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CONTEXT:Mindfulness-based cognitive therapy (MBCT) is a group-based psychosocial intervention designed to enhance self-management of prodromal symptoms associated with depressive relapse.
OBJECTIVE:
To compare rates of relapse in depressed patients in remission receiving MBCT against maintenance antidepressant pharmacotherapy, the current standard of care.
DESIGN:
Patients who met remission criteria after 8 months of algorithm-informed antidepressant treatment were randomized to receive maintenance antidepressant medication, MBCT, or placebo and were followed up for 18 months.
SETTING:
Outpatient clinics at the Centre for Addiction and Mental Health, Toronto, Ontario, Canada, and St Joseph's Healthcare, Hamilton, Ontario.
PARTICIPANTS:
One hundred sixty patients aged 18 to 65 years meeting DSM-IV criteria for major depressive disorder with a minimum of 2 past episodes. Of these, 84 achieved remission (52.5%) and were assigned to 1 of the 3 study conditions.
INTERVENTIONS:
Patients in remission discontinued their antidepressants and attended 8 weekly group sessions of MBCT, continued taking their therapeutic dose of antidepressant medication, or discontinued active medication and were switched to placebo.
MAIN OUTCOME MEASURE:
Relapse was defined as a return, for at least 2 weeks, of symptoms sufficient to meet the criteria for major depression on module A of the Structured Clinical Interview for DSM-IV.
RESULTS:
Intention-to-treat analyses showed a significant interaction between the quality of acute-phase remission and subsequent prevention of relapse in randomized patients (P = .03). Among unstable remitters (1 or more Hamilton Rating Scale for Depression score >7 during remission), patients in both MBCT and maintenance treatment showed a 73% decrease in hazard compared with placebo (P = .03), whereas for stable remitters (all Hamilton Rating Scale for Depression scores ≤7 during remission) there were no group differences in survival.
CONCLUSIONS:
For depressed patients achieving stable or unstable clinical remission, MBCT offers protection against relapse/recurrence on a par with that of maintenance antidepressant pharmacotherapy. Our data also highlight the importance of maintaining at least 1 long-term active treatment in unstable remitters.
CONTEXT:Episode remission in unipolar major depression, while distinguished by minimal symptom burden, can also be a period of marked sensitivity to emotional stress as well as an increased risk of relapse.
OBJECTIVE:
To examine whether mood-linked changes in dysfunctional thinking predict relapse in recovered patients who were depressed.
DESIGN:
In phase 1 of this study, patients with major depressive disorder were randomly assigned to receive either antidepressant medication or cognitive behavior therapy. In phase 2, patients who achieved clinical remission underwent sad mood provocation and were then observed with regular clinical assessments for 18 months.
SETTING:
Outpatient psychiatric clinics at the Centre for Addiction and Mental Health, Toronto, Ontario.
PARTICIPANTS:
A total of 301 outpatients with major depressive disorder, aged 18 to 65 years, participated in phase 1 of this study and 99 outpatients with major depressive disorder in remission, aged 18 to 65 years, participated in phase 2.
MAIN OUTCOME MEASURE:
Occurrence of a relapse meeting DSM-IV criteria for a major depressive episode as assessed by the longitudinal interval follow-up evaluation and a Hamilton Depression Rating Scale score of 16 or greater.
RESULTS:
Patients who recovered through antidepressant medication showed greater cognitive reactivity following the mood provocation than those who received cognitive behavior therapy. Regardless of type of prior treatment, the magnitude of mood-linked cognitive reactivity was a significant predictor of relapse over the subsequent 18 months. Patients whose mood-linked endorsement of dysfunctional attitudes increased by a minimum of 8 points had a significantly shorter time to relapse than those whose scores were not as elevated.
CONCLUSIONS:
The vulnerability of remitted depressed patients for illness relapse may be related to the (re)activation of depressive thinking styles triggered by temporary dysphoric states. This is the first study to link such differences to prognosis following successful treatment for depression. Further understanding of factors predisposing to relapse/recurrence in recovered patients may help to shorten the potentially lifelong course of depression.
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.
