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Hello and welcome to the new psychology of Depression.

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A series of programmes with me, Dr. Danny Pennyman and Professor Mark Williams of Oxford University.

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In the previous programme, we discussed mindfulness based cognitive therapy, a new approach to preventing depression.

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In this programme, we're going to ask, is mindfulness based cognitive therapy effective?

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Mark, can you describe some of the key landmark pieces of evidence that say that and BCT is very effective?

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The first study that we did was to offer this eight week programme to people who had been depressed recurrent.

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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,

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maybe for a minimum of twice or three or more times because they turned out to have different risks and different profiles.

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So we randomly allocated people. That's almost like a coin toss.

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But a computer does it or somebody does it outside the research team in what's called a randomised controlled trial.

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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.

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So some people were allowed in for all the people were allowed to go back to their doctor, have more anti-depressants.

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They wanted to. All the people that had antidepressants in the past when they started the trial,

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but all of them were now off antidepressants and they'd been free from depression for at least two months.

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That means they were definitely in remission and not suffering from depression when they started.

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Remember that we wanted to test out whether this could prevent new episodes of depression,

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not whether it actually treated depression, because we already had treatments for that.

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So here's two groups randomly allocated to receive actual mindfulness based cognitive therapy,

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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.

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Then we followed them up every two months for 12 months, which is the critical time if they're going to relapse.

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They're going to relapse probably in that time. And indeed, you find that if they work in a relapse.

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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.

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If it had the mindfulness, however, that we're down to thirty seven percent. So almost halving the rate of of relapse.

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Now, people that only had two episodes are somewhat different. Their relapse rates are fairly low anyway.

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And actually, there's a small subsample, only 25 percent of our 145 in that trial actually had only two episodes.

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And monthlies didn't seem to make that any better. So that was the pattern that people with three or more episodes.

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That is the people that we were very interested in,

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75 percent of the sample who had been recurrently depressed actually had a halving, almost a halving of the rate of relapse.

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Now, of course, the problem is, would that be a flash in the pan?

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It might be that that's just the one study. And so Jon Teesdale decided in his replication study to do precisely the same.

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But now, just with a new sample of people just at Cambridge, he and Helen Marr did what's called a procedure replication.

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And that's where you do almost exactly the same thing. Same entry criteria for the trial.

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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.

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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.

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Actually, it more than halved in fat in those cases.

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If they didn't have mindfulness, 78 percent of them relapsed and that came down to about 35, 36 percent.

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So more than halving the rate of relapse in that trial.

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Why is it most effective with people who are most afflicted by depression?

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This is the curious thing,

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because most treatments in in the world of psychological treatments actually have the biggest challenge with people that have been ill the longest.

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And here's an approach which seems to have the reverse of that.

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People that have the most challenging problem that have been around for longer get most benefit.

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I think it's because when you've been depressed three or more times and indeed,

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Martin Teesdale confirmed this, your depression has started early, often in teenage years.

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You've had difficult problems. Your parents, by the time we come to see them, the mean number of episodes is four.

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And you've you've had a 20 year history of depression. And so you've got stuck in these mental grooves.

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And therefore, the sort of depression we're seeing,

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there are just this sort of depression which mindfulness is very good for helping people to stand back from these mental grooves

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and get that sense of being liberated from the patterns of the mind that have become so habitual with people of any two episodes.

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Those patterns haven't become so habitual yet. They get a lot from the meditation.

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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,

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it's usually because something really toxic has happened again in the time that we're following them up.

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And mindfulness doesn't prevent the depression that follows immediately on the heels of a big life event.

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Maybe they've let mindfulness too recently and they struggle to try to use it as a way to fix their problems.

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Maybe they would do better take a holiday from mindfulness during the real storm of their life event for whatever reason.

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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.

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Not probably unless you learnt meditation a long time before it's part of your practise.

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It's often very difficult to get hard, solid evidence that a psychological approach to depression is actually effective.

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In that case, how do we know that MBT is actually effective?

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You've got to do trials. You've got to do randomised controlled trials. That's the recent discovery over 20, 30 years.

