Psychiatric Annals

CME Article 

Mindfulness as an Intervention for Depression

Christina A. Metcalf, MA; Alexandra K. Gold, MA; Brett J. Davis, BA; Louisa G. Sylvia, PhD; Cynthia L. Battle, PhD

Abstract

Mindfulness-based interventions (MBIs) for depression have become a frequent focus of research and clinical practice in recent decades. This article summarizes evidence regarding the use of MBIs in the prevention of depressive episodes and relief of depressive symptoms across different phases of depression. Much of the review is focused on evidence for mindfulness-based cognitive therapy (MBCT), a widely studied MBI for depression. There is strong evidence for MBCT in preventing depressive relapse among people with recurrent depression in remission. The evidence is less robust and consistent with respect to MBCT as a treatment for acute depression and treatment refractory depression. For some populations of people who are depressed, particularly those who prefer alternatives to antidepressant medications, MBIs may provide an adjunctive treatment option. Emerging work on MBIs suggests that online and other mobile health strategies may be used in the future. [Psychiatr Ann. 2019;49(1):16–20.]

Abstract

Mindfulness-based interventions (MBIs) for depression have become a frequent focus of research and clinical practice in recent decades. This article summarizes evidence regarding the use of MBIs in the prevention of depressive episodes and relief of depressive symptoms across different phases of depression. Much of the review is focused on evidence for mindfulness-based cognitive therapy (MBCT), a widely studied MBI for depression. There is strong evidence for MBCT in preventing depressive relapse among people with recurrent depression in remission. The evidence is less robust and consistent with respect to MBCT as a treatment for acute depression and treatment refractory depression. For some populations of people who are depressed, particularly those who prefer alternatives to antidepressant medications, MBIs may provide an adjunctive treatment option. Emerging work on MBIs suggests that online and other mobile health strategies may be used in the future. [Psychiatr Ann. 2019;49(1):16–20.]

Although psychiatric treatment guidelines for major depression have been established1 and several evidence-based psychological treatments for depression exist,2 the chronic and recurrent course of depression can nonetheless present significant treatment challenges. In the past 25 years, mindfulness-based interventions (MBIs) have been increasingly examined as treatments for depression across a range of populations, with a recent meta-analysis providing strong evidence that MBI effects are equivalent to those of existing evidence-based treatments for depression.3

Mindfulness, which forms the foundation of MBIs, may be defined as “paying attention in a particular way, on purpose, in the present moment, and nonjudgmentally.”4 Mindfulness is often cultivated through formal practices such as meditation. Kabat-Zinn5 recognized the potentially stress-reducing impact of mindfulness practice and developed one of the earliest MBIs—mindfulness-based stress reduction (MBSR). Kabat-Zinn5 initially developed MBSR to alleviate stress and suffering for patients with chronic pain. MBSR features mindfulness meditation training in the service of developing awareness capacities, the latter of which can be applied to both physical sensations and everyday life experiences.

Some years after the creation of MBSR, Segal et al.6 developed mindfulness-based cognitive therapy (MBCT) as a prophylactic intervention to prevent depressive relapse for people who were presently euthymic but had a history of depression. MBCT was innovative in its approach of combining mindfulness meditation techniques with cognitive-behavioral therapy to target reactivity to depressogenic thoughts and sensations. By bringing awareness to negative internal experiences, MBCT aimed to help people with recurrent depression prevent formerly depressogenic experiences from escalating into a depressive episode.6 Although the majority of research with populations of people who are clinically depressed has been with MBCT, other MBIs have been developed or adapted for this population, such as mindfulness-based relapse prevention and person-based cognitive therapy (PBCT) (Table 1).

Mindfulness-Based Interventions for Depression

Table 1.

Mindfulness-Based Interventions for Depression

In this article, we review the current empirical literature on MBIs for depression. Although several other therapies also incorporate elements of mindfulness (eg, Dialectical Behavior Therapy, Acceptance and Commitment Therapy), we focus our review on those MBIs in which mindfulness is the most central element of the treatment. We discuss evidence for MBIs that have been applied specifically for populations of people who are clinically depressed (Table 1) with emphasis on MBCT, given its history as a pioneering MBI for depression.

