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Intervention Summary

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Mindfulness-Based Cognitive Therapy (MBCT)

Mindfulness-Based Cognitive Therapy (MBCT) is a program for adults with recurrent major depressive disorder (as diagnosed by DSM-III-R or DSM-IV criteria). MBCT represents an integration of components from two interventions: Mindfulness-Based Stress Reduction, which is based on the core principle of "mindfulness" (i.e., a mental state whereby one attends to and purposefully manages one's awareness of what is happening in the moment), and cognitive behavioral therapy for depression. By teaching participants how to engage in the formal practice of mindfulness meditation and how to develop a more open acceptance of behavioral difficulties and affective discomfort, MBCT aims to prevent major depression relapse or recurrence, reduce residual depression symptoms and DSM-IV Axis I psychiatric comorbidity, facilitate the successful tapering and discontinuation of antidepressant medication (ADM), and improve physical and psychological quality of life.

MBCT is a manual-driven program that is delivered by trained instructors through the following sessions:

  • An initial one-on-one orientation session
  • Eight 2-hour core sessions delivered weekly in a group format with 9-15 participants who are either in full remission (having a clinically normal mood) and using no ADM or in partial remission (having residual depression symptoms) and continuing use of ADM
  • Up to four 2-hour follow-up reinforcement sessions delivered in a group format 4-12 months after the eight core sessions

MBCT instructors help participants to strengthen their mindfulness meditation through practice and to develop cognitive skills that assist them in disengaging from habitual ("automatic") and dysfunctional cognitive routines. Participants learn 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 learn 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 core sessions include the formulation of individually customized strategies that a participant can 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).

MBCT instructors (typically cognitive therapists) are required to personally practice mindfulness meditation and have at least 1 year of experience working with mood disorder patients.

Descriptive Information

Areas of Interest Mental health treatment
Outcomes Review Date: March 2012
1: Major depression episode relapse
2: Residual depression symptoms
3: Psychiatric comorbidity
4: Antidepressant medication use
5: Quality of life
Outcome Categories Mental health
Quality of life
Ages 26-55 (Adult)
55+ (Older adult)
Genders Male
Female
Races/Ethnicities Non-U.S. population
Settings Outpatient
Geographic Locations Urban
Suburban
Rural and/or frontier
Implementation History Mindfulness-Based Cognitive Therapy was developed in 1995 by Zindel Segal, John Teasdale, and Mark Williams. Initially offered in academic teaching hospitals, the intervention has been implemented in a variety of settings, including community-based settings, mental health clinics, primary care centers, and general hospitals. Hundreds of adults with a diagnosis of recurrent major depressive disorder have received MBCT at more than 20 sites in California, Colorado, Georgia, Illinois, Massachusetts, Michigan, New York, and Washington, as well as in Canada, England, France, Germany, Switzerland, and Wales. MBCT has been evaluated in approximately eight randomized controlled clinical trials and a meta-analysis.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: Yes
Evaluated in comparative effectiveness research studies: Yes
Adaptations MBCT has been adapted for use with children. MBCT materials have been translated into French, Italian, and Spanish.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories IOM prevention categories are not applicable.

Quality of Research
Review Date: March 2012

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Teasdale, J. D., Segal, Z. V., Williams, J. M. G., Ridgeway, V. A., Soulsby, J. M., & Lau, M. A. (2000). Prevention of relapse/recurrence in major depression by Mindfulness-Based Cognitive Therapy. Journal of Consulting and Clinical Psychology, 68(4), 615-623.  Pub Med icon

Study 2

Ma, S. H., & Teasdale, J. D. (2004). Mindfulness-Based Cognitive Therapy for depression: Replication and exploration of differential relapse prevention effects. Journal of Consulting and Clinical Psychology, 72(1), 31-40.  Pub Med icon

Study 3

Kuyken, W., Byford, S., Taylor, R. S., Watkins, E., Holden, E., White, K., et al. (2008). Mindfulness-Based Cognitive Therapy to prevent relapse in recurrent depression. Journal of Consulting and Clinical Psychology, 76(6), 966-978.  Pub Med icon

Supplementary Materials

Harper, A., & Power, M. (1998). Development of the World Health Organization WHOQOL-BREF quality of life assessment. Psychological Medicine, 28(3), 551-558.

