The effect of mindfulness-based cognitive therapy for prevention of relapse in recurrent major depressive disorder: A systematic review and meta-analysis
Research highlights
► Mindfulness-based cognitive therapy (MBCT) for relapse prevention of major depression. ► We conducted a systematic review and meta-analysis. ► Six randomized controlled trials with a total of 593 participants were included. ► MBCT reduced the risk of relapse with 34% relative to controls.
Introduction
Originating from ancient eastern meditation and yoga traditions, mindfulness is generally described as a particular way of paying attention characterized by intentional and non-judgmental observation of present moment experiences, including bodily sensations, feelings, thoughts, and external stimuli from the environment (e.g. Baer, 2003, Grossman et al., 2004, Kabat-Zinn, 1994). Mindfulness-training, assumed to cultivate this capacity of awareness, has been adapted into clinical intervention programs including mindfulness-based stress reduction (MBSR) (Kabat-Zinn, 1990), and mindfulness-based cognitive therapy (MBCT) (Segal, Williams, & Teasdale, 2002). MBCT is an 8-session group intervention program with 8–15 participants designed for prevention of relapse or recurrence among patients with major depressive disorder (MDD) in remission.
MDD is a common mental disorder with a lifetime prevalence rate of about 20% (Kessler et al., 2005), and it is associated with a high degree of subjective distress and psychosocial disability (Judd et al., 2000). According to a recent report by the World Health Organization (WHO), MDD is currently the leading cause of disease burden, as measured by disability-adjusted life years (DALYs), in the United States of America and other middle- and high-income countries (WHO, 2008). Furthermore MDD is expected to be the leading cause of disease burden worldwide by the year 2030 (Ibid.). While the outlook for a first episode of MDD is rather good with spontaneous remission in most cases, the prognosis in the long run will often be poor with very high relapse or recurrence rates (50–90%); especially in case of prior depressive episodes (Judd, 1997, Mueller et al., 1999). With each new MDD episode the risk of worsening the course of the disease increases (Kessing, Hansen, Andersen, & Angst, 2004), and about 20% develops into chronic MDD with symptoms persisting for more than two years (Keller & Boland, 1998). Therefore, development of effective prevention interventions for MDD is a high priority enterprise within mental health.
The underlying model of MBCT specifies that previously depressed persons are characterized by greater cognitive vulnerability to states of low mood, as even mild dysphoric states may reactivate patterns of negative, ruminative thinking similar to those of previous episodes, causing the configuration of depression to be re-established (Segal et al., 1996, Teasdale, 1988, Teasdale et al., 1995). MBCT may be assumed to work by targeting rumination and emotional avoidance, both considered to be maintaining processes across mood and anxiety disorders (e.g. Barlow et al., 2004, Harvey et al., 2004, Hayes et al., 1996).
It has been claimed (e.g., Teasdale, Segal, & Williams, 2003) that MBCT particularly benefits patients with three or more MDD episodes, since such patients are especially prone to engage in ruminative thinking. In fact, two randomized controlled trials (RCTs) (Ma and Teasdale, 2004, Teasdale et al., 2000), both of which stratified participants prior to randomization by number of episodes (2 versus 3 or more), found that MBCT only lowered risk of relapse in case of three or more MDD episodes.
MBCT integrates elements of cognitive behavioral therapy for depression (CBT) (Beck, Rush, Shaw, & Emery, 1979) with training in mindfulness meditation (Kabat-Zinn, 1990). The aim of MBCT is to teach patients to become more aware of and relate differently to their thoughts, feelings, and bodily sensations. Through the practice of mindfulness exercises, such as the body scan, simple yoga exercises, and prolonged periods of sitting meditation, patients are taught to ‘turn towards’ and accept intense bodily sensations and emotional discomfort, and they are provided with cognitive skills that allow them to recognize the automatic activation of habitual dysfunctional cognitive processes, such as depression-related rumination, to detach or “decentre” from the content of negative thoughts, and to disengage from these processes by redirecting attention to experiences as they flux and change moment by moment.
