Hello and welcome to the new psychology of Depression.
A series of programmes with me, Dr. Danny Pennyman and Professor Mark Williams of Oxford University.
In the previous programme, we discussed mindfulness based cognitive therapy, a new approach to preventing depression.
In this programme, we're going to ask, is mindfulness based cognitive therapy effective?
Mark, can you describe some of the key landmark pieces of evidence that say that and BCT is very effective?
The first study that we did was to offer this eight week programme to people who had been depressed recurrent.
That is, they'd been depressed at least twice. But we knew that you have to divide the sample into people who've been depressed,
maybe for a minimum of twice or three or more times because they turned out to have different risks and different profiles.
So we randomly allocated people. That's almost like a coin toss.
But a computer does it or somebody does it outside the research team in what's called a randomised controlled trial.
Now, that takes the idea randomness so that you can make sure that the people in both groups and we were contrasting MBT, but with treatment as usual.
So some people were allowed in for all the people were allowed to go back to their doctor, have more anti-depressants.
They wanted to. All the people that had antidepressants in the past when they started the trial,
but all of them were now off antidepressants and they'd been free from depression for at least two months.
That means they were definitely in remission and not suffering from depression when they started.
Remember that we wanted to test out whether this could prevent new episodes of depression,
not whether it actually treated depression, because we already had treatments for that.
So here's two groups randomly allocated to receive actual mindfulness based cognitive therapy,
as well as the treatment as usual or treatment as usual alone. Then the people have been allocated to have minds, we have the eight week programme.
Then we followed them up every two months for 12 months, which is the critical time if they're going to relapse.
They're going to relapse probably in that time. And indeed, you find that if they work in a relapse.
That's exactly what happened. People who had three or more episodes before they came to us relapsed at the rate of 66 percent over that 12 months.
If it had the mindfulness, however, that we're down to thirty seven percent. So almost halving the rate of of relapse.
Now, people that only had two episodes are somewhat different. Their relapse rates are fairly low anyway.
And actually, there's a small subsample, only 25 percent of our 145 in that trial actually had only two episodes.
And monthlies didn't seem to make that any better. So that was the pattern that people with three or more episodes.
That is the people that we were very interested in,
75 percent of the sample who had been recurrently depressed actually had a halving, almost a halving of the rate of relapse.
Now, of course, the problem is, would that be a flash in the pan?
It might be that that's just the one study. And so Jon Teesdale decided in his replication study to do precisely the same.
But now, just with a new sample of people just at Cambridge, he and Helen Marr did what's called a procedure replication.
And that's where you do almost exactly the same thing. Same entry criteria for the trial.
People with two or more episodes of depression. He found precisely the same pattern of results that people with only have two episodes of depression.
They were the minority, didn't seem to have any effect on them. But people with three episodes, that is the most needy, chronic, recurrent cases.
Actually, it more than halved in fat in those cases.
If they didn't have mindfulness, 78 percent of them relapsed and that came down to about 35, 36 percent.
So more than halving the rate of relapse in that trial.
Why is it most effective with people who are most afflicted by depression?
This is the curious thing,
because most treatments in in the world of psychological treatments actually have the biggest challenge with people that have been ill the longest.
And here's an approach which seems to have the reverse of that.
People that have the most challenging problem that have been around for longer get most benefit.
I think it's because when you've been depressed three or more times and indeed,
Martin Teesdale confirmed this, your depression has started early, often in teenage years.
You've had difficult problems. Your parents, by the time we come to see them, the mean number of episodes is four.
And you've you've had a 20 year history of depression. And so you've got stuck in these mental grooves.
And therefore, the sort of depression we're seeing,
there are just this sort of depression which mindfulness is very good for helping people to stand back from these mental grooves
and get that sense of being liberated from the patterns of the mind that have become so habitual with people of any two episodes.
Those patterns haven't become so habitual yet. They get a lot from the meditation.
They actually find it very relaxing. But often when another life event strikes and with these people with only two episodes, if they do get depressed,
it's usually because something really toxic has happened again in the time that we're following them up.
And mindfulness doesn't prevent the depression that follows immediately on the heels of a big life event.
Maybe they've let mindfulness too recently and they struggle to try to use it as a way to fix their problems.
Maybe they would do better take a holiday from mindfulness during the real storm of their life event for whatever reason.
And more research is needed here. It doesn't affect the depression that follows hard on the heels of a major accident or upset or bereavement, so on.
Not probably unless you learnt meditation a long time before it's part of your practise.
It's often very difficult to get hard, solid evidence that a psychological approach to depression is actually effective.
In that case, how do we know that MBT is actually effective?
You've got to do trials. You've got to do randomised controlled trials. That's the recent discovery over 20, 30 years.
