Mindfulness 'as good as drugs for preventing depression relapse'

"Mindfulness-based cognitive therapy may be as good as pills at stopping people relapsing after recovering from major bouts of depression," The Guardian reports.

Researchers wanted to see if a type of therapy known as mindfulness-based cognitive therapy (MBCT) could be an effective alternative treatment to antidepressants for people with major depression at high risk of relapse.

MBCT combines the problem-solving approach of cognitive behavioural therapy (CBT) with mindfulness techniques. These are designed to fix your awareness on the "here and now" instead of having unhelpful thoughts about the past and the future.

In a two-year clinical trial, people already taking antidepressants were assigned to a MBCT programme with a view to reducing or stopping their medication, or were asked to continue antidepressants alone. With support from their GP and therapist, around 70% of the mindfulness group were able to stop taking antidepressants.

The trial suggests MBCT might help some people with major recurrent depression reduce or cut out their medication. However, between four and five people out of every 10 in the trial relapsed within two years, regardless of their treatment. Depending on your perspective, the treatments were equally good or equally bad.

Research does suggest that mindfulness can benefit all of us, not just people with a history of severe depression. Read more about mindfulness for mental wellbeing. 

Where did the story come from?

The study was led by researchers from Oxford University and was funded by the National Institute for Health Research.

Two authors, including the first author, are co-directors of the Mindfulness Network Community Interest Company and teach nationally and internationally on mindfulness-based cognitive therapy. The other authors declare no competing interests.

The study was published in the peer-reviewed medical journal The Lancet on an open-access basis, so it is free to access online.

The media generally reported the story accurately and overall took a positive spin on the results, with some exceptions. The Daily Telegraph, for example, added some balance by saying that, "Some experts warned that the trial was not large enough to come to a definitive conclusion and had not included a placebo group".

However, few sources mentioned the potential conflicts of interest. Some did not recognise that MBCT as well as antidepressants are already recommended treatment options in national guidelines on depression for England and Wales for the prevention of relapse.

The Mail Online's headline, "Meditation is as effective as drugs for treating depression", is also quite careless, as this may give the impression that this is the kind of meditation that may be practised in a yoga class, for example, when it was actually a structured programme of mindfulness-based cognitive therapy.  

What kind of research was this?

This was a single-blind randomised control trial (RCT) comparing mindfulness-based cognitive therapy with antidepressant treatments to prevent the relapse or recurrence of depression.

People with depression often have relapses, and an increasing number of past episodes or ongoing health or life problems can increase the risk of further relapses. People who have had three or more depression episodes are reported to have relapse rates as high as 80% over two years.

For people at high risk of relapse, taking antidepressants for at least two years is the current recommended treatment. However, psychological therapies, including mindfulness-based cognitive therapy (MBCT), are also a recommended option.

This may be given either alongside antidepressant treatment, as an alternative for people who cannot, or do not want to, take antidepressants for this long, or for people who have not responded to antidepressants.

MBCT is a psychosocial intervention specifically designed to teach people with recurrent depression the skills to stay well in the long term. It uses a combination of problem-solving techniques, as well as teaching people how to focus on their immediate environment instead of dwelling on the past or worrying about their future.

MBCT, say the study team, has been shown to reduce the risk of relapse or recurrence compared with usual care, but has not yet been compared with maintenance antidepressant treatment in an RCT.

The aim of the study was to see whether MBCT with support to taper or discontinue antidepressant treatment (MBCT) was better than taking antidepressants for the prevention of depressive relapse or recurrence over 24 months.

Randomised controlled trials are an appropriate and effective way of testing how well different treatments work, such as MBCT compared with antidepressants. 

What did the research involve?

The study analysed 424 adults from urban and rural areas in the UK. All had a diagnosis of recurrent major depressive disorder (currently in remission), had three or more previous major depressive episodes, and were taking maintenance antidepressants to prevent further relapses.

The recruits were randomly assigned to receive an eight-week MBCT class or continue on maintenance antidepressants (212 in each group). Recurrence of depression was assessed over the following two-year period.

Both groups took antidepressants to begin with. The MBCT intervention was added on top, and included efforts to lessen the use of antidepressants, in consultation with their GP, if they felt they didn't need them or needed less of them.

MBCT is intended to enable people to learn to become more aware of their bodily sensations, thoughts and feelings associated with depressive relapse or recurrence, and to relate constructively to these experiences.

