The Reliability of Rating via Audio-Recording Using the Mindfulness-Based Interventions: Teaching Assessment Criteria.

Background: The Mindfulness-Based Interventions: Teaching Assessment Criteria (MBI:TAC) is an important tool for assessing teacher skill and aspects of the fidelity of mindfulness-based interventions, but prior research on and implementation of the MBI:TAC has used video recordings, which can be difficult to obtain, share for assessments, and which increase privacy concerns for participants. Audio-only recordings might be a useful alternative, but their reliability is unknown. Objective: To assess evaluator perception of the rating process and inter-rater reliability of MBI:TAC ratings using audio-only recordings. Methods: We prepared audio-only files from video recordings of 21 previously rated Mindfulness-Based Stress Reduction teachers. Each audio recording was rated by 3 trained MBI:TAC assessors drawn from a pool of 12 who had previously participated in rating the video recordings. Teachers were rated by evaluators who had not viewed the video recording and did not know the teacher. We then conducted semi-structured interviews with evaluators. Results: On the 6 MBI:TAC domains, the intraclass correlation coefficients (ICCs) for audio recordings ranged from .53 to .69 using an average across 3 evaluators. Using a single rating resulted in lower ICCs (.27-.38). Bland-Altman plots showed audio ratings had little consistent bias compared to video recordings and agreed more closely for teachers with higher ratings. Qualitative analysis identified 3 themes: video recordings were particularly helpful when rating less skillful teachers, video recordings tended to provide a more complete picture for rating, and audio rating had some positive features. Conclusions: Inter-rater reliability of the MBI:TAC using audio-only recordings was adequate for many research and clinical purposes, and reliability is improved when using an average across several evaluators. Ratings using audio-only recordings may be more challenging when rating less experienced teachers.

Mindfulness-Based Stress Reduction for Our Time: A Curriculum that is up to the Task.

There is current heightened public consciousness of the intersecting challenges of social and racial injustice, other forms of inequity, and the climate and biodiversity crisis. We examine how these current realities influence how we engage as Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Program (MBP) teachers and researchers. Although Kabat-Zinn developed MBSR as a vehicle to enable engagement with both the individual and the collective drivers of distress and flourishing, predominant research and practice trends within the MBP field have prioritised individual wellbeing, and have not been accessible to the full societal demographic. Furthermore, there is increasing recognition that the systemic social inequities that influence access to public services have not been addressed in the MBP field. In response, there is now an increasing trend exploring how MBP participation can influence 'bigger than self' concerns, with research, practice and theory suggesting that the inner personal transformation that mindfulness practice enables, supports individuals to compassionately reconnect to self, other and the natural world in ways that foster prosocial behaviour change, and enables awareness building of personal bias and conditioning. In this paper we present perspectives on ways of both retaining fidelity to the existing MBSR program, and simultaneously embracing anti-oppression teaching methods and content, and an inclusive recognition of the micro, meso and macro causes and conditions that drive distress and flourishing. We are a group of racially diverse MBP teachers and trainers from both sides of the Atlantic, who are engaged in training initiatives with people from Black, Latinex, Indigenous, Asian, and People of Color communities.

Clinical Effectiveness and Cost-Effectiveness of Supported Mindfulness-Based Cognitive Therapy Self-help Compared With Supported Cognitive Behavioral Therapy Self-help for Adults Experiencing Depression: The Low-Intensity Guided Help Through Mindfulness (LIGHTMind) Randomized Clinical Trial.