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You can't just do it on a few people show that it works, then write it up.

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That's what people used to do. And it's often the very first step.

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Of course, in seeing whether new psychological approach works,

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you've got to find a clinical series of patients to discover that it works not just with the first patient,

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but with the second, with a third, with the fourth. But then sooner or later,

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you have to do the hard work of randomly allocated some people to receive the treatment you think is going to

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be great and compare it with people that don't have that treatment but who are in other respects identical.

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And that's what they are S.T.

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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.

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You've got a good idea, but you're fooling yourself. I mean, what's very interesting.

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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.

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So that's very, very interesting. Major trials have been done in other countries as well, which is always very heartening.

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If you had to choose two or three trials that really backed up your claims, which ones would they be?

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You raise an important point that it's not enough just for the developers of a treatment to do the trials.

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It's got to be somebody outside who weren't the developers to see if it actually works in other countries, in other settings.

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So in addition to those first two trials and after those two trials,

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the UK's National Institute of Clinical Excellence picked it up and put it there as

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a recommended treatment for people who have three or more episodes of depression. That was in 2004 and again in 2009.

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Even with that evidence, they picked it up and established it as a treatment of choice for recurrent depression.

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But you still need the data from outside. So there was a third trial also in the United Kingdom.

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But now not done by the developers, by a colleague, Willem Caking in Exeter.

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And they contrasted MBT with antidepressant medication and found that it was just as good,

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in fact, in some measures better than people continuing to take their medication.

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That was then backed up by a trial in Switzerland that found that you could delay

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the onset of depression by 20 weeks or so with months based cognitive therapy.

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And another trial in Belgium and the Belgium trial based at the University of Ghent,

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found that the relapse rate went down from 68 percent to 30 percent.

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So, again, halving the rate of relapse.

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That was interesting trial because it showed that people could do it, whether they were anti-depressants or not.

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In the early trials, we had asked people to to only come to the trial if they were not taking antidepressant medication.

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And we found that we could prevent it in that group. But, of course, many people continue taking the antidepressant medication.

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The Belgian trial found that even if you allowed people to take their antidepressant medication right throughout,

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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.

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And the sixth trial that was published in 2010 by Zengel Sehgal in Toronto.

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So one of the original developers with us of the mindfulness based cognitive therapy was even

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more interesting because they contrasted mindfulness with people taking their anti-depressants,

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carrying on, taking the antidepressants or coming off and taking a pill placebo instead of antidepressants.

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And what was striking there was people who had the most difficult form of depression.

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That's what's called so unstable remission. So people they feel better, but then they become depressed again.

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And then they have another period where they feel better. Then they get depressed against it.

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Very unstable pattern of remission and recovery.

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And for those people, they were helped equally by antidepressants or by monthlies based cognitive therapy.

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But if they got the placebo pill, they relapsed at about 70 percent.

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But both antidepressants and mindfulness took it down to just below 30 percent.

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So once again, the pattern is emerging of mindfulness being better than treatment as usual and being at least as good as antidepressant medication.

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Is there any way of enhancing the effectiveness of mindfulness based cognitive therapy?

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There always will be. In other words, we always need more research.

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Getting the relapse rate down to 30 percent is effectively taking out of the picture.

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The effect of everything more than the first two episodes.

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So basically getting people back to where they were, you know, where they only had two episodes where their risk was about 30 percent.

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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.

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Another way might be to do more behavioural work, actually inviting people to go out and try things,

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which is one of the hallmarks of cognitive therapy and behaviour activation. And if you summarise all the trials, you see that on balance,

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you take all the six trials together, which has totalled about five and 90 patients altogether.

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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.

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It's about 44 percent for people with three or more episodes depression. But there are questions like,

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is it good for people that don't respond to other treatments there that's officially known as treatment resistant depression.

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Is it good for chronic depression? Is it how long the effects last?

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And is it as good as CBT? Well, each of those have now begun to have trials done throughout the world.

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And we know some of the preliminary answers to that.

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So Stuart Eyssen, Drath in California has used NBC t for people who don't respond to medication, at least two trials and medication.