Participants learn mindfulness practices and cognitive-behavioural skills both in sessions and through homework assignments. Therapists provide support to patients in learning to respond adaptively to thoughts, feelings and experiences that might otherwise have triggered a relapse.

The programme involved eight 2¼-hour group sessions, normally over consecutive weeks, with four refresher sessions offered roughly every three months for the following year.

Patients in the maintenance antidepressant group received support from their GPs to maintain a therapeutic level of antidepressant medication in line with prescribing guidelines for the two-year follow-up period.

The main success measure was the time to relapse or recurrence of depression, with patients followed up at five separate intervals over two years. Secondary measures of success were the number of depression-free days, residual depressive symptoms, psychiatric and medical comorbidity, quality of life, and cost effectiveness. 

What were the basic results?

Most people completed the two-year trial (86%). In the MBCT group, 13% did not lower their antidepressant dose, 17% did, and 71% stopped completely.

Time to relapse or recurrence of depression over 24 months did not differ between people in the MBCT group or those taking maintenance antidepressants alone (hazard ratio [HR] 0.89, 95% confidence interval [CI] 0.67 to 1.18). A total of 94 (44%) of 212 patients in the MBCT group relapsed, compared with 100 (47%) of 212 in the maintenance antidepressants group.

Nor did the number of serious adverse events differ. Five adverse events were reported, including two deaths in each of the MBCT and maintenance antidepressants groups. No adverse events were attributable to the interventions or the trial.

MBCT was no better than antidepressants for the number of depression-free days, residual depressive symptoms, psychiatric and medical comorbidity, and quality of life.

The cost effectiveness analysis showed MBCT is not more cost effective than maintenance antidepressants alone. 

How did the researchers interpret the results?

The researchers said that, "We found no evidence that MBCT [combined with support to reduce antidepressant treatment] is superior to maintenance antidepressant treatment for the prevention of depressive relapse in individuals at risk for depressive relapse or recurrence.

"Both treatments were associated with enduring positive outcomes in terms of relapse or recurrence, residual depressive symptoms, and quality of life." 

Conclusion

This trial showed that mindfulness-based cognitive therapy enabled many people at high risk of a relapse of depression to discontinue their medicines, and achieve similar levels of relapse over a two-year period.

The number of depression-free days, residual depressive symptoms, psychiatric and medical comorbidity, and quality of life ratings were also similar. This suggests the mindfulness programme in the trial may help those who can't, or do not want to, use antidepressant drugs over the long term.

These results are consistent with current national guidelines for the prevention of depression relapse in England and Wales.

These recommend that people with depression who are considered to be at significant risk of relapse – including those who have relapsed despite antidepressant treatment, or who are unable or choose not to continue antidepressant treatment – or who have residual symptoms should be offered one of the following psychological interventions:

• individual cognitive behaviour therapy (CBT) – for people who have relapsed despite antidepressant medication, and for people with a significant history of depression and residual symptoms despite treatment
• mindfulness-based cognitive therapy – for people who are currently well but have experienced three or more previous episodes of depression

The results remind us that treatments to prevent depression relapse in this high-risk group don't have a high success rate. Between four and five people out of every 10 in the trial relapsed, regardless of their treatment.

Depending on your perspective, the treatments were equally good or equally bad. This highlights that people at high risk of relapse need to receive tailored care and regular follow-up so they can find the best treatment approach for them.

But this study has a number of limitations. As the researchers say, the people in the trial were all willing to try a psychological treatment and try reducing their antidepressant dose. This may mean the results are not generalisable to all people at high risk of depression relapse.

The people in the study had also already tried antidepressants for relapse prevention. They are not the same as people who are considering relapse prevention for the first time and are discussing the first option to use in preventing further episodes.

There was also no control comparison to MBCT. That is, a control intervention where the person still received the same regular group sessions, but without the specific components of the MBCT intervention.

This means it is less able to provide solid proof that the mindfulness intervention is as good as antidepressants for most people with major depression, or whether it is just the regular attention and follow-up that has an effect.

Simply talking to a person could have a significant placebo effect that may improve mood. Larger and longer studies are needed to know this for sure.

This mindfulness intervention was designed specifically to prevent relapses of major depression in those considered to be high risk.

It is not designed or tested to prevent depression in the first place, prevent relapse in lower-risk groups (such as those with only one previous episode of depression), and was not being tested here as an initial treatment for depression.

If you are concerned you are depressed, it is usually recommended that the first person you talk to about your concerns is your GP.