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Mindfulness therapy is at least as effective as emdication in the treatment of recurrent depression!

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By Dr. W.A. Arrindell, psychologist

Patients with a history of multiple depressive episodes who want to protect themselves against another episode may benefit as much from meditation-based cognitive therapy, a psychological intervention, as from taking antidepressants. This is an important finding in view of (a) the burden that many patients in general, and severely depressed patients in particular, experience in taking pills; (b) the potential harmful side-effects that psychopharmacological drugs may have; and, accordingly, (c) the wish that many depressed patients have to replace their use of medication by a better alternative.

Depression

A usual fluctuation in mood or a short-lived emotional response to a challenge in everyday life is not the same as depression. However, when long-lasting and with moderate or severe intensity, we may be dealing with depression as it then becomes a serious health condition that can cause the affected person to suffer greatly and function poorly at work, at school, and in the family. In a typical depressive episode, an individual experiences feelings of sadness or emptiness (depressed mood), loss of interest and enjoyment, thoughts of death and dying, and reduced energy leading to diminished activity for at least two weeks. The depressed may also suffer from anxiety symptoms, disturbed sleep and appetite, and may have feelings of guilt, hopelessness, helplessness, or of worthlessness, poor concentration and even medically unexplained symptoms (see also Key facts on depression).

Key facts about depression

● Depression is a common mental disorder. Globally, more than 350 million people of all ages suffer from depression.

● Depression is the leading cause of disability worldwide, and is a major contributor to the global burden of disease.

● More women are affected by depression than men.

● At its worst, depression can lead to suicide. Worldwide, suicide results in an estimated 1 million deaths every year.

● There are known, effective treatments for depression – psychological or medical, or a combination of both. However, fewer than half of those affected in the world (in some countries, fewer than 10%) receive such treatments.

Source: World Health Organization (adapted).

 

Treatment

Cognitive behavioural therapy (CBT) is among the effective non-medical, psychosocial treatments for depression. At the heart of CBT is an assumption that a person's mood and behaviour are directly related to his or her patterns of thinking. Faulty (dysfunctional) thinking affects a person's mood, sense of self, behaviour, and even physical health. The goal of cognitive behavioural therapy is to help a person learn to recognize faulty patterns of thinking, evaluate their validity, and replace them with healthier (functional) ways of thinking. CBT is based on two specific tasks: (a) the therapist and patient work together to change faulty thinking patterns (cognitive restructuring), and (b) patients learn to overcome obstacles in order to participate in enjoyable activities (behavioural activation). CBT focuses on the immediate present: what and how a person thinks – more than why a person thinks the way he or she does.

Chronicity

In spite of treatment, many patients fail to get better and suffer for a long period of time or experience symptoms that are marked by frequent recurrence. Among depressed outpatients and inpatients, less than a third recover and remain well in the 18 months after an episode of depression; in general practice and the general population, the proportion of patients with recurrence hovers between 35% and 65%. Patients with a history of recurrent depression have a high risk of repeated depressive relapse or recurrence. In such cases, treatment needs to focus on maintenance and prevention of relapse as well as on the acute mood episode. For such patients, using maintenance antidepressants, for at least two years, is currently the recommended treatment. The problem with this approach, however, is that many patients might not wish to remain on medication (see under Significance) or cannot tolerate the side-effects (see Box), in which case alternative non-medication strategies would be most desirable.

Some common side effects of antidepressants

 ● anxiety

● irritability

● agitation (jitteriness)

● nausea

● increased appetite and weight gain

● loss of sexual desire and other sexual problems, such as erectile dysfunction and decreased orgasm

● fatigue and drowsiness

● sleep difficulties and nightmares

● dry mouth

● blurred vision

● constipation

● dizziness

● diarrhoea

 Non-medication

To help patients who do not wish to or cannot remain on medication, scientists have developed a combination of cognitive behavioural therapy and a mindfulness-based stress reduction (meditation) program. Over a decade ago, it was demonstrated that meditation, like psychotherapy (talk therapy), produces changes in the brain that lead to normalized (healthy) brain activity (and increased immune function). Indeed, meditation and psychotherapy at times have been shown to work in similar ways as medications; at other times, meditation and psychotherapy appear to have mechanisms of action that differ from those produced by medication.