Mindfulness-Based Cognitive Therapy--Adherence Rating Scale (Version 2002)

Piet, J., & Hougaard, E. (2011). The effect of Mindfulness-Based Cognitive Therapy for prevention of relapse in recurrent major depressive disorder: A systematic review and meta-analysis. Clinical Psychology Review, 31(6), 1032-1040.  Pub Med icon

Segal, Z. V., Bieling, P., Young, T., MacQueen, G., Cooke, R., Martin, L., et al. (2010). Antidepressant monotherapy vs sequential pharmacotherapy and Mindfulness-Based Cognitive Therapy, or placebo, for relapse prophylaxis in recurrent depression. Archives of General Psychiatry, 67(12), 1256-1264.  Pub Med icon

Segal, Z. V., Teasdale, J. D., Williams, J. M., & Gemar, M. C. (2002). The Mindfulness-Based Cognitive Therapy Adherence Scale: Inter-rater reliability, adherence to protocol and treatment distinctiveness. Clinical Psychology and Psychotherapy, 9, 131-138.

Spitzer, R. L., Williams, J. B. W., Gibbon, M., & First, M. B. (1992). The Structured Clinical Interview for DSM-III-R (SCID). I: History, rationale, and description. Archives of General Psychiatry, 49(8), 624-629.  Pub Med icon

Spruance, S. L., Reid, J. E., Grace, M., & Samore, M. (2004). Hazard ratio in clinical trials. Antimicrobial Agents and Chemotherapy, 48(8), 2787-2792.  Pub Med icon

Outcomes

Outcome 1: Major depression episode relapse
Description of Measures Major depression episode relapse was measured by the Structured Clinical Interview for the Axis I DSM Clinical Disorders (SCID-I), a clinician-administered instrument used for making major DSM diagnoses. In one study, the DSM-III-R SCID-I was administered by trained doctoral-level psychologists and an experienced psychiatric social worker who were blind to the study groups. In another study, the DSM-IV SCID-I was administered by a clinical psychologist who was blind to the study groups.
Key Findings In one study, a randomized clinical trial (RCT) was conducted across three treatment sites with patients who had a diagnosis of recurrent major depression, were in recovery or remission, and were not using ADM at study entry. Recurrent major depression was defined as having at least two episodes of major depression according to DSM-III-R criteria in the past 5 years, with one episode in the past 2 years, and a history of ADM treatment. Participants were randomly assigned to the intervention group, which received 2-hour weekly sessions of MBCT over 8 weeks in addition to usual care, or the control group, which received usual care. Usual care was defined as being instructed to seek help from a family doctor or other source for a symptomatic deterioration or other psychological difficulties experienced over the course of the 14-month study period.

Both groups were assessed at baseline; about 8 weeks later, after the intervention group completed the sessions of MBCT (posttreatment); and then bimonthly to 12 months after treatment (12-month posttreatment follow-up period). For each study group, the percentage of participants who had an episode of major depression during the 12-month posttreatment follow-up period was calculated. Results for participants with three or more previous episodes of major depression indicated that the percentage who relapsed into a depressive episode during the 12-month posttreatment follow-up period was smaller for the intervention group than the control group (40% vs. 66%; p < .01). This group difference was associated with a medium effect size (Cohen's h = 0.53).

In a second study, an RCT was conducted at one treatment site with patients who had a diagnosis of recurrent major depression, were in recovery or remission, and were not using ADM at study entry. Recurrent major depression was defined as having at least two episodes of major depression according to DSM-IV criteria in the past 5 years, with one episode in the past 2 years, and a history of ADM treatment. Participants were randomly assigned to the intervention group, which received 2-hour weekly sessions of MBCT over 8 weeks in addition to usual care, or the control group, which received usual care. Usual care was defined as being instructed to seek help from a family doctor or other source for a symptomatic deterioration or other psychological difficulties experienced over the course of the 14-month study period.