Importance: Depression is prevalent. Treatment guidelines recommend practitioner-supported cognitive behavioral therapy self-help (CBT-SH) for mild to moderate depression in adults; however, dropout rates are high. Alternative approaches are required. Objective: To determine if practitioner-supported mindfulness-based cognitive therapy self-help (MBCT-SH) is superior to practitioner-supported CBT-SH at reducing depressive symptom severity at 16 weeks postrandomization among patients with mild to moderate depression and secondarily to examine if practitioner-supported MBCT-SH is cost-effective compared with practitioner-supported CBT-SH. Design, Setting, and Participants: This was an assessor- and participant-blinded superiority randomized clinical trial with 1:1 automated online allocation stratified by center and depression severity comparing practitioner-supported MBCT-SH with practitioner-supported CBT-SH for adults experiencing mild to moderate depression. Recruitment took place between November 24, 2017, and January 31, 2020. The study took place in 10 publicly funded psychological therapy services in England (Improving Access to Psychological Therapies [IAPT]). A total of 600 clients attending IAPT services were assessed for eligibility, and 410 were enrolled. Participants met diagnostic criteria for mild to moderate depression. Data were analyzed from January to October 2021. Interventions: Participants received a copy of either an MBCT-SH or CBT-SH workbook and were offered 6 support sessions with a trained practitioner. Main Outcomes and Measures: The preregistered primary outcome was Patient Health Questionnaire (PHQ-9) score at 16 weeks postrandomization. The primary analysis was intention-to-treat with treatment arms masked. Results: Of 410 randomized participants, 255 (62.2%) were female, and the median (IQR) age was 32 (25-45) years. At 16 weeks postrandomization, practitioner-supported MBCT-SH (n = 204; mean [SD] PHQ-9 score, 7.2 [4.8]) led to significantly greater reductions in depression symptom severity compared with practitioner-supported CBT-SH (n = 206; mean [SD] PHQ-9 score, 8.6 [5.5]), with a between-group difference of -1.5 PHQ-9 points (95% CI, -2.6 to -0.4; P = .009; d = -0.36). The probability of MBCT-SH being cost-effective compared with CBT-SH exceeded 95%. However, although between-group effects on secondary outcomes were in the hypothesized direction, they were mostly nonsignificant. Three serious adverse events were reported, all deemed not study related. Conclusions and Relevance: In this randomized clinical trial, practitioner-supported MBCT-SH was superior to standard recommended treatment (ie, practitioner-supported CBT-SH) for mild to moderate depression in terms of both clinical effectiveness and cost-effectiveness. Findings suggest that MBCT-SH for mild to moderate depression should be routinely offered to adults in primary care services. Trial Registration: isrctn.org Identifier: ISRCTN13495752.

Mindfulness-based programmes and 'bigger than self' issues: protocol for a scoping review.

INTRODUCTION: Mindfulness-based programmes (MBPs) have an established, growing evidence base as interventions to optimise health, well-being and performance of individual participants. Emerging evidence suggests that MBPs also enhance prosociality, encouraging individuals to contribute to positive social change. This study focuses on the potential of MBPs to facilitate development of participants' inner resources that support prosocial shifts. The review seeks to detect shifts in MBP benefit from individual toward 'bigger than self', informing and empowering individual and collective responses to complex societal and global issues. The review aims to map current literature on MBPs and social change, into a descriptive overview with commentary on quality, trends, theoretical models and gaps, and on how training in MBPs potentially enables individual and collective responses to societal and global issues. Recommendations for future directions for researchers seeking to advance this evidence base, and practitioners developing innovative MBPs for this purpose will be provided. METHODS AND ANALYSIS: A scoping review of peer-reviewed literature will be undertaken and reported on according to the Joanna Briggs Institute (JBI) Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidance. Systematic searches of four scientific databases will be undertaken to identify potentially eligible articles published from all time to current date. Data will be extracted using an extraction template and analysed descriptively using narrative synthesis. ETHICS AND DISSEMINATION: This scoping review involves no human participants, so ethics is not required. Findings will be shared through professional networks, conference presentations and journal publication.

What Next After MBSR/MBCT? An Open Trial of an 8-Week Follow-on Program Exploring Mindfulness of Feeling Tone (vedana).

Objectives: The effectiveness of mindfulness-based programs (MBPs) has been established in many randomized controlled trials. However, effect sizes are often modest, and there remains ample scope to improve their effectiveness. One approach to this challenge is to offer a "follow-on" course to people who have completed an MBP and are interested in further skill development. We developed and tested a new 8-week course for this purpose based on awareness of feeling tone (vedana), an understudied aspect of mindfulness in many current MBPs, incorporating new developments in neuroscience and trauma sensitivity. We examined its effectiveness and the frequency and severity of unpleasant experience and harm. Methods: In an open trial, 83 participants, 78 of whom had previously taken part in an MBP (majority MBSR or MBCT), completed the program in nine groups. Participants completed questionnaires before and after and gave qualitative written feedback at completion. Results: Participants reported significantly reduced depression (d = 0.56), stress (d = 0.36), and anxiety (d = 0.53) and increased well-being (d = 0.54) and mindfulness (d = 0.65) with 38% meeting criteria for reliable change on anxiety and depression. As expected, about three-quarters of participants reported some unpleasant experiences associated with mindfulness practice during the course, but none reported harm. Five participants showed "reliable deterioration" (an increase) in either depression or anxiety, but four of these five also gave anonymous qualitative feedback describing benefits of the course. Conclusions: Findings support the added value of a follow-on course based on the exploration of feeling tone for participants who have a range of previous mindfulness experience. Supplementary Information: The online version contains supplementary material available at 10.1007/s12671-022-01929-0.