This study evaluated mindfulness-based cognitive therapy (MBCT), a group intervention designed to train recovered recurrently depressed patients to disengage from dysphoria-activated depressogenic thinking that may mediate relapse/recurrence. Recovered recurrently depressed patients (n = 145) were randomized to continue with treatment as usual or, in addition, to receive MBCT. Relapse/recurrence to major depression was assessed over a 60-week study period. For patients with 3 or more previous episodes of depression (77% of the sample), MBCT significantly reduced risk of relapse/recurrence. For patients with only 2 previous episodes, MBCT did not reduce relapse/recurrence. MBCT offers a promising cost-efficient psychological approach to preventing relapse/recurrence in recovered recurrently depressed patients.
Background/AimsThe persistence of residual depressive symptoms (RDS) among patients in clinical remission predicts a negative prognosis and is considered an important target for adjunctive treatment. Mindfulness-Based Cognitive Therapy (MBCT) is effective in reducing RDS. Delivered in 8 in-person group sessions, MBCT teaches disengagement from depression-related ruminative thought patterns to reduce RDS and vulnerability to relapse. However, MBCT faces barriers to dissemination including service costs and access. We developed an 8 session web-based version of MBCT (Mindful Mood Balance, or MMB), incorporating experiential practice, video-based vicarious learning, and didactic information that replicate core components of in-person MBCT.
Background/Aims Mindfulness-based cognitive therapy (MBCT) is an empirically supported intervention designed to teach emotion regulation skills for reducing residual depressive symptoms and avoiding relapse triggers that contribute to chronic illness course. MBCT faces common challenges to dissemination, including: service costs, waiting lists, and access. Online treatments address these challenges by increasing treatment accessibility and flexibility, but present other challenges of high dropout rates and decreased engagement. The present study is the first qualitative investigation of patients’ experiences with Mindful Mood Balance (MMB), an 8 week online treatment that features the core elements of in-person MBCT.Methods Conducted qualitative content analysis on 38 exit interviews with adult patients who participated in MMB. Interviews gathered constructive feedback on website activities and content, program administration, as well as on skills learned and personal insights achieved through participation. Participation required current PHQ-9 score less than or equal to 12 and lifetime history of one or more major depressive episodes.
Results Participants were majority female (71%), white (89.5%), employed (79%), married (73.7%), with a mean age of 46.89. Majority of participants had 3 or more past major depressive episodes (68.4%) and were currently using anti-depressant medications (71%). Codes were organized into four main themes: evidence of concept comprehension, translation of MBCT content, translation of MBCT group process, and home practice. Within these four areas, participants highlighted the advantages and challenges of delivering MBCT in an online environment and endorsed learning and retaining central skills taught.
Conclusions This work will be used to inform programmatic changes to MMB including addition of an online community and alternatives to home practice expectations. Participants endorsed retaining central skills observed previously during in-person delivery of MBCT, and identified several advantages to online delivery including flexibility, reduced cost and time commitment. Overall feedback indicated a high level of participant satisfaction, which is encouraging as MMB could drastically widen the availability of an empirically based depression relapse prevention treatment.
BACKGROUND:Due to the clinical challenges of treatment-resistant depression (TRD), we evaluated the efficacy of mindfulness-based cognitive therapy (MBCT) relative to a structurally equivalent active comparison condition as adjuncts to treatment-as-usual (TAU) pharmacotherapy in TRD.
METHODS:
This single-site, randomized controlled trial compared 8-week courses of MBCT and the Health Enhancement Program (HEP), comprising physical fitness, music therapy and nutritional education, as adjuncts to TAU pharmacotherapy for outpatient adults with TRD. The primary outcome was change in depression severity, measured by percent reduction in the total score on the 17-item Hamilton Depression Rating Scale (HAM-D17), with secondary depression indicators of treatment response and remission.
RESULTS:
We enrolled 173 adults; mean length of a current depressive episode was 6.8 years (SD = 8.9). At the end of 8 weeks of treatment, a multivariate analysis showed that relative to the HEP condition, the MBCT condition was associated with a significantly greater mean percent reduction in the HAM-D17 (36.6 vs. 25.3%; p = 0.01) and a significantly higher rate of treatment responders (30.3 vs. 15.3%; p = 0.03). Although numerically superior for MBCT than for HEP, the rates of remission did not significantly differ between treatments (22.4 vs. 13.9%; p = 0.15). In these models, state anxiety, perceived stress and the presence of personality disorder had adverse effects on outcomes.
