Rebecca S. Crane

Mindfulness-Based Cognitive Therapy for Preventing Relapse in Recurrent Depression: A Randomized Dismantling Trial.

Objective: We compared mindfulness-based cognitive therapy (MBCT) with both cognitive psychological education (CPE) and treatment as usual (TAU) in preventing relapse to major depressive disorder (MDD) in people currently in remission following at least 3 previous episodes. Method: A randomized controlled trial in which 274 participants were allocated in the ratio 2:2:1 to MBCT plus TAU, CPE plus TAU, and TAU alone, and data were analyzed for the 255 (93%; MBCT = 99, CPE = 103, TAU = 53) retained to follow-up. MBCT was delivered in accordance with its published manual, modified to address suicidal cognitions; CPE was modeled on MBCT, but without training in meditation. Both treatments were delivered through 8 weekly classes. Results: Allocated treatment had no significant effect on risk of relapse to MDD over 12 months follow-up, hazard ratio for MBCT vs. CPE = 0.88, 95% CI [0.58, 1.35]; for MBCT vs. TAU = 0.69, 95% CI [0.42, 1.12]. However, severity of childhood trauma affected relapse, hazard ratio for increase of 1 standard deviation = 1.26 (95% CI [1.05, 1.50]), and significantly interacted with allocated treatment. Among participants above median severity, the hazard ratio was 0.61, 95% CI [0.34, 1.09], for MBCT vs. CPE, and 0.43, 95% CI [0.22, 0.87], for MBCT vs. TAU. For those below median severity, there were no such differences between treatment groups. Conclusion: MBCT provided significant protection against relapse for participants with increased vulnerability due to history of childhood trauma, but showed no significant advantage in comparison to an active control treatment and usual care over the whole group of patients with recurrent depression.

Competence in Teaching Mindfulness-Based Courses: Concepts, Development and Assessment

There has been a groundswell of interest in the UK in Mindfulness-Based Stress Reduction (MBSR) and its derivatives, particularly Mindfulness-Based Cognitive Therapy (MBCT). Many health, education and social work practitioners have sought ways to develop their competencies as mindfulness-based teachers, and increasing numbers of organisations are developing mindfulness-based training programmes. However, the rapid expansion of interest in mindfulness-based approaches has meant that those people offering training for MBSR and MBCT teachers have had to consider some quite fundamental questions about training processes, standards and competence. They also need to consider how to develop a robust professional context for the next generation of mindfulness-based teachers. The ways in which competencies are addressed in the secular mainstream contexts in which MBSR and MBCT are taught are examined to enable a consideration of the particularities of mindfulness-based teaching competence. A framework suggesting how competencies develop in trainees is presented. The current status of methodologies for assessing competencies used in mindfulness-based training and research programmes is reviewed. We argue that the time is ripe to continue to develop these dialogues across the international community of mindfulness-based trainers and teachers.

Training Teachers to Deliver Mindfulness-Based Interventions: Learning from the UK Experience.

Several randomised controlled trials suggest that mindfulness-based approaches are helpful in preventing depressive relapse and recurrence, and the UK Government’s National Institute for Health and Clinical Excellence has recommended these interventions for use in the National Health Service. There are good grounds to suggest that mindfulness-based approaches are also helpful with anxiety disorders and a range of chronic physical health problems, and there is much clinical and research interest in applying mindfulness approaches to other populations and problems such as people with personality disorders, substance abuse, and eating disorders. We review the UK context for developments in mindfulness-based approaches and set out criteria for mindfulness teacher competence and training steps, as well as some of the challenges and future directions that can be anticipated in ensuring that evidence-based mindfulness approaches are available in health care and other settings.

Development and Validation of the Mindfulness-Based Interventions – Teaching Assessment Criteria (MBI:TAC):

Background. The assessment of intervention integrity is essential in psychotherapeutic intervention outcome research and psychotherapist training. There has been little attention given to it in mindfulness-based interventions research, training programs, and practice. Aims. To address this, the Mindfulness-Based Interventions: Teaching Assessment Criteria (MBI:TAC) was developed. This article describes the MBI:TAC and its development and presents initial data on reliability and validity. Method. Sixteen assessors from three centers evaluated teaching integrity of 43 teachers using the MBI:TAC. Results. Internal consistency (α = .94) and interrater reliability (overall intraclass correlation coefficient = .81; range = .60-.81) were high. Face and content validity were established through the MBI:TAC development process. Data on construct validity were acceptable. Conclusions. Initial data indicate that the MBI:TAC is a reliable and valid tool. It can be used in Mindfulness-Based Stress Reduction/Mindfulness-Based Cognitive Therapy outcome evaluation research, training and pragmatic practice settings, and in research to assess the impact of teaching integrity on participant outcome.

