Mindfulness Group Therapy Equal to CBT for Depression

Deborah Brauser

December 04, 2014

Mindfulness group therapy is as effective as individual cognitive-behavioral therapy (CBT) for treating depression, anxiety, and stress, new research suggests.

Dr Jan Sundquist

A randomized controlled trial of more than 200 primary care patients with at least one of these disorders showed that patients receiving 8 weeks of a structured group mindfulness program and those receiving CBT had significantly improved scores on the Patient Health Questionnaire–9 (PHQ-9), the Hospital Anxiety and Depression Scale (HADS), and the Montgomery-Åsberg Depression Rating Scale (MADRS).

Although there were no significant between-group differences, the investigators note that they were pleased to see that mindfulness was not inferior to the more standard treatment, especially because individual-based CBT "is in short supply and expensive."

Lead author Jan Sundquist, MD, PhD, professor and directors at the Center for Primary Health Care Research, Department of Clinicial Sciences, at Lund University in Malmö, Sweden, told Medscape Medical News that he was actually surprised that the two treatments were equal.

"Although we had read earlier reports that mindfulness is effective at preventing and treating psychiatric disorders and has fundamental effects on the brain that may explain its effectiveness, we were still skeptical," he said. "I was surprised when mean scores for two depression scales (MADRS-S and HADS-D) decreased by 50% in the mindfulness group."

He added that group mindfulness treatment "should be considered as an alternative to individual psychotherapy, especially at primary healthcare centers that can't offer everyone individual therapy."

The study was published online November 27 in the British Journal of Psychiatry.

Therapists in Short Supply

Approximately 12% to 32% of patients visiting a general practitioner in Europe have depressive, anxiety, and/or stress and adjustment disorders.

"In my work as a [general practitioner], I see many patients with depression and anxiety and just want to do more for them. We need simple, effective tools for treating them when financial resources are limited," said Dr Sundquist.

The researchers add that CBT "is currently being introduced as a standard treatment in Swedish general practice" for depressive disorder; many clinical psychologists and social counselors in the country offer an individualized form of the therapy.

"However, CBT therapists are in short supply, and the individual therapeutic approach is expensive for the tax-financed healthcare system."

On the other hand, the investigators note that mindfulness-based therapies may offer the advantage of being accessible to larger groups of patients because after going through introductory sessions, they can practice the therapy on their own.

For the study, 215 patients between the ages of 20 and 64 years who had depression, anxiety, and/or stress and adjustment disorders were recruited in the spring of 2012 from 16 primary healthcare centers in a southern region of Sweden.

At baseline, all participants had a score of at least 10 on the PHQ-9, a score of at least 7 on the HADS, or a score of 13 to 34 on the self-rated version of the MADRS.

The patients were randomly assigned to receive 8 weeks of either mindfulness group therapy (n = 100; 81% women; mean age, 42 years) or "treatment as usual" (n = 105; 90% women; mean age, 41 years).

The mindfulness program combined elements from both mindfulness-based stress reduction and mindfulness-based cognitive therapy, and included meditative exercises. Each session included two mindfulness instructors who previously underwent a 6-day training course.

The group sessions each included a maximum of 10 individuals. Participants were told to practice learned techniques for 20 minutes per day in their homes. They were also given a compact disc, training manual, and diary.

Treatment as usual sometimes included pharmacologic treatment and mostly included psychotherapy or counseling. Of the 80 patients in the group receiving treatment as usual, most received individual CBT; the average number of sessions was 6.

Measurements included changes from baseline to end of treatment on the PHQ-9, MADRS, HADS–anxiety subscale (HADS-A), or HADS–depression subscale (HADS-D).

Clinical Implications

Results showed that "for all scales and in both groups, the scores decreased significantly," report the investigators (for all, P < .001).

For the MADRS, median baseline and after-treatment scores for the mindfulness group were 20 and 11, respectively. For the treatment-as-usual group, the scores were 23 and 13.

For the HADS-D, scores for the mindfulness group were 8 and 3; scores were 9 and 5 for the treatment-as-usual group. For the HADS-A, scores for each group were 12 and 7, and 13 and 9, respectively.

Scores for each group on the PHQ-9 were 12 and 5, and 14 and 8, respectively.

"Before the treatment started, the scores indicated mild to moderate symptoms of depression and anxiety in the different subgroups. After the intervention had ended, the scores indicated no to mild symptoms," write the researchers.

There were no significant between-group differences on any of the measures. Further analysis showed no difference in results between the participants who were and those who were not receiving antidepressants.

Finally, a noninferiority analysis, which had an upper limit of 3.5, showed that mindfulness was not inferior to treatment as usual (showing an upper limit of 3.17).

"The study's results indicate that group mindfulness treatment, conducted by certified instructors in primary healthcare, is as effective a treatment method as individual CBT for treating depression and anxiety," said Dr Sundquist.

The investigators add that the findings have potential clinical implications, including the fact that "certified instructors, that do not necessarily need to be psychologists or counselors, can give mindfulness-based therapy to a group of patients with psychiatric symptoms common in primary care."

However, they note that not all patients are suited to group-based therapy and that more research is needed in larger patient populations.

Best Option

"I thought this was an interesting study from several perspectives," Renee Binder, MD, president-elect of the American Psychiatric Association, told Medscape Medical News.

Dr Renee Binder

"First, it's important that people are paying attention to depression, anxiety, and stress and adjustment disorders in primary care ― especially considering the direction that healthcare is taking in the United States, where we are moving towards integrated and collaborative care," she said.

Dr Binder, who was not involved with this research, is professor and director of the Psychiatry and Law Program at the University of California–San Francisco (UCSF) Medical School and associate dean of academic affairs at UCSF.

She noted that it was also good to see that treatment for depression and anxiety can lead to "a tremendous amount of improvement" in symptoms. However, she said that caution should be used when interpreting the specific results.

"It showed that both of these treatments were in mild to moderate depression. But there are also many other techniques that work that they did not look at," she said, adding that other limitations included the inclusion/exclusion criteria and that the investigators provided only six CBT sessions, which is usually higher in the United States. Also, comparatively, the mindfulness program used "was quite intensive."

"Overall, I think it showed that the best therapy for anxiety and depression is where the therapist, whether it's for groups or individuals, uses individual techniques that a patient can use on their own. And most good psychotherapies do that," she said.

She added that some patients like group therapy, being around other people, and knowing that "they're not alone." However, others may feel that that type of treatment is too intrusive.

"Mindfulness is definitely a tool in the toolbox. The thing with therapy is that one size doesn't fit all. It's good to have multiple tools so if one thing doesn't work, you can try something else," said Dr Binder.

She reiterated that the results showed that treatment is effective for this patient population ― even short-term treatment.

"And I think that's a very important message from this study."

The study authors and Dr Binder have reported no relevant financial relationships.

Br J Psychiatry. Published online November 27, 2014. Abstract


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