Mindfulness-Based Cognitive Therapy in Managing Depressive Symptoms in Older People: A Non-Randomised Controlled Trial
Phase: NA
Conditions: Depressive Symptoms
Sponsor: The University of Hong Kong

Mindfulness-Based Cognitive Therapy in Managing Depressive Symptoms in Older 
People: A Non-Randomised Controlled Trial   
 
NCT ID not yet assigned 
Unique Protocol ID: EA220105 
Date of the document: 8th August, 2023 
 
INVESTIGATORS  
Terry YS Lum (Principal Investigator)  
Department of Social Work and Social Administration, HKU  
Gloria HY Wong (Co-Principal Investigator)  
Department of Social Work and Social Administration, HKU  
Tianyin Liu   
Department of Social Work and Social Administration, HKU  
Dara KY Leung  
Department of Social Work and Social Administration, HKU  
Raymond CL Chan  
Department of Social Work and Social Administration, HKU  
Yun-Lin Wang 
Department of Social Work and Social Administration, HKU  
Yun-Han Wang 
Department of Social Work and Social Administration, HKU  
 
PARTNERING ORGANIZATIONS 
The Hong Kong Jockey Club Charities Trust 
Christian Family Service Centre 
The Mental Health Association of Hong Kong 
The Salvation Army, Hong Kong and Macau Command 
Caritas - Hong Kong  
Haven of Hope Christian Service 
 
 
 
 
 

Background 
Depression is one of the most common yet under-recognized mental disorders in older adults 
in Hong Kong, and it is estimated that approximately one in 10 older people has clinically 
significant depression (Sun et al., 2012). With population aging, the number of older people 
with depression is slated to double in the next two decades, creating a substantial burden on 
the individuals, caregivers, and health care system. While pharmacological interventions are 
effective in reducing depression, medical risks can be complicated due to polypharmacy in 
older people. Non-pharmacological interventions may benefit the population by addressing 
the underlying dysfunctional cognitive processes associated with depression. 
 
Mindfulness-based interventions, such as mindfulness-based cognitive therapy (MBCT), have 
the potential in improving psychological health in older people. MBCT is a group 
intervention originally designed to prevent recurrent depressive disorders (Segal et al., 2012). 
It combines mindfulness practices and cognitive-behavioural elements to enhance an 
individual’s understanding of the interacting relationships among thoughts, emotions, bodily 
sensations, and behaviours. Mindfulness practice emphasizes on developing a moment-to-
moment, non-judgmental awareness and may be helpful in alleviating depression by directing 
individual’s attention to the present instead of ruminating in the past. Systematic reviews 
have shown the efficacy of MBCT in reducing depression, anxiety, loneliness, stress, sleep 
problems, ruminations, general mood, and positive affect (Geiger et al., 2016; Thomas et al., 
2020). However, over half of the included studies lacked a control group and mixed findings 
were observed possibly because of inconsistent modifications to the protocol, methodological 
flaws, and study limitations. 
 
The application of MBCT in the Chinese older population is understudied. Recently, a 
randomized controlled trial on MBCT for older people were conducted in Hong Kong. Shih 
et al. (2021) compared a standard MBCT to an active control group (physical exercise + 
health education) for older people with depression and revealed that, while both groups 
showed a reduction in the severity of depressive symptoms, only the MBCT group showed 
improvement in mindfulness.  
 
With these promising findings, more studies are needed to establish the evidence base for the 
intervention and inform clinical practice in this population. We aim to explore whether a 
modified MBCT based on older people’s feedback can reduce depressive symptoms and 

improve mindfulness. With the growing older people population, there is a need for greater 
social welfare capacity to promote their well-being, we also examine whether a modified 
MBCT led by social workers under the supervision of a mindfulness teacher can benefit the 
population. 
 
Objectives 
• To evaluate the effectiveness of MBCT in improving mental health and mindfulness 
in older people with depressive symptoms as compared to care as usual 
• To compare the effectiveness between MBCT led by mindfulness teacher and that led 
by social workers 
• To examine psychological flexibility as a potential mechanism of change 
 
Methods 
Design 
This is a non-randomised controlled trial with three arms, comparing older people with mild 
to moderately severe depressive symptoms receiving modified MBCT led by a mindfulness 
teacher, MBCT led by social workers, and care as usual. 
 
