Abstract for MBCT and Chronic-Recurrent Depression
This pilot study investigated the effectiveness of Mindfulness-Based Cognitive Therapy (MBCT), a treatment combining mindfulness meditation and interventions taken from cognitive therapy, in patients suffering from chronic-recurrent depression. Currently, symptomatic patients with at least three previous episodes of depression and a history of suicidal ideation were randomly allocated to receive either MBCT delivered in addition to treatment-as-usual (TAU; N = 14 completers) or TAU alone (N = 14 completers). Depressive symptoms and diagnostic status were assessed before and after treatment phase. Self-reported symptoms of depression decreased from severe to mild levels in the MBCT group while there was no significant change in the TAU group. Similarly, numbers of patients meeting full criteria for depression decreased significantly more in the MBCT group than in the TAU group. Results are consistent with previous uncontrolled studies. Although based on a small sample and, therefore, limited in their generalizability, they provide further preliminary evidence that MBCT can be used to successfully reduce current symptoms in patients suffering from a protracted course of the disorder.
Introduction to MBCT and Chronic-Recurrent Depression
In a significant number of those affected, Major Depression follows a protracted lifetime course with patients suffering from either full episodes or sub-syndromal levels of symptoms over considerable amounts of time (Kessing, Hansen, & Andersen, 2004; Solomon et al., 2000). While views of depression often stress its episodic nature, it has also become clear that in many cases, patients do not recover fully from episodes but continue to show residual symptoms, which themselves have been found to be an important predictor of relapse (Judd et al., 1998; Paykel et al., 1995; Pintor, Gasto, Navarro, Torres, & Fananas, 2003; Pintor, Torres, Navarro, Matrai, & Gasto, 2004). In particular, after severe episodes, sub-syndromal levels of depression are common and persistent (Kennedy, Abbott, & Paykel, 2004). In other patients, symptoms remain relatively stable at the level of full episodes over periods of more than 24 months (Mueller et al., 1996). Recent research has indicated that regardless of their presentation, i.e., whether patients continue to suffer from syndromal levels of the disorder or fluctuate between syndromal and sub-syndromal levels, chronic forms of depression are broadly homogeneous with regard to both their clinical and etiological features, while, at the same time, differing in important regards from episodic forms of the disorder (McCullough et al., 2003). For example, individuals suffering from chronic forms of depression have been found to be more likely to have a familial history of chronic depression (Klein et al., 1995), to be more likely to have suffered from early adversity (Lizardi et al., 1995), to be more likely to suffer from high levels of chronic stress (Klein, Taylor, Dickstein, & Harding, 1988; Ravindran, Griffiths, Waddell, & Anisman, 1995) and neuroticism (Hirschfeld, Klerman, Andreasen, & Clayton, 1986; Weissman, Prusoff, & Klerman, 1978), and to be more likely to suffer from co-morbid disorders, particularly personality (Garyfallos et al., 1999; Pepper et al., 1995) and anxiety disorders (Weissman, Leaf, Bruce, & Florio, 1988). Most importantly, chronic forms of depression have been found to be significantly less responsive to treatment (Thase, Reynolds, Frank, & Simons, 1994) with reports of rates of responders to single modality treatments in trials aimed at chronic depression or based on samples with highly recurrent forms of depression at about 50% (DeRubeis et al., 2005; Keller et al., 2000). There is, thus, an important need for further refinement of treatments for those who have developed a more protracted course of the disorder.
Mindfulness-Based Cognitive Therapy (MBCT; Segal, Williams, & Teasdale, 2002)
is a treatment programme that was specifically designed to address the latent vulnerability in depression. It combines training in mindfulness meditation and interventions from cognitive therapy for acute depression and is delivered in a group setting. The rationale of the treatment is based on findings from cognitive research on vulnerability that has linked relapse to mood-related reactivation of negative thinking patterns (Lau, Segal, & Williams, 2004; Scher, Ingram, & Segal, 2005) and maladaptive ways of responding to negative cognitions and emotions such as rumination (e.g., Watkins, 2008), thought suppression (Wenzlaff & Bates, 1998) and experiential avoidance, i.e., an unwillingness to remain in contact with one’s private experiences, leading to attempts at altering experience so that it is less aversive (Hayes et al., 2004). Through the use of mindfulness meditation, participants are taught to develop their ability to recognize and disengage from maladaptive forms of negative automatic and repetitive thinking. In two randomized controlled trials (RCTs), in which previously depressed patients were followed up over a period of one year following the treatment phase, MBCT has been found to reduce risk of relapse by approximately half in patients with three or more previous episodes of depression (Ma & Teasdale, 2004; Teasdale et al., 2000). A recent study has found MBCT to be as effective in reducing relapse over a follow-up period of 15 months as maintenance therapy with antidepressants (Kuyken et al., 2008).
Each of these three previous RCTs of MBCT studied only patients who were in remission or recovery. The use of MBCT in current depression had been discouraged because it was unclear whether the cognitive demands of a regular meditation practice would exceed the restricted capacities of depressed patients. However, as factors specifically addressed by MBCT are likely to play an important role not only in recurrence but also in the maintenance and persistence of depression, interest in applying MBCT to a wider range of patients has recently increased. In chronically depressed patients, maladaptive thinking patterns such as rumination and experiential avoidance are likely to have acquired a habitual nature, and mental training using mindfulness meditation may hold particular promise in reversing such tendencies. In line with this, there are now a number of reports that suggest that MBCT can successfully reduce symptoms in currently depressed patients (Finucane & Mercer, 2006; Kingston, Dooley, Bates, Lawler, & Malone, 2007), with two of the studies showing effects in patients who had been found to be resistant to established forms of treatment (Eisendrath et al., 2008; Kenny & Williams, 2007). However, with the exception of the study by Kingston et al. which only included participants with residual symptoms, all of these reports are based on uncontrolled pre–post-comparisons.
Chronic-Recurrent Depression Preliminary study
The purpose of the current study was to carry out a preliminary study to investigate the effects of MBCT in patients suffering from chronic forms of depression using a randomized controlled design with blind assessments. We compared the immediate effects of MBCT delivered in addition to treatment-as-usual (TAU) to TAU alone. At this stage of knowledge and given the high vulnerability of this group, we offered MBCT to the TAU group as soon as the post-treatment assessments were complete, effectively establishing a waitlist condition. The study focused on patients with a history of suicidality in the past, a group in which cognitive vulnerability has been found to be particularly pronounced (Williams, Barnhofer, Crane, & Beck, 2005; Williams, Van der Does, Barnhofer, Crane, & Segal, 2008), thus, addressing the most severe end of the depressive spectrum. We hypothesized that participants in the MBCT condition would show significant decreases in severity of depressive symptoms, while no such changes were expected in the TAU group, and that number of responders at the end of the treatment phase would be significantly higher in the MBCT than in the TAU condition.