Mindfulness-Based Programs: Why, When, and How to Adapt?

This paper provides a framework for understanding why, when and how to adapt mindfulness-based programs (MBPs) to specific populations and contexts, based on research that developed and adapted multiple MBPs. In doing so, we hope to support teachers, researchers and innovators who are considering adapting an MBP to ensure that changes made are necessary, acceptable, effective, cost-effective, and implementable. Specific questions for reflection are provided such as (1) Why is an adaptation needed? (2) Does the theoretical premise underpinning mainstream MBPs extend to the population you are considering? (3) Do the benefits of the proposed adaptation outweigh the time and costs involved to all in research and implementation? (4) Is there already an evidenced-based approach to address this issue in the population or context? Fundamental knowledge that is important for the adaptation team to have includes the following: (1) essential ingredients of MBPs, (2) etiology of the target health outcome, (3) existing interventions that work for the health outcome, population, and context, (4) delivery systems and settings, and (5) culture, values, and communication patterns of the target population. A series of steps to follow for adaptations is provided, as are case examples. Adapting MBPs happens not only by researchers, but also by MBP teachers and developers, who endeavor to best serve the populations and contexts they work within. We hope that these recommendations for best practice provide a practical framework for skilfully understanding why, when, and how to adapt MBPs; and that this careful approach to adaptation maximizes MBP safety and efficacy.

Effectiveness of virtual mindfulness-based interventions on perceived anxiety and depression of physicians during the COVID-19 pandemic: A pre-post experimental study.

Background: The outbreak of coronavirus disease 2019 (COVID-19) created unprecedented stress on physicians. Mindfulness is a type of meditation that focuses on being fully present, aware of senses, and emotions in the present moment without analyzing or judging them, and it may help reduce psychological distress in physicians. This study aimed to examine the effectiveness of virtual mindfulness-based intervention (MBI) on physicians' perceived anxiety and depression and different facets of mindfulness. Methods: During the COVID-19 pandemic, an online survey was administered to physicians to assess depression, anxiety, and awareness using the 9-item Patient Health Questionnaire (PHQ-9), 7-item General Anxiety Disorder (GAD-7), and Five-Facets Mindfulness Questionnaire (FFMQ), respectively. Physicians that received the virtual MBI sessions also completed post-questionnaires at a 3-week follow-up time point. Results: A total of 125 physicians responded to the online survey, with 56 completing the MBI. The prevalence of moderate to severe anxiety and depression was 45.0 and 46.7%, respectively. Mindfulness scores were negatively associated with depression (r = -0.38, P < 0.001) and anxiety (r = -0.36, p < 0.001). Mindfulness scores for the 56 physicians who received virtual MBI sessions were significantly improved (mean difference ± SD, 17.7 ± 16.1, p = 0.001). Significant reductions were also evidenced in anxiety (4.4 ± 4.2) and depression (4.5 ± 5.1) scores (p's < 0.001). There was also an improvement in mindfulness facets of observing (5.1 ± 4.7), describing (2.3 ± 4.3), acting with awareness (2.7 ± 5.3), non-judging of inner experience (3.6 ± 6.1), and non-reactivity to inner experience (3.9 ± 4.0) (p's < 0.001). A facet of mindfulness, acting with awareness was most efficiently associated with improved anxiety (B = -0.3, p = 0.02) and depression (B = -0.4, p = 0.01). Conclusion: This study has demonstrated that virtual MBI improved physicians' psychological wellbeing and mindfulness during the crisis. Regular mindfulness practice may help physicians to tolerate and handle unpleasant circumstances, such as future epidemics or pandemics.

The Implementation of Mindfulness-Based Programs in the Swedish Healthcare System-A Qualitative Study.

