Research report
Depression relapse prophylaxis with Mindfulness-Based Cognitive Therapy: Replication and extension in the Swiss health care system

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Abstract

Background

Mindfulness-Based Cognitive Therapy (MBCT) is a group intervention that integrates elements of Cognitive Behavioural Therapy (CBT) with components of mindfulness training to prevent depressive relapse. The efficacy of MBCT compared to Treatment As Usual (TAU), shown in two randomized controlled trials indicates a significant decrease in 1-year relapse rates for patients with at least three past depressive episodes. The present study is the first independent replication trial comparing MBCT + TAU to TAU alone across both language and culture (Swiss health care system).

Methods

Sixty unmedicated patients in remission from recurrent depression (≥ 3 episodes) were randomly assigned to MBCT + TAU or TAU. Relapse rate and time to relapse were measured over a 60 week observation period. The frequency of mindfulness practices during the study was also evaluated.

Results

Over a 14-month prospective follow-up period, time to relapse was significantly longer with MBCT + TAU than TAU alone (median 204 and 69 days, respectively), although both groups relapsed at similar rates. Analyses of homework adherence revealed that following treatment termination, the frequency of brief and informal mindfulness practice remained unchanged over 14 months, whereas the use of longer formal meditation decreased over time.

Limitations

Relapse monitoring was 14 months in duration and prospective reporting of mindfulness practice would have yielded more precise frequency estimates compared to the retrospective methods we utilized.

Conclusions

Further studies are required to determine which patient characteristics, beyond the number of past depressive episodes, may predict differential benefits from this therapeutic approach.

Introduction

Relapse and recurrence following remission and recovery from a major depressive episode are common and debilitating outcomes that carry enormous social costs (Judd et al., 2000, Paykel et al., 2005). Since routine clinical management of depressed patients targets symptom reduction during the acute episode as its primary goal, little attention has been paid to strategies for maintaining treatment benefits over time. One approach that has recently shown promise involves sequencing antidepressant pharmacotherapy with a prophylactic intervention that teaches prevention skills to patients in pharmacologically-induced remission. Mindfulness-Based Cognitive Therapy (MBCT; Segal et al., 2002b) consists of 8 weekly sessions comprising a group intervention that integrates elements of Cognitive Behavioural Therapy (CBT; Beck et al., 1979) with components of the Mindfulness-Based Stress Reduction program (MBSR; Kabat-Zinn, 1990) to prevent depressive relapse.

The theoretical background of MBCT is based on the differential activation hypothesis developed by Teasdale (1988) who suggests that individuals who have experienced several depressive episodes are vulnerable to recurrences as even a mild dysphoric state may reactivate the depressive thinking patterns present during previous depressive episodes, thus precipitating a full-blown new episode. In this context, a treatment manual was developed (MBCT – Segal et al., 2002b) describing a preventive group protocol that teaches recovered depressed patients how to disengage from automatic, cognitive processing patterns linked to relapse. Teasdale et al. (1995) proposed that attentional control skills taught in mindfulness meditation could be helpful in preventing relapse by enabling formerly depressed individuals to observe their thoughts and feelings non-judgementally and to view them simply as passing mental events rather than as aspects of themselves or as accurate reflections of reality.

To date, two randomized controlled trials (Ma and Teasdale, 2004, Teasdale et al., 2000) explored the efficacy of MBCT compared to Treatment As Usual (TAU). More precisely, Teasdale et al. (2000) examined the effects of MBCT on rates of depressive relapse in a large multicenter sample of patients having remitted from major depressive episode and off antidepressant medication (N = 145). All participants had discontinued their medication at least 12 weeks before the study began. Patients were randomly assigned to either TAU or MBCT + TAU conditions and then followed for 1 year. For patients with three or more previous depressive episodes (77% of the study sample), results showed much lower relapse rates for MBCT + TAU patients (40% of patients relapsed) than for the TAU group (66% of patients relapsed) during the 1-year follow-up period. However, relapse rates did not differ between MBCT + TAU and TAU conditions for patients having experienced only one or two previous episodes. These results were later confirmed in a single site replication study (N = 75) of the efficacy of MBCT + TAU versus TAU (Ma and Teasdale, 2004) in preventing depressive relapse. A significant reduction in the relapse rate during the 1-year follow-up period was observed in MBCT + TAU patients compared to the TAU group (36% vs. 78%), again only for patients with three or more past episodes of depression.

