Title: Strong Evidence Shows that Mindfulness Based Cognitive Therapy is Successful in Preventing Relapse among People with Recurrent Major Depression

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1 1 Title: Strong Evidence Shows that Mindfulness Based Cognitive Therapy is Successful in Preventing Relapse among People with Recurrent Major Depression Prepared by: Amanda Doverspike, Date: December 13 th, 2010 Review date: December 13 th, 2012 CLINICAL SCENARIO: Client population: Adults with recurrent major depression according to DSM-IV criteria, who are in remission (not currently symptomatic). Treatment context: In the featured studies, treatment was done within a community setting, however it would be appropriate for both inpatient and outpatient settings as well. Problem/condition: Major depressive disorder (MDD) is classified as being a chronic, recurrent disorder. Individuals with a history of three or more episodes have a 90% chance of suffering another future episode, yet there are a limited number of strategies proven to prevent future relapse (Dimidjian, Kleiber, & Segal, 2010). Intervention: Mindfulness-based cognitive therapy (MBCT) is a synthesis of mindfulness-based stress reduction, mindfulness meditation, and traditional cognitive behavioral therapy. MBCT strategies help individuals recognize and understand the automatic patterns of sensation, cognition, behavior, and emotion which ultimately lead one to a depressive episode. Instead of trying to eliminate or fix the negative thoughts and emotions which precede depressive episodes, mindfulness-based cognitive therapy teaches the person to allow them to occur and become aware of what he or she is experiencing during their onset. Ideally, in understanding these processes, one would be able to recognize the onset of symptoms and prevent them from developing into a depressive episode. MBCT is an eight week program which uses mindfulness exercises and homework to engage clients in experiencing the present and to avoid worrying about its relation to the past or future (Dimidjian et al., 2010). How does the intervention work?: Individuals who are depressed tend to interpret their life experiences in a negative and biased way. These thoughts tend to be global, self-critical, and involve the past and future. Over time, these individuals develop automatic, habitual patterns based on associated thoughts and moods. As these patterns develop and become automatic, the negative thoughts may easily perpetuate the sad moods previously associated with the same or similar thoughts, thus it becomes easier for the individual to fall into a downward spiral of depression. As this process progresses, even mild changes in mood may lead to major changes in thinking, a concept termed cognitive reactivity. Using MBCT strategies, these individuals learn to recognize and welcome these patterns in order to understand them. Eventually, the individual would be able to recognize the onset of these patterns, and disrupt the automatic processes (feedback loops) thus, is believed, by modifying the neural circuits in their brain that are involved with emotion (e.g. amygdala, hippocampus). Essentially MBCT is thought to alter the emotional/cognitive and physiological experiences of the present in order to prevent depressive relapse in the future (Dimidjian et al., 2010). Research shows that such cognitive behavioral strategies may actually modify similar brain circuits which are targeted by medications (Porto, 2009). OT framework: Although this intervention may affect multiple systems of the body, including both physiological and mental, its main focus is on the individual s thoughts and emotions. Within the framework is a section on client factors. Within this section are body functions, and within that section

2 2 are mental functions. Mental functions may include one s perceptions, thoughts, emotions, and experience of self and time. These functions address logical thoughts, awareness of reality, coping, behavioral regulation, body image, self-concept, and self-esteem, all of which may be related to depression. It is when this area of the framework is disrupted (e.g. irrational, negative thoughts leading to a depressive state of emotion) that an occupational therapist may choose MBCT as a potential intervention. Any intervention that helps to lengthen the time between major depressive episodes helps the person remain as functional as possible in his/her occupational performance. MBCT would be appropriate for an occupational therapist to use in conjunction with addressing occupational performance deficits. This is further developed in the next section on theory. OT Theory: It has been suggested that MBCT be used in occupational therapy as a compliment to the Model of Human Occupation (MOHO). MOHO is a holistic model which emphasizes the importance of a mind-body connection. The developers of MOHO believed that a person s motivation, behavior and performance are all integrated. It follows that internal processes (thoughts, feelings, motivation) will affect a person s external occupational performance (Cole, 2008). MBCT compliments this model in that it too is based on a holistic mind-body connection. MBCT works to change internal, mental processes that could lead to relapse into a depressive episode, in which case there would likely be a decrease in external occupational performance. In the big picture, occupational therapists may utilize MOHO and MBCT together to help their patients become aware of their present mind-body state and use that awareness to be adaptive, healthy beings (Hudson, 2009). FOCUSED CLINICAL QUESTION: Patient/Client Group: Adults suffering from recurrent major depression Intervention (or Assessment): Mindfulness-based cognitive theory Comparison Intervention: Treatment as usual Outcome(s): Preventing relapse of depressive episodes SUMMARY Is mindfulness-based cognitive therapy effective in preventing relapse of depressive episodes in adults suffering from recurrent major depression as compared to treatment-as-usual? Search: o Number of data bases searched: 3 o Total Number of relevant articles located: 7 o 3 randomized controlled trials; strength of article critiqued: 8/10 (PEDro Scale) o Rationale for selection of articles: I chose the three main articles that I did because the two more recent articles were replications of the original study. The three studies were nearly identical and directly addressed my PICO question. Also, the two other randomized controlled trials that I found utilized populations who were taking medication during treatment, whereas in my selected articles, they were not. This eliminated an additional variable. o Summarized findings: The three selected articles provide strong evidence that mindfulness-based cognitive therapy is successful in preventing relapse among people with recurrent major depression.