Both groups were assessed at baseline; about 8 weeks later, after the intervention group completed the sessions of MBCT (posttreatment); and then at 3-month intervals to 12 months after treatment (12-month posttreatment follow-up period). For each study group, the percentage of participants who had an episode of major depression during the 12-month posttreatment follow-up period was calculated. Results for participants with three or more previous episodes of major depression indicated that the percentage who relapsed into a depressive episode during the 12-month posttreatment follow-up period was smaller for the intervention group than the control group (36% vs. 78%; p = .002). This group difference was associated with a large effect size (Cohen's h = 0.88).
Studies Measuring Outcome Study 1, Study 2
Study Designs Experimental
Quality of Research Rating 3.1 (0.0-4.0 scale)
Outcome 2: Residual depression symptoms
Description of Measures Residual depression symptoms were measured by the 17-item Hamilton Rating Scale for Depression (HAM-D). The HAM-D is a semistructured clinician-administered interview that evaluates the presence and severity of depressed mood, vegetative and cognitive symptoms of depression, and comorbid anxiety symptoms, according to DSM-IV criteria. Items are rated with either a 5-point scale ranging from 0 (absent) to 4 (very severe) or a 3-point scale ranging from 0 (absent) to 2 (definite). Higher scores indicate more symptoms of depression with greater severity.
Key Findings An RCT was conducted with patients who had a diagnosis of recurrent major depression (defined as having three or more previous episodes of major depression according to DSM-IV criteria), were either in full or partial remission from depression symptoms, and were receiving a therapeutic ADM regimen (according to the British National Formulary) for at least 6 months prior to study entry. Participants were randomly assigned to the intervention group, which received 2-hour weekly sessions of MBCT over 8 weeks plus tapering or discontinuation of ADM, or the comparison group, which received an ADM maintenance/management program. Participants in the intervention group were supported by their primary care physician in tapering or discontinuation of ADM, beginning in weeks 4-5 of the intervention and ending 6 months after the intervention. Participants in the comparison group were managed by their primary care physician according to standard clinical practice and the British National Formulary to ensure that the ADM dose remained within therapeutic limits throughout the 15-month study period.

Both groups were assessed at baseline and at 3-month intervals to 15 months after randomization (study end). The 3-month follow-up was assessed about 1 month after the intervention group completed the sessions of MBCT (1-month posttreatment assessment), and the 15-month follow-up was assessed about 13 months after the intervention group completed the sessions of MBCT (13-month posttreatment assessment). Results indicated that at the 1- and 13-month posttreatment assessments, participants in the intervention group had fewer and less severe residual depression symptoms than participants in the comparison group (p = .02), after controlling for baseline assessments. This group difference was associated with a medium effect size (eta-squared = .06).
Studies Measuring Outcome Study 3
Study Designs Experimental
Quality of Research Rating 3.6 (0.0-4.0 scale)
Outcome 3: Psychiatric comorbidity
Description of Measures Psychiatric comorbidity was measured by the SCID-I, a clinician-administered instrument used for making major DSM diagnoses. Comorbid Axis I psychiatric diagnoses from DSM-IV include the following mental health areas: mood disorders; delirium, dementia, and amnestic disorders; substance-related disorders; schizophrenia; anxiety disorders; social phobias; dissociative disorders; sexual and gender identity disorders; eating disorders; impulse-control disorders; adjustment disorders; and sleep disorders. The DSM-IV SCID-I was administered by a clinical psychologist who was blind to the study groups.
Key Findings An RCT was conducted with patients who had a diagnosis of recurrent major depression (defined as having three or more previous episodes of major depression according to DSM-IV criteria), were either in full or partial remission from depression symptoms, and were receiving a therapeutic ADM regimen (according to the British National Formulary) for at least 6 months prior to study entry. Participants were randomly assigned to the intervention group, which received 2-hour weekly sessions of MBCT over 8 weeks plus tapering or discontinuation of ADM, or the comparison group, which received an ADM maintenance/management program. Participants in the intervention group were supported by their primary care physician in tapering or discontinuation of ADM, beginning in weeks 4-5 of the intervention and ending 6 months after the intervention. Participants in the comparison group were managed by their primary care physician according to standard clinical practice and the British National Formulary to ensure that the ADM dose remained within therapeutic limits throughout the 15-month study period.

Both groups were assessed at study intake and at 15 months after randomization (study end). Results indicated that at study end relative to intake, participants in the intervention group had fewer comorbid psychiatric diagnoses (DSM-IV Axis I) than participants in the comparison group (p < .05). This group difference was associated with a small effect size (Cohen's d = 0.43).
Studies Measuring Outcome Study 3
Study Designs Experimental
Quality of Research Rating 3.5 (0.0-4.0 scale)
Outcome 4: Antidepressant medication use
Description of Measures Antidepressant medication use was measured as the number of days that the study participant used ADM during the 15-month study (up to 450 days). This information was obtained from three convergent sources:

  • The Morisky Medication Adherence Scale (MMAS), a 4-item self-report adherence measure. Participants responded to each item with "yes" or "no."
  • Patient self-report. Participants indicated daily ADM use.
  • Medical records from the prescribing physician.
Key Findings An RCT was conducted with patients who had a diagnosis of recurrent major depression (defined as having three or more previous episodes of major depression according to DSM-IV criteria), were either in full or partial remission from depression symptoms, and were receiving a therapeutic ADM regimen (according to the British National Formulary) for at least 6 months prior to study entry. Participants were randomly assigned to the intervention group, which received 2-hour weekly sessions of MBCT over 8 weeks plus tapering or discontinuation of ADM, or the comparison group, which received an ADM maintenance/management program. Participants in the intervention group were supported by their primary care physician in tapering or discontinuation of ADM, beginning in weeks 4-5 of the intervention and ending 6 months after the intervention. Participants in the comparison group were managed by their primary care physician according to standard clinical practice and the British National Formulary to ensure that the ADM dose remained within therapeutic limits throughout the 15-month study period.