Evidence for MBCT and Other Mindfulness-Based Interventions in Treating Depression

Recurrent Depression

According to a meta-analysis of six randomized controlled trials, MBCT has a 34% relative risk reduction of depressive relapse compared to usual care or placebo for people with recurrent depression.7 In this same population, MBCT is associated with a significantly lower risk of depressive relapse over a 60-week period compared to both maintenance antidepressant medications and usual care, based on a recent meta-analysis of nine randomized controlled trials.8 Thus, MBCT appears to be a viable prophylactic alternative for people who are nonadherent to their maintenance antidepressant medication regimen or who have contraindications or preferences to avoid taking maintenance antidepressant medication (eg, pregnant women); however, the gold standard care for recurrent depression remains combination treatment of maintenance antidepressant medications—for those who responded well in the acute phase—and depression-focused psychotherapy.1

MBCT may be especially efficacious at preventing depressive relapse for certain subgroups. Specifically, data suggest that people with recurrent depression with more severe8 or fluctuating9 residual depressive symptoms experience greater effects from MBCT. Some research also indicates that MBCT is efficacious for people who have had three or more depressive episodes7 or have experienced childhood trauma.10

Because of this strong collective evidence, the National Institute for Health and Clinical Excellence recommends MBCT for people with a history of at least three episodes of depression.11

Acute Depression

Studies have examined whether MBCT can also serve as an efficacious treatment for acute depressive episodes. A large-scale trial (n = 205) evaluated the benefits of MBCT between two groups of people with recurrent depression: (1) those who were actively depressed and (2) those who were not currently in a depressive episode.12 Post-treatment reductions in depressive symptom severity were comparable for both groups.12 This evidence suggests that people experiencing current episodes of depression may benefit equally from MBCT as those whose depression has remitted.

In a smaller randomized controlled trial, MBCT was compared to sertraline in the treatment of acute depression (n = 43).13 The MBCT and sertraline groups did not have statistically different changes on clinician-assessed depressive symptom severity. However, the MBCT group had greater improvements in self-reported depressive symptom severity relative to the sertraline group. This provides preliminary indication that MBCT may be comparable to first-line antidepressant treatment for acute depression, although replication and larger trials are necessary.

A recent meta-analysis of 11 randomized controlled trials of various MBIs (MBCT = 5, MBSR = 2, PBCT = 1, MBIs = 2, and mindfulness-based yoga = 1) applied to acute depressive episodes indicated that, overall, MBIs reduced depressive symptoms from pre- to postintervention.14 Depressive symptoms were not statistically different between MBIs and control groups at follow-up.14 However, follow-up analyses could only be conducted with a subset of studies (4 of 11); thus, these findings should be interpreted with caution.

Although these studies provide some evidence regarding the application of MBCT and other MBIs with people experiencing acute depression, we note that MBCT was not originally designed to be implemented with people in a depressive episode.6 Some authors have proposed that without adequate clinical monitoring, MBIs may be contraindicated for certain clinical presentations.15 Other authors have cited potential problems such as difficulty engaging with mindfulness interventions in the presence of severe symptoms that may interfere with motivation and concentration.16 Nonetheless, application of MBCT and other MBIs to populations with acute depression symptoms is increasingly frequent and evidence is beginning to accrue with respect to the safety and efficacy of these interventions with populations of people who are acutely depressed.

Treatment Refractory Depression

The few MBCT trials conducted with patients with treatment refractory depression (ie, depression nonresponsive to effective interventions) have yielded promising findings. In two randomized controlled trials, MBCT participants experienced greater improvements in depressive symptom severity and quality of life relative to those in a psychoeducation group (n = 43)17 and treatment as usual (n = 106).16 Although this outcome was only found among those who completed MBCT in the second randomized controlled trial, remission proportions (41.5% vs 21.6%) were superior in the MBCT group relative to treatment as usual.18

Additional Considerations of Mindfulness-Based Interventions

Stand-Alone Meditation Practices

Meditation practices that are performed outside of the context of a larger therapeutic framework reflect the real-world behavior of many practitioners (eg, a daily routine of mindfulness meditation for 10–15 minutes each morning). Preliminary meta-analytic evidence suggests that these types of stand-alone meditation practices provide small to medium effects on depressive symptom relief relative to inactive controls.19 Heterogeneous, primarily nonclinical student samples limit generalizability of these findings, although initial data are promising.