3 CLINICAL BOTTOM LINE Strong evidence shows that mindfulness-based cognitive therapy is successful in preventing relapse among people with recurrent major depression. 3 Limitation of this CAT: This critically appraised paper (or topic) has been reviewed by occupational therapy graduate students and the course instructor. SEARCH STRATEGY: Databases Searched Cinahl (EBCSOhost) Cochrane (EBSCOhost) PsychINFO Table 1: Search Strategy Search Terms Limits used Inclusion and Exclusion Criteria And Inclusion English Only Full-Text Adult population diagnosed with recurrent depression, currently stable (in remission) Exclusion Articles older than 2000 Currently depressed patients (according to DSM) Cognitive Behavioral Therapy + Mindfulness Cognitive Behavioral Therapy + Mindfulness + Depression Mindfulness Based Cognitive Therapy Mindfulness Based Cognitive Therapy + Depression RESULTS OF SEARCH: Table 2: Summary of Study Designs of Articles Retrieved Level Study Design/ Methodology of Articles Retrieved Randomized Controlled Trial Non-randomized Control Group (one group) Qualitative Number Located Source Journal of Consulting and Clinical Psychology Behaviour Research and Therapy Journal of Affective Disorders The Journal of Nervous and Mental Disease Aging and Mental Health Citation (Name, Year) Teasdale, 2000 Teasdale, 2004 Teasdale, 2008 Godfrin, 2010 Bondolfi, 2010 Michalak, 2008 Smith, 2007

4 4 STUDIES INCLUDED: Table 3: Summary of Included Studies Teasdale, 2000 Teasdale, 2004 Bondolfi, 2010 Intervention Investigated Comparison Intervention Outcome Variables & Measures Mindfulness Based Cognitive Therapy (MBCT) 8 weeks of treatment, 52 weeks of follow-up. 2 hour session done once a week. Mindfulness Based Cognitive Therapy (MBCT) 8 weeks of treatment, 52 weeks of follow-up. 2 hour session done once a week. Mindfulness Based Cognitive Therapy (MBCT) 8 weeks of treatment, 52 weeks of follow-up. 2 hour session done once a week. Treatment as Usual (TAU) Treatment as Usual (TAU) Treatment as Usual (TAU) Relapse/Recurrence of Depression: Structured Clinical Interview for the DSM-III-R (SCID) Findings Patients with 3 or more previous depressive episodes: 37% of MBCT group relapsed, 66% of TAU group relapsed (p <.005) with a medium effect size. Patients with 2 previous depressive episodes: 54% of MBCT group relapsed, 31% of TAU group relapsed (p >.10). For adults with three or more previous episodes of depression, MBCT was a statistically and clinically significant intervention; however it was not for individuals with two previous episodes. Relapse/Recurrence of Depression: Structured Clinical Interview for the DSM-IV (SCID) Patients with 3 or more previous depressive episodes: 36% of MBCT group relapsed, 78% of TAU group relapsed (p =.002) with a large effect size. Patients with 2 previous episodes: 50% of MBCT group relapsed, 20% of TAU group relapsed (p =.387). Participants with three or more previous depressive episodes are a different population as compared to those with two previous episodes, and the two populations respond differently to MBCT. Relapse/Recurrence of Depression: Structured Clinical Interview for the DSM-IV (SCID) 33% of the MBCT group and 36% of the TAU group relapsed (p = 1). Median # of days to relapse for MBCT group was 204 (range of ) and for the TAU group was 69 (range of ) with p =.006. Differences in relapse rates between the two groups may be attributed to the health care system/context in which the study is conducted.

