Mindfulness May Cut Relapse Risk in Recurrent Depression Benefits of mindfulness-based cognitive therapy rose with worsening residual symptoms

Mindfulness-based cognitive therapy (MBCT) was effective at reducing risk of relapse in patients with recurrent depression, especially in those with the most severe residual symptoms, a meta-analysis showed.
Patients receiving MBCT had a significantly reduced risk of depressive relapse within a 60-week follow-up period compared with those who received usual care (HR 0.69, 95% CI 0.58-0.82), Willem Kuyken, PhD, of the Warneford Hospital at Oxford University, and colleagues reported online in JAMA Psychiatry.

Patients receiving MBCT had comparable outcomes to those who received other active treatments (HR 0.79, 95% CI 0.64-0.97), they reported.
“While previous research has shown the superiority of MBCT compared with usual care, this study provides important new evidence that MBCT is also effective compared with other active treatments and that its effects are not restricted to particular groups defined by age, educational level, marital status, or sex,” the researchers wrote.
“The finding that MBCT may be most helpful for patients with higher levels of depressive symptoms adds to an emerging consensus that the greater the risk for depressive relapse/recurrence, the more benefit MBCT offers.”
These results both replicate and extend previous work, Kuyken and colleagues said: “We found that MBCT reduces the risk of depressive relapse/recurrence compared with the current mainstay approach, maintenance antidepressants.”
Although MBCT teaches patients at high risk of relapse how to keep depressive symptoms at bay, its protective effect appears to fade over time. In addition, patients whose symptoms were not as severe “appeared to receive less benefit,” they said.

In the study — an update to a previous meta-analysis — individual patient data was compiled from 9 published randomized trials of MBCT in Europe and North America. The data were identified using EMBASE, PubMed/Medline, PsycINFO, Web of Science, Scopus, and the Cochrane Controlled Trials Register, and had been conducted from November 2010 to November 2014.
A total of 1,258 patients were included. Three-quarters were female and the mean age was 47.1 years. Among 1,234 participants, the mean age at onset of depression was 26 years and in 1,200 participants, 694 (57.8%) had 5 or more past depressive episodes.
The analysis demonstrated that there was no statistically significant interaction with MBCT treatment between sociodemographic factors such as age, sex, education, and relationship status or psychiatric variables including age at onset and the number of previous episodes of depression.
The researchers pointed out that a recent meta-analysis comparing the effectiveness of all psychological interventions to prevent recurrence with usual care and antidepressants has suggested that protective effects of MBCT are comparable to cognitive therapy versus usual care and interpersonal therapy versus usual care.
“The meta-analysis by Kuyken et al provides strong evidence that MBCT is effective in reducing risk of depressive relapse and is particularly effective for patients with higher levels of depressive severity before treatment,” Richard Davidson, PhD, founder of the Center for Healthy Minds at the University of Wisconsin-Madison, commented in an accompanying editorial.

Previous studies have indicated that one of the key variables behind the effectiveness of MBCT is how often individuals put it into practice, Davidson noted. “While this type of association is not always present, it is a potentially very important variable and may account for considerable variability across patients and across studies.”
Daily practice logs “can provide useful information with which to correlate changes in clinical and other outcomes,” he added.
Looking ahead, there is an opportunity to take a closer look at which patients benefit most from MBCT, the mechanisms behind its beneficial effect, and how to more effectively measure the mediators of therapeutic change, Davidson said.
“Combining insights and methods from basic cognitive and affective neuroscientific research on mindfulness with future clinical trials provides a framework for addressing these additional questions,” he wrote.
An examination of the synergistic effect of MBCT and “neuroplasticity enhancers” such as physical exercise might also be of interest, he said.

The researchers made a number of recommendations for future trials that relate directly to the limitations of their analysis and which could help “address remaining uncertainties and improve the rigor of the field.”
An active control group should be considered, as well as the use of comparable primary and secondary outcomes such as the Structured Clinical Interview for DSM for depressive relapse, they said. In addition, they recommended that key variables such as race/ethnicity and employment be considered, that follow-up time be lengthened, that steps be taken to ensure generalizability of results, and that data sharing systems be created to systematically record and report adverse events.
The study was supported by the Wellcome Trust, the National Institute for Health Research Healthy Technology Assessment program, the National Institute for Health Research Collaboration for Leadership in Applied Health Research, Care South West Peninsula at the Royal Devon, Exeter National Health Service Foundation Trust, and the Medical Research Council.

Kuyken is director of the Oxford Mindfulness Centre, which was founded by study co-author, Mark Williams, PhD, its director until 2013. Anne Speckens, MD, is founder and clinical director of the Radboud UMC Centre for Mindfulness; and Helen Ma, PhD, is director of the Centre for Mindfulness, Hong Kong. Zindel Segal, PhD, disclosed a relationship with NogginLabs.

Davidson disclosed that his editorial research was funded by the National Center for Complementary and Integrative Health of the National Institutes of Health as well as several gifts to the Center for Healthy Minds, a nonprofit corporation associated with the Center for Healthy Minds at the University of Wisconsin-Madison. Davidson also disclosed that he is founder and president of Healthy Minds Innovations.


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