[ Table of Contents ]

Mindfulness-Based Cognitive Therapy Working to Prevent Depression's Return

Results provide a non-pharmaceutical option

Sir Winston Churchill, one of the greatest wartime leaders of the 20th century, often gets credit for popularizing the image of depression as a black dog. Like Churchill, anyone who has faced the darkness of depression knows that while the black dog can be chased away, it has a cruel habit of returning and lingering for increasingly longer periods of time.

“Relapse has become recognized as an important aspect in the comprehensive treatment of depression,” says Dr. Zindel Segal, head of the Cognitive Behavioural Therapy Clinic of the Mood and Anxiety Disorders Program at the Centre for Addiction and Mental Health in Toronto.

“It is quite common and puts people at risk of developing a more chronic course of depression,” says Dr. Segal, who is also the Cameron Wilson Chair in Depression Studies in the Department of Psychiatry at the University of Toronto.

Depression itself is a common condition: about 8% of Canadians will face a major depression at some point in their lives, with 4% to 5% of Canadians in a depressed state in any given year.¹ The most common treatments for this chronic illness are antidepressants and counselling.

But what do patients do when they have recovered? For those taking drugs such as antidepressants, the prospect of discontinuing medication can be worrisome – particularly because it can take weeks for some drugs to reach therapeutic level should depression return. “It’s a large decision that should only be made with a family doctor or psychiatrist, because there can be consequences that might increase the chance of relapse,” says Dr. Segal. “But if they’re doing well and the side effects are difficult or, for women, they want to get pregnant, those may be reasons to come off it.”

Until recently, however, there has been no option – beyond discontinuing medication and hoping for the best.

“I was looking for a way to break the dysphoric cycle,” says Dr. Segal, a co-developer of mindfulness-based cognitive therapy (MBCT), which has proven successful in preventing relapse into depression.

Evidence in Action: U.S. Mental Health Leader Sees MBCT as Model 'Of What We Can Do'

Dr. David J. Kupfer, chair of the task force for the fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5), was instrumental in the emergence of MBCT. In the late 1990s, as Director of the Psychobiology of Depression Research Network sponsored by the John D. and Catherine T. MacArthur Foundation, he encouraged Dr. Segal to devise a maintenance version of cognitive therapy to fight depression relapse. “I have been very impressed with where Dr. Segal has gone with this,” says the University of Pittsburgh’s Dr. Kupfer. “The integration of mindfulness with cognitive therapy makes it even more accessible to patients.” MBCT, he says, sets “a model of what we can do in other serious psychiatric disorders.”

MBCT blends elements of mindfulness, a form of meditation that involves focusing attention on thoughts and sensations in the present moment, with cognitive behavioural therapy to increase awareness of negative or inaccurate thinking. It is offered in group therapy sessions in which patients get training and are assigned “homework” to develop strategies to keep depression at bay. 

Unchecked Negativity Rekindles Depression

“We’ve done a lot of research on cognition and emotion that has revealed mood-dependent processing biases that kick in if people have suffered from depression in the past,” says Dr. Segal. “These biases, if left unchecked, make it more likely that people will magnify their failures and minimize their successes, thereby quickly leading them down the rabbit hole of becoming depressed again.”

MBCT, Dr. Segal says, helps those at risk “observe and separate their experiences from judgments about their self-worth and in doing this they learn to make better choices for regulating their moods.”

A 2010 study in the Archives of General Psychiatry ² indicates that MBCT provides protection against relapse/recurrence of depression that is equal to maintaining antidepressant pharmacotherapy and notes that three other studies indicate “a 50% reduction in relapse for patients receiving MBCT compared with treatment as usual.”

But what is actually going on in the brain of an MBCT-trained patient when negative thoughts arise? To better understand the “mechanisms of action,” Dr. Segal’s research team conducted brain-imaging studies of participants’ reactions to sad segments from popular movies, comparing the neural expressions generated by participants who had completed mindfulness training to those who had not. The MRI results indicated the participants who were trained in mindfulness tapped into more areas of the brain when responding to potentially depressing stimuli.³

Evidence in Action: MBCT Recommended as Priority for Implementation

In the United Kingdom, MBCT is offered through the National Health Service (NHS). In fact, the National Institute for Health and Clinical Excellence (NICE), which promotes evidence-based practice in the NHS, recommends MBCT. “NICE doesn’t mess around,” says Dr. Willem Kuyken, co-founder of the Mood Disorders Centre at the University of Exeter. “They look at randomized controlled evidence and high-quality clinical trials. What they want to see is that a treatment is unambiguously better than usual care. MBCT has been in the NICE guidance since 2004 and in the 2009 update it was identified as a key priority for implementation.”

"Instead of the pattern of neural activations during sadness being one in which the prefrontal cortex predominates, people with mindfulness training seem to show a division of activations in prefrontal and lateral cortical regions," says Dr. Segal. "This may provide such patients with additional information about the meaning of sad moods."

In effect, instead of going to one "expert" for a solution to a problem, the mindful mind has access to a "panel of experts" that can provide a more balanced perspective and nuanced response to the problem.

Dr. Segal developed MBCT in collaboration with Dr. John Teasdale of Cambridge University and Dr. Mark Williams at Oxford University, and in 2002 they co-authored the book Mindfulness-Based Cognitive Therapy for Depression. Their work was a logical application of earlier theories championed by the University of Massachusetts' Dr. Jon Kabat-Zinn, founder of mindfulness-based stress reduction therapy. The four also co-authored the 2007 book The Mindful Way Through Depression.

Although less than a decade old, the therapy has taken firm root in Western Europe, particularly Switzerland, France, Belgium and Germany, says Dr. Lucio Bizzini of the University Hospitals of Geneva, who became interested in MBCT in 2002 after attending a workshop Dr. Segal led near Toronto.

"We invited Dr. Segal to come to Geneva in 2003 and organized an intensive five-day training workshop for local psychiatrists, psychologists and psychotherapists to learn how to deliver MBCT," says Dr. Bizzini. "Since then, there continues to be demand for this modality among trainees in Belgium, Switzerland and France," where up to 80 mental health professionals now lead MBCT group sessions

In Canada, use of MBCT as a treatment option is growing. "I took a training course with Dr. Segal about three years ago and I've been running a group at North York General Hospital in Toronto since then. I've probably done about 20 groups, so maybe 300 patients. I see a lot of benefits," says Dr. Neil Levitsky, a Toronto-based psychiatrist. Meanwhile, Dr. Steven Selchen, who is offering a number of groups based on MBCT at Toronto's Mount Sinai Hospital, says the therapy has other applications waiting to be explored. "The original model was designed for relapse prevention in recurrent depression, but it has branched out since then," he says. "The best research still addresses that initial question; but it's branching out into chronic depression and anxiety and other areas. We're adapting it as well here at Mount Sinai and conducting research on those adaptations."

1. Public Health Agency of Canada, A Report on Mental Health Illnesses in Canada.
2. Antidepressant Monotherapy vs. Sequential Pharmacotherapy and Mindfulness-Based Cognitive Therapy, or Placebo, for Relapse Prophylaxis in Recurrent Depression, Archives of General Psychiatry 67, 12 (December 2010): 1256–1264.
3. Minding One's Emotions: Mindfulness Training Alters the Neural Expression of Sadness, Emotion 10, 1 (February 2010): 25–33.