Mindfulness Therapy May Prevent Depression Relapse

Liam Davenport

May 26, 2016

Mindfulness-based cognitive therapy (MBCT) reduces the risk for depression relapse in patients with recurrent depression, with the greatest effect seen in those with the worst baseline symptoms, the results of an individual patient data meta-analysis indicate.

Synthesizing data from more than 1200 patients in nine studies, European investigators found that MBCT reduced the risk for depression relapse by more than 30% overall and by more than 20% when compared directly against active treatments.

Willem Kuyken, PhD, Department of Psychiatry, Warneford Hospital, Prince of Wales International Centre, University of Oxford, in the United Kingdom, and colleagues write that "MBCT addresses a particular clinical problem, namely teaching skills to stay well to people currently well but at high risk of depressive relapse. The finding that MBCT may be most helpful for patients with higher levels of depressive symptoms adds to an emerging consensus that the greater the risk for depressive relapse/recurrence, the more benefit MBCT offers," they write.

The research was published online April 27 in JAMA Psychiatry.

"Important New Evidence"

The current research was an update to a previous meta-analysis that showed that MBCT was an effective intervention for the prevention of relapse in patients with recurrent depression, particularly for those with three or more previous episodes.

The team conducted a search of the EMBASE, PubMed/Medline, PsychINFO, Web of Science, Scopus, and Cochrane Controlled Trials Register databases for English-language randomized controlled trials comparing MBCT with non-MBCT, including usual care, for the prevention of relapse of recurrent depression in patients in full or partial remission.

From the original cutoff date of November 2010, the search was extended to November 2014. Nine studies from a total of 2555 records identified were selected for quantitative synthesis and analysis of individual patient data. These included 1258 patients. The average age of the patients was 47.1 years; 75.0% of the patients were women.

The mean age at onset of depression was 26.0 years; 694 of 1200 participants had five or more previous depressive episodes. Of 596 individuals who received MBCT, 38% experienced a depressive relapse within 60 weeks of follow-up. In comparison, of the 662 patients who did not undergo MBCT, 59% experienced relapse.

Two-stage meta-analysis revealed that MBCT was associated with a reduction in the risk of having a depression relapse within 60 weeks compared with non-MBCT care (hazard ratio [HR], 0.69).

An equivalent analysis of MBCT vs all active treatments using data from five studies showed that MBCT was associated with a reduced risk for relapse within 60 weeks (HR, at 0.79).

A fixed effects one-stage model indicated that patient age, sex, education status, relationship status, baseline depression score, age at onset, and number of previous episodes were all significantly associated with the risk for relapse (P < .10).

None of those factors were found to interact significantly with MBCT treatment with the exception of severity of baseline depression symptoms; patients with worse baseline symptoms derived a greater benefit from MBCT.

"While previous research has shown the superiority of MBCT compared with usual care, this study provides important new evidence that MBCT is also effective compared with other active treatments and that its effects are not restricted to particular groups defined by age, educational level, marital status, or sex," the authors write.

Few Downsides

In an accompanying commentary, Richard J. Davidson, PhD, Center for Healthy Minds, University of Wisconsin–Madison, points out that mindfulness practices were not originally developed as therapeutic treatments and so the evidence base is in an "embryonic stage," with many unanswered questions remaining.

Nevertheless, Dr Davidson told Medscape Medical News that there are "relatively few downsides" to MBCT and that, unlike use of an experimental medication that may be associated with serious potential side effects, "here the side effects are really quite benign."

"I certainly believe, based in particular on this meta-analysis, that there is a rationale for exploring the use of these methods clinically," he said.

With the development in recent years of a number of cognitive-based therapies for depression, one point of interest is whether a core set of approaches or therapies individualized to the patient will emerge.

Describing that as an "important question," Dr Davidson said, "My own conviction is that this is where the scientific research needs to go in the future.

"We can assess an individual's cognitive and emotional style, for example, before implementing any therapeutic treatment, and we can more rationally assign a particular treatment strategy based on an individual's cognitive and emotional style," he added.

"That is, in principle, possible for us to begin to do today, but the requisite research has not yet been done, and so this is a high-priority area for future research."

Nevertheless, Dr Davidson believes that "at some point in the future, we're likely to proceed in that kind of way."

A potential issue for the widespread implementation of MBCT is that of obtaining local healthcare funding for practitioners.

Dr Davidson said that MBCT provides "an individual with kind of a lifelong skill," and once the impact of the therapy on individual patients and the wider financial basis are determined, funding will not be a limiting factor.

"One of the critical issues that needs to be addressed empirically is the extent to which this kind of treatment can be cost-effective. In terms of the costs of recurrent depression, which are enormous in terms of productivity and absenteeism...it may well be that this is indeed very cost-effective, and whatever modest costs are associated with this are far exceeded by the cost savings that are achieved through this kind of prevention strategy," he said.

The study was supported by Wellcome Trust grants. The original article contains a full listing of the authors' relevant financial relationships. The research upon which the editorial is based was supported by a grant from the National Center for Complementary and Integrative Health of the National Institutes of Health and several gifts to the Center for Healthy Minds.

JAMA Psychiatry. Published online April 27, 2016. Abstract, Commentary

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