Mindfulness‐based cognitive therapy for relapse prophylaxis in mood disorders
Authors: Zindel V. Segal, Le‐Anh Dinh‐Williams
Journal: World Psychiatry (2016)

Relapse and recurrence are common and debilitating aspects of major depressive disorder. Furthermore, the risk of developing a chronic course of illness increases with each successive episode and, even among patients who achieve clinical remission, residual depressive symptoms are commonly reported. Maintenance antidepressant monotherapy is effective as long as it is continued, yet in practice side effect burden, tachyphylaxis, safety concerns and premature discontinuation can combine to push non-compliance rates as high as 40%1. Alternatives to long-term antidepressant monotherapy, especially those addressing mood outcomes in a broader context of well-being, may appeal to patients wary of continued intervention. Studies have shown that, for a number of recovered depressed patients, mild dysphoria activates patterns of ruminative self-focus that can maintain and intensify the dysphoric state2. The task of relapse prevention, therefore, can be to pre-empt the establishment of these dysfunctional patterns. Mindfulness-based cognitive therapy (MBCT) was designed to achieve this aim by teaching formerly depressed patients how to be more aware of negative thoughts and feelings at times of potential relapse/recurrence, and to respond to those thoughts and feelings in ways that allow them to disengage from treating them as facts or identifying them with one's sense of self-worth. In order to increase its potential cost-efficiency, this strategy was designed as a group skills training approach rather than as an individual psychological therapy. The MBCT program3 integrates the practice of mindfulness meditation with the tools of cognitive therapy (CT). A significant component consists of formal meditation exercises such as the body scan, sitting and walking meditations, as well as mindful movement in the form of gentle yoga and stretching. The generalization of mindfulness skills to aspects of everyday life is supported through informal practices such as mindful eating; noticing body sensations, affect and thoughts during pleasant and unpleasant experiences; as well as taking a mindful approach to aspects of one's daily routine which are typically completed on "automatic pilot". A novel aspect is the addition of the "three-minute breathing space", a brief centering meditation exercise designed for use during times of emotional challenges or stress. The CT components include psychoeducation about depressive symptoms and discussion of the cognitive model, including automatic thoughts, and how thoughts are impacted by situations and moods. Participants are also encouraged to identify activities that generate a sense of pleasure or mastery, to be implemented during times of low mood. The first four sessions of the 8-week program provide a framework for patients to learn to approach present moment experiences in a non-judgmental way. This message is conveyed tacitly through the formal meditation practices, which promote learning to focus (and re-focus as needed) attentional resources to anchors such as the breath and bodily sensations. This process facilitates the ability to observe the structure of one's internal experience as it arises in a given moment, with the intention not to judge the content, knowing that the "judgment" or "reaction" component of one's experience can be more detrimental than the raw experience itself. The skill to deconstruct experience in this way is then applied to depression, using exercises from CT that underscore how reactions to given situations can be colored by thought and interpretation. Thus, the understanding is cultivated that thoughts are not facts, and that thoughts, feelings and body sensations are often transient and dynamic aspects of experience. In the fourth session, psychoeducation specific to depressive illness is formally introduced. In addition to information surrounding the nature of commonly discussed depressive symptoms (neurovegetative and mood), the types of negative thinking that are associated with depression are explored. Thus, individuals are encouraged to build upon their ability to detect the early warning signs of relapse, and to identify their unique "relapse signatures". The latter four sessions of the program emphasize the development of a thoughtful and flexible response style for dealing with the signs and symptoms of relapse. The theme "thoughts are not facts" is the focus in the sixth session, which employs a CT exercise to illustrate how readily mood can impact thoughts. In the seventh session, relapse prevention strategies drawn from CT are discussed. The groundwork is laid for an individualized relapse prevention plan for each participant that includes the involvement of family members in an early warning system, keeping a list of highly effective pleasure and mastery activities, as well as noting familiar automatic thoughts and cognitive themes that have preceded relapse in the past. Randomized controlled trials evaluating MBCT efficacy have found it to be superior to treatment as usual4 and to perform as well as continuation antidepressant pharmacotherapy5 in preventing depression relapse/recurrence. These outcomes are supported by a meta-analysis6 reporting a relative risk reduction of 34% for those receiving MBCT. Of particular interest is that patients with recurrent depression (three or more past episodes) are more likely to benefit from treatment than those who have experienced only one or two episodes of illness. In a recent study of 424 patients who were on a therapeutic dose of maintenance antidepressant pharmacotherapy, one half continued on this therapeutic regimen, while the other half was randomized to MBCT and discontinued their medication7. There were no differences in relapse/recurrence rates between the two groups (47% antidepressant vs. 44% MBCT) over a two year follow-up. These findings, among others, have supported the adoption of MBCT within a broader matrix of mental health treatments for mood disorders. For example, the UK National Institute of Health and Care Excellence (NICE) Guidelines for preventing depressive recurrence include a recommendation to provide MBCT for patients who have experienced more than two prior depressive episodes. It is surprising that relatively little is known about how MBCT prevention effects occur. According to one recent review, the most reliable pattern of change predicting outcome in MBCT is bivariate in nature: increases in mindfulness and metacognitive awareness of emotions are matched by decreases in rumination and worry8. These findings are consistent with qualitative interviews of patients, who describe developing a different type of relationship to sad moods, rather than their elimination altogether. Expanding MBCT's public health impact will require addressing two outstanding issues. First, MBCT faces challenges to dissemination that are common to all psychotherapeutic treatments, including service costs, waiting lists, travel time and a shortage of trained therapists. Web-based psychological interventions offer one solution to many of these barriers. Mindful mood balance (MMB) is an online treatment which provides high fidelity and widespread access to the core benefits of the in-person MBCT program9. Second, a clear understanding of the type and amount of practice required to achieve positive clinical outcomes still eludes the field. Perhaps the most reliable finding is that program benefits have been associated with formal (30-40 min) compared to informal (3-5 min) mindfulness practice10. As the evidence base evolves, it can be expected that the establishment of competency standards for clinicians working within the MBCT model will yield more targeted recommendations regarding optimum levels of practice density. Zindel V. Segal, Le-Anh Dinh-Williams Program in Psychological Clinical Science, University of Toronto Scarborough, Toronto, Ontario, Canada