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Centre for Suicide Research | Professor Mark Williams | Wellcome Trust Research Programme | Mindfulness Based Cognitive Therapy |
Mindfulness Based Cognitive Therapy and the prevention of relapse in depression
Background
Mindfulness-based Cognitive Therapy
has been developed with the aim of reducing relapse and recurrence for those
who are vulnerable to episodes of depression.
It is needed because the risk of relapse and recurrence in those who have
been depressed is very high, and the amount of triggering required for each
subsequent episode becomes lower each time depression recurs. Research by
Zindel Segal (Toronto), Mark Williams (Wales) and John Teasdale (Cambridge)
has been investigating how meditation may help people stay well after recovery
from depression.
Their work is based on the observation that, once a person has recovered
from an episode of depression, a relatively small amount of negative mood
can trigger a large amount of negative thoughts (eg. ‘I am a failure’,
‘I am weak’, ‘I am worthless’) together with bodily
sensations of weakness or fatigue or unexplained pain. Both the negative
thoughts and the fatigue often seem out of proportion to the situation.
Patients who believed they had recovered may find themselves feeling ‘back
to square one’. They end up inside a rumination loop that constantly
asks ‘what has gone wrong?’, ‘why is this happening to
me?’, ‘where will it all end?’. Such rumination feels
to the person as if it ought to help find an answer, but it only succeeds
in prolonging and deepening the mood disturbance.
Why do people remain vulnerable to relapse?
During an episode of depression,
negative mood occurs alongside negative thinking and bodily sensations of
sluggishness and fatigue. When the episode is past, and the mood has returned
to normal, the negative thinking and body sensations tend to disappear as
well. However, during the episode an association has been learned between
the various symptoms. This means that when negative mood happens again (for
any reason) it will tend to trigger all the other symptoms in proportion
to the strength of association (this is called ‘differential activation’).
When this happens, the old habits of negative thinking will start up again,
negative thinking gets into the same rut, and a full-blown episode of depression
may be the result.
The discovery that, even when people feel well, the link between negative
moods and negative thoughts remains ready to be re-activated, is of enormous
importance. It means that sustaining recovery from depression depends on
learning how to keep mild states of depression from spiralling out of control.
Mindfulness-based cognitive therapy (MBCT)
Based on Jon Kabat Zinn’s
Stress Reduction program at the University of Massachusetts Medical Center,
Mindfulness-based Cognitive Therapy includes simple breathing meditations
and yoga stretches to help participants become more aware of the present
moment, including getting in touch with moment-to-moment changes in the
mind and the body. In eight weekly classes (the atmosphere is that of a
class, rather then a therapy group), and by listening to tapes at home during
the week, class participants learn the practice of mindfulness meditation.
MBCT also includes basic education about depression, and several exercises
from cognitive therapy that show the links between thinking and feeling
and how best participants can look after themselves when depression threatens
to overwhelm them. These more structured exercises make MBCT different from
mindfulness meditation as it is normally taught at retreat centres, but
the approach is embedded within, and seeks to remain true to the insight
meditation tradition that has been taught for two and a half thousand years.
Mindfulness-based cognitive therapy helps participants in the classes to
see more clearly the patterns of the mind; and to learn how recognise when
their mood is beginning to go down. It helps break the link between negative
mood and the negative thinking that it would normally have triggered. Participants
develop the capacity to allow distressing mood, thoughts and sensations
to come and go, without having to battle with them. They find that they
can stay in touch with the present moment, without having to ruminate about
the past, or worry about the future.
Evaluation of MBCT
In a multi-centre RCT conducted
in Toronto, Cambridge and Bangor, 145 participants were allocated to receive
either treatment-a-usual (TAU), or, in addition to TAU, to receive eight
classes of MBCT. All the participants in the study had been symptom free
for at least 3 months, and off antidepressant medication, when they entered
the trial. They were known to be vulnerable to future depression because
they had had at least two episodes in their past that met criteria for DSM
Major Depression (the final episode having occurred within 2 years). The
sample was stratified on entry by the number of previous episodes (2 only,
or more than 2). The researchers followed them up for twelve months after
the eight weeks classes.
The results showed that MBCT helped most those who had suffered the most
number of previous episodes. It had no effect on those who had only 2 episodes
in the past (the minimum criteria for entry to the trial – about a
quarter of the trial sample). By contrast, it substantially reduced the
risk of relapse in those who had three or more previous episodes of depression
(from 66 per cent to 37 per cent). Participants reported being able to develop
a different (‘decentred’) relationship to their experience,
so that their depression-inducing thoughts could be viewed from a wider
perspective as they were occurring. (For a report of this trial see: Teasdale,
J.D., Segal, Z.V., Williams, J.M.G., Ridgeway, V., Lau, M., & Soulsby,
J. (2000) Reducing risk of recurrence of major depression using Mindfulness-based
Cognitive Therapy. Journal of Consulting and Clinical Psychology,
68, 615-23. For other data from the trial, see Williams, J.M.G., Teasdale,
J.D., Segal, Z.V. & Soulsby, J. (2000) Mindfulness-Based Cognitive Therapy
reduces overgeneral autobiographical memory in formerly depressed patients.
Journal of Abnormal Psychology 109, 150-155.)
These findings have now been replicated in a study by Helen Ma and John
Teasdale in Cambridge. It found the same pattern of results, with MBCT reducing
the rate of relapse from 78% in those with three episodes or more, to 36%.
The treatment was, once again, found not to affect those who had experienced
only 2 episodes, and for a discussion of this, see both the book (Segal
et al., 2002, see further information on
MBCT) and the report of the trial (Teasdale et al., 2000).
In Oxford, Mark Williams, Melanie Fennell and their colleagues will be piloting
the use of MBCT with people who have had a suicidal crisis, and now recovered,
with the aim of reducing the risk of further self-harm. It is too early
to say how many patients will find this approach useful.
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Background
Vulnerability to relapse
Mindfulness Based Cognitive Therapy
Evaluation
More information on Mindfulness Based Cognitive
Therapy