What defines mindfulness-based programs? The warp and the weft

There has been an explosion of interest in mindfulness-based programs (MBPs) such as Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy. This is demonstrated in increased research, implementation of MBPs in healthcare, educational, criminal justice and workplace settings, and in mainstream interest. For the sustainable development of the field there is a need to articulate a definition of what an MBP is and what it is not. This paper provides a framework to define the essential characteristics of the family of MBPs originating from the parent program MBSR, and the processes which inform adaptations of MBPs for different populations or contexts. The framework addresses the essential characteristics of the program and of teacher. MBPs: are informed by theories and practices that draw from a confluence of contemplative traditions, science, and the major disciplines of medicine, psychology and education; underpinned by a model of human experience which addresses the causes of human distress and the pathways to relieving it; develop a new relationship with experience characterized by present moment focus, decentering and an approach orientation; catalyze the development of qualities such as joy, compassion, wisdom, equanimity and greater attentional, emotional and behavioral self-regulation, and engage participants in a sustained intensive training in mindfulness meditation practice, in an experiential inquiry-based learning process and in exercises to develop understanding. The papers aim is to support clarity, which will in turn support the systematic development of MBP research, and the integrity of the field during the process of implementation in the mainstream.

The effects of amount of home meditation practice in Mindfulness Based Cognitive Therapy on hazard of relapse to depression in the Staying Well after Depression Trial

Few empirical studies have explored the associations between formal and informal mindfulness home practice and outcome in Mindfulness-based Cognitive Therapy (MBCT). In this study ninety-nine participants randomised to MBCT in a multi-centre randomised controlled trial completed self-reported ratings of home practice over 7 treatment weeks. Recurrence of Major Depression was assessed immediately after treatment, and at 3, 6, 9, and 12-months post-treatment. Results identified a significant association between mean daily duration of formal home practice and outcome and additionally indicated that participants who reported that they engaged in formal home practice on at least 3 days a week during the treatment phase were almost half as likely to relapse as those who reported fewer days of formal practice. These associations were independent of the potentially confounding variable of participant-rated treatment plausibility. The current study identified no significant association between informal home practice and outcome, although this may relate to the inherent difficulties in quantifying informal home mindfulness practice. These findings have important implications for clinicians discussing mindfulness-based interventions with their participants, in particular in relation to MBCT, where the amount of participant engagement in home practice appears to have a significant positive impact on outcome.

The Implementation of Mindfulness-Based Cognitive Therapy: Learning From the UK Health Service Experience

Mindfulness-based cognitive therapy (MBCT) is an effective depression prevention programme for people with a history of recurrent depression. In the UK, the National Institute for Clinical Excellence (NICE) has suggested that MBCT is a priority for implementation. This paper explores the exchange, synthesis and application of evidence and guidance on MBCT between the academic settings generating the evidence and delivering practitioner training and the practice settings where implementation takes place. Fifty-seven participants in a workshop on MBCT implementation in the NHS were asked for their experience of facilitators and obstacles to implementation, and a UK-wide online survey of 103 MBCT teachers and stakeholders was conducted. While MBCT is starting to become available in the NHS, this is rarely part of a strategic, coherent or appropriately resourced approach. A series of structural, political cultural, educational, emotional and physical/technological obstacles and facilitators to implementation were identified. Nearly a decade since NICE first recommended MBCT, only a small number of mental health services in the UK have systematically implemented the guidance. Guiding principles for implementation are set out. We offer an implementation resource to facilitate the transfer of MBCT knowledge into action.