5 5 SYNTHESIS: IMPLICATIONS FOR PRACTICE, EDUCATION and FUTURE RESEARCH Introduction Is mindfulness-based cognitive therapy effective in preventing relapse of depressive episodes in adults suffering from recurrent major depression as compared to treatment-as-usual? Overall conclusions Three randomized controlled trials were investigated. The latter two were replication studies of the original study by Teasdale et al. in The earliest two studies (Teasdale et al., 2000) and (Teasdale & Ma, 2004) both found statistically and clinically significant results in that mindfulness-based cognitive therapy reduced the number of participants who relapsed as compared to the control group who received treatment as usual; relapse rates were nearly halved in both studies. These two studies had medium and large effect sizes. However, in the third study, this was not the case. It was proposed that the third study did not reach significant results because the study occurred within a different context (health care system in Switzerland) than the previous two (in the UK and Canada), and the Swiss health care system provided ample mental health care for its citizens as compared to the other two studies. Since mental health care was readily available for those participants who did not receive the mindfulness-based cognitive therapy, rates of relapse were similar between the two groups. Also, the first two studies both found that MBCT had worked well for participants who had three or more previous episodes, but not for those who only had two previous episodes. The implication of this finding is that the more previous episodes one has experienced, the easier it is for that individual to become aware of when it is happening again. Teasdale and Ma (2004) had some additional findings to support this. They found that those patients who had an earlier initial onset of depression benefitted more from MBCT than those who had a later initial onset. They noted that the participants who suffered three or more previous episodes had a much earlier mean age of initial depression (28.4 versus 37.5). They also noted that the participants with two previous depressive episodes suffered their episodes as the result of a significant life event and MBCT did not appear to work in those cases. Also, patients with only two previous episodes reported less abuse and family problems earlier in their life. In sum, those with three or more episodes benefitted more from the treatment than those with only two previous episodes. Although the difference between the MBCT and TAU relapse rates did not reach statistical significance in the Bondolfi et al., 2010, study, the MBCT group did not relapse as quickly (mean of 204 days compared with mean of 69 days for the TAU group). Also, this study did not find a significant difference between the amount of MBCT practice done by those who relapsed and those who did not. Boundaries The main limitation to all three of the selected studies is that the mindfulness based cognitive therapy group was not compared to another active group intervention comparison. Because of this, researchers can not be fully confident that the significant results which were reached were due to the actual practices of MBCT or aspects such as receiving group support and therapeutic attention in general. Also, the earlier two studies were both partially conducted by the developers of MBCT. This raises the question of whether or not other instructors would be able to reach the same results. The main variable which these three studies observed was relapse rates of a depressive episode. This variable was examined over a one-year period, therefore the only conclusions that may be made from these studies are the short-term affects of mindfulness-based cognitive therapy. Further research would need to be conducted in order to gather thorough evidence about the other impacts that MBCT may have for people with recurrent depressive disorder and what its long term affects may be.

6 6 Implications for practice Although mindfulness-based cognitive therapy was developed fairly recently, research has provided strong evidence supporting its use in preventing relapse of depression in adults with recurrent major depression. Any therapist who chooses to administer MBCT as a treatment intervention should be completely familiar with and educated on the eight week program which it follows. Researchers and practitioners, such as occupational therapists, may want to explore other variables associated with this intervention such as its affect on occupational performance and quality of life; at this point in time, these factors have not been thoroughly addressed by research. Based on the suggestion that individuals with three or more previous depressive episodes were more successful with this intervention due to it being easier for them to recognize the onset of symptoms, practitioners should consider their patient s awareness of their symptoms when using this intervention. For patients who have only suffered two previous depressive episodes, it is recommended that the health care practitioner check how well the patients do at symptom recognition before and after the training session. This may help clarify the role of recognition of symptoms and emphasize that this is a major aspect of MBCT.