CONCLUSIONS:
MBCT significantly decreased depression severity and improved treatment response rates at 8 weeks but not remission rates. MBCT appears to be a viable adjunct in the management of TRD.
BACKGROUND:Due to the clinical challenges of treatment-resistant depression (TRD), we evaluated the efficacy of mindfulness-based cognitive therapy (MBCT) relative to a structurally equivalent active comparison condition as adjuncts to treatment-as-usual (TAU) pharmacotherapy in TRD.
METHODS:
This single-site, randomized controlled trial compared 8-week courses of MBCT and the Health Enhancement Program (HEP), comprising physical fitness, music therapy and nutritional education, as adjuncts to TAU pharmacotherapy for outpatient adults with TRD. The primary outcome was change in depression severity, measured by percent reduction in the total score on the 17-item Hamilton Depression Rating Scale (HAM-D17), with secondary depression indicators of treatment response and remission.
RESULTS:
We enrolled 173 adults; mean length of a current depressive episode was 6.8 years (SD = 8.9). At the end of 8 weeks of treatment, a multivariate analysis showed that relative to the HEP condition, the MBCT condition was associated with a significantly greater mean percent reduction in the HAM-D17 (36.6 vs. 25.3%; p = 0.01) and a significantly higher rate of treatment responders (30.3 vs. 15.3%; p = 0.03). Although numerically superior for MBCT than for HEP, the rates of remission did not significantly differ between treatments (22.4 vs. 13.9%; p = 0.15). In these models, state anxiety, perceived stress and the presence of personality disorder had adverse effects on outcomes.
CONCLUSIONS:
MBCT significantly decreased depression severity and improved treatment response rates at 8 weeks but not remission rates. MBCT appears to be a viable adjunct in the management of TRD.
In this study, the authors both developed and validated a self-report mind- fulness measure, the Toronto Mindfulness Scale (TMS). In Study 1, partici- pants were individuals with and without meditation experience. Results showed good internal consistency and two factors, Curiosity and Decen- tering. Most of the expected relationships with other constructs were as expected. The TMS scores increased with increasing mindfulness medita- tion experience. In Study 2, criterion and incremental validity of the TMS were investigated on a group of individuals participating in 8-week mindfulness-based stress reduction programs. Results showed that TMS scores increased following treatment, and Decentering scores predicted improvements in clinical outcome. Thus, the TMS is a promising measure of the mindfulness state with good psychometric properties and predic- tive of treatment outcome.
BACKGROUND:Mindful Mood Balance (MMB) is a Web-based intervention designed to treat residual depressive symptoms and prevent relapse. MMB was designed to deliver the core concepts of mindfulness-based cognitive therapy (MBCT), a group treatment, which, despite its strong evidence base, faces a number of dissemination challenges.
OBJECTIVE:
The present study is a qualitative investigation of participants' experiences with MMB.
METHODS:
Qualitative content analysis was conducted via 38 exit interviews with MMB participants. Study inclusion required a current PHQ-9 (Patient Health Questionnaire) score ≤12 and lifetime history ≥1 major depressive episode. Feedback was obtained on specific website components, program content, and administration as well as skills learned.
RESULTS:
Codes were assigned to interview responses and organized into four main themes: MBCT Web content, MBCT Web-based group process, home practice, and evidence of concept comprehension. Within these four areas, participants highlighted the advantages and obstacles of translating and delivering MBCT in a Web-based format. Adding increased support was suggested for troubleshooting session content as well as managing time challenges for completing home mindfulness practice. Participants endorsed developing affect regulation skills and identified several advantages to Web-based delivery including flexibility, reduced cost, and time commitment.
CONCLUSIONS:
These findings support the viability of providing MBCT online and are consistent with prior qualitative accounts derived from in-person MBCT groups. While there is certainly room for innovation in the domains of program support and engagement, the high levels of participant satisfaction indicated that MMB can significantly increase access to evidence-based psychological treatments for sub-threshold symptoms of unipolar affective disorder.
