Wednesday December 3 2008
MBCT involves group sessions
“Buddhist meditation techniques can be just as effective at combating depression as medication,” the Daily Mail reported. It said a study has found that “mindfulness-based cognitive therapy (MBCT)” helps people to focus on the present rather than looking to past or future events. The newspaper continued that 15 months after an eight-week trial in people with long-term depression, 47% of those who had the therapy relapsed compared to 60% of those taking antidepressants.
This well-designed trial has been oversimplified by the news reports. The trial did not compare MBCT alone with antidepressants alone, but examined how relapse rates compared between combined MBCT and antidepressants and simply continuing with antidepressants. Therefore, MBCT cannot be said to be “as effective as medication”. It did, however, significantly reduce the amount of time the participants spent on antidepressants with the same relapse rates.
How comparable Buddhist meditation is to MBCT is also questionable, as the therapy involves a schedule of group education by a trained therapist, of which meditation is only a part.
Where did the story come from?
This research was carried out by Willem Kuyken and colleagues from the University of Exeter, the Peninsula Medical School, Kings College London, and Devon Primary Care Trust. The work was funded by the UK Medical Research Council. The study was published in the peer-reviewed, Journal of Consulting and Clinical Psychology.
What kind of scientific study was this?
In this randomised controlled trial, the researchers compared the effectiveness of cognitive therapy and ‘maintenance antidepressant’ medication with maintenance antidepressants alone for preventing relapse in people with recurrent depression. Maintenance antidepressants, means the continued use of antidepressants by people who have recovered following treatment for an episode of depression, but the drug is continued at a lower dose with the aim of preventing recurrence.
The therapy that the researchers were interested in was Mindfulness Based Cognitive Therapy (MBCT). It consists of classes involving group-based education in skills for easing distress and preventing the recurrence of depression. It aims to make people more aware of the thoughts and feelings that are counterproductive and contribute to depression and self-criticism. In this study, sessions included mindfulness practises (including yoga and meditation), teaching and discussion, weekly homework and a review of the participants’ experiences.
The researchers recruited 123 people over 18 years of age with recurrent depression who had been diagnosed using recognised criteria. All the participants had a history of at least three previous episodes of depression. They had received MBCT treatment for the previous six months and were now in either full or partial remission and taking antidepressant medication. The researchers excluded those with other psychiatric disorders or substance abuse.
The participants were randomly allocated to either continue on antidepressants alone or have an additional eight-week MBCT course. The course was made up of eight, once weekly two-hour sessions, and four follow-up sessions the next year.
The MBCT included support in decreasing or discontinuing antidepressants. This subject was initially raised with participants during weeks four to five of the regime. Participants were asked to consider decreasing or discontinuing their medication as soon as they and their physician deemed appropriate following MBCT and within six months of the course ending. An ‘adequate dose’ of MBCT was considered to be participation in four of the eight sessions. Medication adherence was monitored by the participants’ self-report at each three-month follow-up and scored on an adherence scale.
The participants were followed up at three-monthly intervals for 15 months. The main outcome that was examined was the relapse or recurrence of depression. Secondary outcomes including cost effectiveness and quality of life measures were also examined, but are not discussed here.
What were the results of the study?
Of the 123 participants, 85% completed the study, with exclusions/drop-outs balanced between the two treatment groups. There was generally good adherence to study protocol. The average number of days that antidepressants were taken was significantly shorter in the MBCT group (266 days) compared to those taking antidepressants alone (411 days). At the end of six months, 75% of the MBCT group had stopped taking antidepressants.
There was a general trend towards reduction in the risk of relapse/recurrence among those treated with MBCT and antidepressants compared to antidepressants alone. Over the total 15-month follow-up, 47% of the MBCT patients relapsed compared to 60% of those on antidepressants alone; however, this difference was not statistically significant.
What interpretations did the researchers draw from these results?
The authors conclude that in people with recurrent depression, MBCT in addition to antidepressants produces comparable outcomes to antidepressants alone in terms of relapse and recurrence rates, and therefore significantly reduces antidepressant use.
What does the NHS Knowledge Service make of this study?
This was a well-designed randomised controlled trial. It demonstrated that MBCT with antidepressants produces comparable outcomes to antidepressants alone in terms of relapse and recurrence rates. MBCT also has significant benefit in terms of helping to reduce antidepressant use.
However, this trial has been over simplified by the news report:
- This study was in a very select group of people. All had recurrent episodes of depression, for which they had recently received antidepressant treatment, and were currently receiving lower dose antidepressants. The results cannot therefore be generalised to people with depression who do not fulfil these specific criteria.
- Although there was a trend towards reduced relapse and recurrence rates with MBCT, this difference was not statistically significant when compared to taking antidepressants alone.
- The news incorrectly refers to the treatment as meditation. Although meditation was involved, this was only a part of the sessions, which involved a complex schedule of group education by a trained clinical psychologist or occupational therapist. This cannot be considered comparable to unsupervised meditation alone at home.
- As the researchers state, it is likely the participants had a greater adherence to their medication compared to what would be found in general practise due to the measures that the researchers took to enhance adherence.
- The trial could not be blinded and so the participants knew the nature of the trial when they chose to take part. This could have led to some people with an interest in psychological interventions to take part and therefore introduce some possible bias in the results (i.e. believing that MBCT was helping them).
This is the first trial to investigate what is a relatively new therapy (MBCT) and compare it to another active treatment (antidepressant medication). It should be noted, however, that the study only examined whether combined MBCT and antidepressants had a different outcome to taking antidepressants alone. It did not make a direct comparison between MBCT and antidepressants and so it cannot be concluded that one is more effective than the other. Further research into MBCT is required for a clearer picture.
Sir Muir Gray adds...
Good study and worth trying. Combine it with an extra 3,000 steps a day as walking is also effective for depression.
Links to the headlines
Meditation 'as effective as medication' in treating depression. Daily Mail, December 01 2008
Group therapy 'beats depression'. BBC News, December 01 2008
Links to the science
Kuyken W, Taylor RS, Barrett B, et al. Mindfulness based cognitive therapy to prevent relapse in recurrent depression. Journal of Consulting and Clinical Psychology 2008
Further readingThere are several reviews in the Cochrane Library that deal with treatments (including psychological) for depression, including the examples below. None specifically considers MBCT.
Lane DA, Chong AY, Lip GYH. Psychological interventions for depression in heart failure. Cochrane Database Syst Rev 2005, Issue 1
Dennis CL, Ross LE, Grigoriadis S. Psychosocial and psychological interventions for treating antenatal depression. Cochrane Database Syst Rev 2007, Issue 3
Jorm AF, Morgan AJ, Hetrick SE. Relaxation for depression. Cochrane Database Syst Rev 2008, Issue 4