BACKGROUND: As the provision of Mindfulness-Based Programs (MBPs) in health care settings progresses, more research is needed to develop guidelines and structures for implementation in various contexts. This study is part of a larger project were MBP provision in Sweden is explored. OBJECTIVE: The objective is to provide knowledge for the next steps of MBP implementation both in Sweden and internationally. The specific aim of the study is to explore how MBP teachers and other relevant stakeholders experience the implementation of MBP. METHODS: Qualitative in-depth interviews were conducted with 15 MBP providers and 2 other stakeholders from a range of health care settings in Sweden. RESULTS: The results, presented in 3 themes, provide insights into the factors that are crucial for facilitating or hindering MBP implementation; (1) MBP teachers and their training, including the importance of champion individuals and the benefit and shortcomings of various forms of MBP; (2) Patients and patient referrals, including patient characteristics and referral pathways; (3) Organizational prerequisites to successful implementation, highlighting the importance of financial factors and managers' and colleagues' knowledge and acceptance of MBP; and (4) the need for structural changes, including future recommendations on quality assessment and guidelines. CONCLUSION: This study highlights the need for national guidelines for MBP provision and teacher training pathways, as well as improved availability of teacher training. Also, the benefit of a stepped-care model of MBP provision is indicated by the findings. Finally, increasing awareness of MBPs among referrers, managers, and the public may enable successful implementation.

The Implementation of Mindfulness-Based Programs in the Swedish Healthcare System - A Survey Study of Service Providers.

BACKGROUND: The burden of depression and anxiety is on the rise globally. Mindfulness-Based Programs (MBPs) are a particular group of psychosocial programs targeting depression and anxiety. There is growing research and practice interest in MBPs internationally, and they are becoming more commonly implemented in a number of countries' healthcare services. OBJECTIVE: To systematically map the existing provision of MBPs in the Swedish healthcare sector, in order to understand facilitators and barriers to uptake, and so inform future implementation efforts. METHODS: We assessed the experiences of MBP implementation among relevant stakeholders in Swedish healthcare settings through an online survey. The survey was designed to gather data on (1) the evidence-base of practice being implemented; (2) the context in which implementation was taking place and (3) the process of facilitation. Respondents were identified through snowball sampling of key stakeholders. RESULTS: In total, 129 individuals from 20 of the 21 healthcare regions in Sweden responded to the survey. Our findings showed that there is variation in the types of MBP models being implemented, and that the delivery structure of evidence-based programs were often being modified for implementation. We found some divergence from international guidance on good practice standards for the training of MBP teachers within Swedish implementation processes. The main service context for implementation is primary care; the most important facilitating factors for successful MBP implementation were the presence of a championing individual and support from leadership. The most influential hindering factors for implementation were lack of time, and lack of funding. CONCLUSION: To support integrity and fidelity of MBP implementation in Sweden, a strategic plan and good practice guidelines seem necessary. Also, an evidence-based stepped care model for implementation may work to ensure intervention fidelity in cases where time and funding constraints permit.

Introducing the Mindfulness-Based Interventions: Teaching and Learning Companion (The TLC).

BACKGROUND: Reflective practice is a key skill which can enable the development of teaching competence among Mindfulness-Based Program (MBP) teachers. PURPOSE: In this article, the Mindfulness-Based Interventions: Teaching and Learning Companion (TLC) is introduced. This new tool is based upon the established teaching competence assessment tool, the Mindfulness-Based Interventions: Teaching Assessment Criteria (MBI:TAC). The MBI:TAC has enabled benchmarking of international standards of MBP teaching which helps ensure high fidelity to MBP curricula and contributes to the overall integrity of the field. This in turn, underpins the potential of MBPs to be effective interventions for the enhancement of participants' mental health and wellbeing. CONCLUSIONS: The TLC aims to facilitate MBP teachers' development by enabling active reflection focused on the key features of MBP teaching skills.

Audit of a Mindfulness-Based Cognitive Therapy Course Within a Prison.

This article examines the effectiveness of the 8-week mindfulness-based cognitive therapy course for depression within the prison population. Prisons see higher rates of mental ill health across the spectrum. This study examined how a manualized mindfulness approach to treating depression, a major cause of ill health, would affect this cohort. At the beginning of the course, participants were experiencing high levels of depression and anxiety, with low levels of mindfulness. At the end of 8 weeks, levels of depression and anxiety were reduced while mindfulness scores had increased, suggesting that mindfulness helped participants cope with difficult feelings and sensations. Retrospective study informed consent given by participants.

Using the Mindfulness-Based Interventions: Teaching Assessment Criteria (MBI:TAC) in Supervision.

