Efficacy of Mindfulness-Based Cognitive Therapy in Prevention of Depressive Relapse: An Individual Patient Data Meta-analysis From Randomized Trials.

IMPORTANCE: Relapse prevention in recurrent depression is a significant public health problem, and antidepressants are the current first-line treatment approach. Identifying an equally efficacious nonpharmacological intervention would be an important development. OBJECTIVE: To conduct a meta-analysis on individual patient data to examine the efficacy of mindfulness-based cognitive therapy (MBCT) compared with usual care and other active treatments, including antidepressants, in treating those with recurrent depression. DATA SOURCES: English-language studies published or accepted for publication in peer-reviewed journals identified from EMBASE, PubMed/Medline, PsycINFO, Web of Science, Scopus, and the Cochrane Controlled Trials Register from the first available year to November 22, 2014. Searches were conducted from November 2010 to November 2014. STUDY SELECTION: Randomized trials of manualized MBCT for relapse prevention in recurrent depression in full or partial remission that compared MBCT with at least 1 non-MBCT treatment, including usual care. DATA EXTRACTION AND SYNTHESIS: This was an update to a previous meta-analysis. We screened 2555 new records after removing duplicates. Abstracts were screened for full-text extraction (S.S.) and checked by another researcher (T.D.). There were no disagreements. Of the original 2555 studies, 766 were evaluated against full study inclusion criteria, and we acquired full text for 8. Of these, 4 studies were excluded, and the remaining 4 were combined with the 6 studies identified from the previous meta-analysis, yielding 10 studies for qualitative synthesis. Full patient data were not available for 1 of these studies, resulting in 9 studies with individual patient data, which were included in the quantitative synthesis. RESULTS: Of the 1258 patients included, the mean (SD) age was 47.1 (11.9) years, and 944 (75.0%) were female. A 2-stage random effects approach showed that patients receiving MBCT had a reduced risk of depressive relapse within a 60-week follow-up period compared with those who did not receive MBCT (hazard ratio, 0.69; 95% CI, 0.58-0.82). Furthermore, comparisons with active treatments suggest a reduced risk of depressive relapse within a 60-week follow-up period (hazard ratio, 0.79; 95% CI, 0.64-0.97). Using a 1-stage approach, sociodemographic (ie, age, sex, education, and relationship status) and psychiatric (ie, age at onset and number of previous episodes of depression) variables showed no statistically significant interaction with MBCT treatment. However, there was some evidence to suggest that a greater severity of depressive symptoms prior to treatment was associated with a larger effect of MBCT compared with other treatments. CONCLUSIONS AND RELEVANCE: Mindfulness-based cognitive therapy appears efficacious as a treatment for relapse prevention for those with recurrent depression, particularly those with more pronounced residual symptoms. Recommendations are made concerning how future trials can address remaining uncertainties and improve the rigor of the field.

How does mindfulness-based cognitive therapy work?

Mindfulness-based cognitive therapy (MBCT) is an efficacious psychosocial intervention for recurrent depression (Kuyken et al., 2008; Ma & Teasdale, 2004; Teasdale et al., 2000). To date, no compelling research addresses MBCT's mechanisms of change. This study determines whether MBCT's treatment effects are mediated by enhancement of mindfulness and self-compassion across treatment, and/or by alterations in post-treatment cognitive reactivity. The study was embedded in a randomized controlled trial comparing MBCT with maintenance antidepressants (mADM) with 15-month follow-up (Kuyken et al., 2008). Mindfulness and self-compassion were assessed before and after MBCT treatment (or at equivalent time points in the mADM group). Post-treatment reactivity was assessed one month after the MBCT group sessions or at the equivalent time point in the mADM group. One hundred and twenty-three patients with ≥3 prior depressive episodes, and successfully treated with antidepressants, were randomized either to mADM or MBCT. The MBCT arm involved participation in MBCT, a group-based psychosocial intervention that teaches mindfulness skills, and discontinuation of ADM. The mADM arm involved maintenance on a therapeutic ADM dose for the duration of follow-up. Interviewer-administered outcome measures assessed depressive symptoms and relapse/recurrence across 15-month follow-up. Mindfulness and self-compassion were measured using self-report questionnaire. Cognitive reactivity was operationalized as change in depressive thinking during a laboratory mood induction. MBCT's effects were mediated by enhancement of mindfulness and self-compassion across treatment. MBCT also changed the nature of the relationship between post-treatment cognitive reactivity and outcome. Greater reactivity predicted worse outcome for mADM participants but this relationship was not evident in the MBCT group. MBCT's treatment effects are mediated by augmented self-compassion and mindfulness, along with a decoupling of the relationship between reactivity of depressive thinking and poor outcome. This decoupling is associated with the cultivation of self-compassion across treatment.