You can't just do it on a few people show that it works, then write it up.
That's what people used to do. And it's often the very first step.
Of course, in seeing whether new psychological approach works,
you've got to find a clinical series of patients to discover that it works not just with the first patient,
but with the second, with a third, with the fourth. But then sooner or later,
you have to do the hard work of randomly allocated some people to receive the treatment you think is going to
be great and compare it with people that don't have that treatment but who are in other respects identical.
And that's what they are S.T.
The randomised controlled trial gives you, for all its faults, it does give you that confidence that basically you're not just as it were.
You've got a good idea, but you're fooling yourself. I mean, what's very interesting.
About this work is is obviously you and your co-workers developed and BCT, but it seems to have been picked up by many groups around the world.
So that's very, very interesting. Major trials have been done in other countries as well, which is always very heartening.
If you had to choose two or three trials that really backed up your claims, which ones would they be?
You raise an important point that it's not enough just for the developers of a treatment to do the trials.
It's got to be somebody outside who weren't the developers to see if it actually works in other countries, in other settings.
So in addition to those first two trials and after those two trials,
the UK's National Institute of Clinical Excellence picked it up and put it there as
a recommended treatment for people who have three or more episodes of depression. That was in 2004 and again in 2009.
Even with that evidence, they picked it up and established it as a treatment of choice for recurrent depression.
But you still need the data from outside. So there was a third trial also in the United Kingdom.
But now not done by the developers, by a colleague, Willem Caking in Exeter.
And they contrasted MBT with antidepressant medication and found that it was just as good,
in fact, in some measures better than people continuing to take their medication.
That was then backed up by a trial in Switzerland that found that you could delay
the onset of depression by 20 weeks or so with months based cognitive therapy.
And another trial in Belgium and the Belgium trial based at the University of Ghent,
found that the relapse rate went down from 68 percent to 30 percent.
So, again, halving the rate of relapse.
That was interesting trial because it showed that people could do it, whether they were anti-depressants or not.
In the early trials, we had asked people to to only come to the trial if they were not taking antidepressant medication.
And we found that we could prevent it in that group. But, of course, many people continue taking the antidepressant medication.
The Belgian trial found that even if you allowed people to take their antidepressant medication right throughout,
randomly allocated people to end BCT or the treatment, as usual, you've got this large change from 68 percent to 30 percent in the relapse rate.
And the sixth trial that was published in 2010 by Zengel Sehgal in Toronto.
So one of the original developers with us of the mindfulness based cognitive therapy was even
more interesting because they contrasted mindfulness with people taking their anti-depressants,
carrying on, taking the antidepressants or coming off and taking a pill placebo instead of antidepressants.
And what was striking there was people who had the most difficult form of depression.
That's what's called so unstable remission. So people they feel better, but then they become depressed again.
And then they have another period where they feel better. Then they get depressed against it.
Very unstable pattern of remission and recovery.
And for those people, they were helped equally by antidepressants or by monthlies based cognitive therapy.
But if they got the placebo pill, they relapsed at about 70 percent.
But both antidepressants and mindfulness took it down to just below 30 percent.
So once again, the pattern is emerging of mindfulness being better than treatment as usual and being at least as good as antidepressant medication.
Is there any way of enhancing the effectiveness of mindfulness based cognitive therapy?
There always will be. In other words, we always need more research.
Getting the relapse rate down to 30 percent is effectively taking out of the picture.
The effect of everything more than the first two episodes.
So basically getting people back to where they were, you know, where they only had two episodes where their risk was about 30 percent.
But we'd like to do more. And one way is to develop more methods for inviting people to really notice them, rumination their avoidance patterns.
Another way might be to do more behavioural work, actually inviting people to go out and try things,
which is one of the hallmarks of cognitive therapy and behaviour activation. And if you summarise all the trials, you see that on balance,
you take all the six trials together, which has totalled about five and 90 patients altogether.
There's a group at the university or who's led by Jacob Peate, and he's done a meta analysis of this overall reduction in relapse risk.
It's about 44 percent for people with three or more episodes depression. But there are questions like,
is it good for people that don't respond to other treatments there that's officially known as treatment resistant depression.
Is it good for chronic depression? Is it how long the effects last?
And is it as good as CBT? Well, each of those have now begun to have trials done throughout the world.
And we know some of the preliminary answers to that.
So Stuart Eyssen, Drath in California has used NBC t for people who don't respond to medication, at least two trials and medication.
For the third trial of medication, he'd have expected about a 14 percent recovery rate with MBT,
he more than doubled that same pattern with more Kenny in her work in Adelaide in Australia.
She found that nearly 50 percent responded to embassy tea despite the fact that they
hadn't responded to cognitive therapy and they hadn't responded to antidepressants.