The Mindfulness-Based Interventions: Teaching Assessment Criteria (MBI:TAC) is a useful framework for supporting teacher development in the context of mindfulness-based supervision (MBS). It offers a framework that enhances clarity, develops reflexive practice, gives a structure for feedback, and supports learning. MBS is a key component of Mindfulness-Based Program (MBP) teacher training and ongoing good practice. Integrating the MBI:TAC within the MBS process adds value in a number of ways including: offering a shared language around MBP teaching skills and processes; framing the core pedagogical features of MBP teaching; enabling assessment of developmental stage; and empowering supervisees to be proactive in their own development. The paper lays out principles for integrating the MBI:TAC framework into MBS. The supervisor needs awareness of the ways in which the tool can add value, and the ways it can inadvertently interrupt learning. The tool enables skills clarification, but the learning process needs to remain open to spontaneous experiential discovery; it can enable structured feedback but space is also needed for open reflective feedback; and it can enable conceptual engagement with the teaching process but space is needed for the supervisee to experientially sense the teaching process. The tool needs to be introduced in a carefully staged way to create optimal conditions for learning at the various stages of the MBP teacher-training journey. Practical guidance is presented to consolidate and develop current practice. The principles and processes discussed can be generalized to other forms of reflective dialogue such as mentoring, tutoring and peer reflection groups.

Assessing Mindfulness-Based Teaching Competence: Good Practice Guidance.

Inclusion of assessment of teaching competence in Mindfulness-Based Program (MBP) teacher training enables international benchmarking of standards, which in turn underpins the integrity of this emerging field and the potential to deliver effective, transformative interventions. However, there is a risk that the inclusion of competence assessment could lead to reductionism and undermining of the pedagogical features that make mindfulness-based teaching distinct. It can also make the costs of training prohibitive. The science underpinning the integrity of competence assessment is not yet robust enough to justify wide scale implementation, but when feasible, including the option for assessment enables trainees to engage in rigorous and effective training processes. When assessment is included, it is critically important that the process is held with awareness and sensitivity, and is implemented by experienced assessors with thoughtful governance. Navigating these issues involves balancing rigour with accessibility and pragmatism. This paper lays out some guidelines for good practice for MBP teaching assessment, and raises unresolved dilemmas and questions.

Can We Agree What Skilled Mindfulness-Based Teaching Looks Like? Lessons From Studying the MBI:TAC.

BACKGROUND: The Mindfulness-Based Interventions: Teaching Assessment Criteria (MBI:TAC) is a widely used tool for assessing fidelity in mindfulness-based program (MBP) research and training. It also supports MBP teacher reflective and skill development. MBI:TAC assessors review MBP teaching and rate the teaching on 6 domains. The MBI:TAC yields individual domain and overall scores, using 6 levels of competence. Although the MBI:TAC is widely used in MBP research and training, research is at an early stage. OBJECTIVE: We developed and tested a method of training MBI:TAC assessors to use the tool reliably and examined interrater reliability of the tool. METHODS: A total of 31 international senior MBP teachers were recruited to join an online training to build their skills in using the MBI:TAC. The training systematically and iteratively built familiarity and skills in assessing the 6 MBI:TAC domains. Qualitative and quantitative data on trainee's experience of the training were gathered. Interrater reliability in using the tool was tested each week of the training. At the end of the training, interrater reliability was tested by asking trainees to individually assess videos that they had not previously seen. Their ratings were compared to benchmark assessments, which had been established via consensus agreement between 4 expert users of the MBI:TAC. RESULTS: The training was well received and appreciated, with some challenges experienced in applying the assessment methodology. Participants' ratings became progressively more in line with one another and the benchmark ratings during the training. At the end, interrater reliability was high (ranging from 0.67 to 1.0). CONCLUSION: It is possible for senior MBP trainers, coming from different regions in the world, to align toward common understandings of the elements of MBP teaching competence and program integrity. An assessor training methodology was tested, and the learning from this project has led to refinements for future delivery.

The Mississippi Delta Health Collaborative Medication Therapy Management Model: Public Health and Pharmacy Working Together to Improve Population Health in the Mississippi Delta.