Participants 
Participants will be recruited from District Elderly Community Centres (DECC) and 
Integrated Community Centre for Mental Wellness (ICCMW). We aimed to recruit 32 
participants for each arm, totaling 96 participants in the study. They will be included if they 
are aged (1) 60 years or older, (2) have depressive symptoms of mild level or above, as 
indicated by scoring 5 or more in PHQ-9, and (3) can give informed consent to participate. 
The exclusion criteria are (1) known history of autism, intellectual disability, schizophrenia-
spectrum disorder, bipolar disorder, Parkinson’s disease, or dementia, (2) imminent suicidal 
risk, and (3) difficulty in communication. 
 
Intervention 
The MBCT protocol has been modified according to our pilot test with older people with 
depressive symptoms and suggestions from existing literature in teaching mindfulness to the 
older population. It consists of eight 2-hour weekly sessions, but the whole day retreat is 
excluded. Each session contains guided mindfulness exercises, feedback and discussion, 

homework review, and psychoeducation. The programme is conducted in Cantonese and led 
by either a MBCT teacher who received formal training organized by the Oxford 
Mindfulness Centre and the Hong Kong Centre for Mindfulness or a social worker supervised 
by the MBCT teacher. The care as usual group received usual service provided in DECC and 
ICCMW. 
 
Outcomes 
Demographic information will be collected at baseline. All outcome measures will be 
collected at baseline (T0), 8-week (T1: immediately after the intervention), and 12-week 
(T2). The questionnaires are self-administered but trained social workers or research 
assistants will provide support in completing the questionnaire when needed. The 
questionnaire is expected to last for roughly 30 minutes. 
 
Depressive symptoms will be assessed using the validated Chinese version of the Patient 
Health Questionnaire (PHQ-9; Wang et al., 2014). The 9-item instrument incorporates 
depression diagnostic criteria with other leading major depressive symptoms and rates the 
frequency of the symptoms on a four-point Likert scale ranging from 0 (not at all) to 3 
(nearly every day). PHQ-9 scores of 5-9, 10-14, 15-19, 20 and above represent mild, 
moderate, moderately severe, and severe depression. 
 
Anxiety symptoms will be assessed adopting the validated Chinese version of the 
Generalized Anxiety Disorder 7-item scale (GAD-7; Tong et al., 2016). The instrument taps 
on the most prominent diagnostic features for GAD and rates the frequency of symptoms on a 
four-point Likert scale, ranging from 0 (not at all) to 3 (nearly every day). GAD scores of 5, 
10, and 15 are taken as the cut off points for mild, moderate, and severe anxiety, respectively. 
 
Stress will be measured by the Chinese validated Perceived Stress Scale (PSS;Ng, 2013). The 
10-item instrument measures the degree to which an individual’s life situations are perceived 
as stressful. Respondents rate the frequency of how they felt a certain way during the last 
month on a Likert scale ranging from 0 (never) to 4 (very often). Higher scores indicate 
higher perceived stress. 
 
Mindfulness will be assessed using the Chinese validated Five Facet Mindfulness 
Questionnaire Short Form (FFMQ-SF; Hou et al., 2014). The 20-item instrument measures 

mindfulness by five domains: ‘observe’, ‘describe’, ‘acting with awareness’, ‘non‐judging’ 
and ‘non‐reactivity’. Respondents rate how much each statement reflects their lives on a 5-
point Likert scale ranging from 1 (never) to 5 (always). Higher scores indicate higher 
mindfulness. 
 
Psychological flexibility will be assessed using the 8-item abbreviated version of the 
Comprehensive assessment of Acceptance and Commitment Therapy processes (CompACT-
8; Morris, 2019), which has been translated into Chinese for use in the current study. The 
instrument measures psychological flexibility by three domains: ‘openness to experience’, 
‘valued action’, and ‘behavioural awareness’. Respondents rate the items on a 7-point Likert 
scale, ranging from 0 (strongly disagree) to 6 (strongly agree). Higher scores indicate greater 
psychological flexibility. 
 
Data analysis 
Baseline demographic information and outcome measures among the three groups will be 
compared using independent sample t-test. Mixed ANOVA will be used to compare outcome 
changes from T0 to T2 among the groups. Post-hoc analyses, such as pairwise comparisons, 
will be performed to identify groups with significant changes. All results will be reported 
with appropriate effect sizes, statistical significances, and confidence intervals. If the findings 
demonstrate intervention effects, a regression model will be conducted to examine whether 
psychological flexibility (change scores) are associated with lower depressive symptoms post 
intervention, while controlling for baseline depression. 
 
 

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