Both groups were assessed at baseline and at 3-month intervals to 15 months after randomization (study end). Results indicated the following:

  • Across the 15-month study period, ADM use by participants in the intervention group was approximately 65% that of participants in the comparison group (266.46 days vs. 411.40 days; p < .0001). This group difference was associated with a large effect size (Cohen's d = 1.07).
  • By the 6-month assessment (i.e., the end of the period for tapering or discontinuation of ADM), 75% of participants in the intervention group had discontinued use of ADM.
Studies Measuring Outcome Study 3
Study Designs Experimental
Quality of Research Rating 3.2 (0.0-4.0 scale)
Outcome 5: Quality of life
Description of Measures Quality of life was evaluated by the short version of the World Health Organization Quality of Life instrument (WHOQOL-BREF), a 26-item self-report instrument that assesses the respondent's perceived quality of life. Using a 5-point Likert scale, respondents rate items in four domains: physical health (e.g., "How satisfied are you with your sleep?"), psychological health (e.g., "How much do you enjoy life?"), social relationships (e.g., "How satisfied are you with your personal relationships?"), and environment (e.g., "How satisfied are you with the conditions of your living place?"). Respondents also rate two global items: one regarding the respondent's overall perception of quality of life and another regarding the respondent's overall perception of his or her health. Only three domains--physical health, psychological health, and social relationships--were considered relevant for use in the study.
Key Findings An RCT was conducted with patients who had a diagnosis of recurrent major depression (defined as having three or more previous episodes of major depression according to DSM-IV criteria), were either in full or partial remission from depression symptoms, and were receiving a therapeutic ADM regimen (according to the British National Formulary) for at least 6 months prior to study entry. Participants were randomly assigned to the intervention group, which received 2-hour weekly sessions of MBCT over 8 weeks plus tapering or discontinuation of ADM, or the comparison group, which received an ADM maintenance/management program. Participants in the intervention group were supported by their primary care physician in tapering or discontinuation of ADM, beginning in weeks 4-5 of the intervention and ending 6 months after the intervention. Participants in the comparison group were managed by their primary care physician according to standard clinical practice and the British National Formulary to ensure that the ADM dose remained within therapeutic limits throughout the 15-month study period.

Both groups were assessed at baseline and at 3-month intervals to 15 months after randomization (study end). The 3-month follow-up was assessed about 1 month after the intervention group completed the sessions of MBCT (1-month posttreatment assessment), and the 15-month follow-up was assessed about 13 months after the intervention group completed the sessions of MBCT (13-month posttreatment assessment). Results indicated that relative to participants in the comparison group, those in the intervention group perceived themselves as having a better quality of life in the physical health (p = .04) and psychological health (p = .01) domains of the WHOQOL-BREF at the 1- and 13-month posttreatment assessments, after controlling for baseline assessments. These group differences were associated with small and medium effect sizes (eta-squared = .05 and .06, respectively).
Studies Measuring Outcome Study 3
Study Designs Experimental
Quality of Research Rating 3.6 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 26-55 (Adult) 75.9% Female
24.1% Male
100% Non-U.S. population
Study 2 26-55 (Adult) 76% Female
24% Male
100% Non-U.S. population
Study 3 26-55 (Adult)
55+ (Older adult)
76.4% Female
23.6% Male
100% Non-U.S. population

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Major depression episode relapse 3.3 3.3 2.0 3.3 2.8 4.0 3.1
2: Residual depression symptoms 3.8 3.8 3.8 3.8 2.8 4.0 3.6
3: Psychiatric comorbidity 3.3 3.3 3.8 3.8 2.8 4.0 3.5
4: Antidepressant medication use 2.0 2.8 3.8 3.8 2.8 4.0 3.2
5: Quality of life 3.8 3.8 3.8 3.8 2.8 4.0 3.6

