Mindfulnessbased cognitive therapy for prevention of relapse recurrence in depression

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Mindfulness-based cognitive therapy for
prevention of relapse/ recurrence in depression

• Mark Williams
• University of Oxford
• Department of Psychology

Collaborators Zindel Segal, John Teasdale,
Judith Soulsby
Plus Slides from http//obssr.od.nih.gov/BSSRCC/M
indfulness/Zindel20Segal.pdf
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Mindfulness Based Cognitive Therapy

• Background
• Relapse and recurrence in depression
• Previous approaches to maintenance of treatment
  gains
• Modelling cognitive risk
• Development of MBCT
• Outcome evidence

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Depression recurrence

• Lifetime risk estimates 6-17
• For 5-10, full episode persists 2 years
• For 20-25, only partially recovery between
  episodes
• More than 50 who do recover will have at least
  one further episode
• Those with history of 2 or more episodes have
  70-80 chance of recurrence

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Previous approaches - 1

• Continue treatment beyond initial response
• antidepressant medication
• continue patients at dosage used to achieve
  remission
• psychotherapies
• Interpersonal Psychotherapy (IPT-M)
• Cognitive Behaviour Therapy (CBT)

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Previous approaches - 2

• Use acute treatments that give long-term
  protection
• best evidence is when CBT has been used in acute
  phase

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Questions

• How does CBT reduce risk?
• What are the psychological factors that make
  someone high risk for relapse and recurrence?
• Can we teach these skills to patients after they
  have recovered using antidepressants?

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Cognitive risk factors

• CBT Model Dysfunctional attitudes represent
  high risk
• I cannot find happiness without being loved by
  another person
• I should be happy all the time
• Turning to someone else for advice or help is an
  admission of weakness
• BUT Most show Dysfunctional Attitudes get back
  to normal when patient recovered
• Later research Reactivation of Content and
  Process

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Differential Activation
Hopelessness
Negative Self-referent Thinking
Memory Bias
Depressed Mood
Dysfunctional Attitude
Fatigue
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Differential Activation
Hopelessness reduced
Self-referent Thinking normal
Memory Unbiased
Non-Depressed
Attitudes Normal
Fatigue normal
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Effect of Mood Challenge
Hopelessness
Hopelessness
Negative Self-referent Thinking
Negative Self-referent Thinking
Memory Bias
Memory Bias
Depressed Mood
Depressed Mood
Dysfunctional Attitude
Dysfunctional Attitude
Fatigue
Fatigue
Never depressed
Recovered depressed
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Priming and recurrence

• Segal et al (J. Abnormal Psychology, 1999)
• CBT vs Pharmacotherapy
• Patients in remission
• DAS (Time 1) mood priming DAS (Time 2)
• Results
• Priming affected DAS more in pharmacotherapy than
  CBT patients
• primed DAS (Time 2) predicted relapse and
  recurrence
• How does the mind react when feeling off-track?

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Cognitive risk mechanism
NO RELAPSE
Negative thinking patterns nipped in the bud
Negative thinking EPISODE
Non-negative thinking REMISSION
POTENTIAL RELAPSE
Negative thinking patterns re-established
LOW MOOD Reactivation of negative thinking
RELAPSE
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Spiralling Down
This is not what I want Discrepancy between
where I am and where I want to be
Rumination Where did I go wrong? Where will it
end?
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Outcome Achieved! How?

• Discrepancy-based processing
• I had to compare
• where I was now (current state)
• with
• where I wanted to be (my destination or desired
  outcome
• and
• where I did not want to be (my non-destination or
  outcome to be avoided)

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Doing Mode

• Judging discrepancies
• Uses thoughts (conceptual)
• Takes thoughts as real
• Uses past and future
• Keeps in mind what to avoid
• Automatic

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Applying Doing Mode to mood

• Where am I?
• feeling lonely
• What do I want to be?
• to be happy
• What do I want to avoid?
• another episode of depression
• feeling dreadful
• having no friends

Judging discrepancies Uses thought Thoughts as
real Past and future Avoidant Automatic
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• Can mindfulness approach help?
• Jon Kabat-Zinn Full Catastrophe Living
• Mindfulness-based Stress Reduction (MBSR U-Mass
  Medical Centre)

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Mindfulness

• Mindfulness means paying attention in a
  particular way.
• on purpose
• in the present moment
• non-judgmentally.
• Jon Kabat-Zinn

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Being mode a different way of seeing
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Overview of MCBT

• Eight weekly classes plus all-day session. Each
  2 2.5 hours
• Pre-class interview
• To explain, motivate and point out the commitment
  that will be necessary
• Up to 12 in each class (Kabat-Zinn 30 in each
  class)
• Homework up to one hour per day, 6 days a week
  mostly audiotapes of mindfulness practice
  generalisation practice
• Pattern
• First half concentration/steadying the mind
• Second half wider awareness relapse prevention

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Key practices in MBCT

• Mindfulness of routine activities (e.g eating)
• Body scan
• (awareness of sensations in the body learning to
  direct attention to different parts of the body)
• Mindfulness of the breath
• (concentration on a single focus), then moving to
  mindfulness of
• sounds, the whole body, and thoughts
• Yoga practice and gentle movement exercises
• Three minute Breathing Space
• Scheduled regularly in working day, and
  additionally when under stress

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Homework Overview (Weeks 1-4)
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Homework Overview (Weeks 5-8)
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Teasdale et al. (2000)
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Teasdale et al. (2000)
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Baseline differences between patients with
patients with 2 vs 3 previous episodes

• Age
• 2 episodes 38.9
• 3 episodes 44.6 (p
• Age at first onset of depression
• 2 episodes 33.4
• 3 episodes 25.0 (p
• History (years)
• 2 episode 5.5
• 3 episode 19.6 (p

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Outcome trial results

• No difference in use of Antidepressant medication
  over 12 month follow-up period
• Risk of relapse in TAU determined by history
• Number of previous episodes in TAU
• If 2 p(relapse) 31
• If 3 p(relapse) 56
• If 4 p(relapse) 72
• In MBCT Effect of previous episodes removed

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Procedural replication (Ma Teasdale, 2004, J.
Consult. Clin. Psychol.)

• N 75 recovered from MDD
• 3 or more episodes (75 of sample)
• TAU -78 relapse
• MBCT -36 relapse
• 2 episodes (25 of sample N18)
• TAU -2/10
• MBCT -4/8

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Outcome trials summary

• First multi-centre RCTs of clinical intervention
  based on mindfulness
• For more serious patients (history of 3
  episodes), MBCT halves chances of relapse
• MBCT may be effective for autonomous relapse
  processes
• Highly cost effective (because class-based
  approach) Clinician time per patient average