Staying well after depression: trial design and protocol

BackgroundDepression is often a chronic relapsing condition, with relapse rates of 50-80% in those who have been depressed before. This is particularly problematic for those who become suicidal when depressed since habitual recurrence of suicidal thoughts increases likelihood of further acute suicidal episodes. Therefore the question how to prevent relapse is of particular urgency in this group.Methods/DesignThis trial compares Mindfulness-Based Cognitive Therapy (MBCT), a novel form of treatment combining mindfulness meditation and cognitive therapy for depression, with both Cognitive Psycho-Education (CPE), an equally plausible cognitive treatment but without meditation, and treatment as usual (TAU). It will test whether MBCT reduces the risk of relapse in recurrently depressed patients and the incidence of suicidal symptoms in those with a history of suicidality who do relapse. It recruits participants, screens them by telephone for main inclusion and exclusion criteria and, if they are eligible, invites them to a pre-treatment session to assess eligibility in more detail. This trial allocates eligible participants at random between MBCT and TAU, CPE and TAU, and TAU alone in a ratio of 2:2:1, stratified by presence of suicidal ideation or behaviour and current anti-depressant use. We aim to recruit sufficient participants to allow for retention of 300 following attrition. We deliver both active treatments in groups meeting for two hours every week for eight weeks. We shall estimate effects on rates of relapse and suicidal symptoms over 12 months following treatment and assess clinical status immediately after treatment, and three, six, nine and twelve months thereafter.DiscussionThis will be the first trial of MBCT to investigate whether MCBT is effective in preventing relapse to depression when compared with a control psychological treatment of equal plausibility; and to explore the use of MBCT for the most severe recurrent depression - that in people who become suicidal when depressed.Trial RegistrationCurrent Controlled Trials: ISRCTN97185214.

Does mindfulness based cognitive therapy prevent relapse of depression

Depression typically runs a relapsing and recurrent course.1 Without ongoing treatment people with recurrent depression have a very high risk of repeated depressive relapses throughout their life, even after successful acute treatment. Major inroads into the substantial health burden attributable to depression could be offset through interventions that prevent depressive relapse among people at high risk of recurrent episodes.2 If the factors that make people vulnerable to depressive relapse can be attenuated, the relapsing course of depression could potentially be broken. Currently, most depression is treated in primary care, and maintenance antidepressants are the mainstay approach to preventing relapse.3 The UK’s National Institute for Health and Clinical Excellence (NICE) recommends that to stay well, people with a history of recurrent depression should continue taking antidepressants for at least two years. However, many patients experience side effects, and some express a preference for psychosocial interventions, which provide long term protection against relapse.4 Mindfulness based cognitive therapy (MBCT)5 was developed as a psychosocial intervention for teaching people with a history of depression the skills to stay well in the long term (see box for a description of MBCT). #### Description of mindfulness based cognitive therapy Mindfulness based cognitive therapy (www.bemindful.co.uk/mbct/about) is a psychosocial, group based, relapse prevention programme for people with a history of depression who wish to learn long term skills for staying well. It combines systematic mindfulness training—meditation exercises targeted at enhancing awareness and developing self compassion—with elements from cognitive behavioural therapy. MBCT is based on a theoretical premise similar to that on which cognitive behavioural therapy is based, and it uses strategies from that therapy too. However, MBCT helps people to learn that the negative thoughts that can signal the start of a depressive episode are fleeting events in the mind that they can choose to engage with or not. Through …

Mindfulness-based cognitive therapy (MBCT) reduces the association between depressive symptoms and suicidal cognitions in patients with a history of suicidal depression.

Objective: In patients with a history of suicidal depression, recurrence of depressive symptoms can easily reactivate suicidal thinking. In this study, we investigated whether training in mindfulness, which is aimed at helping patients “decenter” from negative thinking, could help weaken the link between depressive symptoms and suicidal cognitions. Method: Analyses were based on data from a recent randomized controlled trial, in which previously suicidal patients were allocated to mindfulness-based cognitive therapy (MBCT), an active control treatment, cognitive psychoeducation (CPE), which did not include any meditation practice, or treatment as usual (TAU). After the end of the treatment phase, we compared the associations between depressive symptoms, as assessed through self-reports on the Beck Depression Inventory–II (Beck, Steer, & Brown, 1996), and suicidal thinking, as assessed through the Suicidal Cognitions Scale (Rudd et al., 2001). Results: In patients with minimal to moderate symptoms at the time of assessment, comparisons of the correlations between depressive symptoms and suicidal cognitions showed significant differences between the groups. Although suicidal cognitions were significantly related to levels of symptoms in the 2 control groups, there was no such relation in the MBCT group. Conclusion: The findings suggest that, in patients with a history of suicidal depression, training in mindfulness can help to weaken the association between depressive symptoms and suicidal thinking, and thus reduce an important vulnerability for relapse to suicidal depression.