Abstract
Mindfulness-based cognitive therapy (MBCT) teaches the patient to recognize a deteriorating mood with the goal of avoiding self-perpetuating patterns of ruminative, negative thoughts and thus depressive disorders. MBCT was initially conceived as an intervention to prevent relapse of major depression, but it has since been studied in patients with current episodes of depression. MBCT has been shown to nearly halve the risk of relapse in persons currently well with a history of at least 3 prior episodes of depression and is comparable to the use of an antidepressant in preventing recurrence. Although theoretical drawbacks exist to using MBCT in a currently depressed patient, randomized controlled data suggest it may be as effective in currently depressed patients as those in remission and similar in efficacy to cognitive-behavioral therapy.
‘Mindfulness is a style of meditative practice in which nonjudgmental awareness is focused on one’s moment-by-moment experience.’
Mindfulness-Based Meditation Interventions
Mindfulness is a style of meditative practice in which nonjudgmental awareness is focused on one’s moment-by-moment experience. This awareness includes both external inputs such as physical sensation as well as internal inputs including cognitions and emotions. Various forms of mindfulness-based meditation, in particular, mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT), have been studied as clinical interventions with strong evidence documenting their effectiveness for overall well-being and certain psychiatric disorders. MBSR was developed in the 1970s with an emphasis on stress reduction and improving overall well-being. The practice includes education about stress as well as training on coping mechanisms and assertiveness.
MBCT was developed in the 1990s and incorporates MBSR with elements of cognitive-behavioral therapy (CBT) as an intervention for psychiatric disorders. MBCT was initially conceived as an intervention to prevent relapse of major depressive disorders, but has since been studied in patients with current episodes of depression. The evidence regarding the effectiveness of MBCT in the treatment of acute episodes of depression as well as the prevention of depression relapse will be discussed below.
Mindfulness-Based Cognitive Therapy
MBCT teaches the patient to recognize a deteriorating mood with the goal of avoiding self-perpetuating patterns of ruminative, negative thoughts and thus depressive relapse. 1 Mindfully aware patients can distance themselves from their thoughts and feelings, which allows the patient to stand back and observe rather than be controlled by unpleasant sensations. This decreases emotional reactivity and maladaptive responses and enhances self-regulation and adaptive coping skills.
MBCT is traditionally delivered through an 8-week, highly experiential educational course. A large portion of each weekly, 2-hour session is spent practicing mindfulness meditation. Other course content includes a teaching and discussion of cognitive-behavioral skills. 1 While the MBCT course is taught in a group setting, patients undergoing MBCT are encouraged to practice mindfulness meditation on their own each day as a part of the intervention and long-term following conclusion of the course.
Efficacy in Depression Relapse Prevention
It is well established that MBCT is effective in reducing depression relapse in patients with a history of recurrent depression.2,3 In fact, MBCT has been shown to nearly halve the risk of relapse in persons currently well with a history of at least 3 prior episodes of depression.2,3 Much of the initial research supporting MBCT for relapse prevention was designed without an active control arm, such as maintenance antidepressant medication (m-ADM). However, a more recent study has found that MBCT is comparable to m-ADM in preventing depression relapse and may be offered as an alternative to long-term pharmacotherapy when relapse is a concern. 4 This may be particularly beneficial to those patients who do not tolerate antidepressant medication, those who prefer not to use long-term pharmacotherapy, and those who have poor medication adherence.
A study by Kuyken et al assessed depression relapse rate in 123 patients randomized to either continue m-ADM or undergo MBCT with support to taper/discontinue m-ADM. 4 The study found that in patients with recurrent depression, MBCT is comparable to m-ADM in reducing the rate of depression relapse and superior to maintenance pharmacotherapy in improvement in residual depressive symptoms and physical and psychological quality of life. The rates of ADM use significantly reduced in the MBCT group, with 75% of patients completely discontinuing m-ADM within 6 months of the group MBCT course.
