Summary: Yes, mindfulness can help depression that doesn’t respond to a first attempt at treatment, but does not yet qualify as treatment-resistant depression (TRD).
Key Points:
- Most patients with mild-to-moderate depression respond well to standard treatment
- About 30% of people with moderate-to-severe depression have treatment-resistant depression (TRD), which means they’ve have two unsuccessful attempts at standard depression treatment.
- About 50% of people with moderate-to-severe depression don’t make satisfactory progress after one attempt at treatment, and are in the hard-to-treat category
- For these patients, new research shows a mindfulness-based intervention can help
Depression, Hard-to-Treat Depression, and Treatment-Resistant Depression (TRD)
For people with mild-to-moderate depression – meaning a clinical diagnosis for mild-to-moderate major depressive disorder (MDD) – the standard, first-line course of treatment, which typically includes antidepressant medication, psychotherapy, integrative therapies, and lifestyle changes, is effective and can lead to significant symptom reduction. However, close to half of people with moderate-to-severe depression don’t respond to these first-line treatment approaches. Their depression does not enter remission, which is the ultimate goal of treatment for depression: remission of depressive symptoms.
Patients in this category do not meet criteria for treatment-resistant depression (TRD), which requires at least two unsuccessful attempts at standard, first-line therapies. That means they may not qualify for treatments that target TRD, such as psychedelic therapies – ketamine and esketamine, for example – and various types of brain stimulation therapies.
This leaves them in a difficult position. Should they try standard treatment a second time, with the hope that it will either work, or qualify them for therapies reserved for people with TRD?
A new publication from the U.K., the study “Mindfulness-Based Cognitive Therapy Versus Treatment ss Usual After Non-Remission With NHS Talking Therapies” presents another option. As a second-line treatment for people with MDD who don’t respond to first-line treatments, a group of researchers designed a study to assess the effectiveness of mindfulness-based cognitive therapy (MBCBT) on people with hard-to-treat depression that doesn’t yet meet criteria for treatment-resistant depression (TRD).
In the U.K., this could meet a real need in the population of people with depression. Here’s how a researcher on the study describes the situation:
“We know there’s a gap in services for people with depression who haven’t got better through NHS Talking Therapies. These people often don’t qualify for further specialist mental health care, and so are left with no further options.”
This is analogous to circumstances here in the U.S. where people with depression may be caught in between: not wanting to wait through another attempt at standard treatment but not yet qualifying for coverage for treatments for TRD.
Can MBCBT Fill this Gap?
That’s why this study on MBCBT is important. If MBCBT is effective for hard-to-treat, but not treatment-resistant depression, then patients in this category may find relief from symptoms, and possible remission from depression, more quickly than they thought possible.
To learn whether mindfulness can help depression for people in this category, researchers recruited 234 adult patients with an MDD diagnosis with an unsatisfactory attempt at standard treatment for depression, which, in the U.K., involves intensive psychotherapy and antidepressant medication. Researchers assigned patients to one of two groups:
- MBCBT + treatment as usual (MBCBT + TAU)
- Treatment as usual (TAU)
In this study, patients received all treatment – aside from medication – via telehealth/video conferencing. Researchers excluded patients who reported the following:
- Current suicidality
- Diagnosis of psychosis
- Current posttraumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), or eating disorder
- Presence of mania/manic symptoms
- Diagnosed alcohol or substance misuse
To measure the effectiveness of MBCBT + TAU vs. TAU, researchers focused on the following outcomes:
- Reduction in scores on the PHQ-9 at 34 weeks post-treatment
- Reduction in scores on the PHQ-9 at 10 weeks post-treatment
PHQ -9 refers to the Patient Health Questionnaire-9, a nine-item patient self-report designed to align with MDD diagnostic criteria established in the Diagnostic and Statistical Manual of Mental and Behavioral Disorders, Volume 5 (DSM-5), In addition, researchers assessed the following secondary outcomes:
- Scores on anxiety metrics
- Scores on phobia scales
- Answers on mindfulness surveys
- Answers on general wellbeing questionnaires
Patients in the MBCBT+TAU group received MBCBT in the following manner:
- Once weekly group sessions for 8 weeks
- Weeks 1-4 focused on learning mindfulness
- Weeks 5-8 focused on applying mindfulness to depressive symptoms/difficult emotions
- All MBCBT sessions delivered via telehealth
The treatment-as-usual group followed the same protocol, with the difference being the presence of MBCBT: treatment for the TAU group had no mindfulness component. Participants in both groups may or may not have been on antidepressants, depending on the individual. Researchers did not consider this a confounder, since antidepressants are a common component of TAU for depression.