INTRODUCTION: The Mississippi Delta has high rates of chronic disease and is known for its poor health outcomes and health disparities. The University of Mississippi School of Pharmacy (UMSOP) and the Mississippi State Department of Health partnered in 2009 through the Mississippi Delta Health Collaborative to reduce health disparities and improve clinical outcomes by expanding the UMSOP's evidence-based medication therapy management (MTM) initiative, focused in Mississippi's 18-county Delta region, to federally qualified health centers (FQHCs) in 4 of those counties. METHODS: Between January 2009 and August 2018, the MTM initiative targeted FQHC patients aged 18 years or older with a diagnosis of diabetes, hypertension, and/or dyslipidemia. Pharmacists initially met face-to-face with patients to review all medications, provide education about chronic diseases, identify and resolve drug therapy problems, and take appropriate actions to help improve the effectiveness of medication therapies. Clinical parameters evaluated were systolic blood pressure (SBP), diastolic blood pressure (DBP), total cholesterol, low-density lipoprotein (LDL) cholesterol, triglycerides, and hemoglobin A1c (HbA1c). RESULTS: The analysis included 335 patients with hypertension (n = 287), dyslipidemia (n = 131), and/or diabetes (n = 331). Significant mean reductions occurred in the following metrics: SBP (7.1 mm Hg), DBP (6.3 mm Hg), LDL cholesterol (24.9 mg/dL), triglycerides (45.5 mg/dL), total cholesterol (37.7 mg/dL), and HbA1c (1.6% [baseline ≥6%] and 1.9% [baseline ≥9%]). CONCLUSION: Despite the cultural and environmental disadvantages present in the Mississippi Delta, the integrated MTM treatment program demonstrated significant health improvements across 3 chronic diseases: hypertension, dyslipidemia, and diabetes. This model demonstrates that a partnership between public health and pharmacy is a successful and innovative approach to care.

Low-Intensity Guided Help Through Mindfulness (LIGHTMIND): study protocol for a randomised controlled trial comparing supported mindfulness-based cognitive therapy self-help to supported cognitive behavioural therapy self-help for adults experiencing depression.

BACKGROUND: Depression has serious personal, family and economic consequences. It is estimated that it will cost £12.15 billion to the economy each year in England by 2026. Improving access to psychological therapies (IAPT) is the National Health Service talking therapies service in England for adults experiencing anxiety or depression. Over 1 million people are referred to IAPT every year, over half experiencing depression. Where symptoms of depression are mild to moderate, people are typically offered cognitive behavioural therapy (CBT) self-help (CBT-SH) supported by a psychological well-being practitioner. The problem is that over half of people who complete treatment for depression in IAPT remain depressed despite receiving National Institute of Health and Care Excellent recommended treatment. Furthermore, less than half of IAPT service users complete treatment. This study seeks to investigate the effectiveness of an alternative to CBT-SH. Mindfulness-based cognitive therapy (MBCT) differs from CBT in focus, approach and practice, and may be more effective with a higher number of treatment completions. METHODS/DESIGN: This is a definitive randomised controlled trial comparing supported MBCT self-help (MBCT-SH) with CBT-SH for adults experiencing mild to moderate depression being treated in IAPT services. We will recruit 410 participants experiencing mild to moderate depression from IAPT services and randomise these to receive either an MBCT-based self-help workbook or a CBT-based self-help workbook. Participants will be asked to complete their workbook within 16 weeks, with six support sessions with a psychological well-being practitioner. The primary outcome is depression symptom severity on treatment completion. Secondary outcomes are treatment completion rates and measures of generalized anxiety, well-being, functioning and mindfulness. An exploratory non-inferiority analysis will be conducted in the event the primary hypothesis is not supported. A semi-structured interview with participants will guide understanding of change processes. DISCUSSION: If the findings from this randomised controlled trial demonstrate that MBCT-SH is more effective than CBT-SH for adults experiencing depression, this will provide evidence for policy makers and lead to changes to clinical practice in IAPT services, leading to greater choice of self-help treatment options and better outcomes for service users. If the exploratory non-inferiority analysis is conducted and this indicates non-inferiority of MBCT-SH in comparison to CBT-SH this will also be of interest to policy makers when seeking to increase service user choice of self-help treatment options for depression. TRIAL REGISTRATION: Current Controlled Trial registration number: ISRCTN 13495752. Registered on 31 August 2017 (www.isrctn.com/ISRCTN13495752).

'Mind the gaps': the accessibility and implementation of an effective depression relapse prevention programme in UK NHS services: learning from mindfulness-based cognitive therapy through a mixed-methods study.