Online MBIs

Online MBIs could be a promising strategy to treat depression and improve access to care. Quasi-experimental data found that people with a history of depression who received Mindful Mood Balance, a digital version of MBCT, reported a significant reduction in depressive symptom severity relative to propensity matched case-controls.18 In addition, participants found the program to be acceptable.20 Data from a larger randomized controlled trial of Mindful Mood Balance is forthcoming. Intervention efficacy and acceptability remain important factors to examine in this growing area.

In addition to online interventions developed in a research context, there are many commercially available, free, or inexpensive mindfulness mobile applications (“apps”). As an indication of the popularity of mindfulness, current reports suggest that such apps have been downloaded by millions of people.21 Although it is common for such applications to claim to be “backed by research,” many mindfulness apps currently lack an empirical foundation. Thus, the safety and efficacy of these apps in populations of people who are clinically depressed have not been formally studied and caution is warranted regarding use of mindfulness apps in clinical practice.

Recommendations Regarding Mindfulness Practice

MBIs vary in the amount of mindfulness practice that is recommended between treatment sessions. Examples of home practice recommendations include practicing a 45-minute body scan meditation (MBCT and MBSR) or practicing the 3-minute breathing space 3 times a day (MBCT) for 6 days of the week. A meta-analysis of 43 MBCT and MBSR trials for healthy and clinical populations suggests that, on average across 47 trials, participants complete 64% of the assigned mindfulness practices—the equivalent of 30 minutes of practice 6 days per week.22 Notably, the amount of home practice in 27 trials was significantly correlated with psychological intervention outcomes, including reduced depressive symptom severity reduction postintervention in this meta-analysis.22 The majority of MBI trials do not report home practice, and most include home practice only during the intervention and not practice sustained after the intervention. These limitations make it difficult to determine how much practice is needed during MBIs to maintain benefits of intervention after discontinuation of the intervention. Randomized controlled trials evaluating effects of home practice dose or length of intervention would aid in answering this question.23

Practitioner Training

Various institutions offer training in MBIs, most frequently providing trainings in MBSR and MBCT. Because MBCT has the most empirical support among MBIs as an intervention for depression, practitioners working with populations of people who are depressed may be interested in receiving training to deliver MBCT. Prerequisites to become trained as an MBCT instructor include completion of accredited counseling or psychotherapy training, experience treating mood disorders, training in cognitive-behavioral therapy or another evidence-based treatment for depression, group therapy experience, and a personal mindfulness practice.6 Certification programs vary in requirements but often include leading a MBCT course under the supervision of a mentor (see http://accessmbct.com for a list of organizations that provide certification programs).

Summary and Conclusion

Mindfulness is increasingly a topic of research, clinical practice, and popular press, and its popularity has grown at an almost exponential rate over the past 20 years. In fact, some researchers have expressed caution regarding conceptualizing mindfulness as a “panacea” to be applied across a range of conditions in the absence of proper empirical evidence.23

Although caution is warranted as the field expands its attention to mindfulness interventions, enthusiasm for MBIs is understandable in light of the strong evidence base to date. Current evidence supports the use of MBCT in preventing depressive relapse in populations with recurrent depression. A small body of evidence indicates MBCT may be efficacious at reducing depressive symptom severity among people in an acute episode. Initial evidence indicates MBCT for treatment-resistant depression may reduce depressive symptoms for those who receive a full dose of treatment.

Given increased attention to MBIs in both research and clinical arenas, the next years ought to advance knowledge about populations of people who are depressed for whom MBIs are indicated—including patient subgroups who may especially benefit from MBIs—and about how MBIs perform relative to evidence-based treatments. Moreover, increased research regarding the efficacy of stand-alone meditation practices and digital forms of mindfulness delivery outside of the context of a larger intervention in the reduction of depression symptom severity are likely. Attention to issues of access to care and dissemination in upcoming years will influence clinical practice, particularly with respect to interventions delivered by Internet and mobile applications.