Let’s take a look at what they found.
Does Mindfulness Help Depression That’s Hard to Treat?
Participants completed the survey assessments we describe above at baseline, i.e. the beginning of the study, and at 10- and 34-weeks post treatment. Here are the results:
How Much Can Mindfulness Help Depression
Note: for the depression, anxiety, and phobia scales, a higher score meant more symptoms, reflecting a poorer outcome, whereas on the wellbeing and mindfulness scales, higher scores mean higher wellbeing/mindfulness, reflecting a superior outcome.
10 weeks post-treatment:
- MBCBCT + TAU
- PHQ-9: 13.9
- Anxiety (GAD-7): 11.1
- Phobias: 9.9
- Wellbeing: 35.5
- Mindfulness: 43.4
- TAU
- PHQ-9: 16.1
- Anxiety (GAD-7): 12.7
- Phobias: 10.7
- Wellbeing: 32.8
- Mindfulness: 48.9
34 weeks post-treatment:
- MBCBCT + TAU
- PHQ-9: 12.6
- Anxiety (GAD-7): 10.4
- Phobias: 9.4
- Wellbeing: 36.6
- Mindfulness: 43.4
- TAU
- PHQ-9: 14.8
- Anxiety (GAD-7): 11.9
- Phobias: 10.5
- Wellbeing: 33.2
- Mindfulness: 39.0
For depression, patients in the mindfulness group scored an average of 2.5 points below treatment-as-usual at 10 weeks and 34 weeks, differences the researchers label as statistically significant. For anxiety and phobias, although scores were lower in the mindfulness group, the differences were non-significant. However, for wellbeing, the mindfulness group showed significant differences of 3.3 and 3.2 at 10- and 34-weeks post-treatment, respectively. For mindfulness, the mindfulness group showed significant differences of 5.9 and 4.6 at 10- and 34-weeks post-treatment, respectively.
We’ll discuss these results below.
Mindfulness Can Help Depression, With a Notable Benefit
One thing we haven’t mentioned is that the study also tracked the cost of mindfulness vs. other interventions, and determined that in the long-run, MBCBT is less expensive than other approaches to hard-to-treat depression.
In addition, Dr. Clara Strauss, a study author, concludes:
“For vulnerable people with depression, MBCT is particularly helpful for a number of reasons.”
Why?
Dr. Strauss indicates MBCBT or mindfulness can help depression in the following ways:
- Patients learn to recognize thoughts that may be negative or self-critical as their personal thoughts, rather than objective facts
- This recognition mitigates the impact of those thoughts on emotion and behavior
- It can help people accept rather than judge their personal experiences, which can help improve self-esteem and boost self-directed compassion and kindness
- This can help people move past persistent patterns of negative thinking that reinforce symptoms of depression
Dr. Strauss identifies one last area that makes this research relevant to people with hard-to-treat depression:
“Encouragingly, our trial shows MBCT can even work for people where other forms of talking therapy have had little effect.”
This research is a positive development in depression treatment for a specific group of people with depression, and offers a new avenue of treatment that offers relief for people in the gray area between hard-to-treat depression and depression that meets clinical criteria for treatment-resistant depression.
Gianna Melendez
Jodie Dahl, CpHT