Mindfulness: Have we found the ultimate solution for depression?
I once delivered an undergraduate lecture on the history of the development of psychological therapies. I dressed up as a witch (not joking, you can find photographic proof here) as a way to remind students just now far we have gone from the ignorant time when mental health was understood in the context of witchcraft or the like. Thankfully nowadays, at least in the UK, we have a relatively strong respect for an evidence-based approach, by which treatment effectiveness is subjected to rigorous scientific scrutiny before implementation in routine clinical practice. Many people may not fully appreciate just how much intellectual dedication and financial investment are required to deliver a robust clinical trial. It is in this context that I was overjoyed to see how much positive media coverage a recent publication in the Lancet has attracted.
This research article reported a randomised controlled trial comparing the effectiveness and cost-effectiveness between mindfulness-based cognitive therapy and antidepressant treatment in the prevention of depression relapse or recurrence. The key findings suggest that the psychological and pharmacological approaches were no different, yielding a relapse rate of 44% vs. 47% respectively. While the results did not suggest mindfulness as a superior treatment, they strongly argued for the benefits of providing depressed patients a non-medication alternative, which is equally effective and not more costly from the service delivery perspective.
Scanning through a selection of newspaper articles, on the whole, the essence of the research has been accurately portrayed. In particular, a Guardian article by Daniel and Jason Freeman provided a brief but comprehensive background of mindfulness therapy, including how the treatment was developed from traditional Buddhist practices, what mindfulness is about, and the relative merits and limitations of current routine maintenance medication.
By contrast, another Guardian article warned us of the risk of hype by pointing out that there are a variety of so-called ‘mindfulness’ therapies available in the market that are mingled with religious or spiritual practices which have not been clinically tested. While it is helpful not to get over-excited about one research finding, I think this newspaper article might have been over-cautious. It emphasised that ‘There is no specific definition of mindfulness that is agreed on 100% by scientists and practitioners’. This might sound daunting, but in the reality of research and clinical practice the same could be said about almost any treatments, psychological or pharmacological, because of the complexity of the subject matter, and this itself does not necessarily prevent the treatment from being useful. It is also important to note that the mindfulness-based cognitive therapy reported in this clinical trial was delivered based on a well-developed manual with therapists’ competence being monitored regularly throughout. Furthermore, the subheading ‘an army of therapists and counsellors would be needed for mindfulness to have the reach and effectiveness of drug-based interventions’ was misleading given that this research reported no difference between cost-effectiveness between mindfulness therapy and antidepressants.
The Telegraph on the whole presented a balanced summary of the research but was somewhat let down by the subheading ‘Mindfulness meditation stopped more people sliding back into depression than anti-depressants’, which was obviously contradictory to its own top headline ‘Mindfulness as good as anti-depressants for tackling depression’. Towards the end, it stated ‘some experts warned that the trial was not large enough to come to a definitive conclusive and had not included a placebo group.’ The research article did provide a comprehensive account of sample size calculation; it is difficult to comment on these ‘experts’ comments’ without even knowing who these ‘experts’ are and what they actually said. I agree that without a placebo control group, this clinical trial itself cannot conclude whether the two treatments were equally effective or equally ineffective. However, as mindfulness therapy and antidepressants have both been shown to be superior to routine care or placebo in previous research, it is reasonable to conclude that they are equally effective.
No research is perfect, but this clinical trial is so far the largest clinical trial, with the longest follow-up period, comparing these two treatment approaches, and one that was conducted with a commendable level of scientific rigour. Like any research, there is a limit as to how far the findings could be generalised. This studied sample was over-represented by ethnically white females, and targeted individuals who have experienced at least three depressive episodes. The current finding therefore cannot be taken to imply that mindfulness therapy is beneficial for everyone for everything. Most importantly, a relapse rate of 44 – 47% means that nearly half of the individuals still experience a recurrent illness within 24 months. This is a sobering fact.
As I said at the start, mental health research has come a long way, but we still have a very long way to go.
Kuyken, W. et al., (2015). Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): a randomised controlled trial. The Lancet. DOI:10.1016/S0140-6736(14)62222-4.
Piet J, & Hougaard E. (2011). The effect of mindfulness-based cognitive therapy for prevention of relapse in recurrent major depressive disorder: A systematic review and meta-analysis. Clinical Psychology Review. DOI:10.1016/j.cpr.2011.05.002.