And that's a remarkable result for people who've been depressed for years and years and years.
My colleague here, Thorsten Bon Hoffer, has looked at chronic depression in a group that were chronically depressed,
weren't responding to treatment and had suicidal depression and found that in a little randomised controlled
trial that you could reduce the back depression inventory score by one standard deviation using an BCT,
which was very, very new for these people to feel that sort of sense of relief and release from their depression for the first time.
More Morricone is now followed up her patients from that Adelaide study for
three years and find that those effects are maintained for up to three years.
And another Australian group in Gordon Parker's group in Sydney has found that its group,
cognitive therapy and classes of MBT have about the same effect.
So research is progressing all over the world as we speak.
And it's showing the power of doing something that is not, in a sense, psychotherapy.
It's not therapy. In one sense, it's actually skills training in mindfulness meditation.
These trials and relapse rates, are they just for people who've done the eight week course and then stopped and BCT?
Or is it for people who've carried on doing and BCT after the eight weeks?
Everybody who does the eight week course are invited to carry on if they want to, but there's no compulsion to do so.
They all get the seeds to keep. They can use it and most people do do some but not everybody.
And what they do is generally less than they did on the eight week course.
But because they've got the seeds available to them, they might do a daily three minute breathing space two or three times a day.
Maybe they use it whenever they need it.
And then maybe if they feel depression coming on, they've got the seeds there, they can actually put on the seeds.
One of them is a mindful movement, seeds, for example, which got something based on yoga.
And many people find that very helpful way of actually putting their body through some
movement as a way of actually dealing with with the mind's tendency to go spinning around.
And so, yeah, many people do, but some don't. And it's too early to say whether this is a critical thing.
What we know is that virtually any skill that you learn, if you do a little bit each day,
it means that you maintain this go where it's learning a language, you know, juggling whatever, playing the piano.
If you do a bit each day, it's going to be better for you. It's getting more accessible for you.
And therefore, there's a very strong prima facie case for if people do a little bit of this each day, it's going to be more available for them.
But that's further research needs to find out exactly how much each day.
And it's about the same time as you spend in brushing your teeth each day.
For example, is it two, three minutes? Or does it take 10 minutes a day? We don't yet know yet.
That's for further research to determine. So I know there's no hard evidence.
But what's your hunch? Do you think the people who tend to relapse are the ones who've tended to do either
less meditation or have completely stopped meditating after the eight weeks?
There is some evidence from the long term Australian study in Adelaide that is that people were Weller, as it were, two or three years later.
If they'd come to reunion meetings and they'd actually spent longer meditating on a daily basis.
Now, that, of course, does suggest that you need to do the meditation and maintain it.
Practise, practise, practise. Every minute counts.
However, in if you want to be really critical of that sort of research, you would have to say that we don't know which causal way round it is.
It might be that people who are actually were enjoying meditating are those who actually aren't going to relapse much anyway, and they meditate more.
So maybe there are certain people who take to the eight weeks they really enjoy it and they carry or meditate because they enjoy it.
And their enjoyment of it is a marker of the fact that it suits them.
And they're the people that turn up for reunion's and they're the people meditate a lot.
And it might be that people who don't enjoy it don't meditate. And that's a marker of the fact that meditation isn't going to work for them.
They need another approach. We're not claiming this is a cure all and that there are lots of approaches out
there and people need to be able to have all these things available to them.
Ultimately, we'll need to do the research to find out whether people that are, as it were, encouraged not to meditate.
But those people are encouraged to carry on meditating, whether that's got different long term outcomes.
It's a hard question, of course, because it's difficult to keep track of what people are doing and we don't want to impose on people's lives.
But ultimately, that. The assumption. And in science, the best thing is to try to falsify your favourite hypotheses.
So it means that you've really got to look critically at all the things that might be wrong with just assuming that, OK.
You've got to meditate. And if you don't meditate, you've had it. I think that may be true of some people.
And for other people, they make so much transformation during the eight weeks.
And maybe they can survive without meditating anymore. What I say to the patients when they finished the classes is, you know, we just don't know.
We just don't know. And therefore, it's best. It's up to you.
It's up to you to discover how this practise can nourish your life from day to day.
And of course, most of us brush our teeth. Why do we do that? We're not going to get a filling in a cavity immediately if we don't brush our teeth.
Why do we do it? Because we've got that habit of dental hygiene.
And why not see this as being something like hygiene for the mind,
where you just take a few minutes of silence to cultivate the art of stillness every day?
It's been at the heart of many cultures for centuries. And I don't think that's an accident.
So is there any evidence that mindfulness can serve as almost like a vaccine in ordinary people who've never suffered depression?