7 7 REFERENCES Reviewed Articles Bondolfi, G., Jermann, F., Van der Linden, M., Gex-Fabry, M., Bizzini, L., Weber Rouget, B.,... Bertschy, G. (2010). Depression relapse prophylaxis with mindfulness-based cognitive therapy: Replication and extension in the Swiss health care system. Journal of Affective Disorders, 122, doi: /j.jad &AN= &site=ehost-live (permalink) Teasdale, J.D., Williams, M. G., Soulsby, J.M., Segal, Z. V., Ridgeway, V. A., & Lau M.A. (2000). Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. Journal of Consulting and Clinical Psychology, 68, doi: // X (No permalink available, hard copy available upon request) Teasdale, J.D., & Ma, S.H. (2004). Mindfulness-based cognitive therapy for depression: Replication and exploration of differential relapse prevention effects. Journal of Consulting and Clinical Psychology, 72, doi: / X (No permalink available, hard copy available upon request) Related Articles (not individually appraised) Godfrin, K.A., & Heeringen, C.V. (2010). The effects of mindfulness-based cognitive therapy on recurrence of depressive episodes, mental health, and quality of life: A randomized controlled study. Behaviour Research and Therapy, 48, doi: /j.brat Michalak, J., Heidenreich, T., Meibert, P., & Schulte, D. (2008). Mindfulness predicts relapse/recurrence in major depressive disorder after mindfulness-based cognitive therapy. Journal of Nervous and Mental Disease, 196, doi: /NMD.0b013e31817d0546. Smith, A., Graham, L., & Senthinathan S. (2007). Mindfulness-based cognitive therapy for recurring depression in older people: A qualitative study. Aging and Mental Health, 11, doi: / Teasdale, J.D., Kuyken, W., Taylor, R.S., Barrett, B., Evans, A., Byford, S.,... Mullan, E. (2008). Mindfulness-based cognitive therapy to prevent relapse in recurrent depression. Journal of Consulting and Clinical Psychology, 76, doi: /a Additional Sources Cole, M.B., & Tufano, R. (2008, Chapter 7). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: SLACK Incorporated. Dimidjian, S., Kleiber, B.V., & Segal, Z.V. (2010). Mindfulness-based cognitive therapy. In N. Kazantzis, M. Reinecke, & A. Freeman (Eds.), Cognitive and behavioral theories in clinical practice (pp ). New York, NY: Guilford Press.

8 8 Hick, S., & Chan, L. (2010). Mindfulness-based cognitive therapy for depression: effectiveness and limitations. Social Work in Mental Health, 8(3), doi: / Hudson, F. (2009). Mindfulness based cognitive therapy (MBCT) and occupational therapy in mental health. Mental Health Occupational Therapy, 14(2), Mathew, K., Whitford, H., Kenny, M., & Denson, L. (2010). The long-term effects of mindfulness-based cognitive therapy as a relapse prevention treatment for major depressive disorder. Behavioural and Cognitive Psychotherapy, 38, doi: /s x. Porto, P., Oliveira, L., Mari, J., Volchan, E., Figueira, I., & Ventura, P. (2009). Does cognitive behavioral therapy change the brain? A systematic review of neuroimaging in anxiety disorders. The Journal Of Neuropsychiatry And Clinical Neurosciences, 21(2), doi: 1176/appi.neuropsych Scherer-Dickson, N. (2004). Current developments of metacognitive concepts and their clinical implications: mindfulness-based cognitive therapy for depression. Counselling Psychology Quarterly, 17(2), doi: / Segal, Z.V., Teasdale, J.D., & Williams, M.G. (2004). Mindfulness based cognitive therapy: Theoretical rationale and empirical status. In S. Hayes, V. Follette, & M.Linehan (Eds.), Mindfulness and acceptance: expanding the cognitive-behavioral tradition. New York, NY: Guilford Publications Guilford Press.