Mindfulness-based cognitive therapy to prevent relapse in recurrent depression.

For people at risk of depressive relapse, mindfulness-based cognitive therapy (MBCT) has an additive benefit to usual care (H. F. Coelho, P. H. Canter, & E. Ernst, 2007). This study asked if, among patients with recurrent depression who are treated with antidepressant medication (ADM), MBCT is comparable to treatment with maintenance ADM (m-ADM) in (a) depressive relapse prevention, (b) key secondary outcomes, and (c) cost effectiveness. The study design was a parallel 2-group randomized controlled trial comparing those on m-ADM (N = 62) with those receiving MBCT plus support to taper/discontinue antidepressants (N = 61). Relapse/recurrence rates over 15-month follow-ups in MBCT were 47%, compared with 60% in the m-ADM group (hazard ratio = 0.63; 95% confidence interval: 0.39 to 1.04). MBCT was more effective than m-ADM in reducing residual depressive symptoms and psychiatric comorbidity and in improving quality of life in the physical and psychological domains. There was no difference in average annual cost between the 2 groups. Rates of ADM usage in the MBCT group was significantly reduced, and 46 patients (75%) completely discontinued their ADM. For patients treated with ADM, MBCT may provide an alternative approach for relapse prevention.

Initial psychometric properties of the experiences questionnaire: validation of a self-report measure of decentering.

Decentering is defined as the ability to observe one's thoughts and feelings as temporary, objective events in the mind, as opposed to reflections of the self that are necessarily true. The Experiences Questionnaire (EQ) was designed to measure both decentering and rumination but has not been empirically validated. The current study investigated the factor structure of the EQ in both undergraduate and clinical populations. A single, unifactorial decentering construct emerged using 2 undergraduate samples. The convergent and discriminant validity of this decentering factor was demonstrated in negative relationships with measures of depression symptoms, depressive rumination, experiential avoidance, and emotion regulation. Finally, the factor structure of the EQ was replicated in a clinical sample of individuals in remission from depression, and the decentering factor evidenced a negative relationship to concurrent levels of depression symptoms. Findings from this series of studies offer initial support for the EQ as a measure of decentering.

The development of the P-CAN, a measure to operationalize the pros and cons of anorexia nervosa.

OBJECTIVE: Research has suggested that a fundamental aspect of anorexia nervosa (AN) is its egosyntonic nature, the fact that it is often valued by individuals with the disorder. The current study describes the development of the P-CAN, a quantitative measure of both positive (valued) and negative aspects of AN. METHOD: Items were derived from a previous qualitative study (Serpell, Treasure, Teasdale, & Sullivan. 1999. International Journal of Eating Disorders, 25, 177-186). Data from 233 women with AN were subjected to a principal components analysis. RESULTS: Ten subscales were identified, six describing the pros of AN and four describing the cons of the illness. DISCUSSION: The P-CAN shows good psychometric properties and should prove a useful tool for the measurement of attitudes towards AN, as well as offer insights into the maintenance of the disorder.

Neuropsychological processing associated with recovery from depression after stereotactic subcaudate tractotomy.

OBJECTIVE: The authors compared patients who underwent stereotactic subcaudate tractotomy for depression, who were still depressed or recovered from depression, to identify therapeutic mechanisms. METHOD: Ten depressed and eight recovered psychosurgery patients, along with nine never-depressed subjects and nine who had recovered from depression with medication, completed the Iowa Gambling Task, a measure of decision making in the face of feedback. Psychosurgery patients also completed general neuropsychological testing. RESULTS: Recovered psychosurgery patients exhibited insensitivity to negative feedback on the Iowa Gambling Task compared to the other three groups. This difference between the groups remained when general neuropsychological performance was covaried out. CONCLUSIONS: These findings suggest acquired relative insensitivity to negative information as a specific mechanism mediating the antidepressant effect of stereotactic subcaudate tractotomy. Such insensitivity is not secondary to deficits in general neuropsychological functioning and is not a function of recovery from depression per se.

Adaptive and maladaptive self-focus in depression.

