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Mindfulness has generated much excitement over recent years – and won many admirers, including the novelist Julie Myerson, writing above in The Guardian. A twenty-first century reworking of traditional Buddhist meditation, mindfulness teaches us to develop what Myerson calls a “new relationship” with our thoughts: “I could see that they were simply that: thoughts. I did not have to judge them, act on them or indeed do anything very much about them. Sometimes they were interesting, sometimes less so, but they were no more than “events” that arose in the mind and then dispersed again. They did not, as I’d previously imagined, have the power to undo me.”
There’s certainly evidence that mindfulness can help with anxiety, low mood, and stress, but can it play a part in preventing recurrent clinical depression? This is a key question, not least because recurrence is a hallmark of the problem. If we look at those with a history of repeated depression, more than 50% who’ve recently recovered from an episode will relapse over the next 12 months. And with every relapse, the more likely it is that another will follow.
So how do we break the cycle of depressions? The National Institute for Health and Care Excellence (Nice), which provides evidence-based treatment guidelines to the NHS, recommends: “Advise people with depression to continue antidepressants for at least 2 years if they are at risk of relapse.”
However, Nice also highlights the value of psychological therapy and advises that patient preference should be taken into account when making decisions about treatment. It suggests that cognitive behavioural therapy (CBT) be considered, and that mindfulness-based cognitive therapy (MBCT) be offered to “people who are currently well but have experienced three or more previous episodes of depression”. MBCT, developed by the eminent psychologists Zindel Segal, Mark Williams and John Teasdale, combines mindfulness meditation with cognitive behaviour therapy. But Nice recommendations are one thing; the reality on the ground is often very different, with patients far more likely to be offered antidepressants than MBCT.
Antidepressants don’t suit everyone: many people are reluctant to take medication every day for years on end. And even though the pills may help with the depression – they don’t in all cases – side effects are common. But is MBCT really a viable alternative for treatment of recurrent depression? Does it work better than simply continuing with the medication? (Interestingly, there’s no evidence that it prevents relapse for people who haven’t already experienced at least three previous episodes.)
Answering that question is the objective of a new multi-centre study led by Professor Willem Kuyken and reporting today in the Lancet (declaration of interest: Kuyken carried out the work while he was at the University of Exeter but, like one of the authors of this blog, is now based in the Department of Psychiatry at the University of Oxford). The study is the largest to compare MBCT and antidepressants, and it’s the first to track the effects of the treatments over a lengthy period (two years).
MBCT builds on the insight that when people with a history of depression experience even a brief period of feeling low they tend to be especially vulnerable to negative thinking. That negative thinking is often accompanied by what’s known as “processing biases”: worrying about past problems, for example, or returning to unpleasant memories. Thinking like this raises the risk of a full-blown depressive episode.
MBCT focuses on helping people to become more aware of these thoughts and feelings, and thus better able to gain distance from them. As its founders put it: “We discover that difficult and unwanted thoughts and feelings can be held in awareness, and seen from an altogether different perspective – a perspective that brings with it a sense of warmth and compassion to the suffering we are experiencing.”
Kuyken’s team recruited (via GPs) 424 patients with a history of three or more depressive episodes. All were taking antidepressant medication. Half of the group were randomly assigned to an eight-week course of MBCT, during which they were also given help to come off the medication. The other fifty percent continued with their antidepressants for two years. (As it turned out, most of the MBCT group stopped taking the medication, while most of the antidepressant group carried on. And there was no evidence that this affected the trial results.)
The results of Kuyken’s trial may disappoint some mindfulness advocates. Mindfulness didn’t prove superior to antidepressants. The relapse rate for both groups over 24 months was more or less identical: 44% for the MBCT cohort and 47% for those taking antidepressant medication.
However, MBCT was especially helpful for patients with a history of childhood physical or sexual abuse. Relapse rates among these individuals were 47% with MBCT and 59% with antidepressant medication (47% to 59%). This finding is particularly persuasive given that a similar pattern has been observed in another MBCT trial. Because the overall rates for the two treatments were so similar, one might expect that those with low levels of childhood abuse would fare better with antidepressants, but the evidence for this was weaker in Kuyken’s study (42% to 35%).
Glass half-full readers, of course, will see that the trial results demonstrate that we actually have two similarly effective treatment options for recurrent depression: one involves eight weeks of a psychological therapy, the other relies on taking medication for two years. The challenge now is to make both equally available in treatment services.