I think it's a very interesting concept. The immunisation concept, because as you and I know from the Frantic World Book,
the emphasis there is not so much on clinical depression, but on the precursors of depression.
That is the burnout, exhaustion, high stress, you know, high levels of cortisol, the work that John Cabot,
Zen, his colleague, has done and lots of work on stress in America showing how mindfulness can reduce stress.
We know that that affects all sorts of things that would normally cause physical damage to the body as well as the untold damage to the mind.
And it's extremely likely that the idea of the vaccine or the cognitive vaccine is, I think, a very good one.
So it not only works for depression, it also works for anxiety, stress, mental exhaustion.
Is there anything else that it might be effective for?
Well, when we're talking about when you get outside the clinical conditions of anxiety, depression,
I mean, we just finished the trial on health anxiety, for example, where it seems to be very useful.
We've done some initial work with eating disorders to try to work out how very severe anorexia might be helped with this approach.
Work in America on eating disorders also going ahead.
But also, when you think about it as a vaccine that releases all sorts of things, because one of things about a vaccine is you give it to everybody.
It's a universal intervention. You offer it to everybody. I mean, measles vaccines offer to everybody in the United Kingdom.
Now, why is that important? Well, we've recently started do some work with Nancy Bodarky,
who is a nurse midwife from California who's developed mindfulness based childbirth and parenting.
She invites couples to come when they're expecting a new baby to come to a nine week mindfulness course.
And what they do is they deal with the issue of first world childbirth, which for many people is a very exciting but also fear provoking.
There's a lot of fear of the pain of childbirth, for example. And she modifies just like we modified and BSR for depression.
She modifieds and BSR for childbirth and parenting, talking about fear and pain.
And her mindful birthing dot org Web site is a wonderful opening up of the possibility not of what you might call natural childbirth,
but what you might call,
don't know, childbirth, because you just don't know how what's going to happen so that you can take all these steps to make a birth plan.
But how are you going to cope if something is different from what you expect?
Nancy Bardic, whose work is great for that, and she's been training people in the UK based at the Oxford Mindfulness Centre,
so we can develop here a new European initiative on how to train midwives to offer a mindfulness based childbirth and parenting,
either as a universal intervention or at least to those mums and dads that we know are vulnerable around the time of the birth of a new child.
Is there evidence that mindfulness can work for heart disease and cancer and any other increasingly common diseases in the Western world?
There's no evidence that mindfulness is very good at increasing the quality of life for people with cancer.
And so both work in America and Canada using BSR and work in using embassy tea in North Wales.
And now there's been a trial in 2010 by Foley and colleagues in Australia in which
they've looked at a randomising people to mindfulness or to treatment as usual,
and finding it. It helps reduce the stress, reduce the rumination, because when you've got a real tragedy in your life,
then what you don't need is all the other stuff, you know, to get depression and stress and so on.
You don't need you need all your resources to deal with. The day to day of the illness,
without dragging up everything and feeling a failure and feeling extra suffering
that often can come with these with these very challenging health conditions.
Do you think there's any downsides to mindfulness?
I think if people tried to use it as a way of a clever way of fixing things, then it may be a problem in that often when people meditate.
They feel very relaxed. And that's lovely. It's a lovely by-product of meditation.
But if you begin to think, ah, now that's what I need for my relaxation.
So every time you feel tense, right, mindfulness meditation go. You can just get back into the trap of just a sort of discrepancy based processing.
And there is a danger that if you start to meditate with a goal in mind, then it's fine.
But if you don't meet the goal, if you don't if you're not relaxed within a minute, then you get frustrated with yourself for not being relaxed.
So what we have to remember is that mindfulness is about cultivating the sort of stillness that arises from allowing things to be as they are,
rather than wanting things to be different in every respect. You've obviously worked in this whole area for 30, 35 years now.
Which directions is the research going on? What do you find most exciting at the moment?
I think there's a number of different ways in which mindfulness and neuroscience, the study of brain imaging is bringing this all together.
We can actually see what happens in the brain.
I think in the next episode we need to look in in greater detail at what happens to the brain when you meditate.
And this will help us to see what the future holds for this research.
Thanks very much. In this episode, we're looking at the effectiveness of mindfulness based cognitive therapy.
And in the next episode, we'll be looking at mindfulness and the brain and the future applications of mindfulness based cognitive therapy.
For further information about mindfulness based cognitive therapy,
you can read Mark Williams and his co-workers book The Mind Four Way Through Depression.
Or you can read our book Mindfulness Finding Peace in a Frantic World.
That's by Mark Williams and me. Danny Penman.
Or you could visit the website Frantic World Dot Com if you'd like to support further research in this area.
You could visit Oxford University's Web site devoted to this area, and that is Oxford Mindfulness dot org.
And then follow the links to the development campaign.