A convergent parallel mixed methods investigation into the role of mindfulness in moderate to severe, persistent depression

Introduction The construct of mindfulness, a non-judgemental awareness of present moment experience, has been increasingly recognised in recent years as being positively associated with psychological wellbeing. In light of accumulating evidence pointing to an inverse relationship between mindfulness and a wide range of psychological distress outcomes, including depression, mindfulness has been increasingly incorporated into modern psychotherapies and healthcare services, and the importance of psychometrically quantifying the construct of mindfulness has become paramount. One of the most reliable and valid instruments developed for the assessment of different aspects of dispositional mindfulness is the Five Facets Mindfulness Questionnaire (FFMQ; Baer et al., 2006), which measures the dimensions of ‘Nonreact’, ‘Observe’, ‘Actaware’, ‘Describe’ and ‘Nonjudge’. However, the psychometric properties of the FFMQ are yet to be tested in clinically depressed individuals with substantial levels of persistent depression. Moreover, there has been no attempt to date to qualitatively explore the experience of mindfulness in those naive to mindfulness training in order to further determine its role in the management of depressive symptomatology. Methods Using a convergent parallel mixed methods design, the present study investigated the psychometric properties of the FFMQ in a sample of 187 adults with moderate to severe, persistent depression recruited from a large National Institute for Health Research funded randomised controlled trial (Morriss et al., 2010). Internal consistency and test retest reliability (at six months) were assessed and construct validity was examined with confirmatory factor analyses (CFA) and by statistically correlating the FFMQ to measures of depression, and mindfulness-related constructs; self-compassion, rumination and experiential avoidance. In addition, using semi-structured interviews, a subset of 20 participants were interviewed to explore their experience of depression and perceived associated changes in dispositional mindfulness. Interview data were analysed using qualitative thematic analysis Results Results of psychometric testing supported the internal consistency and test-retest reliability of the FFMQ. CFA indicated that both a correlated and hierarchical model fit the data acceptably, with results slightly favouring the correlated model. Contrary to predictions however, CFA showed that the facet ‘Nonjudge’ did not load onto an overarching factor of mindfulness. ‘Nonjudge’ was further found to show a non-significant correlation with depression and only a weak correlation with experiential avoidance and rumination. Thematic analysis of the qualitative data indicated that participants’ ability to retain a non-judgmental awareness of present moment experience deteriorates with the onset of depressed mood. This seemed to occur automatically and deliberately as a strategy to avoid contact with painful internal and external experiences, hence indicating a self-inflicted process of awareness restriction that appears to be a contributing factor to the maintenance of depression Conclusions Contrary to what has been previously understood, albeit with different populations, the factor structure of the FFMQ alters in the face of moderate to severe, persistent depression, with the facet ‘Nonjudge’ no longer forming a component of this construct. Therefore, a four factor model (excluding Nonjudge) is proposed for use in this population. The qualitative data has provided possible explanations for the idiosyncratic behaviour of the facet Nonjudge in people experiencing moderate to severe, persistent depression. Both data sets converge to confirm an inverse relationship between mindfulness and depression. Moreover, the qualitative data suggests that deliberate efforts to restrict facets of mindfulness represents a conscious attempt to manage negative experiences that paradoxically maintains and aggravates depression. Future research following-up participants with substantial levels of depression into remission may shed further light on the role of mindfulness in moderate to severe, persistent depression