OBJECTIVES: Mindfulness-based cognitive therapy (MBCT) is an evidence-based approach for people at risk of depressive relapse to support their long-term recovery. However, despite its inclusion in guidelines, there is an 'implementation cliff'. The study objective was to develop a better explanation of what facilitates MBCT implementation. SETTING: UK primary and secondary care mental health services. DESIGN, PARTICIPANTS AND METHODS: A national two-phase, multi-method qualitative study was conducted, which was conceptually underpinned by the Promoting Action on Research Implementation in Health Services framework. Phase I involved interviews with stakeholders from 40 service providers about current provision of MBCT. Phase II involved 10 purposively sampled case studies to obtain a more detailed understanding of MBCT implementation. Data were analysed using adapted framework analysis, refined through stakeholder consultation. RESULTS: Access to MBCT is variable across the UK services. Where available, services have adapted MBCT to fit their context by integrating it into their care pathways. Evidence was often important to implementation but took different forms: the NICE depression guideline, audits, evaluations, first person accounts, experiential taster sessions and pilots. These were used to build a platform from which to develop MBCT services. The most important aspect of facilitation was the central role of the MBCT implementers. These were generally self-designated individuals who 'championed' grass-roots implementation. Our explanatory framework mapped out a prototypical implementation journey, often over many years with a balance of bottom-up and top-down factors influencing the fit of MBCT into service pathways. 'Pivot points' in the implementation journey provided windows of either challenge or opportunity. CONCLUSIONS: This is one of the largest systematic studies of the implementation of a psychological therapy. While access to MBCT across the UK is improving, it remains patchy. The resultant explanatory framework about MBCT implementation provides a heuristic that informed an implementation resource.

Intervention integrity in mindfulness-based research: strengthening a key aspect of methodological rigor.

To ensure methodological rigour, research on Mindfulness-Based Programs (MBPs) should include systems for assessing and reporting the integrity of the intervention. The critical variable of the quality of the teaching and the degree of adherence to the curriculum are likely to influence research outcomes and their interpretation. Currently, three tools for assessing intervention integrity in the MBP field have been developed, but they need further research and development. Research going forward needs to include systematic methods for demonstrating and verifying the integrity of the MBP, both to ensure the rigor of individual studies and to enable different studies of the same MBP to be fairly and validly compared with each other.

The Mindfulness-Based Interventions: Teaching Assessment Criteria (MBI:TAC): reflections on implementation and development.

The Mindfulness-Based Interventions: Teaching Assessment Criteria (MBI:TAC) is a tool for supporting good practice in mindfulness-based teaching, training supervision and research contexts. It has been taken up in practice in teacher training organizations worldwide. The MBI:TAC sits within the wider consideration within research contexts of building methodological rigor by developing robust systems for ensuring intervention integrity. Research on the tool is at an early stage and needs development. The process of implementation needs careful attention to ensure reliability and good practice. Future research is needed on the tool's reliability, validity and sensitivity to change, and on the relationships between mindfulness-based teaching, participant outcomes and key contextual factors, including the influence of participant population, culture and context.

Intervention Integrity in Mindfulness-Based Research.

Assessing program or intervention fidelity/integrity is an important methodological consideration in clinical and educational research. These critical variables influence the degree to which outcomes can be attributed to the program and the success of the transition from research to practice and back again. Research in the Mindfulness-Based Program (MBP) field has been expanding rapidly over the last 20 years, but little attention has been given to how to assess intervention integrity within research and practice settings. The proliferation of different program forms, inconsistency in adhering to published curriculum guides, and variability of training levels and competency of trial teachers all pose grave risks to the sustainable development of the science of MBPs going forward. Three tools for assessing intervention integrity in the MBP field have been developed and researched to assess adherence and/or teaching competence: the Mindfulness-Based Cognitive Therapy-Adherence Scale (MBCT-AS), the Mindfulness-Based Relapse Prevention-Adherence and Competence Scale (MBRP-AC), and the Mindfulness-Based Interventions: Teaching Assessment Criteria (MBI:TAC). Further research is needed on these tools to better define their inter-rater reliability and their ability to measure elements of teaching competence that are important for participant outcomes. Research going forward needs to include systematic and consistent methods for demonstrating and verifying that the MBP was delivered as intended, both to ensure the rigor of individual studies and to enable different studies of the same MBP to be fairly and validly compared with each other. The critical variable of the teaching also needs direct investigation in future research. We recommend the use of the "Template for Intervention Description and Replication" (TIDieR) guidelines for addressing and reporting on intervention integrity during the various phases of the conduct of research and provide specific suggestions about how to implement these guidelines when reporting studies of mindfulness-based programs.