Since the protocol release in 2002, MBCT has been adapted to different psychological disorders and conditions, and empirical research on the effectiveness of MBCT has expanded greatly. There is preliminary evidence of the effect of MBCT on pre-post symptoms of depression in people with fully or partially remitted depression (Britton et al., 2010, Crane et al., 2008, Kingston et al., 2007); currently symptomatic depression (Barnhofer et al., 2009, Eisendrath et al., 2008, Kenny and Williams, 2007, Manicavasgar et al., 2011, Mathew et al., 2010); bipolar disorder (Miklowitz et al., 2009, Williams et al., 2008); social phobia (Piet, Hougaard, Hecksher, & Rosenberg, 2010); and generalized anxiety disorder (Craigie et al., 2008, Evans et al., 2008). In a recent meta-analysis of mindfulness-based therapy, including MBSR and MBCT for different medical and psychological disorders, Hofmann, Sawyer, Witt, and Oh (2010) found a large pre-post effect size (Hedges's g = 0.85) of MBCT for symptoms of depression. Additionally, studies have found that MBCT reduces overgeneral autobiographical memory, which has been associated with depression and a number of detrimental effects on functioning (Heeren et al., 2009, Williams et al., 2000).
Research investigating potential mechanisms of action in MBCT is in its infancy. Recent studies suggest that the effect of MBCT may be facilitated or mediated by improved meta-awareness (Hargus et al., 2010, Teasdale et al., 2002); increased mindfulness and self-compassion (Kuyken et al., 2010); decreased rumination (Shahar, Britton, Sbarra, Figueredo, & Bootzin, 2010); reduced cognitive reactivity (Raes, Dewulf, Van Heeringen, & Williams, 2009); and a balanced pattern of emotion related brain activation (Barnhofer et al., 2007). Two studies on recovered recurrently depressed patients, respectively found increased mindfulness and reduced rumination during MBCT, and showed that post treatment levels of mindfulness and rumination significantly predicted MDD relapse over a 12 month follow-up period, even after controlling for residual depressive symptoms and number of previous episodes (Michalak et al., 2008, Michalak et al., 2010).
Coelho, Canter, and Ernst (2007) conducted the first narrative review of controlled clinical trials of MBCT for participants with a history of depression. They identified two studies focussing on MBCT as a preventive treatment for recurrent MDD, and tentatively concluded that the program had an additive benefit to usual care for patients with three or more previous episodes of depression. Chiesa and Serretti (2011) recently reviewed 16 controlled studies of MBCT for different psychiatric disorders, including four studies on MBCT for MDD relapse prevention, thus further consolidating the tentative conclusions of Coelho et al. (2007).
While former research broadly has reviewed the effect of MBCT for different disorders, this article reports the first formally adequate meta-analytic evaluation, following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA); (Moher, Liberati, Tetzlaff, Altman, & The PRISMA Group, 2009), of the effectiveness of MBCT for relapse prevention among patients with recurrent MDD in remission.
The aim of this study was by means of a meta-analysis to evaluate the effect of MBCT for prevention of relapse or recurrence among patients with recurrent MDD in remission; both for different control conditions, and for subgroups of patients (< or ≥ 3 MDD episodes).
Section snippets
Method
The study was conducted in accordance with the PRISMA statement, which provides a detailed guideline of preferred reporting style for systematic reviews and meta-analyses (Liberati et al., 2009, Moher et al., 2009).
Trial flow
The flow of information from identification to inclusion of studies is summarized in Fig. 1 using the PRISMA flow diagram (Moher et al., 2009). Our search strategy identified 666 publications. Duplicates were removed, and abstracts from the remaining 317 publications were screened. Initially reviews, qualitative studies, case studies, dissertation abstracts, study protocols, and non-English articles were excluded (N = 171) (in this article, N refers to number of studies; n to number of
Discussion
The overall risk ratio for relapse or recurrence in MBCT versus control groups (TAU or PLA) of 0.66 in this meta-analysis is highly significant, indicating that MBCT (added to TAU) is an effective intervention for relapse prevention in recurrent MDD in remission. The ES corresponds to a relative risk reduction of 34%, with relapse rates of 38% and 58% for MBCT and controls, respectively. As can be seen from Table 2, the studies are generally of a high methodological quality with a mean revised
Acknowledgments
The authors thank Professor Mark Williams, University of Oxford Department of Psychiatry, for helpful comments to a former version of the manuscript.
Declaration of interests
This study was not funded by any grants. There are no financial or other conflicts of interest.
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References marked with an asterisk indicate studies included in the meta-analysis.