Mindfulness-based cognitive therapy (MBCT): Recent research and developments
Katharine Rimes (Convener & Chair)
Institute of Psychiatry, King's College London
Mindfulness-based cognitive therapy (MBCT) is a group-based intervention applying cognitive approaches within a mindfulness framework. The original form of the intervention was aimed at reducing the risk of relapse in people with a history of depression, for which it has been shown to be effective compared to usual care. The approach has subsequently been adapted for various other conditions and the papers in this symposium present recent research and developments in MBCT. The first paper by Ed Watkins presents results from a randomised controlled trial for people with recurrent depression who have been treated with antidepressants, comparing maintenance antidepressants with MBCT plus support to taper/discontinue antidepressants. He will also discuss mediators of outcome. The second paper by Katharine Rimes describes a new use of MBCT, for the treatment of people with chronic fatigue syndrome who have already undergone standard cognitive behaviour therapy but who are still experiencing excessive fatigue. Results from a pilot randomised controlled study comparing this form of MBCT to waiting list will be presented. Another new form of MBCT will be described by Christina Surawy, who will present a theoretical overview of how mindfulness approaches may help people with health anxiety. Lastly, Freda McManus will present preliminary results from an RCT comparing MBCT with usual care for people with severe health anxiety (hypochondriasis).
Paper 1: Mindfulness-based cognitive therapy for relapse prevention in recurrent depression: Process-outcome analysis
Emily Holden on behalf of Exeter MBCT Trial Team
(PI: Willem Kuyken), University of Birmingham
Objectives: For people at risk of depressive relapse, mindfulness-based cognitive therapy (MBCT) has an additive benefit to usual care. This study asked if among patients with recurrent depression and treated with antidepressants MBCT is comparable to maintenance antidepressant treatment in (1) preventing depressive relapse, (2) key secondary outcomes and (3) cost effectiveness. The study also examined whether change in mindfulness, rumination, and compassion were mediators of the treatment outcome.
Design: The study design was a parallel two group randomised controlled trial comparing maintenance antidepressants (N = 62) with MBCT plus support to taper/ discontinue antidepressants (N = 61).
Methods: Participants were recruited from GP practices. Participants were individuals with a history of at least three previous episodes of major depression, who were not currently depressed. Diagnostic status was assessed with the SCID. Symptom levels were assessed with the BDI and HAMD. Levels of potential mediators were assessed with self-report measures including the Kentucky Index of Mindfulness (KIMS); Self-Compassion Scale (SCS) and brooding subscale of the Response Styles Questionnaire. Participants were followed up for 1 year at 3 month intervals with assessments made by researchers blind to treatment allocation.
Results: Relapse/recurrence rates over 15-month follow-ups in MBCT were 47 per cent, compared with 60 per cent in the maintenance antidepressant group (Hazard ratio: 0.65, 95 per cent CI: 0.40 to1.01). MBCT was more effective than maintenance antidepressants in reducing residual depressive symptoms, psychiatric co-morbidity and in improving quality of life in the physical and psychological domains. The data analytic strategy for testing moderation and mediation advocated by Kraemer et al. was used, testing each potential moderator and mediator in turn. For the mediation analyses a linear regression model is built, adding treatment group (m-ADM or MBCT, dummy coded 0/1), the hypothesised mediator (change in the mediator variable from baseline to post-treatment) and the treatment by mediator interaction (i.e., the product of the two main effects). Both changes in mindfulness and self-compassion across treatment mediated MBCT’s treatment effects on residual depressive symptoms at 15 months follow-up. Further process-outcome analyses will be reported.
Conclusions: MBCT appears to be of equivalence to maintenance antidepressants as a relapse prevention strategy over 1 year. These findings provide preliminary support for the idea that MBCT is effective through some of the hypothesised mechanisms.
Paper 2: Can mindfulness-based cognitive therapy (MBCT) help people with chronic fatigue syndrome still experiencing excessive fatigue after a course of standard cognitive behaviour therapy?
Katharine Rimes, Institute of Psychiatry, King's College London & Janet Wingrove, South London and Maudsley NHS Trust
Objectives: Cognitive behaviour therapy (CBT) is an effective treatment for chronic fatigue syndrome (CFS), but a recent systematic review indicated that only about 40–50 per cent people show clinical improvement. This pilot study was undertaken to investigate whether mindfulness-based cognitive therapy (MBCT) would offer benefits to people with CFS who are still experiencing excessive fatigue after having already completed a course of standard CBT. The programme was based on the overall structure of the Segal et al. programme, but modified to be applicable for people with chronic fatigue syndrome. The main hypothesis was that people who underwent a course of MBCT would report lower levels of fatigue than people on the waiting list for MBCT, after controlling for baseline fatigue levels. Questionnaire measures of factors that may be involved in the process of change were also administered to gain preliminary information about possible treatment mechanisms.