9 9 APPENDIX (Article Critique) Title: Bondolfi, G., Jermann, F., Van der Linden, M., Gex-Fabry, M., Bizzini, L., Weber Rouget, B.,... Bertschy, G. (2010). Depression relapse prophylaxis with mindfulness-based cognitive therapy: Replication and extension in the Swiss health care system. Journal of Affective Disorders, 122, doi: /j.jad &AN= &site=ehost-live (permalink) Purpose of the study: The purpose of this study was to investigate relapse rates as well as time until relapse of depression in participants receiving both treatment as usual (TAU) and mindfulness based cognitive therapy (MBCT) as compared to a control group receiving only treatment as usual. Also, this study investigated whether or not regular practice of what was learned in the MBCT program was associated with diminished relapse rates. Hypothesis: Mindfulness based cognitive therapy in addition to treatment as usual will reduce the risk of depressive relapse when compared to treatment as usual alone in the context of the Swiss health care system in a sample of remitted depressed patients with three or more past depressive episodes (Bondolfi, 2010). Study Design: AOTA level I: Randomized, controlled trial; control group (treatment as usual), experimental group (treatment as usual + mindfulness based cognitive therapy). Setting: Two sites were involved in a community setting: Geneva Hospital and Lausanne University Hospital. Participants: Diagnosis: Recurrent major depression. Recruitment: Media announcements were made, and mailings were sent to psychiatrists and general practitioners in the French speaking region of Switzerland (convenience sampling method). Potential participants were screening during an over the phone interview. Those that passed the screen were scheduled for a person-to-person interview. Those who met the inclusion criteria were entered into a three month run-on phase in which they were expected to remain stable and not relapse into a depressive episode. After this phase, remaining recruitments were given a second person-to-person enrollment interview to verify that inclusion criteria were still met at that time. Each participant then provided written informed consent before being formally enrolled in the study. Inclusion criteria o History of recurrent major depression according to the DSM-IV o History of at least three previous depressive episodes (two of which were within the last five years, and at least one of which was in the past two years)

10 10 o In remission for at least the past three months prior to recruitment o Score on the Montgomery-Asberg Depression Rating Scale of equal to or less than 13 o A history of using antidepressant medications, however had been off of the medications at least three months prior to enrollment Exclusion criteria o History of Schizophrenia or schizoaffective disorder o Current substance abuse, eating disorder, or obsessive compulsive disorder o Having an organic mental disorder, pervasive developmental disorder or borderline personality disorder o Onset of Dysthymia before the age of 20 o Having had more than four sessions of cognitive behavioral therapy ever o Currently receiving psychotherapy or counseling more than once per month o Currently practicing meditation more than once a week o Currently practicing yoga more than twice a week Required sample size: Following calculations, it was found that in order to have 80% power, this study needed 56 patients (28 in each group). Patient flow: Originally, over 600 interested potential participants contacted the research team to partake in the preliminary over-the-phone screening. Following the phone screening, 142 potential patients were invited to participate in the first person-to-person selection interview. Half (71) of these individuals were excluded due to not meeting inclusion criteria, falling with exclusion criteria, or simply refusing to participate (one individual). That left 71 participants which were entered into a three month run-in phase during which time their depressive mood was expected to remain stable. 11 people were excluded after no longer meeting inclusion criteria or no longer making themselves available to the study. The original intent-to-treat population was divided into n=29 (TAU) and n=31(mbct + TAU). Upon completion of the 14- month administration and follow period, complete data was available for 55 patients (the perprotocol sample, meaning those who received MBCT completed a minimum adequate dose of at least four MBCT sessions), with the TAU group n=28 and the MBCT group n=27. A diagram of patient flow is provided on page 228 of the article. Patient characteristics: It was found at baseline, that the intent-to-treat population (n=31 for MBCT and n=29 for TAU) did not differ statistically in the following variables: age, gender, education, age at onset of depression, number of past episodes, and number of hospitalizations. Also, there were no statistical differences between the two groups in regards to the use of antidepressants and non-pharmacological treatments during the time of the study. It should be noted, that during randomization of the two groups, a stratified block procedure was implemented for the following variables: site (between the two hospitals), number of previous episodes (three or greater than three), and the duration of remission since the participants last episode (either 0-12 or months). See Table 1 on page 229 of the article to see the patient characteristics broken down.