References

  1. American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder. 3rd ed. http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf. Accessed December 5, 2018.
  2. Society of Clinical Psychology. Research-supported psychological treatments. https://www.div12.org/diagnosis/depression/. Accessed December 11, 2018.
  3. Goldberg SB, Tucker RP, Greene PA, et al. Mindfulness-based interventions for psychiatric disorders: a systematic review and meta-analysis. Clin Psychol Rev. 2018;59:52–60. doi:. doi:10.1016/j.cpr.2017.10.011 [CrossRef]
  4. Kabat-Zinn J. Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life. 1st ed. New York, NY: Hyperion; 1994.
  5. Kabat-Zinn J. An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: theoretical considerations and preliminary results. Gen Hosp Psychiatry. 1982;4(1):33–47. doi:10.1016/0163-8343(82)90026-3 [CrossRef]
  6. Segal ZV, Williams JMG, Teasdale JD. Mindfulness-Based Cognitive Therapy for Depression: A New Approach to Preventing Relapse. New York, NY: Guilford Press; 2002.
  7. Piet J, Hougaard E. The effect of mindfulness-based cognitive therapy for prevention of relapse in recurrent major depressive disorder: a systematic review and meta-analysis. Clin Psychol Rev. 2011;31(6):1032–1040. doi:. doi:10.1016/j.cpr.2011.05.002 [CrossRef]
  8. Kuyken W, Warren FC, Taylor RS, et al. Efficacy of mindfulness-based cognitive therapy in prevention of depressive relapse: an individual patient data meta-analysis from randomized trials. JAMA Psychiatry. 2016;73(6):565. doi:. doi:10.1001/jamapsychiatry.2016.0076 [CrossRef]
  9. Segal ZV, Bieling P, Young T, et al. Antidepressant monotherapy vs sequential pharmacotherapy and mindfulness-based cognitive therapy, or placebo, for relapse prophylaxis in recurrent depression. Arch Gen Psychiatry. 2010;67(12):1256–1264. doi:. doi:10.1001/archgenpsychiatry.2010.168 [CrossRef]
  10. Williams JMG, Crane C, Barnhofer T, et al. Mindfulness-based cognitive therapy for preventing relapse in recurrent depression: a randomized dismantling trial. J Consult Clin Psychol. 2014;82(2):275–286. doi:. doi:10.1037/a0035036 [CrossRef]
  11. National Institute for Health Care and Excellence. Depression in adults: recognition and management. http://guidance.nice.org.uk/CG90/QuickRefGuide/pdf/English. Accessed December 5, 2018.
  12. van Aalderen JR, Donders ART, Giommi F, Spinhoven P, Barendregt HP, Speckens AEM. The efficacy of mindfulness-based cognitive therapy in recurrent depressed patients with and without a current depressive episode: a randomized controlled trial. Psychol Med. 2012;42(05):989–1001. doi:. doi:10.1017/S0033291711002054 [CrossRef]
  13. Eisendrath SJ, Gillung E, Delucchi K, et al. A preliminary study: efficacy of mindfulness-based cognitive therapy versus sertraline as first-line treatments for major depressive disorder. Mindfulness. 2015;6(3):475–482. doi:. doi:10.1007/s12671-014-0280-8 [CrossRef]
  14. Wang Y-Y, Li X-H, Zheng W, et al. Mindfulness-based interventions for major depressive disorder: a comprehensive meta-analysis of randomized controlled trials. J Affect Disord. 2018;229:429–436. doi:. doi:10.1016/j.jad.2017.12.093 [CrossRef]
  15. Van Dam NT, van Vugt MK, Vago DR, et al. Mind the hype: a critical evaluation and prescriptive agenda for research on mindfulness and meditation. Perspect Psychol Sci. 2018;13(1):36–61. doi:. doi:10.1177/1745691617709589 [CrossRef]
  16. Strauss C, Cavanagh K, Oliver A, Pettman D. Mindfulness-based interventions for people diagnosed with a current episode of an anxiety or depressive disorder: a meta-analysis of randomised controlled trials. PLoS ONE. 2014;9(4):e96110. doi:. doi:10.1371/journal.pone.0096110 [CrossRef]
  17. Chiesa A, Castagner V, Andrisano C, et al. Mindfulness-based cognitive therapy vs. psycho-education for patients with major depression who did not achieve remission following antidepressant treatment. Psychiatry Res. 2015;226(2–3):474–483. doi:. doi:10.1016/j.psychres.2015.02.003 [CrossRef]
  18. Cladder-Micus MB, Speckens AEM, Vrijsen JN, T Donders AR, Becker ES, Spijker J. Mindfulness-based cognitive therapy for patients with chronic, treatment-resistant depression: a pragmatic randomized controlled trial. Depress Anxiety. 2018;35(10):914–924. doi:. doi:10.1002/da.22788 [CrossRef]
  19. Blanck P, Perleth S, Heidenreich T, et al. Effects of mindfulness exercises as stand-alone intervention on symptoms of anxiety and depression: Systematic review and meta-analysis. Behav Res Ther. 2018;102:25–35. doi:. doi:10.1016/j.brat.2017.12.002 [CrossRef]
  20. Dimidjian S, Beck A, Felder JN, Boggs JM, Gallop R, Segal ZV. Web-based Mindfulness-based Cognitive Therapy for reducing residual depressive symptoms: An open trial and quasi-experimental comparison to propensity score matched controls. Behav Res Ther. 2014;63:83–89. doi:. doi:10.1016/j.brat.2014.09.004 [CrossRef]
  21. Tlalka S. The trouble with mindfulness apps. https://www.mindful.org/trouble-mindfulness-apps/. Accessed December 5, 2018.
  22. Parsons CE, Crane C, Parsons LJ, Fjorback LO, Kuyken W. Home practice in mindfulness-based cognitive therapy and mindfulness-based stress reduction: a systematic review and meta-analysis of participants' mindfulness practice and its association with outcomes. Behav Res Ther. 2017;95:29–41. doi:. doi:10.1016/j.brat.2017.05.004 [CrossRef]
  23. Dimidjian S, Segal ZV. Prospects for a clinical science of mindfulness-based intervention. Am Psychol. 2015;70(7):593–620. doi:. doi:10.1037/a0039589 [CrossRef]
  24. Kabat-Zinn J. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. New York, NY: Delta; 1990.
  25. Chadwick P. Person-Based Cognitive Therapy for Distressing Psychosis. Chichester, UK: John Wiley & Sons Ltd; 2006. doi:10.1002/9780470713075 [CrossRef]
  26. Bowen S, Chawla N, Marlatt G. A.Mindfulness-Based Relapse Prevention for Addictive Behaviors: A Clinician's Guide. London, UK: Guilford Press; 2010.