Mindfulness-based-cognitive-therapy

Mindfulness-based cognitive therapy (MBCT) is a group-based (it is delivered to a small group of patients simultaneously) training program designed to enable patients to learn skills that prevent the recurrence of depression. MBCT is intended to teach people to become more aware of their bodily sensations, thoughts, and feelings associated with depressive relapse or recurrence and to relate constructively to these experiences. Basically, MBCT teaches patients that negative feelings and thoughts will recur and that, rather than worrying or obsessively ruminating about these experiences, it is possible to become aware of and disengage from them, thereby preventing a downward spiral into depression. Participants learn mindfulness practices and cognitive-behavioural skills both in group sessions and through homework assignments. Therapists provide support to patients, again, while learning to respond adaptively to thoughts, feelings, and experiences that might otherwise have triggered depressive relapse. In the study described below, the therapy program consisted of eight 2.25 h group sessions, normally over consecutive weeks, with four refresher sessions offered roughly every three months for the following year.

Study

Willem Kuyken, Professor of Clinical Psychology at the University of Oxford (Oxford, United Kingdom), and 25 associates from different universities, colleges and scientific institutes in the UK, recruited 424 adult patients with three or more previous major depressive episodes and on a therapeutic dose of maintenance antidepressants from 95 primary care general practices in urban and rural settings (in the UK) and randomly assigned 212 patients to mindfulness-based cognitive therapy and 212 to maintenance antidepressants. The primary outcome was time to relapse or recurrence of depression, with patients followed up at five separate intervals during the 24-month study period.

Number of depressive symptoms, quality of life, and financial costs associated with treatment were also assessed. Kuyken and his associates found no evidence that MBCT is superior to maintenance antidepressant treatment for the prevention of relapse in individuals at risk for depressive relapse or recurrence. Both treatments were associated with enduring positive outcomes in terms of relapse or recurrence, residual depressive symptoms, and quality of life; there was also no difference in the number of adverse advents (for example, deaths) across the two treatment methods, and both were comparable in terms of financial costs [The Lancet, 2015; http://dx.doi.org/10.1016/S0140-6736(14)6222-4].

Meta-analysis

In addition, Kuyken and associates pooled their data with those from two previous trials (123 and 54 patients), and used the equivalent 60-week follow-up point available across all three studies. In doing so, this overall analysis demonstrated a risk reduction of 24% for MBCT in relation to maintenance antidepressants.

Significance

Mindfulness-based cognitive therapy is a promising new treatment that is also applicable to a large group of patients, and a good alternative to maintenance antidepressants for prevention of depressive relapse or recurrence at similar costs. MCBT allows patients to stay well and maintain good quality of life. This is an important and almost revolutionary finding in view of the, for many patients, intolerable side effects that antidepressants may have. In addition, taking pills is a burden for many patients, irrespective of the condition from which they are suffering. Even ignoring the side-effects of pills, other studies have shown that the act of taking a pill – obtaining it, remembering to take it, and actually taking it – interferes with one's quality of life. Not adhering to or partly adhering to a prescription of a medical doctor, however, may have serious consequences for health and life-expectancy, for example, suicide in a severely depressed patient. As an illustration of how burdensome people experience the act of having to take pills, other researchers surveyed people (average age 50) via the internet hypothetically asking how much time they were willing to forfeit at the end of their lives to avoid taking daily medication. They were also asked the amount of money they would pay and the hypothetical risk of death they were willing to accept to avoid taking medications to prevent cardiovascular disease. It was found that one in three people were willing to risk living a shorter life instead of having to take a daily pill to prevent cardiovascular disease; as many as just over 8% of the population were willing to trade as much as two years of life to avoid taking daily medication for cardiovascular disease; and about one in five said they would pay $1,000 or more to avoid taking a pill each day for the rest of their lives [Circulation: Cardiovascular Quality and Outcomes, 2015; DOI: 10.1161/CIRCOUTCOMES.114.001240]. Thus, it makes sense to argue that to have an alternative non-medication strategy to reduce relapse and recurrence of depressive episodes is an important means to help depressed patients.

 

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