11 11 Intervention Investigated Method: 1. Participants were recruited by a single research team through convenience sampling (media announcements and mailings). 2. Through the patient flow discussed above, participants who made it to the intent-to-treat population were randomly assigned to either the control group or treatment group. 3. The treatment group was given eight weekly 2-hour training sessions of mindfulness based cognitive therapy at one of the two designated hospital locations (Geneva or Lausanne University Hospital). Specific strategies discussed include body scanning, sitting meditation, three-minute breathing space, and informal practice. The treatment-as-usual control group were not given a designated amount of therapy, but were told to seek help from their family doctor or other sources that they would normally use when they felt symptomatic or in need of help. 4. Following the initial eight weeks, a 52-week follow-up (one complete year) was conducted. Four MBCT booster sessions were given at regular three month intervals during the follow up period. All participants (TAU and MBCT groups) were assessed at three month intervals by the original research team. Researchers monitored their moods, use of medications, and any contact with medical staff, such as a general practitioner or mental health practitioner. It should be noted that patients were instructed to not tell the researchers which group they were a part of in order to keep the research team blind to the treatment of each participant and ultimately lead to blind outcome assessment data. 5. From recruitment to final follow-up, this study last from October of 2005 to June of Administering therapists: Consisted of three senior cognitive behavioral therapy psychologists and one senior cognitive behavioral therapy psychiatrist. All therapists had attended at least one training program taught by one of the developers of MBCT. Two of the administrators also attended a nine day professional trainings in mindfulness based stress reduction (an aspect which MBCT was built upon) seminar. Before the study was conducted, each therapist led at least three supervised MBCT groups which were audiotaped and reviewed by two psychologists familiar with MBCT but not a part of this research group. The two psychologists rated the sessions using a MBCT adherence scale and found that there was a high degree of adherence regarding the MBCT protocol between the four therapists. Dependent variables and Outcome Measures Outcome Data Measure Type Dependent Variable *Relapse/recurr ence of a major depressive episode (primary outcome measure) Structured clinical interview of the DSM-IV (SCID) Scoring ICF Level OT Framework Terms Nominal N/A Impairment variable Client factors: Mental functions Administration Baseline, 2 months later (end of MCBT therapy for treatment group), and 3 month intervals during follow-up.

12 12 Time to relapse Severity of depressive symptoms Severity of depressive symptoms Mindfulness practice Counting the number of days between enrollment and relapse Montgomery- Asberg Scale (MADRS) Beck Depression Inventory II (BDI- II) (A self-rating questionnaire) Ad Hoc Questionnaire (developed for this study) Ratio Ordinal Ordinal Interval (likert scale) A longer time until relapse was considered ideal. Higher score means more severe symptoms. Scale is 0-6 Higher score means more severe symptoms.sc ale is 0-3 A higher score meant it was practiced more often. Scale is 0-3 Impairment variable Impairment variable Impairment variable Activity variable Client factors: Mental functions Client factors: Mental functions Client factors: Mental functions Performance patterns: routines *Two research team staff were trained by an experienced clinical psychologist in how to administer this interview. Interviews were audiotaped and reviewed by the clinical psychologist, who was also blind to the participants treatment (just as the researchers were). Any disagreements between the researcher who conducted the interview, and the senior psychologist were discussed by the two individuals in order to reach a consensus regarding whether or not that participant had relapsed. Main Findings Relapse rates: In the per protocol sample, 33% (9/27) of the treatment group and 36% (10/28) of the control group participants were found to have relapsed (p = 1). Time to relapse: For those patients who were identified as having relapsed (n=19), the median number of days from enrolment to relapse were 69 days (range of ) for the control group, and 204 days (range of ) for the treatment group (p =.006). MBCT practice: Researchers found the percentages of participants practicing the MBCT activities at least once a week for each of the four activities. The following data is in regards to period one, two, and three and is expressed in percentage of those who still practiced that activity: body scanning (65.4, 38.5, 11.5), sitting meditation (88.0, 61.5, 46.2), 3-minute breathing space (91.7, 68.0, 60.0), and informal practice (76.0, 65.4, 61.5). With regards to body scanning, researchers found no significant difference during period 1 ( p = 1) or period 2 (p =.69), however they did during period 3 (p =.032). At whatever point it was decided that a participant had relapsed. Baseline, 2 months later (end of MCBT therapy for treatment group), and 3 month intervals during follow-up. Baseline, 2 months later (end of MCBT therapy for treatment group), and 3 month intervals during follow-up. 3 periods: during the MBCT sessions, the first 6 months of follow up, the last 6 months of follow up.