A second study, by Segal et al, assessed depression relapse rates in patients following, at minimum, 7 months of clinical remission, achieved through antidepressant therapy. Following remission, patients were randomized to 1 of 3 maintenance phases: m-ADM, MBCT + medication taper, or medication taper + placebo. Unlike the Kuyken trial where an attempt to taper medications occurred over 6 months following the group MBCT course, medication discontinuation in the Segal trial was sequential with remission, and doses were tapered and eliminated within 4 weeks of entering the maintenance phase for patients in the MBCT and placebo groups. Segal et al found that MBCT offers protection against depression relapse comparable to that of m-ADM in both patients achieving stable and unstable remission.
Efficacy in Current Depression Episodes
While MBCT was initially conceived to prevent depression relapse, recent study has been devoted to assessing its effect on current depression episodes. In theory, there are several drawbacks to this intervention. Unlike well individuals with a history of depression, currently depressed patients can have low mood and may be preoccupied by negative thoughts and feelings. Depressed individuals often avoid these unpleasant thoughts and feelings. This characteristic runs counter to the practice of mindfulness, which promotes awareness of one’s thoughts and feelings. 5 Likewise, mindfulness requires focus of attention on the current moment. This may present barriers to currently depressed patients who often present with lack of motivation and difficulty concentrating. 6 Despite these drawbacks, MBCT has shown promising results in 3 randomized controlled trials.
The first study, by Van Aalderen et al, used the Hamilton Rating Scale for Depression (HAMD) and Beck Depression Inventory, Second Edition (BDI-II), to measure posttreatment depression symptoms in patients randomized to MBCT + treatment as usual compared with patients randomized to treatment as usual alone. 7 The study population included patients with 3 or more previous depressive episodes with or without a current episode of major depression. The study found that patients randomized to receive MBCT had less depressive symptoms, worry, and rumination as compared with patients receiving treatment as usual alone. The study also found that MBCT resulted in comparable reduction of depressive symptoms in patients with and without a current depressive episode, supporting the notion that MBCT might also be beneficial for currently depressed patients. The study is limited by a small sample size, with 205 total patients assessed and only 69 patients diagnosed with a current episode of major depression.
In the second study, Chiesa et al compared MBCT to psycho-education for the treatment of patients with major depression. 8 The psycho-education was designed to be structurally equivalent to MBCT with the exclusion of the mindfulness meditation practice. The study population included Italian patients who did not achieve active remission following, at minimum, 8 weeks of therapy with an antidepressant. The HAMD scale was used to assess depressive symptoms and the Beck Anxiety Inventory assessed quality of life. The study was limited by the small sample size (only 9 subjects were randomized to each group), but the results were favorable. A significantly higher improvement in HAMD scores was observed over time in the MBCT group compared with the psycho-education group. Subjects in the MBCT group also reported greater improvement in quality of life.
The third study, by Manicavasagar et al, compared the effect of MBCT versus CBT on depression scores in 69 patients suffering from a current episode of major depression. 9 Both the MBCT and CBT were administered in a group setting with 8 weekly sessions. Depression scores, as assessed by the BDI-II, improved in both groups with no significant difference between interventions.
The results of the aforementioned randomized controlled trials were affirmed in a meta-analysis designed to assess the effect of mindfulness-based interventions (MBIs) on patients with a current episode of an anxiety or depressive disorder. 10 While this analysis included both MBSR and MBCT interventions in patients with depression and/or anxiety, the study concluded that MBIs significantly decreased depressive symptoms regardless of primary presenting problem (anxiety or depression). The same analysis also found that effects on primary symptom severity were significant for MBCT but not MBSR, supporting the use of MBCT over MBSR for depressive disorders.
Conclusions
MBCT has been shown to nearly halve the risk of relapse in persons currently well with a history of at least 3 prior episodes of depression. The intervention has been found to be comparable to the use of an antidepressant in reducing relapse risk. As such, MBCT is strongly recommended as an adjunctive intervention for relapse prevention of depressive disorders and can be recommended in place of m-ADM for patients who prefer not to continue pharmacotherapy long-term.
While there are theoretical drawbacks to using MBCT in a currently depressed patient, randomized controlled data suggest it is just as effective in this population as it is for patients with a history of recurrent depression currently in remission. Randomized controlled data also show MBCT to be comparable to CBT in the treatment of currently depressed patients and superior to psycho-education. Although the data supporting MBCT for patients with a current episode of depression are limited by sample size, it is promising and seems to warrant its place as a viable option among other evidence-based interventions in this population.