BACKGROUND:Mindful Mood Balance (MMB) is a Web-based intervention designed to treat residual depressive symptoms and prevent relapse. MMB was designed to deliver the core concepts of mindfulness-based cognitive therapy (MBCT), a group treatment, which, despite its strong evidence base, faces a number of dissemination challenges.
OBJECTIVE:
The present study is a qualitative investigation of participants' experiences with MMB.
METHODS:
Qualitative content analysis was conducted via 38 exit interviews with MMB participants. Study inclusion required a current PHQ-9 (Patient Health Questionnaire) score ≤12 and lifetime history ≥1 major depressive episode. Feedback was obtained on specific website components, program content, and administration as well as skills learned.
RESULTS:
Codes were assigned to interview responses and organized into four main themes: MBCT Web content, MBCT Web-based group process, home practice, and evidence of concept comprehension. Within these four areas, participants highlighted the advantages and obstacles of translating and delivering MBCT in a Web-based format. Adding increased support was suggested for troubleshooting session content as well as managing time challenges for completing home mindfulness practice. Participants endorsed developing affect regulation skills and identified several advantages to Web-based delivery including flexibility, reduced cost, and time commitment.
CONCLUSIONS:
These findings support the viability of providing MBCT online and are consistent with prior qualitative accounts derived from in-person MBCT groups. While there is certainly room for innovation in the domains of program support and engagement, the high levels of participant satisfaction indicated that MMB can significantly increase access to evidence-based psychological treatments for sub-threshold symptoms of unipolar affective disorder.
Mindfulness-based Cognitive Therapy (MBCT) has been shown to effectively prevent relapse and reduce residual depressive symptoms (RDS), yet it faces barriers to dissemination. The present study examined Mindful Mood Balance (MMB), the first web-based approach to deliver the core content of MBCT. Of the 107 recurrently depressed individuals screened, 100 elected to enroll in the study and received MMB in an 8-session open trial with 6-month follow-up. Outcomes included depressive symptom severity, rumination and mindful awareness, and program engagement. A quasi-experimental comparison between MMB participants and propensity matched case-controls receiving usual depression care (UDC) (N = 100) also was conducted. The full sample and the subgroup with residual depressive symptoms (N = 42) showed significantly reduced depressive severity, which was sustained over six months, and improvement on rumination and mindfulness. Examination of acceptability of MMB indicated that 42% of participants within the full sample and 36% of the RDS subgroup completed all 8 sessions and 53% within the full sample and 50% within the RDS subgroup completed at least 4 sessions, and that participants engaged with daily mindfulness practice. MMB also was associated with significant reduction in RDS severity as compared to quasi-experimental propensity matched controls. Although the use of a non-randomized design, with potential unmeasured differences between groups, and short interval of clinical follow-up were limitations, findings from this study support the web-based delivery of MBCT and suggest clinical benefits for participants with histories of depression and with RDS, relative to those receiving usual care alone.
Mindfulness-based Cognitive Therapy (MBCT) has been shown to effectively prevent relapse and reduce residual depressive symptoms (RDS), yet it faces barriers to dissemination. The present study examined Mindful Mood Balance (MMB), the first web-based approach to deliver the core content of MBCT. Of the 107 recurrently depressed individuals screened, 100 elected to enroll in the study and received MMB in an 8-session open trial with 6-month follow-up. Outcomes included depressive symptom severity, rumination and mindful awareness, and program engagement. A quasi-experimental comparison between MMB participants and propensity matched case-controls receiving usual depression care (UDC) (N = 100) also was conducted. The full sample and the subgroup with residual depressive symptoms (N = 42) showed significantly reduced depressive severity, which was sustained over six months, and improvement on rumination and mindfulness. Examination of acceptability of MMB indicated that 42% of participants within the full sample and 36% of the RDS subgroup completed all 8 sessions and 53% within the full sample and 50% within the RDS subgroup completed at least 4 sessions, and that participants engaged with daily mindfulness practice. MMB also was associated with significant reduction in RDS severity as compared to quasi-experimental propensity matched controls. Although the use of a non-randomized design, with potential unmeasured differences between groups, and short interval of clinical follow-up were limitations, findings from this study support the web-based delivery of MBCT and suggest clinical benefits for participants with histories of depression and with RDS, relative to those receiving usual care alone.