BACKGROUND: Studies of rumination suggest that self-focused attention is maladaptive and perpetuates depression. Conversely, self-focused attention can be adaptive, facilitating self-knowledge and the development of the alternative functional interpretations of negative thoughts and feelings on which cognitive therapy of depression depends. Increasing evidence suggests there are distinct varieties of self-focus, each with distinct functional properties. This study tested the prediction that in depressed patients brief inductions of analytical versus experiential self-focus would differentially affect overgeneral autobiographical memory, a phenomenon associated with poor clinical course. It was predicted that, relative to analytical self-focus, experiential self-focus would reduce overgeneral memory. METHODS: 28 depressed patients either thought analytically about, or focused on their momentary experience of, identical symptom-focused induction items from [Cogn. Emotion 7 (1993) 561] rumination task. Participants completed the Autobiographical Memory Test [J. Abnorm. Psychol. 95 (1986) 144] before and after self-focus manipulations. RESULTS: Experiential self-focus reduced overgeneral memory compared to analytical self-focus. Analytical and experiential self-focus did not differ in their effects on mood. LIMITATIONS: In the absence of a reference condition, only conclusions concerning the relative effects of analytical and experiential self-focus can be made. CONCLUSIONS: Results (1) support the differentiation of self-focus into distinct modes of self-attention with distinct functional effects in depression; (2) provide further evidence for the modifiability of overgeneral memory; and (3) provide further evidence for the dissociation of overgeneral memory and depressed mood. Clinically, results support the usefulness of training recovered depressed patients in adaptive experiential forms of self-awareness, as in mindfulness-based cognitive therapy.

How does dysfunctional thinking decrease during recovery from major depression?

Decreased dysfunctional thinking in recovering depressed patents could reflect predominantly (a). reduced access to dysfunctional schemas or (b). increased metacognitive monitoring of dysfunctional schematic products. Twenty acutely depressed patients, 20 partially remitted depressed patients, and 20 controls were compared on tasks primarily reflecting one or the other of these processes. On both tasks, acutely depressed patients differed significantly from controls. Partially remitted patients resembled acutely depressed patients on the task assessing dysfunctional schema access but resembled controls on the metacognitive monitoring task. Results suggest that reduced dysfunctional thinking associated with partial remission is mediated primarily by increased metacognitive monitoring of dysfunctional cognitive products rather than reduced access to dysfunctional schemas.

Mindfulness-based cognitive therapy for depression: replication and exploration of differential relapse prevention effects.

Recovered recurrently depressed patients were randomized to treatment as usual (TAU) or TAU plus mindfulness-based cognitive therapy (MBCT). Replicating previous findings, MBCT reduced relapse from 78% to 36% in 55 patients with 3 or more previous episodes; but in 18 patients with only 2 (recent) episodes corresponding figures were 20% and 50%. MBCT was most effective in preventing relapses not preceded by life events. Relapses were more often associated with significant life events in the 2-episode group. This group also reported less childhood adversity and later first depression onset than the 3-or-more-episode group, suggesting that these groups represented distinct populations. MBCT is an effective and efficient way to prevent relapse/recurrence in recovered depressed patients with 3 or more previous episodes.

Neural abnormalities during cognitive generation of affect in treatment-resistant depression.

BACKGROUND: Dysfunctions in brain regions known to be involved in affect and mood states are thought to be implicated in depression and may have a role in determining the type and symptoms of this illness. METHODS: Functional magnetic resonance imaging was used to elucidate neural correlates of cognitive generation of affect, using a previously published paradigm of evoking affect with picture-caption pairs, in patients with unipolar, treatment-resistant depression. RESULTS: Compared with control participants, patients showed relatively decreased response in the anterior cingulate (rostral; right) with both negative and positive picture-caption pairs and in the medial frontal gyrus and hippocampus (all left) with positive picture-caption pairs. They demonstrated increased response in the inferior (right) and middle temporal gyri (left) with negative picture-caption pairs, and in the parahippocampal gyrus (right), inferior frontal gyrus (left), subgenual cingulate (right), striatum (right), and brain stem (left) with positive picture-caption pairs. CONCLUSIONS: Reduced medial/middle prefrontal and hippocampal activity may account for positive affect disturbances and temporal lobe hyperactivity for negative affect disturbances in treatment-resistant depression. The results also corroborate previous observations from resting positron emission tomography studies and further elucidate the association between hypoactive rostral cingulate and nonresponsiveness to treatment in depression.

Metacognitive awareness and prevention of relapse in depression: empirical evidence.

Metacognitive awareness is a cognitive set in which negative thoughts/feelings are experienced as mental events, rather than as the self. The authors hypothesized that (a) reduced metacognitive awareness would be associated with vulnerability to depression and (b) cognitive therapy (CT) and mindfulness-based CT (MBCT) would reduce depressive relapse by increasing metacognitive awareness. They found (a) accessibility of metacognitive sets to depressive cues was less in a vulnerable group (residually depressed patients) than in nondepressed controls; (b) accessibility of metacognitive sets predicted relapse in residually depressed patients; (c) where CT reduced relapse in residually depressed patients, it increased accessibility of metacognitive sets; and (d) where MBCT reduced relapse in recovered depressed patients, it increased accessibility of metacognitive sets. CT and MBCT may reduce relapse by changing relationships to negative thoughts rather than by changing belief in thought content.