Depression and anxiety are amongst the commonest reasons for consultation in UK general practice. Participants with a history of depression who had depression or depression and anxiety were recruited from a single practice in Ayrshire, Scotland to take part in a study using Mindfulness Based Cognitive Therapy (MBCT).
Mindfulness Based Cognitive Therapy (MBCT) is an 8-week course developed for patients with relapsing depression that integrates mindfulness meditation practices and cognitive theory.
Previous studies have demonstrated that non-depressed participants with a history of relapsing depression are protected from relapse by participating in the course.
This exploratory study examined the acceptability and effectiveness of Mindfulness Based Cognitive Therapy (MBCT) for patients in primary care with active symptoms of depression and anxiety
The problem of relapse in depression is a significant one and for many individuals depression is a chronic relapsing condition.
While a high percentage of first episodes of depression are triggered by a major life event, further episodes are less likely to have such a clear precipitant. A ruminative thinking style in response to low mood appears to be a key feature in relapsing depression (a preoccupation with certain thoughts and ideas).
Thirteen patients with recurrent depression or recurrent depression and anxiety were recruited to take part in the study. Semi-structured qualitative interviews were conducted three months after completing the MBCT programme
Mindfulness Based Cognitive Therapy (MBCT) is an innovative, empirically validated treatment program designed to prevent relapse in people who have recovered from depression.
Two randomised controlled trials have found that MBCT, when taught to patients in the remission phase, reduced the rate of relapsing depression, in patients with a history of 3 or more episodes of depression, by about 50%.
The problem of relapse in depression is a significant one and for many individuals depression is a chronic relapsing condition. In a recent review on the natural history of depression Judd concludes that “unipolar depression is a chronic and life long illness, the risk of repeated episodes exceeds 80% and patients will experience an average of 4 lifetime major depressive episodes of 20 weeks duration”. (Archives of General Psychiatry. 1997;54:989â€“991).
While a high percentage of first episodes of depression are triggered by a major life event, further episodes are less likely to have such a clear precipitant.
A ruminative thinking style (a preoccupation with certain thoughts and ideas) in response to low mood appears to be a key feature in relapsing depression. Nolen-Hoeksema defines rumination as ‘behaviours and thoughts that focus one’s attention on one’s depressive symptoms and on the implications of those symptoms’.
Ruminative thinking often involves extended pondering over personal shortcomings and problematic situations and perpetuates rather than alleviates the depressed state.
Mindfulness Based Cognitive Therapy (MBCT) teaches participants to recognise and let go of ruminative thinking about negative affect and instead participants are encouraged to simply remain open to what is there â€“ to experience it fully, without aversion or attachment.
Hence mindfulness training involves an attitudinal shift toward difficult experience. The heart of MBCT lies in acquainting patients with the modes of mind that often characterize mood disorders while simultaneously inviting them to develop a new relationship to these modes.
Patients learn to view thoughts as events in the mind, independent of their content and emotional charge.
While the two major studies cited above have focused on patients who have recovered from depression, it is not known whether MBCT may have a wider role to play in treating chronic mood disorders during their active phase, which is when patients tend to seek help from primary care.
If acceptable and effective we can envisage a number of potential advantages to such an approach.
Firstly while psychotropic medication has a role to play in treating mood disorders, it is not always effective, nor is it acceptable to many patients.
Secondly the group-based approach with its emphasis on the development of mindfulness skills confers a number of possible benefits over both individual and group psychotherapy.
Apart from treating a greater number of patients and helping to shorten waiting lists for psychological services, the mindfulness meditation format may appeal to patients who would otherwise find talking about personal problems in group therapy too threatening.
By focusing on the development of mindfulness skills and basing MBCT in primary care, MBCT may be seen by patients more along the lines of adult education rather than a mental health intervention, thus helping to de-stigmatise depression and anxiety.
Finally non-specific group effects, such as validation and normalisation, are likely to play an important role in the treatment of depression and anxiety.
The aim of this exploratory pilot study was to investigate the acceptability and effectiveness of Mindfulness Based Cognitive Therapy (MBCT) in primary care for patients with a history of relapsing depression who had current symptoms of depression or depression and anxiety.
A mixed method approach was adopted, involving both quantitative data (pre and post course validated depression and anxiety measures) and qualitative data from semi-structured interviews 3 months after completion of the course.
The following research questions were considered.
1. Is MBCT an acceptable intervention to patients with anxiety and depression?
2. What benefit, if any, do patients derive from the mindfulness approach? (Does meditation practice aggravate depression?)
3. Do patients continue to employ mindfulness techniques to cope with adverse mental states, three months after the course has finished?
4. Does an 8-week course result in improved mood as measured on Beck Depression Inventory (BDI-II) and Beck Anxiety Inventory?
