Evidence-Based Reviews

Mindfulness-based interventions: Effective for depression and anxiety

Current Psychiatry. 2009 December;8(12):39-55

References

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2. Segal ZV, Williams JMG, Teasdale JD. Mindfulness-based cognitive therapy for depression: a new approach for preventing relapse. New York, NY: Guilford Press; 2002.

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Meta-analytic and narrative reviews generally support MBSR’s efficacy for a wide range of clinical presentations, including improved quality of life for chronic pain and cancer patients.^5,8-11 Variability in the methodologic rigor of clinical trials of mindfulness-based interventions—such as lack of active control groups and small sample sizes—limits the strength of these studies’ conclusions, however.⁸

Clinical Point

MBCT integrates mindfulness training with cognitive therapy techniques

MBCT integrates the mindfulness training of MBSR with cognitive therapy techniques ( Table 1 ) to prevent the consolidation of ruminative, negative thinking patterns that contribute to depressive relapse.² These cognitive therapy techniques include:

psychoeducation about depression symptoms and automatic thoughts
exercises designed to demonstrate the cognitive model
identifying activities that provide feelings of mastery and/or pleasure
creating a specific relapse prevention plan.

In addition, MBCT introduces a new informal meditation—the 3-minute breathing space—to facilitate present-moment awareness in upsetting everyday situations.

Evidence supporting MBCT comes from randomized, controlled trials (RCTs) and uncontrolled trials ( Table 2 ).^12-18 A systematic review of RCTs supported using MBCT in addition to usual care to prevent depressive relapse in individuals with a history of ≥3 depressive episodes.¹⁹ Since that review was published, a large RCT (123 patients) comparing antidepressant medication alone to antidepressants plus adjunctive MBCT with support to taper/discontinue antidepressant therapy found:

MBCT comparable to maintenance antidepressant medication in preventing depressive relapse for individuals with ≥3 depressive episodes
no difference in cost between these 2 treatments.¹²

In this study, MBCT was more effective than maintenance pharmacotherapy in reducing residual depressive symptoms and in improving quality of life; 75% in the MBCT group discontinued antidepressants. MBCT is included in the United Kingdom’s National Institute for Clinical Excellence Clinical Practice Guidelines for Depression²⁰ for prevention of recurrent depression.

Clinical Point

MBCT was shown to reduce depressive symptoms, anxiety, and risk of depressive relapse

RCTs and uncontrolled studies have shown that MBCT reduces depressive and anxious symptoms in individuals suffering from mood disorders. In an open-label pilot study of MBCT’s efficacy in reducing depressive symptoms in patients with treatment-resistant depression and ≥3 depressive episodes, 61% of patients achieved a post-MBCT Beck Depression Inventory-II (BDI-II) score <14, which represents normal or near-normal mood (mean BDI-II scores decreased from 24.3 to 13.9; effect size 1.04).¹⁷

Clinical Point

Mindfulness-based treatments may reduce symptoms of eating disorders, ADHD, GAD, and other psychiatric conditions

Mindfulness for other psychiatric conditions. A review by Toneatto and Nguyen²¹ of MBSR in the treatment of anxiety and depression symptoms in a range of clinical populations concluded that the evidence supporting a beneficial effect was equivocal. On the other hand, several uncontrolled studies and 1 RCT indicate that mindfulness-based treatments can reduce symptoms in other psychiatric conditions, including eating disorders,²² generalized anxiety disorder,²³ bipolar disorder,²⁴ and attention-deficit/hyperactivity disorder.²⁵ Many of these studies were developed to target mood and anxiety symptoms by linking mindfulness and symptom management; this differs from MBSR, which focuses on stress reduction. Methodologically rigorous studies are necessary to evaluate mindfulness-based treatments in these and other psychiatric conditions.

Table 1

Skills and practices taught in mindfulness training

MBCT session themes	Mindfulness skill	Associated practices
‘Automatic pilot’ (acting without conscious awareness)	Awareness of automatic pilot Awareness of body	Mindful eating Body scan (intentionally bringing awareness to bodily sensations)
Dealing with barriers	Awareness of how the chatter of the mind influences feelings and behaviors	Body scan Short breathing meditation
Mindfulness of the breath	Awareness of breath and body	Breathing meditation 3-minute breathing space Mindful yoga
Staying present	Awareness of attachment and aversion	Breathing meditation Working with intense physical sensations
Acceptance	Acceptance of thoughts and emotions as fleeting events	Explicit instructions to practice acceptance are included in the breathing meditation and the 3-minute breathing space
Thoughts are not facts	Decentering or re-perceiving	Sitting meditation (awareness of thoughts)
How can I best take care of myself?	Awareness of signs of relapse; develop more flexible, deliberate responses at time of potential relapse	3-minute coping breathing space
Dealing with future depression	Awareness of intention	Identifying coping strategies to address barriers to maintaining practice
MBCT: mindfulness-based cognitive therapy
Source: Reference 2

Table 2

Evidence of reduced depressive symptoms, anxiety with MBCT

Study	Patients	Findings
Randomized controlled trials
Kuyken et al, 2008¹²	123 patients with recurrent depression treated with antidepressants received maintenance antidepressants alone or adjunctive MBCT with support to taper/discontinue antidepressant therapy	Adjunctive MBCT was as effective as maintenance antidepressants in reducing relapse/recurrence rates but more effective in reducing residual depressive symptoms and improving quality of life; 75% in the MBCT group discontinued antidepressants
Kingston et al, 2007¹³	19 outpatients with residual depressive symptoms following a depressive episode assigned to MBCT or treatment as usual	MBCT significantly reduced depressive symptoms, and these improvements were maintained over a 1-month follow-up period
Williams et al, 2008¹⁴	14 patients with bipolar disorder who had no manic episodes in the last 6 months and ≤1 week of depressive symptoms in the last 8 weeks	MBCT resulted in a significant reduction in anxiety scores on the BAI compared with wait-list controls
Uncontrolled trials
Eisendrath et al, 2008¹⁵	15 patients with treatment-resistant depression (failure to remit with ≥2 antidepressant trials)	MBCT significantly reduced anxiety and depression; increased mindfulness and decreased rumination and anxiety were associated with decreased depression
Finucane and Mercer, 2006¹⁶	13 patients with recurrent depression or recurrent depression and anxiety	MBCT significantly reduced depression and anxiety scores on BDI-II and BAI
Kenny and Williams, 2007¹⁷	46 depressed patients who had not fully responded to standard treatments	MBCT significantly reduced depression scores
Ree and Craigie, 2007¹⁸	26 outpatients with mood and/or anxiety disorders	MBCT significantly improved symptoms of depression, anxiety, stress, and insomnia; improvements in insomnia were maintained at 3-month follow-up
BAI: Beck Anxiety Inventory; BDI-II: Beck Depression Inventory; MBCT: mindfulness-based cognitive therapy