This suggests
MBCT attenuated the interfering or previously required compensatory
information processing brain mechanisms in BD individuals.
A number of limitations should be noted. First given the small size, we cannot
determine whether some of the negative findings are false negatives, the
trends towards statistical significance here may reach significance with larger
sample. Second, the effect of medication on brain wave activity and/or
activation were not included in the analysis, nevertheless medications were
stable prior and post MBCT intervention Third, the control group did not
undergo MBCT, which limits our understanding in the effects of MBCT on brain
activity and activation. Fourth, no control bipolar group was included in the
presented data, future studies would benefit with inclusion of a control bipolar
group. Fifth, we had intended to have a gender balanced group, however
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during the recruitment process, mostly women volunteered, which limits the
generalizability of the present study.
Conclusions
This is the first brain imaging report on the effects of MBCT in BD. Individuals
with BD show decreased attentional readiness and activated of non-relevant
information processing during attentional processes. MBCT slightly improved
attentional readiness, and attenuated activation of non-relevant information
processing during attentional processes.

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