13 13 Interpretation of Results Although the percentage of participants who relapsed did not differ significantly in this study (with a significance level of.05), it was found that the time until relapse was significantly delayed in the treatment group as compared to the control group. In fact, according to this study, MBCT increased the average time until relapse by 18 weeks. Since this study did not have an active control treatment which to compare the MBCT to, researchers were not able to necessarily attribute the increased time to relapse to the specific MBCT treatment. It is possible that the participants in the treatment group benefitted from more general aspects, such as being in a therapeutic group context and receiving support, destigmatization, and therapeutic attention. Therefore, it can not be said with complete confidence that MBCT is clinically significant according to this article. Regarding MBCT practice, researchers found that there was not a significant difference between those who did and did not relapse in the amount the participants who practiced sitting meditation, 3-minute breathing space, and informal practice. They also found that there was no significant difference between those who did and did not relapse for body scanning during periods one and two, however those who did relapse actually practiced this activity more than those who did not during the third period. Validity This study randomly assigned participants in the intent-to-treat population to the treatment or control group. At this time, a stratified block procedure was implemented to reassure that the two groups were equal regarding site (between the two hospitals), number of previous episodes and the duration of remission since the participant s last episode. Also, at baseline, researchers found no significant difference in multiple demographic and clinical characteristics between the two groups. Researchers who assessed the participants at various points throughout the study were blind to which group the participant had been a member of. PEDro scale 1. Participants were randomly allocated to groups. (1 point) 2. Allocation was concealed. (1 point) 3. The groups were similar at baseline regarding the most important prognostic indicators. (1 point) 4. There was not blinding of all participants, as this was not possible. (0 points) 5. There was not blinding of the therapists who administered therapy, as this was not possible (0 points). 6. There was blinding of all assessors who measured at least one key outcome. (1 point) 7. Measures of at least one component were obtained for more than 85% of the participants initially allocated to groups; 87% of the treatment group, and 97% of the control group. (1 point) 8. All participants for whom outcome measures were available received the treatment or control condition as allocated. (1 point)

14 14 9. The results of between-group statistical comparisons are reported for at least one key outcome measure; median and range were found for time to relapse. (1 point) 10. The study provides both point measures and measures of variability for at least one key outcome. (1 point) 11. TOTAL SCORE = 8/10, according to the PEDro rating scale, this was considered a rigorous study. Original Authors Conclusions Relapse rates: The researchers compared their results with previous studies which explored the same question of whether or not relapse rates differed between MBCT and TAU groups. They found that their relapse rate for those in the treatment group was in line with other studies, however their relapse rate for the TAU group was significantly lower; earlier studies found 68 and 78 percent relapse rates, versus the 36 percent rate these researchers arrived at. They reasoned that a possible explanation for this is the difference in health care systems (they ruled out demographics, clinical history and adjunctive treatments as possible explanations since these variables were all found to be similar between groups at baseline, throughout the study, and as compared to the groups in the previous studies). This study took place in Switzerland, where availability and accessibility for mental health care is high. The previous studies took place in the United Kingdom and Canada, where the ratio of number of psychiatrists per 10,000 habitants is much lower. Time to relapse: Although the authors found a clear delay time to relapse in their treatment group, they decided further studies are warranted in order to conclude whether or not this was due to the specific MBCT treatment, or general aspects of being in a group therapy setting. MBCT practice: Researchers concluded that their participants had good initial adherence to practicing the skills learned in their treatment sessions. This initial adherence was reinforced during the initial eight weeks when the participants were actually in treatment. Although they observed a significant drop during the second period (first six months of follow-up) in two of the activities (body scanning and sitting meditation), researchers did not provide a reason as to why they thought this was so. They also did not provide a reason as to why at least 60% of the participants continued to practice 3-minute breathing space and informal practice activities regularly at the end of the third period (12 months after treatment). Summary/Conclusion (Take Away Message) Mindfulness based cognitive therapy was developed fairly recently, and it is possible that the studies so far have been measuring variables that are not necessarily relevant to whether or not MBCT has true, long-term effects. Relapse rates and time to relapse may be subject to influence regarding the context of treatment, i.e. different health care systems. It may be more beneficial to conduct research on participant s quality of life and functional abilities as a product of this treatment. Instead of focusing on who relapses and when he/she relapses, I suggest researchers investigate how MBCT does or does not change the functional abilities and satisfaction in occupational performance in patients with recurring major depression.