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For the third trial of medication, he'd have expected about a 14 percent recovery rate with MBT,

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he more than doubled that same pattern with more Kenny in her work in Adelaide in Australia.

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She found that nearly 50 percent responded to embassy tea despite the fact that they

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hadn't responded to cognitive therapy and they hadn't responded to antidepressants.

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And that's a remarkable result for people who've been depressed for years and years and years.

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My colleague here, Thorsten Bon Hoffer, has looked at chronic depression in a group that were chronically depressed,

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weren't responding to treatment and had suicidal depression and found that in a little randomised controlled

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trial that you could reduce the back depression inventory score by one standard deviation using an BCT,

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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.

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More Morricone is now followed up her patients from that Adelaide study for

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three years and find that those effects are maintained for up to three years.

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And another Australian group in Gordon Parker's group in Sydney has found that its group,

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cognitive therapy and classes of MBT have about the same effect.

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So research is progressing all over the world as we speak.

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And it's showing the power of doing something that is not, in a sense, psychotherapy.

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It's not therapy. In one sense, it's actually skills training in mindfulness meditation.

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These trials and relapse rates, are they just for people who've done the eight week course and then stopped and BCT?

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Or is it for people who've carried on doing and BCT after the eight weeks?

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Everybody who does the eight week course are invited to carry on if they want to, but there's no compulsion to do so.

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They all get the seeds to keep. They can use it and most people do do some but not everybody.

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And what they do is generally less than they did on the eight week course.

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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.

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Maybe they use it whenever they need it.

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And then maybe if they feel depression coming on, they've got the seeds there, they can actually put on the seeds.

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One of them is a mindful movement, seeds, for example, which got something based on yoga.

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And many people find that very helpful way of actually putting their body through some

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movement as a way of actually dealing with with the mind's tendency to go spinning around.

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And so, yeah, many people do, but some don't. And it's too early to say whether this is a critical thing.

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What we know is that virtually any skill that you learn, if you do a little bit each day,

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it means that you maintain this go where it's learning a language, you know, juggling whatever, playing the piano.

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If you do a bit each day, it's going to be better for you. It's getting more accessible for you.

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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.

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But that's further research needs to find out exactly how much each day.

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And it's about the same time as you spend in brushing your teeth each day.

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For example, is it two, three minutes? Or does it take 10 minutes a day? We don't yet know yet.

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That's for further research to determine. So I know there's no hard evidence.

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But what's your hunch? Do you think the people who tend to relapse are the ones who've tended to do either

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less meditation or have completely stopped meditating after the eight weeks?

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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.

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If they'd come to reunion meetings and they'd actually spent longer meditating on a daily basis.

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Now, that, of course, does suggest that you need to do the meditation and maintain it.

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Practise, practise, practise. Every minute counts.

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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.

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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.

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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.

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And their enjoyment of it is a marker of the fact that it suits them.

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And they're the people that turn up for reunion's and they're the people meditate a lot.

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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.

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They need another approach. We're not claiming this is a cure all and that there are lots of approaches out

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there and people need to be able to have all these things available to them.

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Ultimately, we'll need to do the research to find out whether people that are, as it were, encouraged not to meditate.

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But those people are encouraged to carry on meditating, whether that's got different long term outcomes.

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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.

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But ultimately, that. The assumption. And in science, the best thing is to try to falsify your favourite hypotheses.

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So it means that you've really got to look critically at all the things that might be wrong with just assuming that, OK.

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You've got to meditate. And if you don't meditate, you've had it. I think that may be true of some people.

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And for other people, they make so much transformation during the eight weeks.

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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.

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We just don't know. And therefore, it's best. It's up to you.

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It's up to you to discover how this practise can nourish your life from day to day.

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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.

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Why do we do it? Because we've got that habit of dental hygiene.

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And why not see this as being something like hygiene for the mind,

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where you just take a few minutes of silence to cultivate the art of stillness every day?

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It's been at the heart of many cultures for centuries. And I don't think that's an accident.

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So is there any evidence that mindfulness can serve as almost like a vaccine in ordinary people who've never suffered depression?