Two researchers were involved in the study; Andy Finucane a General practitioner (GP) with training in CBT, meditation and Mindfulness Based Cognitive Therapy (MBCT) and Stewart W Mercer, a GP and senior clinical research fellow at the University of Glasgow, with training in MBCT and experience in qualitative research.
Andy Finucane had previously completed the MBCT 8-week course as a participant to gain first hand experience of the process. Further training was undertaken in the form of an intensive course with the North Wales Centre for Mindfulness Research and Practice (University of Wales) to become an Mindfulness Based Cognitive Therapy (MBCT) instructor. Only Andy Finucane was involved in the delivery of the MBCT program and Stewart W Mercer conducted the interviews.
The structure and format of the mindfulness course closely followed that of the original 8-week MBCT course, found in Williams, Segal and Teasdale’s book “Mindfulness Based Cognitive Therapy; a new approach for relapsing depression” (2000). This course teaches a variety of methods for developing mindfulness:
a) The body-scan â€“ becoming aware of bodily sensations.
b) Guided Sitting meditation â€“ cultivating a decentred awareness in relation to physical sensations, sound and cognition.
c) Mindful Stretching and Mindful Walking â€“ developing awareness of bodily sensations through movement
d) The 3-minute breathing space â€“ an exercise in bringing attention into the present moment, developing a greater awareness of the effects of difficult experience on thoughts, feeling and physical sensations.
e) Mindfulness in everyday life â€“ bringing awareness to routine tasks such as eating and washing
Because concentration is affected in depression, a decision was taken to shorten some of the longer meditations; the body scan was reduced from 40 to 30 minutes and the guided sitting meditation reduced from 40 to 25 minutes.
Shortening the practices is a contentious issue within MBCT circles. While on the one hand mindfulness training involves developing a more decentred approach to difficult experience, and longer meditation sessions provide a greater opportunity to encounter experiences such as frustration, physical discomfort and painful emotional states, this in turn must be balanced by participants ability to be able to ‘stay with’ these difficult experiences.
Because the participants in this study had a range of affective symptoms we believed that shorter sessions with these patients were as likely to produce difficulties as longer meditation sessions in recovered depressed patients.
Stewart Mercer, an experienced interviewer and qualitative researcher, conducted one-to-one semi-structured interviews, with 11 out of the 13 participants at a mutual agreed location.
Some of the interviews were done face to face and others were done by telephone. The interviews, which followed a relaxed conversational style and covered issues indicated in (table 3), lasted approximately 30â€“45 minutes.
All were recorded and transcribed verbatim. After the first few interviews were conducted the interviewer added other questions based on themes that had emerged from the previous interviews. For example specific questions were asked about ‘being in a group’ or ‘impressions of the facilitator’.
Qualitative Interview format
Semi-structured using questions around 5 themes
1. Participants overall impressions â€“ “in general what did you think of the overall approach?”
2. The course techniques/methods/materials â€“ “what aspects of the course did you find beneficial”, “what aspects of the course did you find difficult/unhelpful?”
3. The format of the course â€“ “what did you think about the length of the course?”
4. Ongoing mindfulness practice â€“ “are there any techniques you continue to use?”
5. Coping skills â€“ “do you feel better able to cope with adversity than before you started the course?”, “has anything changed for you since you completed the course?”
BMC Psychiatry. 2006; 6: 14.
Published online 2006 April 7. doi: 10.1186/1471-244X-6-14. Copyright Â© 2006 Finucane and Mercer; licensee BioMed Central Ltd.
Two participants were not interviewed; one because she had moved out of the area following a break down of her marriage and the second participant because she could not be contacted. All the other participants agreed to be interviewed.
Because of the subjective nature of qualitative research and the potential for researcher bias, the analysis remained predominantly descriptive rather than interpretive, allowing patients’ narratives speak for themselves.
Particular attention was directed not only at emergent themes that were similar to each other but also to looking at data that diverged from the norm.
Three participants were male and ten female. The average age of the group was 43 (range 29â€“58).
â€¢ 11 participants had an ICD diagnosable depression, 9 of whom satisfied ICD-10 criteria for recurrent depressive disorder â€“ current episode mild/moderate or severe. The other 2 participants with depression had primary diagnosis of generalised anxiety disorder.
â€¢ 2 participants had mixed anxiety and depressive disorder and past histories of depression.
Two participants also had a past diagnosis of post-traumatic stress disorder given by a consultant psychiatrist. Two others probably had past diagnosis of PTSD and two individuals also divulged a history of significant childhood sexual abuse. Overall there was a significant degree of psychological morbidity in the group.
Part 2 to be published soon – Read what the participants had to say!
Andy Finucane and Stewart W Mercer. An exploratory mixed methods study of the acceptability and effectiveness of mindfulness -based cognitive therapy for patients with active depression and anxiety in primary care. Copyright Â© 2006 Finucane and Mercer; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the (http://creativecommons.org/licenses/by/2.0).
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