Design: A pilot randomised controlled trial was conducted to compare the effects of MBCT with being on a waiting list for the same intervention.
Methods: Participants who had previously completed a course of standard CBT for CFS and were still experiencing excessive fatigue were invited to take part in the study. Current major depression was an exclusion factor. Participants were randomly allocated to either MBCT or waiting list. Sixteen people in the MBCT group and nineteen in the waiting list group completed questionnaires before and after training and at two month follow-up, to assess fatigue, disability, beliefs about emotions, cognitive and behavioural responses to symptoms, mindfulness, self-compassion, depression, anxiety and perceived stress. For a selection of the measures, mid-treatment ratings were also taken to provide further information about possible processes of change. The intervention was delivered in two separate groups.
Results: Analysis of covariance controlling for baseline fatigue indicated that after MBCT, participants reported lower levels of fatigue than people on the waiting list, with effects being maintained at two month follow-up. Some of the measures of hypothesised process factors, such as beliefs about emotions, self-compassion and ‘all-or-nothing’ behaviour also showed significant group differences, as well as signs of change at mid-treatment.
Conclusions: MBCT is a promising intervention for people with CFS who still experience excessive fatigue after a course of standard CBT. The study provides preliminary indications of possible mechanisms of change that could be investigated in future research.
Paper 3: What has mindfulness got to offer people with health anxiety?
Christina Surawy, University of Oxford & Lupina Foundation
Objective: To consider the question of why might MBCT be of value to people with health anxiety and how to design an eight-week programme specifically for people with this problem.
Issues considered: The aims and intentions of mindfulness training are essentially to enable people to see clearly the contents and processes which occur in their minds and bodies and to practice relating to them with equanimity. For people with health anxiety, preoccupations with body sensations, thoughts about the future and unpleasant emotions such as worry frequently lead to behaviours designed to suppress or eradicate these difficult experiences. Mindfulness training can help people to approach even difficult experiences with a friendly interest rather than using strategies to get rid of them. Also, the practice can help to bring into focus aspects of life which may be sidelined and which could be rewarding. The paper discusses why might MBCT be of value in this population, and describes how we are applying the approach in an 8-week course.
Conclusions: Based on cognitive accounts of health anxiety, there are theoretical reasons why mindfulness training may be helpful for people with this problem. The traditional eight-week programme can be adapted for the needs of this population.
Paper 4: A randomised controlled trial of MBCT for severe health anxiety (hypochondriasis): Interim results
Freda McManus, Oxford Cognitive Therapy Centre & University of Oxford, Mark J.M.G. Williams, Christina Surawy & Kate Muse, University of Oxford
Objectives: Severe health anxiety (hypochondriasis) is a common and disabling problem with high costs for sufferers, their families and health care providers alike. Previous attempts to treat health anxiety have met with limited success. Whilst it has been possible to demonstrate that CBT is an effective treatment for health anxiety, it has been difficult to establish the superiority of CBT over other psychological treatments in the treatment of health anxiety, particularly at longer-term follow-up. Furthermore, the reported effect sizes of CBT for health anxiety are not as large as those reported for other anxiety disorders. The relative lack of efficacy of CBT for health anxiety in comparison to other anxiety disorders may be in part due to the inherent difficulty in disconfirming patients’ feared predictions in health anxiety in comparison to other anxiety disorders. Because health anxious patients’ fears tend to have a much longer time course (e.g., developing cancer and dying in 5 years’ time as compared to, for example, the panic patient who fears he will pass out in the next ten minutes) they are much harder to disconfirm via the use of standard CBT methods. If there is, as the literature suggests, an equivalence of effect amongst psychological treatments for health anxiety then patient preference, comparative cost-effectiveness, and the ease of dissemination of the approach become important factors in determining the treatment of choice for health anxiety. Hence, treatments that are acceptable to patients, which can be carried out in cost-effective ways (e.g., group formats) and which can be effectively disseminated into routine clinical practice warrant further investigation. For these reasons we have investigated the applicability of mindfulness-based cognitive therapy (MBCT) to the treatment of severe health anxiety.
Design: A randomised controlled trial of MBCT vs treatment as usual (TAU). Methods: Sixty patients will be randomly allocated to either MBCT or TAU and followed up for one year after treatment. Assessment is via blind structured clinical interview and self-report on standardized measures.
Results: The MBCT and TAU groups will be compared on measured of health anxiety, general anxiety, depression and life functioning. Changes in diagnostic status will be compared across the groups. In addition, data from a qualitative study of patients’ experiences of the treatment will also be reported.
Conclusions: The findings of the study will be discussed in terms of both the efficacy of MBCT for hypochondriasis and its acceptability to health anxious patients.