Mindfulness-Based Interventions for Depression

Intervention Features Mindfulness-Based Stress Reduction Mindfulness-Based Cognitive Therapy Person-Based Cognitive Therapy Mindfulness-Based Relapse Prevention
Intervention format Group Group Group Group
Intervention length 8 weeks 8 weeks 12 weeks 8 weeks
Session duration 2–2.5 hours ∼2 hours 1.5 hours 2 hours
Half-day meditation retreat Yes Yes No No
Structure of home practice Up to 45 minutes per day of formal and informal mindfulness practices Up to 45 minutes per day of formal and informal mindfulness practices Daily practice encouraged using 10- and 3-minute formal meditations provided Formal and informal meditation exercises and daily mood and craving tracking forms
Examples of home practice exercises 45-minute body scan: progressively focusing attention on each part of the body 30-minute sitting meditation: focusing attention on breath, body, sounds, thoughts, and open awareness 10-minute sitting meditation: focusing attention on breath, body, and open awareness 10-minute walking meditation: focusing attention on the sensations of walking
Cognitive-behavioral therapy element No Yes Yes (more than MBCT) Yes
Authors

Christina A. Metcalf, MA, is a Clinical Psychology Resident, Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University; and a Doctoral Candidate, Department of Psychology and Neuroscience, University of Colorado Boulder. Alexandra K. Gold, MA, is a Doctoral Student, Department of Psychological and Brain Sciences, Boston University. Brett J. Davis, BA, is a Clinical Research Coordinator, Dauten Family Center for Bipolar Treatment Innovation, Department of Psychiatry, Massachusetts General Hospital. Louisa G. Sylvia, PhD, is an Associate Professor, Massachusetts General Hospital, Harvard Medical School. Cynthia L. Battle, PhD, is an Associate Professor, Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University.

Address correspondence to Louisa G. Sylvia, PhD, Department of Psychiatry, Massachusetts General Hospital, 50 Staniford Street, Boston, MA 02114-2517; email: lsylvia2@mgh.harvard.edu.

Grant: A.K.G. discloses a grant (F31MH116557) received from the National Institute of Mental Health.

Disclosure: Louisa G. Sylvia receives royalties from New Harbinger Publications, owns stock in Concordant Rater Systems, and is a consultant for United Biosource Corporation and Clinatra. The remaining authors have no relevant financial relationships to disclose.

10.3928/00485713-20181205-01

Sign up to receive

Journal E-contents