More recently, it has also been shown, that in people with three or more past episodes of depression, MBCT produces comparable relapse/recurrence rates over 15-month follow-up (47%) to maintenance antidepressant medication (60%) (Kuyken et al., 2008). Additionally, preliminary results on MBCT for patients currently actively symptomatic are very encouraging (Eisendrath et al., 2008, Kenny and Williams, 2007, Kingston et al., 2007).

Still, there are a number of questions that remain to be answered. Chief among these is the fact that the prevention effects reported in studies comparing MBCT + TAU to TAU come from trials in which MBCT groups were conducted by the developers of this treatment approach. This makes it difficult to determine the MBCT's generalizability and to rule out allegiance effects (Luborsky and Luborsky, 2006). The major emphasis on efficacy in these early studies has also left questions such as the patient's experience while learning mindfulness practices largely unanswered (Mason and Hargreaves, 2001). For example, little is known about which mindfulness practices patients continue to use or abandon once the 8-session treatment has ended (Carmody and Baer, 2008).

In the present study, we tested the hypothesis that MBCT in addition to TAU would reduce the risk of depressive relapse when compared with TAU alone in the context of the Swiss health care system in a sample of remitted depressed patients with three or more past depressive episodes. Moreover, we investigated whether a regular degree of practice was associated with diminished relapse rates.

Section snippets

Inclusion/exclusion criteria

As the present study aims to be a replication trial of the two previous MBCT trials (Ma and Teasdale, 2004, Teasdale et al., 2000), inclusion/exclusion criteria and treatment framework were identical. The only difference between these studies and the present trial was the number of previous depressive episodes. Whereas a portion of the sample in the former studies (appx 20%) had 1–2 past episodes, we limited the inclusion to patients with 3 or more previous episodes. The rationale for this was

Patients flow

The patient flow chart is provided in Fig. 1.

More than 600 interested participants contacted the research team by phone or e-mail and a preliminary semi-structured phone screening was performed prior to an in person selection interview. The main reasons for exclusion from the phone screening interview were that participants presented with an ongoing acute depressive episode, they had less than three previous depressive episodes, they were older than 65 or younger than 18, they could not

Discussion

To our knowledge, the present study is the first replication trial comparing MBCT + TAU to TAU performed without direct involvement of the MBCT developers, considered as a frequent bias in psychotherapy research (Chambless and Hollon, 1998). In remitted patients with three or more previous depressive episodes who relapsed, time to relapse was significantly delayed in the MBCT + TAU group (median 29 weeks) compared with TAU (10 weeks), in line with findings showing that MBCT increases the average

Role of funding source

This study was supported by a grant of the Swiss National Science Foundation (Grant no. 3200BO-108432 to Guido Bondolfi, Gilles Bertschy, Jean-Michel Aubry and Martial Van der Linden).

Conflict of interest

There is no conflict of interest in this research.

Acknowledgments

This study was supported by a grant of the Swiss National Science Foundation (Grant no. 3200BO-108432 to Guido Bondolfi, Gilles Bertschy, Jean-Michel Aubry and Martial Van der Linden). Zindel Segal, PhD was consulted on the clinical competencies of the Swiss instructors and MBCT treatment fidelity. The authors thank Jean-Nicolas Despland from the Department of Psychiatry of the University Hospital in Lausanne for putting offices at the disposal of the research team. We also thank Sandra Ter

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