by Michael D. Anestis, M.S.
By definition, depression often leaves people feeling hopeless, as though there is no path that will lead them out of their current struggles. This point is particularly true for individuals unfortunate enough to suffer from chronic depression. By nature, depression is episodic, meaning that individuals will experience temporary peaks in symptomatology that will eventually either remit entirely, or fade below clinically significant levels before peaking again in the future. For some individuals, however, depression is a constant - a lingering obstacle resistant to treatment and constantly interfering in all aspects of life. In a recent article, we discussed Cognitive Behavioral Analysis System of Psychotherapy (CBASP), an empirically supported treatment (EST) for chronic depression. Today, I would like to discuss another treatment approach for chronic depression that has been subject to increasing empirical attention and which has shown highly promising results: mindfulness-based cognitive therapy (MBCT; Segal, Williams, & Teasdale, 2002).
As the name indicates, MBCT merges mindfulness meditation as developed by John Kabat-Zinn (Kabat-Zinn, 1990) with skills utilized in cognitive behavioral therapy (CBT). MBCT is administered in a group setting and structured much like an academic class, with significant attention given to education on the nature of negative automatic thoughts, rumination, mindfulness skills, and cognitive remediation skills. Treatment typically lasts approximately 8 weeks and groups include 8-15 clients (Segal, Williams, & Teasdale, 2002). As explained in Barnhofer et al. (2009), MBCT was designed in an effort to counteract a variety cognitive vulnerabilities that have been implicated in depression relapse. Such vulnerabilities include a tendency to revert to depressive thinking patterns such as experiential avoidance when experiencing a negative mood (Hayes et al., 2004). As we discussed in our article on mindfulness skills in dialectical behavior therapy (DBT), mindfulness teaches individuals to control their attention, focusing solely on the present moment and accepting things as they are rather than allowing ruminative spirals to consume them. Individuals are taught exercises that increase their ability to step back and examine their thoughts objectively, thus allowing for a calmer, more effective approach towards problem solving. Essentially, the key in mindfulness is developing the ability to refocus attention on neutral objects, thus allowing negative emotions to naturally run their course. Mindfulness skills include focusing on breath, focusing on an image (imaginal or in the immediate environment), and mindful eating among others.
Studies on MBCT have produced impressive results. In two randomized clinical trials comparing MBCT and treatment as usual (TAU) to only TAU, both Teasdale and colleagues (2000) and Ma and Teasdale (2002) found that MBCT plus TAU resulted in lower rates of relapse in individuals with a past history of three or more episodes of depression. There was no difference between groups for individuals with two or fewer episodes of depression, indicating that the benefits of mindfulness skills are specific to individuals with chronic depression. In an additional trial, Williams, Teasdale, Segal, and Soulsby (2000) found that MBCT plus TAU resulted in significant improvement in cognitive styles relative to individuals who received only TAU. Specifically, the authors found that MBCT reduced categoric memories - the tendency to experience vague memories devoid of nuance - which has been implicated in depressive thought patterns (Williams et al., 2000). Kuyken and colleagues (2008) found that MBCT was more successful than maintenance treatment with antidepressant medication at reducing residual symptoms of depression and psychiatric comorbidity and also resulted in greater physical and psychological improvements at 15-month follow-up. Importantly, relapse rates in the MBCT group, while high (47%), were significantly lower than relapse rates in the group receiving maintenance treatment with antidepressant medication (60%).
In all of these studies, MBCT was utilized as a treatment component intended to help reduce the rate of relapse. Because of this, participants in the studies were between episodes of depression. Other studies, however, have examined the utility of MBCT for clients currently experiencing depressive episodes. Kenny and Williams (2007) found that MBCT resulted in significant reductions in depressive symptoms. Contrary to their hypotheses, clients experiencing suicidal ideation also benefited from MBCT. The authors believed that suicidal ideation would result in a level of heightened reactivity to negative moods that would interfere with participants' ability to utilize mindfulness skills, but in fact, no such difficulty was found. Finally, Barnhofer and colleagues (2009) found that, while self-reported depressive symptoms did not improve in a TAU group, individuals receiving MBCT plus TAU self-reported significant decreases in depressive symptoms. Additionally, the number of individuals who met criteria for depression after treatment in the MBCT plus TAU group was significantly lower than the number of individuals meeting criteria for depression in the pure TAU group.
I realize I just listed quite a few studies in the previous two paragraphs, so let me attempt to summarize what these studies have found. Primarily, data indicate that MBCT is highly beneficial in preventing relapse in individuals who have experienced three or more episodes of depression. In fact, it appears to be more effective at reducing relapse than antidepressant medications. Additionally, there is preliminary evidence that MBCT can be effective in reducing symptoms in individuals currently experiencing depressive episodes. Importantly, however, there are limitations to the research on MBCT. As of yet, MBCT has only been compared to one other active treatment (maintenance antidepressant medication), so the degree to which the effects of MBCT can be explained simply by the presence of a treatment is unclear. Additionally, the data do not provide clear evidence that the mindfulness component of MBCT adds incremental value to the CBT skills that already have a rich foundation of empirical support. That being said, there is no reason to assume that the findings for MBCT are spurious, but future research is needed to increase our confidence in the results.
If you would like to learn more about mindfulness-based cognitive therapy, we recommend the following products, all of which are available through our online store:
Mindfulness-Based Cognitive Therapy for Depression: A New Approach to Preventing Relapse
Mindfulness-based Cognitive Therapy for Depression [VHS]
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University
Additionally, if you would like to see an example of a mindfulness session led by John Kabat-Zinn, we recommend viewing the following video:
Subscribe in a reader
