Mindfulness-based interventions: Effective for depression and anxiety
Evidence supports adjunctive role for the combination of meditative practices and CBT
Mr. A, age 45, reports irritability, loss of interest, sleep disturbance, increased self-criticism, and decreased self care during the last month after a promotion at work. He has a history of 3 major depressive episodes, 1 of which required hospitalization. For the last 2 years his depressive symptoms had been successfully managed with escitalopram, 10 mg/d, plus bupropion, 150 mg/d. Mr. A wants to discontinue these medications because of sexual dysfunction. He asks if nonpharmacologic strategies might help.
One option to consider for Mr. A is mindfulness-based cognitive therapy (MBCT), which was originally developed to help prevent depressive relapse. MBCT also can reduce depression and anxiety symptoms. More recently, MBCT was shown to help individuals discontinue antidepressants after recovering from depression.
Regular mindfulness meditation has been shown to result in structural brain changes that may help explain how the practice effectively addresses psychiatric symptoms ( Box ). With appropriate training, psychiatrists can help patients reap the benefits of this cognitive treatment.
How mindfulness attunes the brain to the body
Regular mindfulness practice has been shown to increase cortical thickness in areas associated with attention, interoception, and sensory processing, such as the prefrontal cortex and right anterior insula.a This supports the hypothesis that mindfulness is a way of attuning the mind to one’s internal processes, and that this involves the same social neural circuits involved in interpersonal attunement—middle prefrontal regions, insula, superior temporal cortex, and the mirror neuron system.b
Amygdala responses. Mindfulness improves affect regulation by optimizing prefrontal cortex regulation of the amygdala. Recent developments in understanding the pathophysiology of depression have highlighted the lack of engagement of left lateral-ventromedial prefrontal circuitry important for the down-regulation of amygdala responses to negative stimuli.c Dispositional mindfulness is associated with greater prefrontal cortical activation and associated greater reduction in amygdala activity during affect labeling tasks, which results in enhanced affect regulation in individuals with higher levels of mindfulness.d
Left-sided anterior activation. Other researchers have examined mindfulness’ role in maintaining balanced prefrontal asymmetry. Relative left prefrontal activation is related to an affective style characterized by stronger tendencies toward positive emotional responses and approach/reward oriented behavior, whereas relative right-sided activation is associated with stronger tendencies toward negative emotional responses and avoidant/withdrawal oriented behavior.
One study found significant increases in left-sided anterior activation in mindfulness-based stress reduction participants compared with controls.e Similarly, in a study evaluating the effect of mindfulness-based cognitive therapy (MBCT) on frontal asymmetry in previously suicidal individuals, MBCT participants retained a balanced pattern of prefrontal activation, whereas the treatment-as-usual group showed significant deterioration toward decreased relative left frontal activation. These findings suggest a protective effect of the mindfulness intervention.f
What is mindfulness meditation?
Meditation refers to a variety of practices that intentionally focus attention to help the practitioner disengage from unconscious absorption in thoughts and feelings. Unlike concentrative meditation—in which practitioners focus attention on a single object such as a word (mantra), body part, or external object—in mindfulness meditation participants bring their attention to a wide range of objects (such as breath, body, emotions, or thoughts) as they appear in moment-by-moment awareness.
Mindfulness is a nonjudgmental, present-centered awareness in which each thought, feeling, or sensation that arises in the attentional field is acknowledged and accepted as it is. 1-3 Bishop et al 4 defined a 2-component model of mindfulness:
- self-regulating attention of immediate experience, thereby allowing for increased recognition of mental events in the present moment
- adopting an orientation of curiosity, openness, and acceptance toward one’s experiences in each moment.
Buddhist and Western psychology inform the theoretical framework of most mindfulness-based clinical interventions, such as:
- acceptance and commitment therapy (ACT)
- dialectical behavioral therapy (DBT)
- mindfulness-based stress reduction (MBSR)
Because mindfulness is only 1 of several components of ACT and DBT, 5 this review focuses on MBCT and MBSR, in which teaching mindfulness skills is the central focus of treatment.
- formal mindfulness meditation practices such as body scan (intentionally bringing awareness to bodily sensations), mindful stretching, and mindfulness of breath/body/sounds/thoughts
- informal practices, including mindfulness of daily activities such as eating. 1
MBSR typically involves 8 to 10 weekly group sessions of 2 to 2.5 hours with 10 to 40 participants with heterogeneous or homogenous clinical presentations. At each session, patients are taught mindfulness skills and practices. Typically, a full day of meditation practice on a weekend follows session 5 or 6. Participants also engage in a daily meditation practice and homework exercises directed at integrating awareness skills into daily life.
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
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 Depression 20 for prevention of recurrent depression.
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
Mindfulness for other psychiatric conditions. A review by Toneatto and Nguyen 21 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.
Skills and practices taught in mindfulness training
MBCT session themes
‘Automatic pilot’ (acting without conscious awareness)
Awareness of automatic pilot
Dealing with barriers
Awareness of how the chatter of the mind influences feelings and behaviors
Mindfulness of the breath
Awareness of breath and body
Breathing meditation 3-minute breathing space
Awareness of attachment and aversion
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
Evidence of reduced depressive symptoms, anxiety with MBCT
Randomized controlled trials
Kuyken et al, 2008 12
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, 2007 13
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, 2008 14
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
Eisendrath et al, 2008 15
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, 2006 16
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, 2007 17
46 depressed patients who had not fully responded to standard treatments
MBCT significantly reduced depression scores
Ree and Craigie, 2007 18
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
CASE CONTINUED: Explaining the potential benefits
You inform Mr. A that MBCT has been shown to improve acute mild-to-moderate depressive symptoms, may decrease his risk of depressive relapse by 50% 26 and could help him discontinue his medications. 12 He asks how mindfulness exercises will help his symptoms.
How mindfulness works
The assumption that increased mindfulness mediates treatment outcomes 4 has been addressed systematically only recently, following the development of operational definitions of mindfulness and self-report mindfulness measures, including the:
- Mindful Attention Awareness Scale (MAAS) 27
- Five Facet Mindfulness Questionnaire (FFMQ) 12
- Toronto Mindfulness Scale (TMS). 28
Uncontrolled studies using these measures demonstrated that self-reported mindfulness increased following MBSR 28,29 and MBCT 15,18 in individuals with general stress, anxiety disorder or primary depression, cancer, chronic pain disorder, diabetes, and multiple sclerosis. Accumulating evidence from 1 RCT 30 and 2 other uncontrolled studies 28,31 demonstrates that mindfulness is associated with symptom reduction following MBSR.