Study Strengths

The clinician-administered SCID-I is a gold standard measure for deriving clinical psychiatric diagnoses in the mental health field. The instrument has strong interrater reliability among clinicians trained in standardized protocols for its administration and strong validity for establishing a psychiatric diagnosis. The clinician-administered HAM-D is also considered a gold standard measure with strong psychometric properties. It is the most widely used and accepted outcome measure for evaluating depression severity in the mental health field and is the usual standard against which other depression rating scales are validated. The WHOQOL-BREF self-report instrument has high internal consistency reliability (Cronbach's alpha values of .82-.95) and high test-retest reliability for a 2-week interval (correlation coefficients of .83-.96), with good content, discriminant, convergent, and construct validity. The intervention was manual driven in all three studies, and in two of the studies, it was delivered by experienced cognitive therapists (i.e., the program developers) who had previously provided MBCT to at least one cohort of patients who had a diagnosis of recurrent major depression and were in recovery or remission. In a third study, the interventionists were a clinical psychologist and an occupational therapist who were trained by one of the program developers and whose competency was established by an experienced MBCT therapist who was independent of the study. In the same study, all program sessions were videotaped and rated by an experienced MBCT therapist with a fidelity instrument that had documented psychometric properties, including strong interrater reliability. All three studies compared study completers with noncompleters for differences and incorporated intent-to-treat approaches in the statistical analyses, even in the case of the two studies with very low attrition rates of 5% and 3%. In one study, missing data were handled by imputing the final scores recorded for all subsequent assessments and conducting sensitivity analyses to confirm that the outcome findings were unaffected by the missing data imputation. All three studies used random assignment to control for potential confounding variables. All three studies used a variety of appropriate analyses, including sophisticated Cox proportional hazard survival modeling of the data, and examined potential moderators of outcome effects.

Study Weaknesses

The SCID-I includes skip options that allow a clinician to incorrectly decide not to examine a particular area of psychopathology, thereby decreasing the instrument's reliability and validity in diagnosing psychiatric comorbidity. The reliability of the MMAS is not reported for the sample, and self-report and physician practice databases of ADM adherence may not be reliable. Discrepancies in daily ADM adherence among the MMAS, the patient's self-report, and medical records from the prescribing physician were resolved through discussions among the prescribing physician, the patient, and a research team member who was not blind to the study groups, which may have compromised internal validity. In two of the studies, intervention fidelity was not measured by a fidelity instrument with demonstrated psychometric properties. In two of the studies, results suggested that two subgroups of participants, from different populations, were clustered within each study group and responded differentially to the program. Additionally, the absence of an attention control comparison group in the three studies precludes the elimination of potential confounding influences of expectancy and trust in the instructors.

Readiness for Dissemination
Review Date: March 2012

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

MBCT--Adherence Scale Rating Form (Version 2002)

MBCT session handouts

Mindfulness-Based Cognitive Therapy--Adherence Rating Scale (Version 2002)

Mindfulness meditation audio files for personal practice

Program Web site, http://www.mbct.com/

Segal, Z., Teasdale, J., & Williams, M. (2002). Mindfulness-Based Cognitive Therapy for depression: A new approach to preventing relapse. New York, NY: Guilford Press.

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
3.5 3.0 2.8 3.1

Dissemination Strengths

The manual presents detailed, step-by-step guidance for the planning and execution of each session and the navigation of potentially difficult issues. Well-articulated and comprehensive information on intervention delivery and group management is provided to new implementers, along with information on the role of clinicians in MBCT compared with the traditional role of clinicians. Exemplary scripts provide insight on the common reactions of clients and articulate the many facets of mindfulness practices. Training is required and provided by the developer, and individual supervision is available to help implementers build proficiency in intervention delivery. Several online resources, including audio files for practicing mindfulness meditation techniques and helpful articles, are available to support training and intervention delivery. The manual includes structured session content to facilitate success in maintaining intervention fidelity. An adherence scale and suggested outcome measure are provided to support quality assurance.

Dissemination Weaknesses

The manual provides limited information on implementation planning. Although materials stress the importance of the implementer's knowledge of mindfulness, limited resources beyond the training are identified to help new implementers build skills in this area. Although some materials are available to facilitate training, little information is provided on the format and organization of training and the incorporation of available materials into a standardized training protocol. The developer notes that the adherence scale is not typically used in a clinical setting, requiring implementers in this setting to identify their own means for tracking fidelity. Limited guidance is provided on the procedures for using or interpreting the suggested fidelity and outcome tools. The role of implementation supervision in quality assurance is not described.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
Mindfulness-Based Cognitive Therapy for Depression: A New Approach to Preventing Relapse $45 each Yes
Mindfulness meditation audio files for personal practice Free Yes
5-day, off-site training $1,000 per participant Yes
Individual implementation supervision $100-$150 per hour, depending on the consultant No
Adherence Rating Scale Free Yes
Adherence Scale Rating Form Free Yes
Contact Information

To learn more about implementation or research, contact:
Zindel V. Segal, Ph.D., CPsych
+ 4169796856
zindel_segal@camh.net

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

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