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I think it's a very interesting concept. The immunisation concept, because as you and I know from the Frantic World Book,

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the emphasis there is not so much on clinical depression, but on the precursors of depression.

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That is the burnout, exhaustion, high stress, you know, high levels of cortisol, the work that John Cabot,

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Zen, his colleague, has done and lots of work on stress in America showing how mindfulness can reduce stress.

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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.

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And it's extremely likely that the idea of the vaccine or the cognitive vaccine is, I think, a very good one.

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So it not only works for depression, it also works for anxiety, stress, mental exhaustion.

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Is there anything else that it might be effective for?

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Well, when we're talking about when you get outside the clinical conditions of anxiety, depression,

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I mean, we just finished the trial on health anxiety, for example, where it seems to be very useful.

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We've done some initial work with eating disorders to try to work out how very severe anorexia might be helped with this approach.

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Work in America on eating disorders also going ahead.

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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.

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It's a universal intervention. You offer it to everybody. I mean, measles vaccines offer to everybody in the United Kingdom.

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Now, why is that important? Well, we've recently started do some work with Nancy Bodarky,

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who is a nurse midwife from California who's developed mindfulness based childbirth and parenting.

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She invites couples to come when they're expecting a new baby to come to a nine week mindfulness course.

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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.

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There's a lot of fear of the pain of childbirth, for example. And she modifies just like we modified and BSR for depression.

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She modifieds and BSR for childbirth and parenting, talking about fear and pain.

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And her mindful birthing dot org Web site is a wonderful opening up of the possibility not of what you might call natural childbirth,

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but what you might call,

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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.

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But how are you going to cope if something is different from what you expect?

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Nancy Bardic, whose work is great for that, and she's been training people in the UK based at the Oxford Mindfulness Centre,

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so we can develop here a new European initiative on how to train midwives to offer a mindfulness based childbirth and parenting,

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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.

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Is there evidence that mindfulness can work for heart disease and cancer and any other increasingly common diseases in the Western world?

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There's no evidence that mindfulness is very good at increasing the quality of life for people with cancer.

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And so both work in America and Canada using BSR and work in using embassy tea in North Wales.

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And now there's been a trial in 2010 by Foley and colleagues in Australia in which

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they've looked at a randomising people to mindfulness or to treatment as usual,

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and finding it. It helps reduce the stress, reduce the rumination, because when you've got a real tragedy in your life,

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then what you don't need is all the other stuff, you know, to get depression and stress and so on.

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You don't need you need all your resources to deal with. The day to day of the illness,

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without dragging up everything and feeling a failure and feeling extra suffering

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that often can come with these with these very challenging health conditions.

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Do you think there's any downsides to mindfulness?

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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.

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They feel very relaxed. And that's lovely. It's a lovely by-product of meditation.

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But if you begin to think, ah, now that's what I need for my relaxation.

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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.

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And there is a danger that if you start to meditate with a goal in mind, then it's fine.

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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.

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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,

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rather than wanting things to be different in every respect. You've obviously worked in this whole area for 30, 35 years now.

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Which directions is the research going on? What do you find most exciting at the moment?

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I think there's a number of different ways in which mindfulness and neuroscience, the study of brain imaging is bringing this all together.

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We can actually see what happens in the brain.

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I think in the next episode we need to look in in greater detail at what happens to the brain when you meditate.

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And this will help us to see what the future holds for this research.

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Thanks very much. In this episode, we're looking at the effectiveness of mindfulness based cognitive therapy.

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And in the next episode, we'll be looking at mindfulness and the brain and the future applications of mindfulness based cognitive therapy.

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For further information about mindfulness based cognitive therapy,

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you can read Mark Williams and his co-workers book The Mind Four Way Through Depression.

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Or you can read our book Mindfulness Finding Peace in a Frantic World.

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That's by Mark Williams and me. Danny Penman.

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Or you could visit the website Frantic World Dot Com if you'd like to support further research in this area.

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You could visit Oxford University's Web site devoted to this area, and that is Oxford Mindfulness dot org.

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And then follow the links to the development campaign.